Perioperative and frailty outcomes after total knee arthroplasty: a retrospective cohort study

BACKGROUND

Total knee arthroplasty (TKA) is a common procedure with an increasing demand, especially among the elderly. Frailty is known to be associated with adverse perioperative outcomes in the older population. In this article, we aimed to understand the associations of preoperative frailty status and comorbid conditions in relation to their clinical and healthcare outcomes after TKA, and to describe the perioperative factors leading to improvement in a patient's frailty status after TKA.

METHODS

This is a retrospective cohort study, and the outcomes were assessed over 2 years. Frailty is defined by the Clinical Frailty Score.

RESULTS

A total of 96 patient records were assessed, of which 13 (13.5%) patients were robust and 83 (86.5%) patients were prefrail or frail. Two years after TKA, the number of robust patients increased to 58 (61.7%) patients, showing a reversal of frailty in 48.2% of patients.

CONCLUSION

Total knee arthroplasty in prefrail and frail patients is a safe procedure that leads to improvement of frailty status, with an increase in the proportion of patients becoming robust within 2 years after the operation.

Associations of 2 Established Methods of Measuring Gait Speed and Sit-To-Stand Performance with Frailty and Life-Space Mobility in Community-Dwelling Older Adults

OBJECTIVES

The 4-m gait speed (4mGS) and 10-m gait speed (10mGS) tests and the 30-second sit-to-stand (30sSTS) and 5-times sit-to-stand (5xSTS) tests are commonly used and advocated in consensus recommendations. We compared these tests on their predictive and clinical value concerning the risk of prefrailty/frailty and restricted life-space mobility (RLSM).

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A sample of 1235 community-dwelling adults (mean ± SD, 68 ± 7 years) participated in this prospective cohort study.

METHODS

At baseline assessment, participants completed a survey and functional assessment, from which gait speed, sit-to-stand performance, self-reported mobility limitation, 40-item Frailty Index, and Life Space Assessment were measured. Participants with a 40-item Frailty Index >0.15 and a Life Space Assessment <60 points were classified as having prefrailty/frailty and RLSM, respectively. At 1-year follow-up assessment, prefrailty/frailty and RLSM were evaluated.

RESULTS

Correlations between gait speed and sit-to-stand measures were high (ρ values >0.80). In multivariable ordinal models, these measures added incremental prognostic value beyond a base model comprising demographics and self-reported mobility limitation variables in predicting baseline and 1-year outcomes. Between 10mGS and 4mGS, models with 10mGS had higher concordance indices (differences, 0.005-0.009), and these differences translated to generally greater net benefit in decision curve analyses. Between 30sSTS and 5xSTS measures, no one measure consistently outperformed the other, with small net benefit differences between measures (<0.2%).

CONCLUSIONS AND IMPLICATIONS

In community-dwelling older adults, gait speed and sit-to-stand measures meaningfully predicted prefrailty/frailty and RLSM. 10mGS provided more robust prognostic information than the 4mGS, whereas 5xSTS and 30sSTS measures showed near equivalence of performance. These findings could guide the choice of functional measures in clinical and research settings.

Association between Physical Function, Mental Function and Frailty in Community-Dwelling Older Adults: A Cross-Sectional Study

Background: This study examines the relationship between physical and mental function and frailty, independently and in conjunction with polypharmacy, among older adults. Methods: This cross-sectional study consisted of 368 participants aged ≥60 years. The participants were categorized into either robust or frail groups using Fried's frailty phenotype. Physical functions were assessed using grip strength, gait speed, Timed Up and Go (TUG), the Five Chair Sit to Stand Test (FCSST) and the Six-Minute Walk Test (SMWT). Mental functions were assessed using cognitive function and depression. Cognitive function was measured using Mini-Mental State Examination (MMSE). Depression was assessed with the Korean version of the Short Geriatric Depression Scale (SGDS). Results: The mean age of study population was 75.4 years. In this population, we identified 78.8% (n = 290) robust participants and 21.2% (n = 78) frail participants. The study examined frailty status (frail vs. non-frail) and frailty with and without polypharmacy using multivariate logistic regressions, adjusting for age and sex. In the logistic regression model estimating the risk of frailty, after adjustments for age, sex, BMI, and number of medications, individuals with low SMWT showed a significantly increased risk of frailty, with an odds ratio (OR) of 8.66 and a 95% confidence interval (CI) of 4.55-16.48. Additionally, global cognitive function was associated with a 1.97-fold increase in frailty risk (95% CI: 1.02-3.67). Moreover, in models adjusted for age, sex, and BMI to assess frailty risk linked to polypharmacy, the TUG, SMWT, and SGDS all showed increased risks, with ORs of 3.65 (95% CI: 1.07-12.47), 5.06 (95% CI: 1.40-18.32), and 5.71 (95% CI: 1.79-18.18), respectively. Conclusions: Physical function (SMWT, FCSST, TUG) and mental function (depression, cognition) were associated with frailty. By comprehensively examining these factors, we will gain valuable insights into frailty and enable more precise strategies for intervention and prevention.

Intrinsic capacity assessment using World Health Organization Integrated Care for Older People Step 1, and the association with frailty in community dwelling older adults

AIM

This study aimed to investigate the association between intrinsic capacity (IC) and frailty in community-dwelling older adults. Specifically, we examined the utility of the World Health Organization's Integrated Care for Older People Step 1 screen for identifying frail older persons in the community.

METHODS

This is a cross-sectional analysis of a community frailty screening initiative. IC loss was ascertained using the World Health Organization's Integrated Care for Older People Step 1 questions. The Clinical Frailty Scale was used to categorize participants as robust (Clinical Frailty Scale S1-3) or frail (Clinical Frailty Scale ≥4). Logistic regression was used to analyze the association of individual and cumulative IC losses with frailty, adjusting for confounders. Additionally, the diagnostic performance of using cumulative IC losses to identify frailty was assessed.

RESULTS

This study included 1164 participants (28.2% frail). Loss in locomotion (adjusted odds ratio [AOR] 1.47, 95% CI 1.07-2.02), vitality (AOR 1.58, 95% CI 1.04-2.39), sensory (AOR 1.99, 95% CI 1.51-2.64) and psychological capacities (AOR 1.92, 95% CI 1.45-2.56) were significantly associated with frailty. Loss in more than three IC domains was associated with frailty. Using loss in at least three ICs identifies frailty, with sensitivity of 38.6%, specificity of 83.5% and positive predictive value of 47.4%. Using loss in at least four ICs improved specificity to 96.9%, and is associated with the highest positive predictive value of 57.6% and highest positive likelihood ratio of 3.55 for frailty among all cut-off values. The area under the receiver operating characteristic curve was 0.64 (95% CI 0.61-0.68).

CONCLUSIONS

IC loss as identified through World Health Organization's Integrated Care for Older People Step 1 is associated with frailty community-dwelling older adults. Geriatr Gerontol Int 2024; 24: 457-463.

Using item response theory to estimate interpretation threshold values for the Frailty Index in community dwelling older adults

BACKGROUND

Although the frailty index (FI) is designed as a continuous measure of frailty, thresholds are often needed to guide its interpretation. This study aimed to introduce and demonstrate the utility of an item response theory (IRT) method in estimating FI interpretation thresholds in community-dwelling adults and to compare them with cutoffs estimated using the receiver operating characteristics (ROC) method.

METHODS

A sample of 1,149 community-dwelling adults (mean[SD], 68[7] years) participated in this cross-sectional study. Participants completed a multi-domain geriatric screen from which the 40-item FI and 3 clinical anchors were computed - namely, (i)self-reported mobility limitations (SRML), (ii)"fair" or "poor" self-rated health (SRH), and (iii) restricted life-space mobility (RLSM). Participants were classified as having SRML-1 if they responded "Yes" to either of the 2 questions regarding walking and stair climbing difficulty and SRML-2 if they reported having walking and stair climbing difficulty. Participants with a Life Space Assessment score <60 points were classified as having RLSM. Threshold values for all anchor questions were estimated using the IRT method and ROC analysis with Youden criterion.

RESULTS

The proportions of participants with SRML-1, SRML-2, Fair/Poor SRH, and RLSM were 21 %, 8 %, 22 %, and 9 %, respectively. The IRT-based thresholds for SRML-2 (0.26), fair/poor SRH (0.29), and RLSM (0.32) were significantly higher than those for SRML-1 (0.18). ROC-based FI cutoffs were significantly lower than IRT-based values for SRML-2, SRH, and RLSM (0.12 to 0.17), and they varied minimally and non-systematically across the anchors.

CONCLUSIONS

The IRT method identifies biologically plausible FI thresholds that could meaningfully complement and contextualize existing thresholds for defining frailty.

Estimating cutpoints of gait speed and sit-to-stand test values for self-reported mobility limitations in a cohort of community-dwelling older adults from Singapore: comparing receiver operating characteristic (ROC) analysis with adjusted predictive modelling

OBJECTIVES

Clinical interpretability of the gait speed and 5-times sit-to-stand (5-STS) tests is commonly established by comparing older adults with and without self-reported mobility limitations (SRML) on gait speed and 5-STS performance, and estimating clinical cutpoints for SRML using the receiver operating characteristics (ROC) method. Accumulating evidence, however, suggests that the adjusted predictive modeling (APM) method may be more appropriate to estimate these interpretational cutpoints. Thus, we aimed to compare, in community-dwelling older adults, gait speed and 5-STS cutpoints estimated using the ROC and APM methods.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This study analyzed data from 955 community-dwelling independently walking older adults (73%women) aged ≥60 years (mean, 68; range, 60-88).

METHODS

Participants completed the 10-metre gait speed and 5-STS tests. Participants were classified as having SRML if they responded "Yes" to either of the 2 questions regarding walking and stair climbing difficulty. Cutpoints for SRML and its component questions were estimated using ROC analysis with Youden criterion and the APM method.

RESULTS

The proportions of participants with self-reported walking difficulty, self-reported stair climbing difficulty, and SRML were 10%, 19%, and 22%, respectively. Gait speed and 5-STS time were moderately correlated with each other (r=-0.56) and with the self-reported measures (absolute r-values, 0.39-0.44). ROC-based gait speed cutpoints were 0.14 to 0.16 m/s greater than APM-based cutpoints (P < 0.05) whilst ROC-based 5-STS time cutpoints were 0.8 to 3.3 s lower than APM-based cutpoints (P < 0.05 for walking difficulty). Compared with ROC-based cutpoints, APM-based cutptoints were more precise and they varied monotonically with self-reported walking difficulty, self-reported stair climbing difficulty, and SRML.

CONCLUSIONS AND IMPLICATIONS

In a sample of 955 older adults, our findings of precise and biologically plausible gait speed and 5-STS cutpoints for SRML estimated using the APM method indicate that this promising method could potentially complement or even replace traditional ROC methods.

Associations of height, weight, and body mass index with handgrip strength: A Bayesian comparison in older adults

BACKGROUND & AIMS

Handgrip strength is commonly normalized or stratified by body size to define subgroup-specific cut-points and reference limits values. However, it remains unclear which anthropometric variable is most strongly associated with handgrip strength. We aimed to, in older adults with no self-reported mobility limitations, determine whether height, weight, and body mass index (BMI) were meaningfully associated with handgrip strength.

METHODS

This cross-sectional study included community-dwelling ambulant participants, and we identified 775 older adults who reported no difficulty walking 100 m, climbing stairs, and rising from the chair. Handgrip strength was measured with a digital dynamometer. Bayesian linear regression was used to estimate the probabilities that the positive associations of height, weight, and BMI with handgrip strength exceeded 0 kg (the null value) and 2.5 kg (the clinically meaningful threshold value).

RESULTS

Mean handgrip strength was 22.1 kg (SD, 4) for women and 32.9 kg (SD, 6) for men. Body height, weight, and BMI had >99.9% probabilities of a positive association with handgrip strength; however, the associations of per interquartile increase in body weight and BMI with handgrip strength had low probabilities (<5%) of exceeding the clinically meaningful threshold of 2.5 kg. In contrast, body height had the highest probability (99.6%) of a clinically meaningful association with handgrip strength: adjusting for age and gender, handgrip strength was 3.2 kg (95% CrI, 2.7 to 3.8) greater in older adults 1.61 m tall than in older adults 1.51 m tall.

CONCLUSIONS

In a large sample of mobile-intact older adults, handgrip strength differed meaningfully by body height. Although requiring validation, our findings suggest that future efforts should be directed at normalizing handgrip strength by body height to better define subgroup-specific handgrip weakness. A web-based application (https://sghpt.shinyapps.io/ippts/) was created to allow interactive exploration of predicted values and reference limits of age-, gender-, and height-subgroups.

Association between B-vitamins intake and frailty among patients with chronic obstructive pulmonary disease

PURPOSE

Gain insight into the impact of B vitamins, including vitamin B1, vitamin B2, niacin, vitamin B6, total folate, and vitamin B12 on the risk of frailty in patients with chronic obstructive pulmonary disease (COPD).

METHODS

This study was an American population-based cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES). A total of 1201 COPD patients were included in the analysis. Of these, the intake of B vitamins was determined by the two 24-h recall interviews. We followed the method constructed by Hakeem et al. to calculate the frailty index (FI), which is used as a reliable tool to assess the debilitating status of patients with COPD. Missing data were imputed by the MissForest method based on random forests. Multivariate logistic regression model and inverse probability weighted based on propensity scores were used to correct for confoundings.

RESULTS

Logistic regression models showed that vitamin B6 intake was negatively correlated with frailty risk in COPD patients, while other B vitamins including B1, B2, niacin (vitamin B3), total folic acid and vitamin B12 were not. After adjusting for covariates, the association between vitamin B6 and frailty risk (adjusted OR = 0.80, 95%CI = 0.66-0.95, P = 0.013) remained significant. At the same time, sensitivity analysis proves the robustness of the results.

CONCLUSION

COPD patients with lower vitamin B6 intake have a higher risk of frailty. However, intake of vitamin B1, B2, niacin, total folic acid, and vitamin B12 was not associated with frailty risk in COPD patients.

Development and validation of a physical frailty phenotype index-based model to estimate the frailty index

BACKGROUND

The conventional count-based physical frailty phenotype (PFP) dichotomizes its criterion predictors-an approach that creates information loss and depends on the availability of population-derived cut-points. This study proposes an alternative approach to computing the PFP by developing and validating a model that uses PFP components to predict the frailty index (FI) in community-dwelling older adults, without the need for predictor dichotomization.

METHODS

A sample of 998 community-dwelling older adults (mean [SD], 68 [7] years) participated in this prospective cohort study. Participants completed a multi-domain geriatric screen and a physical fitness assessment from which the count-based PFP and the 36-item FI were computed. One-year prospective falls and hospitalization rates were also measured. Bayesian beta regression analysis, allowing for nonlinear effects of the non-dichotomized PFP criterion predictors, was used to develop a model for FI ("model-based PFP"). Approximate leave-one-out (LOO) cross-validation was used to examine model overfitting.

RESULTS

The model-based PFP showed good calibration with the FI, and it had better out-of-sample predictive performance than the count-based PFP (LOO-R2, 0.35 vs 0.22). In clinical terms, the improvement in prediction (i) translated to improved classification agreement with the FI (Cohen's kw, 0.47 vs 0.36) and (ii) resulted primarily in a 23% (95%CI, 18-28%) net increase in FI-defined "prefrail/frail" participants correctly classified. The model-based PFP showed stronger prognostic performance for predicting falls and hospitalization than did the count-based PFP.

CONCLUSION

The developed model-based PFP predicted FI and clinical outcomes more strongly than did the count-based PFP in community-dwelling older adults. By not requiring predictor cut-points, the model-based PFP potentially facilitates usage and feasibility. Future validation studies should aim to obtain clear evidence on the benefits of this approach.

Intrinsic capacity rather than intervention exposure influences reversal to robustness among prefrail community-dwelling older adults: A non-randomized controlled study of a multidomain exercise and nutrition intervention

Background

The differential risk profiles associated with prefrailty may be attributable to underlying intrinsic capacity (IC).

Objectives

We examine (i) effect of a multi-domain physical exercise and nutrition intervention on pre-frailty reversal in community-dwelling older adults at 1-year, and (ii) whether IC contributes to pre-frailty reversal.

Methods

Prefrail participants in this non-randomized study were invited to attend a 4-month exercise and nutritional intervention following a frailty screen in the community. Prefrailty was operationalized as (i) FRAIL score 1-2 or (ii) 0 positive response on FRAIL but with weak grip strength or slow gait speed based on the Asian Working Group for Sarcopenia cut-offs. Participants who fulfilled operational criteria for prefrailty but declined enrolment in the intervention programme served as the control group. All participants completed baseline IC assessment: locomotion (Short Physical Performance Battery, 6-minute walk test), vitality (nutritional status, muscle mass), sensory (self-reported hearing and vision), cognition (self-reported memory, age- and education adjusted cognitive performance), psychological (Geriatric Depression Scale-15, self-reported anxiety/ depression). Reversal of prefrailty was defined as achieving a FRAIL score of 0, with unimpaired grip strength and gait speed at 1-year follow-up.

Results

Of 81 participants (70.0 ± 6.6 years, 79.0% female), 52 participants (64.2%) were enrolled in the multi-domain intervention, and 29 participants (35.8%) who declined intervention constituted the control group. There was no difference in age, gender and baseline composite IC between groups. Reversal to robustness at 1-year was similar between intervention and control groups (30.8% vs. 44.8% respectively, p = 0.206). Reduced prevalence of depression was observed among participants in the intervention group at 1-year relative to baseline (7.8% vs. 23.1%, p = 0.022). In multiple logistic regression, intervention had no effect on prefrailty reversal, while higher composite IC exhibited reduced likelihood of remaining prefrail at 1-year (OR = 0.67, 95% CI 0.45-1.00, p = 0.049).

Conclusion

Focusing only on the locomotion and vitality domains through a combined exercise and nutritional intervention may not adequately address component domain losses to optimize prefrailty reversal. Future studies should examine whether an IC-guided approach to target identified domain declines may be more effective in preventing frailty progression.

Sensory and motor correlates of frailty: dissociation between frailty phenotype and frailty index

Background

Frailty has been associated with a decline in sensory and motor function. However, given that different frailty measures were shown to overlap but also differ in their diagnostic properties, sensory and motor correlates of frailty might be different depending on the operationalization of frailty. Our objective was to identify sensory and motor determinants of frailty and compare the results between frailty phenotype (FP) and frailty index (FI).

Methods

Data from 44 pre-frail and frail subjects aged 65 and above were used. Frailty was measured using the FP and the FI. Sensory function in the visual, auditory, and tactile domain was assessed using visual acuity, absolute hearing threshold and mechanical detection threshold. Upper extremity motor performance was evaluated by the Purdue Pegboard Test and the Short Physical Performance Battery was used to assess lower extremity motor function. Multiple logistic regression models were employed to determine associations of sensory and motor function with frailty vs. pre-frailty for both frailty measures.

Results

The frailty measures were moderately correlated (0.497, p ≤ 0.01) and had a Kappa agreement of 0.467 (p = 0.002). Using the FP, frailty was significantly associated with reduced upper extremity motor function only (OR = 0.50, 95% CI 0.29–0.87, p = 0.014). Frailty as assessed by the FI was significantly related to higher hearing thresholds (OR = 1.21, 95% CI 1.02–1.43, p = 0.027) and reduced lower extremity performance (OR = 0.32, 95% CI 0.13–0.77, p = 0.012).

Conclusion

Frailty is related to reduced performance in measures of sensory and motor function. However, traditional measures of frailty might be differentially sensitive to capture sensory and motor decline, possibly contributing to the much-observed discordance between the diagnostic instruments. This should be taken into account by researchers and clinicians when planning and evaluating therapeutic interventions for frailty.

Trial registration

ClinicalTrials.gov NCT03666039. Registered 11 September 2018 – Retrospectively registered.

Depressive symptoms and malnutrition are associated with other geriatric syndromes and increase risk for 30-Day readmission in hospitalized older adults: a prospective cohort study

BACKGROUND

Readmission in older adults is typically complex with multiple contributing factors. We aim to examine how two prevalent and potentially modifiable geriatric conditions - depressive symptoms and malnutrition - relate to other geriatric syndromes and 30-day readmission in hospitalized older adults.

METHODS

Consecutive admissions of patients ≥ 65 years to a general medical department were recruited over 16 months. Patients were screened for depression, malnutrition, delirium, cognitive impairment, and frailty at admission. Medical records were reviewed for poor oral intake and functional decline during hospitalization. Unplanned readmission within 30-days of discharge was tracked through the hospital's electronic health records and follow-up telephone interviews. We use directed acyclic graphs (DAGs) to depict the relationship of depressive symptoms and malnutrition with geriatric syndromes that constitute covariates of interest and 30-day readmission outcome. Multiple logistic regression was performed for the independent associations of depressive symptoms and malnutrition with 30-day readmission, adjusting for variables based on DAG-identified minimal adjustment set.

RESULTS

We recruited 1619 consecutive admissions, with mean age 76.4 (7.9) years and 51.3% females. 30-day readmission occurred in 331 (22.0%) of 1,507 patients with follow-up data. Depressive symptoms, malnutrition, higher comorbidity burden, hospitalization in the one-year preceding index admission, frailty, delirium, as well as functional decline and poor oral intake during the index admission, were more commonly observed among patients who were readmitted within 30 days of discharge (P < 0.05). Patients with active depressive symptoms were significantly more likely to be frail (OR = 1.62, 95% CI 1.22-2.16), had poor oral intake (OR = 1.35, 95% CI 1.02-1.79) and functional decline during admission (OR = 1.58, 95% CI 1.11-2.23). Malnutrition at admission was significantly associated with frailty (OR = 1.53, 95% CI 1.07-2.19), delirium (OR = 2.33, 95% CI 1.60-3.39) cognitive impairment (OR = 1.88, 95% CI 1.39-2.54) and poor oral intake during hospitalization (OR = 2.70, 95% CI 2.01-3.64). In minimal adjustment set identified by DAG, depressive symptoms (OR = 1.38, 95% CI 1.02-1.86) remained significantly associated with 30-day readmission. The association of malnutrition with 30-day readmission was no longer statistically significant after adjusting for age, ethnicity and depressive symptoms in the minimal adjustment set (OR = 1.40, 95% CI 0.99-1.98).

CONCLUSION

The observed causal associations support screening and targeted interventions for depressive symptoms and malnutrition during admission and in the post-acute period.

Screening accuracy of percentage predicted gait speed for prefrailty/frailty in community-dwelling older adults

AIM

In order to account for the variability in gait speed due to demographic factors, an observed gait speed value can be compared with its predicted value based on age, sex, and body height (observed gait speed divided by predicted gait speed, termed "GS%predicted" henceforth). This study aimed to examine the screening accuracy of an optimal GS%predicted threshold for prefrailty/frailty.

METHODS

This cross-sectional study included 998 community-dwelling ambulant participants aged >50 years (mean age = 68 years). Participants completed a multi-domain geriatric screen and a physical fitness assessment, from which the 10-m habitual gait speed, GS%predicted, Physical Frailty Phenotype (PFP) index, and 36-item Frailty Index (FI) were computed.

RESULTS

Based on the FI, ~49% of participants had pre-frailty or frailty. The optimal threshold of GS%predicted (0.93) had greater screening accuracy than the 1.0 m/s fixed threshold for gait speed (AUC, 0.65 vs. 0.60; DeLong's P < 0.001). Replacing gait speed with GS%predicted in the PFP improved its overall discrimination (AUC, 0.70 vs. 0.67 of original PFP; DeLong's P < 0.001).

CONCLUSIONS

Defining a "slow" gait speed by a GS%predicted value of <0.93 provided greater screening accuracy than the traditional 1.0 m/s threshold for gait speed. Our results also support the use of GS%predicted-derived PFP to identify older adults at risk of prefrailty/frailty. Geriatr Gerontol Int 2022; ••: ••-••.