Aging, frailty and complex networks

Emergency laparotomy in older adults with geriatric medicine input: implications of demographics, frailty and comorbidities on outcomes

BACKGROUND

We (1) describe West Australian (WA) older adults undergoing emergency laparotomy (EL) in a tertiary-centre Acute Surgical Unit (ASU) with proactive geriatrician input and (2) explore the impact of Clinical Frailty Scale (CFS) and Charlson's Comorbidity Index (CCI) on patient outcomes.

METHODS

We performed a prospective cohort-study of older adults undergoing EL, between April 2021 and April 2022, in a tertiary ASU, with dedicated geriatrician-led perioperative care via the Older Adult Surgical Inpatient Service (OASIS).

RESULTS

Of 114 patients, average age was 76.7 ± 7.61 years-old (range 65-96), with 35.1% (n = 40) frail (CFS 5-7), 18.4% (n = 21) vulnerable (CFS 4) and 46.5% (n = 74) not frail (CFS 1-3). 61.4% (n = 70) were severely comorbid (CCI ≥5), 34.2% (n = 39) moderately comorbid (CCI 3-4), and 4.4% (n = 5) mildly comorbid (CCI 1-2). 95.9% (n = 109) EL patients were reviewed by OASIS. Inpatient mortality was 7.9% (n = 9) and 1-year mortality 16.7% (n = 19). Majority, 64.9% (n = 74), were discharged directly home with 17.5% (n = 20) discharged with in-home rehabilitation. Each increment in CCI was associated with increased in-hospital (HR 1.38, p = 0.034) and 1-year (HR 1.39, p = 0.006) mortality, and each increment in CFS with 1-year mortality (HR 1.62, p = 0.016). Higher CFS but not CCI was associated with increased level of care at discharge. Age was not statistically significant with any outcomes.

CONCLUSION

We describe demographics, frailty and comorbidity of 114 older adults undergoing EL in ASU. We suggest CFS and CCI as independent risk-stratification tools, and proactive management of both comorbidity, and frailty, should be incorporated into preoperative optimisation.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

The Gompertz Law emerges naturally from the inter-dependencies between sub-components in complex organisms

Understanding and facilitating healthy aging has become a major goal in medical research and it is becoming increasingly acknowledged that there is a need for understanding the aging phenotype as a whole rather than focusing on individual factors. Here, we provide a universal explanation for the emergence of Gompertzian mortality patterns using a systems approach to describe aging in complex organisms that consist of many inter-dependent subsystems. Our model relates to the Sufficient-Component Cause Model, widely used within the field of epidemiology, and we show that including inter-dependencies between subsystems and modeling the temporal evolution of subsystem failure results in Gompertizan mortality on the population level. Our model also provides temporal trajectories of mortality-risk for the individual. These results may give insight into understanding how biological age evolves stochastically within the individual, and how this in turn leads to a natural heterogeneity of biological age in a population.

Network dynamical stability analysis reveals key "mallostatic" natural variables that erode homeostasis and drive age-related decline of health

Using longitudinal study data, we dynamically model how aging affects homeostasis in both mice and humans. We operationalize homeostasis as a multivariate mean-reverting stochastic process. We hypothesize that biomarkers have stable equilibrium values, but that deviations from equilibrium of each biomarker affects other biomarkers through an interaction network-this precludes univariate analysis. We therefore looked for age-related changes to homeostasis using dynamic network stability analysis, which transforms observed biomarker data into independent "natural" variables and determines their associated recovery rates. Most natural variables remained near equilibrium and were essentially constant in time. A small number of natural variables were unable to equilibrate due to a gradual drift with age in their homeostatic equilibrium, i.e. allostasis. This drift caused them to accumulate over the lifespan course and makes them natural aging variables. Their rate of accumulation was correlated with risk of adverse outcomes: death or dementia onset. We call this tendency for aging organisms to drift towards an equilibrium position of ever-worsening health "mallostasis". We demonstrate that the effects of mallostasis on observed biomarkers are spread out through the interaction network. This could provide a redundancy mechanism to preserve functioning until multi-system dysfunction emerges at advanced ages.

Correlation of frailty assessment metrics in one-year follow-up of aged care residents: a sub-study of a randomised controlled trial

INTRODUCTION

Frailty is increasingly recognised as a dynamic syndrome, with multiple causes, dimensions and consequences. There is little understanding of how those frailty assessment metrics interact over time. The aim of this study was to describe the longitudinal correlation between five frailty metrics, namely multimorbidity, muscular strength, mood alterations, cognitive capacity, and functional capacity in a cohort study of aged care (nursing home) residents.

METHODS

248 aged care residents with Frailty Index at baseline of < 0.4 and no dementia were followed for 12 months. A multimorbidity score and an activity of daily living limitation score were created using individual items of the Frailty Index. Muscular strength was measured by grip strength. Cognitive capacity was measured using the Montreal Cognitive Assessment (MoCA) test. Mood alterations were measured using the anxiety/depression screening question from EQ-5D. We analysed the inter-individual correlation at baseline, association between baseline and future change, and within-individual correlation at baseline, 6 and 12 months.

RESULTS

Population analysis shows that metrics were not associated at baseline. All of the studied metrics at baseline were associated with change in 12 months, with the exception of anxiety/depression scores. Pairwise within-individual correlation was strong between MoCA and grip strength (0.13, p = 0.02) and activity of daily living (- 0.48, p < 0.001), and between activities of daily living and multimorbidity index (0.28, p < 0.001). No within-individual correlation was found between anxiety depression score and other metrics.

CONCLUSION

The results suggest an interdependence between comorbidities, physical capacity, cognition and activities of daily living in aged care residents. Comprehensive measurement of frailty-related metrics may provide improved understanding of frailty progression at later life stages.

Assessment of an embedded primary care-derived electronic health record (EHR) frailty index (eFI) in older adults with acute myeloid leukemia

INTRODUCTION

Assessing frailty is integral to treatment decision-making for older adults with acute myeloid leukemia (AML). Prior electronic frailty indices (eFI) derive from an accumulated-deficit model and are associated with mortality in older primary care populations. We evaluated use of an embedded eFI in AML by describing baseline eFI categories by treatment type and exploring associations between eFI categories, survival, and treatment received.

MATERIALS AND METHODS

This was a retrospective study of subjects ≥60 years old with new AML treated at an academic medical center from 1/2018-10/2020. The eFI requires ≥2 ambulatory visits over two years and uses demographics, vitals, ICD-10 codes, outpatient labs, and available functional information from Medicare Annual Wellness Visits. Frailty was defined as fit (eFI ≤ 0.10), pre-frail (0.10 < eFI ≤ 0.21), and frail (eFI > 0.21). Chemotherapy was intensive (anthracycline-based) or less-intensive (hypomethylating agent, low dose cytarabine +/- venetoclax). Therapy type, pre-treatment characteristics, and chemotherapy cycles were compared by eFI category using chi-square and Fisher's exact tests and ANOVA. Median survival was compared by eFI category using log-rank tests stratified by therapy type.

RESULTS

Among 166 older adults treated for AML (mean age 74 years, 61% male, 85% Caucasian), only 79 (48%) had a calculable eFI score before treatment. Of these, baseline eFI category was associated with treatment received (fit (n = 31): 68% intensive, 32% less intensive; pre-frail (n = 38): 37% intensive, 63% less intensive; frail (n = 10): 0% intensive, 100% less intensive; not calculable (n = 87): 48% intensive, 52% less-intensive; p < 0.01). The prevalence of congestive heart failure and secondary AML differed by frailty status (p < 0.01). Median survival did not differ between eFI categories for intensively (p = 0.48) or less-intensively (p = 0.09) treated patients. For those with less-intensive therapy who lived ≥6 months, eFI category was not associated with the number of chemotherapy cycles received (p = 0.97). The main reason for an incalculable eFI was a lack of outpatient visits in our health system prior to AML diagnosis.

DISCUSSION

A primary care-derived eFI was incalculable for half of older adults with AML at an academic medical center. Frailty was associated with chemotherapy intensity but not survival or treatment duration. Next steps include testing adaptations of the eFI to the AML setting.

Late life depression and concepts of aging: an emerging paradigm

Late life depression (LLD) is an emerging challenge, and recognized as a significant barrier to long-term healthy aging. Viewed within the context of the medical/biological model, advances in brain sciences over the last several decades have led to a deeper understanding of the biology of LLD. These advances in current knowledge include the description of aging brain pathophysiology; the biology and biochemistry of neurotransmitters; the correspondence between changes in neurological structure, function, and neural network; the description of neural, hormonal and inflammatory biomarkers; and identification of typical phenotypic subtypes of LLD. Despite these advances, current treatment of LLD, which remains largely pharmacological with accompanying cognitive and behavioral interventions, has poor success rate for long-term remission among older people. A wider perspective, in keeping with several emerging aging concepts, is suggested as an alternative framework within which to view LLD. A growing body of research supports the important role in LLD of frailty, resilience, intrinsic capacity, and functional integrity. Similarly, important social determinants need to be addressed in the etiology of LLD, rooted largely in negative stereotypes of aging, with consequent repercussions of reduced participation and inclusion, growing social isolation, with loss of identity, meaning and hope. This perspective suggests the importance of a wider integrative conceptualization of depression, set against a background of emerging aging concepts.

Toxicology of pharmaceutical and nutritional longevity compounds

Aging is the most prominent risk factor for many diseases, which is considered to be a complicated biological process. The rate of aging depends on the effectiveness of important mechanisms such as the protection of DNA from free radicals, which protects the structural and functional integrity of cells and tissues. In any organism, not all organs may age at the same rate. Slowing down primary aging and reaching maximum lifespan is the most basic necessity. In this process, it may be possible to slow down or stabilise some diseases by using the compounds for both dietary and pharmacological purposes. Natural compounds with antioxidant and anti-inflammatory effects, mostly plant-based nutraceuticals, are preferred in the treatment of age-related chronic diseases and can also be used for other diseases. An increasing number of long-term studies on synthetic and natural compounds aim to elucidate preclinically and clinically the mechanisms underlying being healthy and prolongation of life. To delay age-related diseases and prolong the lifespan, it is necessary to take these compounds with diet or pharmaceuticals, along with detailed toxicological results. In this review, the most promising and utilised compounds will be highlighted and it will be discussed whether they have toxic effects in short/long-term use, although they are thought to be used safely.

Effectiveness of Theory-Based Physical Activity and Nutrition Interventions in Aging Latino Adults: A Scoping Review

In the United States (US), Latino individuals older than 50 years face health disparities compared to their White counterparts. Considering the rising life expectancy and the projected increase of older Latino adults in the US, this scoping review aimed to determine the effectiveness of theory-based and culturally relevant strategies that promote healthy aging in Latinos. Web of Science and PubMed databases were searched between December 2022 and February 2023 for peer-reviewed articles assessing healthy aging interventions tailored to community-dwelling aging Latino adults. We included nine studies describing the effects of seven interventions on physical activity- or nutrition-related outcomes. Although not always statistically significant, interventions had a beneficial impact on well-being indicators. The most commonly used behavioral theories were Social Cognitive Theory and Attribution Theory. Latino cultural elements in these studies included partnering with community organizations that serve Latinos (such as Catholic churches), delivery of in-person bilingual group sessions by trusted community members (such as promotoras or Latino dance instructors), and incorporating values such as family and religion into the health curriculum, among others. Future strategies that promote healthy aging in Latino adults should proactively culturally adapt the theoretical foundations and the design, recruitment, and implementation processes to ensure their relevance and effectiveness.

"I Have a Lotta Sad Feelin'" - Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

OBJECTIVE

To investigate mental health needs and barriers to seeking mental health support in Medicaid-funded Assisted Living Facility (M-ALF).

DESIGN

A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS

The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or African American, 2 Asian) using purposive sampling.

METHODS

Demographic data and mental health indicators (depression, anxiety, stress, hopelessness) were measured with questionnaires (Center for Epidemiological Studies Depression Scale, Edmonton Symptom Assessment System, Perceived Stress Scale, Beck Hopelessness Survey) and analyzed with descriptive statistics. Interviews were conducted between June and November 2021, transcribed, and analyzed using conventional content analysis.

RESULTS

Thirteen residents (mean age: 73.4 years, mean length of stay: 3.5 years; range: 1.0-7.5) completed data collection. Quantitatively indicators of unmet mental health were common. Qualitatively, residents reported barriers to mental health access to address depression, anxiety, and substance use. This was accompanied by concerns surrounding loss of autonomy, mistrust for M-ALF organizational support, isolation and uncertainty about how to receive mental health support. Perspectives were shaped by past experiences with institutional living, serious illness, and being unhoused. Themes and subthemes were (1) mental health need (unmet mental health need, depression, and anxiety and seeking support through non-mental health resources) and (2) barriers to mental health support (dissatisfaction with M-ALF care, perceived threats to autonomy, desire for autonomy that leads to diminished care seeking).

CONCLUSION AND IMPLICATIONS

Residents of M-ALF have mental health needs for which care is stymied by loss of autonomy, lack of resources, and the M-ALF environment. Residents use unconventional resources to address needs that may be neither efficient nor effective. Novel mental health interventions and processes are needed to improve mental health access and should prioritize residents' desire for autonomy and the unique circumstances of living in M-ALF.

Development, validation and performance of laboratory frailty indices: A scoping review

INTRODUCTION

Frailty is a syndrome characterised by decline in functional ability and increasing vulnerability to disease and associated with adverse outcomes. Several established methods exist for assessing frailty. This scoping review aims to characterise the development and validation of frailty indices based on laboratory test results (FI-Lab) and to assess their utility.

METHODS

Studies were included in the review if they included data concerning the development and/or testing an FI-Lab using the deficit accumulation method. Studies were identified using PubMed/MEDLINE, Embase (Elsevier), OpenGrey and Google Scholar from 2010 to 2021. Two reviewers independently screened all abstracts, and those that met the inclusion criteria were reviewed in detail. Data extracted included details about the study characteristics, number, type and coding of laboratory variables included, validation, and outcomes. A narrative synthesis of the available evidence was adopted.

RESULTS

The search yielded 915 articles, of which 29 studies were included. In general, 89% of studies were conducted after 2016 and 51% in a hospital-based setting. The number of variables included in FI-Labs ranged from 13 to 77, and 51% included some non-laboratory variables in their indices, with pulse and blood pressure being the most frequent. The validity of FI-Lab was demonstrated through change with age, correlation with established frailty indices and association with adverse health outcomes. The most frequent outcome studied was mortality (79% of the studies), with FI-Lab associated with increased mortality in all but one. Other outcomes studied included self-reported health, institutionalisation, and activities of daily living. The effect of combining the FI-Lab with a non-laboratory-based FI was assessed in 7 studies with a marginal increase in predictive ability.

CONCLUSION

Frailty indices constructed based on the assessment of laboratory variables, appear to be a valid measure of frailty and robust to the choice of variables included.

Association of the Systemic Lupus International Collaborating Clinics Frailty Index and Damage Accrual in Longstanding Systemic Lupus Erythematosus

OBJECTIVE

To externally validate the Systemic Lupus International Collaborating Clinics Frailty Index (SLICC-FI) in a prevalent systemic lupus erythematosus (SLE) cohort and to assess the ability of the SLICC-FI to predict organ damage accrual among individuals with longstanding SLE.

METHODS

This was a secondary analysis of data from the Study of Lupus Vascular and Bone Long-Term Endpoints (SOLVABLE) cohort, which consists of adult women from the Chicago Lupus Database who met the 1997 revised American College of Rheumatology (ACR) classification criteria for SLE. There were 185 patients with SLE enrolled, of whom 149 patients were included in a 5-year follow-up analysis. The SLICC-FI and SLICC/ACR Damage Index (SDI) scores were calculated at baseline and 5-year follow-up. Unadjusted and adjusted logistic regression models estimated the association of baseline SLICC-FI scores (per 0.05 increase) with damage accrual at 5-year follow-up.

RESULTS

At enrollment the mean ± SD age of the 149 patients was 43.30 ± 10.15 years, the mean ± SD disease duration was 11.93 ± 8.46 years, and the mean ± SD SDI score was 1.64 ± 1.83. At baseline, the mean ± SD SLICC-FI score was 0.18 ± 0.08, and 36% of participants were categorized as frail (SLICC-FI score >0.21). In a model adjusted for age, race, and disease duration, each 0.05-unit increase in the baseline SLICC-FI score was associated with 28% higher odds of subsequent damage accrual (odds ratio 1.28, 95% confidence interval 1.01-1.63).

CONCLUSION

In a prevalent cohort of women with established SLE, higher baseline SLICC-FI scores were associated with a higher risk of subsequent damage accrual at 5-year follow-up.

Structural brain signatures of frailty, defined as accumulation of self-reported health deficits in older adults

Background

Frailty in older adults has been associated with reduced brain health. However, structural brain signatures of frailty remain understudied. Our aims were: (1) Explore associations between a frailty index (FI) and brain structure on magnetic resonance imaging (MRI). (2) Identify the most important FI features driving the associations.

Methods

We designed a cross-sectional observational study from a population-based study (The Irish Longitudinal Study on Aging: TILDA). Participants aged ≥50 years who underwent the wave 3 MRI sub-study were included. We measured cortex, basal ganglia, and each of the Desikan-Killiany regional volumes. Age-and sex-adjusted correlations were performed with a 32-item self-reported FI that included conditions commonly tested for frailty in research and clinical settings. A graph theory analysis of the network composed by each FI item and cortex volume was performed. White matter fiber integrity was quantified using diffusion tensor imaging (DTI).

Results

In 523 participants (mean age 69, 49% men), lower cortex and thalamic volumes were independently associated with higher FI. Sensory and functional difficulties, diabetes, polypharmacy, knee pain, and self-reported health were the main FI associations with cortex volume. In the network analysis, cortex volume had a modest influence within the frailty network. Regionally, higher FI was significantly associated with lower volumes in both orbitofrontal and temporal cortices. DTI analyses revealed inverse associations between the FI and the integrity of some association bundles.

Conclusion

The FI used had a recognizable but subtle structural brain signature in this sample. Only some FI deficits were directly associated with cortex volume, suggesting scope for developing FIs that include metrics more specifically related with brain health in future aging neuroscience studies.

Frailty Index was Associated With Adverse Outcomes in Admitted Elderly Patients With Type 2 Diabetes Mellitus

We aimed to investigate the role of the laboratory frailty index (LFI) in diabetic complications and incident disability in admitted older patients with type 2 diabetes mellitus (T2DM). We retrospectively collected the clinical data of older patients with T2DM from December 2018 to May 2020. Frailty was quantified using the LFI, which considers the accumulation of 27 items of abnormal laboratory outcomes. Univariate and multivariate analyses were performed to evaluate the relationship between LFI and diabetes-related adverse outcomes. In total, 293 consecutive older patients with T2DM were recruited for this study. According to the predefined LFI criteria, 110 (37.5%) participants were non-frail, 131 (44.7%) were prefrail, and 52 (17.8%) were frail. Univariate and multivariate analysis revealed that LFI was associated with the diabetic microangiopathy complications (odds ratio for prefrail [ORprefrail] 1.760, 95% confidence interval for prefrail [CIprefrail] 1.019-3.041, P = .043; ORfrail 4.667, 95% CIfrail 2.012-10.826, P < .001) and activities of daily living (ADL) disability (ORprefrail 2.323, 95% CIprefrail 1.209-4.463, P = .011; ORfrail 9.367, 95% CIfrail 4.030-21.775, P < .001), but not with the diabetic macroangiopathy complications and diabetic peripheral neuropathy. Frailty, as determined by the LFI, was proven to be an effective tool for the prediction of diabetic microangiopathy complications and ADL disability.

Height loss as an indicator of ageing through its association with frailty and sarcopenia: An observational cohort study

BACKGROUND

Height loss is associated with various health-related variables such as cardiovascular disease, osteoporosis, cognitive function, and mortality. We hypothesized that height loss can be used as an indicator of aging, and we assessed whether the degree of height loss for 2 years was associated with frailty and sarcopenia.

METHODS

This study was based on a longitudinal cohort, the Pyeongchang Rural Area cohort. The cohort included people aged 65 years or older, ambulatory, and living at home. We divided individuals according to the ratio of height change (height change for 2 years divided by height at 2 years from baseline): HL2 (<-2%), HL1 (-2%--1%), and REF (-1%≤). We compared the frailty index, diagnosis of sarcopenia after 2 years from baseline, and the incidence of a composite outcome (mortality and institutionalization).

RESULTS

In total, 59 (6.9%), 116 (13.5%), and 686 (79.7%) were included in the HL2, HL1, and REF groups, respectively. Compared with the REF group, groups HL2 and HL1 had a higher frailty index, and higher risks of sarcopenia and composite outcome. When groups HL2 and HL1 were merged, the merged group had higher frailty index (standardized B, 0.06; p = 0.049), a higher risk of sarcopenia (OR, 2.30; p = 0.006), and a higher risk of composite outcome (HR, 1.78; p = 0.017) after adjusting for age and sex.

CONCLUSIONS

Individuals with greater height loss were frailer, more likely to be diagnosed with sarcopenia and had worse outcomes regardless of age and sex.

Does the association between smoking and mortality differ due to frailty status? A secondary analysis from the Mexican Health and Aging Study

BACKGROUND

despite the well-known adverse health effects of smoking, evidence of these effects on frail individuals is still scarce.

AIMS

to assess whether frailty influences the association between smoking and mortality.

METHODS

individuals ≥50 years from the Mexican Health and Aging Study were analysed. Mortality rates from a 17-year follow-up were compared between smoking status groups (never, previous and current) and other smoking behaviour-related characteristics (pack-years, age commenced and cessation). Baseline variables were included to adjust the Cox regression models. First, models were adjusted for the whole sample, including an interaction term between the frailty index (FI) and smoking variables. A second set of models were stratified by FI levels: 0.00-0.10, 0.11-0.20, 0.21-0.30 and ≥ 0.31.

RESULTS

from a total 14,025 individuals, mean age was 62.4 (95% confidence interval [95% CI]: 62.1-62.8) and 53.9% were women (95% CI: 52.4-55.6). Main results from the survival analyses showed that when including FI interaction term with smoking status, comparing current to never smoking, the hazard ratio (HR) was 2.03 (95% CI: 1.07-3.85, P = 0.029), and comparing current to previous smoking, the HR was 2.13 (95% CI: 1.06-4.26, P = 0.032). Models stratified by FI levels showed a significant HR only for the two highest level groups. Similar results were found for the smoking behaviour-related characteristics.

DISCUSSION

our results suggest that frailty could modify smoking mortality risk. Other smoking characteristics were impacted by frailty, in particular, cessation. It was noteworthy that having ≥10 years of tobacco cessation was beneficial for frail individuals.

CONCLUSIONS

smoking has a higher toll on frail individuals, but ceasing is still beneficial for this group.

Astragalin alleviates cognitive deficits and neuronal damage in SAMP8 mice through upregulating estrogen receptor expression

Senile plaques composed of β-amyloid protein (Aβ) and neurofibrillary tangles (NFTs) composed of intracellular hyper-phosphorylated tau are major causes of cognitive impairment and neuronal damage in Alzheimer disease (AD). Astragalin (AST), a naturally-occurring flavonoid compound, was reported to have neuroprotective effects in the brain, but its effects in AD remain unknown. Herein, the learning and memory deficits were alleviated and neuronal damage in the hippocampus were inhibited after the senescence-accelerated mouse prone 8 (SAMP8) mouse were given AST (5 mg/kg or 10 mg/kg) daily by gavage for 2 months. Furthermore, AST reduced Aβ_1-40 and Aβ_1-42 deposition, decreased β-carboxyl-terminal fragment (β-CTF) protein level and tau hyper-phosphorylation, but increased α-CTF protein level and glycogen synthase kinase-3beta (GSK-3β) phosphorylation in hippocampus of SAMP8 mice. Meanwhile, the effects of AST on AD were also explored in vitro by treating primary neurons with amyloid-β1-42 oligomers (Aβ_1-42O). Consistently, AST also alleviated amyloid-β1-42 oligomers (Aβ_1-42O)-induced neuronal damage, amyloid plaques, and tau phosphorylation in vitro model. Of note, estrogen receptor (ER)α and ERβ expression in the hippocampus of SAMP8 mice and Aβ_1-42O-treated neurons was significantly decreased but their levels were increased by AST. Moreover, in vivo and in vitro experiments revealed that ER antagonist, Fulvestrant, reversed the effects caused by AST. Altogether, our investigation indicates that AST may ameliorate cognitive deficits and AD-type pathologies in SAMP8 mice and Aβ_1-42O-treated neurons through upregulating ERα and ERβ expression. Our findings indicate the value of AST as a potential reagent for AD treatment.

Nutrition and stem cell integrity in aging

Adult stem cells (SCs) represent the regenerative capacity of organisms throughout their lifespan. The maintenance of robust SC populations capable of renewing organs and physiological systems is one hallmark of healthy aging. The local environment of SCs, referred to as the niche, includes the nutritional milieu, which is essential to maintain the quantity and quality of SCs available for renewal and regeneration. There is increased recognition that SCs have unique metabolism and conditional nutrient needs compared to fully differentiated cells. However, the contribution of SC nutrition to overall human nutritional requirements is an understudied and underappreciated area of investigation. Nutrient needs vary across the lifespan and are modified by many factors including individual health, disease, physiological states including pregnancy, age, sex, and during recovery from injury. Although current nutrition guidance is generally derived for apparently healthy populations and to prevent nutritional deficiency diseases, there are increased efforts to establish nutrient-based and food-based recommendations based on reducing chronic disease. Understanding the dynamics of SC nutritional needs throughout the life span, including the role of nutrition in extending biological age by blunting biological systems decay, is fundamental to establishing food and nutrient guidance for chronic disease reduction and health maintenance. This review summarizes a 3-day symposium of the Marabou Foundation (www.marabousymposium.org) held to examine the metabolic properties and unique nutritional needs of adult SCs and their role in healthy aging and age-related chronic disease.

Estimating the causal effect of frailty index on vestibular disorders: A two-sample Mendelian randomization

Background

Frailty index and vestibular disorders appear to be associated in observational studies, but causality of the association remains unclear.

Methods

A two-sample Mendelian randomization (MR) study was implemented to explore the causal relationship between the frailty index and vestibular disorders in individuals of European descent. A genome-wide association study (GWAS) of frailty index was used as the exposure (n = 175, 226), whereas the GWAS of vestibular disorders was the outcome (n = 462,933). MR Steiger filtering method was conducted to investigate the causal effect of the frailty index on vestibular disorders. An inverse variance weighted (IVW) approach was used as the essential approach to examine the causality. Additionally, the MR-Egger methods, the simple mode analysis, the weighted median analysis, and the weighted mode analysis were used as supplementary methods. The MR-PRESSO analysis, the MR-Egger intercept analysis, and Cochran's Q statistical analysis also were used to detect the possible heterogeneity as well as directional pleiotropy. To evaluate this association, the odds ratio (OR) with 95% confidence intervals (CIs) was used. All statistical analyses were performed in R. The STROBE-MR checklist for the reporting of MR studies was used in this study.

Results

In total, 14 single nucleotide polymorphisms (SNPs) were identified as effective instrumental variables (IVs) in the two sample MR analyses. The significant causal effect of the frailty index on vestibular disorders was demonstrated by IVW method [OR 1.008 (95% CI 1.003, 1.013), p = 0.001]. Results from the various sensitivity analysis were consistent. The “leave-one-out” analysis indicated that our results were robust even without a single SNP. According to the MR-Egger intercept test [intercept = −0.000151, SE = 0.011, p = 0.544], genetic pleiotropy did not affect the results. No heterogeneity was detected by Cochran's Q test. Results of MR Steiger directionality test indicated the accuracy of our estimate of the potential causal direction (Steiger p < 0.001).

Conclusion

The MR study suggested that genetically predicted frailty index may be associated with an increased risk of vestibular disorders. Notably, considering the limitations of this study, the causal effects between frailty index and vestibular disorders need further investigation. These results support the importance of effectively managing frailty which may minimize vestibular disorders and improve the quality of life for those with vestibular disorders.

A frailty index based on routine laboratory data predicts increased risk of mortality in Chinese community-dwelling adults aged over 55 years: a five-year prospective study

Background

Frailty can be operationalized based on the accumulation of deficits using a frailty index (FI) and is associated with an increased risk of adverse health outcomes. Here, we aim to compare validity of a FI from laboratory data with that of the common clinical FI for prediction of mortality in adults aged 55 + years, also examine whether combined FI could improve identification of adults aged 55 + years at increased risk of death.

Methods

Data for this analysis were obtained from the Beijing Longitudinal Study of Aging that involved 1,257 community-dwelling Chinese people, aged 55 + years at baseline. The main outcome measure was 5-year mortality. An FI-self-report based on 30 self-reported health-related data was constructed. An FI-lab was developed using laboratory data, in addition to pulse, systolic and diastolic blood pressure, pulse pressure, body mass index (BMI) and waist. A combined FI comprised all items from each FI. Kaplan–Meier survival curve and Cox proportional hazards models were performed to evaluate the risk of each FI on death. The area under receiver operating characteristic(ROC) curves were used to compare the discriminative performance of each FI.

Results

Of 1257 participants, 155 died and 156 lost at the end of the 5-year follow-up. The mean FI-self-report score was 0.11 ± 0.10, the FI-lab score was 0.33 ± 0.14 and FI-combined score was 0.19 ± 0.09. Higher frailty level defined by each FI was associated with higher risk of death. After adjustment for age and sex, Cox proportional hazards models showed that the higher scores of frailty were associated with a higher risk of mortality for each FI, the hazard ratios for the FI-self-report and FI-lab and FI-combined were 1.04 (1.03 to 1.05) and 1.02 (1.01 to 1.03) and 1.05 (1.04 to 1.07), respectively. The areas under the ROC curve were 0.79 (0.77–0.82) for the FI-self-report, 0.77(0.75–0.80) for the FI-lab and 0.81(0.78–0.82) for FI-combined.

Conclusions

A FI from laboratory data can stratify older adults at increased risk of death alone and in combination with FI based on self-report data. Assessment in clinical settings of creating an FI using routine collected laboratory data needs to be further developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03374-z.

Benefits of a 3-month cycle of weekly virtual museum tours in community dwelling older adults: Results of a randomized controlled trial

Background

Museums can be instrumental in fostering social inclusion and may improve the overall health of the older population. Over the course of the 2019 coronavirus pandemic, many older adults suffered as a result of confinement measures, which may have accelerated the processes that lead to physical frailty and increased mental health risks. This study aims to examine whether a 3-month cycle of weekly virtual tours of the Montreal Museum of Fine Arts (MMFA) may have improved feelings of social inclusion, wellbeing and quality of life, and reduced physical frailty in older adults living within the community of Montreal.

Methods and design

A total of 106 older adults, who were community-dwellers living in Montreal (Quebec, Canada), were recruited for a randomized controlled trial in two parallel groups (intervention with n = 53 vs control with n = 53) between January and April 2022. The intervention consisted of a 3-month cycle of weekly virtual museum tours of the MMFA. Social isolation, wellbeing, quality of life and frailty were evaluated using validated scales that were assessed on a web platform at baseline (M0) and after 3 months (M3) in the intervention group. The control group completed the same assessment according to the same schedule. The outcomes were the mean scores at M0 and M3, and changes in mean scores between M0 and M3.

Results

The intervention group showed significant improvements in their social isolation, wellbeing, quality of life and frailty scores when compared to the control group, the highest benefits being observed with frailty.

Conclusion

The results suggest that the 3-month cycle of weekly virtual MMFA tours may improve social inclusion, physical and mental health in community-dwelling older adults living in Montreal.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT05046288, identifier NCT05046288.

Treating advanced lung cancer in older veterans with comorbid conditions and frailty

Advanced lung cancer is a deadly malignancy that is a common cause of death among Veterans. Significant advancements in lung cancer therapeutics have been made over the past decade and survival outcomes have improved. The Veteran population is older, has more medical comorbidities and frailty compared to the general population. These factors must be accounted for when evaluating patients for treatment and selecting treatment options. This article explores the impact of these important issues in the management of advanced lung cancer. Recent clinical trials leading to the approval of modern therapies will be outlined and treatment outcomes specific to older patients discussed. The impact of key comorbidities that are common in Veterans and their impact on lung cancer treatment will be reviewed. There is no gold standard frailty index for assessment of frailty in patients with advanced lung cancer and the ability to predict tolerability and benefit from systemic therapies. Currently available systemic therapies are associated with higher risk of adverse events and lower potential for clinically meaningful improvement in outcomes. Future research needs to focus on designing better frailty indices and developing novel therapies that are safer and more effective therapies for frail patients, who constitute a considerable proportion of individuals diagnosed with lung cancer.

We can do better: Addressing ageism against older adults in healthcare

Ageism in healthcare is a pervasive reality that leads to negative health outcomes for older adults. While it is often implicit, the COVID-19 pandemic threw explicit age discrimination in healthcare into sharp relief globally. In medicine, ageism translates into myriad forms of age discrimination that impact the provision of ethical care and range from 'micro' individual issues like paternalistic medicine or therapeutic nihilism to 'macro' system issues including barriers to timely and effective healthcare or exclusion from research trials. The culture of ageism in medicine can be unintentionally transmitted through role-modelling and the hidden curriculum. Strategies to combat ageism and provide ethical healthcare include intergenerational learning, educational programs, and strong leadership from organizations to enact policy and practice changes.

Study of a Quasi-Experimental Trial to Compare Two Models of Home Care for the Elderly in an Urban Primary Care Setting in Spain: Results of Intermediate Analysis

Functional dependence is associated with an increase in need for resources, mortality, and institutionalization. Different models of home care have been developed to improve these results, but very few studies contain relevant information. This quasi-experimental study was conducted to evaluate two models of home care (HC) in a Primary Care setting: an Integrated Model (IM) (control model) and a Functional Model (FM) (study model).

MATERIAL AND METHODS

Two years follow-up of patients 65 years old and older from two Primary Health Care Centres (58 IM, 68 FM) was carried out, recruited between June-October 2018 in Badalona (Barcelona, Spain). Results of the mid-term evaluation are presented in this article. Health status, quality of care, and resource utilization have been evaluated through comprehensive geriatric assessment, quality of life and perception of health care scales, consumption of resources and complementary tests.

RESULTS

A significant difference was detected in the number of hospital admissions (FM/IM 0.71 (1.24)/1.35 (1.90), p: 0.031) in the Accident and Emergency department (FM/IM 2.01 (2.12)/3.53 (3.59), p: 0.006) and cumulative days of admission per year (FM/IM 5.43 (10.92)/14.69 (20.90), p: 0.003).

CONCLUSIONS

FM offers greater continuity of care at home for the patient and reduces hospital admissions, as well as admission time, thereby saving on costs.

Interpretable machine learning for high-dimensional trajectories of aging health

We have built a computational model for individual aging trajectories of health and survival, which contains physical, functional, and biological variables, and is conditioned on demographic, lifestyle, and medical background information. We combine techniques of modern machine learning with an interpretable interaction network, where health variables are coupled by explicit pair-wise interactions within a stochastic dynamical system. Our dynamic joint interpretable network (DJIN) model is scalable to large longitudinal data sets, is predictive of individual high-dimensional health trajectories and survival from baseline health states, and infers an interpretable network of directed interactions between the health variables. The network identifies plausible physiological connections between health variables as well as clusters of strongly connected health variables. We use English Longitudinal Study of Aging (ELSA) data to train our model and show that it performs better than multiple dedicated linear models for health outcomes and survival. We compare our model with flexible lower-dimensional latent-space models to explore the dimensionality required to accurately model aging health outcomes. Our DJIN model can be used to generate synthetic individuals that age realistically, to impute missing data, and to simulate future aging outcomes given arbitrary initial health states.

Oxidative Stress in ICU Patients: ROS as Mortality Long-Term Predictor

Lipid peroxidation, protein oxidation, and mutations in mitochondrial DNA generate reactive oxygen species (ROS) that are involved in cell death and inflammatory response syndrome. ROS can also act as a signal in the intracellular pathways involved in normal cell growth and homeostasis, as well as in response to metabolic adaptations, autophagy, immunity, differentiation and cell aging, the latter of which is an important characteristic in acute and chronic pathologies. Thus, the measurement of ROS levels of critically ill patients, upon admission, enables a prediction not only of the severity of the inflammatory response, but also of its subsequent potential outcome. The aim of this study was to measure the levels of mitochondrial ROS (superoxide anion) in the peripheral blood lymphocytes within 24 h of admission and correlate them with survival at one year after ICU and hospital discharge. We designed an observational prospective study in 51 critical care patients, in which clinical variables and ROS production were identified and correlated with mortality at 12 months post-ICU hospitalization. Oxidative stress levels, measured as DHE fluorescence, show a positive correlation with increased long-term mortality. In ICU patients the major determinant of survival is oxidative stress, which determines inflammation and outlines the cellular response to inflammatory stimuli.

Epigenetic age is associated with baseline and 3-year change in frailty in the Canadian Longitudinal Study on Aging

BACKGROUND

The trajectory of frailty in older adults is important to public health; therefore, markers that may help predict this and other important outcomes could be beneficial. Epigenetic clocks have been developed and are associated with various health-related outcomes and sociodemographic factors, but associations with frailty are poorly described. Further, it is uncertain whether newer generations of epigenetic clocks, trained on variables other than chronological age, would be more strongly associated with frailty than earlier developed clocks. Using data from the Canadian Longitudinal Study on Aging (CLSA), we tested the hypothesis that clocks trained on phenotypic markers of health or mortality (i.e., Dunedin PoAm, GrimAge, PhenoAge and Zhang in Nat Commun 8:14617, 2017) would best predict changes in a 76-item frailty index (FI) over a 3-year interval, as compared to clocks trained on chronological age (i.e., Hannum in Mol Cell 49:359-367, 2013, Horvath in Genome Biol 14:R115, 2013, Lin in Aging 8:394-401, 2016, and Yang Genome Biol 17:205, 2016).

RESULTS

We show that in 1446 participants, phenotype/mortality-trained clocks outperformed age-trained clocks with regard to the association with baseline frailty (mean = 0.141, SD = 0.075), the greatest of which is GrimAge, where a 1-SD increase in ΔGrimAge (i.e., the difference from chronological age) was associated with a 0.020 increase in frailty (95% CI 0.016, 0.024), or ~ 27% relative to the SD in frailty. Only GrimAge and Hannum (Mol Cell 49:359-367, 2013) were significantly associated with change in frailty over time, where a 1-SD increase in ΔGrimAge and ΔHannum 2013 was associated with a 0.0030 (95% CI 0.0007, 0.0050) and 0.0028 (95% CI 0.0007, 0.0050) increase over 3 years, respectively, or ~ 7% relative to the SD in frailty change.

CONCLUSION

Both prevalence and change in frailty are associated with increased epigenetic age. However, not all clocks are equally sensitive to these outcomes and depend on their underlying relationship with chronological age, healthspan and lifespan. Certain clocks were significantly associated with relatively short-term changes in frailty, thereby supporting their utility in initiatives and interventions to promote healthy aging.

Premature Aging in Chronic Kidney Disease: The Outcome of Persistent Inflammation beyond the Bounds

Over the last hundred years, life expectancy in developed countries has increased because of healthier living habits and the treatment of chronic pathologies causing premature aging. Aging is an inexorable, time-dependent, multifactorial process characterized by a series of progressive and irreversible physiological changes associated with loss of functional, psychological, and social capabilities. Numerous factors, such as oxidative stress, inflammation, and cellular senescence, and an irreversible geriatric syndrome known as frailty, contribute to human body deterioration in aging. The speed of aging may differ between individuals depending on the presence or absence of multiple factors (genetic and/or environment) and the subsequent misbalance of homeostasis, together with the increase of frailty, which also plays a key role in developing chronic diseases. In addition, pathological circumstances have been reported to precipitate or accelerate the aging process. This review investigated the mechanisms involved in the developing pathologies, particularly chronic kidney disease, associated with aging.

Non-use of information and communication technology as a predictor of frailty in postmenopausal midlife and older women

BACKGROUND

Frailty is a clinically discernible state in which decreased physiological reserve and function result in a reduced ability to cope with stressors. Information and communication technology (ICT) has been proposed as an aid to help with frailty, yet the use of ICT by older people, particularly women, is an understudied area.

AIM

To analyze the association between use of ICT (specifically internet functions and social media) and frailty status in postmenopausal midlife and elderly women.

METHODS

A cross-sectional study was designed to investigate whether frailty status is related to ICT use in postmenopausal midlife and older women. Community-dwelling women attending primary health care centers for health checks were invited to participate in the study. Postmenopausal status was the only inclusion criterion, whereas limitations that could interfere with use of ICT were exclusion criteria. The Fried phenotype was used to assess frailty. Four types of ICT use were examined: the internet for e-mail, the internet for other functions, and social media (WhatsApp or Facebook). Chi-square test and multivariate multinomial regression analysis were used to examine the association between frailty status and ICT use.

RESULTS

We included 409 women (age = 67.45 ± 7.81 years, mean ± SD), who were frail (n = 135, 33.01%), pre-frail (n = 159, 38.87%), or robust (n  =  115, 28.11%). Frailty status was significantly and inversely associated with any ICT use, showing a strong association with use of WhatsApp (P < 0.001) and internet searches (P < 0.001). ICT non-use was a predictor of frailty, while ICT users were more likely to be robust (OR 10.62; 95% [CI], 5.34-21.10) or pre-frail (OR 9.03; [CI], 95% 5.18-15.74).

CONCLUSION

Postmenopausal midlife and older women not using ICT were more likely to be frail.

Bloodstream infections in the elderly: what is the real goal?

Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.

Frailty in Older Adults With Multiple Myeloma: A Study of US Veterans

PURPOSE

Age-associated cumulative decline across physiologic systems results in a diminished resistance to stressors, including cancer and its treatment, creating a vulnerable state known as frailty. Frailty is associated with increased risk of adverse outcomes in patients with cancer. Identification of frailty in administrative data can allow for assessment of prognosis and facilitate control for confounding variables. The purpose of this study was to assess frailty from claims-based data using the accumulation of deficits approach in veterans with multiple myeloma (MM).

METHODS

From the Veterans Administration Central Cancer Registry, we identified patients who were diagnosed with MM between 1999 and 2014. Using the accumulation of deficits approach, we calculated a Frailty Index (FI) using 31 health-associated deficits and categorized scores into five groups: nonfrail (FI, 0 to 0.1), prefrail (FI, 0.11 to 0.20), mild frailty (FI, 0.21 to 0.30), moderate frailty (FI, 0.31 to 0.40), and severe frailty (FI, > 0.4). We used Cox proportional hazards regression analysis to assess association between FI score and mortality while adjusting for potential confounders.

RESULTS

We calculated an FI for 3,807 veterans age 65 years or older. Among the cohort, 28.7% were classified as nonfrail, 41.3% prefrail, 21.6% mildly frail, 6.6% moderately frail, and 1.7% severely frail. Frailty was strongly associated with mortality independent of age, race, MM treatment, body mass index, or statin use. Higher FI score was associated with higher mortality with hazard ratios of 1.33 (95% CI, 1.21 to 1.47), 1.97 (95% CI, 1.70 to 2.20), 2.86 (95% CI, 2.45 to 3.34), and 3.22 (95% CI, 2.46 to 4.22) for prefrail, mildly frail, moderately frail, and severely frail, respectively.

CONCLUSION

Frailty status is a significant predictor of mortality in older veterans with MM. Assessment of frailty status using the readily available electronic medical records data in administrative data allows for assessment of prognosis.

Cumulative Deficits Frailty Index Predicts Outcomes for Solid Organ Transplant Candidates

Supplemental Digital Content is available in the text.

Despite comprehensive multidisciplinary candidacy assessments to determine appropriateness for solid organ transplantation, limitations persist in identifying candidates at risk of adverse outcomes. Frailty measures may help inform candidacy evaluation. Our main objective was to create a solid organ transplant frailty index (FI), using the cumulative deficits model, from data routinely collected during candidacy assessments. Secondary objectives included creating a social vulnerability index (SVI) from assessment data and evaluating associations between the FI and assessment, waitlist, and posttransplant outcomes.

Use of the Thrombolysis in Myocardial Infarction Risk Index for Elderly Patients With ST-Segment Elevation Myocardial Infarction

Background: Thrombolysis in Myocardial Infarction (TIMI) Risk Index (TRI) is a simple risk assessment tool for patients with ST-segment elevation myocardial infarction (STEMI). However, its applicability to elderly patients with STEMI undergoing percutaneous coronary intervention (PCI) is uncertain. Methods: This was a retrospective analysis of elderly (≥60 years) patients who underwent PCI for STEMI from January 2010 to April 2016. TRI was calculated on admission using the following formula: heart rate × (age/10)²/systolic blood pressure. Discrimination and calibration of TRI for in-hospital events and 1 year mortality were analyzed. Results: Totally 1,054 patients were divided into three groups according to the tertiles of the TRI: <27 (n = 348), 27-36 (n = 360) and >36 (n = 346). The incidence of acute kidney injury (AKI; 7.8 vs. 8.6 vs. 24.0%, p < 0.001), AHF (3.5 vs. 6.6 vs. 16.2%, p < 0.001), in-hospital death (0.6 vs. 3.3 vs. 11.6%, p < 0.001) and MACEs (5.2 vs. 5.8 vs. 15.9%, p < 0.001) was significantly higher in the third tertile. TRI showed good discrimination for in-hospital death [area under the curve (AUC) = 0.804, p < 0.001; Hosmer-Lemeshow p = 0.302], which was superior to its prediction for AKI (AUC = 0.678, p < 0.001; Hosmer-Lemeshow p = 0.121), and in-hospital MACEs (AUC = 0.669, p < 0.001; Hosmer-Lemeshow p = 0.077). Receiver-operation characteristics curve showed that TRI > 42.0 had a sensitivity of 64.8% and specificity of 82.2% for predicting in-hospital death. Kaplan-Meier analysis showed that patients with TRI > 42.0 had higher 1 year mortality (Log-rank = 79.2, p < 0.001). Conclusion: TRI is suitable for risk stratification in elderly patients with STEMI undergoing PCI, and is thus of continuing value for an aging population.

Tissue Failure Propagation as Mediated by Circulatory Flow

Aging is driven by subcellular processes that are relatively well understood. However, the qualitative mechanisms and quantitative dynamics of how these micro-level failures cascade to a macro-level catastrophe in a tissue or organs remain largely unexplored. Here, we experimentally and theoretically study how cell failure propagates in an engineered tissue in the presence of advective flow. We argue that cells secrete cooperative factors, thereby forming a network of interdependence governed by diffusion and flow, which fails with a propagating front parallel to advective circulation.

Generating synthetic aging trajectories with a weighted network model using cross-sectional data

We develop a computational model of human aging that generates individual health trajectories with a set of observed health attributes. Our model consists of a network of interacting health attributes that stochastically damage with age to form health deficits, leading to eventual mortality. We train and test the model for two different cross-sectional observational aging studies that include simple binarized clinical indicators of health. In both studies, we find that cohorts of simulated individuals generated from the model resemble the observed cross-sectional data in both health characteristics and mortality. We can generate large numbers of synthetic individual aging trajectories with our weighted network model. Predicted average health trajectories and survival probabilities agree well with the observed data.

Evidence from two cohorts for the frailty syndrome as an emergent state of parallel dysregulation in multiple physiological systems

Frailty is a clinical syndrome often present in older adults and characterized by a heightened vulnerability to stressors. The biological antecedents and etiology of frailty are unclear despite decades of research: frailty is associated with dysregulation in a wide range of physiological systems, but no specific cause has been identified. Here, we test predictions stemming from the hypothesis that there is no specific cause: that frailty is an emergent property arising from the complex systems dynamics of the broad loss of organismal homeostasis. Specifically, we use dysregulation of six physiological systems using the Mahalanobis distance approach in two cohorts of older adults to test the breadth, diffuseness, and nonlinearity of associations between frailty and system-specific dysregulation. We find clear support for the breadth of associations between frailty and physiological dysregulation: positive associations of all systems with frailty in at least some analyses. We find partial support for diffuseness: the number of systems or total amount of dysregulation is more important than the identity of the systems dysregulated, but results only partially replicate across cohorts. We find partial support for nonlinearity: trends are exponential but not always significantly so, and power is limited for groups with very high levels of dysregulation. Overall, results are consistent with-but not definitive proof of-frailty as an emergent property of complex systems dynamics. Substantial work remains to understand how frailty relates to underlying physiological dynamics across systems.

Association between frailty and risk of fall among diabetic patients

BACKGROUND

Several epidemiological studies have demonstrated the risk factors for fall, while few studies investigated the association between frailty and risk of fall in diabetic patients aged ≥45 years.

METHODS

In this multicity observational study, participants with type 2 diabetes aged ≥45 years were enrolled. Frailty status was measured by a frailty index (FI) of deficit accumulation. We used multivariable regression models to examine the relationship between frailty and fall in diabetic patients, and further investigated the associations between frailty and fall in varied subgroups.

RESULTS

A total of 2049 participants with type 2 diabetes were identified in our study. Our results showed a per-s.d. and a per-0.01 increment of FI were associated with an increased risk of fall, with a fully adjusted OR of 1.89 (95% CI: 1.50, 2.38), 1.06 (95% CI: 1.04, 1.09), respectively. The effects were magnified when frailty was considered as dichotomous, with an OR of 3.08 (95% CI: 2.18, 4.34). In further subgroup analyses, we found that the females, the older, rural residents, individuals with no sitting toilet, people with poor balance performance and those in poor health status were susceptible to fall. Especially, for the risk of fall in the older, a per-s.d. increase of FI corresponded to an OR of 2.46 (95% CI: 1.68, 3.62). When frailty was regarded as a binary variable, the effect increased to 4.62 (95% CI: 2.54, 8.38) in the older subgroup.

CONCLUSION

Frailty was associated with a higher risk of fall in people with type 2 diabetes, and the effects were higher in vulnerable groups. This evidence suggested that more attention should be paid to vulnerable groups for fall prevention.

Physical Frailty among Urban-Living Community-Dwelling Older Adults in Malaysia

Frailty is a multidimensional syndrome, which is a worldwide concern within the field of geriatrics due to the aggravating effect on the physical and mental functions of the elderly. This study aimed to determine the prevalence and risk factors of the frailty syndrome among urban-living community-dwelling elderly in Malaysia. A cross-sectional study was conducted among 301 community-dwelling elders. Frailty status was assessed using the Fried phenotype criteria. Depressive symptoms were assessed using the Geriatric Depression Scale (M-GDS-14), whereas the functional abilities and cognitive status were measured using the Lawton Instrumental Activities of Daily Living (Lawton IADL) scale and the Mini-Mental State Examination (MMSE-M), respectively. Malnutrition risk was observed through the abridged version (Short Form) of the Mini Nutritional Assessment (MNA-SF). Multinomial logistic regression analysis was employed to determine the significant predictors of the frailty syndrome. Three hundred and one elderly persons engaged in this study, with a mean age of 67.08 ± 5.536 ranging between 60 to 84 years old. The prevalence values of frailty and pre-frail were 15.9% and 72.8%, respectively, in which women appeared to be at a higher risk of frailty. The multivariate model revealed that frailty could be predicted from an increase in age, lower household income, being at risk of malnutrition, wasting (low skeletal muscle mass), and high serum C-reactive protein (CRP) level. A holistic approach is suggested for managing the frailty syndrome as it involves a decline in the multiple components of the geriatric syndrome.

Optimal control of aging in complex networks

Many complex systems experience damage accumulation, which leads to aging, manifest as an increasing probability of system collapse with time. This naturally raises the question of how to maximize health and longevity in an aging system at minimal cost of maintenance and intervention. Here, we pose this question in the context of a simple interdependent network model of aging in complex systems and show that it exhibits cascading failures. We then use both optimal control theory and reinforcement learning alongside a combination of analysis and simulation to determine optimal maintenance protocols. These protocols may motivate the rational design of strategies for promoting longevity in aging complex systems with potential applications in therapeutic schedules and engineered system maintenance.

Short Physical Performance Battery and Incident Cardiovascular Events Among Older Women

Background The Short Physical Performance Battery (SPPB) is an inexpensive, reliable, and easy-to-implement measure of lower-extremity physical function. Strong evidence links SPPB scores with all-cause mortality, but little is known about its relationship with incident cardiovascular disease (CVD). Methods and Results Women (n=5043, mean age=79±7) with no history of myocardial infarction or stroke completed 3 timed assessments-standing balance, strength (5 chair stands), and usual gait speed (4 m walk)-yielding an SPPB score from 0 (worst) to 12 (best). Women were followed for CVD events (myocardial infarction, stroke, or CVD death) up to 6 years. Hazard ratios were estimated for women with Very Low (0-3), Low (4-6), Moderate (7-9), and High (10-12) SPPB scores using Cox proportional hazard models adjusted for demographic, behavioral, and health-related variables including objective measurements of physical activity, blood pressure, lipids, and glucose levels. Restricted cubic splines tested linearity of associations. With 361 CVD cases, crude incidence rates/1000 person-years were 41.0, 24.3, 16.1, and 8.6 for Very Low, Low, Moderate, and High SPPB categories, respectively. Corresponding fully adjusted hazard ratios (95% CIs) were 2.28 (1.50-3.48), 1.70 (1.23-2.36) 1.49 (1.12-1.98), and 1.00 (referent); P-trend <0.001. The dose-response relationship was linear (linear P<0.001; nonlinear P>0.38). Conclusions Results suggest SPPB may provide a measure of cardiovascular health in older adults beyond that captured by traditional risk factors. Because of its high test-retest reliability and low administrative burden, the SPPB should be a routine part of office-based CVD risk assessment.

The Burden of Frailty Among U.S. Veterans and Its Association With Mortality, 2002-2012

BACKGROUND

Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality.

METHODS

Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002-2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality.

RESULTS

A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0-0.10), 32.6% were pre-frail (FI = 0.11-0.20), 18.9% were mildly frail (FI = 0.21-0.30), 8.7% were moderately frail (FI = 0.31-0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years' hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97-2.04), 3.49 (3.44-3.55), 5.88 (5.79-5.97), and 10.39 (10.23-10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49-1.53), 2.36 (2.33-2.39), 3.68 (3.63-3.73), 6.62 (6.53-6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites.

CONCLUSIONS

Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.

Prefrailty in older adults: A concept analysis

BACKGROUND

The concept of prefrailty lacks clarity. Often, prefrailty is defined in relation to frailty and less often as a distinct concept. Theoretical evidence for prefrailty is minimal unlike frailty, which has been examined for decades although consensus about how to measure frailty has not been achieved.

OBJECTIVE

The aim of this study was to conduct a concept analysis of prefrailty to provide greater understanding of this phenomenon in the context of older adults.

DESIGN

Rodgers and Knafl's evolutionary concept analysis approach.

DATA SOURCES

The literature search for the concept analysis was conducted as follows: three databases (MEDLINE, CINAHL, and Abstracts in Social Gerontology databases) were searched using carefully selected search terms; and grey literature was not included.

REVIEW METHODS

In phase one, we used the search strategy and search terms to narrow the search for relevant articles. We selected articles that met the following inclusion criteria: (1) how prefrailty was conceptualized; (2) how prefrailty was measured; and (3) interventions targeted towards prefrailty. In phase two, we extracted data from included articles. In phase three, we analyzed data using thematic analysis and findings were presented as attributes, antecedents, consequences, and related concepts of prefrailty. One example of prefrailty in older adults was presented to highlight the concept in praxis. In phase four, methodological and substantive area experts reviewed and contributed to discussion and interpretation of findings including disciplinary perspectives of prefrailty.

RESULTS

A total of 41 articles were included for synthesis. The attributes of prefrailty were predisposing in nature, non-specific, multidimensional, and cumulative in effects. Antecedents of prefrailty were categorized into the following domains: sociodemographic characteristics, comorbidity, behaviours, and laboratory/clinical markers. Consequences of prefrailty were separated into two themes: increased risk of adverse outcomes and advancing levels of frailty. Surrogate and related terms (noted in the literature) that had shared attributes with prefrailty were increased vulnerability, transitional stage, dynamic process, progressive process with latent phase, and physical frailty.

CONCLUSIONS

As a result of conducting this concept analysis, we found that prefrailty was defined as a clinically silent process that predisposes individuals to frailty. Prefrailty, as a concept, was derived from the Fried's operational definition for frailty. Attributes, antecedents, consequences, and related terms will help clinicians consider how prefrailty presents in older adults separate from frailty. Further research is needed to build upon our understanding from this concept analysis. Tweetable Abstract: Prefrailty is unclear as a concept - Research on sociodemographic characteristics of older adults living with frailty will help clarify.

Study protocol of a quasi-experimental trial to compare two models of home care for older people in the primary setting

BACKGROUND

Preventive home visits are suited for patients with reduced mobility, such as older people. Healthcare needs for older patients are expected to increase due to the extended life expectancy estimated in coming years. The implementation of low-cost, patient-centered methodologies may buffer this rise in health care costs without affecting the quality of service. In order to find the best home care model with less investment, this paper describes a study protocol comparing two models of home care for older people.

METHODS

We describe a quasi-experimental study that compares the outcome of two different home care models already implemented in two primary care centers in Badalona (Barcelona, Spain). The traditional model (control model) is integrated in the sense that is continuous, the same primary care center team looks after its assigned patients both at the center and in preventive home visits. The new functional home care model (study model), consisting of a highly trained team, is specifically designed to meet patient needs and give total attention to preventive home interventions. The study will start and end on the expected dates, June 2018 to October 2020, and include all patients over 65 years old already enrolled in the home care programs of the primary care centers selected. The primary endpoint assessed will be the difference in hospitalization days between patients included in both home care programs. Other variables regarding health status, quality of care and resource utilization will also be compared between the two models.

DISCUSSION

The study in progress will assess whether a functional and highly trained home care team will meet the ever-aging population needs in terms of cost and health outcomes better than a traditional, integrated one. Lessons learned from this pilot study will provide guidelines for a future model of home care based on the IHI Triple Aim: better care, better health, and lower costs.

TRIAL REGISTRATION

Registered in ClinicalTrials.gov (Identifier: NCT03461315; March 12, 2018).

Age-Related Frailty: A Clinical Model for Geroscience?

In their everyday practice, geriatricians are confronted with the fact that older age and multimorbidity are associated to frailty. Indeed, if we take the example of a very old person with no diseases that progressively becomes frail with no other explanation, there is a natural temptation to link frailty to aging. On the other hand, when an old person with a medical history of diabetes, arthritis and congestive heart failure becomes frail there appears an obvious relationship between frailty and comorbidity. The unsolved question is: Considering that frailty is multifactorial and in the majority of cases comorbidity and aging are acting synergistically, can we disentangle the main contributor to the origin of frailty: disease or aging? We believe that it is important to be able to differentiate age-related frailty from frailty related to comorbidity. In fact, with the emergence of geroscience, the physiopathology, diagnosis, prognosis and treatment will probably have to be different in the future.