Frailty, Diabetes, and Mortality in Middle-Aged African Americans

Association of frailty and pre-frailty with all-cause and cardiovascular mortality in diabetes: Three prospective cohorts and a meta-analysis

OBJECTIVE

To investigate the association of frailty status with all-cause and cardiovascular disease (CVD) mortality in individuals with diabetes.

METHODS

Data was sourced from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994), NHANES (1999-2006), and the UK Biobank. Frailty status was assessed using the Fried phenotype and classified as non-frailty, pre-frailty, and frailty. We further performed a meta-analysis involving 19 prospective cohort studies (753,480 patients) to summarize the existing evidence.

RESULTS

We included 31,225 diabetes patients from NHANES III (mean age 63.3 ± 0.8, 56.4 % female), NHANES 1999-2006 (mean age 61.6 ± 0.4, 49.7 % female), and the UK Biobank (mean age 59.6 ± 7.2, 39.5 % female). The prevalence of frailty was 9.9 %, 10.7 %, and 12.1 % across respective cohorts. During a follow-up period exceeding 13 years, we observed consistent results that frailty and pre-frailty were significantly associated with increased risks of all-cause and CVD mortality in diabetes. Notably, of the five domains used to assess frailty phenotypes, low gait speed showed the strongest association with all-cause and CVD mortality risks. Meta-analysis showed that, compared to non-frailty, frailty in patients with diabetes was associated with a 1.8-fold higher risk of all-cause mortality and a 2.0-fold higher risk of CVD mortality. Similarly, pre-frailty was associated with a 1.3-fold higher risk of all-cause mortality and a 1.4-fold higher risk of CVD mortality.

CONCLUSIONS

This study established a strong association between frailty, pre-frailty, and increased all-cause and CVD-related mortality in diabetes. Integrating frailty assessment into routine practice to identify frail and pre-frail status early on is recommended, followed by the implementation of targeted healthy lifestyle interventions to mitigate adverse outcomes.

Frailty Assessment Tools Influence the Outcome Associations Among Patients With Diabetes: A Retrospective Cohort Study

BACKGROUND

Frailty, characterized by aging-associated physiological reserve decline, leads to functional loss and adverse outcomes. Patients with diabetes mellitus (DM) have a high frailty risk. However, whether frailty assessment results derived from different tools diverge regarding their outcome correlations remains unclear.

OBJECTIVES

The authors analyzed associations between different frailty assessment results and DM patients' outcomes METHODS: Between 2008 and 2016, adults (age >40 years) with type 2 DM were identified from the National Taiwan University Hospital Integrated Medical Database. The frailty assessment was performed using modified FRAIL scale and frailty index. Cox proportional hazard and Poisson regression analyses were used to determine the relationship between frailty and multiple outcomes after multivariate adjustment.

RESULTS

In total, 30,012 patients (mean 64.1 years, 45.4% women) with type 2 DM were included. The 2 frailty assessments were moderately positively correlated (r = 0.49; 95% CI: 0.48-0.49). After a median of 7.1 years (Q1-Q3: 3.9-10.4 years) of follow-up, FRAIL-identified mild and moderate-to-severe frailty did not correlate with a high mortality probability, but frailty index-identified severe and moderate frailty did. However, FRAIL-identified moderate-to-severe frailty correlated with a higher probability of all-cause hospitalization (incidence rate ratio [IRR]: 1.2; 95% CI: 1.09-1.32), intensive care unit admission (IRR 4.19; 95% CI: 1.69-10.38), and cardiovascular hospitalization (IRR: 1.46; 95% CI: 1.28-1.66), whereas frailty index-identified mild, moderate, and severe frailty increased the probability of all-cause and cardiovascular hospitalizations only.

CONCLUSIONS

We observed major discrepancies in outcome associations between FRAIL scale and frailty index among DM patients. Carefully selecting tools for measuring DM-associated frailty is important.

The association of muscle weakness with functional disability in older patients with Diabetes mellitus: Measured by three different grip strength thresholds

The association of muscle weakness with poor outcomes is well defined in general older population, but there is insufficient data on the association of muscle weakness with functionality in older patients with diabetes mellitus (DM). We aimed to investigate the predictivity of muscle weakness defined as low grip strength thresholds determined by EWGSOP2, and two regional thresholds in older patients with DM for functional disability. Activities of Daily Living (ADL), Instrumental ADL (IADL), grip strength, comorbidities, anthropometric and biochemical data from outpatient clinic medical records were screened retrospectively. Low grip strength was determined by EWGSOP2, and two regional thresholds. Receiver operating characteristic (ROC) analysis, sensitivity and negative predictive values were conducted to identify the discrimination power of three different grip strength thresholds for functional disability in patients with DM. A total of 197 patients with DM and 215 controls were included. In ROC analyses, regional thresholds were with higher sensitivity and negative predictive values for functional disability in both groups. For patients with DM, regional normative thresholds predicted functional disability both for ADLs and IADLs whereas for patients without DM normative thresholds predicted ADL, and calculated thresholds predicted IADL disability. Regional normative thresholds predicted both ADL and IADL functional disability in older patients with DM.

Impact of frailty on mortality, hospitalization, cardiovascular events, and complications in patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Several studies have focused on the impact of frailty on the health outcomes of individuals with diabetes mellitus (DM). This meta-analysis aims to systematically synthesize the existing evidence on frailty and its association with mortality, hospitalizations, cardiovascular diseases, and diabetic complications in DM.

METHODS

A comprehensive search in PubMed, Embase, and SCOPUS was carried out to identify relevant studies assessing the impact of frailty on mortality, hospitalizations, complications, and cardiovascular events in individuals with DM. The quality of the included studies was evaluated using the New Castle Ottawa Scale.

RESULTS

From the 22 studies included, our meta-analysis revealed significant associations between frailty and adverse outcomes in individuals with DM. The pooled hazard ratios for mortality and frailty showed a substantial effect size of 1.84 (95% CI 1.46-2.31). Similarly, the odds ratio for hospitalization and frailty demonstrated a significant risk with an effect size of 1.63 (95% CI 1.50-1.78). In addition, frailty was associated with an increased risk of developing diabetic nephropathy (HR, 3.17; 95% CI 1.16-8.68) and diabetic retinopathy (HR, 1.94; 95% CI 0.80-4.71).

CONCLUSION

Our results show a consistent link between frailty and increased mortality, heightened hospitalization rates, and higher risks of cardiovascular disease, diabetic nephropathy, and diabetic retinopathy for patients with DM. PROSPERO Registration Number: CRD42023485166.

Which people with diabetes are treated with a disposable, half-unit insulin pen? A real-world, retrospective, database study in Spain

INTRODUCTION

Insulin lispro 100 units/mL Jr KwikPen is the first prefilled, disposable, half-unit insulin pen that delivers 0.5-30 units in increments of 0.5 units for the treatment of patients with diabetes. This study describes the profile of patients in Spain who initiated insulin therapy with Jr KwikPen in a real-world setting.

METHODS

This retrospective, observational study based on IQVIA's electronic medical records database included patients with Type 1 (T1D) or Type 2 (T2D) diabetes who initiated therapy with Jr KwikPen between May 2018 and December 2020. Sociodemographic, clinical, and treatment characteristics at treatment initiation were analysed descriptively.

RESULTS

A total of 416 patients were included. The main characteristics of the T1D/T2D groups (N = 326/90), respectively were as follows: female sex, 61.7%/65.6%; mean age (standard deviation [SD]), 32.5 (20.7)/55.5 (16.6) years; body mass index, 20.9 (4.2)/25.2 (4.6) kg/m2 (N = 239/77); HbA1c, 7.8 (1.7)%/8.0 (1.5)% (N = 141/64); and presence of diabetes-associated comorbidities, 27.9%/64.4%. Only 32.8% of patients with T1D were < 18 years old. Among Jr KwikPen users, 12.3% (T1D/T2D, 7.7%/28.9%) were ≥ 65 years old, 17.1% patients were newly diagnosed, and 3.8% were pregnant women. The mean (SD) total insulin dose pre-index for T1D/T2D was 43.1 (23.6) and 40.7 (21.6) UI/day, respectively. The mean (SD) insulin dose at the start of Jr KwikPen use was 26.63 (16.56) and 22.58 (13.59) UI/day for T1D/T2D, respectively. Jr KwikPen was first prescribed mainly by endocrinologists (58.7%) or paediatricians (22.6%).

CONCLUSIONS

The profile of patients who initiated therapy with Jr KwikPen in routine practice was broad with many patients being adults. Most of these patients had T1D, inadequate glycemic control, and multiple associated comorbidities. These results suggest that Jr KwikPen is prescribed in patients who may benefit from finer insulin dose adjustments, namely children, adolescents, adults, older individuals, or pregnant women with T1D or T2D.

Association of estimated carotid-femoral pulse wave velocity with frailty in middle-aged and older adults with cardiometabolic disease

PURPOSE

The prevalence of frailty in individuals with cardiometabolic disease (CMD) has become a growing concern in public health. The purpose of this study was to investigate the association between estimated pulse wave velocity (ePWV) and frailty in middle-aged and older adults with CMD.

METHODS

We analyzed data from 23,313 non-institutionalized adults with CMD from the National Health and Nutrition Examination Survey 2003-2018. Frailty status was determined using the frailty index, and logistic regression models were used to assess the association of ePWV with frailty risk. Multivariable logistic regression and propensity-score matching (PSM) were used to adjust for potential confounders. The restricted cubic spline regression model was used to evaluate the non-linear association between ePWV and frailty risk.

RESULTS

After adjusting for potential confounding factors, we found that each one m/s increase in ePWV was associated with a 15% higher risk of frailty (odds ratio [OR] = 1.15, 95% confidence interval [CI] 1.12 to 1.18, P < 0.001). After PSM, the association remained significant (OR = 1.05, 95% CI 1.03 to 1.08, P < 0.001). The logistic models with restricted cubic splines showed a non-linear dose-response association, with the risk of frailty increasing more rapidly when ePWV exceeded 9.5 m/s.

CONCLUSIONS

The findings of this study suggest that a higher level of ePWV is associated with an increased risk of frailty in middle-aged and older adults with CMD, and may serve as a viable alternative to directly measured cfPWV.

Association of frailty index with congestive heart failure, all-cause and cardiovascular mortality among individuals with type 2 diabetes: a study from National Health and Nutrition Examination Surveys (NHANES), 1999-2018

BACKGROUND

Both type 2 diabetes mellitus (T2DM) and frailty are strongly associated with congestive heart failure (CHF). Individuals with T2DM and CHF have a high frailty burden. The association of frailty with HF, all-cause, and cardiovascular mortality in patients with T2DM has not been thoroughly explored.

METHODS

This study included 2894 adults with T2DM from the National Health and Nutrition Examination Survey (NHANES) database over ten cycles (1999-2018) and followed up for all-cause and cardiovascular mortality through 31 December 2019. The frailty index (FI) was calculated using a 46-item deficit model to assess frailty status. Weighted multivariable logistic regression was performed to explore the relationship between frailty and CHF in patients with T2DM. Weighted restricted cubic splines were used to evaluate the non-linear relationship between FI and outcome. All-cause mortality and cardiovascular mortality association with FI was assessed using the Kaplan-Meier curve and COX proportional hazards regression accounting for sampling weights. Subgroup and sensitivity analyses were performed to evaluate the robustness of the results.

RESULTS

After the adjustment of essential confounders, a higher frailty index in T2DM was associated with increased odds of CHF (odds ratio [OR] for per 1-SD increase, 2.02, 95% confidence interval [CI] 1.67-2.45; P < 0.0001). The presence of frailty T2DM (OR, 3.60; 95% CI 2.34-5.54; P < 0.0001) was associated with a significant increase in the prevalence of CHF compared to non-frailty T2DM in a fully adjusted model. During the median follow-up of 6.75 years, per 1-SD increase in FI was associated with a 41% higher risk of all-cause mortality and a 30% higher risk of cardiovascular mortality after being adjusted for all confounders. Similar results were observed when sensitivity analyses were performed. There was also a non-linear relationship between FI and all-cause mortality. In a weighted multivariate COX proportional model adjusted for full confounders, frailty T2DM increased all-cause (HR, 1.86; 95% CI 1.55-2.24; P < 0.0001) and cardiovascular (HR 1.66; 95% CI 1.18-2.33; P = 0.003) mortality and compared to non-frailty T2DM. The positive association of frailty index and all-cause mortality was only in participants without CHF. The positive association of frailty index and cardiovascular mortality was only in non-anti-diabetic drug users.

CONCLUSIONS

Frailty index in T2DM was positively associated with CHF in linear fashions. The Frailty index was positively correlated with all-cause and cardiovascular death in patients with T2DM. Frailty T2DM was positively associated with CHF, all-cause mortality, and cardiovascular mortality compared to non-frailty T2DM. Promoting frailty measurement and management in T2DM may be beneficial to reduce the burden of CHF and mortality.

Associations Between Frailty and the Increased Risk of Adverse Outcomes Among 38,950 UK Biobank Participants With Prediabetes: Prospective Cohort Study

BACKGROUND

Compared with adults with normal glucose metabolism, those with prediabetes tend to be frail. However, it remains poorly understood whether frailty could identify adults who are most at risk of adverse outcomes related to prediabetes.

OBJECTIVE

We aimed to systematically evaluate the associations between frailty, a simple health indicator, and risks of multiple adverse outcomes including incident type 2 diabetes mellitus (T2DM), diabetes-related microvascular disease, cardiovascular disease (CVD), chronic kidney disease (CKD), eye disease, dementia, depression, and all-cause mortality in late life among middle-aged adults with prediabetes.

METHODS

We evaluated 38,950 adults aged 40 years to 64 years with prediabetes using the baseline survey from the UK Biobank. Frailty was assessed using the frailty phenotype (FP; range 0-5), and participants were grouped into nonfrail (FP=0), prefrail (1≤FP≤2), and frail (FP≥3). Multiple adverse outcomes (ie, T2DM, diabetes-related microvascular disease, CVD, CKD, eye disease, dementia, depression, and all-cause mortality) were ascertained during a median follow-up of 12 years. Cox proportional hazards regression models were used to estimate the associations. Several sensitivity analyses were performed to test the robustness of the results.

RESULTS

At baseline, 49.1% (19,122/38,950) and 5.9% (2289/38,950) of adults with prediabetes were identified as prefrail and frail, respectively. Both prefrailty and frailty were associated with higher risks of multiple adverse outcomes in adults with prediabetes (P for trend <.001). For instance, compared with their nonfrail counterparts, frail participants with prediabetes had a significantly higher risk (P<.001) of T2DM (hazard ratio [HR]=1.73, 95% CI 1.55-1.92), diabetes-related microvascular disease (HR=1.89, 95% CI 1.64-2.18), CVD (HR=1.66, 95% CI 1.44-1.91), CKD (HR=1.76, 95% CI 1.45-2.13), eye disease (HR=1.31, 95% CI 1.14-1.51), dementia (HR=2.03, 95% CI 1.33-3.09), depression (HR=3.01, 95% CI 2.47-3.67), and all-cause mortality (HR=1.81, 95% CI 1.51-2.16) in the multivariable-adjusted models. Furthermore, with each 1-point increase in FP score, the risk of these adverse outcomes increased by 10% to 42%. Robust results were generally observed in sensitivity analyses.

CONCLUSIONS

In UK Biobank participants with prediabetes, both prefrailty and frailty are significantly associated with higher risks of multiple adverse outcomes, including T2DM, diabetes-related diseases, and all-cause mortality. Our findings suggest that frailty assessment should be incorporated into routine care for middle-aged adults with prediabetes, to improve the allocation of health care resources and reduce diabetes-related burden.

Healthcare utilization among pre-frail and frail Puerto Ricans

Frailty is associated with adverse health outcomes and greater healthcare utilization. Less is known about the relationship between frailty and healthcare utilization in Puerto Rico, where high rates of chronic conditions and limited healthcare may put this group at a higher likelihood of using healthcare resources. This study examined the association between pre-frailty and frailty with healthcare utilization at baseline and 4-year follow-up among a cohort of community dwelling Puerto Ricans living on the island. We examined data from 3,040 Puerto Ricans (mean age 70.6 years) from The Puerto Rican Elderly: Health Conditions (PREHCO) study between 2002-2003 and 2006-2007. We used a modified version of the Fried criteria defined as 3 or more of the following: shrinking, weakness, poor energy, slowness, and low physical activity. Pre-frailty was defined as 1-2 components. The number of emergency room visits, hospital stays, and doctor visits within the last year were self-reported. Zero-inflated negative binomial regression models were used for ER visits and hospital stays. Negative binomial models were used for doctor visits. Pre-frailty was associated with a higher rate of doctor visits with a rate ratio of 1.11 (95% CI = 1.01-1.22) at baseline. Frailty was associated with a higher rate of ER visits (1.48, 95% CI = 1.13-1.95), hospital stays (1.69, 95% CI = 1.08-2.65), and doctor visits (1.24, 95% CI = 1.10-1.39) at baseline. Pre-frailty and frailty were not associated with any healthcare outcomes at follow-up. Pre-frailty and frailty are associated with an increased rate of healthcare services cross-sectionally among Puerto Rican adults, which may cause additional burdens on the already pressured healthcare infrastructure on the island.

Relationship between Frailty, Glycemic Control, and Nutritional Status among the Elderly with Diabetes Mellitus Residing in an Urban Community of Mysuru

Background

In India, the elderly (aged 60 and above) constitute 8.2% of the total population and are expected to increase to 10% by the year 2020. Globally, around 450 million people are suffering from diabetes mellitus. Frailty is regarded as a predisability state and, therefore, if identified early, may avert many adverse health outcomes in the elderly. Diabetes and frailty are found to be close associates.

Materials and Methods

This community-based cross-sectional study was conducted among 104 elderlies with diabetes mellitus residing in an urban slum situated in Mysuru for a period of 6 months. Pretested structured questionnaire was used to collect the information on sociodemographic characteristics and details of diabetes. The Tilburg's Frailty Scale was used to assess frailty, and the Mini Nutritional Assessment Scale was used to assess the nutritional status.

Results

The prevalence of frailty among the study population was 53.8%. 51% of the subjects were found to have their glycemic status under control, 16.3% were malnourished, and 70.2% were at risk of malnutrition (RMN). The majority of the subjects with malnourishment were frail (76.5%) followed by those at RMN, 36 (49.3%). Gender, marital status, engaging in occupation, socio economic status, poor glycemic control were found to be significantly associated with frailty.

Conclusion

The prevalence of frailty is significantly higher among elderly diabetics. The poorer glycemic control is a significant factor associated with frailty, and malnourished elderlies are more at risk of developing frailty.

Kinematic characteristics during gait in frail older women identified by principal component analysis

Frailty is associated with gait variability in several quantitative parameters, including high stride time variability. However, the associations between joint kinematics during walking and increased gait variability with frailty remain unclear. In the current study, principal component analysis was used to identify the key joint kinematics characteristics of gait related to frailty. We analyzed whole kinematic waveforms during the entire gait cycle obtained from the pelvis and lower limb joint angle in 30 older women (frail/prefrail: 15 participants; non-frail: 15 participants). Principal component analysis was conducted using a 60 × 1224 input matrix constructed from participants’ time-normalized pelvic and lower-limb-joint angles along three axes (each leg of 30 participants, 51 time points, four angles, three axes, and two variables). Statistical analyses revealed that only principal component vectors 6 and 9 were related to frailty. Recombining the joint kinematics corresponding to these principal component vectors revealed that frail older women tended to exhibit greater variability of knee- and ankle-joint angles in the sagittal plane while walking compared with non-frail older women. We concluded that greater variability of knee- and ankle-joint angles in the sagittal plane are joint kinematic characteristics of gait related to frailty.

Self-management interventions for Type 2 Diabetes: systematic review protocol focusing on patient workload and capacity support

INTRODUCTION

People living with type 2 diabetes undertake a range of tasks to manage their condition, collectively referred to as self-management. Interventions designed to support self-management vary in their content, and efficacy. This systematic review will analyse self-management interventions for type 2 diabetes drawing on theoretical models of patient workload and capacity.

METHODS AND ANALYSIS

Five electronic databases (Medline, Embase, CENTRAL, CINAHL and PsycINFO) will be searched from inception to 27th April 2021, supplemented by citation searching and hand-searching of reference lists. Two reviewers will independently review titles, abstracts and full texts. Inclusion criteria include Population: Adults with type 2 diabetes mellitus; Intervention: Randomised controlled trials of self-management support interventions; Comparison: Usual care; Outcomes: HbA1c (primary outcome) health-related quality of life (QOL), medication adherence, self-efficacy, treatment burden, healthcare utilization (e.g. number of appointment, hospital admissions), complications of type 2 diabetes (e.g. nephropathy, retinopathy, neuropathy, macrovascular disease) and mortality; Setting: Community. Study quality will be assessed using the Effective Practice and Organisation of Care (EPOC) risk of bias tool. Interventions will be classified according to the EPOC taxonomy and the PRISMS self-management taxonomy and grouped into similar interventions for analysis. Clinical and methodological heterogeneity will be assessed within subgroups, and random effects meta-analyses performed if appropriate. Otherwise, a narrative synthesis will be performed. Interventions will be graded on their likely impact on patient workload and support for patient capacity. The impact of these theoretical constructs on study outcomes will be explored using meta-regression. Conclusion This review will provide a broad overview of self-management interventions, analysed within the cumulative complexity model theoretical framework. Analyses will explore how the workload associated with self-management, and support for patient capacity, impact on outcomes of self-management interventions.

REGISTRATION NUMBER

PROSPERO CRD42021236980.

Risk factors associated with frailty in older adults with type 2 diabetes: A cross-sectional study

AIMS AND OBJECTIVES

The aims of the study were to (i) estimate the prevalence of frailty among older adults with type 2 diabetes, and (ii) investigate risk factors associated with frailty in the study group.

BACKGROUND

The high prevalence of frailty among older adults and its adverse health impacts including higher risks for physical disabilities and a higher mortality rate is quickly evolving to become an important public health issue.

DESIGN

A cross-sectional design.

METHODS

Data were collected from the Clinical Diabetes Centre of our study group. Frailty was assessed using the Chinese version of the Tilburg frailty indicator. Other questionnaires included Activities of Daily Living, Mini-Mental State Examination, Taiwan Geriatric Depression Scale and Instrumental Activities of Daily Living. Multivariable logistic regression was established to identify factors associated with frailty. The STrengthening the Reporting of OBservational studies in Epidemiology checklist was used preparing the manuscript.

RESULTS

A total of 248 subjects were recruited in this study, a total of 66 participants had frailty (26.6%). Our results showed that factors including age, number of chronic diseases, cerebrovascular accident, renal diseases, frequency of falling, frequency of hyperglycaemia, Activities of Daily Living, depression, Mini-Mental State Examination, and Instrumental Activities of Daily Living ≧1 task disability were correlated with frailty in older adults with type 2 diabetes. After adjusting for confounding factors, multivariate logistic regression analyses showed a significant increase in the probability of frailty by 1.72-times when comparing type 2 diabetes subjects with depression to those without depression.

CONCLUSION

This study revealed that depression is a significant factor associated with the occurrence of frailty among older adults with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Our results provided strong clinical evidence showing depression as an important factor associated with the risk of frailty in older individuals with type 2 diabetes. We recommend early detection via routine screenings for symptoms of depression during diabetes care to achieve early prevention or the delay of frailty and its implicated adverse health consequences.

Frailty Pathogenesis, Assessment, and Management in Older Adults With COVID-19

The 2019 coronavirus disease (COVID-19) is a highly contagious and deadly disease. The elderly people are often accompanied by chronic inflammation and immunodeficiency, showing a frail state. The strength, endurance, and physiological function of the elderly are significantly decreased, and the ability to deal with stress response is weakened. They are the high-risk group that suffering from COVID-19, and rapidly developing to critical illness. Several recent studies suggest that the incidence rate of COVID-19 in elderly patients with frailty is high. Early assessment, detection, and effective intervention of frailty in COVID-19 patients are conducive to significantly improve the quality of life and improve prognosis. However, there are insufficient understanding and standards for the current evaluation methods, pathogenesis and intervention measures for COVID-19 combined with frailty. This study reviews the progress of the research on the potential pathogenesis, evaluation methods and intervention measures of the elderly COVID-19 patients with frailty, which provides a reference for scientific and reasonable comprehensive diagnosis and treatment in clinical.

High Frequency of Recurrent Falls Among Prefrail and Frail Women With and Without HIV

BACKGROUND

Frailty may occur at younger ages among HIV+ populations. We evaluated associations of the frailty status with self-reported single and recurrent falls in the Women's Interagency HIV Study (WIHS).

METHODS

The frailty status was defined using the Fried Frailty Phenotype (FFP) among 897 HIV+ and 392 HIV- women; median age 53 years. Women were classified as robust (FFP 0), prefrail (FFP 1-2), and frail (FFP 3-5). Stepwise logistic regression models adjusting for the HIV status and study site were fit to evaluate associations of the FFP with self-reported single (1 vs. 0) and recurrent falls (≥2 vs. 0) over the prior 12 months.

RESULTS

HIV+ women were less likely to be frail (9% vs. 14% vs. P = 0.009), but frequency of falls did not differ by the HIV status. In multivariate analyses, recurrent falls were more common among prefrail [adjusted odds ratio (AOR) 2.23, 95% confidence interval (CI): 1.40 to 3.57, P = 0.0008] and frail (AOR 3.61, 95% CI: 1.90 to 6.89, P < 0.0001) than robust women. Among HIV+ women, single (AOR 2.88, 95% CI: 1.16 to 7.20, P = 0.023) and recurrent falls (AOR 3.50, 95% CI: 1.24 to 9.88, P = 0.018) were more common among those who were frail; recurrent, but not single falls, were more common among prefrail than robust HIV+ women (AOR 2.00, 95% CI: 1.03 to 3.91, P = 0.042).

CONCLUSIONS

HIV+ women were less likely to be frail. Compared with robust women, prefrail and frail women with and without HIV were more likely to experience single or recurrent falls within a 12-month period. Additional studies are needed to develop interventions that decrease development of frailty and reduce risk of recurrent falls among HIV+ women.

Measuring frailty in younger populations: a rapid review of evidence

OBJECTIVES

Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.

DESIGN

A rapid review of primary studies was conducted.

DATA SOURCES

Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.

ELIGIBILITY CRITERIA

Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.

DATA EXTRACTION AND SYNTHESIS

Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.

RESULTS

We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.

CONCLUSIONS

Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.

Frailty and Quality of Life in Older Adults with Metabolic Syndrome - Findings from the Healthy Older People Everyday (HOPE) Study

OBJECTIVES

Metabolic syndrome (MetS) and frailty are both associated with increased morbidity and mortality. Frailty is associated with reduced quality of life (QoL) but association of QoL with MetS have produced mixed results suggesting that other factors such as disease burden, obesity and depression may have a more significant influence. We aim to investigate the demographics of frail participants with MetS, and relationship between frailty and QoL in MetS.

METHODS

Cross-sectional population study involving 292 older adults ≥ 65 years with MetS. MetS was defined using the Modified ATP III for Asians which requires the presence of 3 or more of the following 5 components 1) waist circumference ≥ 90cm for males or ≥ 80cm for females, 2) TG ≥ 150mg/dL, 3) HDLc < 40mg/dL in males or < 50mg/dL in females, 4) blood pressure ≥ 130/85mmHg or use of anti-hypertensive medication, and 5) fasting plasma glucose ≥ 100mg/dL or use of pharmacological treatment for diabetes mellitus. Data were collected on demographics, frailty (FRAIL), QoL (Euroqol-5D), perceived health, functional status, cognition, Timed-Up-and-Go (TUG), and hand-grip strength (HGS).

RESULTS

40.4% of the participants were pre-frail (MetSprefrail) and 7.2% were frail (MetSfrail). MetSfrail were significantly older, had lower education level, higher polypharmacy burden and higher prevalence of diabetes. The prevalence of at least 1 activity of daily living impairment was 4 times higher, and depression 9 times higher than their robust counterparts. MetSfrail also had longer TUG, higher prevalence of poor grip strength and poor perceived health. After adjusting for age, gender and education, MetSfrail was significantly associated with much higher odds of EQ-5D moderate to extreme problems with mobility (Odds Ratio (OR) =10.99, CI 2.62-46.14), usual activities (OR=37.82, CI 3.77-379.04) and pain (OR=10.79, CI 3.18-36.62). EQ-5D Index Value and Perceived Health improved by 0.1 (Mean Difference (MD) =0.07, CI 0.04-0.10) and 6.0 (MD=6.01, CI 3.29-8.73) respectively as frailty status improved.

CONCLUSION

Frailty in MetS is associated with depression, polypharmacy, greater functional impairment, poorer QoL and perceived health. Frailty screening and personalized management is crucial in MetS as frailty may be a mediator for negative outcomes in MetS, and frailty may be reversible.

Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysis

Background

Frailty, a state of increased vulnerability to adverse health outcomes, is important in diabetes management. We aimed to quantify the prevalence of frailty in people with diabetes, and to summarise the association between frailty and generic outcomes (eg, mortality) and diabetes-specific outcomes (eg, hypoglycaemia).

Methods

In this systematic review and study-level meta-analysis, we searched MEDLINE, Embase, and Web of Science for observational studies published between Jan 1, 2001 (the year of the original publication of the Fried frailty phenotype), to Nov 26, 2019. We included studies that assessed and quantified frailty in adults with diabetes, aged 18 years and older; and excluded conference abstracts, grey literature, and studies not published in English. Data from eligible studies were extracted using a piloted data extraction form. Our primary outcome was the prevalence of frailty in people with diabetes. Secondary outcomes were incidence of frailty and generic and diabetes-specific outcomes. Data were assessed by random-effects meta-analysis where possible and by narrative synthesis where populations were too heterogeneous to allow meta-analysis. This study is registered with PROSPERO, CRD42020163109.

Findings

Of the 3038 studies we identified, 118 studies using 20 different frailty measures were eligible for inclusion (n=1 375 373). The most commonly used measures of frailty were the frailty phenotype (69 [58%] of 118 studies), frailty (16 [14%]), and FRAIL scale (10 [8%]). Studies were heterogenous in setting (88 studies were community-based, 18 were outpatient-based, ten were inpatient-based, and two were based in residential care facilities), demographics, and inclusion criteria; therefore, we could not do a meta-analysis for the primary outcome and instead summarised prevalence data using a narrative synthesis. Median community frailty prevalence using frailty phenotype was 13% (IQR 9-21). Frailty was consistently associated with mortality in 13 (93%) of 14 studies assessing this outcome (pooled hazard ratio 1·51 [95% CI 1·30-1·76]), with hospital admission in seven (100%) of seven, and with disability in five (100%) of five studies. Frailty was associated with hypoglycaemia events in one study (<1%), microvascular and macrovascular complications in nine (82%) of 11 studies assessing complications, lower quality of life in three (100%) of three studies assessing quality of life, and cognitive impairment in three (100%) of three studies assessing cognitive impairment. 13 (11%) of 118 studies assessed glycated haemoglobin finding no consistent relationship with frailty.

Interpretation

The identification and assessment of frailty should become a routine aspect of diabetes care. The relationship between frailty and glycaemia, and the effect of frailty in specific groups (eg, middle-aged [aged <65 years] people and people in low-income and lower-middle-income countries) needs to be better understood to enable diabetes guidelines to be tailored to individuals with frailty.

Funding

Medical Research Council.

Does Postoperative Cognitive Decline Result in New Disability After Surgery?

OBJECTIVE

Establish whether POCD is associated with new disability after surgery, which would inform whether POCD impacts patient-centered outcomes.

BACKGROUND

POCD is a decline in neuropsychiatric tests scores from presurgical baseline which occurs in approximately 15% of older patients 3 months after surgery. POCD is a research construct meant to investigate patient and family reports of older adults who were "never the same after surgery." However, many patients with POCD do not perceive difficulty with thinking and memory, and the question remains whether POCD impacts patient function.

METHODS

We performed a prospective cohort study of 167 older adults undergoing major noncardiac surgery (requiring at least a 2-day hospital stay). Exclusion criteria were: history of dementia, cardiac or intracranial procedure, inability to consent for themselves, or emergency surgery. We administered formal neuropsychiatric testing (Alzheimer Disease Research Center UDS battery), basic and instrumental activities of daily living (Alzheimer Disease Research Center IADLs), pain (geriatric pain measure), and depression screening (hospital depression and anxiety scale) before and 3 months after surgery. We recorded all patient refined diagnostic related groups codes, blood pressure, anesthetics and narcotics administered, surgical and anesthesia duration, and measured complications and severity, length of stay, and readmissions.

RESULTS

Patients with POCD (21/167, 14.1%) had twice the proportion of new impairment in IADL as compared to those without POCD (57% vs 27%, P = .01). The most common areas of decline were social activities, ability to find items around the house, remember appointments, shop and pay for items, do laundry, drive a car/use public transport, and do housework. Predictors of IADL change after surgery included POCD, presurgical cognition, presurgical function, postoperative depression, and the development of postoperative complications.

CONCLUSIONS

Patients with POCD experience a much higher incidence of new disability after surgery. Baseline cognitive or functional limitations are also risk factors for new disability. Many patients are not aware of their limitations before surgery. Future study is needed to identify practical ways to routinely screen patients and reduce risk. Patients need to be informed of their risk for new disability after surgery to inform their medical decision making.

Hypoglycemic episodes are associated with an increased risk of incident frailty among new onset diabetic patients

AIMS

Patients with diabetes mellitus (DM) are at risk for developing frailty due to the complex interplay between different cardiometabolic factors. We examined whether hypoglycemia could independently increase frailty risk besides these factors.

METHODS

From the Longitudinal Cohort of Diabetic Patients, 210,254 patients with new onset DM between 2004 and 2011 were identified, among whom 2119 non-frail patients had at least 1 hypoglycemic episode within 3 years of DM diagnosis. They were propensity score-matched to 8432 non-frail ones without hypoglycemia throughout the study period. Both groups were followed up longitudinally for incident physical frailty according to a modified FRAIL scale (Fatigue, Resistance, Ambulation, Illness, and Loss of weight). We analyzed the risk of frailty (primary) and mortality (secondary outcome) introduced by hypoglycemia, adjusted for known risk factors of frailty.

RESULTS

The mean age of patients (46.2% male) was 65.9 ± 14 years; diabetic patients with hypoglycemia had significantly higher comorbidity burden than those without. After 2.68 years, 172 (1.6%) patients with hypoglycemia developed incident frailty, representing a 60% higher risk (hazard ratio [HR] 1.599, 95% confidence interval [CI] 1.14-2.42). After adjusting for other risk factors, those with hypoglycemia had a significantly higher risk of frailty than those without (HR 1.443, 95% CI 1.01-2.05). Additionally, the mortality of those with hypoglycemia was 2-fold higher than those without, and the risk persisted despite confounder adjustment (HR 1.462, 95% CI 1.3-1.65).

CONCLUSION

In this population-based cohort, hypoglycemic episodes among diabetic patients increased the risk of incident frailty and mortality.

Prevalence of Metabolic Syndrome and Association with Grip Strength in Older Adults: Findings from the HOPE Study

OBJECTIVE

To determine the prevalence of metabolic syndrome (MetS) in older adults and assess the association of MetS and adverse outcomes with handgrip strength (HGS), HGS/body weight (BWT), and HGS/body mass index (BMI).

METHODS

A cross-sectional population study in Singapore. Data were collected on demographics, HGS, Timed-Up and Go (TUG), fasting glucose, lipid profile, blood pressure, waist circumference, frailty status, and cognition in 722 older adults ≥65 years old. MetS was defined using the Modified ATP III for Asians where at least three of the following conditions must be fulfilled, central obesity, high blood glucose (or diagnosed diabetes mellitus), high blood pressure (or diagnosed hypertension), low high-density lipoprotein, and high triglycerides. The waist circumference in the Modified ATP III for Asians is ≥90 cm for males or ≥80 cm for females. HGS and HGS normalized by BWT or BMI were used for the association.

RESULTS

The prevalence of MetS in older adults was 41.0%, and those ≥85 years old 50.0%. The prevalence was higher in females ≥70 years old, with 8 in 10 females ≥85 years having MetS. After adjusting for age, years of education, physical exercise, as well as history of smoking and alcohol consumption, higher HGS normalized by BWT or BMI was significantly associated with lower odds of having MetS (OR: 0.51,95% CI 0.43-0.61, p<0.01) and (OR: 0.13, 95% CI 0.07-0.24, p<0.01).

CONCLUSION

Almost 1 in 2 older adults had MetS, with the prevalence in females much higher than that in males over 70 years old. Our findings suggest that both HGS/BWT and HGS/BMI had a significant negative association with MetS, its components, and adverse effects. Further studies are needed to validate the association and to determine optimal cutoffs of HGS/BWT and HGS/BMI for MetS, and the effectiveness of interventions in averting the risk.

More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation

GOAL

To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival.

BACKGROUND

While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT.

METHODS

Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models.

RESULTS

Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma.

CONCLUSIONS

Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.

Relationship between frailty and mortality, hospitalization, and cardiovascular diseases in diabetes: a systematic review and meta-analysis

Background

In patients with diabetes, death and cardiovascular diseases are attributed to classical risk factors such as hypertension, dyslipidemia, and smoking habit, whereas these events are attributed to frailty in the remaining patients. In this meta-analysis, we examined the relationship between frailty and mortality, hospitalization, and cardiovascular diseases in patients with diabetes.

Methods

Literature search was conducted using databases such as MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. Studies that examined the relationship between frailty and mortality, hospitalization, and cardiovascular disease and included hazard ratios (HRs), odds ratios (ORs), and 95% confidence intervals (CIs) were included. Statistical analysis was performed using a random effects model, and pooled HRs, pooled ORs, and 95% CIs were calculated.

Results

The literature search extracted 8 studies (565,039 patients) that met our inclusion criteria, which were included in this meta-analysis. The pooled HR of prefrailty and frailty related to mortality was 1.09 (95% CI 1.01–1.17; P = 0.02) and 1.35 (95% CI 1.05–1.74; P = 0.02), respectively, indicating a significant relationship between them. The pooled OR of prefrailty and frailty related to hospitalization was 2.15 (95% CI 1.30–3.54; P = 0.003) and 5.18 (95% CI 2.68–9.99; P < 0.001), respectively, indicating a significant relationship. Although a significant relationship was found between frailty and cardiovascular diseases, we found only few related studies; thus, robust results could not be obtained.

Conclusions

In patients with diabetes, a significant relationship was observed between frailty and mortality and hospitalization. However, only few heterogeneous studies were included, warranting further examination.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

OBJECTIVE

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.

METHODS

These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Frailty status as a predictor of 3-month cognitive and functional recovery following spinal surgery: a prospective pilot study

BACKGROUND CONTEXT

As increasing numbers of elderly Americans undergo spinal surgery, it is important to identify which patients are at highest risk for poor cognitive and functional recovery. Frailty is a geriatric syndrome that has been closely linked to poor outcomes, and short-form screening may be a helpful tool for preoperative identification of at-risk patients.

PURPOSE

This study aimed to conduct a pilot study on the usefulness of a short-form screening tool to identify elderly patients at increased risk for prolonged cognitive and functional recovery following elective spine surgery.

STUDY DESIGN/SETTING

This is a prospective, comparative cohort study.

PATIENT SAMPLE

The sample comprised 100 patients over age 65 who underwent elective spinal surgery (cervical or lumbar) at a single, large academic medical center from 2013 to 2014.

OUTCOME MEASURES

Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale, Postoperative Quality of Recovery Scale (PQRS), and instrumental activities of daily living (IADL) scores were the outcome measures.

METHODS

Included patients were assessed with the FRAIL scale and stratified as robust, pre-frail, or frail. The PQRS and IADL scores were also obtained. Patients were re-examined at 1 day, 3 days, 1 month, and 3 months after surgery for cognitive recovery at 3 months, and secondarily, functional recovery at 3 months.

RESULTS

At 3 months, only 50% of frail patients had recovered to their cognitive baseline compared with 60.7% of pre-frail and 69.2% of robust patients (trend). At 3 months, 66.7% of frail patients had recovered to their functional baseline compared with 57% of pre-frail and 76.9% of robust patients (trend). Using multivariate regression modeling, at 3 months, frail patients were less likely to have recovered to their cognitive baseline compared with pre-frail and robust patients (odds ratio 0.39, confidence interval 0.131-1.161).

CONCLUSIONS

This pilot study demonstrates a trend toward poorer cognitive recovery 3 months following elective spinal surgery for frail patients. Frailty screening can help preoperatively identify patients who may experience protracted cognitive and functional recovery.

Frailty and health care use among community-dwelling older adults with diabetes: a population-based study

Purpose

The aims of this study were to investigate the prevalence of frailty and its relationship with health care use among community-dwelling older adults with diabetes.

Methods

We analyzed data from a nationally representative sample of people aged 65 years and above (n=3,203) participating in the 2013 National Health Interview Survey in Taiwan. A total of 719 participants had a history of self-reported physician-diagnosed diabetes. The presence of frailty was determined based on the Fatigue, Resistance, Ambulation, Illness, and Loss of weight (FRAIL) scale proposed by the International Association of Nutrition and Aging. FRAIL scores range from 0 to 5 and are categorized as frail (3–5), pre-frail (1–2), and robust (0). Participants were asked whether they had been hospitalized or had visited an emergency department in the past year.

Results

Among community-dwelling older adults with diabetes, 9.4% of participants were frail and 35.3 % were pre-frail. After adjustment for other factors, being frail was significantly associated with hospitalization during the past year (OR =5.31, 95% CI =1.87–15.10), whereas being pre-frail was not associated with hospitalization. Both being pre-frail and frail were significantly associated with emergency department visits during the past year (OR =2.64, 95% CI =1.35–5.17 and OR =4.05, 95% CI =1.31–12.49, respectively) after adjustment for other factors.

Conclusion

Our results highlight the high prevalence of frailty in community-dwelling older adults with diabetes. Furthermore, being frail is associated with a greater burden of hospitalizations and emergency department visits.

Both pre-frailty and frailty increase healthcare utilization and adverse health outcomes in patients with type 2 diabetes mellitus

Background

Diabetes mellitus (DM) correlates with accelerated aging and earlier appearance of geriatric phenotypes, including frailty. However, whether pre-frailty or frailty predicts greater healthcare utilization in diabetes patients is unclear.

Methods

From the Longitudinal Cohort of Diabetes Patients in Taiwan (n = 840,000) between 2004 and 2010, we identified 560,795 patients with incident type 2 DM, categorized into patients without frailty, or with 1, 2 (pre-frail) and ≥ 3 frailty components, based on FRAIL scale (Fatigue, Resistance, Ambulation, Illness, and body weight Loss). We examined their long-term mortality, cardiovascular risk, all-cause hospitalization, and intensive care unit (ICU) admission.

Results

Among all participants (56.4 ± 13.8 year-old, 46.1% female, and 84.8% community-dwelling), 77.8% (n = 436,521), 19.2% (n = 107,757), 2.7% (n = 15,101), and 0.3% (n = 1416) patients did not have or had 1, 2 (pre-frail), and ≥ 3 frailty components (frail), respectively, with Fatigue and Illness being the most common components. After 3.14 years of follow-up, 7.8% patients died, whereas 36.6% and 9.1% experienced hospitalization and ICU stay, respectively. Cox proportional hazard modeling discovered that patients with 1, 2 (pre-frail), and ≥ 3 frailty components (frail) had an increased risk of mortality (for 1, 2, and ≥ 3 components, hazard ratio [HR] 1.05, 1.13, and 1.25; 95% confidence interval [CI] 1.02–1.07, 1.08–1.17, and 1.15–1.36, respectively), cardiovascular events (HR 1.05, 1.15, and 1.13; 95% CI 1.02–1.07, 1.1–1.2, and 1.01–1.25, respectively), hospitalization (HR 1.06, 1.16, and 1.25; 95% CI 1.05–1.07, 1.14–1.19, and 1.18–1.33, respectively), and ICU admission (HR 1.05, 1.13, and 1.17; 95% CI 1.03–1.07, 1.08–1.14, and 1.06–1.28, respectively) compared to non-frail ones. Approximately 6–7% risk elevation in mortality and healthcare utilization was noted for every frailty component increase.

Conclusion

Pre-frailty and frailty increased the risk of mortality and cardiovascular events, and entailed greater healthcare utilization in patients with type 2 DM.

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0772-2) contains supplementary material, which is available to authorized users.

Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants

BACKGROUND

Frailty is associated with older age and multimorbidity (two or more long-term conditions); however, little is known about its prevalence or effects on mortality in younger populations. This paper aims to examine the association between frailty, multimorbidity, specific long-term conditions, and mortality in a middle-aged and older aged population.

METHODS

Data were sourced from the UK Biobank. Frailty phenotype was based on five criteria (weight loss, exhaustion, grip strength, low physical activity, slow walking pace). Participants were deemed frail if they met at least three criteria, pre-frail if they fulfilled one or two criteria, and not frail if no criteria were met. Sociodemographic characteristics and long-term conditions were examined. The outcome was all-cause mortality, which was measured at a median of 7 years follow-up. Multinomial logistic regression compared sociodemographic characteristics and long-term conditions of frail or pre-frail participants with non-frail participants. Cox proportional hazards models examined associations between frailty or pre-frailty and mortality. Results were stratified by age group (37-45, 45-55, 55-65, 65-73 years) and sex, and were adjusted for multimorbidity count, socioeconomic status, body-mass index, smoking status, and alcohol use.

FINDINGS

493 737 participants aged 37-73 years were included in the study, of whom 16 538 (3%) were considered frail, 185 360 (38%) pre-frail, and 291 839 (59%) not frail. Frailty was significantly associated with multimorbidity (prevalence 18% [4435/25 338] in those with four or more long-term conditions; odds ratio [OR] 27·1, 95% CI 25·3-29·1) socioeconomic deprivation, smoking, obesity, and infrequent alcohol consumption. The top five long-term conditions associated with frailty were multiple sclerosis (OR 15·3; 99·75% CI 12·8-18·2); chronic fatigue syndrome (12·9; 11·1-15·0); chronic obstructive pulmonary disease (5·6; 5·2-6·1); connective tissue disease (5·4; 5·0-5·8); and diabetes (5·0; 4·7-5·2). Pre-frailty and frailty were significantly associated with mortality for all age strata in men and women (except in women aged 37-45 years) after adjustment for confounders.

INTERPRETATION

Efforts to identify, manage, and prevent frailty should include middle-aged individuals with multimorbidity, in whom frailty is significantly associated with mortality, even after adjustment for number of long-term conditions, sociodemographics, and lifestyle. Research, clinical guidelines, and health-care services must shift focus from single conditions to the requirements of increasingly complex patient populations.

FUNDING

CSO Catalyst Grant and National Health Service Research for Scotland Career Research Fellowship.

Identifying Frail-Related Biomarkers among Community-Dwelling Older Adults in Japan: A Research Example from the Japanese Gerontological Evaluation Study

We examined correlating clinical biomarkers for the physical aspect of frailty among community-dwelling older adults in Japan, using Japanese Gerontological Evaluation Study (JAGES). We used information from the JAGES participants (N = 3,128) who also participated in the community health screening in 2010. We grouped participants' response to the Study of Osteoporotic Fracture (SOF) Frailty Index into robust (=0), intermediate frail (=1), and frail (=2+) ones to indicate physical aspect of frailty. Independent of sex and age, results from multinomial logistic regression showed above normal albumin and below normal HDL and haemoglobin levels were positively associated with intermediate frail (RRR = 1.99, 95% CI = 1.22–3.23; RRR = 1.36, 95% CI = 1.33–1.39; RRR = 1.36, 95% CI = 1.23–1.51, resp.) and frail cases (RRR = 2.27, 95% CI = 1.91–2.70; RRR = 1.59, 95% CI = 1.51–1.68; RRR = 1.40, 95% CI = 1.28–1.52, resp.). Limited to women, above normal Hb1Ac level was similarly associated with intermediate frail and frail cases (RRR = 1.18, 95% CI = 1.02, 1.38; RRR = 2.56, 95% CI = 2.23–2.95, resp.). Use of relevant clinical biomarkers can help in assessment of older adults' physical aspect of frailty.

The Influence of Clinically Diagnosed Neuropathy on Respiratory Muscle Strength in Type 2 Diabetes Mellitus

OBJECTIVES

This cross-sectional study investigated the influence of clinically diagnosed neuropathy (cdNP) on respiratory muscle strength in patients with type 2 diabetes mellitus (T2DM).

METHODS

110 T2DM patients and 35 nondiabetic healthy controls (≥60 years) were allocated to one of three groups depending on the presence of cdNP: T2DM without cdNP (D-; n = 28), T2DM with cdNP (D+; n = 82), and controls without cdNP (C; n = 35). Clinical neurological diagnostic examination consisted of Vibration Perception Threshold and Diabetic Neuropathy Symptom score. Respiratory muscle strength was registered by maximal Inspiratory and Expiratory Pressures (PI_max and PE_max), and respiratory function by Peak Expiratory Flow (PEF). Isometric Handgrip Strength and Short Physical Performance Battery were used to evaluate peripheral skeletal muscle strength and physical performance. Univariate analysis of covariance was used with age, level of physical activity, and body mass index as covariates.

RESULTS

PI_max, PE_max, and PEF were higher in C compared to D- and D+. Exploring more in detail, PI_max, PE_max, and PEF were significantly lower in D+ compared to C. PE_max and PEF were also significantly lower in D- versus C. Measures of peripheral muscle strength and physical performance showed less associations with cdNP and T2DM.

CONCLUSIONS

The presence of cdNP affects respiratory muscle strength in T2DM patients compared to healthy controls. Both cdNP and diabetes in themselves showed a distinctive impact on respiratory muscle strength and function; however, an accumulating effect could not be ascertained in this study. As commonly used measures of peripheral muscle strength and physical performance seemed to be less affected at the given time, the integration of PI_max, PE_max, and PEF measurements in the assessment of respiratory muscle weakness could be of added value in the (early) screening for neuropathy in patients with T2DM.