Frailty Assessment in Community-Dwelling Older Adults: A Comparison of 3 Diagnostic Instruments

Prevalence and risk factors of frailty in people experiencing homelessness: A systematic review and meta-analysis

BACKGROUND

The experience of homelessness has been associated with premature ageing and an earlier onset of geriatric syndromes. Identification of frailty and appropriate intervention, may help improve health outcomes for people experiencing homelessness (PEH). This review aimed to identify prevalence, use of screening tools and risk factors for frailty in PEH.

METHOD

A systematic review, conducted and reported following the PRISMA checklist, was undertaken investigating the prevalence and risk factors of frailty among PEH. Searches were conducted in Ovid MEDLINE, PsycInfo, Web of Science and CINAHL from inception to July 2024. A meta-analysis examining prevalence of frailty and pre-frailty was completed with a narrative synthesis of related risk factors.

RESULTS

A total of 1672 articles were screened for eligibility and 11 studies were included, containing 1017 participants from seven countries. Six different screening tools were employed to detect frailty in the included studies. The range of frailty prevalence was 16-70 % and pre-frailty prevalence was 18-60 %. The pooled frailty prevalence from studies employing the Fried Criteria was 39 % (95 % CI 15-66); the Clinical Frailty Scale: 37 % (95 % CI 24-51); the Edmonton Frailty Scale: 53 % (95 % CI 44-63); and the Tilburg Fraily Indicator: 31 % (95 % CI 8-60). High heterogeneity was observed between the studies. Identified risk factors for developing frailty in PEH included being female, increased years spent homeless, and drug addiction.

CONCLUSION

This study highlights a high prevalence of frailty and pre-frailty in PEH. The identified risk factors illustrate potential areas to target interventions to reverse frailty. Future research should focus on the role of screening for frailty in PEH and developing appropriate frailty detection tools in this group.

Comparative analysis of frailty identification tools in community services across the Asia-Pacific: A systematic review and meta-analysis

OBJECTIVES

This study aimed to compare various frailty screening and assessment tools with the Frailty Phenotype (FP), Frailty Index (FI), and Comprehensive Geriatric Assessment (CGA), which are considered the current gold standards, among the Asia-Pacific population in community settings.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

This review included studies evaluating frailty identification tools based on the criteria of population, index and reference tests, and diagnosis of interest.

METHODS

A diagnostic test accuracy review was conducted to assess frailty instruments recommended by the Asia-Pacific Clinical Practice Guidelines. Comprehensive electronic database searches and manual searches were conducted up to August 20, 2024. Study quality, including risks of bias and applicability, was assessed using the QUADAS-2 tool. Hierarchical analysis and Youden's index were employed to identify the optimal tool and cutoff points, and pooled frailty prevalence was calculated.

RESULTS

Fourteen studies were included: 10 for the FRAIL scale, 3 for TUG, and 2 for the SOF index (screening tools), and 2 each for the CFS and KCL, and 1 for the REFS (assessment tools). All studies demonstrated a high risk of bias. The pooled sensitivity and specificity for screening tools were 0.63 and 0.89, respectively, whereas for assessment tools, they were 0.79 and 0.85. The pooled prevalence of frailty and pre-frailty was 19.7% and 31.7%, respectively. The pooled diagnostic odds ratios were highest for the FRAIL scale (15.72) and CFS (35.03) among the screening and assessment tools. The subgroup analysis revealed that the setting had no significant impact on screening tool performance (p = 0.58), but a borderline significant effect was observed for assessment tools (p = 0.06), although this result is limited by the small number of studies, with only one conducted in a community setting. The FRAIL scale, with a cutoff of 2, had a Youden's index of 0.60, signifying optimal screening performance.

CONCLUSION

Among the frailty instruments recommended by the Asia-Pacific Clinical Practice Guidelines, this meta-analysis identifies the FRAIL scale as the most robust tool for distinguishing frailty, with a cutoff of 2 significantly enhancing diagnostic accuracy. Furthermore, the estimated prevalence of frailty in the Asia-Pacific region is 19.7% across various community settings, underscoring the need for further research and the development of validated assessment tools tailored to this population.

Cross-sectional assessment of the Tinetti performance-oriented mobility tool for screening physical frailty syndrome in older adults

BACKGROUND

Physical-functional fitness (PFF) assessments have become crucial tools for identifying physical frailty syndrome (PFS) in older adults, helping guide preventive and interventional strategies.

PURPOSE

This study aimed to evaluate the predictive value of performance-based PFF tests for detecting PFS among community-dwelling older adults in Tehran, Iran. Additionally, it sought to compare PFF variables between PFS groups to assess the applicability of these tests as practical screening tools in clinical and community settings.

METHODS

Data were collected from 161 participants (91 males, 56.5%; 70 females, 43.5%), including sociodemographic, anthropometric, medical history, PFF, and PFS assessments.

RESULTS

Frail participants exhibited significantly lower scores in various PFF tests, including the Tinetti balance, walking, and total score components, physical activity levels (PAL), mean hand grip strength (MGS), 30-s arm curl (30 s-AC), 30 s-chair stand (30 s-CS), Standing Stork Balance (SSB), and back stretch (BST) tests (p < 0.001). Frail individuals also had lower levels of education, shorter stature, and higher BMI compared to non-frail/pre-frail participants, highlighting broader vulnerabilities. Logistic regression analyses showed that all PFF tests, including Tinetti balance and walking components, MGS, 30 s-AC, 30 s-CS, were significant protective factors against FS. However, ROC curve analysis revealed optimal cutoff points for PFS identification, with PAL and MGS demonstrating the highest sensitivity and specificity for predicting PFS. The all components of Tinetti scale also proved to be strong predictors of FS.

CONCLUSION

Our findings demonstrate that, regardless of age, sex, education level, stature, and fall incidence, PFF assessments remain critical for identifying older adults at risk for PFS. The study highlights the predictive strength of key variables, such as PAL, MGS, and the Tinetti-POMA components, offering novel insights into the role of these tests in improving PFS screening accuracy. These results underscore the importance of integrating PFF assessments into routine clinical and community-based health evaluations, enabling early detection and timely interventions to promote healthier aging trajectories.

Assessment of muscle fatigability using isometric repetitive handgrip strength in frail older adults. A cross-sectional study

BACKGROUND

Fatigue has a significant impact on physical performance and quality of life in older adults, but is subjectively assessed in the Fried phenotype, so early deterioration may be overlooked. This study explores whether repetitive handgrip strength (HGS) provides an objective method of differentiating levels of frailty by comparing fatigue and recovery ratios with subjective measures and their correlations with frailty indicators.

METHODS

Participants (n = 217) were included based on mobility and cognitive function (MMSE > 17), with exclusions for neuromuscular disease or hand injury. The protocol consisted of two 10-maximal grip assessments one hour apart, calculating fatigue ratios 1 and 2 (maximum/mean force) at each session and recovery ratios between sessions. Logistic regression analysed associations between Fried's criteria components (Unintentional Weight Loss, Exhaustion Single Question, Multidimensional Fatigue Inventory (MFI), Short Physical Performance Battery (SPPB), Physical Activity Scale for the Elderly (PASE), standard Maximum HGS, Fatigue Ratio, and Recovery Ratio).

RESULTS

Among the participants (58 non-frail, 68 pre-frail, 91 frail; ages 74.7, 79.4, 83.8 years), significant differences were found for Fatigue Ratio 1 of 1.12 (non-frail), 1.23 (pre-frail), 1.40 (frail), Fatigue Ratio 2 of 1.12, 1.21, 1.45, and Recovery Ratio of 1.03, 1.01, 0.90, respectively. Fatigue Ratios 1, 2 and Recovery correlated more strongly with frailty status (r = 0.67, 0.69, -0.68) than MFI (r = 0.50), standard maximum HGS (r = -0.51) or a single fatigue question (r = 0.21). In logistic regression for predicting fatigue (MFI), Fatigue Ratio (OR = 1.51, p < 0.001) and Recovery Ratio (OR = 0.83, p = 0.022) were stronger predictors than single-question fatigue (OR = 1.15, p = 0.047) and maximum HGS. For predicting frailty, physical performance (SPPB) was the strongest predictor (OR = 0.72, p < 0.001), followed by Fatigue Ratio 1 (OR = 1.28, p < 0.001), with a higher Recovery Ratio reducing frailty risk (OR = 0.86, p = 0.050).

CONCLUSION

The repetitive HGS protocol is equivalent to the SPPB in assessing frailty and outperforms standard HGS and subjective fatigue measures. This objective method supports the identification of frailty by measuring strength, fatigue resistance and recovery capacity.

Unmet Questions About Frailty in Kidney Transplant Candidates

Frailty occurs frequently among patients with advanced chronic kidney disease, especially among women. Assessing frailty in kidney transplant (KT) candidates is crucial for informing them about associated risks. However, there is poor agreement between frailty scales and research on their correlation with transplant outcomes. Being prefrail significantly impacts both graft and patient survival, often beginning with just 1 Fried criterion. Rather than viewing frailty as a categorical state, it should be regarded as a spectrum ranging from 1 to 5 criteria, with the risk of adverse outcomes escalating as frailty worsens. Frailty status fluctuates during the waiting period for KT; hence, a 1-time frailty evaluation is insufficient to determine risks and implement strategies for improving functional status. Further research should investigate the components of frailty that most frequently change during this waiting period and establish strategies to prevent or reverse frailty. Although careful evaluation of frail KT candidates is necessary to prevent early complications and mortality, exclusion based solely on a frailty score is unwarranted. Instead, efforts should focus on timely interventions to enhance their condition before transplantation. Although evidence is limited, exercise programs appear feasible and yield positive results. A pretransplant clinical framework encompassing multimodal prehabilitation-comprising physical therapy, nutritional measures, and psychological support-during the waiting list period may help alleviate the effects of frailty and poor fitness after KT, ultimately improving key outcomes. Despite logistical challenges, there is a pressing need for interventional trials in this area.

Intrinsic capacity transitions as predictors of frailty transitions in community-dwelling older adults: Findings from the Korean Frailty and Aging Cohort Study

BACKGROUND

Frailty is associated with reduced intrinsic capacity (IC). However, studies evaluating longitudinal transitions between IC and frailty are limited. We conducted longitudinal analyses to investigate the association between intrinsic capacity (IC) and frailty transitions among community-dwelling older adults in Korea.

METHODS

A total of 2,345 older adults who completed baseline and two-year follow-up surveys were selected from the Korean Frailty and Aging Cohort Study. IC was measured in five domains: locomotion, vitality, cognition, psychology, and sensory function. Frailty was defined using the Fried frailty phenotype. Transitions in IC and frailty were assessed. Logistic regression analysis was used to analyze the association between baseline IC, IC transitions, and frailty transitions.

RESULTS

During the two-year follow-up, 17.8 % of participants improved, 20.4 % worsened, and 61.8 % maintained the same frailty status. Low IC (odds ratio [OR]=1.93; 95 % confidence interval [CI]=1.42-2.61) significantly predicted remaining frail or worsening frailty. Worsened IC increased the risk of remaining frail or worsening frailty, whereas improved IC decreased this risk. Among the IC domains, the onset of new locomotion (OR=3.33; 95 % CI=2.39-4.64), vitality (OR=2.12; 95 % CI=1.55-2.91), and psychological (OR=3.61; 95 % CI=2.64-4.92) impairment predicted remaining frail or worsening frailty.

CONCLUSIONS

Low and worsened IC were associated with an increased risk of remaining frail or worsening frailty over two years. These findings indicate that changes in IC can predict frailty transitions, thereby emphasizing the importance of enhancing IC in preventing frailty progression.

Frailty trajectories and determinants in Chinese older adults: A longitudinal study

OBJECTIVES

This study aimed to enrich the research on frailty trajectories by using FRAIL scale and frailty index (FI), and analyze the determinants of the different trajectories in older Chinese.

METHODS

2268 older adults from the Chinese Longitudinal Healthy Longevity Survey were included. The FRAIL scale was constructed from 5 items and FI was constructed from 39 deficits. Latent Class Trajectory Model was used to depict frailty trajectories. Lasso - logistic model was applied to exploration of influencing factors.

RESULTS

Four FRAIL trajectories and three FI trajectories were identified. Women, smoking, illiteracy, more than two chronic diseases, and poor instrumental activities of daily living (all p < 0.05) were associated with frailty trajectories, regardless of the frailty instrument employed.

CONCLUSIONS

Frailty trajectories of older Chinese adults are diverse and they are influenced by different frailty measurement tools. Long-term assessment and management of frailty are recommended as routine care in community healthcare centers.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between frailty and social vulnerability: a systematic review

Both frailty (reduced physiological reserve) and social vulnerability (scarcity of adequate social connections, support, or interaction) become more common as people age and are associated with adverse consequences. Analyses of the relationships between these constructs can be limited by the wide range of measures used to assess them. In this systematic review, we synthesised 130 observational studies assessing the association between frailty and social vulnerability, the bidirectional longitudinal relationships between constructs, and their joint associations with adverse health outcomes. Frailty, across assessment type, was associated with increased loneliness and social isolation, perceived inadequacy of social support, and reduced social participation. Each of these social vulnerability components was also associated with more rapid progression of frailty and lower odds of improvement compared with the absence of that social vulnerability component (eg, more rapid frailty progression in people with social isolation vs those who were not socially isolated). Combinations of frailty and social vulnerability were associated with increased mortality, decline in physical function, and cognitive impairment. Clinical and public health measures targeting frailty or social vulnerability should, therefore, account for both frailty and social vulnerability.

Screening for Frailty Using the FRAIL Scale in Older Cancer Survivors: A Cross-sectional Comparison With the Fried Phenotype

OBJECTIVES

To examine the diagnostic performance of the FRAIL Scale for frailty screening with reference to the Fried phenotype and investigate its association with health outcomes in older cancer survivors.

DATA SOURCE

In this cross-sectional quantitative study, participants were post-treatment cancer survivors aged 65 or above. Measurements included the FRAIL Scale, Fried phenotype, Geriatric Depression Scale-15 item, Modified Barthel Inventory, and EORTC Core Quality of Life Questionnaire. Receiver operating characteristic curve analysis was performed to evaluate the diagnostic performance of the FRAIL Scale with reference to the Fried phenotype. Health outcomes associated with being frail as estimated by the FRAIL Scale and Fried phenotype were also examined using regressions.

RESULTS

Based on 293 older cancer survivors, the area under curve (AUC) of the FRAIL Scale was 0.79, and the optimal cut-off of 1 yielded a sensitivity of 92% and specificity of 41%. According to regression results, the FRAIL Scale was modified by adding an item on time since cancer treatment completion (AUC = 0.81), and using a cut-off of 2 for older cancer survivors, which yielded a sensitivity of 74% and specificity of 67%. The modified FRAIL Scale was associated with depressive symptoms, functional independence, fatigue, dyspnea, physical functioning, and role functioning.

CONCLUSIONS

The modified FRAIL Scale is proposed for use in older cancer survivors, and a cut-off of 2 should be used.

IMPLICATIONS FOR NURSING PRACTICE

The modified FRAIL Scale can serve as a brief screening tool for identifying frailty among older cancer survivors in practice.

Prevalence and correlates of frailty in older hypertensive outpatients according to different tools: the HYPER-FRAIL pilot study

OBJECTIVES

To date, few studies have investigated frailty in hypertensive individuals. This study aimed at identifying the prevalence of frailty in a sample of hypertensive older outpatients using six different identification tools. Clinical correlates of frailty and agreement between different frailty definitions were also investigated.

METHODS

The HYPER-FRAIL pilot study recruited hypertensive patients aged at least 75 years from two geriatric outpatient clinics of Careggi Hospital, Florence, Italy. Four frailty scales [Fried Frailty Phenotype, Frailty Index, Clinical Frailty Scale (CFS), Frailty Postal Score] and two physical performance tests [Short Physical Performance Battery (SPPB) and usual gait speed] were applied. The Cohen's kappa coefficient was calculated to assess agreement between measures. Multiple logistic regression was used to identify clinical features independently associated with frailty.

RESULTS

Among 121 participants (mean age 81, 60% women), frailty prevalence varied between 33 and 50% according to the tool used. Moderate agreement was observed between Fried Frailty Phenotype, Frailty Index and SPPB, and between Frailty Index and CFS. Agreement was minimal or weak between the remaining measures (K < 0.60). Use of walking aids and depressive symptoms were independently associated with frailty, regardless of the definition used. Frailty correlates also included dementia, disability and comorbidity burden, but not office and 24-h blood pressure values.

CONCLUSION

Frailty is highly prevalent among older hypertensive outpatients, but agreement between different frailty tools was moderate-to-weak. Longitudinal studies are needed to assess the prognostic role of different frailty tools and their clinical utility in the choice of antihypertensive treatment.

Prevalence of Frailty Among Chinese Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

Objectives: To systematically review the epidemiology of frailty in China, one of the world's most populous countries, and to provide insightful guidance for countries to deal with fast population ageing. Methods: Six electronic databases were searched until November 2022. Data from cross-sectional studies with a clear definition of frailty and a mean age ≥60 years were pooled using meta-analysis. Results: 64 studies (n = 106,826 participants) from 23 (67.6%) of China's provinces were included. The overall prevalence of frailty and prefrailty among older community dwellers was 10.1% (95% CI: 8.5%-11.7%) and 43.9% (95% CI: 40.1%-47.8%), respectively. Adults over 70 years, women, unmarried, living alone, and those with less education had higher odds of being frail. Furthermore, regional disparities in frailty were observed; people in rural areas or areas with worse economic conditions had a higher prevalence of frailty. Conclusion: A great variation in frailty prevalence was observed between subgroups of older adults stratified by common risk factors. The Chinese government should pay more attentions to seniors at high risk and regions with a high prevalence of frailty.

Diagnostic accuracy of the FRAIL scale for frailty screening in community-dwelling older adults with diabetes: A cross-sectional study

There is limited evidence on the diagnostic accuracy of the FRAIL scale in community-dwelling older adults with diabetes. This study aimed to validate the diagnostic accuracy and determine the optimal cutoff point of the FRAIL scale in community-dwelling older adults with diabetes using the Fried Frailty Phenotype as the reference standard. A total of 489 community-dwelling older adults with diabetes aged 60 or above were recruited in this cross-sectional study. The FRAIL scale showed good diagnostic accuracy for frailty screening. The optimal cutoff point for frailty screening in older adults with diabetes was 2. The agreement between the FRAIL scale and the Fried Frailty Phenotype was substantial. The FRAIL scale classified more participants as frail (29.24%) than the Fried Frailty Phenotype (22.09%). These findings provide evidence that the FRAIL scale is a valid tool that can be applied to community-dwelling older adults with diabetes.

Is Frailty Diagnosis Important in Patients with COPD? A Narrative Review of the Literature

Frailty is prevalent in older adults and is related to a worsening functionality, quality of life, and health outcomes. Though there is an increasing interest in this field, the relationship between frailty and worsening COPD outcomes remains unknown. A narrative review of the literature with studies published between 2018 and 2022 was carried out to address three questions: the prevalence of frailty and other geriatric syndromes in COPD patients, the link between frailty and worsening health outcomes in COPD patients, and the non-pharmacological interventions performed in order to reverse frailty in these patients. A total of 25 articles were selected. Frailty prevalence ranged from 6% and 85.9%, depending on the COPD severity and the frailty measurement tool used. Frailty in COPD patients was related to a high prevalence of geriatric syndromes and to a high incidence of adverse events such as exacerbations, admissions, readmissions, and mortality. One study showed improvements in functionality after physical intervention. In conclusion, the prevalence of frailty is associated with a high incidence of geriatric syndromes and adverse events in COPD patients. The use of frailty screenings and a comprehensive geriatric assessment of COPD patients is advisable in order to detect associated problems and to establish individualized approaches for better outcomes.

Association of Intrinsic Capacity with Frailty, Physical Fitness and Adverse Health Outcomes in Community-Dwelling Older Adults

BACKGROUND

Intrinsic capacity (IC) and frailty are complementary in advancing disability prevention through maintaining functionality.

OBJECTIVES

We examined the relationship between IC and frailty status at baseline and 1-year, and evaluated if IC decline predicts frailty onset among robust older adults. The secondary objectives investigated associations between IC, physical fitness and health-related outcomes.

DESIGN

Prospective cohort study.

SETTING

Community-based assessments.

PARTICIPANTS

Older adults aged>55 years, who were independent in ambulation (walking aids permitted).

MEASUREMENTS

5 domains of IC were assessed at baseline: locomotion (Short Physical Performance Battery, 6-minute walk test), vitality (nutritional status, muscle mass), sensory (self-reported hearing and vision), cognition (self-reported memory, age- and education adjusted cognitive performance), psychological (Geriatric Depression Scale-15, self-reported anxiety/ depression). Composite IC (0-10) was calculated, with higher scores representing greater IC. Frailty status was based on modified Fried criteria, with frailty progression defined as incremental Fried score at 1-year.

RESULTS

809 participants (67.6+6.8 years) had complete data for all 5 IC domains. 489 (60.4%) participants were robust but only 213 (26.3%) had no decline in any IC domain. Pre-frail and frail participants were more likely to exhibit decline in all 5 IC domains (p<0.05), with decremental composite IC [9 (8-9), 8 (6-9), 5.5 (4-7.5), p<0.001] across robust, prefrail and frail. IC was significantly associated with fitness performance, independent of age and gender. Higher composite IC reduced risk for frailty progression (OR=0.62, 95% CI 0.48-0.80), and reduced frailty onset among robust older adults (OR=0.53, 95% CI 0.37-0.77), independent of age, comorbidities and social vulnerability. Participants with higher IC were less likely to experience health deterioration (OR=0.70, 95% CI 0.58-0.83), falls (OR=0.76, 95% CI 0.65-0.90) and functional decline (OR=0.64, 95% CI 0.50-0.83) at 1-year.

CONCLUSION

Declining IC may present before frailty becomes clinically manifest, increasing risk for poor outcomes. Monitoring of IC domains potentially facilitates personalized interventions to avoid progressive frailty.

Association of Baseline and Longitudinal Changes in Frailty Burden and Risk of Heart Failure in Type 2 Diabetes-Findings from the Look AHEAD Trial

BACKGROUND

Individuals with diabetes have a high frailty burden and increased risk of heart failure (HF). In this study, we evaluated the association of baseline and longitudinal changes in frailty with risk of HF and its subtypes: HF with preserved ejection fraction (HFpEF), and HF with reduced ejection fraction (HFrEF).

METHODS

Participants (age: 45-76 years) of the Look AHEAD trial without prevalent HF were included. The frailty index (FI) was used to assess frailty burden using a 35-variable deficit model. The association between baseline and longitudinal changes (1- and 4-year follow-up) in FI with risk of overall HF, HFpEF (ejection fraction [EF] ≥ 50%), and HFrEF (EF < 50%) independent of other risk factors and cardiorespiratory fitness was assessed using adjusted Cox models.

RESULTS

The study included 5 100 participants with type 2 diabetes mellitus, of which 257 developed HF. In adjusted analysis, higher frailty burden was significantly associated with a greater risk of overall HF. Among HF subtypes, higher baseline FI was significantly associated with risk of HFpEF (hazard ratio [HR] [95% CI] per 1-SD higher FI: 1.37 [1.15-1.63]) but not HFrEF (HR [95% CI]: 1.19 [0.96-1.46]) after adjustment for potential confounders, including traditional HF risk factors. Among participants with repeat measures of FI at 1- and 4-year follow-up, an increase in frailty burden was associated with a higher risk of HFpEF (HR [95% CI] per 1-SD increase in FI at 4 years: 1.78 [1.35-2.34]) but not HFrEF after adjustment for other confounders.

CONCLUSIONS

Among individuals with type 2 diabetes mellitus, higher baseline frailty and worsening frailty burden over time were independently associated with higher risk of HF, particularly HFpEF after adjustment for other confounders.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

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

Frailty and Potentially Inappropriate Prescribing in Older People with Polypharmacy: A Bi-Directional Relationship?

Frail older adults commonly experience multiple co-morbid illnesses and other risk factors for potentially inappropriate prescribing. However, determination of frailty varies depending on the frailty instrument used. Older people’s degree of frailty often influences their care and treatment priorities. Research investigating the association between frailty and potentially inappropriate prescribing is hindered by a wide variety of frailty definitions and measurement tools. We undertook a narrative review of selected articles of PubMed and Google Scholar databases. Articles were selected on the basis of relevance to the core themes of frailty and potentially inappropriate prescribing. We identified observational studies that clearly link potentially inappropriate prescribing, potential prescribing omissions, and adverse drug reactions with frailty in older adults. Equally, the literature illustrates that measured frailty in older adults predisposes to inappropriate polypharmacy and associated adverse drug reactions and events. In essence, there is a bi-directional relationship between frailty and potentially inappropriate prescribing, the underlying substrates being multimorbidity and inappropriate polypharmacy. We conclude that there is a need for consensus on rapid and accurate identification of frailty in older people using appropriate and user-friendly methods for routine clinical practice as a means of identifying older multimorbid patients at risk of potentially inappropriate prescribing. Detection of frailty should, we contend, lead to structured screening for inappropriate prescribing in this high-risk population. Of equal importance, detection of potentially inappropriate prescribing in older people should trigger screening for frailty. All clinicians undertaking a medication review of multimorbid patients with associated polypharmacy should take account of the important interaction between frailty and potentially inappropriate prescribing in the interest of minimizing patient harm.

Perspectives of older adults, caregivers, healthcare providers on frailty screening in primary care: a systematic review and qualitative meta-synthesis

Background

Screening is often recommended as a first step in frailty management. Many guidelines call to implicate frailty screening into practice in the primary care setting. However, few countries or organizations implement it. Understanding and clarifying the stakeholders’ views and issues faced by the implementation is essential to the successful implementation of frailty screening. However, the systematic review on stakeholders’ views of frailty screening in primary care is decidedly limited. Our objective was to explore the perspective of older adults, caregivers, and healthcare providers on frailty screening and determine the enablers and barriers to implementing frailty screening in primary care.

Methods

A systematic search of six databases and other resources was conducted following JBI’s three-step search strategy. The search resulted in 7362 articles, of which 97 were identified for further assessment according to the inclusion criteria. After the full-text screening, quality assessment and data extraction were carried out using the tools from Joanna Briggs Institute (JBI). Moreover, reviewers used the approach of meta-aggregative of JBI to analyze data and synthesis the findings.

Results

Six studies were included. A total of 63 findings were aggregated into 12 categories and then further grouped into three synthesized findings:1) capacity of healthcare providers and older adults; 2) opportunity in the implementation of frailty screening; 3) motivation in the implementation of frailty screening. These themes can help identify what influences the implementation of screening from the perspective of stakeholders.

Conclusions

This meta-synthesis provides evidence on the barriers and enablers of frailty screening in primary care, from the aspects of psychological, physical, social, material, etc. However, stakeholder perspectives of frailty screening have not been adequately studied. More research and efforts are needed to explore the influencing factors and address the existing barriers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03173-6.

Aging metrics incorporating cognitive and physical function capture mortality risk: results from two prospective cohort studies

BACKGROUND

Aging metrics incorporating cognitive and physical function are not fully understood, hampering their utility in research and clinical practice. This study aimed to determine the proportions of vulnerable persons identified by three existing aging metrics that incorporate cognitive and physical function and the associations of the three metrics with mortality.

METHODS

We considered three existing aging metrics including the combined presence of cognitive impairment and physical frailty (CI-PF), the frailty index (FI), and the motoric cognitive risk syndrome (MCR). We operationalized them using data from the China Health and Retirement Longitudinal Study (CHARLS) and the US National Health and Nutrition Examination Survey (NHANES). Logistic regression models or Cox proportional hazards regression models, and receiver operating characteristic curves were used to examine the associations of the three metrics with mortality.

RESULTS

In CHARLS, the proportions of vulnerable persons identified by CI-PF, FI, and MCR were 2.2, 16.6, and 19.6%, respectively. Each metric predicted mortality after adjustment for age and sex, with some variations in the strength of the associations (CI-PF, odds ratio (OR) (95% confidence interval (CI)) 2.87 (1.74-4.74); FI, OR (95% CI) 1.94 (1.50-2.50); MCR, OR (95% CI) 1.27 (1.00-1.62)). CI-PF and FI had additional predictive utility beyond age and sex, as demonstrated by integrated discrimination improvement and continuous net reclassification improvement (all P < 0.001). These results were replicated in NHANES.

CONCLUSIONS

Despite the inherent differences in the aging metrics incorporating cognitive and physical function, they consistently capture mortality risk. The findings support the incorporation of cognitive and physical function for risk stratification in both Chinese and US persons, but call for caution when applying them in specific study settings.

Outcomes of Frail Patients While Waiting for Kidney Transplantation: Differences between Physical Frailty Phenotype and FRAIL Scale

Frailty is associated with poorer outcomes among patients waiting for kidney transplantation (KT). Several different tools to measure frailty have been used; however, their predictive value is unknown. This is a prospective longitudinal study of 449 KT candidates evaluated for frailty by the Physical Frailty Phenotype (PFP) and the FRAIL scale. During the study period, 296 patients received a KT, while 153 remained listed. Patients who did not get receive a transplant were more frequently frail according to PFP (16.3 vs. 7.4%, p = 0.013). Robust patients had fewer hospital admissions during the 1st year after listing (20.8% if PFP = 0 vs. 43.4% if ≥1, and 27.1% if FRAIL = 0 vs. 48.9% if ≥1) and fewer cardiovascular events (than FRAIL ≥ 1) or major infectious events (than PFP ≥ 1). According to PFP, scoring 1 point had an impact on patient survival and chance of transplantation in the univariate analysis. The multivariable analysis corroborated the result, as candidates with PFP ≥ 3 had less likelihood of transplantation (HR 0.45 [0.26–0.77]). The FRAIL scale did not associate with any of these outcomes. In KT candidates, pre-frailty and frailty according to both the PFP and the FRAIL scale were associated with poorer results while listed. The PFP detected that frail patients were less likely to receive a KT, while the FRAIL scale did not.

Prediction of Physical Frailty in Orthogeriatric Patients Using Sensor Insole-Based Gait Analysis and Machine Learning Algorithms: Cross-sectional Study

Background

Assessment of the physical frailty of older patients is of great importance in many medical disciplines to be able to implement individualized therapies. For physical tests, time is usually used as the only objective measure. To record other objective factors, modern wearables offer great potential for generating valid data and integrating the data into medical decision-making.

Objective

The aim of this study was to compare the predictive value of insole data, which were collected during the Timed-Up-and-Go (TUG) test, to the benchmark standard questionnaire for sarcopenia (SARC-F: strength, assistance with walking, rising from a chair, climbing stairs, and falls) and physical assessment (TUG test) for evaluating physical frailty, defined by the Short Physical Performance Battery (SPPB), using machine learning algorithms.

Methods

This cross-sectional study included patients aged >60 years with independent ambulation and no mental or neurological impairment. A comprehensive set of parameters associated with physical frailty were assessed, including body composition, questionnaires (European Quality of Life 5-dimension [EQ 5D 5L], SARC-F), and physical performance tests (SPPB, TUG), along with digital sensor insole gait parameters collected during the TUG test. Physical frailty was defined as an SPPB score≤8. Advanced statistics, including random forest (RF) feature selection and machine learning algorithms (K-nearest neighbor [KNN] and RF) were used to compare the diagnostic value of these parameters to identify patients with physical frailty.

Results

Classified by the SPPB, 23 of the 57 eligible patients were defined as having physical frailty. Several gait parameters were significantly different between the two groups (with and without physical frailty). The area under the receiver operating characteristic curve (AUROC) of the TUG test was superior to that of the SARC-F (0.862 vs 0.639). The recursive feature elimination algorithm identified 9 parameters, 8 of which were digital insole gait parameters. Both the KNN and RF algorithms trained with these parameters resulted in excellent results (AUROC of 0.801 and 0.919, respectively).

Conclusions

A gait analysis based on machine learning algorithms using sensor soles is superior to the SARC-F and the TUG test to identify physical frailty in orthogeriatric patients.

Frailty in kidney transplant candidates: a comparison between physical frailty phenotype and FRAIL scales

BACKGROUND

Frailty is common among advanced chronic kidney disease (CKD) patients who are kidney transplant (KT) candidates, and predisposes to poor outcomes after transplantation. However, frailty is not routinely measured during pretransplant work-up and it is unknown which metric should be used in this specific population. Our aim was to establish frailty prevalence in KT candidates according to different frailty scales.

METHODS

Prospective longitudinal study of 451 KT candidates evaluated for frailty by both Physical Frailty Phenotype (PFP) and FRAIL scale at the time of inclusion on the KT waiting list. Clinical and functional characteristics including sociodemographics, comorbidities, disability and nutritional status were recorded. Agreement between PFP and FRAIL scales as well as dissonant patients were analyzed.

RESULTS

Mean age was 60.9 years and 31.7% were female. Comorbidity burden among patients was high, with 36.9% and 16.2% presenting with diabetes and ischemic coronary disease, respectively. Disabilities were also frequent. More than 70% of patients presented with ≥ 1 PFP criteria while this percentage for ≥ 1 FRAIL criteria was 45.4%. Agreement between PFP and FRAIL was not good (kappa index 0.317). There were 132 patients who were pre-frail or frail according to PFP but non-frail according to the FRAIL scale and they presented with fewer comorbidities and less disability.

CONCLUSIONS

Frailty is frequent in advanced CKD patients, although its prevalence may vary according to different scales. Agreement between PFP and FRAIL scale is not good, and FRAIL scale might misclassify as robust patients those frail/prefrail patients who are in better health conditions.

Outcome of older adults at risk of frailty

BACKGROUND

The integral part of the definition of frailty is the outcome associated with it. Older adults at risk of frailty are in the process of becoming frail. This study looked at the clinical characteristics and outcomes of older adults at risk of frailty.

METHODOLOGY

The study population was selected from outpatient department of the geriatric medicine department in a tertiary care hospital. Older adults identified as at risk of frailty were assessed at baseline and then followed up after 1 year for the composite primary outcome of death, falls, hospitalization, and self-rated poor quality of life in the follow-up period.

RESULTS

The study included 324 older adults who had completed 1-year follow up. Mean (SD) age was 74.49 (4.58) years, and males were 241 (74.15%). Frail and pre-frail at baseline among the study population were 31.17% and 61.11%, respectively. The primary outcome occurred in 43 (13.27%) patients. Poor baseline IADL was significantly associated with primary outcome at the end of 1 year.

CONCLUSION

An unfavorable outcome in older adults at risk of frailty was significantly higher and independent of their baseline frailty status. Poor baseline IADL value may be considered as a predictor for primary outcome at 1 year of follow up.

Functional Frailty, Dietary Intake, and Risk of Malnutrition. Are Nutrients Involved in Muscle Synthesis the Key for Frailty Prevention?

Frailty is a reversible condition, which is strongly related to physical function and nutritional status. Different scales are used to screened older adults and their risk of being frail, however, Short Physical Performance Battery (SPPB) may be more adequate than others to measure physical function in exercise interventions and has been less studied. Thus, the main aims of our study were: (1) to describe differences in nutritional intakes by SPPB groups (robust, pre-frail and frail); (2) to study the relationship between being at risk of malnourishment and frailty; and (3) to describe differences in nutrient intake between those at risk of malnourishment and those without risk in the no-frail individuals. One hundred one participants (80.4 ± 6.0 year old) were included in this cross-sectional study. A validated semi-quantitative food frequency questionnaire was used to determine food intake and Mini Nutritional Assessment to determine malnutrition. Results revealed differences for the intake of carbohydrates, n-3 fatty acids (n3), and saturated fatty acids for frail, pre-frail, and robust individuals and differences in vitamin D intake between frail and robust (all p < 0.05). Those at risk of malnutrition were approximately 8 times more likely to be frail than those with no risk. Significant differences in nutrient intake were found between those at risk of malnourishment and those without risk, specifically in: protein, PUFA n-3, retinol, ascorbic acid, niacin equivalents, folic acid, magnesium, and potassium, respectively. Moreover, differences in alcohol were also observed showing higher intake for those at risk of malnourishment (all p < 0.05). In conclusion, nutrients related to muscle metabolism showed to have different intakes across SPPB physical function groups. The intake of these specific nutrients related with risk of malnourishment need to be promoted in order to prevent frailty.

Performance of the Short Physical Performance Battery in Identifying the Frailty Phenotype and Predicting Geriatric Syndromes in Community-Dwelling Elderly

The early identification of seniors at high risk of geriatric syndromes is fundamental for targeting interventions to those who most need them. To date, the predictive value of the Short Physical Performance Battery (SPPB) for multifactorial clinical conditions has not been clearly established. Thus, the aim of the present study was to determine whether the SPPB could identify frailty and predict geriatric syndromes in community-dwelling older adults. Participants comprised men and women aged 60 years and older who participated in the Health and Well-being and Aging Survey in Colombia 2015 (n=4125, 57.6% women). A structured interview was administered to obtain socio-demographic data which included age, sex, ethnicity, socioeconomic status, and urbanicity. The study included the measurement of body mass, grip strength, SPPB, Lawton´s instrumental ADL scale, specific subjective memory complaints (SSMC), frailty phenotype (Fried and FRAIL Scale), and self-reported falls, geriatric syndromes and/or medical conditions. ROC analysis was used to examine the ability of the SPPB test to predict frailty and geriatric syndromes. The cutoff that maximized both sensitivity and specificity for the frailty phenotype was 8 points or below for men and 7 points or below for women. These cutoff values significantly predicted four geriatric syndromes in descending order: mild dementia (♂ ORajus 3.34, and ♀ ORajus 2.79), low grip strength (♂ ORajus 1.98, and ♀ ORajus 2.45), falls (♂ ORajus 1.39, and ♀ ORajus 1.49), and SSMC (♂ ORajus 1.39). In summary, the main finding of the present study was that SPPB score (i.e., ≤ 8 ♂ and ≤ 7 ♀) seems to be a useful measure for identifying the physical frailty phenotype and predicting geriatric syndromes in community-dwelling older adults.