Using the Multidimensional Prognostic Index (MPI) to improve cost-effectiveness of interventions in multimorbid frail older persons: results and final recommendations from the MPI_AGE European Project

Comorbidity patterns and mortality in atrial fibrillation: a latent class analysis of the EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF)

BACKGROUND

Most older patients with atrial fibrillation (AF) have comorbidities. However, it is unclear whether specific comorbidity patterns are associated with adverse outcomes. We identified comorbidity patterns and their association with mortality in multimorbid older AF patients with different multidimensional frailty.

METHODS

Hospitalised adults aged ≥65 years with non-valvular AF were followed for 12 months in the multicentre EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF). Demographic characteristics, coexisting medical conditions, use of medications including anticoagulants, and the Multidimensional Prognostic Index (MPI) were captured on discharge. We used latent class analysis (LCA) to identify comorbidity phenotypes and Cox regression to determine associations between identified phenotypes and 12-month mortality.

RESULTS

Amongst n = 2,019 AF patients (mean ± SD age 82.9 ± 7.5 years), a 3-class LCA solution was considered optimal for phenotyping. The model identified phenotype 1 (hypertensive, other circulatory conditions, metabolic diseases; 33%), phenotype 2 (digestive diseases, infection, injury, non-specific clinical and laboratory abnormalities; 26%), and phenotype 3 (heart failure, respiratory diseases; 41%). Overall, 512 patients (25%) died within 12 months. Compared to phenotype 1, after adjusting for age, sex, use of anticoagulants, cardiovascular medications, and proton pump inhibitors, and individual MPI domains, phenotype 3 had a significantly higher risk of mortality (adjusted hazard ratio = 1.27, 95% CI = 1.01 to 1.60). In contrast, the risk of mortality in phenotype 2 was not different to phenotype 1.

CONCLUSION

We observed an association between comorbidity phenotypes identified using LCA and mortality in older AF patients. Further research is warranted to identify the mechanisms underpinning such associations.

Long-Term Outcome of Elderly Patients with Severe Aortic Stenosis Undergoing a Tailored Interventional Treatment Using Frailty-Based Management: Beyond the Five-Year Horizon

Background: Elderly patients with severe aortic stenosis (AS) need individualized decision-making in their management in order to benefit in terms of survival and improvement of quality of life. Frailty, a common condition in elderly patients, needs to be considered when weighing treatment options. Aim: We aimed to evaluate outcomes including survival and functional parameters according to disability criteria at six years of follow-up in an older population treated for severe AS using a frailty-based management. Methods: We evaluated data derived from a pilot clinical project involving elderly patients with severe AS referred to a tailored management based on classification by Fried's score into pre-frail, early frail, and frail and a multidimensional geriatric assessment. A Frailty, Inflammation, Malnutrition, and Sarcopenia (FIMS) score was used to predict the risk of mortality at six years of follow-up. Functional status was evaluated by telephonic interview. Results: At six years of follow-up, we found a survival rate of 40%. It was higher in the pre-frail patients (long rank < 0.001) and in the patients who underwent TAVR treatment (long rank < 0.001). The cut-off FIMS score value of ≥1.28 was an independent determinant associated with a higher risk of mortality at six years of follow-up (HR 2.91; CI 95% 1.7-5.1; p-value 0.001). We found a moderate increase of disability levels, malnutrition status, comorbidities, and number of drugs, but none of them self-reported advanced NYHA class III-IV heart failure. Conclusion: An accurate clinical-instrumental and functional geriatric evaluation in an elderly population with AS is required for a non-futile interventional treatment in terms of survival and functional status even in long-term follow-up.

Technological monitoring of motor parameters to assess multidimensional frailty of older people in the PRO-HOME project

An interconnected system employing Kinect Azure and Fitbit Sense for continuous and non-intrusive data collection was used in the PRO-HOME protected discharge program, aiming at monitoring functional and clinical parameters in hospitalized older patients at different risks of frailty. The present study shows the findings on 30 older patients included in the PRO-HOME project. The Fitbit Sense recorded the mean daily and hourly number of steps, mean daily walked distance, and time spent inactive. Moreover, Kinect infrared camera captured gait speed and daily mean latero-lateral (body sway) and antero-posterior oscillations (lean-in). Patients underwent a standard Comprehensive Geriatric Assessment (CGA) to compute the Multidimensional Prognostic Index (MPI), including basic and instrumental activities of daily living (ADL, IADL), cognition (Short Portable Mental Status Questionnaire, SPMSQ) and nutrition, risk of pressure sores (Exton-Smith Scale, ESS), comorbidity, number of drugs and cohabitation status. Significant correlations between the mean hourly number of steps and MPI (p = 0.022), IADL (p = 0.013), SPMSQ (p = 0.006), ESS (p = 0.009), and both mean and maximum automated gait speed (p = 0.046 and p = 0.048) were found. Automated gait speed was also correlated with mean walked distance per day (p = 0.007) and lean-in (p = 0.047). Domotic technological monitoring through Fitbit Sense and Kinect Azure provides information on multidimensional frailty, including mobility and cognitive and functional status, in older people.

Management of Clostridioides difficile infection: an Italian Delphi consensus

BACKGROUND

Clostridioides difficile infection (CDI), a leading cause of nosocomial deaths, is a microbiota-mediated disease. As such, the use of broader spectrum antibiotics, such as vancomycin and metronidazole, can prime the gastrointestinal tract to become more prone to CDI recurrences. Fidaxomicin, a narrow-spectrum antibiotic, has been demonstrated to be superior in preventing recurrence and in preserving the intestinal microbiota; however, widespread employment worldwide has been hindered due to high acquisition costs.

OBJECTIVES

To integrate the currently available guidelines on the management of CDI and to shed light on the timeliest employment of fidaxomicin.

METHODS

An expert panel was gathered to obtain consensus using Delphi methodology on a series of statements regarding the management of CDI and on appropriate antibiotic use.

RESULTS

Consensus was reached on 21 of the 25 statements addressing the management of CDI.

CONCLUSIONS

Delphi methodology was used to achieve consensus on the management of CDI, on the identification of patients at risk of recurrences or severe infection, and on the most appropriate use of fidaxomicin, with the final aim of fostering clinical practice application of treatment algorithms proposed by previous guidelines, in absolute synergy. It could be an important tool to promote more appropriate and cost-effective CDI treatments in European settings with limited resources, like Italy.

The Multidimensional Prognostic Index predicts incident delirium among hospitalized older patients with COVID-19: a multicenter prospective European study

PURPOSE

Incident delirium is a frequent complication among hospitalized older people with COVID-19, associated with increased length of hospital stay, higher morbidity and mortality rates. Although delirium is preventable with early detection, systematic assessment methods and predictive models are not universally defined, thus delirium is often underrated. In this study, we tested the role of the Multidimensional Prognostic Index (MPI), a prognostic tool based on Comprehensive Geriatric Assessment, to predict the risk of incident delirium.

METHODS

Hospitalized older patients (≥ 65 years) with COVID-19 infection were enrolled (n = 502) from ten centers across Europe. At hospital admission, the MPI was administered to all the patients and two already validated delirium prediction models were computed (AWOL delirium risk-stratification score and Martinez model). Delirium occurrence during hospitalization was ascertained using the 4A's Test (4AT). Accuracy of the MPI and the other delirium predictive models was assessed through logistic regression models and the area under the curve (AUC).

RESULTS

We analyzed 293 patients without delirium at hospital admission. Of them 33 (11.3%) developed delirium during hospitalization. Higher MPI score at admission (higher multidimensional frailty) was associated with higher risk of incident delirium also adjusting for the other delirium predictive models and COVID-19 severity (OR = 12.72, 95% CI = 2.11-76.86 for MPI-2 vs MPI-1, and OR = 33.44, 95% CI = 4.55-146.61 for MPI-3 vs MPI-1). The MPI showed good accuracy in predicting incident delirium (AUC = 0.71) also superior to AWOL tool, (AUC = 0.63) and Martinez model (AUC = 0.61) (p < 0.0001 for both comparisons).

CONCLUSIONS

The MPI is a sensitive tool for early identification of older patients with incident delirium.

A Comprehensive Geriatric Workup and Frailty Assessment in Older Patients with Severe Aortic Stenosis

Aortic stenosis (AS) represents a notable paradigm for cardiovascular (CV) and geriatric disorders owing to comorbidity. Transcatheter aortic valve replacement (TAVR) was initially considered a therapeutic strategy in elderly individuals deemed unsuitable for or at high risk of surgical valve replacement. The progressive improvement in TAVR technology has led to the need to refine older patients' stratification, progressively incorporating the concept of frailty and other geriatric vulnerabilities. Recognizing the intricate nature of the aging process, reliance exclusively on chronological age for stratification resulted in an initial but inadequate tool to assess both CV and non-CV risks effectively. A comprehensive geriatric evaluation should be performed before TAVR procedures, taking into account both physical and cognitive capabilities and post-procedural outcomes through a multidisciplinary framework. This review adopts a multidisciplinary perspective to delve into the diagnosis and holistic management of AS in elderly populations in order to facilitate decision-making, thereby optimizing outcomes centered around patient well-being.

Clinical prognostic factors for older people: A systematic review and meta-analysis

OBJECTIVE

To explore the accuracy and precision of prognostic tools used in older people in predicting mortality, hospitalization, and nursing home admission across different settings and timings.

DESIGN

Systematic review and meta-analysis of prospective and retrospective studies.

DATA SOURCES

A systematic search from database inception until 01st February 2023 was run in Medline, Embase, Cinhal, Cochrane Library.

ELIGIBILITY CRITERIA

Studies were eligible if they reported accuracy (area under the curve [AUC]) and/or precision (C-index) for the prognostic index in relation to any of the following outcomes: mortality, hospitalization, and nursing home admission.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data. Data were pooled using a random effects model. The risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. If more than three studies for the same setting and time were available, a meta-analysis was performed and evaluated using the GRADE tool; other data were reported descriptively.

RESULTS

Among 16,082 studies initially considered, 159 studies with a total of 2398856 older people (mean age: 78 years) were included. The majority of the studies was carried out in hospital or medical wards. In the community setting, only two tools (Health Assessment Tool and the Multidimensional Prognostic Index, MPI) had good precision for long-term mortality. In emergency department setting, Barthel Index had an excellent accuracy in predicting short-term mortality. In medical wards, the MPI had a moderate certainty of the evidence in predicting short-term mortality (13 studies; 11,787 patients; AUC=0.79 and 4 studies; 3915 patients; C-index=0.82). Similar findings were available for MPI when considering longer follow-up periods. When considering nursing home and surgical wards, the literature was limited. The risk of bias was generally acceptable; observed bias was mainly owing to attrition and confounding.

CONCLUSIONS

Several tools are used to predict poor prognosis in geriatric patients, but only those derived from a multidimensional evaluation have the characteristics of precision and accuracy.

Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study

OBJECTIVE

To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes.

DESIGN

Multicenter retrospective cohort study.

SETTING AND PARTICIPANTS

Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018.

METHODS

Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis.

RESULTS

Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB.

CONCLUSIONS AND IMPLICATIONS

CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.

Association of Vulnerability Screening on Hospital Admission with Discharge to Rehabilitation-Oriented Care after Acute Hospital Stay

BACKGROUND

We assessed the vulnerability of patients aged ≥70 years during hospital admission based on the Short Dutch Safety Management Screening (DSMS). Screening of four geriatric domains aims to prevent adverse outcomes and may support targeted discharge planning for post-acute care. We explored whether the DSMS criteria for acutely admitted patients were associated with rehabilitation-oriented care needs.

METHODS

This retrospective cohort study included community-dwelling patients aged ≥70 years acutely admitted to a tertiary hospital. We recorded patient demographics, morbidity, functional status, malnutrition, fall risk, and delirium and used descriptive analysis to calculate the risks by comparing the discharge destination groups.

RESULTS

Among 491 hospital discharges, 349 patients (71.1%) returned home, 60 (12.2%) were referred for geriatric rehabilitation, and 82 (16.7%) to other inpatient post-acute care. Non-home referrals increased with age from 21% (70-80 years) to 61% (>90 years). A surgical diagnosis (odds ratio [OR]=4.92; 95% confidence interval [CI], 2.03-11.95), functional decline represented by Katz-activities of daily living positive screening (OR=3.79; 95% CI, 1.76-8.14), and positive fall risk (OR=2.87; 95% CI, 1.31-6.30) were associated with non-home discharge. The Charlson Comorbidity Index did not differ significantly between the groups.

CONCLUSION

Admission diagnosis and vulnerability screening outcomes were associated with discharge to rehabilitation-oriented care in patients >70 years of age. The usual care data from DSMS vulnerability screening can raise awareness of discharge complexity and provide opportunities to support timely and personalized transitional care.

Frailty and anticoagulants in older subjects with atrial fibrillation: the EUROSAF study

AIMS

Literature regarding anticoagulants in older people affected by atrial fibrillation (AF) is limited to retrospective studies, poorly considering the importance of multidimensional frailty. The main objective of this study is to evaluate in hospitalised older persons with AF the benefit/risk ratio of the anticoagulant treatments, considering the severity of frailty, determined by the multidimensional prognostic index (MPI).

METHODS

In this European, multicentre, prospective study, older hospitalised patients (≥65 years) with non-valvular AF were followed-up for 12 months. Anticoagulants' use at discharge ascertained using medical records. MPI was calculated using tools derived from comprehensive geriatric assessment, classifying participants in robust, pre-frail or frail. Mortality (primary outcome); vascular events, including ischemic heart disease or ischemic stroke, hemorrhagic stroke or gastrointestinal bleedings (secondary outcomes).

RESULTS

2,022 participants (mean age 82.9 years; females 56.6%) were included. Compared with people not taking anticoagulants (n = 823), people using vitamin K antagonists (n = 450) showed a decreased risk of mortality (hazard ratio, HR = 0.74; 95% CI: 0.59-0.93), more pronounced in patients using direct oral anticoagulants (DOACs) (n = 749) (HR = 0.46; 95% CI: 0.37-0.57). Only people taking DOACs reported a significantly lower risk of vascular events (HR = 0.55; 95% CI: 0.31-0.97). The efficacy of DOACs was present independently from frailty status. The risk of gastrointestinal bleedings and hemorrhagic stroke did not differ based on the anticoagulant treatments and by MPI values.

CONCLUSIONS

Anticoagulant treatment, particularly with DOACs, was associated with reduced mortality in older people, without increasing the risk of hemorrhagic events, overall suggesting the importance of treating with anticoagulants older people with AF.

Implementation and Core Components of a Multimodal Program including Exercise and Nutrition in Prevention and Treatment of Frailty in Community-Dwelling Older Adults: A Narrative Review

Increasing disability-free life expectancy is a crucial issue to optimize active ageing and to reduce the burden of evitable medical costs. One of the main challenges is to develop pragmatic and personalized prevention strategies in order to prevent frailty, counteract adverse outcomes such as falls and mobility disability, and to improve quality of life. Strong evidence reports the effectiveness of exercise interventions to improve various physical parameters and muscle function that are cornerstones of frailty. Other findings also suggest that the interactions between nutrition and physical exercise with or without health behavior promotion prevent the development of frailty. Multimodal programs, including structured exercise, adequate dietary intervention and health behavior promotion, appear increasingly consensual. However, in order for implementation in real-life settings, some pitfalls need to be addressed. In this perspective, structuring and tailoring feasible, acceptable and sustainable interventions to optimize exercise training responses are essential conditions to warrant short, medium and long-term individual benefits. The different components of exercise programs appear to be fairly consensual and effective. However, specific composition of the programs proposed (frequency, intensity, type, time, volume and progressiveness) have to be tailored to individual characteristics and objectives in order to improve exercise responses. The intervention approaches, behavioral strategies and indications for these programs also need to be refined and framed. The main objective of this work is to guide the actions of healthcare professionals and enable them to widely and effectively implement multimodal programs including exercise, nutrition and behavioral strategies in real-life settings.

Can the Multidimensional Prognostic Index (MPI) be a predictive instrument for mortality in older adult liver transplant candidates?

PURPOSE

The most recent guidelines recommend that selection of liver transplant recipient patients be guided by a multidimensional approach that includes frailty assessment. Different scales have been developed to identify frail patients and determine their prognosis, but the data on older adult candidates are still inconclusive. The aim of this study was to compare the accuracy of the Liver Frailty Index (LFI) and the Multidimensional Prognostic Index (MPI) as predictors of mortality in a cohort of older people patients being evaluated for liver transplantation.

METHODS

This retrospective study was conducted on 68 patients > 70 years being followed at the University Hospital of Padua in 2018. Clinical information on each patient, Model For End-Stage Liver Disease (MELD), Body Mass Index (BMI), Activities of Daily Living (ADL), Mini Nutritional Assessment (MNA), LFI, MPI, and date-of-death, were recorded. The observational period was 3 years.

RESULTS

We studied 68 individuals (25 women), with a mean age 72.21 ± 1.64 years. Twenty-five (36.2%) patients died during the observational period. ROC curve analysis showed both MPI and LFI to be good predictors of mortality (AUC 0.7, p = 0.007, and AUC 0.689, p = 0.015, respectively). MELD (HR 1.99, p = 0.001), BMI (HR 2.34, p = 0.001), and poor ADL (HR 3.34, p = 0.04) were risk factors for mortality in these patients, while male sex (HR 0.1, p = 0.01) and high MNA scores (HR 0.57, p = 0.01) were protective factors.

CONCLUSION

Our study confirmed the prognostic value of MPI in older adult patients awaiting liver transplantation. In this cohort, good nutritional status and male sex were protective factors, while high MELD and BMI scores and poor functional status were risk factors.

Medium and long-term prognosis in hospitalised older adults with multimorbidity. A prospective cohort study

BACKGROUND

Data about long-term prognosis after hospitalisation of elderly multimorbid patients remains scarce.

OBJECTIVES

Evaluate medium and long-term prognosis in hospitalised patients older than 75 years of age with multimorbidity. Explore the impact of gender, age, frailty, physical dependence, and chronic diseases on mortality over a seven-year period.

METHODS

We included prospectively all patients hospitalised for medical reasons over 75 years of age with two or more chronic illnesses in a specialised ward. Data on chronic diseases were collected using the Charlson comorbidity index and a questionnaire for disorders not included in this index. Demographic characteristics, Clinical Frailty Scale, Barthel index, and complications during hospitalisation were collected.

RESULTS

514 patients (46% males) with a mean age of 85 (± 5) years were included. The median follow-up was 755 days (interquartile range 25-75%: 76-1,342). Mortality ranged from 44% to 68%, 82% and 91% at one, three, five, and seven years. At inclusion, men were slightly younger and with lower levels of physical impairment. Nevertheless, in the multivariate analysis, men had higher mortality (p<0.001; H.R.:1.43; 95% C.I.95%:1.16-1.75). Age, Clinical Frailty Scale, Barthel, and Charlson indexes were significant predictors in the univariate and multivariate analysis (all p<0.001). Dementia and neoplastic diseases were statistically significant in the unadjusted but not the adjusted model. In a cluster analysis, three patterns of patients were identified, with increasing significant mortality differences between them (p<0.001; H.R.:1.67; 95% CI: 1.49-1.88).

CONCLUSIONS

In our cohort, individual diseases had a limited predictive prognostic capacity, while the combination of chronic illness, frailty, and physical dependence were independent predictors of survival.

Biomarkers for risk stratification and antibiotic stewardship in elderly patients

PURPOSE

Optimal treatment of infections in the elderly patients population is challenging because clinical symptoms and signs may be less specific potentially resulting in both, over- and undertreatment. Elderly patients also have a less pronounced immune response to infection, which may influence kinetics of biomarkers of infection.

METHODS

Within a group of experts, we critically reviewed the current literature regarding biomarkers for risk stratification and antibiotic stewardship in elderly patients with emphasis on procalcitonin (PCT).

RESULTS

The expert group agreed that there is strong evidence that the elderly patient population is particularly vulnerable for infections and due to ambiguity of clinical signs and parameters in the elderly, there is considerable risk for undertreatment. At the same time, however, this group of patients is particularly vulnerable for off-target effects from antibiotic treatment and limiting the use of antibiotics is therefore important. The use of infection markers including PCT to guide individual treatment decisions has thus particular appeal in geriatric patients. For the elderly, there is evidence that PCT is a valuable biomarker for assessing the risk of septic complications and adverse outcomes, and helpful for guiding individual decisions for or against antibiotic treatment. There is need for additional educational efforts regarding the concept of "biomarker-guided antibiotic stewardship" for health care providers caring for elderly patients.

CONCLUSION

Use of biomarkers, most notably PCT, has high potential to improve the antibiotic management of elderly patients with possible infection for improving both, undertreatment and overtreatment. Within this narrative review, we aim to provide evidence-based concepts for the safe and efficient use of PCT in elderly patients.

Older People Hospitalized for COVID-19: Prognostic Role of Multidimensional Prognostic Index and Other Prognostic Scores

During the SARS-CoV-2 pandemic, frailty and patients’ poor outcomes seem to be closely related. However, there is no clear indication of the significance of this connection and the most adequate risk index in clinical practice. In this study, we compared a short version of MPI (multidimensional prognostic index) and other two prognostic scores for COVID-19 as potential predictors of poor patient outcomes. The patients were consecutively enrolled in the hospital of Palermo for COVID-19. The accuracy of Brief-MPI, 4C score and COVID-GRAM score in points was evaluated using the area under the curve (AUC) with 95% CI, taking mortality or sub-ICU admission as outcome. The study included 112 participants (mean age 77.6, 55.4% males). During a mean of 16 days of hospitalization, Brief-MPI significantly increased by 0.03 ± 0.14 (p = 0.04), whilst COVID-GRAM did not. Brief-MPI, 4C score and COVID-GRAM scores had good accuracy in predicting negative outcomes (AUC > 0.70 for all three scores). Brief-MPI was significantly associated with an increased mortality/ICU admission risk, indicating the importance of multidimensional impairment in clinical decision-making with an accuracy similar to other prognostic scores commonly used in COVID-19 study, providing information regarding domains for which interventions can be proposed.

High Prevalence of Geriatric Conditions Among Older Adults With Cardiovascular Disease

As the population ages, the global cardiovascular disease burden will continue to increase, particularly among older adults. Increases in life expectancy and better cardiovascular care have significantly reshaped the epidemiology of cardiovascular disease and have created new patient profiles. The combination of older age, multiple comorbidities, polypharmacy, frailty, and adverse noncardiovascular outcomes is challenging our routine clinical practice in this field. In this review, we examine noncardiovascular factors that statistically interact in a relevant way with health status and quality of life in older people with cardiovascular disease. We focused on specific geriatric conditions (multimorbidity, polypharmacy, geriatric syndromes, and frailty) that are responsible for a major risk of functional decline and have an important impact on the overall prognosis in this patient population.

The role of comprehensive geriatric assessment in older patients affected by knee osteoarthritis: a systematic review

Osteoarthritis (OA) is one of the most common musculoskeletal diseases and highly prevalent in older people. Whilst the management of knee OA is usually multidisciplinary, the use of comprehensive geriatric assessment (CGA) for this condition is still limited. Given this background, with this systematic review, we summarized the current literature regarding the importance of CGA in people affected by knee OA. A systematic search across several databases was run until 10th April 2022 and updated on 21st November 2022 for any study investigating the use of CGA in patients with knee OA. The data were summarized descriptively. Among 295 articles initially included, three studies made in the context of the osteoarthritis initiative (OAI) were included. All the three studies used the OAI multidimensional prognostic index (MPI), a composite score derived from the CGA. Higher MPI values were associated with a higher risk of falls, cardiovascular conditions, and fractures across a follow-up period of 8 years and after adjusting for potential confounders. In conclusion, in this systematic review we summarized the current evidence of CGA in knee OA, finding that the MPI, a CGA derived tool, could be useful to early find people at higher risk of conditions that are associated with knee OA and therefore that can be the target of personalized interventions for preventing these conditions.

Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review

BACKGROUND

Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT.

METHODS

Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628).

FINDINGS

Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed.

CONCLUSIONS

Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.

The role of prognostic stratification on prescription of anticoagulants in older patients with atrial fibrillation: a multicenter, observational, prospective European study (EUROSAF)

BACKGROUND

Literature suggests that different risks of mortality could influence physicians in prescribing or not anticoagulants in older patients with atrial fibrillation (AF). The Multidimensional Prognostic Index (MPI) can be considered a tool for the detection of multidimensional frailty. The aim of this cross-sectional study was to evaluate whether prescription patterns of oral anticoagulants exist, based on MPI values.

METHODS

Older hospitalised patients (age ≥ 65 years) with non-valvular AF were included across 24 European centres. MPI was calculated using validated and standardised tools derived from a comprehensive geriatric assessment. Other functional and clinical information were collected to calculate indexes specific for haemorrhagic and thromboembolic risk in AF.

RESULTS

Altogether, 2,012 participants affected by AF (mean age was 83.2 ± 7.5, range: 65-104 years), with a higher presence of women (57.0%), were included. Overall, 440 took vitamin K antagonists VKAs (22.0%), 667 (33.4%) direct oral anticoagulants (DOACs), whilst 44.6% did not take any anticoagulant treatment. Prescription of anticoagulants was associated with MPI values, with people taking anticoagulants having lower mean MPI values. Anticoagulant therapy was not used in 53.1% of the group with the highest risk of mortality, compared with 32.3% of those in the group with the lowest mortality risk. People with higher scores in MPI were less frequently treated with anticoagulant therapy, after adjusting for several potential confounders.

CONCLUSIONS

The EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF) suggested that almost half of the older persons with AF do not receive anticoagulants and that MPI is an important determinant in prescribing or not anticoagulants. Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02973984KEY POINTSAtrial fibrillation is a common condition in older people. The data regarding the use of anticoagulants is mainly derived from randomised controlled trials that do not include a sufficient number of older frail people.Our study suggests that a consistent part of older people affected by atrial fibrillation was not treated with anticoagulants, in particular, older frail patients; however, it is unclear if this choice is supported or not by evidence.The prognostic evaluation through the multidimensional prognostic index could be useful information for the choice in the prescription of anticoagulants in older people affected by atrial fibrillation.

Multidimensional frailty and quality of life: data from the English Longitudinal Study of Ageing

PURPOSE

Frailty has been found to be associated with poor quality of life (QoL) in older people, but data available are limited to cross-sectional studies. We therefore aimed to assess the association between multidimensional frailty, determined by Multidimensional Prognostic Index (MPI), with mortality and good QoL expectancy (GQoLE) in a large representative sample of older adults, over 10 years of follow-up.

METHODS

In the English Longitudinal Study of Ageing, using the data from 2004-2005 and 2014-2015, MPI was calculated using a weighted score of domains of comprehensive geriatric assessment, i.e., number of difficulties in activities of daily living (ADL) and instrumental ADL, depressive symptoms, number of medical conditions, body mass index, physical activity level, and social aspects. Mortality was assessed using administrative data, GQoLE indicators were used for longitudinal changes in QoL.

RESULTS

6244 Participants (mean age 71.8 years, 44.5% males) were followed up for 10 years. After adjusting for potential confounders, compared to people in the MPI low-risk group, people in the moderate (hazard ratio, HR = 4.27; 95% confidence interval, CI 3.55-5.14) and severe-risk group (HR = 10.3; 95% CI 7.88-13.5) experienced a significantly higher mortality rate. During the follow-up period, people in the moderate and severe-risk groups reported lower GQoLE values than their counterparts, independently from age and gender.

CONCLUSIONS

Multidimensional frailty was associated with a higher risk of mortality and significantly lower GQoLE, suggesting that the multifactorial nature of frailty is associated not only with mortality, but also poor QoL.

It Is Time for Senescience

Aging is the most impressive demographic phenomenon in human history [...]

Validation of Abbreviated Form of the Multidimensional Prognostic Index (MPI): The BRIEF-MPI Project

PURPOSE

To screen multidimensional frailty in older people, using a comprehensive geriatric assessment (CGA) tool such as the multidimensional prognostic index (MPI), is a public health priority. Unfortunately, the screening tools available are not able to capture multidimensional frailty. In this work, we aimed to evaluate in a population of hospitalized and ambulatory older patients, the agreement between an abbreviated form of the MPI (ie, BRIEF-MPI) and the standard/full version.

PARTICIPANTS AND METHODS

All participants included in the study completed both versions of the MPI, brief and full, which share the following domains: 1) basic and 2) instrumental activities of daily living, 3) mobility/risk of pressure sores, 4) cognition, 5) nutrition, 6) comorbidity, 7) social and 8) number of medications. The agreement between the two instruments was reported using either the mean comparisons with a t-test matched sample, a simple correlation analysis and the Bland-Altman methodology.

RESULTS

The study sample included 110 participants (mean age=83.2 years, 51.8% women). The mean difference was statistically and clinically irrelevant (mean difference=0.01±0.10; p=0.27). The correlation between brief and full MPI versions was optimal (R=0.82, p<0.0001). Using the Bland-Altman methodology, we observed that only three participants over 110 (=2.73%) were outside the limits of agreement. The accuracy of BRIEF-MPI in predicting multidimensional frailty, as full MPI>0.66, was optimal (area under the curve=0.92, p<0.0001). A BRIEF-MPI value of 0.59 yielded the highest sensitivity and specificity in predicting multidimensional frailty.

CONCLUSION

BRIEF-MPI had a good agreement with the full/standard version of the MPI, making this tool as ideal for the screening of multidimensional frailty in older people.

Predictors of short- and long-term mortality among acutely admitted older patients: role of inflammation and frailty

BACKGROUND

Frailty, demographic and clinical variables linked to incident diseases (e.g., dehydration, inflammation) contribute to poor outcomes in older patients acutely hospitalized. Their predictivity on short-, intermediate- and long-term mortality in a comprehensive model has been scarcely investigated.

AIMS

To test the performance of a predictive tool considering frailty and inflammation as well as age, sex and impaired hydration status on 1-year mortality in acutely admitted older patients.

METHODS

Retrospective observational study including 529 medical patients (age 84.6 ± 7.3 years). At hospital admission, frailty was assessed by the Multidimensional Prognostic Index (MPI). The Glasgow Prognostic Score (GPS) was used to grade systemic inflammation. Serum osmolarity was calculated to assess hydration.

RESULTS

After adjusting for age, sex, GPS and osmolarity, the severe-risk MPI was a strong predictor for 1-year mortality (OR 4.133; 95% CI 2.273-7.516; p < 0.001). Age > 85 years, male sex, GPS-2 and serum osmolarity > 300 mOsm/L were independent predictors of mortality in the same multivariable model. The MPI alone showed a moderate discrimination power (AUC 0.678; 95% CI 0.628-0.729; p < 0.001) on 1-year mortality, which increased by 12.5% after the addition of the above predictors in the fully adjusted regression model (AUC 0.763; 95% CI 0.719-0.807; p < 0.001). The severe-risk MPI adjusted for the same factors was also an independent predictor of mortality after 60 and 180 days since hospital admission.

DISCUSSION

Inflammation and impaired hydration are potentially modifiable risk factors for severe outcomes in older acutely hospitalized patients. A model combining GPS, age, gender, and plasma osmolarity improved the accuracy of MPI at admission in predicting long-term mortality.

Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines

BACKGROUND

The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS).

METHODS AND RESULTS

In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms.

CONCLUSIONS

On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.

Multidimensional prognostic index and the risk of fractures: an 8-year longitudinal cohort study in the Osteoarthritis Initiative

In this longitudinal study, with a follow-up of 8 years, multidimensional prognostic index (MPI), a product of the comprehensive geriatric assessment, significantly predicted the onset of fractures in older people affected by knee osteoarthritis.

PURPOSE

Frailty may be associated with higher fracture risk, but limited research has been carried out using a multidimensional approach to frailty assessment and diagnosis. The present research aimed to investigate whether the MPI, based on comprehensive geriatric assessment (CGA), is associated with the risk of fractures in the Osteoarthritis Initiative (OAI) study.

METHODS

Community-dwellers affected by knee OA or at high risk for this condition were followed-up for 8 years. A standardized CGA including information on functional, nutritional, mood, comorbidity, medication, quality of life, and co-habitation status was used to calculate the MPI. Fractures were diagnosed using self-reported information. Cox's regression analysis was carried out and results are reported as hazard ratios (HRs), with their 95% confidence intervals (CIs), adjusted for potential confounders.

RESULTS

The sample consisted of 4024 individuals (mean age 61.0 years, females = 59.0%). People with incident fractures had a significant higher MPI baseline value than those without (0.42 ± 0.18 vs. 0.40 ± 0.17). After adjusting for several potential confounders, people with an MPI over 0.66 (HR = 1.49; 95%CI: 1.11-2.00) experienced a higher risk of fractures. An increase in 0.10 point in MPI score corresponded to an increase in fracture risk of 4% (HR = 1.04; 95%CI: 1.008-1.07). Higher MPI values were also associated with a higher risk of non-vertebral clinical fractures.

CONCLUSION

Higher MPI values at baseline were associated with an increased risk of fractures, reinforcing the importance of CGA in predicting fractures in older people affected by knee OA.

Validation and implementation of telephone-administered version of the Multidimensional Prognostic Index (TELE-MPI) for remote monitoring of community-dwelling older adults

BACKGROUND

During the recent lockdown measures adopted by national authorities to contain the COVID-19 pandemic, many vulnerable older patients with chronic conditions, normally followed in ambulatory setting, needed to be monitored and managed in alternative ways, including telemedicine.

AIMS

In the framework of a telemedicine program, we aimed to validate and implement a telephone-administered version of the Multidimensional Prognostic Index (TELE-MPI) among community-dwelling older outpatients.

METHOD

From March 9 to May 11, 2020, 131 older patients (82.1 years; 74% females) were interviewed using a telephone-based survey to calculate the TELE-MPI. The standard MPI was performed face-to-face three months apart. The Bland-Altman methodology measured the agreement between the two tools. Multivariate logistic regression models were built to ascertain the prognostic value of TELE-MPI and TELE-MPI classes (low, moderate, or severe risk) on negative outcomes occurring during the lockdown period.

RESULTS

Mean MPI and TELE-MPI values were 0.523 and 0.522, respectively. Lower and upper 95% limits of agreement were - 0.122 and + 0.124, respectively, with only 4.6% of observations outside the limits. Each 0.1 increase of TELE-MPI score was significantly correlated with higher incidence of psychiatric disorders [odd ratio (OR): 1.57; 95% confidence interval (CI) 1.27, 1.95] and falls (OR: 1.41; 95% CI 1.08, 1.82) in community-dwelling-older adults.

DISCUSSION

TELE-MPI showed a strong agreement with the standard MPI and was able to predict psychiatric disorders and falls during lockdown period.

CONCLUSION

TELE-MPI may represent a useful way to follow by remote the health status of older adults.

Multidimensional Frailty Predicts Mortality Better than Physical Frailty in Community-Dwelling Older People: A Five-Year Longitudinal Cohort Study

Frailty is a common syndrome in older people that carries an increased risk of mortality. Two main models describe frailty, either as a loss of physical functions or as an accumulation of multiple deficits. The aim of our study was to compare the physical frailty index developed in the Cardiovascular Health Study (CHS) with a multidimensional frailty tool, the Multidimensional Prognostic Index (MPI), in predicting death in community-dwelling older subjects. Four hundred and seven community-dwelling older subjects were enrolled. Each subject underwent a comprehensive geriatric assessment (CGA) with calculation of the MPI and CHS index. Mortality was recorded over the following 5 years. In the overall sample (mean age of 77.9 ± 4.5 years; 51.6% female), 53 subjects (13%) died during the 5-year follow-up period. Both the MPI and CHS index were able to predict mortality; however, the MPI was significantly more accurate than the CHS index in predicting mortality (C-index = 0.69 and 0.59, respectively; p < 0.001), with a statistically significant difference of 10%. In conclusion, multidimensional frailty, assessed by the MPI, predicts five-year mortality in community-dwelling older people better than physical frailty, as assessed by the CHS index. These findings suggest the usefulness of assessing frailty by means of CGA-based tools to predict relevant health-negative outcomes in older people.

Predicting physiological aging rates from a range of quantitative traits using machine learning

It is widely thought that individuals age at different rates. A method that measures “physiological age” or physiological aging rate independent of chronological age could therefore help elucidate mechanisms of aging and inform an individual’s risk of morbidity and mortality. Here we present machine learning frameworks for inferring individual physiological age from a broad range of biochemical and physiological traits including blood phenotypes (e.g., high-density lipoprotein), cardiovascular functions (e.g., pulse wave velocity) and psychological traits (e.g., neuroticism) as main groups in two population cohorts SardiNIA (~6,100 participants) and InCHIANTI (~1,400 participants). The inferred physiological age was highly correlated with chronological age (R2 > 0.8). We further defined an individual’s physiological aging rate (PAR) as the ratio of the predicted physiological age to the chronological age. Notably, PAR was a significant predictor of survival, indicating an effect of aging rate on mortality. Our trait-based PAR was correlated with DNA methylation-based epigenetic aging score (r = 0.6), suggesting that both scores capture a common aging process. PAR was also substantially heritable (h2~0.3), and a subsequent genome-wide association study of PAR identified significant associations with two genetic loci, one of which is implicated in telomerase activity. Our findings support PAR as a proxy for an underlying whole-body aging mechanism. PAR may thus be useful to evaluate the efficacy of treatments that target aging-related deficits and controllable epidemiological factors.

An interdisciplinary intervention is associated with overall improvement of older inpatients in a non-geriatric setting: A retrospective analysis of an observational, longitudinal study with one-year follow up

Older persons often loose independence during hospitalization. This analysis aimed at retrospectively evaluating the effects of a pilot individualized multidimensional intervention (IMI) on the comprehensive geriatric assessment (CGA)-based prognosis of older multimorbid patients in an acute internal medicine setting. Records from 72 patients aged 65 years and above who received the IMI were compared to those from 403 patients who received standard of care (SOC). All patients had undergone the CGA-based Multidimensional Prognostic Index (MPI) calculation on admission and at discharge. Patients were divided into three risk groups according to MPI score: Low-risk (MPI-1, 0-0.33), medium-risk (MPI-2, 0.34-0.66) and high-risk (MPI-3, 0.67-1). From admission to discharge, IMI patients showed significant improvements in their MPI score (P=0.014) and subdomains compared to SOC. This was particularly evident in MPI-2 and MPI-3 as well as in patients with poorer functions on MPI admission subdomains. An early geriatric intervention during hospitalization for disease-specific treatments in internal medicine settings improves overall individual prognosis in older multimorbid patients. Prospective randomized studies are needed to confirm these preliminary retrospective observations.

Multidimensional prognostic index (MPI) predicts successful application for disability social benefits in older people

AIM

The economic recognition of disability is of importance in daily practice, but the tools used in older people are still limited. Therefore, we aimed to investigate the effectiveness of the multidimensional prognostic index (MPI) to identify frail older subjects to be submitted to civil invalidity application for disability benefits including Attendance Allowance (AA) indemnity, Carer's Leave (Law 104) and/or Parking Card for people with disabilities.

METHODS

From March 2018 to January 2019, 80 older people were included. The MPI was calculated from comprehensive geriatric assessment information including eight different domains. Civil benefits included attendance allowance (AA) indemnity by the Local Medico-Legal Committee (MLC-NHS) and by the National Institute of Social Security Committee (INPS), Carer's Leave (Law 104), and Parking Card for people with disabilities.

RESULTS

MPI values were associated with an increased probability to obtain a 100% civil disability, AA indemnity, Carer's Leave and a parking card for people with disabilities. MPI score showed a very good accuracy in predicting the civil invalidity benefits with a area-under-curve (AUC) of 87.3 (95% CI 80.6-97.4) to predict the release of AA indemnity, 81.3 (95% CI 68.5-91.1) to predict Care's leave and 70.7 (95% CI 59.4-84.7) to predict the Parking Card release. Moreover, data showed that a cut-off score of MPI ≥ 0.75 could identify the 100% of older subjects who successfully obtained the indemnity release.

CONCLUSION

MPI is an excellent predictor of social benefits' release by local and national agencies.

Mortality and readmission risk can be predicted by the record-based Multidimensional Prognostic Index: a cohort study of medical inpatients older than 75 years

PURPOSE

To examine the predictive value of the record-based Multidimensional Prognostic Index (MPI) on mortality, readmission and length of hospital stay (LOS) among older medical inpatients.

METHODS

A cohort of medical inpatients aged ≥ 75 years was rated using the record-based MPI to assess frailty retrospectively. 90-day and 1-year mortality hazard ratios (HRs) were calculated in a sex- and age-adjusted Cox proportional hazards model. 30-day readmission relative risk (RR) estimates were calculated in a binary regression model with mortality as a competing risk. Discrimination was expressed by the area under the receiver operating characteristic (ROC) curve. Median LOS was calculated using the non-parametric Kruskal-Wallis one-way ANOVA.

RESULTS

In total, 1190 patients with a median age of 83 years were included. 50% were male. 335 patients (28%) were categorized as non-frail (MPI score 0.0-0.33), 522 (44%) moderately frail (MPI score 0.34-0.66) and 333 (28%) severely frail (MPI score 0.67-1.0). 90-day mortality HR was 7.4 (95% confidence interval (CI) 2.9-18.6, p < 0.001) for the moderately frail and 18.5 (95% CI 7.5-46.1, p < 0.001) for the severely frail compared with the non-frail. ROC area was 0.76 (95% CI 0.72-0.80). Similarly, 1-year mortality HR was 3.3 (95% CI 2.2-5.0, p < 0.001) for the moderately frail and 7.1 (95% CI 4.7-10.6, p < 0.001) for the severely frail. 30-day readmission RR was 2.1 (95% CI 1.5-2.9, p < 0.001) for the moderately frail and 1.8 (95% CI 1.3-2.6, p = 0.001) for the severely frail. LOS was significantly longer with increasing MPI score (p < 0.001).

CONCLUSION

The record-based MPI assessed at discharge predicts dose-dependent post-discharge mortality and readmission risk and is associated with LOS in older medical inpatients.

Relationship between multidimensional prognostic index and incident depressive symptoms in older people: Findings from the Irish Longitudinal Study on Ageing

OBJECTIVES

The multidimensional prognostic index (MPI) is a useful prognostic tool for evaluating adverse health outcomes in older individuals. However, the association between MPI and depressive symptoms has never been explored, despite depression being a common condition in older people. We therefore aimed to evaluate whether MPI may predict incident depressive symptoms.

METHODS

Longitudinal, cohort study, with 2 years of follow-up (W1: October 2009-February 2011; W2: April 2012-January 2013), including people aged ≥65 years without depressive symptoms at baseline. A comprehensive geriatric assessment including information on functional, nutritional, cognitive status, mobility, comorbidities, medications, and cohabitation status was used to calculate the MPI dividing the participants into low, moderate, or severe risk. Those who scored ≥16/60 with the Center of Epidemiology Studies Depression (CES-D) tool were considered to have depressive symptoms. Multivariable logistic regression models were built to explore the association between MPI and incident depressive symptoms.

RESULTS

The sample consisted of 1854 participants (mean age: 72.8 ± SD 5.1 years; females: 52.1%). The prevalence of incident depressive symptoms by MPI tertiles at baseline were: low 2.5%, moderate 3.9%, and severe 6.7%. In multivariable analyses, baseline MPI values were significantly associated with incident depressive symptoms (increase in 0.1 points in MPI: odds ratio, OR = 1.47; 95% confidence intervals, CI: 1.17-1.85; MPI tertile severe vs low: OR = 2.96; 95%CI: 1.50-5.85).

CONCLUSION

Baseline MPI values were associated with incident depressive symptoms indicating that multidimensional assessment of older people may lead to early identification of individuals at increased risk of depression onset.

Association Between the Multidimensional Prognostic Index and Mortality During 15 Years of Follow-up in the InCHIANTI Study

BACKGROUND

Multidimensional Prognostic Index (MPI) is recognized as a prognostic tool in hospitalized patients, but data on the value of MPI in community-dwelling older persons are limited. Using data from a representative cohort of community-dwelling persons, we tested the hypothesis that MPI explains mortality during 15 years of follow-up.

METHODS

A standardized comprehensive geriatric assessment was used to calculate the MPI and to categorize participants in low-, moderate-, and high-risk classes. The results were reported as hazard ratios (HRs) and the accuracy was evaluated with the area under the curve (AUC), with 95% confidence intervals (CIs) and the C-index. We also reported the median survival time by standard age groups.

RESULTS

All 1453 participants (mean age 68.9 years, women = 55.8%) enrolled in the InCHIANTI study at baseline were included. Compared to low-risk group, participants in moderate (HR = 2.10; 95% CI: 1.73-2.55) and high-risk MPI group (HR = 4.94; 95% CI: 3.91-6.24) had significantly higher mortality risk. The C-index of the model containing age, sex, and MPI was 82.1, indicating a very good accuracy of this model in explaining mortality. Additionally, the time-dependent AUC indicated that the accuracy of the model incorporating MPI to age and sex was excellent (>85.0) during the whole follow-up period. Compared to participants in the low-risk MPI group across different age groups, those in moderate- and high-risk groups survived 2.9-7.0 years less and 4.3-8.9 years less, respectively.

CONCLUSIONS

In community-dwelling individuals, higher MPI values are associated with higher risk of all-cause mortality with a dose-response effect.