Comparing the predictive value of three definitions of frailty: Results from the Three-City study

Prevalence of multidimensional frailty among community-dwelling older adults: A systematic review and meta-analysis

OBJECTIVE

The aims of this systematic review were to explore the pooled prevalence of multidimensional frailty assessed by the Tilburg Frailty Indicator among community-dwelling older adults.

DESIGN

A systematic review and meta-analysis.

METHODS

A comprehensive literature search was conducted across multiple databases, including PubMed, Web of Science, Embase, the Cochrane Library, CINAHL and three Chinese databases. Two independent researchers selected the literatures, extracted the data and evaluated the quality. All statistical analyses were performed using STATA version 16.0.

RESULTS

There were 66 studies with a total of 40,597 individuals that were eligible for the meta-analysis. Data from the meta-analysis revealed the pooled prevalence of 42 % for multidimensional frailty (95 % CI: 38 %-45 %, I2 = 98.9 %, T2 = 0.024, p < 0.001). Among the six studies that provided data for different age groups, the results demonstrated an increasing trend in the prevalence of multidimensional frailty with advancing age. The results of gender-stratified analysis proved that the pooled prevalence of multidimensional frailty in women (45 %, 95 % CI: 39 %-51 %, p < 0.001) was higher than that in men (33 %, 95 % CI: 28 %-39 %, p < 0.001). Based on different education levels, the prevalence of multidimensional frailty is highest in the primary elementary or illiterate group (41 %, 95 % CI: 30 %-52 %, p < 0.001). According to different marital status types, the pooled prevalence of multidimensional frailty in the married group was significantly lower (36 %, 95 % CI: 28 %-43 %) than that in the unmarried, divorced or widowed group (51 %, 95 % CI: 37 %-65 %).

CONCLUSIONS

Through a comprehensive review, we identified that 42 % of elderly individuals living in communities exhibit multidimensional frailty, indicating that multidimensional frailty is relatively common in this population. Stratified analysis revealed that advanced age, female gender, lower education level and unmarried status were associated with higher rates of multidimensional frailty.

Comparison of different frailty instruments for prediction of functional decline in older hypertensive outpatients (HYPER-FRAIL pilot study 2)

BACKGROUND AND AIMS

Few studies have evaluated frailty in older hypertensive individuals and the most appropriate tools to identify frailty in this population have yet to be identified. This study compared the performance of six frailty instruments in the prediction of 1-year functional decline in older hypertensive outpatients.

METHODS

The HYPERtension and FRAILty in Older Adults (HYPER-FRAIL) longitudinal pilot study involved hypertensive participants ≥75 years from two geriatric outpatient clinics at Careggi Hospital, Florence, Italy, undergoing identification of frailty with four frailty scales (Fried Frailty Phenotype, Frailty Index [FI], Clinical Frailty Scale [CFS], Frailty Postal Score) and two physical performance tests (Short Physical Performance Battery [SPPB] and gait speed). Prediction of 1-year functional decline (i.e. a ≥ 10-point Barthel Index decrease between baseline and follow-up) was examined based on ROC curve analysis and multivariable logistic regression.

RESULTS

Among 116 participants, 24 % reported functional decline. In the ROC curve analyses, FI (AUC=0.76), CFS (AUC=0.77), gait speed (AUC=0.73) and the SPPB (AUC=0.77) achieved the best predictive performance, with FI ≥0.21 and CFS ≥4 showing the highest sensitivity (82 %) and negative predictive value (91 %). Frailty identified with FI, CFS or physical performance tests was associated with an increased risk of 1-year functional decline, independently of baseline functional status and comorbidity burden.

CONCLUSIONS

FI, CFS and physical performance tests showed similar predictive ability for functional decline in hypertensive outpatients. The CFS and gait speed might be more suitable for clinical use and may be useful to identify non-frail individuals at lower risk of functional decline.

Correlates of frailty in older female cancer survivors

INTRODUCTION

Cancer survivors are at risk of frailty because of cancer and its treatment. Understanding the factors that increase the risk of frailty is an important aspect of cancer care for the development of interventions to prevent or manage frailty, thus improving cancer survival and overall quality of life of cancer survivors. This study aimed to identify demographic, clinical, and psychosocial correlates of frailty in older, female cancer survivors.

MATERIALS AND METHODS

This is a sub-study focusing on the exploratory aim of a larger cross-sectional study (NURS-IIR-IUSCC-0748). A total of 213 female cancer survivors aged 59-87 years old were included from the parent study in the current analysis. Frailty, the primary outcome, was measured using the Tilburg Frailty Indicator scale. The independent variables were age, relationship status, clinical stage of cancer, treatment type, comorbidity, depression, affect, optimism, stress, and social support. Stepwise linear regression modeling identified the independent variables that were significantly associated with frailty.

RESULTS

The final regression model revealed that high patient-reported stress and depression, comorbidity, not being married or living with a partner, and low positive affect were significantly associated with worsening frailty in this population.

DISCUSSION

Understanding the context of frailty is important for the design of interventions that target factors known to be associated with frailty in older cancer survivors. Further validation with a larger and a more diverse sample from a broad spectrum of sociodemographic and clinical population would fully account for the multiple independent variables influencing frailty in cancer survivors.

Comparing four frailty assessment tools against seven-year mortality in the Malaysian elders longitudinal research study

AIM

Several frailty assessment tools are currently used in clinics and research, however, there appears to be a lack of head-to-head comparisons between these tools among older adults in developing countries. This study compared the Cardiovascular Health Study, Study of Osteoporotic Fractures, the Tilburg Frailty Indicator and the Canadian Study of Health and Aging frailty assessment tools and evaluated performance of these individual frailty assessment tools with mortality.

METHODS

This prospective cohort study utilized stratified simple random sampling to recruit 1614 participants from the Malaysian Elders Longitudinal Research aged above 55 years within the Klang Valley region from 2013 to 2015. Individual items for the frailty tools, alongside baseline physical and cognitive measures were extracted from the initial survey. Mortality data up to 31 December 2020 were obtained through data linkage from the death registry data obtained from the Malaysian National Registration Department.

RESULTS

Data were available for over 1609 participants, age (68.92 ± 7.52) years and 57 % women, during recruitment. Mortality data revealed 13.4 % had died as of 31 December 2020. Five to 25 % of our study population fulfilled the criteria for frailty using all four frailty tools. This study found an increased risk of mortality with frailty following adjustments for potential factors of falls, total number of illnesses and cognitive impairment, alongside moderate to strong correlation and agreement between frailty tools.

CONCLUSION

Frailty was associated with increased mortality. All four frailty assessment tools can be used to assess frailty within the Malaysian older adult population. The four available tools, however, may not be interchangeable.

Utilizing multimodal approach to identify candidate pathways and biomarkers and predicting frailty syndrome in individuals from UK Biobank

Frailty, a prevalent clinical syndrome in aging adults, is characterized by poor health outcomes, represented via a standardized frailty-phenotype (FP), and Frailty Index (FI). While the relevance of the syndrome is gaining awareness, much remains unclear about its underlying biology. Further elucidation of the genetic determinants and possible underlying mechanisms may help improve patients' outcomes allowing healthy aging.Genotype, clinical and demographic data of subjects (aged 60-73 years) from UK Biobank were utilized. FP was defined on Fried's criteria. FI was calculated using electronic-health-records. Genome-wide-association-studies (GWAS) were conducted and polygenic-risk-scores (PRS) were calculated for both FP and FI. Functional analysis provided interpretations of underlying biology. Finally, machine-learning (ML) models were trained using clinical, demographic and PRS towards identifying frail from non-frail individuals.Thirty-one loci were significantly associated with FI accounting for 12% heritability. Seventeen of those were known associations for body-mass-index, coronary diseases, cholesterol-levels, and longevity, while the rest were novel. Significant genes CDKN2B and APOE, previously implicated in aging, were reported to be enriched in lipoprotein-particle-remodeling. Linkage-disequilibrium-regression identified specific regulation in limbic-system, associated with long-term memory and cognitive-function. XGboost was established as the best performing ML model with area-under-curve as 85%, sensitivity and specificity as 0.75 and 0.8, respectively.This study provides novel insights into increased vulnerability and risk stratification of frailty syndrome via a multi-modal approach. The findings suggest frailty as a highly polygenic-trait, enriched in cholesterol-remodeling and metabolism and to be genetically associated with cognitive abilities. ML models utilizing FP and FI + PRS were established that identified frailty-syndrome patients with high accuracy.

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.

Monitoring Gait and Physical Activity of Elderly Frail Individuals in Free-Living Environment: A Feasibility Study

INTRODUCTION

Frailty is conventionally diagnosed using clinical tests and self-reported assessments. However, digital health technologies (DHTs), such as wearable accelerometers, can capture physical activity and gait during daily life, enabling more objective assessments. In this study, we assess the feasibility of deploying DHTs in community-dwelling older individuals, and investigate the relationship between digital measurements of physical activity and gait in naturalistic environments and participants' frailty status, as measured by conventional assessments.

METHODS

Fried Frailty Score (FFS) was used to classify fifty healthy individuals as non-frail (FFS = 0, n/female = 21/11, mean ± SD age: 71.10 ± 3.59 years), pre-frail (FFS = 1-2, n/female = 23/9, age: 73.74 ± 5.52 years), or frail (FFS = 3+, n/female = 6/6, age: 70.70 ± 6.53 years). Participants wore wrist-worn and lumbar-worn GENEActiv accelerometers (Activinsights Ltd., Kimbolton, UK) during three in-laboratory visits, and at-home for 2 weeks, to measure physical activity and gait. After this period, they completed a comfort and usability questionnaire. Compliant days at-home were defined as follows: those with ≥18 h of wear time, for the wrist-worn accelerometer, and those with ≥1 detected walking bout, for the lumbar-worn accelerometer. For each at-home measurement, a group analysis was performed using a linear regression model followed by ANOVA, to investigate the effect of frailty on physical activity and gait. Correlation between at-home digital measurements and conventional in-laboratory assessments was also investigated.

RESULTS

Participants were highly compliant in wearing the accelerometers, as 94% indicated willingness to wear the wrist device, and 66% the lumbar device, for at least 1 week. Time spent in sedentary activity and time spent in moderate activity as measured from the wrist device, as well as average gait speed and its 95th percentile from the lumbar device were significantly different between frailty groups. Moderate correlations between digital measurements and self-reported physical activity were found.

CONCLUSIONS

This work highlights the feasibility of deploying DHTs in studies involving older individuals. The potential of digital measurements in distinguishing frailty phenotypes, while unobtrusively collecting unbiased data, thus minimizing participants' travels to sites, will be further assessed in a follow-up study.

Physical frailty, activity limitation and mortality in older Brazilians: longitudinal findings from FIBRA-BH study (2009-2019)

The aim was to investigate the longitudinal association between physical frailty and change in the profile of limitation to perform basic and instrumental activities of daily living (BADL and IADL) and mortality in a 10-year period in Brazilian community-dwelling older people. A longitudinal study was conducted with data from the Frailty in Brazilian Older People (FIBRA) study, 2009-2019. Physical frailty was categorized into vulnerability (pre-frail and frail) and robustness (non-frail). The generalized estimating equation and the Cox proportional hazards models were used in the data analysis. Out of 200 older people evaluated in 2009 (moment 1), 139 were located in 2019 (moment 2). Of these, 102 were interviewed and 37 deaths were recorded. The chance of vulnerable older people at moment 1 being dependent on performing BADL at moment 2 was 4.19-fold the chance of robust older people. For IADL, the chance of vulnerable older people at moment 1 being dependent at moment 2 was 3.12-fold the chance of robust older people. Cox's analysis showed that the risk of death among vulnerable older people was 2.50-fold that among robust older people. The results reinforce the importance of monitoring and early intervention to prevent frailty, and the limitation to performing activities of daily living and death among Brazilian older people.

Veterans Aging Cohort Study Index and Frailty: One Part of the Whole

In HIV medicine, the Veterans Aging Cohort Study (VACS) index is associated to some geriatric syndromes and has also been recently used as a proxy of frailty. However, using it as a proxy for the frailty phenotype may inadvertently interchange two different concepts. The purpose of this study was to evaluate to what extent the frailty phenotype may be explained by the index. Cross-sectional analysis included 393 participants with HIV aged 50 or older. Somers' delta (d) was calculated, and a multinomial logistic regression model was run to determine to what extent the VACS index scores explained the probability of being prefrail or frail. Mean age was 57.6 (standard deviation 6.5) years and 87.3% men. A weak, but positive association between the VACS 2.0 index score and the frailty phenotype was established (Somers' d = 0.120, p < .001). The multinomial logistic regression showed that prefrail and frail participants had higher probabilities for greater VACS index scores [OR = 1.05, 95% confidence intervals (CI) 1.01-1.09; p = .006 and OR = 1.17, 95% CI 1.09-1.26; p < .001, respectively]; however, VACS index only explained <12% of the variability observed in the frailty phenotype. High VACS index scores were associated with a greater probability of being frail; however, with a weak association. Thus, we should be cautious when using the VACS index as a general proxy of frailty, particularly for the frailty phenotype. However, the VACS index may be used as a means to identify persons who might benefit from further comprehensive geriatric assessment.

Systematic review of the utility of the frailty index and frailty phenotype to predict all-cause mortality in older people

BACKGROUND

Current guidelines for healthcare of community-dwelling older people advocate screening for frailty to predict adverse health outcomes, but there is no consensus on the optimum instrument to use in such settings. The objective of this systematic review of population studies was to compare the ability of the frailty index (FI) and frailty phenotype (FP) instruments to predict all-cause mortality in older people.

METHODS

Studies published before 27 July 2022 were identified using Ovid MEDLINE, Embase, Scopus, Web of Science and CINAHL databases. The eligibility criteria were population-based prospective studies of community-dwelling older adults (aged 65 years or older) and evaluation of both the FI and FP for prediction of all-cause mortality. The Scottish Intercollegiate Guidelines Network's Methodology checklist was used to assess study quality. The areas under the receiver operator characteristic curves (AUC) were compared, and the proportions of included studies that achieved acceptable discriminatory power (AUC>0.7) were calculated for each frailty instrument. The results were stratified by the use of continuous or categorical formats of each instrument. The review was reported in accordance with the PRISMA and SWiM guidelines.

RESULTS

Among 8 studies (range: 909 to 7713 participants), both FI and FP had comparable predictive power for all-cause mortality. The AUC values ranged from 0.66 to 0.84 for FI continuous, 0.60 to 0.80 for FI categorical, 0.63 to 0.80 for FP continuous and 0.57 to 0.79 for FP categorical. The proportion of studies achieving acceptable discriminatory power were 75%, 50%, 63%, and 50%, respectively. The predictive ability of each frailty instrument was unaltered by the number of included items.

CONCLUSIONS

Despite differences in their content, both the FI and FP instruments had modest but comparable ability to predict all-cause mortality. The use of continuous rather than categorical formats in either instrument enhanced their ability to predict all-cause mortality.

The Tilburg Frailty Indicator: A psychometric systematic review

BACKGROUND

The Tilburg Frailty Indicator (TFI) is one of the most prominent multidimensional frailty assessment instruments. This review aimed to critically appraise and summarise its measurement properties.

METHODS

Reports were eligible if they included results of studies aimed at developing the TFI or evaluating its measurement properties. We performed a literature search in MEDLINE, CINAHL, and PsycINFO databases from their inception until December 8, 2021. We also searched grey literature databases. We assessed the methodological quality of the included studies using the "COSMIN Risk of Bias". The measurement properties were evaluated using specific criteria. We graded the quality of the evidence using a GRADE approach.

RESULTS

Sixty-three studies were included. We found moderate sufficient evidence for TFI content validity, although it is still insufficient for the comprehensiveness of its items. TFI construct validity was based on sufficient evidence from two studies of its structural validity as well as multiple hypothesis-testing for construct validity studies with inconsistent results. We did not find any studies that assessed cross-cultural validity. Only one of TFI's three dimensions showed sufficient evidence for the internal consistency of its scores, and results in test-retest reliability were inconsistent. The TFI showed high sufficient concurrent validity with the comprehensive geriatric assessment. We identified several studies assessing its predictive validity for adverse frailty-related outcomes, although most of the evidence from these studies was insufficient. We did not find any studies that assessed the responsiveness of TFI scores.

CONCLUSIONS

The TFI had evidence gaps in several relevant measurement properties. Further research is needed to strengthen its usefulness as a clinical decision-making tool.

Relationship between the Kihon Checklist and all-cause hospitalization among community-dwelling older adults

AIM

To examine the relationship between the Kihon Checklist (KCL) and incidence of hospitalization among community-dwelling older adults.

METHOD

We analyzed the cohort data of 2920 community-dwelling adults aged ≥65 years, who were living independently in a city in Shiga prefecture. We investigated the frailty status, instrumental activities of daily living, physical function, nutritional status, oral function, homebound status, cognitive function and mood using the KCL in the baseline survey. The outcome was incident all-cause hospitalization in the 2-year period. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationships between the frailty status and each domain of the KCL as well as all-cause hospitalization.

RESULTS

The prevalence of frailty, pre-frailty and robustness were 29.7%, 34.5% and 35.8%, respectively. During the 2-year follow-up period, 417 participants (14.3%) underwent an incident of all-cause hospitalization. The participants with frailty (adjusted OR 1.38, 95% CI 1.05-1.81) had a significantly elevated incidence of hospitalization according to the multivariate analysis compared with patients with robustness, but not in participants with pre-frailty (adjusted OR 1.07, 95% CI 0.82-1.40). Participants with low physical function (adjusted OR 1.45, 95% CI 1.12-1.87) and depressed mood (adjusted OR 1.35, 95% CI 1.08-1.70) had a significantly elevated incidence of hospitalization according to multivariate analysis compared with non-risk.

CONCLUSION

These results suggest that older adults with frailty are more likely to be hospitalized and that the KCL may be the screening tool to estimate the hospitalization risk. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.

Frail by different measures: a comparison of 8-year mortality in The Irish Longitudinal Study on Ageing (TILDA)

PURPOSE

We compared the ability of four frailty identification tools (frailty phenotype: FP; FRAIL scale; 32-item Frailty Index: FI; and Clinical Frailty Scale: CFS) to predict 8-year mortality in TILDA.

METHODS

We included wave 1 (2010) participants with data for all four tools. Mortality was ascertained at wave 5 (2018). Age, sex and education-adjusted binary logistic regression models were computed.

RESULTS

At baseline, there were 5700 participants (mean age 63, range 50-98, 54% women). Frailty prevalences were 2.3% by FRAIL, 3.8% by FP, 10.9% by CFS, and 12.8% by FI. Mortality was 41.2%, 44.9%, 25.3% and 27.0%, respectively. The highest adjusted OR for mortality was for FRAIL (OR 4.48, 95% CI 2.93-6.85, P < 0.001), followed by FP (OR 3.55, 95% CI 2.52-5.00, P < 0.001), FI (OR 2.10, 95% CI 1.68-2.62, P < 0.001), and CFS (OR 1.88, 95% CI 1.48-2.38, P < 0.001).

CONCLUSIONS

All tools significantly predicted mortality, but FRAIL and FP seemed more specific.

Frailty and Cognitive Function in Older Adults: A Systematic Review and Meta-Analysis of Cross-Sectional Studies

The relationship between cognitive function and frailty among older adults is a growing area of research due to the implications of cognitive and physical decline for functional independence in late life. Multiple studies demonstrate a meaningful relationship between these two factors, which together may constitute increased risk of negative health outcomes for older adults. The current analysis was conducted to 1) systematically review current evidence for differences in cognitive performance based on frailty status among older adults and provide quantitative evidence for the magnitude of this effect, and 2) assess the influence of demographic and methodological variables on this effect. The preregistered protocol (CRD42018087138) included a search of EBSCOhost, Pubmed, and Embase online databases and reference lists to identify cross-sectional studies comparing frail and non-frail or robust older adults (60+) on cognitive performance. In total, 42 effects were retrieved from 38 studies, expressed as Hedges' g, and pooled based on a random-effects model. Results indicated an overall significant, negative effect of frailty status on cognitive function among tests of global cognitive function (g = 0.734: 95% CI = 0.601-0.867) and individual cognitive domains (g = 0.439: 95% CI = 0.342-0.535). Age, frailty assessment used, and cognitive status of the sample did not significantly moderate the overall effect. Post-hoc moderator analysis revealed that difference in mean age of frail and robust groups significantly moderated the overall effect (R² = 0.38, β = .0974, 95% CI = 0.0537-0.141). Implications for future research are discussed.

Frailty, walking ability and self-rated health in predicting institutionalization: an 18-year follow-up study among Finnish community-dwelling older people

Background

In clinical practice, there is a need for an instrument to screen older people at risk of institutionalization.

Aims

To analyze the association of frailty, walking-ability and self-rated health (SRH) with institutionalization in Finnish community-dwelling older people.

Methods

In this prospective study with 10- and 18-year follow-ups, frailty was assessed using FRAIL Scale (FS) (n = 1087), Frailty Index (FI) (n = 1061) and PRISMA-7 (n = 1055). Walking ability was assessed as self-reported ability to walk 400 m (n = 1101). SRH was assessed by a question of general SRH (n = 1105). Cox regression model was used to analyze the association of the explanatory variables with institutionalization.

Results

The mean age of the participants was 73.0 (range 64.0‒97.0) years. Prevalence of institutionalization was 40.8%. In unadjusted models, frailty was associated with a higher risk of institutionalization by FS in 10-year follow-up, and FI in both follow-ups. Associations by FI persisted after age- and gender-adjustments in both follow-ups. By PRISMA-7, frailty predicted a higher risk of institutionalization in both follow-ups. In unadjusted models, inability to walk 400 m predicted a higher risk of institutionalization in both follow-ups and after adjustments in 10-year follow-up. Poor SRH predicted a higher risk of institutionalization in unadjusted models in both follow-ups and after adjustments in 10-year follow-up.

Discussion

Simple self-reported items of walking ability and SRH seemed to be comparable with frailty indexes in predicting institutionalization among community-dwelling older people in 10-year follow-up.

Conclusions

In clinical practice, self-reported walking ability and SRH could be used to screen those at risk.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01551-x) contains supplementary material, which is available to authorized users.

Predictive performance of 7 frailty instruments for short-term disability, falls and hospitalization among Chinese community-dwelling older adults: A prospective cohort study

BACKGROUND

Frailty becomes a great challenge with population aging. The proactive identification of frailty is considered as a rational solution in the community. Previous studies found that frailty instruments had insufficient predictive accuracy for adverse outcomes, but they mainly focused on long-term outcomes and constructed frailty instruments based on available data not original forms. The predictive performance of original frailty instruments for short-term outcomes in community-dwelling older adults remains unknown.

OBJECTIVE

To examine the predictive performance of seven frailty instruments in their original forms for 1-year incident outcomes among community-dwelling older adults.

DESIGN

A prospective cohort study.

SETTINGS

A total of 22 communities were selected by a stratified sampling method from one Chinese city.

PARTICIPANTS

A total of 749 older adults aged ≥ 60 years (mean age of 69.2 years, 69.8% female) were followed up after 1 year.

METHODS

Baseline frailty was assessed by three purely physical dimensional instruments (i.e. Frailty Phenotype, the Study of Osteoporotic Fracture and FRAIL Scale) and four multidimensional instruments (i.e. Frailty Index, Groningen Frailty Indicator, Tilburg Frailty Indicator and Comprehensive Frailty Assessment Instrument), respectively. Outcomes included incident disability, falls, hospitalization and the combined outcome at 1-year follow-up. The receiver operating characteristic curves were plotted to assess the predictive performance of frailty instruments.

RESULTS

The areas under the curves of seven frailty instruments in predicting incident outcomes ranged from 0.55 [95% confidence interval (CI): 0.51-0.60] to 0.67 (95% CI: 0.61-0.72), with high specificity (72.3-99.2%) and low sensitivity (4.0-49.6%). Four multidimensional instruments had much higher sensitivity (20.9-49.6% versus 4.0-11.7%) than three purely physical dimensional instruments. Overall, the Frailty Index was more accurate than some instruments in predicting incident outcomes, while several self-report instruments had comparable predictive accuracy to the Frailty Index for all (FRAIL Scale) or some (Groningen Frailty Indicator and Tilburg Frailty Indicator) of the incident outcomes.

CONCLUSIONS

All frailty instruments have inadequate predictive accuracy for short-term outcomes among community-dwelling older adults. The Frailty Index roughly performs better but self-report instruments are comparable to the Frailty Index for all or some of the outcomes. An accurate frailty instrument needs to be developed, and the simple self-report instruments could be used temporarily as practical and efficient tools in primary care.

Portals to frailty? Data-driven analyses detect early frailty profiles

BACKGROUND

Frailty is an aging condition that reflects multisystem decline and an increased risk for adverse outcomes, including differential cognitive decline and impairment. Two prominent approaches for measuring frailty are the frailty phenotype and the frailty index. We explored a complementary data-driven approach for frailty assessment that could detect early frailty profiles (or subtypes) in relatively healthy older adults. Specifically, we tested whether (1) modalities of early frailty profiles could be empirically determined, (2) the extracted profiles were differentially related to longitudinal cognitive decline, and (3) the profile and prediction patterns were robust for males and females.

METHODS

Participants (n = 649; M age = 70.61, range 53-95) were community-dwelling older adults from the Victoria Longitudinal Study who contributed data for baseline multi-morbidity assessment and longitudinal cognitive trajectory analyses. An exploratory factor analysis on 50 multi-morbidity items produced 7 separable health domains. The proportion of deficits in each domain was calculated and used as continuous indicators in a data-driven latent profile analysis (LPA). We subsequently examined how frailty profiles related to the level and rate of change in a latent neurocognitive speed variable.

RESULTS

LPA results distinguished three profiles: not-clinically-frail (NCF; characterized by limited impairment across indicators; 84%), mobility-type frailty (MTF; characterized by impaired mobility function; 9%), and respiratory-type frailty (RTF; characterized by impaired respiratory function; 7%). These profiles showed differential neurocognitive slowing, such that MTF was associated with the steepest decline, followed by RTF, and then NCF. The baseline frailty index scores were the highest for MTF and RTF and increased over time. All observations were robust across sex.

CONCLUSIONS

A data-driven approach to early frailty assessment detected differentiable profiles that may be characterized as morbidity-intensive portals into broader and chronic frailty. Early inventions targeting mobility or respiratory deficits may have positive downstream effects on frailty progression and cognitive decline.

Frailty in community-dwelling older people: comparing screening instruments

OBJECTIVE:

To compare the Edmonton Frail Scale (EFS) and Clinical-Functional Vulnerability Index-20 (CFVI-20) instruments regarding degree of agreement and correlation and compare descriptive models with frailty-associated variables in community-dwelling older people in Brazil.

METHODS:

Cross-sectional study, nested in a population-based and household cohort. Baseline sampling was calculated based on a probabilistic approach by conglomerate in two stages. In the first stage, census tract was used as sampling unit. In the second, the number of households was defined according to the population density of individuals aged ≥ 60 years. The Kappa statistic evaluated the agreement between instruments and Pearson's coefficient their correlation. Factors associated with frailty and high risk of clinical-functional vulnerability were identified by multiple analysis of Poisson regression with robust variance.

RESULTS:

Kappa statistics was 0.599 and Pearson's correlation coefficient 0.755 (p < 0.001). The EFS found a 28.2% prevalence of frailty, and the CFVI-20 found a 19.5% prevalence of high risk of clinical-functional vulnerability. Age equal to or greater than 80 years, history of stroke, polypharmacy, negative self-perceived health, fall in the past 12 months, and hospitalization in the past 12 months were variables associated with frailty in both instruments after multiple analysis. Less than four years of education, osteoarticular disease, and weight loss were associated with frailty only by EFS, and having a caregiver was associated with a high risk of clinical-functional vulnerability only by CFVI-20.

CONCLUSIONS:

Although the analyses show moderate agreement and strong positive correlation between the instruments, the indicated prevalence of frailty is discrepant. Our results attest the need to standardize the instrument for assessing frailty in community-dwelling older people.

Frailty and mortality: an 18-year follow-up study among Finnish community-dwelling older people

BACKGROUND

There is a lack of agreement about applicable instrument to screen frailty in clinical settings.

AIMS

To analyze the association between frailty and mortality in Finnish community-dwelling older people.

METHODS

This was a prospective study with 10- and 18-year follow-ups. Frailty was assessed using FRAIL scale (FS) (n = 1152), Rockwood's frailty index (FI) (n = 1126), and PRISMA-7 (n = 1124). To analyze the association between frailty and mortality, Cox regression model was used.

RESULTS

Prevalence of frailty varied from 2 to 24% based on the index used. In unadjusted models, frailty was associated with higher mortality according to FS (hazard ratio 7.96 [95% confidence interval 5.10-12.41] in 10-year follow-up, and 6.32 [4.17-9.57] in 18-year follow-up) and FI (5.97 [4.13-8.64], and 3.95 [3.16-4.94], respectively) in both follow-ups. Also being pre-frail was associated with higher mortality according to both indexes in both follow-ups (FS 2.19 [1.78-2.69], and 1.69 [1.46-1.96]; FI 1.81[1.25-2.62], and 1.31 [1.07-1.61], respectively). Associations persisted even after adjustments. Also according to PRISMA-7, a binary index (robust or frail), frailty was associated with higher mortality in 10- (4.41 [3.55-5.34]) and 18-year follow-ups (3.78 [3.19-4.49]).

DISCUSSION

Frailty was associated with higher mortality risk according to all three frailty screening instrument used. Simple and fast frailty indexes, FS and PRISMA-7, seemed to be comparable with a multidimensional time-consuming FI in predicting mortality among community-dwelling Finnish older people.

CONCLUSIONS

FS and PRISMA-7 are applicable frailty screening instruments in clinical setting among community-dwelling Finnish older people.

Comparison of 6 frailty screening tools in diagnostic properties among Chinese community-dwelling older people

We aimed to compare the diagnostic test accuracy (DTA) of six frailty screening tools against comprehensive geriatric assessment (CGA) in the community. A total of 1177 community-dwelling older people were recruited. Frailty was assessed by purely physical tools including Physical Frailty Phenotype (PFP), FRAIL (fatigue, resistance, ambulation, illness and loss of weight), Study of Osteoporotic Fracture (SOF), and multidimensional tools including Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI) and Comprehensive Frailty Assessment Instrument (CFAI). The receiver operating characteristic curve analyses were performed. The GFI, TFI and CFAI [areas under the curve (AUCs): 0.78-0.80] had better diagnostic accuracy than SOF, PFP and FRAIL (AUCs: 0.69-0.72) (χ²: 6.37-26.76, P<.05). The optimal cut-offs for the PFP, FRAIL and SOF were identical to their original prefrail cut-offs. These results implicate that the multidimensional tools are more effective to identify frailty in the whole community setting, while the self-report FRAIL may be used to identify the prefrail and facilitate early interventions particularly in the community setting with adequate healthcare resources.

Are frail elderly people in Europe high-need subjects? First evidence from the SPRINTT data

Physical frailty and sarcopenia (PF&S) has received growing attention in empirical models of health care use. However, few articles focused on objective measures of PF&S to assess the extent of care consumption among the frail population at risk of dependency. Using baseline data from the SPRINTT study, a sample of 1518 elderly people aged 70+ recruited in eleven European countries, we analyse the association between various PF&S measures and health care / long term care (LTC) use. Multiple health care and LTC outcomes are modelled using linear probability models adjusted for a range of individual characteristics and country fixed effects. We find that PF&S is associated with a significant increase in emergency admissions and hospitalizations, especially among low-income elders. All PF&S measures are significantly associated with increased use of formal and informal LTC. There is a moderating effect of income on LTC use: poor frail elders are more likely to use any of the formal LTC services than rich frail elders. Our results are robust to various statistical specifications. They suggest that the inclusion of PF&S in the eligibility criteria of public LTC allowances could contribute to decrease the economic gradient in care use among the elderly community-dwelling European population.

Comparing Diagnostic Properties of the FRAIL-NH Scale and 4 Frailty Screening Instruments among Chinese Institutionalized Older Adults

OBJECTIVE

To examine the diagnostic test accuracy (DTA) of the FRAIL-NH and four frailty screening instruments among institutionalized older adults.

DESIGN

Cross-sectional study.

SETTING

Institutionalized setting, Jinan, China.

PARTICIPANTS

A total of 305 older adults (mean age 79.3 ± 8.4 years, 57.0% female) were enrolled from nursing homes.

MEASUREMENTS

Frailty was assessed by the FRAIL-NH, Physical Frailty Phenotype (PFP), FRAIL, Tilburg Frailty Indicator (TFI), and Groningen Frailty Indicator (GFI), respectively. The Comprehensive Geriatric Assessment (CGA) was used as a reference standard of frailty. The receiver operating characteristic (ROC) curve was plotted to examine the DTA of five frailty screening instruments against the CGA. The optimal cut-point was determined by the maximum value of the Youden index (YI, calculated as sensitivity + specificity - 1).

RESULTS

The prevalence of frailty ranged from 25.9% (FRAIL) to 56.4% (GFI). Areas under the curve (AUCs) against the CGA ranged from 0.80 [95% confidence interval (CI) 0.74 - 0.85: FRAIL] to 0.83 (95% CI 0.78 - 0.88: PFP). At their original cut-points, all five frailty screening instruments presented low sensitivity (32.9% - 69.3%) and high specificity (80.0% - 93.8%), as well as high positive predictive values (90.7% - 94.9%) and low negative predictive values (33.2% - 48.1%). At their optimal cut-points, the sensitivity and specificity of the FRAIL-NH, PFP, and FRAIL tended to be balanced, and their correctly classified rates (76.1% - 81.3%) and kappa values (0.465 - 0.523) increased a lot. ROC contrasts showed that all five frailty screening instruments had similarly good diagnostic accuracy (χ2: 0.0003 - 1.38, P > .05).

CONCLUSION

In the institutionalized setting, the specific FRAIL-NH, self-report FRAIL, TFI, and GFI as well as hybrid PFP, show similarly good diagnostic properties in identifying frailty against the CGA.

Nutrition and frailty: Current knowledge

PURPOSE OF THE REVIEW

Nutrition, as part of lifestyle and modifiable environmental factors, constitutes an interesting approach for the prevention of geriatric syndromes. The objective of this review was to examine the most recent evidence on the association between nutrition, from dietary patterns to specific nutrients, and frailty, before the onset of disability, among elderly individuals.

RECENT FINDINGS

Based on available epidemiological studies, three meta-analyses published in 2018 have outlined a protective effect of greater adherence to a Mediterranean-type diet (MeDi) on the risk for frailty, with up to a 60% reduction in risk. Several studies focusing on particular food groups, macronutrients and micronutrients have also been published and have highlighted that a protein intake of 1 g/kg in body weight per day should be fulfilled (except for patients suffering from kidney or hepatic dysfunction) and that vitamin deficiencies should be avoided. Available interventional studies of nutritional supplements and/or physical activity programs have mainly been limited to disabled participants to date.

SUMMARY

Research efforts should target both developing a better understanding of the mechanisms underlying frailty and improving detection tools and the effectiveness of intervention studies, alongside efforts to address the specific needs of older people. For instance, ensuring an adequate nutritional status, by fighting the age-related increased prevalence of undernutrition or sarcopenic obesity, should be privileged.

Predictive Accuracy of Frailty Tools for Adverse Outcomes in a Cohort of Adults 80 Years and Older: A Decision Curve Analysis

OBJECTIVES

To compare the predictive performance of 3 frailty identification tools for mortality, hospitalization, and functional decline in adults aged ≥80 years using risk reclassification statistics and decision curve analysis.

DESIGN

Population-based, prospective cohort.

SETTING

BELFRAIL study, Belgium.

PARTICIPANTS

560 community-dwelling adults aged ≥80 years.

MEASUREMENTS

Frailty by Cardiovascular Health Study (CHS) phenotype, Longitudinal Aging Study Amsterdam (LASA) markers, and Groeningen Frailty Indicator (GFI); mortality until 5.1 ± 0.25 years from baseline and hospitalization until 3.0 ± 0.25 years; and functional status assessed by activities of daily living at baseline and after 1.7 ± 0.21 years.

RESULTS

Frailty prevalence was 7.3% by CHS phenotype, 21.6% by LASA markers, and 22% by GFI. Participants determined to be frail by each tool had a significantly higher risk for all-cause mortality and first hospitalization. For functional decline, only frail by GFI had a higher adjusted odds ratio. Harrell 's C-statistic for mortality and hospitalization and area under receiver operating characteristic curve for functional decline were similar for all tools and <0.70. Reclassification statistics showed improvement only by LASA markers for hospitalization and mortality. In decision curve analysis, all tools had higher net benefit than the 2 default strategies of "treat all" and "treat none" for mortality risk ≥20%, hospitalization risk ≥35%, and functional decline probability ≥10%, but their curves overlapped across all relevant risk thresholds for these outcomes.

CONCLUSIONS AND IMPLICATIONS

In a cohort of adults aged ≥80 years, 3 frailty tools based on different conceptualizations and assessment sources had comparable but unsatisfactory discrimination for predicting mortality, hospitalization, and functional decline. All showed clinical utility for predicting these outcomes over relevant risk thresholds, but none was significantly superior. Future research on frailty tools should include a focus on the specific group of adults aged ≥80 years, and the predictive accuracy for adverse outcomes of different tools needs a comprehensive assessment that includes decision curve analysis.

A comparison between physical and biopsychosocial measures of frailty: Prevalence and associated factors in Brazilian older adults

PURPOSE

To estimate the prevalence of frailty, according to Tilburg Frailty Indicator (TFI) and CHS index, to investigate the correlation between both instruments and to identify the factors associated with this condition in older users of primary health care.

METHODS

This is a sectional study with 302 individuals aged 60 years or more of Rio de Janeiro/Brazil. Sociodemographic, health, functional dependence and lifestyle variables were collected. Frailty was evaluated by the TFI (biopsychosocial frailty) and the CHS index (physical frailty).

RESULTS

The prevalence of frailty estimated by the TFI was 35.8% and by the CHS index was 23.5%, while 19.2% were considered frail by both instruments. Significant correlations were observed between the two measures (r = 0.675, p < 0.001) and between the CHS index and the physical (r = 0.744, p < 0.001) and psychological domains (r = 0.322, p < 0.001) of the TFI. Considering the TFI, sex, age, healthy lifestyle, osteoarticular diseases, stroke/ischemia and functional dependence in IADL were associated with frailty. By the CHS index, marital status, satisfaction with housing environment, osteoarticular diseases, medication, functional dependence in ADL and IADL were associated with frailty.

CONCLUSION

Our study demonstrates that the CHS index and the TFI identify different groups of frail older adults, and the factors associated with physical frailty and biopsychosocial frailty, also differ. Both instruments seem suitable to be used by primary health care professionals in Brazil. Nevertheless, we believe that a fully self-rated assessment is more practical to be applied routinely in this level of attention in the country.

Exploring the efficiency of the Tilburg Frailty Indicator: a review

Due to rapidly aging human populations, frailty has become an essential concept, as it identifies older people who have higher risk of adverse outcomes, such as disability, institutionalization, lower quality of life, and premature death. The Tilburg Frailty Indicator (TFI) is a user-friendly questionnaire based on a multidimensional approach to frailty, assessing physical, psychologic, and social aspects of human functioning. This review aims to explore the efficiency of the TFI in assessing frailty as a means to carry out research into the antecedents and consequences of frailty, and its use both in daily practice and for future intervention studies. Using a multidimensional approach to frailty, in contexts where health care professionals or researchers may have no time to interview or examine the client, we recommend employing the TFI because there is robust evidence of its reliability and validity and it is easy and quick to administer. More studies are needed to establish whether the TFI is suitable for intervention studies not only in the community, but also for specific groups such as patients in the hospital or admitted to an emergency department. We conclude that it is important to not only determine the deficits that frail older people may have, but also to assess their balancing strengths and resources. In order to be able to meet the individual needs of frail older persons, traditional and often fragmented elderly care should be developed toward a more proactive elderly care, in which frail older persons and their informal network are in charge.