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

Bidirectional relationship between diabetes and frailty in middle-aged and older adults: A systematic review and meta-analysis

BACKGROUND

Diabetes and frailty are prevalent and burdensome in middle-aged and older adults. However, current evidence on their association is inconsistent, and no quantitative meta-analysis exists. We conducted a systematic review and meta-analysis to examine whether diabetes increased the risk of frailty and vice versa.

METHODS

We systematically searched PubMed, Web of Science, Embase, and CINAHL databases from inception to 10 April 2025. Random-effects models were used to calculate pooled odds ratio (OR) and 95 % confidence interval (CI) for cross-sectional analysis and pooled relative risk (RR) for longitudinal analysis. The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS

From 8559 non-duplicated records, 31 articles were included. People with diabetes had increased risks of prevalent frailty (OR=2.21, 95 %CI: 1.60-3.06, I2=99.0 %, n = 15; GRADE=Low), prevalent pre-frailty (OR=2.23, 95 %CI: 2.19-2.28, I2=0.0 %, n = 2; GRADE=Very low), and incident frailty (RR=1.50, 95 %CI: 1.36-1.65, I2=0.0 %, n = 7; GRADE=Moderate). Those with pre-frailty (OR=1.95, 95 %CI: 1.61-2.36, I2=0.0 %; GRADE=Very low) but not with frailty (OR=2.28, 95 %CI:0.96-5.46, I2=92.3 %; GRADE=Very low) had increased odds of prevalent diabetes in two studies. In 15 studies, the pooled RRs for incident diabetes were 1.47 (95 %CI: 1.37-1.57, I2=91.0 %; GRADE=Moderate) in pre-frail participants and 1.96 (95 %CI: 1.73-2.23, I2=92.7 %; GRADE=Moderate) in frail participants.

CONCLUSION

Our findings support the bidirectional relationship between diabetes and frailty in middle-aged and older adults, with each condition contributing to the development of the other. This highlights the importance of early detection and integrated management strategies for diabetes and frailty.

Associations between social support and frailty and the mediating role of mental and physical health: evidence from CHARLS

BACKGROUND

Although studies have demonstrated associations between social support and frailty in older adults, the direction and underlying mechanisms of this relationship are yet to be better delineated. We aimed to investigate the association between different forms of social support and frailty, as well as the mediating role of physical and mental health in this association.

METHODS

Participants were adults aged ≥ 60 from the 2011 China Health and Retirement Longitudinal Study (CHARLS). Social support (including formal and informal support), physical health, and mental health were the main variables. Frailty was evaluated using the Physical Frailty Phenotype (PFP) scale, and the relationships among these variables were examined using a structural equation model (SEM).

RESULTS

The final analysis included 4,511 participants, with a median age of 66.0 years. And the prevalence of frailty was 7.7%. Frailty was found to be influenced by both formal (β = -0.221, P < 0.001) and informal social support (β = -0.221, P < 0.001). Moreover, formal and informal social support demonstrated positive associations with mental and physical health (β = 0.720, 0.347, 0.679, and 0.484, respectively, all P < 0.001). Mental and physical health were negatively associated with frailty (β = -0.374, -0.202, respectively, both P < 0.001).

CONCLUSIONS

The relationship between social support and frailty appears to be mediated by mental and physical health, primarily through psychological pathways. Therefore, comprehensive interventions aimed at improving social support and mental and physical health are recommended to prevent frailty.

Comparison of the long-term prognostic value of different frailty instruments in older inpatients: a 5-year prospective cohort study

BACKGROUND

Frailty is associated with increased mortality in older adults, but limited studies compare frailty instruments among inpatients with long-term follow-up.

AIMS

To evaluate five frailty scales for predicting 5-year all-cause mortality in older inpatients.

METHODS

This prospective cohort study enrolled 917 inpatients aged ≥ 65 years. We used five commonly used scales [Clinical Frailty Scale (CFS), FRAIL, Fried, Edmonton, and the comprehensive geriatric assessment-frailty index (CGA-FI)] to screen or assess frailty and then conducted a 5-year telephone follow-up. The primary endpoint was 5-year all-cause mortality. The predictive value of different frailty scales was compared using Kaplan-Meier (K-M) survival analysis, COX regression models, and the receiver operating characteristic (ROC) curves.

RESULTS

The prevalence of frailty ranged from 19.5 to 36.5%. Both K-M survival curves and Cox regression confirmed that frailty patients had higher mortality risk across all scales. After multivariate adjustment, the hazard ratios from highest to lowest, were: CGA-FI, FRAIL, Fried, CFS, and Edmonton (all p < 0.05). Frailty demonstrated moderate performance, with area under the curves (AUCs) ranging from 0.70 to 0.75 (all p < 0.001). CGA-FI had the largest AUC of 0.724, revealing the best predictive value, while FRAIL had the smallest AUC of 0.666. The AUCs of Fried, Edmonton, and CFS gradually decreased, with no statistical differences. Furthermore, CFS has the highest sensitivity (77.5%).

CONCLUSIONS

Frailty identified by all scales is associated with an increased risk of long-term mortality. CFS is the preferred frailty screening scale, while CGA-FI is the most accurate assessment scale. Trial registration ChiCTR1800017204 (07/18/2018).

Joint association of frailty index and biological age with chronic obstructive pulmonary disease: a cohort study from CHARLS

Chronic Obstructive Pulmonary Disease (COPD) is associated with frailty and ageing, but there is insufficient evidence from existing longitudinal studies. This research explored the longitudinal association between frailty, ageing and COPD. We used the China Health and Retirement Longitudinal Study (CHARLS) data to perform a cohort study. The study population was non-COPD patients in wave 1 (2011), and the outcome was the occurrence of COPD at the end of follow-up (wave 4-wave 5). Frailty was assessed using the CHARLS modified frailty index (CMFI), and ageing was evaluated using the biological age (BA). We used multivariate logistic regression to examine the longitudinal associations between CMFI and BA with COPD. Fitted curves were used to analyze the dose-response relationship of CMFI and BA with COPD. A 3D surface diagram was used to analyze the association between BA and CMFI with COPD. In addition, subgroup and sensitivity analyses were performed. 6452 non-COPD patients were enrolled in the study, and after follow-up, 616 participants were diagnosed with COPD. Logistic regression and fitted curves showed a positive correlation between CMFI and BA and the development of COPD. The risk of COPD increased by 19% for every one standard deviation (SD) increase in BA and 32% for every one SD increase in CMFI. A 3D surface diagram shows a joint association between CMFI and BA with the COPD. Subgroup and sensitivity analysis results are stable. This study found a joint association between CMFI and BA with COPD, suggesting that CMFI and BA are risk factors for the development of COPD.

Interpretable machine learning models to predict decline in intrinsic capacity among older adults in China: a prospective cohort study

BACKGROUND

Monitoring intrinsic capacity and implementing appropriate interventions can support healthy aging. There are, though, few tools available for predicting decline in intrinsic capacity among older adults. This study aimed to develop and validate an interpretable machine learning model designed to identify populations at elevated risk of a decline in intrinsic capacity.

METHODS

Using data from the China Health and Retirement Longitudinal Study baseline (2011) and 4-year follow-up (2015), a total of 822 participants were randomly allocated to a training set and a testing set at a 7:3 ratio. Five machine learning methods were employed to train the model and assess its performance through various metrics. The SHapley Additive exPlanation method was subsequently used to interpret the optimal model.

RESULTS

The 4-year incidence of decline in intrinsic capacity among the older adults in the sample was 44.6 % (n = 367). Nine variables were screened for model construction, among which eXtreme gradient boosting demonstrated the best predictive performance, achieving an area under the receiver operating characteristic curve (AUC) of 0.715 (95 % CI 0.651-0.780) in the testing set. The SHapley Additive exPlanation method identified educational level, smoking, handgrip strength, self-rated health, and residence as the top five significant predictors.

CONCLUSIONS

The developed model can serve as a highly effective tool for primary care teams to identify older adults with early signs of decline in intrinsic capacity, facilitating the provision of subsequent screening and tailored interventions for intrinsic capacity.

Association of frailty index with incidence of chronic kidney disease: China Health and Retirement Longitudinal Study

AIM

Frailty is an important risk factor for a wide range of chronic diseases and for mortality risk. This study aims to explore the relationship between frailty and incidence of chronic kidney disease (CKD), particularly on the change and accumulation of frailty.

METHODS

Frailty status was assessed using the frailty index (FI, constructed by 31 items) and categorized as robust, pre-frail, and frail. The accumulation and change in frailty were assessed on the basis of frailty status at baseline and a second survey 4 years after baseline. Logistic regression was used to estimate the association between frailty and developing CKD.

RESULTS

A total of 3597 participants (mean age: 59.08 ± 8.94 years old, male: 49.9%) from CHARLS were included. Participants with pre-frailty or frailty status had a higher risk of developing CKD compared with robust participants (pre-frail vs robust, OR 1.78, 95% CI 1.37-2.32, p < 0.001; frail vs robust, OR 2.52, 95% CI 1.67-3.79, p < 0.001). Participants who had a robust status in the two surveys had a significantly lower risk of developing CKD (OR 0.51, 95% CI 0.36-0.75, p < 0.001) compared with those who never had a robust status.

CONCLUSION

Frailty status is significantly associated with the incidence of CKD. The risk of CKD was lower in those who ever had a robust status than in participants who never had a robust status.

Pre-frailty is associated with higher risk of gastroesophageal reflux disease: a large prospective cohort study

To investigate the prospective association of frailty status, especially the early stage, with the long-term risk of Gastroesophageal reflux disease (GERD) in a large prospective cohort. We included participants who were free of GERD and cancer at baseline and use of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) from the UK Biobank (UKB). Frailty status was assessed using Fried phenotype including five items (weight loss, exhaustion, low grip strength, low physical activity, slow walking pace) and classified as non-frail, pre-frail, and frail. The outcome was incident GERD. The frailty status was assessed using Cox proportional hazard model. Among 327,965 participants (mean age 56.6 years) at baseline, 151,689 (46.3%) were pre-frail and 14,288 (4.4%) were frail. During a median of 13.5-years of follow-up, 31,027 (9.5%) participants developed GERD. Compared with non-frail participants, pre-frail (hazard ratios [HR] = 1.21, 95% confidence interval [CI] 1.18-1.24) and frail (HR = 1.60, 95% CI 1.52-1.68) participants had significantly higher risks of GERD. Among the five indicators of frailty, exhaustion demonstrated the strongest association with the risk of GERD (HR = 1.42, 95% CI 1.38-1.47). Subgroup analysis showed strong associations among younger (< 60 years), female, high-educated, unemployed participants, and those who had BMI < 18.5 kg/m2 (all P for interaction < 0.05). Frailty, especially pre-frail, which is potentially reversible, was associated with higher risk of GERD in middle-aged and older individuals. The findings underscore the importance of integrating routine frailty assessments and interventions, especially at the early stage, to improve digestive health.

Association between physical activity and frailty transitions in middle-aged and older adults: a nationwide longitudinal study

BACKGROUND

Frailty has become an important health problem in the middle-aged and older people population. Physical activity (PA) is a key intervention for frailty prevention and management. However, studies of the association between COVID-19 pre-pandemic PA and the worsening or improvement of frailty during the pandemic remain unclear.

METHODS

This longitudinal cohort study used data from the English Longitudinal Study of Ageing (ELSA), including participants aged 50 and over. Three intensities of PA (vigorous, moderate, and mild) were categorized as less than once per week and at least once per week, respectively, based on participant self-report. The frailty index (FI) assessed the frailty status, defining frailty as FI ≥ 25. Logistic regression was applied to examine the association between PA and frailty, estimating odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Of the 4379 non-frail participants at baseline (median age 67, 54.9% female), 8.1% developed frailty during a mean follow-up of 3.5 years. Among 564 frail participants at baseline (median age 71, 66.5% female), 17.9% regained health. Compared to those engaging in PA less than once per week, participants who engaged in vigorous (OR: 0.47 [95% CI: 0.35-0.62]), moderate (OR: 0.37 [95% CI: 0.29-0.48]), or mild (OR: 0.38 [95% CI: 0.26-0.56]) PA at least once a week had a lower risk of frailty worsening. Additionally, participants who engaged in moderate (OR: 2.04 [95% CI: 1.29-3.21]) or mild (OR: 2.93 [95% CI: 1.54-5.58]) PA at least once a week had a higher likelihood of frailty improvement. Sensitivity analyses based on comprehensive PA levels confirmed these findings. Participants who maintained at least one PA per week had lower frailty worsening (Vigorous, OR: 0.20 [95%CI: 0.12-0.33]; Moderate, OR: 0.13 [95%CI: 0.09-0.19]; Mild, OR: 0.20 [95%CI: 0.11-0.38]) and higher frailty improvement rates (Moderate, OR: 3.43 [95%CI: 1.93-6.11]; Mild, OR: 4.65 [95%CI: 1.90-11.42]). In addition, individuals (Vigorous, OR: 0.35 [95%CI: 0.20-0.60]; Moderate, OR: 0.36 [95%CI: 0.22-0.56]) who transitioned from inactive to active also exhibited a lower risk of frailty.

CONCLUSIONS

This study emphasized the critical role of PA in preventing and improving frailty in middle-aged and older people, especially during the COVID-19 pandemic. Our study also highlighted the importance of maintaining PA habits to reduce frailty risk and promote its improvement. Also, the study indicated that individuals who transitioned from inactive to active had a lower risk of frailty. These findings enriched the understanding of the association between PA and frailty and provided valuable insights for addressing the health impact of future pandemics on middle-aged and older people.

Analysis of the relationship between abdominal aortic calcification and frailty in the middle-aged and older US population

Background and Objective: Abdominal aortic calcification (AAC) is a marker of cardiovascular disease and is associated with increased mortality in middle-aged and older populations. However, its relationship with frailty remains unclear. Methods: Data were obtained from the 2013-2014 National Health and Nutrition Examination Survey. AAC was quantified using the Kauppila scoring system based on dual-energy X-ray absorptiometry. Frailty was assessed using the frailty index. Multivariable logistic regression models examined the association between AAC and frailty. Results: A total of 2987 adults aged ≥40 years were included. Compared to individuals with an AAC-8 score of 0, low-risk (AAC-8 score = 1-2; OR: 1.24; 95 % CI, 1.00-1.53) and high-risk AAC (AAC-8 score ≥ 3; OR: 1.83; 95 % CI, 1.03-3.23) were associated with higher odds of frailty. Similarly, mild to moderate AAC (0 < AAC-24 score ≤ 6; OR: 1.26; 95 % CI, 1.03-1.54) and severe AAC (AAC-24 score > 6; OR: 1.79; 95 % CI, 1.07-2.99) showed positive associations with frailty. Conclusions: Among middle-aged and older populations in the United States, there exists a positive correlation between AAC and frailty. Our findings suggest that the AAC score holds promise as a valuable tool for the early identification of frailty.

The validity of Turkish version of Social Frailty Index in older adults: An index of social attributes predictive of mortality

PURPOSE

The aim of this study was to examine the validity of Turkish version of Social Frailty Index in older adults.

MATERIAL AND METHODS

102 older adults aged 65 and over were included in the study. Hodkinson Mental Test was first applied to older adults. Older adults who scored 6 points or above were included. To evaluate the validity of "Social Frailty Index", Social Inclusion Scale, Older People's Quality of Life-Brief (OPQOL-Brief) and Lubben Social Network Scale were applied to the participants. To determine the reliability of "Social Frailty Index", the test was re-tested at one-week intervals on older adults who did not receive any treatment. Confirmatory factor analysis AMOS 23.0 was used to determine the conformity of the structure to the original model. For concurrent validity, the correlation analysis applied. Intraclass correlation coefficient (ICC [2,1], absolute agreement, 2-way random effects model) was used to determine the reliability of the scale.

RESULTS

The fit of the Turkish version of Social Frailty Index to the model described in the original article was determined to be acceptable-excellent (Demographics (DEM), General Resources and Life History (GRLH), Social Activities (SA) and Fulfillment of Basic Social Needs (FBSN)) (CMIN/DF=1.36, GFI=0.93, IFI=0.90, RMSEA=0.06 and SRMR=0.07). In the correlation analysis conducted to determine its concurrent validity, Social Frailty Index had a moderate correlation with Social Inclusion Scale (r: -0.47; p<0.001) and OPQOL-Brief (r: -0.47; p<0.001). Social Frailty Index had no correlation with Lubben Social Network Scale (r: -0.03; p: 0.81). Test-retest reliability of Social Frailty Index was excellent [ICC(2,1)=0.90, %95 CI 0.84-0.93, p<0.001].

CONCLUSION

The Turkish version of the Social Frailty Index is valid and can be used to predict mortality risk based on the estimated social risk. The adapted Social Frailty Index is not adequately capturing aspects related to the network and social support.

CLINICAL TRIALS NUMBER

NCT06288789.

The relationship between frailty and major adverse cardiovascular and cerebrovascular events in Chinese older adults: the mediating effect of lipid accumulation products

BACKGROUND

Previous studies have proven the relationship between frailty and major adverse cardiovascular and cerebrovascular events (MACCE). However, the potential mechanisms need to be further explored. This study aimed to investigate the mediating effect of lipid accumulation products (LAP) in the relationship between frailty and MACCE.

METHODS

This study recruited 7901 participants aged 45 and above from wave 2011 and 2018 of the China Longitudinal Study of Health and Retirement (CHARLS). Logistic regression models were employed to examine the relationship between frailty and MACCE and the mediating effects of LAP, using the bootstrap method to confirm path effects.

RESULTS

Frailty group presented the highest risk of MACCE (OR 1.07, 95% CI 1.03-1.10). Frailty directly impacted MACCE (β = 0.045, P = 0.007). Frailty had a significant effect on LAP (β = 12.21, P < 0.01), while LAP had a significant impact on MACCE (β = 11.14, p = 0.014). The mediation effect of LAP accounted for 1.7% of the total effect regarding the frailty with MACCE.

CONCLUSION

LAP mediate the relationship between frailty and MACCE. Our findings suggest that instructing frailty patients to have a reasonable diet and exercise to control LAP at a low level may be an effective measure to reduce MACCE.

Development and Validation of Prediction Models for Incident Reversible Cognitive Frailty Based on Social-Ecological Predictors Using Generalized Linear Mixed Model and Machine Learning Algorithms: A Prospective Cohort Study

This study aimed to develop and validate prediction models for incident reversible cognitive frailty (RCF) based on social-ecological predictors. Older adults aged ≥60 years from China Health and Retirement Longitudinal Study (CHARLS) 2011-2013 survey were included as training set (n = 1230). The generalized linear mixed model (GLMM), eXtreme Gradient Boosting, support vector machine, random forest, and Binary Mixed Model forest were used to develop prediction models. All models were evaluated internally with 5-fold cross-validation and evaluated externally via CHARLS 2013-2015 survey (n = 1631). Only GLMM showed good discrimination (AUC = 0.765, 95% CI = 0.736, 0.795) in training set, and all models showed fair discrimination (AUC = 0.578-0.667, 95% CI = 0.545, 0.725) in internal and external validation. All models showed acceptable calibration, overall prediction performance, and clinical usefulness in training and validation sets. Older adults were divided into three groups using risk score based on GLMM, which could assist healthcare providers to predict incident RCF, facilitating early identification of high-risk population.

Association of frailty index with new-onset diabetes: from the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND

To investigate the association of frailty status and its changes with new-onset diabetes.

METHODS

A total of 4638 participants from the China Health and Retirement Longitudinal Study (CHARLS) were included. Frailty status was assessed by the frailty index (FI) and categorized as robust, pre-frail, and frail. Changes in frailty were assessed based on frailty status at wave1 and wave3 of CHARLS. New-onset diabetes was identified by self-reported physician-diagnosed or diagnosed by glucose or glycosylated haemoglobin during follow-up period. Logistic regression was used to examine the association of frailty and outcomes.

RESULTS

51.6%, 38.1% and 10.3% of the individuals were respectively classified as robust, pre-frail, and frail at baseline. The risk of new-onset diabetes was significantly higher in the pre-frailty [odds ratio (OR) (95% confidence interval (CI)): 1.326 (1.101-1.597), p = 0.003)] and frailty [OR(95% CI): 1.721 (1.304-2.271), p < 0.001)] than the robust. A total of 3145 participants were included in the changes of frailty status analyses. Compared with the stable robust individuals, individuals who developed from robust to frailty status [OR (95%CI): 3.752 (1.647-8.547), p = 0.002] had an elevated risk of new-onset diabetes. In addition, participants who ever had a robust status in the two surveys had a significantly lower risk of new-onset diabetes compared to those who never had a robust status [OR (95%CI) 0.666 (0.483-0.920), p = 0.014)].

CONCLUSION

Frailty status is significantly associated with the risk of new-onset diabetes. The progression from robust to frailty or pre-frailty increased the risk of new-onset diabetes.

Exploring the mechanism of change in exercise behavior during a theory-based exercise intervention among community-dwelling (pre)frail older adults: A stepped wedge cluster randomized trial

This study evaluated the effectiveness of a theory-based exercise intervention on exercise beliefs and behavior, and clarified the underlying mechanism of the exercise intervention among community-dwelling (pre)frail older adults. A 12-week exercise intervention based on the integration of Health Belief Model, Theory of Planned Behavior and Health Action Process Approach was implemented to 149 participants. The positive effects were significant on exercise beliefs (β = -1.630 - 3.500, P < 0.05) and exercise behavior (β = 0.851, P < 0.001), and most of them persisted at 12- and 24-week postintervention. Furthermore, perceived barriers (β1β2 = 0.118, P = 0.037) and descriptive norms (β1β2 = 0.144, P = 0.047) mediated the relationship between exercise intervention and exercise behavior. The theory-based exercise intervention improves exercise beliefs and behavior, and perceived barriers and descriptive norms play a crucial role in increasing exercise behavior among the target population.

Effectiveness of a theory-underpinning exercise intervention among community-dwelling (pre)frail older adults: A stepped-wedge cluster-randomized trial

OBJECTIVES

To evaluate the effectiveness of a theory-underpinning exercise intervention among Chinese community-dwelling (pre)frail older adults, and the impacts of intervening late as opposed to intervening early.

METHODS

This was a stepped-wedge cluster-randomized trial. Participants were enrolled from six communities in a county of central China from January to November in 2021 (n = 149). A 12-week exercise intervention based on the integration of Health Belief Model, Theory of Planned Behavior and Health Action Process Approach was implemented among 149 community-dwelling (pre)frail older adults during the study period. The primary outcomes were frailty and muscle mass, muscle strength and physical performance. Secondary outcomes included physical disability, fear of falling, cognitive function, depressive symptoms, social support and quality of life. Assessments were conducted at baseline and at 12, 24 and 36 weeks. A multilevel regression model was used for statistical analysis.

RESULTS

The positive effects were statistically significant on frailty (β = -1.166, p = 0.016), muscle mass (β = 1.499, p = 0.005), handgrip strength (β = 14.758, p < 0.001), physical performance (Short Physical Performance Battery, β = 6.043, p < 0.001), physical disability (Activities of Daily Living: β = 0.462, p = 0.043; Instrumental Activities of Daily Living: β = 0.693, p = 0.049;) and fear of falling (β = -1.490, p = 0.003), cognitive function (β = -0.466, p = 0.011), depressive symptoms (β = -0.541, p < 0.001), social support (β = 27.661, p < 0.001), physical (β = 2.413, p = 0.013) and mental (β = 7.837, p < 0.001) components of quality of life at 0-week postintervention, and most of them persisted at 12- and 24-week postintervention. The effectiveness significantly differed by the time of interventions on muscle mass (β = -1.217, p = 0.002), 5-time chair stand test (β = -1.172, p = 0.018), cognitive function (β = 0.600, p = 0.014) and mental component of quality of life (β = -12.679, p = 0.002).

CONCLUSION

The theory-underpinning exercise intervention has positive immediate and persistent effects on frailty, frailty-related characteristics as well as physical, mental and social functioning among Chinese community-dwelling (pre)frail older adults. Late intervention attenuated the significant intervention effect.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100041981.

Unveiling the multi-dimensional frailty network among older cancer survivors in China: A network analysis study

INTRODUCTION

Frailty has a significant impact on the overall quality of life of older cancer survivors, but the relationships among frailty symptoms are not well understood. This study aims to explore the specific associations among multidimensional symptoms of frailty among older cancer survivors by employing network analysis to provide supportive evidence for targeted interventions in the future.

MATERIALS AND METHODS

Data were obtained by cluster sampling from three large Grade-A tertiary hospitals in Shandong Province, China, and collected through face-to-face interviews by trained investigators. We included patients who were diagnosed with a solid malignant tumor at the age of 60 years or older. Frailty indicators were measured by the Groningen Frailty Indicator (GFI) and analyzed primarily through network analysis, including network estimation, centrality, and stability analysis. The relative importance of a node in a network was tested by centrality analyses, and Spearman correlations were applied to estimate the relationships between symptom pairs (symptom score) and symptom clusters (standardized symptom score) in the symptom network. In terms of centrality, the indexes of strength, closeness, and betweenness were adopted to measure the importance of nodes.

RESULTS

Five hundred and eight older cancer survivors were included, with an average age of 68.4 years (standard deviation [SD] = 5.4), and a higher proportion were male (n = 307[60.4%]). The prevalence of frailty among older cancer survivors was 58.9% (n = 299), with a mean GFI score of 4.46 (SD = 2.87). The strongest edge was between "dressing and undressing" and "going to the toilet" (r = 0.58). The nodes with the higher strength centrality were "going to the toilet" (rS=1.09), "walking around outside" (rS=0.97), and "part of social network" (rS=0.96); and the nodes with the higher closeness centrality were "mark physical fitness" (rC=0.005), "calm and relaxed" (rC=0.005), and "nervous or downhearted" (rC=0.005).

DISCUSSION

This study demonstrated that older cancer survivors in China have a high prevalence of frailty, with self-care and social participation-related symptoms playing a key role in the multidimensional network of frailty symptoms. Psychological symptoms can rapidly influence other symptoms within this network. Therefore, prioritizing psychological symptoms in the assessment of older adults with cancer is essential for effective frailty management.

Psychometric Properties of the FRAIL Scale for Frailty Screening: A Scoping Review

OBJECTIVES

The aim of this study was to identify and map the available psychometric evidence of the FRAIL scale to screen frailty among older adults.

DESIGN

Scoping review of published articles on 9 databases (PubMed, Scopus, Web of Science, CINAHL, Cochrane, Embase, PsycINFO, VHL Regional Portal, and Epistemonikos) and 8 gray literature sources.

SETTING AND PARTICIPANTS

Studies in adults or older adults, in both inpatient and outpatient settings (without context restrictions).

METHODS

Cross-cultural adaptations, validity and reliability evidence studies, whose main objective was to develop and/or validate and/or culturally adapt the FRAIL Scale to assess frailty in adults or older adults, published since 2007 were included in this scoping review. The databases were searched between February and March 2023.The JBI methodology for scoping reviews was used to guide the process. The protocol of this study was registered on the Open Science Framework platform.

RESULTS

Of the 1031 records found during the search, 40 articles that met the established criteria for analysis were included. Nearly 1 in 10 countries worldwide (11.9%) have psychometric evidence regarding this scale. Ten studies were identified with the goal of cross-cultural adaptation and/or validation in a different cultural context for the first time. Twenty-one of 40 studies used Morley 2012 operationalization of FRAIL Scale criteria. Thirty-nine studies provided evidence of associations with other variables. The rest of the evidence for content, internal structure, response processes, and reliability was only evaluated in cross-cultural adaptation studies, with limitations.

CONCLUSIONS AND IMPLICATIONS

In conclusion, there is some evidence of validity for FRAIL Scale; nevertheless, studies are needed to adapt the scale to new cultures, using rigorous Cross-Cultural Adaptation processes, and to provide new evidence of validity and reliability, to strengthen and consolidate the body of knowledge for its application to various patient groups and context.

Internet use and frailty in middle-aged and older adults: findings from developed and developing countries

BACKGROUND

With increasing trend of internet use in all age groups, whether internet use can prevent frailty in middle-aged and older adults remains unclear.

METHODS

Five cohorts, including Health and Retirement Study (HRS), China Health and Retirement Longitudinal Study (CHARLS), the Survey of Health, Ageing and Retirement in Europe (SHARE), English Longitudinal Study of Aging (ELSA), and Mexican Health and Aging Study (MHAS), were used in this study. Internet use, social isolation, and frailty status was assessed using similar questions. The Generalized estimating equations models, random effects meta-analysis, COX regression, and mediation analysis were utilized.

RESULTS

In the multicohort study, a total of 155,695 participants were included in main analysis. The proportion of internet use was varied across countries, ranging from 5.56% in China (CHARLS) to 83.46% in Denmark (SHARE). According to the generalized estimating equations models and meta-analysis, internet use was inversely associated with frailty, with the pooled ORs (95%CIs) of 0.72 (0.67,0.79). The COX regression also showed that participants with internet use had a lower risk of frailty incidence. Additionally, the association was partially mediated by social isolation and slightly pronounced in participants aged 65 and over, male, not working for payment, not married or partnered, not smoking, drinking, and not co-residence with children.

CONCLUSIONS

Our findings highlight the important role of internet use in preventing frailty and recommend more engagements in social communication and activities to avoid social isolation among middle-aged and older adults.

The impact of frailty on short-term prognosis in discharged adult stroke patients: A multicenter prospective cohort study

BACKGROUND

Frailty is commonly observed in stroke patients and it is associated with adverse outcomes. However, there remains a gap in longitudinal studies investigating the causal relationship between baseline frailty and short-term prognosis in discharged adult stroke patients.

OBJECTIVE

To examine the causal impact of frailty on non-elective readmission and major adverse cardiac and cerebral events, and investigate its associations with cognitive impairment and post-stroke disability.

DESIGN

A multicenter prospective cohort study.

SETTING

Two tertiary hospitals in Central and Northwest China.

PARTICIPANTS

667 adult stroke patients in stroke units were included from January 2022 to June 2022.

METHODS

Baseline frailty was assessed by the Frailty Scale. Custom-designed questions were utilized to assess non-elective readmission and major adverse cardiac and cerebral events as primary outcomes. Cognitive impairment, assessed using the Mini-Mental State Examination Scale (MMSE), and post-stroke disability, measured with the Modified Rankin Scale (mRS), were considered secondary outcomes at a 3-month follow-up. The impact of baseline frailty on non-elective readmission and major adverse cardiac and cerebral events was examined using bivariate and multiple Cox regression analyses. Furthermore, associations between baseline frailty and cognitive impairment, or post-stroke disability, were investigated through generalized linear models.

RESULTS

A total of 5 participants died, 12 had major adverse cardiac and cerebral events, and 57 had non-selective readmission among 667 adult stroke patients. Frailty was an independent risk factor for non-selective readmission (hazard ratio [HR]: 2.71, 95 % confidence interval [CI]: 1.59, 4.62) and major adverse cardiac and cerebral events (HR: 3.77, 95 % CI: 1.07, 13.22) for stroke patients. Baseline frailty was correlated with cognitive impairment (regression coefficient [β]: -2.68, 95 % CI: -3.78, -1.58) adjusting for socio-demographic and clinical factors and follow-up interval. However, the relationship between frailty and cognitive impairment did not reach statistical significance when further adjusting for baseline MMSE (β: -0.39, 95 % CI: -1.43, 0.64). Moreover, baseline frailty was associated with post-stroke disability (β: 0.36, 95 % CI: 0.08, 0.65) adjusting for socio-demographic and clinical variables, follow-up interval, and baseline mRS.

CONCLUSIONS

The finding highlights the importance of assessing baseline frailty in discharged adult stroke patients, as it is significantly associated with non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability at 3 months. These results highlight the crucial role of screening and evaluating frailty status in improving short-term prognosis for adult stroke patients. Interventions should be developed to address baseline frailty and mitigate the short-term prognosis of stroke.

TWEETABLE ABSTRACT

Baseline frailty predicts non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability in adult stroke patients. @haiyanhexyyy.

Preserved Ratio Impaired Spirometry and COPD Accelerate Frailty Progression: Evidence From a Prospective Cohort Study

BACKGROUND

COPD has been found to be associated with frailty. However, longitudinal evidence for associations of COPD with frailty progression is inadequate. Furthermore, recent studies revealed a new phenotype of lung function impairment: preserved ratio impaired spirometry (PRISm) findings. Associations of PRISm findings and their transitions with frailty progression are unclear.

RESEARCH QUESTION

What are the associations of PRISm findings, transitions of PRISm findings, and COPD with frailty progression?

STUDY DESIGN AND METHODS

To analyze the associations of PRISm findings and COPD with frailty progression, 5,901 patients were included from the English Longitudinal Study of Ageing. Patients were classified into three lung function patterns of normal spirometry (NS) findings, PRISm findings, and COPD. Frailty progression was assessed by repeated measurements of the frailty index (FI) during follow-up. Among these 5,901 patients, 3,765 patients were included to analyze the associations of PRISm findings transitions with frailty progression. PRISm findings transitions were assessed based on the changes of lung function patterns after a 4-year interval. Linear mixed-effect models were used for statistical analyses.

RESULTS

The median follow-up periods were 9.5 years for the analyses of PRISm findings and COPD with frailty progression and 5.8 years for PRISm findings transitions with frailty progression. When compared with participants with NS findings, patients with PRISm findings and COPD demonstrated accelerated FI progression with additional annual increases of 0.301 (95% CI, 0.211-0.392; P < .001) and 0.172 (95% CI, 0.102-0.242; P < .001), respectively. Patients who transitioned from NS findings to PRISm findings also demonstrated accelerated FI progression when compared with those with stable NS findings (β = 0.242; 95% CI, 0.008-0.476; P = .042). However, no accelerated FI progression was found in patients with PRISm findings who transitioned to NS findings (β = 0.119; 95% CI, -0.181 to 0.418; P = .438).

INTERPRETATION

Our findings indicate that PRISm findings and COPD are associated with accelerated frailty progression. Further studies are needed to elucidate the causality of the association of PRISm findings and COPD with frailty.

Changes in frailty and incident cardiovascular disease in three prospective cohorts

BACKGROUND AND AIMS

Previous studies found that frailty was an important risk factor for cardiovascular disease (CVD). However, previous studies only focused on baseline frailty status, not taking into consideration the changes in frailty status during follow-up. The aim of this study was to investigate the associations of changes in frailty status with incident CVD.

METHODS

This study used data of three prospective cohorts: China Health and Retirement Longitudinal Study (CHARLS), English Longitudinal Study of Ageing (ELSA), and Health and Retirement Study (HRS). Frailty status was evaluated by the Rockwood frailty index and classified as robust, pre-frail, or frail. Changes in frailty status were assessed by frailty status at baseline and the second survey which was two years after the baseline. Cardiovascular disease was ascertained by self-reported physician-diagnosed heart disease (including angina, heart attack, congestive heart failure, and other heart problems) or stroke. Cox proportional hazard models were used to calculate the hazard ratio (HR) and 95% confidence interval (95% CI) after adjusting for potential confounders.

RESULTS

A total of 7116 participants from CHARLS (female: 48.6%, mean age: 57.4 years), 5303 from ELSA (female: 57.7%, mean age: 63.7 years), and 7266 from HRS (female: 64.9%, mean age: 65.1 years) were included according to inclusion and exclusion criteria. The median follow-up periods were 5.0 years in the CHARLS, 10.7 years in the ELSA, and 9.5 years in the HRS. Compared with stable robust participants, robust participants who progressed to pre-frail or frail status had increased risks of incident CVD (CHARLS, HR = 1.84, 95% CI: 1.54-2.21; ELSA, HR = 1.53, 95% CI: 1.25-1.86; HRS, HR = 1.59, 95% CI: 1.31-1.92). In contrast, frail participants who recovered to robust or pre-frail status presented decreased risks of incident CVD (CHARLS, HR = 0.62, 95% CI: 0.47-0.81; ELSA, HR = 0.49, 95% CI: 0.34-0.69; HRS, HR = 0.70, 95% CI: 0.55-0.89) when compared with stable frail participants. These decreased risks of incident CVD were also observed in pre-frail participants who recovered to robust status (CHARLS, HR = 0.66, 95% CI: 0.52-0.83; ELSA, HR = 0.65, 95% CI: 0.49-0.85; HRS, HR = 0.71, 95% CI: 0.56-0.91) when compared with stable pre-frail participants.

CONCLUSIONS

Different changes in frailty status are associated with different risks of incident CVD. Progression of frailty status increases incident CVD risks, while recovery of frailty status decreases incident CVD risks.

Development and validation of a preliminary clinical support system for measuring the probability of incident 2-year (pre)frailty among community-dwelling older adults: A prospective cohort study

OBJECTIVE

To develop the wed-based system for predicting risk of (pre)frailty among community-dwelling older adults.

MATERIALS AND METHODS

(Pre)frailty was determined by physical frailty phenotype scale. A total of 2802 robust older adults aged ≥60 years from the China Health and Retirement Longitudinal Study (CHARLS) 2013-2015 survey were randomly assigned to derivation or internal validation cohort at a ratio of 8:2. Logistic regression, Random Forest, Support Vector Machine and eXtreme Gradient Boosting (XGBoost) were used to construct (pre)frailty prediction models. The Grid search and 5-fold cross validation were combined to find the optimal parameters. All models were evaluated externally using the temporal validation method via the CHARLS 2011-2013 survey. The (pre)frailty predictive system was web-based and built upon representational state transfer application program interfaces.

RESULTS

The incidence of (pre)frailty was 34.2 % in derivation cohort, 34.8 % in internal validation cohort, and 32.4 % in external validation cohort. The XGBoost model achieved better prediction performance in derivation and internal validation cohorts, and all models had similar performance in external validation cohort. For internal validation cohort, XGBoost model showed acceptable discrimination (AUC: 0.701, 95 % CI: [0.655-0.746]), calibration (p-value of Hosmer-Lemeshow test > 0.05; good agreement on calibration plot), overall performance (Brier score: 0.200), and clinical usefulness (decision curve analysis: more net benefit than default strategies within the threshold of 0.15-0.80). The top 3 of 14 important predictors generally available in community were age, waist circumference and cognitive function. We embedded XGBoost model into the server and this (pre)frailty predictive system is accessible at http://www.frailtyprediction.com.cn. A nomogram was also conducted to enhance the practical use.

CONCLUSIONS

A user-friendly web-based system was developed with good performance to assist healthcare providers to measure the probability of being (pre)frail among community-dwelling older adults in the next two years, facilitating the early identification of high-risk population of (pre)frailty. Further research is needed to validate this preliminary system across more controlled cohorts.

Use of the Tilburg frailty indicator in longitudinal studies with older adults: A scoping review

AIM

To understand how researchers applied the Tilburg Frailty Indicator (TFI) to older adults. The use of the TFI was examined based on the Integral Conceptual Model of Frailty (ICMF).

DESIGN

A scoping review.

DATA SOURCES

A database search was conducted without a time limit in PubMed, CINAHL, Embase and the Cochrane library. A hand search was also conducted.

REVIEW METHODS

Research questions were developed based on the population-concept-context framework suggested by the Joanna Briggs Institute (2017). Studies were included if topics were related to the use of the TFI or ICMF and designs were longitudinal studies.

RESULTS

A total of 37 studies met the inclusion criteria. Studies were reviewed according to the tested pathways of the ICMF: determinants of frailty or adverse outcomes, adverse outcomes of frailty and comparison of predictive power between frailty measures.

CONCLUSION

The TFI is a useful tool to screen for frailty and predict health outcomes in older adults. Among the pathways of the ICMF, relationships between social factors and frailty were reported in several studies. Despite this relationship, social factors were considered as items to assess the social domain of frailty rather than determinants of frailty. The predictive power of the TFI was not superior to other frailty measures, but it had a high sensitivity.

IMPACT

This study demonstrates the usability of the TFI in older adults living in various conditions. Further studies are required to identify more effective ways to screen frailty using the TFI.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement in this study.

Social frailty as a predictor of adverse outcomes among older adults: a systematic review and meta-analysis

BACKGROUND

With the aging of the population, frailty has attracted much attention, and the social dimension of frailty, namely social frailty, has also attracted attention. Studies have shown that social frailty can bring some adverse effects to the elderly, such as physical and cognitive function.

AIMS

To explore the risk of adverse health outcomes in older adults with social frailty compared with older adults with non-social frailty.

METHODS

Five databases were systematically searched from inception to February 28, 2023. Screening, data extraction and quality assessment were conducted independently by two researchers. The included studies were longitudinal studies of adverse outcomes in community-dwelling socially frail older adults, and the quality of each study was assessed using the Newcastle‒Ottawa Scale.

RESULTS

A total of 15 studies were included based on the inclusion criteria, of which 4 were subjected to meta-analysis. The mean age of the included population ranged from 66.3 to 86.5 years. According to existing research, social frailty was predictive of some adverse outcomes, such as incident disability, depressive symptoms, and reduced neuropsychological function. The meta-analysis showed that social frailty had a significant predictive effect on mortality among older adults [HR = 2.27, (95% CI = 1.03-5.00)].

CONCLUSION

In community-dwelling older adults, social frailty was a predictor of mortality, incident disability, depressive symptoms and other adverse outcomes. Social frailty had a negative impact on older adults, so it was necessary to strengthen the screening of social frailty to reduce the incidence of adverse outcomes.

Associations of metabolic heterogeneity of obesity with frailty progression: Results from two prospective cohorts

BACKGROUND

Previous studies indicated that obesity would accelerate frailty progression. However, obesity is heterogeneous by different metabolic status. The associations of metabolic heterogeneity of obesity with frailty progression remain unclear.

METHODS

A total of 6730 participants from the China Health and Retirement Longitudinal Study (CHARLS) and 4713 from the English Longitudinal Study of Ageing (ELSA) were included at baseline. Metabolic heterogeneity of obesity was evaluated based on four obesity and metabolic phenotypes as metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy overweight/obesity (MHOO), and metabolically unhealthy overweight/obesity (MUOO). Frailty status was assessed by the frailty index (FI) ranging from 0 to 100 and frailty was defined as FI ≥ 25. Linear mixed-effect models were used to analyse the associations of metabolic heterogeneity of obesity with frailty progression.

RESULTS

In the CHARLS, MUOO and MUNW presented the accelerated FI progression with additional annual increases of 0.284 (95% CI: 0.155 to 0.413, P < 0.001) and 0.169 (95% CI: 0.035 to 0.303, P = 0.013) as compared with MHNW. MHOO presented no accelerated FI progression (β: -0.011, 95% CI: -0.196 to 0.173, P = 0.904) as compared with MHNW. In the ELSA, the accelerated FI progression was marginally significant for MUOO (β: 0.103, 95% CI: -0.005 to 0.210, P = 0.061) and MUNW (β: 0.157, 95% CI: -0.011 to 0.324, P = 0.066), but not for MHOO (β: -0.047, 95% CI: -0.157 to 0.062, P = 0.396) in comparison with MHNW. The associations of MUOO and MUNW with the accelerated FI progression were stronger after excluding the baseline frail participants in both cohorts. The metabolic status changed over time. When compared with stable MHNW, participants who changed from MHNW to MUNW presented the accelerated FI progression with additional annual increases of 0.356 (95% CI: 0.113 to 0.599, P = 0.004) and 0.255 (95% CI: 0.033 to 0.477, P = 0.024) in the CHARLS and ELSA, respectively. The accelerated FI progression was also found in MHOO participants who transitioned to MUOO (CHARLS, β: 0.358, 95% CI: 0.053 to 0.663, P = 0.022; ELSA, β: 0.210, 95% CI: 0.049 to 0.370, P = 0.011).

CONCLUSIONS

Metabolically unhealthy overweight/obesity and normal weight, but not metabolically healthy overweight/obesity, accelerated frailty progression as compared with metabolically healthy normal weight. Regardless of obesity status, transitions from healthy metabolic status to unhealthy metabolic status accelerated frailty progression as compared with stable metabolically healthy normal weight. Our findings highlight the important role of metabolic status in frailty progression and recommend the stratified management of obesity based on metabolic status.

Comparison of the Clinical-Functional Vulnerability Index and the frailty phenotype for the identification of falls in older individuals: A cross-sectional study

BACKGROUND

Frailty increases the risk of falls, disability and death in older adults. The Cardiovascular Health Study identified a frailty phenotype (the Fried Phenotype) that was primarily based on physical domains. Instruments that incorporate additional domains (e.g., cognitive, disability or mood) may more accurately identify falls.

OBJECTIVES

The study aimed i) to evaluate the association between falls and the number of phenotypes identified by the Fried Phenotype and CFVI-20 scores and ii) to compare the strength of the association between falls and each frailty instrument.

METHODS

This study used the CFVI-20 and the Fried Phenotype and reported falls during the last twelve months. Logistic regression models, odds ratios (ORs), and ROC curves were used to identify associations and perform comparisons (p<0.05). The reporting of the study followed the Strobe guidelines.

RESULTS

This study included 1,826 individuals (mean 70.9 (SD 7.3) years old). Prevalence of pre-frailty and low vulnerability was high (72% and 69%) and comparable between frailty instruments. The number of Fried phenotypes increased the odds of having fallen in the past 12 months (OR: 1.5 to 29.5) and the CFVI-20 scores (11% increase/unit change). The CFVI-20 identified falls more accurately than the Fried Phenotype (AUC: 0.68 vs. 0.60, p < 0.001).

CONCLUSIONS

The number of phenotypes and the CFVI-20 scores were associated with falls; continuous scores identified falls more accurately than categorical classifications. The CFVI-20 was more strongly associated with falls in community-dwelling older adults than the Fried Phenotype.

Frailty Transitions in Older Persons With Lung Function Impairment: A Population-Based Study

BACKGROUND

The aging population and its burden on health care systems warrant early detection of patients at risk of functional decline and mortality. We aimed to assess frailty transitions and its accuracy for mortality prediction in participants with impaired spirometry (Preserved Ratio Impaired Spirometry [PRISm] or chronic obstructive pulmonary disease [COPD]).

METHODS

In participants from the population-based Rotterdam Study (mean age 69.1 ± 8.9 years), we examined whether PRISm (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ≥ 70% and FEV1 < 80%) or COPD (FEV1/FVC < 70%) affected frailty transitions (progression/recovery between frailty states [robust, prefrailty, and frailty], lost to follow-up, or death) using age-, sex- and smoking state-adjusted multinomial regression models yielding odds ratios (OR). Second, we assessed the diagnostic accuracy of frailty score for predicting mortality in participants with COPD using c-statistics.

RESULTS

Compared to participants with normal spirometry, participants with PRISm were more likely to transit from robust (OR 2.2 [1.2-4.2], p < .05) or prefrailty (OR 2.6 [1.3-5.5], p < .01) toward frailty. Participants with PRISm (OR 0.4 [0.2-0.8], p < .05) and COPD (OR 0.6 [0.4-1.0], NS) were less likely to recover from their frail state, and were more likely to progress from any frailty state toward death (OR between 1.1 and 2.8, p < .01). Accuracy for predicting mortality in participants with COPD significantly improved when adding frailty score to age, sex, and smoking status (90.5 [82.3-89.8] vs 77.9 [67.2-88.6], p < .05).

CONCLUSION

Participants with PRISm or COPD more often developed frailty with poor reversibility. Assessing physical frailty improved risk stratification for participants with impaired spirometry for predicting increased life years.

Frailty as a Predictor of Adverse Outcomes among Spanish Community-Dwelling Older Adults

Spain is one of the European countries with the oldest populations. The prevalence of frailty among Spanish older people ranges from 8.4 to 29.4% and currently, is one of the most relevant public health challenges. The Tilburg Frailty indicator (TFI) has been widely used in the community and in healthcare settings for assessing frailty. The objective of this study is to evaluate the predictive performance of the TFI for several adverse outcomes among Spanish community-dwelling older adults. The predictive performance was tested through linear regression analyses and receiver operating characteristics (ROC) curves. A total of 552 Spanish older adults composed the study sample. Participants were assessed at baseline and after 6 months. Main results showed that frailty was strongly and significantly correlated with disability, physical health, mental health and falls efficacy. The TFI score predicted most of these adverse outcomes. The ROC analyses confirmed the acceptable predictive performance of the total frailty. This study provides new evidence confirming that the TFI is a valid tool to predict several adverse outcomes in Spanish older adults, which may allow professionals to plan and activate health and social care resources to support frail patients' needs.

Consistency in the prevalence and associated factors of frailty determined by two instruments among hospitalised older adults: A cross-sectional study

AIMS AND OBJECTIVES

To investigate the consistency in the prevalence and associated factors of frailty determined by the physical-originated Fatigue, Resistance, Ambulation, Illnesses and Loss of weight (FRAIL) scale and the multidimensional Tilburg Frailty Indicators (TFI) scale.

BACKGROUND

Accurate assessment of frailty and the identification of its associated factors could guide the development and implementation of holistic and individualised treatment plan. However, recommendations regarding the selection of frailty assessment tools are inconclusive.

DESIGN

This is a cross-sectional study, the reporting of which followed the STROBE guidelines.

METHODS

A total of 1220 older adults were recruited from a university affiliated tertiary hospital in Xi'an City, Northwest China, and administrated with a social-demographic and health-related information sheet, the FRAIL, the TFI, the Short-Form Mini-Nutritional Assessment, the Pittsburgh Sleep Quality Index and the 5-level EuroQol 5 dimensions questionnaire. Descriptive statistics and binary logistic regression analysis were used to investigate the prevalence of frailty and its associated factors.

RESULTS

The prevalence of physical-originated and multidimensional frailty was 55.2% and 77.6%, respectively. The consistency between the two scales was low. Taking the combined use of the two instruments as the reference, the TFI and FRAIL could identify 89.99% and 64.02% of the participants with frailty. Polypharmacy, health-related quality of life and sleep quality were found to be associated with both physical-originated and multidimensional frailty. Nutritional status and level of physical activity were additionally identified as the independent associated factors of multidimensional frailty.

CONCLUSIONS

The prevalence of frailty among hospitalised older adults is high. There is low consistency between the FRAIL and TFI in detecting frailty. The TFI exhibited higher sensitivity in detecting individuals with frailty and its associated factors.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study supported a single use of the TFI for the assessment of frailty in the hospital setting.

Diagnostic accuracy of the frail scale plus functional measures for frailty screening

BACKGROUND

There is little knowledge of the diagnostic accuracy of screening programmes for frailty in primary care settings.

AIM

To assess a two-step strategy consisting of the administration of the FRAIL scale to those who are non-dependent, aged ≥75 years, followed-up by measurement of the Short Physical Performance Battery (SPPB) or gait speed in those who are positive.

DESIGN & SETTING

Cross-sectional and longitudinal cohort study. Analysis of primary care data from the FRAILTOOLS project at five European cities.

METHOD

All patients consecutively attending were enrolled. They received the index tests plus the Fried phenotype and the frailty index to assess their frailty status. Mortality and worsening of dependency in basic (BADL) and instrumental (IADL) activities of daily living over a year were ascertained.

RESULTS

Prevalence of frailty based on frailty phenotype was 14.9% in the 362 participants. A FRAIL scale score ≥1 had a sensitivity of 83.3% (95%CI:73.1-93.6) to detect frailty. A positive result and a SPPB score <11 had a sensitivity of 72.2% (95%CI: 59.9-84.6); when combined with a gait speed <1.1 m/s, the sensitivity was 80% (95%CI: 68.5-91.5). Two thirds of those screened as positive were not frail. In the best scenario, sensitivities of this last combination to detect IADL and BADL worsening were 69.4% (95%CI: 59.4-79.4) and 63.6% (95%CI: 53.4-73.9).

CONCLUSION

Combining the FRAIL scale with other functional measures offers an acceptable screening approach for frailty. Accurate prediction of worsening dependency and death need to be confirmed through the piloting of a frailty screening programme.

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.

Variability and agreement of frailty measures and risk of falls, hospital admissions and mortality in TILDA

Little is known about the within-person variability of different frailty instruments, their agreement over time, and whether use of repeat assessments could improve the strength of associations with adverse health outcomes. Repeat measurements recorded in 2010–2011 (Wave 1) and 2012 (Wave 2) from The Irish Longitudinal Study on Ageing (TILDA) were used to classify individuals with frailty using the frailty phenotype (FP) and frailty index (FI). Within-person variability and agreement of frailty classifications were assessed using ANOVA and kappa (K) statistics, respectively. Associations of each frailty measure (wave 1, wave 2, or mean of both waves) with risk of falls, hospitalisations and all-cause mortality were assessed using logistic regression. Among 7455 individuals (mean age 64.7 [SD 9.9] years), within-person SD was 0.664 units (95% CI 0.654–0.671) for FP and 2 health deficits (SD 0.050 [0.048–0.051]) for FI. Agreement of frailty was modest for both measures, but higher for FI (K 0.600 [0.584–0.615]) than FP (K 0.370 [0.348–0.401]). The odds ratios (ORs) for all-cause mortality were higher for frailty assessed using the mean of two versus single measurements for FI (ORs for mortality 3.5 [2.6–4.9] vs. 2.7 [1.9–3.4], respectively) and FP (ORs for mortality 6.9 [4.6–10.3] vs. 4.0 [2.8–5.635], respectively). Frailty scores based on single measurements had substantial within-person variability, but the agreement in classification of frailty was higher for FI than FP. Frailty assessed using the mean of two or more measurements recorded at separate visits was more strongly associated with adverse health outcomes than those recorded at a single visit.

Effects of social support on frailty trajectory classes among community-dwelling older adults: The mediating role of depressive symptoms and physical activity

OBJECTIVES

To investigate whether and how social support influenced frailty progression through depressive symptoms and physical activity.

METHODS

Of 1235 community-dwelling older adults enrolled at baseline, 778 (63.0%) undergoing at least one yearly follow-up were included in the final analysis. Data were collected on frailty, social support, depressive symptoms, physical activity and covariates.

RESULTS

Two frailty trajectory classes were identified and labeled as alleviated frailty and deteriorated frailty. Subjective support prevented the deterioration of frailty through decreased depressive symptoms, while objective support and support utilization prevented the deterioration of frailty through increased physical activity.

CONCLUSIONS

The pathways through which social support ameliorates frailty vary by support types. Subjective support interventions should be included in the multifactorial interdisciplinary management of frailty to address social and psychological vulnerabilities, along with objective support and support utilization interventions addressing physical inactivity.

T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis

BACKGROUND

Despite the magnitude of fracture and the consequences in patients receiving hemodialysis, optimal risk assessment tools in this population are not well explored. Frailty and falls-known risk factors for fracture in chronic kidney disease (CKD) and non-CKD populations-are common in patients receiving hemodialysis (HD) therapy. While the relationship between T scores in relation to fractures in patients receiving HD is recognized, there is a paucity of data to the additional contributions of fracture assessment tool (FRAX), frailty status, and falls in its relationship with fracture.

OBJECTIVES

To evaluate the clinical utility of adding FRAX, frailty status, and falls to T scores at the femoral neck to determine whether it enhances fracture discrimination in patients on maintenance HD.

DESIGN

A cross-sectional observational study.

SETTING

Two main dialysis units in Regina, Saskatchewan, Canada.

PATIENTS

A total of 109 patients on maintenance HD at two dialysis units from January 1, 2017, to December 31, 2018, were included in the study.

MEASUREMENTS

Fracture (the main outcome) was documented based on the review of medical charts, self-recall, and additionally vertebral fractures were identified by an x-ray. Areal bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). FRAX score was calculated using an online algorithm based on 11 clinical risk factors. We calculated the FRAX score for hip fracture and major osteoprotoic fracture with and without the inclusion of BMD. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Patients were enquired about the history and frequency of falls.

METHODS

A total of 131 patients underwent frailty assessments at the two dialysis units during the dialysis treatment. Following frailty assessments, they were referred for DXA scans and upon receipt of the results undertook FRAX questionnaires. They were additionally sent for lumbar x-rays and contacted for a history of falls. Association between the BMD-T score, FRAX, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. Differences were considered statistically significant at P values <.05.

RESULTS

A total of 109 patients were included in the data analysis. The composite of fracture occurred in 37.6% of patients. About 59.3% were identified as frail, and 29% of the participants had at least one fall in the last year. On multivariate regression analysis, each lower standard deviation (SD) in femoral neck T score was associated with 48% higher odds of fracture (odds ratio [OR] = 1.48; 95% confidence interval [CI] 1.20-1.68, P = .005). With the inclusion for FRAX scores (hip), the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04-1.63, P = .043). The addition of frailty status and history of falls did not further improve the model. Low T score and FRAX were both independent risk factors in patients on HD therapy.

LIMITATIONS

This is a single-center study with a small sample size which limits the generalizability of the findings. Due to the cross-sectional study, associations identified may be difficult to interpret.

CONCLUSIONS

Both BMD measurements by DXA and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Larger prospective studies are needed to determine whether the inclusion of frailty and falls to the conventional models will improve fracture assessment in the population receiving HD.

TRIAL REGISTRATION

The study was not registered on a publicly accessible registry as it did not involve health care intervention on human participants.

An early predictive model of frailty for older inpatients according to nutritional risk: protocol for a cohort study in China

BACKGROUND

Previous reports suggest that the attributes of frailty are multidimensional and include nutrition, cognition, mentality, and other aspects. We aim to develop an early warning model of frailty based on nutritional risk screening and apply the frailty early warning model in the clinic to screen high-risk patients and provide corresponding intervention target information.

METHODS

The proposed study includes two stages. In the first stage, we aim to develop a prediction model of frailty among older inpatients with nutritional risk. Study data were collected from a population-based aging cohort study in China. A prospective cohort study design will be used in the second stage of the study. We will recruit 266 older inpatients (age 65 years or older) with nutritional risk, and we will apply the frailty model in the clinic to explore the predictive ability of the model in participants, assess patients' health outcomes with implementation of the frailty model, and compare the model with existing frailty assessment tools. Patients' health outcomes will be measured at admission and at 30-day follow-up.

DISCUSSION

This project is the first to develop an early prediction model of frailty for older inpatients according to nutritional risk in a nationally representative sample of Chinese older inpatients of tertiary hospitals. The results will hopefully help to promote the development of more detailed frailty assessment tools according to nutritional risk, which may ultimately lead to reduced health care costs and improvement in independence and quality of life among geriatric patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1800017682 , registered August 9, 2018; and ChiCTR2100044148 , registered March 11, 2021.