Biopsychosocial frailty and the risk of incident dementia: The Italian longitudinal study on aging

The association between social frailty, psychological resilience, and subsequent cognitive outcomes in older adults: A prospective cohort study

BACKGROUND

The associations among social frailty, psychological resilience, and cognitive function, as well as their variations across sex and age, remain to be explored. The objective of the present study was to investigate these complex relationships in older adults.

METHODS

This study included 5555 participants from the CLHLS and categorized them into socially robust (n = 2229; 40.12%), social pre-frailty (n = 2624; 47.24%), and social frailty (n = 702; 12.64%) groups. The relationship between social frailty and cognitive outcomes was analyzed using logistic regression models and restricted cubic splines. The combined effects of social frailty and psychological resilience on cognitive outcomes were also analyzed. The mediating role of psychological resilience was evaluated using the SPSS PROCESS macro program.

RESULTS

Social pre-frailty (odds ratio [OR]: 1.81, 95%CI: 1.48-2.21) and social frailty (OR: 2.40, 95%CI: 1.87-3.09) were positively associated with cognitive impairment. Furthermore, social pre-frailty (OR: 1.71, 95%CI: 1.47-2.00), and social frailty (OR: 2.10, 95%CI: 1.69-2.60) were also positively associated with greater cognitive decline. Adverse cognitive outcomes demonstrated a nonlinear relationship with social frailty. Compared to individuals with social robustness and high psychological resilience, those with social frailty and low psychological resilience demonstrated higher odds ratios of developing cognitive impairment (OR: 3.65, 95%CI: 2.61-5.10) and experiencing greater cognitive decline (OR: 3.05; 95%CI: 2.33-4.00). The relationship between social frailty and negative cognitive outcomes was more pronounced among women and individuals younger than 80 years and exhibited a nonlinear pattern. Psychological resilience mediated the relationship between social frailty and cognitive outcomes in men (β = -0.0091, P < 0.05) and individuals with advanced age (β = -0.0087, P < 0.05).

CONCLUSIONS

Social frailty is an independent influencing factor of adverse cognitive outcomes. Psychological resilience mediates the relationship between social frailty and cognitive function in men and subjects of advanced age.

Physical and biopsychosocial frailty, cognitive phenotypes, and plasma biomarkers for Alzheimer's disease in Chinese older adults: A population-based study

INTRODUCTION

We sought to examine the associations of physical frailty (PF) and biopsychological frailty (BF) with dementia and mild cognitive impairment (MCI) among Chinese older adults and further to explore neuropathological mechanisms underlying the associations.

METHODS

This population-based cross-sectional study included 5149 participants in the MIND-China baseline examination (2018); of these, we measured plasma amyloid-β (Aβ), neurofilament light chain (NfL), and total tau in 1371 persons and phosphorylated tau 217 (p-tau217) and glial fibrillary acidic protein (GFAP) in 3387 persons.

RESULTS

PF and BF were significantly associated with increased likelihoods of dementia, Alzheimer's disease (AD), vascular dementia (VaD), and MCI. PF was significantly correlated with increased plasma p-tau217, GFAP, and NfL, and reduced Aβ42/Aβ40 ratio; BF was related to higher plasma total tau and NfL and lower Aβ42/Aβ40 ratio. PF in combination with demographics performed excellent in differentiating dementia from non-dementia (area under the curve [AUC] = 0.83).

DISCUSSION

PF and BF are potential clinical biomarkers for dementia and MCI in older adults. Alzheimer's pathology, neuroinflammation, and neurodegeneration may underlie their associations.

HIGHLIGHTS

Physical (PF) and biopsychosocial frailty (BF) were strongly associated with dementia and mild cognitive impairment (MCI) in rural Chinese older adults. Frailty, especially PF, was associated with increased plasma phosphorylated tau 217 (p-tau217), glial fibrillary acidic protein (GFAP), and neurofilament light chain (NfL) and a reduced plasma amyloid-β (Aβ)42/Aβ40 ratio. Alzheimer's pathology, neuroinflammation, and neurodegeneration may underlie the associations of frailty with dementia. PF, in combination with demographic factors, performed excellent (area under the curve [AUC] = 0.83) in differentiating dementia from non-dementia in rural older adults.

The Biological Rationale for Integrating Intrinsic Capacity Into Frailty Models

The assessment and management of two function-centered clinical care models, frailty and intrinsic capacity decline have been proposed to achieve healthy aging. To implement these two care models, several different guidelines have been advocated by different health organizations, which has resulted in confusion and cost-ineffective results in healthcare practice. Although there are various operational definitions and screening tools of frailty, the most accepted operational definitions are based on the recognition of frailty phenotypes or deficit accumulation-based frailty indexes. Intrinsic capacity, referred to as the total physical and mental capacities for individual to undertake daily tasks in everyday life, is another care model, including five domains. Similar or identical instruments have been used to assess frailty and intrinsic capacity. In the present narrative review, we outlined the biological rationale for integrating intrinsic capacity into frailty models and highlighted the hierarchical and energy-dependent order of the intrinsic capacity domains. The vitality domain or energy metabolism-related capacity, is the highest order dimension and the basis of other intrinsic capacity domains. Vitality vulnerability manifests as a pre-frailty status in function-centered healthy aging. We provided a conceptual framework of frailty phenotypes and frailty indexes based on the hierarchical and energy-dependent order of the intrinsic capacity domains, particularly vitality capacity. To facilitate the clinical translation of the framework, some potential energy metabolism-related biomarkers have also been proposed as critical components for assessing and screening vitality capacity in older age. The integrating framework not only provides testable theoretical hypotheses, particularly about vitality as a foundational element in aging, but could serve as a starting point for further research to unravel the mechanisms of frailty. It also improves cost-effectiveness for optimizing aging interventions in clinical healthcare and public health policies of healthy aging.

Social frailty in older adults: A concept analysis

BACKGROUND

Social frailty has been increasingly prevalent due to the aging populations. This concept is a relatively new topic in the gerontology. Older adults experiencing social isolation because of social frailty remain in a state of loneliness or depression. Many misconceptions exist regarding the association between social frailty and high levels of loneliness and depression in older adults, which may exacerbate their condition.

OBJECTIVE

To analyze the concept of social frailty on the basis of method introduced by Rodgers and Knafl.

DESIGN

Rodgers and Knafl' evolutionary concept analysis INFORMATION SOURCES: PubMed, Cochrane Library, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase were searched for the terms "Social frailty" and "Elderly" OR "Older adults" OR "Aged."

RESULTS

A total of 65 articles on social frailty were selected from 4 databases and subjected to concept analysis based on Rodgers and Knafl' evolutionary concept. Data extraction and analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The analysis yielded 4 domains (11 subdomains) of antecedents, 3 attributes, and 2 domains (28 subdomains) of consequences.

CONCLUSION

The study findings contribute to a comprehensive and structured understanding of social frailty for health-care workers and the general public. Emphasizing the concept of social frailty can increase the levels of awareness and vigilance among health-care workers regarding the risks associated with social frailty in older adults.

Risk prediction model of physical frailty for a rural older population: a cross-sectional study in Hunan Province, China

Introduction

Physical frailty is a common medical syndrome characterized by low muscle strength, low endurance, and reduced physiological function that leads to significantly negative health outcomes in older adults. This study investigated the risk variables among rural older adults in Hunan Province, China, and developed a physical frailty prediction model to inform policymaking to enhance their health and well-being.

Methods

This study was conducted from July 22 to September 3, 2022. A total of 291 participants were recruited using stratified cluster random sampling from five large villages in Hunan Province. Frailty screening was performed based on the Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight (FRAIL) scale, Geriatric Depression Scale 15-item version (GDS-15), Falls Efficacy Scale-International (FES-I), and Mini Nutrition Assessment-Short Form (MNA-SF). A logistic regression analysis was performed to identify the predictive factors for physical frailty and develop a physical frailty prediction model based on the area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, and Youden index.

Results

The physical frailty prevalence among rural older adults in Hunan Province was 21.31% (n = 62). Household income and expenditure [odds ratio (OR): 1.826, 95% confidence interval (CI): 1.142-2.918], physical exercise frequency (OR: 1.669, 95% CI: 1.137-2.451), depressive symptoms (OR: 9.069, 95% CI: 3.497-23.516), and fear of falling (OR: 3.135, 95% CI: 1.689-5.818) were identified as significant predictors of physical frailty in rural older individuals. The AUC for the frailty predictive model was 0.860 (95% CI: 0.805, 0.914). The sensitivity and specificity at the optimal cutoff value were 80.6 and 76.0%, respectively, with a Youden index of 0.566.

Conclusion

The prediction model constructed in this study demonstrated promise as a potential tool for evaluating physical frailty risk in older adults, which can contribute to healthcare providers' screenings for high-risk populations. Further multidimensional and experimental intervention studies should be conducted to prevent the occurrence and delay the progression of physical frailty in older adults.

Association of Longitudinal Trajectories of Physical Frailty With Dementia Status in Older Adults: A National Cohort Study

BACKGROUND AND OBJECTIVES

The longitudinal patterns of change in physical frailty and their associations with the subsequent dementia risk remain unclear. This study aimed to (1) explore the long-term trajectories of physical frailty over a 6-year period in older adults without dementia at baseline; (2) identify the socio-demographic and health-related factors associated with different physical frailty trajectories; and (3) examine the longitudinal relationships between different physical frailty trajectories and subsequent risk of dementia.

RESEARCH DESIGN AND METHODS

This national cohort study used data from the National Health and Aging Trends Study (NHATS) conducted in the United States from 2015 to 2021 and included adults aged ≥ 65 without dementia (n = 2245) at baseline in 2015. Group-based trajectory modeling was used to describe the longitudinal changes. Socio-demographic and health-related characteristics were compared across the identified physical frailty trajectories using bivariate analyses, employing Rao-Scott chi-square tests for categorical variables and design-based F-tests for continuous variables. Multinomial logistic regression analyses were conducted to examine the relationships between different frailty trajectories and subsequent dementia status.

RESULTS

Three frailty trajectories were identified: low-stable (74.00%), low-increasing (21.14%), and high-level (4.86%). Participants in the low-increasing and high-level groups were predominantly older, female, minorities, unmarried, and less educated and had a lower income, more comorbidities, and greater anxiety and depression symptoms (p < 0.001). Compared with the low-stable group, older adults in the low-increasing group had higher risk of possible dementia (RRR: 2.37, 95% CI: 1.41-3.97, p < 0.001) and probable dementia (RRR: 1.71, 95% CI: 1.08-2.73, p = 0.02); similarly, older adults in the high-level group had higher risks of possible dementia (RRR: 4.24, 95% CI: 1.74-10.36, p < 0.001) and probable dementia (RRR: 2.99, 95% CI: 1.32-6.76, p = 0.01). No significant differences were found in the risk of dementia between the high-level frailty group and the low-increasing frailty group (p > 0.05).

CONCLUSION AND IMPLICATIONS

This study highlighted the importance of regular frailty monitoring for early detection and informed future interventions that could delay frailty progression and potentially reduce dementia risk.

The impact of the interaction between BDNF rs7103411 gene polymorphism and social activities on mild cognitive impairment in community-dwelling elderly adults

Objective

To investigate the correlation between BDNF gene polymorphism, BDNF levels, and susceptibility to mild cognitive impairment (MCI).

Methods

In this study, we investigated 107 elderly adults individuals from a community in Zhongshan, Guangdong Province, with an average age of 73.17 ± 7.081 years. The participants included 52 patients with Mild Cognitive Impairment due to Alzheimer's Disease and 55 cognitively normal elderly adults control subjects. The two groups were matched based on gender, age, and education level. We assessed their cognitive functions and analyzed their genotypes and serum BDNF levels. Analysis of covariance (ANCOVA) was used to evaluate the differences in serum BDNF levels between the MCI group and the control group. Multivariate linear regression was utilized to analyze the association between BDNF levels and susceptibility to MCI, as well as cognitive functions. Multivariate logistic regression was employed to investigate the association between BDNF gene polymorphisms and the risk of developing MCI, along with their interactions.

Results

The ANCOVA analysis indicated that there was no significant difference in serum BDNF levels between the MCI group and the control group (P > 0.05). Correlation analysis revealed a negative correlation between Mini-Mental Status Examination (MMSE) total scores and MCI (r = -0.461, P = 0.001), with significant correlations observed in orientation (r = -0.420, P = 0.002). Multiple linear regression analysis showed that specific polymorphisms, including rs7103411 (CT+TT vs. CC), rs6265 (CT and CT+TT vs. CC), rs11030104 (AG and AG+GG vs. AA), and rs988748 (CG+CC vs. GG), were significantly associated with decreased serum BDNF levels (P < 0.05). Multivariate logistic regression showed that rs7103411 polymorphism was associated with susceptibility to MCI; individuals with the CT or CC genotype had a 0.370 times lower risk of developing MCI compared to those with the TT genotype (OR = 0.370, 95% CI: 0.141-0.970, P = 0.043). A significant interaction was found between rs7103411 and social activity, which influenced the risk of developing MCI. Specifically, individuals with the CT or TT genotype of rs7103411 who engaged in social activities had a significantly lower risk of developing MCI (OR = 0.32, 95% CI: 0.117-0.878, P = 0.027).

Conclusion

This study indicates that BDNF rs7103411、rs6265、rs11030104 and rs988748 are associated with decreased serum BDNF levels in MCI patients. Individuals carrying the TT genotype in the BDNF rs7103411 gene are associated with an increased susceptibility to MCI. Individuals with the rs7103411 CT or TT genotype who participated in social activities showed a significantly reduced risk of developing MCI, suggesting that the interaction between the BDNF rs7103411 genotype and social activity can help reduce the risk of MCI.

The application of machine learning for identifying frailty in older patients during hospital admission

BACKGROUND

Early identification of frail patients and early interventional treatment can minimize the frailty-related medical burden. This study investigated the use of machine learning (ML) to detect frailty in hospitalized older adults with acute illnesses.

METHODS

We enrolled inpatients of the geriatric medicine ward at Taichung veterans general hospital between 2012 and 2022. We compared four ML models including logistic regression, random forest (RF), extreme gradient boosting, and support vector machine (SVM) for the prediction of frailty. The feature window as well as the prediction window was set as half a year before admission. Furthermore, Shapley additive explanation plots and partial dependence plots were used to identify Fried's frailty phenotype for interpreting the model across various levels including domain, feature, and individual aspects.

RESULTS

We enrolled 3367 patients. Of these, 2843 were frail. We used 21 features to train the prediction model. Of the 4 tested algorithms, SVM yielded the highest AUROC, precision and F1-score (78.05%, 94.53% and 82.10%). Of the 21 features, age, gender, multimorbidity frailty index, triage, hemoglobin, neutrophil ratio, estimated glomerular filtration rate, blood urea nitrogen, and potassium were identified as more impactful due to their absolute values.

CONCLUSIONS

Our results demonstrated that some easily accessed parameters from the hospital clinical data system can be used to predict frailty in older hospitalized patients using supervised ML methods.

Sustained frailty remission and dementia risk in older adults: A longitudinal study

INTRODUCTION

Physical frailty is reversible, but little is known about the sustainability of frailty remission and its impact on dementia.

METHODS

Data were derived from the National Health and Aging Trends Study (NHATS) (2011 to 2021). Physical frailty was assessed using the Fried frailty phenotype, and frailty transition patterns across three waves were defined. The relationship of sustained frailty remission with incident dementia was examined using Cox proportional regression, stratified by age and gender.

RESULTS

Among 1931 participants, 348 (18.0%) were capable of sustained frailty remission. During the 8-year follow-up, 279 participants developed dementia. In a fully adjusted model, sustained remission was associated with a lower risk of dementia (hazard ratio = 0.66, 95% confidence interval = 0.47 to 0.93). The association was more pronounced among younger-old and male participants but not observed among their counterparts.

DISCUSSION

Sustained frailty remission was associated with a reduced risk of developing dementia. Physical frailty could be an essential forewarning of dementia and a target for interventions.

HIGHLIGHTS

We provided new insights into the natural progression of frailty and its impact on dementia risk using a nationally representative sample Sustained frailty remission reduced risk of incident dementia. Age and gender played a role in the frailty-dementia link, and thus individualized dementia risk screening is necessary. Physical frailty could be an essential forewarning of cognitive decline and an ideal target for interventions to prevent dementia.

Physical frailty, genetic predisposition, and incident dementia: a large prospective cohort study

Physical frailty and genetic factors are both risk factors for increased dementia; nevertheless, the joint effect remains unclear. This study aimed to investigated the long-term relationship between physical frailty, genetic risk, and dementia incidence. A total of 274,194 participants from the UK Biobank were included. We applied Cox proportional hazards regression models to estimate the association between physical frailty and genetic and dementia risks. Among the participants (146,574 females [53.45%]; mean age, 57.24 years), 3,353 (1.22%) new-onset dementia events were recorded. Compared to non-frailty, the hazard ratio (HR) for dementia incidence in prefrailty and frailty was 1.396 (95% confidence interval [CI], 1.294-1.506, P < 0.001) and 2.304 (95% CI, 2.030-2.616, P < 0.001), respectively. Compared to non-frailty and low polygenic risk score (PRS), the HR for dementia risk was 3.908 (95% CI, 3.051-5.006, P < 0.001) for frailty and high PRS. Furthermore, among the participants, slow walking speed (HR, 1.817; 95% CI, 1.640-2.014, P < 0.001), low physical activity (HR, 1.719; 95% CI, 1.545-1.912, P < 0.001), exhaustion (HR, 1.670; 95% CI, 1.502-1.856, P < 0.001), low grip strength (HR, 1.606; 95% CI, 1.479-1.744, P < 0.001), and weight loss (HR, 1.464; 95% CI, 1.328-1.615, P < 0.001) were independently associated with dementia risk compared to non-frailty. Particularly, precise modulation for different dementia genetic risk populations can also be identified due to differences in dementia risk resulting from the constitutive pattern of frailty in different genetic risk populations. In conclusion, both physical frailty and high genetic risk are significantly associated with higher dementia risk. Early intervention to modify frailty is beneficial for achieving primary and precise prevention of dementia, especially in those at high genetic risk.

The epigenetics of frailty

The conceptual change of frailty, from a physical to a biopsychosocial phenotype, expanded the field of frailty, including social and behavioral domains with critical interaction between different frailty models. Environmental exposures - including physical exercise, psychosocial factors and diet - may play a role in the frailty pathophysiology. Complex underlying mechanisms involve the progressive interactions of genetics with epigenetics and of multimorbidity with environmental factors. Here we review the literature on possible mechanisms explaining the association between epigenetic hallmarks (i.e., global DNA methylation, DNA methylation age acceleration and microRNAs) and frailty, considered as biomarkers of aging. Frailty could be considered the result of environmental epigenetic factors on biological aging, caused by conflicting DNA methylation age and chronological age.

Explore the Role of Frailty as a Contributor to the Association Between AT(N) Profiles and Cognition in Alzheimer's Disease

Background

The relationship between Alzheimer's disease (AD)-related pathology and cognition was not exactly consistent.

Objective

To explore whether the association between AD pathology and cognition can be moderated by frailty.

Methods

We included 1711 participants from the Alzheimer's Disease Neuroimaging Initiative database. Levels of cerebrospinal fluid amyloid-β, p-tau, and t-tau were identified for AD-related pathology based on the amyloid-β/tau/neurodegeneration (AT[N]) framework. Frailty was measured using a modified Frailty Index-11 (mFI-11). Regression and interaction models were utilized to assess the relationship among frailty, AT(N) profiles, and cognition. Moderation models analyzed the correlation between AT(N) profiles and cognition across three frailty levels. All analyses were corrected for age, sex, education, and APOEɛ4 status.

Results

In this study, frailty (odds ratio [OR] = 1.71, p < 0.001) and AT(N) profiles (OR = 2.00, p < 0.001) were independently associated with cognitive status. The model fit was improved when frailty was added to the model examining the relationship between AT(N) profiles and cognition (p < 0.001). There was a significant interaction between frailty and AT(N) profiles in relation to cognitive status (OR = 1.12, pinteraction = 0.028). Comparable results were obtained when Mini-Mental State Examination scores were utilized as the measure of cognitive performance. The association between AT(N) profiles and cognition was stronger with the levels of frailty.

Conclusions

Frailty may diminish patients' resilience to AD pathology and accelerate cognitive decline resulting from abnormal AD-related pathology. In summary, frailty contributes to elucidating the relationship between AD-related pathology and cognitive impairment.

Associations of Frailty with Neuropsychiatric Symptoms of Alzheimer's Disease: A Longitudinal Study

Background

Frailty is a vulnerability state increasing the risk of many adverse health outcomes, but little is known about the effects of frailty on neuropsychiatric health.

Objective

To explore the associations between frailty and the risk of neuropsychiatric symptoms (NPSs) in Alzheimer's disease (AD), especially in its different clinical stages.

Methods

We included 2,155 individuals assessed using modified frailty index-11 (mFI-11), Neuropsychiatric Inventory (NPI) and Neuropsychiatric Inventory Questionnaire (NPI-Q) in the Alzheimer's Disease Neuroimaging Initiative (ADNI). The relationships between frailty and NPSs were explored with logistic regression models and Cox proportional hazard regression models. Causal mediation analyses were conducted to explore the mediation factors between frailty and NPSs.

Results

Among mild cognitive impairment (MCI) participants, frailty was cross-sectionally associated with an increased risk of apathy, and longitudinally associated with increased risk of depression and apathy. Among AD participants, frailty was cross-sectionally associated with increased risk of depression and anxiety, and longitudinally associated with an increased risk of apathy. Among participants with cognitive progression, frailty was associated with increased risk of depression and apathy. In MCI participants, the influence of frailty on NPSs was partially mediated by hippocampus volume, whole brain volume, and monocytes, with mediating proportions ranging from 8.40% to 9.29%.

Conclusions

Frailty was associated with NPSs such as depression, anxiety, and apathy among MCI, AD, and cognitive progression participants. Atrophy of the hippocampus and whole brain, as well as peripheral immunity may be involved in the potential mechanisms underlying the above associations.

Biopsychosocial frailty and mild cognitive impairment subtypes: Findings from the Italian project on the epidemiology of Alzheimer's disease (IPREA)

INTRODUCTION

Frailty is a critical intermediate status of the aging process including physical, cognitive, and psychosocial phenotypes. We operationalized a biopsychosocial frailty construct, estimating its association with mild cognitive impairment (MCI) and its subtypes.

METHODS

In 1980, older individuals from the population-based Italian PRoject on the Epidemiology of Alzheimer's disease (IPREA), we investigated cross-sectional associations among biopsychosocial frailty, MCI, and its subtypes.

RESULTS

Participants with biopsychosocial frailty showed an increased odds ratio (OR) of MCI [OR: 4.36; 95% confidence interval (CI): 2.60-7.29; Fisher's exact p < 0.01], particularly for nonamnestic MCI single domain (naMCI-SD, OR:3.28; 95% CI: 1.35-7.97; Fisher's exact p = 0.02) and for nonamnestic MCI multiple domain (naMCI-MD, OR:6.92; 95% CI: 3.37-14.21; Fisher's exact p < 0.01). No statistically significant associations between amnestic MCI single or multiple domain and biopsychosocial frailty were observed.

DISCUSSION

In a large, older Italian cohort, a biopsychosocial frailty phenotype was associated with MCI, in particular, could be associated with some of its subtypes, that is, naMCI-SD, and naMCI-MD.

Digital health technology combining wearable gait sensors and machine learning improve the accuracy in prediction of frailty

Background

Frailty is a dynamic and complex geriatric condition characterized by multi-domain declines in physiological, gait and cognitive function. This study examined whether digital health technology can facilitate frailty identification and improve the efficiency of diagnosis by optimizing analytical and machine learning approaches using select factors from comprehensive geriatric assessment and gait characteristics.

Methods

As part of an ongoing study on observational study of Aging, we prospectively recruited 214 individuals living independently in the community of Southern China. Clinical information and fragility were assessed using comprehensive geriatric assessment (CGA). Digital tool box consisted of wearable sensor-enabled 6-min walk test (6MWT) and five machine learning algorithms allowing feature selections and frailty classifications.

Results

It was found that a model combining CGA and gait parameters was successful in predicting frailty. The combination of these features in a machine learning model performed better than using either CGA or gait parameters alone, with an area under the curve of 0.93. The performance of the machine learning models improved by 4.3-11.4% after further feature selection using a smaller subset of 16 variables. SHapley Additive exPlanation (SHAP) dependence plot analysis revealed that the most important features for predicting frailty were large-step walking speed, average step size, age, total step walking distance, and Mini Mental State Examination score.

Conclusion

This study provides evidence that digital health technology can be used for predicting frailty and identifying the key gait parameters in targeted health assessments.

Depressive and Biopsychosocial Frailty Phenotypes: Impact on Late-life Cognitive Disorders

 In older age, frailty is a detrimental transitional status of the aging process featuring an increased susceptibility to stressors defined by a clinical reduction of homoeostatic reserves. Multidimensional frailty phenotypes have been associated with all-cause dementia, mild cognitive impairment (MCI), Alzheimer's disease (AD), AD neuropathology, vascular dementia, and non-AD dementias. In the present article, we reviewed current evidence on the existing links among depressive and biopsychosocial frailty phenotypes and late-life cognitive disorders, also examining common pathways and mechanisms underlying these links. The depressive frailty phenotype suggested by the construct of late-life depression (LLD) plus physical frailty is poorly operationalized. The biopsychosocial frailty phenotype, with its coexistent biological/physical and psychosocial dimensions, defines a biological aging status and includes motivational, emotional, and socioeconomic domains. Shared biological pathways/substrates among depressive and biopsychosocial frailty phenotypes and late-life cognitive disorders are hypothesized to be inflammatory and cardiometabolic processes, together with multimorbidity, loneliness, mitochondrial dysfunction, dopaminergic neurotransmission, specific personality traits, lack of subjective/objective social support, and neuroendocrine dysregulation. The cognitive frailty phenotype, combining frailty and cognitive impairment, may be a risk factor for LLD and vice versa, and a construct of depressive frailty linking physical frailty and LLD may be a good dementia predictor. Frailty assessment may enable clinicians to better target the pharmacological and psychological treatment of LLD. Given the epidemiological links of biopsychosocial frailty with dementia and MCI, multidomain interventions might contribute to delay the onset of late-life cognitive disorders and other adverse health-related outcomes, such as institutionalization, more frequent hospitalization, disability, and mortality.

Synthesis, anti-aging and mechanism of magnolol derivatives

Magnolol (M), a hydroquinone containing an allyl side chain, is one of the major active components of Houpoea officinalis for antioxidation and anti-aging. To enhance the antioxidant activity of magnolol, the different sites of magnolol were structurally modified in this experiment, and a total of 12 magnolol derivatives were obtained. Based on the preliminary exploration of the anti-aging effect of magnolol derivatives in a Caenorhabditis elegans (C. elegans) model. Our results indicate that the active groups of magnolol exerting anti-aging effects were allyl groups and hydroxyl on the phenyl. Meanwhile, the anti-aging effect of the novel magnolol derivative M27 was found to be significantly superior to that of magnolol. To investigate the effect of M27 on senescence and the potential mechanism of action, we investigated the effect of M27 on senescence in C. elegans. In this study, we investigated the effect of M27 on C. elegans physiology by examining body length, body curvature and pharyngeal pumping frequency. The effect of M27 on stress resistance in C. elegans was explored by acute stress experiments. The mechanism of M27 anti-aging was investigated by measuring ROS content, DAF-16 nuclear translocation, sod-3 expression, and lifespan of transgenic nematodes. Our results indicate that M27 prolonged the lifespan of C. elegans. Meanwhile, M27 improved the healthy lifespan of C. elegans by improving pharyngeal pumping ability and reducing lipofuscin accumulation in C. elegans. M27 increased resistance to high temperature and oxidative stress in C. elegans by reducing ROS. M27 induced DAF-16 translocation from cytoplasm to nucleus in transgenic TJ356 nematodes and upregulated the expression of sod-3 (a gene downstream of DAF-16) in CF1553 nematodes. Furthermore, M27 did not extend the lifespan of daf-16, age-1, daf-2, and hsp-16.2 mutants. This work suggests that M27 may ameliorate aging and extend lifespan in C. elegans through the IIS pathway.

Associations of a biopsychosocial frailty phenotype with all-cause dementia, Alzheimer's disease, vascular dementia, and other dementias: the Italian PRoject on the Epidemiology of Alzheimer's disease (IPREA)

Frailty is a critical intermediate status of the aging process including physical, cognitive, and psychosocial domains/phenotypes. We operationalized a new biopsychosocial frailty construct, estimating its impact on the odds of all-cause dementia, Alzheimer's disease (AD), vascular dementia (VaD), and other dementias in 2838 older individuals from the population-based Italian PRoject on the Epidemiology of Alzheimer's disease (IPREA). Biopsychosocial frailty operationalization was based on the results of a previous comprehensive geriatric assessment and the presence of physical frailty. In this cross-sectional study, participants with biopsychosocial frailty showed an increased odds ratio of all-cause dementia [odds ratio (OR): 5.55, 95% confidence interval (CI): 3.72-8.28, p < 0.001], in particular for probable AD (OR: 3.62, 95% CI: 1.55-8.45, p < 0.001), probable VaD (OR: 10.05, 95% CI: 5.05-19.97, p < 0.001), and possible VaD (OR: 17.61, 95% CI: 6.42-48.32, p < 0.001). No statistically significant association was found between this biopsychosocial frailty phenotype and possible AD (OR: 2.84, 95% CI: 0.81-9.97, p = 0.09) or other dementias (OR: 1.77, 95% CI: 0.75-0.21, p = 0.19). In conclusion, in a large cohort of Italian older individuals, a biopsychosocial frailty model was associated to all-cause dementia, probable AD, and probable and possible VaD. In the next future, other large and prospective population-based studies evaluating the association between the biopsychosocial frailty phenotype and incident all-cause dementia, AD, and VaD are needed, addressing also potential bias and confounding sources.

Dietary profiling of physical frailty in older age phenotypes using a machine learning approach: the Salus in Apulia Study

PURPOSE

Growing awareness of the biological and clinical value of nutrition in frailty settings calls for further efforts to investigate dietary gaps to act sooner to achieve focused management of aging populations. We cross-sectionally examined the eating habits of an older Mediterranean population to profile dietary features most associated with physical frailty.

METHODS

Clinical and physical examination, routine biomarkers, medical history, and anthropometry were analyzed in 1502 older adults (65 +). CHS criteria were applied to classify physical frailty, and a validated Food Frequency Questionnaire to assess diet. The population was subdivided by physical frailty status (frail or non-frail). Raw and adjusted logistic regression models were applied to three clusters of dietary variables (food groups, macronutrients, and micronutrients), previously selected by a LASSO approach to better predict diet-related frailty determinants.

RESULTS

A lower consumption of wine (OR 0.998, 95% CI 0.997-0.999) and coffee (OR 0.994, 95% CI 0.989-0.999), as well as a cluster of macro and micronutrients led by PUFAs (OR 0.939, 95% CI 0.896-0.991), zinc (OR 0.977, 95% CI 0.952-0.998), and coumarins (OR 0.631, 95% CI 0.431-0.971), was predictive of non-frailty, but higher legumes intake (OR 1.005, 95%CI 1.000-1.009) of physical frailty, regardless of age, gender, and education level.

CONCLUSIONS

Higher consumption of coffee and wine, as well as PUFAs, zinc, and coumarins, as opposed to legumes, may work well in protecting against a physical frailty profile of aging in a Mediterranean setting. Longitudinal investigations are needed to better understand the causal potential of diet as a modifiable contributor to frailty during aging.

Vulnerability to chronic stress and the phenotypic heterogeneity of presbycusis with subjective tinnitus

Age-related functional reserve decline and vulnerability of multiple physiological systems and organs, as well as at the cellular and molecular levels, result in different frailty phenotypes, such as physical, cognitive, and psychosocial frailty, and multiple comorbidities, including age-related hearing loss (ARHL) and/or tinnitus due to the decline in auditory reserve. However, the contributions of chronic non-audiogenic cumulative exposure, and chronic audiogenic stress to phenotypic heterogeneity of presbycusis and/or tinnitus remain elusive. Because of the cumulative environmental stressors throughout life, allostasis systems, the hypothalamus-pituitary-adrenal (HPA) and the sympathetic adrenal-medullary (SAM) axes become dysregulated and less able to maintain homeostasis, which leads to allostatic load and maladaptation. Brain-body communication via the neuroendocrine system promotes systemic chronic inflammation, overmobilization of energetic substances (glucose and lipids), and neuroplastic changes via the non-genomic and genomic actions of glucocorticoids, catecholamines, and their receptors. These systemic maladaptive alterations might lead to different frailty phenotypes and physical, cognitive, and psychological comorbidities, which, in turn, cause and exacerbate ARHL and/or tinnitus with phenotypic heterogeneity. Chronic audiogenic stressors, including aging accompanying ontological diseases, cumulative noise exposure, and ototoxic drugs as well as tinnitus, activate the HPA axis and SAM directly and indirectly by the amygdala, promoting allostatic load and maladaptive neuroplasticity in the auditory system and other vulnerable brain regions, such as the hippocampus, amygdala, and medial prefrontal cortex (mPFC). In the auditory system, peripheral deafferentation, central disinhibition, and tonotopic map reorganization may trigger tinnitus. Cross-modal maladaptive neuroplasticity between the auditory and other sensory systems is involved in tinnitus modulation. Persistent dendritic growth and formation, reduction in GABAergic inhibitory synaptic inputs induced by chronic audiogenic stresses in the amygdala, and increased dendritic atrophy in the hippocampus and mPFC, might involve the enhancement of attentional processing and long-term memory storage of chronic subjective tinnitus, accompanied by cognitive impairments and emotional comorbidities. Therefore, presbycusis and tinnitus are multisystem disorders with phenotypic heterogeneity. Stressors play a critical role in the phenotypic heterogeneity of presbycusis. Differential diagnosis based on biomarkers of metabonomics study, and interventions tailored to different ARHL phenotypes and/or tinnitus will contribute to healthy aging and improvement in the quality of life.

Antioxidant and anti-aging activities of Laminaria japonica polysaccharide in Caenorhabditis elegans based on metabonomic analysis

In this study, Laminaria japonica polysaccharide (LJP) was measured in vitro against three antioxidant indicators: DPPH, ABTS, and hydroxyl. In vivo, LJP investigated thermal tolerance, H2O2-induced oxidative stress tolerance, and lipofuscin in Caenorhabditis elegans (C. elegans). Following that, after LJP treatment, the effects and underlying mechanisms were investigated at the mRNA and metabolite levels. We discovered the free radical scavenging activity of LJP. The thermal tolerance of C. elegans improved significantly, lowering levels of malondialdehyde, lipofuscin, and reactive oxygen species. Upregulation of Glp-1, Daf-16, Skn-1, and Sod-3 expression and downregulation of Age-1 and Daf-2 expression increased the ability to resist oxidative stress. Metabolomic analysis revealed that LJP promoted alanine, aspartate, and glutamate metabolism, the TCA cycle, butanoate metabolism, and the FOXO signaling pathway expression, resulting in significant changes in (R)-3-hydroxybutyric acid, palmitic acid, L-glutamic acid, L-malic acid, and oleic acid. The present study shows that LJP, as a functional food, has the potential to boost antioxidant capacity and delay aging.

Social frailty increases the risk of all-cause mortality: A longitudinal analysis of the English Longitudinal Study of Ageing

OBJECTIVES

Social frailty is a common condition in older people, but its consequences are largely unknown. Therefore, in this longitudinal analysis, we aimed to investigate the association between social frailty and risk of all-cause mortality in a large sample of older people.

DESIGN

Longitudinal, cohort.

SETTINGS AND PARTICIPANTS

Older people participating to the English Longitudinal Study of Ageing (ELSA).

METHODS

Social frailty was defined based on financial difficulty, household status, social activity, and contacts with other people: social frailty was defined as ≥2 points, social pre-frailty (1 point), and robustness (0 points). Survival status during ten years of follow-up was assessed using administrative data. Cox proportional hazard models were used to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (95 % CI) of the association between social frailty status and all-cause mortality.

RESULTS

At baseline, compared to social robust participants, social frail subjects reported a significant higher presence of potential risk factors for all-cause mortality. During the ten years of follow-up, after adjusting for 10 potential confounders, social frailty at baseline (vs. robustness) was associated with a significantly higher risk of death (HR = 1.31; 95 % CI: 1.04-1.64; p = 0.02), whilst social pre-frail was not. Among the single factors contributing to social frailty, poverty increased the risk of all-cause mortality by approximately 60 % (HR = 1.60; 95 % CI: 1.33-1.93; p < 0.0001) as well as living alone (HR = 1.46; 95 % CI: 1.10-1.94; p = 0.009).

CONCLUSIONS AND IMPLICATIONS

Social frailty was significantly associated with all-cause mortality in a large cohort of older people, highlighting the importance of identifying this phenomenon in older adults to inform targeted intervention efforts.

Frailty and its associated factors among older adults with cancer undergoing chemotherapy as outpatients: A cross-sectional study

PURPOSE

Frailty can affect cancer treatment decisions and outcomes. Depression, fatigue, and cognitive impairment often experienced by patients with cancer are expected to be associated with frailty. We aimed to identify frailty and its related factors in older adults with cancer undergoing chemotherapy.

METHODS

We conducted a cross-sectional descriptive study in a Korean urban tertiary hospital. A structured self-report questionnaire was used including frailty and its related variables and measured heart rate variability (HRV). Multinomial logistic regression was performed to identify the factors related to frailty.

RESULTS

Data from 124 out of 136 patients with stomach, colorectal, and lung cancers were analyzed. Approximately 90% of the participants were in the pre-frail and frail groups. There were significant differences among the three groups in terms of depression (p = 0.006) and HRV (p = 0.041). The factor associated with higher frailty levels was depression across groups (pre-frail odds ratio (OR): 1.31, 95% CI: 1.14-1.51; frail OR: 1.29, 95% CI: 1.11-1.49). However, only deficits observed or commented on by others were retained as factors significantly associated with higher frailty in the pre-frail group (OR: 2.40, 95% CI: 1.40-4.13). In contrast, increased HRV (OR: 0.35, 95% CI: 0.13-0.95) was associated with lower frailty levels in the frail group.

CONCLUSION

It is important to classify older adult patients with cancer into pre-frail and frail groups so that interventions can be provided on time. Understanding the characteristics associated with frailty in older adult patients with cancer can positively affect their health-related quality of life and treatment outcomes.

Frailty in rodents: Models, underlying mechanisms, and management

Frailty is a clinical geriatric syndrome characterized by decreased multisystem function and increased vulnerability to adverse outcomes. Although numerous studies have been conducted on frailty, the underlying mechanisms and management strategies remain unclear. As rodents share homology with humans, they are used extensively as animal models to study human diseases. Rodent frailty models can be classified broadly into the genetic modification and non-genetic modification models, the latter of which include frailty assessment models (based on the Fried frailty phenotype and frailty index methods) and induced frailty models. Such models were developed for use in investigating frailty-related physiological changes at the gene, cellular, molecular, and system levels, including the organ system level. Furthermore, exercise, diet, and medication interventions, in addition to their combinations, could improve frailty status in rodents. Rodent frailty models provide novel and effective tools for frailty research. In the present paper, we review research progress in rodent frailty models, mechanisms, and management, which could facilitate and guide further clinical research on frailty in older adults.

Multi-Concept Frailty Predicts the Late-Life Occurrence of Cognitive Decline or Dementia: An Updated Systematic Review and Meta-Analysis of Longitudinal Studies

Background

Frailty is a multidimensional syndrome that increases an individual’s vulnerability for developing adverse health outcomes, which include dementia. It might serve as a promising target for dementia prevention. However, there are currently no studies summarizing the association between multi-concept frailty and the risk of cognitive disorders. This study aims to summarize the evidence of associations between multi-concept frailty and cognitive disorders based on longitudinal studies.

Methods

Scopus, The Cochrane Library, PsycINFO, CINAHL, PubMed, and EMBASE databases were searched from inception to January 2, 2022. Longitudinal studies, which explored the association of frailty with incident risk of cognitive decline or dementia, were included. The multivariable-adjusted effect estimates were pooled by random-effects models. The evidence credibility was depicted according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method.

Results

A total of 30 longitudinal studies were included. Four types of frailty concepts were involved, including physical, cognitive, social, and biopsychosocial frailty. The meta-analysis comprised 20 studies of 252,571 older adults (mean age: 64.1–80.4 years), among whom 7,388 participants developed cognitive decline or dementia. Physical frailty was associated with higher risk of developing cognitive disorders [pooled relative risk (pRR) = 1.52, 95% confidence interval (CI): 1.28–1.80, I2 = 21.2%, pRR = 1.62 for cognitive decline, 95% CI: 1.07–2.45, I2 = 40.2%, pRR = 1.37 for all-cause dementia (ACD), 95% CI: 1.13–1.66, I2 = 0.0%]. Cognitive frailty (pRR = 2.90, 95% CI: 1.28–6.55, I2 = 78.1%) and pre-frailty (pRR = 4.24, 95% CI: 2.74–6.56, I2 = 30.2%) were linked to higher risk of ACD. Biopsychosocial frailty could predict a 41% (pRR = 1.41, 95% CI: 1.17–1.71) elevated risk of cognitive decline or dementia [pRR = 1.53 (95% CI: 1.19–1.96) for ACD and 1.11 (95% CI: 1.05–1.17) for Alzheimer’s disease (AD)]. In the systematic review, social frailty was associated with a 53% higher risk of AD. Preventing frailty could avoid a maximum of 9.9% cognitive disorders globally. The overall evidence strength is rated as low-to-moderate. Inconsistency and imprecision are major sources of bias.

Conclusion

Frailty in late life is a promising risk factor for cognitive disorders. Frail elderly should be monitored for their cognitive dynamics and initiate early prevention of dementia.

Systematic Review Registration

www.ClinicalTrials.gov, identifier CRD4202127 3434.

L-Arginine Improves Cognitive Impairment in Hypertensive Frail Older Adults

Cognitive impairment is a prevailing event in hypertensive patients and in frail older adults. Endothelial dysfunction has been shown to underlie both hypertension and cognitive dysfunction. Our hypothesis is that L-Arginine, which is known to ameliorate endothelial dysfunction, could counteract cognitive impairment in a high-risk population of hypertensive frail older adults. We designed a clinical trial to verify the effects of 4-weeks oral supplementation of L-Arginine on global cognitive function of hypertensive frail older patients. The study was successfully completed by 35 frail hypertensive elderly patients assigned to L-Arginine and 37 assigned to placebo. At follow-up, we found a significant difference in the Montreal Cognitive Assessment (MoCA) test score between the L-Arginine treated group and placebo (p: 0.0178). Moreover, we demonstrated that L-Arginine significantly attenuates Angiotensin II-induced mitochondrial oxidative stress in human endothelial cells. In conclusion, our findings indicate for the first time that oral L-Arginine supplementation significantly improves cognitive impairment in frail hypertensive older adults.

Correlation of physical and cognitive impairment in diabetic and hypertensive frail older adults

BACKGROUND

Diabetes and hypertension are common in older adults and represent established risk factors for frailty. Frailty is a multidimensional condition due to reserve loss and susceptibility to stressors with a high risk of death, hospitalizations, functional and cognitive impairment. Comorbidities such as diabetes and hypertension play a key role in increasing the risk of mortality, hospitalization, and disability. Moreover, frail patients with diabetes and hypertension are known to have an increased risk of cognitive and physical impairment. Nevertheless, no study assessed the correlation between physical and cognitive impairment in frail older adults with diabetes and hypertension.

METHODS

We evaluated consecutive frail older patients with diabetes and hypertension who presented at ASL (local health unit of the Italian Ministry of Health) Avellino, Italy, from March 2021 to October 2021. The inclusion criteria were: a previous diagnosis of diabetes and hypertension with no evidence of secondary causes; age > 65 years; a frailty status; Montreal Cognitive Assessment (MoCA) score < 26.

RESULTS

179 patients successfully completed the study. We found a strong and significant correlation between MoCA score and 5-m gait speed test (r: 0.877; p < 0.001). To further verify our results, we performed a linear multivariate analysis adjusting for potential confounding factors, with MoCA score as dependent variable, which confirmed the significant association with glycemia (p < 0.001).

CONCLUSIONS

This is the first study showing a significant correlation between 5-m gait speed test and MoCA score in frail diabetic and hypertensive older adults.

An update on cognitive frailty: Its definition, impact, associated factors and underlying mechanisms, and interventions

Since the concept and operational definition of "cognitive frailty" (simultaneous presence of physical frailty and cognitive impairment without concurrent dementia) were proposed by the International Academy of Nutrition and Aging and the International Association of Gerontology and Geriatrics, cognitive frailty has been widely investigated. This review is intended to address the operational definition of cognitive frailty, its consequences, contributing factors and underlying mechanisms, as well as interventions for cognitive frailty. Although the definitions and assessments of cognitive frailty vary among researchers, older adults with both physical frailty and cognitive impairment are shown to be at higher risk of adverse health outcomes, including death, disability, hospitalization and incident dementia, than those with either condition alone. While the underlying mechanisms of cognitive frailty are still unclear, factors shown to be associated with cognitive frailty include sociodemographic factors, social status, nutritional status, geriatric syndrome, physical and cognitive activities, functional status, comorbidities, medication use, gut-derived metabolites and structural changes in the brain. Accumulating evidence indicates the need for comprehensive geriatric assessment that helps identify the possible causes of cognitive frailty and develop a multimodal individualized intervention to prevent adverse health outcomes for older adults with cognitive frailty. Further studies are required to clarify the mechanisms through which physical frailty and cognitive impairment interact to accelerate adverse health outcomes, particularly cognitive outcomes. In addition, for older adults with cognitive frailty, an effective flow diagram from primary screening through comprehensive assessment to multidimensional intervention needs to be developed for future implementation in both clinical and community settings. Geriatr Gerontol Int 2021; ••: ••-••.

The state of frailty in research: A mapping review of its clinical applicability to practice

Research on frailty has expanded in the last decade, but direct evidence supporting its implementation in clinical practice may be limited. This mapping review synthesizes the contexts-of-use and overall clinical applicability of recent pre-COVID frailty research. We sampled 476 articles from articles published on frailty in PubMed and EMBASE in 2017-2018, of which 150 articles were fully appraised for the contexts-of-use, definitions, and interventions. A clinical applicability framework was used to classify articles as practice-changing, practice-informing, or not practice-informing. Of the 476 sampled articles, 31% (n = 150) used frailty in functions that could inform a clinical indication: predictor or mediator (26%, n = 125), selection criterion (3%, n = 15), and effect modifier (2%, n = 10). Articles spanned all health disciplines, and cohort studies comprised 91% (n = 137) of studies and trials 9% (n = 13). Thirty-eight frailty definitions using varied cut-offs and a wide range of interventions were identified. Among all articles, 13% (n = 63) of articles were practice-informing, 2% (n = 11) potentially practice-changing, and 0.2% (n = 1) clearly practice-changing. Lack of well-defined intervention and identifiable effect (96%) or originality (83%) were predominant reasons reducing applicability. Only a minority of recent frailty research provides direct evidence of applicability to practice. Future research on frailty should focus on translating frailty, as a risk factor, into a clinical indication and address definition ambiguity.

Associations between nutritional frailty and 8-year all-cause mortality in older adults: The Salus in Apulia Study

INTRODUCTION

Preventive nutritional management of frailty, a multidimensional intermediate status in the ageing process, may reduce the risk of adverse health-related outcomes. We investigated the ability of a measure combining physical frailty with nutritional imbalance, defined as nutritional frailty, to predict all-cause mortality over a period of up to 8 years.

METHODS

We analysed data on 1,943 older adults from the population-based 'Salus in Apulia Study'. Physical frailty was operationalized using Cardiovascular Health Study criteria and cognitive frailty by combining physical frailty with cognitive impairment. A novel five-item construct was built to assess the extent of nutritional imbalance identified with a machine learning algorithm. Cox models and Kaplan-Meier survival probability analyses of physical frailty, nutritional imbalance (two or more of the following: low body mass index, low skeletal muscle index, ≥2.3 g/day sodium intake, <3.35 g/day potassium intake and <9.9 g/day iron intake), cognitive frailty and the novel nutritional frailty phenotype (physical frailty plus nutritional imbalance) were applied to assess all-cause mortality risk, adjusted for age, sex, education and multimorbidity.

RESULTS

The overall prevalence of nutritional frailty was 4.52% (95% confidence interval, CI:3.55-5.44), being more frequent in males. Subjects with nutritional frailty were at higher risk for all-cause mortality [hazard ratio (HR):2.31; 95%CI:1.41-3.79] than those with physical frailty (HR:1.45,95% CI:1.0-2.02), nutritional imbalance (HR:1.39; 95%CI:1.05-1.83) and cognitive frailty (HR:1.06; 95%CI:0.56-2.01).

CONCLUSIONS

Efforts to identify, manage and prevent frailty should include the nutritional domain. The nutritional frailty phenotype may highlight major nutritional determinants that could drive survival and health trajectories in older adults.

Assessing the Impact of A Community-Based Pro-Active Monitoring Program Addressing the need for Care of Community-Dwelling Citizens aged more than 80: Protocol for a Prospective Pragmatic Trial and Results of the Baseline Assessment

The aim of this paper is to describe the protocol of a study assessing the impact of a Community-based pro-Active Monitoring Program, by measuring the effect in counteracting the adverse outcomes related to frailty.

Methods

a prospective pragmatic trial will be carried out to describe the impact of an intervention on people aged>80, adjusted for relevant parameters: demographic variables, comorbidities, disability and bio-psycho-social frailty. They have been assessed with the Functional Geriatric Evaluation questionnaire that is a validated tool. Mortality, Acute Hospital Admission rates, Emergency Room Visit rates and Institutionalization rates are the main outcomes to be evaluated annually, over three years. Two groups of patients, made up by 578 cases (undergoing the intervention under study) and 607 controls have been enrolled and interviewed.

Results

at baseline the two groups are quite similar for age, living arrangement, comorbidity, disability and cognitive status. They differ in education, economic resources and physical status (that are better in the control group) and in social resources (that is better in the case group). The latter was expected since the intervention is focused on increasing social capital at individual and community level and aimed at improving survival among the cases as well as reducing the recourse to hospital and residential Long Term Care.

Conclusion

The proposed study addresses a crucial issue: assessing the impact of a bottom up care service consisting of social and health interventions aimed at reducing social isolation and improving access to health care services.

Cognitive Impairment in Frail Hypertensive Elderly Patients: Role of Hyperglycemia

Endothelial dysfunction is a key hallmark of hypertension, which is a leading risk factor for cognitive decline in older adults with or without frailty. Similarly, hyperglycemia is known to impair endothelial function and is a predictor of severe cardiovascular outcomes, independent of the presence of diabetes. On these grounds, we designed a study to assess the effects of high-glucose and metformin on brain microvascular endothelial cells (ECs) and on cognitive impairment in frail hypertensive patients. We tested the effects of metformin on high-glucose-induced cell death, cell permeability, and generation of reactive oxygen species in vitro, in human brain microvascular ECs. To investigate the consequences of hyperglycemia and metformin in the clinical scenario, we recruited frail hypertensive patients and we evaluated their Montreal Cognitive Assessment (MoCA) scores, comparing them according to the glycemic status (normoglycemic vs. hyperglycemic) and the use of metformin. We enrolled 376 patients, of which 209 successfully completed the study. We observed a significant correlation between MoCA score and glycemia. We found that hyperglycemic patients treated with metformin had a significantly better MoCA score than hyperglycemic patients treated with insulin (18.32 ± 3.9 vs. 14.94 ± 3.8; p < 0.001). Our in vitro assays confirmed the beneficial effects of metformin on human brain microvascular ECs. To our knowledge, this is the first study correlating MoCA score and glycemia in frail and hypertensive older adults, showing that hyperglycemia aggravates cognitive impairment.

Towards a Redefinition of Cognitive Frailty

Background:

The progressive aging of the population will dramatically increase the burden of dementia related to Alzheimer’s disease (AD) and other neurodegenerative disorders in the future. Because of the absence of drugs that can modify the neuropathological substrate of AD, research is focusing on the application of preemptive and disease-modifying strategies in the pre-symptomatic period of the disease. In this perspective, the identification of people with cognitive frailty (CF), i.e., those individuals with higher risk of developing dementia, on solid pathophysiological bases and with clear operational clinical criteria is of paramount importance.

Objective/Methods:

This hypothesis paper reviews the current definitions of CF, presents and discusses some of their limitations, and proposes a framework for updating and improving the conceptual and operational definition of the CF construct.

Results:

The potential for reversibility of CF should be supported by the assessment of amyloid, tau, and neuronal damage biomarkers, especially in younger patients. Physical and cognitive components of frailty should be considered as separate entities, instead of part of a single macro-phenotype. CF should not be limited to the geriatric population, because trajectories of amyloid accumulation are supposed to start earlier than 65 years in AD. Operational criteria are needed to standardize assessment of CF.

Conclusion:

Based on the limitations of current CF definitions, we propose a revised one according to a multidimensional subtyping. This new definition might help stratifying CF patients for future trials to explore new lifestyle interventions or disease-modifying pharmacological strategies for AD and dementia.

How gait influences frailty models and health-related outcomes in clinical-based and population-based studies: a systematic review

Aging is often associated with a decline in physical function that eventually leads to loss of autonomy in activities of daily living (ADL). Walking is a very common ADL, important for main determinants of quality of life in older age, and it requires the integration of many physiological systems. Gait speed has been described as the 'sixth vital sign' because it is a core indicator of health and function in aging and disease. We reviewed original studies up to June 2020 that assessed frailty in both longitudinal and cross-sectional observational studies, paying particular attention to how gait is measured in older population and how the gait parameter adopted may influence the estimated frailty models and the health-related outcomes of the various studies (i.e. clinical, cognitive, physical, and nutritional outcomes). Eighty-five studies met the search strategy and were included in the present systematic review. According to the frailty tools, more than 60% of the studies used the physical phenotype model proposed by Fried and colleagues, while one-third referred to multi-domain indexes or models and only 5% referred to other single-domain frailty models (social or cognitive). The great heterogeneity observed in gait measurements and protocols limited the possibility to directly compare the results of the studies and it could represent an important issue causing variability in the different outcome measures in both clinical-and population-based settings. Gait appeared to be an indicator of health and function also in frail older adults, and different gait parameters appeared to predict adverse health-related outcomes in clinical, cognitive, and physical domains and, to a lesser extent, in nutritional domain. Gait has the potential to elucidate the common basic mechanisms of cognitive and motor decline. Advances in technology may extend the validity of gait in different clinical settings also in frail older adults, and technology-based assessment should be encouraged. Combining various gait parameters may enhance frailty prediction and classification of different frailty phenotypes.

Heterogeneous Influence of Frailty Phenotypes in Age-Related Hearing Loss and Tinnitus in Chinese Older Adults: An Explorative Study

Background

Fried physical frailty, with mobility frailty and non-motor frailty phenotypes, is a heterogeneous syndrome. The coexistence of the two phenotypes and cognitive impairment is referred to as cognitive frailty (CF). It remains unknown whether frailty phenotype has a different association with hearing loss (HL) and tinnitus.

Methods

Of the 5,328 community-dwelling older adults, 429 participants aged ≥58 years were enrolled in the study. The participants were divided into robust, mobility, and non-mobility frailty, mobility and non-mobility CF (subdivided into reversible and potentially reversible CF, RCF, and PRCF), and cognitive decline [subdivided into mild cognitive impairment (MCI) and pre-MCI] groups. The severity and presentations of HL and/or tinnitus were used as dependent variables in the multivariate logistic or nominal regression analyses with forward elimination adjusted for frailty phenotype stratifications and other covariates.

Results

Patients with physical frailty (mobility frailty) or who are robust were found to have lower probability of developing severe HL and tinnitus, and presented HL and/or tinnitus than those with only cognitive decline, or CF. Patients with RCF and non-mobility RCF had higher probability with less HL and tinnitus, and the presentation of HL and/or tinnitus than those with PRCF and mobility RCF. Other confounders, age, cognitive and social function, cardiovascular disease, depression, and body mass index, independently mediated the severity of HL and tinnitus, and presented HL and/or tinnitus.

Conclusion

Frailty phenotypes have divergent association with HL and tinnitus. Further research is required to understand the differential mechanisms and the personalized intervention of HL and tinnitus.

Clinical Trial Registration

ClinicalTrials.gov identifier, NCT2017K020.

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

OBJECTIVE

A systematic review and meta-analysis basing on the prospective cohort studies were conducted to explore the risk of all-cause mortality and dementia in cognitively frail older adults compared to robust older adults and to determine whether it was a predictor of adverse outcomes.

METHODS

Pubmed, Web of Science, The Cochrane Library, EMBASE, and CINAHL databases were searched to retrieve studies on adverse outcomes of cognitive frailty. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. Stata 15.0 Software was used to perform the meta-analysis. The all-cause mortality and dementia were observed to be the primary outcomes, while the other data were considered as the secondary outcome.

RESULTS

A total of 14 studies were included in qualitative analysis and 12 studies were included in the meta-analysis, with low risk of bias and moderate to good methodological quality. The results showed that cognitive frailty in older people had a higher risk of all-cause mortality [HR = 1.93, 95%CI (1.67, 2.23), p < .001] and dementia [HR = 3.66, 95%CI (2.86, 4.70) as compared with robust. The subgroup analysis showed that the assessment tools were the main source of heterogeneity.

CONCLUSION

In older adults living in communities, the cognitive frailty was found to be a significant predictor of all-cause mortality and dementia. Nonetheless, cognitive frailty was found to be a better predictor of all-cause mortality and dementia than just frailty.

Nutritional domains in frailty tools: Working towards an operational definition of nutritional frailty

Different methods have been proposed for the assessment of the nutritional status in frailty phenotypes. In the present narrative review article, we have summarized the number and specifications of nutritional items in existing frailty tools, in order to develop a possible means of assessment and operational definition of the nutritional frailty phenotype. In six different databases until December 2019, we searched for original articles regarding frailty tools (i.e., scales, indexes, scores, questionnaires, instruments, evaluations, screening, indicators), analyzing each tool regarding nutritional items. We identified 160 articles describing 71 frailty tools. Among the selected frailty tools, 54 were community-based (70 %), 17 hospital-based (22 %), 4 validated in long-term care institutions for older adults (LTCIOA) (5.1 %) and 2 validated in both community- and hospital-based settings, including LTCIOA (2.5 %). Fifty-two of these tools (73 %) included at least one nutritional item. Twenty-two (42 %) reported two or more nutritional items. The items were grouped in the following categories: A) anthropometric measurements, B) laboratory measurements, and C) other nutritional-related measurements. Anthropometric measurements stood out compared to all other items. Nutritional items are included in the majority of frailty tools, strengthening the concept that they may have a direct implication on an increased risk of adverse health-related outcomes in frail subjects. This supports the development of the concept of nutritional frailty as an independent frailty phenotype. Subsequent steps will be to assess the contribution of each nutritional item to a possible operational definition of nutritional frailty and define the items that may best identify this new frailty phenotype.

Cross-Sectional Association Between Cognitive Frailty and White Matter Hyperintensity Among Memory Clinic Patients

BACKGROUND

Cognitive frailty (CF) is defined as simultaneous presence of physical frailty (PF) and cognitive impairment among older adults without dementia. Although white matter hyperintensities (WMH) as expressions of cerebral small vessel disease are associated with physical and cognitive decline and could manifest as CF, this association remains yet to be clarified.

OBJECTS

To clarify the association between CF and WMH among memory clinic patients.

METHODS

The subjects of this cross-sectional study were 121 cognitively normal (CN) and 212 mildly cognitively impaired (MCI) patients who presented to the Memory Clinic at the National Center for Geriatrics and Gerontology of Japan. PF status was defined based on the definition proposed by Fried and colleagues. CF was defined as simultaneous presence of pre-PF or PF and MCI. WMH volumes were measured using an automatic segmentation application. Multiple liner regression analyses with adjustment for cardiovascular risk factors were performed.

RESULTS

Of all subjects, 77 (63.6%) and 22 (18.2%) CN patients and 132 (62.3%) and 65 (30.7%) MCI patients were categorized into pre-PF and PF, respectively. Multiple liner regression analysis showed that those with CF had higher WMH volumes than those without (β= 0.23). When categorized into six groups according to PF and cognitive status, the PF/CN (β= 0.15), pre-PF/MCI (β= 0.41), and PF/MCI (β= 0.34) groups had higher WMH volumes than the non-PF/CN group.

CONCLUSIONS

This study showed increased WMH volumes in CF and PF, indicating that WMH could be one of the key underlying brain pathologies of CF.

Neuropathologic burden and the degree of frailty in relation to global cognition and dementia

OBJECTIVE

To test the hypothesis that degree of frailty and neuropathologic burden independently contribute to global cognition and odds of dementia.

METHODS

This was a secondary analysis of a prospective cohort study of older adults living in Illinois. Participants underwent an annual neuropsychological and clinical evaluation. We included 625 participants (mean age 89.7 ± 6.1 years; 67.5% female) who died and underwent autopsy. We quantified neuropathology using an index measure of 10 neuropathologic features: β-amyloid deposition, hippocampal sclerosis, Lewy bodies, tangle density, TDP-43, cerebral amyloid angiopathy, arteriolosclerosis, atherosclerosis, and gross and chronic cerebral infarcts. Clinical consensus determined dementia status, which we coded as no cognitive impairment, mild cognitive impairment, or dementia. A battery of 19 tests spanning multiple domains quantified global cognition. We operationalized frailty using a 41-item frailty index. We employed regression analyses to model relationships between neuropathology, frailty, and dementia.

RESULTS

Both frailty and a neuropathology index were independently associated with global cognition and dementia status. These results held after controlling for traditional pathologic measures in a sample of participants with Alzheimer clinical syndrome. Frailty improved the fit of the model for dementia status (χ²[2] 72.64; p < 0.0001) and explained an additional 11%-12% of the variance in the outcomes.

CONCLUSION

Dementia is a multiply determined condition, to which both general health, as captured by frailty, and neuropathology significantly contribute. This integrative view of dementia and health has implications for prevention and therapy; specifically, future research should evaluate frailty as a means of dementia risk reduction.

Prevalence of multimorbidity with frailty and associations with socioeconomic position in an adult population: findings from the cross-sectional HUNT Study in Norway

OBJECTIVES

To explore prevalences and occupational group inequalities of two measures of multimorbidity with frailty.

DESIGN

Cross-sectional study.

SETTING

The Nord-Trøndelag Health Study (HUNT), Norway, a total county population health survey, 2006-2008.

PARTICIPANTS

Participants older than 25 years, with complete questionnaires, measurements and occupation data were included.

OUTCOMES

≥2 of 51 multimorbid conditions with ≥1 of 4 frailty measures (poor health, mental illness, physical impairment or social impairment) and ≥3 of 51 multimorbid conditions with ≥2 of 4 frailty measures.

ANALYSIS

Logistic regression models with age and occupational group were specified for each sex separately.

RESULTS

Of 41 193 adults, 38 027 (55% female; 25-100 years old) were included. Of them, 39% had ≥2 multimorbid conditions with ≥1 frailty measure, and 17% had ≥3 multimorbid conditions with ≥2 frailty measures. Prevalence differences in percentage points (pp) with 95% confidence intervals of those in high versus low occupational group with ≥2 multimorbid conditions and ≥1 frailty measure were largest in women age 30 years, 17 (14 to 20) pp and 55 years, 15 (13 to 17) pp and in men age 55 years, 15 (13 to 17) pp and 80 years, 14 (9 to 18) pp. In those with ≥3 multimorbid conditions and ≥2 frailty measures, prevalence differences were largest in women age 30 years, 8 (6 to 10) pp and 55 years, 10 (8 to 11) ppand in men age 55 years, 9 (8 to 11) pp and 80 years, 6 (95% CI 1 to 10) pp.

CONCLUSION

Multimorbidity with frailty is common, and social inequalities persist until age 80 years in women and throughout the lifespan in men. To manage complex multimorbidity, strategies for proportionate universalism in medical education, healthcare, public health prevention and promotion seem necessary.

Social Frailty in the COVID-19 Pandemic Era

Special attention and efforts to protect from or reduce health-related outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus triggering coronavirus disease 2019 (COVID-19), should be applied in susceptible populations, including frail older people. In particular, the early death cases occurred primarily in older people with a frailty status, possibly due to a weaker immune system fostering faster progression of the viral infection. Frailty is an age-related multidimensional clinical condition defined as a non-specific state of vulnerability, identifying older people at increased risk of falls, institutionalization, hospitalization, disability, dementia, and death. Among frailty phenotypes, social frailty has been least studied. It considers the role of socioeconomic context as a vulnerability status later in life. COVID-19 does not affect all populations equally, and social inequalities contribute to drive the spread of infections. It was known that the perception of social isolation, e.g., loneliness, affects mental and physical health, but the implicated molecular mechanisms, also related to the immune system, and its associated cognitive and health-related sequelae, are poorly understood. The increasing psychological distress derived by prolonged exposure to stress due to the lockdown scenario, and the reduced sources of support, contributed to making heavy demands on personal resources, i.e., self-efficacy and interpersonal variables. So, perceived loneliness may be a factor associated with psychological distress and an outcome in itself. In the COVID-19 pandemic era, a correct assessment of social frailty may be essential in terms of the prevention of late-life neuropsychiatric disorders.

Prevalence of Cognitive Frailty Phenotypes and Associated Factors in a Community-Dwelling Elderly Population

OBJECTIVES

Cognitive frailty was notable target for the prevention of adverse health outcomes in future. The goal of this study was to use a population-based survey to investigate cognitive frailty phenotypes and potentially sociodemographic factors in elderly Chinese individuals.

DESIGN

Cross-sectional study.

SETTING

General community.

PARTICIPANTS

A total of 5328 elderly adults (aged 60 years or older, mean age 71.36 years) enrolled in the Shanghai study of health promotion for elderly individuals with frailty.

MEASUREMENTS

The 5-item FRAIL scale and the 3-item Rapid Cognitive Screen tools were used to assess physical frailty and cognitive impairment, including dementia or mild cognitive impairment (MCI). Physical frailty was diagnosed by limitations in 3 or more of the FRAIL scale domains and pre-physical frailty by 1-2 limitations. Subjective cognitive decline (SCD) and pre-MCI SCD, was diagnosed with two self-report measures based on memory and other cognitive domains in elderly adults.

RESULTS

Of the participating individuals, 97.17% (n= 5177, female 53.4%) were eligible. Notably, 9.67%, 41.61% and 35.20% of participants were MCI, SCD and pre-MCI SCD; 35.86% and 4.41% exhibited physical pre-frailty and frailty; and 19.86% and 6.30% exhibited reversible and potential reversible cognitive frailty. Logistic regression analyses indicated that physical frailty phenotypes were significantly associated with MCI with SCD, and pre-MCI with SCD. Older single females with a high education level were more likely to exhibit the reversible cognitive frailty; and younger elderly individuals with a middle education level were at lower risk for potentially reversible cognitive frailty.

CONCLUSIONS

The prevalence of pre-physical and reversible cognitive frailty was high in elderly individuals and age was the most significant risk factor for all types of frailty phenotypes. To promote the rapid screening protocol of cognitive frailty in community-dwelling elderly is important to find high-risk population, implement effective intervention, and decrease adverse prognosis.

Determinants of frailty development and progression using a multidimensional frailty index: Evidence from the English Longitudinal Study of Ageing

Objective

To identify modifiable risk factors for development and progression of frailty in older adults living in England, as conceptualised by a multidimensional frailty index (FI).

Methods

Data from participants aged 50 and over from the English Longitudinal Study of Ageing (ELSA) was used to examine potential determinants of frailty, using a 56-item FI comprised of self-reported health conditions, disabilities, cognitive function, hearing, eyesight, depressive symptoms and ability to carry out activities of daily living. Cox proportional hazards regression models were used to measure frailty development (n = 7420) and linear regression models to measure frailty progression over 12 years follow-up (n = 8780).

Results

Increasing age (HR: 1.08 (CI: 1.08–1.09)), being in the lowest wealth quintile (HR: 1.79 (CI: 1.54–2.08)), lack of educational qualifications (HR: 1.19 (CI: 1.09–1.30)), obesity (HR: 1.33 (CI: 1.18–1.50) and a high waist-hip ratio (HR: 1.25 (CI: 1.13–1.38)), being a current or previous smoker (HR: 1.29 (CI: 1.18–1.41)), pain (HR: 1.39 (CI: 1.34–1.45)), sedentary behaviour (HR: 2.17 (CI: 1.76–2.78) and lower body strength (HR: 1.07 (CI: 1.06–1.08)), were all significant risk factors for frailty progression and incidence after simultaneous adjustment for all examined factors.

Conclusion

The findings of this study suggest that there may be scope to reduce both frailty incidence and progression by trialling interventions aimed at reducing obesity and sedentary behaviour, increasing intensity of physical activity, and improving success of smoking cessation tools. Furthermore, improving educational outcomes and reducing poverty may also reduce inequalities in frailty.