Explaining the association between frailty and mortality in older adults: The mediating role of lifestyle, social, psychological, cognitive, and physical factors

Joint association of frailty index and biological aging with all-cause and cause-specific mortality: a population-based longitudinal cohort study

BACKGROUND

The role of frailty in all-cause, cardiovascular, and cancer mortality is debatable, and the modification effect of biological aging remains unclear. Therefore, we aimed to evaluate the joint association of frailty index and biological aging with all-cause and cause-specific mortality.

METHODS

In this population-based cohort study, data were obtained from the National Health and Nutrition Examination Survey (NHANES) and National Death Index (NDI). Demographic variables were extracted, frailty index was constructed, and biological aging was calculated. All-cause deaths, cancer deaths, and cardiovascular disease (CVD) deaths were extracted as outcomes. Cox proportional hazards regression models were used to estimate the correlations, stratified subgroup analyses were used to figure out effect modifiers, and sensitivity analyses were used to confirm the robustness.

RESULTS

A total of 22,729 NHANES participants were included in this study, with 6786 all-cause deaths, 1830 CVD deaths, and 1396 cancer deaths occurred during an average follow-up of 8.5 years over a total of 192,601 person-years. The hazard ratios (HRs) of delayed aging group for all-cause mortality, CVD mortality, and cancer mortality were 0.45 (95 % CI: 0.41-0.49), 0.39 (95 % CI: 0.34-0.45), and 0.54 (95 % CI: 0.46-0.63), respectively, compared to accelerated aging group (P for all comparisons < 0.001). Likewise, the frailty index score was positively associated with all-cause mortality (HR, 1.06 [95 % CI, 1.06-1.06] per 0.01 increase in the frailty index), cardiovascular (CVD) mortality (HR, 1.07 [95 % CI, 1.06-1.07] per 0.01 increase in the frailty index), and cancer mortality (HR, 1.04 [95 % CI, 1.03-1.04] per 0.01 increase in the frailty index). The associations of frailty index with all-cause mortality and CVD mortality were modified by biological aging (P for interaction = 0.044), but cancer mortality was not (P for interaction = 0.482).

CONCLUSIONS

Accelerated biological aging is associated with higher frailty index, whereas delayed biological aging is inversely associated with risk of all-cause mortality, CVD mortality, and cancer mortality. Biological aging is effect modification among the associations of frailty index with all-cause mortality and CVD mortality, but not for cancer mortality. These findings suggest that for people with high frailty index and acceleration biological aging, to lower frailty degree and decrease biological aging acceleration by approaches such as lifestyle modifications might be beneficial for individual's longevity and lifespan.

The Longitudinal Aging Study Amsterdam: design and cohort update 2025

The Longitudinal Aging Study Amsterdam (LASA) is an ongoing prospective cohort study of older adults in the Netherlands, with data on multiple domains of functioning available over a period of more than 30 years of follow-up. The study started in 1992 with a nationally representative sample of older adults aged 55-84 years. Over the years, three refresher cohorts (two cohorts aged 55-64 years in 2002 and in 2012, and one cohort aged 60-86 years in 2024) were added. The main aim of LASA was to describe determinants, trajectories and consequences of (changes in) physical, cognitive, emotional and social functioning. LASA has multiple strengths, including its multidisciplinary character, the very long period of follow-up, and the cohort-sequential design which enables the study of longitudinal changes as well as historical time trends in functioning. So far, findings based on data from LASA have been reported in more than 800 scientific publications (see www.lasa-vu.nl ). In this article, we provide an update of the design and methods of LASA, including a description of several ancillary studies such as the Loneliness study and the COVID-19 study.

The association between multimorbidity patterns and physical frailty among middle-aged and older community-dwelling adults: the mediating role of depressive symptoms

Background

This study aimed to investigate the association between multimorbidity and frailty, and the potential mediating role of depressive symptoms in Chinese middle-aged and older community-dwelling adults.

Methods

We selected a total of 5,232 adults with two or more chronic diseases from the China Health and Retirement Longitudinal Study (CHARLS) database. Clusters of participants with similar multimorbidity patterns were identified through fuzzy c-means cluster analyses. The cross-sectional association between multimorbidity and frailty was measured through logistic regression analyses. Mediation analysis was applied to examine direct and indirect associations within the counterfactual framework.

Results

At baseline, we identified five multimorbidity patterns. Two of these patterns significantly increased the risk of frailty compared to a non-specific pattern. Depression mediated 35.20% of the effect of multimorbidity on frailty (p = 0.042). Notably, in adults aged 60 years and older, this mediation accounted for 69.84% of the total effect, surpassing the direct impact of multimorbidity on frailty. Among individuals with economic support (0.020, 95% CI: 0.002-0.040), high school education (0.062, 95% CI: 0.007-0.120), and no alcohol consumption (0.024, 95% CI: 0.003-0.050), depression entirely mediated the impact of comorbidities.

Conclusion

This study reveals strong links between specific multimorbidity patterns and physical frailty, with depression significantly mediating these effects, particularly in certain populations. Findings emphasize tailored mental health interventions' necessity in specific groups.

Integrating frailty interventions into existing care models: a comprehensive approach to enhancing patient outcomes in chronic disease management

Frailty syndrome (FS) is a complex and multifaceted condition commonly observed in old adults patients with chronic diseases, often accompanied by cognitive impairments. This review explores the integration of frailty interventions into existing care models to improve patient outcomes, focusing on four key areas. First, it emphasizes the importance of comprehensive assessment tools to identify frailty and cognitive impairments early, facilitating targeted care planning. Second, it highlights the value of personalized interventions, such as dietary modifications, exercise programs, and cognitive training, tailored to individual patient needs and preferences. Third, the review underscores the critical role of multidisciplinary care teams in providing holistic and coordinated care, leveraging the expertise of diverse healthcare professionals. Finally, it examines the potential of technological innovations and caregiver support systems in enhancing frailty management and addressing the challenges posed by cognitive impairments. By integrating these approaches, this review presents a patient-centered framework aimed at mitigating the impact of frailty and improving long-term outcomes. The findings emphasize the need for a unified strategy that combines personalized care, interdisciplinary collaboration, and technological advancements to address the multifaceted challenges of frailty in chronic disease management.

The co-occurrence of multimorbidity and polypharmacy among middle-aged and older adults in Canada: A cross-sectional study using the Canadian Longitudinal Study on Aging (CLSA) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN)

BACKGROUND

There is an increasing prevalence of multiple conditions (multimorbidity) and multiple medications (polypharmacy) across many populations. Previous literature has focused on the prevalence and impact of these health states separately, but there is a need to better understand their co-occurrence.

METHODS AND FINDINGS

This study reported on multimorbidity and polypharmacy among middle-aged and older adults in two national datasets: the Canadian Longitudinal Study on Aging (CLSA) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Using consistent methodology, we conducted a cross-sectional analysis of CLSA participants and CPCSSN patients aged 45 to 85 years as of 2015. When multimorbidity was defined as two or more conditions, the prevalence was 66.7% and 52.0% in the CLSA and CPCSSN cohorts, respectively. The prevalence of polypharmacy was 14.9% in the CLSA cohort and 22.6% in the CPCSSN cohort when defined as five or more medications. Using the same cut-points, the co-occurrence of multimorbidity and polypharmacy was similar between the two cohorts (CLSA: 14.3%; CPCSSN: 13.5%). Approximately 20% of older adults (65 to 85 years) were living with both multimorbidity and polypharmacy (CLSA: 21.4%; CPCSSN: 18.3%), as compared to almost 10% of middle-aged adults (45 to 64 years) living with this co-occurrence (CLSA: 9.2%; CPCSSN: 9.9%). Across both cohorts and age groups, females had consistently higher estimates of multimorbidity, polypharmacy and the co-occurrence of multimorbidity and polypharmacy.

CONCLUSIONS

This study found that multimorbidity and polypharmacy are not interchangeable in understanding population health needs. Approximately one in five older adults in the CLSA and CPCSSN cohorts were living with both multimorbidity and polypharmacy, double the proportion in the younger cohorts. This has implications for future research, as well as health policy and clinical practice, that aim to reduce the occurrence and impact of multimorbidity and unnecessary polypharmacy to enhance the well-being of aging populations.

The Impact of Frailty on Patients With AF and HFrEF Undergoing Catheter Ablation: A Nationwide Population Study

Background

Frailty is a common geriatric syndrome often coexisting with cardiovascular diseases such as atrial fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF). While catheter ablation (CA) has demonstrated efficacy in reducing major adverse cardiovascular events and improving mortality and quality of life, the influence of frailty among this population remains unknown.

Objectives

The authors aimed to identify the prevalence of frailty among patients with HFrEF and AF undergoing CA and its influence on cardiovascular mortality and discharge disposition.

Methods

From January 2016 to December 2019, we used the Nationwide Inpatient Sample to identify patients with AF and HFrEF. Frailty was identified by the presence of ≥1 diagnostic cluster utilizing the Johns Hopkins Adjusted Clinical Groups with malnutrition, dementia, impaired vision, decubitus ulcer, urinary incontinence, loss of weight, poverty, barriers to access to care, difficulty walking, and falls as indicators. We compared clinical outcomes among frail vs nonfrail patients, including all-cause in-hospital mortality, major adverse cardiovascular events, other major complications, discharge disposition, and hospital length of stay using multivariable regression analysis.

Results

Of 113,115 weighted admissions, 11,725 (10.4%) were classified as frail. Frail patients were older (median age: 76 [IQR: 15] years vs 70 [IQR: 15] years, P < 0.001) than nonfrail patients. Frailty was associated with increased odds of all-cause hospital mortality (adjusted odds ratio [aOR]: 2.64; 95% CI: 1.87-3.72; P < 0.001), major adverse cardiovascular events (aOR: 2.00; 95% CI: 1.62-2.47; P < 0.001), and nonhome discharge (aOR: 3.31; 95% CI: 2.78-3.94; P < 0.001). Frail patients also experienced longer hospital length of stay (median 9 [IQR: 10] days vs 5 [IQR: 5] days, P < 0.001) after adjustment by Poisson regression (coefficient: 0.53; 95% CI: 0.46-0.59; P < 0.001).

Conclusions

Frailty is associated with worse outcomes in patients with HFrEF undergoing CA for AF. The integration of frailty models in clinical practice may facilitate prognostication and risk stratification to optimize patient selection for CA.

Development and Validation of a Game for Older Adults on Lifestyles and Frailty

BACKGROUND

Games are a promising strategy for rehabilitating older adults. The effect of games on promoting healthy lifestyles and preventing frailty remains uncertain. This article aims to describe the process of development and validation of the game "Bem-me-quer para a saúde"® to promote the acquisition of healthy lifestyles and prevent frailty in over 65-year-olds.

METHODS

This study comprised three distinct phases, spanning from December 2023 to June 2024. The first phase comprised a thorough review of the scientific literature on the frailty and lifestyles of older adults, a second phase of game design, and a third phase of content and semantic validation conducted by specialized nurses and older adults.

RESULTS

After revising literature, this study utilized an e-Delphi with a panel of 14 specialist nurses who underwent two rounds of evaluation. The "Bem-me-quer para a saúde"® game includes a puzzle board with 54 pieces and 30 educational cards. In the final phase, we evaluated the game on a cohort of 50 older adults, highlighting its reflective, interactive, and educational aspects.

CONCLUSIONS

The game presented sufficient evidence of content validity and relevance to clinical practice. We should conduct additional research to evaluate its impact on lifestyle modification and frailty prevention.

Association of Sitting Time With All-Cause and Cardiovascular Mortality: How Does Frailty Modify This Association?

To investigate how frailty modifies the association of sitting time with all-cause and cardiovascular mortality in Chilean adults. This prospective study included 2,604 participants aged ≥35 from the Chilean National Health Survey 2009-2010. Sitting time was self-reported, while frailty was assessed using a 36-item Frailty Index. Sitting time was categorized as low, medium, and high. Cox proportional hazard models were used to estimate the risk of mortality stratified for the sitting time categories. Over a median follow-up of 8.9 years, 311 participants died, 28% of them due to cardiovascular events. Frail people with prolonged sitting time were at higher risk of all-cause and cardiovascular mortality (hazard ratio 3.13; 95% confidence interval [2.06, 4.71] and hazard ratio 2.41; 95% confidence interval [1.50, 3.64], respectively). The observed risk was higher in women than men. Public health and individual strategies should be implemented to decrease sitting time across the population, with special attention on frail people.

The role of lifestyle in the association between frailty and all-cause mortality amongst older adults: a mediation analysis in the UK Biobank

OBJECTIVE

frailty is a syndrome characterised by increased vulnerability to stressors, which manifests as higher death risk. Whilst guidelines for frailty management usually entails lifestyle modifications (e.g. physical exercise, diet), the mediating role of lifestyle on the excess mortality associated with frailty is unclear. This study estimates the death risk due to frailty that could be avoided with a healthy lifestyle in older adults.

SUBJECTS AND METHODS

we analysed data from 91,906 British individuals aged ≥60 years recruited between 2006 and 2010. At baseline, frailty was identified according to Fried's phenotype, and a four-item Healthy Lifestyle Index (HLS) was calculated based on physical activity, diet, smoking and alcohol consumption. Mortality was ascertained from baseline through 2021. A mediation analysis under the counterfactual framework was performed adjusting for the main confounders.

RESULTS

during a median follow-up of 12.5 years, 9,383 deaths occurred. Frailty was directly associated with all-cause mortality (hazard ratio: 2.30 [95% confidence interval {CI} 2.07, 2.54]), and inversely associated with the HLS (ß: -0.45 points [-0.49, -0.40]). The hazard ratio [95%CI] for the direct effect of frailty on mortality was 2.12 [1.91, 2.34], whilst for the indirect effect (mediated by HLS) was 1.08 [1.07, 1.10]. The mediated proportion of HLS on mortality was 13.55% [11.26, 16.20], with physical activity having the highest proportion amongst the four HLS items (7.69% [5.00, 10.40]).

CONCLUSIONS

a healthy lifestyle partly mediates the association between frailty and mortality in British older adults. Since this was an exploratory mediation analysis, these results should be specifically tested in future research.

Targeting the hallmarks of aging to improve influenza vaccine responses in older adults

Age-related declines in immune response pose a challenge in combating diseases later in life. Influenza (flu) infection remains a significant burden on older populations and often results in catastrophic disability in those who survive infection. Despite having vaccines designed specifically for older adults, the burden of flu remains high and overall flu vaccine efficacy remains inadequate in this population. Recent geroscience research has highlighted the utility in targeting biological aging to improve multiple age-related declines. Indeed, the response to vaccination is highly coordinated, and diminished responses in older adults are likely not due to a singular deficit, but rather a multitude of age-related declines. In this review we highlight deficits in the aged vaccine responses and potential geroscience guided approaches to overcome these deficits. More specifically, we propose that alternative vaccine platforms and interventions that target the hallmarks of aging, including inflammation, cellular senescence, microbiome disturbances, and mitochondrial dysfunction, may improve vaccine responses and overall immunological resilience in older adults. Elucidating novel interventions and approaches that enhance immunological protection from vaccination is crucial to minimize the disproportionate effect of flu and other infectious diseases on older adults.

Relationship Between Frailty, Sociodemographic and Clinical Characteristics, and Disease Severity of Older Adults With Acute Coronary Syndrome

This study aimed to evaluate the relationship between frailty, sociodemographic and clinical characteristics, and disease severity of older adults with acute coronary syndrome (ACS). A total of 57 hospitalized patients ≥60 years with ACS were assessed for frailty through the Tilburg Frailty Indicator. Disease severity was assessed by the Global Registry of Acute Coronary Events, by the maximum troponin level, and by the number of severely obstructed coronary arteries. The relationship between variables was assessed by Mann Whitney's test, Pearson's chi-square test, likelihood-ratio test, Fisher's exact test, or Student's t test. Analyses were bootstrapped to 1,000 to reduce potential sample bias. About 54.4% were frail. Frailty was associated with ethnicity (p = .02), marital status (p = .05), ischemic equivalents (p = .01), self-perceived health (p = .002), arthritis/rheumatism/arthrosis (p = .002), and number of severely obstructed coronary arteries (p = .05). These relationships can support intensified surveillance planning for the elderly at greatest risk, structuring of transitional care, appropriate nurse-coordinated secondary prevention delivery in primary care, and cardiac rehabilitation following ACS.

Frailty modifies the effect of polypharmacy and multimorbidity on the risk of death among nursing home residents: Results from the SHELTER study

Background

Frailty, disability, and polypharmacy are prevalent in nursing home (NH) residents, often co-occurring with multimorbidity. There may be a complex interplay among them in terms of outcomes such as mortality. Aims of the study were to (i) assess whether nursing home residents with polypharmacy (5-9 medications) or hyperpolypharmacy (≥10 drugs), have an increased risk of death and (ii) whether any association is modified by the co-presence of frailty or disability.

Methods

Cohort study with longitudinal mortality data including 4,023 residents from 50 European and 7 Israeli NH facilities (mean age = 83.6 years, 73.2% female) in The Services and Health for Elderly in Long Term care (SHELTER) cohort study. Participants were evaluated with the interRAI-LongTerm Care assessment tool. Frailty was evaluated with the FRAIL-NH scale. Hazard ratio (HR) of death over 12 months was assessed with stratified Cox proportional hazards models adjusted for demographics, facilities, and cognitive status.

Results

1,042 (25.9%) participants were not on polypharmacy, 49.8% (n = 2,002) were on polypharmacy, and 24.3% (n = 979) on hyperpolypharmacy. Frailty and disability mostly increased risk of death in the study population (frailty: HR = 1.85, 95%CI 1.49-2.28; disability: HR = 2.10, 95%CI 1.86-2.47). Among non-frail participants, multimorbidity (HR = 1.34, 95%CI = 1.01-1.82) and hyperpolypharmacy (HR = 1.61, 95%CI = 1.09-2.40) were associated with higher risk of death. Among frail participants, no other factors were associated with mortality. Polypharmacy and multimorbidity were not associated with mortality after stratification for disability.

Conclusions

Frailty and disability are the strongest predictors of death in NH residents. Multimorbidity and hyperpolypharmacy increase mortality only in people without frailty. These findings may be relevant to identify patients who could benefit from tailored deprescription.

Hospital frailty risk score predicts worse outcomes in patients with chronic pancreatitis

Background

Chronic pancreatitis (CP) is a pathological fibroinflammatory response to persistent inflammation or stress to the pancreas. The effect of frailty on outcomes in patients with CP has not been previously examined. In this study, we examined the effect of frailty on outcomes in hospitalized patients with CP.

Methods

Records of patients with a primary or secondary discharge diagnosis of CP (ICD10-CM codes K86.0, K86.1) between January 2016 and December 2019 were obtained from the National Inpatient Sample database. Data were collected on patient demographics, hospital characteristics, comorbidities, and etiology of CP. The relationship between frailty and outcomes, including mortality, intensive care unit (ICU) admission, sepsis, shock, length of stay (LOS), and total hospitalization charges (THC), were analyzed using multivariate analysis.

Results

722,160 patients were included in the analysis. Patients with a high hospital frailty risk score had a higher mortality risk (adjusted odds ratio [aOR] 12.57, 95% confidence interval [CI] 10.42-15.16; P<0.001) compared to patients with low frailty scores. Patients with high frailty scores also had a higher risk of sepsis (aOR 5.75, 95%CI 4.97-6.66; P<0.001), shock (aOR- 26.25, 95%CI-22.83-30.19; P<0.001), ICU admission (aOR 25.86, 95% CI-22.58-29.62; P<0.001), and acute kidney injury (aOR 24.4, 95%CI 22.39-26.66; P<0.001). They also had a longer LOS (7.04 days, 95%CI 6.57-7.52; P<0.001) and higher THC ($72,200, 95%CI 65,904.52-78,496.66; P<0.001).

Conclusions

Frail patients, as determined by their hospital frailty risk score, are at high risk of worse outcomes. This data suggests opportunities for physicians to risk-stratify patients and predict outcomes.