Frailty and healthcare costs-longitudinal results of a prospective cohort study

Reweighting and validation of the hospital frailty risk score using electronic health records in Germany: a retrospective observational study

BACKGROUND

In the hospital setting, frailty is a significant risk factor, but difficult to measure in clinical practice. We propose a reweighting of an existing diagnoses-based frailty score using routine data from a tertiary care teaching hospital in southern Germany.

METHODS

The dataset includes patient characteristics such as sex, age, primary and secondary diagnoses and in-hospital mortality. Based on this information, we recalculate the existing Hospital Frailty Risk Score. The cohort includes patients aged ≥ 75 and was divided into a development cohort (admission year 2011 to 2013, N = 30,525) and a validation cohort (2014, N = 11,202). A limited external validation is also conducted in a second validation cohort containing inpatient cases aged ≥ 75 in 2022 throughout Germany (N = 491,251). In the development cohort, LASSO regression analysis was used to select the most relevant variables and to generate a reweighted Frailty Score for the German setting. Discrimination is assessed using the area under the receiver operating characteristic curve (AUC). Visualization of calibration curves and decision curve analysis were carried out. Applicability of the reweighted Frailty Score in a non-elderly population was assessed using logistic regression models.

RESULTS

Reweighting of the Frailty Score included only 53 out of the 109 frailty-related diagnoses and resulted in substantially better discrimination than the initial weighting of the score (AUC = 0.89 vs. AUC = 0.80, p < 0.001 in the validation cohort). Calibration curves show a good agreement between score-based predictions and actual observed mortality. Additional external validation using inpatient cases aged ≥ 75 in 2022 throughout Germany (N = 491,251) confirms the results regarding discrimination and calibration and underlines the geographic and temporal validity of the reweighted Frailty Score. Decision curve analysis indicates that the clinical usefulness of the reweighted score as a general decision support tool is superior to the initial version of the score. Assessment of the applicability of the reweighted Frailty Score in a non-elderly population (N = 198,819) shows that discrimination is superior to the initial version of the score (AUC = 0.92 vs. AUC = 0.87, p < 0.001). In addition, we observe a fairly age-stable influence of the reweighted Frailty Score on in-hospital mortality, which does not differ substantially for women and men.

CONCLUSIONS

Our data indicate that the reweighted Frailty Score is superior to the original Frailty Score for identification of older, frail patients at risk for in-hospital mortality. Hence, we recommend using the reweighted Frailty Score in the German in-hospital setting.

Combating Barriers to the Development of a Patient-Oriented Frailty Website

Unlabelled

This viewpoint article, which represents the opinions of the authors, discusses the barriers to developing a patient-oriented frailty website and potential solutions. A patient-oriented frailty website is a health resource where community-dwelling older adults can navigate to and answer a series of health-related questions to receive a frailty score and health summary. This information could then be shared with health care professionals to help with the understanding of health status prior to acute illness, as well as to screen and identify older adult individuals for frailty. Our viewpoints were drawn from 2 discussion sessions that included caregivers and care providers, as well as community-dwelling older adults. We found that barriers to a patient-oriented frailty website include, but are not limited to, its inherent restrictiveness to frail persons, concerns over data privacy, time commitment worries, and the need for health and lifestyle resources in addition to an assessment summary. For each barrier, we discuss potential solutions and caveats to those solutions, including assistance from caregivers, hosting the website on a trusted source, reducing the number of health questions that need to be answered, and providing resources tailored to each users' responses, respectively. In addition to screening and identifying frail older adults, a patient-oriented frailty website will help promote healthy aging in nonfrail adults, encourage aging in place, support real-time monitoring, and enable personalized and preventative care.

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis

BACKGROUND

The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.

METHODS

We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.

RESULTS

One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.

CONCLUSION

Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

Validation of the Hospital Frailty Risk Score in older adults hospitalized with community-acquired pneumonia

AIM

Frailty results from age-associated declines in physiological reserve and function and is prevalent in older people. Our aim is to examine the association of the Hospital Frailty Risk Score (HFRS) with adverse events in older patients hospitalized with community-acquired pneumonia (CAP) and hypothesise that frailty is a comparable predictor of outcomes in CAP versus traditional severity indices such as CURB-65.

METHODS

Retrospective review of electronic medical records in patients ≥65 years with CAP admitted to a tertiary hospital from 1 January to 30 April 2021. Patients were identified using ICD codes for CAP and categorized as high risk (>15), intermediate risk (5-15) and low risk (<5) of frailty using the HFRS.

RESULTS

Of 429 patients with CAP, 53.8% male, mean age of 82.9 years, older patients (85 vs. 79.7 years, P < 0.001) were at higher risk of frailty. Using the HFRS, 47.6% were deemed at high risk, 35.9% at intermediate risk, and 16.6% at low risk of frailty. Multivariate logistic regression shows that HFRS was more strongly associated (≥7 days, OR 1.042, CI 1.017-1.069) than CURB-65 (OR 0.995, CI 0.810-1.222) with long hospital length of stay (LOS), while CURB-65 (Confusion, Urea >7mmol/L, Respiratory rate >30, Blood pressure, age => 65 years old) was more strongly associated with mortality at 30, 90 and 365 days, compared with the HFRS. Comparing the values for the area under the receiver operator characteristic curve, the HFRS was found to be a better predictor of long LOS, while CURB-65 remains a better predictor of mortality.

CONCLUSIONS

Patients with high risk of frailty have higher healthcare utilization and HFRS is a better predictor of long LOS than CURB-65 but CURB-65 was a better predictor of mortality. Geriatr Gerontol Int 2024; 24: 135-141.

Association between frailty and oral health services use in Brazilian older adults

OBJECTIVES

To assess the association between frailty and oral health services use in Brazilian older adults.

METHODS

This cross-sectional study analysed the baseline data from the Longitudinal Study on Brazilian Ageing (ELSI-Brazil) representative of Brazilians aged 50 or over. The outcome was oral health services used in the year prior to the interview. The main exposure variable was Frailty defined by the frailty phenotype. Age, skin colour, wealth, sex, education, type of service, health insurance, number of teeth and self-perceived oral health were included as covariates. Prevalence ratios (PR) with their respective 95% confidence intervals (CI) were estimated using Poisson regression with robust variance.

RESULTS

8405 individuals were included in this study. The prevalence of frailty was 7.5%. Regarding frailty status, the prevalence of dental service use was 47.0%, 48.5% and 4.5% for robust, pre-frail and frail individuals, respectively. Frail individuals had a 7% higher prevalence of not using dental (PR: 1.07; 95% CI: 1.01-1.13) than robust individuals. Frailty was independently associated with not using oral health services.

CONCLUSION

Given the complexity of the determinants of dental service use, frailty adds another dimension to be examined in older adults. Public health strategies considering a common risk factor approach should be endorsed.

Weak grip strength predicts higher unplanned healthcare utilization among patients with heart failure

AIMS

Frailty increases healthcare utilization and costs for patients with heart failure but is challenging to assess in clinical settings. Hand grip strength (GS) is a single-item measure of frailty yet lacks evidence as a potential screening tool to identify patients at risk of higher unplanned events and related healthcare costs. We examined the association of baseline and longitudinal GS measurements with healthcare utilization and costs among patients with advanced heart failure.

METHODS AND RESULTS

Between July 2017 and April 2019, we enrolled 251 patients with symptoms of advanced heart failure (New York Heart Association class III or IV) in a prospective cohort study in Singapore. We measured GS at baseline and every 4 months for 2 years and linked patients' survey data with their medical and billing records. We categorized patients as having weak GS if their GS measurement was below the 5th percentile of the age- and gender-specific normative GS values in Singapore. We assessed the association between baseline GS and healthcare utilization (unplanned and planned events and healthcare costs, total costs, and length of inpatient stay) over the next 2 years using regression models. We investigated the association between longitudinal 4-monthly GS assessments and the ensuing 4 months of healthcare utilization and costs using mixed-effects logistic and two-part regression models. At baseline, 22.5% of patients had weak GS. Baseline and longitudinal GS measurements were significantly associated with longer length of inpatient stay, greater likelihood of unplanned events, and higher related costs. Patients with weak GS had higher odds of an unplanned event occurring by 8 percentage points [95% confidence interval (CI) (0.01, 0.14), P = 0.026], incurred longer inpatient stays by 4 days [95% CI (1.97, 6.79), P = 0.003], and additional SG$ 4792 [US$ ~ 3594, 95% CI (1894, 7689), P = 0.014] in unplanned healthcare costs over the next 4 months.

CONCLUSIONS

GS is a simple tool to identify and monitor heart failure patients at risk of unplanned events, longer inpatient stays, and higher related healthcare costs. Findings support its routine use in clinical settings.

Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit

BACKGROUND

Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people.

METHODS

In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30 days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180 days pre- and post-first assessment.

RESULTS

Among 533 patients (mean/SD age = 75.0/17.5 years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30 days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180 days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22 days, P = 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients.

DISCUSSION AND CONCLUSION

SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.

Recovery of surgery in the elderly (ROSE) program: The efficacy of a multi-modal prehabilitation program implemented in frail and pre-frail elderly undergoing major abdominal surgery

BACKGROUND

Major abdominal surgery is associated with a high rate of post-operative complications with increased risk of adverse surgical outcomes due to the presence of frailty. This study aims to evaluate the effectiveness of the multimodal Recovery of Surgery in the Elderly (ROSE) prehabilitation program with supervised exercise in mitigating postoperative functional decline when compared to standard care.

METHOD

The ROSE program enrolled ambulant patients who were 65 years and above, had a Clinical Frailty Scale score of 4 or more and were planned for major abdominal surgery. Participation in supervised exercise sessions before surgery were compared with standard physiotherapy advice. The primary outcome was 6-min walk test (6MWT) distance assessed at baseline, after prehabilitation and 30 days follow-up after surgery. Secondary outcomes included physical performance, length of hospital stay and postoperative morbidity.

RESULTS

Data from 74 eligible patients, 37 in each group, were included. Median age was 78 years old. Forty-two patients (22 in Prehab group and 20 in control group) with complete 6MWT follow-up data at 30 days follow-up were analysed for outcomes. Most patients underwent laparoscopic surgery (63.5%) and almost all of the surgeries were for abdominal malignancies (97.3%). The Prehab group had an increase in 6MWT distance at the 30-day follow up, from a baseline mean (SD) of 277.4 (125) m to 287.6 (143.5) m (p = 0.415). The 6MWT distance in the control group decreased from a baseline mean (SD) of 281.7 (100.5) m to 260.1 (78.6) m at the 30-day follow up (p = 0.086). After adjusting for baseline 6MWT distance and frailty score, the Prehab group had significantly higher 6MWT distance at 30-day follow-up than control (difference in adjusted means 41.7 m, 95% confidence interval 8.7-74.8 m, p = 0.015). There were no significant between-group differences in the secondary outcomes.

CONCLUSION

A multimodal prehabilitation program with supervised exercise within a short time frame can improve preoperative functional capacity and maintain baseline functional capacity in frail older adults undergoing major abdominal surgery.

Cluster analysis to identify the profiles of individuals with compromised bone health versus unfortunate wrist fractures within the Canadian Longitudinal Study of Aging (CLSA) database

We used cluster analysis to determine the profiles of individuals who sustained wrist fractures. We found two groups: (1) young and active and (2) older and less active. This information may be used to identify individuals who require further bone health interventions to optimize healthy aging.

INTRODUCTION

Distal radial fractures (DRF) are the most common of all fractures, with 6% of males and 33% of females having one at some point in their lifetime. We hypothesize that DRF consists of two subpopulations: one with compromised bone health that is early in the osteoporosis (OP) trajectory and another which are active and healthy and suffer a misfortune fracture due to their high activity levels or risk-taking behaviors. The latter is likely to recover with a minimal disability, while the former may signal a negative health trajectory of disability and early mortality.

OBJECTIVE

To determine the profiles of individuals who sustained wrist fractures using cluster analysis within the Comprehensive Cohort of the Canadian Longitudinal Study on Aging (CLSA) database considering factors that reflect bone health and activity levels.

METHODS

We included all the individuals who had a wrist fracture within the CLSA comprehensive cohort of the database (n = 968). The baseline data was used for this analysis. A 2-step cluster analysis was used to identify profiles that were both statistically and clinically meaningful. Variables that were used in the cluster analysis include demographic variables, physical activity status indicators, general health indicators, mobility indicators, bone health indicators, comorbid conditions, and lifestyle factors.

RESULTS

We were able to identify two distinct profiles that were statistically and clinically meaningful confirming our hypothesis. One cluster included a predominantly younger cohort, who are physically active, with less comorbid conditions, better bone health, and better general health, while the opposite was true of the first cohort.

CONCLUSION

We were able to identify two clusters-a healthy profile and a bone health compromised profile. This information may be used to identify the subgroup of people who should be targeted in the future for more intensive preventive health services to optimize healthy aging.

Frailty syndrome in women with osteoporosis, should physicians consider screening? A cross-sectional study

Despite its high prevalence and profound impact, frailty syndrome often goes undiagnosed. The study revealed a significant correlation between osteoporosis and frailty syndrome, with predictive accuracy exceeding 75 %. Given these findings and the existing recommendation for osteoporosis screening in older women, we underscore the importance of concurrently screening osteoporotic women for frailty.

Introduction

Frailty syndrome, a prevalent and significant geriatric condition, impacts healthcare costs and quality of life. Previous reviews have associated frailty syndrome with osteoporosis, but original research on this link is limited and has produced conflicting results. This study aims to investigate the relationship between frailty syndrome, osteoporosis, bone mineral densitometry T-score, and other influencing factors.

Methods

In this cross-sectional study, post-menopausal women underwent screening for osteoporosis and frailty syndrome using bone mineral densitometry and the Fried phenotype. Exclusion criteria included a history of diseases related to bone loss or medications affecting bone metabolism. Bivariate and multivariable tests were used to examine the correlation between frailty syndrome and various covariates, including the diagnosis of osteoporosis.

Results

A total of 272 women aged 60 to 89 years (mean age 68.57 ± 6.22) were evaluated. Osteoporosis was prevalent in 44.9 % of participants, and frailty syndrome was identified in 36.4 %. The regression model identified age, menopausal age, and the diagnosis of osteoporosis as variables significantly and independently associated with frailty syndrome. A T-score lower than -2.5 in the femur neck or lumbar spine exhibited a sensitivity of 86.6 % and specificity of 76.5 % in predicting frailty syndrome.

Conclusion

Older adults with osteoporosis face an increased risk of frailty syndrome. Therefore, we recommend that primary care providers screen osteoporotic women for frailty syndrome and, when appropriate, refer this group to geriatric specialists for further evaluation.

Effects of the bio-psycho-social frailty dimensions on healthcare utilisation among elderly in Europe: A cross-country longitudinal analysis

Frailty represents an emerging challenge and has major implications for clinical practice, public health, and the sustainability of health systems. It is a geriatric condition, related to but distinct from disability and multimorbidity and characterized by a diminished physiological reserve of multiple organs. Despite limited consensus and evidence, it has been argued that cognitive and social aspects influence the condition. Therefore, we aim to provide evidence on the importance of taking a broader approach in defining frailty, by investigating the role of its physical, social, and psychological subdomains to predict healthcare utilisation in elderly Europeans. The study is based on the Survey of Health, Ageing and Retirement in Europe (SHARE), and uses 185,169 total observations from 12 European countries included in wave 4, 5, 6, and 8. The analysis investigates the influence of the physical frailty index (a proxy of the Frailty Phenotype definition), psychological and social frailty indexes (built to proxy the Tilburg Frailty Index) on the likelihood of hospitalisation and the number of doctor visits. We addressed missing values due to item non-response with fully conditional specification multivariate imputation and exploited the longitudinal structure of the data to control for time-fixed unobserved characteristics. In addition, our two multivariate models included regressors to correct for demand side factors (health status, socio-economic status, and behavioral risk) as well as for country-specific characteristics. Physical and psychological frailty positively influence the likelihood of hospitalisation (OR = 1.90 and OR = 1.31, respectively) and the number of doctor visits (IRR = 1.30 and IRR = 1.07), while social frailty reduces the two types of health services utilisation (OR = 0.53 and IRR = 0.90). The three frailty dimensions are relevant risk stratification factors in elderly Europeans, and health policies should focus more on the psycho-social aspects of this condition, as a strategy to both contain expenditures and avoid potential healthcare inequalities.

Development of a hospital frailty risk score for community-dwelling older adults using data from electronic hospital records in South Korea

PURPOSE

We aimed to develop the Korean Hospital Frailty Risk Score (K-HFRS) by applying the International Classification of Diseases-10 codes to community-dwelling older adults' medical data.

METHODS

We selected data from 2,761 people with no missing main variable values from the Korean Frailty and Aging Cohort Data (KFACD) and National Health Insurance Database (NHID) for analysis. Frailty was determined based on modified Fried's phenotype [MFP] and Korean Frailty Index for Primary Care [KFI-PC] in the KFACD. A previously established method calculated the K-HFRS, verified by the area under the receiver operating characteristic (ROC) curve. The calculated cutoff value predicted the medical use.

RESULTS

The respective K-HFRSs of the frailty group using the MFP and KFI-PC criteria ranged from 3.64 (±3.03) to 8.15 (±5.72) and 4.07 (±3.42) to 9.10 (±6.28), with 7.67 (±5.40) and 8.59 (±6.03) when four diagnoses were included. The K-HFRS of the frailty group using the KFI-PC criteria was higher than that using the MFP criteria. With four diagnoses included using the MFP criteria, the adjusted odds ratio (OR) for medical expenditures in the frailty group compared to the non-frailty group was 3.01 (95% confidence interval [CI] 2.52-3.60, p < .001); for the number of emergency room (ER) visits was 2.19 (95% CI 1.77-2.70, p < .001); for inpatient days was 2.48 (95% CI 2.08-2.96, p < .001). With four diagnoses included using the KFI-PC criteria, the adjusted OR value for medical expenditures was 2.77 (95% CI 2.35-3.27, p < .001); for the number of ER visits was 1.87 (95% CI 1.51-2.32, p < .001); for inpatient days was 2.07 (95% CI 1.75-2.45, p < .001).

CONCLUSION

This study substantiated that the K-HFRS can measure frailty efficiently at a lower cost. Follow-up studies are needed for additional validity.

Associations of intrinsic capacity, fall risk and frailty in old inpatients

Introduction

This study explored the associations of intrinsic capacity (IC), fall risk, and frailty in geriatric inpatients.

Methods

A total of 703 hospitalized patients aged 75 years or older were recruited for this retrospective observational study from Zhejiang Hospital using a comprehensive geriatric assessment. The IC composite score was constructed from the scores of the Chinese version of the Mini-Mental State Examination, Short Physical Performance Battery, Short Form Mini Nutritional Assessment, 15-item Geriatric Depression Scale, and self-reported hearing and vision impairment. Adverse outcomes were recorded as the fall risk and frailty using the Morse Fall Scale and the Clinical Frailty Scale. Spearman's correlation coefficient analyses and multivariate logistic regression models were used to explore the associations between IC, high fall risk, and frailty.

Results

Declined IC composite scores were associated with increased risks of falls [odds ratio (OR) = 0.64, 95% confidence interval (CI): 0.57-0.72] and frailty (OR = 0.45, 95%CI: 0.37-0.54) among older hospitalized patients after adjusting for the related potential confounders. In addition, decreased cognitive, vitality, locomotion, and psychological scores were associated with increased adverse health conditions, with ORs ranging from 0.26 to 0.70. Vision impairment was observed to increase the risk of frailty (OR = 0.42, 95%CI: 0.23-0.76) after adjusting for the related potential confounders.

Discussion

This study indicated that declined IC was associated with fall risk and frailty in older inpatients. Further prospective studies are needed to explore the longitudinal associations between baseline IC and subsequent risk of falls and frailty.

Chronic inflammation does not mediate the effect of adiposity on grip strength: results from a multivariable Mendelian randomization study

The relationship between adiposity and grip strength (GS) is complex. We investigated whether one pathway through which adiposity affects GS was via chronic inflammation. 367,583 UK Biobank participants had body mass index (BMI), waist-hip-ratio (WHR), C-reactive protein (CRP) and GS data. Univariable Mendelian randomization (MR) and multivariable Mendelian randomization (MVMR) analyses (using inverse variance weighted (IVW) weighted median estimates (WME) and MR-Egger models) estimated total, direct and indirect effects of adiposity traits on GS using genetic instruments for BMI and WHR (exposures) and CRP (mediator). Observational findings suggested higher BMI was associated with stronger grip, e.g., in males, per standard deviation (SD) higher BMI, GS was higher by 0.48 kg (95% confidence interval(CI):0.44,0.51), independent of CRP. For males MR estimates were directionally consistent; for females, estimates were consistent with the null. Observational findings for WHR suggested that higher WHR was associated with weaker grip. In multivariable MR-IVW analyses, effects in males were consistent with the null. In females, there were consistent effects such that higher WHR was associated with stronger grip, e.g., 1-SD higher WHR was associated with 1.25 kg (MVMR-Egger; 95% CI:0.72,1.78) stronger grip, independent of CRP. Across sexes and adiposity indicators, CRP's mediating role was minor. Greater adiposity may increase GS in early old age, but effects vary by sex and adiposity location. There was no evidence that inflammation mediated these effects.

Health Access, Health Promotion, and Health Self-Management: Barriers When Building Comprehensive Ageing Communities

A new intervention model for promoting healthy ageing grounded on integrated value-based care was developed and tested in the city of Valencia (Spain). Its implementation raised relevant barriers for older adults in their access to health, health promotion, and health self-management linked with their health and digital literacy. This new intervention model included several aspects. On the one hand, researchers together with older adults and their informal caregivers participating in the study, designed personalized care plans, based on older adults' specific needs, to be implemented with the support of a digital solution. On the other hand, researchers and health and social professionals implemented a series of workshops in different locations of the city to encourage a sense of community among participants, reinforcing their trust in the new care model and increasing their adherence. Social activities were at the core of the workshops to understand older people's interaction with the health and social services provided in the neighborhood. Qualitative and quantitative methods were combined to extract information from older participants on how to engage them as active actors of their health and understand their values and preferences. In the present manuscript, we focus on the qualitative results, which show that after a post-pandemic situation, they were more concerned about social isolation and desired face-to-face contact with their professional care team; however, feelings of loneliness and/or sadness were not considered among the reasons to visit health professionals. Some of the conclusions revealed that the use of technology as a supportive tool is well received but with a stress on its role as "supportive", and not replacing the close contact with healthcare professionals. Professionals recognized the benefits of this new approach but required more time and incentives to dedicate the effort needed. The main aim of this study was to present these barriers related to health access, health promotion, and health self-management, as well as the actions developed to face them.

The 5-item modified frailty index predicts spinal osteotomy outcomes better than age in adult spinal deformity patients: an ACS - NSQIP analysis

PURPOSE

To evaluate the utility of 5-Item Modified Frailty Index (mFI-5) as compared to chronological age in predicting outcomes of spinal osteotomy in Adult Spinal Deformity (ASD) patients.

METHODS

Using Current Procedural and Terminology (CPT) codes, the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database was queried for adult patients undergoing spinal osteotomy from 2015 to 2019. Multivariate regression analysis was performed to evaluate the effect of baseline frailty status, measured by mFI-5 score, and chronological age on postoperative outcomes. Receiver-operating characteristic (ROC) curve analysis was performed to analyze the discriminative performance of age versus mFI-5.

RESULTS

A total of 1,789 spinal osteotomy patients (median age 62 years) were included in the analysis. Among the patients assessed, 38.5% (n = 689) were pre-frail, 14.6% frail (n = 262), and 2.2% (n = 39) severely frail using the mFI-5. Based on the multivariate analysis, increasing frailty tier was associated with worsening outcomes, and higher odds ratios (OR) for poor outcomes were found for increasing frailty tiers as compared to age. Severe frailty was associated with the worst outcomes, e.g., unplanned readmission (OR 9.618, [95% CI 4.054-22.818], p < 0.001) and major complications (OR 5.172, [95% CI 2.271-11.783], p < 0.001). In the ROC curve analysis, mFI-5 score (AUC 0.838) demonstrated superior discriminative performance than age (AUC 0.601) for mortality.

CONCLUSIONS

The mFI5 frailty score was found to be a better predictor than age of worse postoperative outcomes in ASD patients. Incorporating frailty in preoperative risk stratification is recommended in ASD surgery.

Impact of exercise and leucine-enriched protein supplementation on physical function, body composition, and inflammation in pre-frail older adults: a quasi-experimental study

Background

Exercise and a protein-enriched diet are essential for muscle protein synthesis, cellular growth, mitochondrial function, and immune function. The U.S. Food and Nutrition Board's current guideline on recommended dietary allowance for protein in older adults is 0.8 g/kg per day, which may not be sufficient in vulnerable pre-frail older adults.

Aims

This study aimed to evaluate the impact of leucine-enriched protein supplementation with or without exercise over 3 months in pre-frail older adults who consumed ≤1 g/kg/day of protein on improving (i) physical function, (ii) body composition measures, and (iii) inflammatory biomarkers such as interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α).

Methods

A non-randomized cluster quasi-experimental study guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist of 178 pre-frail older adults [112 control, 44 nutrition (Nu), and 22 in the nutrition with exercise (Nu+Ex) group] comparing the effect of Nu+Ex and Nu on physical function, body composition, and inflammation. At 0, 3, and 6 months, questionnaires on demographics, depression, perceived health, and cognition were administered. Physical function assessment (short physical performance battery [SPPB] test, gait speed, handgrip strength, 5× sit-to-stand [STS]) was conducted, and body composition analysis was performed using a bioelectrical impedance analysis machine. IL-6 and TNF-α were measured at 0 and 3 months.

Results

At 3 months, there were significant improvements in gait speed, 5× STS, SPPB scores, depression, perceived health, fat-free mass, and appendicular skeletal muscle mass indices in the Nu+Ex group. Both Nu+Ex and Nu groups had improvements in body cell mass and reductions in IL-6 and TNF-α. The improvements were not sustained after 6 months.

Conclusion

Our study results need to be validated in future longitudinal randomized studies with a larger sample size focusing on populations at risk.

Healthcare Utilization and Costs According to Frailty Transitions After Two Years: A Korean Frailty and Aging Cohort Study

BACKGROUND

Korea's aging population has raised several challenges, especially concerning healthcare costs. Consequently, this study evaluated the association of frailty transitions with healthcare utilization and costs for older adults aged 70 to 84.

METHODS

This study linked the frailty status data of the Korean Frailty and Aging Cohort Study to the National Health Insurance Database. We included 2,291 participants who had frailty measured by Fried Frailty phenotype at baseline in 2016-2017 and follow-up in 2018-2019. We conducted a multivariate regression analysis to determine the association between their healthcare utilization and costs by frailty transition groups.

RESULTS

After 2 years, changes from "pre-frail" to "frail" (Group 6) and "frail" to "pre-frail" (Group 8) were significantly associated with increased inpatient days (P < 0.001), inpatient frequency (P < 0.001), inpatient cost (P < 0.001 and P < 0.01, respectively), and total healthcare cost (P < 0.001) than "robust" to "robust" (Group 1) older adults. A transition to frailty from "pre-frail" to "frail" (Group 6) resulted in a $2,339 total healthcare cost increase, and from "frail" to "pre-frail" (Group 8), a $1,605, compared to "robust" to "robust" older adults.

CONCLUSION

Frailty among community-dwelling older adults is economically relevant. Therefore, it is crucial to study the burden of medical expenses and countermeasures for older adults to not only provide appropriate medical services but also to prevent the decline in their living standards due to medical expenses.

Relationship of frailty status with health resource use and healthcare costs in the population aged 65 and over in Catalonia

BACKGROUND

Frailty is a geriatric syndrome with repercussions on health, disability, and dependency.

OBJECTIVES

To assess health resource use and costs attributable to frailty in the aged population.

METHODS

A population-based observational longitudinal study was performed, with follow-up from January 2018 to December 2019. Data were obtained retrospectively from computerized primary care and hospital medical records. The study population included all inhabitants aged ≥ 65 years ascribed to 3 primary care centres in Barcelona (Spain). Frailty status was established according to the Electronic Screening Index of Frailty. Health costs considered were hospitalizations, emergency visits, outpatient visits, day hospital sessions, and primary care visits. Cost analysis was performed from a public health financing perspective.

RESULTS

For 9315 included subjects (age 75.4 years, 56% women), frailty prevalence was 12.3%. Mean (SD) healthcare cost in the study period was €1420.19 for robust subjects, €2845.51 for pre-frail subjects, €4200.05 for frail subjects, and €5610.73 for very frail subjects. Independently of age and sex, frailty implies an additional healthcare cost of €1171 per person and year, i.e., 2.25-fold greater for frail compared to non-frail.

CONCLUSIONS

Our findings underline the economic relevance of frailty in the aged population, with healthcare spending increasing as frailty increases.

Mortality Risks after Two Years in Frail and Pre-Frail Older Adults Admitted to Hospital

BACKGROUND

Frailty is characterized by a progressive decline in the physiological functions of multiple body systems that lead to a more vulnerable condition, which is prone to the development of various adverse events, such as falls, hospitalization, and mortality. This study aims to determine whether frailty increases mortality compared to pre-frailty and to identify variables associated with a higher risk of mortality.

MATERIALS

Two cohorts, frail and pre-frail subjects, are evaluated according to the Fried phenotype. A complete examination of frailty, cognitive status, comorbidities and pharmacology was carried out at hospital admission and was extracted through electronic health record (EHR). Mortality was evaluated from the EHR.

METHODS

Kaplan-Meier estimates of survival probability functions were calculated at two years censoring time for frail and pre-frail cohorts. The log-rank test assessed significant differences between survival probability functions. Significant variables for frailty (p < 0-05) were extracted by independent sample t-test. Further selection was based on variable significance found in multivariate logistic regression discrimination between frail and pre-frail subjects. Cox regression over univariate t-test-selected variables was calculated to identify variables associated with higher proportional hazard risks (HR) at two years.

RESULTS

Frailty is associated with greater mortality at two years censoring time than pre-frailty (log-rank test, p < 0.0001). Variables with significant (p < 0.05) association with mortality identified in both cohorts (HR 95% (CI in the frail cohort) are male sex (0.44 (0.29-0.66)), age (1.05 (1.01-1.09)), weight (0.98 (0.96-1.00)), and use of proton-pump inhibitors (PPIs) (0.60 (0.41-0.87)). Specific high-risk factors in the frail cohort are readmission at 30 days (0.50 (0.33-0.74)), SPPB sit and stand (0.62 (0.45-0.85)), heart failure (0.67 (0.46-0.98)), use of antiplatelets (1.80 (1.19-2.71)), and quetiapine (0.31 (0.12-0.81)). Specific high-risk factors in the pre-frail cohort are Barthel's score (120 (7.7-1700)), Pfeiffer test (8.4; (2.3-31)), Mini Nutritional Assessment (MNA) (1200 (18-88,000)), constipation (0.025 (0.0027-0.24)), falls (18,000 (150-2,200,000)), deep venous thrombosis (8400 (19-3,700,000)), cerebrovascular disease (0.01 (0.00064-0.16)), diabetes (360 (3.4-39,000)), thyroid disease (0.00099 (0.000012-0.085)), and the use of PPIs (0.062 (0.0072-0.54)), Zolpidem (0.000014 (0.0000000021-0.092)), antidiabetics (0.00015 (0.00000042-0.051)), diuretics (0.0003 (0.000004-0.022)), and opiates (0.000069 (0.00000035-0.013)).

CONCLUSIONS

Frailty is associated with higher mortality at two years than pre-frailty. Frailty is recognized as a systemic syndrome with many links to older-age comorbidities, which are also found in our study. Polypharmacy is strongly associated with frailty, and several commonly prescribed drugs are strongly associated with increased mortality. It must be considered that frail patients need coordinated attention where the diverse specialist taking care of them jointly examines the interactions between the diversity of treatments prescribed.

Development and validation of a risk prediction model for frailty in patients with diabetes

BACKGROUND

Frailty is the third most common complication of diabetes after macrovascular and microvascular complications. The aim of this study was to develop a validated risk prediction model for frailty in patients with diabetes.

METHODS

The research used data from the China Health and Retirement Longitudinal Study (CHARLS), a dataset representative of the Chinese population. Twenty-five indicators, including socio-demographic variables, behavioral factors, health status, and mental health parameters, were analyzed in this study. The study cohort was randomly divided into a training set and a validation set at a ratio of 70 to 30%. LASSO regression analysis was used to screen the variables for the best predictors of the model based on a 10-fold cross-validation. The logistic regression model was applied to explore the associated factors of frailty in patients with diabetes. A nomogram was constructed to develop the prediction model. Calibration curves were applied to evaluate the accuracy of the nomogram model. The area under the receiver operating characteristic curve and decision curve analysis were conducted to assess predictive performance.

RESULTS

One thousand four hundred thirty-six patients with diabetes from the CHARLS database collected in 2013 (n = 793) and 2015 (n = 643) were included in the final analysis. A total of 145 (10.9%) had frailty symptoms. Multivariate logistic regression analysis showed that marital status, activities of daily living, waist circumference, cognitive function, grip strength, social activity, and depression as predictors of frailty in people with diabetes. These factors were used to construct the nomogram model, which showed good concordance and accuracy. The AUC values of the predictive model and the internal validation set were 0.912 (95%CI 0.887-0.937) and 0.881 (95% CI 0.829-0.934). Hosmer-Lemeshow test values were P = 0.824 and P = 0.608 (both > 0.05). Calibration curves showed significant agreement between the nomogram model and actual observations. ROC and DCA indicated that the nomogram had a good predictive performance.

CONCLUSIONS

Comprehensive nomogram constructed in this study was a promising and convenient tool to evaluate the risk of frailty in patients with diabetes, and contributed clinicians to screening the high-risk population.

Assessment of Frailty Index at 66 Years of Age and Association With Age-Related Diseases, Disability, and Death Over 10 Years in Korea

IMPORTANCE

A frailty index has been proposed as a measure of aging among older individuals. However, few studies have examined whether a frailty index measured at the same chronologic age at younger ages could forecast the development of new age-related conditions.

OBJECTIVE

To examine the association of the frailty index at 66 years of age with incident age-related diseases, disability, and death over 10 years.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective nationwide cohort study used the Korean National Health Insurance database to identify 968 885 Korean individuals who attended the National Screening Program for Transitional Ages at 66 years of age between January 1, 2007, and December 31, 2017. Data were analyzed from October 1, 2020, to January 2022.

EXPOSURES

Frailty was defined using a 39-item frailty index ranging from 0 to 1.00 as robust (<0.15), prefrail (0.15-0.24), mildly frail (0.25-0.34), and moderately to severely frail (≥0.35).

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause death. Secondary outcomes were 8 age-related chronic diseases (congestive heart failure, coronary artery disease, stroke, type 2 diabetes, cancer, dementia, fall, and fracture) and disability qualifying for long-term care services. Cox proportional hazards regression and cause-specific and subdistribution hazards regression were used to examine hazard ratios (HRs) and 95% CIs for the outcomes until the earliest of date of death, the occurrence of relevant age-related conditions, 10 years from the screening examination, or December 31, 2019.

RESULTS

Among the 968 885 participants included in the analysis (517 052 women [53.4%]), the majority were classified as robust (65.2%) or prefrail (28.2%); only a small fraction were classified as mildly frail (5.7%) or moderately to severely frail (1.0%). The mean frailty index was 0.13 (SD, 0.07), and 64 415 (6.6%) were frail. Compared with the robust group, those in the moderately to severely frail group were more likely to be women (47.8% vs 61.7%), receiving medical aid insurance for low income (2.1% vs 18.9%), and less active (median, 657 [IQR, 219-1133] vs 319 [IQR, 0-693] metabolic equivalent task [min/wk]). After adjusting for sociodemographic and lifestyle characteristics, moderate to severe frailty was associated with increased rates of death (HR, 4.43 [95% CI, 4.24-4.64]) and new diagnosis of all chronic diseases, including congestive heart failure (adjusted cause-specific HR, 2.90 [95% CI, 2.67-3.15]), coronary artery disease (adjusted cause-specific HR, 1.98 [95% CI, 1.85-2.12]), stroke (adjusted cause-specific HR, 2.22 [95% CI, 2.10-2.34]), diabetes (adjusted cause-specific HR, 2.34 [95% CI, 2.21-2.47]), cancer (adjusted cause-specific HR, 1.10 [95% CI, 1.03-1.18]), dementia (adjusted cause-specific HR, 3.59 [95% CI, 3.42-3.77]), fall (adjusted cause-specific HR, 2.76 [95% CI, 2.29-3.32]), fracture (adjusted cause-specific HR, 1.54 [95% CI, 1.48-1.62]), and disability (adjusted cause-specific HR, 10.85 [95% CI, 10.00-11.70]). Frailty was associated with increased 10-year incidence of all the outcomes, except for cancer (moderate to severe frailty adjusted subdistribution HR, 0.99 [95% CI, 0.92-1.06]). Frailty at 66 years of age was associated with greater acquisition of age-related conditions (mean [SD] conditions per year for the robust group, 0.14 [0.32]; for the moderately to severely frail group, 0.45 [0.87]) in the next 10 years.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that a frailty index measured at 66 years of age was associated with accelerated acquisition of age-related conditions, disability, and death over the next 10 years. Measuring frailty at this age may offer opportunities to prevent age-related health decline.

Frailty and pain in an acute private hospital: an observational point prevalence study

Frailty and pain in hospitalised patients are associated with adverse clinical outcomes. However, there is limited data on the associations between frailty and pain in this group of patients. Understanding the prevalence, distribution and interaction of frailty and pain in hospitals will help to determine the magnitude of this association and assist health care professionals to target interventions and develop resources to improve patient outcomes. This study reports the point prevalence concurrence of frailty and pain in adult patients in an acute hospital. A point prevalence, observational study of frailty and pain was conducted. All adult inpatients (excluding high dependency units) at an acute, private, 860-bed metropolitan hospital were eligible to participate. Frailty was assessed using the self-report modified Reported Edmonton Frail Scale. Current pain and worst pain in the last 24 h were self-reported using the standard 0-10 numeric rating scale. Pain scores were categorised by severity (none, mild, moderate, severe). Demographic and clinical information including admitting services (medical, mental health, rehabilitation, surgical) were collected. The STROBE checklist was followed. Data were collected from 251 participants (54.9% of eligible). The prevalence of frailty was 26.7%, prevalence of current pain was 68.1% and prevalence of pain in the last 24 h was 81.3%. After adjusting for age, sex, admitting service and pain severity, admitting services medical (AOR: 13.5 95% CI 5.7-32.8), mental health (AOR: 6.3, 95% CI 1. 9-20.9) and rehabilitation (AOR: 8.1, 95% CI 2.4-37.1) and moderate pain (AOR: 3.9, 95% CI 1. 6-9.8) were associated with increased frailty. The number of older patients identified in this study who were frail has implications for managing this group in a hospital setting. This indicates a need to focus on developing strategies including frailty assessment on admission, and the development of interventions to meet the care needs of these patients. The findings also highlight the need for increased pain assessment, particularly in those who are frail, for more effective pain management.Trial registration: The study was prospectively registered (ACTRN12620000904976; 14th September 2020).

The increased medical burden associated with frailty is partly attributable to household solid fuel: A nationwide prospective study of middle-aged and older people in China

BACKGROUND

Frail individuals often face a high medical burden, and household solid fuel use is associated with a range of functional declines or diseases, but evidence on the relationship between household solid fuel and frailty and the resulting medical burden is limited. We aim to investigate the effect of household solid fuel on frailty and further quantify how much of the increased medical burden associated with frailty is attributable to household solid fuel.

METHODS

The prospective data were from the China Health and Retirement Longitudinal Study, 4685 non-frail participants at baseline were included. Inverse probability weighting was used to balance the covariates between groups. The modified Poisson regression was used to analyze the association of household solid fuel (including baseline and switching across three-wave survey) with frailty, and the generalized linear model was used to analyze the association of frailty with the change in medical burden. Further, the increased medical burden associated with frailty attributable to household solid fuel was quantified.

RESULTS

Using solid fuel for cooking (RR = 1.29, 95%CI, 1.07-1.57), heating (RR = 1.38, 95%CI, 1.09-1.73), or both (RR = 1.40, 95%CI, 1.05-1.86) had a higher risk of frailty than using clean fuel. In addition, the risk of frailty generally increases with the times of solid fuel use across the three-wave survey. Then, frailty participants had a greater increase in the annual number of hospitalizations (β = 0.11, 95%CI, 0.02-0.19) and annual costs of hospitalizations (β = 2953.35, 95%CI, 1149.87-4756.83) than those non-frailty. Heating coal caused the largest frailty-related increase in the annual number of hospitalizations and annual costs of hospitalizations, with 0.04 and 1195.40, respectively.

CONCLUSION

The increased medical burden associated with frailty was partly attributable to household solid fuel, which suggested that intervention targeting household solid fuels can delay frailty and thus reduce individual medical burden.

Translational research into frailty from bench to bedside: Salivary biomarkers for inflammaging

Frailty is a complex physiological syndrome associated with adverse ageing and decreased physiological reserves. Frailty leads to cognitive and physical disability and is a significant cause of morbidity, mortality and economic costs. The underlying cause of frailty is multifaceted, including immunosenescence and inflammaging, changes in microbiota and metabolic dysfunction. Currently, salivary biomarkers are used as early predictors for some clinical diseases, contributing to the effective prevention and treatment of diseases, including frailty. Sample collection for salivary analysis is non-invasive and simple, which are paramount factors for testing in the vulnerable frail population. The aim of this review is to describe the current knowledge on the association between frailty and the inflammatory process and discuss methods to identify putative biomarkers in salivary fluids to predict this syndrome. This study describes the relationship between i.-inflammatory process and frailty; ii.-infectious, chronic, skeletal, metabolic and cognitive diseases with inflammation and frailty; iii.-inflammatory biomarkers and salivary fluids. There is a limited number of previous studies focusing on the analysis of inflammatory salivary biomarkers and frailty syndrome; hence, the study of salivary fluids as a source for biomarkers is an open area of research with the potential to address the increasing demands for frailty-associated biomarkers.

Predictive validity of the Short Functional Geriatric Evaluation for mortality, hospitalization and institutionalization in older adults: A retrospective cohort survey

Objectives

Bio-psycho-social frailty is related to increased risk of death and utilization of health services. This paper reports the predictive validity of a 10-min multidimensional questionnaire on the risk of death, hospitalization and institutionalization.

Methods

A retrospective cohort study was performed based on data from the "Long Live the Elderly!" program, involving 8,561 community-dwelling Italian people >75, followed for an average of 516.6 days (Median = 448, P ₂₅-P ₇₅: 309-692). Mortality, hospitalization, and institutionalization rates according to frailty levels assessed by the Short Functional Geriatric Evaluation (SFGE) have been calculated.

Results

Compared with the robust, the pre-frail, frail, and very frail faced a statistically significant increase in the risk of mortality (RR = 1.40, 2.78 and 5.41), hospitalization (OR = 1.31, 1.67, and 2.08) and institutionalization (OR = 3.63, 9.52, and 10.62). Similar results were obtained in the sub-sample of those with only socio-economic issues. Frailty predicted mortality with an area under the ROC curve of 0.70 (95% CI 0.68-0.72) with sensitivity and specificity of 83.2% and 40.4%. Analyses of single determinants of these negative outcomes showed a multivariable pattern of determinants for all the events.

Conclusions

The SFGE predicts death, hospitalization and institutionalization by stratifying older people according to the levels of frailty. The short administration time, the socio-economic variables and the characteristics of personnel administering the questionnaire make it suitable for being used in public health as a screening tool for a large population, to put frailty at the core of the care for community-dwelling older adults. The difficulty in capturing the complexity of the frailty is witnessed by the moderate sensitivity and specificity of the questionnaire.

Structural Basal Ganglia Correlates of Subjective Fatigue in Middle-Aged and Older Adults

OBJECTIVE

Fatigue is among the most common complaints in community-dwelling older adults, yet its etiology is poorly understood. Based on models implicating frontostriatal pathways in fatigue pathogenesis, we hypothesized that smaller basal ganglia volume would be associated with higher levels of subjective fatigue and reduced set-shifting in middle-aged and older adults without dementia or other neurologic conditions.

METHODS

Forty-eight non-demented middle-aged and older adults (M_age = 68.1, SD = 9.4; M_MMSE = 27.3, SD = 1.9) completed the Fatigue Symptom Inventory, set-shifting measures, and structural MRI as part of a clinical evaluation for subjective cognitive complaints. Associations were examined cross-sectionally.

RESULTS

Linear regression analyses showed that smaller normalized basal ganglia volumes were associated with more severe fatigue (β = -.29, P = .041) and poorer Trail Making Test B-A (TMT B-A) performance (β = .30, P = .033) controlling for depression, sleep quality, vascular risk factors, and global cognitive status. Putamen emerged as a key structure linked with both fatigue (r = -.43, P = .003) and TMT B-A (β = .35, P = .021). The link between total basal ganglia volume and reduced TMT B-A was particularly strong in clinically fatigued patients.

CONCLUSION

This study is among the first to show that reduced basal ganglia volume is an important neurostructural correlate of subjective fatigue in physically able middle-aged and older adults without neurological conditions. Findings suggest that fatigue and rapid set-shifting deficits may share common neural underpinnings involving the basal ganglia, and provide a framework for studying the neuropathogenesis and treatment of subjective fatigue.

Effects of Multicomponent Training Followed by a Detraining Period on Frailty Level and Functional Capacity of Older Adults with or at Risk of Frailty: Results of 10-Month Quasi-Experimental Study

This study aimed: To analyze the effects of 6-month multicomponent training (MCT) and 4-month detraining on functional capacity and frailty among older adults with/at risk of frailty and to analyze the influence of frailty status on training and detraining adaptations. A total of 106 older adults (80.5 ± 6.0 years) were divided into a control (CON) or training group (TRAIN). The TRAIN performed a 6-month MCT (Eelder-fit), while CON continued their usual lifestyle. Functional capacity was assessed by the Short Physical Performance Battery (SPPB), while frailty was evaluated through Fried (FP) and the short version of the Frailty Trait Scale (FTS-5). Linear mixed models were performed to analyze group effects and to compare differences in changes within and between groups. TRAIN showed improvements in SPPB (3.2 ± 2.4), FP (-0.7 ± 1.3), and FTS-5 (-5.9 ± 5.8), whereas CON improved in SPPB (0.7 ± 2.9) and deteriorated in FTS-5 (2.8 ± 7.6) (all p < 0.05). Group effects favorable to TRAIN were found for all scales during this period (all p < 0.05). After detraining, TRAIN worsened in SPPB (-1.2 ± 2.7) and FTS-5 (4.1 ± 6.1) (both p < 0.05). No relevant differences were observed, accounting for frailty status between TRAIN subgroups. Eelder-fit improved the functional capacity and frailty of this population, whereas 4-months of detraining caused a drop of these variables except in FP.

Healthcare cost expenditures associated to frailty and sarcopenia

Objectives

Frailty and sarcopenia have been related with adverse events, including hospitalization. However, its combined effect with hospitalization-related outcomes, including costs, has not been previously investigated. Our purpose was to explore how frailty, sarcopenia and its interaction could impact on healthcare expenditures.

Methods

1358 community-dwelling older adults from the Toledo Study of Healthy Ageing (TSHA) were included. Sarcopenia was measured using the Foundation for the National Institutes of Health criteria fitted to our cohort. Frailty was defined according to Frailty Trait Scale 5 (FTS5) and the Frailty Index fitted to the cut-off points of TSHA population. Hospitalization costs were taken from hospital records and costs were attributed according to Diagnostic-Related Groups, using as the cost base year 2015. Two-part regression models were used to analyze the relationship between frailty and sarcopenia and hospital admission, number of hospitalizations, length of stay and hospitalization costs.

Results

Sarcopenia was associated only with the probability of being admitted to hospital. Frailty was also associated with higher hospital use, regardless of the frailty tool used, but in addition increased hospital admission costs at follow-up by 23.72% per year and by 19.73% in the full model compared with non-frail individuals. The presence of sarcopenia did not increase the costs of frailty but, by opposite, frailty significantly increased the costs in people with sarcopenia, reaching by 46–56%/patient/year at follow-up. Older adults with frailty and sarcopenia had a higher risk of hospitalization, disregarding the tool used to assess frailty, and higher hospitalization costs (FTS5) in the full model, at the cross-sectional and at the follow-up level.

Conclusions

Frailty is associated with increased hospitalization costs and accounts for the potential effects of sarcopenia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03439-z.

Co-designing Being Your Best program-A holistic approach to frailty in older community dwelling Australians

Frailty is a condition characterised by increased vulnerability and decline of physical and cognitive reserves, most often affecting older people. This can lead to a cascade of repeated hospitalisations, further decline and ultimately loss of independence. Frailty and pre-frailty are modifiable; interventions such as physical exercise, cognitive training, social connection and improved nutrition, especially in a group setting, can mitigate frailty. Existing healthcare guidelines for managing frailty focus predominantly on falls, delirium, acute confusion and immobility. Uptake of referrals to services following hospital discharge is sub-optimal, indicating that a more proactive, person-centred and integrated approach to frailty is required. The aim was to co-design a program to help pre-frail and frail older people return to their homes following hospital discharge by increasing resilience and promoting independence. We engaged healthcare consumers, and healthcare professionals from three tertiary hospitals in metropolitan Melbourne (Alfred Hospital, Monash Health and Cabrini Health), and from Bolton Clarke home-based support services. Co-design is a process whereby the input of service consumers is included in the development of a program. In the healthcare sector, co-design involves discussions with healthcare consumers alongside healthcare professionals to identify issues and build knowledge to ultimately work on improving the healthcare system. From co-design sessions with 23 healthcare consumers and 17 healthcare professionals, it was apparent that frailty was perceived to affect physical and mental well-being. The co-design process resulted in refinement of the Being Your Best program to incorporate a holistic approach, addressing four domains supported by research evidence, to improve health and well-being through community- or home-based physical activity, cognitive training, social support and nutritional support. Being Your Best was developed in consultation with older people with lived experience as well as healthcare professionals and aims to mitigate the effects of frailty, and will now be tested for feasibility and acceptability.

Frailty's Prevalence and the Association with Aging-Related Health Conditions in Chinese Community Dwelling Elderly

In this paper, we have investigated the frailty's prevalence and the association with aging-related health conditions in Chinese community dwelling elderly aged ≥60 years in Lianyungang City of China. In this regard, participants were 1,072 adults aged ≥60 years from Houhe Community of Lianyungang City of China. All the enrolled participants were tested for following parameters: (1) the related risk factors of frailty: including economic status, personal health, understanding and communication skills, and mental and psychological status; (2) aging-related health conditions related to frailty: Charlson's comorbidity index (CCI), Mini Nutritional Assessment Short Form (MNA-SF), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder 7-item (GAD-7); (3) body composition, physical strength, and function testing: appendicular skeletal muscle mass index (ASMI), grip strength, five-repetition sit-to-stand test, 6 m walking speed, and strength assistance rise-climb-fall (SARC-F); (4) assessment of the degree and severity of frailty: physical frailty phenotype (PFP), Morse fall scale (MFS), and activities of daily living (ADL). The frailty's prevalence among the elderly aged ≥60 years in the community of Lianyungang City was 13.8%, 55.4% were prefrail, and 30.8% were robust. The independent risk factors of frailty were age, appendicular skeletal muscle mass index, sarcopenia, education, nutrition, and strength assistance rise-climb-fall (P < 0.05). Aging-related health conditions were associated with frailty, including sarcopenia, nutrition, and falls. However, mental and psychological statuses were not significantly associated with frailty.

Measuring the Frailty Phenotype and its Association with Cognition in Mid-Life and Older Age

Background: Frailty is directly linked to physical robustness and cognitive decline in older age. The Fried Frailty phenotype (FP) is a construct composed of five core symptoms that has been studied predominately in older age. There is little research contrasting the psychometric properties of the FP in mid-life versus older age. Objective: We compared the psychometric properties of the FP in mid-life and older age and investigated relationships between the FP and cognition. Methods: Frailty and neuropsychological assessments were completed on 361 adults, between 45 and 92 years of age, without primary neurological disorders. Confirmatory factor analysis was used to examine FP, indicated by Grip Strength, Gait Speed, Physical Activity, Fatigue, and Weight Loss. Measurement invariance was tested in mid-life (45–64 years) versus older age (≥65 years). Associations were examined between FP and language, executive functions, memory, processing speed, and visuospatial domains as well as a Generalized Cognition factor. Age was tested as a moderator of these associations. Results: Weight Loss was a poor indicator of FP. Factor loadings were comparable across age groups; however, Fatigue was disproportionately higher among those in mid-life. FP was negatively associated with all cognitive domains and remained invariant across age groups. Conclusion: Results support the construct validity of the FP and document its stable associations with poorer cognition in middle and older life. Future research investigating central features of frailty earlier in life may offer avenues for developing targeted prevention measures and better characterization of individuals with elevated dementia risk.

Frail Older People Ageing in Place in Italy: Use of Health Services and Relationship with General Practitioner

Functional limitations, chronic diseases and frailty often occur in later life. These aspects become very challenging when older people age alone in place, thus needing support in the activities of daily living, and in this context, it is important they can access and use health services. The present study aimed to explore these issues in Italy. In 2019, 120 qualitative interviews were carried out within the “Inclusive Ageing in Place” (IN-AGE) project, involving frail older people living at home in three Italian regions (Lombardy, Marche, and Calabria). A content analysis and some quantifications of main statements are presented. Results showed that the majority of seniors report poor self-rated health (SRH), suffer from many chronic diseases, and mainly use the General Practitioner (GP) and Medical Specialists (MSs), even though long waiting list in the public sector and high costs in the private one act as barriers to access health services. Complaints regarding GPs mainly refer to the almost exclusive provision of prescriptions and the lack of home visits. Some regional peculiarities highlighted a better overall context in the north than in the south, especially with regards to the public health sector. These results can provide useful insights for policy makers, in order to deliver health services assuring frail, older people the continuity of assistance needed at home.

Does nutritional status influence the effects of a multicomponent exercise programme on body composition and physical fitness in older adults with limited physical function?

Physical exercise effects and ageing on fitness may be influenced by nutritional status. This study investigates the effects of a 6-month multicomponent exercise training (MCT) on nutritional status and evaluates if this type of exercise could affect differently body composition and physical fitness depending on the nutritional status of older adults with decreased functional capacity. Ninety-three participants (80.4 ± 6.0 y) were divided into control (n = 45) and intervention (n = 48) groups. The intervention consisted of a 6-month multicomponent training. Comparisons between changes in body composition and fitness during the 6-months were performed between individuals at risk of malnutrition and those well-nourished, according to the Mini Nutritional Assessment. Model mixed-effect analyses were used to investigate differences after the 6 months of MCT between groups. Well-nourished participants compared with those at risk of malnutrition had higher: arm (13.4 ± 3.5 vs 14.3 ± 33.6 repetitions) and leg strength (9.0 ± 3.0 vs 11.1 ± 3.3 repetitions), maximum walking speed (31.6 ± 13.1 vs 23.7 ± 6.3s), agility (11.9 ± 5.8 vs 8.3 ± 2.1s), and aerobic capacity (31.6 ± 13.1 vs 23.7 ± 6.3 m), at baseline. After the training, those without risk of malnutrition in CON decreased their nutritional status (-1.7 + 0.7 points). Those well-nourished that performed the intervention decreased total fat mass (-1.0 ± 0.3 kg) and body fat percentage (-1.2 ± 0.4%). Both groups of training improved similarly in all tests, except for balance, in which the well-nourished showed improvements of 6.3 ± 1.9s. These results underline the usefulness of MCT in improving physical fitness regardless of nutritional status and preventing nutritional status detriment in well-nourished older adults, who are fitter and benefit more, in terms of body composition.Trial registration: ClinicalTrials.gov identifier: NCT03831841.Highlights Multicomponent exercise programme seems to be effective in delaying detriments in the nutritional status of well-nourished people.Well-nourished older people obtain more benefits in body composition from the multicomponent exercise than those at risk of malnutrition, decreasing adiposity.The positive effect of multicomponent exercise was observed in physical fitness independently of nutritional status.

Protein Intake and Frailty in Older Adults: A Systematic Review and Meta-Analysis of Observational Studies

Background: The present systematic review and meta-analysis investigated the cross-sectional and longitudinal associations between protein intake and frailty in older adults. Methods: We conducted a systematic review and meta-analysis of cross-sectional and longitudinal studies that investigated the association between protein intake and frailty in older adults. Cross-sectional, case-control, and longitudinal cohort studies that investigated the association between protein intake and frailty as a primary or secondary outcome in people aged 60+ years were included. Studies published in languages other than English, Italian, Portuguese, or Spanish were excluded. Studies were retrieved on 31 January 2022. Results: Twelve cross-sectional and five longitudinal studies that investigated 46,469 community-dwelling older adults were included. The meta-analysis indicated that absolute, bodyweight-adjusted, and percentage of protein relative to total energy consumption were not cross-sectionally associated with frailty. However, frail older adults consumed significantly less animal-derived protein than robust people. Finally, high protein consumption was associated with a significantly lower risk of frailty. Conclusions: Our pooled analysis indicates that protein intake, whether absolute, adjusted, or relative to total energy intake, is not significantly associated with frailty in older adults. However, we observed that frail older adults consumed significantly less animal protein than their robust counterparts.

Clinical and cost-effectiveness of a personalised health promotion intervention enabling independence in older people with mild frailty (‘HomeHealth’) compared to treatment as usual: study protocol for a randomised controlled trial

Background

Frailty is clinically associated with multiple adverse outcomes, including reduced quality of life and functioning, falls, hospitalisations, moves to long-term care and mortality. Health services commonly focus on the frailest, with highest levels of need. However, evidence suggests that frailty is likely to be more reversible in people who are less frail. Evidence is emerging on what interventions may help prevent or reduce frailty, such as resistance exercises and multi-component interventions, but few interventions are based on behaviour change theory. There is little evidence of cost-effectiveness.

Previously, we co-designed a new behaviour change health promotion intervention (“HomeHealth”) to support people with mild frailty. HomeHealth is delivered by trained voluntary sector support workers over six months who support older people to work on self-identified goals to maintain their independence, such as strength and balance exercises, nutrition, mood and enhancing social engagement. The service was well received in our feasibility randomised controlled trial and showed promising effects upon outcomes.

Aim

To test the clinical and cost-effectiveness of the HomeHealth intervention on maintaining independence in older people with mild frailty in comparison to treatment as usual (TAU).

Methods

Single-blind individually randomised controlled trial comparing the HomeHealth intervention to TAU. We will recruit 386 participants from general practices and the community across three English regions. Participants are included if they are community-dwelling, aged 65 + , with mild frailty according to the Clinical Frailty Scale. Participants will be randomised 1:1 to receive HomeHealth or TAU for 6 months. The primary outcome is independence in activities of daily living (modified Barthel Index) at 12 months. Secondary outcomes include instrumental activities of daily living, quality of life, frailty, wellbeing, psychological distress, loneliness, cognition, capability, falls, carer burden, service use, costs and mortality. Outcomes will be analysed using linear mixed models, controlling for baseline Barthel score and site. A health economic analysis and embedded mixed-methods process evaluation will be conducted.

Discussion

This trial will provide definitive evidence on the effectiveness and cost-effectiveness of a home-based, individualised intervention to maintain independence in older people with mild frailty in comparison to TAU, that could be implemented at scale if effective.

Trial registration

ISRCTN, ISRCTN54268283. Registered 06/04/2020.

Adiposity and grip strength: a Mendelian randomisation study in UK Biobank

BACKGROUND

Muscle weakness, which increases in prevalence with age, is a major public health concern. Grip strength is commonly used to identify weakness and an improved understanding of its determinants is required. We aimed to investigate if total and central adiposity are causally associated with grip strength.

METHODS

Up to 470,786 UK Biobank participants, aged 38-73 years, with baseline data on four adiposity indicators (body mass index (BMI), body fat percentage (BF%), waist circumference (WC) and waist-hip-ratio (WHR)) and maximum grip strength were included. We examined sex-specific associations between each adiposity indicator and grip strength. We explored whether associations varied by age, by examining age-stratified associations (< 50 years, 50-59 years, 60-64 years,65 years +). Using Mendelian randomisation (MR), we estimated the strength of the adiposity-grip strength associations using genetic instruments for each adiposity trait as our exposure.

RESULTS

In males, observed and MR associations were generally consistent: higher BMI and WC were associated with stronger grip; higher BF% and WHR were associated with weaker grip: 1-SD higher BMI was associated with 0.49 kg (95% CI: 0.45 kg, 0.53 kg) stronger grip; 1-SD higher WHR was associated with 0.45 kg (95% CI:0.41 kg, 0.48 kg) weaker grip (covariate adjusted observational analyses). Associations of BMI and WC with grip strength were weaker at older ages: in males aged < 50 years and 65 years + , 1-SD higher BMI was associated with 0.93 kg (95% CI: 0.84 kg, 1.01 kg) and 0.13 kg (95% CI: 0.05 kg, 0.21 kg) stronger grip, respectively. In females, higher BF% was associated with weaker grip and higher WC was associated with stronger grip; other associations were inconsistent.

CONCLUSIONS

Using different methods to triangulate evidence, our findings suggest causal links between adiposity and grip strength. Specifically, higher BF% (in both sexes) and WHR (males only) were associated with weaker grip strength.

The Development and Concurrent Validity of a Multi-Sensor-Based Frailty Toolkit for In-Home Frailty Assessment

Early identification of frailty is crucial to prevent or reverse its progression but faces challenges due to frailty’s insidious onset. Monitoring behavioral changes in real life may offer opportunities for the early identification of frailty before clinical visits. This study presented a sensor-based system that used heterogeneous sensors and cloud technologies to monitor behavioral and physical signs of frailty from home settings. We aimed to validate the concurrent validity of the sensor measurements. The sensor system consisted of multiple types of ambient sensors, a smart speaker, and a smart weight scale. The selection of these sensors was based on behavioral and physical signs associated with frailty. Older adults’ perspectives were also included in the system design. The sensor system prototype was tested in a simulated home lab environment with nine young, healthy participants. Cohen’s Kappa and Bland−Altman Plot were used to evaluate the agreements between the sensor and ground truth measurements. Excellent concurrent validity was achieved for all sensors except for the smart weight scale. The bivariate correlation between the smart and traditional weight scales showed a strong, positive correlation between the two measurements (r = 0.942, n = 24, p < 0.001). Overall, this work showed that the Frailty Toolkit (FT) is reliable for monitoring physical and behavioral signs of frailty in home settings.

Ethnic differences in the relationship between step cadence and physical function in older adults

This study investigated associations between step cadence and physical function in healthy South Asian (SA) and White European (WE) older adults, aged ≥60. Participants completed the 60-s Sit-to-Stand (STS-60) test of physical function. Free-living stepping was measured using the activPAL3™. Seventy-one WEs (age = 72 ± 5, 53% male) and 33 SAs (age = 71 ± 5, 55% male) were included. WEs scored higher than SAs in the STS-60 (23 vs 20 repetitions, p = 0.045). Compared to WEs, SAs had significantly lower total and brisk (≥100 steps/min) steps (total: 8971 vs 7780 steps/day, p = 0.041; brisk: 5515 vs 3723 steps/day, p = 0.001). In WEs, 1000 brisk steps and each decile higher proportion of steps spent brisk stepping were associated with STS-60 (β = 0.72 95% CI 0.05, 1.38 and β = 1.01 95% CI 0.19, 1.82, respectively), with associations persisting across mean peak 1 min (β = 1.42 95% CI 0.12, 2.71), 30 min (β = 1.71 95% CI 0.22, 3.20), and 60 min (β = 2.16 95% CI 0.62, 3.71) stepping periods. Associations were not observed in SAs. Ethnic differences in associations between ambulation and physical function may exist in older adults which warrant further investigationi.

Healthcare Costs Associated with Potentially Inappropriate Medication Prescribing Detected by Computer Algorithm Among Older Patients

INTRODUCTION

Potentially inappropriate medication prescribing (PIP) among older patients is associated with an increased risk of adverse events and hospitalization, and sometimes increased healthcare costs.

OBJECTIVE

The aim of this study was to explore the association between healthcare costs and PIP exposure among older patients.

METHODS

Analyses were conducted using data from the Multidomain Alzheimer Preventive Trial (MAPT). A computer algorithm was constructed to detect PIP based on various different explicit criteria-based tools, and the results were expressed in number of medication-related potential non-compliances (MRNCs). A prescription was considered potentially inappropriate if there were one or more MRNCs. We performed a cost analysis from the French National Health Insurance perspective, and also performed a multivariate analysis to identify the association between healthcare costs and PIP (number of MRNCs).

RESULTS

The computer algorithm analyzed medication prescribing from included patients (N = 1525 aged 75.3 ± 4.4 years; 64% women [n = 978]). PIP was associated with increased total healthcare costs and non-medication healthcare costs after adjusting for potential confounders. We also noted that healthcare costs tended to increase with the number of MRNCs. The mean additional healthcare costs were €517, €921, and €1669 per patient and year for patients with one or two MRNCs, three or four MRNCs, and five or more MRNCs, respectively, in comparison with patients with appropriate medication prescriptions.

CONCLUSION

These observations led us to conclude that interventions focused on reducing PIP could result in savings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00672685.

Prevalence of Prefrailty and Frailty Among Older Adults in Germany: A Systematic Review, Meta-Analysis and Meta-Regression

Background

Various studies have identified the prevalence of prefrailty and frailty among older adults in Germany. Nevertheless, there is no review systematically synthesizing these studies. Thus, our aim was to close this gap in knowledge. Moreover, another aim was to perform a meta-analysis to synthesize the pooled prevalence of prefrailty and frailty. A further aim was to explore potential sources of heterogeneity based on a meta-regression.

Methods

A number of three electronic databases (PubMed, PsycINFO, and CINAHL) were searched (plus an additional hand search). The observational studies that determine the prevalence of frailty among older adults aged 65 years and above in Germany were included, whereas disease-specific samples were excluded. Data extraction included the description of the sample, operationalization of frailty, statistical analysis, sample characteristics and main findings. The established Joanna Briggs Institute (JBI) standardized critical appraisal instrument for prevalence studies was used for evaluating the quality of the studies. Important steps were performed by two reviewers.

Results

In sum, a number of 12 studies were included. The prevalence of frailty varied from about 2.4 to 25.6%. The pooled prevalence of frailty was 13.7% (95% CI: 9.0 to 18.5%). There was a significant heterogeneity among the studies (I² = 98.9%, p < 0.001). The pooled prevalence of prefrailty was 40.2% (95% CI: 28.3 to 52.1%; I² = 99.6%, p < 0.001). Some evidence of a publication bias exists. Meta-regressions showed that some of the heterogeneity was explained by the tool to quantify frailty and the average age of the respective sample.

Conclusion

Particularly, the high prevalence of prefrailty should be highlighted since it is important to prevent individuals in old age from developing to frail status. This knowledge is important for the German society as a whole and for relevant stakeholders.

Systematic Review Registration

PROSPERO, identifier: CRD42021293648.

Development of an electronic frailty index for hospitalized older adults in Sweden

BACKGROUND

Frailty assessment in the Swedish health system relies on the Clinical Frailty Scale (CFS), but it requires training, in-person evaluation, and is often missing in medical records. We aimed to develop an electronic frailty index (eFI) from routinely collected electronic health records (EHRs) and assess its association with adverse outcomes in hospitalized older adults.

METHODS

EHRs were extracted for 18,225 patients with unplanned admissions between 1 March 2020 and 17 June 2021 from nine geriatric clinics in Stockholm, Sweden. A 48-item eFI was constructed using diagnostic codes, functioning and other health indicators, and laboratory data. The CFS, Hospital Frailty Risk Score, and Charlson Comorbidity Index were used for comparative assessment of the eFI. We modelled in-hospital mortality and 30-day readmission using logistic regression; 30-day and 6-month mortality using Cox regression; and length of stay using linear regression.

RESULTS

13,188 patients were included in analyses (mean age 83.1 years). A 0.03 increment in the eFI was associated with higher risks of in-hospital (odds ratio: 1.65; 95% confidence interval: 1.54-1.78), 30-day (hazard ratio [HR]: 1.43; 1.38-1.48), and 6-month mortality (HR: 1.34; 1.31-1.37) adjusted for age and sex. Of the frailty and comorbidity measures, the eFI had the highest area under receiver operating characteristic curve for in-hospital mortality of 0.813. Higher eFI was associated with longer length of stay, but had a rather poor discrimination for 30-day readmission.

CONCLUSIONS

An EHR-based eFI has robust associations with adverse outcomes, suggesting that it can be used in risk stratification in hospitalized older adults.

Health Care Utilization and Out-of-Pocket Payments among Elderly with Cognitive Frailty in Malaysia

Background: Cognitive frailty (CF) as a potential risk factor for dementia, functional disability, poor quality of life, and mortality. The aim of this study was to explore the health care-related utilization and out-of-pocket (OOP) expenditures, sociodemographic characteristics, and comorbidities among elderly Malaysians with CF. Methods: A cross-sectional study targeting elderly Malaysian aged ≥65 years was conducted. The study included all participants of the fourth phase of the Malaysian representative Long-Term-Research-Grant-Scheme Towards-Useful-Aging (LRGS-TUA) community-based study. A structured and validated interview questionnaire was used. Results: In total, 1006 elderly were interviewed, with a 66.18% response rate. Only 730 respondents met the inclusion criteria. Of the eligible respondents, the CF prevalence was 4.5%. Around 60.6% of the participants with CF had utilized outpatient care at government clinics within the past 6 months. The estimated mean total OOP payments for CF during the past 6 months was 84 Malaysian Ringgit (RM) (SD 96.0). Conclusions: CF among elderly Malaysians is within the internationally recognized range of prevalence. The OOP payments for seeking health care among CF elderly are not different from that of other elderly categories. There is a high possibility of underutilization of the health care services of CF cases while they are still needy.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

Background

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

Methods

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4–6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

Discussion

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

Trial registration

German Clinical Trials Register, . Registered on March 11, 2021.

Patient perspectives on states worse than death: A qualitative study with implications for patient-centered outcomes and values elicitation

BACKGROUND

Seriously ill patients rate several health outcomes as states worse than death. It is unclear what factors underlie such valuations, and whether consideration of such states is useful when making medical decisions.

AIM

We sought to (1) use qualitative approaches to identify states worse than death, (2) identify attributes common to such undesirable health states, and (3) determine how participants might use information on these states in making medical decisions.

DESIGN

Qualitative study of semi-structured interviews utilizing content analysis with constant comparison techniques.

SETTING, PARTICIPANTS

We interviewed adults age 65 or older with serious illnesses after discharge home from one of two urban, academic hospitals. Eligible patients were purposively sampled to achieve balance in gender and race.

RESULTS

Of 29 participants, 15 (52%) were female, and 15 were white (52%), with a median age of 72 (interquartile range 69, 75). Various physical, cognitive, and social impairments were identified as states worse than death. The most commonly reported attributes underlying states worse than death were perceived burden on loved ones and inability to maintain human connection. Patients believed information on states worse than death must be individualized, and were concerned their opinions could change with time and fluctuations in health status.

CONCLUSIONS

Common factors underlying undesirable states suggest that for care to be patient-centered it must also be family-centered. Patients' views on using states worse than death in decision making highlight barriers to using avoidance of such states as a quality measure, but also suggest opportunities for eliciting patients' values.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.