Declines and Impairment in Executive Function Predict Onset of Physical Frailty

Impact of menopause-associated frailty on traumatic brain injury

Navigating menopause involves traversing a complex terrain of hormonal changes that extend far beyond reproductive consequences. Menopausal transition is characterized by a decrease in estradiol-17β (E2), and the impact of menopause resonates not only in the reproductive system but also through the central nervous system, musculoskeletal, and gastrointestinal domains. As women undergo menopausal transition, they become more susceptible to frailty, amplifying the risk and severity of injuries, including traumatic brain injury (TBI). Menopause triggers a cascade of changes leading to a decline in muscle mass, accompanied by diminished tone and excitability, thereby restricting the availability of irisin, a crucial hormone derived from muscles. Concurrently, bone mass undergoes reduction, culminating in the onset of osteoporosis and altering the dynamics of osteocalcin, a hormone originating from bones. The diminishing levels of E2 during menopause extend their influence on the gut microbiota, resulting in a reduction in the availability of tyrosine, tryptophan, and serotonin metabolites, affecting neurotransmitter synthesis and function. Understanding the interplay between menopause, frailty, E2 decline, and the intricate metabolisms of bone, gut, and muscle is imperative when unraveling the nuances of TBI after menopause. The current review underscores the significance of accounting for menopause-associated frailty in the incidence and consequences of TBI. The review also explores potential mechanisms to enhance gut, bone, and muscle health in menopausal women, aiming to mitigate frailty and improve TBI outcomes.

Frailty, but not cognitive impairment, improves mortality risk prediction among those with chronic kidney disease-a nationally representative study

BACKGROUND

Though older adults with chronic kidney disease (CKD) have a greater mortality risk than those without CKD, traditional risk factors poorly predict mortality in this population. Therefore, we tested our hypothesis that two common geriatric risk factors, frailty and cognitive impairment, and their co-occurrence, might improve mortality risk prediction in CKD.

METHODS

Among participants aged ≥ 60 years from National Health and Nutrition Examination Survey (2011-2014), we quantified associations between frailty (physical frailty phenotype) and global/domain-specific cognitive function (immediate-recall [CERAD-WL], delayed-recall [CERAD-DL], verbal fluency [AF], executive function/processing speed [DSST], and global [standardized-average of 4 domain-specific tests]) using linear regression, and tested whether associations differed by CKD using a Wald test. We then tested whether frailty, global cognitive impairment (1.5SD below the mean), or their combination improved prediction of mortality (Cox models, c-statistics) compared to base models (likelihood-ratios) among those with and without CKD.

RESULTS

Among 3,211 participants, 1.4% were cognitively impaired, and 10.0% were frail; frailty and cognitive impairment co-occurrence was greater among those with CKD versus those without (1.2%vs.0.1%). Frailty was associated with worse global cognitive function (Cohen's d = -0.26SD,95%CI -0.36,-0.17), and worse cognitive function across all domains; these associations did not differ by CKD (pinteractions > 0.05). Mortality risk prediction improved only among those with CKD when accounting for frailty (p[likelihood ratio test] < 0.001) but not cognitive impairment.

CONCLUSIONS

Frailty is associated with worse cognitive function regardless of CKD status. While CKD and frailty improved mortality prediction, cognitive impairment did not. Risk prediction tools should incorporate frailty to improve mortality prediction among those with CKD.

White matter hyperintensities mediate the association between frailty and cognitive impairment in moyamoya disease

OBJECTIVES

The relationship between cognitive function and frailty in moyamoya disease (MMD) remains unclear, and the underlying mechanism is poorly understood. This study aims to investigate whether white matter hyperintensities (WMHs) mediate the association between frailty and cognitive impairment in MMD.

METHODS

Patients with MMD were consecutively enrolled in our study from January 2021 to May 2023. Pre-admission frailty and cognition were assessed using the Clinical Frailty Scale (CFS) and cognitive tests, respectively. Regional deep WMH (DWMH) and periventricular WMH (PWMH) volumes were calculated using the Brain Anatomical Analysis using Diffeomorphic deformation toolbox based on SPM 12 software. Multivariate logistic regression analysis was conducted to evaluate the association between frailty and cognitive function in MMD. Mediation analysis was performed to assess whether WMHs explained the association between frailty and cognition.

RESULTS

A total of 85 patients with MMD were enrolled in this study. On the basis of the CFS scores, 24 patients were classified as frail, 38 as pre-frail, and 23 as robust. Significant differences were observed in learning, memory, processing speed, executive functions, and semantic memory among the three groups (p < 0.001). Frailty was independently associated with memory and executive functions (p < 0.05); even after controlling for WMH. Mediation analysis indicated that the associations of frailty with memory and executive functions were partially mediated by WMH, DWMH, and PWMH (p < 0.05).

CONCLUSION

Frailty is significantly correlated with a higher risk of cognitive impairment in MMD, even after adjusting for other covariates. WMHs partially mediate the association between frailty and cognitive impairment.

Trail making test - black & white (TMT B&W): Normative study for the Chilean population

The trailmaking test (TMT) has an educational bias that makes it inapplicable to people with low levels of education due to its dependence on the alphabet. The TMT standardization is the only one available in Chile, and there is a need for alternative ways of using the TMT that do not depend on the level of education for its applicability. To determine the normative scores of the TMT - black & white (TMT B&W), considering sociodemographic factors in adult and elderly Chilean population. A total sample of 227 participants (133 healthy, 94 cognitively impaired) from the Ageing Mets cohort were recruited from three areas in Chile (Antofagasta, Santiago, and Puerto Montt). The TMT B&W was administered to all participants. A multiple regression model was used to generate normative data only in the cognitively healthy group, considering the effect of age, education and sex. A significant effect of age was found in the score of the TMT B&W Parts A and B. The level of education influenced the part B of the test; however, the completion rate of the TMT B&W parts A and B was over 90% in cognitively healthy people. Norms for the number of errors were obtained, and differences between groups were found after controlling for the effect of age and education. This study is the first to provide normative data for the Chilean version of the TMT B&W and will benefit clinical neuropsychologists by improving the procedures for more accurately assessing executive functions and its impairments.

Exploring the relationship between frailty and executive dysfunction: the role of frontal white matter hyperintensities

Introduction

Frailty is a geriatric syndrome frequently associated with executive dysfunction and white matter hyperintensities (WMH). But the relation between executive dysfunction and brain changes is poorly understood in frail subjects. Our hypothesis is that frontal-WMH mediates the association between frailty and executive dysfunction.

Methods

A convenience sample of 113 subjects older than 65 years without dementia was studied with neuropsychological test, a structured clinical interview, physical examination and brain MRI. They were classified as robust or pre-frail and frail using the frailty phenotype score (0-5). The frontal WMH (F-WMH) were manually graduated (0-6) using the "Age-Related White Matter Changes score" from FLAIR sequences at a 3 Tesla brain MRI. A mediation analysis was done for testing whether F-WMH could act as a link factor between frailty phenotype score and executive dysfunction.

Results

The group's mean age was 74 ± 6 years, subjects with higher frailty score had more depressive symptoms and worse performance in executive function tests. A regression analysis that explained 52% of the variability in executive functions, revealed a significant direct effect of frailty score (Standardized βcoeff [95% CI] -0.201, [-0.319, -0.049], and F-WMH (-0.152[-0.269, -0.009]) on executive functions, while the F-WMH showed a small partial mediation effect between frailty and executive functions (-0.0395, [-0.09, -0.004]).

Discussion

Frontal matter hyperintensities had a small mediation effect on the association between frailty and executive dysfunction, suggesting that other neuropathological and neurofunctional changes might also be associated with executive dysfunction in frail subjects.

Floor Maze Test is capable of differentiating spatial navigation between frail and pre-frail institutionalized older persons

Investigation of the association between physical frailty and cognitive performance through spatial navigation is important to enable the identification of individuals with cognitive impairment and physical comorbidity.

Objective

To analyze the association between spatial navigation and frailty in frail and pre-frail institutionalized older adults.

Methods

Forty older people of both sexes, aged 60 years or over, residing in four Brazilian Long-Term Care Facilities (LTCFs) participated in this study. The following tests were applied: Mini-Mental State Examination (MMSE), 2.44m Timed Up and Go, Floor Maze Test (FMT), and Fried's frailty criteria. For data analysis, the Mann-Whitney and independent t-tests were used to compare the groups (frail x pre-frail), principal component analysis was used to explore the main variables related to the data variance, and binary logistic regression to estimate associations.

Results

There was a significant difference in performance in the FMT immediate maze time (IMT) (p=0.02) and in the delayed maze time (DMT) (p=0.009) between the pre-frail and frail older adults. An association between FMT DMT performance and frailty was found, showing that older people with shorter times on the DMT (better performance) had approximately four times the chance of not being frail (odds ratio - OR=4.219, 95% confidence interval - 95%CI 1.084-16.426, p=0.038).

Conclusion

Frailty is associated with impaired spatial navigation ability in institutionalized older adults, regardless of gait speed performance.

Associations between circulating cell-free mitochondrial DNA, inflammatory markers, and cognitive and physical outcomes in community dwelling older adults

BACKGROUND

Dementia and frailty are common age-related syndromes often linked to chronic inflammation. Identifying the biological factors and pathways that contribute to chronic inflammation is crucial for developing new therapeutic targets. Circulating cell-free mitochondrial DNA (ccf-mtDNA) has been proposed as an immune stimulator and potential predictor of mortality in acute illnesses. Dementia and frailty are both associated with mitochondrial dysfunction, impaired cellular energetics, and cell death. The size and abundance of ccf-mtDNA fragments may indicate the mechanism of cell death: long fragments typically result from necrosis, while short fragments arise from apoptosis. We hypothesize that increased levels of necrosis-associated long ccf-mtDNA fragments and inflammatory markers in serum are linked to declines in cognitive and physical function, as well as increased mortality risk.

RESULTS

Our study of 672 community-dwelling older adults revealed that inflammatory markers (C-Reactive Protein, soluble tumor necrosis factor alpha, tumor necrosis factor alpha receptor 1 [sTNFR1], and interleukin-6 [IL-6]) positively correlated with ccf-mtDNA levels in serum. Although cross-sectional analysis revealed no significant associations between short and long ccf-mtDNA fragments, longitudinal analysis demonstrated a connection between higher long ccf-mtDNA fragments (necrosis-associated) and worsening composite gait scores over time. Additionally, increased mortality risk was observed only in individuals with elevated sTNFR1 levels.

CONCLUSION

In a community dwelling cohort of older adults, there are cross-sectional and longitudinal associations between ccf-mtDNA and sTNFR1 with impaired physical and cognitive function and increased hazard of death. This work suggests a role for long ccf-mtDNA as a blood-based marker predictive of future physical decline.

Order of Onset of Physical Frailty and Cognitive Impairment and Risk of Repeated Falls in Community-Dwelling Older Adults

OBJECTIVES

To examine whether physical frailty onset before, after, or in concert with cognitive impairment is differentially associated with fall incidence in community-dwelling older adults.

DESIGN

A longitudinal observational study.

SETTING AND PARTICIPANTS

Data from 1337 older adults age ≥65 years and free of physical frailty or cognitive impairment at baseline were obtained from the National Health Aging Trends Study (2011‒2017), a nationally representative cohort study of US older adult Medicare beneficiaries.

METHODS

Participants were assessed annually for frailty (physical frailty phenotype) and cognitive impairment (bottom quintile of clock drawing test or immediate and delayed recall; or proxy-report of diagnosis of dementia or AD8 score of ≥2). Incident falls were ascertained annually via self-report. Multinomial logistic regression was performed to estimate the association between order of first onset of cognitive impairment and/or frailty and incident single or repeated falls in the 1-year interval following their first onset.

RESULTS

Of the 1,337, 832 developed cognitive impairment first (termed "CI first"), 286 developed frailty first (termed "frailty first") and 219 had co-occurrence of cognitive impairment and frailty within one year (termed "CI-frailty co-occurrence") over 5 years. Overall, 491 (34.5%) had at least 1 fall during the 1-year interval following the onset of physical frailty and/or cognitive impairment. After adjustment, "CI-frailty co-occurrence" was associated with a more than 2-fold increased risk of repeated falls than "CI first" (odds ratio 2.35, 95% confidence interval 1.51‒3.67; P < .001). No significant difference was found between participants with "frailty first" and "CI first" (P = .07). In addition, the order of onset was not associated with risk of a single fall.

CONCLUSIONS AND IMPLICATIONS

Older adults experiencing "CI-frailty co-occurrence" had the greatest risk of repeated falls compared with those with "CI first" and "frailty first". Fall risk screening should consider the order and timing of onset of physical frailty and cognitive impairment.

Frailty and cognitive impairment in Parkinson’s disease: a systematic review

BACKGROUND

Frailty can lead to increased vulnerability in older people and patients with Parkinson's disease (pwPD) and worsen their health conditions. These patients can also develop cognitive function impairment. The objective is to analyze whether there is a relationship between frailty and cognitive impairment in pwPD, and to find out which instruments to use for its evaluation.

METHODS

Publications were searched in PubMed, Medline, Web of Science, Cinalh, Cochrane Library, Embase, Phycinfo, and Scopus. The results were measured with the instruments that are used to assess frailty and cognitive impairment, and analyze their relationship.

RESULTS

Two hundred seventy-one articles were identified, of which 12 met the inclusion criteria. All studies assessed frailty and cognitive function in pwPD. Five studies analyzed the relationship between frailty and cognitive impairment. The most used instruments were the Fried scale followed by the Clinical Frailty Scale (CFS) for frailty. Cognitive impairment was mostly evaluated with the Mini-Mental State Examination and the Montreal Cognitive Assessment. The prevalence data ranged from 20.2 to 51.5% with the Fried scale and from 35.6 to 83.9% with the CFS. Cognitive impairment was present in 15 to 45.2% of the pwPD.

CONCLUSION

Analysis of the included studies shows a relationship between frailty and cognitive impairment in pwPD. There was significant variability in the application of the scales used, which influences the prevalence data. More observational and experimental studies are needed to provide more evidence on this association and to determine which is the optimal tool to identify frailty in pwPD using multidimensional scales.

Long-Term Recreational Cannabis Use Is Associated With Lower Executive Function and Processing Speed in a Pilot Sample of Older Adults

More older adults are using cannabis for recreational and/or medical purposes, but most studies examining cognitive function and cannabis use do not include older adults. The current small pilot study sought to compare cognitive function and emotional functioning among adults age 60 and older who were regular, primarily recreational cannabis users (n = 28) and nonusers (n = 10). A bimodal distribution was observed among cannabis users such that they had either initiated regular use more recently ("short-term" users; ≤7 years, n = 13) or earlier in life ("long-term" users; ≥19 years, n = 15). Nonusers, short-term, and long-term users were not different in depression, anxiety, or emotion regulation, or alcohol use. Nonusers scored significantly higher than long-term users in executive function. Short-term users scored significantly higher than long-term users in executive function, processing speed, and general cognition. Additionally, greater recent cannabis use frequency was negatively associated with working memory. The current findings suggest that short-term recreational cannabis use does not result in differences in cognitive performance compared to nonusers, which may indicate that short-term use is relatively benign in older adults. However, longer duration of use is associated with poorer processing speed and executive functioning, and more recent cannabis use is associated with poorer working memory, which may impact older adults' overall cognitive functioning.

Associations between apathy and comprehensive frailty as assessed by the Kihon Checklist among community-dwelling Japanese older adults

BACKGROUND

Frailty is a multidimensional condition characterised by reduced physical and psychological resilience. Older adults also frequently demonstrate apathy, suggesting that it shares similar neuro-physiological pathways with frailty. This cross-sectional study aimed to investigate the association between apathy and frailty as defined by a comprehensive assessment.

METHODS

We analyzed 882 older adults (mean age: 74.4 ± 6.4 years; 62.1% female) who participated in a community-based health check survey (Tarumizu Study). Apathy was measured by the Geriatric Depression Scale-3A, a three-item subset of the Geriatric Depression Scale-15, and frailty by the Kihon Checklist of physical, psychological, functional, and social status. Associations were examined by multinomial logistic regression with frailty status (robust, pre-frailty, frailty) as the dependent variable, apathy as the independent variable, and sociodemographic factors, medications, cognitive function, functional capacity, and mood symptoms as potential confounders.

RESULTS

Apathy was observed in 23.7% of individuals, and logistic regression revealed significant associations with both pre-frailty and frailty after confounder adjustment (pre-frailty: odds ratio (OR) 1.80, 95% CI 1.22-2.64; frailty: OR 3.24, 95% CI 1.63-6.42). Participants with apathy also exhibited greater deficits in the Kihon Checklist subdomains instrumental activities of daily living (P = 0.022), physical function (P < 0.001), oral function (P < 0.001), and cognitive function (P = 0.001).

CONCLUSIONS

Our findings underscore the importance of comprehensive frailty assessment and demonstrate that apathy can have pervasive deleterious effects on geriatric health.

Post-stroke low-frequency whole-body vibration improves cognition in middle-aged rats of both sexes

Low-frequency whole-body vibration (WBV; 40 Hz), a low impact form of exercise, intervention for a month following moderate transient middle-cerebral artery occlusion (tMCAO) reduces infarct volume and improves motor function in reproductively senescent, middle-aged female rats. Since post-stroke cognitive decline remains a significant problem, the current study aims to investigate the efficacy of WBV in ameliorating post-tMCAO cognitive deficits and to determine the underlying putative mechanism(s) conferring benefits of WBV in middle-aged rats. Middle-aged rats of both sexes were randomly assigned to tMCAO (90 min) or sham surgery followed by exposure to either WBV (twice a day for 15 min each for 5 days a week over a month) or no WBV treatment groups. Following the last WBV treatment, rats were tested for hippocampus-dependent learning and memory using a water maze followed by harvesting brain and blood samples for histopathological and inflammatory marker analyses, respectively. Results show that post-tMCAO WBV significantly lessens cognitive deficits in rats of both sexes. Post-tMCAO WBV significantly decreased circulating pro-inflammatory cytokines and increased serum levels of irisin, a muscle-derived hormone that may play a role in brain metabolism and inflammation regulation, which suggests putative beneficial mechanisms of WBV.

Association of the prefrailty with global brain atrophy and white matter lesions among cognitively unimpaired older adults: the Nakajima study

Physical frailty has been associated with adverse outcomes such as dementia. However, the underlying structural brain abnormalities of physical frailty are unclear. We investigated the relationship between physical frailty and structural brain abnormalities in 670 cognitively unimpaired individuals (mean age 70.1 years). Total brain volume (TBV), hippocampal volume (HV), total white matter hypointensities volume (WMHV), and estimated total intracranial volume (eTIV) on the 3D T1-weighted images were automatically computed using FreeSurfer software. Participants were divided into two states of physical frailty (robust vs. prefrail) based on the revised Japanese version of the Cardiovascular Health Study criteria. The multivariable-adjusted mean values of the TBV-to-eTIV ratio was significantly decreased, whereas that of the WMHV-to-eTIV ratio was significantly increased in the prefrail group compared with the robust group. Slowness, one of the components of physical frailty, was significantly associated with reduced TBV-to-eTIV and HV-to-eTIV ratios, and slowness and weakness were significantly associated with an increased WMHV-to-eTIV ratio. Our results suggest that the prefrail state is significantly associated with global brain atrophy and white matter hypointensities. Furthermore, slowness was significantly associated with hippocampal atrophy.

Physiological Systems in Promoting Frailty

Frailty is a complex syndrome affecting a growing sector of the global population as medical developments have advanced human mortality rates across the world. Our current understanding of frailty is derived from studies conducted in the laboratory as well as the clinic, which have generated largely phenotypic information. Far fewer studies have uncovered biological underpinnings driving the onset and progression of frailty, but the stage is set to advance the field with preclinical and clinical assessment tools, multiomics approaches together with physiological and biochemical methodologies. In this article, we provide comprehensive coverage of topics regarding frailty assessment, preclinical models, interventions, and challenges as well as clinical frameworks and prevalence. We also identify central biological mechanisms that may be at play including mitochondrial dysfunction, epigenetic alterations, and oxidative stress that in turn, affect metabolism, stress responses, and endocrine and neuromuscular systems. We review the role of metabolic syndrome, insulin resistance and visceral obesity, focusing on glucose homeostasis, adenosine monophosphate-activated protein kinase (AMPK), mammalian target of rapamycin (mTOR), and nicotinamide adenine dinucleotide (NAD⁺ ) as critical players influencing the age-related loss of health. We further focus on how immunometabolic dysfunction associates with oxidative stress in promoting sarcopenia, a key contributor to slowness, weakness, and fatigue. We explore the biological mechanisms involved in stem cell exhaustion that affect regeneration and may contribute to the frailty-associated decline in resilience and adaptation to stress. Together, an overview of the interplay of aging biology with genetic, lifestyle, and environmental factors that contribute to frailty, as well as potential therapeutic targets to lower risk and slow the progression of ongoing disease is covered. © 2022 American Physiological Society. Compr Physiol 12:1-46, 2022.

Social Frailty and Executive Function: Association with Geriatric Syndromes, Life Space and Quality of Life in Healthy Community-Dwelling Older Adults

BACKGROUND

Despite emerging evidence about the association between social frailty and cognitive impairment, little is known about the role of executive function in this interplay, and whether the co-existence of social frailty and cognitive impairment predisposes to adverse health outcomes in healthy community-dwelling older adults.

OBJECTIVES

We aim to examine independent associations between social frailty with the MMSE and FAB, and to determine if having both social frailty and cognitive impairment is associated with worse health outcomes than either or neither condition.

METHODS

We studied 229 cognitively intact and functionally independent community-dwelling older adults (mean age= 67.2±7.43). Outcome measures comprise physical activity; physical performance and frailty; geriatric syndromes; life space and quality of life. We compared Chinese Mini Mental State Examination (CMMSE) and Chinese Frontal Assessment Battery (FAB) scores across the socially non-frail, socially pre-frail and socially frail. Participants were further recategorized into three subgroups (neither, either or both) based on presence of social frailty and cognitive impairment. Cognitive impairment was defined as a score below the educational adjusted cut-offs in either CMMSE or FAB. We performed logistic regression adjusted for significant covariates and mood to examine association with outcomes across the three subgroups.

RESULTS

Compared with CMMSE, Chinese FAB scores significantly decreased across the social frailty spectrum (p<0.001), suggesting strong association between executive function with social frailty. We derived three subgroups relative to relationship with socially frailty and executive dysfunction: (i) Neither, N=140(61.1%), (ii) Either, N=79(34.5%), and (iii) Both, N=10(4.4%). Compared with neither or either subgroups, having both social frailty and executive dysfunction was associated with anorexia (OR=4.79, 95% CI= 1.04-22.02), near falls and falls (OR= 5.23, 95% CI= 1.10-24.90), lower life-space mobility (odds ratio, OR=9.80, 95% CI=2.07-46.31) and poorer quality of life (OR= 13.2, 95% CI= 2.38-73.4).

CONCLUSION

Our results explicated the association of executive dysfunction with social frailty, and their synergistic relationship independent of mood with geriatric syndromes, decreased life space and poorer quality of life. In light of the current COVID-19 pandemic, the association between social frailty and executive dysfunction merits further study as a possible target for early intervention in relatively healthy older adults.

Exploring bi-directional temporal associations between timed-up-and-go and cognitive domains in the Irish longitudinal study on ageing (TILDA)

INTRODUCTION

The bi-directional longitudinal associations between mobility and cognition in older adults are poorly understood. Our objective was to study the temporal associations between timed-up-and-go (TUG) and five cognitive function domains: global cognition, processing speed, verbal fluency, executive function, and sustained attention.

METHODS

We designed two longitudinal samples: A (for cognition as predictor of mobility), and B (for mobility as predictor of cognition). To examine the associations between the five cognitive domains at wave 1 and change in TUG times up to wave 5 (eight years), five linear mixed-effect models were fitted. To examine the associations between TUG times at wave 1 and change in the five cognitive domains between waves 1 and 3 (four years), five linear-regression models were fitted.

RESULTS

After removing participants with missing data, sample A numbered 4913 participants (mean age 62), and sample B 3675 (mean age 61). Baseline cognitive domains were all significant predictors of future change in TUG times. Baseline TUG time was also a significant predictor of future change in all five cognitive domains. In both cases, poorer performance at baseline predicted greater future loss of function.

CONCLUSION

There was evidence of bi-directional temporal relationships between cognition and mobility. In both directions, the effect of the explanatory variable was small, though cognition as predictor of future mobility may have greater clinical relevance than vice versa. Our findings underscore the importance for clinicians of considering the bi-directional associations between cognition and mobility when observing subtle changes in either, especially as impairments emerge.

Cognitive impairment burden in older and younger adults across the kidney transplant care continuum

BACKGROUND

Younger kidney transplant (KT) candidates and recipients may have cognitive impairment due to chronic diseases and reliance on dialysis.

METHODS

To quantify cognitive impairment burden by age across the KT care continuum, we leveraged a two-center cohort study of 3854 KT candidates at evaluation, 1114 recipients at admission, and 405 recipients at 1-year post-KT with measured global cognitive performance (3MS) or executive function (Trail Making Test). We also estimated burden of severe cognitive impairment that affects functional dependence (activities of daily living [ADL] < 6 or instrumental activities of daily living [IADL] < 8).

RESULTS

Among KT candidates, global cognitive impairment (18-34 years: 11.1%; 35-49 years: 14.0%; 50-64 years: 19.5%; ≥65 years: 22.0%) and severe cognitive impairment burden (18-34 years: 1.1%; 35-49 years: 3.0%; 50-64 years: 6.2%; ≥65 years: 7.7%) increased linearly with age. Among KT recipients at admission, global cognitive impairment (18-34 years: 9.1%; 35-49 years: 6.1%; 50-64 years: 9.3%; ≥65 years: 15.7%) and severe cognitive impairment burden (18-34 years: 1.4%; 35-49 years: 1.4%; 50-64 years: 2.2%; ≥65 years: 4.6%) was lower. Despite lowest burden of cognitive impairment among KT recipients at 1-year post-KT across all ages (18-34 years: 1.7%; 35-49 years: 3.4%; 50-64 years: 4.3%; ≥65 years: 6.5%), many still exhibited severe cognitive impairment (18-34 years: .0%; 35-49 years: 1.9%; 50-64 years: 2.4%; ≥65 years: 3.5%).

CONCLUSION

Findings were consistent for executive function impairment. While cognitive impairment increases with age, younger KT candidates have a high burden comparable to community-dwelling older adults, with some potentially suffering from severe forms. Transplant centers should consider routinely screening patients during clinical care encounters regardless of age.

Qualitative Evaluation Informs Understanding of Motor Cognition and Therapies in Older Adults with Mild Cognitive Impairment

BACKGROUND

10%to 20%of Americans aged 65 and older have mild cognitive impairment (MCI) with 10%progressing to Alzheimer's disease (AD) each year. Underserved groups, including African Americans (AAs), are among the most vulnerable to MCI and AD. Although evidence continues to amass, the benefits of exercise and movement for AD is still understudied in AD.

OBJECTIVE

Understanding the attitudes, perceptions, and beliefs about motor-cognitive integration and examining the physical activity of a sample of predominantly Black women community members with self-reported memory problems will allow improved recruitment and refinement of multimodal interventions designed to improve motor-cognitive and cognitive function.

METHODS

We conducted focus groups with older adults who reported subjective memory complaints (n = 15; Black: n = 12, White: n = 3, mean age 71.7±5.8).

RESULTS

Findings from thematic analysis showed most participants knew of benefits of exercise. However, most participants reported not getting adequate exercise due to factors such as pain, increased responsibilities, and fear of injury. Despite barriers, participants expressed enthusiasm for multimodal interventions designed to target body and brain health and provided several suggestions to improve or enhance the proposed interventions.

CONCLUSION

Results provide useful insights regarding improving participation among historically under-represented groups in clinical movement-based research. Participants' discussion focused primarily on the way motor-cognitive integration prevents falls, maintains memory, and provides a social benefit. The reported perceived benefits and limitations of exercise, as this population understands it, can help researchers and physicians better engage the community for lifestyle changes that will support greater motor-cognitive health.

Frailty-a risk factor of global and domain-specific cognitive decline among a nationally representative sample of community-dwelling older adult U.S. Medicare beneficiaries

OBJECTIVES

frail older adults may be more vulnerable to stressors, resulting in steeper declines in cognitive function. Whether the frailty-cognition link differs by cognitive domain remains unclear; however, it could lend insight into underlying mechanisms.

METHODS

we tested whether domain-specific cognitive trajectories (clock-drawing test, (CDT), immediate and delayed recall, orientation to date, time, president and vice-president naming) measured annually (2011-2016) differ by baseline frailty (physical frailty phenotype) in the National Health and Aging Trends Study (n = 7,439), a nationally representative sample of older adult U.S. Medicare beneficiaries, using mixed effects models to describe repeated measures of each cognitive outcome. To determine if the association between frailty and subsequent cognitive change differed by education, we tested for interaction using the Wald test.

RESULTS

we observed steeper declines for frail compared to non-frail participants in each domain-specific outcome, except for immediate recall. Largest differences in slope were observed for CDT (difference = -0.12 (standard deviations) SD/year, 95%CI: -0.15, -0.08). By 2016, mean CDT scores for frail participants were 1.8 SD below the mean (95%CI: -1.99, -1.67); for non-frail participants, scores were 0.8 SD below the mean (95%CI: -0.89, -0.69). Associations differed by education for global cognitive function (Pinteraction < 0.001) and for each domain-specific outcome: CDT (Pinteraction < 0.001), orientation (Pinteraction < 0.001), immediate (Pinteraction < 0.001) and delayed (Pinteraction < 0.001) word recalls.

CONCLUSION

frailty is associated with lower levels and steeper declines in cognitive function, with strongest associations for executive function. These findings suggest that aetiologies are multifactorial, though primarily vascular related; further research into its association with dementia sub-types and related pathologies is critical.

Physical frailty and cognitive impairment in older nursing home residents: a latent class analysis

BACKGROUND

Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents.

METHODS

Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy ≥6 months and length of stay ≥100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs).

RESULTS

In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI)moderate cognitive impairment: 1.01 (0.99-1.03); aOR (95%CI)severe cognitive impairment: 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI)moderate cognitive impairment: 2.41 (2.35-2.47); aOR (95%CI)severe cognitive impairment: 5.74 (5.58-5.90)].

CONCLUSIONS

Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment.

Choosing the Right Therapy for Patients with Relapsed/Refractory Multiple Myeloma (RRMM) in Consideration of Patient-, Disease- and Treatment-Related Factors

Treatment of relapsed/refractory multiple myeloma (RRMM) is more complex today due to the availability of novel therapeutic options, mostly applied as combination regimens. immunotherapy options have especially increased substantially, likewise the understanding that patient-, disease- and treatment-related factors should be considered at all stages of the disease. RRMM is based on definitions of the international myeloma working group (IMWG) and includes biochemical progression, such as paraprotein increase, or symptomatic relapse with CRAB criteria (hypercalcemia, renal impairment, anemia, bone lesions). When choosing RRMM-treatment, the biochemical markers for progression and severity of the disease, dynamic of disease relapse, type and number of prior therapy lines, including toxicity and underlying health status, need to be considered, and shared decision making should be pursued. Objectively characterizing health status via geriatric assessment (GA) at each multiple myeloma (MM) treatment decision point has been shown to be a better estimate than via age and comorbidities alone. The well-established national comprehensive cancer network, IMWG, European myeloma network and other national treatment algorithms consider these issues. Ideally, GA-based clinical trials should be supported in the future to choose wisely and efficaciously from available intervention and treatment options in often-older MM adults in order to further improve morbidity and mortality.

Comparing the effect of cognitive vs. exercise training on brain MRI outcomes in healthy older adults: A systematic review

Aging is associated with cognitive decline. Importantly cognition and cerebral health is enhanced with interventions like cognitive (CT) and exercise training (ET). However, effects of CT and ET interventions on brain magnetic resonance imaging outcomes have never been compared systematically. Here, the primary objective was to critically and systematically compare CT to ET in healthy older adults on brain MRI outcomes. A total of 38 studies were included in the final review. Although results were mixed, patterns were identified: CT showed improvements in white matter microstructure, while ET demonstrated macrostructural enhancements, and both demonstrated changes to task-based BOLD signal changes. Importantly, beneficial effects for cognitive and cerebral outcomes were observed by almost all, regardless of intervention type. Overall, it is suggested that future work include more than one MRI outcome, and report all results including null. To better understand the MRI changes associated with CT or ET, more studies explicitly comparing interventions within the same domain (i.e. resistance vs. aerobic) and between domains (i.e. CT vs. ET) are needed.

Promoting neuroplasticity and neuropsychological functioning in frailty through an app-based sensorimotor training: study protocol for a randomized trial

BACKGROUND

Frailty is characterized by an age-related decline in multiple physiological systems, leading to a high vulnerability to stressors, adverse health outcomes, and low quality of life. Neuroscientific models of pathological aging emphasize the loss of sensorimotor stimulation and reduced neuromodulatory capacities as core processes in age-related cognitive and bodily decline, which may be associated with maladaptive plastic changes in the brain. We plan to increase sensorimotor stimulation in frail persons through a newly developed app-based training program and link the training trials to biological and psychological correlates of age-associated vulnerability and health indices.

METHODS

We will conduct a randomized trial, applying an app-based sensorimotor home training (N = 30) in people suffering from frailty. An app-based relaxation training will serve as an active control condition (N = 30). Both interventions will last for 90 days each. The sensorimotor training includes unimodal and multimodal sensory discrimination tasks in the visual, auditory, and tactile domain, as well as sensorimotor precision tasks. The tasks will be implemented using an adaptive training algorithm and enriched with motivational components embedded in a virtual training environment. We expect a pre-post reduction of frailty status and associated functional decline related to refinement of representational maps within the sensorimotor system and improved sensorimotor function such as extremity function. Secondary analyses will study the influence of BDNF genotype as moderating variable. Additional outcomes will include measures of perceptual and cognitive functioning, quality of life as well as BDNF serum levels. Measurements will take place before training (baseline), after 60 days (assessment 1), and at the end of the training after 90 days (assessment 2).

DISCUSSION

In our randomized trial, we aim to characterize a multidimensional concept of frailty and to target maladaptive behaviors and neuroplasticity using an app-based sensorimotor training. This type of intervention might provide further knowledge and new possibilities for preventing decline and preserving function in older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03666039 . Registered 11 September 2018 - Retrospectively registered. Protocol version: Version 4 revised (issue date: 19 May 2021).

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

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

Physical Frailty and Cognitive Impairment in Older Adults in United States Nursing Homes

INTRODUCTION

In older US nursing home (NH) residents, there is limited research on the prevalence of physical frailty, its potential dynamic changes, and its association with cognitive impairment in older adults' first 6 months of NH stay.

METHODS

Minimum Data Set (MDS) 3.0 is the national database on residents in US Medicare-/Medicaid-certified NHs. MDS 3.0 was used to identify older adults aged ≥65 years, newly admitted to NHs during January 1, 2014, and June 30, 2016, with life expectancy ≥6 months at admission and NH length of stay ≥6 months (N = 571,139). MDS 3.0 assessments at admission, 3 months, and 6 months were used. In each assessment, physical frailty was measured by FRAIL-NH (robust, prefrail, and frail) and cognitive impairment by Brief Interview for Mental Status and Cognitive Performance Scale (none/mild, moderate, and severe). Demographic characteristics and diagnosed conditions were measured at admission, while presence of pain and receipt of psychotropic medications were at each assessment. Distribution of physical frailty and its change over time by cognitive impairment were described. A nonproportional odds model was fitted with a generalized estimation equation to longitudinally examine the association between physical frailty and cognitive impairment, adjusting for demographic and clinical characteristics.

RESULTS

Around 60% of older residents were physically frail in the first 6 months. Improvement and worsening across physical frailty levels were observed. Particularly, in those who were prefrail at admission, 23% improved to robust by 3 months. At admission, 3 months, and 6 months, over 37% of older residents had severe cognitive impairment and about 70% of those with cognitive impairment were physically frail. At admission, older residents with moderate cognitive impairment were 35% more likely (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.33-1.37) and those with severe impairment were 74% more likely (aOR: 1.74, 95% CI: 1.72-1.77) to be frail than prefrail/robust, compared to those with none/mild impairment. The association between the 2 conditions remained positive and consistently increased over time.

DISCUSSION/CONCLUSION

Physical frailty was prevalent in NHs with potential to improve and was strongly associated with cognitive impairment. Physical frailty could be a modifiable target, and interventions may include efforts to address cognitive impairment.

Polypharmacy and Lack of Joy Are Related to Physical Frailty among Northern Japanese Community-Dwellers from the ORANGE Cohort Study

INTRODUCTION

A prevalence of frailty is gradually increasing with the progress of aging in Japan, and critical challenges regarding early diagnosis and prevention of frailty were necessary in community. Although previous studies have well documented the characteristics of physical disability, there is limited information on frail state differences among older adults in Japanese rural areas. The aim of our cross-sectional observational study was to clarify the association of frail status in northern Japanese community-dwellers aged 65 or more.

METHODS

345 participants were recruited from 2018 to 2020, and after getting informed consent from each participant, assessments and outcomes were evaluated according to the ORANGE protocol. We applied the frailty index of Gerontology-the Study of Geriatric Syndromes (NCGG-SGS) to classify frailty status by collecting data of demographics and psychosocial status using the Kihon checklist (KCL) and cognitive domains used by the National Center for Geriatrics and Gerontology-Functional Assessment Tool (NCGG-FAT).

RESULTS

Our subjects included 313 older adults divided into 138 robust, 163 prefrail, and 12 frail. For statistical analysis, we found that the frail group had a lower educational duration, worsened KCL items, lower cognitive functions, and a tendency toward depression compared to the other groups. Moreover, physical frailty and cognitive decline were related, and polypharmacy and a lack of joy in daily life were explanatory variables of frail status.

CONCLUSIONS

We suggest that KCL is important for frail discrimination, and in order to prevent physical frailty, our community should take care of not only exercise and nutrition but also cognitive functioning and depressive tendencies. In particular, polypharmacy and the presence of fun in your life are possible to be related to frailty.

A Possible Association Between Executive Dysfunction and Frailty in Patients With Neurocognitive Disorders

Frailty is an age-related dynamic status, characterized by a reduced resistance to stressors due to the cumulative decline of multiple physiological systems. Several researches have highlighted a relationship between physical frailty and cognitive decline; however, the role of specific cognitive domains has not been deeply clarified yet. Current studies have hypothesized that physical frailty and neuropsychological deficits may share systemic inflammation and increased oxidative stress in different neurodegenerative disorders, such as Alzheimer’s and Parkinson’s disease. However, the role of the executive dysfunction should be investigated in a more detailed way using a multidimensional approach. With this aim, we conducted a review of the literature on the few experimental articles published to discuss the existence of a relationship between frailty and cognitive impairment in neurocognitive disorders, particularly focusing on the domain of executive dysfunction. The data suggest that physical frailty and cognitive decline, especially executive dysfunction, are two aspects strongly linked in mild and major neurocognitive disorders due to Alzheimer’s and Parkinson’s disease. In light of this, a new framework linking aging, cognitive decline, and neurodegenerative diseases is needed. In order to analyze the effects that aging processes have on neural decline and neurocognitive disease, and to identify relevant groups of users and patients, future longitudinal studies should adopt a multidimensional approach, in the field of primary prevention and in the continuum from mild to major neurocognitive disorder.

Physical Frailty Phenotype Criteria and Their Synergistic Association on Cognitive Functioning

BACKGROUND

Frailty (physical frailty phenotype [PFP]) and its criteria (slow gait, weakness, weight loss, low activity, and exhaustion) are each associated with cognitive dysfunction. The extent to which the PFP is associated with cognition beyond that expected from its component parts remains uncertain.

METHOD

We used the National Health and Aging Trends Study to quantify associations between PFP criteria and cognitive performance (level/change) using adjusted mixed effects models. We tested whether frailty was associated with excess cognitive vulnerability (synergistic/excess effects, Cohen's d) beyond criteria contributions by assessing interactions between each criterion and frailty.

RESULTS

Among 7439 community-dwelling older adults (mean age = 75.2 years) followed for a mean of 3.2 years (SE = 0.03), 14.1% were frail. The PFP and PFP criteria were all associated with lower baseline cognitive performance, among which slow gait (-0.31 SD, SE = 0.02) and frailty (-0.23 SD, SE = 0.02) were strongest. Only slow gait (-0.03 SD/year, SE = 0.01), frailty (-0.02 SD/year, SE = 0.01), weight loss (-0.02 SD/year, SE = 0.01), and weakness (-0.02 SD/year, SE = 0.01) were associated with cognitive decline. Frailty was associated with cognitive performance above and beyond each criterion (excess effects ranging from -0.07 SD [SE = -0.05] for slow gait to -0.23 SD [SE = 0.03] for weakness); the same was not true for cognitive decline. Slow gait was the only criterion associated with cognitive change among both frail and nonfrail participants (frail: Cohen's d/year = -0.03, SE = 0.01; nonfrail: Cohen's d/year = -0.02, SE = 0.01).

CONCLUSIONS

PFP is an important frailty measure that is cross-sectionally associated with lower cognitive performance, but not with subsequent cognitive decline, above and beyond its criteria contributions. Further research into the construct of frailty as a "syndrome" correlated with cognition and other adverse outcomes is needed.

Osteocalcin, ovarian senescence, and brain health

Menopause, an inevitable event in a woman's life, significantly increases risk of bone resorption and diseases such as Alzheimer's, vascular dementia, cardiac arrest, and stroke. The sole role of bones, as traditionally regarded, is to provide structural support for skeletal muscles and allow for ambulation, however this concept is becoming quickly outdated. New literature has emerged that suggests the bone cell-derived hormone osteocalcin (OCN) plays a pivotal role in cognition. OCN levels are correlated with bone mass density and bone turnover, and thus are strongly influenced by the changes associated with menopause. The goal of the current review is to discuss potential gaps in our knowledge of OCN and cognition, discrepancies in methods of OCN quantification, and therapies to enhance circulating OCN. A discussion on implementing exercise or low frequency vibration interventions at the menopausal transition to reduce risk and severity of neurological diseases and associated cognitive decline is included.

Mind the Rhythm: ECG QT Dispersion and Cognition in Healthy Older Adults

Background

Autonomic function has been linked to cognitive abilities in aging. Even in non-clinical states, a certain variability in heart rhythm regulation can be measured with QT dispersion (QTcD), an ECG marker of ventricular repolarization which has been linked to autonomic function and cardiovascular health. QTcD has been shown to be higher in individuals with mild cognitive impairment, and the highest in individuals with Alzheimer’s disease. The goal of this study was to see if QTcD is associated with cognitive performance in healthy individuals.

Methods

Sixty-three healthy inactive older adults (> 60 years) completed an extensive cognitive assessment (including inhibition, divided attention, updating, working memory, and processing speed), a physical fitness assessment, and underwent a resting ECG.

Results

After controlling for age, sex, and education, QTcD significantly predicted global cognition (MoCA) scores (R² = 0.17, F_(4.58) = 3.00, p < 0.03, β = −0.36). Exploratory analysis on the MoCA subcomponents revealed a significant association between the visual/executive subcomponent and QTcD (R² = 0.12, F_(1.61) = 7.99, p < 0.01, β = −0.34). In individuals with high QTcD, QTcD values were linked to executive functions (R² = 0.37), processing speed (R² = 0.34), and dual-task performances (R² = 0.47). No significant associations were found within the low QTcD group.

Conclusion

This study shows an association between ventricular repolarization (QTcD) and cognitive performance, in particular speed and executive functions, in healthy older adults. The results provide further support for linking autonomic heart regulation and age-related cognitive changes, and suggest that deviations on ECG, even within-normal range, could help detect early cognitive deficits.

The use of Bayesian network models to identify factors related to frailty phenotype and health outcomes in middle-aged and older persons

BACKGROUND

Studies on frailty frequently only include older persons. The mapping of factors related to this syndrome and negative outcomes associated with it, also in middle age, may assist in health strategies to each age group.

OBJECTIVES

To investigate social and health factors related to the frailty phenotype and to analyze the probabilistic relationships between frailty, falls and hospitalization in middle-aged and older persons.

METHODS

This is a cross-sectional study using data for 4442 middle-aged (50-59 years) and older participants (60 years or older) from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) 2015 and 2016. Bayesian network models were estimated with the score-based hill-climbing algorithm to identify factors associated with frailty, falls and hospitalization.

RESULTS

Mean age was 63.7 years, and prevalence of frailty was 8.5 % and 11.9 % among middle-aged and older participants, respectively. In the former, the probability of frailty increased when "poor" self-rated memory was considered in the model; and in the latter, the probability of frailty was greatest among individuals who did not participate socially and had the lowest level of education. In both age groups, frailty was an important factor that influenced the probability of negative health outcomes such as falls and hospitalization. However, this result depended on combinations of health factors in each sample.

CONCLUSIONS

This study has identified potential vulnerabilities that should be considered when undertaking a comprehensive assessment of middle-aged and older persons and developing suitable health strategies for each of these phases of life.

Hierarchical Development of Frailty and Cognitive Impairment: Clues Into Etiological Pathways

BACKGROUND

Frailty and cognitive impairment (CI) are associated and often coexist in older adults. Whether temporal patterns of occurrence reflect different etiologies remain unknown.

METHODS

Participants from the National Health and Aging Trends Study were assessed annually (2011-2016) for frailty (Fried's criteria) and CI (bottom quintile of clock drawing test or immediate and delayed recall; proxy-report of dementia diagnosis or AD8 ≥ 2). We used the Fine & Gray model to identify correlates of frailty onset before CI, CI onset before frailty, and frailty-CI co-occurrence, accounting for death as a competing risk.

RESULTS

Of 3,848 free of frailty, CI, and dementia at baseline, 2,183 (61.2%) developed neither frailty nor CI during the 5-year follow-up; 343 (8.3%) developed frailty first; 1,014 (24.4%) developed CI first; and 308 (6.0%) developed frailty-CI co-occurrence. Incident dementia, as a marker of underlying neuropathologies, was associated with greater likelihood of CI onset first (subdistribution hazard ratios [SHR] = 2.60, 95% confidence interval [ci] 2.09 to 3.24), and frailty-CI co-occurrence (SHR = 8.77, 95% ci 5.79 to 13.28), but lower likelihood of frailty onset first (SHR = 0.38, 95% ci 0.21 to 0.68). Number of comorbidities was only associated with frailty occurrence first (1 comorbidity: SHR = 2.51, 95% ci 1.15 to 5.47; 4+ comorbidities: SHR = 6.48, 95% ci 2.78 to 15.48).

CONCLUSIONS

Different patterns of frailty and CI occurrence exist, and dementia-related pathologies and comorbidities may be important correlates of order of emergence, potentially reflecting different etiologies. Future investigation into relationships between these patterns and dementia subtypes and related pathologies is needed to elucidate etiologic pathways and to provide new targets for prevention, intervention, and risk screening.

Understated Cognitive Impairment Assessed with the Clock-Drawing Test in Community-Dwelling Individuals Aged ≥50 Years

OBJECTIVES

To estimate the prevalence of understated cognitive impairment by administering the Clock-Drawing Test (CDT) to community-dwelling individuals aged ≥50 years and to investigate the associated clinical phenotype.

DESIGN

A cross-sectional analysis of baseline data on community-dwelling individuals assessed at an outpatient clinic in the Paris region of France.

SETTING AND PARTICIPANTS

Participants aged ≥50 years (n = 488, median age: 62.1 years) prospectively included in the SUCCessful agEing outpatiEnt's Department survey between 2010 and 2014.

METHODS

A multidimensional geriatric assessment, including cognition [7-point CDT, Mini-Mental State Examination (MMSE), the 5-word screening test (5-WT), and the Frontal Assessment Battery (FAB)], gait speed in dual tasks, mood [the Geriatric Depression Scale (GDS)], balance, physical functions (gait speed and handgrip strength), nutrition, bone density, and comorbidities; major cardiovascular risk factors, and Scheltens and Fazekas scores on brain magnetic resonance imaging. Baseline characteristics were analyzed as a function of the CDT score (<7 vs 7), using age-adjusted logistic models.

RESULTS

The prevalence of impairment in the CDT was 23.6%; higher than the values for the MMSE (12.7%), 5-WT (2.3%), and FAB (16.6%). In age-adjusted analyses, a lower educational level (odds ratio [95% confidence interval] = 0.72 [0.58‒0.89]), diabetes (2.57 [1.14‒5.79]), metabolic syndrome (1.93 [1.05‒3.56]), lower gait speed in the cognitive dual task (1.27 [1.05‒1.53]), a poorer Geriatric Depression Scale score (1.86 [1.04‒3.32]), a poorer MMSE score (2.56 [1.35‒4.88]), a poorer FAB score (1.79 [1.01‒3.16]), impaired episodic memory in the 5-WT (4.11 [1.12‒15.02]), and a higher Scheltens score (P = .001) were significantly associated with CDT impairment.

CONCLUSIONS AND IMPLICATIONS

Understated cognitive impairment is common among young seniors and is associated with factors known to be linked to a higher risk of cognitive decline and dementia. These findings suggest that the CDT may be of value for identifying high-risk individuals who may then benefit from targeted multidomain prevention actions (diet, exercise, cognitive training, and vascular risk factor management).

Frailty and Its Correlates in Adults With Late Life Depression

OBJECTIVE

To investigate the rates of frailty and frailty characteristics and examine the clinical and neuropsychological correlates of frailty in adults with late life depression (LLD).

METHODS

Data were used from the evaluation of 134 individuals over the age of 60 years (45 men, 89 women) with a depressive diagnosis who enrolled in studies for the treatment of their depression. Depression, neuropsychological functioning, white matter hyperintensity (WMH) burden via magnetic resonance imaging, and characteristics of frailty were assessed.

RESULTS

Fried frailty burden (≥3 characteristics) was present in 25% of the sample, with this rate increasing to 45.5% when using clinically meaningful cut-scores for gait speed (<1 m/s) and physical activity levels (<1000 kcal/week). Moreover, 62% of the sample exhibited gait slowing (<1 m/s) or weakness (grip strength), with 29% demonstrating both. Greater frailty burden was associated with greater Hamilton Depression Rating Scale severity in covariate adjusted linear regression models (t₁₂₇ = 2.41, p = 0.02). Greater frailty burden was not associated with neuropsychological dysfunction, nor was it associated with greater WMH burden.

CONCLUSION

Findings from this study show that frailty, specifically physical frailty deficits in mobility and strength, is highly comorbid in adults with LLD, associated with greater depressive symptom severity, and does not appear to be associated with the vascular depression subtype of LLD. Future research should investigate the relationship between frailty and antidepressant treatment response as well as test whether there are age-related biological processes that result in the manifestation of the frail-depressed subtype of LLD.

Correlation between Executive Network Integrity and Sarcopenia in Patients with Parkinson's Disease

Background: Sarcopenia is critically associated with morbidity and mortality in the progression of Parkinson's disease (PD). However, analyses of clinical severity and brain changes, such as white matter (WM) alterations in PD patients with sarcopenia are limited. Further understanding of the factors associated with sarcopenia may provide a focused screen and potential for early intervention in PD patients. Methods: 52 PD patients and 19 healthy participants accepted dual-energy X-ray absorptiometry to measure the body composition. Using diffusion tensor imaging, the difference of WM integrity was measured between PD patients with sarcopenia (PDSa) and without sarcopenia (PDNSa). Multivariate analysis was performed to explore the relationships between clinical factors, WM integrity, and sarcopenia in PD patients. Results: 21 PD patients (40.4%) had sarcopenia. PDSa had a higher Unified Parkinson's Disease Rating Scale (UPDRS III) score, lower body mass index (BMI) and lower fat weight compared with the PDNSa. Additionally, PDSa patients exhibited lower fractional anisotropy accompanied by higher radial diffusivity and/or higher mean diffusivity in the fronto-striato-thalamic circuits, including bilateral cingulum, left superior longitudinal fasciculus, left genu of corpus callosum, and right anterior thalamic radiation, which participate in the executive function. In addition, decreased muscle mass was associated with worse WM integrity in these regions. Multiple linear regression analysis revealed that WM integrity in the left cingulum, right anterior thalamic radiation, together with gender (male) significantly predicted muscle mass in PD patients. Conclusions: WM alterations in the executive network, such as the fronto-striato-thalamic circuits, may indicate a risk factor for ongoing sarcopenia in PD patients. The effectiveness of using executive function to serve as a prodromal marker of sarcopenia in PD patients should be evaluated in future studies.

Associations Between Cognitive Functions and Physical Frailty in Patients With Parkinson's Disease

Background: Parkinson’s disease (PD) is a neurodegenerative disease manifested by both motor and non-motor dysfunctions and co-existence of cognitive impairment and physical frailty is common. Given that research in this area is limited, a better understanding of associated factors with physical frailty could provide a focused screening method and facilitate early intervention in PD.

Methods: Seventy-six patients with idiopathic PD were recruited and Fried’s criteria of physical frailty were used to group all participants. Comprehensive cognitive tests and clinical characteristics were measured, and univariate and multivariate analysis was performed to explore the relationship between clinical factors or neuropsychological functions.

Results: Twenty-nine patients with PD (38%) exhibited physical frailty. Compared to PD patients without frailty, PD patients with frailty were older in age and demonstrated worse disease severity and poorer cognitive functions, including attention, executive function, memory, speech and language, and visuospatial function (p < 0.05). Further, stepwise logistic regression analysis revealed that disease severity by the Unified Parkinson’s Disease Rating Scale (UPDRS) total score (OR: 1.065; 95% CI: 1.033–1.099) and executive function (OR: 0.724; 95% CI: 0.581–0.877) were independent risk factors for predicting physical frailty (p = 0.003 and 0.002). The best cut-off points are 46 in UPDRS (sensitivity: 62.1%; specificity: 91.5%).

Conclusions: Executive function impairment is an independent risk factor for the development of physical frailty with disease progression. Awareness of such comorbidity might provide a screening tool to facilitate investigation in their underlying etiology and early intervention for frailty prevention.

Frailty syndrome and cognitive impairment in older adults: systematic review of the literature

OBJECTIVE

to synthesize the knowledge about the association of frailty syndrome and cognitive impairment in older adults.

METHOD

the Joanna Briggs Institute's systematic review of etiology and risk factors was adopted. The search for the studies was conducted by two independent reviewers in the databases MEDLINE, Embase, CINAHL and LILACS and by manual search was performed by tow reviewers independently. The measures of association Odds Ratio and Relative Risk were used in the meta-analysis. The software R version 3.4.3 and the meta-analysis package Metafor 2.0 were used for figure analysis.

RESULTS

three studies identified the association of frailty syndrome and cognitive impairment through Odds Ratio values show that frail older adults are 1.4 times more likely to present cognitive impairment than non-frail older adults. Four studies analyzed the association through the measure of Relative Risk and found no statistical significance, and four studies used mean values.

CONCLUSION

despite of the methodological differences of the studies and the lack of definition of an exact proportion in the cause and effect relationship, most studies indicate Frailty Syndrome as a trigger for Cognitive decline.

Predictors of instrumental activities of daily living in community-dwelling older adults

Psychiatric mental health clinicians often rely on proxy and self-report evaluations to determine the cognitive function of older adults however, performance measures have greater accuracy and predictive ability for everyday function. This study tested physical and cognitive predictors of functional abilities in fifty-one community residing older adults. We administered a computerized battery of executive function tasks, a performance-based measure of instrumental activities of daily living (IADL), and three physical function measures (grip strength, 30-second Chair Stand Test, and 8-foot Up and Go). Regression models assessed the associations of three components of executive function (updating, shifting, and inhibition) with IADLs and physical functions. Updating was a significant predictor of the Medications and Financial DAFS scores and of grip strength. Shifting also predicted grip strength. In conclusion, different executive functions predict different domains of IADL functioning. Working memory was a robust predictor of IADL functioning in older adults, especially medication management skills.

Joint impact of dementia and frailty on healthcare utilisation and outcomes: a retrospective cohort study of long-stay home care recipients

OBJECTIVES

To examine the associations between dementia and 1-year health outcomes (urgent hospitalisation, long-term care (LTC) admission, mortality) among long-stay home care recipients and the extent to which these associations vary by clients' frailty level.

DESIGN

A retrospective cohort study using linked clinical and health administrative databases.

SETTING

Home care in Ontario, Canada.

PARTICIPANTS

Long-stay (≥60 days) care clients (n=153 125) aged ≥50 years assessed between April 2014 and March 2015.

MAIN OUTCOME MEASURES

Dementia was ascertained with a validated administrative data algorithm and frailty with a 66-item frailty index (FI) based on a previously validated FI derived from the clinical assessment. We examined associations between dementia, FI and their interactions, with 1-year outcomes using multivariable Fine-Gray competing risk (urgent hospitalisation and LTC admission) and Cox proportional hazards (mortality) models.

RESULTS

Clients with dementia (vs without) were older (mean±SD, 83.3±7.9 vs 78.9±11.3 years, p<0.001) and more likely to be frail (30.3% vs 24.2%, p<0.001). In models adjusted for FI (as a continuous variable) and other confounders, clients with dementia showed a lower incidence of urgent hospitalisation (adjusted subdistribution HR (sHR)=0.84, 95% CI: 0.83 to 0.86) and mortality rate (adjusted HR=0.87, 95% CI: 0.84 to 0.89) but higher incidence of LTC admission (adjusted sHR=2.60, 95% CI: 2.53 to 2.67). The impact of dementia on LTC admission and mortality was significantly modified by clients' FI (p<0.001 interaction terms), showing a lower magnitude of association (ie, attenuated positive (for LTC admission) and negative (for mortality) association) with increasing frailty.

CONCLUSIONS

The strength of associations between dementia and LTC admission and death (but not urgent hospitalisation) among home care recipients was significantly modified by their frailty status. Understanding the public health impact of dementia requires consideration of frailty levels among older populations, including those with and without dementia and varying degrees of multimorbidity.

Integrating Frailty and Cognitive Phenotypes: Why, How, Now What?

PURPOSE OF REVIEW

This review elucidates the concept of frailty in relationship to reserve and resilience, the relationships and shared pathophysiology between physical frailty and cognitive impairment, the theoretical underpinnings of three integrated phenotypes of physical and cognitive impairments, and the potential of incorporating biomarkers into phenotype refinement and validation.

RECENT FINDINGS

The fact that frailty and cognitive impairment are associated and often coexist in older adults has led to the popular view of expanding the definition of frailty to include cognitive impairment. However, there is great variability in approaches to and assumptions regarding the integrated phenotypes of physical frailty and cognitive impairment.

SUMMARY

The development of integrated frailty and cognitive phenotypes should explicate the types of frailty and cognitive impairment they intend to capture and prioritize the incorporation of biological theories that help determine shared and distinct pathways in the progression to physical and cognitive impairments.

Frailty and Changes in Cognitive Function after Kidney Transplantation

BACKGROUND

Restoration of kidney function after kidney transplant generally improves cognitive function. It is unclear whether frail recipients, with higher susceptibility to surgical stressors, achieve such post-transplant cognitive improvements or whether they experience subsequent cognitive decline as they age with a functioning graft.

METHODS

In this two-center cohort study, we assessed pretransplant frailty (Fried physical frailty phenotype) and cognitive function (Modified Mini-Mental State Examination) in adult kidney transplant recipients. To investigate potential short- and medium-term effects of frailty on post-transplant cognitive trajectories, we measured cognitive function up to 4 years post-transplant. Using an adjusted mixed effects model with a random slope (time) and intercept (person), we characterized post-transplant cognitive trajectories by pretransplant frailty, accounting for nonlinear trajectories.

RESULTS

Of 665 recipients (mean age 52.0 years) followed for a median of 1.5 years, 15.0% were frail. After adjustment, pretransplant cognitive scores were significantly lower among frail patients compared with nonfrail patients (89.0 versus 90.8 points). By 3 months post-transplant, cognitive performance improved for both frail (slope =0.22 points per week) and nonfrail (slope =0.14 points per week) recipients. Between 1 and 4 years post-transplant, improvements plateaued among nonfrail recipients (slope =0.005 points per week), whereas cognitive function declined among frail recipients (slope =-0.04 points per week). At 4 years post-transplant, cognitive scores were 5.8 points lower for frail recipients compared with nonfrail recipients.

CONCLUSIONS

On average, both frail and nonfrail recipients experience short-term cognitive improvement post-transplant. However, frailty is associated with medium-term cognitive decline post-transplant. Interventions to prevent cognitive decline among frail recipients should be identified.

Calf Circumference as a Screening Tool for Cognitive Frailty in Community-Dwelling Older Adults: The Korean Frailty and Aging Cohort Study (KFACS)

The aim of this study was to examine calf circumference in relation to cognitive frailty in community-dwelling older adults. Cross-sectional analysis was performed on the first-year baseline data of 1559 adults aged 70–84 years enrolled in the Korean Frailty and Aging Cohort Study. The final analysis included 1221 adults who were non-dependent in terms of instrumental activities of daily living, who underwent frailty and cognitive function assessments. Physical frailty was defined using the Fried Frailty Index. Cognitive impairment was defined as a score 1.5 standard deviations below the age-, sex- and education-matched norms on any of four cognitive-function tests. The prevalence of cognitive frailty was 2.8% for men and 3.8% for women. After adjusting for potential confounders, in comparison to the “physically robust without cognitive impairment” group, the estimates of increased odds ratios (ORs) for low calf circumference (<32 cm) were much greater in the prefrail with cognitive impairment (OR 4.62, 95% confidence interval (CI): 2.02–10.61) and frail with cognitive impairment (OR 10.94, 95% CI: 2.87–41.68) groups in men but not in women. Low calf circumference was strongly related to cognitive frailty in men only, suggesting calf circumference can be used as an indicator of these outcomes.

Increasing use of cognitive measures in the operational definition of frailty-A systematic review

Ageing is associated both with frailty and cognitive decline. The quest for a unifying approach has led to a new concept: cognitive frailty. This systematic review explores the contribution of cognitive assessment in frailty operationalization. PubMed, Web of Knowledge and PsycINFO were searched until December 2016 using the keywords aged; frail elderly; aged, 80 and over; frailty; diagnosis; risk assessment and classification, yielding 2863 hits. Seventy-nine articles were included, describing 94 frailty instruments. Two instruments were not sufficiently specified and excluded. 46% of the identified frailty instruments included cognition. Of these, 85% were published after 2010, with a significant difference for publication date (X² = 8.45, p < .05), indicating increasing awareness of the contribution of cognitive deficits to functional decline. This review identified 7 methods of cognitive assessment: dementia as co-morbidity; objective cognitive-screening instruments; self-reported; specific signs and symptoms; delirium/clouding of consciousness; non-specific cognitive terms and mixed assessments. Although cognitive assessment has been increasingly integrated in recently published frailty instruments, this has been heterogeneously operationalized. Once the domains most strongly linked to functional decline will have been identified and operationalized, this will be the groundwork for the identification of reversible components, and for the development of preventive interventional strategies.

Relevance of frailty to mortality associated with the use of antipsychotics among community-residing older adults with impaired cognition

PURPOSE

To examine the association between new antipsychotic use and mortality over 6 months among community-based older adults with cognitive impairment, and variation in risk by frailty and sex.

METHODS

We conducted a retrospective cohort study of older (aged 66+) home care clients in Ontario, Canada, using linked administrative health and clinical databases. Included were clients with dementia and/or significant cognitive impairment assessed during April 2008 to March 2013. Frailty was defined using a validated 72-item index. Exposed were those newly dispensed an antipsychotic in the 6 months post cohort entry, with no such claims in the year prior to drug index date. Two-stage matching defined unexposed clients and their index date (matching on age, sex, frailty, assessment year, and propensity score). Outcome was time to death following index date. Cause-specific hazards models were used, and number needed to harm at 6 months was estimated from cumulative incidence function curves.

RESULTS

Among 4955 matched exposed-unexposed pairs, new antipsychotic users showed a significantly increased hazard of mortality at 1, 3, and 6 months relative to unexposed, with the highest risk observed in the first month (hazard ratio [HR] = 2.08 [95% CI, 1.79-2.43]). At 1 month, risk was significantly higher for robust (HR = 3.72 [95% CI, 2.45-5.66]) vs frail (HR = 1.74 [95% CI, 1.40-2.17], P = .002) clients. The number needed to harm was 22.7 and did not vary by frailty but was lower for men (14.9) than for women (35.0).

CONCLUSIONS

Risk of antipsychotic-associated mortality was highest in the first month following exposure, varied significantly by client frailty, and was greater among men than among women.

Assessing robustness of hazard ratio estimates to outcome misclassification in longitudinal panel studies with application to Alzheimer's disease

Analyses of imperfectly assessed time to event outcomes give rise to biased hazard ratio estimates. This bias is a common challenge for studies of Alzheimer’s Disease (AD) because AD neuropathology can only be identified through brain autopsy and is therefore not available for most study participants. Clinical AD diagnosis, although more widely available, has imperfect sensitivity and specificity relative to AD neuropathology. In this study we present a sensitivity analysis approach using a bias-adjusted discrete proportional hazards model to quantify robustness of results to misclassification of a time to event outcome and apply this method to data from a longitudinal panel study of AD. Using data on 1,955 participants from the Adult Changes in Thought study we analyzed the association between average glucose level and AD neuropathology and conducted sensitivity analyses to explore how estimated hazard ratios varied according to AD classification accuracy. Unadjusted hazard ratios were closer to the null than estimates obtained under most scenarios for misclassification investigated. Confidence interval estimates from the unadjusted model were substantially underestimated compared to adjusted estimates. This study demonstrates the importance of exploring outcome misclassification in time to event analyses and provides an approach that can be undertaken without requiring validation data.

Defining Aging Phenotypes and Related Outcomes: Clues to Recognize Frailty in Hospitalized Older Patients

Background

Because frailty is a complex phenomenon associated with poor outcomes, the identification of patient profiles with different care needs might be of greater practical help than to look for a unifying definition. This study aimed at identifying aging phenotypes and their related outcomes in order to recognize frailty in hospitalized older patients.

Methods

Patients aged 65 or older enrolled in internal medicine and geriatric wards participating in the REPOSI registry. Relationships among variables associated to sociodemographic, physical, cognitive, functional, and medical status were explored using a multiple correspondence analysis. The hierarchical cluster analysis was then performed to identify possible patient profiles. Multivariable logistic regression was used to verify the association between clusters and outcomes (in-hospital mortality and 3-month postdischarge mortality and rehospitalization).

Results

2,841 patients were included in the statistical analyses. Four clusters were identified: the healthiest (I); those with multimorbidity (II); the functionally independent women with osteoporosis and arthritis (III); and the functionally dependent oldest old patients with cognitive impairment (IV). There was a significantly higher in-hospital mortality in Cluster II (odds ratio [OR] = 2.27, 95% confidence interval [CI] = 1.15-4.46) and Cluster IV (OR = 5.15, 95% CI = 2.58-10.26) and a higher 3-month mortality in Cluster II (OR = 1.66, 95% CI = 1.13-2.44) and Cluster IV (OR = 1.86, 95% CI = 1.15-3.00) than in Cluster I.

Conclusions

Using alternative analytical techniques among hospitalized older patients, we could distinguish different frailty phenotypes, differently associated with adverse events. The identification of different patient profiles can help defining the best care strategy according to specific patient needs.