The Association Between Cardiometabolic Risk Factors and Frailty in Older Adults: A Systematic Review

Frailty, comorbidity, and multimorbidity and their relation with medications adherence in primary care older adults

PURPOSE

To assess and compare, through a retrospective cohort study, the relationships between frailty, comorbidity, multimorbidity, and levels of adherence to lipid-lowering drugs (LLDs), antihypertensives and antidepressants.

METHODS

In a primary care database, we selected a cohort of patients aged 60 or older on December 31, 2022. The date of the first prescription of the aforementioned medications was the study index date. Patients with Variable Medication Possession Ratio (VMPR) > = 80% were classified as properly adherent. Frailty (i.e. Primary Care-Frailty Index), comorbidity (i.e. Charlson Index) and multimorbidity (i.e. disease counts) alternatively entered multivariate logistic regressions along with age and sex. Models' performances in prediction of medications adherence were compared in terms of information (AIC; BIC) and discrimination values (AUC).

RESULTS

Incident users of LLDs, antihypertensives or antidepressants were 4310 (mean age: 67.9 (SD: 6.9); 56.0% females), 5969 (mean age: 69.1 (SD: 7.6); 58.0% females), and 3834 (mean age: 68.7 (SD: 6.9); 66.5% females), respectively. Among users of LLDs (46% adherent) and antidepressants (22% adherent), those who were moderately or severely frail showed a significant 30-32% decrease in adherence. In contrast, users of antihypertensives (46% adherent) showed a 41% increase in adherence when multimorbid. As a whole, the three multivariate models were equally effective in informing on medication adherence, as per AIC and BIC. They also displayed similar discriminatory ability, with AUC scores ranging from 53 to 58%. Regarding the workload of GPs, the number of elderly patients classified as moderately/high frail was less than those with co-morbidities or multimorbidities. For instance, there were approximately 35 users of antihypertensive medications per GP for the moderately frail group, compared to 46 and 66 for the co-morbid and multi-morbid groups, respectively.

CONCLUSIONS

These findings showed similar capacity for frailty, comorbidity, and multimorbidity in capturing medications adherence. Given the existence of a validated tool in primary care that aligns well with GPs' workload, frailty seems the most suitable measure for assessing the complexity of older adults in relation to their adherence to long-term medications.

Factors associated with frailty in older people: an umbrella review

BACKGROUND

The number of frail older people is increasing worldwide, and all countries will be confronted with their growing needs for healthcare and social support. The aim of this umbrella review was to summarize the evidence on the factors associated with frailty in older people, using a socioecological approach.

METHODS

PubMed (MEDLINE), Scopus, Web of Science, ScienceDirect, Hinari (research4life), and the Trip database were systematically searched up to April 2023. Systematic reviews of observational studies that explored factors associated with frailty in older adults aged 60 years and over were considered for inclusion. No language, geographical or setting restrictions were applied. However, we excluded systematic reviews that investigated frailty factors in the context of specific diseases. The Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the ROBIS tool were used to assess the quality and risk of bias in the included studies.

RESULTS

Forty-four systematic reviews were included, covering 1,150 primary studies with approximately 2,687,911 participants overall. Several risk factors, protective factors and biomarkers were found to be associated with frailty, especially in community-dwelling older people, including 67 significant associations from meta-analyses. The certainty of the evidence was rated as moderate or reached moderate levels for seven factors relevant to older people. These factors include depression (OR 4.66, 95% CI 4.07 to 5.34), loneliness (OR 3.51, 95% CI 2.70 to 4.56), limitations in activities of daily living (OR 2.59, 95% CI 1.71 to 3.48), risk of malnutrition (OR 3.52, 95% CI 2.96 to 4.17), Dietary Inflammatory Index score (OR 1.24, 95% CI 1.16 to 1.33), maximal walking speed (Standardized Mean Difference (SMD) -0.97, 95% CI -1.25 to -0.68), and self-reported masticatory dysfunction (OR 1.83, 95% CI 1.55 to 2.18). Additionally, only greater adherence to a Mediterranean diet showed a high level of evidence (OR 0.44, 95% CI 0.31 to 0.64).

CONCLUSIONS

This umbrella review will provide guidance for prevention strategies and clinical practice by promoting healthy lifestyles and addressing all modifiable risk factors associated with frailty. Future systematic reviews should consider heterogeneity and publication bias, as these were the main reasons for downgrading the level of evidence in our review.

REGISTRATION

PROSPERO 2022, CRD42022328902.

Cardiovascular disease risk factors and frailty syndrome in community-dwelling older adults: Results from the Amirkola Health and Aging Project Cohort Study

BACKGROUND

Early diagnosis and control of risk factors affecting frailty syndrome (FS) in older adults may lead to changes in the health/disease process, prevention of disability and dependency in the older adults, and reduction of health care costs and mortality rates. The aim of this study was to determine the predictive role of CVD risk factors and FS in community-dwelling older adults of Amirkola city in Iran.

METHODS

This descriptive-analytic cross-sectional study is part of the second phase of the Amirkola Health and Aging Project (AHAP) cohort study conducted since 2011 on all individuals ≥ 60 years in the city of Amirkola in northern Iran. Totally, 1000 older adults were included in the study and divided into three groups: frail (n = 299), pre-frail (n = 455), and non-frail (n = 246) older adults. In the present study, age ≥ 60 years, female sex, fasting blood sugar (FBS) ≥ 126 mg/dl, affected diabetes mellitus (DM), body mass index (BMI) ≥ 27 kg/m², waist circumference (WC) or abdominal obesity > 102 cm in men and > 88 cm in women, low-density lipoprotein (LDL) > 100 mg/dl, triglyceride > 150 mg/dl, cholesterol > 200 mg/dl, high-density lipoprotein (HDL) < 40 mg/dl and blood pressure (BP) > 90/140 mmHg, uric acid > 7 mg/dl and a positive smoking history were considered CVD risk factors.

RESULTS

The results showed that with each centimeter increase in WC, the odds of frailty compared with non-frailty was 79% higher, and the odds of frailty compared with pre-frailty was 1.43 times higher in older adults. In addition, the prevalence of pre-frailty compared with non-frailty, pre-frailty, and non-frailty was 10.59 times, 6.08 times, and 73.83 times higher in older individuals > 84 years old, respectively. The results of the present study indicated that the prevalence of pre-frailty compared with non-frailty, frailty compared with pre-frailty, and frailty compared with non-frailty was 2.86 times, 3.01 times, and 14.83 times higher in older adults women, respectively. The comparison between frail and non-frail groups represented that in DM older adults, the prevalence of frailty compared with non-frailty was 1.84 times higher and that of frailty compared with pre-frailty was 98% higher. The older adults with an FBS ≥ 126 mg/dl were 53% more likely to become frail, and with each unit increase in uric acid, the odds of becoming frail increased 2.05 times compared with non-frail older adults, and pre-frail compared with non-frail increased 99%.

CONCLUSION

The results demonstrated that CVD risk factors predictive of FS included central obesity, age > 84 years, female sex, DM, FBS ≥ 126, and uric acid > 7. This problem highlights the need for preventive strategies in the older adults who are simultaneously vulnerable to CVD and frailty.

Frailty and Cardiovascular Health

The incidence of frailty and cardiovascular disease (CVD) increases as the population ages. There is a bidirectional relationship between frailty and CVD, and both conditions share several risk factors and underlying biological mechanisms. Frailty has been established as an independent prognostic marker in patients with CVD. Moreover, its presence significantly influences both primary and secondary prevention strategies for adults with CVD while also posing a barrier to the inclusion of these patients in pivotal clinical trials and advanced cardiac interventions. This review discusses the current knowledge base on the relationship between frailty and CVD, how managing CVD risk factors can modify frailty, the influence of frailty on CVD management, and future directions for frailty detection and modification in patients with CVD.

Differential interplay between multimorbidity patterns and frailty and their mutual mediation effect on mortality in old age

BACKGROUND

Multimorbidity and frailty often concurrently occur among older adults.

OBJECTIVES

To assess the reciprocal association between multimorbidity (condition count and patterns) and frailty and examine the mutual mediation effect of multimorbidity and frailty in their associations with mortality among Chinese older adults.

METHODS

This nationwide population-based longitudinal study included 16,563 participants aged ≥65 years in the Chinese Longitudinal Healthy Longevity Survey who were surveyed in 2008 and followed up in 2011, 2014, and 2018. Frailty phenotype was assessed by the modified Fried criteria and vital status was ascertained from family members. Cross-lagged panel model (CLPM) was used to test bidirectional associations between multimorbidity and frailty. The direct and indirect effects of multimorbidity and frailty on mortality were evaluated using the combined CLPM with survival analysis.

RESULTS

Three multimorbidity patterns were identified: cardiometabolic diseases, cognitive-sensory disorder, and arthritis-digestive-respiratory diseases. The number of chronic conditions and cognitive-sensory disease pattern showed bidirectional associations with frailty across waves (range for β: 0.046-0.109; all P < 0.001), while cardiometabolic and arthritis-digestive-respiratory patterns unidirectionally predicted frailty change. Furthermore, frailty mediated 23%-27% of the association between multimorbidity and mortality. Only the number of conditions and cognitive-sensory disease pattern were significant mediators in the association between frailty and mortality, with the proportion of mediation ranging 4%-12%.

CONCLUSIONS

Multimorbidity measures including condition count and cognitive-sensory disease pattern are bi-directionally associated with frailty in older adults. These multimorbidity measures and frailty partially mediated each other's association with mortality, with frailty acting as a more prominent pathway in the association between multimorbidity and mortality.

Nutrition for the older adult - Current concepts. Report from an ESPEN symposium

BACKGROUND & AIMS

In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge.

METHODS

Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report.

RESULTS

Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia.

CONCLUSIONS

In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults.

Prevalence and Factors Associated With Frailty Among Community-Dwelling Middle-Aged and Older Adults in Malaysia

Frailty is identified in middle-aged and older adults, and frail individuals are vulnerable to dependency and poor health. In this study, we analyzed nationally representative data that includes 5592 participants aged 40 years and above to determine the prevalence and factors associated with frailty among community-dwelling middle-aged and older adults in Malaysia. Using a 40-item Frailty Index, the overall prevalence of frailty and prefrailty was 19.5% and 64.1%, respectively. A total of 38.6% of older adults (≥60 years) were frail and 56.2% were prefrail. Among middle-aged adults (<60 years), the prevalence of frailty was 10.4% and that of prefrailty was 67.9%. Factors associated with frailty include older age, ethnicity, low education and income level, moderate to poor self-rated health, abdominal obesity, absence of a spouse, and previous history of falls. These findings may serve as evidence for the implementation of a frailty policy and health care planning in Malaysia.

Preliminary evaluation of home-delivered meals for reducing frailty in older adults at risk for mal-nutrition

OBJECTIVE

To examine the potential benefit of home-delivered meals for reducing frailty levels among community-dwelling older adults at risk for malnutrition.

DESIGN

A retrospective, single-group observational approach.

SETTING

One large home-delivered meal agency in the Midwest United States.

PARTICIPANTS

1090 community-dwelling older adults who received home-delivered meal services, funded through the Older Americans Act, between June 2020 and December 2021.

MEASUREMENT

Frailty status was measured by the Home Care Frailty Scale (HCFS) which was routinely administered by agency staff to home-delivered meal clients as part of a quality improvement project. The HCFS was administered at the start of meal services, 3-months after meals began, and 6-months after meals began.

RESULTS

At baseline, 55.4% of clients were found to be at high risk for malnutrition. While there was a significant and consistent decline in HCFS throughout the follow-up period for both high and low nutritional risk groups, the reduction in frailty from baseline to 6-months was greater for the high nutritional risk group (Δ = -1.9; 95% CI: [-2.7, -1.1]; p < 0.001) compared to those with low nutritional risk (Δ = -1.5; 95% CI: [-2.3, -0.7]; p < 0.001). Compared to those who lived alone, clients who lived with other individuals presented with higher levels of frailty at baseline and 3-month follow-up for both low and high malnutrition risk groups.

CONCLUSION

Home-delivered meal clients are commonly at risk for both frailty and malnutrition. Home-delivered meal programs, which are intended to reduce malnutrition among older adults, may serve as a promising solution for reducing frailty in the vulnerable aging population.

Interplay of body mass index and metabolic syndrome: association with physiological age from midlife to late-life

Obesity and metabolic syndrome (MetS) share common pathophysiological characteristics with aging. To better understand their interplay, we examined how body mass index (BMI) and MetS jointly associate with physiological age, and if the associations changed from midlife to late-life. We used longitudinal data from 1,825 Swedish twins. Physiological age was measured as frailty index (FI) and functional aging index (FAI) and modeled independently in linear mixed-effects models adjusted for chronological age, sex, education, and smoking. We assessed curvilinear associations of BMI and chronological age with physiological age, and interactions between BMI, MetS, and chronological age. We found a significant three-way interaction between BMI, MetS, and chronological age on FI (p-interaction = 0·006), not FAI. Consequently, we stratified FI analyses by age: < 65, 65-85, and ≥ 85 years, and modeled FAI across ages. Except for FI at ages ≥ 85, BMI had U-shaped associations with FI and FAI, where BMI around 26-28 kg/m2 was associated with the lowest physiological age. MetS was associated with higher FI and FAI, except for FI at ages < 65, and modified the BMI-FI association at ages 65-85 (p-interaction = 0·02), whereby the association between higher BMI levels and FI was stronger in individuals with MetS. Age modified the MetS-FI association in ages ≥ 85, such that it was stronger at higher ages (p-interaction = 0·01). Low BMI, high BMI, and metabolic syndrome were associated with higher physiological age, contributing to overall health status among older individuals and potentially accelerating aging.

Structural determinants and cardiometabolic typologies related to frailty in community-dwelling older adults

Frailty is a geriatric syndrome linked to adverse outcomes. Co-occurring cardiometabolic factors increase frailty risk; however, their distinct combinations (typologies) associated with frailty are unclear. We aimed to identify subgroups of older adults with distinct cardiometabolic typologies and characterize their relationship with structural determinants and frailty to inform tailored approaches to prevent and delay frailty. This study was cross-sectional design and included 7984 community-dwelling older adults (65+ years) enrolled in the Health and Retirement Study (2006 and 2008). Latent class analysis was performed using seven cardiometabolic indicators (abdominal obesity, obesity, low high-density lipoprotein; and elevated blood pressure, blood sugar, total cholesterol, C-reactive protein). Frailty was indicated by ≥3 features (weakness, slowness, fatigue, low physical activity, unintentional weight loss). Logistic regression was used to examine the relationship between structural determinants (gender, race/ethnicity, and education), cardiometabolic typologies, and frailty. Three cardiometabolic subgroups were identified: insulin-resistant (n = 3547), hypertensive dyslipidemia (n = 1246), and hypertensive (n = 3191). Insulin-resistant subgroup members were more likely to be female, non-Hispanic Black, and college non-graduates; hypertensive dyslipidemia subgroup members were more likely to be non-Hispanic Others and report high school education; and hypertensive subgroup members were more likely to be male and college educated (p≤.05). Frailty risk was higher for females, Hispanic or Non-Hispanic Black older adults, and those with lower education (p≤.001). Frailty risk was greater in the insulin-resistant compared to the other subgroups (both aOR=2.0, both p<.001). Findings highlight a need to design tailored interventions targeting cardiometabolic typologies to prevent and delay frailty.

Association of changes in frailty status with the risk of all-cause mortality and cardiovascular death in older people: results from the Chinese Longitudinal Healthy Longevity Survey (CLHLS)

BACKGROUND

Few studies have investigated the association between changes in frailty status and all-cause mortality, inconsistent results were reported. What's more, studies that evaluated the effect of changes of frailty on cardiovascular death in older population are scanty. Therefore, the present study aims to investigate the association of such changes with the risk of all-cause mortality and cardiovascular death in older people, using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS).

METHODS

A total of 2805 older participants from two consecutive waves (i.e. 2011 and 2014) of the CLHLS were included for analysis. Based on the changes in frailty status from wave 2011 to wave 2014, participants were categorized into 4 subgroups, including sustained pre/frailty, robustness to pre/frailty, pre/frailty to robustness and sustained robustness. Study outcomes were all-cause mortality and cardiovascular death, and Cox regression analysis examined the association of changes in frailty status with outcomes.

RESULTS

From wave 2011 to wave 2014, 33.2% of the participants had frailty transitions. From wave 2014 to wave 2018, there were 952 all-cause mortalities and 170 cardiovascular deaths during a follow-up of 9530.1 person-years, and Kaplan-Meier analysis demonstrated that cumulative incidences of the two outcomes were significantly lower in more robust participants (all log-rank p < 0.001). Compared with the subgroup of sustained pre/frailty, the fully adjusted HRs of all-cause mortality were 0.61 (95% CI: 0.51-0.73, p < 0.001), 0.51 (95% CI: 0.42-0.63, p < 0.001) and 0.41 (0.34-0.49, p < 0.001) in the subgroup of robustness to pre/frailty, the subgroup of pre/frailty to robustness, and the subgroup of sustained robustness, respectively. The fully adjusted HRs of cardiovascular death were 0.79 (95% CI: 0.52-1.19, p = 0.256) in the subgroup of robustness to pre/frailty, 0.45 (95% CI: 0.26-0.76, p = 0.003) in the subgroup of pre/frailty to robustness and 0.51 (0.33-0.78, p = 0.002) in the subgroup of sustained robustness when comparing to the subgroup of sustained pre/frailty, respectively. Stratified analysis and extensive sensitivity analyses revealed similar results.

CONCLUSIONS

Frailty is a dynamic process, and improved frailty and remaining robust are significantly associated with lower risk of all-cause mortality and cardiovascular death in older people.

Metabolic dysfunction-associated steatotic liver disease in older adults is associated with frailty and social disadvantage

BACKGROUND & AIMS

The burden of metabolic dysfunction-associated steatotic liver disease (MASLD) is growing rapidly, as is the number of older adults globally. However, relatively few studies have been performed evaluating the prevalence and risk factors for MASLD in older adults. As such, we aimed to identify the prevalence of MASLD in older adults, as well as sociodemographic, clinical, functional and biochemical associations.

METHODS

The study population included older adults without a history of cardiovascular disease, dementia or independence-limiting functional impairment who had participated in the ASPirin in Reducing Events in the Elderly (ASPREE) randomised trial. MASLD was defined using the Fatty Liver Index (FLI). Associations were identified using Poisson regression with robust variance for FLI ≥ 60 vs FLI < 30.

RESULTS

9097 Australian participants aged ≥70 years had complete biochemical and anthropometric data to identify MASLD. The study population had a mean age of 75.1 ± 4.3 years and was 45.0% male. Almost one-third (33.0%) had prevalent MASLD, and the prevalence decreased with increasing age (adjusted RR [aRR] 0.96, 95% CI: 0.96-0.97). MASLD was also negatively associated with social advantage (aRR 0.94, 95% CI: 0.90-0.99) and exercise tolerance and was positively associated with diabetes mellitus (aRR: 1.22, 95% CI: 1.16-1.29), hypertension (aRR: 1.31, 95% CI: 1.22-1.41), male sex (aRR: 1.66, 95% CI: 1.57-1.74), pre-frailty (aRR: 1.99, 95% CI: 1.82-2.12) and frailty (aRR: 2.36, 95% CI: 2.16-2.56). MASLD and nonalcoholic fatty liver disease (NAFLD) results were 100% concordant.

CONCLUSION

This study in a large cohort of relatively healthy community-dwelling older adults shows that MASLD is common, decreases with age and is associated with poorer metabolic health, social disadvantage and frailty.

Vascular frailty, a proposal for new frailty type: A narrative review

Frailty is the incremental accumulation of minute defects that progressively impair health and performance. Frailty is commonly observed in older adults; however, secondary frailty may also occur in patients with metabolic disorders or major organ failure. In addition to physical frailty, several distinct types of frailty have been identified, including oral, cognitive, and social frailty, each of which is of practical importance. This nomenclature suggests that detailed descriptions of frailty can potentially advance relevant researches. In this narrative review, we first summarize the clinical value and plausible biological origin of frailty, as well as how to appropriately assess it using physical frailty phenotypes and frailty indexes. In the second part, we discuss the issue of vascular tissue as a relatively underappreciated organ whose pathologies contribute to the development of physical frailty. Moreover, when vascular tissue undergoes degeneration, it exhibits vulnerability to subtle injuries and manifests a unique phenotype amenable to clinical assessment prior to or accompanying physical frailty development. Finally, we propose that vascular frailty, based on an extensive set of experimental and clinical evidence, can be considered a new frailty type that requires our attention. We also outline potential methods for the operationalization of vascular frailty. Further studies are required to validate our claim and sharpen the spectrum of this degenerative phenotype.

Effect of a Low-Moderate Exercise Program on Dysmetabolism in Older Adults: Results of a Randomized Controlled Trial

Physical exercise has been shown to improve dysmetabolism in older adults, reducing cardiovascular risk, while its role in preventing dysmetabolism is less known. Moreover, most of the trials use exercise programs that are difficult to put into daily practice. The purpose of this Randomized Controlled Trial (RCT) was to evaluate the effectiveness of a 3-month moderate exercise program in improving or preventing dysmetabolism in 120 older adults, randomly selected for the exercise program (experimental group) or cultural activities (control group). None of the subjects were following a hypocaloric diet, and all of them reported healthy eating habits. Anthropometric (Body Mass Index (BMI) and Waist Circumference (WC)) and metabolic variables (fasting plasma glucose (FPG), High-Density Lipoprotein Cholesterol (HDL-C), and triglycerides (TG)) were assessed at baseline (T0) and at the end of the trial (T1). Dysmetabolism was defined by the presence of an increased WC plus at least two metabolic alterations. At T0, the two groups did not differ by sex, age, education, BMI, WC, FPG, HDL-C levels, and prevalence of dysmetabolism. The mean BMI value indicated overweight, and WC values were higher than the cut-off. At T1, a slight reduction in the number of people with dysmetabolism was found only in the experimental group. However, none of the individuals without dysmetabolism at T0 in the experimental group developed it at T1, while 11.4% developed it in the control group (p = 0.032). This study highlights that a moderate exercise program, accessible in daily practice, can prevent dysmetabolism in older adults, even while being overweight, while if dysmetabolism is already present, more prolonged combined nutritional and exercise interventions will be needed.