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Grohmann D, Wellsted D, Mengoni SE. Definition, assessment and management of frailty for people with intellectual disabilities: A scoping review. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13219. [PMID: 38485891 DOI: 10.1111/jar.13219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 01/30/2024] [Accepted: 02/17/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND People with intellectual disabilities may experience frailty earlier than the general population. This scoping review aimed to investigate how frailty is defined, assessed, and managed in adults with an intellectual disability; factors associated with frailty; and the potential impact of COVID-19 on frailty identification and management. METHOD Databases were searched from January 2016 to July 2023 for studies that investigated frailty in individuals with intellectual disabilities. RESULTS Twenty studies met the inclusion criteria. Frailty prevalence varied between 9% and 84%. Greater severity of intellectual disability, presence of Down syndrome, older age, polypharmacy, and group home living were associated with frailty. Multiagency working, trusted relationships and provision of evidence-based information may all be beneficial in frailty management. CONCLUSION Frailty is common for people with intellectual disabilities and is best identified with measures specifically designed for this population. Future research should evaluate interventions to manage frailty and improve lives.
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Affiliation(s)
- Dominique Grohmann
- Centre for Health Services and Clinical Research, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - David Wellsted
- Centre for Health Services and Clinical Research, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Silvana E Mengoni
- Centre for Health Services and Clinical Research, University of Hertfordshire, Hatfield, Hertfordshire, UK
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2
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Zhang S, Zhang K, Chen Y, Wu C. Prediction models of all-cause mortality among older adults in nursing home setting: A systematic review and meta-analysis. Health Sci Rep 2023; 6:e1309. [PMID: 37275670 PMCID: PMC10233853 DOI: 10.1002/hsr2.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 06/07/2023] Open
Abstract
Background and Aims Few studies have meta-analyzed different prognostic models developed for older adults, especially nursing home residents. We aimed to systematically review and meta-analyze the performance of all published models that predicted all-cause mortality among older nursing home residents. Methods We systematically searched PubMed and EMBASE from the databases' inception to January 1, 2020 to capture studies developing and/or validating a prognostic/prediction model for all-cause mortality among nursing home residents. We then carried out both qualitative and quantitative analyses evaluating these models' risks of bias and applicability. Results The systematic search yielded 23,975 articles. We identified 28 indices that predicted the risk of all-cause mortality from 14 days to 39 months among older adults in nursing homes. The most used predictors were age, sex, body weight, swallowing problem, congestive heart failure, shortness of breath, body mass index, and activities of daily living. Of the 28 indices, 8 (29%) and 3 (11%) were internally and externally validated, respectively. None of the indices was validated in more than one cohort. Of the 28 indices, 22 (79%) reported the C-statistic, while only 6 (6%) reported the 95% confidence interval for the C statistic in the development cohorts. In the validation cohorts, 11 (39%) reported the C-statistic and 8 (29%) reported the 95% confidence interval. The meta-analyzed C statistic for all indices is 0.733 (95% prediction interval: 0.669-0.797). All studies/indices had high risks of bias and high concern for applicability according to PROBAST. Conclusion We identified 28 indices for predicting all-cause mortality among older nursing home residents. The overall quality of evidence was low due to a high degree of bias and poor reporting of model performance statistics. Before any prediction model could be recommended in routine care, future research is needed to rigorously validate existing prediction models and evaluate their applicability and develop new prediction models.
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Affiliation(s)
- Shengruo Zhang
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Global Health Research CenterDuke Kunshan UniversityKunshanJiangsuChina
| | - Kehan Zhang
- Global Health Research CenterDuke Kunshan UniversityKunshanJiangsuChina
| | - Yan Chen
- Global Health Research CenterDuke Kunshan UniversityKunshanJiangsuChina
- School of Public HealthWuhan UniversityWuhanHubeiChina
| | - Chenkai Wu
- Global Health Research CenterDuke Kunshan UniversityKunshanJiangsuChina
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3
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Schoufour JD, Oppewal A, van Maurik MC, Hilgenkamp TIM, Elbers RG, Maes‐Festen DAM. Development and validation of a shortened and practical frailty index for people with intellectual disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2022; 66:240-249. [PMID: 34939710 PMCID: PMC9305773 DOI: 10.1111/jir.12907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 10/01/2021] [Accepted: 11/17/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND There is no widely used instrument to detect frailty in people with intellectual disabilities (IDs). We aimed to develop and validate a shorter and more practical version of a published frailty index for people with IDs. METHOD This study was part of the longitudinal 'Healthy Ageing and Intellectual Disability' study. We included 982 people with IDs aged 50 years and over. The previously developed and validated ID-Frailty Index consisting of 51 deficits was used as the basis for the shortened version, the ID-FI Short Form. Content of the ID-FI Short Form was based on statistics and clinical and practical feasibility. We evaluated the precision and validity of the ID-FI Short Form using the internal consistency, the correlation between the ID-FI Short Form and the original ID-Frailty Index, the agreement in dividing participants in the categories non-frail, pre-frail and frail, and the association with survival. RESULTS Seventeen deficits from the original ID-Frailty Index were selected for inclusion in the ID-FI Short Form. All deficits of the ID-FI Short Form are clinically and practically feasible to assess for caregivers and therapists supporting people with ID. We showed acceptable internal consistency with Cronbach's alpha of 0.75. The Pearson correlation between the ID-Frailty Index and the ID-FI Short Form was excellent (r = 0.94, P < 0.001). We observed a good agreement between the full and short forms in dividing the participants in the frailty categories, with a kappa statistic of 0.63. The ID-FI Short Form was associated with survival; with every 1/100 increase on the ID-FI Short Form, the mortality probability increased by 7% (hazard ratio 1.07, P < 0.001). CONCLUSION The first validation of the ID-FI Short Form shows it to be a promising, practical tool to assess the frailty status of people with ID.
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Affiliation(s)
- J. D. Schoufour
- Faculty of Sports and Nutrition, Faculty of Health, Center of Expertise Urban VitalityAmsterdam University of Applied SciencesAmsterdamThe Netherlands
| | - A. Oppewal
- Department of General Practice, Intellectual Disability MedicineErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - M. C. van Maurik
- Department of General Practice, Intellectual Disability MedicineErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - T. I. M. Hilgenkamp
- Department of General Practice, Intellectual Disability MedicineErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
- Department of Physical TherapyUniversity of Nevada, Las VegasLas VegasNVUSA
| | - R. G. Elbers
- Department of General Practice, Intellectual Disability MedicineErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - D. A. M. Maes‐Festen
- Department of General Practice, Intellectual Disability MedicineErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
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4
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de Leeuw MJ, Oppewal A, Elbers RG, Knulst MWEJ, van Maurik MC, van Bruggen MC, Hilgenkamp TIM, Bindels PJE, Maes-Festen DAM. Healthy Ageing and Intellectual Disability study: summary of findings and the protocol for the 10-year follow-up study. BMJ Open 2022; 12:e053499. [PMID: 35193910 PMCID: PMC8867312 DOI: 10.1136/bmjopen-2021-053499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The Healthy Ageing and Intellectual Disability (HA-ID) study is a prospective multicentre cohort study in the Netherlands that started in 2008, including 1050 older adults (aged ≥50) with intellectual disabilities (ID). The study is designed to learn more about the health and health risks of this group as they age. Compared with the amount of research in the general population, epidemiological research into the health of older adults with ID is still in its infancy. Longitudinal data about the health of this vulnerable and relatively unhealthy group are needed so that policy and care can be prioritised and for guiding clinical decision making about screening, prevention and treatment to improve healthy ageing. METHODS AND ANALYSIS This article presents a summary of the previous findings of the HA-ID study and describes the design of the 10-year follow-up in which a wide range of health data will be collected within five research themes: (1) cardiovascular disease; (2) physical activity, fitness and musculoskeletal disorders; (3) psychological problems and psychiatric disorders; (4) nutrition and nutritional state; and (5) frailty. ETHICS AND DISSEMINATION Ethical approval for the 10-year follow-up measurements of the HA-ID study has been obtained from the Medical Ethics Review Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2019-0562). TRIAL REGISTRATION NUMBER This cohort study is registered in the Dutch Trial Register (NTR number NL8564) and has been conducted according to the principles of the Declaration of Helsinki.
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Affiliation(s)
- Marleen J de Leeuw
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Alyt Oppewal
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Roy G Elbers
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Mireille W E J Knulst
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Marco C van Maurik
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Marjoleine C van Bruggen
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Thessa I M Hilgenkamp
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Patrick J E Bindels
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Dederieke A M Maes-Festen
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
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Lin SY, Tseng HC. Short-Term Changes of Frailty in Prematurely Aging Adults With Intellectual Disability. INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2022; 60:57-65. [PMID: 35104351 DOI: 10.1352/1934-9556-60.1.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/02/2021] [Indexed: 06/14/2023]
Abstract
The purpose of this study was to investigate short-term changes of frailty in adults and identify predictors of frailty and disability changes between baseline and the follow-up. A cohort study was conducted in 85 adults with intellectual disability (ID) in southern Taiwan. Variables of frailty phenotype, Barthel Index, fall, comorbidity, and hospitalization were measured at baseline and at a 9-month follow-up. Descriptive statistics, correlations, and generalized linear model technique were used for data analysis. The percentages of frailty and pre-frail conditions were high at baseline. Improvement or deterioration on frailty was noticed in 37.6% of participants. Disability and comorbidity were significant predictors to changes in frailty, and severity of ID and frailty conditions were significant predictors to changes in disability.
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Affiliation(s)
- Shu-Yuan Lin
- Shu-Yuan Lin and Hui-Chen Tseng, Kaohsiung Medical University, Taiwan
| | - Hui-Chen Tseng
- Shu-Yuan Lin and Hui-Chen Tseng, Kaohsiung Medical University, Taiwan
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6
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Kim YS, Kim JH, Kwon S, Ho S. Mortality rate and cause among people with intellectual disabilities in South Korea: A nationwide representative cross-sectional study from 2015 to 2019. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000744. [PMID: 36962442 PMCID: PMC10021350 DOI: 10.1371/journal.pgph.0000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/14/2022] [Indexed: 11/19/2022]
Abstract
People with intellectual disabilities (ID) age faster and have a higher prevalence of degenerative diseases. The aim of this study was to identify the patterns/ causes of death among people with ID. We conducted a nationwide, retrospective, cross-sectional study of people with ID in South Korea. The database was compiled by merging data of people registered with ID, based on the 2015-2019 Standards from the Ministry of Health and Welfare, with the cause of death data published by the Korea National Statistical Office. The International Classification of Diseases-10 (ICD-10) was used to categorize causes of death. The mortality and standardized mortality rates were calculated and major causes of death were analyzed. As of 2019, the mortality rate of people with ID in South Korea was 784.6. The rate showed an irregular pattern, increasing or decreasing year by year (increasing from 725 in 2015 to 834 in 2018). The mortality rate of people with ID was approximately 1.4 times higher than the general population; the standardized mortality rate was 3.2 times higher. The main causes of death (48%) in people with ID were, in order of prevalence, circulatory diseases (cerebrovascular disease), neoplasms (malignant neoplasms of the digestive system), and diseases of the respiratory system (pneumonia). The leading causes of death (>60%) in the general population were, in order of prevalence, neoplasms, diseases of the circulatory system, and respiratory system diseases. An accurate understanding of the causes of death of people with ID is important to promote the development and application of health promotion programs and management thereof.
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Affiliation(s)
- Ye-Soon Kim
- Department of Healthcare and Public Health Research, National Rehabilitation Center, Seoul, South Korea
| | - Joo-Hee Kim
- Department of Healthcare and Public Health Research, National Rehabilitation Center, Seoul, South Korea
| | - Sooyoung Kwon
- Department of Healthcare and Public Health Research, National Rehabilitation Center, Seoul, South Korea
| | - Seunghee Ho
- Department of Healthcare and Public Health Research, National Rehabilitation Center, Seoul, South Korea
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Dee B, Burke E, Romero-Ortuno R, McCallion P, McCarron M. Factors associated with the progression of deficit accumulation frailty among adults with an intellectual disability: a systematic review revealing research gaps. HRB Open Res 2021. [DOI: 10.12688/hrbopenres.13257.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: People with an intellectual disability are more likely to experience frailty earlier in life and with greater severity compared to the general population. There is growing consideration of determinants of frailty and identifying factors which may influence the change in frailty status over time. The objective of this review was to investigate factors associated with the progression of frailty over time among adults with an intellectual disability. Methods: A systematic review of literature was conducted using PRISMA guidelines to identify studies reporting factors associated with transitions and trajectories in deficit accumulation frailty among adults with an intellectual disability. The following eligibility criteria was used: defined frailty as deficit accumulation; longitudinal design; reported at least one individual characteristic associated with change in frailty status; sample was people with an intellectual disability aged ≥18 years; English language. No limitation on publication date was applied. Studies which did not measure frailty according to deficit accumulation, did not report the frailty measure used, or had a cross-sectional design were excluded. Selected studies were assessed for quality using the Critical Appraisal Skills Programme (CASP) framework. Results: In total, two studies qualified for inclusion in this review. Findings revealed that frailty defined as deficit accumulation is a dynamic process and improvements are possible. Changes in the direction of frailty states over time among adults with an intellectual disability may be influenced by several factors including baseline frailty status, age, the presence of Down syndrome, functional ability, cognitive ability, living in a group home, and the use of nursing services and therapies. Conclusions: There is a relative paucity of research on frailty among adults with an intellectual disability and the evidence base must be grown. Exploration of the social domain of frailty in this group should be a priority of future research. PROSPERO registration: 179803 (05/07/2020)
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8
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Lin SY. Effects of exercise interventions on frailty in pre-maturely aging adults with intellectual disabilities- a preliminary study. Disabil Health J 2021; 14:101105. [PMID: 33910765 DOI: 10.1016/j.dhjo.2021.101105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Effects of exercise interventions targeting frail adults with intellectual disabilities (ID) are unknown. OBJECTIVE This study compared the effects of a combined exercise, walking programs and no intervention on frailty and muscle mass in adults with ID and pre-frail or frail conditions. METHODS This study was a quasi-experimental design, with 103 adults from six residential care and day-care centers in southern Taiwan completing study participation. A 10-week combined exercise and walking program were administered to the experimental (n = 36) and comparison (n = 32) groups respectively, with no intervention provided to the control group (n = 35). A questionnaire, measurements of frailty phenotype and a body composition machine were used to collect data. Descriptive statistics, chi-squared test, ANOVA and repeated measure ANOVA tests were conducted in the Chinese IBM SPSS 20.0. RESULTS Significant differences on level of frailty among the three groups were revealed after interventions. Mean differences of muscle mass demonstrated significant changes between baseline and after interventions, although improvements of frailty score between baseline and after interventions were not significant. CONCLUSIONS Our preliminary findings demonstrated the tendency of positive effects of combined exercise or walking programs in improving level of frailty and muscle mass in adults with ID. Early implementation of exercise interventions might be beneficial for prematurely aging adults with ID.
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Affiliation(s)
- Shu-Yuan Lin
- College of Nursing, Kaohsiung Medical University, Research Associate in Department of Medical Research, Kaohsiung Medical University Hospital, #100 Shih-Chuan 1st Rd, Kaohsiung, 807, Taiwan.
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9
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Festen DAM, Schoufour JD, Hilgenkamp TIM, Oppewal A. Determining Frailty in People With Intellectual Disabilities in the COVID-19 Pandemic. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2021; 18:203-206. [PMID: 33821163 PMCID: PMC8014292 DOI: 10.1111/jppi.12371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/27/2020] [Accepted: 12/02/2020] [Indexed: 01/03/2023]
Abstract
Background Across the world, frailty is part of the guidelines that are being developed in the COVID-19 pandemic for triaging in crisis situations. The Clinical Frailty Scale (CFS) evaluates the ability to perform daily tasks to identify frail individuals, potentially excluding those from intensive care (IC) treatment. Individuals with intellectual disabilities (ID) experience varying degrees of dependence, distinct from age-related physical deterioration. Using the CFS for triage in crisis situations could potentially unjustifiably exclude individuals with ID from IC treatment. Our objective was to compare the classification of individuals with ID into different frailty categories based on the CFS and the well-studied ID-frailty index and to determine suitability of CFS for evaluation of frailty in individuals with ID during the COVID-19 pandemic. Methods This retrospective analysis of the observational healthy aging and intellectual disabilities (HA-ID) study included 982 individuals with ID of ≥50 years, who were classified according to the CFS and the ID-frailty index. Results Of the cohort of 982 older adults with ID, 626 (63.7%) would be classified as moderately frail (CFS score 6), but 92% of this group is not moderately frail according to the ID-frailty index. Furthermore, 199 (20.3%) would be classified as at least severely frail (CFS score 7-9), but 74.9% of this group is not severely frail according to the ID-frailty index. Overall, 730 out of 982 (74.9%) individuals would be incorrectly classified by the CFS as too frail to have a good probability of survival. The ID-frailty index predicts mortality better than the CFS in individuals with ID. Conclusions Our results show the CFS is not suitable to evaluate frailty in individuals with ID, with potential dramatic consequences for triage and decision-making during the COVID-19 pandemic. We strongly recommend using the ID-frailty index when assessing probability of survival for individuals with ID.
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Affiliation(s)
| | | | - Thessa I M Hilgenkamp
- Erasmus MC University Medical Center Rotterdam Rotterdam the Netherlands.,University of Nevada, Las Vegas Las Vegas NV USA
| | - Alyt Oppewal
- Erasmus MC University Medical Center Rotterdam Rotterdam the Netherlands
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Picca A, Calvani R, Coelho-Junior HJ, Landi F, Bernabei R, Marzetti E. Mitochondrial Dysfunction, Oxidative Stress, and Neuroinflammation: Intertwined Roads to Neurodegeneration. Antioxidants (Basel) 2020; 9:antiox9080647. [PMID: 32707949 PMCID: PMC7466131 DOI: 10.3390/antiox9080647] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/18/2022] Open
Abstract
Oxidative stress develops as a response to injury and reflects a breach in the cell’s antioxidant capacity. Therefore, the fine-tuning of reactive oxygen species (ROS) generation is crucial for preserving cell’s homeostasis. Mitochondria are a major source and an immediate target of ROS. Under different stimuli, including oxidative stress and impaired quality control, mitochondrial constituents (e.g., mitochondrial DNA, mtDNA) are displaced toward intra- or extracellular compartments. However, the mechanisms responsible for mtDNA unloading remain largely unclear. While shuttling freely within the cell, mtDNA can be delivered into the extracellular compartment via either extrusion of entire nucleoids or the generation and release of extracellular vesicles. Once discarded, mtDNA may act as a damage-associated molecular pattern (DAMP) and trigger an innate immune inflammatory response by binding to danger-signal receptors. Neuroinflammation is associated with a large array of neurological disorders for which mitochondrial DAMPs could represent a common thread supporting disease progression. The exploration of non-canonical pathways involved in mitochondrial quality control and neurodegeneration may unveil novel targets for the development of therapeutic agents. Here, we discuss these processes in the setting of two common neurodegenerative diseases (Alzheimer’s and Parkinson’s disease) and Down syndrome, the most frequent progeroid syndrome.
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Affiliation(s)
- Anna Picca
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (F.L.); (E.M.)
| | - Riccardo Calvani
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (F.L.); (E.M.)
- Correspondence: (R.C.); (R.B.); Tel.: +39-06-3015-5559 (R.C. & R.B.); Fax: +39-06-3051-911 (R.C. & R.B.)
| | | | - Francesco Landi
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (F.L.); (E.M.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Roberto Bernabei
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (F.L.); (E.M.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Correspondence: (R.C.); (R.B.); Tel.: +39-06-3015-5559 (R.C. & R.B.); Fax: +39-06-3051-911 (R.C. & R.B.)
| | - Emanuele Marzetti
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (A.P.); (F.L.); (E.M.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
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Carfì A, Romano A, Zaccaria G, Villani ER, Manes Gravina E, Vetrano DL, Bernabei R, Onder G. The burden of chronic disease, multimorbidity, and polypharmacy in adults with Down syndrome. Am J Med Genet A 2020; 182:1735-1743. [PMID: 32449279 DOI: 10.1002/ajmg.a.61636] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/02/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023]
Abstract
Data on clinical characteristics of adults with Down syndrome (DS) are limited and the clinical phenotype of these persons is poorly described. This study aimed to describe the occurrence of chronic diseases and pattern of medication use in a population of adults with DS. Participants were 421 community dwelling adults with DS, aged 18 years or older. Individuals were assessed through a standardized clinical protocol. Multimorbidity was defined as the occurrence of two or more chronic conditions and polypharmacy as the concomitant use of five or more medications. The mean age of study participants was 38.3 ± 12.8 years and 214 (51%) were women. Three hundred and seventy-four participants (88.8%) presented with multimorbidity. The most prevalent condition was visual impairment (72.9%), followed by thyroid disease (50.1%) and hearing impairment (26.8%). Chronic diseases were more prevalent among participants aged >40 years. The mean number of medications used was 2.09 and polypharmacy was observed in 10.5% of the study sample. Psychotropic medications were used by a mean of 0.7 individuals of the total sample. The high prevalence of multimorbidity and the common use of multiple medications contributes to a high level of clinical complexity, which appears to be similar to the degree of complexity of the older non-trisomic population. A comprehensive and holistic approach, commonly adopted in geriatric medicine, may provide the most appropriate care to persons with DS as they grow into adulthood.
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Affiliation(s)
- Angelo Carfì
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Allegra Romano
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Zaccaria
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Emanuele Rocco Villani
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ester Manes Gravina
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Davide Liborio Vetrano
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Roberto Bernabei
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Graziano Onder
- Centro Medicina dell'Invecchiamento, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy
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Oppewal A, Hilgenkamp TIM. Is fatness or fitness key for survival in older adults with intellectual disabilities? JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 33:1016-1025. [PMID: 32168552 PMCID: PMC7496297 DOI: 10.1111/jar.12724] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 01/29/2020] [Accepted: 02/23/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Overweight/obesity and poor physical fitness are two prevalent lifestyle-related problems in older adults with intellectual disabilities, which each require a different approach. To improve healthy ageing, we assessed whether fatness or fitness is more important for survival in older adults with intellectual disabilities. METHODS In the HA-ID study, we measured obesity and fitness of 874 older adults with intellectual disabilities (61.4 ± 7.8 years). All-cause mortality was assessed over a 5-year follow-up period. RESULTS Fitness, but not obesity, was significantly related to survival (HR range of 0.17-0.22). People who were unfit were 3.58 (95% CI = 1.72-7.46) to 4.59 (95% CI = 1.97-10.68) times more likely to die within the follow-up period than people who were fit, regardless of obesity. CONCLUSION This was the first study to show that being fit is more important for survival than fatness in older adults with intellectual disabilities. The emphasis should, therefore, shift from weight reduction to improving physical fitness.
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Affiliation(s)
- Alyt Oppewal
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thessa I M Hilgenkamp
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois
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13
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Age-related deficit accumulation and the diseases of ageing. Mech Ageing Dev 2019; 180:107-116. [DOI: 10.1016/j.mad.2019.04.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/10/2019] [Accepted: 04/15/2019] [Indexed: 12/25/2022]
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14
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Oppewal A, Hilgenkamp TIM. Physical fitness is predictive for 5-year survival in older adults with intellectual disabilities. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2019; 32:958-966. [PMID: 30950160 PMCID: PMC6850021 DOI: 10.1111/jar.12589] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 12/19/2018] [Accepted: 02/27/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The very low physical fitness levels of people with intellectual disabilities (ID) may influence their life expectancy. Therefore, we investigated the predictive value of physical fitness for survival in older adults with intellectual disabilities. METHOD In the Healthy Ageing and Intellectual Disabilities (HA-ID) study,the physical fitness levels of 900 older adults (≥50 years; 61.5 ± 8.1 years) were measured at baseline. All-cause mortality was collected over a 5-year follow-up period. Cox proportional hazard models were used to determine the association between each physical fitness test and survival, adjusted for age, sex, level of ID, and Down syndrome. RESULTS The physical fitness components that were independently predictive for survival were manual dexterity (HR = 0.96 [0.94-0.98]), visual reaction time (HR = 1.57 [1.28-1.94]), balance (HR = 0.97 [0.95-0.99]), comfortable gait speed (HR = 0.65 [0.54-0.78]), fast gait speed (HR = 0.81 [0.72-0.91]), grip strength (HR = 0.97 [0.94-0.99]) and cardiorespiratory fitness (HR = 0.997 [0.995-0.999]), with a better physical fitness showing a lower mortality risk. CONCLUSION We showed for the first time that physical fitness was independently associated with survival in older adults with intellectual disabilities. Improving and maintaining physical fitness must become an essential part of care and support for this population.
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Affiliation(s)
- Alyt Oppewal
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thessa I M Hilgenkamp
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois
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15
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Miot S, Akbaraly T, Michelon C, Couderc S, Crepiat S, Loubersac J, Picot MC, Pernon É, Gonnier V, Jeandel C, Blain H, Baghdadli A. Comorbidity Burden in Adults With Autism Spectrum Disorders and Intellectual Disabilities-A Report From the EFAAR (Frailty Assessment in Ageing Adults With Autism Spectrum and Intellectual Disabilities) Study. Front Psychiatry 2019; 10:617. [PMID: 31607957 PMCID: PMC6761800 DOI: 10.3389/fpsyt.2019.00617] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
Background: Autism spectrum disorder (ASD) is an early-onset and lifelong neurodevelopmental condition frequently associated with intellectual disability (ID). Although emerging studies suggest that ASD is associated with premature ageing and various medical comorbidities, as described for ID, data are scarce. Objectives: To determine the comorbidity burden and its association with distinct clinical presentation in terms of ASD severity, adaptive skills, level of autonomy, and drug exposure in a well-phenotyped sample of individuals with ASD-ID-the EFAAR (Frailty Assessment in Ageing Adults with Autism Spectrum and Intellectual Disabilities) cohort. Methods: A total of 63 adults with ASD-ID, with a mean age of 42.9 ± 15.1 years, were recruited from 2015 to 2017 from nine specialized institutions. They underwent detailed clinical examinations, including screening for comorbidities, ASD severity [Childhood Autism Rating Scale (CARS)], adaptive functioning [Vineland Adaptive Behavior Scale II (VABS-II)], autonomy [activities of daily living (ADLs)], and drug use [polypharmacy and the Drug Burden Index (DBI)]. The comorbidity burden was evaluated using the Cumulative Illness Rating Scale (CIRS-G) and its sub-scores [the severity index (CIRS-SI) and severe comorbidity (CIRS-SC)]. Results: We found a large range of comorbidities, including gastrointestinal disorders and mental and neurological diseases. Overall, 25% of our ASD-ID sample had chronic kidney disease with the associated increased cardiovascular risk factors. The comorbidity burden was high (mean CIRS-G total score of 10.6 ± 4.8), comparable with that observed among patients older than those in our population hospitalized in geriatric departments. Furthermore, the comorbidity burden positively correlated with age, decreased autonomy, and polypharmacy. Conclusion: The severity of the comorbidity burden associated with premature ageing in adults with ASD and ID highlight their crucial need of personalized medical care.
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Affiliation(s)
- Stéphanie Miot
- CESP, INSERM U1178, Centre de recherche en Epidemiologie et Santé des Populations, Paris, France.,Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France.,Gerontology Centre, Antonin Balmès, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Tasnime Akbaraly
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France.,MMDN, Univ. Montpellier, EPHE, INSERM, U1198, Montpellier, France.,Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Cecile Michelon
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Sylvie Couderc
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Sophie Crepiat
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Julie Loubersac
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Marie-Christine Picot
- Biostatistic Department, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Éric Pernon
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Véronique Gonnier
- Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Claude Jeandel
- Gerontology Centre, Antonin Balmès, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Hubert Blain
- Gerontology Centre, Antonin Balmès, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
| | - Amaria Baghdadli
- CESP, INSERM U1178, Centre de recherche en Epidemiologie et Santé des Populations, Paris, France.,Autism Resources Centre of Languedoc-Roussillon, University Hospital of Montpellier, CHRU de Montpellier, Univ. Montpellier, Montpellier, France
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16
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de Haas SCM, de Jonge EAL, Voortman T, Graaff JSD, Franco OH, Ikram MA, Rivadeneira F, Kiefte-de Jong JC, Schoufour JD. Dietary patterns and changes in frailty status: the Rotterdam study. Eur J Nutr 2018; 57:2365-2375. [PMID: 28744573 PMCID: PMC6182690 DOI: 10.1007/s00394-017-1509-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/11/2017] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine the associations between a priori and a posteriori derived dietary patterns and a general state of health, measured as the accumulation of deficits in a frailty index. METHODS Cross-sectional and longitudinal analysis embedded in the population-based Rotterdam Study (n = 2632) aged 45 years. Diet was assessed at baseline (year 2006) using food frequency questionnaires. Dietary patterns were defined a priori using an existing index reflecting adherence to national dietary guidelines and a posteriori using principal component analysis. A frailty index was composed of 38 health deficits and measured at baseline and follow-up (4 years later). Linear regression analyses were performed using adherence to each of the dietary patterns as exposure and the frailty index as outcome (all in Z-scores). RESULTS Adherence to the national dietary guidelines was associated with lower frailty at baseline (β -0.05, 95% CI -0.08, -0.02). Additionally, high adherence was associated with lower frailty scores over time (β -0.08, 95% CI -0.12, -0.04). The PCA revealed three dietary patterns that we named a "Traditional" pattern, high in legumes, eggs and savory snacks; a "Carnivore" pattern, high in meat and poultry; and a "Health Conscious" pattern, high in whole grain products, vegetables and fruit. In the cross-sectional analyses adherence to these patterns was not associated with frailty. However, adherence to the "Traditional" pattern was associated with less frailty over time (β -0.09, 95% CI -0.14, -0.05). CONCLUSION No associations were found for adherence to a "healthy" pattern or "Carnivore" pattern. However, Even in a population that is relatively young and healthy, adherence to dietary guidelines or adherence to the Traditional pattern could help to prevent, delay or reverse frailty levels.
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Affiliation(s)
- Sandra C M de Haas
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- VU University Amsterdam, Amsterdam, The Netherlands
| | - Ester A L de Jonge
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Trudy Voortman
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jolien Steenweg-de Graaff
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Oscar H Franco
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Fernando Rivadeneira
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Global Public Health, Leiden University College The Hague, P.O. Box 13228, 2501 EE, The Hague, The Netherlands
| | - Josje D Schoufour
- Department of Epidemiology, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Internal Medicine, University Medical Centre, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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17
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Schoufour JD, Oppewal A, van der Maarl HJK, Hermans H, Evenhuis HM, Hilgenkamp TIM, Festen DA. Multimorbidity and Polypharmacy Are Independently Associated With Mortality in Older People With Intellectual Disabilities: A 5-Year Follow-Up From the HA-ID Study. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2018; 123:72-82. [PMID: 29281324 DOI: 10.1352/1944-7558-123.1.72] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We studied the association between multimorbidity, polypharmacy, and mortality in 1,050 older adults (50+) with intellectual disability (ID). Multimorbidity (presence of ≥ 4 chronic health conditions) and polypharmacy (presence ≥ 5 chronic medication prescriptions) were collected at baseline. Multimorbidity included a wide range of disorders, including hearing impairment, thyroid dysfunction, autism, and cancer. Mortality data were collected during a 5-year follow-up period. Cox proportional hazards models were used to determine the independent association between multimorbidity and polypharmacy with survival. Models were adjusted for age, sex, level of ID, and the presence of Down syndrome. We observed that people classified as having multimorbidity or polypharmacy at baseline were 2.60 (95% CI = 1.86-3.66) and 2.32 (95% CI = 1.70-3.16) times more likely to decease during the follow-up period, respectively, independent of age, sex, level of ID, and the presence of Down syndrome. Although slightly attenuated, we found similar hazard ratios if the model for multimorbidity was adjusted for polypharmacy and vice versa. We showed for the first time that multimorbidity and polypharmacy are strong predictors for mortality in people with ID. Awareness and screening of these conditions is important to start existing treatments as soon as possible. Future research is required to develop interventions for older people with ID, aiming to reduce the incidence of polypharmacy and multimorbidity.
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Affiliation(s)
- Josje D Schoufour
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Alyt Oppewal
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Hanne J K van der Maarl
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Heidi Hermans
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Heleen M Evenhuis
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Thessa I M Hilgenkamp
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Dederieke A Festen
- Josje D. Schoufour, Alyt Oppewal, Hanne J.K. van der Maarl, Heidi Hermans, Heleen M. Evenhuis, Thessa I.M. Hilgenkamp, and Dederieke A. Festen, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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18
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McKenzie K, Ouellette-Kuntz H, Martin L. Applying a General Measure of Frailty to Assess the Aging Related Needs of Adults with Intellectual and Developmental Disabilities. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2017. [DOI: 10.1111/jppi.12197] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Katherine McKenzie
- Department of Public Health Sciences; Queen's University; Kingston, ON Canada
| | - Hélène Ouellette-Kuntz
- Department of Public Health Sciences; Queen's University; Kingston, ON Canada
- Department of Public Health Sciences; Queen's University; Kingston, ON Canada & Ongwanada
| | - Lynn Martin
- Department of Health Sciences; Lakehead University; Thunder Bay, Ontario Canada
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19
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Schoufour JD, Erler NS, Jaspers L, Kiefte-de Jong JC, Voortman T, Ziere G, Lindemans J, Klaver CC, Tiemeier H, Stricker B, Ikram AM, Laven JSE, Brusselle GGO, Rivadeneira F, Franco OH. Design of a frailty index among community living middle-aged and older people: The Rotterdam study. Maturitas 2016; 97:14-20. [PMID: 28159055 DOI: 10.1016/j.maturitas.2016.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/28/2016] [Accepted: 12/09/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To design a frailty index (FI) and evaluate three methods to handle missing data. Furthermore, we evaluated its construct (i.e., skewed distribution, correlation with age and sub-maximum score) and criterion validity (based on mortality risk). STUDY DESIGN We included 11,539 participants (45± years) from a population-based cohort in the Netherlands. Frailty was measured with a FI, which we constructed based on the accumulation of 45 health-related variables, related to mood, cognition, functional status, diseases and conditions, biomarkers, and nutritional status. A total FI-score was calculated by averaging the scores of the deficits, resulting in a score between 0 and 1, with higher scores indicating increasing frailty. Mean imputation, single- and multiple imputation were applied. MAIN OUTCOME MEASURE Mortality data were obtained by notification from the municipal administration. Median follow-up time was 9.5 years, during which 3902 (34%) participants died. RESULTS The median FI for the full population was 0.16 (IQR=0.11-0.23). The distribution of the FI was slightly right-skewed, the absolute maximum score was 0.78 and there was a strong correlation with age (Pearson correlation=0.52;95%CI=0.51-0.54). The adjusted HR per unit increase in FI-score on mortality was 1.05 (95%CI=1.05-1.06). Multiple imputation seemed to provide more robust results than mean imputation. CONCLUSION Based on our results we advise to the use of at least 30 deficits from different health domains to construct a FI if data are not imputed. Future research should use the continuous nature of the FI to monitor trajectories in frailty and find preventive strategies.
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Affiliation(s)
| | - Nicole S Erler
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands
| | - Loes Jaspers
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Leiden University College, The Hague,the Netherlands
| | - Trudy Voortman
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Gijsbertus Ziere
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Jan Lindemans
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Caroline C Klaver
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Ophthalmology, Erasmus MC, Rotterdam, the Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Bruno Stricker
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Arfan M Ikram
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Joop S E Laven
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, the Netherlands
| | - Guy G O Brusselle
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Respiratory Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Fernando Rivadeneira
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, 3000 CA Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
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20
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Oppewal A, Schoufour JD, Evenhuis HM, Festen DAM, Hilgenkamp TIM. [Older adults with intellectual disabilities markedly decline in daily functioning over a 3‑year period: Results of the HA-ID study]. Tijdschr Gerontol Geriatr 2016; 47:258-271. [PMID: 27848168 DOI: 10.1007/s12439-016-0198-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The responsibilities for the care of a significant portion of the population with an intellectual disability (ID) were recently transferred from the government to the municipalities. It is therefore important that policymakers and care professionals know how much support this population needs in their daily life. Therefore, this study focuses on the decline in daily functioning of older adults with ID (≥50 years, n = 703) over 3 years, and if daily functioning is a predictor for all-cause mortality. Daily functioning was operationalized as basic and instrumental activities of daily living (ADL and IADL) and mobility. Fifty-five percent of the total group declined in ADL, 42 % in IADL, and 38 % in mobility. Thirty-nine percent of the participants with mild ID declined in ADL, 55 % in IADL, and 27 % in mobility. Poor daily functioning and mobility was a risk factor for all-cause mortality. This epidemiological study shows a clear decline in the daily functioning of older adults with intellectual disabilities over a 3-year follow-up period. Care providers should be aware of this decline and focus on maintaining as much independence as possible.
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Affiliation(s)
- Alyt Oppewal
- Geneeskunde voor verstandelijk gehandicapten, Huisartsgeneeskunde, Erasmus MC, Universitair Medisch Centrum Rotterdam, Postbus 2040, 3000 CA, Rotterdam, Nederland.
| | - Josje D Schoufour
- Geneeskunde voor verstandelijk gehandicapten, Huisartsgeneeskunde, Erasmus MC, Universitair Medisch Centrum Rotterdam, Postbus 2040, 3000 CA, Rotterdam, Nederland
| | - Heleen M Evenhuis
- Geneeskunde voor verstandelijk gehandicapten, Huisartsgeneeskunde, Erasmus MC, Universitair Medisch Centrum Rotterdam, Postbus 2040, 3000 CA, Rotterdam, Nederland
| | - Dederieke A M Festen
- Geneeskunde voor verstandelijk gehandicapten, Huisartsgeneeskunde, Erasmus MC, Universitair Medisch Centrum Rotterdam, Postbus 2040, 3000 CA, Rotterdam, Nederland
- Ipse de Bruggen, Postbus 7027, 2701 AA, Zoetermeer, Nederland
| | - Thessa I M Hilgenkamp
- Geneeskunde voor verstandelijk gehandicapten, Huisartsgeneeskunde, Erasmus MC, Universitair Medisch Centrum Rotterdam, Postbus 2040, 3000 CA, Rotterdam, Nederland
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21
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Vrijmoeth C, Barten P, Assendelft WJJ, Christians MGM, Festen DAM, Tonino M, Vissers KCP, Groot M. Physicians' identification of the need for palliative care in people with intellectual disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 59:55-64. [PMID: 27501524 DOI: 10.1016/j.ridd.2016.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 07/13/2016] [Accepted: 07/15/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND A growing number of people with intellectual disabilities (ID) is suffering from life-threatening chronic illnesses and is therefore in need for palliative care. AIMS We aimed to explore how the need for palliative care is recognized in people with ID. METHODS AND PROCEDURES We conducted a semi-structured interview study among 10 ID-physicians in the Netherlands. OUTCOMES AND RESULTS Identification of people with ID in need for palliative care mostly results from a process in which multiple signals from different information sources converge and lead to a growing awareness. As a result, ID-physicians do not expect people to return to their prior level of health or functioning, but rather expect an irreversible decline leading to death. The presence, stage and prognosis of the disease, physician-patient interaction, and communication with proxies who provide contextual information are factors influencing the process. CONCLUSIONS AND IMPLICATIONS Distinctive for a population of people with ID are the frequent diagnostic uncertainty in people with ID, the patients' communicational abilities and the reliance of ID-physicians on close proxies. We argue for a proactive attitude of physicians regarding care and support of people with ID with palliative care needs.
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Affiliation(s)
- Cis Vrijmoeth
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboudumc Nijmegen, PO box 9101 (route 68), 6500 HB Nijmegen, The Netherlands; Intellectual Disability Medicine, Department of General Practice, Erasmus MC Rotterdam, PO Box 2040 (NA 1909), 3000 CA Rotterdam, The Netherlands.
| | - Pleun Barten
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboudumc Nijmegen, PO box 9101 (route 68), 6500 HB Nijmegen, The Netherlands.
| | - Willem J J Assendelft
- Department of Primary and Community Health Care, Radboudumc Nijmegen, PO box 9101 (route 117), 6500 HB Nijmegen, The Netherlands.
| | - Milou G M Christians
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboudumc Nijmegen, PO box 9101 (route 68), 6500 HB Nijmegen, The Netherlands.
| | - Dederieke A M Festen
- Intellectual Disability Medicine, Department of General Practice, Erasmus MC Rotterdam, PO Box 2040 (NA 1909), 3000 CA Rotterdam, The Netherlands.
| | - Marijke Tonino
- Prisma Foundation Biezenmortel, Hooghoutseweg 3, 5074 NA Biezenmortel, The Netherlands.
| | - Kris C P Vissers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboudumc Nijmegen, PO box 9101 (route 549), 6500 HB Nijmegen, The Netherlands.
| | - Marieke Groot
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboudumc Nijmegen, PO box 9101 (route 549), 6500 HB Nijmegen, The Netherlands.
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McKenzie K, Martin L, Ouellette-Kuntz H. Frailty and Intellectual and Developmental Disabilities: a Scoping Review. Can Geriatr J 2016; 19:103-112. [PMID: 27729949 PMCID: PMC5038926 DOI: 10.5770/cgj.19.225] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Individuals with intellectual and developmental disabilities (IDD) are both living longer than in previous generations and experiencing premature aging. Improved understanding of frailty in this aging population may inform community supports and avoid negative outcomes. Methods The objective of this study was to review the literature on frailty and IDD and determine areas for future research and application. The methodological framework for a scoping review as developed by H. Arksey and L. O’Malley was applied to identify and select original studies published since 2000. Results Seventeen studies were identified; these were based on the work of researchers from four research programs. The studies utilized six measures of frailty, including two frailty indices, the VFQ-ID(-R), the frailty phenotype, and the frailty marker. Frailty was equally studied as an outcome and as predictor for other outcomes (e.g., mobility, falls, care intensity, institutionalization, and survival). Conclusions There is evidence of a growing interest in the measurement of frailty in aging adults with IDD. As in the general population, frailty in this group is associated with many negative outcomes. While a few measures have emerged, more work is required to replicate results, validate tools, and test the feasibility of applying frailty measures in practice and to inform policy.
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Affiliation(s)
| | - Lynn Martin
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada
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Frailty Index Predicts All-Cause Mortality for Middle-Aged and Older Taiwanese: Implications for Active-Aging Programs. PLoS One 2016; 11:e0161456. [PMID: 27537684 PMCID: PMC4990295 DOI: 10.1371/journal.pone.0161456] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/05/2016] [Indexed: 01/15/2023] Open
Abstract
Background Frailty Index, defined as an individual’s accumulated proportion of listed health-related deficits, is a well-established metric used to assess the health status of old adults; however, it has not yet been developed in Taiwan, and its local related structure factors remain unclear. The objectives were to construct a Taiwan Frailty Index to predict mortality risk, and to explore the structure of its factors. Methods Analytic data on 1,284 participants aged 53 and older were excerpted from the Social Environment and Biomarkers of Aging Study (2006), in Taiwan. A consensus workgroup of geriatricians selected 159 items according to the standard procedure for creating a Frailty Index. Cox proportional hazard modeling was used to explore the association between the Taiwan Frailty Index and mortality. Exploratory factor analysis was used to identify structure factors and produce a shorter version–the Taiwan Frailty Index Short-Form. Results During an average follow-up of 4.3 ± 0.8 years, 140 (11%) subjects died. Compared to those in the lowest Taiwan Frailty Index tertile (< 0.18), those in the uppermost tertile (> 0.23) had significantly higher risk of death (Hazard ratio: 3.2; 95% CI 1.9–5.4). Thirty-five items of five structure factors identified by exploratory factor analysis, included: physical activities, life satisfaction and financial status, health status, cognitive function, and stresses. Area under the receiver operating characteristic curves (C-statistics) of the Taiwan Frailty Index and its Short-Form were 0.80 and 0.78, respectively, with no statistically significant difference between them. Conclusion Although both the Taiwan Frailty Index and Short-Form were associated with mortality, the Short-Form, which had similar accuracy in predicting mortality as the full Taiwan Frailty Index, would be more expedient in clinical practice and community settings to target frailty screening and intervention.
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de Winter CF, van den Berge APJ, Schoufour JD, Oppewal A, Evenhuis HM. A 3-year follow-up study on cardiovascular disease and mortality in older people with intellectual disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 53-54:115-126. [PMID: 26874209 DOI: 10.1016/j.ridd.2016.01.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/21/2016] [Accepted: 01/28/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND With increasing longevity and a similar or increased prevalence of cardiovascular disease risk factors (as compared to the general population), people with intellectual disabilities (IDs) are at risk of developing cardiovascular disease. However, prospective studies on incidence and influencing factors of cardiovascular disease and mortality are lacking. METHODS A three year follow-up study was undertaken to study the incidence and symptoms at presentation of myocardial accident, stroke and heart failure in older people with ID. Furthermore, the predictive value of cardiovascular disease risk factors on myocardial accident, stroke and heart failure and on all-cause mortality were studied. The baseline group consisted of the 1050 participants, aged 50 years and over, in the Dutch Healthy Ageing and Intellectual Disability (HA-ID) study. Baseline measurements were conducted between November 2008 and July 2010. Three years after baseline, medical files of 790 participants were studied. RESULTS Cardiovascular disease (myocardial infarction, stroke and heart failure) occurred in 5.9% of the population during 3 year follow-up, and 32% of them died due to the condition. Incidence of myocardial infarction is 2.8 per 1000 personyears, for stroke 3.2 per 1000 personyears and for heart failure 12.5 per 1000 personyears. Incidence of these conditions is probably underestimated, due to atypical symptom presentation. The use of atypical antipsychotics and a history of heart failure were predictive for myocardial infarction. Heart failure was predicted by abdominal obesity, chronic kidney disease and a history of heart failure. A total of cardiovascular disease (myocardial infarction, stroke or heart failure) was predicted by abdominal obesity, a history of stroke and a history of heart failure. A low body-mass index, peripheral arterial disease, chronic kidney disease and inflammation were predictive for 3-year all-cause mortality. CONCLUSION Incidence of cardiovascular disease in older people with ID is similar to that in the general population. A pro-active assessment and treatment of the presented cardiovascular disease risk factors may reduce cardiovascular disease and mortality in older people with ID.
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Affiliation(s)
- C F de Winter
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands; Reinaerde, Den Dolder, The Netherlands.
| | - A P J van den Berge
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands
| | - J D Schoufour
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands
| | - A Oppewal
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands
| | - H M Evenhuis
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands
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25
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Schoufour JD, Echteld MA, Boonstra A, Groothuismink ZMA, Evenhuis HM. Biochemical measures and frailty in people with intellectual disabilities. Age Ageing 2016; 45:142-8. [PMID: 26563885 DOI: 10.1093/ageing/afv152] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 09/23/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION People with intellectual disabilities (ID) are earlier frail than people in the general population. Although this may be explained by lifelong unfavourable social, psychological and clinical causes, underlying physiological pathways might be considered too. Biological measures can help identify pathophysiological pathways. Therefore, we examined the association between frailty and a range of serum markers on inflammation, anaemia, the metabolic system, micronutrients and renal functioning. METHODS Participants (n = 757) with borderline to severe ID (50+) were recruited from three Dutch ID care and support services. RESULTS Frailty was measured with a frailty index, a measure based on the accumulation of deficits. Linear regression analyses were performed to identify associations between frailty and biochemical measures independent of age, gender, level of ID and the presence of Down syndrome. Frailty appears associated with inflammation (IL-6 and CRP), anaemia, metabolic markers (glucose, cholesterol and albumin) and renal functioning (cystatin-C and creatinine). DISCUSSION These results are in line with results observed in the general population. Future research needs to investigate the causal relation between biochemical measures and frailty, with a special focus on inflammation and nutrition. Furthermore, the possibility to screen for frailty using biochemical measures needs to be used.
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Affiliation(s)
- Josje D Schoufour
- Department of General Practice, Intellectual Disabilities Medicine, Erasmus University Medical Center, P.O. box 2040, 3000 CA, Rotterdam, The Netherlands Department of Epidemiology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Michael A Echteld
- Department of General Practice, Intellectual Disabilities Medicine, Erasmus University Medical Center, P.O. box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andre Boonstra
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Zwier M A Groothuismink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Heleen M Evenhuis
- Department of Epidemiology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
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26
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[Frailty in people with intellectual disabilities: operationalization, risks and detection]. Tijdschr Gerontol Geriatr 2015; 46:92-103. [PMID: 25824155 DOI: 10.1007/s12439-015-0126-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although the population with intellectual disabilities (ID) is increasingly growing older, there seems to be an early onset of functional decline in this group, which could be explained by frailty. We used data from the Healthy Aging and Intellectual Disability study (HA-ID) to measure frailty in people with ID. Frailty was measured with an adapted version of the frailty index, consisting of 50 health and age related deficits. We were the first to measure frailty with a frailty index in this population, and therefore its validity, in terms of predictive value, needed to be established. In the current article we provide an overview of the design of the frailty index and its relation with adverse health outcomes. In a nearly representative study population of 982 50-plus older adults with ID, we studied the prevalence of frailty and its validity over a 3-year follow-up period. Results show that people with ID were earlier and more severely frail than people from the general population. Frailty was related to early mortality, to disabilities in daily functioning and mobility, to increased medication use, and increased care intensity, but not to hospitalization. Using a hypothetical model, we identify possible interventions to increase the healthy life years in people with ID.
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Schoufour JD, Evenhuis HM, Mitnitski A, Rockwood K, Echteld MA. The Benefits of a Frailty Index for People With Intellectual Disability: A Commentary. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2015. [DOI: 10.1111/jppi.12125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Schoufour JD, Echteld MA, Bastiaanse LP, Evenhuis HM. The use of a frailty index to predict adverse health outcomes (falls, fractures, hospitalization, medication use, comorbid conditions) in people with intellectual disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2015; 38:39-47. [PMID: 25576875 DOI: 10.1016/j.ridd.2014.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/01/2014] [Accepted: 12/03/2014] [Indexed: 05/17/2023]
Abstract
Frailty in older people can be seen as the increased likelihood of future negative health outcomes. Lifelong disabilities in people with intellectual disabilities (ID) may not only influence their frailty status but also the consequences. Here, we report the relation between frailty and adverse health outcomes in older people with ID (50 years and over). In a prospective population based study, frailty was measured at baseline with a frailty index in 982 older adults with ID (≥50 yr). Information on negative health outcomes (falls, fractures, hospitalization, increased medication use, and comorbid conditions) was collected at baseline and after a three-year follow-up period. Odds ratios or regression coefficients for negative health outcomes were estimated with the frailty index, adjusted for gender, age, level of ID, Down syndrome and baseline adverse health condition. The frailty index was related to an increased risk of higher medication use and several comorbid conditions, but not to falls, fractures and hospitalization. Frailty at baseline was related to negative health outcomes three years later in older people with ID, but to a lesser extent than found in the general population.
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Affiliation(s)
- Josje D Schoufour
- Intellectual Disability Medicine, Department of General Practice, Erasmus University Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Michael A Echteld
- Intellectual Disability Medicine, Department of General Practice, Erasmus University Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Luc P Bastiaanse
- Intellectual Disability Medicine, Department of General Practice, Erasmus University Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; Ipse de Bruggen, P.O. Box 2027, 2470 AA Zwammerdam, The Netherlands.
| | - Heleen M Evenhuis
- Intellectual Disability Medicine, Department of General Practice, Erasmus University Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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