Impact of Social Frailty in Hospitalized Elderly Patients With Heart Failure: A FRAGILE-HF Registry Subanalysis

Prognostic Value of Objective Social Isolation and Loneliness in Older Patients With Heart Failure: Subanalysis of FRAGILE-HF and Kitasato Cohort

BACKGROUND

Social factors encompass a broad spectrum of nonmedical factors, including objective (social isolation [SI]) and perceived (loneliness) conditions. Although social factors have attracted considerable research attention, information regarding their impact on patients with heart failure is scarce. We aimed to investigate the prognostic impact of objective SI and loneliness in older patients with heart failure.

METHODS AND RESULTS

This study was conducted using the FRAGILE-HF (Prevalence and Prognostic Value of Physical and Social Frailty in Geriatric Patients Hospitalized for Heart Failure; derivation cohort) and Kitasato cohorts (validation cohort), which included hospitalized patients with heart failure aged ≥65 years. Objective SI and loneliness were defined using the Japanese version of Lubben Social Network Scale-6 and diagnosed when the total score for objective and perceived questions on the Lubben Social Network Scale-6 was below the median in the FRAGILE-HF. The primary outcome was 1-year death. Overall, 1232 and 405 patients in the FRAGILE-HF and Kitasato cohorts, respectively, were analyzed. Objective SI and loneliness were observed in 57.8% and 51.4% of patients in the FRAGILE-HF and 55.4% and 46.2% of those in the Kitasato cohort, respectively. During the 1-year follow-up, 149 and 31 patients died in the FRAGILE-HF and Kitasato cohorts, respectively. Cox proportional hazard analysis revealed that objective SI, but not loneliness, was significantly associated with 1-year death after adjustment for conventional risk factors in the FRAGILE-HF. These findings were consistent with the validation cohort.

CONCLUSIONS

Objective SI assessed using the Lubben Social Network Scale-6 may be a prognostic indicator in older patients with heart failure. Given the lack of established SI assessment methods in this population, further research is required to refine such methods.

Prognostic impact of MitraScore in elderly Asian patients with heart failure: sub-analysis of FRAGILE-HF

AIMS

MitraScore is a novel, simple, and manually calculatable risk score developed as a prognostic model for patients undergoing transcatheter edge-to-edge repair (TEER) for mitral regurgitation. As its components are considered prognostic in heart failure (HF), we aimed to investigate the usefulness of the MitraScore in HF patients.

METHODS AND RESULTS

We calculated MitraScore for 1100 elderly patients (>65 years old) hospitalized for HF in the prospective multicentre FRAGILE-HF study and compared its prognostic ability with other simple risk scores. The primary endpoint was all-cause deaths, and the secondary endpoints were the composite of all-cause deaths and HF rehospitalization and cardiovascular deaths. Overall, the mean age of 1100 patients was 80 ± 8 years, and 58% were men. The mean MitraScore was 3.2 ± 1.4, with a median of 3 (interquartile range: 2-4). A total of 326 (29.6%), 571 (51.9%), and 203 (18.5%) patients were classified into low-, moderate-, and high-risk groups based on the MitraScore, respectively. During a follow-up of 2 years, 226 all-cause deaths, 478 composite endpoints, and 183 cardiovascular deaths were observed. MitraScore successfully stratified patients for all endpoints in the Kaplan-Meier analysis (P < 0.001 for all). In multivariate analyses, MitraScore was significantly associated with all endpoints after covariate adjustments [adjusted hazard ratio (HR) (95% confidence interval): 1.22 (1.10-1.36), P < 0.001 for all-cause deaths; adjusted HR 1.17 (1.09-1.26), P < 0.001 for combined endpoints; and adjusted HR 1.24 (1.10-1.39), P < 0.001 for cardiovascular deaths]. The Hosmer-Lemeshow plot showed good calibration for all endpoints. The net reclassification improvement (NRI) analyses revealed that the MitraScore performed significantly better than other manually calculatable risk scores of HF: the GWTG-HF risk score, the BIOSTAT compact model, the AHEAD score, the AHEAD-U score, and the HANBAH score for all-cause and cardiovascular deaths, with respective continuous NRIs of 0.20, 0.22, 0.39, 0.39, and 0.29 for all-cause mortality (all P-values < 0.01) and 0.20, 0.22, 0.42, 0.40, and 0.29 for cardiovascular mortality (all P-values < 0.02).

CONCLUSIONS

MitraScore developed for patients undergoing TEER also showed strong discriminative power in HF patients. MitraScore was superior to other manually calculable simple risk scores and might be a good choice for risk assessment in clinical practice for patients receiving TEER and those with HF.

Association and Prognostic Value of Multidomain Frailty Defined by Cumulative Deficit and Phenotype Models in Patients With Heart Failure

BACKGROUND

Frailty is associated with a poor prognosis in older patients with heart failure (HF). However, multidomain frailty assessment tools have not been established in patients with HF, and the association between the frailty phenotype and the deficit-accumulation frailty index in these patients is unclear. We aimed to understand this relationship and evaluate the prognostic value of the deficit-accumulation frailty index in older patients with HF.

METHODS

We retrospectively analyzed FRAGILE-HF cohort, which consisted of prospectively registered hospitalized patients with HF aged ≥ 65 years. The frailty index was calculated using 34 health-related items. The physical, social, and cognitive domains of frailty were evaluated using a phenotypic approach. The primary endpoint was all-cause mortality.

RESULTS

Among 1027 patients with HF (median age, 81 years; male, 58.1%; median frailty index, 0.44), a higher frailty index was associated with a higher prevalence in all domains of cognitive, physical, and social frailty defined by the phenotype model. During the 2-year follow-up period, a higher frailty index was independently associated with all-cause death even after adjustment for Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score plus log B-type natriuretic peptide (per 0.1 increase: hazard ratio, 1.21; 95% confidence interval, 1.07-1.37; P = 0.002). The addition of the frailty index to the baseline model yielded statistically significant incremental prognostic value (net reclassification improvement, 0.165; 95% confidence interval, 0.012-0.318; P = 0.034).

CONCLUSIONS

A higher frailty index was associated with a higher prevalence of all domains of frailty defined by the phenotype model and provided incremental prognostic information with pre-existing risk factors in older patients with HF.

Prognosis of acute heart failure in patients followed up in nursing homes in Spain: Results from the RICA registry

BACKGROUND

Patients with chronic diseases such as heart failure (HF) are at risk of hospital admission. We evaluated the impact of living in nursing homes (NH) on readmissions and all-cause mortality of HF patients during a one-year follow up.

METHODS

An observational and multicenter study from the Spanish National Registry of Heart Failure (RICA) was performed. We compared clinical and prognostic characteristics between both groups. Bivariate analyses were performed using Student's t-test and Tukey's method and a Kaplan-Meier survival at one-year follow up. A multivariate proportional hazards analysis of [Cox] regression by the conditional backward method was conducted for the variables being statistically significant related to the probability of death in the univariate.

RESULTS

There were 5644 patients included, 462 (8.2%) of whom were nursing home residents. There were 52.7% women and mean age was 79.7±8.8 years. NH residents had lower Barthel (74.07), Charlson (3.27), and Pfeiffer index (2.2), p<0.001). Mean pro-BNP was 6686pg/ml without statistical significance differences between groups. After 1-year follow-up, crude analysis showed no differences in readmissions 74.7% vs. 72.3%, p=0.292, or mortality 63.9% vs. 61.1%, p=0.239 between groups. However, after controlling for confounding variables, NH residents had a higher 1-year all-cause mortality (HR 1.153; 95% CI 1.011-1.317; p=0.034). Kaplan-Meier analysis showed worse survival in nursing home residents (log-rank of 7.12, p=0.008).

CONCLUSIONS

Nursing home residents with heart failure showed higher one-year mortality which could be due to worse functional status, higher comorbidity, and cognitive deterioration.

Social frailty as a predictor of all-cause mortality and functional disability: a systematic review and meta-analysis

The association between social frailty and adverse health outcomes, especially mortality and functional disability, which are essential health outcomes, has not been systematically summarized or meta-analyzed. In this study, we conducted a systematic review and meta-analysis of the impact of social frailty on all-cause mortality and functional disability, while addressing the components of social frailty. In this study, social frailty was operationally defined in alignment with the previous literature, as follows: "a state of increased vulnerability to the interactive back-and-forth of the community, including general resources, social resources, social behaviors, and needs." Hazard ratios or odds ratios described in each selected literature were used as the meta-analytic results. Considering the impact of social frailty on all-cause mortality, the hazard ratio was 1.96 (95% CI 1.20-3.19), indicating a significant association between the two but high heterogeneity. The hazard and odds ratios for the impact of social frailty on functional disability were 1.43 (95% CI 1.20-1.69) and 2.06 (95% CI 1.55-2.74), respectively. A significant association was found between social frailty and functional disability; both hazard and odds ratios were found, and low heterogeneity between these articles was observed. These results highlight the importance of assessing social frailty using more standardized methods and examining its effects on various health outcomes.

Prevalence, overlap, and prognostic impact of multiple frailty domains in older patients on hemodialysis

BACKGROUND

Frailty is a state of increased vulnerability owing to adverse health outcomes and is recognized as a multidimensional construct. There is limited evidence on the association between multiple domains of frailty and the risk of adverse events in patients undergoing hemodialysis. We aimed to report on the prevalence, degree of overlap, and prognostic impact of multiple frailty domains in older patients undergoing hemodialysis.

METHODS

We retrospectively enrolled outpatients (aged ≥60 years) undergoing hemodialysis at two dialysis centers in Japan. The physical domain of frailty was defined as slow gait speed and low handgrip strength. The psychological and social domains of frailty were defined using a questionnaire to assess depressive symptoms and define social frailty status. The outcomes were all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization. Cox proportional hazard and negative binomial models were used to examine these associations.

RESULTS

Among the 344 older patients (mean age, 72 years; male, 61%), 15.4% had an overlap in all three domains. Patients with a higher number of frailty domains had a higher risk of all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization (P for trend = 0.001, 0.001, and 0.08, respectively).

CONCLUSIONS

These results suggest that multiple-domain assessment of frailty is an important strategy to prevent adverse events in patients requiring hemodialysis.

Frailty and heart failure: State-of-the-art review

At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.

Prevalence and Impact of Social Frailty in Patients with Chronic Obstructive Pulmonary Disease

Background

Patients with chronic obstructive pulmonary disease (COPD) are more inclined to have a high level of social vulnerability due to their physical and psychological burden. However, to date, there have been no study on social frailty in patients with COPD. This study aimed to investigate the prevalence, characteristics, and impact of social frailty in patients with COPD.

Methods

Social frailty was assessed using five items in a questionnaire. A patient was diagnosed with social frailty if responses to two or more items were positive. Four hundred and five patients with COPD were assessed for social frailty, dyspnea, and appetite. We also prospectively examined the number of acute exacerbation and unexpected hospitalization for 1 year.

Results

Thirty-six percent of patients with COPD had social frailty. They had reduced appetite and more severe dyspnea [Simplified Nutritional Appetite Questionnaire score: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.69‒0.95, p < 0.01; modified Medical Research Council score: OR 1.42, 95% CI 1.05‒1.93, P = 0.02] than patients without social frailty. Social frailty was not a risk factor for moderate acute exacerbation of COPD but a risk factor for severe acute exacerbation and all-cause unexpected hospitalization (severe acute exacerbation: β, standardized regression coefficient: 0.13, 95% CI 0.01‒0.25, P = 0.04, unexpected hospitalization: β 0.17, 95% CI 0.05‒0.29, P = 0.01).

Conclusion

The prevalence of social frailty is 36%; however, social frailty has a marked clinical impact in patients with COPD.

The mediating effects of social support and depressive symptoms on activities of daily living and social frailty in older patients with chronic heart failure

OBJECTIVES

To investigate the level of social frailty (SF) in older patients with chronic heart failure (CHF) and examine the mediating role of social support and depressive symptoms between activities of daily living and SF.

METHODS

Using a convenience sampling method, 205 older patients with CHF were recruited from China between November 2021 and May 2022. Activities of daily living, social support, depressive symptoms, and SF were assessed using a self-administered questionnaire. Data were analyzed using structural equation modeling.

RESULTS

The final model obtained a good fit. Activities of daily living in older patients with CHF were directly related to SF. The multiple mediation analysis revealed that the relationship between activities of daily living and SF was mediated by social support (effect: -0.010, 95% CI [-0.021, -0.003]) and depressive symptoms (effect: -0.011, 95% CI [-0.019, -0.005) separately, and serially (effect: -0.007, 95% CI [-0.012, -0.003).

CONCLUSIONS

Social support and depressive symptoms are multiple mediating variables in the relationship between activities of daily living and SF. Activities of daily living can improve patients' SF through social support and depressive symptoms.

Prognostic effects of cardiac rehabilitation in heart failure patients classified according to physical frailty: A propensity score-matched analysis of a nationwide prospective cohort study

Background

Research regarding cardiac rehabilitation (CR) in the prognosis of heart failure (HF) patients and frailty remains lacking. Here, the effects of CR on the 2-year prognosis of HF patients were examined according to their frailty status.

Methods

This multicenter prospective cohort study enrolled patients hospitalized for HF. Patients who underwent ≥1 session per 2 weeks of CR within 3 months after discharge were categorized in the CR group. Patients were divided in a non-frailty (≤8 points) and physical frailty group (≥9 points) based on their FLAGSHIP frailty score. The score is based on HF prognosis, with a higher score indicating worsened physical frailty. A propensity score-matched analysis was performed to compare survival rates between the two groups according to their physical frailty status. Endpoints included HF re-hospitalization and all-cause mortality during a 2-year follow-up period.

Results

Of 2697 patients included in the analysis, 285 and 95 matched pairs were distributed in the non-frailty and physical frailty groups, respectively, after propensity-score matching. CR was associated with lower incidence of HF rehospitalization in both non-frailty (hazard ratio 0.65; 95% confidence interval 0.44-0.96; p = 0.032) and physical frailty (0.54; 0.32-0.90; p = 0.019) groups. CR was not associated with all-cause mortality in either group (log-rank test, p > 0.05).

Conclusion

These findings suggest the effects of CR on reduced HF rehospitalization, regardless of physical frailty status.

Analysis of the status of social frailty in Chinese older adults with cardiovascular and cerebrovascular diseases: a national cross-sectional study

Background

Social frailty is one type of frailty. Physical frailty with cardiovascular and cerebrovascular diseases (CCVD) have been studied a lot, but less research on social frailty.

Objectives

To study the prevalence, related risk factors and regional differences of social frailty with CCVD in Chinese older adults.

Methods

SSAPUR was a national cross-sectional survey. Participants aged 60 years or older were recruited in August 2015. Demographic data and information regarding family, health and medical conditions, living environment conditions, social participation, spiritual and cultural life, and health condition were obtained. Social frailty was assessed in five areas (HALFE Social Frailty Index) including inability to help others, limited social participation, loneliness, financial difficulty, and living alone. The prevalence of CCVD with social frailty, related risk factors and regional differences in CCVD with social frailty were studied.

Results

A total of 222,179 participants were enrolled. 28.4% of them had CCVD history. The prevalence of social frailty in the CCVD group was 16.03%. In CCVD participants, compared with the group without social frailty, there were significant differences in gender, age, urban-rural distribution, ethnicity, marital status, and education levels in the social frailty group. Significant differences were also found in physical exercise participation, health status, cataract, hypertension, diabetes mellitus, hospitalization within 1 year, self-assessed health status, crutch or wheelchair usage, urinary and fecal incontinence, need for care from others, fall history, housing satisfaction, and self-assessed happiness in the social frailty group. Women with CCVD had a higher prevalence of social frailty than men. By age in CCVD with social frailty, the highest prevalence was found in participants 75-79 years old. The prevalence of CCVD was significant difference between social frailty in urban and rural group. The prevalence of social frailty with CCVD was significantly different in different regions. The highest prevalence was 20.4% in southwest area, and the lowest prevalence was 12.5% in northeast with area.

Conclusion

The prevalence of social frailty among the CCVD older adults is high. Factors such as gender, age, region, urban-rural residence, and the state of the disease may be associated with social frailty.

Exploring the Frailty Components Related to Hospitalization-Associated Disability in Older Patients After Cardiac Surgery Using a Comprehensive Frailty Assessment

BACKGROUND

We investigated the components of frailty associated with hospitalization-associated disability (HAD) after cardiac surgery.Methods and Results: This retrospective, observational study evaluated 1,446 older patients after elective cardiac surgery at the Sakakibara Heart Institute. We examined the association between HAD and 7 domains of frailty assessed by the Kihon Checklist. HAD was defined as a decline in the ability to perform activities of daily living (ADL) between admission and discharge, as assessed by the Barthel Index. Logistic regression and decision tree analysis were used to identify associations between the number and type of frailty components and HAD. Of the 1,446 patients, 190 were excluded, and 90 (7%) developed HAD. An increase in the number of frailty components was a risk factor for HAD (odds ratio: 1.88, 95% confidence interval: 1.62-2.17). Decision tree analysis identified physical functional decline, depression, and cognitive dysfunction as factors associated with HAD. The incidence of HAD was highest in cases of physical functional decline (21%) and lowest for cases in which the 3 aforementioned factors were absent (2.8%).

CONCLUSIONS

An increased number of frailty factors increased the risk of HAD and the findings also reaffirmed the importance of a comprehensive assessment to evaluate the risk of HAD, including evaluation of physical function, cognitive function, and depression.

Frailty and caregiver relationship quality in older patients diagnosed with transthyretin cardiac amyloidosis

Aim of the study was to explore frailty and quality of the relationship with the caregiver in a cohort of older patients with transthyretin cardiac amyloidosis (ATTR-CA). Sixty-eight consecutive ATTR-CA patients were recruited and assessed for frailty, depressive symptoms, quality of the relationship in terms of social support, or conflict toward caregivers, New York Heart Association Class (NYHA), and National Amyloid Center score (NAC Score) for grading disease severity. Results showed that 10% of patients were frail. Depressive symptoms were present in 46% of patients. Regression analyses showed that both mFI and depression were associated with worse perception of social support, and that mFI and NAC score were associated with higher levels of conflict perceived in the caregivers' relationship. Overall, the mFI score was associated with worse perceived social support and caregiver relationship quality. Tertiary care heart failure clinics should actively support the patient-caregiver relationship to improve quality of life.

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

BACKGROUND

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

MATERIALS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences in clinical outcomes between octogenarian and nonagenarian patients with acute heart failure

AIM

The number of hospitalized super-elderly patients with heart failure (HF) has increased with aging of the population. These patients are associated with poor clinical outcomes with the advance of age; however, few reports regarding acute HF have compared the clinical outcomes of nonagenarians with those of octogenarians.

METHODS

This study enrolled 683 patients aged ≥80 years who were admitted to our institution for acute HF between 2016 and 2020. The outcomes of interest were the 1-year all-cause mortality, incidence of cardiac events (cardiac-related death or HF-related readmission), and physical function during hospitalization of patients with survival-to-discharge. Physical function was evaluated using the Barthel index.

RESULTS

Post-discharge all-cause mortality, particularly non-cardiac mortality, was significantly higher in nonagenarians than octogenarians. Conversely, the incidence of cardiac death or rehospitalization for HF after discharge was comparable between the two groups. On admission, the Barthel index score was significantly lower in nonagenarians than octogenarians, and further decreased during hospitalization. Nonagenarians required social support at discharge more often than octogenarians (67.4% vs. 44.4%; P < 0.001).

CONCLUSIONS

The current study demonstrated that nonagenarians have poorer non-cardiac outcomes and were more vulnerable regarding physical activities than octogenarians among patients with acute HF. Holistic medical care, including palliative care and social support, will be increasingly required with increasing age. Geriatr Gerontol Int 2023; 23: 227-233.

The Prevalence of Social Frailty Among Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

To report the overall prevalence of social frailty among older people and provide information for policymakers and authorities to use in developing policies and social care.

DESIGN

A systematic review and meta-analysis.

SETTING AND PARTICIPANTS

We searched 4 databases (PubMed, Embase, Web of Science, and Google Scholar) to find articles from inception to July 30, 2022. We included cross-sectional and cohort studies that provided the prevalence of social frailty among adults aged 60 years or older, in any setting.

METHODS

Three researchers independently reviewed the literature and retrieved the data. A risk of bias tool was used to assess each study's quality. A random-effect meta-analysis was performed to pool the data, followed by subgroup analysis, sensitivity analysis, and meta-regression.

RESULTS

From 761 records, we extracted 43 studies with 83,907 participants for meta-analysis. The pooled prevalence of social frailty in hospital settings was 47.3% (95% CI: 32.2%-62.4%); among studies in community settings, the pooled prevalence was 18.8% (95% CI: 14.9%-22.7%; P < .001). The prevalence of social frailty was higher when assessed using the Tilburg Frailty Indicator (32.3%; 95% CI: 23.1%-41.5%) than the Makizako Social Frailty Index (27.7%; 95% CI: 21.6%-33.8%) or Social Frailty Screening Index (13.4%; 95% CI: 8.4%-18.4%). Based on limited community studies in individual countries using various instruments, social frailty was lowest in China (4.9%; 95% CI: 4.2%-5.7%), followed by Spain (11.6%; 95% CI: 9.9%-13.3%), Japan (16.2%; 95% CI: 12.2%-20.3%), Korea (26.6%; 95% CI: 7.1%-46.1%), European urban centers (29.2%; 95% CI: 27.9%-30.5%), and the Netherlands (27.2%; 95% CI: 16.9%-37.5%). No other subgroup analyses showed any statistically significant prevalence difference between groups.

CONCLUSION AND IMPLICATIONS

The prevalence of social frailty among older adults is high. Settings, country, and method for assessing social frailty affected the prevalence. More valid comparisons will await consensus on measurement tools and more research on geographically representative populations. Nevertheless, these results suggest that public health professionals and policymakers should seriously consider social frailty in research and program planning involving older adults.

The prevalence of social frailty among older adults: A systematic review and meta-analysis

Social frailty is a geriatric public health problem that deeply affects healthy aging. Currently, evidence on the prevalence and factors associated with social frailty in older adults remains unclear. Our study aims to estimate the prevalence and related factors of social frailty in older adults. This study retrieved nine electronic databases searched through July 5th, 2022. The prevalence of social frailty was pooled using Stata software. It was found that older adults suffered from a "moderate" level of social frailty. We found a higher prevalence of social frailty in the United Kingdom, Greece, Croatia, The Netherlands, and Spain, in people over 75 years, in hospitals, and during the Coronavirus Disease 2019 (COVID-19). We believed that countries, age, research sites, and the pandemic of COVID-19 were influencing factors of social frailty among older adults. These findings may provide a theoretical basis for the development of ameliorating social frailty among older adults.

Loss of perceived social role, an index of social frailty, is an independent predictor of future adverse events in hospitalized patients with heart failure

Aims

Although the impact of physical frailty on prognosis and the effect of cardiac rehabilitation in HF patients has been well established, data for the prognostic impact of social frailty (SF) in HF patients are limited. In addition, the relative importance of each SF domain in clinical outcomes remains unclear. We aimed to get a new insight into the associations of SF with clinical outcomes in elderly hospitalized HF patients.

Methods

A single-center, retrospective cohort study was conducted using data from 310 in-hospital HF patients aged ≥ 65 years (mean age of 78 ± 8 years; 49% women). Makizako's five questions, a self-reported questionnaire, were used to define SF. The primary outcome was composite events defined by all-cause death and cardiovascular events.

Results

Of the 310 elderly HF patients, 188 patients (61%) had SF. Seventy-five patients (24%) had composite events during a mean follow-up period of 1.93 ± 0.91 years. Kaplan-Meier curves showed that patients with SF had a significantly higher composite event rate than patients without SF. In multivariate Cox regression analyses, SF was independently associated with a higher composite event rate after adjusting for prognostic markers [adjusted hazard ratio (HR), 2.01; 95% confidence interval (CI), 1.07-3.78; p = 0.04]. Of the 5 questions for defining SF, an answer of yes to the question about not feeling helpful toward friends or family, which indicates loss of perceived social role, was an independent predictor of composite events (adjusted HR, 2.28; 95% CI, 1.36-3.82; p < 0.01). Inclusion of loss of perceived social role into the baseline prognostic model improved both the continuous net reclassification improvement (0.562; 95% CI, 0.298-0.827; p < 0.01) and integrated discrimination improvement (0.031; 95% CI, 0.006-0.056; p = 0.02).

Conclusion

Loss of perceived social role is associated with increased adverse event risk and provides additive prognostic information in elderly HF patients.

Relationship between the spread of COVID-19, social frailty, and depressive symptoms in patients with heart failure

In community-dwelling older people, coronavirus disease 2019 (COVID-19) has been reported to be associated with the development of frailty and depressive symptoms. We aimed to investigate whether the spread of COVID-19 is associated with the development of frailty in patients with heart failure (HF). The presence of the multi-domain of frailty in 257 patients with HF was assessed at hospital discharge. The spread of COVID-19 was significantly associated with the development of social frailty and depressive symptoms. Evaluation of these symptoms during hospitalization would support disease management and understanding of their social and psychological conditions.

Social Frailty and Meaningful Activities among Community-Dwelling Older Adults with Heart Disease

Patients with heart disease are more likely to experience social frailty due to physical inactivity, which may affect meaningful activities such as hobbies. This study aimed to investigate (1) the association between heart disease and social frailty in community-dwelling older adults and (2) the characteristics of meaningful activities in community-dwelling older adults with heart disease. Data from 630 older adults who participated in a community-based health survey were obtained, including clinical history, meaningful activities, social frailty and psychosomatic functions. Participants were divided into two groups: those with heart disease (n = 79) and those without (n = 551), and comparisons were made. Social frailty was observed in 23.7% of participants with heart disease, and logistic regression revealed significant associations with heart disease and social frailty after adjusting for potential covariates (OR, 1.97; 95% CI, 1.06 3.67; p = 0.032). Participants with heart disease did not differ significantly in terms of satisfaction or performance; their frequency of engagement in meaningful activities was significantly lower than without heart disease (p = 0.041). These results suggest that heart disease and social frailty are associated in community-dwelling older adults, and that this demographic is inclined to engage in meaningful activities less frequently.

Clinical Perspectives on Cardiac Rehabilitation After Heart Failure in Elderly Patients with Frailty: A Narrative Review

The purpose of this narrative review is to examine rehabilitation modalities for patients with heart failure and Frailty who require comprehensive intervention. Ischemic heart disease is the leading cause of death worldwide, accounting for 16% of global mortality. Due to population growing and aging, the total number of heart failure patients continues to rise, a condition known as the heart failure pandemic. Furthermore, frailty has been associated with an increased risk for heart failure and increased morbidity and mortality. The 2021 update of the 2017 ACC expert consensus decision pathway for optimization of HF treatment has become more concerning, citing frailty as one of the 10 most important issues associated with heart failure with reduced ejection fraction (HFrEF). Frailty and heart failure share common pathological mechanisms and are associated with poor clinical outcomes. Most studies of frailty in patients with heart failure primarily focus on physical frailty, and associations between psycho-psychological and social factors such as cognitive dysfunction and social isolation have also been reported. These results suggest that a more comprehensive assessment of frailty is important to determine the risk in patients with heart failure. Therefore, mechanisms of the three domains, including not only physical frailty but also cognitive, psychological, spiritual, and social aspects, should be understood. In addition to interventions in these three domains, nutritional and pharmacological interventions are also important and require tailor-made interventions for the widely varied conditions associated with heart failure and frailty. Although several studies have shown a relationship between frailty and prognosis in patients with heart failure, interventions to improve the prognosis have not yet been established. Further information is needed on frailty intervention by a multidisciplinary team to improve the prognosis.

Social Isolation and Implementation of Advanced Care Planning Among Hospitalized Patients With Heart Failure

Background

The implementation of advance care planning (ACP) in heart failure management is insufficient. Social isolation (SI) could be a barrier to ACP initiation, albeit the relationship between SI and patients' preference for ACP or end‐of‐life care remains unknown.

Methods and Results

We conducted a questionnaire survey, including assessments of SI using the 6‐item Lubben Social Network Scale as well as patients' perspectives on ACP and end‐of‐life care. Of the 160 patients approached by our multidisciplinary heart failure team during admission, 120 patients (75.0%) completed the survey (median age, 73.0 years; men, 74.2%). A Cox proportional hazard model was constructed to elucidate the short‐term (180‐day) prognostic impact of SI. Overall, 28.3% of participants were at high risk for SI (6‐item Lubben Social Network Scale score <12). High‐risk patients had more negative attitudes toward ACP than those without (61.8% versus 80.2%; P =0.035). The actual performance of ACP conversation in patients with and without high risk were 20.6% and 30.2%, respectively. Regarding preference in end‐of‐life care, “Saying what one wants to tell loved ones” (73.5% versus 90.6%; P =0.016) and “Spending enough time with family” (58.8% versus 77.9%; P =0.035) were less important in high‐risk patients. High risk for SI was associated with higher 180‐day risk‐adjusted all‐cause mortality (hazard ratio, 7.89 [95% CI, 1.53–40.75]).

Conclusions

In hospitalized patients with heart failure, high risk for SI was frequently observed. High‐risk patients were associated with a negative attitude toward ACP, despite higher mortality. Further research is required to establish an ideal approach to provide ACP in socially vulnerable patients.

Association among mild cognitive impairment, social frailty, and clinical events in elderly patients with cardiovascular disease

BACKGROUND

Social support is considered a key factor for secondary prevention in patients with cardiovascular disease (CVD) and mild cognitive impairment (MCI). Recent studies have suggested the clinical importance of social frailty in CVD.

OBJECTIVE

This study aimed to examine the association among coexistent MCI, social frailty, and clinical events in patients with CVD.

METHODS

This study included 184 hospitalized elderly patients with CVD who participated in inpatient cardiac rehabilitation (median age, 75 years; male, 66.3%). MCI was defined as a Montreal Cognitive Assessment score of ≤25 points at discharge. Social frailty was defined using the Makizako criteria. Lack of caregiver support was also assessed as an indicator of poor social support. The Kaplan-Meier survival curve analysis and Cox regression analysis were conducted to evaluate the combined impact of MCI and social frailty or the lack of caregiver support on the composite endpoint of all-cause mortality or unplanned rehospitalization.

RESULTS

The prevalence of MCI, social frailty, and lack of caregiver support were 65.2%, 70.7%, and 19.0%, respectively. There was a significant difference among subgroups by MCI and a lack of caregiver support (log-rank test, p = 0.018), and the MCI/non-caregiver group showed the worst prognosis (adjusted hazard ratio 3.96; 95% confidence interval 1.57-9.98). Likewise, MCI/social frailty group showed a significantly high event risk (3.94; 1.20-12.9) among the subgroups by MCI and social frailty.

CONCLUSION

Our results highlight the clinical importance of assessing the presence of caregiver support along with conventional social frailty for patients with CVD and MCI.

Social frailty increases the risk of all-cause mortality: A longitudinal analysis of the English Longitudinal Study of Ageing

OBJECTIVES

Social frailty is a common condition in older people, but its consequences are largely unknown. Therefore, in this longitudinal analysis, we aimed to investigate the association between social frailty and risk of all-cause mortality in a large sample of older people.

DESIGN

Longitudinal, cohort.

SETTINGS AND PARTICIPANTS

Older people participating to the English Longitudinal Study of Ageing (ELSA).

METHODS

Social frailty was defined based on financial difficulty, household status, social activity, and contacts with other people: social frailty was defined as ≥2 points, social pre-frailty (1 point), and robustness (0 points). Survival status during ten years of follow-up was assessed using administrative data. Cox proportional hazard models were used to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (95 % CI) of the association between social frailty status and all-cause mortality.

RESULTS

At baseline, compared to social robust participants, social frail subjects reported a significant higher presence of potential risk factors for all-cause mortality. During the ten years of follow-up, after adjusting for 10 potential confounders, social frailty at baseline (vs. robustness) was associated with a significantly higher risk of death (HR = 1.31; 95 % CI: 1.04-1.64; p = 0.02), whilst social pre-frail was not. Among the single factors contributing to social frailty, poverty increased the risk of all-cause mortality by approximately 60 % (HR = 1.60; 95 % CI: 1.33-1.93; p < 0.0001) as well as living alone (HR = 1.46; 95 % CI: 1.10-1.94; p = 0.009).

CONCLUSIONS AND IMPLICATIONS

Social frailty was significantly associated with all-cause mortality in a large cohort of older people, highlighting the importance of identifying this phenomenon in older adults to inform targeted intervention efforts.