A frailty index to predict the mortality risk in a population of senior Mexican adults

Comparing four frailty assessment tools against seven-year mortality in the Malaysian elders longitudinal research study

AIM

Several frailty assessment tools are currently used in clinics and research, however, there appears to be a lack of head-to-head comparisons between these tools among older adults in developing countries. This study compared the Cardiovascular Health Study, Study of Osteoporotic Fractures, the Tilburg Frailty Indicator and the Canadian Study of Health and Aging frailty assessment tools and evaluated performance of these individual frailty assessment tools with mortality.

METHODS

This prospective cohort study utilized stratified simple random sampling to recruit 1614 participants from the Malaysian Elders Longitudinal Research aged above 55 years within the Klang Valley region from 2013 to 2015. Individual items for the frailty tools, alongside baseline physical and cognitive measures were extracted from the initial survey. Mortality data up to 31 December 2020 were obtained through data linkage from the death registry data obtained from the Malaysian National Registration Department.

RESULTS

Data were available for over 1609 participants, age (68.92 ± 7.52) years and 57 % women, during recruitment. Mortality data revealed 13.4 % had died as of 31 December 2020. Five to 25 % of our study population fulfilled the criteria for frailty using all four frailty tools. This study found an increased risk of mortality with frailty following adjustments for potential factors of falls, total number of illnesses and cognitive impairment, alongside moderate to strong correlation and agreement between frailty tools.

CONCLUSION

Frailty was associated with increased mortality. All four frailty assessment tools can be used to assess frailty within the Malaysian older adult population. The four available tools, however, may not be interchangeable.

Sex differences in the frailty phenotype and mortality in the I-Lan longitudinal aging study cohort

BACKGROUND

Frailty is a common geriatric syndrome related to multiple adverse outcomes. Sex differences in its prevalence and impact on mortality remain incompletely understood.

METHODS

This study was conducted with data from the I-Lan Longitudinal Aging Study, in which community-dwelling subjects aged > 50 years without coronary artery disease or diabetes were enrolled. Sex disparities in phenotypically defined frailty and sex-morality predictor interactions were evaluated. Sex- and frailty-stratified analyses of mortality were performed.

RESULTS

The sample comprised 1371 subjects (51.4% women, median age 61 years). The median follow-up period was 6.3 (interquartile range, 5.8-7.0) years. The frailty prevalence did not differ between men (5.3%) and women (5.8%). Frail individuals were older and less educated and had poorer renal function than did non-frail individuals. Body composition trends differed between sexes, regardless of frailty. Relative to non-frail men, frail men had significantly lower body mass indices (BMIs; 24.5 vs. 23.4 kg/m2, p = 0.04) and relative appendicular skeletal muscle masses (7.87 vs. 7.05 kg/m2, p < 0.001). Frail women had significantly higher BMIs (25.2 vs. 23.9 kg/m2, p = 0.02) and waist circumferences (88 vs. 80 cm, p < 0.001) than did non-frail women. Frailty was an independent mortality predictor for men only [hazard ratio (95% confidence interval) = 3.395 (1.809-6.371), psex-frailty interaction = 0.03].

CONCLUSION

Frailty reflected poorer health in men than in women in the present cohort. This study revealed sex disparities in the impact of frailty on mortality among relatively healthy community-dwelling older adults.

Rural and urban differences in lifetime occupation and its influence on mortality among Mexican adults

OBJECTIVE

To determine how primary lifetime occupation type is associated with mortality, and how the relationship varies by rural and urban dwelling.

MATERIALS AND METHODS

Data come from 2001-2018 Mexican Health and Aging Study (adults aged 50+, n=11 094). We created five occupation categories. Cox proportional hazard models predicted mortality using baseline covariates.

RESULTS

In both rural and urban settings, participants with manual jobs, such as agriculture and production/industrial jobs, had an increased risk of mortality compared to those with administrative/professional jobs. In urban settings, participants in the domestic/service and no main job categories had higher risk of mortality than those in the administrative/professional category. For men these differences remained, but not for women.

CONCLUSION

In a context of rural and urban demographic shifts, it is crucial to consider the implications that occupation as a socioeconomic factor can have on health and to identify the most vulnerable groups.

Progression of frailty as measured by a cumulative deficit index: A systematic review

BACKGROUND

Frailty is a risk factor for adverse health outcomes. There is a paucity of literature on frailty progression defined by a cumulative deficit model among community dwelling older people. The objective of this review was to synthesise evidence on these changes in health and mortality among community-dwelling older people.

METHODS

Six databases (Medline, Embase, CINAHL, Cochrane, PsycInfo, Web of Science) and a clinical trials registry were searched in July 2021. The inclusion criteria were studies using a frailty index and providing information on transition between frailty states or to death in community-dwelling older people aged ≥ 50. Exclusion criteria were studies examining specific health conditions, conference abstracts and non-English studies. To standardise the follow-up period and facilitate comparison, we converted the transition probabilities to annual transition rates.

RESULTS

Two reviewers independently screened 5078 studies and 61 studies were included for analysis. Of these, only three used the same frailty state cut-points to facilitate cross-cohort comparison. This review found that frailty tends to increase with time, people who are frail at baseline have greater likelihood to progress in frailty and die, and the main factor that accelerates frailty progression is age. Other risk factors for progression are having chronic disease, smoking, obesity, low-income or/and low-education levels. A frailty index is an accurate predictor of adverse outcomes and death.

DISCUSSION

This systematic review demonstrated that worsening in frailty was a common frailty transition, and older people who are frail at baseline are more likely to die. A frailty index has significant power to predict adverse health outcomes. It is a useful tool for within-cohort comparison but there are challenges comparing different cohorts due to dependence of frailty progression on age and differences in how frailty index is defined and measured.

Sex differences in frailty manifestations in patients with coronary artery disease

Aim. To analyze the differences in detection rate of prefrailty and frailty syndrome (FS) in male and female patients with multivessel coronary artery disease (CAD) undergoing elective coronary artery bypass grafting (CABG).

Material and methods. The study included 387 patients admitted for elective primary CABG. Screening for prefrailty and FS in patients before surgery was performed using the questionnaire "Age is not a drawback".

Results. In the age group of 45 to 59 years, 25% of females and only 6% of males had signs of FS, while 25% of women and 34% of men did not present with signs of frailty and prefrailty. Half of middle-aged women and 60% of middle-aged men had prefrailty. Between the ages of 60 and 74, only 14% of women and 24% of men were not frail. Elderly women are more likely than elderly men to present with signs of FS (p=0,040). The symptoms of prefrailty in elderly patients were detected at equal rate in men and women (59% and 60%, respectively). All senile-aged patients presented with the signs of prefrailty or FS.

Conclusion. Patients with multivessel CAD present with manifestation of frailty in senile, elderly, and middle age. At the same time, middle-aged and elderly women with the higher rates of comorbid disorders require special attention.

Mediating effects of cognitive reserve on the relationship between frailty and cognition in older people without dementia

PURPOSE

This study aimed to explore the potential mediating effects of cognitive reserve on the association between frailty and cognition in the older people without dementia.

METHODS

We performed a cross-sectional analysis of data from 3122 community-dwelling older adults (≥ 65-years-old) without dementia of the Cognitive Function and Ageing Study in Wales. A 31-item frailty index was used to assess frailty. A cognitive lifestyle score was constructed to evaluate cognitive reserve, which includes participants' educational level, occupational attainment, and engagement in social and cognitive activities in later life. Linear regression and mediation modeling were used to investigate the relationship between frailty and cognition and the mediating effects of cognitive reserve as well as social and cognitive activities, an alterable component of cognitive reserve for older adults.

RESULTS

Frailty was negatively associated with cognition. Cognitive reserve was a mediator of the association between frailty and global cognition (- 1.92; 95% CI: - 2.50, - 1.35), as well as individual cognitive domains, with indirect effects contributing to 13-59% of the total effects. Social and cognitive activities have smaller but similar mediating effects on these associations.

CONCLUSIONS

Negative effect of frailty on cognition was partially mediated by a reduction in cognitive reserve. Our results support the possibility that enhancing cognitive reserve, especially engagement in social and cognitive activities may protect cognitive health against frailty.

Physical frailty, activity limitation and mortality in older Brazilians: longitudinal findings from FIBRA-BH study (2009-2019)

The aim was to investigate the longitudinal association between physical frailty and change in the profile of limitation to perform basic and instrumental activities of daily living (BADL and IADL) and mortality in a 10-year period in Brazilian community-dwelling older people. A longitudinal study was conducted with data from the Frailty in Brazilian Older People (FIBRA) study, 2009-2019. Physical frailty was categorized into vulnerability (pre-frail and frail) and robustness (non-frail). The generalized estimating equation and the Cox proportional hazards models were used in the data analysis. Out of 200 older people evaluated in 2009 (moment 1), 139 were located in 2019 (moment 2). Of these, 102 were interviewed and 37 deaths were recorded. The chance of vulnerable older people at moment 1 being dependent on performing BADL at moment 2 was 4.19-fold the chance of robust older people. For IADL, the chance of vulnerable older people at moment 1 being dependent at moment 2 was 3.12-fold the chance of robust older people. Cox's analysis showed that the risk of death among vulnerable older people was 2.50-fold that among robust older people. The results reinforce the importance of monitoring and early intervention to prevent frailty, and the limitation to performing activities of daily living and death among Brazilian older people.

Functional Dependency in Mexico: Measurement Issues and Policy Challenges

BACKGROUND

Different definitions have been used to measure functional dependency (FD) in Mexico. This study aims to explore if different definitions of FD lead to low consistency between the estimations of its prevalence. Accurate estimations of FD are useful to estimate the potential demand for long-term care (LTC) services in the country.

METHODS

A literature review including documents with estimations on the number or prevalence of dependents in Mexico with national representativeness between 2000 and 2019 was performed as well as estimations of different definitions of FD, using the National Study on Health and Aging in Mexico (ENASEM).

RESULTS

There is a lack of consensus on the definition of FD. Among the most frequently used terms to define FD are "disability" and "dependency." The heterogeneity of definitions results in a wide range of estimations of the demand for LTC. Methodological choices can lead to important differences in FD prevalence estimations. Results from ENASEM 2001 show that FD prevalence could range from 13% to 35% in people 60+; sex prevalences also vary when using different ways to measure FD.

CONCLUSION

Besides the highlighted issues in calculating FD in the population, Mexico should consider broadening the assessment of FD, including people with dementia and younger populations. Although the literature search is not systematic, it helps exemplifying the current issues when measuring FD in Mexico. A consensual definition of dependency is required to have a more accurate estimated demand for LTC. Having good data sources is not enough when dissimilar estimations of an indicator like dependency result from the same study. Wide heterogeneity in estimations of dependency could be an obstacle to inform public policies during the construction of a care system in Mexico.

Trajectories of frailty and related factors of elderly people in Mexico

Introduction

Frailty is an indicator of health status in old age and a common clinical syndrome in older adults that carries an increased risk of poor health outcomes, including falls, incidents of disability, hospitalization, and mortality. This study aimed to identify the different trajectories of frailty and the factors related to frailty among Mexican older adults over time.

Methods

Data are from a four-wave panel composed of older Mexican adults from 2001 to 2015 of the Mexican Health and Aging Study (MHAS). Frailty is the accumulation of deficits using a frailty index. A multilevel analysis, using hierarchical models, was applied to know the changes of frailty trajectories and what factors are related to it.

Results

Being female, older, being widowhood, and having a lower level of education were risk factors for having a high frailty index and lower financial satisfaction doing activities at home have adverse effects.

Conclusion

The findings of this work present information about the prevalence of frailty considering the proportion of deficits that individuals possess and their main associated components in older Mexican adults. It is necessary to improve socioeconomic health conditions in phases before old age to avoid developing frailty in the future.

The Science of Frailty: Sex Differences

Frailty is an important clinical syndrome of age-related decline in physiologic reserve and increased vulnerability. In older adults, frailty leads to progressive multisystem decline and increased adverse clinical outcomes. The pathophysiology of frailty is hypothesized to be driven by dysregulation of neuroendocrine, inflammatory, and metabolic pathways. Sex-specific differences in the prevalence of frailty have been observed. Treatment interventions of geriatric care can be applied to the care of frail older women with these differences in mind. As additional evidence regarding sex-specific differences in frailty emerges, research efforts should encompass the development of screening tools and therapeutic interventions that optimize outcomes.

Frailty Index in the Colonias on the US-Mexico Border: A Special Report

Frailty is the age-related decline in well-being. The Frailty index (FI) measures the accumulation of health deficits and reflects biopsychosocial and cultural determinants of well-being. Frailty is measured as a static phenotype or as a Frailty Index comprising a ratio of suffered health deficits and total deficits. We report a Frailty Index calculated from routinely measured clinical variables gathered from residents of two Colonias (neighborhoods) in South Texas. A Colonia is a predominantly Hispanic, economically distressed, unincorporated neighborhood. We analyzed retrospective data from 894 patients that live in two Colonias located on the Texas-Mexico border. We calculated the FI with seven physiological variables, PHQ-9 score, and the 11 domain-specific Duke Profile scores, for a total of 19 possible health deficits. FI against age separately in males (n = 272) and females (n = 622) was regressed. Females had a significantly higher starting frailty, and males had a significantly greater change rate with age. FI against age for Cameron Park Colonia and Indian Hills Colonia was regressed. We calculated a significantly higher starting FI in Indian Hills and a significantly greater change rate in Cameron Park residents. Frailty's contributors are complex, especially in neighborhoods of poverty, immigration, low education level, and high prevalence of chronic disease. We report baseline Frailty Index data from two Colonias in South Texas and the clinical and research implications.

Sex differences in frailty: Comparisons between humans and preclinical models

Frailty can be viewed as a state of physiological decline that increases susceptibility to adverse health outcomes. This loss of physiological reserve means that even small stressors can lead to disability and death in frail individuals. Frailty can be measured with various clinical tools; the two most popular are the frailty index and the frailty phenotype. Clinical studies have used these tools to show that women are frailer than men even though they have longer lifespans. Still, factors responsible for this frailty-mortality paradox are not well understood. This review highlights evidence for male-female differences in frailty from both the clinical literature and in animal models of frailty. We review evidence for higher frailty levels in female animals as seen in many preclinical models. Mechanisms that may contribute to sex differences in frailty are highlighted. In addition, we review work that suggests frailty may play a role in susceptibility to chronic diseases of aging in a sex-specific fashion. Additional mechanistic studies in preclinical models are needed to understand factors involved in male-female differences in frailty in late life.

Frailty and mortality: an 18-year follow-up study among Finnish community-dwelling older people

BACKGROUND

There is a lack of agreement about applicable instrument to screen frailty in clinical settings.

AIMS

To analyze the association between frailty and mortality in Finnish community-dwelling older people.

METHODS

This was a prospective study with 10- and 18-year follow-ups. Frailty was assessed using FRAIL scale (FS) (n = 1152), Rockwood's frailty index (FI) (n = 1126), and PRISMA-7 (n = 1124). To analyze the association between frailty and mortality, Cox regression model was used.

RESULTS

Prevalence of frailty varied from 2 to 24% based on the index used. In unadjusted models, frailty was associated with higher mortality according to FS (hazard ratio 7.96 [95% confidence interval 5.10-12.41] in 10-year follow-up, and 6.32 [4.17-9.57] in 18-year follow-up) and FI (5.97 [4.13-8.64], and 3.95 [3.16-4.94], respectively) in both follow-ups. Also being pre-frail was associated with higher mortality according to both indexes in both follow-ups (FS 2.19 [1.78-2.69], and 1.69 [1.46-1.96]; FI 1.81[1.25-2.62], and 1.31 [1.07-1.61], respectively). Associations persisted even after adjustments. Also according to PRISMA-7, a binary index (robust or frail), frailty was associated with higher mortality in 10- (4.41 [3.55-5.34]) and 18-year follow-ups (3.78 [3.19-4.49]).

DISCUSSION

Frailty was associated with higher mortality risk according to all three frailty screening instrument used. Simple and fast frailty indexes, FS and PRISMA-7, seemed to be comparable with a multidimensional time-consuming FI in predicting mortality among community-dwelling Finnish older people.

CONCLUSIONS

FS and PRISMA-7 are applicable frailty screening instruments in clinical setting among community-dwelling Finnish older people.

Hospital Complications and Frailty in Mexican Older Adults: An Emergency Care Cohort Analysis

Objectives: To describe the association of frailty level on admittance to the Emergency Department (ED) with various hospital complications including delirium, low phase angle, and low handgrip strength.

Design: Prospective cohort.

Setting: ED rooms of two public general hospitals in Mexico City.

Participants: A total of 548 persons 60 years or older who were admitted to the ED and who were alive during follow-up testing at home were included.

Measurements: A 32-item frailty index (FI) was measured on admission to the ED. Outcome measures included delirium, phase angle, and hand grip strength measured during different stages of the hospitalization (i.e., from admission to the ED through to follow-up at home).

Results: From this final sample, mean age was 76 years (± SD 7.2) and 58.4% (n = 320) were women. Mean waiting time in the ED was 5.1 h (± SD 6.2), the average stay in the ED was 99.9 (±68.2) h, and 274 subjects (50%) were admitted to a general ward after ED admission. FI was not associated with phase angle and was negatively associated with handgrip strength at admission to ED (β = −3.97, confidence interval [CI] 95% −5.56 −2.38, p < 0.001), discharge from ED (β = −3.94, CI 95% −5.97 −1.90, p < 0.001), and discharge from hospital (β = −4.93, CI 95% −7.68 −2.18, p = 0.01). FI was positively associated with delirium (β = 3.68, CI 95% 1.53–5.83, p < 0.01).

Conclusion: Higher frailty at ED admission was associated with lower hand grip strength and delirium during hospitalization in Mexican older adults.

Frailty Index and Sex-Specific 6-Year Mortality in Community-Dwelling Older People: The ActiFE Study

BACKGROUND

Considering that mortality rate and deficit accumulation varies considerably in men and women, we performed a sex-stratified analysis of the association between an estimated frailty index (eFI) with 6-year mortality in the Activity and Function in the Elderly (ActiFE) Study.

METHODS

We constructed an eFI using a score (0 [no deficit] to 1 [deficit]) from 32 baseline items representing multiple domains. eFI represents the sum of all scores divided by 32. Cox proportional hazards models adjusted for age, smoking, alcohol intake, and education were used to evaluate this association.

RESULTS

Among 1,204 participants (57.5% men), 18.5% men and 26.0% women were frail (eFI ≥ 0.2) with an age-adjusted mean eFI of 0.13 (95% confidence interval [CI] 0.12, 0.13) and 0.15 (95% CI 0.15, 0.16), respectively. Mortality rate in men (146 deaths) was 34.4 (95% CI 29.3, 40.5) and in women (50 deaths) 15.1 (95% CI 11.5, 19.9) per 1,000 person-years. A 0.1 increment of eFI was associated with a hazard ratio (HR) of 1.94 (95% CI 1.60, 2.35) in men and 2.06 (95% CI 1.58, 2.69) in women. Frail versus nonfrail men and women had a HR of 2.46 (95% CI 1.74, 3.48), and 2.98 (95% CI 1.55, 5.70), respectively. We detected sex differences in the order of the eight common contributor items to the eFI.

CONCLUSIONS

We observed a statistically significant difference for the age-adjusted eFI and the frailty prevalence in men and women. However, our analysis does not suggest the presence of effect modification by sex in the association with mortality.

Is frailty a prognostic factor for adverse outcomes in older patients with acute coronary syndrome?

BACKGROUND

There is very limited guidance in regard to how biological age should be estimated and how different comorbidity conditions influence the benefit-risk ration of interventions. Frailty is an important health-related problem in patients, especially in older adults. It is a reflection of biologic rather than chronologic age; frailty may explain why there remains substantial heterogeneity in clinical outcomes within the older patients' population.

AIMS

We aimed to review the prognostic value of frailty for adverse outcomes in older patients with acute coronary syndrome (ACS).

METHODS

Studies published until December 31, 2018, identified by systematic Medline, Embase, and Cochrane Controlled Register of Trials (CENTRAL) searches were reviewed for the association between frailty and mortality in older patients with ACS. We used the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the included studies. We extracted the information of hazard ratios (HR) and odds ratios (OR) with accompanying 95% confidence intervals (CI), and P values of multivariable analysis. Heterogeneity across studies was determined using the Cochran Q value by Review Manager 5.3.

RESULTS

A total of 11 articles involving 7212 patients were included in this meta-analysis. Two studies (Sujino, Y 2015 and Alonso, S.GL 2016; n = 264) reported that frailty was significantly associated with in-hospital mortality in patients with ACS (range of reported OR between 6.38 and 12.0). We performed a subgroup analysis of the other nine studies based on differences in the follow-up time. Pooled meta-analysis demonstrates that frailty was associated with short-term, medium-term, and long-term mortality (HR = 3.67, 4.09, 1.66). There was no association between frailty and bleeding in older patients with ACS.

CONCLUSIONS

Frailty measured by Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS), the Edmonton Frail Scale (EFS), Fried score, Green scores, frailty instrument from the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) index, and FRAIL (Fatigue, Resistance, Ambulation, Illnesses, Loss of weight) scale, leads to significantly higher mortality rates in older patients with ACS.

The Frailty Index in older women with gynecological cancer

INTRODUCTION

Frailty is a key condition to be screened among elderly oncological patients. Aim of our work is to measure the functional and prognostic value for 1-year mortality of the Frailty Index (FI) in a cohort of older women with gynecological cancer.

METHODS

The prognostic value of FI was tested in 200 older women with gynaecological cancer (mean age = 73.5 years). FI was retrospectively calculated following the Rockwood model. Spearman's rho test was used for correlations with other oncological scales: Eastern Cooperative Oncology Group Performance Status (ECOG); Karnofsky Performance Status (KPS); Vulnerable Elders Scale-13 (VES-13). Cox proportional hazard models and ROC curve were performed to estimate prognostic role of 1-year mortality. Sensitivity and specificity were also calculated.

RESULTS

FI is normally distributed and descriptive statistics define our population as frail (mean = 0.25±0.11, range 0.08-0.51). 0.7 is confirmed as an upper limit compatible with life. FI does not significantly correlates with age, ECOG and KPS while it positively correlates with VES-13 (r = 0.7, p < 0.01). FI is the strongest predictor for 1-year mortality confirmed after all adjustments for confounders (OR 3.40; 95% CI 1.55-7.45, p < 0.01) and by ROC curve analyses (0.66, 95% CI 0.51-0.81, p = 0.01).

CONCLUSIONS

Frailty Index is a useful tool to detect vulnerability in onco-geriatrics and it predicts 1-year mortality. Further studies are needed to confirm and extend these findings.

Inter-relationships between Gender, Frailty and 10-Year Survival in Older Italian Adults: an observational longitudinal study

Aim of the present study was to assess the impact of gender on the relationship between long-term mortality and clinical frailty. In an observational, longitudinal study on 10-year mortality, we examined 1284 subjects. The Frailty Staging System was used to assess frailty. The Cox model was employed to assess variables independently associated with survival using a backward stepwise algorithm. To investigate the possible interactions between gender and the selected variables, an extension of the multivariable fractional polynomial algorithm was adopted. Women were more likely to be older, have a higher disability, present with more comorbidities, consume more drugs, be frail and have a higher rate of survival at the follow-up than were men. At the Cox multivariate analysis only age (HR 2.26), female gender (HR 0.43), and number of drugs (HR 1.57) were significant and independent factors associated with all-cause mortality. In the survival analyses, only frailty (vs no frailty) showed significant interaction with gender (p < 0.001, HR = 1.92). While the presence of frailty reduced the survival rate in women, no effect was observed in men. Importantly, frail women showed higher survival rates than did both frail and no frail men. The main finding of the present study is that gender shapes up the association between frailty and long-term survival rates.

Can Waterlow score predict 30-day mortality and length of stay in acutely admitted medical patients (aged ≥65 years)? Evidence from a single centre prospective cohort study

OBJECTIVE

This study aimed to explore the potential for the Waterlow score (WS) to be used as a predictor of 30-day mortality and length of hospital stay (LHS) in acutely admitted medical patients aged 65 years and older.

DESIGN

Prospective observational cohort study.

SETTING

UK District General Hospital.

SUBJECTS

834 consecutive patients aged 65 years and older admitted acutely to medical specialties between 30 May and 22 July 2014.

METHODS

Admission WS (range 4-64) assessment paired with the patient's status at 30 days in terms of mortality and their LHS.

PRIMARY OUTCOMES

30-day mortality and length of inpatient stay.

RESULTS

834 consecutive acute medical admissions had their WS recorded. 30-day mortality was 13.1% (109 deaths). A significant difference in the distribution of WS (p<0.001) was seen between those who survived (median 12) and those who died (median 16) within 30 days, particularly within respiratory (p<0.001), stroke (p<0.001), cardiology (p<0.016), non-respiratory infections (p<0.018) and trauma (p<0.044) subgroups. Odds of dying within 30 days increased threefold for every 10-unit increase in the WS (p<0.001, 95% CI 2.1 to 4.3). LHS was also positively linearly associated with the WS in those who survived 30 days (median=5, IQR=10; r=0.32, p<0.01). A five-unit increase in WS was associated with approximately 5 days increase in LHS. On the other hand, quadratic regression showed this relationship was curvilinear and negative (concave) for those who died within 30 days where a five-unit increase in WS was associated with an approximately 10 days decrease in LHS.

CONCLUSION

This study demonstrates an association between a high WS and both 30-day mortality and LHS. This is particularly significant for mortality in patients in the respiratory, stroke and cardiac subcategories. The WS, a nursing-led screening tool that is carried out on virtually all admissions to UK hospitals, could have additional use at the time of patient admission as a risk assessment tool for 30-day mortality as well as a predictor of LHS.

Individual and cumulative association of commonly used biomarkers on frailty: a cross-sectional analysis of the Mexican Health and Aging Study

Frailty has been recognized as a common condition in older adults, however, there is scarce information on the association between frailty and commonly used biomarkers. The aim of this study was to assess the individual and cumulative association of biomarkers with frailty status. This is a cross-sectional analysis of the 2012 wave of the Mexican Health and Aging Study. A sub-sample of 60-year or older adults with anthropometric measurements was analyzed. Frailty was defined with a 31-item frailty index and those considered frail had a score ≥ 0.21. Biomarkers were further categorized as normal/abnormal and tested both one by one and grouped (according to their usual cutoff values). Adjusted logistic models were performed. A total of 1128 older adults were analyzed and their mean age was 69.45 years and 51.24% of them were women. 26.7% (n = 301) were categorized as frail. Individual biomarkers associated with frailty after adjusting for confounding were: hemoglobin [odds ratio (OR) 1.67, 95% confidence interval (CI) 1.13-2.46, p = 0.009], glycated hemoglobin (OR 2.04, 95% CI 1.54-2.7, p < 0.001) and vitamin D (OR 1.53, 95% CI 1.13-2.07, p = 0.005). Those with ≥ 4 abnormal biomarkers had an independent association with frailty when compared to those without any abnormal biomarker (OR 2.64, 95% CI 1.3-5.25, p = 0.005). Aside from the individual associations of specific biomarkers, our findings show that an incremental association of abnormal biomarkers increases the probability of frailty, accounting for the multidimensional nature of frailty and the possible interplay between components of the system that potentiate to give rise to a negative condition such as frailty.

Frailty in Older American Indians: The Native Elder Care Study

Introduction: Frailty is often described as a reduction in energy reserves, especially with respect to physical ability and endurance, and it has not been examined in American Indians. The goals of this study were to estimate the prevalence of frailty and identify its correlates in a sample of American Indians. Methods: We examined data from 411 community-dwelling American Indians aged ≥55 years. Frailty was measured with weight loss, exhaustion, low energy expenditure, slowness, and weakness characteristics. Results: Slightly over 44% of participants were classified as pre-frail and 2.9% as frail. Significant correlates of a combined pre-frail and frail status identified in the fully adjusted analyses were younger age, female gender, lower levels of education, increased number of chronic medical conditions, and increased number of activities of daily living limitations. Marital status, chronic pain, and social support were not associated with pre-frail/frail status. Conclusions: Our findings point to specific areas in need of further research, including use of frailty measures that also capture psychosocial components and examining constructs of physical resilience. Targeting those with multiple chronic medical conditions may be an important area in which to intervene, with the goal of reducing risk factors and preventing frailty onset.

The frailty index is a predictor of cause-specific mortality independent of familial effects from midlife onwards: a large cohort study

BACKGROUND

Frailty index (FI) is a well-established predictor of all-cause mortality, but less is known for cause-specific mortality and whether familial effects influence the associations. Middle-aged individuals are also understudied for the association between FI and mortality. Furthermore, the population mortality impact of frailty remains understudied.

METHODS

We estimated the predictive value of FI for all-cause and cause-specific mortality, taking into account familial factors, and tested whether the associations are time-dependent. We also assessed the proportion of all-cause and cause-specific deaths that are attributable to increased levels of frailty. We analyzed 42,953 participants from the Screening Across the Lifespan Twin Study (aged 41-95 years at baseline) with up to 20 years' mortality follow-up. The FI was constructed using 44 health-related items. Deaths due to cardiovascular disease (CVD), respiratory-related causes, and cancer were considered in the cause-specific analysis. Generalized survival models were used in the analysis.

RESULTS

Increased FI was associated with higher risks of all-cause, CVD, and respiratory-related mortality, with the corresponding hazard ratios of 1.28 (1.24, 1.32), 1.31 (1.23, 1.40), and 1.23 (1.11, 1.38) associated with a 10% increase in FI in male single responders, and 1.21 (1.18, 1.25), 1.27 (1.15, 1.34), and 1.26 (1.15, 1.39) in female single responders. No significant associations were observed for cancer mortality. No attenuation of the mortality associations in unrelated individuals was observed when adjusting for familial effects in twin pairs. The associations were time-dependent with relatively greater effects observed in younger ages. Before the age of 80, the proportions of deaths attributable to FI levels > 0.21 were 18.4% of all-cause deaths, 25.4% of CVD deaths, and 20.4% of respiratory-related deaths in men and 19.2% of all-cause deaths, 27.8% of CVD deaths, and 28.5% of respiratory-related deaths in women. After the age of 80, the attributable proportions decreased, most notably for all-cause and CVD mortality.

CONCLUSIONS

Increased FI predicts higher risks of all-cause, CVD, and respiratory-related mortality independent of familial effects. Increased FI presents a relatively greater risk factor at midlife than in old age. Increased FI has a significant population mortality impact that is greatest through midlife until the age of 80.

Diet quality in relation to healthy ageing: the Israeli Longitudinal Study on Aging (ILSA)-a study protocol

INTRODUCTION

Population ageing is accelerating rapidly in Israel as well as worldwide, necessitating adaptation of the healthcare system and consideration of new approaches that serve the specific needs of older adults. In addition to cognitive function, frailty is one of the most challenging expressions of physical and mental ageing, a multidimensional syndrome of increased vulnerability. Several studies have shown that low intake of certain micronutrients and protein is associated with higher risk of frailty and cognitive impairment. However, whether global diet quality is involved in the aetiology of the latter outcomes is unclear.

METHODS AND ANALYSIS

We are conducting, among older adult subjects who took part in 'Mabat Zahav' (Israeli National Health and Nutrition Survey of Older Adults) in 2005-2006 (T0, n=1852), an extensive follow-up interview (T1) that includes comprehensive geriatric assessment and evaluation of general health and quality of life. Diet quality is evaluated using the Healthy Eating Index (HEI) 2010, based on 24-hour diet recall measured at T0 and T1. Frailty is assessed using two different approaches: the phenotype framework and the accumulation of deficits model. Cognitive function is assessed by Mini-Mental State Examination (MMSE) and cognitive decline is assessed by the difference between repeated MMSE measurements. Different analytic methods will be applied to evaluate the role of diet quality in development of frailty and cognitive decline with inverse probability weighting used to minimise attrition bias. About 600 subjects are expected to be interviewed between May 2017 and December 2019.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Helsinki Committee of Sheba Medical Center, Tel Hashomer, Israel and the Ethical Committee of Tel-Aviv University. All participants sign an informed consent form. The findings of the study will be published in peer-reviewed journals.

Frailty, diabetes, and the convergence of chronic disease in an age-related condition: a population-based nationwide cross-sectional analysis of the Mexican nutrition and health survey

AIMS

To describe the associations of frailty with diabetes mellitus and related conditions in older adults.

METHODS

We conducted a cross-sectional analysis of a representative sample of older adults (n = 5379). We generated a 35-item frailty index (FI) and obtained information on diabetes and related conditions (peripheral neuropathy, lower limb amputation, diabetic coma, number of physician visits due to diabetes-related conditions, all-cause hospitalizations in the past year, years since diabetes diagnosis, and type of treatment). Logistic and Poisson regression models were used to determine the associations between frailty and diabetes and its complications.

RESULTS

The mean age was 70.3 years (± 7.8); 54.7% were women. Those with an FI ≤ 0.082 composed the reference group. Multivariate analysis showed an OR of 2.32 (95% CI 1.93-2.73, p < 0.001) for the association between diabetes and frailty. People who were hospitalized for any cause during the previous year, those receiving both insulin and an oral compound to manage diabetes, and those with peripheral neuropathy showed ORs of 2.32 (95% CI 1.69-3.18, p < 0.001), 5.6 (95% CI 1.58-19.8, p = 0.008), and 2.02 (95% CI 1.42-2.86, p < 0.001), respectively, for being in the most frail group.

CONCLUSIONS

People with diabetes have higher frailty scores. Furthermore, older adults with diabetes and higher burden of frailty have more diabetes-related complications.

The analysis of correlation between frailty index and postoperative complications of aged patients with nodular goiter

OBJECTIVE

To explore the correlation between frailty index (FI) and postoperative complications of aged patients with nodular goiter (NG).

METHODS

A total of 120 aged patients with NG undergoing operative treatment from May 2013 to October 2015 in our hospital were selected. All of them were divided into 3 groups according to the FI as follows: nonfrail group (FI < 0.2), intermediately frail group (0.2 ≤ FI < 0.4), and frail group (FI ≥ 0.4). Clinical data of patients about general data, body mass index, American Society of Anesthesiology (ASA) classification, hospital stays, and postoperative complications were examined. Then, the correlations between the indexes above and FI were examined.

RESULTS

Frailty index and the ASA classification have some relevance (r = .265, P = .007). The postoperative complication rates of total nonfrail group, intermediately frail group, and frail group were, respectively, 4 cases (11.4%), 11 cases (31.4%), and 24 cases (48.0%). With the increase in FI, the incidence of postoperative complications and hospital stays had also significantly increased. The area under receiver operating characteristic curve examining frailty's ability to forecast postoperative complications was 0. 815 (95% CI: 0.675-0.954, P = .000).

CONCLUSION

The level of frailty index is a risk factor for postoperative complications of aged patients with NG. The preoperative frailty index evaluation can provide reference evidence for the treatment of aged NG patients undergoing surgery.

Anthropometric measurements and mortality in frail older adults

BACKGROUND

As the number of older adults increases, so does the number of frail older adults. Although anthropometry has been widely used as a way to stratify the overall mortality risk of a person, the significance of these measurements becomes blurred in the case of frail older adults who have changes in body composition. Therefore, the aim of this study is to determine the association of anthropometric measurements (body mass index, knee-adjusted height body mass index, waist-to-hip ratio and calf circumference) with mortality risk in a group of older Mexican adults.

METHODS

This is a longitudinal analysis of the Mexican Health and Aging sub-sample (with biomarkers, n = 2573) from the first wave in 2001, followed-up to the last available wave in 2015. Only frail 50-year or older adults (Frailty Index with a cut-off value of 0.21 or higher, was used) were considered for this analysis (n = 1298). A survival analysis was performed with Kaplan-Meier curves and Cox regression models (unadjusted and adjusted for confounding). Socio-demographic, health risks, physical activity and comorbidities were variables used for adjusting the multivariate models.

RESULTS

From the total sample of 1298 older adults, 32.5% (n = 422) died during follow-up. The highest hazard ratio in the adjusted model was for calf circumference 1.31 (95% confidence interval 1.02-1.69, p = 0.034). Other measurements were not significant.

CONCLUSIONS

Anthropometric measurements have different significance in frail older adults, and these differences could have implications on adverse outcomes. Calf circumference has a potential value in predicting negative health outcomes.

Predicting the mortality in geriatric patients with dengue fever

Geriatric patients have high mortality for dengue fever (DF); however, there is no adequate method to predict mortality in geriatric patients. Therefore, we conducted this study to develop a tool in an attempt to address this issue.We conducted a retrospective case-control study in a tertiary medical center during the DF outbreak in Taiwan in 2015. All the geriatric patients (aged ≥65 years) who visited the study hospital between September 1, 2015, and December 31, 2015, were recruited into this study. Variables included demographic data, vital signs, symptoms and signs, comorbidities, living status, laboratory data, and 30-day mortality. We investigated independent mortality predictors by univariate analysis and multivariate logistic regression analysis and then combined these predictors to predict the mortality.A total of 627 geriatric DF patients were recruited, with a mortality rate of 4.3% (27 deaths and 600 survivals). The following 4 independent mortality predictors were identified: severe coma [Glasgow Coma Scale: ≤8; adjusted odds ratio (AOR): 11.36; 95% confidence interval (CI): 1.89-68.19], bedridden (AOR: 10.46; 95% CI: 1.58-69.16), severe hepatitis (aspartate aminotransferase >1000 U/L; AOR: 96.08; 95% CI: 14.11-654.40), and renal failure (serum creatinine >2 mg/dL; AOR: 6.03; 95% CI: 1.50-24.24). When we combined the predictors, we found that the sensitivity, specificity, positive predictive value, and negative predictive value for patients with 1 or more predictors were 70.37%, 88.17%, 21.11%, and 98.51%, respectively. For patients with 2 or more predictors, the respective values were 33.33%, 99.44%, 57.14%, and 98.51%.We developed a new method to help decision making. Among geriatric patients with none of the predictors, the survival rate was 98.51%, and among those with 2 or more predictors, the mortality rate was 57.14%. This method is simple and useful, especially in an outbreak.

Cost-Effectiveness of a Proactive Primary Care Program for Frail Older People: A Cluster-Randomized Controlled Trial

BACKGROUND

A proactive integrated approach has shown to preserve daily functioning among older people in the community. The aim is to determine the cost-effectiveness of a proactive integrated primary care program.

METHODS

Economic evaluation embedded in a single-blind, 3-armed, cluster-randomized controlled trial with 12 months' follow-up in 39 general practices in the Netherlands. General practices were randomized to one of 3 trial arms: (1) an electronic frailty screening instrument using routine medical record data followed by standard general practitioner (GP) care; (2) this screening instrument followed by a nurse-led care program; or (3) usual care. Health resource utilization data were collected using electronic medical records and questionnaires. Associated costs were calculated. A cost-effectiveness analysis from a societal perspective was undertaken. The incremental cost per quality-adjusted life-year was calculated comparing proactive screening arm with usual care, and screening plus nurse-led care arm with usual care, as well as the screening arm with screening plus nurse-led care arm.

RESULTS

Out of 7638 potential participants, 3092 (40.5%) older adults participated. Whereas effect differences were minor, the total costs per patient were lower in both intervention groups compared with usual care. The probability of cost-effectiveness at €20,000 per QALY threshold was 87% and 91% for screening plus GP care versus usual care and for screening plus nurse-led care compared to usual care, respectively. For screening plus nurse-led care vs screening plus standard GP care, the probability was 55%.

CONCLUSION

A proactive screening intervention has a high probability of being cost-effective compared to usual care. The combined intervention showed less value for money.

A Frailty Index from Next-of-Kin Data: A Cross-Sectional Analysis from the Mexican Health and Aging Study

Objectives. To construct a frailty index from next-of-kin information of the last year of life of community-dwelling 50 years old or older adults and test its association with health services utilization. Methods. Cross-sectional analysis from next-of-kin data available from the last wave of the Mexican Health and Aging Study (MHAS). Measurements. Along with descriptive statistics, the frailty index (FI) was tested in regression models to assess its association with adverse outcomes previous to death: number of hospitalized days in the previous year and number of visits to a physician in the previous year, in unadjusted and adjusted models. Results. From a total of 2,649 individuals the mean of age was 74.8 (±11.4) and 56.3% (n = 1,183) were women. The mean of the FI was of 0.279 (±SD 0.131, R = 0.0–0.738) and distribution was biased to the right. There was a significant association (p < 0.001) between the FI and number of hospitalized days (β = 45.7, 95% CI 36.1–55.4, p < 0.001) and for the number of visits to a physician (β = 25.93, 95% CI 19.27–32.6, p < 0.001) both models adjusted for age and sex. Conclusion. The FI constructed with next-of-kin data showed similar characteristics to similar indexes of older adults. It was independently associated with health care use.

Frailty and sarcopenia in Bogotá: results from the SABE Bogotá Study

BACKGROUND

Latin American countries like Colombia are experiencing a unique aging process due to a mixed epidemiological regime of communicable and non-communicable diseases.

AIMS

To estimate the prevalence of frailty and sarcopenia among older adults in Colombia and identify variables associated with these conditions.

METHODS

Data come from the "Salud Bienestar y Envejecimiento" (SABE) Bogotá Study, a cross-sectional study conducted in 2012 in Bogotá, Colombia. Sociodemographic, health, cognitive and anthropometric measures were collected from 2000 community-dwelling adults aged 60 years and older. Frailty variable was created using the Fried phenotype and sarcopenia following the European Working Group on Sarcopenia in Older People algorithm. Logistic regression analyses were used to identify factors associated with frailty and sarcopenia.

RESULTS

A total of 135 older adults are frail (9.4 %), while 166 have sarcopenia (11.5 %). Older age and female gender have a significant association with both conditions (Frailty: Age OR 1.05, 95 % CI 1.03-1.06, Gender OR 1.44, 95 % CI 1.12-1.84; Sarcopenia: Age 1.04, 95 % CI 1.02-1.07, Gender OR 1.51, 95 % CI 1.05-2.17). Depression was also significantly associated with frailty (OR 1.17, 95 % CI 1.12-1.22), while smoking was significantly associated with sarcopenia (OR 2.38, 95 % CI 1.29-4.37). Finally, higher function, measured by independence in IADL (Instrumental Activities of Daily Living) was significantly associated with less frailty (OR 0.74, 95 % CI 0.64-0.86). Education, higher number of comorbidities, better MMSE score, activities of daily living disability and alcohol consumption were not significantly associated with frailty or sarcopenia.

CONCLUSIONS

Frailty, sarcopenia and multimorbidity are overlapping, yet distinct conditions in this sample. There are potentially reversible factors that are associated with frailty and sarcopenia in this sample. Future studies need to analyze the best way to prevent these conditions, and examine individuals that have frailty, sarcopenia and comorbidities to design interventions to improve their quality of life.

Risk of death in elderly persons based on the frailty phenotype and the frailty index: a review study

Abstract Objective: to systematize studies evaluating the relationship between frailty and mortality in community-dwelling elderly persons. Method: Frailty was defined according to the frailty phenotype proposed by Fried et al. and the frailty index described by Rockwood et al. The study included epidemiologic population-based studies, cohort surveys, systematic reviews and meta-analyses published in English between 2006 and March 2016 based on the use of the terms: "frail elderly" and "mortality". Only study samples that exclusively comprised adults 65 years old or older who lived in the community were included. Studies investigating hospitalized and institutionalized elderly persons, and those examining the relationship between frailty and mortality through a disease-specific target were excluded. Results: a total of 244 studies were identified, of which 17 met the inclusion criteria. Thirteen studies used the frailty phenotype and four studies used the frailty index. Conclusion: both assessment measures found that frail elderly persons have a higher risk of death than robust elderly persons.

Sex differences in frailty: A systematic review and meta-analysis

BACKGROUND

It is a well-described clinical phenomenon that females live longer than males, yet tend to experience greater levels of co-morbidity and disability. Females can therefore be considered both more frail (because they have poorer health status) and less frail (because they have a lower risk of mortality). This systematic review aimed to determine whether this ageing paradox is demonstrated when the Frailty Index (FI) is used to measure frailty.

METHODS

Medline, EMBASE and CINAHL databases were searched for observational studies that measured FI and mortality in community-dwellers over 65years of age. In five-year age groups, meta-analysis determined the sex differences in mean FI (MD=mean FI_female-mean FI_male) and mortality rate.

RESULTS

Of 6482 articles screened, seven articles were included. Meta-analysis of data from five studies (37,426 participants) found that MD values were positive (p<0.001; MD range=0.02-0.06) in all age groups, indicating that females had higher FI scores than males at all ages. This finding was consistent across individual studies. Heterogeneity was high (I²=72.7%), reflecting methodological differences. Meta-analysis of mortality data (13,127 participants) showed that male mortality rates exceeded female mortality rates up until the 90 to 94-years age group. Individual studies reported higher mortality for males at each level of FI, and higher risk of death for males when controlling for age and FI.

CONCLUSIONS

The pattern of sex differences in the FI and mortality of older adults was consistent across populations and confirmed a 'male-female health-survival paradox'.

Relationship between employment histories and frailty trajectories in later life: evidence from the English Longitudinal Study of Ageing

Background

Given the acceleration of population ageing and policy changes to extend working lives, evidence is needed on the ability of older adults to work for longer. To understand more about the health impacts of work, this study examined the relationship between employment histories before retirement and trajectories of frailty thereafter.

Methods

The sample comprised 2765 women and 1621 men from the English Longitudinal Study of Ageing. We used gendered typologies of life-time employment and a frailty index (FI). Multilevel growth curve models were used to predict frailty trajectories by employment histories.

Results

Women who had a short break for family care, then did part-time work till 59 years had a lower FI after 60 years than those who undertook full-time work until 59 years. Women who were largely family carers or non-employed throughout adulthood, had higher levels of frailty at 60 years but experienced a slower decline with age. Men who worked full-time but early exited at either 49 or 60 years had a higher FI at 65 years than those who worked full-time up to 65 years. Interaction between employment histories and age indicated that men in full-time work who experienced an early exit at 49 tended to report slower declines.

Conclusions

For women, experiencing distinct periods throughout the lifecourse of either work or family care may be advantageous for lessening frailty risk in later life. For men, leaving paid employment before 65 years seems to be beneficial for decelerating increases in frailty thereafter. Continuous full-time work until retirement age conferred no long-term health benefits.

Validation of the FRAIL scale in Mexican elderly: results from the Mexican Health and Aging Study

BACKGROUND

The aging population in Latin America is characterized by not optimal conditions for good health, experiencing high burden of comorbidity, which contribute to increase the frequency of frailty; thus, identification should be a priority, to classify patients at high risk to develop its negative consequences.

AIM

The objective of this analysis was to validate the FRAIL instrument to measure frailty in Mexican elderly population, from the database of the Mexican Health and Aging Study (MHAS).

MATERIALS AND METHODS

Prospective, population study in Mexico, that included subjects of 60 years and older who were evaluated for the variables of frailty during the year 2001 (first wave of the study). Frailty was measured with the five-item FRAIL scale (fatigue, resistance, ambulation, illnesses, and weight loss). The robust, pre-frail or intermediate, and the frail group were considered when they had zero, one, and at least two components, respectively. Mortality, hospitalizations, falls, and functional dependency were evaluated during 2003 (second wave of the study). Relative risk was calculated for each complications, as well as hazard ratio (for mortality) through Cox regression model and odds ratio with logistic regression (for the rest of the outcomes), adjusted for covariates.

RESULTS

The state of frailty was independently associated with mortality, hospitalizations, functional dependency, and falls. The pre-frailty state was only independently associated with hospitalizations, functional dependency, and falls.

CONCLUSIONS

Frailty measured through the FRAIL scale, is associated with an increase in the rate of mortality, hospitalizations, dependency in activities of daily life, and falls.

Frailty Screening in Low- and Middle-Income Countries: A Systematic Review

OBJECTIVES

To conduct a systematic review of frailty screening tools used in low- and middle-income countries (LMICs).

DESIGN

Systematic review.

SETTING

LMICs, as defined by the World Bank on June 30, 2014.

PARTICIPANTS

Elderly adults (as defined by the authors) living in LMICs.

MEASUREMENTS

Studies were included if the population under consideration lived in a LMIC, the study involved an assessment of frailty, the study population was elderly adults, and the full text of the study was available in English. The Medline, Embase, CINAHL and PsychINFO databases were searched up to June 30, 2014.

RESULTS

Seventy studies with data from 22 LMICs were included in the review. Brazil, Mexico, and China provided data for 60 of the 70 studies (85.7%), and 15 countries contributed data to only one study. Thirty-six studies used the Fried criteria to assess frailty, 20 used a Frailty Index, and eight used the Edmonton Frailty Scale; none of the assessment tools used had been fully validated for use in a LMIC.

CONCLUSION

There has been a rapid increase in the number of published studies of frailty in LMICs over the last 5 years. Further validation of the assessment tools used to identify frail elderly people in LMICs is needed if they are to be efficient in identifying those most in need of health care in such settings.

Diabetes mellitus, hypertension and frailty: A population-based, cross-sectional study of Mexican older adults

AIM

Chronic diseases are frequent in older adults, particularly hypertension and diabetes. The relationship between frailty and these two conditions is still unclear. The aim of the present analyses was to explore the association between frailty with diabetes and hypertension in Mexican older adults.

METHODS

Analyses of the Mexican Health and Nutrition Survey, a cross-sectional survey, are presented. Data on diabetes and hypertension were acquired along with associated conditions (time since diagnosis, pharmacological treatment, among others). A 36-item frailty index was constructed and rescaled to z-values (individual scores minus population mean divided by one standard deviation). Multiple linear regression models were carried out, adjusted for age and sex.

RESULTS

From 7164 older adults, 54.8% were women, and their mean age was 70.6 years with a mean frailty index score of 0.175. The prevalence of diabetes was of 22.2%, and 37.3% for hypertension. An independent association between diabetes, hypertension or both conditions (coefficients 0.28, 0.4 and 0.63, respectively, P < 0.001) with frailty was found. Having any diabetic complication was significantly associated with frailty with a coefficient of 0.55 (95% CI 0.45-0.65, P < 0.001) in the adjusted model. The number of years since diagnosis was also associated with frailty for both conditions.

CONCLUSIONS

Diabetes and hypertension are associated with frailty. In addition, an incremental association was found when both conditions were present or with worse associated features (any complication, more time since diagnosis). Frailty should be of particular concern in populations with a high prevalence of these conditions. Geriatr Gerontol Int 2017; 17: 925-930.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa

BACKGROUND

The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries.

METHODS

Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa.

RESULTS

This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa.

CONCLUSIONS

Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Frailty and Mortality Outcomes in Cognitively Normal Older People: Sex Differences in a Population-Based Study

OBJECTIVES

To characterize frailty in cognitively normal older adults at baseline and to investigate the relationship between frailty and mortality.

DESIGN

Population-based prospective cohort study: Mayo Clinic Study of Aging.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

Cognitively normal older persons aged 70 and older (mean age 78.8±5.2, 50.2% male; N=2,356).

MEASUREMENTS

Frailty was assessed at baseline using a 36-item Frailty Index. Four frailty subgroups were identified based on the Frailty Index (≤0.10 (fit), 0.11-0.20 (at risk), 0.21-0.30 (frail), >0.30 (frailest)). All participants underwent comprehensive clinical and cognitive assessments. The association between frailty and mortality was assessed using Cox proportional hazards models.

RESULTS

The median Frailty Index was 0.17 (interquartile range 0.11-0.22). Frailty increased with age and was more common in older men than in older women. Over a median follow-up of 6.5 years (range 7 days to 8.9 years), 500 of the 2,356 participants died, including 292 men. The frailest participants had the greatest risk of death (hazard ratio (HR)=3.91, 95% confidence interval (CI)=2.69-5.68). The association was stronger in women (HR=5.26, 95% CI=2.88-9.61) than men (HR=3.15, 95% CI=1.98-5.02).

CONCLUSION

Baseline frailty was common, especially in older men, and increased with age. Frailty was associated with significantly greater risk of death, particularly in women. These sex differences should be considered when designing a geriatric care plan.

Frailty and food insecurity in older adults

Objective

The objective of the current work was to determine the association between food insecurity and frailty in older adults, within the context of a country with accelerated ageing and nutritional problems.

Design

Cross-sectional analysis of a representative nationwide survey on health and nutrition.

Setting

Mexican nationwide survey.

Subjects

A sample of 7108 adults aged 60 years or older living in communities, representative of Mexican older adults.

Results

Multivariate regression and descriptive analyses of food insecurity and frailty were performed. From a total of 7108 adults aged 60 years or older, with a mean age of 70·7 years, most (54·7 %) were women. Food security categories were: 26·3 % had food security, 40·3 % had mild food insecurity, 20·5 % had moderate food insecurity and 12·9 % had severe food insecurity. Food insecurity categories were associated with frailty, with the severe category having the highest odds ratio of 2·41 (95 % CI 2·03, 2·86; P<0·001) after adjustment for confounding factors.

Conclusions

According to our results, food insecurity is associated to frailty, which in turn is a condition that renders the older adult at a higher risk of developing adverse outcomes. Targeted food programmes for older adults with a high risk of having food insecurity or of being frail may improve health in this population group.

Frailty prevalence and associated factors in the Mexican health and aging study: A comparison of the frailty index and the phenotype

BACKGROUND

Frailty is a relatively new phenomenon described mainly in the older population. There are a number of different tools that aim at categorizing an older adult as frail. Two of the main tools for this purpose are the Fried's frailty phenotype (FFP) and the frailty index (FI). The aim of this report is to determine the prevalence of frailty and associated factors using both FFP and the FI.

METHODS

Secondary analysis of 1108 individuals aged 60 or older is participating in the third (2012) wave from the Mexican Health and Aging Study (MHAS). The FFP and the FI were constructed and a set of variables from different domains were used to explore associations. Domains included were: socio-demographic, health-related, and psychological factors. Regarding prevalence, concordance was tested with a kappa statistic. To test significant associations when classifying with each of the tools, multiple logistic regression models were fitted.

RESULTS

Mean (SD) age was 69.8 (7.6) years, and 54.6% (n=606) were women. The prevalence of frailty with FFP was 24.9% (n=276) while with FI 27.5% (n=305). Kappa statistics for concordance between tools was 0.34 (p<0.001). Age, years in school, number of past days in bed due to health problems, number of times that consulted a physician last year for health problems, having smoked in the past, and life satisfaction were associated with frailty when using any of the tools.

CONCLUSIONS

There is a persistent heterogeneity on how frailty is measured that should be addressed in future research.

Use of the frailty index in evaluating the prognosis of older people in Beijing: A cohort study with an 8-year follow-up

OBJECTIVE

Frailty is a significant healthcare challenge in China. However, the relationship between frailty and the prognosis of older people in China remains unclear. The present study aimed to evaluate the prevalence of frailty and determine if the frailty index, a comprehensive geriatric assessment, was associated with the prognosis of older people in a Chinese population.

METHODS

Data were drawn from the Beijing Longitudinal Study of Aging, a representative cohort study with an 8-year follow-up. Evaluations based on the use of the frailty index were performed in a cohort of 1808 people aged 60 years and over residing in Beijing urban and rural areas. The initial survey was conducted in 2004, with follow-up surveys at 3, 5, and 8 years. Mortality data for all individuals were collected and analyzed.

RESULTS

The frailty index and the age of individuals showed the same trend, with a higher frailty index expected as age increased. Respondents with the same frailty index level differed across factors such as sex and location. Male individuals, rural dwellers, and older individuals showed higher frailty rates than female individuals, urban dwellers, and younger individuals.

CONCLUSIONS

Frailty is a condition associated with problems across multiple physiological systems. The frailty index increases with age, and may be a significant tool for evaluation of the prognosis of older people in China.

Association of frailty with endothelial dysfunction and its possible impact on negative outcomes in Brazilian predialysis patients with chronic kidney disease

BACKGROUND

Frailty is a state of physiological vulnerability common in the elderly. It is more predominant in patients with Chronic Kidney Disease in comparison to healthy subjects, which can also be diagnosed in non-elderly individuals and be associated with innumerous causes such as muscle strength, body composition and inflammation. The association between frailty and endothelial function, as well as the association between frailty and the combined outcome of mortality multiple cause and start of renal replace therapy were assessed.

METHODS

In the initial analysis, sixty-one predialysis patients with Chronic Kidney Disease stages were evaluated and included in this study. Due to patient drop-out during follow-up, fifty-seven patients were subsequently re-evaluated 12 months later. The diagnosis of frailty was based on the Johansen et al. (J Am Soc Nephrol 18(11):2960-67, 2007) criteria. The groups were divided into Non-frail and Frail. Sociodemographic, inflammatory markers (IL-6, TNF-?, CRP-us), endothelial dysfunction (flow-mediated vasodilatation - FMD), body composition (DXA) and the 25-hidroxi-vitamin D parameters were analyzed.

RESULTS

The average age of the patients used in the study was 64.9 ± 10.3 years old. The predominance of frailty was 42.6%, of which 46% were non-elderly. After some adjustments, frailty was associated with gender (OR = 11.32; IC 95% = 2.30 to 55.67), advanced age (OR = 4.07; IC 95% = 1.02 to 16.20), obesity (OR = 6.63; IC 95% = 0.82 to 11.44) and endothelial dysfunction (OR = 3.86; IC 95% = 1.00 to 14.88). The ratio of the incidence of frail subjects to the variable outcome was 2.5 (CI 95%, 1.04 to 6.50).

CONCLUSIONS

Although an observational study does not allow one to determine the casual relation between frailty and endothelial dysfunction, we conclude that frailty was predominant in our sample of Brazilian patients with chronic kidney disease on predialysis, even in elderly individuals. This was linked to either worse endothelial function or mortality.

Frailty and the risk of cognitive impairment

Aging occurs as a series of small steps, first causing cellular damage and then affecting tissues and organs. This is also true in the brain. Frailty, a state of increased risk due to accelerated deficit accumulation, is robustly a risk factor for cognitive impairment. Community-based autopsy studies show that frail individuals have brains that show multiple deficits without necessarily demonstrating cognitive impairment. These facts cast a new light on the growing number of risk factors for cognitive impairment, suggesting that, on a population basis, most health deficits can be associated with late-life cognitive impairment. The systems mechanism by which things that are bad for the body are likely to be bad for the brain can be understood like this: the burden of health deficits anywhere indicates impaired ability to withstand or repair endogenous and environmental damage. This in turn makes additional damage more likely. If true, this suggests that a life course approach to preventing cognitive impairment is desirable. Furthermore, conducting studies in highly selected, younger, healthier individuals to provide ‘proof of concept’ information is now common. This strategy might exclude the very circumstances that are required for disease expression in the people in whom dementia chiefly occurs (that is, older adults who are often in poor health).

Frailty and the prediction of dependence and mortality in low- and middle-income countries: a 10/66 population-based cohort study

BACKGROUND

In countries with high incomes, frailty indicators predict adverse outcomes in older people, despite a lack of consensus on definition or measurement. We tested the predictive validity of physical and multidimensional frailty phenotypes in settings in Latin America, India, and China.

METHODS

Population-based cohort studies were conducted in catchment area sites in Cuba, Dominican Republic, Venezuela, Mexico, Peru, India, and China. Seven frailty indicators, namely gait speed, self-reported exhaustion, weight loss, low energy expenditure, undernutrition, cognitive, and sensory impairment were assessed to estimate frailty phenotypes. Mortality and onset of dependence were ascertained after a median of 3.9 years.

RESULTS

Overall, 13,924 older people were assessed at baseline, with 47,438 person-years follow-up for mortality and 30,689 for dependence. Both frailty phenotypes predicted the onset of dependence and mortality, even adjusting for chronic diseases and disability, with little heterogeneity of effect among sites. However, population attributable fractions (PAF) summarising etiologic force were highest for the aggregate effect of the individual indicators, as opposed to either the number of indicators or the dichotomised frailty phenotypes. The aggregate of all seven indicators provided the best overall prediction (weighted mean PAF 41.8 % for dependence and 38.3 % for mortality). While weight loss, underactivity, slow walking speed, and cognitive impairment predicted both outcomes, whereas undernutrition predicted only mortality and sensory impairment only dependence. Exhaustion predicted neither outcome.

CONCLUSIONS

Simply assessed frailty indicators identify older people at risk of dependence and mortality, beyond information provided by chronic disease diagnoses and disability. Frailty is likely to be multidimensional. A better understanding of the construct and pathways to adverse outcomes could inform multidimensional assessment and intervention to prevent or manage dependence in frail older people, with potential to add life to years, and years to life.

The rate of aging: the rate of deficit accumulation does not change over the adult life span

People age at different rates. We have proposed that rates of aging can be quantified by the rate at which individuals accumulate health deficits. Earlier estimates, using cross-sectional analyses suggested that deficits accumulated exponentially, at an annual rate of 3.5%. Here, we estimate the rate of deficit accumulation using longitudinal data from the Canadian National Population Health Survey. By analyzing age-specific trajectories of deficit accumulation in people aged 20 years and over (n = 13,668) followed biannually for 16 years, we found that the longitudinal average annual rate of deficit accumulation was 4.5% (±0.75%). This estimate was notably stable during the adult life span. The corresponding average doubling time in the number of deficits was 15.4 (95% CI 14.82-16.03) years, roughly 30% less than we had reported from the cross-sectional analysis. Earlier work also established that the average number of deficits accumulated by individuals (N), equals the product of the intensity of environmental stresses (λ) causing damage to the organism, by the average recovery time (W). At the individual level, changes in deficit accumulation can be attributed to both changes in environmental stresses and changes in recovery time. By contrast, at the population level, changes in the number of deficits are proportional to the changes in recovery time. In consequence, we propose here that the average recovery time, W doubles approximately every 15.4 years, independently of age. Such changes quantify the increase of vulnerability to stressors as people age that gives rise to increasing risk of frailty, disability and death. That deficit accumulation will, on average, double twice between ages 50 and 80 highlights the importance of health in middle age on late life outcomes.