The Association between Frailty and All-Cause Mortality in Community-Dwelling Older Individuals: An Umbrella Review

Sex differences in biological aging and the association with clinical measures in older adults

Females live longer than males, and there are sex disparities in physical health and disease incidence. However, sex differences in biological aging have not been consistently reported and may differ depending on the measure used. This study aimed to determine the correlations between epigenetic age acceleration (AA), and other markers of biological aging, separately in males and females. We additionally explored the extent to which these AA measures differed according to socioeconomic characteristics, clinical markers, and diseases. Epigenetic clocks (HorvathAge, HannumAge, PhenoAge, GrimAge, GrimAge2, and DunedinPACE) were estimated in blood from 560 relatively healthy Australians aged ≥ 70 years (females, 50.7%) enrolled in the ASPREE study. A system-wide deficit accumulation frailty index (FI) composed of 67 health-related measures was generated. Brain age and subsequently brain-predicted age difference (brain-PAD) were estimated from neuroimaging. Females had significantly reduced AA than males, but higher FI, and there was no difference in brain-PAD. FI had the strongest correlation with DunedinPACE (range r: 0.21 to 0.24 in both sexes). Brain-PAD was not correlated with any biological aging measures. Significant correlations between AA and sociodemographic characteristics and health markers were more commonly found in females (e.g., for DunedinPACE and systolic blood pressure r = 0.2, p < 0.001) than in males. GrimAA and Grim2AA were significantly associated with obesity and depression in females, while in males, hypertension, diabetes, and chronic kidney disease were associated with these clocks, as well as DunedinPACE. Our findings highlight the importance of considering sex differences when investigating the link between biological age and clinical measures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Social frailty as a predictor of adverse outcomes among older adults: a systematic review and meta-analysis

BACKGROUND

With the aging of the population, frailty has attracted much attention, and the social dimension of frailty, namely social frailty, has also attracted attention. Studies have shown that social frailty can bring some adverse effects to the elderly, such as physical and cognitive function.

AIMS

To explore the risk of adverse health outcomes in older adults with social frailty compared with older adults with non-social frailty.

METHODS

Five databases were systematically searched from inception to February 28, 2023. Screening, data extraction and quality assessment were conducted independently by two researchers. The included studies were longitudinal studies of adverse outcomes in community-dwelling socially frail older adults, and the quality of each study was assessed using the Newcastle‒Ottawa Scale.

RESULTS

A total of 15 studies were included based on the inclusion criteria, of which 4 were subjected to meta-analysis. The mean age of the included population ranged from 66.3 to 86.5 years. According to existing research, social frailty was predictive of some adverse outcomes, such as incident disability, depressive symptoms, and reduced neuropsychological function. The meta-analysis showed that social frailty had a significant predictive effect on mortality among older adults [HR = 2.27, (95% CI = 1.03-5.00)].

CONCLUSION

In community-dwelling older adults, social frailty was a predictor of mortality, incident disability, depressive symptoms and other adverse outcomes. Social frailty had a negative impact on older adults, so it was necessary to strengthen the screening of social frailty to reduce the incidence of adverse outcomes.

Associations of Change in Body Size With All-Cause and Cause-Specific Mortality Among Healthy Older Adults

Importance

The association between weight change and subsequent cause-specific mortality among older adults is not well described. The significance of changes in waist circumference (WC) has also not been compared with weight change for this purpose.

Objective

To examine the associations of changes in body weight and WC with all-cause and cause-specific mortality.

Design, Setting, and Participants

This cohort study is a post hoc analysis of data from the Aspirin in Reducing Events in the Elderly (ASPREE) randomized clinical trial, which recruited participants between March 1, 2010, and December 31, 2014. The study included community-based older adults (16 703 Australian participants aged ≥70 years and 2411 US participants aged ≥65 years) without evident cardiovascular disease (CVD), dementia, physical disability, or life-limiting chronic illness. Data analysis was performed from April to September 2022.

Exposures

Body weight and WC were measured at baseline and at annual visit 2. Analysis models were adjusted for baseline body mass index because height and weight were measured at baseline, allowing for calculation of body mass index and other variables. Both body weight and WC changes were categorized as change within 5% (stable), decrease by 5% to 10%, decrease by more than 10%, increase by 5% to 10%, and increase by more than 10%.

Main Outcomes and Measures

All-cause, cancer-specific, CVD-specific, and noncancer non-CVD-specific mortality. Mortality events were adjudicated by an expert review panel. Cox proportional hazards regression and competing risk analyses were used to calculate hazard ratios (HRs) and 95% CIs.

Results

Among 16 523 participants (mean [SD] age, 75.0 [4.3] years; 9193 women [55.6%]), 1256 deaths were observed over a mean (SD) of 4.4 (1.7) years. Compared with men with stable weight, those with a 5% to 10% weight loss had a 33% higher (HR, 1.33; 95% CI, 1.07-1.66) risk of all-cause mortality, and those with more than a 10% decrease in body weight had a 289% higher (HR, 3.89; 95% CI, 2.93-5.18) risk. Compared with women with stable weight, those with a 5% to 10% weight loss had a 26% higher (HR, 1.26; 95% CI, 1.00-1.60) risk of all-cause mortality, and those with more than a 10% decrease in body weight had a 114% higher (HR, 2.14; 95% CI, 1.58-2.91) risk. Weight loss was associated with a higher cancer-specific mortality (>10% decrease among men: HR, 3.49; 95% CI, 2.26-5.40; 5%-10% decrease among women: HR, 1.44; 95% CI, 1.46-2.04; >10% decrease among women: HR, 2.78; 95% CI, 1.82-4.26), CVD-specific mortality (>10% decrease among men: HR, 3.14; 95% CI, 1.63-6.04; >10% decrease among women: HR, 1.92; 95% CI, 1.05-3.51), and noncancer non-CVD-specific mortality (>10% decrease among men: HR, 4.98; 95% CI, 3.14-7.91). A decrease in WC was also associated with mortality.

Conclusions and Relevance

This cohort study of healthy older adults suggests that weight loss was associated with an increase in all-cause and cause-specific mortality, including an increased risk of cancer, CVD, and other life-limiting conditions. Physicians should be aware of the significance of weight loss, especially among older men.

Effects of exercise interventions on physical and psychological outcomes in frail older adults: Protocol for an overview of systematic reviews

AIMS

To systematically summarize the existing evidence regarding the effects of exercise interventions on physical and psychological outcomes in frail older adults and appraise the quality and strength of the evidence.

DESIGN

An overview protocol.

METHODS

A literature search of PubMed, Embase, Web of Science, CINAHL and Cochrane Database of Systematic Reviews will be conducted to identify relevant systematic reviews with or without meta-analysis on exercise interventions for frail older adults. Two independent reviewers will select articles, extract data and appraise the quality of included reviews. Physical and psychological outcomes will be synthesized using narrative summaries. The methodological quality of included reviews and the quality of evidence will also be assessed.

RESULTS

This overview will present the evidence on the effects of exercise interventions on physical and psychological outcomes for frail older adults, contributing to the implementation of exercise interventions to improve health outcomes for this population.

The Association between Frailty and Dementia-Free and Physical Disability-Free Survival in Community-Dwelling Older Adults

INTRODUCTION

Frailty is a common geriatric syndrome that adversely impacts health outcomes. This study examined correlates of physical frailty in healthy community-dwelling older adults and studied the effect of frailty on disability-free survival (DFS), defined as survival free of independence-limiting physical disability or dementia.

METHODS

This is a post hoc analysis of 19,114 community-dwelling older adults (median age: 74.0 years, interquartile range or IQR: 6.1 years) from Australia and the USA enrolled in the "ASPirin in Reducing Events in the Elderly (ASPREE)" clinical trial. Frailty was assessed using a modified Fried phenotype and a deficit accumulation frailty index (FI) utilizing a ratio score derived from 66 items. Multinomial logistic regression was used to examine the correlates of frailty and Cox regression to analyze the association between frailty and DFS (and its components).

RESULTS

At study enrollment, 39.0% were prefrail, and 2.2% of participants were frail, according to Fried phenotype. Older age, higher waist circumference, lower education, ethnoracial origin, current smoking, depression, and polypharmacy were associated with prefrailty and frailty according to Fried phenotype and FI. Fried phenotype defined prefrailty and frailty predicted reduced DFS (prefrail: HR: 1.67; 95% CI: 1.50-1.86 and frail: HR: 2.80; 95% CI: 2.27-3.46), affecting each component of DFS including dementia, physical disability, and mortality. Effect sizes were larger, according to FI.

CONCLUSION

Our study showed that prefrailty is common in community-dwelling older adults initially free of cardiovascular disease, dementia, or independence-limiting physical disability. Prefrailty and frailty significantly reduced disability-free survival. Addressing modifiable correlates, like depression and polypharmacy, might reduce the adverse impact of frailty on dementia-free and physical disability-free survival.

Frailty and risks of all-cause and cause-specific death in community-dwelling adults: a systematic review and meta-analysis

Background

The associations of frailty with all-cause and cause-specific mortality remain unclear. Therefore, we performed this meta-analysis to fill this gap.

Methods

We searched the PubMed and Embase databases through June 2022. Prospective cohort studies or clinical trials examining frailty were evaluated, and the multiple adjusted risk estimates of all-cause and cause-specific mortality, such as death from cardiovascular disease (CVD), cancer, respiratory illness, dementia, infection, and coronavirus disease 2019 (COVID-19), were included. A random effects model was used to calculate the summary hazard ratio (HR).

Results

Fifty-eight studies were included for the qualitative systematic review, of which fifty-six studies were eligible for the quantitative meta-analysis, and the studies included a total of 1,852,951 individuals and more than 145,276 deaths. Compared with healthy adults, frail adults had a significantly higher risk of mortality from all causes (HR 2.40; 95% CI 2.17–2.65), CVD (HR 2.64; 95% CI 2.20–3.17), respiratory illness (HR 4.91; 95% CI 2.97–8.12), and cancer (HR 1.97; 95% CI 1.50–2.57). Similar results were found for the association between prefrail adults and mortality risk. In addition, based on the studies that have reported the HRs of the mortality risk per 0.1 and per 0.01 increase in the frailty index, we obtained consistent results.

Conclusions

The present study demonstrated that frailty was not only significantly related to an increased risk of all-cause mortality but was also a strong predictor of cause-specific mortality from CVD, cancer, and respiratory illness in community-dwelling adults. More studies are warranted to clarify the relationship between frailty and cause-specific mortality from dementia, infection, and COVID-19.

Trial registration

PROSPERO (CRD42021276021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03404-w.

Predictors of Adverse Outcomes in Healthy Aging Adults: Coronary Artery Disease, Lower Educational Status and Higher P-Selectin Levels

Background

Societal aging – as a global demographic phenomenon – shows no indication of abating. As a result, the problem of age-associated disability and related long-term care is emerging as a major public health challenge. It is important that methods for identifying older adults at risk of adverse outcomes are implemented early.

Methods

The study group consisted of 145 individuals, 44.1% women, who were randomized from community-dwelling 60–74-year-old adults. A comprehensive geriatric assessment was supplemented with Fried frailty phenotype evaluation and blood tests (including adhesion molecules, matrix metalloproteinases and neurotrophic factors). A follow-up by phone call was made for at least 3 years after the initial examination. Composite endpoint (CE) included falls, hospitalization, institutionalization and death.

Results

Mean study group age was 66.5 ± 4.1 years (\documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$\overline {\rm{X}} {\rm{ \pm SD}}$$ \end{document}) and mean number of diseases was 3.7 ± 2.2. Functional status of the subjects was good, as indicated by high Barthel Index scores of 99.1 ± 2.4, MMSE scores of 29.0 ±1.5 and no frailty case. During a three-year follow-up, 71 participants (49.0%) experienced any CE-events. The Wilcoxon-Gehan test indicates that a higher probability of three-year CE completion was associated with an age >65 years (P = 0.006), coronary artery disease (CAD) (P = 0.008), 6-Minute Walk Test <432 m (P = 0.034), serum glucose >120 mg/dL (P = 0.047), serum cortisol >10 μg/dL (P = 0.011), leptin ≥15 ng/mL (P = 0.018), P-selectin ≥23 ng/mL (P = 0.006) and GDNF ≥20 pg/mL (P = 0.004). CAD (OR = 3.64, 95% CI = 1.53−8.69, P = 0.004), educational status (OR = 0.87, 95% CI = 0.77−0.98, P = 0.022) and P-selectin levels (OR = 1.07, 95% CI = 1.02−1.13, P = 0.013) were independent measures predicting three-year CE occurrence in multivariate logistic regression analysis adjusted for clinical and functional measures, and blood tests.

Conclusion

Coronary artery disease, poorer lower educational status and higher P-selectin levels were predictive of adverse outcomes in the community-dwelling healthy-aging early-old adults during three-year follow-up.

Association of Oral Function and Dysphagia with Frailty and Sarcopenia in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

Studies investigating the associations of oral function and dysphagia with frailty and sarcopenia in community-dwelling older adults are increasing; however, they have not been systematically summarized. We conducted a systematic review to investigate these associations. We searched electronic databases and synthesized relevant data using conventional (frequentist-style) and Bayesian meta-analyses. Twenty-four studies were found to be eligible for our review, including 20 cross-sectional and four prospective cohort studies. Older adults with frailty or sarcopenia had lower tongue pressure, according to the results of conventional meta-analysis (mean difference [95% confidence interval or credible interval]: −6.80 kPa [−10.22 to −3.38] for frailty and −5.40 kPa [−6.62 to −4.17] for sarcopenia) and Bayesian meta-analysis (−6.90 kPa [−9.0 to −4.8] for frailty, −5.35 kPa [−6.78 to −3.89] for sarcopenia). People with frailty had a higher odds ratio (OR) for dysphagia according to the results of conventional meta-analysis (3.99 [2.17 to 7.32]) and Bayesian meta-analysis (1.38 [0.77 to 1.98]). However, the results were inconclusive for people with sarcopenia. A prospective association could not be determined because of the lack of information and the limited number of studies. Decreased oral function and dysphagia can be important characteristics of frailty and sarcopenia in community-dwelling older adults.

Frailty Among Older Individuals with and without COPD: A Cohort Study of Prevalence and Association with Adverse Outcomes

Rationale

Frailty prevalence estimates among individuals with COPD have varied widely, and few studies have investigated relationships between frailty and adverse outcomes in a COPD population.

Objective(s)

Describe frailty prevalence among individuals with and without COPD and examine associations between frailty and mortality and other adverse outcomes in the next two years.

Methods

This was an observational cohort study using Health and Retirement Study data (2006–2018) of community living individuals ages 50–64 and ≥65 with and without COPD (non-COPD). Frailty (Fried phenotype [5 items], and a modified Frailty Index-Comprehensive Geriatric Assessment [Enhanced FI-CGA] [37 items], and debility (modified BODE Index [4 items]) were assessed. Two-year post-assessment outcomes (mortality, ≥1 inpatient stay, home health and skilled nursing facility (SNF) use) were reviewed in a population matched 3:1 (non-COPD: COPD) on age, sex, race, and year using univariate and multivariate logistic regression (adjusted for morbidities). Area-under-the-curve (AUC) was used to evaluate regressions.

Results

The study included 18,979 survey observations for age 50–64, and 24,162 age ≥65; 7.8% and 12.0% respectively reporting a diagnosis of COPD. Fried phenotype frailty prevalence for age ≥65 was 23.1% (COPD) and 9.4% (non-COPD), and for the Enhanced FI-CGA, 45.9% (COPD) and 22.4% (non-COPD). Two-year mortality for COPD was more than double non-COPD for age 50–64 (95% CI: 3.8–5.9% vs 0.7–1.3%) and age ≥65 (95% CI: 11.9–14.3% vs 5.6–6.6%). Inpatient utilization, home health care use, or at least temporary SNF placement were also more frequent for COPD. Measures were predictive of adverse outcomes. In adjusted models, the Fried phenotype and modified BODE score performed similarly, and both performed better than the Enhanced FI-CGA index. AUC values were higher for morality regressions.

Conclusion

Frailty prevalence among individuals with COPD in this national survey is substantially greater than without COPD, even at pre-retirement (50–64 years). These measures identify patients with increased risk of poor outcomes.

Drug Treatment of Hypercholesterolemia in Older Adults: Focus on Newer Agents

There is increasing research interest in cholesterol-lowering therapy in older patients. The newer lipid-lowering agents (the proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors evolocumab and alirocumab; the PCSK9 synthesis inhibitor inclisiran, and the adenosine triphosphate–citrate lyase inhibitor bempedoic acid) might also provide more options for the future treatment of older patients. Data analyses of the phase III outcome trials of the PCSK9 inhibitors suggest that their clinical benefits are maintained at older ages and that there is no increased relative risk of adverse events in older patients; however, data from patients aged ≥ 75 years and particularly aged ≥ 85 years are limited, and the trials did not collect information on the frailty status of patients. Frailty is a predictor of adverse outcomes, including mortality, and might help guide therapy decisions. To date, no outcome data are available for cardiovascular endpoints for the low-density lipoprotein cholesterol-lowering drugs inclisiran and bempedoic acid. Except for the risk of gout and tendon rupture with bempedoic acid, which remains to be further characterized in larger populations, the safety profile of the novel lipid-lowering agents in older patients seems favorable. The newer lipid-lowering agents could be added to other lipid-lowering medication or used as an alternative treatment in older patients with documented statin intolerance (as is already recommended in guidelines for the PCSK9 inhibitors), such as myopathy. Especially in older patients needing high-intensity therapy despite polypharmacy or certain comedications, the absence of clinically relevant drug–drug interactions with the PCSK9 inhibitors and inclisiran might be an advantage.

Associations of pre-pandemic levels of physical function and physical activity with COVID-19-like symptoms during the outbreak

Background

One’s physical function and physical activity levels can predispose or protect from the development of respiratory infections. We aimed to explore the associations between pre-pandemic levels of physical function and physical activity and the development of COVID-19-like symptoms in Swedish older adults.

Methods

We analyzed data from 904 individuals aged ≥ 68 years from the population-based Swedish National study on Aging and Care in Kungsholmen. COVID-19-like symptoms were assessed by phone interview (March–June 2020) and included fever, cough, sore throat and/or a cold, headache, pain in muscles, legs and joints, loss of taste and/or odor, breathing difficulties, chest pain, gastrointestinal symptoms, and eye inflammation. Muscle strength, mobility, and physical activity were examined in 2016–2018 by objective testing. Data were analyzed using logistic regression models in the total sample and stratifying by age.

Results

During the first outbreak of the pandemic, 325 (36%) individuals from our sample developed COVID-19-like symptoms. Those with slower performance in the chair stand test had an odds ratio (OR) of 1.5 (95% confidence interval [CI] 1.1–2.1) for presenting with COVID-19-like symptoms compared to better performers, after adjusting for potential confounders. The association was even higher among people aged ≥ 80 years (OR 2.6; 95% CI 1.5–4.7). No significant associations were found between walking speed or engagement in moderate-to-vigorous physical activity and the likelihood to develop COVID-19-like symptoms.

Conclusion

Poor muscle strength, a possible indicator of frailty, may predispose older adults to higher odds of developing COVID-19-like symptoms, especially among the oldest-old.