Conceptualisation and measurement of frailty in elderly people

Frailty in Geriatrics: A Critical Review with Content Analysis of Instruments, Overlapping Constructs, and Challenges in Diagnosis and Prognostic Precision

Frailty is a key concept in geriatric care; yet its definition and assessment remain debated. Since the early 2000s, two main models have emerged: the Fried frailty phenotype, focusing on physical deficits, and the Mitnitski frailty index, which incorporates broader health factors. These divergent approaches have led to over 50 frailty instruments, reflecting the absence of a unified framework. This review explores the content, weighting, and scoring methods of frailty instruments, identifying potential concerns derived from this. This review exposes the overlap of frailty with other constructs including function, disability, morbidity, and sarcopenia. Many instruments lack content validity, and detect highly heterogeneous samples within and between scales, all labeled under the "frail" tag. This poses challenges to interpreting instrument responsiveness. In addition, frailty should not be considered a clinical entity with a unique etiology. This review discusses how the broad nature of frailty conflicts with modern paradigms of individualization and precision. They may be useful in primary care, but lack the specificity for secondary care evaluations. This article also discusses how the predictive validity of frailty should be interpreted with caution. Finally, we summarize our findings and propose a new definition of frailty, highlighting the strengths and weaknesses of the construct. The identified inconsistencies should serve as a guide for refining the concept of frailty, both in research and in its application to geriatric care.

Role of Biological Age in the Determination of Long-Term Cause-Specific Death Following Percutaneous Coronary Interventions

BACKGROUND

We tested whether biologic age, as estimated by deficits, functional impairments, or Age-Gap or their combination, provide improved estimation of cause-specific death as compared with chronological age.

METHODS

Cardiovascular and noncardiovascular deficits, functional impairments, and Age-Gap were prospectively collected in 535 patients aged ≥55 years undergoing percutaneous coronary interventions between August 1, 2014, and March 31, 2018. Age-Gap was calculated as the difference between chronological age and age estimated by artificial intelligence ECG using a convolutional neural network. The full biological age model included deficits, functional impairments, and Age-Gap >2 SD. A multivariable reduced model with the least number of variables was also created to provide a comparable C index to the full model.

RESULTS

The average chronological age was 72.1±9.5 years, and there were 68% of men. During a median follow-up of 2.61 years, 124 (23%) patients died. There was a modest correlation between Age-Gap and biological age (r=0.28 [95% CI, 0.20-0.35]; P<0.001). When modeled with chronologic age as a covariate, Age-Gap predicted all-cause (hazard ratio [HR], 1.07 [95% CI, 1.04-1.10]; P<0.001) and cardiovascular (HR, 1.07 [95% CI, 1.04-1.11]; P<0.001) mortality. As compared with chronological age, the full biological age model noted significant improvement in the prediction of long-term overall (95% CI, 0.65-0.78), cardiovascular (95% CI, 0.69-0.77), and noncardiovascular (95% CI, 0.55-0.86) mortality. In the reduced models, most prognostic information for noncardiovascular mortality (C index: 0.79) was obtained by subjective difficulty in performing tasks, whereas the deficit-based estimation predicted cardiovascular mortality (C index: 0.72).

CONCLUSIONS

Estimated biological age from deficits and functional impairments was superior to chronological age in predicting long-term cause-specific mortality following percutaneous coronary interventions.

Association between a geriatric measure tool and adverse outcomes among older adults treated in an emergency department: a retrospective cohort study

The COVID-19 pandemic provided an ideal scenario for studying the care of the elderly population, we implemented a tool named the Geriatric Measure (GM) tool to determine the severity and need for hospitalization. The objective of the study is to evaluate if the results of a brief Geriatric Measure tool are associated with mortality and other outcomes among older adults with COVID-19 treated in the emergency department. Retrospective observational cohort study. Participants were older adults (65 years and over) who required hospitalization for SARS CoV2 pneumonia. Patients were evaluated with the GM tool and were followed-up until death or discharge and associations between GM tool scores and mortality and other outcomes were assessed. A total of 275 patients were included. The proportion of patients who died increased with every category of the GM tool. Patients in category 1 (fit with good functional status) had a mortality of 24.7% versus those in category 4 (frail with poor functional status) who had a mortality of 51%. Our results show an association between our GM tool and mortality among older adults with pneumonia caused by SARS CoV2 and treated in the emergency department, and highlight the need of individualizing care for older patients.

Enhancing the convenience of frailty index assessment for elderly Chinese people with machine learning methods

Frailty is a state that is closely associated with adverse health outcomes in the aging process. The frailty index (FI), which measures frailty in terms of cumulative deficits, has been widely used for frailty assessment in elderly people, and its advantage of self-reported information collection makes it applicable to a broader group of elderly people. Our study aims to simplify the Frailty Index Assessment Scale, while maintaining its reliability and accuracy, to easily and quickly assess frailty in elderly people. In this study, participants (age ≥ 65 years) from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which had 13,339, 372 and 1214 participants in 2008, 2011, and 2014, respectively, were used. The 2008 dataset was split into 80% for training and 20% for internal validation, and the data from 2011 to 2014 as external validation. In order to obtain effective predictors, we used Lasso regression, Boruta algorithm and random forest classifier score for feature selection. We used six models for predictive model construction and evaluated the models in the validation dataset. Model performance was measured by area under the curve (AUC), accuracy and F1 score. Logistic regression was found to be the best performing and most interpretable algorithm with AUC, accuracy and F1 of 0.974, 0.932 and 0.880 for the validation dataset, respectively. The AUCs for the external independent validation dataset were 0.963 and 0.977, respectively. Subgroup analysis showed that the model had good predictive power in both males and females. The predictive power was stronger among the elderly people over 80 years old, with AUC, accuracy and F1 of 0.973,0.914, and 0.893, respectively. The model also obtained good predictive power in the case of FI measured by different indicators. The model showed good robustness in the follow-up assessment of frailty status in elderly people, with the AUC remaining above 0.95 and accuracy above 0.9 over the long-term follow-up. Using machine learning techniques, we have successfully developed a simple frailty assessment prediction model based on 10 key features to shorten the frailty assessment scale with near full-scale accuracy. A user-friendly website was created to facilitate the application of this prediction model ( https://healthy-aging.shinyapps.io/Frailty_Assessment/ ).

Identifying the palliative care needs of frail, older, housebound patients in the community: A cross-sectional study

BACKGROUND

The early introduction of palliative care can have a positive impact on the quality of life of patients suffering from life-limiting diseases. However, the palliative care needs of older, frail, housebound patients are still mostly unknown, as is the impact of frailty on the importance of these needs.

OBJECTIVES

To identify the palliative care needs of frail, older, housebound patients in the community.

METHODS

We conducted a cross-sectional observational study. This study took place in a single primary care center and included patients who were ≥65 years old, housebound, followed by the Geriatric Community Unit of the Geneva University Hospitals.

RESULTS

Seventy-one patients completed the study. Most patients were female (56.9%), and mean age (SD) was 81.1 (±7.9). The Edmonton Symptom Assessment Scale mean (SD) score was higher in frail patients as opposed to vulnerable patients for tiredness (p = 0.016), drowsiness (p = 0.0196), loss of appetite (p = 0.0124), and impaired feeling of well-being (p = 0.0132). There was no difference in spiritual well-being, measured by the spiritual scale subgroup of the Functional Assessment of the Chronic Illness Therapy-Spiritual Well-Being scale (FACIT-sp) between frail and vulnerable participants, although scores in both groups were low. Caregivers were mainly spouses (45%) and daughters (27.5%) with a mean (SD) age of 70.7 (±13.6). The overall carer-burden measured by the Mini-Zarit was low.

SIGNIFICANCE OF RESULTS

Older, frail, housebound patients have specific needs that differ from non-frail patients and should guide future palliative care provision. How and when palliative care should be provided to this population remains to be determined.

Physical Exercise for Healthy Older Adults and Those with Frailty: What Exercise Is Best and Is There a Difference? A Systematic Review and Meta-Analyses

Methods

All English studies published after 1989 with a controlled design, investigating PE in adults 65 years and over were considered if the study design compared PE to a nonexercise control group. Health-related outcomes included physical, cognitive, and psychological function. Studies that investigated cardiorespiratory disease and used designs like systematic review were excluded. Results and Discussion. Altogether, 57 studies were included of which 38 had data that were useable for meta-analysis. In the healthy aged, a significant benefit of multicomponent exercises (p=0.006, SMD = 1.40, CI = 0.41, 2.40) and tai chi (p=0.01, MD = 0.51, CI = 0.12, 0.91) on physical function was revealed, while strength exercise benefitted cognitive function (p=0.04, SMD = 0.86, CI = 0.03, 1.68). In frail older adults, there was a significant benefit of multicomponent exercises on physical function (p < 0.0001, SMD = -10.85, CI = 5.66, 16.04) and mental health (p=0.0002, SMD = -0.39, CI=-0.18, 0.59). Strength exercise had a significant benefit on activity of daily living (ADL) (p < 0.0003, SMD = 15.78, CI = 7.28, 24.28).

Conclusion

The substantial disparity of research in the field of exercise in older adults renders synthesis of the evidence problematic. However, it appears that multicomponent exercise is the most suitable approach for both healthy and frail older adults although the benefit may be reflected in different health outcomes.

Age-Related Dysfunction in Balance: A Comprehensive Review of Causes, Consequences, and Interventions

This review delves into the multifaceted aspects of age-related balance changes, highlighting their prevalence, underlying causes, and the impact they have on the elderly population. Central to this discussion is the exploration of various physiological changes that occur with aging, such as alterations in the vestibular, visual, proprioceptive systems, and musculoskeletal degeneration. We examine the role of neurological disorders, cognitive decline, and medication side effects in exacerbating balance issues. The review underscores the significance of early detection and effective intervention strategies in mitigating the risks associated with balance problems, such as falls and reduced mobility. It discusses the effectiveness of diverse intervention strategies, including exercise programs, rehabilitation techniques, and technological advancements like virtual reality, wearable devices, and telemedicine. Additionally, the review stresses the importance of a holistic approach in managing balance disorders, encompassing medication review, addressing comorbidities, and environmental modifications. The paper also presents future research directions, emphasizing the need for a deeper understanding of the complex mechanisms underlying balance changes with aging and the potential of emerging technologies and interdisciplinary approaches in enhancing assessment and intervention methods. This comprehensive review aims to provide valuable insights for healthcare providers, researchers, and policymakers in developing targeted strategies to improve the quality of life and ensure the well-being of the aging population.

Frailty detection in older adults via fractal analysis of acceleration signals from wrist-worn sensors

Purpose

Frailty is a reversible multidimensional syndrome that puts older people at a high risk of adverse health outcomes. It has been proposed to emerge from the dysregulation of the complex system dynamics of physiologic control systems. We propose the analysis of the fractal complexity of hand movements as a new method to detect frailty in older adults.

Methods

FRAIL scale and Fried's phenotype scores were calculated for 1209 subjects-72.4 (5.2) y.o. 569 women-and 1279 subjects-72.6 (5.3) y.o. 604 women-in the pubicly available NHANES 2011-2014 data set, respectively. The fractal complexity of their hand movements was assessed with a detrended fluctuation analysis (DFA) of their accelerometry records and a logistic regression model for frailty detection was fit.

Results

Goodness-of-fit to a power law was excellent (R2 > 0.98 ). The association between complexity loss and frailty level was significant, Kruskal-Wallis test (df = 2, Chisq = 27.545, p-value < 0.001 ). The AUC of the logistic classifier was moderate (AUC with complexity = 0.69 vs. AUC without complexity = 0.67).

Conclusion

Frailty can be characterized in this data set with the Fried phenotype. Non-dominant hand movements in free-living conditions are fractal processes regardless of age or frailty level and its complexity can be quantified with the exponent of a power law. Higher levels of complexity loss are associated with higher levels of frailty. This association is not strong enough to justify the use of complexity loss after adjusting for sex, age, and multimorbidity.

Analysis of the relationship between body habitus and frailty of community adults in Chongqing: a cross-sectional survey study

Objective

Currently, a multitude of studies are underway to investigate the factors affecting the degree of frailty, with a significant focus on the critical role of body mass index (BMI). This study aims to conduct a cross-sectional survey to investigate the multifaceted relationship between multiple body habitus and the factors that influence the degree of frailty.

Methods

A questionnaire survey was conducted among 840 adult residents in Chongqing communities. A total of 723 participants were included in the data analysis, with an effective response rate of 92.0%. Fried's frailty scale was used to classify individuals into fit, pre-frail, or frail. Non-parametric tests and chi-square tests were employed to evaluate the inter-group differences in frailty levels under different influencing factors. Multivariate logistic regression analysis was performed to select the independent variables associated with frailty statistics. According to the results of the parallel line test, ordered or disordered multivariate logistic regression was used to evaluate the impact of a single independent variable on frailty for different variables.

Results

Adult community residents in Chongqing accounted for 29.18 and 5.67% in pre-frailty and frailty, respectively. In multivariate logistic regression analysis, high BMI, and high waist-hip ratio (WHR) were identified as major risk factors for frailty. Furthermore, the process of aging, coupled with moderate to heavy alcohol consumption, active weight loss behavior in the past year, and the presence of comorbidities, emerged as significant contributors to frailty. Conversely, factors such as a positive inclination toward taste, consistent meal timing, habitual breakfast consumption, sound nutritional intake, and the cultivation of healthy dietary practices were recognized as pivotal elements that act as protective factors against frailty.

Conclusion

The integration of both BMI and WHR provides a more comprehensive perspective, effectively capturing the intertwined influence of obesity and sarcopenia on the extent of frailty. To mitigate the risk of community-wide frailty, a multipronged approach is essential, involving the promotion of favorable dietary practices and achieving nutritional equilibrium, diligent management of coexisting medical conditions, moderation in alcohol consumption, and the enhancement of physical functionality.

Clinical Significance of Biological Age in Patients Undergoing Percutaneous Coronary Intervention

OBJECTIVE

To test whether biological age calculated using deficits, functional impairments, or their combination will provide improved estimation of long-term mortality among older adults undergoing percutaneous coronary intervention.

PATIENTS AND METHODS

Cardiovascular deficits, noncardiovascular deficits, and functional impairments were prospectively studied in 535 patients aged 55 years or older from August 1, 2014, to March 31, 2018. Models for biological age included deficits (acquired, increase with age, associated with worse prognosis, did not saturate early), functional impairments (subjective-help with daily activities, difficulty with sensory input, continence, weight, balance, mobility; or objective-timed up and go, functional reach), or their combination.

RESULTS

The mean ± SD age of the study patients was 72.1±9.5 years. For every 5-year increase in chronological age, the mean number of cardiovascular deficits increased from 2.36 among patients younger than 70 years to 3.44 in nonagenarians. The mean number of functional impairments increased from 2.15 for those younger than 70 years to 6.74 for nonagenarians. During a median follow-up of 2.05 years, 99 patients died. Significant improvement in the Harrell concordance index (C index) for prediction of long-term all-cause mortality was noted with biological age calculated from deficits and impairments compared with chronological age (0.77 vs 0.65; P<.001) and when estimating biological age via functional impairments alone vs chronological age (0.75 vs 0.65; P<.001) but not via deficits alone (0.71 vs 0.65; P=.08). Biological age estimates from subjective functional impairments captured most of the prognostic information related to all-cause and noncardiac mortality, whereas deficit-based estimation favored cardiovascular mortality.

CONCLUSION

The derivation of biological age from deficits and functional impairments provides a major improvement in the estimation of survival as estimated by chronological age.

Novel therapeutic approaches to target neurodegeneration

Ageing is the main risk factor common to most primary neurodegenerative disorders. Indeed, age-related brain alterations have been long considered to predispose to neurodegeneration. Although protein misfolding and the accumulation of toxic protein aggregates have been considered as causative events in neurodegeneration, several other biological pathways affected by brain ageing also contribute to pathogenesis. Here, we discuss the evidence showing the involvement of the mechanisms controlling neuronal structure, gene expression, autophagy, cell metabolism and neuroinflammation in the onset and progression of neurodegenerative disorders. Furthermore, we review the therapeutic strategies currently under development or as future approaches designed to normalize these pathways, which may then increase brain resilience to cope with toxic protein species. In addition to therapies targeting the insoluble protein aggregates specifically associated with each neurodegenerative disorder, these novel pharmacological approaches may be part of combined therapies designed to rescue brain function.

Preoperative Frailty Risk in Cranioplasty Patients: Risk Analysis Index Predicts Adverse Outcomes

Cranioplasty is a common surgical procedure used to repair cranial defects, and it is associated with significant morbidity and mortality. Although frailty is a strong predictor of poor postoperative outcomes across surgical specialties, little is known about frailty's impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing the effect of the Risk Analysis Index-Administrative (RAI-A) and the Modified Frailty Index-5 (mFI-5) on cranioplasty outcomes.

Methods

The National Surgical Quality Improvement Program was queried for patients undergoing cranioplasty between 2012 and 2020. Receiver operating characteristics and multivariable analyses were used to assess the relationship of postoperative outcomes and the RAI-A, mFI-5, and increasing patient age.

Results

There were 2864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were women (57.0%) and White (68.5%). The RAI-A had a more robust predictive ability for 30-day mortality (C-Statistic, 0.741; 95% confidence interval (CI), 0.678-0.804) compared with mFI-5 (C-Statistic, 0.574; 95% CI, 0.489-0.659) and increasing patient age (C-Statistic, 0.671; 95% CI, 0.610-0.732). On multivariable analyses, frailty was independently associated with mortality and other poor postoperative outcomes (P < 0.05).

Conclusions

The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting mortality. Additionally, the RAI-A showed independent associations with nonhome discharge and postoperative complications (CDII, CDIIIb, and CDIV). The high rates of operative morbidity (5.0%-36.5%) and mortality (0.4%-3.2%) after cranioplasty highlight the importance of identifying independent risk factors for poor cranioplasty outcomes.

Inflammation and Oxidative Stress in Frailty and Metabolic Syndromes-Two Sides of the Same Coin

In developed countries, aging is often seen as typical, but it is made complicated by many disorders and co-morbidities. Insulin resistance seems to be an underlying pathomechanism in frailty and metabolic syndromes. The decline in insulin sensitivity leads to changes in the oxidant-antioxidant balance and an accelerated inflammatory response, especially by adipocytes and macrophages in adipose tissue, as well as muscle mass density. Thus, in the pathophysiology of syndemic disorders-the metabolic syndrome and frailty syndrome-an extremely important role may be played by increased oxidative stress and pro-inflammatory state. Papers included in this review explored available full texts and the reference lists of relevant studies from the last 20 years, before the end of 2022; we also investigated the PubMed and Google Scholar electronic databases. The online resources describing an elderly population (≥65 years old) published as full texts were searched for the following terms: "oxidative stress and/or inflammation", "frailty and/or metabolic syndrome". Then, all resources were analyzed and narratively described in the context of oxidative stress and/or inflammation markers which underlie pathomechanisms of frailty and/or metabolic syndromes in elderly patients. So far, different metabolic pathways discussed in this review show that a similar pathogenesis underlies the development of the metabolic as well as frailty syndromes in the context of increased oxidative stress and acceleration of inflammation. Thus, we argue that the syndemia of the syndromes represents two sides of the same coin.

Validating biologic age in selecting elderly patients with pancreatic cancer for surgical resection

BACKGROUND AND OBJECTIVES

Selecting frail elderly patients with pancreatic cancer (PC) for pancreas resection using biologic age has not been elucidated. This study determined the feasibility of the deficit accumulation frailty index (DAFI) in identifying such patients and its association with surgical outcomes.

METHODS

The DAFI, which assesses frailty based on biologic age, was used to identify frail patients using clinical and health-related quality-of-life data. The characteristics of frail and nonfrail patients were compared.

RESULTS

Of 242 patients (median age, 75.5 years), 61.2% were frail and 32.6% had undergone pancreas resection (surgery group). Median overall survival (mOS) decreased in frail patients (7.13 months, 95% confidence interval [CI]: 5.65-10.1) compared with nonfrail patients (16.1 months, 95% CI: 11.47-34.40, p = 0.001). In the surgery group, mOS improved in the nonfrail patients (49.4%; 49.2 months, 95% CI: 29.3-79.9) compared with frail patients (50.6%, 22.1 months, 95% CI: 18.3-52.4, p = 0.10). In the no-surgery group, mOS was better in nonfrail patients (54%; 10.81 months, CI 7.85-16.03) compared with frail patients (66%; 5.45 months, 95% CI: 4.34-7.03, p = 0.02).

CONCLUSIONS

The DAFI identified elderly patients with PC at risk of poor outcomes and can identify patients who can tolerate more aggressive treatments.

Identifying the Biomarker Profile of Pre-Frail and Frail People: A Cross-Sectional Analysis from UK Biobank

OBJECTIVE

This study aimed to compare the biomarker profile of pre-frail and frail adults in the UK Biobank cohort by sex.

METHODS

In total, 202,537 participants (67.8% women, aged 37 to 73 years) were included in this cross-sectional analysis. Further, 31 biomarkers were investigated in this study. Frailty was defined using a modified version of the Frailty Phenotype. Multiple linear regression analyses were performed to explore the biomarker profile of pre-frail and frail individuals categorized by sex.

RESULTS

Lower concentrations of apoA1, total, LDL, and HDL cholesterol, albumin, eGFRcys, vitamin D, total bilirubin, apoB, and testosterone (differences ranged from -0.30 to -0.02 per 1-SD change), as well as higher concentrations of triglycerides, GGT, cystatin C, CRP, ALP, and phosphate (differences ranged from 0.01 to 0.53 per 1-SD change), were identified both in pre-frail and frail men and women. However, some of the associations differed by sex. For instance, higher rheumatoid factor and urate concentrations were identified in pre-frail and frail women, while lower calcium, total protein, and IGF-1 concentrations were identified in pre-frail women and frail women and men. When the analyses were further adjusted for CRP, similar results were found.

CONCLUSIONS

Several biomarkers were linked to pre-frailty and frailty. Nonetheless, some of the associations differed by sex. Our findings contribute to a broader understanding of the pathophysiology of frailty as currently defined.

Association of shorter leucocyte telomere length with risk of frailty

BACKGROUND

Frailty is a multidimensional syndrome of decline that affects multiple systems and predisposes to adverse health outcomes. Although chronological age is the major risk factor, inter-individual variation in risk is not fully understood. Leucocyte telomere length (LTL), a proposed marker of biological age, has been associated with risk of many diseases. We sought to determine whether LTL is associated with risk of frailty.

METHODS

We utilized cross-sectional data from 441 781 UK Biobank participants (aged 40-69 years), with complete data on frailty indicators and LTL. Frailty was defined as the presence of at least three of five indicators: weaker grip strength, slower walking pace, weight loss in the past year, lower physical activity, and exhaustion in the past 2 weeks. LTL was measured using a validated qPCR method and reported as a ratio of the telomere repeat number (T) to a single-copy gene (S) (T/S ratio). Association of LTL with frailty was evaluated using adjusted (chronological age, sex, deprivation, smoking, alcohol intake, body mass index, and multimorbidity) multinomial and ordinal regression models, and results are presented as relative risk (RRR) or odds ratios (OR), respectively, alongside the 95% confidence interval (CI). Mendelian randomization (MR), using 131 genetic variants associated with LTL, was used to assess if the association of LTL with frailty was causal.

RESULTS

Frail participants (4.6%) were older (median age difference (95% CI): 3 (2.5; 3.5) years, P = 2.73 × 10-33 ), more likely to be female (61%, P = 1.97 × 10-129 ), and had shorter LTL (-0.13SD vs. 0.03SD, P = 5.43 × 10-111 ) than non-frail. In adjusted analyses, both age and LTL were associated with frailty (RRR = 1.03 (95% CI: 1.02; 1.04) per year of older chronological age, P = 3.99 × 10-12 ; 1.10 (1.08; 1.11) per SD shorter LTL, P = 1.46 × 10-30 ). Within each age group (40-49, 50-59, 60-69 years), the prevalence of frailty was about 33% higher in participants with shorter (-2SD) versus longer telomeres (+2SD). MR analysis showed an association of LTL with frailty that was directionally consistent with the observational association, but not statistically significant (MR-Median: OR (95% CI): 1.08 (0.98; 1.19) per SD shorter LTL, P = 0.13).

CONCLUSIONS

Inter-individual variation in LTL is associated with the risk of frailty independently of chronological age and other risk factors. Our findings provide evidence for an additional biological determinant of frailty.

Effects of a Multicomponent Exercise Program on Prevalence and Severity of the Frailty Syndrome in a Sample of Italian Community-Dwelling Older Adults

Background: Frailty is a well-known condition that leads to a lack of resilience, with a reduced homeostatic capacity and a consequent higher risk of suffering adverse health outcomes. This study investigated the effectiveness of an exercise program to improve and reverse physical frailty amongst Italian older adults. Methods: One hundred and twenty-three community dwelling older adults (mean age 74 years, SD = 6; 64% women) were involved in an experimental (EG; n = 62) and a control (CG; n = 61) group. Frailty was assessed at baseline and after the intervention using an adapted version of the frailty phenotype. The EG took part in a 16-week exercise program, consisting of endurance, strength, balance and flexibility exercises, while the CG maintained the same routine. Results: After the exercise program, the EG was more robust than the CG (F = 43.51, p < 0.001). Within the EG, 46% of pre-frail and 50% of frail people reached the robust and pre-frail levels, respectively. Effects of training were higher in frail and pre-frail people (reduction of frailty of 0.67 and 0.76 points, respectively) compared to robust ones (who frailty levels increased by 0.23 points; F = 11.32, p < 0.001). Conclusions: A multicomponent exercise program may be effective at improving and reverting frailty, specifically for frail and pre-frail people.

The clinical impact of frailty on the postoperative outcomes of patients undergoing gastrectomy for gastric cancer: a propensity-score matched database study

BACKGROUND

Frailty aggregates a composite of geriatric and elderly features that is classified into a singular syndrome; literature thus far has proven its influence over postoperative outcomes. In this study, we evaluate the effects of frailty following gastrectomy for gastric cancer.

METHODS

2011-2017 National Inpatient Sample was used to isolate patients with gastric cancer undergoing gastrectomy; from this, the Johns Hopkins ACG frailty criteria were applied to segregate frailty-present and absent populations. The case-controls were matched using propensity-score matching and compared to various endpoints.

RESULTS

Post match, there were 1171 with and without frailty who were undergoing gastrectomy for gastric cancer. Those with frailty had higher mortality (6.83 vs 3.50% p < 0.001, OR 2.02 95% CI 1.37-2.97), length of stay (16.7 vs 12.0d; p < 0.001), and costs ($191,418 vs $131,367; p < 0.001); frail patients also had higher rates of complications including wound complications (3.42 vs 0.94% p < 0.001, OR 3.73 95% CI 1.90-7.31), infection (5.98 vs 3.67% p = 0.012, OR 1.67 95% CI 1.13-2.46), and respiratory failure (6.32 vs 3.84% p = 0.0084, OR 1.69 95% CI 1.15-2.47). In multivariate, those with frailty had higher mortality (p < 0.001, aOR 2.04 95% CI 1.38-3.01), length of stay (p < 0.001, aOR 1.40 95% CI 1.37-1.43), and costs (p < 0.001, aOR 1.46 95% CI 1.46-1.46).

CONCLUSION

This study finding demonstrates the presence of frailty is an independent risk factor of adverse outcomes following gastrectomy; as such, it is important that these high-risk patients are stratified preoperatively and provided risk-averting procedures to alleviate their frailty-defining features.

The impact of frailty on mortality in non-surgical head and neck cancer treatment: Shifting the clinical paradigm

OBJECTIVE

Compare survival of head and neck cancer (HNC) patients treated with surgical or non-surgical management according to frailty, quantify frailty with the Risk Analysis Index (RAI), a validated 14-item instrument.

MATERIALS AND METHODS

Prospective cohort study of newly diagnosed HNC patients (≥18 years) who had frailty assessment from April 13, 2016 to September 30, 2016. Primary outcome was overall survival at 1- and 3-years. Cox proportional hazard models were utilized to examine mortality with predictor variables. Adjusted and unadjusted (Kaplan-Meier) survival curves stratified by either RAI scores or treatment modality were plotted. Kruskal-Wallis and likelihood ratio chi-square tests were used for comparing clinicodemographic variables.

RESULTS

Of 165 patients, 54 (32.7%) were managed non-surgically, 49 (29.7%) were treated with definitive surgery only, and 62 (37.6%) were treated with multimodality (surgery + adjuvant) therapy. Among the full cohort and subgroup analysis of the frail/very frail (RAI ≥ 37), non-surgical patients had worse or similar 3-year survival than those treated with surgery +/- adjuvant therapy. Multivariable Cox proportional hazard models demonstrate that frail patients treated non-surgically experienced worse survival than their counterparts treated with surgery (HR = 2.50, p = 0.015, 95% CI: 1.19, 5.23) or multimodality therapy (HR = 3.91, p < 0.001, 95% CI: 1.94-7.89).

CONCLUSION

Across all levels of frailty, long term survival of HNC patients treated without surgery is either worse than or like those treated with surgery. These findings (1) challenge current practices of steering patients "too frail for surgery" towards non-surgical, "non-invasive" therapy, and (2) suggest equipoise warranting randomized trials to clarify treatment of frail patients.

A Simplified Frailty Index Predicts Mortality in Older Adults in Beijing

Objective

The comprehensive geriatric assessment (CGA) is an integral tool used to identify vulnerable older adults in need of individualized plans to delay the course of diseases and monitor treatment outcomes. We previously developed and validated a 68-item frailty index (FI) based on the CGA in a large, older, Chinese population. However, substantial time is needed to evaluate the 68 items. Therefore, we aimed to develop and validate a simplified FI for use in Chinese older population.

Design

Longitudinal study.

Setting and Participants

Data were drawn from the Beijing Longitudinal Study of Aging. The study was conducted in 2004 with 1808 participants evaluated using the CGA and was followed-up for 13 years. Mortality was recorded at 3, 5, 8, 10, and 13 years intervals.

Measures

27-Item, 50-item, and 68-item frailty indices were investigated. A Cox proportional hazards model and area under the curve of the receiver operating characteristic (AUC-ROC) were calculated to compare mortality predictions.

Results

The FI was positively correlated with age in males (r = 0.174, P <0.001) and females (r = 0.270, P <0.001). The mean baseline FI was 0.225 ± 0.085 (range: 0.04-0.56) as evaluated by the 27-item FI, 0.181 ± 0.117 (range: 0.02-0.62) by the 50-item FI, and 0.167 ± 0.101 (range: 0.02-0.59) by the 68-item FI. Cox regression models showed that mortality was significantly higher in frail people than in non-frail people for all 3 indices (p<0.001). The AUCs of the 68-item FI, 50-item FI, and 27-item FI for predicting mortality were 0.720, 0.717, and 0.677, respectively (p<0.001).

Conclusion

The 27-item FI is reasonable to expect that the AUC of the indices with the higher items number is inferior to the performance of the indices with higher number of items (FI50 and FI68). But 27-item maybe used as a tool to identify frail older adults and predict mortality in clinical and primary care practices in China.

Review of frailty measurement of older people: Evaluation of the conceptualization, included domains, psychometric properties, and applicability

The purposes of this review are to describe the existing research on frailty measurement of older people and to understand their characteristics, with a focus on conceptual definitions, psychometric properties, and diagnostic accuracies. We reviewed the published literature to explore if cross-cultural studies of different types of frailty measurements have been conducted and to determine their applicability in the community setting. Narrative review with limited electronic database search and cross reference searching of included studies was performed. Studies published after year 2001 were searched for using MEDLINE and CINAHL Plus databases with keywords. A total of 5144 search results were obtained, but only 42 frailty measurements were identified in 68 studies. For the type, three different measurements were indicated, namely, self-report instrument (n = 17), clinical observation assessment (n = 19), and mixed frailty assessment instrument (n = 6). Only 12 (29%) measurements examined reliability and validity. Nevertheless, over 35% did not perform any psychometric testing before applying. For diagnosis accuracies, 35 (83%) frailty measurements reported the cut-off value(s) for determining level of the frailty. However, the sensitivity (56%-89.5%) and specificity (52%-91.3%) varied. The applicability was also diverse and some frailty instruments should be only used in some specific population and mode of administration. This review provides an overview of three major types of frailty measurements used in different settings with different purposes. For estimating the prevalence of frailty of older people in a community, the self-report type may be appropriate. The psychometric properties of many reviewed instruments are reported insufficiently. The cut-off value(s) are usually suggested with diverse sensitivity and specificity. Self-report instruments, such as Groningen Frailty Indicator (GFI) and Tilburg Frailty Indicator (TFI), are the most extensively examined in terms of satisfactory psychometric properties. Thus, GFI and TFI, with the current evidence, are recommended to be used in the community setting for frailty screening tools.

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.

Efficacy and safety of pharmacotherapy for Alzheimer's disease and for behavioural and psychological symptoms of dementia in older patients with moderate and severe functional impairments: a systematic review of controlled trials

BACKGROUND

Many patients with Alzheimer's disease (AD) are physically frail or have substantial functional impairments. There is growing evidence that such patients are at higher risk for medication-induced adverse events. Furthermore, frailty seems to be more predictive of poor clinical outcomes than chronological age alone. To our knowledge, no systematic review of clinical trials examining drug therapy of AD or behavioural and psychological symptoms of dementia (BPSD) has specifically focused on the topic of physical frailty. Our objective was to evaluate the efficacy and safety of pharmacotherapy in AD patients with frailty or significant functional impairments.

METHODS

We performed a systematic literature search in MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for randomized controlled trials (RCTs) of drug therapy of AD and BPSD in patients with significant functional impairments according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Cochrane research criteria. Significant functionally impaired patient populations were identified using the recommendations of the Medication and Quality of Life in frail older persons (MedQoL) Research Group. Screening, selection of studies, data extraction and risk of bias assessment were performed independently by two reviewers. Outcomes including functional status, cognitive function, changes in BPSD symptoms, clinical global impression and quality of life were analysed. For assessing harm, we assessed adverse events, drop-outs as a proxy for treatment tolerability and death. Results were analysed according to Cochrane standards and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Of 45,045 search results, 38,447 abstracts and 187 full texts were screened, and finally, 10 RCTs were included in the systematic review. Selected articles evaluated pharmacotherapy with acetylcholinesterase-inhibitors (AChEI), anticonvulsants, antidepressants and antipsychotics. Studies of AChEIs suggested that patients with significant functional impairments had slight but significant improvements in cognition and that AChEIs were generally well tolerated. Studies of antidepressants did not show significant improvements in depressive symptoms. Antipsychotics and anticonvulsants showed small effects on some BPSD items but also higher rates of adverse events. However, due to the very small number of identified trials, the quality of evidence for all outcomes was low to very low. Overall, the small number of eligible studies demonstrates that significantly functional impaired older patients have not been adequately taken into consideration in most clinical trials investigating drug therapy of AD and BPSD.

CONCLUSION

Due to lack of evidence, it is not possible to give specific recommendations for drug therapy of AD and BSPD in frail older patients or older patients with significant functional impairments. Therefore, clinical trials focussing on frail older adults are urgently required. A standardized approach to physical frailty in future clinical studies is highly desirable.

Unobtrusive Sensors for the Assessment of Older Adult's Frailty: A Scoping Review

Ubiquity (devices becoming part of the context) and transparency (devices not interfering with daily activities) are very significant in healthcare monitoring applications for elders. The present study undertakes a scoping review to map the literature on sensor-based unobtrusive monitoring of older adults' frailty. We aim to determine what types of devices comply with unobtrusiveness requirements, which frailty markers have been unobtrusively assessed, which unsupervised devices have been tested, the relationships between sensor outcomes and frailty markers, and which devices can assess multiple markers. SCOPUS, PUBMED, and Web of Science were used to identify papers published 2010-2020. We selected 67 documents involving non-hospitalized older adults (65+ y.o.) and assessing frailty level or some specific frailty-marker with some sensor. Among the nine types of body worn sensors, only inertial measurement units (IMUs) on the waist and wrist-worn sensors comply with ubiquity. The former can transparently assess all variables but weight loss. Wrist-worn devices have not been tested in unsupervised conditions. Unsupervised presence detectors can predict frailty, slowness, performance, and physical activity. Waist IMUs and presence detectors are the most promising candidates for unobtrusive and unsupervised monitoring of frailty. Further research is necessary to give specific predictions of frailty level with unsupervised waist IMUs.

A Comprehensive Overview of Activities of Daily Living in Existing Frailty Instruments: A Systematic Literature Search

BACKGROUND AND OBJECTIVES

The relationship between frailty and disability in activities of daily living (ADLs) can be seen in different ways, with disability being-to varying degrees-a characteristic, negative outcome, or predictor of frailty. This conflation of definitions is partly a result of the different frailty tools used in research. Aiming to provide a comprehensive overview, this systematic literature search analyzed (i) if, (ii) to what extent, and (iii) how ADLs are evaluated by frailty instruments.

RESEARCH DESIGN AND METHODS

A search was performed in PubMed, Web of Knowledge, and PsycINFO to identify all frailty instruments, followed by categorization of the ADL items into basic (b-), instrumental (i-), and advanced (a-) ADLs.

RESULTS

In total, 192 articles described 217 frailty instruments, from which 52.1% contained ADL items: 45.2% b-ADLs, 35.0% i-ADLs, and 10.1% a-ADLs. The most commonly included ADL items were bathing (b-ADLs); using transportation (i-ADLs); and semiprofessional work engagement in organized social life or leisure activities (a-ADLs). These instruments all had a multidomain origin (χ 2 = 122.4, p < .001).

DISCUSSION AND IMPLICATIONS

Because 52.1% of all instruments included ADL items, the concepts of frailty and disability appear to be highly entangled. This might lead to circular reasoning, serious concerns regarding contamination, and invalid research results.

IL-6 can singlehandedly drive many features of frailty in mice

Frailty is a geriatric syndrome characterized by age-related declines in function and reserve resulting in increased vulnerability to stressors. The most consistent laboratory finding in frail subjects is elevation of serum IL-6, but it is unclear whether IL-6 is a causal driver of frailty. Here, we characterize a new mouse model of inducible IL-6 expression (IL-6^TET-ON/+ mice) following administration of doxycycline (Dox) in food. In this model, IL-6 induction was Dox dose-dependent. The Dox dose that increased IL-6 levels to those observed in frail old mice directly led to an increase in frailty index, decrease in grip strength, and disrupted muscle mitochondrial homeostasis. Littermate mice lacking the knock-in construct failed to exhibit frailty after Dox feeding. Both naturally old mice and young Dox-induced IL-6^TET-ON/+ mice exhibited increased IL-6 levels in sera and spleen homogenates but not in other tissues. Moreover, Dox-induced IL-6^TET-ON/+ mice exhibited selective elevation in IL-6 but not in other cytokines. Finally, bone marrow chimera and splenectomy experiments demonstrated that non-hematopoietic cells are the key source of IL-6 in our model. We conclude that elevated IL-6 serum levels directly drive age-related frailty, possibly via mitochondrial mechanisms.

Feasibility of Frailty Assessment Integrated with Cardiac Implantable Electronic Device Clinic Follow-up: A Pilot Investigation

Background: The concept of frailty was originally created to explain why individuals of the same age have differing risk of disease, and it has since been found to be negatively associated with outcomes for a wide range of medical conditions, including cardiovascular disease and cardiac procedures. Although numerous risk scores and assessment tools have been proposed, opportunities for practical assessment of frailty remain limited. In this pilot study, we examine the feasibility of using routine follow-up of patients with cardiac implantable electronic devices (CIEDs) for assessment of frailty. Methods: From September 2017 through March 2018, 49 consecutive patients seen in CIED clinic were enrolled. Among the frailty assessments performed at the clinic visit included a 4-meter walk time, FRAIL scale calculation, Rockwood Frailty score assessment by another treating provider, mini-cog assessment, and analysis of daily activity measures on the CIED. Results: Among the three device manufacturers of patients' CIEDs, only Boston Scientific released analyzable activity time series data. On nine patients in whom daily activity data could be analyzed, there was no difference in mean daily activity (148.3 ± 31.9 vs. 100.1 ± 25.1 min/day, p = .27) between patients with and without an abnormal frailty or cognitive assessment, although interestingly, those with an abnormal assessment had a higher standard deviation of activity per day (52.6 ± 5.9 vs. 31.4 ± 4.7 min/day, p = .03). Conclusion: It is possible that a higher variation in daily activity over the course of a year could be a better indicator of frailty or cognitive impairment than average daily activity.

Performance of the Short Physical Performance Battery in Identifying the Frailty Phenotype and Predicting Geriatric Syndromes in Community-Dwelling Elderly

The early identification of seniors at high risk of geriatric syndromes is fundamental for targeting interventions to those who most need them. To date, the predictive value of the Short Physical Performance Battery (SPPB) for multifactorial clinical conditions has not been clearly established. Thus, the aim of the present study was to determine whether the SPPB could identify frailty and predict geriatric syndromes in community-dwelling older adults. Participants comprised men and women aged 60 years and older who participated in the Health and Well-being and Aging Survey in Colombia 2015 (n=4125, 57.6% women). A structured interview was administered to obtain socio-demographic data which included age, sex, ethnicity, socioeconomic status, and urbanicity. The study included the measurement of body mass, grip strength, SPPB, Lawton´s instrumental ADL scale, specific subjective memory complaints (SSMC), frailty phenotype (Fried and FRAIL Scale), and self-reported falls, geriatric syndromes and/or medical conditions. ROC analysis was used to examine the ability of the SPPB test to predict frailty and geriatric syndromes. The cutoff that maximized both sensitivity and specificity for the frailty phenotype was 8 points or below for men and 7 points or below for women. These cutoff values significantly predicted four geriatric syndromes in descending order: mild dementia (♂ ORajus 3.34, and ♀ ORajus 2.79), low grip strength (♂ ORajus 1.98, and ♀ ORajus 2.45), falls (♂ ORajus 1.39, and ♀ ORajus 1.49), and SSMC (♂ ORajus 1.39). In summary, the main finding of the present study was that SPPB score (i.e., ≤ 8 ♂ and ≤ 7 ♀) seems to be a useful measure for identifying the physical frailty phenotype and predicting geriatric syndromes in community-dwelling older adults.

Preoperative assessment and optimization of cognitive dysfunction and frailty in the ambulatory surgical patient

PURPOSE OF REVIEW

The number and the complexity of procedures taking place at ambulatory surgery centers is steadily increasing. The rate at which medically complex patients, including those with baseline neurocognitive disorders, are undergoing ambulatory procedures is seeing a concurrent rise. Given the significant physical and psychological stress associated with surgery even in the ambulatory setting, it is essential to evaluate the ability of a patient to acclimate to stressful triggers in order to assess risk of subpar medical outcomes and increased mortality. In this review, we discuss recent advances in the assessment of both cognition and frailty and describe the implementation of these tools in the ambulatory surgery setting.

RECENT FINDINGS

Recent Society for Perioperative Assessment and Quality Improvement (SPAQI) recommendations for evaluating at-risk patients focus on a two-pronged approach that encompasses screening for both impaired cognition and frailty. Screening should ideally occur as early as possible, but tools such as the Mini-Cog examination and FRAIL Questionnaire are efficient and effective even when used the day of surgery in high-risk patients.

SUMMARY

The recognition of at-risk patients using standardized screening and the use of this assessment to guide perioperative monitoring and interventions is essential for optimizing outcomes for the complex ambulatory surgery patient.

Epidemiology of Hypoalbuminemia in Hospitalized Patients: A Clinical Matter or an Emerging Public Health Problem?

Serum albumin levels are strongly associated with the morbidity, prognosis, and mortality rates of patients with hypoalbuminemia, which is a frequent problem during hospitalization. An observational retrospective study was carried out to analyze changes in albumin levels in hospitalized patients at the “Fondazione Policlinico Tor Vergata—PTV” in 2018. The prevalence of preexisting hypoalbuminemia at the time of discharge from hospital was investigated using a sample of 9428 patients. Information was collected from the discharge files recorded in the central informatics system of the hospital. Analysis of albumin levels at admission and at discharge was conducted by classes of albuminemia and then stratified by age. At the time of admission, hypoalbuminemia was found to be present in more than half of the sample, with no sex differences. The serum albumin level tended to decrease with age, with pathologic levels appearing from 50 years and progressive worsening thereafter. The condition of marked and mild hypoalbuminemia was more prevalent in patients over 65 years of age. Our findings suggest that hypoalbuminemia should be considered a dangerous condition in itself and a serious public health problem. We aimed to emphasize the role of albumin as useful marker of the in-hospital malnutrition and frailty, to be integrated in the routinely assessment of patients for reconsidering ad hoc healthcare pathways after discharge from hospital, especially when dealing with fragile populations.

Automatic and Real-Time Computation of the 30-Seconds Chair-Stand Test without Professional Supervision for Community-Dwelling Older Adults

The present paper describes a system for older people to self-administer the 30-s chair stand test (CST) at home without supervision. The system comprises a low-cost sensor to count sit-to-stand (SiSt) transitions, and an Android application to guide older people through the procedure. Two observational studies were conducted to test (i) the sensor in a supervised environment (n = 7; m = 83.29 years old, sd = 4.19; 5 female), and (ii) the complete system in an unsupervised one (n = 7; age 64–74 years old; 3 female). The participants in the supervised test were asked to perform a 30-s CST with the sensor, while a member of the research team manually counted valid transitions. Automatic and manual counts were perfectly correlated (Pearson’s r = 1, p = 0.00). Even though the sample was small, none of the signals around the critical score were affected by harmful noise; p (harmless noise) = 1, 95% CI = (0.98, 1). The participants in the unsupervised test used the system in their homes for a month. None of them dropped out, and they reported it to be easy to use, comfortable, and easy to understand. Thus, the system is suitable to be used by older adults in their homes without professional supervision.

Insights into the neuropathology of cerebral ischemia and its mechanisms

Cerebral ischemia is a result of insufficient blood flow to the brain. It leads to limited supply of oxygen and other nutrients to meet metabolic demands. These phenomena lead to brain damage. There are two types of cerebral ischemia: focal and global ischemia. This condition has significant impact on patient’s health and health care system requirements. Animal models such as transient occlusion of the middle cerebral artery and permanent occlusion of extracranial vessels have been established to mimic the conditions of the respective type of cerebral ischemia and to further understand pathophysiological mechanisms of these ischemic conditions. It is important to understand the pathophysiology of cerebral ischemia in order to identify therapeutic strategies for prevention and treatment. Here, we review the neuropathologies that are caused by cerebral ischemia and discuss the mechanisms that occur in cerebral ischemia such as reduction of cerebral blood flow, hippocampal damage, white matter lesions, neuronal cell death, cholinergic dysfunction, excitotoxicity, calcium overload, cytotoxic oedema, a decline in adenosine triphosphate (ATP), malfunctioning of Na+/K+-ATPase, and the blood-brain barrier breakdown. Altogether, the information provided can be used to guide therapeutic strategies for cerebral ischemia.

Trajectories of Frailty and Cognitive Decline Among Older Mexican Americans

BACKGROUND

Progressive physical frailty and cognitive decline in older adults is associated with increased risk of falls, disability, institutionalization, and mortality; however, there is considerable heterogeneity in progression over time. We identified heterogeneous frailty and cognitive decline trajectory groups and examined the specific contribution of health conditions to these trajectories among older Mexican origin adults.

METHODS

We use a sample from the Hispanic Established Population for the Epidemiological Study of the Elderly (HEPESE) with at least two measures of frailty criteria during 18 years follow-up: slow gait, weak handgrip strength, exhaustion, and unexplained weight loss (n = 1362, mean age 72). Cognition was measured using the Mini-Mental State Examination (MMSE).

RESULTS

Using group-based trajectory models we identified three frailty groups-non-frail (n = 331), moderate progressive (n = 855), and progressive high (n = 149)-and three cognitive decline groups-non-cognitively impaired (476), moderate decline (677) and rapid decline (n = 209). The probability of membership in a high-frailty group given membership in a progressive cognitive decline group was 63%, while the probability of being in a non-frail group given membership in a non-cognitively impaired group was 68%. Predictors of membership into both the progressive high frailty and rapid cognitive decline groups combined were low education and diabetes. Weekly church attendance was associated with a 66% reduction in the odds of being in the combined groups.

CONCLUSIONS

Interventions to reduce frailty rates and cognitive decline might focus on the management of underlying chronic disease and on increasing participation in activities outside the home.

Frailty: A cost incurred by reproduction?

Evolutionary theories of senescence, such as the ‘disposable soma’ theory, propose that natural selection trades late survival for early fecundity. ‘Frailty’, a multidimensional measure of health status, may help to better define the long-term consequences of reproduction. We examined the relationship between parity and later life frailty (as measured by the Frailty Index) in a sample of 3,534 adults aged 65 years and older who participated in the English Longitudinal Study of Ageing. We found that the most parous adults were the most frail and that the parity-frailty relationship was similar for both sexes. Whilst this study provided some evidence for a ‘parity-frailty trade-off’, there was little support for our hypothesis that the physiological costs of childbearing influence later life frailty. Rather, behavioural and social factors associated with rearing many children may have contributed to the development of frailty in both sexes.

Thyroid hormones and frailty in persons experiencing extreme longevity

CONTEXT

The aging phenotype is quite heterogeneous, being the result of the capability of each individual to successfully or unsuccessfully response to stressors. The reduction of homeostatic reserve characterizing aging is accompanied by a remodeling of the endocrine system. Frailty has been indicated as a promising way for capturing the physiological decline as well as the biological aging of the individuals. In particular, the Frailty Index (FI), based on the assumption that health deficits tend to accumulate with aging, represents a quantitative measure of extreme interest.

OBJECTIVE

The study aims to correlate the thyroid hormone levels with FI in a population of centenarians and their offspring to capture the effects of thyroid remodeling in extreme longevity.

STUDY DESIGN

The study described 593 well-characterized Italian subjects, including 180 centenarians, as well as 276 centenarian's offspring and 137 age-matched controls.

RESULTS

FT3 levels and FT3/FT4 ratio were significantly lower (p < 0.001) and TSH levels higher (p < 0.001) in centenarians compared to the other groups, analysing both overall subjects and excluding subjects with hormone levels out of the normal ranges. In overall centenarians, we observed a negative correlation between FI and FT3 (ρ: -0.281, p < 0.001), FT3/FT4 (ρ: -0.344, p < 0.001) and TSH (ρ: -0.223, p 0.003) and a positive association between FI and FT4 (ρ: 0.189, p = 0.001). In centenarians with hormone levels within the normal ranges, similar negative correlations were observed between FI and FT3 (ρ: -0.201, p = 0.02) and FT3/FT4 (ρ: -0.264, p = 0.002). In this sub-analysis, FI positively correlated with FT4 and age (ρ: 0.167, p = 0.05; ρ: 0.219, p = 0.005, respectively). Conversely, no significant correlations were observed between hormone levels and FI in offspring and controls.

CONCLUSIONS

We found an association between thyroid hormone levels and frailty in centenarians, underlying the significant role of thyroid in the aging process and longevity.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Are We Ill Because We Age?

Growing elderly populations, sometimes referred to as gray (or silver) tsunami, are an increasingly serious health and socioeconomic concern for modern societies. Science has made tremendous progress in the understanding of aging itself, which has helped medicine to extend life expectancies. With the increase of the life expectancy, the incidence of chronic age-related diseases (ARDs) has also increased. A new approach trying to solve this problem is the concept of geroscience. This concept implies that the aging process itself is the common cause of all ARDs. The corollary and consequence of such thinking is that we can and should treat aging itself as a disease. How to translate this into the medical practice is a big challenge, but if we consider aging as a disease the problem is solved. However, as there is no common definition of what aging is, what its causes are, why it occurs, and what should be the target(s) for interventions, it is impossible to conclude that aging is a disease. On the contrary, aging should be strongly considered not to be a disease and as such should not be treated; nonetheless, aging is likely amenable to optimization of changes/adaptations at an individual level to achieve a better functional healthspan.

Network analysis of frailty and aging: Empirical data from the Mexican Health and Aging Study

BACKGROUND

Frailty remains a challenge in the aging research area with a number of gaps in knowledge still to be filled. Frailty seems to behave as a network, and in silico evidence is available on this matter. Having in vivo evidence that frailty behaves as a complex network was the main purpose of our study.

METHODS

Data from the Mexican Health and Aging Study (main data 2012, mortality 2015) was used. Frailty was operationalized with a 35-deficit frailty index (FI). Analyzed nodes were the deficits plus death. The edges, linking those nodes were obtained through structural learning, and an undirected graph associated with a discrete probabilistic graphical model (Markov network) was derived. Two algorithms, hill-climbing (hc) and Peter and Clark (PC), were used to derive the graph structure. Analyses were performed for the whole population and tertiles of the total FI score.

RESULTS

From the total sample of 10,983 adults aged 50 or older, 43.8% were women, and the mean age was 64.6 years (SD = 9.3). The number of connections increased according to the tertile level of the FI score. As the FI score raised, groups of interconnected deficits increased and how the nodes are connected changed.

CONCLUSIONS

Frailty phenomenon can be modeled using a Bayesian network. Using the full sample, the most central nodes were self-report of health (most connected node) and difficulty walking a block, and all deficits related to mobility were very interconnected. When frailty levels are considered, the most connected nodes differ, but are related with vitality, mainly at lower frailty levels. We derived that not all deficits are equally related since clusters of very related deficits and non-connected deficits were obtained, which might be considered in the construction of the FI score. Further research should aim to identify the nature of all observed interactions, which might allow the development of specific interventions to mitigate the consequences of frailty in older adults.

Ethnic differences in the prevalence of frailty in the United Kingdom assessed using the electronic Frailty Index

OBJECTIVE

There have been few studies in which the prevalence of frailty of different ethnic groups has been assessed in multiethnic countries. The aim of this study was to evaluate the prevalence of frailty in different ethnic groups in the United Kingdom.

METHODS

Anonymized electronic health records (EHR) of 13 510 people aged 65 years and over were extracted from the database of a network of general practitioners, covering 16 clinical commissioning groups in London. Frailty was determined using the electronic Frailty Index (eFI), which was automatically calculated using EHR data. The eFI was used as a categorical variable with fit and mild frailty grouped together, and moderate and severe frailty grouped as frail.

RESULTS

The overall prevalence of frailty was 18.1% (95% confidence interval [CI], 17.4%-18.9%). The prevalence of frailty increased with age (odds ratio [OR], 1.11; 95% CI, 1.10-1.12) and body mass index (BMI; OR, 1.05; 95% CI, 1.04-1.06). The highest prevalence of frailty was observed for Bangladeshis, with 32.9% classified as frail (95% CI, 29.2-36.7); and the lowest prevalence of 14.0% (95% CI, 12.6-15.5) was observed for the Black ethnic group. Stepwise logistic regression retained ethnicity, age, and BMI as predictors of frailty.

CONCLUSION

This pilot study identified differences in the prevalence of frailty between ethnic groups in a sample of older people living in London. Additional studies are warranted to determine the causes of such differences, including migration and socioeconomic status. It would be worthwhile carrying out a validation study of the eFI in different ethnic populations.

Preoperative frailty and its association with postsurgical pain in an older patient cohort

BACKGROUND AND OBJECTIVES

Chronic postsurgical pain in patients over 65 negatively impacts recovery, quality of life and physical functioning. In the community setting, chronic pain has been shown to be related to frailty, a syndrome more commonly seen in older adults and characterized by limited physiologic reserve and ability to withstand stressors. While frailty is an important preoperative risk factor for poor surgical outcomes in older adults, the relationship between frailty and postsurgical pain in this population has not been investigated. We hypothesized that preoperative frailty would be associated with greater odds of postsurgical chronic pain.

METHODS

We conducted a prospective cohort study of 116 patients older than 65 years old who underwent major elective non-cardiac surgery. Patients were assessed for frailty within 30 days prior to surgery using the FRAIL Scale assessment and pain was evaluated before surgery and at 3 months after surgery using the Geriatric Pain Measure.

RESULTS

After adjusting for baseline characteristics, we found that frail patients were almost five times more likely to have intrusive postsurgical pain compared with patients who were not frail (OR 4.73, 95% CI 1.24 to 18.09). Intrusive preoperative pain and spine surgery were also associated with increased postsurgical pain (OR 10.13, 95% CI 2.81 to 36.57 and OR 4.02, 95% CI 1.22 to 13.17, respectively).

CONCLUSION

Although future studies are needed to establish a causal relationship between preoperative frailty and postsurgical pain, our findings suggest that older patients should have preoperative frailty assessments and frail older adults may need additional resources to improve postsurgical pain outcomes.

TRIAL REGISTRATION NUMBER

NCT02650687.

Identification of community-dwelling older adults at risk of frailty using the PERSSILAA screening pathway: a methodological guide and results of a large-scale deployment in the Netherlands

Background

Among community-dwelling older adults, frailty is highly prevalent and recognized as a major public health concern. To prevent frailty it is important to identify those at risk of becoming frail, but at present, no accepted screening procedure is available.

Methods

The screening process developed as part of the PERSSILAA project is a two-step screening pathway. First, older adults are asked to complete a self-screening questionnaire to assess their general health status and their level of decline on physical, cognitive and nutritional domains. Second, older adults who, according to step one, are at risk of becoming frail, are invited for a face-to-face assessment focusing on the domains in depth. We deployed the PERSSILAA screening procedure in primary care in the Netherlands.

Results

In total, baseline data were available for 3777 community-dwelling older adults (mean age 69.9 (SD ± 3.8)) who completed first step screening. Based on predefined cut-off scores, 16.8% of the sample were classified as frail (n = 634), 20.6% as pre-frail (n = 777), and 62.3% as robust (n = 2353). Frail subjects were referred back to their GP without going through the second step. Of the pre-frail older adults, 69.7% had evidence of functional decline on the physical domain, 67% were overweight or obese and 31.0% had evidence of cognitive decline.

Conclusion

Pre-frailty is common among community-dwelling older adults. The PERSSILAA screening approach is a multi-factor, two-step screening process, potentially useful for primary prevention to identify those at risk of frailty and who will benefit most from preventive strategies.

Positive balance: a hierarchical perspective of positive mental health

An attempt is made in this paper to provide the community of health-related quality-of-life scholars with a hierarchical perspective of positive mental health guided by the concept of positive balance. Specifically, individuals with positive mental health are characterized to experience: (1) a preponderance of neurochemicals related to positive emotions (dopamine, serotonin, etc.) relative to neurochemicals related to negative emotions (cortisol), at a physiological level; (2) a preponderance of positive affect (happiness, joy, etc.) relative to negative affect (anger, sadness, etc.), at an emotional level; (3) a preponderance of domain satisfaction (satisfaction in salient and multiple life domains such as family life and work life) relative to dissatisfaction in other life domains, at a cognitive level; (4) a preponderance of positive evaluations about one's life using certain standards of comparison (satisfaction with one's life compared to one's past life, the life of family members, etc.) relative to negative evaluations about one's life using similar or other standards of comparison, at a meta-cognitive level; (5) a preponderance of positive psychological traits (self-acceptance, personal growth, etc.) relative to negative psychological traits (pessimism, hopelessness, etc.), at a development level; and (6) a preponderance of perceived social resources (social acceptance, social actualization, etc.) relative to perceived social constraints (social exclusion, ostracism, etc.), at a social-ecological level.

Preoperative Frailty and Surgical Outcomes Across Diverse Surgical Subspecialties in a Large Health Care System

BACKGROUND

Frailty is an emerging risk factor for surgical outcomes; however, its application across large populations is not well defined. We hypothesized that frailty affects postoperative outcomes in a large health care system.

STUDY DESIGN

Frailty was prospectively measured in elective surgery patients (January 2016 to June 2017) in a health care system (4 hospitals/901 beds). Frailty classifications-low (0), intermediate (1 to 2), high (3 to 5)-were assigned based on the modified Hopkins score. Operations were classified as inpatient (IP) vs outpatient (OP). Outcomes measured (30-day) included major morbidity, discharge location, emergency department (ED) visit, readmission, length of stay (LOS), mortality, and direct-cost/patient.

RESULTS

There were 14,530 elective surgery patients (68.1% outpatient, 31.9% inpatient) preoperatively assessed (cardiothoracic 4%, colorectal 4%, general 29%, oral maxillofacial 2%, otolaryngology 8%, plastic surgery 13%, podiatry 6%, surgical oncology 5%, transplant 3%, urology 24%, vascular 2%). High frailty was found in 3.4% of patients (5.3% IP, 2.5% OP). Incidence of major morbidity, readmission, and mortality correlated with frailty classification in all patients (p < 0.05). In the IP cohort, length of stay in days (low 1.6, intermediate 2.3, high 4.1, p < 0.0001) and discharge to facility increased with frailty (p < 0.05). In the OP cohort, ED visits increased with frailty (p < 0.05). Frailty was associated with increased direct-cost in the IP cohort (low, $7,045; intermediate, $7,995; high, $8,599; p < 0.05).

CONCLUSIONS

Frailty affects morbidity, mortality, and health care resource use in both IP and OP operations. Additionally, IP cost increased with frailty. The broad applicability of frailty (across surgical specialties) represents an opportunity for risk stratification and patient optimization across a large health care system.

Rodent models of frailty and their application in preclinical research

In clinical medicine, the concept of frailty is viewed as a state of high vulnerability to adverse health outcomes in people of the same age. Frailty is an important challenge because the loss of physiological reserve means that even minor stressors can lead to disability and death in those who are frail. Even so, the biology of frailty is not well understood. Rodent models of frailty are stimulating research into the biology of frailty. These pre-clinical models are based on "reverse-translation". Investigators have adapted either the "frailty phenotype" approach or the "frailty index" approach, originally developed in humans, for use in animals. This review briefly describes rodent models of frailty, discusses how these models have been used to explore mechanisms of frailty and how they have been employed to assess the impact of frailty on various experimental outcomes. The review also highlights studies that have used rodent models to investigate interventions to attenuate frailty, including drug treatment, dietary modifications and exercise. The ability to model frailty in animals is an exciting development that promises to accelerate the translation of laboratory discoveries into new clinical interventions, and situates frailty research in the larger context of geroscience.

Association between frailty and bone loss in patients undergoing maintenance hemodialysis

Frailty is significantly associated with bone loss in the general population. However, it is unclear whether this association also exists in patients undergoing hemodialysis who have chronic kidney disease-mineral and bone disorder (CKD-MBD). This study aimed to assess the association between frailty and bone loss in patients undergoing hemodialysis. This cross-sectional study included 214 (90 women, 124 men) Japanese outpatients undergoing maintenance hemodialysis three times per week, with a mean age of 67.1 years (women) and 66.8 years (men). Frailty was defined based on criteria set forth by the Cardiovascular Health Study (CHS)-19 (21.1%) women and 47 (37.9%) men were robust, 41 (45.6%) women and 43 (34.7%) men were pre-frail, and 30 (33.3%) women and 34 (27.4%) men were frail. For bone mass, quantitative ultrasound (QUS) parameters (speed of sound, broadband ultrasound attenuation, stiffness index) of the calcaneus were measured. The association between frailty and QUS parameters was determined separately for women and men using multivariate analysis of covariance (ANCOVA), with adjustments for clinical characteristics including age, body mass index, hemodialysis vintage, diabetes, current smoking, serum albumin, phosphate, corrected calcium, intact parathyroid hormone, and medication for CKD-MBD (vitamin D receptor activator, calcimimetics). ANCOVA revealed that all QUS parameters declined significantly with increasing levels of frailty in both sexes (P < 0.05). In conclusion, frailty (as defined by CHS criteria) should be considered a risk factor for bone loss in patients undergoing hemodialysis.

Current situation of frailty screening tools for older adults

Frailty is a geriatric syndrome associated with adverse outcomes such as falls, disability, and mortality. Frailty is common and contributes to rising health care costs. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in older adults. Studies on frailty and its specific measurement tools are increasing in number, but the debate on the screening instruments remains. Currently, self-reported screening tools can identify frailty and predict the risk of adverse outcomes in older adults. Because they are easy to use and quickly provide information, self-reported frailty screening tools have significant implication in primary care settings and clinics. We reviewed the frailty screening instruments in older adults and proposed a two-step pathway for frailty identification, and to manage declines in intrinsic capacity as well as boost resilience.