Associations of Multidomain Lifestyle Intervention with Frailty: Secondary Analysis of a Randomized Controlled Trial

Technology-Enabled Senior Living: A Preliminary Report on Stakeholder Perspectives

BACKGROUND

The integration of stakeholders is crucial in developing smart living technologies to support the autonomy of elderly populations. Despite the clear benefits of these technologies, there remains a significant gap in comprehensive research.

METHODS

This study presents the viewpoints of 19 stakeholders from Europe and Japan, focusing on the sustainability of smart living solutions for Active and Healthy Ageing (AHA). Data were gathered through qualitative semi-structured interviews and analysed using a Framework Analysis approach.

RESULTS

Analysis of the interviews revealed six key sustainability categories: addressing the unmet needs of older adults, functionalities of the smart living coach, integration within organizations, identified barriers, financial considerations, and the social role of the smart living coach.

CONCLUSIONS

This research underscores the importance of evaluating user needs through the involvement of various stakeholders, including the elderly, their caregivers, professionals, technicians, service providers, and government bodies. Collaborative efforts are essential to generate new evidence demonstrating the value of smart living solutions in facilitating Active and Healthy Ageing.

Sustained improvement of intrinsic capacity in community-dwelling older adults: The +AGIL Barcelona multidomain program

BACKGROUND

Different programs promote healthy ageing through the optimization of intrinsic capacity. However, a major challenge is to assess their sustained effects over time. +AGIL Barcelona, a consolidated multidomain program, aims to optimize older adults' intrinsic capacity through a coordinated approach among primary care, geriatrics and community resources, in agreement with the integrated care for older people (ICOPE) guidelines. We aimed to evaluate the +AGIL Barcelona longitudinal effect on older adults' physical performance.

METHODS

All +AGIL Barcelona consecutive participants since 2016 were enrolled. After a comprehensive geriatric assessment, a tailored, multidisciplinary intervention aligned with the ICOPE guidelines is offered. It includes a 10-week boost multicomponent exercise program, nutritional and sleep-hygiene counselling, revision and optimization of pharmacological treatments and screening for cognitive impairment, depression and loneliness. Changes in physical performance after 3 and 6 months were assessed using mixed models including baseline frailty degree, time and all potential significant confounders.

RESULTS

We included 194 participants in the analysis (mean age = 81.6 [standard deviation = 5.8], 68% women). An independent, clinically and statistically significant improvement in physical performance (Short Physical Performance Battery [SPPB] test, combining gait speed, strength and balance) was found at 3 months (SPPB mean change: 1.4; 95% CI: 1.1-1.6) and 6 months (SPPB mean change: 1.1; 95% CI 0.8-1.5). Equivalent results were observed for all the SPPB sub-tests.

CONCLUSIONS

A coordinated, multidisciplinary and integrated program can benefit older adults' intrinsic capacity. The participants' empowerment and the connection with the available community resources are critical points for a successful intervention.

Reversing frailty in older adults: a scoping review

BACKGROUND

Individuals 65 years or older are presumably more susceptible to becoming frail, which increases their risk of multiple adverse health outcomes. Reversing frailty has received recent attention; however, little is understood about what it means and how to achieve it. Thus, the purpose of this scoping review is to synthesize the evidence regarding the impact of frail-related interventions on older adults living with frailty, identify what interventions resulted in frailty reversal and clarify the concept of reverse frailty.

METHODS

We followed Arksey and O'Malley's five-stage scoping review approach and conducted searches in CINAHL, EMBASE, PubMed, and Web of Science. We hand-searched the reference list of included studies and conducted a grey literature search. Two independent reviewers completed the title, abstract screenings, and full-text review using the eligibility criteria, and independently extracted approximately 10% of the studies. We critically appraised studies using Joanna Briggs critical appraisal checklist/tool, and we used a descriptive and narrative method to synthesize and analyze data.

RESULTS

Of 7499 articles, thirty met the criteria and three studies were identified in the references of included studies. Seventeen studies (56.7%) framed frailty as a reversible condition, with 11 studies (36.7%) selecting it as their primary outcome. Reversing frailty varied from either frail to pre-frail, frail to non-frail, and severe to mild frailty. We identified different types of single and multi-component interventions each targeting various domains of frailty. The physical domain was most frequently targeted (n = 32, 97%). Interventions also varied in their frequencies of delivery, intensities, and durations, and targeted participants from different settings, most commonly from community dwellings (n = 23; 69.7%).

CONCLUSION

Some studies indicated that it is possible to reverse frailty. However, this depended on how the researchers assessed or measured frailty. The current understanding of reverse frailty is a shift from a frail or severely frail state to at least a pre-frail or mildly frail state. To gain further insight into reversing frailty, we recommend a concept analysis. Furthermore, we recommend more primary studies considering the participant's lived experiences to guide intervention delivery.

Intrinsic Capacity and Active and Healthy Aging Domains Supported by Personalized Digital Coaching: Survey Study Among Geriatricians in Europe and Japan on eHealth Opportunities for Older Adults

BACKGROUND

The worldwide aging trend requires conceptually new prevention, care, and innovative living solutions to support human-based care using smart technology, and this concerns the whole world. Enabling access to active and healthy aging through personalized digital coaching services like physical activity coaching, cognitive training, emotional well-being, and social connection for older adults in real life could offer valuable advantages to both individuals and societies. A starting point might be the analysis of the perspectives of different professionals (eg, geriatricians) on such technologies. The perspectives of experts in the sector may allow the individualization of areas of improvement of clinical interventions, supporting the positive perspective pointed out by the intrinsic capacity framework.

OBJECTIVE

The overall aim of this study was to explore the cross-national perspectives and experiences of different professionals in the field of intrinsic capacity, and how it can be supported by eHealth interventions. To our knowledge, this is the first study to explore geriatric care providers' perspectives about technology-based interventions to support intrinsic capacity.

METHODS

A survey involving 20 geriatricians or clinical experts in the fields of intrinsic capacity and active and healthy aging was conducted in Italy, France, Germany, and Japan between August and September 2021.

RESULTS

The qualitative findings pointed out relevant domains for eHealth interventions and provided examples for successful practices that support subjective well-being under the intrinsic capacity framework (the benefits offered by personalized interventions, especially by promoting health literacy but avoiding intrusiveness). Moreover, eHealth interventions could be used as a bridge that facilitates and enables social engagement; an instrument that facilitates communication between doctors and patients; and a tool to enrich the monitoring actions of medical staff.

CONCLUSIONS

There is an unexplored and significant role for such geriatric perspectives to help the development process and evaluate the evidence-based results on the effectiveness of technologies for older people. This is possible only when clinicians collaborate with data scientists, engineers, and developers in order to match the complex daily needs of older adults.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Psychological therapies for depression and cardiovascular risk: evidence from national healthcare records in England

AIMS

People with depression are up to 72% more at risk to develop cardiovascular disease (CVD) in their lifetime. Evidence-based psychotherapies are first-line interventions for the treatment of depression and are delivered nationally in England through the National Health Service via the Improving Access to Psychological Therapy (IAPT) primary care programme. It is currently unknown whether positive therapy outcomes may be associated with cardiovascular risk reduction. This study aimed to examine the association between psychotherapy outcomes for depression and incident CVD.

METHODS AND RESULTS

A cohort of 636 955 individuals who have completed a course of psychotherapy was built from linked electronic healthcare record databases of national coverage in England: the national IAPT database, the Hospital Episode Statistics (HES) database, and the HES-ONS (Office of National Statistics) mortality database. Multivariable Cox models adjusting for clinical and demographic covariates were run to estimate the association between reliable improvement from depression and the risk of subsequent incidence of cardiovascular events. After a median follow-up of 3.1 years, reliable improvement from depression symptoms was associated with a lower risk of new onset of any CVD [hazard ratio (HR): 0.88, 95% confidence interval (CI): 0.86, 0.89], coronary heart disease (HR: 0.89, 95% CI: 0.86, 0.92), stroke (HR: 0.88, 95% CI: 0.83, 0.94), and all-cause mortality (HR: 0.81, 95% CI: 0.78, 0.84). This association was stronger in the under 60 compared with the over 60 for all outcomes. Results were confirmed in sensitivity analyses.

CONCLUSION

Management of depression through psychological interventions may be associated with reduced risk of CVD. More research is needed to understand the causality of these associations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Cross-sectional and prospective associations between homocysteine and a frailty index: A post-hoc analysis of the multidomain Alzheimer's prevention trial (MAPT)

BACKGROUND

Homocysteine (Hcy) has been associated with several health problems, including reduced physical capacity. No study appears to have looked at the role of Hcy values longitudinally on physical capacity deterioration in older adults. The objective is to examine cross-sectional and prospective associations between Hcy values and frailty in the elderly and investigate Hcy potential association with the onset of frailty.

METHODS

769 community-dwelling older adults from the MAPT study were recruited for this study. Total Hcy was measured at baseline. Frailty was evaluated at 5 different collection timepoints: baseline, 6-month, 1-, 2-, and 3-year using a frailty index (FI) composed of 19 items. Linear regressions adjusted for all the confounders (age, gender, educational level, MAPT group allocation and Omega-3) were performed to examine the cross-sectional associations of homocysteine values with the FI. A cox model was used to test the association of Hcy with the onset of frailty.

RESULTS

Mean Hcy values (15.9 ± 5.6 μmol\L) were obtained from 769 community-dwelling adults (75.7 ± 4.6 years old). After adjustments, a significant (β = 0.002, (00002-0.003)) and positive association between baseline Hcy values and FI was found (ß = 0.002). Additionally, higher values of Hcy were associated with a worsening of FI after 3 years (ß = 0.002, p = 0.003). A significant association between baseline Hcy values and the likelihood of developing frailty was discovered by incident event analysis (HR: 1.04 (1.01-1.06), p = 0.004).

CONCLUSION

High levels of Hcy are associated with the fragility process in community-dwelling older adults.

A systematic review of multidomain and lifestyle interventions to support the intrinsic capacity of the older population

Introduction

The focus on intrinsic capacity (IC) could help clinicians to design interventions to improve the health of the older population. This review aims to map the current state of the art in the field of multi-domain interventions based on the IC framework, to allow health professionals in identifying personalized clinical interventions, oriented to empower the older people with a holistic and positive approach.

Methods

A systematic review of the literature was conducted in July 2021 analyzing manuscripts and articles of the last 10.5 years from PubMed, Scopus, Embase, Google Scholar and Elsevier databases. A total of 12 papers were included.

Results

The majority of successful interventions are based on a goal setting approach where the older people are involved in the definition of the strategy to follow to remain active and independent. None of the study have used the IC as a framework to design a clinical intervention.

Conclusion

To the best of our knowledge, no other reviews are reported in the literature regarding the IC. Our study offers several research directions, which may take the existing debates to the next level.

The Dose-Response Efficacy of Physical Training on Frailty Status and Physical Performance in Community-Dwelling Elderly: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose: This systematic review and meta-analysis was conducted to explore the effect of physical training on frailty status and physical performance in the community dwelling elderly. Methods: We set keywords and used the Boolean operator to search the CEPS, CINAHL, Cochrane Library, PubMed, MEDLINE, and EMBASE databases from inception to 10 August 2021. The search was limited to randomized controlled trials (RCTs) conducted within a five-year period. The Cochrane Collaboration bias assessment tool was used to assess article quality, and RevMan 5.4.1. software (Cochrane Training site based in London, UK) was used to conduct the meta-analysis. Results: Physical training was found to improve frailty status, physical performance, lower limb strength and balance. The best dose-response for physical training was 60 min per time, 2–3 times per week, for 3 months. Conclusion: Designing an appropriate physical training program can decrease the frailty score and increase physical performance in frail elderly in the community.

Association between social capital and frailty and the mediating effect of health-promoting lifestyles in Chinese older adults: a cross-sectional study

BACKGROUND

To explore the association between social capital and frailty and the mediating effect of health-promoting lifestyles among Chinese older adults, while providing scientific evidence for frailty intervention.

METHODS

In May 2021, a cross-sectional study was conducted among 674 Chinese older adults in Changsha city. Data was collected using the Chinese Shortened Social Capital Scale (comprising structural social capital and cognitive social capital as two subscales), a simplified version of the Health-Promoting Lifestyle Profile and the Tilburg Frailty Indicator. Linear regression analysis was used to examine the association between social capital and frailty. Structural equation modeling was used to test the mediating effect of health-promoting lifestyles.

RESULTS

Cognitive social capital was significantly negatively associated with frailty and its three dimensions (physical, psychological, and social frailty), but structural social capital was not. Health-promoting lifestyles played a mediating role in the associations of cognitive social capital with frailty, physical and psychological frailty, but not with social frailty.

CONCLUSIONS

Higher cognitive social capital was associated with a reduced likelihood of frailty. The health-promoting lifestyles partially mediated the association between cognitive social capital and frailty. The use of health-promoting lifestyles or appropriate cognitive social capital interventions may reduce frailty among older adults.

Development of risk prediction models for incident frailty and their performance evaluation

There is currently no tool to predict incident frailty despite various frailty assessment tools. This study aimed to develop risk prediction models for incident frailty and evaluated their performance on discrimination, calibration, and internal validity. This 2-year follow-up study used data from 5076 non-frail older adults (51% women) living in Tokyo at baseline. We used the Kaigo-Yobo checklist, a standardised assessment instrument, to determine frailty. Twenty questionnaire-based variables that include sociodemographic, medical, behavioural, and subjective factors were entered into binary logistic regression analysis with stepwise backward elimination (p < 0.1 for retention in the model). Discrimination and calibration were assessed by area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test, respectively. For the assessment of internal validity, we used a 5-fold cross-validation method and calculated the mean AUC. At the follow-up survey, 15.0% of men and 10.2% of women were frail. The frailty risk prediction model was composed of 10 variables for men and 11 for women. AUC of the model was 0.71 in men and 0.72 in women. The P-value for the Hosmer-Lemeshow test in both models was more than 0.05. For internal validity, the mean AUC was 0.71 in men and 0.72 in women. Probability of incident frailty rose with an increasing risk score that was calculated from the developed models. These results demonstrated that the developed models enable the identification of non-frail older adults at high risk of incident frailty, which could help to implement preventive approaches in community settings.

Frailty and HIV: Moving from Characterization to Intervention

PURPOSE OF REVIEW

While the characteristics associated with frailty in people with HIV (PWH) have been well described, little is known regarding interventions to slow or reverse frailty. Here we review interventions to prevent or treat frailty in the general population and in people with HIV (PWH).

RECENT FINDINGS

Frailty interventions have primarily relied on nonpharmacologic interventions (e.g., exercise and nutrition). Although few have addressed frailty, many of these therapies have shown benefit on components of frailty including gait speed, strength, and low activity among PWH. When nonpharmacologic interventions are insufficient, pharmacologic interventions may be necessary. Many interventions have been tested in preclinical models, but few have been tested or shown benefit among older adults with or without HIV. Ultimately, pharmacologic and nonpharmacologic interventions have the potential to improve vulnerability that underlies frailty in PWH, though clinical data is currently sparse.

Exploring Clinically Meaningful Changes for the Frailty Index in a Longitudinal Cohort of Hospitalized Older Patients

BACKGROUND

Clinically meaningful change (CMC) for frailty index (FI) scores is little studied. We estimated the CMC by associating changes in FI scores with changes in the Clinical Frailty Scale (CFS) in hospitalized patients.

METHODS

The Serious Outcomes Surveillance Network of the Canadian Immunization Research Network enrolled older adults (65+ years) admitted to hospital with acute respiratory illness (mean age = 79.6 ± 8.4 years; 52.7% female). Patients were assigned CFS and 39-item FI scores in-person at admission and via telephone at 1-month postdischarge. Baseline frailty state was assessed at admission using health status 2 weeks before admission. We classified those whose CFS scores remained unchanged (n = 1,534) or increased (n = 4,390) from baseline to hospital admission, and whose CFS scores remained unchanged (n = 1,565) or decreased (n = 2,546) from admission to postdischarge. For each group, the CMC was represented as the FI score change value that best predicted one level CFS change, having the largest Youden J value in comparison to no change.

RESULTS

From baseline to admission, 74.1% increased CFS by ≥1 level. From admission to postdischarge, 61.9% decreased CFS by ≥1 levels. A change in FI score of 0.03 best predicted both one-level CFS increase (sensitivity = 70%; specificity = 69%) and decrease (sensitivity = 66%; specificity = 61%) in comparison to no change. Of those who changed CFS by ≥1 levels, 70.9% (baseline to admission) and 72.4% (admission to postdischarge) changed their FI score by at least 0.03.

CONCLUSIONS

A clinically meaningful change of 0.03 in the frailty index score holds promise as a benchmark for assessing the meaningfulness of frailty interventions.

Impact of Multidomain Lifestyle Intervention on Frailty Through the Lens of Deficit Accumulation in Adults with Type 2 Diabetes Mellitus

BACKGROUND

Type 2 diabetes and obesity increase the accumulation of health deficits and may accelerate biological aging. Multidomain lifestyle interventions may mitigate against this.

METHODS

Within a large, randomized clinical trial of intensive lifestyle intervention including caloric restriction, increased physical activity, dietary counseling, and risk factor monitoring compared with diabetes support and education, we examined the accumulation of health deficits across 8 years. We used two complementary frailty indices (FIs) based on deficit accumulation, one modeled on work in the Systolic Blood Pressure Intervention Trial and the other including additional deficits related to obesity and type 2 diabetes mellitus. Differences between intervention groups and their consistency among subgroups were assessed with re-randomization tests.

RESULTS

Data from 4,859 adults (45-76 years at baseline, 59% female) were analyzed. Random assignment to intensive lifestyle intervention was associated with lower FI scores throughout follow-up as captured by areas under curves traced by longitudinal means (p ≤ .001), over which time mean (SE) differences between intervention groups averaged 5.8% (0.9%) and 5.4% (0.9%) for the two indices. At year 8, the percentage of participants classified as frail (FI > 0.21) was lower among intensive lifestyle intervention (39.8% and 54.5%) compared with diabetes support and education (42.7% and 60.9%) for both FIs (both p < .001). Intervention benefits were relatively greater for participants who were older, not obese, and without history of cardiovascular disease at baseline.

CONCLUSIONS

Eight years of multidomain lifestyle intervention create a buffer against the accumulation of age-related health deficits in overweight or obese adults with type 2 diabetes.ClinicalTrials.gov Identifier: NCT00017953.

[Where and how is multicomponent exercise being applied, and in which elderly people, in order to obtain health benefits? A systematic review]

The aim of this systematic review was to synthesise the characteristics of older adults (OA) and to give an account of how and when multicomponent exercise (MCE) has been used to improve physical and psychological health, as well as their cognitive function. This systematic review was conducted on 21 articles published in PsycINFO, Medline, and Web of Science databases from 2009 to 2019, using the procedures set out in the PRISMA statement. The total sample consisted of 3,768 older adults with a mean age of 74.2. More than three-quarters (76%) of the articles studied older adults that lived in the community. evidenced Frailty was observed in the subjects in 23.8% of the articles. In 76% of the studies, a health professional was responsible for the program. Just under half (48%) of the studies were carried out in places equipped for exercise. The most frequent parameters used were two weekly 45 to 60-minute-long sessions for six months. The most frequent variables for physical health, psychological health, and cognitive function were muscle strength, social function, and memory, respectively. To assess physical health, psychological health, and cognitive function, the most frequent tools used were the timed up and go test (TUG), the geriatric depression scale (GDS), and the mini-mental state examination (MMSE), respectively. It was concluded that there is an age and health profile of OA who participate in MCE. The parameters and times most frequently used in MCE, along with the most frequently used parameters and times were recorded. In addition, the variables of interest, and the tools used to evaluate the effects of MCE on physical and psychological health and cognitive functions, were identified.

Effectiveness of integrated chronic care interventions for older people with different frailty levels: a systematic review protocol

INTRODUCTION

Frailty poses a huge burden to individuals, their families and to healthcare systems. Several interventions have been evaluated for the improvement of outcomes for older people with frailty, including integrated care interventions. Reviews synthesising evidence on the effectiveness of integrated care for older people with frailty have treated them as a single population, without considering the heterogeneity between different frailty levels such as non-frail, mild frailty, moderate frailty and severe frailty. Findings from these studies have shown inconsistent results on the various outcomes assessed. People with different frailty status have different care needs, which should be addressed accordingly. The aim of this study is to synthesise evidence on the effectiveness of integrated care interventions on older people with different frailty status who are community dwelling or living in retirement housing or residential setting but not in care homes or in nursing homes.

METHODS AND ANALYSIS

This is a protocol for a systematic review assessing the effectiveness of integrated chronic care interventions on older people with different frailty status. A literature search will be conducted on the databases Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and clinical trial registers. Two authors will independently conduct search and screening for eligible studies. Full-text screening will be used to include only studies that fulfil the inclusion criteria. Data extraction will be done on a data extraction form and methodological quality of studies will be assessed using the Effective Practice and Organisation of Care risk of bias tool. The interventions will be described following Wagner's Chronic Care Model.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Institute for Health Research Ethics Committee of the University of Bedfordshire (IHREC934). The results of the review will be disseminated through a peer-reviewed journal article, conferences and also with local provider and user stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42020166908.

Efficacy of multidomain interventions to improve physical frailty, depression and cognition: data from cluster-randomized controlled trials

BACKGROUND

Frailty is the pre-eminent exigency of aging. Although frailty-related impairments are preventable, and multidomain interventions appear more effective than unimodal ones, the optimal components remain uncertain.

METHODS

We devised multidomain interventions against physical and cognitive decline among prefrail/frail community-dwelling ≥65-year-olds and evaluated these in complementary cluster-randomized trials of efficacy and participant empowerment. The Efficacy Study compared ~3-monthly telephone consultations vs. 16, 2 h sessions/year comprising communally partaken physical and cognitive training plus nutrition and disease education; the Empowerment Study compared the standard Efficacy Study multidomain intervention (Sessions 1-10) vs. an enhanced version redesigned to empower and motivate individual participants. Changes from baseline in physical, functional, and cognitive performance were measured after 6 and 12 months in the Efficacy Study and after 6 months in the Empowerment Study, with post-intervention follow-up at 9 months. Primary outcomes are as follows: Cardiovascular Health Study frailty score; gait speed; handgrip strength; and Montreal Cognitive Assessment (MoCA). Secondary outcomes are as follows: instrumental activities of daily living; metabolic equivalent of task (MET); depressed mood (Geriatric Depression Scale-5 ≥2); and malnutrition (Mini-Nutritional Assessment short-form ≤11). Intervention effects were analyzed using a generalized linear mixed model.

RESULTS

Efficacy Study participants (n = 1082, 40 clusters) were 75.1 ± 6.3 years old, 68.7% women, and 64.7% prefrail/frail; analytic clusters: 19 intervention (410/549 completed) vs. 21 control (375/533 completed). Empowerment Study participants (n = 440, 14 clusters) were 75.9 ± 7.1 years old, 83.6% women, and 56.7% prefrail/frail; analytic clusters: seven intervention (209/230 completed) vs. seven control (189/210 completed). The standard and enhanced multidomain interventions both reduced frailty and significantly improved aspects of physical, functional, and cognitive performance, especially among ≥75-year-olds. Standard multidomain intervention decreased depression [odds ratio 0.56, 95% confidence interval (CI) 0.32, 0.99] and malnutrition (odds ratio 0.45, 95% CI 0.26, 0.78) by 12 months and improved concentration at Months 6 (0.23, 95% CI 0.04, 0.42) and 12 (0.46, 95% CI 0.22, 0.70). Participant empowerment augmented activity (4.67 MET/h, 95% CI 1.64, 7.69) and gait speed (0.06 m/s, 95% CI 0.00, 0.11) at 6 months, with sustained improvements in delayed recall (0.63, 95% CI 0.20, 1.06) and MoCA performance (1.29, 95% CI 0.54, 2.03), and less prevalent malnutrition (odds ratio 0.39, 95% CI 0.18, 0.84), 3 months after the intervention ceased.

CONCLUSIONS

Pragmatic multidomain intervention can diminish physical frailty, malnutrition, and depression and enhance cognitive performance among community-dwelling elders, especially ≥75-year-olds; this might supplement healthy aging policies, probably more effectively if participants are empowered.

Primary care interventions to address physical frailty among community-dwelling adults aged 60 years or older: A meta-analysis

Introduction

The best interventions to address frailty among older adults have not yet been fully defined, and the diversity of interventions and outcome measures makes this process challenging. Consequently, there is a lack of guidance for clinicians and researchers regarding which interventions are most likely to help older persons remain robust and independent. This paper uses meta-analysis to assess effectiveness of primary care interventions for physical frailty among community-dwelling adults aged 60+ and provides an up-to-date synthesis of literature in this area.

Methods

PubMed, CINAHL, Cochrane Register of Controlled Trials, and PEDro databases were searched, and RCTs, controlled pilot studies, or trials with similar study designs addressing frailty in the primary care setting among persons aged 60+ were chosen. Study data was abstracted following PRISMA guidelines, then meta-analysis was performed using the random effects model.

Results

31 studies with a total of 4794 participants were analysed. Interventions using predominantly resistance-based exercise and nutrition supplementation seemed to improve frailty status versus control (RR = 0.62 (CI 0.48–0.79), I² = 0%). Exercise plus nutrition education also reduced frailty (RR = 0.69 (CI 0.58–0.82), I² = 0%). Exercise alone seemed effective in reducing frailty (RR = 0.63 (CI 0.47–0.84), I² = 0%) and improving physical performance (RR = 0.43 (CI 0.18–0.67), I² = 0%). Exercise alone also appeared superior to control in improving gait speed (SMD = 0.36 (CI 0.10–0.61, I² = 74%), leg strength (SMD = 0.61 (CI 0.09–1.13), I² = 87%), and grip strength (Mean Difference = 1.08 (CI 0.02–2.15), I² = 71%) though a high degree of heterogeneity was observed. Comprehensive geriatric assessment (RR = 0.77 (CI 0.64–0.93), I² = 0%) also seemed superior to control in reducing frailty.

Conclusion

Exercise alone or with nutrition supplementation or education, and comprehensive geriatric assessment, may reduce physical frailty. Individual-level factors and health systems resource availability will likely determine configuration of future interventions.

Replacing Sedentary Time with Light or Moderate-Vigorous Physical Activity Across Levels of Frailty

We sought to examine how much sedentary times needs to be replaced by light or moderate-vigorous physical activity in order to reduce frailty and protect against mortality. We built isotemporal substitution models to assess the theoretical effect of replacing sedentary behavior with and equal amount of light or moderate-vigorous activity on frailty and mortality in community-based adults aged 50 years and older. Controlling for age, sex, body mass index, marital status, race, education, employment status, and National Health and Nutrition Examination Study cycle, replacing one hour of sedentary time with moderate-vigorous or light physical activity daily was associated with a lower Frailty Index. For mortality, results varied based on frailty level. Replacing sedentary behavior with moderate-vigorous exercise was associated with lower mortality risk in vulnerable individuals, however, replacing sedentary behavior with light activity was associated with lower mortality risk in frailer individuals.

Estimated Glomerular Filtration Rate Decline and Incident Frailty in Older Adults

BACKGROUND AND OBJECTIVES

Low eGFR is known to be associated with frailty, but the association between the longitudinal decline of eGFR and incident frailty in older persons remains to be determined. The objective of this study was to investigate whether a fast decline on eGFR would be associated with incident frailty.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Community dwellers, aged ≥70, were included in this secondary analysis of the 5-year Multidomain Alzheimer Preventive Trial (MAPT). eGFR was calculated using CKD-Epidemiology Collaboration equation at baseline and at 6, 12, and 24 months. The lowest quartile of eGFR slope (-4.1 ml/min per 1.73 m² per yr) defined a fast decline. The frailty phenotype (unintentional weight loss, exhaustion, low physical activity, slow gait, low handgrip strength assessed with a 0-5 score, where higher is worse; a score ≥3 defines frailty) was assessed at baseline, 6, 12, 24, 36, 48, and 60 months. Cox models were used to test the association between fast eGFR decline and incident frailty.

RESULTS

A total of 833 participants were frail neither at baseline nor at 2 years and had appropriate follow-up data. Median (IQR) baseline eGFR was 73 (61-84) ml/min per 1.73 m². Frailty occurred in 95 (11%) participants between 24 and 60 months. Among them, 31/207 (15%) had fast eGFR decline between baseline and 24 months, and 64/626 (10%) did not. In a Cox model adjusted for demographic variables, cardiovascular comorbidity, C-reactive protein, and baseline eGFR, a fast eGFR decline was associated with incident frailty (HR 1.67, 95% CI 1.03 to 2.71). Sensitivity analyses provided consistent findings.

CONCLUSIONS

In community-dwelling older adults with relatively preserved baseline eGFR, a fast eGFR decline is associated with incident frailty.

Nutritional interventions to prevent and treat frailty

PURPOSE OF REVIEW

Frailty is a multidimensional condition common in older adults, where reduced resiliency leads to adverse outcomes. It has strong links with malnutrition and sarcopenia, mostly through muscle health. This review explores the links between nutrition and frailty from different perspectives.

RECENT FINDINGS

Studies linking malnutrition and frailty show that most malnourished persons are frail, and malnutrition risk is increased in frail people. Energy and protein intake and some micronutrients are linked to frailty. Research on the role of microbiota and specific amino acids is increasing. Recent literature on the prevention of frailty with nutrition confirms that an appropriate intake of proteins, vitamin D and other nutrients is needed, but this information is still not in the public domain. Interventions to reverse frailty and sarcopenia should include exercise and nutrition interventions, usually with a multidomain approach including other elements.

SUMMARY

Public health recommendations to eat an optimal diet with the right amount of energy and proteins should be moved to the public domain. Whenever frailty is present, nutrition has a role in reverting it and avoiding adverse outcomes, but high-quality research is still needed in this area.

The impact of physical activity and sedentary behaviors on frailty levels

Heterogeneity in aging can be explained by frailty. Lifestyle behaviors such as physical activity can help manage frailty levels. Conversely, sedentary behaviours are associated with frailty independently of physical activity. Here, we summarize epidemiological and clinical trial evidence concerning the impact of physical activity and sedentary behaviors on frailty levels. We also analysed the National Health and Nutrition Examination Survey (NHANES) data to describe physical activity and sedentary behavior accumulation patterns across frailty levels and their impact on mortality risk. The few prospective and intervention studies demonstrate that higher physical activity levels are associated with a lower incidence of frailty. There are no interventions published which limit sedentary behaviors to manage frailty. Using the NHANES data we demonstrate that individuals are less likely to meet physical activity guidelines and are more likely to accumulate sedentary time in prolonged bouts. Prolonged sedentary bouts and total sedentary time were associated with a higher mortality risk in frail individuals but not in the fit group. Non-bouted sedentary time was not associated with mortality risk. Our review and novel data suggest that there is a need for more intervention studies which focus on increasing physical activity or minimizing sedentary time to manage frailty levels.