Prognostic accuracy of 70 individual frailty biomarkers in predicting mortality in the Canadian Longitudinal Study on Aging

The frailty index (FI) uses a deficit accumulation approach to derive a single, comprehensive, and replicable indicator of age-related health status. Yet, many researchers continue to seek a single "frailty biomarker" to facilitate clinical screening. We investigated the prognostic accuracy of 70 individual biomarkers in predicting mortality, comparing each with a composite FI. A total of 29,341 individuals from the comprehensive cohort of the Canadian Longitudinal Study on Aging were included (mean, 59.4 ± 9.9 years; 50.3% female). Twenty-three blood-based biomarkers and 47 test-based biomarkers (e.g., physical, cardiac, cardiology) were examined. Two composite FIs were derived: FI-Blood and FI-Examination. Mortality status was ascertained using provincial vital statistics linkages and contact with next of kin. Areas under the curve were calculated to compare prognostic accuracy across models (i.e., age, sex, biomarker, FI) in predicting mortality. Compared to an age-sex only model, the addition of individual biomarkers demonstrated improved model fit for 24/70 biomarkers (11 blood, 13 test-based). Inclusion of FI-Blood or FI-Examination improved mortality prediction when compared to any of the 70 biomarker-age-sex models. Individual addition of seven biomarkers (walking speed, chair rise, time up and go, pulse, red blood cell distribution width, C-reactive protein, white blood cells) demonstrated an improved fit when added to the age-sex-FI model. FI scores had better mortality risk prediction than any biomarker. Although seven biomarkers demonstrated improved prognostic accuracy when considered alongside an FI score, all biomarkers had worse prognostic accuracy on their own. Rather than a single biomarker test, implementation of routine FI assessment in clinical settings may provide a more accurate and reliable screening tool to identify those at increased risk of adverse outcomes.

Reliability of the Frailty Index Among Community-Dwelling Older Adults

BACKGROUND

Consistent and reproducible estimates of the underlying true level of frailty are essential for risk stratification and monitoring of health changes. The purpose of this study is to examine the reliability of the frailty index (FI).

METHODS

A total of 426 community-dwelling older adults from the FRequent health Assessment In Later life (FRAIL70+) study in Austria were interviewed biweekly up to 7 times. Two versions of the FI, one with 49 deficits (baseline), and another with 44 (follow-up) were created. Internal consistency was assessed using confirmatory factor analysis and coefficient omega. Test-retest reliability was assessed with Pearson correlation coefficients and the intraclass correlation coefficient. Measurement error was assessed with the standard error of measurement, limits of agreement, and smallest detectable change.

RESULTS

Participants (64.6% women) were on average 77.2 (±5.4) years old with mean FI49 at a baseline of 0.19 (±0.14). Internal consistency (coefficient omega) was 0.81. Correlations between biweekly FI44 assessments ranged between 0.86 and 0.94 and reliability (intraclass correlation coefficient) was 0.88. The standard error of measurement was 0.05, and the smallest detectable change and upper limits of agreement were 0.13; the latter is larger than previously reported minimal clinically meaningful changes.

CONCLUSIONS

Both internal consistency and reliability of the FI were good, that is, the FI differentiates well between community-dwelling older adults, which is an important requirement for risk stratification for both group-level oriented research and patient-level clinical purposes. Measurement error, however, was large, suggesting that individual health deteriorations or improvements, cannot be reliably detected for FI changes smaller than 0.13.

Social Vulnerability and Frailty in Hospitalized Older Adults

Background

Social vulnerability is the accumulation of disadvantageous social circumstances resulting in susceptibility to adverse health outcomes. Associated with increased mortality, cognitive decline, and disability, social vulnerability has primarily been studied in large population databases rather than frail hospitalized individuals. We examined how social vulnerability contributes to hospital outcomes and use of hospital resources for older adults presenting to the Emergency Department.

Methods

We analyzed patients 65 years of age or older admitted through the Emergency Department and consulted to internal medicine or geriatrics at a Canadian tertiary care hospital from July 2009 to September 2020. A 20-item social vulnerability index (SVI) and a 57-item frailty index (FI) were calculated, using a deficit accumulation approach. Outcomes were length of stay (LOS), extended hospital LOS designation, alternative level of care (ALC) designation, in-hospital mortality, and discharge to long-term care (LTC).

Results

In 1,146 patients (mean age 80.5±8.3, 54.0% female), mean SVI was 0.40±0.16 and FI was 0.44±0.14. The SVI scores were not associated with admission to hospital. Amongst those admitted, for every 0.1 unit increase in SVI, LOS increased by 1.15 days (p<.001) after adjusting for age, sex and FI. SVI was associated with staying over the expected LOS (aOR: 1.19, 1.05-1.34, p=.009) and ALC status (aOR 1.39, 1.12-1.74, p<.004). SVI was not associated with in-hospital mortality, but was associated with incident discharge to LTC (aOR 1.03, 1.02-1.04, p<.001).

Conclusion

Independent of frailty, being socially vulnerable was associated with increased LOS, designation as ALC, and being discharged to LTC from hospital. Consideration of social vulnerability's influence on prolonged hospitalization and long-term care needs has implications for screening and hospital resources.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial

BACKGROUND

Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty.

METHODS

Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels.

DISCUSSION

This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful.

TRIAL REGISTRATION

The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

The impact of cardiovascular health and frailty on mortality for males and females across the life course

BACKGROUND

The effect of frailty and poor cardiovascular health on mortality for males and females is not fully elucidated. We investigated whether the combined burden of frailty and poor cardiovascular health is associated with all-cause and cardiovascular disease (CVD) mortality by sex and age.

METHODS

We analyzed data of 35,207 non-institutionalized US residents aged 20-85 years old (mean age [standard deviation]: 46.6 [16.7 years], 51.4% female, 70.8% White, 10.3% Black, 13.2% Hispanic) from the National Health and Nutrition Examination Survey (1999-2015). Cardiovascular health was measured with the American Heart Association's Life's Simple 7 score (LS7). A 33-item frailty index (FI) was constructed to exclude cardiovascular health deficits. We grouped the FI into 0.1 increments (non-frail: FI &lt; 0.10, very mildly frail: 0.1 ≤ FI &lt; 0.20, mildly frail: 0.20 ≤ FI &lt; 0.30, and moderately/severely frail: FI ≥ 0.30) and LS7 into tertiles (T1[poor] = 0-7, T2[intermediate] = 8-9, T3[ideal] = 10-14). All-cause and CVD mortality data were analyzed up to 16 years. All regression models were stratified by sex.

RESULTS

The average FI was 0.09 (SD 0.10); 29.6% were at least very mildly frail, and the average LS7 was 7.9 (2.3). Mortality from all-causes and CVD were 8.5% (4228/35,207) and 6.1% (2917/35,207), respectively. The median length of follow-up was 8.1 years. The combined burden of frailty and poor cardiovascular health on mortality risk varied according to age in males (FI*age interaction p = 0.01; LS7*age interaction p &lt; 0.001) but not in females. In females, poor FI and LS7 combined to predict all-cause and CVD mortality in a dose-response manner. All-cause and CVD mortality risk was greater for older males (60 and 70 years old) who were at least mildly frail and had intermediate cardiovascular health or worse (hazard ratio [lower/higher confidence interval ranges] range: all-cause mortality = 2.02-5.30 [1.20-4.04, 3.15-6.94]; CVD-related mortality = 2.22-7.16 [1.03-4.46, 4.49-11.50]) but not for younger males (30, 40, and 50 years old).

CONCLUSIONS

The combined burden of frailty and LS7 on mortality is similar across all ages in females. In males, this burden is greater among older people. Adding frailty to assessments of overall cardiovascular health may identify more individuals at risk for mortality and better inform decisions to implement preventative or treatment approaches.

Relationship of body mass index with frailty and all-cause mortality among middle-aged and older adults

BACKGROUND

Parallel to growth of aging and obese populations, the prevalence of metabolic diseases is rising. How body mass index (BMI) relates to frailty and mortality across frailty levels is controversial. We examined the associations of high BMI with frailty and mortality and explored the effects of percent body fat on these associations.

METHODS

We included 29,937 participants aged ≥50 years from the 2001-2006 National Health and Nutrition Examination Survey (NHANES) cohorts (N=6062; 53.7% females) and from wave 1 (2004) of Survey of Health, Ageing and Retirement in Europe (SHARE) (N=23,875; 54% females). BMI levels were categorized as: normal: 18.5-24.9 kg/m², overweight: 25.0-29.9, obese grade 1: 30.0-34.9, and obese grade 2 or 3: >35.0. A frailty index (FI) was constructed excluding nutrition-related items: 36 items for NHANES and 57 items for SHARE. We categorized the FI using 0.1-point increments: FI ≤ 0.1 (non-frail), 0.1 < FI ≤ 0.2 (very mildly frail), 0.2 < FI ≤ 0.3 (mildly frail), and FI > 0.3 (moderately/severely frail). Percent body fat was measured using DXA for NHANES participants. All-cause mortality data were obtained until 2015 for NHANES and 2017 for SHARE to estimate 10-year mortality risk. All analyses were adjusted for age, sex, educational, marital, employment, and smoking statuses.

RESULTS

Mean age of participants was 63.3±10.2 years for NHANES and 65.0±10.0 years for SHARE. In both cohorts, BMI levels ≥25 kg/m² were associated with higher frailty, compared to normal BMI. In SHARE, having a BMI level greater than 35 kg/m² increased mortality risk in participants with FI≤0.1 (HR 1.31, 95%CI 1.02-1.69). Overweight participants with FI scores >0.3 were at lower risk for mortality compared to normal BMI [NHANES (0.79, 0.64-0.96); SHARE (0.71, 0.63-0.80)]. Higher percent body fat was associated with higher frailty. Percent body fat significantly mediated the relationship between BMI levels and frailty but did not mediate the relationship between BMI levels and mortality risk.

CONCLUSIONS

Being overweight or obese is associated with higher frailty levels. In this study, we found that being overweight is a protective factor of mortality in moderately/severely frail people and obesity grade 1 may be protective for mortality for people with at least a mild level of frailty. In contrast, obesity grades 2 and 3 may be associated with higher mortality risk in non-frail people. The relationship between BMI and frailty is partially explained by body fat.

Physical demands at work and physical activity are associated with frailty in retirement

BACKGROUND: The relationship between occupational physical activity and frailty is complex and understudied. OBJECTIVE: We explore whether moderate-vigorous physical activity (MVPA) in retirement and main lifetime occupation physical demands (OPD) are associated with frailty in retirement. METHODS: Retired adults aged 50 + who participated in waves 3-4 of the Survey of Health, Ageing and Retirement in Europe were included. We constructed a 65-item frailty index (FI; Wave 4). Linear regressions tested the independent associations between OPD (Wave 3) and retirement MVPA (Wave 4) with FI (B: 95% CI) controlling for occupation characteristics (Wave 3) and demographics (Wave 4). These models were repeated across country groups (Nordic; Mediterranean; Continental) and sexes. RESULTS: We included 8,411 adults (51.1% male) aged 72.4 years (SD 8.0). Frequent MVPA was consistently associated with lower FI (-0.09 : 0.10–-0.08, p < .001) while OPD was associated with higher FI (0.02 : 0.01-0.03, p < .001). The MVPA*OPD interaction (-0.02: -0.04–-0.00, p = .043) was weakly associated with FI, but did not explain additional model variance or was significant among any country group or sex. CONCLUSIONS: For a sample of European community-dwelling retirees, a physically demanding main lifetime occupation independently predicts worse frailty, even in individuals who are physically active in retirement.

Effect of a physical activity intervention and frailty on frailty trajectory and major mobility disability

BACKGROUND

Physical activity (PA) interventions may reduce the burden of frailty and can prevent mobility disability for older adults. We explored whether a 2-year PA intervention would improve frailty trajectory, lead to clinically meaningful frailty changes (CMC), or impact major mobility disability (MMD) across baseline frailty levels.

METHODS

We analyzed data for 1635 community-dwelling participants who were 70-89 years old (mean baseline age [SD]: 78.9 [5.2] years, 67.2% female) from the Lifestyle Interventions and Independence Study. Participants were randomized to either PA or health education (HE) intervention. A 44-item frailty index (FI) was constructed at baseline and 0.5, 1, 1.5, and 2 years after baseline. CMC was defined as change in FI of ≥0.03. MMD was the inability to complete a 400 m-walk within 15 min without assistance. Mixed-effects models were used to estimate frailty trajectory and CMC. Cox regression models were used to determine whether the effect of PA on the composite of MMD or death differed by baseline FI.

RESULTS

Mean FI (SD) at baseline for both the PA and HE groups was 0.18 (0.10). Two years after baseline, mean FIs were 0.23 (0.12) for PA and 0.24 (0.12) for HE. The MMD rates were 30.1% (246/818) and 35.5% (290/817) for PA and HE, respectively. There was no time-by-intervention interaction for frailty trajectory or for CMC. Regarding the composite MMD and death, there was no FI-by-intervention interaction. Simple association analyses revealed that when baseline FI was centered at 0.15 or higher, the PA intervention was associated with lower risk of MMD or death compared to HE (HR [CI] range for FI ≥ 0.15: 0.65-0.81 [0.43-0.67, 0.90-0.98]).

CONCLUSION

Participants in both groups showed similar frailty trajectories and CMC. Those who were frailer benefitted more from the PA intervention regarding MMD and death and may be a focus of recruitments for future PA program.

Older Age and Frailty are Associated with Higher Mortality but Lower ICU Admission with COVID-19

Background

We report characteristics and outcomes of adults admitted to Canadian Immunization Research Network (CIRN) Serious Outcomes Surveillance (SOS) Network hospitals with COVID-19 in 2020.

Methods

Patients with laboratory-confirmed COVID-19 admitted to 11 sites in Ontario, Quebec, Alberta, and Nova Scotia up to December 31, 2020 were enrolled in this prospective observational cohort study. Measures included age, sex, demographics, housing, exposures, Clinical Frailty Scale, comorbidities; in addition, length of stay, intensive care unit (ICU) admission, mechanical ventilation, and survival were assessed. Descriptive analyses and multivariable logistic regressions were conducted.

Results

Among 2,011 patients, mean age was 71.0 (range 19–105) years. 29.7% were admitted from assisted living or long-term care facilities. The full spectrum of frailty was represented in both younger and older age groups. 81.8% had at least one underlying comorbidity and 27.2% had obesity. Mortality was 14.3% without ICU admission, and 24.6% for those admitted to ICU. Older age and frailty were independent predictors of lower ICU use and higher mortality; accounting for frailty, obesity was not an independent predictor of mortality, and associations of comorbidities with mortality were weakened.

Conclusions

Frailty is a critical clinical factor in predicting outcomes of COVID-19, which should be considered in research and clinical settings.

Frailty indices based on self-report, blood-based biomarkers and examination-based data in the Canadian Longitudinal Study on Aging

BACKGROUND

Frailty can be operationalised using the deficit accumulation approach, which considers health deficits across multiple domains. We aimed to develop, validate and compare three different frailty indices (FI) constructed from self-reported health measures (FI-Self Report), blood-based biomarkers (FI-Blood) and examination-based assessments (FI-Examination).

METHODS

Up to 30,027 participants aged 45-85 years from the baseline (2011-2015) comprehensive cohort of the Canadian Longitudinal Study on Aging were included in the analyses. Following standard criteria, three FIs were created: a 48-item FI-Self Report, a 23-item FI-Blood and a 47-item FI-Examination. In addition a 118-item FI-Combined was constructed. Mortality status was ascertained in July 2019.

RESULTS

FI-Blood and FI-Examination demonstrated broader distributions than FI-Self Report. FI-Self Report and FI-Blood scores were higher in females, whereas FI-Examination scores were higher in males. All FI scores increased nonlinearly with age and were highest at lower education levels. In sex and age-adjusted models, a 0.01 increase in FI score was associated with a 1.08 [95% confidence interval (CI): 1.07,1.10], 1.05 (1.04,1.06), 1.07 (1.05,1.08) and a 1.13 (1.11,1.16) increased odds of mortality for FI-Self Report, FI-Blood, FI-Examination and FI-Combined, respectively. Inclusion of the three distinct FI types in a single model yielded the best prognostic accuracy and model fit, even compared to the FI-Combined, with all FIs remaining independently associated with mortality.

CONCLUSION

Characteristics of all FIs were largely consistent with previously established FIs. To adequately capture frailty levels and to improve our understanding of the heterogeneity of ageing, FIs should consider multiple types of deficits including self-reported, blood and examination-based measures.

10-year frailty trajectory is associated with Alzheimer's dementia after considering neuropathological burden

MAIN PROBLEM

Frailty is an established risk factor for cognitive decline and Alzheimer's disease. Few studies have examined the longitudinal relationship between frailty and cognition.

METHODS

Participants of Rush Memory and Aging project (n = 625, 67.5% female, 83.2 ± 5.9 years at baseline) underwent annual clinical evaluations (average follow-up 5.6 ± 3.7 years) followed by neuropathologic assessment after death. A frailty index was calculated from 41 health variables at each evaluation. Clinical diagnosis of MCI and/or dementia was ascertained by clinical data review (blinded to neuropathological data) after death. Age, sex, education, and neuropathological burden (10-item index) were evaluated as covariates. Frailty trajectories were calculated using a mixed effects model.

RESULTS

At baseline the mean frailty index = 0.24 ± 0.12 and increased at rate of 0.026 or ~1 deficit per year. At death, 27.7% of the sample had MCI, and 38.6% had dementia. Frailty trajectories were significantly steeper among those individuals who were ultimately diagnosed as clinically impaired prior to death, even after controlling for age, sex, education, and neuropathological index.

CONCLUSIONS

Findings suggest a strong link between health status (frailty index) and dementia, even after considering neuropathology. Frailty trajectories were associated with risk for MCI and dementia, underscoring the importance of addressing frailty to manage dementia risk.

Signs of diastolic dysfunction are graded by serum testosterone levels in aging C57BL/6 male mice

We investigated whether maladaptive, age-associated changes in heart structure and function were linked to circulating testosterone levels. Male C57BL/6 mice had a gonadectomy (GDX) or sham surgery at 4 weeks and effects of GDX on the heart were examined with echocardiography. Serum testosterone was measured with ELISA. Left ventricular (LV) mass increased with age but was smaller in GDX mice than sham at 18 months (144.0 ± 8.7 vs 118.2 ± 11.9 mg; p = 0.009). The isovolumic relaxation time (IVRT) declined with age but was prolonged in GDX mice at 18 months (10.5 ± 0.8 vs 12.5 ± 0.5 msec, p = 0.008). Ejection fraction did not change with age or GDX, but E/A ratios were lower in GDX mice than controls at 18 months (1.6 ± 0.2 vs 1.3 ± 0.1, p = 0.021). When links between serum testosterone and cardiac parameters were examined longitudinally in 18-24-month-old mice, LV mass declined with decreasing testosterone (β = 37.70, p = 0.016), however IVRT increased as testosterone decreased (β=-2.69, p = 0.036). Since longer IVRT and lower E/A ratios are signs of diastolic dysfunction, low circulating testosterone may promote or exacerbate diastolic dysfunction in older males. These findings suggest that lower testosterone directly modifies heart structure and function to promote maladaptive remodeling and diastolic dysfunction in the aging heart.

Relationship between diet quality scores and the risk of frailty and mortality in adults across a wide age spectrum

BACKGROUND

Beyond intakes of total energy and individual nutrient, eating patterns may influence health, and thereby the risk of adverse outcomes. How different diet measures relate to frailty-a general measure of increased vulnerability to unfavorable health outcomes-and mortality risk, and how this might vary across the life course, is not known. We investigated the associations of five dietary indices (Nutrition Index (NI), the energy-density Dietary Inflammatory Index (E-DII™), Healthy Eating Index-2015 (HEI-2015), Mediterranean Diet Score (MDS), and Dietary Approaches to Stop Hypertension (DASH)) with frailty and mortality.

METHODS

We included 15,249 participants aged ≥ 20 years from the 2007-2012 cohorts of the National Health and Nutrition Examination Survey (NHANES). The NI combined 31 nutrition-related deficits. The E-DII is a literature-derived dietary index associated with inflammation. The HEI-2015 assesses adherence to the Dietary Guidelines of Americans. The MDS represents adherence to the traditional Mediterranean diet. DASH combines macronutrients and micronutrients to prevent hypertension. Frailty was evaluated using a 36-item frailty index. Mortality status was ascertained up to December 31, 2015.

RESULTS

Participants' mean age was 47.2 ± 16.7 years and 51.7% were women. After adjusting for age, sex, race, educational level, marital and employment status, smoking, BMI, and study cohort, higher NI and E-DII scores and lower HEI-2015, MDS, and DASH scores were individually significantly associated with frailty. All dietary scores were significantly associated with 8-year mortality risk after adjusting for basic covariates and frailty: NI (hazard ratio per 0.1 point, 1.15, 95%CI 1.10-1.21), E-DII (per 1 point, 1.05, 1.01-1.08), HEI-2015 (per 10 points, 0.93, 0.89-0.97), MDS (per 1 point, 0.94, 0.90-0.97), and DASH (per 1 point, 0.96, 0.93-0.99). The associations of E-DII, HEI-2015, and MDS scores with 8-year mortality risk persisted after additionally adjusting for NI.

CONCLUSIONS

NI, E-DII, HEI-2015, MDS, and DASH scores are associated with frailty and 8-year mortality risk in adults across all ages. Nevertheless, their mechanisms and sensitivity to predict health outcomes may differ. Nutrition scores have the potential to include measures of both consumption and laboratory and physical measures of exposure.

Frailty among middle-aged and older Canadians: population norms for the frailty index using the Canadian Longitudinal Study on Aging

BACKGROUND

frailty is a public health priority now that the global population is ageing at a rapid rate. A scientifically sound tool to measure frailty and generate population-based reference values is a starting point.

OBJECTIVE

in this report, our objectives were to operationalize frailty as deficit accumulation using a standard frailty index (FI), describe levels of frailty in Canadians ≥45 years old and provide national normative data.

DESIGN

this is a secondary analysis of the Canadian Longitudinal Study on Aging (CLSA) baseline data.

SETTING/PARTICIPANTS

about 51,338 individuals (weighted to represent 13,232,651 Canadians), aged 45-85 years, from the tracking and comprehensive cohorts of CLSA.

METHODS

after screening all available variables in the pooled dataset, 52 items were selected to construct an FI. Descriptive statistics for the FI and normative data derived from quantile regressions were developed.

RESULTS

the average age of the participants was 60.3 years (95% confidence interval [CI]: 60.2-60.5), and 51.5% were female (95% CI: 50.8-52.2). The mean FI score was 0.07 (95% CI: 0.07-0.08) with a standard deviation of 0.06. Frailty was higher among females and with increasing age, and scores >0.2 were present in 4.2% of the sample. National normative data were identified for each year of age for males and females.

CONCLUSIONS

the standardized frailty tool and the population-based normative frailty values can help inform discussions about frailty, setting a new bar in the field. Such information can be used by clinicians, researchers, stakeholders and the general public to understand frailty, especially its relationship with age and sex.

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.

Persistent Functional Decline Following Hospitalization with Influenza or Acute Respiratory Illness

Background/objectives

Influenza is associated with significant morbidity and mortality, particularly for older adults. Persistent functional decline following hospitalization has important impacts on older adults' wellbeing and independence, but has been under‐studied in relation to influenza. We aimed to investigate persistent functional change in older adults admitted to hospital with influenza and other acute respiratory illness (ARI).

Design

Protective observational cohort study.

Setting

Canadian Immunization Research Network Serious Outcomes Surveillance Network 2011 to 2012 influenza season.

Participants

A total of 925 patients aged 65 and older admitted to hospital with influenza and other ARI.

Measurements

Influenza was laboratory‐confirmed. Frailty was measured using a Frailty index (FI). Functional status was measured using the Barthel index (BI); moderate persistent functional decline was defined as a clinically meaningful loss of ≥10 to <20 points on the 100‐point BI. Catastrophic disability (CD) was defined as a loss of ≥20 points, equivalent to full loss of independence in two basic activities of daily living.

Results

Five hundred and nineteen (56.1%) were women; mean age was 79.4 (standard deviation=8.4) years. Three hundred and forty‐six (37.4%) had laboratory‐confirmed influenza. Influenza cases had lower baseline function (BI = 77.0 vs 86.9, P < .001) and higher frailty (FI = 0.23 vs 0.20, P < .001) than those with other ARI. A total of 8.4% died, 8.2% experienced persistent moderate functional decline, and 9.9% experienced CD. Higher baseline frailty was associated with increased odds of experiencing functional decline, CD, and death. The experience of functional decline and CD, and its association with frailty, was the same for influenza and other ARI.

Conclusion

Functional loss in hospital is common among older adults; for some this functional loss is persistent and catastrophic. This highlights the importance of prevention and optimal management of acute declines in health, including influenza, to avoid hospitalization. In the case of influenza, for which vaccines exist, this raises the potential of vaccine preventable disability.

Frailty Hinders Recovery From Influenza and Acute Respiratory Illness in Older Adults

BACKGROUND

We examined frailty as a predictor of recovery in older adults hospitalized with influenza and acute respiratory illness.

METHODS

A total of 5011 patients aged ≥65 years were admitted to Canadian Serious Outcomes Surveillance Network hospitals during the 2011/2012, 2012/2013, and 2013/2014 influenza seasons. Frailty was measured using a previously validated frailty index (FI). Poor recovery was defined as death by 30 days postdischarge or an increase of more than 0.06 (≥2 persistent new health deficits) on the FI. Multivariable logistic regression controlled for age, sex, season, influenza diagnosis, and influenza vaccination status.

RESULTS

Mean age was 79.4 (standard deviation = 8.4) years; 53.1% were women. At baseline, 15.0% (n = 750) were nonfrail, 39.3% (n = 1971) were prefrail, 39.8% (n = 1995) were frail, and 5.9% (n = 295) were most frail. Poor recovery was experienced by 21.4%, 52.0% of whom had died. Frailty was associated with lower odds of recovery in all 3 seasons: 2011/2012 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.59-0.84), 2012/2013 (OR = 0.72; 95% CI, 0.66-0.79), and 2013/2014 (OR = 0.75; 95% CI, 0.69-0.82); results varied by season, influenza status, vaccination status, and age.

CONCLUSIONS

Increasing frailty is associated with lower odds of recovery, and persistent worsening frailty is an important adverse outcome of acute illness.

Frailty Hinders Recovery From Influenza and Acute Respiratory Illness in Older Adults

BACKGROUND

We examined frailty as a predictor of recovery in older adults hospitalized with influenza and acute respiratory illness.

METHODS

A total of 5011 patients aged ≥65 years were admitted to Canadian Serious Outcomes Surveillance Network hospitals during the 2011/2012, 2012/2013, and 2013/2014 influenza seasons. Frailty was measured using a previously validated frailty index (FI). Poor recovery was defined as death by 30 days postdischarge or an increase of more than 0.06 (≥2 persistent new health deficits) on the FI. Multivariable logistic regression controlled for age, sex, season, influenza diagnosis, and influenza vaccination status.

RESULTS

Mean age was 79.4 (standard deviation = 8.4) years; 53.1% were women. At baseline, 15.0% (n = 750) were nonfrail, 39.3% (n = 1971) were prefrail, 39.8% (n = 1995) were frail, and 5.9% (n = 295) were most frail. Poor recovery was experienced by 21.4%, 52.0% of whom had died. Frailty was associated with lower odds of recovery in all 3 seasons: 2011/2012 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.59-0.84), 2012/2013 (OR = 0.72; 95% CI, 0.66-0.79), and 2013/2014 (OR = 0.75; 95% CI, 0.69-0.82); results varied by season, influenza status, vaccination status, and age.

CONCLUSIONS

Increasing frailty is associated with lower odds of recovery, and persistent worsening frailty is an important adverse outcome of acute illness.

Frailty Prevalence in the COMPASS-ND Study of Neurodegenerative Disorders

Background

Frailty is characterized by increased vulnerability to adverse health outcomes. The prevalence of frailty across neurodegenerative disorders (NDD) is largely unknown. Symptoms of frailty and NDD overlap, calling into question a tautology in some frailty instruments. Our objectives were 1) to construct a Frailty Index (FI) independent of NDD symptoms, and 2) to estimate frailty prevalence in a broad NDD cohort using both the Frailty Phenotype (FP) and the constructed FI as measures.

Methods

Data from the Canadian COMPASS-ND cohort study were assessed for applicability to FI construction. Frailty status according to FI and FP criteria were ascertained for each participant.

Results

81 items were selected for the FI. In the cohort (150 participants; 46% women; mean age 73.6±7.0; 10 NDD subgroups), frailty was identified in 11% and 14% of participants according to the FI and FP, respectively. The difference between estimates was not significant. The FP classified most participants (84%) as pre-frail.

Conclusion

The presence of frailty elements, regardless of whether they are part of NDD, is likely to influence health status. Given the FP identified a large proportion of the cohort as pre-frail or frail, it is likely worthwhile to identify frailty in the context of NDD.

CROSS-SECTIONAL ASSOCIATION OF FALLS AND POST-TRAUMATIC STRESS IN CANADIANS ACROSS LEVELS OF FRAILTY

Frail older adults are vulnerable to stressors and are more likely to experience adverse outcomes. Post-traumatic stress is common in older adults, and can be related to common adverse outcomes, such as falls. We examined whether falls are associated with post-traumatic stress in middle-aged and older Canadians, by levels of frailty. We conducted cross-sectional analysis of the baseline assessment of the Canadian Longitudinal Study on Aging’s tracking cohort, comprising 21,241 individuals, aged 45 to 85 years. We constructed a 60-item frailty index (FI) and defined post-traumatic stress using the primary care post-traumatic stress disorder four-item tool (score 3 as the cut-point). Logistic regressions with post-traumatic stress as the dependent variable and at least one fall in the past year as the independent variable, were adjusted for socio-demographic variables and stratified according to FI 0.1 groups. Prevalence of post-traumatic stress and falls was of 6.5% and 5.0%, respectively for the whole sample. Among those who did not fall prevalence of post-traumatic stress ranged across frailty levels from 3.2% (FI<0.1) to 24.5% (FI≥0.3). Among those who fell, post-traumatic stress ranged from 3.4% (FI<0.1) to 36.9% (FI≥0.3). Falls were not significantly associated with post-traumatic stress among people who had an FI<0.3, but among those with an FI≥0.3 the odds ratio for having post-traumatic stress for those who fell was 2.25 (95% CI 1.2-4.23, p=0.011) compared to non-fallers. In conclusion, high levels of frailty can impact how a stressor, such as a fall, can be associated with an adverse psychological outcome.

IMPACT OF HIGH BODY MASS INDEX ON FRAILTY AND MORTALITY IN MIDDLE-AGED AND OLDER ADULTS

Obesity is associated with higher risk of metabolic diseases. How body mass index (BMI) relates to mortality across frailty levels is controversial. We investigated the association of high BMI with frailty, and their effects on mortality. We included 36,583 participants aged ≥50 years from the 1999-2006 National Health and Nutrition Examination Survey (NHANES) cohorts (7,372) and 29,211 participants aged ≥50 years from wave 1 (2004) of Survey of Health Ageing and Retirement in Europe (SHARE). BMI was categorized as: normal: 18.5-24.9 kg/m2, overweight: 25-29.9, obese I: 30-34.9 and obese II+III: &gt;35. A frailty index (FI) was constructed excluding nutrition-related items using 36 items for NHANES and 68 items for SHARE. Mortality data were obtained until 2015. All analyses were adjusted for educational, marital, working and smoking status. In participant aged 50-65 years, higher BMI was associated with greater frailty. Being obese level II+III increased mortality risk in male participants aged 50-65 years with FI≤0.1 [NHANES (hazard ratio (HR) 2.10, 95%CI 1.17-3.79); SHARE (2.35,1.14-4.87)]. In males aged &gt;65 years with FI&gt;0.3, being overweight and obese (any level) decreased mortality risk. In females aged 50-65 years, higher BMI was not associated with mortality across all frailty levels. BMI and frailty were cross-sectionally associated. The subsequent mortality impact differed by age, sex, and frailty. Obesity was not associated with mortality in middle-aged females, regardless of the degree of frailty. In males, obesity was harmful in those who were fit in middle age and protective in moderately/severely frail older ones.

Investigating the feasibility and reliability of the Pictorial Fit-Frail Scale

BACKGROUND

the Pictorial Fit-Frail Scale (PFFS) was designed as a simple and practical approach to the identification of frailty.

OBJECTIVES

To investigate the feasibility and reliability of this visual image-based tool, when used by patients, caregivers and healthcare professionals (HCPs) in clinical settings.

DESIGN

observational study.

SETTING

three outpatient geriatric healthcare settings.

SUBJECTS

patients (n = 132), caregivers (n = 84), clinic nurses (n = 7) and physicians (n = 10).

METHODS

the PFFS was administered to all patients. Where available, HCPs and caregivers completed the scale based on the patients' health. In the geriatric day hospital, the PFFS was completed on admission and administered again within 7-14 days. Time and level of assistance needed to complete the scale were recorded. Intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs) were used to assess test-retest and inter-rater reliability.

RESULTS

mean time to complete the scale (minutes:seconds ± SD) was 4:30 ± 1:54 for patients, 3:13 ± 1:34 for caregivers, 1:28 ± 0:57 for nurses and 1:32 ± 1:40 for physicians. Most patients were able to complete the scale unassisted (64%). Mean patient PFFS score was 11.1 ± 5.3, mean caregiver score was 13.2 ± 6.3, mean nurse score was 10.7 ± 4.5 and mean physician score was 11.1 ± 5.6; caregiver scores were significantly higher than patient (P < 0.01), nurse (P < 0.001) and physician (P < 0.01) scores. Test-retest reliability was good for patients (ICC = 0.78, [95%CI = 0.67-0.86]) and nurses (ICC = 0.88 [0.80-0.93]). Inter-rater reliability between HCPs was also good (ICC = 0.75 [0.63-0.83]).

CONCLUSION

the PFFS is a feasible and reliable tool for use with patients, caregivers and HCPs in clinical settings. Further research on the validity and responsiveness of the tool is necessary.

Upright time during hospitalization for older inpatients: A prospective cohort study

BACKGROUND

The purpose of this study was to examine: a) how long and how frequently older hospitalized patients spend upright; b) whether duration and frequency of upright time change by time of the day, the day of the week, and during hospitalization; and c) whether these relationships differ based on the mobility level of patients at admission.

METHODS

This prospective cohort study included 111 patients (82.2 ± 8 years old, 52% female) from the Emergency Department and a Geriatric Assessment Unit who were at least 60 years old and had an anticipated length of stay of at least three days. The main outcomes were accelerometer-measured total upright time and number of bouts of upright time during awake hours.

RESULTS

Patients were upright 15.9 times/day (interquartile range (IQR): 8.4-27.4) for a total of 54.2 min/day (IQR: 17.8-88.9) during awake hours. Time of day and day of week had little impact on the outcomes. Patients who walked independently at admission had 151.5 min (95% CI: 87.7-215.3) of upright time on hospital day 1 and experienced a decline of 4.5 min/day (-7.2 to -1.8). Those who needed personal mobility assistance or were bedridden had 29.5 min (-38.5-97.4) and 25 min (-48.3-100.3) of upright time on day 1, and demonstrated an increase of 3.6 (1.3-5.9) and 2.4 (0.05-4.5) min/day, respectively.

CONCLUSION

Hospitalized older adults spend only 6% of their awake hours upright while in hospital. Patients who can walk independently are more active but experience a decline in their upright time during hospitalization.

Long-Term Care Admissions Following Hospitalization: The Role of Social Vulnerability

We sought to understand the association between social vulnerability and the odds of long-term care (LTC) placement within 30 days of discharge following admission to an acute care facility and whether this association varied based on age, sex, or pre-admission frailty. Patients admitted to hospital with acute respiratory illness were enrolled in the Canadian Immunization Research Network's Serious Outcomes Surveillance Network during the 2011/2012 influenza season. Participants (N = 475) were 65 years or older (mean = 78.6, SD = 7.9) and over half were women (58.9%). Incident LTC placement was rare (N = 15); therefore, we used penalized likelihood logistic regression analysis. Social vulnerability and frailty indices were built using a deficit accumulation approach. Social vulnerability interacted with frailty and age, but not sex. At age 70, higher social vulnerability was associated with lower odds of LTC placement at high levels of frailty (frailty index (FI) = 0.35; odds ratio (OR) = 0.32, 95% confidence interval (CI) = 0.09-0.94), but not at lower levels of frailty. At age 90, higher social vulnerability was associated with greater odds of LTC placement at lower levels of frailty (FI = 0.05; OR = 14.64, 95%CI = 1.55, 127.21 and FI = 0.15; OR = 7.26, 95%CI = 1.06, 41.84), but not at higher levels of frailty. Various sensitivity analyses yielded similar results. Although younger, frailer participants may need LTC, they may not have anyone advocating for them. In older, healthier patients, social vulnerability was associated with increased odds of LTC placement, but there was no difference among those who were frailer, suggesting that at a certain age and frailty level, LTC placement is difficult to avoid even within supportive social situations.

The Pictorial Fit-Frail Scale: Developing a Visual Scale to Assess Frailty

Background

Standardized frailty assessments are needed for early identification and treatment. We aimed to develop a frailty scale using visual images, the Pictorial Fit-Frail Scale (PFFS), and to examine its feasibility and content validity.

Methods

In Phase 1, a multidisciplinary team identified domains for measurement, operationalized impairment levels, and reviewed visual languages for the scale. In Phase 2, feedback was sought from health professionals and the general public. In Phase 3, 366 participants completed preliminary testing on the revised draft, including 162 UK paramedics, and rated the scale on feasibility and usability. In Phase 4, following translation into Malay, the final prototype was tested in 95 participants in Peninsular Malaysia and Borneo.

Results

The final scale incorporated 14 domains, each conceptualized with 3–6 response levels. All domains were rated as “understood well” by most participants (range 64–94%). Percentage agreement with positive statements regarding appearance, feasibility, and usefulness ranged from 66% to 95%. Overall feedback from health-care professionals supported its content validity.

Conclusions

The PFFS is comprehensive, feasible, and appears generalizable across countries, and has face and content validity. Investigation into the reliability and predictive validity of the scale is currently underway.

Improvement in body composition following a supervised exercise-training program of adult patients with cystic fibrosis

OBJECTIVES

Maintenance of optimal nutritional status is a crucial issue for cystic fibrosis (CF) patients. Here, we evaluate the effects of an 8-week exercise training (ET) program on body composition in CF patients.

METHODS

This prospective pilot observational study was conducted in adult CF subjects in stable condition following their annual check-up. The ET program consisted of three sessions per week and included aerobic training (≥30min), muscle strengthening, circuit training, and relaxation. Exercise tolerance (6-minute walk test, 6MWT), pulmonary function, quadriceps isometric strength, and body composition (bioelectrical impedance analysis of fat-free mass [FFM], fat mass, and body cell mass) were analyzed before and immediately after the ET program. A control group of CF patients who preferred not to participate in the ET program received the same evaluations.

RESULTS

A total of 43 CF patients were enrolled and offered the ET program; 28 accepted (aged 28±5 years, forced expiratory volume in 1s [FEV₁] 48.8±19% predicted) and 15 declined the ET program but agreed to be part of the control group (matched for age and CF severity: 30.8±9 years, FEV₁ 51.8±16.5%). Pulmonary function was unchanged at the end of the ET program, but significant improvements were observed in 6MWT distance (from 520±96m to 562±105m, P<0.001) and muscle strength (331±141N to 379±168N, P<0.001). Although mean body mass index did not change, the ET group showed significantly increased FFM (43.85±8kg to 44.5±9.2kg, P=0.03) and a trend towards increased body cell mass (21.4±6 to 22.1±6.6kg, P=0.06). All other parameters were unchanged by ET. There were no significant correlations between the increase in FFM and the improvements in either 6MWT distance or muscle strength. The CF control group exhibited no significant changes in any parameters between evaluations.

CONCLUSIONS

ET significantly improved FFM, but not body mass index, in CF patients. The results illustrate the superiority of bioimpedancemetry for assessing changes in body composition and reveal the importance of ET for improving not only exercise tolerance but also nutritional status in these patients.

Investigation of frailty as a moderator of the relationship between neuropathology and dementia in Alzheimer's disease: a cross-sectional analysis of data from the Rush Memory and Aging Project

BACKGROUND

Some people with substantial Alzheimer's disease pathology at autopsy had shown few characteristic clinical symptoms or signs of the disease, whereas others with little Alzheimer's disease pathology have been diagnosed with Alzheimer's dementia. We aimed to examine whether frailty, which is associated with both age and dementia, moderates the relationship between Alzheimer's disease pathology and Alzheimer's dementia.

METHODS

We did a cross-sectional analysis of data from participants of the Rush Memory and Aging Project, a clinical-pathological cohort study of older adults (older than 59 years) without known dementia at baseline, living in Illinois, USA. Participants in the cohort study underwent annual neuropsychological and clinical evaluations. In the present cross-sectional analysis, we included those participants who did not have any form of dementia or who had Alzheimer's dementia at the time of their last clinical assessment and who had died and for whom complete autopsy data were available. Alzheimer's disease pathology was quantified by a summary measure of neurofibrillary tangles and neuritic and diffuse plaques. Clinical diagnosis of Alzheimer's dementia was based on clinician consensus. Frailty was operationalised retrospectively using health variable information obtained at each clincial evaluation using the deficit accumulation approach (41-item frailty index). Logistic regression and moderation modelling were used to assess relationships between Alzheimer's disease pathology, frailty, and Alzheimer's dementia. All analyses were adjusted for age, sex, and education.

FINDINGS

Up to data cutoff (Jan 20, 2017), we included 456 participants (mean age at death 89·7 years [SD 6·1]; 316 [69%] women). 242 (53%) had a diagnosis of possible or probable Alzheimer's dementia at their last clinical assessment. Frailty (odds ratio 1·76, 95% CI 1·54-2·02; p<0·0001) and Alzheimer's disease pathology (4·81, 3·31-7·01; p<0·0001) were independently associated with Alzheimer's dementia, after adjusting for age, sex, and education. When frailty was added to the model for the relationship between Alzheimer's disease pathology and Alzheimer's dementia, model fit improved (p<0·0001). There was a significant interaction between frailty and Alzheimer's disease pathology (odds ratio 0·73, 95% CI 0·57-0·94; pinteraction=0·015). People with an increased frailty score had a weakened direct link between Alzheimer's disease pathology and Alzheimer's dementia; that is, people with a low amount of frailty were better able to tolerate Alzheimer's disease pathology, whereas those with higher amounts of frailty were more likely both to have more Alzheimer's disease pathology and for it to be expressed as dementia.

INTERPRETATION

The degree of frailty among people of the same age modifies the association between Alzheimer's disease pathology and Alzheimer's dementia. That frailty is related to both odds of Alzheimer's dementia and disease expression has implications for clinical management, since individuals with even a low level of Alzheimer's disease pathology might be at risk for dementia if they have high amounts of frailty. Further research should assess how frailty and cognition change over time to better elucidate this complex relationship.

FUNDING

None.

Determinants of staff commitment to hip protectors in long-term care: A cross-sectional survey

BACKGROUND

If worn, certain models of hip protectors are highly effective at preventing hip fractures from falls in residents of long-term care, but modest acceptance and adherence have limited the effectiveness of hip protectors. Residents of long-term care are more likely to accept the initial offer of hip protectors and to adhere to recommendations concerning the use of hip protectors when staff are committed to supporting the application of hip protectors. Yet, we know very little about the nature of and factors associated with staff commitment to hip protectors in long-term care.

OBJECTIVE

To identify factors associated with staff commitment to hip protectors in long-term care.

DESIGN

A cross-sectional survey.

SETTING

Thirteen long-term care homes (total beds = 1816) from a single regional health district in British Columbia, Canada.

PARTICIPANTS

A convenience sample of 535 paid staff who worked most of their time (>50% of work hours) at a participating long-term care home, for at least one month, and for at least 8 h per week. We excluded six (1.1%) respondents who were unaware of hip protectors. Of the remaining 529 respondents, 90% were female and 55% were health care assistants.

METHODS

Respondents completed the Commitment to Hip Protectors Index to indicate their commitment to hip protectors. We used Bayesian Model Averaging logistic regression to model staff commitment as a function of personal variables, experiences with hip protectors, intraorganizational communication and influence, and organizational context.

RESULTS

Staff commitment was negatively related to organizational tenure >20 years (posterior probability = 97%; logistic regression coefficient = -0.28; 95% confidence interval = -0.48, -0.08), and awareness of a padded hip fracture (100%; -0.57; -0.69, -0.44). Staff commitment was positively related to the existence of a champion of hip protectors within the home (100%; 0.24; 0.17, 0.31), perceived quality of intraorganizational communication (100%; 0.04; 0.02, 0.05), extent of mutual respect between residents and staff and perceived contribution to quality of life of the residents they serve (100%; 0.10; 0.05, 0.15), and frequency of transformational leadership practices by respondents' primary supervisors (100%; 0.01; 0.01, 0.02).

CONCLUSIONS

We provide novel insight into the factors governing staff commitment to hip protectors in long-term care. Targeting of these factors could improve acceptance and adherence with hip protectors, thereby contributing to enhanced effectiveness of hip protectors to prevent hip fractures in long-term care.

Association between sedentary time and mortality across levels of frailty

BACKGROUND

Sedentary behaviours are associated with adverse health outcomes in middle-aged and older adults, even among those who exercise. We examined whether the degree of frailty affects the association between sedentary behaviours and higher risk of mortality.

METHODS

In this prospective cohort study, we used data from 3141 community-dwelling adults 50 years of age or older from the 2003/04 and 2005/06 cohorts of the US National Health and Nutrition Examination Survey. Time engaged in sedentary behaviours was measured using uniaxial accelerometers, and frailty was based on a 46-item frailty index. Mortality data were linked up to 2011. We used Cox proportional hazard models to estimate the hazard ratio (HR) of sedentary behaviour.

RESULTS

We found that for people with low levels of frailty (frailty index score ≤ 0.1), sedentary time was not predictive of mortality, regardless of physical activity level (adjusted HR 0.90, 95% confidence interval [CI] 0.70-1.15). Among people who were vulnerable (0.1 < frailty index score ≤ 0.2) or frail (frailty index score > 0.2), sedentary time was associated with higher mortality only among those who were physically inactive (not meeting the criterion for moderate physical activity) (HR 1.16, 95% CI 1.02-1.33 for the group defined by 0.1 < frailty index score ≤ 0.2; HR 1.27, 95% CI 1.11-1.46 for the group defined by 0.2 < frailty index score ≤ 0.3; HR 1.34, 95% CI 1.19-1.50 for frailty index score > 0.3).

INTERPRETATION

The effect of sedentary behaviours on mortality varied by level of frailty. Adults with the highest frailty level experienced the greatest adverse impact. Low frailty levels (frailty index score ≤ 0.1) seemed to eliminate the increased risk of mortality associated with prolonged sitting, even among people who did not meet recommended physical activity guidelines.

Patient preferences for healthcare delivery through community pharmacy settings in the USA: A discrete choice study

WHAT IS KNOWN AND OBJECTIVE

In order to improve public health, it is necessary to facilitate patients' easy access to affordable high-quality primary health care, and one enhanced approach to do so may be to provide primary healthcare services in the community pharmacy setting. Discrete choice experiments to evaluate patient demand for services in pharmacy are relatively limited and have been hampered by a focus on only a few service alternatives, most focusing on changes in more traditional pharmacy services. The study aim was to gauge patient preferences explicitly for primary healthcare services that could be delivered through community pharmacy settings in the USA, using a very large sample to accommodate multiple service delivery options.

METHODS

An online survey was administered to a total of 9202 adult patients from the general population. A subsequent online survey was administered to 50 payer reimbursement decision-makers. The patient survey included a discrete choice experiment (DCE) which showed competing scenarios describing primary care service offerings. The respondents chose which scenario would be most likely to induce them to switch from their current pharmacy, and an optimal patient primary care service model was derived. The likelihood this model would be reimbursed was then determined in the payer survey.

RESULTS AND DISCUSSION

The final optimal service configuration that would maximize patient preference included the pharmacy: offering appointments to see a healthcare provider in the pharmacy, having access to their full medical record, provide point-of-care diagnostic testing, offer health preventive screening, provide limited physical examinations such as measuring vital signs, and drug prescribing in the pharmacy. The optimal model had the pharmacist as the provider; however, little change in demand was evident if the provider was a nurse-practitioner or physician's assistant. The demand for this optimal model was 2-fold higher (25.5%; 95% Bayesian precision interval (BPI) 23.5%-27.0%) than for a base pharmacy offering minimal primary care services (12.6%; 95% BPI 12.2%-13.2%), and was highest among Hispanic (30.6%; 95% BPI: 25.7%-34.3%) and African American patients (30.7%; 95% BPI: 27.1%-35.2%). In the second reimbursement decision-maker survey, the majority (66%) indicated their organization would be likely to reimburse the services described in the optimal patient model if provided in the pharmacy setting.

WHAT IS NEW AND CONCLUSION

This United States national study provides empirical support for a model of providing primary care services through community pharmacy settings that would increase access, with the potential to improve the public health.

Validation and psychometric properties of the commitment to hip protectors (C-HiP) index in long-term care providers of British Columbia, Canada: a cross-sectional survey

BACKGROUND

If worn during a fall, hip protectors substantially reduce risk for hip fracture. However, a major barrier to their clinical efficacy is poor user adherence. In long-term care, adherence likely depends on how committed care providers are to hip protectors, but empirical evidence is lacking due to the absence of a psychometrically valid assessment tool.

METHODS

We conducted a cross-sectional survey in a convenience sample of 529 paid care providers. We developed the 15-item C-HiP Index to measure commitment, comprised of three subscales: affective, cognitive and behavioural. Responses were subjected to hierarchical factor analysis and internal consistency testing. Eleven experts rated the relevance and clarity of items on 4-point Likert scales. We performed simple linear regression to determine whether C-HiP Index scores were positively related to the question, "Do you think of yourself as a champion of hip protectors", rated on a 5-point Likert scale. We examined whether the C-HiP Index could differentiate respondents: (i) who were aware of a protected fall causing hip fracture from those who were unaware; (ii) who agreed in the existence of a champion of hip protectors within their home from those who didn't.

RESULTS

Hierarchical factor analysis yielded two lower-order factors and a single higher-order factor, representing the overarching concept of commitment to hip protectors. Items from affective and cognitive subscales loaded highest on the first lower-order factor, while items from the behavioural subscale loaded highest on the second. We eliminated one item due to low factor matrix coefficients, and poor expert evaluation. The C-HiP Index had a Cronbach's alpha of 0.96. A one-unit increase in championing was associated with a 5.2-point (p < 0.01) increase in C-HiP Index score. Median C-HiP Index scores were 4.3-points lower (p < 0.01) among respondents aware of a protected fall causing hip fracture, and 7.0-points higher (p < 0.01) among respondents who agreed in the existence of a champion of hip protectors within their home.

CONCLUSIONS

We offer evidence of the psychometric properties of the C-HiP Index. The development of a valid and reliable assessment tool is crucial to understanding the factors that govern adherence to hip protectors in long-term care.

A Frailty Index Based On Deficit Accumulation Quantifies Mortality Risk in Humans and in Mice

Although many common diseases occur mostly in old age, the impact of ageing itself on disease risk and expression often goes unevaluated. To consider the impact of ageing requires some useful means of measuring variability in health in animals of the same age. In humans, this variability has been quantified by counting age-related health deficits in a frailty index. Here we show the results of extending that approach to mice. Across the life course, many important features of deficit accumulation are present in both species. These include gradual rates of deficit accumulation (slope = 0.029 in humans; 0.036 in mice), a submaximal limit (0.54 in humans; 0.44 in mice), and a strong relationship to mortality (1.05 [1.04–1.05] in humans; 1.15 [1.12–1.18] in mice). Quantifying deficit accumulation in individual mice provides a powerful new tool that can facilitate translation of research on ageing, including in relation to disease.

Handling missing Mini-Mental State Examination (MMSE) values: Results from a cross-sectional long-term-care study

Background

Missing values are commonly encountered on the Mini Mental State Examination (MMSE), particularly when administered to frail older people. This presents challenges for MMSE scoring in research settings. We sought to describe missingness in MMSEs administered in long-term-care facilities (LTCF) and to compare and contrast approaches to dealing with missing items.

Methods

As part of the Care and Construction project in Nova Scotia, Canada, LTCF residents completed an MMSE. Different methods of dealing with missing values (e.g., use of raw scores, raw scores/number of items attempted, scale-level multiple imputation [MI], and blended approaches) are compared to item-level MI.

Results

The MMSE was administered to 320 residents living in 23 LTCF. The sample was predominately female (73%), and 38% of participants were aged >85 years. At least one item was missing from 122 (38.2%) of the MMSEs. Data were not Missing Completely at Random (MCAR), χ² (1110) = 1,351, p < 0.001. Using raw scores for those missing <6 items in combination with scale-level MI resulted in the regression coefficients and standard errors closest to item-level MI.

Conclusions

Patterns of missing items often suggest systematic problems, such as trouble with manual dexterity, literacy, or visual impairment. While these observations may be relatively easy to take into account in clinical settings, non-random missingness presents challenges for research and must be considered in statistical analyses. We present suggestions for dealing with missing MMSE data based on the extent of missingness and the goal of analyses.

•

Mini Mental State Examination items were not missing completely at random.

•

Regression and descriptive analyses have different optimum missing-data techniques.

•

Some techniques approximated results obtained using a “gold standard”.

Changes in Frailty Predict Changes in Cognition in Older Men: The Honolulu-Asia Aging Study

BACKGROUND

As cognitive decline mostly occurs in late life, where typically it co-exists with many other ailments, it is important to consider frailty in understanding cognitive change.

OBJECTIVE

Here, we examined the association of change in frailty status with cognitive trajectories in a well-studied cohort of older Japanese-American men.

METHODS

Using the prospective Honolulu-Asia Aging Study (HAAS), 2,817 men of Japanese descent were followed (aged 71-93 at baseline). Starting in 1991 with follow-up health assessments every two to three years, cognition was measured using the Cognitive Abilities Screening Instrument (CASI). For this study, health data was used to construct an accumulation of deficits frailty index (FI). Using six waves of data, multilevel growth curve analyses were constructed to examine simultaneous changes in cognition in relation to changes in FI, controlling for baseline frailty, age, education, and APOE-ɛ4 status.

RESULTS

On average, CASI scores declined by 2.0 points per year (95% confidence interval 1.9-2.1). Across six waves, each 10% within-person increase in frailty from baseline was associated with a 5.0 point reduction in CASI scores (95% confidence interval 4.7-5.2). Baseline frailty and age were associated both with lower initial CASI scores and with greater decline across the five follow-up assessments (p < 0.01).

DISCUSSION

Cognition is adversely affected by impaired health status in old age. Using a multidimensional measure of frailty, both baseline status and within-person changes in frailty were predictive of cognitive trajectories.

Glatiramer acetate in combination with minocycline in patients with relapsing--remitting multiple sclerosis: results of a Canadian, multicenter, double-blind, placebo-controlled trial

Minocycline is proposed as an add-on therapy to improve the efficacy of glatiramer acetate in relapsing-remitting multiple sclerosis. The effect of minocycline plus glatiramer acetate was evaluated in this double-blind, placebo-controlled study by determining the total number of T1 gadolinium-enhanced lesions at months 8 and 9 in patients who were starting glatiramer acetate and had at least one T1 gadolinium-enhanced lesion on screening magnetic resonance imaging. Forty-four participants were randomized to either minocycline 100 mg twice daily or matching placebo for 9 months as add-on therapy. They were assessed at screening and months 1, 3, 6, 8 and 9. Forty participants completed the study. Compared with glatiramer acetate/placebo, glatiramer acetate/minocycline reduced the total number of T1 gadolinium-enhanced lesions by 63% (mean 1.47 versus 2.95; p = 0.08), the total number of new and enlarging T2 lesions by 65% (mean 1.84 versus 5.14; p = 0.06), and the total T2 disease burden (p = 0.10). A higher number of gadolinium-enhanced lesions were present in the glatiramer acetate/minocycline group at baseline; this was incorporated into the analysis of the primary endpoint but makes interpretation of the data more challenging. The risk of relapse tended to be lower in the combination group (0.19 versus 0.41; p = NS). Treatment was safe and well tolerated. We conclude that efficacy endpoints showed a consistent trend favoring combination treatment. As minocycline is a relatively safe oral therapy, further study of this combination is warranted in relapsing-remitting multiple sclerosis.

Head capsule width as an instar indicator for larvae of the cranberry fruitworm (Lepidoptera: Pyralidae) in southeastern New Brunswick

The objective of this study was to determine the number of instars of the cranberry fruitworm Acrobasis vaccinii Riley in southeastern New Brunswick based on the distribution of head capsule widths from field and laboratory observations. In 2000, head capsules from field samples were measured across their widest point, and the results were plotted against observed frequencies. The data from field samples suggested that A. vaccinii exhibited five instars in 2000. In 2001, larvae were reared in the laboratory until the final molt, and head capsules were counted and measured. The results were also plotted against observed frequencies. None of the laboratory specimens exhibited more than five instars, supporting the results of the previous year. Various factors are invoked to explain the difference between these results and those of a previous study conducted 50 yr earlier and 200 km away, in which six instars and larger head capsules were reported.

Negative relationships between erythrocyte Ca-pump activity and lead levels in mothers and newborns

Lead poisoning induces hematological, gastrointestinal and neurological dysfunctions. One of the potential mechanisms is the inhibition of calcium-pump (Ca-pump), a transport protein. We investigated the effects of an environmental low lead exposure on Ca-pump activity in 247 mothers and their newborns. Maternal and cord blood, and newborn and mother hair, were sampled at delivery. Geometric means for mother and cord blood lead (Pb-B), and for mother and newborn hair lead (Pb-H), were 6.3 and 4.8 microg/dl, and 1.7 and 1.1 microg/g. Means for mother and cord basal Ca-pump activities were 2,442 and 2,675 nM/mg/hr. Mother enzymatic activity was negatively related to her Pb-B and Pb-H and to the cord Pb-B and newborn Pb-H levels. Newborn enzymatic activity was negatively related to his Pb-H level only. Adjustment for gestational age, child's sex, mother's age at delivery, alcohol, coffee and tea consumption, and smoking habits during pregnancy did not modify these relationships. Our findings support the hypothesis that lead toxicity could be in part mediated by a reduction of Ca-pump activity. This effect could be observed at low environmental exposure, in mothers and newborns.

Aryl hydrocarbon hydroxylase activity in human placenta and threatened preterm delivery

Induction of aryl hydrocarbon hydroxylase (AHH) activity in the placenta has been well documented. This enzyme may be induced by a variety of Polycyclic Aromatic Hydrocarbons (PAHs) and the AHH inducibility is associated with harmful effects of environmental chemicals. Toxic effects of PAHs in tissues such as placenta have been demonstrated to be due to their metabolites, epoxides, which interact with DNA. Thus, environmental PAHs may be related to its alterations in fetal development. Founded on these findings the PAH metabolites could interfere with the normal course of the pregnancy and may be an aborticide, a teratogen or a carcinogen. We hypothesize that low increased activity of placental Aryl Hydrocarbon Hydroxylase (AHH) may be an important determinant of human fetotoxicity. The present investigation was designed to examine the possible implications of PAH exposure at environmental exposure levels on the normal course of the pregnancy using AHH induction as an indicator of PAH exposure. Threatened Preterm Delivery (TPD) was used as an index of problems in the normal course of pregnancy. A group of forty pregnancies at term with TPD was compared with eighty controls for placental AHH induction. Macroscopic placental examination was also performed. A significant increase in prevalence of placental AHH induction with TPD was shown (Odds-Ratio = 2.8; 95% confidence bounds [1.3-6.2]; chi 2 = 6.7 p < 0.01). No such increases were found associated with placental pathology. When taking into account the group of placenta without basal plate calcifications, the significant increase in prevalence of placental AHH induction with TPD above mentioned was greatly increased (Odds-Ratio = 8.9; 95% confidence bounds [2.4-32.9]; chi 2 = 11.1 p < 0.001) controlling for gestational age. The increase in prevalence of placental AHH induction with TPD disappeared when taking into account the subgroup with basal plate or parenchyma calcifications. It is hypothesized that the high estrogen and progesterone at term may explain these associations.