Circulating Micronutrient Biomarkers Are Associated With 3 Measures of Frailty: Evidence From the Irish Longitudinal Study on Ageing

ObjectivesTo examine the associations between 3 frailty instruments and circulating micronutrients in a large representative sample of older adults.DesignCross-sectional data from a nationally representative cohort study conducted between October 2009 and July 2011.Participants and settingAdults age ≥50 years (n = 4068) living in the community in Ireland.MeasurementsCirculating micronutrients (lutein, zeaxanthin, folate, vitamin B-12, and vitamin D) were measured, transformed, and standardized. Frailty was assessed using the Frailty Phenotype, the Frailty Index, and the FRAIL Scale (fatigue, resistance, ambulation, illnesses, and loss of weight), instruments. Multinomial logistic regression determined associations between micronutrients and prefrailty or frailty. Models were adjusted for sociodemographic, lifestyle, health, and seasonal factors.ResultsAdjusting for age, sex, and educational attainment, all 3 measures of frailty were associated with lower levels of lutein [relative risk ratios (RRRs): 0.43‒0.63], zeaxanthin (RRRs: 0.49‒0.63), and vitamin D (RRRs: 0.51‒0.75), and with the accumulation of micronutrient insufficiencies (RRRs: 1.42‒1.90). Attenuated but significant associations were also observed with all measures of prefrailty for lutein, vitamin D, and number of micronutrient insufficiencies. The associations with frailty persisted following additional adjustment for social, lifestyle, and health and seasonal factors, and following multiple test correction.Conclusions and implicationsWe have presented the most consistent evidence in the largest study to date that micronutrient concentrations are associated with prefrailty and frailty in older adults. Our data suggest that low micronutrient status has potential as an easily modifiable marker and intervention target for frailty and supports further investigation into micronutrient supplementation and fortification to prevent frailty and disability among older adults.     

Self-Reported Frailty Screening Tools: Comparing Construct Validity of the Frailty Phenotype Questionnaire and FRAIL

ObjectivesWe examined the construct validity of 2 self-reported frailty questionnaires, the Frailty Phenotype Questionnaire (FPQ) and FRAIL, against the Cardiovascular Health Study frailty phenotype (CHS-FP).DesignCross-sectional data analysis of longitudinal prospective cohort study.Settings and ParticipantsWe included data from 230 older adults (mean age: 67.2 ± 7.4 years) from the “Longitudinal Assessment of Biomarkers for characterization of early Sarcopenia and Osteosarcopenic Obesity in predicting frailty and functional decline in community-dwelling Asian older adults Study” (GeriLABS 2) recruited between December 2017 and March 2019.MethodsWe compared area under receiver operating characteristic curves (AUC), agreement, correlation, and predictive validity against outcome measures [Short Physical Performance Battery, 5 times repeat chair stand (RCS-5), Frenchay activities index, International Physical Activity Questionnaire, life-space assessment, Social Functioning Scale 8 (SFS-8), EuroQol-5 dimensions (utility value)] using logistic regression adjusted for age, gender, and vascular risk factors. We examined concurrent validity across robust versus prefrail/frail for inflammatory blood biomarkers [tumor necrosis factor receptor 1 and C-reactive protein (CRP)] and dual-energy x-ray absorptiometry body composition [bone mineral density (BMD); appendicular lean mass index (ALMI), and fat mass index (FMI)].ResultsPrevalence of prefrail/frail was 25.7%, 14.8%, and 48.3% for FPQ, FRAIL, and CHS-FP, respectively. Compared with FRAIL, FPQ had better diagnostic performance (AUC = 0.617 vs 0.531, P = .002; sensitivity = 37.8% vs 18.0%; specificity = 85.6% vs 88.2%) and agreement (AC1-Stat = 0.303 vs 0.197). FPQ showed good predictive validity [RCS-5: odds ratio (OR) 2.38; 95% CI: 1.17–4.86; International Physical Activity Questionnaire: OR 3.62; 95% CI:1.78–7.34; SFS-8: OR 2.11; 95% CI: 1.64–5.89 vs FRAIL: all P > .05]. Only FRAIL showed concurrent validity for CRP, compared with both FPQ and FRAIL for TNF-R1. FRAIL showed better concurrent validity for BMD, FMI, and possibly ALMI, unlike FPQ (all P > .05).Conclusions and ImplicationsOur results support complementary validity of FPQ and FRAIL in independent community-dwelling older adults. FPQ has increased case detection sensitivity with good predictive validity, whereas FRAIL demonstrates concurrent validity for inflammation and body composition. With better diagnostic performance and validity for blood biomarkers and clinical outcomes, FPQ has utility for early frailty detection in the community setting.     

Frailty,diabetes, and mortality in middle-aged African Americans

Background

Older adult frail diabetics have high mortality risk, but data are limited regarding frail late middle-aged diabetics, especially for African-Americans. The aim of this study is to examine the association of diabetes with health outcomes and frailty in the African American Health (AAH) study.

Methods

AAH is a population-based longitudinal cohort study. Participants were African Americans (N=998) ages 49 to 65 years at baseline. Cross-sectional comparisons for diabetes included disability, function, physical performance, cytokines, and frailty. Frailty measures included the International Academy of Nutrition and Aging [FRAIL] frailty scale, Study of Osteoporotic Fractures [SOF] frailty scale, Cardiovascular Health Study [CHS] frailty scale, and Frailty Index [FI]). Longitudinal associations for diabetes included new ADLs ≥ 1 and mortality at 9-year follow-up.

Results

Diabetics were more likely to be frail using any of the 4 frailty scales than were non-diabetics. Frail diabetics, compared to nonfrail diabetics, reported significantly increased falls in last 1 year, higher IADLs and higher LBFLs. They demonstrated worse performance on the SPPB, one-leg stand, and grip strength; and higher Tumor Necrosis Factor receptors (sTNFR1 & sTNFR2). Mortality and 1 or more new ADLs also were increased among frail compared to nonfrail diabetics when followed for 9 years.

Conclusions

Frailty in middle-aged African American persons with diabetes is associated with having more disability and functional limitations, worse physical performance, and higher cytokines (sTNFR1 & sTNFR2 only). Middle-aged African Americans with diabetes have an increased risk of mortality and frail diabetics have an even higher risk of death, compared to nonfrail diabetics.

     

A New Operational Definition of Frailty: The Frailty Trait Scale

ObjectivesTo provide a new instrument to diagnose frailty, the Frailty Trait Scale (FTS), that allows a more precise assessment and monitoring of individuals.DesignProspective population-based cohort study.SettingThe Toledo Study for Healthy Aging, Spain.ParticipantsA total of 1972 men and women aged 65 years or older.MeasurementsWe identified 7 frailty dimensions (energy balance–nutrition, physical activity, nervous system, vascular system, strength, endurance, and gait speed) represented by 12 items. Each item was pondered based on the quintiles of its distribution in the study population. Validity was evaluated by testing its association with factors related to frailty and its predictive value for adverse events. This predictive capacity was further compared with the capacity of 2 well-established frailty models (the frailty phenotype and the Frailty Index).ResultsFTS score was associated with several comorbidities and biomarkers classically associated with frailty. The FTS was associated with the incidence of hospitalization and mortality (hazard ratio associated with a score in the highest quartile [versus the first quartile] = 2.3, 95% confidence interval [CI] 1.6–3.4, and 2.5, 95% CI 1.8–3.6, respectively). Compared with Fried et al's definition, the FTS showed a better predictor for hospitalization in persons younger than 80 (area under the curve [AUC] = 0.65 vs 0.62, P = .01), and for mortality in the oldest group (AUC = 0.77 vs 0.72, P = .02). FTS showed similar predictive value to the Frailty Index.ConclusionFTS associates with many of the factors linked to frailty and has a similar predictive capacity to that provided by the classical instruments. Its characteristics offer some advantages over them, with potential utility in research and clinical practice.     

Frailty in Hospitalized Older Adults: Comparing Different Frailty Measures in Predicting Short- and Long-term Patient Outcomes

Objectives

Data for the assessment of frailty in acutely ill hospitalized older adults remains limited. Using the Frailty Index (FI) as “gold standard,” we compared (1) the diagnostic performance of 3 frailty measures (FRAIL, Clinical Frailty Scale [CFS], and Tilburg Frailty Indicator [TFI]) in identifying frailty, and (2) their ability to predict negative outcomes at 12 months after enrollment.

FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes

ObjectivesNo previous studies have assessed the role of the FRAIL scale in predicting long-term outcomes in older patients with acute coronary syndromes (ACS).Design, Setting and ParticipantsThe multicenter observational LONGEVO-SCA registry included unselected patients ≥80 years of age with ACS from 44 centers. A comprehensive geriatric assessment was performed during hospitalization.MeasuresFrailty was measured by the FRAIL scale. For the purpose of this study, main outcome measured was mortality or readmission at 24 months.ResultsA total of 498 patients were included. Mean age was 84.3 years. A total of 198 patients (33.1%) were prefrail and 135 (27.1%) frail. Patients who were prefrail and frail had a higher degree of comorbidities, and higher prevalence of disability, cognitive impairment, and nutritional risk. A total of 165 out of 498 patients (33.1%) died, and 331 patients (66.7%) died or were readmitted at 24 months. Both prefrailty and frailty were associated with a higher mortality compared with robust patients (P < .001). The incidence of mortality or readmission was also higher in patients who were prefrail or frail (P < .001). After adjusting for potential confounders, the association between frailty and mortality or readmission remained significant (hazard ratio 1.28 for prefrailty and hazard ratio 1.96 for frailty, P < .001). The FRAIL scale showed an optimal ability for predicting mortality or readmission (area under the receiver operating characteristics curve 0.86, 95% confidence interval 0.83‒0.89). The area under the receiver operating characteristics curve from the Global Registry of Acute Coronary Events risk score was 0.89. No significant differences were observed between both AUC values (P = .163).Conclusions and ImplicationsThe FRAIL scale independently predicted long-term outcomes in older patients with ACS. The predictive ability of this scale was comparable to the strongly recommended Global Registry of Acute Coronary Events risk score. Frailty assessment is mandatory for improving risk prediction in these complex patients.     

Ability of 3 Frailty Measures to Predict Short-Term Outcomes in Older Patients Admitted for Post-Acute Inpatient Rehabilitation

ObjectivesTo evaluate the ability of 3 commonly used frailty measures to predict short-term clinical outcomes in older patients admitted for post-acute inpatient rehabilitation.DesignObservational cohort study.Setting and ParticipantsConsecutive patients (n = 207) admitted to a geriatric inpatient rehabilitation facility.MethodsFrailty on admission was assessed using a frailty index, the physical frailty phenotype, and the Clinical Frailty Scale (CFS). Predictive capacity of the frailty instruments was analyzed for (1) nonhome discharge, (2) readmission to acute care, (3) functional decline, and (4) prolonged length of stay, using multivariate logistic regression models and receiver operating characteristic (ROC) curves.ResultsThe number of patients classified as frail was 91 (44.0%) with the frailty index, 134 (64.7%) using the frailty phenotype, and 151 (73.0%) with the CFS. The 3 frailty measures revealed acceptable discriminatory accuracy for nonhome discharge (area under the curve ≥ 0.7) but differed in their predictive ability: the adjusted odds ratio (OR) for nonhome discharge was highest for the CFS [6.2, 95% confidence interval (CI) 1.8-21.1], compared to the frailty index (4.1, 95% CI 2.0-8.4) and the frailty phenotype (OR 2.9, 95% CI 1.2-6.6). For the other outcomes, discriminatory accuracy based on ROC tended to be lower and predictive ability varied according to frailty measure. Readmission to acute care from inpatient rehabilitation was predicted by all instruments, most pronounced by the frailty phenotype (OR 5.4, 95% CI 1.6-18.8) and the frailty index (OR 2.5, 95% CI 1.1-5.6), and less so by the CFS (OR 1.4, 95% CI 0.5-3.8).Conclusions and ImplicationsFrailty measures may contribute to improved prediction of outcomes in geriatric inpatient rehabilitation. The choice of the instrument may depend on the individual outcome of interest and the corresponding discriminatory ability of the frailty measure.     

Differential Association of Frailty and Sarcopenia With Mortality and Disability: Insight Supporting Clinical Subtypes of Frailty

ObjectivesSarcopenia and frailty have been shown separately to predict disability and death in old age. Our aim was to determine if sarcopenia may modify the prognosis of frailty regarding both mortality and disability, raising the existence of clinical subtypes of frailty depending on the presence of sarcopenia.DesignA Spanish longitudinal population-based study.Setting and ParticipantsThe population consists of 1531 participants (>65 years of age) from the Toledo Study of Health Aging.MethodsSarcopenia and frailty were assessed following Foundation for the National Institutes of Health criteria and the Fried Frailty Phenotype, respectively. Mortality was assessed using the National Death Index. Functional status was determined using Katz index. We ran multivariate logistics and proportional hazards models adjusting for age, sex, baseline function, and comorbidities.ResultsMean age was 75.4 years (SD 5.9). Overall, 70 participants were frail (4.6%), 565 prefrail (36.9%), and 435 sarcopenic (28.4%). Mean follow-up was 5.5 and 3.0 years for death and worsening function, respectively. Furthermore, 184 participants died (12%) and 324 worsened their functioning (24.8%). Frailty and prefrailty were associated with mortality and remained significant after adjustment by sarcopenia [hazard risk (HR) 3.09, 95% confidence interval (CI) 1.84-5.18; P < .001; HR 1.58, 95% CI 1.12-2.24, P = .01]. However, the association of sarcopenia with mortality was reduced and became nonsignificant (HR 1.43, 95% CI 0.99-2.07, P = .057) when both frailty and sarcopenia were included in the same model. In the disability model, frailty and sarcopenia showed a statistically significant interaction (P = .016): both had to be present to predict worsening of disability.Conclusions and ImplicationsSarcopenia plays a relevant role in the increased risk of functional impairment associated to frailty, but that seems not to be the case with mortality. This finding raises the need of assessing sarcopenia as a cornerstone of the clinical work after diagnosing frailty.     

The Association between Frailty and Healthcare Expenditure among Chinese Older Adults

ObjectivesThe purpose of this study was to examine whether frailty could explain variability in healthcare expenditure beyond multimorbidity and disability among Chinese older adults.DesignCross-sectional.Setting and ParticipantsParticipants were 5300 community-dwelling adults age at least 60 years from the China Health and Retirement Longitudinal Study.MethodsFrailty was identified by the physical frailty phenotype approach that has been created and validated among Chinese older adults. Five criteria were used: slowness, weakness, exhaustion, inactivity, and shrinking. Persons were classified as “nonfrail” (0 criteria), “prefrail” (1‒2 criteria), or “frail” (3‒5 criteria). Healthcare expenditure was measured based on participants’ self-report and was classified into 3 types: outpatient expenditure, inpatient expenditure, and self-treatment expenditure. The association of frailty and healthcare expenditure was analyzed using a 2-part regression model to account for excessive zero expenditures.ResultsFrailty was associated with higher odds of incurring outpatient, inpatient, and self-treatment expenditure. Among persons with non-zero expenditure, prefrail and frail persons, on average, had US $30.62 [95% confidence interval (CI) 8.41, 52.82] and US $60.60 (95% CI 5.84, 115.36) higher outpatient expenditure than the nonfrail, adjusting for sociodemographics, multimorbidity, and disability. After adjustment for all covariates, prefrail persons, on average, had US $3.34 (95% CI 0.54, 6.13) higher self-treatment expenditure than the nonfrail.Conclusions and ImplicationsFrailty is an independent predictor of higher healthcare expenditure among older adults. These findings suggest that timely screening and recognition of frailty are important to reduce healthcare expenditure among older adults.     

Concurrent and Predictive Validity of FRAIL-NH in Hospitalized Older Persons: An Exploratory Study

ObjectivesThe FRAIL-NH was originally developed for frailty assessment of nursing home (NH) residents. We aimed to compare concurrent, predictive, and known-groups validity between FRAIL-NH and FRAIL, using the Frailty Index (FI) as gold standard reference. We also examined for ceiling effect of both measures in the detection of severe frailty.DesignA secondary analysis of a prospective cohort study.Setting & ParticipantsOlder adults (mean age 89.4 years) hospitalized for an acute medical illness in a 1300-bed tertiary hospital.MeasurementsBaseline data on demographics, comorbidities, severity of illness, functional status, and cognitive status were gathered. We also captured outcomes of mortality, length of stay (LOS), institutionalization, and functional decline. For concurrent validity, we compared areas under the operating characteristic curves (AUCs) for both measures against the FI. For predictive validity, univariate analyses and multiple logistic regression were used to compare both measures against the adverse outcomes of interest. For known-groups validity, we compared both measures against comorbidities and functional status via 1-way analysis of variance, and dementia diagnosis via independent t test. Box plots were also derived to investigate for possible ceiling effect.ResultsBoth measures had good concurrent validity (both AUC > 0.8 and P < .001), with FRAIL-NH detecting more frailty cases (79.5% vs 50.0%). Although FRAIL-frail was superior for in-hospital mortality [6.7% vs 1.0%, P = .031, odds ratio (OR) 9.29, 95% confidence interval (CI) 1.09-79.20, P < .042] and LOS (10 vs 8 days, P = .043), FRAIL-NH-frail better predicted mortality (OR 6.62, 95% CI 1.91-22.94, P = .003) and institutionalization (OR 6.03, 95% CI 2.01-18.09, P = .001) up to 12 months postenrollment. Known-groups validity was good for both measures with FRAIL-NH yielding greater F values for functional status and dementia. Lastly, box plots revealed a ceiling effect for FRAIL in the severely frail group.Conclusions and ImplicationsThis exploratory study highlights the potential for expanding the role of FRAIL-NH beyond NH to acute care settings. Contrasted to FRAIL, FRAIL-NH had better overall validity with less ceiling effect in discrimination of severe frailty.     

Comparison of 3 Frailty Instruments in a Geriatric Acute Care Setting in a Low-Middle Income Country

Objective

Comparison of frailty instruments in low-middle income countries, where the prevalence of frailty may be higher, is scarce. In addition, less complex diagnostic tools for frailty are important in these settings, especially in acutely ill patients, because of limited time and economic resources. We aimed to compare the performance of 3 frailty instruments for predicting adverse outcomes after 1 year of follow-up in older adults with an acute event or a chronic decompensated disease.

Frailty Trait Scale–Short Form: A Frailty Instrument for Clinical Practice

ObjectivesTo develop short versions of the Frailty Trait Scale (FTS) for use in clinical settings.DesignProspective population-based cohort study.Setting and ParticipantsData from 1634 participants from the Toledo Study for Healthy Aging.MethodsThe 12-item Frailty Trait Scale (FTS) reduction was performed based on an area under the curve (AUC) analysis adjusted by age, sex, and comorbidity. Items that maximized prognostic information for adverse events were selected. Each item score was done at the same time as the reduction, identifying the score that maximized the predictive ability for adverse events. For each short version of the FTS, cutoffs that optimized the prognostic information (sensitivity and specificity) were chosen, and their predictive value was later compared with a surrogate gold standard for frailty (the Fried Phenotype).ResultsTwo short forms, the 5-item (FTS₅) (range 0-50) and 3-item (FTS₃) (range 0-30), were identified, both with AUCs for health adverse events similar to the 12-item FTS. The identified cutoffs were >25 for the FTS₅ scale and >15 for the FTS₃. The frailty prevalence with these cutoffs was 24% and 20% for the FTS₅ and FTS₃, respectively, whereas frailty according to Fried Phenotype (FP) reached 8% and prefrailty reached 41%. In general, the FTS₅ showed better prognostic performance than the FP, especially with prefrail individuals, in whom the FTS₅ form identified 65% of participants with an almost basal risk and 35% with a very high risk for mortality (OR: 4) and frailty (OR: 6.6-8.7), a high risk for hospitalization (OR: 1.9-2.1), and a moderate risk for disability (OR: 1.7) who could be considered frail. The FTS₃ form had worse performance than the FTS₅, showing 31% of false negatives between frail participants identified by FP with a high risk of adverse events.Conclusions and ImplicationsThe FTS₅ is a short scale that is easy to administer and has a similar performance to the FTS, and it can be used in clinical settings for frailty diagnosis and evolution.     

The Clinical Potential of Frailty Indicators on Identifying Recurrent Fallers in the Community: The Mr. Os and Ms. OS Cohort Study in Hong Kong

ObjectivesTo compare the clinical value of 3 frailty indicators in a screening pathway for identifying older men and women who are at risk of falls.DesignA prospective cohort study.Setting and participantsFour thousand Chinese adults (2000 men) aged ≥65 years were recruited from the community in Hong Kong.MethodsThe Cardiovascular Health Study Criteria, the FRAIL scale, and the Study for Osteoporosis and Fracture Criteria (SOF) were included for evaluation. Fall history was used as a comparative predictor. Recurrent falls during the second year after baseline was the primary outcome. The area under the receiver operating characteristic curve (AUC) was used to evaluate the ability of the frailty indicators and fall history to predict recurrent falls. Independent predictors identified in logistic regression were put in the Classification and Regression Tree (CART) analysis to evaluate their performance in screening high-risk fallers.ResultsFall history predicts recurrent falls in both men and women (AUC: men = 0.681; women = 0.645) better than all frailty indicators (AUC ≤ 0.641). After adjusting for fall history, only FRAIL (AUC = 0.676) and SOF (AUC = 0.673) remained as significant predictors for women whereas no frailty indicator remained significant in men.FRAIL could classify older women into 2 groups with distinct chances of being a recurrent faller in people with no fall history (3.8% vs 7.5%), a single fall history (9.5% vs 37.5%), and history of recurrent falls (16.0% vs 30.8%). SOF has limited ability in identifying recurrent fallers in the group of older adults with a single fall history (no fall history: 3.9% vs 8.6%; single fall history: 10.2% vs 10.9%; history of recurrent falls: 16.5% vs 20.6%).Conclusions and implicationsSOF and FRAIL could provide some additional prediction value to fall history in older women but not men. FRAIL could be clinically useful in identifying older women at risk of recurrent falls, especially in those with a single fall history.     

Effects of a Multicomponent Frailty Prevention Program in Prefrail Community-Dwelling Older Persons: A Randomized Controlled Trial

ObjectiveTo examine the effects of a multicomponent frailty prevention program in community-dwelling older persons with prefrailty.DesignA randomized controlled trial.SettingA community elderly center in Hong Kong.ParticipantsPersons aged ≥50 years who scored 1-2 on a simple frailty questionnaire (FRAIL)MethodsParticipants (n = 127) were randomly assigned to a 12-week multicomponent frailty prevention program (exercise, cognitive training, board game activities) or to a wait-list control group. The primary outcomes were FRAIL scores, frailty status, and a combined frailty measure including subjective (FRAIL total score) and objective (grip strength, muscle endurance, balance, gait speed) measures. The secondary outcomes were verbal fluency assessed by dual-task gait speed, attention and memory assessed by digit span task, executive function assessed by the Frontal Assessment Battery, self-rated health, and life satisfaction. Assessments were conducted at baseline and at week 12.ResultsThe mean age of the participants was 62.2 years, and 88.2% were women. At week 12, the FRAIL score had decreased in the intervention group (−1.3, P < .001) but had increased in the control group (0.3, P < .01) (between-group differences P < .001). In addition, 83.3% and 1.6% of the intervention and control groups, respectively, had reversed from prefrailty to robust phenotype (between-group differences P < .001). Participants in the intervention group also had a greater reduction in the combined frailty score and greater improvements in muscle endurance, balance, verbal fluency, attention and memory, executive function, and self-rated health than those in the control group (all P < .05). There were no significant differences between the groups with respect to grip strength, gait speed, and life satisfaction.Conclusions and implicationsThe multicomponent frailty prevention program reduced frailty and improved physical and cognitive functions, and self-rated health in community-dwelling older persons with prefrailty. Findings can provide insights into the consideration of incorporating frailty prevention programs into the routine practice of community elderly services.     

Utility of the Fatigue,Resistance, Ambulation,Illness, and Loss of weight Scale in Older Patients with Cardiovascular Disease

ObjectivesTo compare the Fried criteria for frailty diagnosis with the Frailty Screening Index (FSI) and the fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale in older patients with cardiovascular disease (CVD).DesignWe conducted a retrospective 1-year follow-up cohort study of adult inpatients who participated in a cardiac rehabilitation program between June 2016 and September 2018.Setting and ParticipantsWe included 1472 Japanese patients age 65 years and older with CVD. After excluding 765 patients with incomplete frailty measurements, 707 patients were included in the analysis.MethodsFrailty and physical function were measured before hospital discharge according to each of the 3 definitions. Outcomes were all-cause mortality and physical dysfunction.ResultsThe prevalence of frailty according to the Fried criteria, the FRAIL scale, and the FSI was 213 (30.1%), 181 (25.6%), and 186 (26.3%), respectively. The FSI and the FRAIL scale showed moderate agreement with the Fried criteria [vs FSI: K = 0.52, 95% confidence interval (CI): 0.45–0.59; vs FRAIL scale: K = 0.45, 95% CI: 0.37–0.52; all P < .001]. We found a significant correlation between all-cause mortality and frailty assessed by all of the definitions, even after multivariate adjustment [FSI: hazard ratio (HR): 2.43, 95% CI: 1.30–4.58, P = .006; FRAIL scale: HR: 2.32, 95% CI: 1.21–4.45, P = .011; Fried criteria: HR: 1.99, 95% CI: 1.04–3.82, P = .038). However, the prediction accuracy of the FRAIL scale was higher than that of the FSI and comparable to that of the Fried criteria for physical dysfunction.Conclusions and ImplicationsThe FSI and the FRAIL scale showed moderate agreement with the Fried criteria regarding frailty diagnostic performance and had comparable prognostic value. However, only the FRAIL scale was as accurate as the Fried criteria in screening for physical dysfunction.     

Association of Depressive Mood and Frailty With Mortality and Health Care Utilization: Korean National Cohort Study

ObjectivesTo investigate the association of depressive mood and frailty with mortality and health care utilization (HCU) and identify the coexisting effect of depressive mood and frailty in older adults.DesignA retrospective study using nationwide longitudinal cohort data.Setting and ParticipantsA total of 27,818 older adults age 66 years from the National Screening Program for Transitional Ages between 2007 and 2008, part of the National Health Insurance Service–Senior cohort.MethodsDepressive mood and frailty were measured by the Geriatric Depression Scale and Timed Up and Go test, respectively. Outcomes were mortality and HCU, including long-term care services (LTCS), hospital admissions, and total length of stay (LOS) from the index date to December 31, 2015. Cox proportional hazards regression and zero-inflated negative binomial regression were performed to identify differences in outcomes by depressive mood and frailty.ResultsParticipants with depressive mood and frailty represented 50.9% and 2.4%, respectively. The prevalence of mortality and LTCS use in the overall participants was 7.1% and 3.0%, respectively. More than 3 hospital admissions (36.7%) and total LOS above 15 days (53.2%) were the most common. Depressive mood was associated with LTCS use [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.05–1.42] and hospital admissions [incidence rate ratio (IRR) 1.05, 95% CI 1.02–1.08]. Frailty had associations with mortality risk (HR 1.96, 95% CI 1.44–2.68), LTCS use (HR 4.86, 95% CI 3.45–6.84), and LOS (IRR 1.30, 95% CI 1.06–1.60). The coexistence of depressive mood and frailty was associated with increased LOS (IRR 1.55, 95% CI 1.16–2.07).Conclusions and ImplicationsOur findings highlight the need to focus on depressive mood and frailty to reduce mortality and HCU. Identifying combined problems in older adults may contribute to healthy aging by reducing adverse health outcomes and the burden of health care costs.     

Association of Frailty with Perioperative Outcomes Following Hepatic Resection: A National Study

ObjectivesRisk of mortality and major comorbidity remains high following hepatic resection. Given recent advancements in nonsurgical techniques to control hepatic malignancy, accurate assessment of surgical candidates, especially those considered frail, has become imperative. The present study aimed to characterize the impact of frailty on clinical and financial outcomes following hepatic resection in older individuals.DesignRetrospective cohort study.Setting and ParticipantsAll older adults (≥65 years) undergoing elective hepatic resection were identified from the 2012 to 2019 National Inpatient Sample.MethodsFrailty was defined by using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Multivariable regression models were developed to assess the independent association of frailty with mortality, perioperative complications, and resource utilization. Marginal effects were tabulated to assess the impact of hospital volume on frailty-associated mortality.ResultsOf an estimated 40,735 patients undergoing major hepatic resection, 9.0% were considered frail. After multivariable adjustment, frailty was associated with increased odds of mortality (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 2.0–4.3; P < .001) and perioperative complication (AOR 2.9; 95% CI 2.4–3.4; P < .001). Furthermore, frail patients incurred longer risk-adjusted length of stay (14.2 vs 6.7 days, P < .001) and greater hospitalization costs ($55,100 vs $29,300, P < .001). In assessing the impact of institutional expertise on perioperative outcomes, the marginal effect of frailty on mortality became less pronounced with increasing operative volume.Conclusions and ImplicationsAs the population of the United States continues to age, surgeons are increasingly likely to encounter candidates for major hepatic resection who are frail. The present study associated frailty with inferior clinical and financial outcomes; however, frailty-associated mortality became less pronounced at centers with high hepatic resection operative volume. Coding-based instruments, such as the Johns Hopkins Adjusted Clinical Groups, may identify patients from electronic medical records who may benefit from further geriatric assessment and targeted treatments.     

Transitions in Frailty States Among Community-Living Older Adults and Their Associated Factors

BackgroundFrailty renders older individuals more prone to adverse health outcomes. Little has been reported about the transitions between the different frailty states. We attempted to examine the rate of these transitions and their associated factors.MethodsWe recruited 3018 Chinese community-living adults 65 years or older. Frailty status was classified according to the Fried criteria in 2 visits 2 years apart. Demographic data, medical conditions, hospitalizations, and cognition were recorded. Rates of transitions and associated factors were studied.ResultsAt baseline, 850 (48.7%) men and 884 (52.6%) women were prefrail. Among these, 23.4% men and 26.6% women improved after 2 years; 11.1% of men and 6.6% of women worsened. More men than women (P < .001) deteriorated into frailty. Hospitalizations, older age, previous stroke, lower cognition, and osteoarthritis were risk factors for decline among prefrail participants. Having diabetes was associated with 50% lower chance of improvement in women. Among the robust, older age and previous cancer, hospitalizations, chronic lung diseases, and stroke were risk factors for worsening. Higher socioeconomic status was protective. Previous stroke reduced the chance of improvement by 78% in frail men. Only younger age was associated with improvement in frail women.ConclusionWomen were less likely to decline in frailty status than men. Hospitalizations, older age, previous stroke, lower cognitive function, diabetes, and osteoarthritis were associated with worsening or less improvement. Older age, previous cancer, hospitalizations, lung diseases, and stroke were risk factors for worsening in the robust and higher socioeconomic status was protective.     

Construct validity and reliability of a two-step tool for the identification of frail older people in primary care

ObjectivesTo study the reliability and construct validity of the EASY-Care Two-step Older persons Screening (EASY-Care TOS), a practice-based tool that helps family physicians (FPs) to identify their frail older patients.Study Design and SettingThis validation study was conducted in six FP practices. We determined the construct validity by comparing the results of the EASY-Care TOS with other commonly used frailty constructs [Fried Frailty Criteria (FFC), Frailty Index (FI)] and with other related constructs (ie, multimorbidity, disability, cognition, mobility, mental well-being, and social context). To determine interrater reliability, an independent second EASY-Care TOS assessment was made for a subpopulation.ResultsWe included 587 older patients (mean age 77 ± 5 years, 56% women). According to EASY-Care TOS, 39.4% of patients were frail. EASY-Care TOS frailty correlated better with FI frailty (0.63) than with FFC frailty (0.52). A high correlation was found with multimorbidity (0.50), disabilities (0.53), and mobility (0.55) and a moderate correlation with cognition (0.31) and mental well-being (0.38). Reliability testing showed 89% agreement (Cohen's κ 0.63) between EASY-Care TOS frailty judgment by two different assessments.ConclusionEASY-Care TOS correlated well with relevant physical and psychosocial measures. Accordingly, these results show that the EASY-Care TOS identifies patients who have a wide spectrum of interacting problems.