Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians

BACKGROUND AND AIMS: Objectives were to develop a frailty index (FI) based on a standard comprehensive geriatric assessment (CGA) derived from a clinical examination; to assess the validity of the FI-CGA and to compare its precision with other frailty measures. METHODS: DESIGN: Secondary analysis of a prospective cohort study, with five-year follow-up data. SETTING: Second phase of the Canadian Study of Health and Aging (CSHA-2); clinical examinations were performed in clinics, nursing homes, and patients' homes. PARTICIPANTS: People selected (as either cognitively impaired cases or unimpaired controls) to receive the CSHA-2 clinical examination (n = 2305; women = 1431). MEASUREMENTS: Clinical and performance-based measures and diagnostic data were extracted to correspond to the 10 impairment domains and the single comorbidity domain of a CGA. The proportion of deficits accumulated in each domain was calculated to yield the FI-CGA. The FI-CGA was validated and its predictive ability compared with other frailty measures. RESULTS: Within the seven grades of fitness/frailty identified, subjects with greater frailty were older, less educated, and more likely to be women. The FI-CGA correlated highly with a previously validated, empirically-derived frailty index (r = 0.76). Frailty was associated with higher risk of death (for each increment in frailty, the hazard ratio, adjusted for age, sex and education, was 1.23 (95% CI 1.18-1.29) and institutionalization (HR 1.20; 1.10-1.32). CONCLUSIONS: In a population survey, the FI-CGA is a valid means of quantifying frailty from routinely collected data.     

Comprehensive geriatric assessment in female elderly patients with Alzheimer disease and other types of dementia

The most visible manifestation of dementia is the progressive inability to activities of daily living (ADL) and to instrumental activities of daily living (IADL). The comprehensive geriatric assessment (CGA) is the validated and recommended instrument to a correct evaluation and decision making in elderly patients. To judge if the decline in cognitive functions is associated with a worsening in functional, emotional and clinical status measured by CGA, we also compared CGA in the same patients stratified for mild, moderate and severe dementia. From September 2004 to November 2005 we studied 47 institutionalized female patients with Alzheimer's disease (AD) and other types of dementia. Mean age was 83.70+/-0.88 years (range 70-101). Their multidimensional evaluation was performed by the CGA. We evaluated geriatric syndromes (AGS, 2004), polypharmacy, frailty, hemoglobin (Hb), serum creatinine (CR) and white blood cells (WBC). We stratified the population in 3 groups for the mini mental state examination (MMSE): severe (MMSE 0-9; 5 patients), moderate (MMSE 10-29; 23 patients) and mild dementia group (MMSE 20-30; 19 patients), and searched for statistical differences in the parameters of CGA. MMSE was significantly related to dependence in ADL (mean=x=1.85), IADL (x=0.57), cumulative illness rating scale-geriatrics (CIRS-G) (x=9.55), geriatric depression scale (GDS) (x=8.71), geriatric syndromes (x=2.49), Hb, CR, WBC and number of drugs (x=6.51, range 2-15) (p=0.001). MMSE low score was also correlated with a worse mini nutritional assessment (MNA) (x=19.5; p=0.003). Frail patients were 61.7%. We found a statistically significant difference in the prevalence of geriatric syndromes between mild vs. moderate dementia group (p=0.02). Mild vs. moderate group, and moderate vs severe group were significantly different concerning Hb levels (p=0.009 and 0.002, respectively). Patients with severe cognitive impairment are more likely to be dependent at ADL and IADL; to present a larger number of comorbidity and geriatric syndromes; to have lower !evels of Hb and higher levels of CR; to be in a worse nutritional status and to take a larger number of drugs. Polypharmacy maybe related to high comorbidity but the risk of irrational drug use should be evaluated. We suggest single testing with CGA as an effective tool providing a comprehensive assessment of elderly, and able to detect unaddressed corrigible problems.     

Impairments in mobility and balance in relation to frailty

We set out to describe the relationship between impaired balance, mobility and frailty, and relate these to risk of death. We examined a subsample of 1295 community-dwelling non-demented adults from the second wave of the Canadian Study of Health and Aging (CSHA), a prospective population-based cohort study. Frailty index (FI) scores were constructed from a standardized comprehensive geriatric assessment (FI-CGA). History of mobility impairments and falls were assessed. Timed-up-and-go (TUG) and functional reach (FR) performance were measured. The CSHA clinical frailty scale (CFS) was judged by a physician. Adverse outcomes were determined at CSHA-3, conducted 5 years later. The FI-CGA varied in association with impaired mobility and balance. A history of mobility problems was demonstrable at FI-CGA scores >0.12. This level of frailty also represented the most marked deterioration in performance measures (TUG and FR). FI-CGA scores best predicted mortality (HR 1.04 ± 0.02), proving to be a dominating factor in multivariate regression models that included mobility and balance markers. Only at the upper range of FI-CGA reported (>0.45) did all participants demonstrate mobility impairment. Impaired balance and mobility contribute to frailty, but neither is sufficient to define a participant as frail.     

Orthostatic hypotension (OH) and mortality in relation to age, blood pressure and frailty

Systolic hypertension and OH, as with many other deficits, accumulate with age. This deficit accumulation results in frailty: enhanced vulnerability to adverse outcomes. This study evaluated OH in relation to age, frailty, systolic hypertension, and mortality. In the population-based Canadian Study of Health and Aging second clinical examination, complete data were available on 1347 people, mean age=83.3 (SD=6.4)years. A frailty index (FI) was calculated from a 52-item Comprehensive Geriatric Assessment (CGA), yielding an FI-CGA from 0 (no deficits) to 1.0 (52 deficits). The mean change in blood pressure from lying to standing was 7.3±15.6 mmHg (range +94 to -60). In total, 239 people (17.7%) had OH (change >20 mmHg systolic or >10 mmHg diastolic). Mean systolic blood pressure was higher (155.8±23.3 mmHg) in people with OH than in those without (141.4±23 mmHg), as was the FI-CGA (0.18 vs. 0.16). OH increased with frailty and systolic hypertension, but not age. Unadjusted, OH was associated with an increased risk of death (relative risk=1.21, 95% confidence interval 1.19-1.23). Adjusted for frailty, this result was not significant. OH may be a marker of the system dysregulation seen in frailty, but as a state variable is a less powerful marker of vulnerability than is the FI-CGA.     

The frailty syndrome: a critical issue in geriatric oncology

Evidence exists that the geriatric intervention guided by Comprehensive Geriatric Assessment (CGA) has positive effects on a number of important health outcomes in frail older patients. Although a number of observational studies, editorials, special articles and clinical reports, suggest that CGA should be used to guide the assessment and clinical decision-making in older cancer patients, there is limited support to this view in the literature. Older patients that are diagnosed with cancer are usually healthier and less problematic than persons of the same age who are randomly sampled from the general population. In these persons, the cancer dominates the clinical picture and, therefore, instruments especially tuned for the frail elderly may provide little information. The concept of the frailty syndrome, characterized by high susceptibility, low functional reserve and unstable homeostasis, has recently received a lot of attention by the geriatric community. A CGA approach, which also evaluates elements of the frailty syndrome, may be of great interest for those oncologists who want to identify older patients likely to develop severe toxicity and severe side effects in response to aggressive treatment. Improvements in the definition of the frailty syndrome may profit from the clinical experience of oncologists.     

Frailty syndrome diagnosed according to the Study of Osteoporotic Fractures (SOF) criteria and adverse health outcomes among community-dwelling older outpatients in Italy. A one-year prospective cohort study

The easy-to-apply SOF criteria for frailty were recently validated in studies conducted in the U.S. only. In order to determine the ability of the SOF criteria to predict adverse health outcomes at a one-year follow-up in a sample of older outpatients in Italy we carried out a prospective cohort study on 265 community-dwelling outpatients aged 65+ (mean age 81.5 years) consecutively referred to a geriatric clinic. At baseline participants underwent a comprehensive geriatric assessment (CGA) including evaluation of their frailty status according to the SOF criteria. At a one-year follow-up, between June and December 2010, we investigated nursing home placement and death in all participants as well as any fall, any admission to the emergency department (ED), any hospitalization and a greater disability among the subset of subjects still living at home. One year after the visit 231 subjects were still living at home (87.2%), 9 had been placed in a nursing home (3.4%) and 25 had died (9.4%). Frailty was associated with a greater risk of falls (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.05-3.83, p=0.035), hospitalization (OR 2.08, 95% CI 1.02-4.24, p=0.045) and death (OR 3.07, 95% 1.02-4.24, p=0.045) after correction for demographic characteristics, comorbidity including dementia and depression, socioeconomic position and severe disability. Thus, in an older outpatient population in Italy the frailty syndrome diagnosed according to the SOF criteria was an independent predictor of several adverse health outcomes.     

Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department

BackgroundOlder people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017.AimTo evaluate if routinely collected CGA metrics were associated with ED disposition outcomes.DesignRetrospective observational study.MethodsWe included all first patients seen by Home FIRsT between 7^th May and 19^th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital.ResultsIn the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 – 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 – 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 – 1.97, P=0.002). Age and sex were not predictive in any of the models.ConclusionsRoutinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.     

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.     

The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized,controlled trial

This randomized, controlled trial assessed the effectiveness of comprehensive geriatric assessment (CGA) and subsequent intervention in pre-frail and frail community-dwelling elderly based on the Fried Frailty Criteria (FFC) and the Barthel Index (BI) A total of 310 pre-frail or frail elderly from a single community were identified using the FFC. Of these, 152 were randomly assigned to the intervention group for CGA and appropriate intervention by medication adjustment, exercise instruction, nutrition support, physical rehabilitation, social worker consultation, and specialty referral. Clinical outcome was re-evaluated by the FFC and BI 6 months later. Compared to the control group, the intervention group tended to have a better outcome, with an odds ratio (OR) = 1.19, 95% confidence interval (95% CI) = 0.48–3.04, p = 0.71) and 3.29 (95% CI = 0.65–16.64, p = 0.15), respectively, and were less likely to deteriorate, with an OR = 0.78 (95% CI = 0.34–1.79, p = 0.57) and 0.94 (95% CI = 0.42–2.12, p = 0.88), respectively. Although no significant differences were observed, the CGA and subsequent intervention showed a favorable outcome in frail and pre-frail elderly based on the frailty status and BI. Inability to complete the CGA and poor compliance with the intervention program appear to be the main reasons for unfavorable outcomes.     

基于照护者的老年综合评估衰弱指数问卷的汉化及信效度检验

目的对国外常用的基于照护者的老年综合评估的衰弱指数（care partner-frailty index-comprehensive geriatric assessment, CP-FI-CGA）问卷进行汉化,并评价其信度和效度。 方法首先对CP-FI-CGA问卷进行翻译修订、跨文化调试,然后采用便利抽样法选取4所综合性三甲医院老年病科的300例患者进行问卷调查,评价其信度和效度。采用独立样本t检验分析条目区分度,采用简单相关分析进行重测信度、评定者间信度、折半信度以及效标关联效度、结构效度分析,内部一致性采用Cronbach's α系数进行计算。 结果删除源问卷条目36（不能开车）,新增条目36"近期（6个月内）有大手术",最终问卷条目总数仍为44个。本问卷重测信度r=0.97、评定者间信度r=0.995、折半信度r=0.851、Cronbach'sα系数（即内部一致性系数）=0.883,均达到较高标准;44个条目的条目内容效度为0.727～1、问卷的总均效度为0.986,均达标;汉化版CP-FI-CGA问卷与加拿大临床衰弱等级量表的简单相关系数r=0.829（P<0.01）,与年龄的简单相关系数r=0.449（P<0.01）;44个条目中各条目与其衰弱指数得分的简单相关系数r为0.131～0.719（均P<0.05）。本问卷条目长度、内容及问卷内容的患者接受度均为100%,问卷长度接受度为98.67%,问卷完成时间为（5.45±0.65）min。本问卷不同衰弱评分等级（<0.3分、0.3～0.5分、>0.5分）患者的年龄、跌倒史发生率以及5种以上用药者的差异均有统计学意义（F=29.522,χ²=60.931、11.469;均P<0.01）。男女患者衰弱等级及衰弱指数的差异均无统计学意义（Z=-0.875,t=1.170;均P>0.05）。 结论汉化版CP-FI-CGA问卷的患者可接受性高,具有良好的信效度,可用于老年病科患者衰弱及等级的筛查,可为临床上分级护理提供参考。     

Validation and Comparison of Two Frailty Indexes: The MOBILIZE Boston Study

OBJECTIVES: To validate two established frailty indexes and compare their ability to predict adverse outcomes in a diverse, elderly, community‐dwelling sample of men and women. DESIGN: Prospective observational study. SETTING: A diverse defined geographic area of Boston. PARTICIPANTS: Seven hundred sixty‐five community‐dwelling participants in the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly Boston Study. MEASUREMENTS: Two published frailty indexes, recurrent falls, disability, overnight hospitalization, emergency department (ED) visits, chronic medical conditions, self‐reported health, physical function, cognitive ability (including executive function), and depression. One index was developed from the Study of Osteoporotic Fractures (SOF) and the other from the Cardiovascular Health Study (CHS). RESULTS: The SOF frailty index classified 77.1% as robust, 18.7% as prefrail, and 4.2% as frail. The CHS frailty index classified 51.2% as robust, 38.8% as prefrail, and 10.0% as frail. Both frailty indexes (SOF; CHS) were similar in their ability to predict key geriatric outcomes such as recurrent falls (hazard ratio (HR)_frail=2.2, 95% confidence interval (CI)=1.2–4.0; HR_frail=1.9, 95% CI=1.2–3.1), overnight hospitalization (odds ratio (OR)_frail=3.5, 95% CI=1.5–8.0; OR_frail=4.4, 95% CI=2.4–8.2), ED visits (OR_frail=3.5, 95% CI=1.4,8.8; OR_frail=3.1, 95% CI=1.6–5.9), and disability (OR_frail=5.4, 95% CI=2.3–12.3; OR_frail=7.7, 95% CI=4.0–14.7), as well as chronic medical conditions, physical function, cognitive ability, and depression. CONCLUSION: Two established frailty indexes were validated using an independent elderly sample of diverse men and women; both indexes were good at distinguishing geriatric conditions and predicting recurrent falls, overnight hospitalization, and ED visits according to level of frailty. Although both indexes are good measures of frailty, the simpler SOF index may be easier and more practical in a clinical setting.     

Comprehensive geriatric assessment in the emergency department for the prediction of readmission among older patients: A 3-month follow-up study

BackgroundOlder people present to the emergency department (ED) with distinct patterns and emergency care needs. This study aimed to use comprehensive geriatric assessment (CGA) surveying the patterns of ED visits among older patients and determine frailty associated with the risk of revisits/readmission.MethodsThis prospective study screened 2270 patients aged ≥75 years in the ED from August 2018 to February 2019. All patients underwent CGA. A 3-months follow-up was conducted to observe the hospital courses of admission and revisit/readmission.ResultsA total of 270 older patients were enrolled. The independent predictors of admission at initial ED visit were the risk of nutritional deficit and instrumental activities of daily living (IADL). In the admission group, the independent predictors of revisit/readmission were a fall in the past year and mobility difficulties. In the discharge group, the independent predictors of revisit/readmission were frailty and insomnia. Regardless if older patients were either admitted or discharged at the initial ED visit, the independent predictor of revisit/readmission for older patients was frailty.ConclusionOur study showed that frailty was the only independent predictor for revisit/readmission after ED discharge during the 3-month follow up. For ED physicians, malnutrition and IADL were independent predictors in recognizing whether the older patient should be admitted to the hospital. For discharged older ED patients, frailty was the independent predictor for the integration of community services for older patients to decrease the rate of revisit/readmission in 3 months.     

衰弱表型和衰弱指数评估老年人衰弱效果的初步研究

目的探讨衰弱表型定义和衰弱指数(FI)这两种衰弱评估法筛查老年人衰弱的效果,为临床和科研应用提供参考。方法选择2015年北京医院参加老年医学门诊体检的106例老年人为研究对象,年龄(79.5±7.6)岁,在完成常规体检的基础上进行综合评估,计算FI并完成衰弱表型定义的评估。比较两种衰弱评估方法筛查同一老年人群的结果并分析两种方法的相关性或一致性,同时评价不同FI临界值对衰弱的筛检价值。结果本组老年人的FI值为0.19±0.07,根据表型定义分期,衰弱前期65例(61.3%),衰弱15例(14.2%),无衰弱26例(24.5%)。两种评估方法均表明衰弱程度随老年人年龄增长而增加。F1值与衰弱表型定义的分期呈正相关(r=0.433,P=0.000)。采用0.09~0.25的FI分级与表型定义分期的一致性Kappa值为0.143(P=0.029),曲线下面积(AUC)为0.760(95%CI:0.616~0.905,P=0.001);而采用0.20~0.35的F1分级与表型定义分期对衰弱评估的一致性Kappa值为0.178(P=0.002),AUC为0.774(95%CI:0.629~0.919,P=0.001)。适合评估该组老年人衰弱水平的FI临界值为0.19~0.27。结论该组老年人中处于衰弱前期者比例较高,衰弱程度随年龄增长而增加。FI值和表型定义分期呈中度正相关,两种F1分级方法均有筛检价值,但准确性并不是很高。     

Impact of geriatric nutritional risk index on prognosis in peripheral artery disease patients undergoing endovascular therapy

The prevalence of peripheral artery disease continues to rise, with major amputations and mortality remaining prominent. Frailty is a significant risk factor for adverse outcomes in the management of the vascular disease. The geriatric nutritional risk index has been used to predict adverse outcomes in lower extremity peripheral artery disease and is a nutrition-based surrogate for frailty. The authors recruited 126 patients with peripheral artery disease who underwent endovascular stent implantation. As in previous reports, malnutrition was diagnosed by the geriatric nutritional risk index. The authors used Kaplan-Meier and multivariate Cox proportional hazards regression analyses to analyze the risk of major adverse limb events, which included mortality, major amputation, and target limb revascularization. There were 67 major adverse limb events during a median follow-up of 480 days. Malnutrition on the basis of the geriatric nutritional risk index was present in 31% of patients. Cox regression analysis showed that malnutrition based on the geriatric nutritional risk index was an independent predictor of major adverse limb events. Kaplan-Meier analysis showed that major adverse limb events increased with worsening malnutrition. Our single-center, retrospective evaluation of geriatric nutritional risk index (as a synonym for body health) correlates with an increased risk of major adverse limb events. Future directions should focus not only on identifying these patients but also on modifying risk factors to optimize long-term outcomes.     

Phenotype of frailty: characterization in the women's health and aging studies

BACKGROUND: "Frailty" is an adverse, primarily gerontologic, health condition regarded as frequent with aging and having severe consequences. Although clinicians claim that the extremes of frailty can be easily recognized, a standardized definition of frailty has proved elusive until recently. This article evaluates the cross-validity, criterion validity, and internal validity in the Women's Health and Aging Studies (WHAS) of a discrete measure of frailty recently validated in the Cardiovascular Health Study (CHS). METHODS: The frailty measure developed in CHS was delineated in the WHAS data sets. Using latent class analysis, we evaluated whether criteria composing the measure aggregate into a syndrome. We verified the criterion validity of the measure by testing whether participants defined as frail were more likely than others to develop adverse geriatric outcomes or to die. RESULTS: The distributions of frailty in the WHAS and CHS were comparable. In latent class analyses, the measures demonstrated strong internal validity vis à vis stated theory characterizing frailty as a medical syndrome. In proportional hazards models, frail women had a higher risk of developing activities of daily living (ADL) and/or instrumental ADL disability, institutionalization, and death, independently of multiple potentially confounding factors. CONCLUSIONS: The findings of this study are consistent with the widely held theory that conceptualizes frailty as a syndrome. The frailty definition developed in the CHS is applicable across diverse population samples and identifies a profile of high risk of multiple adverse outcomes.     

Geriatric assessment of a giant splenic artery aneurysm accidentally diagnosed

Giant splenic artery aneurysms (GSAAs) larger than 8 cm in diameter have rarely been reported, particularly in older people. They are clinically important lesions, often asymptomatic and related to an increased risk of complications such as abrupt rupture, requiring emergency surgical treatment. Comprehensive geriatric assessment (CGA), originally developed for multidimensional clinical evaluation in several geriatric settings, was recently proposed as a fundamental preoperative aid for treatment planning of older patients undergoing elective surgery and preventing adverse post-operative outcomes. We present the first case of an asymptomatic 9-cm partially thrombosed GSAA, accidentally diagnosed during abdominal ultrasound in a 63-year-old woman from the Apulia region in Southern Italy. She successfully underwent aneurysmectomy, highlighting the usefulness of CGA in elective surgical patients.     

Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance

OBJECTIVES: To examine the effect on primary care physicians' implementation and their patients' adherence behaviors of patient-physician concordance about recommended geriatric health care. DESIGN: Case-series, independent interviews of patients and their physicians about their perceptions of the patients' health and the comprehensive geriatric assessment (CGA). SETTING: Community. PARTICIPANTS: Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians. MEASUREMENTS: Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report. RESULTS: In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not. CONCLUSION: Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.     

Prevalence of anemia among elderly inpatients and its association with multidimensional loss of function

The purpose of this cross-sectional prospective study was to determine the prevalence of anemia among elderly hospitalized patients in Germany and to investigate its association with multidimensional loss of function (MLF). One hundred participants aged 70 years or older from two distinct wards (50 each from an emergency department and a medical ward, respectively) underwent a comprehensive geriatric assessment (CGA) consisting of the following six tools: Barthel Index, mini-mental state examination, clock-drawing test, timed up and go test, Esslinger transfer scale, and Daniels test. MLF as an aggregated outcome was diagnosed when three or more tests of the CGA showed an abnormal result. Anemia was defined according to WHO criteria as a hemoglobin (Hb) concentration of <13 g/dL for men and <12 g/dL for women. The prevalence of anemia was 60 %. Overall, 61 % of patients presented with three or more abnormal results in the six tests of the CGA and, thus, with MLF. Using logistic regression, we found a significant association of both anemia and low Hb concentrations with abnormal outcomes in five tests of the CGA and, therefore, with domain-specific deficits like mobility limitations, impaired cognition, and dysphagia. Furthermore, being anemic increased the odds of featuring MLF more than fourfold. This significant relationship persisted after adjustment for various major comorbidities. Both anemia and geriatric conditions are common in the hospitalized elderly. Given the association of anemia with MLF, Hb level might serve as a useful geriatric screening marker to identify frail older people at risk for adverse outcomes.     

Impact of anemia and cardiovascular disease on frailty status of community-dwelling older women: the Women's Health and Aging Studies I and II

BACKGROUND: The physiological basis of the geriatric syndrome of frailty, a clinical state of increased vulnerability to adverse outcomes such as disability and mortality, remains to be better characterized. We examined the cross-sectional relationship between hemoglobin (Hb) and a recently-validated measure of frailty in community-dwelling older women, and whether this relationship was modified by cardiovascular disease (CVD) status. METHODS: Data were pooled from women 70-80 years old participating in the Women's Health and Aging Studies I and II (Baltimore, MD, 1992-1996) with known frailty status and Hb > or = 10 g/dL (n = 670). Logistic regression was used to model the relationship between frailty and Hb, adjusting for demographics, major chronic diseases, and physiologic and functional impairments. RESULTS: Prevalence of frailty was 14%. Frailty risk was highest at the lowest Hb levels, and lowest at mid-normal Hb levels (e.g., 13-14 g/dL). Mildly low and low-normal Hb concentrations were independently associated with frailty. Compared to an Hb concentration equal to 13.5 g/dL, the adjusted odds of being frail were 1.9 (95% confidence interval: 1.1-3.4) and 1.5 (95% confidence interval: 1.0-2.1) times higher for Hb concentrations equal to 11.5 g/dL and 12 g/dL, respectively. A statistically significant (p <.05) multiplicative interaction between Hb level and CVD status with respect to frailty risk was observed. CONCLUSION: In community-dwelling older women, mildly low and low-normal Hb levels were independently associated with increased frailty risk. This risk was synergistically modified by the presence of CVD. These results suggest that mild anemia, and even low-normal Hb levels are independent, potentially modifiable risk factors for frailty in community-dwelling older adults.