Frailty and migration in middle-aged and older Europeans

We evaluated life course influences on health by investigating potential differences in levels of frailty between middle-aged and older European immigrants born in low- and middle-income countries (LMICs), immigrants born in high income countries (HICs), and their native-born European peers. Using data from the Survey of Health, Ageing, and Retirement in Europe (SHARE), we constructed a frailty index from 70 age-related health measures for 33,745 participants aged 50+ (mean = 64.9 ± 10.2 years; 54% women) in 14 European countries. Participants were grouped as native-born or as immigrants born in LMICs or in HICs, and further by current residence in Northern/Western or Southern/Eastern Europe. Seven percent of participants (n = 2369) were immigrants (mean = 64.4 ± 10.2 years; 56% women; LMIC-born = 3.4%, HIC-born = 3.6%). In Northern/Western Europe, after adjustment for age, gender, and education, LMIC-born immigrants demonstrated higher frailty index scores (mean = 0.18, 95% confidence interval = 0.17–0.19) than both HIC-born immigrants (0.16, 0.16–0.17) and native-born participants (0.15, 0.14–0.15 both p < 0.001). In Southern/Eastern Europe, frailty index scores did not differ between groups (p = 0.2). Time since migration explained significant variance in frailty index scores only in HIC-born immigrants to Southern/Eastern Europe (4.3%, p = 0.03). Despite differences in frailty, survival did not differ between groups (p = 0.2). LMIC-born immigrants demonstrated higher levels of frailty in Northern/Western Europe, but not Southern/Eastern Europe. Country of birth and current country of residence were each associated with frailty. Life course influences are demonstrable, but complex.     

The association between frailty and quality of life when aging in place

Background and objectivesAdvanced age is often associated with frailty, which in turn is associated with low quality of life. This study explores to what extent multidimensional frailty is associated with multidimensional quality of life.Material and methodsA cross-sectional survey study was conducted in a sample of 336 Flemish older people aging in place. Data were collected between 2014 and 2016 using two multidimensional self-reporting instruments; the Comprehensive Frailty Assessment Instrument to assess frailty and the World Health Organization Quality of Life Instrument-Short Version to assess quality of life. Bivariate analyses were used to explore the relationship between quality of life, associated factors of quality of life and frailty.ResultsThe mean age of the respondents was 74.9 years and 71.7% were woman. An inverse correlation was found between frailty and quality of life (r = −.683) and the corresponding subdomains. Nevertheless, some respondents perceived their quality of life as high, although they were defined as mild to high frail. Further analysis indicated that neither socio-demographic factors nor being ill contributed to quality of life.Discussion and implicationsPsychological frailty contributed the most to quality of life. However, the results indicate that frailty does not inevitably leads to a lower quality of life and that other factors, besides frailty, play an important role in determining quality of life. Knowledge about these factors and their mutual relationship can help policymakers and services in providing client-centered care to increase or maintain the quality of life of people aging in place.     

Multilevel socioeconomic status and incidence of frailty post myocardial infarction

Background

Frailty predicts mortality and hospitalizations in post-myocardial infarction (MI) patients. Socioeconomic status (SES) demonstrates a clear relationship with post-MI outcomes and is also associated with community frailty; however this relationship has yet to be evaluated in post-MI patients. We investigated the predictive value of socioeconomic factors in the development of post-MI frailty.

Methods

A cohort of 1151 post-MI patients was followed up from initial hospitalization in 1992–1993 for 10–13 years. Individual and neighborhood SES measures were assessed at baseline and frailty was assessed during follow-up via an index of deficit accumulation. Logistic regression models and discrimination indices enabled determination of the predictive value of socioeconomic factors over basic clinical variables in classifying frailty risk.

Results

During follow-up, 399 patients (35%) developed frailty. Individual and neighborhood SES were significantly and independently associated with the risk of developing frailty. Low income patients had more than twice the risk of becoming frail compared with those with high income [odds ratio (OR), 2.29, 95% CI 1.41–3.73]; while being in the lower vs. upper neighborhood SES tertile was associated with a 60% increased odds (OR, 1.60, 95% CI 1.03–2.49). Inclusion of multilevel SES yielded substantial gains in c-statistic (0.70 to 0.76), net reclassification improvement (21.4%) and integrated discrimination improvement (6.4%) over basic clinical factors (all p < 0.001), indicating increased predictive value and gains in sensitivity and specificity.

Conclusions

Individual and neighborhood socioeconomic factors influence the development of frailty post-MI, and contribute to risk discrimination in this population.     

Combined effects of frailty status and cognitive impairment on health-related quality of life among community dwelling older adults

ObjectivesThe aim of the present study was to investigate the combined association of frailty/pre-frailty and cognitive impairment with health related quality of life (HRQOL) among community dwelling older adults.MethodsData came from a cross-sectional study of community-dwelling older adults aged 65 years or older, who participated in the 2013 National Health Interview Survey in Taiwan. Frailty was determined based on the Fatigue, Resistance, Ambulation, Illness, and Loss of weight (FRAIL) scale proposed by the International Association of Nutrition and Aging. The Mini-Mental State Examination was used to assess cognitive function. HRQOL was measured using the European Quality of Life-5 Dimensions questionnaire (EQ-5D) that assesses three levels of functioning for the dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Poisson regression models were performed to estimate prevalence ratios (PR) and 95 % Confidence Intervals (95 % CI) for health problems in all EQ-5D domains.ResultsIn this study, 11.0 % of participants aged 65 years and older had co-occurring frailty/pre-frailty and cognitive impairment. After adjustment for other factors, compared with participants who were physically robust with normal cognition, participants with co-occurring frailty/pre-frailty and cognitive impairment had PRs of 10.38 (95 % CI 7.56–14.26), 9.66 (95 % CI 6.03–15.48), 9.37 (95 % CI 6.92–12.68), 3.04 (95 % CI 2.53–3.64), and 5.63 (95 % CI 3.83–8.28) for reporting problems with mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, respectively.ConclusionsThere is a high prevalence of co-occurrence of frailty/pre-frailty and cognitive impairment in older adults, and this co-occurrence was strongly associated with self-reported health problems across all EQ-5D domains.     

Effects of social isolation,loneliness and frailty on health outcomes and their possible mediators and moderators in community-dwelling older adults: A scoping review

Background/ObjectivesOver the past decade, the quantity and quality of social relationships in later life have become one of the main challenges facing an aging society. Our aims were to map and synthesize the literature addressing the effects of loneliness, three aspects of social isolation, including social networks, social support, and social participation, and frailty on health outcomes and their mediators and moderators among older adults.MethodsWe conducted a scoping review and searched for articles published in English and French from 2001 up to 2019 in the following databases: Medline, Embase, CINAHL Plus, Scopus, Web of Science and PsycINFO.ResultsOur database search initially resulted in 4001 articles of which 1832 were excluded; 26 were eligible. Most of the included studies revealed associations between social isolation, loneliness and frailty. The majority of studies found evidence of associations between frailty and their adverse outcomes; however, only few studies found a relationship between social isolation and health outcomes. In spite of the established link between frailty and adverse outcomes, no study looked at how social isolation and loneliness can alter adverse outcomes of frailty. No study investigated the role of frailty or social isolation and loneliness as a mediator on the pathway related to health.ConclusionsEvidence is limited in examining the role of frailty or social isolation and loneliness as a moderator and mediator. Longitudinal research combining both social isolation and loneliness are warranted to explore whether social isolation or loneliness has more deleterious effects on frailty and health outcomes.     

Associations between multidimensional frailty and quality of life among Dutch older people

PurposeTo examine the associations between components of physical, psychological and social frailty with quality of life among older people.MethodsThis cross-sectional study was carried out in a sample of Dutch citizens. A total of 671 people aged 70 years or older completed a web-based questionnaire (‘the Senioren Barometer’). This questionnaire contained the Tilburg Frailty Indicator (TFI) for measuring physical, psychological and social frailty, and the WHOQOL-OLD for measuring six quality of life facets (sensory abilities, autonomy, past, present and future activities, social participation, death and dying, intimacy) and quality of life total.ResultsNine of fifteen individual frailty components had an effect on at least one facet of quality of life and quality of life total, after controlling for socio-demographic factors, multimorbidity and the other frailty components. Of these nine components five, two and two refer to physical, psychological and social frailty, respectively. Feeling down was the only frailty component associated with all quality of life facets and quality of life total. Both physical inactivity and lack of social relations were associated with four quality of life facets and quality of life total.ConclusionThis study showed that quality of life in older people is associated with physical, psychological and social frailty components, emphasizing the importance of a multidimensional assessment of frailty. Health care and welfare professionals should in particular pay attention to feeling down, physical inactivity and lack of social relations among older people, because their relation with quality of life seems to be the strongest.     

The biology of aging and frailty

In developing and validating the concept of frailty as a geriatric syndrome, it has been necessary to distinguish the clinical expression of frailty from normal age-related changes and other age-related disease pathologies. A framework for excluding potentially confounding disease and a working clinical tool to diagnose frailty have been provided. The associations between frailty and other pathophysiologies has also been shown. However, investigating the underlying biologic basis for the geriatric syndrome of frailty by studying basic homeostatic pathways and mechanisms has not proceeded at the same rate. The following article provides an overview of the homeostatic pathways emphasized in research on aging and explains how this science may help to stimulate frailty research.     

The role of individual characteristics and physical frailty on health related quality of life (HRQOL): A cross sectional study of Italian community-dwelling older adults

The aims of this study were to investigate the relationship between individual characteristics and HRQOL, and to identify which components of physical frailty measured according to Fried's criteria provided a better explanation of HRQOL. Two hundred and fifty-nine older adults (age 74 ± 6 years; 69% were women) living in Piemonte Region were enrolled in this cross-sectional study. Socio-demographic and medical characteristics were captured by self-reported questionnaires. Physical frailty was assessed using the five criteria of Fried: shrinking, weakness, poor endurance and energy, slowness, and low physical activity level. HRQOL was measured with the 36-item Short-Form Health Survey (SF-36), using both the mental (MCS) and the Physical Component Summary (PCS). Among individual characteristics, gender was the best predictor for SF-36, the MCS, and the PCS, with values of R² of 12.7%, 12.1%, and 8.8%, respectively. Among the five Fried's criteria, poor endurance and energy had the largest effect on HRQOL with values of ΔR² of 13.9% for SF-36, 13.4% for the MCS, and 9.4% for the PCS. Results highlighted the role of the individual characteristics and the single weight of the five components of physical frailty on HRQOL. This knowledge may give new insights about the relations between individual functioning and self-rated health, allowing the development of individualized and more effective preventive interventions for a healthy aging.     

Frailty in NHANES: Comparing the frailty index and phenotype

The two most commonly employed frailty measures are the frailty phenotype and the frailty index. We compared them to examine whether they demonstrated common characteristics of frailty scales, and to examine their association with adverse health measures including disability, self-reported health, and healthcare utilization. The study examined adults aged 50+ (n = 4096) from a sequential, cross-sectional sample (2003–2004; 2005–2006), National Health and Nutrition Examination Survey. The frailty phenotype was modified from a previously adapted version and a 46-item frailty index was created following a standard protocol. Both measures demonstrated a right-skewed distribution, higher levels of frailty in women, exponential increase with age and associations with high healthcare utilization and poor self-reported health. More people classified as frail by the modified phenotype had ADL disability (97.8%) compared with the frailty index (56.6%) and similarly for IADL disability (95% vs. 85.6%). The prevalence of frailty was 3.6% using the modified frailty phenotype and 34% using the frailty index. Frailty index scores in those who were classified as robust by the modified phenotype were still significantly associated with poor self-reported health and high healthcare utilization. The frailty index and the modified frailty phenotype each confirmed previously established characteristics of frailty scales. The agreement between frailty and disability was high with each measure, suggesting that frailty is not simply a pre-disability stage. Overall, the frailty index classified more people as frail, and suggested that it may have the ability to discriminate better at the lower to middle end of the frailty continuum.     

Quality-adjusted life years lost to arthritis: Effects of gender,race, and social class

Objective. To estimate the public health impact of self-reported arthritis in terms of Quality-Adjusted Life Years. Method. The Quality of Well-Being Scale (QWB) is a general measure of health-related quality of life that scores levels of wellness on a continuum between death (0.0) and optimum functioning (1.0). Values for the QWB were imputed for the National Health Interview Survey. These estimates were adjusted for mortality based on the life tables. Age-specific estimates were obtained for those reporting arthritis and compared to estimators for the population not reporting arthritis. These estimates were broken down by race (white versus nonwhite), gender, and socioeconomic status. Results. The expected life years lost because of arthritis were 1.86 (95% confidence interval 1.40–2.32 years). Arthritis was reported more often among those of lower income, those living in rural areas, those of lower educational attainment, and older respondents. Men and women did not differ in rates of reporting arthritis, but men with arthritis had lower QWB scores than women with arthritis. Conclusion. Arthritis has a significant public health impact.     

Orthostatic hypotension,orthostatic intolerance and frailty: The Irish Longitudinal Study on Aging-TILDA

Because frailty may represent impaired response to physiological stress we explored the associations between frailty and orthostatic hypotension (OH), and orthostatic intolerance (OI). This study was based on a cross-sectional analysis of 5692 community dwelling adults aged 50 years and older included in wave 1 of the Irish Longitudinal Study on Aging. Frailty was assessed using both the phenotypic (FP) and frailty index (FI) models. OH was defined as a drop of ≥20 mmHg in systolic blood pressure or a drop of ≥10 mmHg diastolic pressure on standing from a seated position. OI was defined as reporting feeling dizzy, light headed or unsteady during this test. 346 (6.1%) participants had OH and 381 (6.7%) participants had OI. The prevalence OH in frail participants was 8.9%, compared to 5% in robust. Similarly the prevalence of OI was 14.3% in frail and 5.7% in robust participants. After adjustment for age and gender, OH was not significantly related to the FP (OR = 1.10 95% CI = 0.67, 1.81). Conversely OI was (OR = 1.80 95% CI = 1.13, 2.87), even after adjustment for age, gender, cardiovascular factors and mental health. In fully adjusted models OI remained related to slowness and low muscle strength and to higher FI scores. These data suggest OI symptoms in older adults may reflect various important underlying health deficits, indicative of increasing levels of frailty. Further assessment of frailty in patients experiencing OI is a potential opportunity for early intervention to delay functional decline.     

The relationship between frailty and serum alpha klotho levels in geriatric patients

BackgroundFrailty is a medical syndrome resulting in loss of endurance, strength and physiological function. There is insufficient data to understand the process of frailty formation at the gene level, however one of the product of Klotho gene known as an anti-aging gene with many functions that prolong lifespan is alpha klotho protein. We aimed to investigate the relationship between frailty and the serum alpha klotho protein levels.MethodsIn this cross-sectional analysis, there were 89 patients aged 65 years old and older, 45 of whom were frail and 44 of whom were not frail, were included in the study. Within the scope of the study, a sociodemographic and clinical information form, the Turkish version of the FRAIL scale and a comprehensive geriatric assessment were evaluated. In addition to routine laboratory tests, plasma alpha klotho protein levels were measured.ResultsThe mean alpha klotho protein levels of the patients were 0.76 ± 1.01 ng/ml in the control group and 0.54 ± 0.61 ng/ml in the frail group, however, there was no statistically significant difference between the two groups (p = 0.286). C-reactive protein (CRP) levels were significantly higher and hemoglobin (Hb) levels were significantly lower in the frail patients compared to the control group (p < 0.05). It was observed that alpha klotho protein level was inversly correlated with increased CRP levels but association was weak (p = 0.022, R: −0.245). Hb levels (p = 0.018, R: 0.250) was weakly correlated with alpha klotho protein level.ConclusionNo significant relationship was found between frailty and alpha klotho protein levels in the geriatric patients. Further comprehensive studies are needed to explore this subject.     

Association between lifestyle behaviors and frailty in Atlantic Canadian males and females

PurposeThe aim of this study was to identify lifestyle factors in males and females that are associated with a greater degree of frailty in a Canadian cohort.MethodsCross-sectional data analysis from participants aged 30−74 yrs of the Atlantic PATH cohort. Inclusion criteria included completion of mental health questionnaires and ≥1 vital measure (n = 9133, 70% female, mean age 55 yrs). A frailty index was created based on 38 items with higher values indicating increasing frailty. The association between lifestyle factors and frailty was assessed by logistic regression.Results805 participants had a high level of frailty (frailty index ≥0.30). There was a significant interaction among sex, age, and lifestyle factors such as smoking status (P < 0.001), alcohol consumption (P < 0.001), physical activity level (P = 0.005), time spent sitting (P < 0.001) and sleeping (P < 0.001) on frailty. Smoking was harmful whereas sleep was protective for both males and females (<60 yrs). Females (<60yrs) that sat for ≥4 h/day were more likely to be highly frail whereas females (all ages) that consumed alcohol at least occasionally were less likely to be highly frail. Males, but not females, that engaged in a high level of physical activity were less likely to have a high level of frailty.ConclusionsHigher frailty is more prevalent among participants with unhealthy lifestyle behaviors related to smoking, alcohol consumption, sedentary and physical activity level, diet, and sleep. Differences in lifestyle behaviors of males and females of specific ages should be considered for managing frailty levels.     

The effect of protein supplements on functional frailty in older persons: A systematic review and meta-analysis

BackgroundThe effect of protein supplementation in attenuating loss of muscle mass, strength and function in community-dwelling older people has been promising, however, its benefits in pre-frail and frail older people remains unclear.ObjectiveTo determine the effect of protein supplementation on muscle mass, strength and function in frail older people by reviewing and conducting meta-analysis of relevant randomized controlled trials (RCTs).DesignThis review was registered at PROSPERO (CRD42017079276) and conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Using a pre-determined e-search strategy, we searched PubMed, Medline, EMBASE, CINAHL, LILACS, Web of Science, Cochrane and Scopus databases. Inclusion criteria were RCTs that assessed the effect of protein supplementation on muscle mass, strength and function in frail individuals aged ≥65 years. The main outcomes were lean body mass (LBM), handgrip, leg extension, leg press strength, short physical performance battery (SPPB) score, and gait velocity.ResultsOf the eight studies included in this review, 503 subjects were enrolled and four different protein supplements were assessed. Despite the variation in methodology, studies were homogenous with I-squared <10.0%. The meta-analysis showed no significant effect of protein supplementation on LBM (mean difference 1.17 kg, 95% CI: −1.97–4.3), handgrip (mean difference 0.15, 95% CI: −0.95–1.24), leg extension (mean difference −3.68 kg, 95% CI: −12.72–5.36), leg press (mean standardized difference 0.26 kg, 95% CI: −0.30–0.82), SPPB (mean difference 0.61, 95% CI: −0.02–1.23), or gait velocity (mean difference -0.20 m/s, 95% CI: −0.95–0.55).ConclusionProtein supplementation alone does not significantly improve muscle mass, strength or function in pre-frail or frail older people.     

Sarcopenia and frailty in individuals with dementia: A systematic review

BackgroundPopulation aging has resulted in an increase in age-related conditions. Sarcopenia, the progressive loss of muscle mass and strength, and frailty, vulnerability to poor resolution of homeostasis after a stressor, are common causes of functional decline in older individuals. There is a paucity of work on how they interrelate with dementia. The objective of this review was to examine the literature on sarcopenia and frailty in dementia.Methods and resultsStudies of sarcopenia and frailty in dementia were searched for in EMBASE, PubMed and Web of Science, and via hand-searching. Citations were screened for independently by two reviewers, with disagreements resolved by a third reviewer. To be eligible for inclusion, the articles needed to fulfil: (1) English language; (2) human studies; and (3) full-text available. Dementia of any aetiology was included. 303 non-duplicate recorders were identified, of which 270 irrelevant papers were excluded. Of the remaining 33, 27 examined frailty and 13 sarcopenia, with six of these measuring both. An increased prevalence of frailty and sarcopenia was noted in dementia patients. However, nine papers did not specify dementia aetiologies. Of those that did (n = 21), 20 examined Alzheimer’s disease, with three also including Lewy body dementia, three vascular dementia, and one Parkinson’s disease dementia.ConclusionMost papers examined frailty, rather than sarcopenia, in dementia. The studies were heterogeneous, using different protocols and non-validated definitions. However, dementia patients may have an increased prevalence of frailty and sarcopenia. This review highlights key gaps in accurate diagnosis of frailty/sarcopenia and in non-Alzheimer’s dementia.     

Frailty phenotypes in the elderly based on cluster analysis: a longitudinal study of two Danish cohorts. Evidence for a genetic influence on frailty

Frailty is a physiological state characterized by the deregulation of multiple physiologic systems of an aging organism determining the loss of homeostatic capacity, which exposes the elderly to disability, diseases, and finally death. An operative definition of frailty, useful for the classification of the individual quality of aging, is needed. On the other hand, the documented heterogeneity in the quality of aging among different geographic areas suggests the necessity for a frailty classification approach providing population-specific results. Moreover, the contribution of the individual genetic background on the frailty status is still questioned. We investigated the applicability of a cluster analysis approach based on specific geriatric parameters, previously set up and validated in a southern Italian population, to two large longitudinal Danish samples. In both cohorts, we identified groups of subjects homogeneous for their frailty status and characterized by different survival patterns. A subsequent survival analysis availing of Accelerated Failure Time models allowed us to formulate an operative index able to correlate classification variables with survival probability. From these models, we quantified the differential effect of various parameters on survival, and we estimated the heritability of the frailty phenotype by exploiting the twin pairs in our sample. These data suggest the presence of a genetic influence on the frailty variability and indicate that cluster analysis can define specific frailty phenotypes in each population.     

Key Topics in the Study of Older Adult Health in Developing Countries that are Experiencing Population Aging

Rapid population aging is occurring in many parts of the developing world. Age structures are shifting from a relative concentration of younger to older individuals. Formal and informal health care needs across the developing world are changing concurrently. Therefore, population aging has enormous implications for health and social policy. This essay, which serves as an introduction to a special issue of Journal of Cross-Cultural Gerontology, highlights several critical research topics that require attention due to their implications for the health of individuals living in developing countries that are experiencing population aging. These include: population health levels, trends, and individual health transitions; influences of socioeconomic status on health and the consequences of rapidly changing socioeconomic structures for population health; and comparative studies on health and aging. Comparative research, in particular, has been underdeveloped and underutilized, but has great potential for providing insights into health determinants as well as the uniformity versus variation of the aging experience across societies. The remaining four papers that make up this special issue deal with these research topics and together highlight the complexity that exists in assessing individual and population health trends in developing countries that are undergoing population aging.     

Education, wealth, and cognitive function in later life

Population-based studies of health often use education as the sole indicator of socioeconomic status (SES); the independent contributions of education and other SES covariates are rarely delineated. Using Wave 1 of the Asset and Health Dynamics Among the Oldest Old study, the authors examined the extent to which educational attainment influences performance on three separate domains of cognitive status by race and Latino ethnicity and introduced controls for wealth and household income. Results indicate that the education effect is minimally weakened after adjusting for wealth; the wealth effect, however, is greatly attenuated after adjusting for education. Blacks and Whites exhibited a similar education--cognition relationship; Latino elderly did not experience commensurate gains in cognitive function with increasing education. Results suggest that although the education--cognition relationship may in part reflect an SES gradient, the association is more likely due to the process and consequences of education itself.