Emiel O. Hoogendijk

Frailty measurement in research and clinical practice: A review

One of the leading causes of morbidity and premature mortality in older people is frailty. Frailty occurs when multiple physiological systems decline, to the extent that an individuals cellular repair mechanisms cannot maintain system homeostasis. This review gives an overview of the definitions and measurement of frailty in research and clinical practice, including: Frieds frailty phenotype; Rockwood and Mitnitskis Frailty Index (FI); the Study of Osteoporotic Fractures (SOF) Index; Edmonton Frailty Scale (EFS); the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) Index; Clinical Frailty Scale (CFS); the Multidimensional Prognostic Index (MPI); Tilburg Frailty Indicator (TFI); PRISMA-7; Groningen Frailty Indicator (GFI), Sherbrooke Postal Questionnaire (SPQ); the Gérontopôle Frailty Screening Tool (GFST) and the Kihon Checklist (KCL), among others. We summarise the main strengths and limitations of existing frailty measurements, and examine how well these measurements operationalise frailty according to Cleggs guidelines for frailty classification - that is: their accuracy in identifying frailty; their basis on biological causative theory; and their ability to reliably predict patient outcomes and response to potential therapies.

The identification of frail older adults in primary care: comparing the accuracy of five simple instruments

BACKGROUND many instruments are available to identify frail older adults who may benefit from geriatric interventions. Most of those instruments are time-consuming and difficult to use in primary care. OBJECTIVE to select a valid instrument to identify frail older adults in primary care, five simple instruments were compared. METHODS instruments included clinical judgement of the general practitioner, prescription of multiple medications, the Groningen frailty indicator (GFI), PRISMA-7 and the self-rated health of the older adult. Frieds frailty criteria and a clinical judgement by a multidisciplinary expert panel were used as reference standards. Data were used from the cross-sectional Dutch Identification of Frail Elderly Study consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. In this study, frail older adults were oversampled. We estimated the accuracy of each instrument by calculating the area under the ROC curve. The agreement between the instruments and the reference standards was determined by kappa. RESULTS frailty prevalence rates in this sample ranged from 11.6 to 36.4%. The accuracy of the instruments ranged from poor (AUC = 0.64) to good (AUC = 0.85). CONCLUSION PRISMA-7 was the best of the five instruments with good accuracy. Further research is needed to establish the predictive validity and clinical utility of the simple instruments used in this study.

Relationship of regional brain β-amyloid to gait speed.

Objective: To investigate in vivo the relationship of regional brain β-amyloid (Aβ) to gait speed in a group of elderly individuals at high risk for dementia. Methods: Cross-sectional associations between brain Aβ as measured with [18F]florbetapir PET and gait speed were examined in 128 elderly participants. Subjects ranged from healthy to mildly cognitively impaired enrolled in the control arm of the multidomain intervention in the Multidomain Alzheimer Preventive Trial (MAPT). Nearly all participants presented spontaneous memory complaints. Regional [18F]florbetapir (AV45) standardized uptake volume ratios were obtained via semiautomated quantitative analysis using the cerebellum as reference region. Gait speed was measured by timing participants while they walked 4 meters. Associations were explored with linear regression, correcting for age, sex, education, body mass index (BMI), and APOE genotype. Results: We found a significant association between Aβ in the posterior and anterior putamen, occipital cortex, precuneus, and anterior cingulate and slow gait speed (all corrected p < 0.05). A multivariate model emphasized the locations of the posterior putamen and the precuneus. Aβ burden explained up to 9% of the variance in gait speed, and significantly improved regression models already containing demographic variables, BMI, and APOE status. Conclusions: The present PET study confirms, in vivo, previous postmortem evidence showing an association between Alzheimer disease (AD) pathology and gait speed, and provides additional evidence on potential regional effects of brain Aβ on motor function. More research is needed to elucidate the neural mechanisms underlying these regional associations, which may involve motor and sensorimotor circuits hitherto largely neglected in the pathophysiology of AD.

Explaining the association between educational level and frailty in older adults: results from a 13-year longitudinal study in the Netherlands

PURPOSE The aim of this study was to examine the longitudinal association between educational level and frailty prevalence in older adults and to investigate the role of material, biomedical, behavioral, social, and mental factors in explaining this association. METHODS Data over a period of 13 years were used from the Longitudinal Aging Study Amsterdam. The study sample consisted of older adults aged 65 years and above at baseline (n = 1205). Frailty was assessed using Frieds frailty criteria. A relative index of inequality was calculated for the level of education. Longitudinal logistic regression analyses based on multilevel modeling were performed. RESULTS Older adults with a low educational level had higher odds of being frail compared with those with a high educational level (relative index of inequality odds ratio, 2.94; 95% confidence interval, 1.84-4.71). These differences persisted during 13 years of follow-up. Adjustment for all explanatory factors reduced the effect of educational level on frailty by 76%. Income, self-efficacy, cognitive impairment, obesity, and number of chronic diseases had the largest individual contribution in reducing the effect. Social factors had no substantial contribution. CONCLUSIONS Our findings highlight the need for a multidimensional approach in developing interventions aimed at reducing frailty, especially in lower educated groups.

Continued and new personal relationships in later life: differential effects of health.

Objectives: The aim of this study is to increase our understanding of declining network size with aging by differentiating between processes of loss and gain and studying the associations with various health problems. Methods: Six observations of the Longitudinal Aging Study Amsterdam (LASA) across a time period of 16 years are used to study detailed network changes in a large sample of Dutch older adults aged 55 to 85 at baseline. Results: Results from multilevel regression analyses show that network size declines with aging, in particular for the oldest old. The decline in network size is to a large degree due to a lack of replacement of lost relationships with new relationships. Results show differential effects of health. Discussion: The older old and people in poor health have limited possibilities to compensate for network losses and may have a serious risk of declining network size in later life.

Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition)

BackgroundCare for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.Methods/designIn a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention. Participants: 1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool. Intervention: Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations. Evaluation: We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the “intention-to-treat” principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.DiscussionThis is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.Trial registrationThe Netherlands National Trial Register NTR2160.

Educational differences in functional limitations: comparisons of 55–65-year-olds in the Netherlands in 1992 and 2002

SummaryObjectives:This study compares educational differences in the functional limitations of 55–65-year-olds in the Netherlands in 1992 and 2002 and examines whether changes are explained by cohort lifestyle and psychosocial changes.Methods:Data from two cohorts of 55–65-year-olds (n = 948 in 1992 and n = 980 in 2002) in the Longitudinal Aging Study Amsterdam are analysed.Results:Men’s disability ratios are similar in both cohorts. The women’s disability ratio is higher in 2002 than in 1992. In 2002 the male and female cohorts both report unhealthier behavior than in 1992. Multivariate logistic regression analyses show that adjusted for age, cohort, lifestyle and psychosocial resources, poorly educated men have higher odds of functional limitations than well-educated men (OR = 2.62, 95% CI = 1.57–4.37). Analyses among women show a significant interaction effect between education and cohort. Poorly educated women have higher odds of functional limitations in 2002 than in 1992 (OR = 3.33, 95% CI = 1.02–10.87).Conclusions:The results underscore the need for policies focused on improving the health and lifestyle of the poorly educated.

Self-perceived met and unmet care needs of frail older adults in primary care.

In order to provide adequate care for frail older adults in primary care it is essential to have insight into their care needs. Our aim was to describe the met and unmet care needs as perceived by frail older adults using a multi-dimensional needs assessment, and to explore their associations with socio-demographic and health-related characteristics. Cross-sectional baseline data were used from the Frail older Adults: Care in Transition (ACT) study in the Netherlands, consisting of 1137 community dwelling frail older adults aged 65 and above. Patients were recruited through 35 primary care practices. Self-perceived care needs were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Socio-demographic characteristics included age, sex, partner status and educational level. Health-related characteristics included functional capacity, hospital admissions, chronic diseases and the degree of frailty. Frail older adults reported on average 4.2 care needs out of 13 CANE topics, of which 0.5 were unmet. The physical and environmental domain constituted the highest number of needs, but these were mostly met. Unmet needs were mainly found in the psychosocial domain. Regression analyses revealed that Activities of Daily Living (ADL) limitations and a higher frailty score were the most important determinants of both met and unmet care needs. A younger age and a higher educational level were associated with the presence of unmet care needs. In conclusion, most frail older adults in primary care report to receive sufficient help for their physical needs. More attention should be paid to their psychosocial needs.

Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial.

BACKGROUND Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults. METHODS A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations. RESULTS Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons. CONCLUSION The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population. TRIAL REGISTRATION The Netherlands National Trial Register NTR2160.

Comparing Measurement Properties of the EQ-5D-3L, ICECAP-O, and ASCOT in Frail Older Adults

BACKGROUND The ICEpop CAPability measure for Older people (ICECAP-O) and the Adult Social Care Outcomes Toolkit (ASCOT) are preference-based measures for assessing quality of life (QOL) from a broader perspective than do traditional health-related QOL measures such as the EuroQol five-dimensional questionnaire (EQ-5D). Measurement properties of these instruments have not yet been directly compared. OBJECTIVE The purpose of this study was to compare the test-retest reliability, construct validity, and responsiveness of the three-level EQ-5D (EQ-5D-3L), ICECAP-O, and ASCOT in frail older adults living at home. METHODS Cross-sectional data and longitudinal data were used. Parameters for reliability (the intraclass correlation coefficient) and agreement (standard error of measurement) were used to assess test-retest reliability after 1 week. We formulated hypotheses about correlations with other measures and tested these to assess construct validity and responsiveness (longitudinal validity). RESULTS The reliability parameters for all three scales were considered good (intraclass correlation coefficient values above 0.70). Standard error of measurement values were less than 10% of the scale. Hypotheses regarding construct validity were in general accepted; the EQ-5D-3L was more strongly associated with physical limitations than were ICECAP-O and ASCOT and less strongly with instruments measuring aspects beyond health. Longitudinally, as hypothesized, mental health was most strongly associated with ICECAP-O, and self-perceived QOL, mastery, and client-centeredness of home care most strongly with ASCOT. CONCLUSIONS Our findings support the adoption of ICECAP-O and ASCOT as outcome measures in economic evaluations of care interventions for older adults that have a broader aim than health-related QOL because they are at least as reliable as the EQ-5D-3L and are associated with aspects of QOL broader than health.