Jean-Marie Degryse

Frailty: an emerging concept for general practice

Ageing of the population in western societies and the rising costs of health and social care are refocusing health policy on health promotion and disability prevention among older people. However, efforts to identify at-risk groups of older people and to alter the trajectory of avoidable problems associated with ageing by early intervention or multidisciplinary case management have been largely unsuccessful. This paper argues that this failure arises from the dominance in primary care of a managerial perspective on health care for older people, and proposes instead the adoption of a clinical paradigm based on the concept of frailty. Frailty, in its simplest definition, is vulnerability to adverse outcomes. It is a dynamic concept that is different from disability and easy to overlook, but also easy to identify using heuristics (rules of thumb) and to measure using simple scales. Conceptually, frailty fits well with the biopsychosocial model of general practice, offers practitioners useful tools for patient care, and provides commissioners of health care with a clinical focus for targeting resources at an ageing population.

Muscle Strength and Physical Performance as Predictors of Mortality, Hospitalization, and Disability in the Oldest Old

To evaluate the predictive value of muscle strength and physical performance in the oldest old for all‐cause mortality; hospitalization; and the onset of disability, defined as a decline in activities of daily living (ADLs), independent of muscle mass, inflammatory markers, and comorbidities.

Methods to evaluate renal function in elderly patients: a systematic literature review

CONTEXT multiple studies of elderly patients show that the prevalence of chronic renal failure in people aged 65 years and older is dependent on the method used to calculate the glomerular filtration rate. We performed a systematic literature search with research question: What is the best method that could be applicable in clinical practice for evaluating renal function in the elderly? Studies using inulin, Cr-51-EDTA, Tc-DTPA or iohexol assays as the gold standard were included. METHODS we searched the PubMed and EMBASE databases. Articles found were screened first by title and abstract and then by five criteria. Retained articles were scored using an adapted version of QUADAS. RESULTS twelve articles had an identified population or subpopulation aged 65 years and older. The studies were heterogeneous with regard to the population investigated and the statistical procedures used to compare the methods and equations with the gold standard. The Cockcroft-Gault (CG) and MDRD equations and the serum cystatin C concentration produced the highest correlations with the gold standard. CONCLUSIONS no accurate method to evaluate renal function in the elderly was found. Serum cystatin C concentration and the CG and MDRD formula might be valuable parameters, although there is insufficient evidence.

The prevalence of sarcopenia in very old individuals according to the European consensus definition: insights from the BELFRAIL study

BACKGROUND the prevalence of sarcopenia varies widely between studies. The objective of this study was to assess the prevalence of sarcopenia in a representative sample of persons aged 80 years and older according to the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm and the proposed cut-off values. A secondary aim was to investigate the relationship between different individual criteria and low physical performance capacity. METHODS baseline data of the prospective BELFRAIL study (BFC80+) were analysed. Sarcopenia status was determined according to the EWGSOP guidelines. The skeletal muscle mass index (SMI) was assessed according to bioelectrical impedance. Muscle strength and muscle performance were evaluated according to grip strength and the modified short physical performance battery (SPPBm). A logistic regression analysis was performed. RESULTS according to the EWGSOP algorithm, 12.5% of the participants were classified in the sarcopenia group. Sixty percent of the female participants had muscle strength values below the cut-off and 70% had low SPPBm values. In males, these prevalence values were 49.5% for grip strength and 39.7% for SPPB. The logistic regression analysis showed that low SPPBm was associated with grip strength (OR: 0.88, 95% CI: 0.84-0.92) independent of SMI. CONCLUSION in a population-based sample of the very old the prevalence of sarcopenia according to the EWGSOP algorithm is similar to the prevalence of sarcopenia with SMI as a single criterion. A large number of participants with a sufficient SMI value showed low muscle strength and/or a poor SPPBm score. A low SPPBm was associated with grip strength but not with SMI.

Associations Between Cytomegalovirus Infection and Functional Impairment and Frailty in the BELFRAIL Cohort

To investigate whether an observed association between cytomegalovirus (CMV) exposure and functional impairment and frailty in older adults is reproducible in a cohort of individuals aged 80 and older.

The relationship between grip strength and muscle mass (MM), inflammatory biomarkers and physical performance in community-dwelling very old persons.

The main consequence of the loss of MM and muscle strength is limitations of physical performance and disability in older people. It is unclear whether a decline in functional capacity results from the loss of MM and/or the qualitative impairment of the muscle tissue. The aim of our research was to investigate the relationship between physical performance and grip strength, inflammatory markers and MM in a population of community-dwelling very old persons. This study is a cross-sectional analysis within the BELFRAIL-study, a cohort study of subjects aged 80 years and older (n=567). MM was assessed by bioelectrical impedance. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) concentrations were determined on fasting blood samples. Logistic regression analysis was build using a low physical performance level evaluated according to Short Physical Performance Battery (SPPB) (dependent variable) and grip strength, pro-inflammatory status and MM (independent variables) adjusted for age and for the total number of chronic diseases. Low SPPB scores were associated with grip strength scores for women (OR 0.86 (95% CI 0.77-0.96)), and for men (OR 0.89 (95% CI 0.81-0.96)). The relationships between low SPPB and MM or inflammatory profile were not significant. Our results show that low physical performance remains associated with low grip strength even after considering other risk factors for sarcopenia in the oldest old and support the hypothesis that low muscle strength is a better indicator than low MM. The role of an inflammatory component in the age-related loss of muscle strength and function could not be confirmed.

Family physicians need easy instruments for frailty

SIR—This is with reference to the article ‘Development of an easy prognostic score for frailty outcomes in the aged’ written by G. Ravaglia, P. Forti, A. Lucicesare, N. Pisacane, E. Rietti, C. Patterson[1]. As general practitioners involved in research about primary care for older people we agree that frailty is an emerging concept with important clinical consequences. Ravaglia et al. describe ‘an easy …

No relation between vitamin D status and physical performance in the oldest old: results from the Belfrail study

BACKGROUND vitamin D deficiency is a well-known cause of bone loss and fractures but its association, especially among the oldest old, with muscle weakness is less obvious. OBJECTIVE to investigate the relationship between 25-hydroxyvitamin D (25-OHD) and muscle performance in persons aged 80 years and older. METHODS baseline results of the Belfrail study, a prospective, population-based cohort study were used to study balance, grip strength and gait speed in relation to 25-OHD serum levels in 367 subjects. RESULTS a sufficient 25-OHD serum level of 30 ng/ml or more was found in 12.8% of the population. The prevalence of vitamin deficiency (20-29 ng/ml), insufficiency (10-19 ng/ml) and severe insufficiency (<10 ng/ml) was 21.5, 33 and 32.7%, respectively. No significant relation between balance, gait speed and grip strength, and serum 25-OHD was detected neither in bivariate analysis nor after adjustment for age, gender, level of education, institutionalisation, smoking status, body mass index, co-morbidity, level of activity, season, CRP, renal function, serum calcium parathyroid hormone levels, vitamin D intake and use of loop or thiazide diuretics. CONCLUSION in this cohort of octogenarians vitamin D deficiency was highly prevalent. We could not confirm the findings of previous studies showing an association between serum 25-OHD and physical performance in elderly.

The relationship of multimorbidity with disability and frailty in the oldest patients: A cross-sectional analysis of three measures of multimorbidity in the BELFRAIL cohort

Abstract Background: Ageing people show increasing morbidity, dependence and vulnerability. Objectives: To compare the relationships of different measures of multimorbidity with dependence (operationalized as disability) and vulnerability (operationalized as frailty). Method: A cross-sectional analysis within the BELFRAIL cohort (567 subjects aged ≥ 80). Multimorbidity was measured using a disease count (DC), the Charlson comorbidity index (CCI) and the cumulative illness rating scale (CIRS), respectively. Associations with disability (based on activities of daily living) and frailty (defined by the Fried frailty criteria) were assessed using bivariable and multivariable analyses. Net reclassification improvement (NRI) values were calculated to compare the abilities of the DC, CCI and CIRS to identify patients with disability or frailty. Results: Disability was associated with the DC (crude odds ratio, OR: 2.1; 95% confidence interval, CI: 1.4–3.4), CCI (crude OR: 1.8; 95% CI: 1.2–2.7) and CIRS (crude OR: 4.0; 95% CI: 2.5–6.5); only the association with CIRS was independent of age, sex, chronic inflammation, impaired cognition and frailty (adjusted OR: 3.2; 95% CI: 1.7–5.8). Frailty was associated with CCI (crude OR: 2.4; 95% CI: 1.2–4.6) and CIRS (crude OR: 2.6; 95% CI: 1.3–5.3); adjusted for age, sex, chronic inflammation, impaired cognition and disability. These associations were not statistically significant. The NRIs demonstrated a similar ability of the DC, CCI, and CIRS to identify patients with disability or frailty, respectively. Conclusion: The associations of different measures of multimorbidity with disability and frailty differ but their ability to identify patients with disability or frailty is similar. Generally, multimorbidity scores incompletely reflect dependence and vulnerability in this age group.

Diagnostic certainty, co-morbidity and medication in a primary care population with presumed airway obstruction : the DIDASCO2 study.

STUDY OBJECTIVES To document the rate of diagnostic certainty, co-morbidity and use of medication in patients with presumed obstructive airway disease (OAD) in a primary care setting. METHODS Twenty-six general practitioners (GPs) were asked to select the last 50 contacts with patients older than 40 years of age who were taking bronchodilators and/or inhaled corticosteroids or who had known OAD. After reviewing their medical data on file, the GPs gave their diagnostic opinion and rated their certainty about the diagnosis using a Likert-type scale. RESULTS Analysis of 1126 files revealed that in at least 523 patients (46.4%), a diagnostic work-up was judged necessary. The GPs judged that 6% of the patients had no OAD. Less than 33% of the study population underwent spirometry during the two years preceding the survey. The number of co-morbid conditions was on average 2.2 for patients with asthma and 3.2 for patients with COPD. Patients with presumed COPD took significantly more drugs (mean, 5.1; 95% CI, 4.8-5.3) than did patients with other diagnostic labels (mean, 4.6 95%; CI, 4.4-4.8). CONCLUSIONS We confirmed the underuse of spirometry as a diagnostic tool in presumed airway obstruction in primary care. Nearly half of the patients older than 40 years who were taking bronchodilators and/or inhaled corticosteroids needed a diagnostic work-up. This population had a high prevalence of co-morbidity and polypharmacy.