Ruth E. Hubbard

Frailty, Body Mass Index, and Abdominal Obesity in Older People

BACKGROUNDnFrailty has been conceptualized as a wasting disorder with weight loss as a key component. However, obesity is associated with disability and with physiological markers also recently linked with frailty, for example, increased inflammation and low antioxidant capacity. We aimed to explore the relationship between frailty and body mass index (BMI) in older people.nnnMETHODSnData were from 3,055 community-dwelling adults aged 65 years and older who participated in the English Longitudinal Study of Ageing. Frailty was defined both by an index of accumulated deficits and by the Fried phenotype. BMI was divided into five categories, and waist circumference 88 cm or more (for women) and 102 cm or more (for men) was defined as high. Analyses were adjusted for sex, age, wealth, level of education, and smoking status.nnnRESULTSnThe association between BMI and frailty showed a U-shaped curve. This relationship was consistent across different frailty measures. The lowest frailty index (FI) scores and lowest prevalence of Fried frailty were in those with BMI 25-29.9. At each BMI category, and using either measure of frailty, those with a high waist circumference were significantly more frail.nnnCONCLUSIONSnBoth the phenotypic definition of frailty and the FI show increased levels of frailty among those with low and very high BMIs. In view of the rise in obesity in older populations, the benefits and feasibility of diet and exercise for obese older adults should be a focus of urgent inquiries. The association of frailty with a high waist circumference, even among underweight older people, suggests that truncal obesity may be an additional target for intervention.

Neighborhood Deprivation, Individual Socioeconomic Status, and Frailty in Older Adults

OBJECTIVES: To assess how individual socioeconomic status and neighborhood deprivation affect frailty.

Comparison of the prognostic importance of diagnosed diabetes, co-morbidity and frailty in older people.

Diabet. Med. 27, 603–606 (2010)

Impact of Exercise in Community-Dwelling Older Adults

Background Concern has been expressed that preventive measures in older people might increase frailty by increasing survival without improving health. We investigated the impact of exercise on the probabilities of health improvement, deterioration and death in community-dwelling older people. Methods and Principal Findings In the Canadian Study of Health and Aging, health status was measured by a frailty index based on the number of health deficits. Exercise was classified as either high or low/no exercise, using a validated, self-administered questionnaire. Health status and survival were re-assessed at 5 years. Of 6297 eligible participants, 5555 had complete data. Across all grades of frailty, death rates for both men and women aged over 75 who exercised were similar to their peers aged 65 to 75 who did not exercise. In addition, while all those who exercised had a greater chance of improving their health status, the greatest benefits were in those who were more frail (e.g. improvement or stability was observed in 34% of high exercisers versus 26% of low/no exercisers for those with 2 deficits compared with 40% of high exercisers versus 22% of low/no exercisers for those with 9 deficits at baseline). Conclusions In community-dwelling older people, exercise attenuated the impact of age on mortality across all grades of frailty. Exercise conferred its greatest benefits to improvements in health status in those who were more frail at baseline. The net effect of exercise should therefore be to improve health status at the population level.

Falls and frailty: lessons from complex systems

Falls and frailty share many significant characteristics. Both are important health issues that affect older people, increase with increasing patient age and are multifactorial phenomena associated with adverse health outcomes. There are also important differences. Falls tend to be viewed by health professionals from a positivist perspective, as predictable events which they have a duty to try and prevent.1 Falls prevention has become an important target of United Kingdom national health policy2 and the focus of dedicated service development. Frailty, on the other hand, still lacks a precise definition3 and is viewed by some as an inevitable consequence of age‐related disease processes.4 The prevention and treatment of frailty, while being fundamental aspirations of many researchers in the ageing field, currently remain enigmatic. n nOne construct for understanding frailty conceptualizes the frail older person as a complex system on the threshold of breakdown.5 In this context, falls are more than just antecedents or associates of frailty but are a manifestation of complex system failure.6 When complex systems fail they exhibit predictable patterns of behaviour and this can shed light on the reason why falls are frequently the ‘atypical’ presentation of illness in frail older adults. n nIn this review, the association between frailty and falls is explored. We consider how the conceptualization of frailty as a complex system failure might help us understand existing evidence regarding the aetiology and prevention of falls and, most importantly, how it might impact our clinical practice.

An index of self-rated health deficits in relation to frailty and adverse outcomes in older adults

Background and aims: Poor self-rated health is associated with adverse outcomes but its relationship with frailty is not completely understood. We examined how self-rated health (SRH) is related to health outcomes and how this relationship might differ by individual level of fitness or frailty in older people. Methods: In the Atlantic Canada sample of the Canadian Study of Health and Aging, individuals aged ≥65 (n=1318) completed a self-administered questionnaire, from which we constructed an index of self-rated health deficits (SRHDI). Heterogeneity in health status was evaluated (n=1260) by determining their Frailty Index (FI). Higher values on the FI indicate worse health status. We evaluated health attitudes in relation to other health markers and to mortality. Results: Comparing those with the lowest vs highest SRHDI, significant differences (p<0.001) were seen in the mean hospital admissions in the past year (0.2 (±0.02) vs 0.8 (±0.08)), 3MS cognitive score (85.0 (±0.5) vs 78.4 (±1.2)) and (p=0.003) for age (75.3 (±0.3) vs 77.1 (±0.6)). The SRHDI and FI were moderately correlated (r=0.49) and both predicted mortality. In the fittest older people, those with poor SRHDI had a significantly increased risk of death (OR=18, 95% CI 6.0–53.6); SRHDI did not affect mortality in those who were frail. Conclusions: Measuring SRH by an index of deficits is a valid construct and is associated with adverse health outcomes. The SRHDI may facilitate exploration of the complex relationships between illness burden and health outcomes in older people. When people are frail, worse health attitude does not seem to increase mortality, but in contrast, appears to increase mortality risk in fit older people.

Effect of parental age at birth on the accumulation of deficits, frailty and survival in older adults

INTRODUCTIONnparental age at conception may affect life expectancy. Adult daughters of older fathers seem to live shorter lives and, in one study, being born to a mother aged <25 was an important predictor of exceptional longevity. The effect of parental age on fitness/frailty in late life is unknown. We aimed to investigate the relationships between parental age and frailty and longevity in older adults.nnnMETHODSnin the Canadian Study of Health and Aging (CSHA), data was collected on individuals aged >or=65 using a Self-Assessed Risk Factor Questionnaire and screening interview. In this secondary analysis, 5112 participants had complete data for parental age, frailty status and 10-year survival. Parental age was divided into three groups, with cut-offs at 25 and 45 for fathers and at 25 and 40 for mothers. Frailty was defined by an index of deficits. Survival was analysed using Kaplan-Meier curves and Cox regression with analyses adjusted for subjects age, sex and age of the other parent.nnnRESULTSnmean maternal age at subjects birth was 29.2y (SD 6.8) and mean paternal age 33.3y (SD 7.8). There was no effect of maternal or paternal age on survival for either sons or daughters. Similarly, there was no association between parental age and subject frailty in old age.nnnCONCLUSIONnwe did not identify an association between parental age and frailty or longevity in older adult participants in the CSHA.

Comparison of two frailty measures in the conselice study of brain ageing

OBJECTIVESnUncertainty about the definition of frailty is reflected by the development of many ways to identify frail people. We aimed to compare the validity of two frailty measures in participants of the Conselice Study of Brain Aging.nnnDESIGNnProspective population-based study with 4 year follow up.nnnPARTICIPANTS/SETTINGn1,016 subjects aged 65 and over in a rural Italian population.nnnMETHODSnFor each participant, a Frailty Index (FI) and a Conselice Study of Brain Aging Score (CSBAS) were determined. The FI was created from 43 deficits according to a standardized methodology; 7 variables derived from a previously validated Easy Prognostic Score comprised the CSBAS.nnnRESULTSnThe FI had characteristic properties described in other population samples, with a gamma distribution, a 99% limit of about 0.64 and higher values in women than men. CSBAS and FI were strongly correlated with each other (r = 0.72) and both correlated with age (r = 0.32, r = 0.27, respectively). Each was independently predictive of death in a multivariate model, with greater specificity and sensitivity than age alone.nnnCONCLUSIONSnFrailty can be measured by different tools and facilitates a more direct quantification of individual vulnerability than chronological age alone. Though the Frailty Index and the Conselice Study of Brain Aging Score are underpinned by different rationales, clinical utility will continue to motivate their development.

Assessment of older adults by emergency medical services: methodology and feasibility of a care partner Comprehensive Geriatric Assessment (CP-CGA)

OBJECTIVESnThe Comprehensive Geriatric Assessment (CGA) is used in geriatric medicine as a means to manage the health care needs of older adults and to grade frailty. We modified the CGA so that it could be completed independently by care partners (usually family) and be used to grade frailty. Our objective was to examine the feasibility of a care partner completing the CGA at the time of the first prehospital encounter.nnnMETHODSnA prospective, observational study was conducted with a convenience sample of patients ≥ 70 years accompanied by a knowledgeable care partner. Feasibility was measured by the time required and percent completeness of items on the form based on completion by the care partner and by paramedic perception of utility.nnnRESULTSnSubjects (N u200a=u200a 104) were enrolled with three postenrolment exclusions due to ineligibility. Most participants were older women living in their own home. The mean time to complete the questionnaire was 18.7 minutes (SD 11.3; median 15 minutes; interquartile range 12-20 minutes). Only 64% of the care partners recorded the time it took. Nineteen percent of paramedics completed a follow-up survey, and all felt screening for frailty was worthwhile and most (> 70%) thought that the CP-CGA may be a useful approach. The study was limited by recruitment bias of potentially eligible patients, a high level of missingness in the outcome measures of interest, and low paramedic participation rates.nnnCONCLUSIONnWe observed a high rate of item completeness of questionnaires with a mean time to complete of 18.7 minutes in a convenience sample of older patients. A small sample of paramedics universally endorsed the utility of screening for frailty in the prehospital setting, and many thought the CP-CGA was a helpful tool.