Samuel D. Searle

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.

Frailty in relation to variations in hormone levels of the hypothalamic-pituitary-testicular axis in older men: results from the European male aging study.

OBJECTIVES: To explore the associations between frailty and reproductive axis hormones (as an important regulatory system) in middle aged and older men.

Frailty and the risk of cognitive impairment

Aging occurs as a series of small steps, first causing cellular damage and then affecting tissues and organs. This is also true in the brain. Frailty, a state of increased risk due to accelerated deficit accumulation, is robustly a risk factor for cognitive impairment. Community-based autopsy studies show that frail individuals have brains that show multiple deficits without necessarily demonstrating cognitive impairment. These facts cast a new light on the growing number of risk factors for cognitive impairment, suggesting that, on a population basis, most health deficits can be associated with late-life cognitive impairment. The systems mechanism by which things that are bad for the body are likely to be bad for the brain can be understood like this: the burden of health deficits anywhere indicates impaired ability to withstand or repair endogenous and environmental damage. This in turn makes additional damage more likely. If true, this suggests that a life course approach to preventing cognitive impairment is desirable. Furthermore, conducting studies in highly selected, younger, healthier individuals to provide ‘proof of concept’ information is now common. This strategy might exclude the very circumstances that are required for disease expression in the people in whom dementia chiefly occurs (that is, older adults who are often in poor health).

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.

An assessment of neurocognitive speed in relation to frailty

OBJECTIVES to evaluate the relationship between neurocognitive speed (NCS) and frailty; to consider how this relationship is affected by how frailty is operationalised. DESIGN secondary analysis of the baseline cohort of the Oxford Project To Investigate Memory and Aging (OPTIMA), a longitudinal observational cohort. SUBJECTS of 388 participants who underwent a comprehensive intake assessment followed by an annual follow-up for at least 3 years, data on all measures were available on 164 people. MEASUREMENTS NCS was defined as a combined score of <18 on the pattern comparison test (<11 is abnormal) and letter comparison test (<7 is abnormal). Frailty was defined from a modified Phenotype model, the Edmonton Frailty Scales (EFS) and a frailty index (FI); the latter two were adapted here to exclude cognitive measures. RESULTS in multivariate logistic (NCS as < or ≥18) and linear regression (NCS as continuous variable), only the FI (OR = 0.87) was significant (P < 0.05). When all frailty measures were included in the multivariate analysis only, FI (OR = 0.88) was significant (P < 0.05). Mini-mental Status Examination remained significantly related to NCS throughout all analysis. CONCLUSION NCS slows with increasing frailty as shown with the FI.

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

OBJECTIVES Uncertainty 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. DESIGN Prospective population-based study with 4 year follow up. PARTICIPANTS/SETTING 1,016 subjects aged 65 and over in a rural Italian population. METHODS For 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. RESULTS The 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. CONCLUSIONS Frailty 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.

What proportion of older adults in hospital are frail

www.thelancet.com Published online April 26, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30907-3 1 Despite the increasing level of knowledge about individual illnesses, modern health-care systems seem lost when seeing patients whose diseases come not one at a time, but all at once—especially when they come with equally complex social needs. Although some geriatricians proclaimed the end of the disease era to focus on the complexity of frailty in geriatric assessment, the argument is falling flat. Disease-focused specialists who push on with the only course they know sometimes decry their frail patients as being unsuitable or requiring social support or failing to cope or thrive. Many hospitals—and practitioners—still somehow expect patients to present with primary complaints that give rise to well defined problems, which they can manage successfully using pathways that can be audited, such as time to thrombolytic event in an acute stroke or myocardial infarction. How does health care get on track? Language should be the starting point. Elderly people whose multiple, interacting medical and social problems put them at greater risk of adverse outcomes have come to be called frail. Hospitals must be encouraged to expect and thereby plan for frail patients as a part of what is required of them. To make this requirement clear, they need the right tools. In The Lancet, Thomas Gilbert and colleagues used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in electronic records to develop a hospital risk stratification tool. The tool was validated in a large English inpatient database (n=1 013 590), and its generalisability tested using various hospitals. Frail or non-frail information was dichotomised and frailty further graded into low, intermediate, and high risk. In a cluster analysis, these frail groups accounted for a fifth of patients and almost a half of all hospitalisation days. The tool classified individual mortality risk no more than moderately well, but, as the investigators point out, individual risk stratification was not their objective. Instead, their goal was to identify “a group of patients who are at greater risk of adverse outcomes and for whom a frailty-attuned approach might be useful”. A metric that identifies for hospitals the extent to which they are serving patients with frailty should signal the need to change from a most responsible diagnosis model to practices that can reduce the hazards of hospital stays for patients who are frail, and perhaps even focus on the goals of patients and their families. Stratification of risk groups might also offer a similarly useful role for the electronic frailty index, based on general practice records. These hypotheses need to be tested. To show what must change, consider a student on her first clinical rotation who encounters a patient with pneumonia. Most of what she has learned about pneumonia must now be set aside. Uncomplicated cases are rarely referred to specialty services; those patients get antibiotics and go home. Her patient cannot give a history. He is not coughing. He cannot even sit up so that she can auscultate his lungs properly, something she knows she must do. Her patient does not have a fever or an increased white cell count. Vague markings on the chest film alone support the diagnosis. No matter; the real issue, apparently, is that her patient cannot go home. She might now turn to her teachers and ask: “What have you been teaching me about pneumonia if none of it works in the patients I’m supposed to see?” More likely, insidious acculturation will lead her to conclude that this patient really does not belong in her hospital. By contrast, those skilled in the care of older people will recognise the delirium and immobility that are typical presentations in a frail patient with pneumonia. They will ascertain whether the cognitive impairment and being bedfast are new. From this information, they will formulate a differential diagnosis and focused examination, and a pragmatic course of action; the term What proportion of older adults in hospital are frail?

Using frailty tools as prognostic markers in patients who are acutely ill

[See related article at [www.cmaj.ca/lookup/doi/10.1503/cmaj.161403][2]][2] KEY POINTS Frailty is a state that arises from a multisystem decline. It compromises the body’s ability to respond to stressors.[1][2] Although frailty has been shown to be a good indicator of poor outcomes across

Standard laboratory tests to identify older adults at increased risk of cognitive decline

Background:A growing body of work investigates liquid biomarkers for dementia and cognitive impairment. Abnormalities in common laboratory tests have been combined (in a frailty index based on laboratory measures the FI-Lab) to predict many adverse health outcomes, including death, independently of a clinical frailty index. We investigated whether the FI-lab was associated with cognitive decline.Methods:This is a secondary analysis of the Canadian Study of Health and Aging, a prospective cohort study of community-dwelling and institutionalized Canadians aged 65 years and older. The FIlab was created from tests done for the first clinical examination. The FI-Lab was correlated with the Mini-Mental State Examination (MMSE) at baseline. Univariate and multivariate logistic regression were conducted for a 2+ point decline in MMSE or an incident dementia diagnosis at the five year follow-up. Results:Of 1013 patients who had complete FI-lab data, 467were alive at follow up, 355 (76%) had baseline and follow upMMSE and 391 had a follow up diagnosis. Patients with missing follow-up data had a lower baseline MMSE (18.6 average) and were more likely to be institutionalized at follow up (71%). A worse FI-lab was associated with a worse baseline MMSE (p<0.001). In univariate analysis, the FI-lab was associated with a clinically significant decline of MMSE at follow up (p1⁄40.033). In multivariate analysis FI-lab and sex were not significantly associated with MMSE decline but a clinical frailty index (p<0.001), age (p<0.001) and education (p1⁄40.031) were significantly associated. The FI-lab was, in multivariate analysis, associated with a future diagnosis of dementia (p1⁄40.019). Conclusions:An incident dementia diagnosis was associated with a frailty index based on common laboratory tests. These data support the notion that dementia in old age is associated with widespread, even subclinical, health deficits, likely reflecting widespread problems of repair. How these relate to biomarkers is a question of some interest, to be pursued.

P2-119: Transitions in cognitive status in people with vascular cognitive impairment

tomy (CEA) and percutaneous transluminal angioplasty with stenting (CAS) on cognitive functions. Methods: We recruited 47 patients 65 years old: 22 underwent CEA (M:82%, F:18%; mean age:72.0 5.6), 25 CAS (M: 56%; F: 44%; mean age: 74.7% 5.7). Subjects were examined with neuropsicological tests the day before the carotid surgical intervention, and three and twelve months later. Cognitive functions, functional and affective state were evaluated at each time with: MMSE, Trail Making Test form A and form B, Babcock Story Recall Test, Rey’s Auditory Verbal Learning Test, Letter Fluency Test, Category Fluency Test, Clock Drawing Test, Copy Drawing Test, ADL, IADL, GDS. Results: No differences on cognitive functions between CAS and EAC groups were detected before and after intervention except at Trail Making Test A at T0 (CEA: 105.1 41.9 vs CAS: 76.5 26.9; p 0.02), at T3 (CEA: 129.0 70.0 vs CAS: 85.0 48.3; p 0.02) and at T12 (CEA: 128.0 52.8 vs CAS 77.5 24.0; P 0.01). There were no statistically significant differences both in CAS and CEA in most of the tests exploring cognitive functions and affective state after surgical intervention. In CEA group Trail Making Test B, improved significantly from T0 to T12 (T0: 238.5 121.0 vs T12: 186.4 111.0; p 0.05), while the Copy Drawing test worsened from T0 to T12 (T0: 12.4 1.8 vs T12: 11.4 2.7; p 0.01). In CAS group there was only a significant improvement in the Clock Drawing Test (Copy) from T0 to T3 (T0: 2.1 1.1 vs T3: 1.3 0.7; p 0.05). Conclusions: This study showed that surgical carotid intervention in subjects over 65 years is an important instrument for prevention of cerebrovascular diseases. Despite the risk of microembolization, it seems to be safe for cognitive functions. Furthermore, due to its lower invasiveness, CAS should be preferred to CEA for chirurgical treatment of carotid atherosclerosis in the elderly.