Relation between frailty and hypertension is partially mediated by physical activity among males and females in the Canadian Longitudinal Study on Aging.

Frailty reflects the heterogeneity in aging and may lead to the development of hypertension and heart disease, but the frailty-cardiovascular relationship and whether physical activity modifies this relationship in males and females are unclear. We tested whether higher frailty was positively associated with hypertension and heart disease in males and females and whether habitual movement mediated this relationship. The relationship between baseline frailty with follow-up hypertension and heart disease was investigated using the Canadian Longitudinal Study on Aging at 3-year follow-up data (males: n = 13,095; females: n = 13,601). Frailty at baseline was determined via a 73-item deficit-based index, activity at follow-up was determined via the Physical Activity Scale for the Elderly, and cardiovascular function was self-reported. Higher baseline frailty level was associated with a greater likelihood of hypertension and heart disease at follow-up, with covariate-adjusted odds ratios of 1.08-1.09 (all, P < 0.001) for a 0.01 increase in frailty index score. Among males and females, sitting time and strenuous physical activity were independently associated with hypertension, with these activity behaviors being partial mediators (except male-sitting time) for the frailty-hypertension relationship (explained 5-10% of relationship). The strength of this relationship was stronger among females. Only light-moderate activity partially mediated the relationship (∼6%) between frailty and heart disease in females, but no activity measure was a mediator for males. Higher frailty levels were associated with a greater incidence of hypertension and heart disease, and strategies that target increases in physical activity and reducing sitting may partially uncouple this relationship with hypertension, particularly among females.NEW & NOTEWORTHY Longitudinally, our study demonstrates that higher baseline frailty levels are associated with an increased risk of hypertension and heart disease in a large sample of Canadian males and females. Movement partially mediated this relationship, particularly among females.

Myths and Methodologies: Understanding the health impact of head down bedrest for the benefit of older adults and astronauts. Study protocol of the Canadian Bedrest Study.

Weightlessness during spaceflight can harm various bodily systems, including bone density, muscle mass, strength and cognitive functions. Exercise appears to somewhat counteract these effects. A terrestrial model for this is head-down bedrest (HDBR), simulating gravity loss. This mirrors challenges faced by older adults in extended bedrest and space environments. The first Canadian study, backed by the Canadian Space Agency, Canadian Institutes of Health Research, and Canadian Frailty Network, aims to explore these issues. The study seeks to: (1) scrutinize the impact of 14-day HDBR on physiological, psychological and neurocognitive systems, and (2) assess the benefits of exercise during HDBR. Eight teams developed distinct protocols, harmonized in three videoconferences, at the McGill University Health Center. Over 26 days, 23 participants aged 55-65 underwent baseline measurements, 14 days of -6° HDBR, and 7 days of recovery. Half did prescribed exercise thrice daily combining resistance and endurance exercise for a total duration of 1 h. Assessments included demographics, cardiorespiratory fitness, bone health, body composition, quality of life, mental health, cognition, muscle health and biomarkers. This study has yielded some published outcomes, with more forthcoming. Findings will enrich our comprehension of HDBR effects, guiding future strategies for astronaut well-being and aiding bedrest-bound older adults. By outlining evidence-based interventions, this research supports both space travellers and those enduring prolonged bedrest.

Development and validation of a frailty index for use in the osteoarthritis initiative.

BACKGROUND: The Osteoarthritis Initiative (OAI) evaluates the development and progression of osteoarthritis. Frailty captures the heterogeneity in aging. Use of this resource-intensive dataset to answer aging-related research questions could be enhanced by a frailty measure. OBJECTIVE: To: (i) develop a deficit accumulation frailty index (FI) for the OAI; (ii) examine its relationship with age and compare between sexes, (iii) validate the FI versus all-cause mortality and (iv) compare this association with mortality with a modified frailty phenotype. DESIGN: OAI cohort study. SETTING: North America. SUBJECTS: An FI was determined for 4,755/4,796 and 4,149/4,796 who had a valid FI and frailty phenotype. METHODS: Fifty-nine-variables were screened for inclusion. Multivariate Cox regression evaluated the impact of FI or phenotype on all-cause mortality at follow-up (up to 146 months), controlling for age and sex. RESULTS: Thirty-one items were included. FI scores (0.16 ± 0.09) were higher in older adults and among females (both, P < 0.001). By follow-up, 264 people had died (6.4%). Older age, being male, and greater FI were associated with a higher risk of all-cause mortality (all, P < 0.001). The model including FI was a better fit than the model including the phenotype (AIC: 4,167 vs. 4,178) and was a better predictor of all-cause mortality than the phenotype with an area under receiver operating characteristic curve: 0.652 vs. 0.581. CONCLUSION: We developed an FI using the OAI and validated it in relation to all-cause mortality. The FI may be used to study aging on clinical, functional and structural aspects of osteoarthritis included in the OAI.

Age- and sex-specific associations of frailty with mortality and healthcare utilization in community-dwelling adults from ontario, Canada.

BACKGROUND: Understanding how health trajectories are related to the likelihood of adverse outcomes and healthcare utilization is key to planning effective strategies for improving health span and the delivery of care to older adults. Frailty measures are useful tools for risk stratification in community-based and primary care settings, although their effectiveness in adults younger than 60 is not well described. METHODS: We performed a 10-year retrospective analysis of secondary data from the Ontario Health Study, which included 161,149 adults aged ≥ 18. Outcomes including all-cause mortality and hospital admissions were obtained through linkage to ICES administrative databases with a median follow-up of 7.1-years. Frailty was characterized using a 30-item frailty index. RESULTS: Frailty increased linearly with age and was higher for women at all ages. A 0.1-increase in frailty was significantly associated with mortality (HR = 1.47), the total number of outpatient (IRR = 1.35) and inpatient (IRR = 1.60) admissions over time, and length of stay (IRR = 1.12). However, with exception to length of stay, these estimates differed depending on age and sex. The hazard of death associated with frailty was greater at younger ages, particularly in women. Associations with admissions also decreased with age, similarly between sexes for outpatient visits and more so in men for inpatient. CONCLUSIONS: These findings suggest that frailty is an important health construct for both younger and older adults. Hence targeted interventions to reduce the impact of frailty before the age of 60 would likely have important economic and social implications in both the short- and long-term.

Validation of the Pictorial Fit-Frail Scale in a Thoracic Surgery Clinic.

OBJECTIVE: Examine feasibility and construct validity of Pictorial Fit-Frail scale (PFFS) for the first time in older surgical patients. BACKGROUND: The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics. METHODS: Patients ≥65 year-old who were evaluated in a multidisciplinary thoracic surgery clinic from November 2020 to May 2021 were prospectively included. Patients completed an in-person PFFS and Vulnerable Elders Survey (VES-13) during their visit, and a frailty index was calculated from the PFFS (PFFStrans). A geriatrician performed a comprehensive geriatric assessment (CGA) either in-person or virtually, from which a Frailty Index (FI-CGA) and Frailty Questionnaire (FRAIL) scale were obtained. To assess the validity of the PFFS in this population, the Spearman rank correlations (r spearman ) between PFFS trans and VES-13, FI-CGA, FRAIL were calculated. RESULTS: All 49 patients invited to participate agreed, of which 46/49 (94%) completed the PFFS so a score could be calculated. The majority of patients (59%) underwent an in-person CGA and the reminder (41%) a virtual CGA. The cohort was mainly female (59.0%), with a median age of 77 (range: 67-90). The median PFFS trans was 0.27 (interquartile range [IQR] 0.12-0.34), PFFS was 11 (IQR 5-14), and 0.24 (IQR 0.13-0.32) for FI-CGA. We observed a strong correlation between the PFFS trans and FI-CGA (r spearman = 0.81, P < 0.001) and a moderate correlation between PFFS trans and VES-13 and FRAIL score (r spearman = 0.68 and 0.64 respectively, P < 0.001). CONCLUSIONS: PFFS had good feasibility and construct validity among older surgical patients when compared to previously validated frailty measurements.

Development and validation of a hospital frailty risk measure using Canadian clinical administrative data.

BACKGROUND: Accessible measures specific to the Canadian context are needed to support health system planning for older adults living with frailty. We sought to develop and validate the Canadian Institute for Health Information (CIHI) Hospital Frailty Risk Measure (HFRM). METHODS: Using CIHI administrative data, we conducted a retrospective cohort study involving patients aged 65 years and older who were discharged from Canadian hospitals from Apr. 1, 2018, to Mar. 31, 2019. We used a 2-phase approach to develop and validate the CIHI HFRM. The first phase, construction of the measure, was based on the deficit accumulation approach (identification of age-related conditions using a 2-year look-back). The second phase involved refinement into 3 formats (continuous risk score, 8 risk groups and binary risk measure), with assessment of their predictive validity for several frailty-related adverse outcomes using data to 2019/20. We assessed convergent validity with the United Kingdom Hospital Frailty Risk Score. RESULTS: The cohort consisted of 788 701 patients. The CIHI HFRM included 36 deficit categories and 595 diagnosis codes that cover morbidity, function, sensory loss, cognition and mood. The median continuous risk score was 0.111 (interquartile range 0.056-0.194, equivalent to 2-7 deficits); 35.1% (n = 277 000) of the cohort were found at risk of frailty (≥ 6 deficits). The CIHI HFRM showed satisfactory predictive validity and reasonable goodness-of-fit. For the continuous risk score format (unit = 0.1), the hazard ratio (HR) for 1-year risk of death was 1.39 (95% confidence interval [CI] 1.38-1.41), with a C-statistic of 0.717 (95% CI 0.715-0.720); the odds ratio for high users of hospital beds was 1.85 (95% CI 1.82-1.88), with a C-statistic of 0.709 (95% CI 0.704-0.714), and the HR of 90-day admission to long-term care was 1.91 (95% CI 1.88-1.93), with a C-statistic of 0.810 (95% CI 0.808-0.813). Compared with the continuous risk score, using a format of 8 risk groups had similar discriminatory ability and the binary risk measure had slightly weaker performance. INTERPRETATION: The CIHI HFRM is a valid tool showing good discriminatory power for several adverse outcomes. The tool can be used by decision-makers and researchers by providing information on hospital-level prevalence of frailty to support system-level capacity planning for Canada's aging population.

How to construct a frailty index from an existing dataset in 10 steps.

BACKGROUND: The frailty index is commonly used in research and clinical practice to quantify health. Using a health deficit accumulation model, a frailty index can be calculated retrospectively from data collected via survey, interview, performance test, laboratory report, clinical or administrative medical record, or any combination of these. Here, we offer a detailed 10-step approach to frailty index creation, with a worked example. METHODS: We identified 10 steps to guide the creation of a valid and reliable frailty index. We then used data from waves 5 to 12 of the Health and Retirement Study (HRS) to illustrate the steps. RESULTS: The 10 steps are as follows: (1) select every variable that measures a health problem; (2) exclude variables with more than 5% missing values; (3) recode the responses to 0 (no deficit) through 1 (deficit); (4) exclude variables when coded deficits are too rare (< 1%) or too common (> 80%); (5) screen the variables for association with age; (6) screen the variables for correlation with each other; (7) count the variables retained; (8) calculate the frailty index scores; (9) test the characteristics of the frailty index; (10) use the frailty index in analyses. In our worked example, we created a 61-item frailty index following these 10 steps. CONCLUSIONS: This 10-step procedure can be used as a template to create one continuous health variable. The resulting high-information variable is suitable for use as an exposure, predictor or control variable, or an outcome measure of overall health and ageing.

The Pictorial Fit-Frail Scale-Malay version (PFFS-M): reliability and validity testing in Malaysian primary care.

BACKGROUND: This study investigated the reliability and convergent validity of the PFFS-Malay version (PFFS-M) among patients (with varying educational levels), caregivers, and health care professionals (HCPs). PFFS-M cutoffs for frailty severity were developed. METHODS: This is a cross-sectional study from 4 primary care clinics where 240 patients aged >60 years and their caregivers were enrolled. Patients were assigned to a nurse or a health care assistant (HCA) for 2 separate PFFS-M assessments administered by HCPs of the same profession, as well as by a doctor during the first visit (inter-rater reliability). Patients were also administered the Self-Assessed Report of Personal Capacity & Healthy Ageing (SEARCH) tool, a 40-item frailty index, by a research officer. The correlation between patients' PFFS-M scores and SEARCH tool scores determined convergent validity. Patients returned 1 week later for PFFS-M reassessment by the same HCPs (test-retest reliability). Caregivers completed the PFFS-M for the patient at both clinic visits. Classification cut-points for the PFFS-M were derived against frailty categories defined through the SEARCH tool. RESULTS: The inter-rater (intraclass correlation coefficient [ICC] = 0.92 [95% CI, 0.90-0.93)] and test-retest (ICC = 0.94 [95% CI, 0.92-0.95]) reliability between all raters was excellent, including by patients' education levels. The convergent validity was moderate (r = 0.637, p < 0.001), including for varying educational background. PFFS-M categories were identified as: 0-3, no frailty; 4-5, at risk of frailty; 6-8, mild frailty; 9-12, moderate frailty; and >13, severe frailty. CONCLUSION: PFFS-M is a reliable and valid tool with frailty severity scores now established for use of this tool in primary care clinics.

Impact of 14 Days of Bed Rest in Older Adults and an Exercise Countermeasure on Body Composition, Muscle Strength, and Cardiovascular Function: Canadian Space Agency Standard Measures.

INTRODUCTION: Head-down bed rest (HDBR) has long been used as an analog to microgravity, and it also enables studying the changes occurring with aging. Exercise is the most effective countermeasure for the deleterious effects of inactivity. The aim of this study was to investigate the efficacy of an exercise countermeasure in healthy older participants on attenuating musculoskeletal deconditioning, cardiovascular fitness level, and muscle strength during 14 days of HDBR as part of the standard measures of the Canadian Space Agency. METHODS: Twenty-three participants (12 males and 11 females), aged 55-65 years, were admitted for a 26-day inpatient stay at the McGill University Health Centre. After 5 days of baseline assessment tests, they underwent 14 days of continuous HDBR followed by 7 days of recovery with repeated tests. Participants were randomized to passive physiotherapy or an exercise countermeasure during the HDBR period consisting of 3 sessions per day of either high-intensity interval training (HIIT) or low-intensity cycling or strength exercises for the lower and upper body. Peak aerobic power (V̇O2peak) was determined using indirect calorimetry. Body composition was assessed by dual-energy X-ray absorptiometry, and several muscle group strengths were evaluated using an adjustable chair dynamometer. A vertical jump was used to assess whole-body power output, and a tilt test was used to measure cardiovascular and orthostatic challenges. Additionally, changes in various blood parameters were measured as well as the effects of exercise countermeasure on these measurements. RESULTS: There were no differences at baseline in main characteristics between the control and exercise groups. The exercise group maintained V̇O2peak levels similar to baseline, whereas it decreased in the control group following 14 days of HDBR. Body weight significantly decreased in both groups. Total and leg lean masses decreased in both groups. However, total body fat mass decreased only in the exercise group. Isometric and isokinetic knee extension muscle strength were significantly reduced in both groups. Peak velocity, flight height, and flight time were significantly reduced in both groups with HDBR. CONCLUSION: In this first Canadian HDBR study in older adults, an exercise countermeasure helped maintain aerobic fitness and lean body mass without affecting the reduction of knee extension strength. However, it was ineffective in protecting against orthostatic intolerance. These results support HIIT as a promising approach to preserve astronaut health and functioning during space missions, and to prevent deconditioning as a result of hospitalization in older adults.

Older adults, clinicians, and researchers' preferences for measuring adherence to resistance and balance exercises.

BACKGROUND: Resistance and balance training are important exercise interventions for older populations living with chronic diseases. Accurately measuring if an individual is adhering to exercises as prescribed is important to determine if lack of improvement in health outcomes is because of issues with adherence. Measuring adherence to resistance and balance exercises is limited by current methods that depend heavily on self-report and are often better at and tailored towards capturing aerobic training parameters (e.g., step count, minutes of moderate to vigorous physical activity). Adherence measures must meet users' needs to be useful. METHODS: Using a Dillman tailored study design, we surveyed researchers who conduct exercise trials, clinicians who prescribe exercise for older adults, and older adults to determine: (1) how they are currently measuring adherence; (2) barriers and facilitators they have experienced to measurement; and (3) the information they would like collected about adherence (e.g., repetitions, sets, intensity, duration, frequency, quality). Surveys were disseminated internationally through professional networks, professional organizations, and social media. Participants completed an online survey between August 2021 and April 2022. RESULTS: Eighty-eight older adults, 149 clinicians, and 41 researchers responded to the surveys. Most clinicians and researchers were between the ages of 30 and 39 years, and 70.0% were female. Most older adults were aged 70-79 years, and 46.6% were female. Diaries and calendars (either analog or digital) were the most common current methods of collecting adherence data. Users would like information about the intensity and quality of exercises completed that are presented in clear, easy to use formats that are meaningful for older adults where all data can be tracked in one place. Most older adults did not measure adherence because they did not want to, while clinicians most frequently reported not having measurement tools for adherence. Time, resources, motivation, and health were also identified as barriers to recording adherence. CONCLUSIONS: Our work provides information about current methods of measuring exercise adherence and suggestions to inform the design of future adherence measures. Future measures should comprehensively track adherence data in one place, including the intensity and quality of exercises.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial.

BACKGROUND: Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty. METHODS: Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels. DISCUSSION: This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful. TRIAL REGISTRATION: The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

Social vulnerability indices: a scoping review.

BACKGROUND: Social vulnerability occurs when the disadvantage conveyed by poor social conditions determines the degree to which one's life and livelihood are at risk from a particular and identifiable event in health, nature, or society. A common way to estimate social vulnerability is through an index aggregating social factors. This scoping review broadly aimed to map the literature on social vulnerability indices. Our main objectives were to characterize social vulnerability indices, understand the composition of social vulnerability indices, and describe how these indices are utilized in the literature. METHODS: A scoping review was conducted in six electronic databases to identify original research, published in English, French, Dutch, Spanish or Portuguese, and which addressed the development or use of a social vulnerability index (SVI). Titles, abstracts, and full texts were screened and assessed for eligibility. Data were extracted on the indices and simple descriptive statistics and counts were used to produce a narrative summary. RESULTS: In total, 292 studies were included, of which 126 studies came from environmental, climate change or disaster planning fields of study and 156 studies were from the fields of health or medicine. The mean number of items per index was 19 (SD 10.5) and the most common source of data was from censuses. There were 122 distinct items in the composition of these indices, categorized into 29 domains. The top three domains included in the SVIs were: at risk populations (e.g., % older adults, children or dependents), education, and socioeconomic status. SVIs were used to predict outcomes in 47.9% of studies, and rate of Covid-19 infection or mortality was the most common outcome measured. CONCLUSIONS: We provide an overview of SVIs in the literature up to December 2021, providing a novel summary of commonly used variables for social vulnerability indices. We also demonstrate that SVIs are commonly used in several fields of research, especially since 2010. Whether in the field of disaster planning, environmental science or health sciences, the SVIs are composed of similar items and domains. SVIs can be used to predict diverse outcomes, with implications for future use as tools in interdisciplinary collaborations.

Sex-specific frailty and chronological age normative carotid artery intima-media thickness values using the Canadian longitudinal study of aging.

OBJECTIVES: Carotid intima-media-thickness (cIMT) is predictive of future cardiovascular events, increases with chronological age, and greater in males. The accumulation of health deficits (or frailty) is a marker of biological age. However, normative cIMT values are lacking and would be an important comparative tool for healthcare providers and researchers. This study aimed to establish sex-specific normative cIMT values across chronological age and frailty levels (i.e. biological age). METHODS: Frailty and right common cIMT data were extracted from the Canadian Longitudinal Study of Aging baseline comprehensive cohort of middle-aged and older adults (n = 10,209; 5000 females). cIMT was assessed via high-resolution ultrasound. Frailty was determined using a 52-item frailty index. Ordinary least squares and quantile regressions were conducted between age (years or frailty index) with cIMT (average or maximum), separately for males and females. RESULTS: In both sexes, average and maximum cIMT increased with higher chronological age and frailty. Both cIMT metrics increased non-linearly (quadratic-cIMT term) with advancing age (ß-coefficients for quadratic and linear terms: all, p < 0.001), except for the linear relationship between average and maximum cIMT with chronological age among males (p < 0.001). Sex-specific normative average and maximum cIMT values were established (1st-99th percentiles, 5% increments), separately for chronological and biological ages. CONCLUSIONS: This is the largest sample of adults to establish normative cIMT outcomes that includes older adults. The chronological age and frailty-related normative cIMT outcomes will serve as a useful resource for healthcare professionals and researchers to establish "normal" age- and sex-specific cIMT values.

The impact of cardiovascular health and frailty on mortality for males and females across the life course.

BACKGROUND: The effect of frailty and poor cardiovascular health on mortality for males and females is not fully elucidated. We investigated whether the combined burden of frailty and poor cardiovascular health is associated with all-cause and cardiovascular disease (CVD) mortality by sex and age. METHODS: We analyzed data of 35,207 non-institutionalized US residents aged 20-85 years old (mean age [standard deviation]: 46.6 [16.7 years], 51.4% female, 70.8% White, 10.3% Black, 13.2% Hispanic) from the National Health and Nutrition Examination Survey (1999-2015). Cardiovascular health was measured with the American Heart Association's Life's Simple 7 score (LS7). A 33-item frailty index (FI) was constructed to exclude cardiovascular health deficits. We grouped the FI into 0.1 increments (non-frail: FI < 0.10, very mildly frail: 0.1 ≤ FI < 0.20, mildly frail: 0.20 ≤ FI < 0.30, and moderately/severely frail: FI ≥ 0.30) and LS7 into tertiles (T1[poor] = 0-7, T2[intermediate] = 8-9, T3[ideal] = 10-14). All-cause and CVD mortality data were analyzed up to 16 years. All regression models were stratified by sex. RESULTS: The average FI was 0.09 (SD 0.10); 29.6% were at least very mildly frail, and the average LS7 was 7.9 (2.3). Mortality from all-causes and CVD were 8.5% (4228/35,207) and 6.1% (2917/35,207), respectively. The median length of follow-up was 8.1 years. The combined burden of frailty and poor cardiovascular health on mortality risk varied according to age in males (FI*age interaction p = 0.01; LS7*age interaction p < 0.001) but not in females. In females, poor FI and LS7 combined to predict all-cause and CVD mortality in a dose-response manner. All-cause and CVD mortality risk was greater for older males (60 and 70 years old) who were at least mildly frail and had intermediate cardiovascular health or worse (hazard ratio [lower/higher confidence interval ranges] range: all-cause mortality = 2.02-5.30 [1.20-4.04, 3.15-6.94]; CVD-related mortality = 2.22-7.16 [1.03-4.46, 4.49-11.50]) but not for younger males (30, 40, and 50 years old). CONCLUSIONS: The combined burden of frailty and LS7 on mortality is similar across all ages in females. In males, this burden is greater among older people. Adding frailty to assessments of overall cardiovascular health may identify more individuals at risk for mortality and better inform decisions to implement preventative or treatment approaches.

Relationship of body mass index with frailty and all-cause mortality among middle-aged and older adults.

BACKGROUND: Parallel to growth of aging and obese populations, the prevalence of metabolic diseases is rising. How body mass index (BMI) relates to frailty and mortality across frailty levels is controversial. We examined the associations of high BMI with frailty and mortality and explored the effects of percent body fat on these associations. METHODS: We included 29,937 participants aged ≥50 years from the 2001-2006 National Health and Nutrition Examination Survey (NHANES) cohorts (N=6062; 53.7% females) and from wave 1 (2004) of Survey of Health, Ageing and Retirement in Europe (SHARE) (N=23,875; 54% females). BMI levels were categorized as: normal: 18.5-24.9 kg/m2, overweight: 25.0-29.9, obese grade 1: 30.0-34.9, and obese grade 2 or 3: >35.0. A frailty index (FI) was constructed excluding nutrition-related items: 36 items for NHANES and 57 items for SHARE. We categorized the FI using 0.1-point increments: FI ≤ 0.1 (non-frail), 0.1 < FI ≤ 0.2 (very mildly frail), 0.2 < FI ≤ 0.3 (mildly frail), and FI > 0.3 (moderately/severely frail). Percent body fat was measured using DXA for NHANES participants. All-cause mortality data were obtained until 2015 for NHANES and 2017 for SHARE to estimate 10-year mortality risk. All analyses were adjusted for age, sex, educational, marital, employment, and smoking statuses. RESULTS: Mean age of participants was 63.3±10.2 years for NHANES and 65.0±10.0 years for SHARE. In both cohorts, BMI levels ≥25 kg/m2 were associated with higher frailty, compared to normal BMI. In SHARE, having a BMI level greater than 35 kg/m2 increased mortality risk in participants with FI≤0.1 (HR 1.31, 95%CI 1.02-1.69). Overweight participants with FI scores >0.3 were at lower risk for mortality compared to normal BMI [NHANES (0.79, 0.64-0.96); SHARE (0.71, 0.63-0.80)]. Higher percent body fat was associated with higher frailty. Percent body fat significantly mediated the relationship between BMI levels and frailty but did not mediate the relationship between BMI levels and mortality risk. CONCLUSIONS: Being overweight or obese is associated with higher frailty levels. In this study, we found that being overweight is a protective factor of mortality in moderately/severely frail people and obesity grade 1 may be protective for mortality for people with at least a mild level of frailty. In contrast, obesity grades 2 and 3 may be associated with higher mortality risk in non-frail people. The relationship between BMI and frailty is partially explained by body fat.

Frailty and Survival After In-Hospital Cardiopulmonary Resuscitation.

BACKGROUND: Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation. OBJECTIVE: To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients ≥ 65 years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail. MAIN MEASURES: In-hospital mortality after cardiopulmonary resuscitation. KEY RESULTS: Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001). CONCLUSIONS: Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population.

Frailty change based on minimally important difference in nursing home residents: FIRST cohort study findings.

BACKGROUND: Frailty is common among residential aged care services (RACS) residents; however, little is known about how frailty changes over time in this population. This study aimed to estimate minimally important difference (MID) in frailty to then describe: frailty change over 12 months; and factors associated with worsening frailty. METHODS: Prospective cohort study across 12 RACS sites of a single aged care organisation in South Australia (n = 548 residents, mean age 87.7 ± 7.2 years, 72.6% female). Frailty was measured using a frailty index (FI) with 12 months between baseline and follow-up. MID was calculated cross-sectionally (anchor-based using self-reported health, and ½SD for distribution-based). RESULTS: Between-person MID for the FI was identified as 0.037 (anchor-based) and 0.063 (distribution-based). Using the conservative value of 0.063 as the basis for change, 32.3% (n = 177) of residents remained stable, 13.7% (n = 75) improved, 33.0% (n = 181) worsened and 21.0% (n = 115) died over 12 months. In a multivariable analysis, significant predictors of the dichotomous outcome of worsening and death at 12 months were: being malnourished (odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.23, 3.75), at risk of malnutrition (OR = 1.98, 95%CI = 1.34, 2.91) and diabetes (OR = 1.61, 95%CI = 1.06, 2.42) compared to those who remained stable or improved. CONCLUSIONS: A 6.3% change in frailty for RACS residents is a conservative MID. Frailty is dynamic in RACS residents, and stability or improvement was possible even for the most-frail. Treatments such as nutritional interventions, exercise and diabetes management are likely to benefit frailty.

The impact of an exercise intervention on frailty levels in hospitalised older adults: secondary analysis of a randomised controlled trial.

BACKGROUND: physical activity reduces frailty in community-dwelling older adults. How exercise influences frailty in hospitalised older adults requires additional investigation. OBJECTIVES: (i) to examine the impact of an exercise intervention on frailty in older adults admitted to an acute care ward, and (ii) to determine the impact of baseline frailty on the effectiveness of this intervention. SETTING/PARTICIPANTS: this is a secondary analysis of a randomised controlled clinical trial that tested an intensive exercise intervention in ≥75-year-old adults admitted to an acute care ward. METHODS: the intervention included two daily sessions of moderate-intensity exercises (control received usual care). A 63-item Frailty Index (FI) was constructed, and three groups were formed: <0.2, 0.2-0.29 and ≥0.3. Other outcomes included Short Physical Performance Battery (SPPB) and Barthel Index (BI). RESULTS: a total of 323 individuals were included. The mean age was 87.1 years (± 4.8 standard deviation [SD]) and 56.3% were females. The intervention group improved FI from 0.26 (± 0.10 SD) to 0.20 (± 0.10 SD), whereas the control group FI worsened from 0.25 (± 0.1 SD) to 0.27 (± 0.10 SD). After stratifying by baseline FI, SPPB and depression improved in the intervention group across all levels of frailty; FI, BI and quality of life only improved in individuals with a baseline FI ≥ 0.2. CONCLUSIONS: frailty improves with an intensive individualised exercise intervention, especially in those with high baseline levels of frailty. In addition, frailty is a useful outcome when examining the impact of an intervention of hospitalised older adults.

Frailty indices based on self-report, blood-based biomarkers and examination-based data in the Canadian Longitudinal Study on Aging.

BACKGROUND: Frailty can be operationalised using the deficit accumulation approach, which considers health deficits across multiple domains. We aimed to develop, validate and compare three different frailty indices (FI) constructed from self-reported health measures (FI-Self Report), blood-based biomarkers (FI-Blood) and examination-based assessments (FI-Examination). METHODS: Up to 30,027 participants aged 45-85 years from the baseline (2011-2015) comprehensive cohort of the Canadian Longitudinal Study on Aging were included in the analyses. Following standard criteria, three FIs were created: a 48-item FI-Self Report, a 23-item FI-Blood and a 47-item FI-Examination. In addition a 118-item FI-Combined was constructed. Mortality status was ascertained in July 2019. RESULTS: FI-Blood and FI-Examination demonstrated broader distributions than FI-Self Report. FI-Self Report and FI-Blood scores were higher in females, whereas FI-Examination scores were higher in males. All FI scores increased nonlinearly with age and were highest at lower education levels. In sex and age-adjusted models, a 0.01 increase in FI score was associated with a 1.08 [95% confidence interval (CI): 1.07,1.10], 1.05 (1.04,1.06), 1.07 (1.05,1.08) and a 1.13 (1.11,1.16) increased odds of mortality for FI-Self Report, FI-Blood, FI-Examination and FI-Combined, respectively. Inclusion of the three distinct FI types in a single model yielded the best prognostic accuracy and model fit, even compared to the FI-Combined, with all FIs remaining independently associated with mortality. CONCLUSION: Characteristics of all FIs were largely consistent with previously established FIs. To adequately capture frailty levels and to improve our understanding of the heterogeneity of ageing, FIs should consider multiple types of deficits including self-reported, blood and examination-based measures.

Relationship between diet quality scores and the risk of frailty and mortality in adults across a wide age spectrum.

BACKGROUND: Beyond intakes of total energy and individual nutrient, eating patterns may influence health, and thereby the risk of adverse outcomes. How different diet measures relate to frailty-a general measure of increased vulnerability to unfavorable health outcomes-and mortality risk, and how this might vary across the life course, is not known. We investigated the associations of five dietary indices (Nutrition Index (NI), the energy-density Dietary Inflammatory Index (E-DII™), Healthy Eating Index-2015 (HEI-2015), Mediterranean Diet Score (MDS), and Dietary Approaches to Stop Hypertension (DASH)) with frailty and mortality. METHODS: We included 15,249 participants aged ≥ 20 years from the 2007-2012 cohorts of the National Health and Nutrition Examination Survey (NHANES). The NI combined 31 nutrition-related deficits. The E-DII is a literature-derived dietary index associated with inflammation. The HEI-2015 assesses adherence to the Dietary Guidelines of Americans. The MDS represents adherence to the traditional Mediterranean diet. DASH combines macronutrients and micronutrients to prevent hypertension. Frailty was evaluated using a 36-item frailty index. Mortality status was ascertained up to December 31, 2015. RESULTS: Participants' mean age was 47.2 ± 16.7 years and 51.7% were women. After adjusting for age, sex, race, educational level, marital and employment status, smoking, BMI, and study cohort, higher NI and E-DII scores and lower HEI-2015, MDS, and DASH scores were individually significantly associated with frailty. All dietary scores were significantly associated with 8-year mortality risk after adjusting for basic covariates and frailty: NI (hazard ratio per 0.1 point, 1.15, 95%CI 1.10-1.21), E-DII (per 1 point, 1.05, 1.01-1.08), HEI-2015 (per 10 points, 0.93, 0.89-0.97), MDS (per 1 point, 0.94, 0.90-0.97), and DASH (per 1 point, 0.96, 0.93-0.99). The associations of E-DII, HEI-2015, and MDS scores with 8-year mortality risk persisted after additionally adjusting for NI. CONCLUSIONS: NI, E-DII, HEI-2015, MDS, and DASH scores are associated with frailty and 8-year mortality risk in adults across all ages. Nevertheless, their mechanisms and sensitivity to predict health outcomes may differ. Nutrition scores have the potential to include measures of both consumption and laboratory and physical measures of exposure.