Prognostic value of short-term decline of forced expiratory volume in 1 s over height cubed (FEV1/Ht3) in a cohort of adults aged 80 and over.

BACKGROUND: Forced expiratory volume in 1 s over height cubed (FEV1/Ht3) is an FEV1 expression that uses no reference values and is independently associated with adverse outcomes in older adults. No studies have reported on the prognostic value of its decline over time in adults aged 80 and over. AIM: To investigate the prognostic value of FEV1/Ht3 decline for adverse outcomes in a cohort of adults aged 80 and over. METHODS: 328 community-dwelling adults aged 80 and over of the BELFRAIL prospective cohort had two valid FEV1 measurements as part of their comprehensive geriatric assessment at baseline and follow-up (after 1.7 ± 0.21 years). Kaplan-Meier survival curves, Cox and logistic multivariable regression, assessed association of excessive decline of FEV1/Ht3 (lowest quintile of percentage change) with all-cause mortality (3 years after follow-up assessment), time to first hospitalization (1 year), and new/ worsened disability in activities of daily living (ADL) at the follow-up assessment. RESULTS: Participants with excessive FEV1/Ht3 decline had increased adjusted hazard ratio for all-cause death 1.61 (95% CI 1.01-2.55) and first hospitalization 1.71 (1.08-2.71) and increased odds ratio for new/worsened ADL disability at follow-up 2.02 (1.10-3.68) compared to the rest of the study population. CONCLUSIONS: Excessive, short-term decline in FEV1/Ht3 was independently associated with all-cause mortality, time to first, unplanned hospitalization, and ADL disability in a cohort of adults aged 80 and over. This FEV1 expression should be further investigated in studies of longitudinal FEV1 change in older adults.

Correlates of dyspnoea and its association with adverse outcomes in a cohort of adults aged 80 and over.

Background: adults aged 80 and over, a fast growing age-group, with increased co-morbidity and frailty have not been the focus of previous research on dyspnoea. We investigate the correlates of dyspnoea and its association with adverse outcomes in a cohort of adults aged 80 and over. Methods: about 565 community-dwelling adults aged 80 and over of the BELFRAIL prospective cohort had assessment of Medical Research Council dyspnoea scale (MRC), forced expiratory volume in 1 s (FEV1), N-terminal pro-brain natriuretic peptide (NT-proBNP), physical performance tests, grip strength, 15 items geriatric depression scale, activities of daily living (ADL), body mass index (BMI) and demographics data. Kaplan-Meier survival curves, Cox and logistic multivariable regression, classification and regression tree (CART) analysis assessed association of dyspnoea (MRC 3-5) with time-to-cardiovascular and all-cause death (5 years), time to first hospitalisation (3 years), new/worsened ADL disability (2 years), and its correlates. Results: participants with dyspnoea MRC 3-5 (29.9%) had increased hazard ratios for cardiovascular mortality 2.85 (95% confidence interval 1.93-4.20), all-cause mortality 2.04 (1.58-2.64), first hospitalisation 1.72 (1.35-2.19); and increased odds ratio for new/worsened disability 2.49 (1.54-4.04), independent of age, sex and smoking status. Only FEV1, physical performance, BMI and NT-proBNP (in order of importance) were selected in the tree-based classification model for dyspnoea. Conclusions: in a cohort of adults aged 80 and over, dyspnoea was common and an independent predictor of adverse outcomes, with cardio-respiratory and physical performance impairments as key independent correlates. Its routine and comprehensive evaluation in primary care could be very valuable in caring for this age-group.

Breathlessness in older adults: What we know and what we still need to know.

Breathlessness is common among older adults, but it is often hidden as "normal aging "or considered narrowly as a symptom of cardio-respiratory diseases. Studies on breathlessness in older adults are mostly focused on specific diseases, whereas older adults are characterized by multimorbidity and multi-system age-related impairments. This article aims to provide an overview of what is known so far on breathlessness in the general population of older adults and identify areas for further research. Research shows that breathlessness in older adults is a multifactorial geriatric condition, crossing the borders of system-based impairments and diseases, and a valuable independent prognostic indicator for adverse outcomes. Further research needs to investigate (1) the multi-factorial mechanisms of breathlessness in community-dwelling older adults including the role of respiratory sarcopenia; (2) the influence of affective and cognitive changes of older age on the perception and report of breathlessness; (3) the best way to assess and use breathlessness for risk prediction of adverse outcomes in general geriatric assessments; and (4) the most appropriate multi-modal rehabilitation interventions and their outcomes. Clinicians need to shift their approach to dyspnea from a disease symptom to a multifactorial geriatric condition that should be proactively searched for, as it identifies higher risk for adverse outcomes, and can be addressed with evidence-based interventions that can improve the quality of life and may reduce the risk of adverse outcomes in older adults.

A standardised physical performance test versus the frailty phenotype as predictors of adverse events in octogenarians / Comparaison de la valeur prédictive d'un test de performance physique standardisé à celle du phénotype de fragilité selon Fried pour les événements indésirables chez les octogénaires

Background: The population of adults aged 80 years and older is heterogenous with some being robust and others having a higher risk for adverse events. This study compares the predictive value of two tools used to identify older adults who are at higher risk for adverse outcomes: frailty phenotype according to Fried and a standardized physical performance test. Methods: The BELFRAIL population-based cohort of 567 community-dwelling adults aged 80 years and older living in Belgium. Fried frailty phenotype and physical performance test (gait, chair stand, standing balance tests and putting on and off a cardigan). The predictive value of the two tools in predicting mortality (up to 5.1 ± 0.25 years), hospitalization (3.0 ± 0.25 years) and decline in activities of daily living (after 1.7 ± 0.21 years) was compared using reclassification statistics and decision curve analysis. Results: Frail participants according to Fried phenotype and those in the lowest quartile of the physical performance test score had higher risk for mortality and hospitalization. Harrell C and area under operator curve were similar (< 0.70). Reclassification statistics and net benefit in decision curve analysis showed no significant difference between the two tools in identifying higher risk for mortality, hospitalization and functional decline. Conclusion: In a cohort of community-dwelling adults 80 years and older a standardized physical performance test was as good as the Fried frailty phenotype in identifying higher risk for adverse outcomes.

Contexte: La population d'octogénaires est hétérogène, avec des sujets robustes et d'autres à risque d'événements indésirables. Dans notre étude, nous comparons la valeur prédictive de deux instruments visant à identifier les sujets à haut risque : le phénotype de fragilité selon Fried et un test de performance physique standardisé. Méthodes: La base de données de l'étude BELFRAIL nous fournit un échantillon représentatif de la population belge d'octogénaires, composé de 567 sujets. Des données sur l'hospitalisation ont été recueillies jusqu'à 3,0 ± 0,25 ans et sur la mortalité jusqu'à 5,1 ± 0,25 ans. Nous avons réalisé et calculé des analyses de survie, des indices de reclassification et des courbes décisionnelles. Résultats: Les participants fragiles (phénotype de Fried) ou dans le quartile inférieur (Short Physical Performance Battery ­ SPPB) ont un risque de mortalité et d'hospitalisation plus élevé. Le C de Harrell et l'aire sous la courbe sont semblables (< 0,70). Les courbes de décision illustrent un bénéfice net supérieur aux stratégies par défaut pour les deux outils. Les indices de reclassification et les courbes décisionnelles ne montrent aucune différence significative entre les instruments. Conclusion: Le SPPB est aussi performant que le phénotype de fragilité pour prédire les événements indésirables chez les octogénaires.

Validity and reliability of the Multidimensional Dyspnoea Profile in older adults.

Breathlessness is a common and distressing symptom in older adults and an independent predictor of adverse outcomes and yet its multidimensional assessment has not been validated in older adults. We apply and validate the Multidimensional Dyspnoea Profile (MDP) in a sample of adults 75 years and older in Belgium. Breathlessness was rated with the MDP, the modified Borg Dyspnoea Scale (mBDS), the Short Physical Performance Battery (SPPB, a numerical rating scale for intensity and unpleasantness both before and after exertion), as well as with the Medical Research Council (MRC) Dyspnoea Scale. The Hospital Anxiety and Depression Scale (HADS) assessed the affective status. Factor structure was analysed with exploratory principal components analysis, internal consistency with Cronbach's alpha and concurrent validity with Spearman's correlation coefficients with other breathlessness scales, HADS and SPPB scores. In 96 participants (mean age 85 years; 34% men) who rated breathlessness at both assessment points, exploratory principal components analysis identified two components: Immediate Perception (IP) and Emotional Reaction (ER), explaining most of the MDP item variance (65.37% before and 71.32% after exertion). Internal consistency was moderate to high for MDP-IP (Cronbach's alpha = 0.86 before and 0.89 after exertion) and MDP-ER (Cronbach's alpha = 0.89 before and 0.91 after exertion). The correlation patterns of MDP-IP and MDP-ER with other tests confirmed concurrent validity. The domain structure, reliability and concurrent validity of MDP for breathlessness before and after exertion were confirmed in a sample of adults 75 years and older, supporting its use and further research for the multidimensional profiling of breathlessness in older adults.

Malnutrition risk and its association with adverse outcomes in a Belgian cohort of community-dwelling adults aged 80 years and over.

Objectives: To investigate the prevalence of malnutrition risk and its association with adverse outcomes in a Belgian cohort of community-dwelling adults aged ≥80 years, a worldwide growing age-group.Methods: In the BELFRAIL cohort, malnutrition risk was evaluated with the Mini Nutritional Assessment (MNA total score <24) and prealbumin levels (<20 mg/dl). Agreement between them was assessed with Kohen's kappa coefficient. Association with first unplanned hospitalization (3.0 ± 0.25 years follow-up) and mortality (5.1 ± 0.25 years follow-up) was investigated with survival analysis and Cox multivariate regression.Results: Out of 567 BELFRAIL participants, 556 (98.1%) had MNA and 545 (96.1%) prealbumin levels. Sixty-eight (12.2%) were at risk of malnutrition based on MNA and 69 (12.7%) based on prealbumin, with very poor agreement between them (Kappa = 0.024, 95% CI -0.064, 0.112). For both MNA and prealbumin, participants with malnutrition risk had lower physical and cognitive performance tests' scores. They had no higher risk for first hospitalization compared to those without malnutrition risk, but higher risk for all-cause mortality even after adjustment for multimorbidity, inflammation, physical and mental functioning (HR 1.35 95%CI 0.92-1.97 for MNA; HR 1.46; 95%CI 1.01-2.12 for prealbumin).Conclusion: Malnutrition risk based on MNA or prealbumin was low in a Belgian cohort of community-dwelling adults aged ≥80 years. Physical and cognitive performance was lower in those with malnutrition risk, but malnutrition risk was not independently associated with hospitalization and mortality (except for malnutrition risk by prealbumin). Further research needs to investigate the best tool to assess malnutrition risk in this age group.

Predictive Accuracy of Frailty Tools for Adverse Outcomes in a Cohort of Adults 80 Years and Older: A Decision Curve Analysis.

OBJECTIVES: To compare the predictive performance of 3 frailty identification tools for mortality, hospitalization, and functional decline in adults aged ≥80 years using risk reclassification statistics and decision curve analysis. DESIGN: Population-based, prospective cohort. SETTING: BELFRAIL study, Belgium. PARTICIPANTS: 560 community-dwelling adults aged ≥80 years. MEASUREMENTS: Frailty by Cardiovascular Health Study (CHS) phenotype, Longitudinal Aging Study Amsterdam (LASA) markers, and Groeningen Frailty Indicator (GFI); mortality until 5.1 ± 0.25 years from baseline and hospitalization until 3.0 ± 0.25 years; and functional status assessed by activities of daily living at baseline and after 1.7 ± 0.21 years. RESULTS: Frailty prevalence was 7.3% by CHS phenotype, 21.6% by LASA markers, and 22% by GFI. Participants determined to be frail by each tool had a significantly higher risk for all-cause mortality and first hospitalization. For functional decline, only frail by GFI had a higher adjusted odds ratio. Harrell 's C-statistic for mortality and hospitalization and area under receiver operating characteristic curve for functional decline were similar for all tools and <0.70. Reclassification statistics showed improvement only by LASA markers for hospitalization and mortality. In decision curve analysis, all tools had higher net benefit than the 2 default strategies of "treat all" and "treat none" for mortality risk ≥20%, hospitalization risk ≥35%, and functional decline probability ≥10%, but their curves overlapped across all relevant risk thresholds for these outcomes. CONCLUSIONS AND IMPLICATIONS: In a cohort of adults aged ≥80 years, 3 frailty tools based on different conceptualizations and assessment sources had comparable but unsatisfactory discrimination for predicting mortality, hospitalization, and functional decline. All showed clinical utility for predicting these outcomes over relevant risk thresholds, but none was significantly superior. Future research on frailty tools should include a focus on the specific group of adults aged ≥80 years, and the predictive accuracy for adverse outcomes of different tools needs a comprehensive assessment that includes decision curve analysis.

Biomarkers versus traditional risk factors to predict cardiovascular events in very old adults: cross-validated prospective cohort study.

OBJECTIVES: To test new cardiovascular (CV) risk models in very old adults with and without a history of CV disease (CVD), based on traditional risk factors and biomarkers. DESIGN: Cross-validated prospective cohort study. The models were tested in the BELFRAIL Study and externally validated in the Leiden 85-plus Study. SETTING: General practice, Belgium and The Netherlands. PARTICIPANTS: The BELFRAIL cohort consisted of 266 patients aged 80 years or older without a history of CVD and 260 with a history of CVD. The Leiden 85-plus Study consisted of 264 patients aged 85 years without a history of CVD and 282 with a history of CVD. OUTCOME MEASURES: The model with traditional risk factors and biomarkers, as well as the model using only biomarkers, was compared with the model with only traditional risk factors to predict 3-year CV morbidity and mortality. A competing-risk analysis was performed, and the continuous net reclassification improvement (NRI), integrated discrimination improvement (IDI) and net benefit were used to compare the predictive value of the different models. RESULTS: Traditional risk factors poorly predicted CV mortality and morbidity. In participants without a history of CVD, adding N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) improved the prediction (NRI 0.56 (95% CI 0.16 to 0.99) and relative IDI 4.01 (95% CI 2.19 to 6.28)). In participants with a history of CVD, the NRI with the addition of NT-pro-BNP and high-sensitivity C reactive protein was 0.38 (95% CI 0.09 to 0.70), and the relative IDI was 0.53 (95% CI 0.23 to 0.90). Moreover, in participants without a history of CVD, NT-pro-BNP performed well as a stand-alone predictor (NRI 0.32 (95% CI -0.12 to 0.74) and relative IDI 3.44 (95% CI 1.56 to 6.09)). CONCLUSIONS: This study tested new risk models to predict CV morbidity and mortality in very old adults. Especially, NT-pro-BNP showed a strong added predictive value. This opens perspectives for clinicians who are in need of an easily applicable strategy for CV risk prediction in very old adults.

Predictive Value of Different Expressions of Forced Expiratory Volume in 1 Second (FEV1) for Adverse Outcomes in a Cohort of Adults Aged 80 and Older.

OBJECTIVES: Forced expiratory volume in 1 second (FEV1) is proposed as a marker of healthy ageing and FEV1 expressions that are independent of reference values have been reported to be better at predicting mortality in older adults. We assess and compare the predictive value of different FEV1 expressions for mortality, hospitalization, and physical and mental decline in adults aged 80 and older. DESIGN: Population-based, prospective, cohort study. SETTING: The BELFRAIL study, Belgium. PARTICIPANTS: A total of 501 community-dwelling adults aged 80 and older (mean age 84.7 years). MEASUREMENTS: Baseline FEV1 expressed as percent predicted (FEV1PP) and z-score (FEV1Z) using the Global Lung Function Initiative 2012 reference values; over lowest sex-specific percentile (FEV1Q), and height squared (FEV1/Ht2) and cubed (FEV1/Ht3). Mortality data until 5.1 ± 0.2 years from baseline; hospitalization data until 3.0 ± 0.25 years. Activities of daily living, battery of physical performance tests, Mini-Mental State Examination, and 15-item Geriatric Depression Scale at baseline and after 1.7 ± 0.2 years. RESULTS: Individuals in the lowest quartile of FEV1 expressions had higher adjusted risk than the rest of study population for all-cause mortality (highest hazard ratio 2.05 [95% Confidence Interval 1.50-2.80] for FEV1Q and 2.01 [1.47-2.76] for FEV1/Ht3), first hospitalization (highest hazard ratio 1.63 [1.21-2.16] for FEV1/Ht2 and 1.61[1.20-2.16] for FEV1/Ht3), mental decline (highest odds ratio 2.80 [1.61-4.89] for FEV1Q) and physical decline (only FEV1/Ht3 with odds ratio 1.93 [1.13-3.30]). Based on risk classification improvement measures, FEV1/Ht3 and FEV1Q performed better than FEV1PP. CONCLUSION: In a cohort of adults aged 80 and older, FEV1 expressions that are independent of reference values (FEV1/Ht3 and FEV1Q) were better at predicting adverse health outcomes than traditional expressions that depend on reference values, and should be used in further research on FEV1 and aging.