Standard laboratory tests to identify older adults at increased risk of death.

BACKGROUND: Older adults are at an increased risk of death, but not all people of the same age have the same risk. Many methods identify frail people (that is, those at increased risk) but these often require time-consuming interactions with health care providers. We evaluated whether standard laboratory tests on their own, or added to a clinical frailty index (FI), could improve identification of older adults at increased risk of death. METHODS: This is a secondary analysis of a prospective cohort study, where community dwelling and institutionalized participants in the Canadian Study of Health and Aging who also volunteered for blood collection (n = 1,013) were followed for up to six years. A standard FI (FI-CSHA) was constructed from data obtained during the clinical evaluation and a second, novel FI was constructed from laboratory data plus systolic and diastolic blood pressure measurements (FI-LAB). A combined FI included all items from each index. Predictive validity was tested using Cox proportional hazards analysis and discriminative ability by the area under receiver operating characteristic (ROC) curves. RESULTS: Of 1,013 participants, 51.3% had died by six years. The mean baseline value of the FI-LAB was 0.27 (standard deviation 0.11; range 0.05 to 0.63), the FI-CSHA was 0.25 (0.11; 0.02 to 0.72), and the combined FI was 0.26 (0.09; 0.06 to 0.59). In an age- and sex-adjusted model, with each increment in the FI-LAB, the hazard ratios increased by 2.8% (95% confidence interval 1.02 to 1.04). The hazard ratios for the FI-CSHA and the combined FI were 1.02 (1.01 to 1.03) and 1.04 (1.03 to 1.05), respectively. The FI-LAB and FI-CSHA remained independently associated with death in the face of the other. The areas under the ROC curves were 0.72 for FI-LAB, 0.73 for FI-CSHA and 0.74 for the combined FI. CONCLUSIONS: An FI based on routine laboratory data can identify older adults at increased risk of death. Additional evaluation of this approach in clinical settings is warranted.

Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans.

BACKGROUND: on an individual level, lower-income has been associated with disability, morbidity and death. On a population level, the relationship of economic indicators with health is unclear. OBJECTIVE: the purpose of this study was to evaluate relative fitness and frailty in relation to national income and healthcare spending, and their relationship with mortality. DESIGN AND SETTING: secondary analysis of data from the Survey of Health, Ageing and Retirement in Europe (SHARE); a longitudinal population-based survey which began in 2004. SUBJECTS: a total of 36,306 community-dwelling people aged 50 and older (16,467 men; 19,839 women) from the 15 countries which participated in the SHARE comprised the study sample. A frailty index was constructed as the proportion of deficits present in relation to the 70 deficits available in SHARE. The characteristics of the frailty index examined were mean, prevalence of frailty and proportion of the fittest group. RESULTS: the mean value of the frailty index was lower in higher-income countries (0.16 ± 0.12) than in lower-income countries (0.20 ± 0.14); the overall mean frailty index was negatively correlated with both gross domestic product (r = -0.79; P < 0.01) and health expenditure (r = -0.63; P < 0.05). Survival in non-frail participants at 24 months was not associated with national income (P = 0.19), whereas survival in frail people was greater in higher-income countries (P < 0.05). CONCLUSIONS: a country's level of frailty and fitness in adults aged 50+ years is strongly correlated with national economic indicators. In higher-income countries, not only is the prevalence of frailty lower, but frail people also live longer.

Assessing balance and mobility to track illness and recovery in older inpatients.

BACKGROUND: Archetypal symptoms and signs are commonly absent in frail older people who are acutely unwell. This challenges both recognition of illness and monitoring of disease progression in people at high risk of prolonged hospital stays, institutionalization and death. OBJECTIVE: To determine whether bedside assessment of balance and mobility could track acute changes in the health status of older people admitted to hospital. DESIGN: Prospective cohort study. PARTICIPANTS: Four hundred nine patients, with a mean age of 81.8 years, admitted to general medical and rehabilitation wards at a tertiary care teaching hospital in Halifax, Nova Scotia. No patient refused assessment, and the only exclusion criterion was age. INTERVENTIONS: The Hierarchical Assessment of Balance and Mobility (HABAM) was completed daily during the first 2 weeks of admission. For each patient, frailty status was measured on admission by a Frailty Index based on a Comprehensive Geriatric Assessment (FI-CGA). MAIN MEASURES: Death and discharge destination. KEY RESULTS: Poor performance in balance, transfers and mobility was associated with adverse outcomes. Forty-eight percent of patients with the lowest scores in all three domains died, compared with none with the highest scores. The relative risk of death for people who deteriorated during the first 48 h of admission was 17.1 (95% confidence interval: 4.9-60.3). Changes in HABAM scores were related to the discharge destination: patients discharged home showed the greatest rate of improvement, whereas those discharged to institutions stabilised at a lower level of performance. Fitter patients tended to have better performance on admission and faster recovery. CONCLUSIONS: Daily bedside observation of mobility and balance allows assessment of acute changes in the health of older people. Frailty slows recovery of mobility and balance, and reduces recovery potential. By identifying patients most vulnerable to adverse outcomes, the HABAM and FI-CGA may facilitate risk stratification in older people admitted to hospital.

Frailty index to measure health status in people with systemic sclerosis.

OBJECTIVE: To develop and validate, as a measure of overall health status, a Frailty Index (FI) for patients (n=1372) in the Canadian Scleroderma Research Group (CSRG) Registry. METHODS: Forty-four items were selected from the CSRG database as health deficits and recoded using FI criteria. To test construct validity, we compared measurement properties of the CSRG-FI to other FI, and related it to measures of damage, age, and time since diagnosis. To test criterion validity, we compared the baseline FI to that at last recorded visit and to mortality. RESULTS: The mean CSRG-FI was 0.33 with a sub-maximal limit of 0.67. In patients with diffuse disease, the mean was 0.38(SD 0.14); in patients with limited disease, the mean was 0.31(SD 0.13). The CSRG-FI was weakly (but significantly) correlated with the Rodnan Skin Score (r=0.28 in people with diffuse disease; 0.18 with limited) and moderately with the Physician Assessment of Damage (r=0.51 for both limited and diffuse). The risk of death increased with higher FI scores and with higher physician ratings of damage. The area under the receiver operating characteristic curve for the baseline FI in relation to death was 0.75, higher than for other measures (range: 0.57-0.67). CONCLUSION: The FI quantifies overall health status in people with scleroderma and predicts mortality. Whether the FI might help with decisions about who might best be served by more aggressive treatment, such as bone marrow transplantation, needs to be evaluated.

A clinical frailty index in aging mice: comparisons with frailty index data in humans.

We previously quantified frailty in aged mice with frailty index (FI) that used specialized equipment to measure health parameters. Here we developed a simplified, noninvasive method to quantify frailty through clinical assessment of C57BL/6J mice (5-28 months) and compared the relationship between FI scores and age in mice and humans. FIs calculated with the original performance-based eight-item FI increased from 0.06 ± 0.01 at 5 months to 0.36 ± 0.06 at 19 months and 0.38 ± 0.04 at 28 months (n = 14). By contrast, the increase was graded with a 31-item clinical FI (0.02 ± 0.005 at 5 months; 0.12 ± 0.008 at 19 months; 0.33 ± 0.02 at 28 months; n = 14). FI scores calculated from 70 self-report items from the first wave of the Survey of Health, Ageing and Retirement in Europe were plotted as function of age (n = 30,025 people). The exponential relationship between FI scores and age (normalized to 90% mortality) was similar in mice and humans for the clinical FI but not the eight-item FI. This noninvasive FI based on clinical measures can be used in longitudinal studies to quantify frailty in mice. Unlike the performance-based eight-item mouse FI, the clinical FI exhibits key features of the FI established for use in humans.

Accumulation of non-traditional risk factors for coronary heart disease is associated with incident coronary heart disease hospitalization and death.

BACKGROUND: Assessing multiple traditional risk factors improves prediction for late-life diseases, including coronary heart disease (CHD). It appears that non-traditional risk factors can also predict risk. The objective was to investigate contributions of non-traditional risk factors to coronary heart disease risk using a deficit accumulation approach. METHODS: Community-dwelling adults with no known history of CHD (n = 2195, mean age 46.9±18.7 years, 51.8% women) participated in the 1995 Nova Scotia Health Survey. Three risk factor indices were constructed to quantify the proportion of deficits present in individuals: 1) a 17-item Non-Traditional Risk Factor Index (e.g. sinusitis, arthritis); 2) a 9-item Traditional Risk Factor Index (e.g. hypertension, diabetes); and 3) a frailty index (25 items combined from the other two index measures). Ten-year risks of CHD events (defined as CHD-related hospitalization and CHD-related mortality) were evaluated. RESULTS: The Non-Traditional Risk Factor Index, made up of health deficits unrelated to CHD, was independently associated with incident CHD events over 10 years after controlling for age, sex, and the Traditional Risk Factor Index [adjusted {adj.} Hazard Ratio {HR} = 1.31; Confidence Interval {CI} 1.14-1.51]. When all health deficits, both those related and unrelated to CHD, were included in a frailty index the corresponding adjusted hazard ratio was 1.61; CI 1.40-1.85. CONCLUSION: Both traditional and non-traditional risk factor indices are independently associated with incident CHD events. CHD risk assessment may benefit from consideration of general health information as well as from traditional risk factors.

Orthostatic hypotension (OH) and mortality in relation to age, blood pressure and frailty.

Systolic hypertension and OH, as with many other deficits, accumulate with age. This deficit accumulation results in frailty: enhanced vulnerability to adverse outcomes. This study evaluated OH in relation to age, frailty, systolic hypertension, and mortality. In the population-based Canadian Study of Health and Aging second clinical examination, complete data were available on 1347 people, mean age=83.3 (SD=6.4)years. A frailty index (FI) was calculated from a 52-item Comprehensive Geriatric Assessment (CGA), yielding an FI-CGA from 0 (no deficits) to 1.0 (52 deficits). The mean change in blood pressure from lying to standing was 7.3±15.6 mmHg (range +94 to -60). In total, 239 people (17.7%) had OH (change >20 mmHg systolic or >10 mmHg diastolic). Mean systolic blood pressure was higher (155.8±23.3 mmHg) in people with OH than in those without (141.4±23 mmHg), as was the FI-CGA (0.18 vs. 0.16). OH increased with frailty and systolic hypertension, but not age. Unadjusted, OH was associated with an increased risk of death (relative risk=1.21, 95% confidence interval 1.19-1.23). Adjusted for frailty, this result was not significant. OH may be a marker of the system dysregulation seen in frailty, but as a state variable is a less powerful marker of vulnerability than is the FI-CGA.

Disability and co-morbidity in relation to frailty: how much do they overlap?

The purpose of this study was to examine the association of disability and co-morbidity with frailty in older adults. 2305 participants aged 65+ from the second wave of the Canadian Study of Health and Aging (CSHA), a prospective population-based cohort study, comprised the study sample. Following a standard procedure, two different frailty index (FI) measures were constructed from 37 deficits by dividing the recorded deficits by the total number of measures. One version excluded disability and co-morbidity items, the other included them. Time to death was measured for up to five years. Frailty was defined using either the frailty phenotype or a cut-point applied to each FI. Of people defined as frail using the frailty phenotype, 15/416 (3.6%) experienced neither disability nor co-morbidity. Using 0.25 as the cut-point score for the FI (without disability/co-morbidity) resulted in 101/1176 (8.6%) frail participants that had neither disability nor co-morbidity. Activities of daily living (ADL) limitations and co-morbidities occurred more often among people with the highest levels of frailty. The first ADLs to become impaired with increasing frailty were bathing, managing medication, and cooking with more than 25% of older adults with a FI score (without disability/co-morbidity) >0.22 experiencing dependency on them. The hazard ratio (HR) per 0.1 increase in FI score was 1.25 (95% CI: 1.20-1.30) when disability and co-morbidity were included in the index and 1.21 (1.16-1.25) when they were not included. In conclusion, disability and co-morbidity greatly overlap with other deficits that might be used to define frailty and add to their ability to predict mortality.

Blood pressure in relation to age and frailty.

BACKGROUND AND PURPOSE: On average, systolic blood pressure (SBP) rises with age, while diastolic blood pressure (DBP) increases to age 50 and then declines. As elevated blood pressure is associated with cardiovascular disease and mortality, it also might be linked to frailty. We assessed the association between blood pressure, age, and frailty in a representative population-based cohort. METHODS: Individuals from the second clinical examination of the Canadian Study of Health and Aging (n = 2305, all 70+ years) were separated into four groups: history of hypertension ± antihypertensive medication, and no history of hypertension ± antihypertensive medication. Frailty was quantified as deficits accumulated in a frailty index (FI). RESULTS: SBP and DBP changed little in relation to age, except in untreated hypertension, where SBP declined in individuals >85 years. In contrast, SBP declined in all groups up to an FI of 0.55, and then rose sharply. DBP changed little in relation to FI. The slope of the line relating FI and age was highest in untreated individuals without a history of hypertension, indicating the highest physiological reserve. CONCLUSIONS: SBP declined as frailty increased in older adults, except at the highest FI levels. SBP and age had little or no relationship.

Impairments in mobility and balance in relation to frailty.

We set out to describe the relationship between impaired balance, mobility and frailty, and relate these to risk of death. We examined a subsample of 1295 community-dwelling non-demented adults from the second wave of the Canadian Study of Health and Aging (CSHA), a prospective population-based cohort study. Frailty index (FI) scores were constructed from a standardized comprehensive geriatric assessment (FI-CGA). History of mobility impairments and falls were assessed. Timed-up-and-go (TUG) and functional reach (FR) performance were measured. The CSHA clinical frailty scale (CFS) was judged by a physician. Adverse outcomes were determined at CSHA-3, conducted 5 years later. The FI-CGA varied in association with impaired mobility and balance. A history of mobility problems was demonstrable at FI-CGA scores >0.12. This level of frailty also represented the most marked deterioration in performance measures (TUG and FR). FI-CGA scores best predicted mortality (HR 1.04±0.02), proving to be a dominating factor in multivariate regression models that included mobility and balance markers. Only at the upper range of FI-CGA reported (>0.45) did all participants demonstrate mobility impairment. Impaired balance and mobility contribute to frailty, but neither is sufficient to define a participant as frail.

Physiological redundancy in older adults in relation to the change with age in the slope of a frailty index.

OBJECTIVES: To test the proposition, using routinely available clinical data, that deficit accumulation results in loss of redundancy. In keeping with the reliability theory of aging, this would be quantitated by attenuation in the slope of a Frailty Index (FI) with age. The more deficits, the less steep the slope and the less redundancy. DESIGN: Cross-sectional analysis of a prospective cohort study, with 5-year mortality data. SETTING: The clinical sample of the second wave of the Canadian Study of Health and Aging. PARTICIPANTS: Two thousand three hundred five people aged 70 and older at baseline. MEASUREMENTS: A FI based on data used for a Comprehensive Geriatric Assessment (CGA), the slope of the relationship between age and the FI-CGA, the limit value of the FI-CGA, mortality. RESULTS: An age-invariant limit to deficit accumulation was demonstrated; the observed 99% limit was 0.66. At the 25th percentile of deficit accumulation (FI-CGA approximately 0.18), the slope of the FI-CGA in relation to age was 0.044 (range 0.038-0.049). When deficits had increased to 75% of the maximum value (FI-CGA approximately 0.52), the slope fell to 0.021 (range 0.016-0.027). By the 85th percentile (FI-CGA approximately 0.6), the slope had become statistically indistinguishable from 0. CONCLUSION: As predicted by the reliability theory of aging, the rate of deficit accumulation slows with increasing frailty. A FI derived from data routinely collected as part of a CGA can in this way quantify loss of redundancy in older adults. Quantifying loss of redundancy can aid clinical decision-making; its application to individual prognostication in clinical samples warrants further evaluation.

Reliability of the hierarchical assessment of balance and mobility in frail older adults.

OBJECTIVES: To study the test-retest and interrater reliability of the Hierarchical Assessment of Balance and Mobility (HABAM) in frail older adults. DESIGN: Convenience sample of 167 frail older adults seen as part of routine care by an academic geriatrician at a tertiary care teaching hospital. SETTING: Inpatient medical and geriatric wards, geriatric ambulatory care clinic, emergency department, home visits. PARTICIPANTS: The interrater reliability sample consisted of 98 inpatients and 69 outpatients. The test-retest reliability sample tracked 63 of the inpatients over the first 2 days of their hospital stay. MEASUREMENTS: Mobility and balance were assessed using the HABAM. Frailty was assessed using a frailty index based on a standardized Comprehensive Geriatric Assessment. Reliability was assessed using Pearson correlations and the intraclass correlation coefficients. RESULTS: The interrater reliability of the HABAM was 0.92 and ranged from 0.88 to 0.96 across settings for the various components (balance, transfers, mobility). Test-retest reliability was 0.91 (range 0.85-0.92). CONCLUSION: The HABAM appears to be a reliable means of assessing mobility and balance in frail older adults.