Cross-cultural adaptation and psychometric evaluation of the social frailty scale in Iranian older adults.

BACKGROUND: Social frailty is a holistic concept encompassing various social determinants of health. Considering its importance and impact on health-related outcomes in older adults, the present study was conducted to cross-culturally adapt and psychometrically evaluate the Social Frailty Scale in Iranian older adults in 2023. METHODS: This was a methodological study. The translation and cross-cultural adaptation of the Social Frailty Scale 8-item (SFS-8) was conducted according to Wild's guideline. Content and face validity were assessed using qualitative and quantitative methods. Then, 250 older adults covered by comprehensive health centers were selected using multistage random sampling. Participants completed the demographic questionnaire, the Abbreviated Mental Test score, the SFS-8, and the Lubben Social Network Scale. Construct validity was assessed by principal component analysis (PCA) and known-group comparisons. The Mann‒Whitney U test was used to compare social frailty scores between the isolated and non-isolated older adults. Internal consistency, equivalence, and stability were assessed using the Kuder-Richardson method, the intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and the minimum detectable change (MDC). The ceiling and floor effects were also assessed. The data were analyzed using JASP 0.17.3. RESULTS: The ratio and index of content validity and the modified kappa coefficient of all the items were 1.00. The impact score of the items was greater than 4.6. PCA identified the scale as a single component by removing two questions that could explain 52.9% of the total variance in the scale score. The Persian version of the Social Frailty Scale could distinguish between isolated and non-isolated older adults (p < 0.001). The Kuder-Richardson coefficient, ICC, SEM, and MDC were 0.606, 0.904, 0.129, and 0.358, respectively. The relative frequencies of the minimum and maximum scores obtained from the scale were 34.8 and 1.2, respectively. CONCLUSIONS: The Persian version of the Social Frailty Scale (P-SFS) can be used as a valid and reliable scale to assess social frailty in Iranian older adults.

Association of multidimensional frailty and quality of life in middle-aged and older people with stroke: A cross-sectional study.

OBJECTIVES: The aims of this study were to (i) compare the prevalence of multidimensional frailty in middle-aged and older people with stroke and to (ii) explore the relationship between multidimensional frailty and quality of life (QoL) in this patient population. BACKGROUND: In recent years, stroke patients have become increasingly younger. As an important risk factor for stroke patients, frailty has gradually drawn research attention because of its multidimensional nature. DESIGN: This study used a cross-sectional design. METHODS: The study included 234 stroke patients aged 45 and older. Multidimensional frailty was defined as a holistic condition in which a person experiences losses in one or more domains of human functioning (physical, psychological and social) based on the Tilburg Frailty Indicator, and QoL was based on the short version of the Stroke-Specific Quality of Life Scale. Hierarchical regression was used to analyse the correlation factors of QoL. STROBE checklist guides the reporting of the manuscript. RESULTS: A total of 128 (54.7%) participants had multidimensional frailty, 48 (44.5%) were middle aged and 80 (63.5%) were older adults. The overall QoL mean score of the participants was 47.86 ± 9.04. Multidimensional frailty was negatively correlated with QoL. Hierarchical regression analysis showed that multidimensional frailty could independently explain 14.6% of the variation in QoL in stroke patients. CONCLUSIONS: Multidimensional frailty was prevalent in middle-aged and older people with stroke, and it was a significant factor associated with QoL in stroke patients. RELEVANCE TO CLINICAL PRACTICE: This study emphasises the importance of the early identification of multidimensional frailty. And targeted interventions should be studied to prevent the occurrence of multidimensional frailty and thereby improve the QoL of patients. PATIENT OR PUBLIC CONTRIBUTION/S: There are no patient or public contributions to this study.

Older Adults' Perceptions of Frailty Language: A Scoping Review.

There is growing interest in conceptualizing and diagnosing frailty. Less is understood, however, about older adults' perceptions of the term "frail", and the implications of being classified as "frail". The purpose of this scoping review was to map the breadth of primary studies; and describe the meaning, perceptions, and perceived implications of frailty language amongst community-dwelling older adults. Eight studies were included in the review and three core themes were identified: (1) understanding frailty as inevitable age-related decline in multiple domains, (2) perceiving frailty as a generalizing label, and (3) perceiving impacts of language on health and health care utilization. Clinical practice recommendations for health care professionals working with individuals with frailty include: (1) maintaining a holistic view of frailty that extends beyond physical function to include psychosocial and environmental constructs, (2) using person-first language, and (3) using a strengths-based approach to discuss aspects of frailty.

Baseline Frailty Status Influences Recovery Patterns and Outcomes Following Alignment Correction of Cervical Deformity.

BACKGROUND: Frailty severity may be an important determinant for impaired recovery after cervical spine deformity (CD) corrective surgery. OBJECTIVE: To evaluate postop clinical recovery among CD patients between frailty states undergoing primary procedures. METHODS: Patients >18 yr old undergoing surgery for CD with health-related quality of life (HRQL) data at baseline, 3-mo, and 1-yr postoperative were identified. Patients were stratified by the modified CD frailty index scale from 0 to 1 (no frailty [NF] <0.3, mild/severe fraily [F] >0.3). Patients in NF and F groups were propensity score matched for TS-CL (T1 slope [TS] minus angle between the C2 inferior end plate and the C7 inferior end plate [CL]) to control for baseline deformity. Area under the curve was calculated for follow-up time intervals determining overall normalized, time-adjusted HRQL outcomes; Integrated Health State (IHS) was compared between NF and F groups. RESULTS: A total of 106 CD patients were included (61.7 yr, 66% F, 27.7 kg/m2)-by frailty group: 52.8% NF, 47.2% F. After propensity score matching for TS-CL (mean: 38.1°), 38 patients remained in each of the NF and F groups. IHS-adjusted HRQL outcomes from baseline to 1 yr showed a significant difference in Euro-Qol 5 Dimension scores (NF: 1.02, F: 1.07, P = .016). No significant differences were found in the IHS Neck Disability Index (NDI) and modified Japanese Orthopedic Association between frailty groups (P > .05). F patients had more postop major complications (31.3%) compared to the NF (8.9%), P = .004, though DJK occurrence and reoperation between the groups was not significant. CONCLUSION: While all groups exhibited improved postop disability and pain scores, frail patients experienced greater amount of improvement in overall health state compared to baseline disability. This signifies that with frailty severity, patients have more room for improvement postop compared to baseline quality of life.

The effects of sitting Tai Chi on physical and psychosocial health outcomes among individuals with impaired physical mobility.

BACKGROUND: Impaired physical mobility, most often seen in people with neurological disorders (i.e., stroke and spinal cord injury survivors), musculoskeletal diseases or frailty, is a limitation in independent and purposeful physical movement of the body or one or more extremities. The physical restrictions result in negative consequences on an individual's physical and psychosocial functions. This proposal describes a systematic review protocol to determine the effectiveness and approaches of sitting Tai Chi intervention for individuals with impaired physical mobility. Our review would inform stakeholders' decisions in integrating this complementary therapy into current rehabilitation services. METHODS: Randomized controlled trials or quasi-experimental studies that compared an intervention group receiving sitting Tai Chi with a control group among adult participants with impaired physical mobility resulting from any health condition(s) will be included. Outcomes of interest will include physical and psychosocial health outcomes. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PubMed, CINAHL, Scopus, Web of Science, AMED, PsycINFO, SPORDiscus, PEDro, WanFang Data and China National Knowledge Infrastructure will be searched from their inception to January 2020. Additional searches will be performed to identify studies that are being refereed, to be published, unpublished or ongoing. Two reviewers will select the trials and extract data independently. The risk of bias of the included studies will be assessed using the Cochrane risk-of-bias tools. The Grading of Recommendations, Assessment, Development and Evaluation will be used to assess evidence quality for each review outcome. Data synthesis will be performed using Review Manager 5.3. When a meta-analysis is possible, we will assess the heterogeneity across the studies by computing the I statistics. RESULTS: A high-quality synthesis of current evidence of sitting Tai Chi for impaired physical mobility will be stated from several aspect using subjective reports and objective measures of performance. CONCLUSION: This protocol will present the evidence of whether sitting Tai Chi is an effective intervention for impaired physical mobility. PROSPERO REGISTRATION NUMBER: CRD 42019142681.

Evaluation of bio-psycho-social frailty in older persons on the territory: the method and the experience of the "Medesano Health House".

BACKGROUND AND AIM OF THE WORK: Frailty in older people is a situation of risk of dependency caused by many factors. On this consideration, the Medesano  city started a survey on the condition of fragility of people >75 aimed at building a monitoring system for timely interventions on the factors of risk and implementation of measures for preventing dependency. METHODS: The survey was conducted jointly by the family doctor and the social worker in the City. The multidimensional assessment considered logistic and housing conditions, disease, medications, basic and instumental acitvities of daily living, neurological and psycological conditions. RESULTS: The survey included 761 older people, with a following definition of condition and levels of frailty both at social (loneliness, lack of supporting network, etc..) and health level (complexity of the regimen, high and / or severe comorbidity) was planned from the beginning as the basis on which developing a continuous in time monitoring program for assessing the frailty, for a early taking in charge by Health and Welfare services, boosting integrated health and welfare interventions and promoting networks of solidarity and sociality. CONCLUSION: The data seem to confirm that the methodology used is sufficiently adequate to intercept frailty in > 75 years unknown to social services indicating that the monitoring on the functionality of the subjects obtained from the surveys by the General Practitioners could be deemed as a privileged way for a survey on large populations. After the survey was activated continuous monitoring of patients with social and clinical frailty.

Effectiveness of a muticomponent workout program integrated in an evidence based multimodal program in hyperfrail elderly patients: POWERAGING randomized clinical trial protocol.

BACKGROUND: Short-term and mid-term comparison of the efficacy of a multimodal program that incorporates a therapeutic workout program, medication review, diet adjustment and health education, in comparison to the standard medical practice in the improvement of the neuromuscular and physiological condition. Furthermore, it is intended to analyse the maintenance of these effects in a long-term follow-up (12 months) from the onset of the intervention. METHODS: A randomized clinical trial of elderly frail patients drawn from the Clinical Management Unit "Tiro de Pichón", Health District of Malaga, will be included in the study (after meeting the inclusion / exclusion criteria) will be randomized in two groups: a control group that will undergo an intervention consistent of medication review + diet adjustment + health education (regular workout recommendations within a complete advice on healthy lifestyles) and an experimental group whose intervention will consist of a multimodal treatment: therapeutic workout program+ medication review+ diet adjustment + health education. The sociodemographic, clinical and tracing variables will be reflected at the beginning of the study. In addition, the follow-up variables will be gathered at the second and sixth months after the beginning of the treatment and at the third and sixth months after the treatment (follow-up). The follow-up variables that will be measured are: body mass index, general health condition, fatigue, frailty, motor control, attention- concentration- memory, motor memory, spatial orientation, grip strength, balance (static, semi-dynamic), gait speed and metabolomics. A descriptive analysis of the sociodemographic variables of the participants will be conducted. One-Factor ANOVA will be used for the Within-Subject analysis and as for the Between-Subject analysis, the outcome variables between both the groups in each moment of the data collection will be compared. DISCUSSION: A multimodal program that incorporates a therapeutic workout program, medication review, diet adjustment and health education may be effective treatment to reduce the functional decline in elderly. The results of the study will provide information on the possible strengths and benefits in multimodal program in elderly. TRIAL REGISTRATION: ClinicalTrials.gov NCT02772952 registered May 2017.

New horizons in frailty: the contingent, the existential and the clinical.

In the past decade, frailty research has focused on refinement of biomedical tools and operationalisations, potentially introducing a reductionist approach. This article suggests that a new horizon in frailty lies in a more holistic approach to health and illness in old age. This would build on approaches that view healthy ageing in terms of functionality, in the sense of intrinsic capacity in interplay with social environment, whilst also emphasising positive attributes. Within this framework, frailty is conceptualised as originating as much in the social as in the biological domain; as co-existing with positive attributes and resilience, and as situated on a continuum with health and illness. Relatedly, social science-based studies involving interviews with, and observations of, frail, older people indicate that the social and biographical context in which frailty arises might be more impactful on the subsequent frailty trajectory than the health crisis which precipitates it. For these reasons, the article suggests that interpretive methodologies, derived from the social sciences and humanities, will be of particular use to the geriatrician in understanding health, illness and frailty from the perspective of the older person. These may be included in a toolkit with the purpose of identifying how biological and social factors jointly underpin the fluctuations of frailty and in designing interventions accordingly. Such an approach will bring clinical approaches closer to the views and experiences of older people who live with frailty, as well as to the holistic traditions of geriatric medicine itself.

[Frailty syndrome and nutritional status: assessment, prevention and treatment]. / Síndrome de fragilidad y estado nutricional: valoración, prevención y tratamiento.

INTRODUCTION: Frailty is a medical, dynamic and multifactorial syndrome characterised by a decreased functional reserve and an increased vulnerability to suffer adverse events. It is a different concept than comorbidity and disability and is potentially reversible. Assessment is also multifactorial and measurements of functional capacity, as gait velocity and Short Physical Performance Battery (SPPB), are very useful in the diagnostic process and in the monitoring treatment´s efficacy. It is important to perform a malnutrition screening, nutritional and cognitive assessment and a review of polypharmacy. Interventions should be also multifactorial; the combination of an individual multicomponent exercise program and nutritional targeted intervention seem to be the most effective.

INTRODUCCIÓN: La fragilidad es un síndrome médico, multidimensional y dinámico caracterizado por una disminución de la reserva funcional y una vulnerabilidad que aumenta el riesgo de padecer eventos adversos. Es un concepto diferente al de discapacidad y comorbilidad y es potencialmente reversible. La valoración es multidimensional y las medidas de capacidad funcional, tales como la velocidad de la marcha y el Short Physical Performance Battery (SPPB), pueden ser muy útiles para el diagnóstico y la monitorización del tratamiento. Como medidas más destacadas, resulta importante realizar un cribado de desnutrición, una valoración nutricional y del estado mental y revisar los fármacos. Las intervenciones son también multidimensionales, pero la combinación de una prescripción de ejercicio físico multicomponente individualizada y una adecuada intervención nutricional parecen las medidas más eficaces.

Frailty: an in-depth qualitative study exploring the views of community care staff.

BACKGROUND: Frailty is seen across various health and social care settings. However, little is known about how healthcare professionals, particularly those who provide care for older adults living in the community view frailty. There is also a dearth of information about the extent to which a shared understanding of frailty exists across the various disciplines of care. Such an understanding is crucial across care professionals as it ensures consistent assessment of frailty and facilitates interdisciplinary working/collaboration which is a key component in the management of frailty. This study aimed to explore: (i) how community care staff from various specialties viewed frailty; (ii) whether they had a shared understanding; and (iii) how they assessed frailty in everyday practice. METHODS: Semi-structured interviews were conducted with a purposive sample of 22 community care staff from seven specialties, namely: healthcare assistants, therapy assistants, psychiatric nurses, general nurses, occupational therapists, physiotherapists and social workers, recruited from four neighbourhood teams across Cambridgeshire, England. Interviews were analysed thematically. RESULTS: There was a shared narrative among participants that frailty is an umbrella term that encompasses interacting physical, mental health and psychological, social, environmental, and economic factors. However, various specialities emphasised the role of specific facets of the frailty umbrella. The assessment and management of frailty was said to require a holistic approach facilitated by interdisciplinary working. Participants voiced a need for interdisciplinary training on frailty, and frailty tools that facilitate peer-learning, a shared understanding of frailty, and consistent assessment of frailty within and across specialities. CONCLUSIONS: These findings underscore the need to: (i) move beyond biomedical descriptions of frailty; (ii) further explore the interacting nature of the various components of the frailty umbrella, particularly the role of modifiable factors such as psychological and socioeconomic resilience; (iii) care for frail older adults using holistic, interdisciplinary approaches; and (iv) promote interdisciplinary training around frailty and frailty tools to facilitate a shared understanding and consistent assessment of frailty within and across specialities.

Technology in geriatrics.

Recently, the interest of industry, government agencies and healthcare professionals in technology for aging people has increased. The challenge is whether technology may play a role in enhancing independence and quality of life and in reducing individual and societal costs of caring. Information and communication technologies, i.e. tools aimed at communicating and informing, assistive technologies designed to maintain older peoples' independence and increasing safety, and human-computer interaction technologies for supporting older people with motility and cognitive impairments as humanoid robots, exoskeletons, rehabilitation robots, service robots and companion-type are interdisciplinary topics both in research and in clinical practice. The most promising clinical applications of technologies are housing and safety to guarantee older people remaining in their own homes and communities, mobility and rehabilitation to improve mobility and gait and communication and quality of life by reducing isolation, improve management of medications and transportation. Many factors impair a broad use of technology in older age, including psychosocial and ethical issues, costs and fear of losing human interaction. A substantial lack of appropriate clinical trials to establish the clinical role of technologies to improve physical or cognitive performances and/or quality of life of subjects and their caregivers may suggest that the classical biomedical research model may not be the optimal choice to evaluate technologies in older people. In conclusion, successful technology development requires a great effort in interdisciplinary collaboration to integrate technologies into the existing health and social service systems with the aim to fit into the older adults' everyday life.

What is Comprehensive Geriatric Assessment (CGA)? An umbrella review.

Background: Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most. Objectives: our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA. Methods: we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources. Results: we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported. Conclusions: we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.

[Why and How Should I Assess Frailty? A Guide for the Preoperative Anesthesia Clinic]. / Warum und wie sollte ich Frailty erfassen? ­ ein Ansatz für die Anästhesieambulanz.

Introduction: Frailty is a condition of decreased physiological reserves seen in approx. one third of elderly anesthesiological patients, and affecting many aspects of treatment as well as outcome. Although there are over 60 measurement instruments, frailty assessment is still poorly implemented. Understanding why and how to assess frailty is key to its implementation in preoperative anesthesia clinics. Method: After presenting the impact of perioperative frailty and the benefits of an early diagnosis on health related quality of life, we present an overview of the most important tools that can be used in the preoperative frailty assessment. Results: Early diagnosis offer several optimization opportunities for the perioperative period. The most efficient frailty assessment tools are presented and discussed, including physical, cognitive, and psychosocial aspects. Conclusion: Frailty assessments vary immensely in terms of required time, equipment, and expertise. We recommend at least one test for each domain of frailty, so as to obtain a more holistic view of the patient's physiological reserve. The implementation of an adequate and consistent preoperative frailty assessment has the potential to improve patient safety as well as short and long term outcomes.

A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission.

BACKGROUND: There is concern that existing models of acute hospital care will become unworkable as the health service admits an increasing number of frail older people with complex health needs, and that there is inadequate evidence to guide the planning of acute hospital level services. We aim to evaluate whether geriatrician-led admission avoidance to hospital at home is an effective alternative to hospital admission. METHODS/DESIGN: We are conducting a multi-site randomised open trial of geriatrician-led admission avoidance hospital at home, compared with admission to hospital. We are recruiting older people with markers of frailty or prior dependence who have been referred to admission avoidance hospital at home for an acute medical event. This includes patients presenting with delirium, functional decline, dependence, falls, immobility or a background of dementia presenting with physical disease. Participants are randomised using a computerised random number generator to geriatrician-led admission avoidance hospital at home or a control group of inpatient admission in a 2:1 ratio in favour of the intervention. The primary endpoint 'living at home' (the inverse of death or living in a residential care setting) is measured at 6 months follow-up, and we also collect data on this outcome at 12 months. Secondary outcomes include the incidence of delirium, mortality, new long-term residential care, cognitive impairment, activities of daily living, quality of life and quality-adjusted survival, length of stay, readmission or transfer to hospital. We will conduct a parallel economic evaluation, and a process evaluation that includes an interview study to explore the experiences of patients and carers. DISCUSSION: Health systems around the world are examining how to provide acute hospital-level care to older adults in greater numbers with a fixed or shrinking hospital resource. This trial is the first large multi-site randomised trial of geriatrician-led admission avoidance hospital at home, and will provide evidence on alternative models of healthcare for older people who require hospital admission. TRIAL REGISTRATION: ISRCTN60477865 : Registered on 10 March 2014. Trial Sponsor: University of Oxford. Version 3.1, 14/06/2016.

Effect of a Combined Tai Chi, Resistance Training and Dietary Intervention on Cognitive Function in Obese Older Women.

Cognitive decline in older adults is a major public health problem and can compromise independence and quality of life. Exercise and diet have been studied independently and have shown to be beneficial for cognitive function, however, a combined Tai Chi, resistance training, and diet intervention and its influence on cognitive function has not been undertaken. The current study used a 12-week non-randomized research design with experiment and control groups to examine the effect of a combined Tai Chi, resistance training, and diet intervention on cognitive function in 25 older obese women. Results revealed improvements in domain specific cognitive function in our sample. Baseline cognitive function was correlated with changes in dietary quality. These findings suggest that Tai Chi and resistance training combined with diet intervention might be beneficial for community-based programs aiming to improve cognitive function.

Acupressure for frail older people in community dwellings-a randomised controlled trial.

Background: 'Frailty' is being increasing recognised as a geriatric syndrome of growing importance in the medical field. Acupressure is a non-pharmacological, non-invasive Traditional Chinese Medicine (TCM) treatment, which may serve to improve the quality of life (QOL) or prevent the progressive advancement of frailty in the aged population. Objective: to investigate the effects of a 12-week, TCM-principle guided acupressure intervention on the QOL of the frail older people living in the community. Methods: this is a randomised controlled trial with waitlist control design. Treatment group received 15 min of acupressure treatment, four times a week from both TCM practitioners and trained caregivers for 12 consecutive weeks. The waitlist control group served as a care-as-usual comparison to the treatment group for the 1st 12 weeks and then received the same treatment. Intention-to-treat principle was followed and mixed-effects models were used for data analysis. Results: the mean age of the participants was 76.12 ± 7.08, with a mean Tilburg frailty index score of 7.13 ± 1.76. Significant between-group differences were found in the change of physical domain score of WHOQOL-BREF (P = 0.001); change of Pittsburgh Sleep Quality Index (P < 0.001) and pain intensity (P = 0.006) with the treatment group demonstrating greater improvement. Within-group effect size analysis also indicated that the acupressure protocol has significant impact on these areas. Conclusions: the study's outcomes indicated that the acupressure protocol, when applied continuously for 12 weeks, 3-4 times a week, could improve the general QOL of frail older people living in community dwellings.

Integrated care for geriatric frailty and sarcopenia: a randomized control trial.

BACKGROUND: Exercise, nutrition, and psychological interventions may all have positive impacts on frailty and sarcopenia. However, it is not known whether an integrated care programme with all three components can be beneficial and the intensity of such programme is also not certain. In this study, we aim to determine the effectiveness of two levels of integrated care on frailty and sarcopenia. METHODS: A randomized control trial was conducted at two community hospitals in Taiwan. Older adults (65-79 years of age, N = 289) who scored ≥1 on the Cardiovascular Health Study Phenotypic Classification of Frailty (CHS_PCF) were enrolled in the trial. Low-level care (LLC) participants received a 2 h education course on frailty, sarcopenia, coping strategy, nutrition, and demonstration of study exercise programme. Educational multimedia material was distributed as reference for home practice with bi-monthly telephone follow-ups on adherences. High-level care (HLC) participants, in addition to LLC instructions, received six sessions of on-site problem solving therapy and 48 exercise sessions within 6 months. Brief nutrition consultation was also provided during the exercise sessions. Primary outcome was improvement of the CHS_PCF by at least one category (from pre-frail to robust, or from frail to pre-frail or robust) from baseline. Secondary outcomes included changes of individual frailty, and sarcopenia indicators. Assessments were done at 3, 6, and 12 months by trained research assistants blinded to randomization status. Intention-to-treat analysis was applied. RESULTS: Mean age was 71.6 ± 4.3 years, with 53% females. For the entire cohort, improvement of primary outcome was 35% at 3 months, increased to 40% at 6 months, and remained stable at 39% at 12 months. Improvement rates were similar in both groups. Compared with the LLC group, HLC participants had greater improvements in the following indices: energy expenditure of walking, 5 m walking time, dominant hand grip strength, timed-up-and-go-test, and one-leg-stand time - mainly at 6 and 12 month assessments. CONCLUSIONS: The 6 month integrated care improved frailty and sarcopenia status among community-dwelling elders, with high-intensity training yielding greater improvements. Low-level care could be promoted as a basic intervention, while HLC could be reserved for those at high risk and with high motivation.

Serving the Very Sick, Very Frail, and Very Old: Geriatrics, Palliative Care, and Clinical Ethics.

How can we provide the best care for growing numbers of very frail, very sick, or very old people? The disciplines of geriatrics, palliative care, and clinical ethics each have a good deal to offer to improve care for elders, yet each field is saddled with heavy historical baggage. Using a case as a springboard, we address specific strengths and shortcomings of each field, and what these disciplines can learn from each other. Geriatrics is currently largely focused on prevention of disability, cognitive impairment, and death; it should reorganize around a palliative approach to providing care for elders living with multiple chronic conditions, disability, and dementia. Palliative care, while paying some attention to the spectrum of advanced illness, concentrates primarily on cancer; it should expand its central purpose to include providing supportive care to elders with serious illness and their caregivers. Ethics committee members and consultants principally stress individual autonomy; they need to expand their approach and develop longitudinal relationships with patients and family members, routinely incorporating them in deliberations and the crafting of recommendations. However, improving these three disciplines will only go so far toward improving the care of very frail, very sick, or very old people. What is most needed is longitudinal care provided by interdisciplinary primary care teams steeped in the core principles of all three disciplines.

Merchants of Health: Shaping the Experience of Illness Among Older People.

Despite nearly universal health-care coverage for older Americans, the quality of care for the sickest and frailest remains sub-optimal. Understanding why requires analysis of the medical ecosystem. This paper considers the role of four of the principal actors in this system: physicians, hospitals, drug companies, and Medicare. Physicians spend more time in the office addressing diabetes and hypertension than they do evaluating falls and impaired cognition because of their training and their interests. Hospital administrators affect the hospital experience by investing in procedural specialties at the expense of low-tech, high-touch care. Pharmaceutical companies affect the medications older patients take by direct-to-consumer advertising and marketing to physicians. Medicare affects the patient's experience by prospective payment for hospitals, resulting in the burgeoning of post-acute care to accommodate early hospital discharges. Determining how to improve the quality of care for older people requires identifying a lever that affects the entire system. Medicare is uniquely positioned to serve this role. Reforming Medicare by introducing cost-effectiveness criteria for reimbursement of expensive devices, by instituting requirements that medical resident training programs include exposure to multidisciplinary team care, and by introducing a new benefit package for the frail elderly could improve American geriatric care.

Developing a model of short-term integrated palliative and supportive care for frail older people in community settings: perspectives of older people, carers and other key stakeholders.

BACKGROUND: understanding how best to provide palliative care for frail older people with non-malignant conditions is an international priority. We aimed to develop a community-based episodic model of short-term integrated palliative and supportive care (SIPS) based on the views of service users and other key stakeholders in the United Kingdom. METHOD: transparent expert consultations with health professionals, voluntary sector and carer representatives including a consensus survey; and focus groups with older people and carers were used to generate recommendations for the SIPS model. Discussions focused on three key components of the model: potential benefit of SIPS, timing of delivery and processes of integrated working between specialist palliative care and generalist practitioners. Content and descriptive analysis was employed and findings were integrated across the data sources. FINDINGS: we conducted two expert consultations (n = 63), a consensus survey (n = 42) and three focus groups (n = 17). Potential benefits of SIPS included holistic assessment, opportunity for end of life discussion, symptom management and carer reassurance. Older people and carers advocated early access to SIPS, while other stakeholders proposed delivery based on complex symptom burden. A priority for integrated working was the assignment of a key worker to co-ordinate care, but the assignment criteria remain uncertain. INTERPRETATION: key stakeholders agree that a model of SIPS for frail older people with non-malignant conditions has potential benefits within community settings, but differ in opinion on the optimal timing and indications for this service. Our findings highlight the importance of consulting all key stakeholders in model development prior to feasibility evaluation.