Frailty detection in older adults via fractal analysis of acceleration signals from wrist-worn sensors.

Purpose: Frailty is a reversible multidimensional syndrome that puts older people at a high risk of adverse health outcomes. It has been proposed to emerge from the dysregulation of the complex system dynamics of physiologic control systems. We propose the analysis of the fractal complexity of hand movements as a new method to detect frailty in older adults. Methods: FRAIL scale and Fried's phenotype scores were calculated for 1209 subjects-72.4 (5.2) y.o. 569 women-and 1279 subjects-72.6 (5.3) y.o. 604 women-in the pubicly available NHANES 2011-2014 data set, respectively. The fractal complexity of their hand movements was assessed with a detrended fluctuation analysis (DFA) of their accelerometry records and a logistic regression model for frailty detection was fit. Results: Goodness-of-fit to a power law was excellent (R2>0.98). The association between complexity loss and frailty level was significant, Kruskal-Wallis test (df = 2, Chisq = 27.545, p-value <0.001). The AUC of the logistic classifier was moderate (AUC with complexity = 0.69 vs. AUC without complexity = 0.67). Conclusion: Frailty can be characterized in this data set with the Fried phenotype. Non-dominant hand movements in free-living conditions are fractal processes regardless of age or frailty level and its complexity can be quantified with the exponent of a power law. Higher levels of complexity loss are associated with higher levels of frailty. This association is not strong enough to justify the use of complexity loss after adjusting for sex, age, and multimorbidity.

Differential utility of various frailty diagnostic tools in non-geriatric hospital departments of several countries: A longitudinal study.

BACKGROUND: There is limited knowledge on the performance of different frailty scales in clinical settings. We sought to evaluate in non-geriatric hospital departments the feasibility, agreement and predictive ability for adverse events after 1 year follow-up of several frailty assessment tools. METHODS: Longitudinal study with 667 older adults recruited from five hospitals in three different countries (Spain, Italy and United Kingdom). Participants were older than 75 years attending the emergency room, cardiology and surgery departments. Frailty scales used were Frailty Phenotype (FP), FRAIL scale, Tilburg and Groningen Frailty Indicators, and Clinical Frailty Scale (CFS). Analyses included the prevalence of frailty, degree of agreement between tools, feasibility and prognostic value for hospital readmission, worsening of disability and mortality, by tool and setting. RESULTS: Emergency Room and cardiology were the settings with the highest frailty prevalence, varying by tool between 40.4% and 67.2%; elective surgery was the one with the lowest prevalence (between 13.2% and 38.2%). The tools showed a fair to moderate agreement. FP showed the lowest feasibility, especially in urgent surgery (35.6%). FRAIL, CFS and FP predicted mortality and readmissions in several settings, but disability worsening only in cardiology. CONCLUSIONS: Frailty is a highly frequent condition in older people attending non-geriatric hospital departments. We recommend that based upon their current feasibility and predictive ability, the FRAIL scale, CFS and FP should be preferentially used in these settings. The low concordance among the tools and differences in prevalence reported and predictive ability suggest the existence of different subtypes of frailty.

Predictors of Maintained Transitions Between Robustness and Prefrailty in Community-Dwelling Older Spaniards.

OBJECTIVES: We aimed to explore predictors of sustained transitions (those that are maintained for an extra follow-up) between robustness and prefrailty in both directions. DESIGN: Longitudinal population-based cohort. SETTING AND PARTICIPANTS: Community-dwelling Spaniards 65 years or older from the Toledo Study of Healthy Ageing. METHODS: The Fried's frailty phenotype was measured over 3 waves (2006-2009, 2011-2013, and 2014-2017). Multiple logistic regressions compared individuals following the pattern robust-prefrail-prefrail with those who remained robust across waves, and those following the pattern prefrail-robust-robust with those who remained prefrail, for sociodemographic, clinical, life-habits, dependency for activities of daily living, upper and lower extremities' strength variables. The Fried's items of those who remained prefrail and those who became robust were compared. RESULTS: Mean age was 72.3 years (95% CI: 71.8-72.8) and 57.9% (52.7%-63.0%) were women. After multivariate adjustment, predictors (apart from age) of the sustained transition robustness-prefrailty were as follows: number of drugs taken (odds ratio: 1.37; 95% CI: 1.14-1.65), not declaring the amount of alcohol consumed (8.32; 1.78-38.88), and grip strength (0.92 per kg; 0.86-0.99). Predictors of the sustained transition prefrailty-robustness were as follows: drinking alcohol (0.2; 0.05-0.83), uricemia (0.67; 0.49-0.93), number of chair stands in 30 seconds (1.14; 1.01-1.28), and grip strength (1.12; 1.05-1.2). Low grip strength was associated with a lower probability of regaining robustness. CONCLUSIONS AND IMPLICATIONS: Prediction of sustained transitions between the first stages of frailty development can be achieved with a reduced number of variables and noting whether the Fried's item leading to a diagnosis of prefrailty is low grip strength. Our results suggest the need to intensify interventions on deprescription, quitting alcohol, and strengthening of upper and lower limbs.

Diagnostic accuracy of the FRAIL scale plus functional measures for frailty screening: a cross-sectional study.

BACKGROUND: There is little knowledge of the diagnostic accuracy of screening programmes for frailty in primary care settings. AIM: To assess a two-step strategy consisting of the administration of the FRAIL scale to those who are non-dependent and aged ≥75 years, followed-up by measurement of the Short Physical Performance Battery (SPPB) or gait speed in those who are positive. DESIGN & SETTING: Cross-sectional and longitudinal cohort study. Analysis of primary care data from the FRAILTOOLS project at five European cities. METHOD: All primary care patients consecutively attending were enrolled. They received the index tests, plus the Fried frailty phenotype (FP) and the frailty index to assess their frailty status. Mortality and worsening of dependency in basic and instrumental activities of daily living (BADL and IADL) over 1 year were ascertained. RESULTS: Prevalence of frailty based on FP was 14.9% in the 362 participants. A FRAIL scale score ≥1 had a sensitivity of 83.3% (95% confidence interval [CI] = 73.1 to 93.6) to detect frailty. A positive result and an SPPB score <11 had a sensitivity of 72.2% (95% CI = 59.9 to 84.6); when combined with a gait speed <1.1 m/s, the sensitivity was 80.0% (95% CI = 68.5 to 91.5). Two-thirds of those screened as positive were not frail. In the best scenario, sensitivities of this last combination to detect IADL and BADL worsening were 69.4% (95% CI = 59.4 to 79.4) and 63.6% (95% CI = 53.4 to 73.9), respectively. CONCLUSION: Combining the FRAIL scale with other functional measures offers an acceptable screening approach for frailty. Accurate prediction of worsening dependency and death need to be confirmed through the piloting of a frailty screening programme.

Diagnostic accuracy of the frail scale plus functional measures for frailty screening.

BACKGROUND: There is little knowledge of the diagnostic accuracy of screening programmes for frailty in primary care settings. AIM: To assess a two-step strategy consisting of the administration of the FRAIL scale to those who are non-dependent, aged ≥75 years, followed-up by measurement of the Short Physical Performance Battery (SPPB) or gait speed in those who are positive. DESIGN & SETTING: Cross-sectional and longitudinal cohort study. Analysis of primary care data from the FRAILTOOLS project at five European cities. METHOD: All patients consecutively attending were enrolled. They received the index tests plus the Fried phenotype and the frailty index to assess their frailty status. Mortality and worsening of dependency in basic (BADL) and instrumental (IADL) activities of daily living over a year were ascertained. RESULTS: Prevalence of frailty based on frailty phenotype was 14.9% in the 362 participants. A FRAIL scale score ≥1 had a sensitivity of 83.3% (95%CI:73.1-93.6) to detect frailty. A positive result and a SPPB score <11 had a sensitivity of 72.2% (95%CI: 59.9-84.6); when combined with a gait speed <1.1 m/s, the sensitivity was 80% (95%CI: 68.5-91.5). Two thirds of those screened as positive were not frail. In the best scenario, sensitivities of this last combination to detect IADL and BADL worsening were 69.4% (95%CI: 59.4-79.4) and 63.6% (95%CI: 53.4-73.9). CONCLUSION: Combining the FRAIL scale with other functional measures offers an acceptable screening approach for frailty. Accurate prediction of worsening dependency and death need to be confirmed through the piloting of a frailty screening programme.

The ability of eight frailty instruments to identify adverse outcomes across different settings: the FRAILTOOLS project.

BACKGROUND: To compare the performance of eight frailty instruments to identify relevant adverse outcomes for older people across different settings over a 12 month follow-up. METHODS: Observational longitudinal prospective study of people aged 75 + years enrolled in different settings (acute geriatric wards, geriatric clinic, primary care clinics, and nursing homes) across five European cities. Frailty was assessed using the following: Frailty Phenotype, SHARE-FI, 5-item Frailty Trait Scale (FTS-5), 3-item FTS (FTS-3), FRAIL scale, 35-item Frailty Index (FI-35), Gérontopôle Frailty Screening Tool, and Clinical Frailty Scale. Adverse outcomes ascertained at follow-up were as follows: falls, hospitalization, increase in limitation in basic (BADL) and instrumental activities of daily living (IADL), and mortality. Sensitivity, specificity, and capacity to predict adverse outcomes in logistic regressions by each instrument above age, gender, and multimorbidity were calculated. RESULTS: A total of 996 individuals were followed (mean age 82.2 SD 5.5 years, 61.3% female). In geriatric wards, the FI-35 (69.1%) and the FTS-5 (67.9%) showed good sensitivity to predict death and good specificity to predict BADL worsening (70.3% and 69.8%, respectively). The FI-35 also showed good sensitivity to predict BADL worsening (74.6%). In nursing homes, the FI-35 and the FTSs predicted mortality and BADL worsening with a sensitivity > 73.9%. In geriatric clinic, the FI-35, the FTS-5, and the FRAIL scale obtained specificities > 85% to predict BADL worsening. No instrument achieved high enough sensitivity nor specificity in primary care. All the instruments predict the risk for all the outcomes in the whole sample after adjusting for age, gender, and multimorbidity. The associations of these instruments that remained significant by setting were for BADL worsening in geriatric wards [FI-35 OR = 5.94 (2.69-13.14), FTS-3 = 3.87 (1.76-8.48)], nursing homes [FI-35 = 4.88 (1.54-15.44), FTS-5 = 3.20 (1.61-6.38), FTS-3 = 2.31 (1.27-4.21), FRAIL scale = 1.91 (1.05-3.48)], and geriatric clinic [FRAIL scale = 4.48 (1.73-11.58), FI-35 = 3.30 (1.55-7.00)]; for IADL worsening in primary care [FTS-5 = 3.99 (1.14-13.89)] and geriatric clinic [FI-35 = 3.42 (1.56-7.49), FRAIL scale = 3.27 (1.21-8.86)]; for hospitalizations in primary care [FI-35 = 3.04 (1.25-7.39)]; and for falls in geriatric clinic [FI-35 = 2.21 (1.01-4.84)]. CONCLUSIONS: No single assessment instrument performs the best for all settings and outcomes. While in inpatients several commonly used frailty instruments showed good sensitivities (mainly for mortality and BADL worsening) but usually poor specificities, the contrary happened in geriatric clinic. None of the instruments showed a good performance in primary care. The FI-35 and the FTS-5 showed the best profile among the instruments assessed.

Differential Association of Frailty and Sarcopenia With Mortality and Disability: Insight Supporting Clinical Subtypes of Frailty.

OBJECTIVES: Sarcopenia and frailty have been shown separately to predict disability and death in old age. Our aim was to determine if sarcopenia may modify the prognosis of frailty regarding both mortality and disability, raising the existence of clinical subtypes of frailty depending on the presence of sarcopenia. DESIGN: A Spanish longitudinal population-based study. SETTING AND PARTICIPANTS: The population consists of 1531 participants (>65 years of age) from the Toledo Study of Health Aging. METHODS: Sarcopenia and frailty were assessed following Foundation for the National Institutes of Health criteria and the Fried Frailty Phenotype, respectively. Mortality was assessed using the National Death Index. Functional status was determined using Katz index. We ran multivariate logistics and proportional hazards models adjusting for age, sex, baseline function, and comorbidities. RESULTS: Mean age was 75.4 years (SD 5.9). Overall, 70 participants were frail (4.6%), 565 prefrail (36.9%), and 435 sarcopenic (28.4%). Mean follow-up was 5.5 and 3.0 years for death and worsening function, respectively. Furthermore, 184 participants died (12%) and 324 worsened their functioning (24.8%). Frailty and prefrailty were associated with mortality and remained significant after adjustment by sarcopenia [hazard risk (HR) 3.09, 95% confidence interval (CI) 1.84-5.18; P < .001; HR 1.58, 95% CI 1.12-2.24, P = .01]. However, the association of sarcopenia with mortality was reduced and became nonsignificant (HR 1.43, 95% CI 0.99-2.07, P = .057) when both frailty and sarcopenia were included in the same model. In the disability model, frailty and sarcopenia showed a statistically significant interaction (P = .016): both had to be present to predict worsening of disability. CONCLUSIONS AND IMPLICATIONS: Sarcopenia plays a relevant role in the increased risk of functional impairment associated to frailty, but that seems not to be the case with mortality. This finding raises the need of assessing sarcopenia as a cornerstone of the clinical work after diagnosing frailty.

Transitions Between Frailty States and Its Predictors in a Cohort of Community-Dwelling Spaniards.

OBJECTIVES: Study the frequency and determinants of frailty transitions in a community-dwelling older population. DESIGN: Population-based prospective longitudinal study [The Toledo Study of Healthy Ageing (TSHA)]. SETTING AND PARTICIPANTS: 1748 community-dwelling individuals aged >65 years living in Toledo, a Spanish province. METHODS: Frailty was measured with the Fried phenotype. Logistic models were used to assess the associations of sociodemographic, clinical, life-habits, functional, physical performance, and analytical variables with frailty transitions (losing robustness, transitioning from prefrailty to robustness, and from prefrailty to frailty) over a median of 5.2 years. RESULTS: Mean age on enrolment was 75 years, and 55.8% were females. At baseline, 10.3% were frail and 43.1% prefrail. At follow-up, 35.8% of the frail individuals recovered to a prefrail and 15.1% to a robust state. In addition, 43.7% of the prefrail participants became robust, but 14.5% developed frailty. Of those robust at baseline, 32.9% became prefrail and 4.2% frail. In multivariate logistic models, chair-stands had a predictive role in all transitions studied: linearly in keeping robustness and with a floor effect (5 stands) in transitions from prefrailty to robustness and (inversely) from prefrailty to frailty. More depressive symptoms were associated with unfavorable transitions. Not declaring the amount of alcohol drunk and low grip strength were associated with loss of robustness. Hearing and cognitive impairment, low physical activity and smoking with transitioning from prefrailty to frailty. Autonomy for instrumental activities of daily living and uricemia were associated with transitions between robustness and prefrailty in both directions. Increasing body mass index in the range of moderate to severe obesity hampered regaining robustness. CONCLUSIONS AND IMPLICATIONS: Spontaneous improvement of frailty measured with the Fried phenotype is frequent, mainly to prefrailty. Most of the variables associated with transitions are modifiable and suggest research topics and interventions to reduce frailty in clinical and social care settings.

Early identification of frailty: Developing an international delphi consensus on pre-frailty.

BACKGROUND: Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent intermediate state before frailty becomes established. Despite being widely-used in the literature and increasingly in clinical practice, it is poorly understood. OBJECTIVE: To establish consensus on the construct and approaches to diagnose and manage pre-frailty. METHODS: We conducted a modified (electronic, two-round) Delphi consensus study. The questionnaire included statements concerning the concept, aspects and causes, types, mechanism, assessment, consequences, prevention and management of pre-frailty. Qualitative and quantitative analysis methods were employed. An agreement level of 70% was applied. RESULTS: Twenty-three experts with different backgrounds from 12 countries participated. In total, 70 statements were circulated in Round 1. Of these, 52.8% were accepted. Following comments, 51 statements were re-circulated in Round 2 and 92.1% were accepted. It was agreed that physical and non-physical factors including psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life. Experts considered pre-frailty to be an age-associated multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It can be reversed or attenuated by targeted interventions. Brief, feasible, and validated tools and multidimensional assessment are recommended to identify pre-frailty. CONCLUSIONS: Consensus suggests that pre-frailty lies along the frailty continuum. It is a multidimensional risk-state associated with one or more of physical impairment, cognitive decline, nutritional deficiencies and socioeconomic disadvantages, predisposing to the development of frailty. More research is needed to agree an operational definition and optimal management strategies.

[Advantage, a joint action to face up to frailty.] / Advantage, una acción conjunta para plantarle cara a la fragilidad.

The European Commission and 22 European Union Member States cofounded the first Joint Action (JA) in frailty: ADVANTAGE. It aimed to build a common framework to push frailty as a public health priority contributing to a homogeneous and evidence-based approach across Europe. This article details how the JA has evolved and its main results, especially in Spain where the Roadmap to Approach Frailty was developed within the Strategy of Health Promotion and Prevention of the National Health System and approved by the Public Health Commission on 14/11/2019. This document includes six actions to be implemented in the coming years.

La Comisión Europea ha cofinanciado, junto 22 estados miembros de la Unión Europea, la primera Acción Conjunta en fragilidad: ADVANTAGE. Su objetivo ha sido definir una estrategia común que posicionase la fragilidad como tema prioritario de salud pública y que contribuyese a impulsar su abordaje, basado en evidencias, de una manera más homogénea en Europa. En este artículo se detalla cómo se desarrolló la acción y cuáles fueron los principales resultados, especialmente en España, donde, en el marco de la Estrategia de Promoción de la Salud y Prevención en el SNS, se elaboró la Hoja de ruta para el abordaje de la fragilidad en España que fue aprobada por la Comisión de Salud Pública el 14/11/2019. Este documento incluye seis acciones a desarrollar en los próximos años.

The Structural and Intercultural Competence for Epidemiological Studies (SICES) guidelines: a 22-item checklist.

Structural and intercultural competence approaches have been widely applied to fields such as medical training, healthcare practice, healthcare policies and health promotion. Nevertheless, their systematic implementation in epidemiological research is absent. Based on a scoping review and a qualitative analysis, in this article we propose a checklist to assess cultural and structural competence in epidemiological research: the Structural and Intercultural Competence for Epidemiological Studies guidelines. These guidelines are organised as a checklist of 22 items and consider four dimensions of competence (awareness and reflexivity, cultural and structural validation, cultural and structural sensitivity, and cultural and structural representativeness), which are applied to the different stages of epidemiological research: (1) research team building and research questions; (2) study design, participant recruitment, data collection and data analysis; and (3) dissemination. These are the first guidelines addressing structural and cultural competence in epidemiological inquiry.

Relationship between self-reported visual impairment and worsening frailty transition states in older people: a longitudinal study.

BACKGROUND: Visual impairment (VI) may lead to worsening functional status and disability. Although disability is very difficult to reverse, it is usually preceded by frailty that may be reverted more easily. It is possible that VI is also related to frailty. AIMS: To assess the relationship between VI and worsening of the frailty status. METHODS: Data were taken from the Toledo Study for Healthy Aging (TSHA), a cohort study of community-dwelling people older than 65 years living in one Spanish province who were followed for 5 years. 1181 participants were included. VI was self-reported and frailty was operationalized using the Fried's phenotype adapted to a Spanish population. Models of multivariate logistic regression were built to assess the associations. RESULTS: The mean age was 73.9 (Standard Deviation (SD) = 5 years) and 58.5% were females. Pre-frailty/frailty prevalence at baseline and follow-up were 41.2/5% and 36.2/12.5%, respectively, and VI was reported by 14.1%. After adjusting for age, gender, education level, tobacco consumption, type 2 diabetes mellitus, high blood pressure, cardiovascular disease, depressive symptoms and cognitive status, odds ratios for the development of frailty by VI were 2.5 (95% Confidence Interval (CI) 1.5-4.4) for non-frail, 2.7 (95% CI 1.3-5.7) for pre-frail and 1.9 (CI 0.6-6.00) for robust participants. The frailty domains whose appearance was most increased by VI were slowness, low energy, low physical activity and weakness. DISCUSSION: Our findings support that VI worsens frailty in the early stages of its development (pre-frailty). VI impairs several frailty items at the same time. CONCLUSIONS: Our study highlights the need to assess both VI and frailty for the prevention of frailty and disability in older people.

The Disease Burden Morbidity Assessment in older adults and its association with mortality and other health outcomes.

The objective of this study was to assess how disease burden caused by chronic conditions is related to mortality (predictive validity) and other health outcomes (convergent validity). This was studied in 625 community-dwelling adults living in Spain aged 65 years and older. Disease burden was measured with the Disease Burden Morbidity Assessment (DBMA). The association with 5-year mortality was assessed using a Cox model and Kaplan-Meier curves. For convergent validity, mean age, sex ratio, patient-centered outcomes and healthcare utilization were compared for high and low DBMA scores (< 10 vs. ≥ 10). Also, a multivariable linear regression model was used to evaluate the DBMA as a function of these variables. Mean DBMA score in our sample was 7.5. After 5 years, 35 participants had died (5.5%). The Cox model displayed a hazard ratio of 1.07, and the Kaplan-Meier curves showed lower survival for high DBMA scores. Among participants with high DBMA scores, low self-perceived health, disability and female sex were more frequent, and this group showed lower mean scores for quality of life (Personal Wellbeing Index), affect balance (Scale of Positive and Negative Experience) and physical activity (Yale Physical Activity Survey), higher mean age and higher healthcare utilization than persons with low DBMA scores. In the multivariable regression, all variables but age were significantly associated with the DBMA. In conclusion, the DBMA showed satisfactory predictive and convergent validity. In our aging society, it can be applied to better understand and improve care for older persons with multiple chronic conditions.

Transitions and trajectories in frailty states over time: a systematic review of the European Joint Action ADVANTAGE.

INTRODUCTION: Frailty is a dynamic syndrome and may be reversible. Despite this, little is known about trajectories or transitions between different stages of frailty. METHODS: A systematic review was conducted, selecting studies reporting frailty trajectories or transition states for adults in any settings in European ADVANTAGE Joint Action Member States. RESULTS: Only three papers were included. Data were from longitudinal community-based cohorts in the United Kingdom, Netherlands and Italy. The English study investigated the effect of physical activity on the progression of frailty over a 10-year period. Two presented data on the proportion of participants experiencing at least one frailty transition over time (32.6% in the Italian sample aged ≥ 65 years followed for 4.4 years; 34.3% in the Dutch sample aged 65-75 years, followed for 2 years). CONCLUSIONS: Data on frailty trajectories and transition states were limited and heterogeneous. Well-designed prospective studies and harmonized approaches to data collection are now needed.

Incidence of frailty: a systematic review of scientific literature from a public health perspective.

INTRODUCTION: Because of the dynamic nature of frailty, prospective epidemiological data are essential to calibrate an adequate public health response. METHODS: A systematic review of literature on frailty incidence was conducted within the European Joint Action ADVANTAGE. RESULTS: Of the 6 studies included, only 3 were specifically aimed at estimating frailty incidence, and only 2 provided disaggregated results by at least gender. The mean follow-up length (1-22.2 years; median 5.1), sample size (74-6306 individuals), and age of participants (≥ 30-65) varied greatly across studies. The adoption of incidence proportions rather than rates further limited comparability of results. After removing one outlier, incidence ranged from 5% (follow-up 22.2 years; age ≥ 30) to 13% (follow-up 1 year, age ≥ 55). CONCLUSIONS: Well-designed prospective studies of frailty are necessary. To facilitate comparison across studies and over time, incidence should be estimated in person-time rate. Analyses of factors associated with the development of frailty are needed to identify high-risk groups.

Population screening, monitoring and surveillance for frailty: three systematic reviews and a grey literature review.

INTRODUCTION: Little is known about programmes or interventions for the screening, monitoring and surveillance of frailty at population level. METHODS: Three systematic searches and an opportunistic grey literature review from the countries participating in the ADVANTAGE Joint Action were performed. RESULTS: Three studies reported local interventions to screen for frailty, two of them using a two-step screening and assessment method and one including monitoring activities. Another paper reviewed both providers' and participants' experiences of screening activities. Three on-going European projects and population-screening programmes in primary care await evaluation. An electronic Frailty Index for use with patients' primary care records has been recently validated. No study described systematic processes for the surveillance of frailty. CONCLUSIONS: There is insufficient evidence for the effectiveness of population-level screening, monitoring and surveillance of frailty. Development and evaluation of community-based two-step programmes including those that incorporate electronic health records, particularly in primary care, are now needed.