Frailty trajectories and associated factors in the years prior to death: evidence from 14 countries in the Survey of Health, Aging and Retirement in Europe.

BACKGROUND: Age-related changes in frailty have been documented in the literature. However, the evidence regarding changes in frailty prior to death is scarce. Understanding patterns of frailty progression as individuals approach death could inform care and potentially lead to interventions to improve individual's well-being at the end of life. In this paper, we estimate the progression of frailty in the years prior to death. METHODS: Using data from 8,317 deceased participants of the Survey of Health, Ageing, and Retirement in Europe, we derived a 56-item Frailty Index. In a coordinated analysis of repeated measures of the frailty index in 14 countries, we fitted growth curve models to estimate trajectories of frailty as a function of distance to death controlling both the level and rate of frailty progression for age, sex, years to death and dementia diagnosis. RESULTS: Across all countries, frailty before death progressed linearly. In 12 of the 14 countries included in our analyses, women had higher levels of frailty close to the time of death, although they progressed at a slower rate than men (e.g. Switzerland (-0.008, SE = 0.003) and Spain (-0.004, SE = 0.002)). Older age at the time of death and incident dementia were associated with higher levels and increased rate of change in frailty, whilst higher education was associated with lower levels of frailty in the year preceding death (e.g. Denmark (0.000, SE = 0.001)). CONCLUSION: The progression of frailty before death was linear. Our results suggest that interventions aimed at slowing frailty progression may need to be different for men and women. Further longitudinal research on individual patterns and changes of frailty is warranted to support the development of personalized care pathways at the end of life.

Trajectories of Frailty With Aging: Coordinated Analysis of Five Longitudinal Studies.

BACKGROUND AND OBJECTIVES: There is an urgent need to better understand frailty and its predisposing factors. Although numerous cross-sectional studies have identified various risk and protective factors of frailty, there is a limited understanding of longitudinal frailty progression. Furthermore, discrepancies in the methodologies of these studies hamper comparability of results. Here, we use a coordinated analytical approach in 5 independent cohorts to evaluate longitudinal trajectories of frailty and the effect of 3 previously identified critical risk factors: sex, age, and education. RESEARCH DESIGN AND METHODS: We derived a frailty index (FI) for 5 cohorts based on the accumulation of deficits approach. Four linear and quadratic growth curve models were fit in each cohort independently. Models were adjusted for sex/gender, age, years of education, and a sex/gender-by-age interaction term. RESULTS: Models describing linear progression of frailty best fit the data. Annual increases in FI ranged from 0.002 in the Invecchiare in Chianti cohort to 0.009 in the Longitudinal Aging Study Amsterdam (LASA). Women had consistently higher levels of frailty than men in all cohorts, ranging from an increase in the mean FI in women from 0.014 in the Health and Retirement Study cohort to 0.046 in the LASA cohort. However, the associations between sex/gender and rate of frailty progression were mixed. There was significant heterogeneity in within-person trajectories of frailty about the mean curves. DISCUSSION AND IMPLICATIONS: Our findings of linear longitudinal increases in frailty highlight important avenues for future research. Specifically, we encourage further research to identify potential effect modifiers or groups that would benefit from targeted or personalized interventions.

Blood-brain barrier disruption and ventricular enlargement are the earliest neuropathological changes in rats with repeated sub-concussive impacts over 2 weeks.

Repeated sub-concussive impact (e.g. soccer ball heading), a significantly lighter form of mild traumatic brain injury, is increasingly suggested to cumulatively alter brain structure and compromise neurobehavioural function in the long-term. However, the underlying mechanisms whereby repeated long-term sub-concussion induces cerebral structural and neurobehavioural changes are currently unknown. Here, we utilised an established rat model to investigate the effects of repeated sub-concussion on size of lateral ventricles, cerebrovascular blood-brain barrier (BBB) integrity, neuroinflammation, oxidative stress, and biochemical distribution. Following repeated sub-concussion 3 days per week for 2 weeks, the rats showed significantly enlarged lateral ventricles compared with the rats receiving sham-only procedure. The sub-concussive rats also presented significant BBB dysfunction in the cerebral cortex and hippocampal formation, whilst neuromotor function assessed by beamwalk and rotarod tests were comparable to the sham rats. Immunofluorescent and spectroscopic microscopy analyses revealed no significant changes in neuroinflammation, oxidative stress, lipid distribution or protein aggregation, within the hippocampus and cortex. These data collectively indicate that repeated sub-concussion for 2 weeks induce significant ventriculomegaly and BBB disruption, preceding neuromotor deficits.

Acceleration of health deficit accumulation in late-life: evidence of terminal decline in frailty index three years before death in the US Health and Retirement Study.

BACKGROUND: Little is known about within-person frailty index (FI) changes during the last years of life. In this study, we assess whether there is a phase of accelerated health deficit accumulation (terminal health decline) in late-life. MATERIAL AND METHODS: A total of 23,393 observations from up to the last 21 years of life of 5713 deceased participants of the AHEAD cohort in the Health and Retirement Study were assessed. A FI with 32 health deficits was calculated for up to 10 successive biannual, self- and proxy-reported assessments (1995-2014), and FI changes according to time-to-death were analyzed with a piecewise linear mixed model with random change points. RESULTS: The average normal (preterminal) health deficit accumulation rate was 0.01 per year, which increased to 0.05 per year at approximately 3 years before death. Terminal decline began earlier in women and was steeper among men. The accelerated (terminal) rate of health deficit accumulation began at a FI-value of 0.29 in the total sample, 0.27 for men, and 0.30 for women. CONCLUSION: We found evidence for an observable terminal health decline in the FI following declining physiological reserves and failing repair mechanisms. Our results suggest a conceptually meaningful cut-off value for the continuous FI around 0.30.

Frailty among middle-aged and older Canadians: population norms for the frailty index using the Canadian Longitudinal Study on Aging.

BACKGROUND: frailty is a public health priority now that the global population is ageing at a rapid rate. A scientifically sound tool to measure frailty and generate population-based reference values is a starting point. OBJECTIVE: in this report, our objectives were to operationalize frailty as deficit accumulation using a standard frailty index (FI), describe levels of frailty in Canadians ≥45 years old and provide national normative data. DESIGN: this is a secondary analysis of the Canadian Longitudinal Study on Aging (CLSA) baseline data. SETTING/PARTICIPANTS: about 51,338 individuals (weighted to represent 13,232,651 Canadians), aged 45-85 years, from the tracking and comprehensive cohorts of CLSA. METHODS: after screening all available variables in the pooled dataset, 52 items were selected to construct an FI. Descriptive statistics for the FI and normative data derived from quantile regressions were developed. RESULTS: the average age of the participants was 60.3 years (95% confidence interval [CI]: 60.2-60.5), and 51.5% were female (95% CI: 50.8-52.2). The mean FI score was 0.07 (95% CI: 0.07-0.08) with a standard deviation of 0.06. Frailty was higher among females and with increasing age, and scores >0.2 were present in 4.2% of the sample. National normative data were identified for each year of age for males and females. CONCLUSIONS: the standardized frailty tool and the population-based normative frailty values can help inform discussions about frailty, setting a new bar in the field. Such information can be used by clinicians, researchers, stakeholders and the general public to understand frailty, especially its relationship with age and sex.

The Rivermead Post-Concussion Questionnaire score is associated with disability and self-reported recovery six months after mild traumatic brain injury in older adults.

Background/Objectives: Post-concussion syndrome refers to the adverse group of symptoms following a mild traumatic brain injury (mTBI). The Rivermead post-concussion syndrome questionnaire (RPQ) is a common clinical tool for assessing baseline post-concussion syndrome symptomology; however, it is unknown if scores on this questionnaire are associated with future disability. Therefore, the goal of this study was to determine the association between baseline RPQ scores and future disability in older adults with mTBI.Methods and Findings: This study used a prospective cohort design, using the RPQ to measure baseline post-concussion syndrome symptomatology. Disability at 6 months was measured using the Glasgow Outcome Scale-Extended (GOSE; disability), short-form 12 (SF-12; physical and mental quality of life), and self-reported recovery. Linear and logistic models adjusted for confounding factors were estimated using 200 bootstrapped samples. Individuals with higher levels of baseline symptomatology were more likely to have poor GOSE scores (RR = 2.13, 95% CI [1.51, 2.31]) and self-reported recovery (RR = 2.64, 95% CI [1.31, 8.98]) 6 months later.Conclusions: High levels of baseline symptomatology may be associated with overall disability and individual perceptions of recovery 6 months post-MTBI. While the RPQ is valid in assessing a patient's post-concussive symptoms following mTBI, it may not predict long-term physical or mental health in older adults.

The Pictorial Fit-Frail Scale: Developing a Visual Scale to Assess Frailty.

BACKGROUND: Standardized frailty assessments are needed for early identification and treatment. We aimed to develop a frailty scale using visual images, the Pictorial Fit-Frail Scale (PFFS), and to examine its feasibility and content validity. METHODS: In Phase 1, a multidisciplinary team identified domains for measurement, operationalized impairment levels, and reviewed visual languages for the scale. In Phase 2, feedback was sought from health professionals and the general public. In Phase 3, 366 participants completed preliminary testing on the revised draft, including 162 UK paramedics, and rated the scale on feasibility and usability. In Phase 4, following translation into Malay, the final prototype was tested in 95 participants in Peninsular Malaysia and Borneo. RESULTS: The final scale incorporated 14 domains, each conceptualized with 3-6 response levels. All domains were rated as "understood well" by most participants (range 64-94%). Percentage agreement with positive statements regarding appearance, feasibility, and usefulness ranged from 66% to 95%. Overall feedback from health-care professionals supported its content validity. CONCLUSIONS: The PFFS is comprehensive, feasible, and appears generalizable across countries, and has face and content validity. Investigation into the reliability and predictive validity of the scale is currently underway.

The impact of frailty and cognitive impairment on quality of life: employment and social context matter.

ABSTRACTBackground:How cognitive impairment and frailty combine to impact on older adults' Quality of Life (QoL) is little studied, but their inter-relationships are important given how often they co-occur. We sought to examine how frailty and cognitive impairment, as well as changes in frailty and cognition, are associated with QoL and how these relationships differ based on employment status and social circumstances. METHODS: Using the Survey of Health, Ageing, and Retirement in Europe data, we employed moderated regression, followed by simple slopes analysis, to examine how the relationships between levels of health (i.e., of frailty and cognition) and QoL varied as a function of sex, age, education, social vulnerability, and employment status. We used the same analysis to test whether the relationships between changes in health (over two years) and QoL varied based on these same moderators. RESULTS: Worse frailty (b = -1.61, p < .001) and cognitive impairment (b = -0.08, p < .05) were each associated with lower QoL. Increase in frailty (b = -2.17, p < .001) and cognitive impairment (b = -0.25, p < .001) were associated with lower QoL. The strength of these relationships varied depending on interactions with age, sex, education, social vulnerability, and employment status. Higher social vulnerability was consistently associated with lower QoL in analyses examining both static health (b = -3.16, p < .001) and change in health (b = -0.66, p < .001). CONCLUSIONS: Many predictors of QoL are modifiable, providing potential targets to improve older adults' QoL. Even so, the relationships between health, cognition, and social circumstances that shape QoL in older adults are complex, highlighting the importance for individualized interventions.

What do we know about frailty in the acute care setting? A scoping review.

BACKGROUND: The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research. METHODS: This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. RESULTS: Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay. CONCLUSIONS: Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined.

Tracking changes in frailty throughout later life: results from a 17-year longitudinal study in the Netherlands.

Background: to better understand the development of frailty with ageing requires longitudinal studies over an extended time period. Objective: to investigate changes in the degree of frailty during later life, and the extent to which changes are determined by socio-demographic characteristics. Methods: six measurement waves of 1,659 Dutch older adults aged 65 years and over in the Longitudinal Aging Study Amsterdam (LASA) yielded 5,211 observations over 17 years. At each wave, the degree of frailty was measured with a 32-item frailty index (FI), employing the deficit accumulation approach. Socio-demographic characteristics included age, sex, educational level and partner status. Generalized Estimating Equation (GEE) analyses were performed to study longitudinal frailty trajectories. Results: higher baseline FI scores were observed in older people, women, and those with lower education or without partner. The overall mean FI score at baseline was 0.17, and increased to 0.39 after 17 years. The average doubling time in the number of deficits was 12.6 years, and this was similar in those aged 65-74 years and those aged 75+. Partner status was associated with changes over time in FI score, whereas sex and educational level were not. Conclusions: this longitudinal study showed that the degree of frailty increased with ageing, faster than the age-related increase previously observed in cross-sectional studies. Even so, the rate of deficit accumulation was relatively stable during later life.

Clinical characteristics and patterns of health deficits of centenarians receiving home care and long-term care services.

Centenarians (persons aged 100years and older) are one of the fastest growing cohorts in countries across the world. With the increasing prevalence of centenarians and growing amount of clinical information in large administrative health databases, it is now possible to more fully characterize the health of this unique and heterogeneous population. This study described patterns of health deficits in the centenarian population receiving care from community-based home care services and long-term care facilities (LTCFs) in Ontario, Canada. All centenarians who received home care and were assessed using the interRAI-Home Care Assessment instrument between 2007 and 2011 (n=1163) and all centenarians who resided in LTCFs between 2005 and 2011 who were assessed using the interRAI Minimum Data Set (MDS 2.0) (n=2228) were included in this study. Bivariate analyses described the centenarian population while K-means clustering analyses were utilized to identify relatively homogeneous subgroups within this heterogeneous population. The 3391 centenarians were aged 100 to 114 (mean age 101.5years ±1.9 SD) and the majority were women (84.7%). Commonly reported deficits included cognitive impairment, physical impairment, and bladder problems. Centenarians residing in LTCFs were significantly more likely than centenarians receiving home care services to report cognitive or functional impairment, or to exhibit symptoms of depression. The commonalities and uniqueness of four clusters of centenarians are described. Although there is great variability, there is also commonality within the centenarian population. Recognizing patterns within the heterogeneity of centenarians is key to providing high-quality person-centered care and to targeting health promotion and intervention strategies.

Dynamics of Frailty and Cognition After Age 50: Why It Matters that Cognitive Decline is Mostly Seen in Old Age.

BACKGROUND: Frailty has been considered an antecedent and, to a lesser extent, an outcome of cognitive impairment. Both frailty and cognitive impairment are multiply determined and each is strongly related to age, making it likely that the two interact, especially as people age. In consequence, understanding their interaction and co-occurrence can offer insight into pathophysiology, prevention, and management. OBJECTIVE: To examine the nature of the relationship between frailty and cognitive impairment using longitudinal data from the Survey of Health Aging and Retirement in Europe (SHARE), assessing for bidirectionality. METHODS: We conducted secondary analyses using data from the first two waves of SHARE. The sample (N = 11,941) was randomly split into two halves: one half for model development and one half for model confirmation. We used a 65 deficit Frailty Index and combined 5 cognitive deficits into a global cognitive impairment index. Cross-lagged path analysis within a structural equation modelling framework was used to examine the bi-directional relationship between the two measures. RESULTS: After controlling for age, sex, social vulnerability, education, and initial cognitive impairment, each 0.10 increase in baseline frailty was associated with a 0.01 increase in cognitive impairment at follow-up (p < 0.001). Likewise, each 0.1 increase in baseline cognitive impairment was associated with a 0.003 increase frailty at follow-up (p < 0.01). CONCLUSION: Our findings underscore the importance of considering cognitive impairment in the context of overall health. Many people with dementia are likely to have other health problems, which need to be considered in concert to achieve optimal health outcomes.

Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System.

Background: Physiotherapy and occupational therapy services can play a critical role in maintaining or improving the physical functioning, quality of life, and overall independence of older home care clients. Despite their importance, however, there is limited understanding of the factors that influence how rehabilitation services are allocated to older home care clients. The aim of this pilot study was to develop a preliminary understanding of the factors that influence decisions to allocate rehabilitation therapy services to older clients in the Ontario home care system, as perceived by three stakeholder groups. Methods: Semi-structured interviews were conducted with 10 key informants from three stakeholder groups: case managers, service providers, and health system policymakers. Results: Drivers of the allocation of occupational therapy and physiotherapy for older adults included functional needs and postoperative care. Participants identified challenges in providing home care rehabilitation to older adults, including impaired cognition and limited capacity in the home care system. Conclusions: Considering the changing demands for home care services, knowledge of current practices across the home care system can inform efforts to optimize rehabilitation services for the growing number of older adults. Further research is needed to advance the understanding of, and optimize rehabilitation service allocation to, older frail clients with multiple morbidities. Developing novel decision-support mechanisms and standardized clinical care pathways for older client populations may be beneficial.

Contexte : les services de physiothérapie et d'ergothérapie peuvent jouer un rôle essentiel dans le maintien ou l'amélioration du fonctionnement physique, de la qualité de vie et de l'autonomie des personnes âgées recevant des soins à domicile. Or, malgré l'importance des services de réadaptation à domicile, les facteurs qui influencent leur attribution auprès de cette clientèle sont mal connus. Cette étude pilote visait à mieux comprendre les facteurs qui influencent les décisions concernant l'attribution de services de réadaptation auprès des clients âgés au sein du système de soins à domicile de l'Ontario, tels que perçus par trois groupes d'intervenants. Méthodes : nous avons réalisé des entrevues semi-dirigées auprès de 10 informateurs-clés appartenant à trois groupes d'intervenants : des gestionnaires de cas, des fournisseurs de services et des responsables des politiques au sein du système de santé. Résultats : les facteurs influençant l'attribution des services d'ergothérapie et de physiothérapie aux personnes âgées comprenaient les besoins fonctionnels et les soins postopératoires. Les participants ont relevé les défis que pose la prestation des soins de réadaptation à domicile aux clients âgés, tels que l'altération de la fonction cognitive des clients et la capacité limitée du système de soins à domicile. Conclusion : compte tenu de l'évolution de la demande pour les soins à domicile, une bonne connaissance des pratiques actuelles à travers tout le système de soins à domicile peut guider les efforts visant à optimiser les services de réadaptation pour le nombre croissant de personnes âgées. Il faudrait approfondir les recherches afin de mieux comprendre la clientèle âgée frêle et multimorbide et d'optimiser l'attribution des services de réadaptation. Il pourrait y avoir lieu de mettre au point des mécanismes de soutien à la prise de décision et des plans de traitement normalisés pour les clients âgés.

A call for comparative effectiveness research to learn whether routine clinical care decisions can protect from dementia and cognitive decline.

Common diseases like diabetes, hypertension, and atrial fibrillation are probable risk factors for dementia, suggesting that their treatments may influence the risk and rate of cognitive and functional decline. Moreover, specific therapies and medications may affect long-term brain health through mechanisms that are independent of their primary indication. While surgery, benzodiazepines, and anti-cholinergic drugs may accelerate decline or even raise the risk of dementia, other medications act directly on the brain to potentially slow the pathology that underlies Alzheimer's and other dementia. In other words, the functional and cognitive decline in vulnerable patients may be influenced by the choice of treatments for other medical conditions. Despite the importance of these questions, very little research is available. The Alzheimer's Drug Discovery Foundation convened an advisory panel to discuss the existing evidence and to recommend strategies to accelerate the development of comparative effectiveness research on how choices in the clinical care of common chronic diseases may protect from cognitive decline and dementia.

Changes in Frailty Predict Changes in Cognition in Older Men: The Honolulu-Asia Aging Study.

BACKGROUND: As cognitive decline mostly occurs in late life, where typically it co-exists with many other ailments, it is important to consider frailty in understanding cognitive change. OBJECTIVE: Here, we examined the association of change in frailty status with cognitive trajectories in a well-studied cohort of older Japanese-American men. METHODS: Using the prospective Honolulu-Asia Aging Study (HAAS), 2,817 men of Japanese descent were followed (aged 71-93 at baseline). Starting in 1991 with follow-up health assessments every two to three years, cognition was measured using the Cognitive Abilities Screening Instrument (CASI). For this study, health data was used to construct an accumulation of deficits frailty index (FI). Using six waves of data, multilevel growth curve analyses were constructed to examine simultaneous changes in cognition in relation to changes in FI, controlling for baseline frailty, age, education, and APOE-ɛ4 status. RESULTS: On average, CASI scores declined by 2.0 points per year (95% confidence interval 1.9-2.1). Across six waves, each 10% within-person increase in frailty from baseline was associated with a 5.0 point reduction in CASI scores (95% confidence interval 4.7-5.2). Baseline frailty and age were associated both with lower initial CASI scores and with greater decline across the five follow-up assessments (p < 0.01). DISCUSSION: Cognition is adversely affected by impaired health status in old age. Using a multidimensional measure of frailty, both baseline status and within-person changes in frailty were predictive of cognitive trajectories.

Cumulative impact of health deficits, social vulnerabilities, and protective factors on cognitive dynamics in late life: a multistate modeling approach.

INTRODUCTION: Many factors influence late-life cognitive changes, and evaluating their joint impact is challenging. Typical approaches focus on average decline and a small number of factors. We used multistate transition models and index variables to look at changes in cognition in relation to frailty (accumulation of health deficits), social vulnerability, and protective factors in the Honolulu-Asia Aging Study (HAAS). METHODS: The HAAS is a prospective cohort study of 3,845 men of Japanese descent, aged 71 to 93 years at baseline. Cognitive function was measured using the Cognitive Abilities Screening Instrument (CASI). Baseline index variables were constructed of health deficits (frailty), social vulnerabilities, and protective factors. The chances of improvement/stability/decline in cognitive function and death were simultaneously estimated using multistate transition modeling for 3- and 6-year transitions from baseline. RESULTS: On average, CASI scores declined by 5.3 points (standard deviation (SD) = 10.0) over 3 years and 9.5 points (SD = 13.9) over 6 years. After adjusting for education and age, baseline frailty was associated with an increased risk of cognitive decline at 3 years (ß = 0.18, 95% confidence interval (CI), 0.08 to 0.29) and 6 years (ß = 0.40, 95% CI, 0.27 to 0.54). The social vulnerability index was associated with 3-year changes (ß = 0.16, 95% CI, 0.09 to 0.23) and 6-year changes (ß = 0.14, 95% CI, 0.05 to 0.24) in CASI scores. The protective index was associated with reductions in cognitive decline over the two intervals (3-year: ß = -0.16, 95% CI, -0.24 to -0.09; 6-year: ß = -0.21, 95% CI, -0.31 to -0.11,). CONCLUSIONS: Research on cognition in late life needs to consider overall health, the accumulation of protective factors, and the dynamics of cognitive change. Index variables and multistate transition models can enhance understanding of the multifactorial nature of late-life changes in cognition.

Successful aging and frailty: mutually exclusive paradigms or two ends of a shared continuum?

The conceptualization of positive and negative states of aging is contentious at the inter- and intraparadigm level; lack of consensus exists within and between states. Working within their respective paradigms, successful aging and frailty researchers may have lost sight of the larger picture. Are successful aging researchers describing nonfrail individuals? Are frailty researchers describing unsuccessful aging? It is imperative that researchers are cognizant of the ways in which their perspectives are contextualized within the literature and within related paradigms, so as to be able to clearly communicate their research and to ensure they are working within the appropriate paradigm to facilitate desired outcomes. Here we discuss the similarities and differences between successful aging and frailty in terms of the scope and emphasis of their constituent components and functioning: both SA and frailty include biomedical components; SA examines the high end, whilst frailty predominately examines the low end of the functioning spectrum. Frailty models emphasize the biomedical realm, whilst SA models emphasize both the biomedical and the psychosocial.

Social vulnerability and survival across levels of frailty in the Honolulu-Asia Aging Study.

PURPOSE: we evaluated mortality risk in relation to social vulnerability across levels of frailty among a cohort of older Japanese-American men. METHODS: in secondary analysis of the Honolulu-Asia Aging Study (HAAS), participants (n = 3,271) were aged 72-93 years at baseline. A frailty index (FI) created using 58 potential health deficits to quantify participants' frailty level at baseline, with four frailty strata: 0.0 < FI ≤ 0.1 (n = 1,074); 0.1 < FI ≤ 0.20 (n = 1,549); 0.2 < FI ≤ 0.30 (n = 472); FI > 0.3 (n = 176). Similarly, a social vulnerability index was created using 19 self-reported social deficits. Cox proportional hazard modelling was employed to estimate the impact of social vulnerability across the four levels of frailty, accounting for age, smoking, alcohol use and variation in health deficits within each frailty level. RESULTS: for the fittest participants, social vulnerability was associated with mortality (hazards ratio (HR) = 1.04, 95% confidence interval (CI) = 1.01, 1.07; P value = 0.008). Similarly, for those considered at risk for frailty, each social deficit was associated with a 5% increased risk of mortality. For frail individuals, the Cox regression analyses indicated that social vulnerability was not significantly associated with mortality (0.2 < FI ≤ 0.3: HR = 1.016, 95% CI = 0.98, 1.06; P value = 0.442; FI > 0.3: HR = 0.98, 95% CI = 0.93, 1.04). CONCLUSIONS: for the fittest and at-risk HAAS participants, the accumulation of social deficits was associated with significant increases in mortality risk. For frail individuals (FI > 0.20), the estimation of mortality risk may depend more so on intrinsic factors related to their health.

Rehabilitation therapies for older clients of the Ontario home care system: regional variation and client-level predictors of service provision.

PURPOSE: To examine regional variation in service provision and identify the client characteristics associated with occupational therapy (OT) and physiotherapy (PT) services for older adults in the Ontario Home Care System. METHODS: Secondary analyses of a provincial database containing comprehensive assessments (RAI-HC) linked with service utilization data from every older long-stay home care client in the system between 2005 and 2010 (n = 299 262). Hierarchical logistic regression models were used to model the dependent variables of OT and PT service use within 90 d of the initial assessment. RESULTS: Regional differences accounted for 9% of the variation in PT service provision and 20% of OT service provision. After controlling for the differences across regions, the most powerful predictors of service provision were identified for both OT and PT. The most highly associated client characteristics related to PT service provision were hip fracture, impairments in activities of daily living/instrumental activities of daily living, cerebrovascular accidents, and cognitive impairment. For OT, hazards in the home environment was the most powerful predictor of future service provision. CONCLUSIONS: Where a client lived was an important determinant of service provision in Ontario, raising the possibility of inequities in access to rehabilitation services. Health care planners and policy makers should review current practices and make adjustments to meet the increasing and changing needs for rehabilitation therapies of the aging population. Implications for Rehabilitation For older adults in home care, the goal of rehabilitation therapy services is to allow individuals to maintain or improve physical functioning, quality of life and overall independence while living within their community. Previous research has demonstrated that a large proportion of home care clients specifically identified as having rehabilitation potential do not receive it. This article used clinical assessment data to identify the predictors of and barriers to rehabilitation services for older adults in the Ontario Home Care System. Barriers of PT included dementia diagnosis and French as a first language. Barriers to OT included dementia diagnosis. Policies and practices related to service provision for older adults should be reconsidered if we are going to meet the demands of aging populations and increasing rates of functional and cognitive impairments.

Frailty in the Honolulu-Asia Aging Study: deficit accumulation in a male cohort followed to 90% mortality.

BACKGROUND: A frailty index (FI) based on the accumulation of deficits typically has a submaximal limit at about 0.70. The objectives of this study were to examine how population characteristics of the FI change in the Honolulu-Asia Aging Study cohort, which has been followed to near-complete mortality. In particular, we were interested to see if the limit was exceeded. METHODS: Secondary analysis of six waves of the Honolulu-Asia Aging Study. Men (n = 3,801) aged 71-93 years at baseline (1991) were followed until death (N = 3,455; 90.9%) or July 2012. FIs were calculated across six waves and the distribution at each wave was evaluated. Kaplan-Meier analyses and Cox proportional hazard models were performed to examine the relationship of frailty with mortality. RESULTS: At each wave, frailty was nonlinearly associated with age, with acceleration in later years. The distributions of the FIs were skewed with long right tails. Despite the increasing mortality in each successive wave, the 99% submaximal limit never exceeded 0.65. The risk of death increased with increasing values of the FI (eg, the hazard rate increased by 1.44 [95% CI = 1.39-1.49] with each increment in the baseline FI grouping). Depending on the wave, the median survival of people with FI more than 0.5 ranged 0.84-2.04 years. CONCLUSIONS: Even in a study population followed to almost complete mortality, the limit to deficit accumulation did not exceed 0.65, confirming a quantifiable, maximum number of health deficits that older men can tolerate.