Effect of leisure activity on frailty trajectories among Chinese older adults: a 16-year longitudinal study.

BACKGROUND: While the significant association between leisure activities and frailty risk among older adults is well-established, the impact of integrated leisure activity scores and different categories of them on frailty trajectories over time remains unclear. METHODS: This study utilized longitudinal data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which enrolled participants aged 65 years and older between 2002 and 2018. Frailty trajectories were derived using group-based trajectory modelling, and based on these trajectories, subjects were classified into various categories. Leisure activity was measured by integrated scores as well as three distinct categories: physically, cognitively, and socially stimulating activity. The effect of leisure activity on frailty trajectories was examined using multinomial logistic regression. RESULTS: By analysing data from 2,299 older adults, three frailty trajectories were identified: non-frail, moderate progressive, and high progressive. The results indicated that an increase in the score of integrated leisure activity was associated with 11% (odds ratio [OR] 0.89; 95% Confidence Interval [CI] 0.85-0.93) and 14% (OR 0.86; 95% CI 0.80-0.91) decrease in the likelihood of being in the moderate and high progressive frailty trajectories, respectively. Engaging in physically stimulating activity lowered the odds of belonging to the moderate and high progressive trajectory by 43% (OR 0.57; 95% CI 0.40-0.81; OR 0.57; 95% CI 0.36-0.92, respectively). Participation in socially stimulating activity showed a lower odd of being in the moderate progressive trajectory (OR 0.68; 95% CI 0.49-0.93) and the high progressive trajectory (OR, 0.61; 95% CI, 0.39-0.95). The effects of leisure activities on frailty trajectories were observed not to vary by age, education level and retirement status. CONCLUSIONS: This study suggests that older adults should be encouraged to increase both the amount and variety of their leisure activities. Physically stimulating activities should be considered the primary choice, followed by socially and cognitively stimulating activities.

Hybrid model of care for older persons for improvement of frailty index-a community-based interventional study in an urban setting.

BACKGROUND: An older person undergoes a 'disablement' process with aging. A comprehensive geriatric assessment centered around the functional status informs the healthcare provider of their frailty status, based on which tailored interventions may be designed to help prevent/reverse frailty. This study was conducted to assess the improvement in frailty index by training older persons for self-care practices using a multi-domain behavioural intervention, assisted by their caregivers. METHODS: It is a community-based interventional trial among older persons aged ≥ 60 years and their primary caregivers conducted in an urban community for a period of 15 months. A hybrid model, which exploits the advantages of every indigenous geriatric model of care, in providing a holistic care to old persons, was developed and adopted. Intervention was designed to incorporate all domains of frailty assessed, based upon self-efficacy and social interdependence theory. Frail-VIG scale and SPPB scores were used to measure the outcomes. RESULTS: 128 older persons and their primary caregivers were recruited. Median age was 70 and 67 years in the intervention and control group respectively, with majority being males. The median frailty index at baseline was 0.36 in both the groups, with improvement in intervention group (0.20) and worsening in control group (0.44) at end-line. From the DID analysis, a reduction of 0.19 points of frailty index was observed (even after adjustment for co-variates) in the intervention group, as compared to the control group. Also, it was observed that age and gender of the old person, their per capita income and the family support played an interactive effect in improvement of the frailty index. There was a significant difference in SPPB scores as well, between the groups [5 (1) in CG vs. 7 (2) in IG, p < 0.001]. CONCLUSION: Frailty could be reversed with appropriate interventions designed on the pillars of self-efficacy, and social interdependence among family members. The hybrid model of care delineates the role of caregivers, who reinforce the old persons to follow prescribed interventions.

An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises.

BACKGROUND: Frail people receiving home care services face an increased risk of developing crisis, which can result in adverse events, coercive measures, and acute institutionalisation. The prevalence of frailty is expected to increase due to the ageing population in most countries. However, our knowledge of the process leading to crises among frail community-dwelling patients remains limited. The aim of our study was to explore how users of home care services and their next of kin experienced crises and how these crises were approached by home care services. METHODS: A qualitative explorative design with 21 interviews was conducted. We explored crises within the last year that had led to an acute institutionalisation (hospital or nursing home) or to an unstable situation with high risk of institutionalisation. Systematic text condensation (STC) was used to analyse the data. RESULTS: Our findings are summarised into one overarching theme; an organisation working mainly reactively instead of proactively, which is supported by four subthemes: (1) insufficient communication-a determinant of crises, (2) the lack of a holistic approach, (3) a sense of being a burden, and (4) the complexity of crises. The reactive approach is demonstrated in the participant's experience of insufficient communication and the lack of a holistic approach from the service, but also in the user's sense of being a burden, which seems to be reinforced by the experienced busyness from the staff in the home care services. This reactive approach to crises seems to have contributed to difficulties in detecting the various stressors involved in the complex process leading to crisis. CONCLUSIONS: Our findings suggest that home care services tend to be characterised by a reactive approach to rising instability and the development of crises for users. This can be interpreted as an emergent property of the organisation and the adaptation towards exceeding demands due to insufficient capacity in health care services. We recommend the use of multicomponent care programmes comprising interdisciplinary case conferences in home care services to implement a cultural change that can shift the service from a reactive, fragmented, and task-oriented approach to a more proactive approach.

Alcohol consumption and frailty risk: a dose-response meta-analysis of cohort studies.

BACKGROUND/AIMS: While previous studies suggest that light-to-moderate alcohol consumption may reduce the frailty risk, the dose-response relationship is still under question. To address the knowledge gap, we conducted a systematic review and dose-response meta-analysis of cohort studies to examine the association of alcohol consumption with the risk of both prefrailty and frailty in adults. METHODS: We searched MEDLINE (Ovid), PubMed and Scopus to identify relevant cohort studies published before 8 May 2024. The dose-response meta-analysis was performed to investigate the associations between alcohol drinking and the risk of developing pre-frailty and frailty. We used random-effects models to calculate pooled relative risks (RR) with 95% CIs. RESULTS: We included nine cohort studies with 64 769 participants and 15 075 cases, of which eight studies were rated to have a serious risk of bias as assessed by the ROBINS tool. Based on our analysis, each 12 g increase in alcohol intake did not appear to be associated with risks of prefrailty (RR: 1.08, 95% CI 0.89, 1.31; I2 = 91%, n = 3; GRADE = very low) and frailty (RR: 0.94, 95% CI 0.88, 1.00; I2 = 63%, n = 9; GRADE = low). The nonlinear dose-response meta-analysis indicates a slight inverse association with frailty risk up to an alcohol intake of 20 grams per day, beyond which an upward trend is observed. CONCLUSION: The inverse association found between moderate alcohol consumption and frailty risk appears to be stronger among older adults, which might be due to the lower and less popular alcohol consumption among older people than the general population. However, because this finding is based on low-quality evidence, more research is needed to develop specific dietary recommendations for alcohol consumption, particularly among young people.

Prevalence and determinants of frailty among the elderly in the province of Essaouira, Morocco.

Introduction: Morocco is no exception to the global phenomenon of an ageing population. The number of people aged 60 and over rose from one million to 4.5 million between 1970 and 2022. In terms of health, 64.4% of Moroccan seniors are affected by at least one chronic disease, and almost a third suffer from disability. We aimed to estimate the prevalence and identify the factors associated with frailty among the elderly in the Essaouira province of Morocco. Methods: a descriptive and analytical cross-sectional survey of 384 people aged 65 and over attending health centres in Essaouira province was conducted between March 2022 and January 2023. Data were collected using a self-administered questionnaire. The Fried phenotype was used to assess frailty in the participants. Results: according to Fried's phenotype, 46.4% of the elderly were frail. Multivariate analyses showed that frailty was associated with family type [OR=1.9; 95% CI 1.4-2.6], professional activity [OR=2.2; 95% CI 1.2-3.9], financial difficulties [OR=1.7; 95% CI 1.1-2.8] and undernutrition [OR=2.9; 95% CI 1.7-4.8]. Conclusion: implementing a screening strategy and speeding up the process of generalising social protection are actions that will make it possible to reduce the prevalence of frailty among the elderly, prevent its complications and act on its main determinants in Morocco.

Influence of Frailty Status on the Efficacy of Epidural Steroid Injections in Elderly Patients With Degenerative Lumbar Spinal Disease.

Background: The global increase in the elderly population has led to a higher prevalence of degenerative lumbar spinal diseases. Epidural steroid injection (ESI) is a widely used procedure for managing lower back pain. This study investigated the association of preprocedural frailty status with the efficacy of ESI in elderly patients diagnosed with degenerative lumbar spinal diseases. Methods: This retrospective observational study included patients aged 65 years and older who underwent lumbar ESI. Frailty status (robust, prefrail, and frail) assessed via the Frailty Phenotype Questionnaire was collected along with demographic and clinical parameters. Good analgesia was defined as a ≥ 50% reduction in pain score at 4-week follow-up evaluation. Multivariable logistic regression analyses were performed to identify factors associated with poor analgesia. Results: We included 289 patients in this study. Frailty status correlated with analgesic outcomes, with worsening frailty status correlating with increasingly poor analgesia after the injection (robust = 34.5%, prefrail = 40.8%, and frail = 60.0%, p=0.003), predominantly in female patients. After adjusting for demographic and clinical factors, frail patients demonstrated much higher odds of poor analgesia than robust individuals (adjusted odds ratio [aOR] = 2.673, 95% confidence interval [CI] = 1.338-5.342, p=0.005). Conversely, prefrail patients did not show a significant association with analgesic outcome (aOR = 1.293, 95% CI = 0.736-2.272, p=0.372). Conclusions: Frailty, but not prefrailty, appeared to be an independent factor associated with poor analgesic efficacy of ESI in elderly patients with symptomatic degenerative lumbar spinal disease receiving conservative care.

Prebiotics improve frailty status in community-dwelling older individuals in a double-blind, randomized, controlled trial.

BACKGROUNDFrailty significantly affects morbidity and mortality rates in the older population (age >65 years). Age-related degenerative diseases are influenced by the intestinal microbiota. However, limited research exists on alterations in the intestinal microbiota in frail older individuals, and the effectiveness of prebiotic intervention for treating frailty remains uncertain.OBJECTIVEWe sought to examine the biological characteristics of the intestinal microbiome in frail older individuals and assess changes in both frailty status and gut microbiota following intervention with a prebiotic blend consisting of inulin and oligofructose.METHODSThe study consisted of 3 components: an observational analysis with a sample size of 1,693, a cross-sectional analysis (n = 300), and a multicenter double-blind, randomized, placebo-controlled trial (n = 200). Body composition, commonly used scales, biochemical markers, intestinal microbiota, and metabolites were examined in 3 groups of older individuals (nonfrail, prefrail, and frail). Subsequently, changes in these indicators were reevaluated after a 3-month intervention using the prebiotic mixture for the prefrail and frail groups.RESULTSThe intervention utilizing a combination of prebiotics significantly improved frailty and renal function among the older population, leading to notable increases in protein levels, body fat percentage, walking speed, and grip strength. Additionally, it stimulated an elevation in gut probiotic count and induced alterations in microbial metabolite expression levels as well as corresponding metabolic pathways.CONCLUSIONSThe findings suggest a potential link between changes in the gut microbiota and frailty in older adults. Prebiotics have the potential to modify the gut microbiota and metabolome, resulting in improved frailty status and prevention of its occurrence.TRIAL REGISTRATIONClinicalTrials.gov NCT03995342.

Hospital-initiated palliative care interventions for adults with frailty: findings from a systematic review and narrative synthesis.

BACKGROUND: Adults with frailty have palliative care needs [1] but have disproportionately less access to palliative care services [2]. Frailty affects ~4000 patients admitted to hospital per day in the UK [3], making the hospital admission a unique opportunity to assess palliative care needs and deliver interventions. OBJECTIVES: Synthesise the evidence regarding hospital palliative care (HPC) for patients with frailty. Narratively analyse the evidence regarding methods used to identify palliative care needs; types of palliative care interventions studied; and whether HPC improves outcomes. METHODS: Systematic literature review and narrative synthesis of experimental, observational and systematic review articles investigating palliative care interventions for hospitalised adults aged ≥65 years with frailty. Electronic search of five databases from database inception to 30 January 2023. Included studies analysed using narrative synthesis according to Popay et al [4]. RESULTS: 15 465 titles retrieved, 12 included. Three studies detailed how they identified palliative care needs; all three used prognostication e.g. the 'surprise question'. Most papers (10/12) investigated specialist palliative care interventions. These interventions addressed a wider range of care needs than non-specialist interventions. Evidence suggested an improvement in some symptom burden and healthcare utilisation outcomes following HPC. CONCLUSION: Prognostication was the main method of identifying palliative care needs, rather than individuals' specific needs. Specialist palliative care interventions were more holistic, indicating that non-specialist palliative care approaches may benefit from specialist team input. Despite suggestions of improvement in some outcomes with palliative care, heterogenous evidence prevented establishment of conclusive effects.

Prehabilitation for frail patients undergoing hip and knee replacement in the UK: Joint PREP feasibility study for a randomised controlled trial.

OBJECTIVE: To determine the feasibility of conducting a randomised controlled trial (RCT) to evaluate a prehabilitation programme for frail patients undergoing total hip replacement (THR) or total knee replacement (TKR). DESIGN: Randomised feasibility study with embedded qualitative work. SETTING: Three National Health Service hospitals. PARTICIPANTS: Adults aged ≥65 years, frail and scheduled for primary THR or TKR. INTERVENTION: Appointment with a physiotherapist to individualise a home-based exercise programme. Participants were encouraged to do the home exercises daily for 12 weeks pre-operative and were provided with a daily protein supplement. Participants were supported by six telephone calls over the 12-week intervention period. OUTCOME MEASURES: Eligibility and recruitment rates, intervention adherence, data completion rates of patient-reported outcome measures, retention rates and acceptability of the trial and intervention. Qualitative interviews were conducted with participants and non-participants and analysed using thematic analysis. RESULTS: Between December 2022 and August 2023, 411 patients were sent a screening pack. Of the 168 patients who returned a screening questionnaire, 79 were eligible and consented to participate, and 64 were randomised. Of the 33 participants randomised to the intervention, 26 attended the intervention appointment. Eighteen participants (69%) received all six intervention follow-up telephone calls. Nineteen participants (73%) completed an intervention adherence log; 13 (68%) adhered to the exercise programme and 11 (58%) adhered to the protein supplementation. The overall retention rate was 86% (55/64 overall) at 12 weeks. The 12-week follow-up questionnaire was returned by 46 of the 55 participants (84%) who were sent a questionnaire. Interviews with 19 patients found that the trial processes and intervention were generally acceptable, but areas of potential improvements were identified. CONCLUSIONS: This study demonstrated that a larger study is possible and has identified improvements to optimise the design of an RCT. TRIAL REGISTRATION NUMBER: ISRCTN11121506.

Dual trajectories of social participation and frailty in Chinese older adults: a longitudinal study based on CLHLS from 2008 to 2018.

Introduction: This study aimed to identify the dual trajectories of social participation (SP) and frailty index (FI) among Chinese older adults, and investigate common influential factors of both trajectories. Methods: Utilizing data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 2008-2018 surveys, 1,645 individuals were analyzed. A group-based dual trajectory model and logistic regression were used to examine trajectories, their interrelations and shared influencing factors. Results: This study identified three SP, two FI trajectories and six distinct sub-groups of individuals. The study confirmed a long-term, interrelated relationship between two outcomes and identified some common factors. Compared to participants in the lower SP trajectory, those who followed the middle SP trajectory and higher SP trajectory had increased probabilities of belonging to the slow-growth FI trajectory (90.28 and 99.71%, respectively). And the participants in the slow-growth FI exhibited higher probabilities of belonging to the middle SP and the higher SP trajectory (37.64 and 25.34% higher, respectively) compared with those in the rapid-growth FI trajectory. Age, marital status, and drinking status were mutual factors associated with the dual trajectories. Discussion: The results showed significant associations between higher levels of frailty and lower levels of social participation. Related intervention policies should consider the dual trajectories and the common factors that underlie these trajectories of SP and FI.

A personalized clinical assessment: multi-sensor approach for understanding musculoskeletal health in the frail population.

BACKGROUND: Sarcopenia is a muscle disorder causing a progressive reduction of muscle mass and strength, but the mechanism of its manifestation is still partially unknown. The three main parameters to assess are: muscle strength, muscle volume or quality and low physical performance. There is not a definitive approach to assess the musculoskeletal condition of frail population and often the available tests to be performed in those clinical bedridden patients is reduced because of physical impairments. In this paper, we propose a novel instrumental multi-domain and non-invasive approach during a well-defined protocol of measurements for overcoming these limitations. A group of 28 bedridden elder people, subjected to surgery after hip fracture, was asked to perform voluntary isometric contractions at the 80% of their maximum voluntary contraction with the non-injured leg. The sensor employed before and/or during the exercise were: ultrasound to determine the muscle architecture (vastus lateralis); force acquisition with a load cell placed on the chair, giving an indication of the muscle strength; surface electromyography (EMG) for monitoring muscular electrical activity; time-domain (TD) near-infrared spectroscopy (NIRS) for evaluating muscle oxidative metabolism. RESULTS: A personalized "report card" for each subject was created. It includes: the force diagram (both instantaneous and cumulative, expected and measured); the EMG-force diagram for a comparison between EMG derived median frequency and measured force; two graphs related to the hemodynamic parameters for muscle oxidative metabolism evaluation, i.e., oxy-, deoxy-, total-hemoglobin and tissue oxygen saturation for the whole exercise period. A table with the absolute values of the previous hemodynamic parameters during the rest and the ultrasound related parameters are also included. CONCLUSIONS: In this work, we present the union of protocols, multi-domain sensors and parameters for the evaluation of the musculoskeletal condition. The novelties are the use of sensors of different nature, i.e., force, electrical and optical, together with a new way to visualize and combine the results, by means of a concise, exhaustive and personalized medical report card for each patient. This assessment, totally non-invasive, is focused on a bedridden population, but can be extended to the monitoring of rehabilitation progresses or of the training of athletes.

Multidimensional-Based Prediction of Pressure Ulcers Development and Severity in Hospitalized Frail Oldest Old: A Retrospective Study.

Purpose: In recent times, growing uncertainty has emerged regarding the effectiveness of standard pressure ulcer (PU) risk assessment tools, which are suspected to be no better than clinical judgment, especially in the frail and comorbid elderly population. This study aimed to identify the primary clinical predictive variables for PU development and severity in hospitalized older adults, utilizing a multidimensional frailty assessment, and compare them with the Braden scale. Patients and methods: The population consisted of 316 patients, admitted to the Geriatric Unit and Transitional Care of San Bartolomeo Hospital in Sarzana (Italy) during the period 21/02/22-01/07/22. The collected information included both anamnestic and laboratory data. A comprehensive geriatric assessment was performed, including also anthropometric and physical performance measurements. Multivariate logistic analysis was used, both in a binary classification test and in the subsequent ordinal classification test of severity levels. The final performance of the model was assessed by ROC curve estimation and AUC comparison with the Braden scale. Results: Within the population, 152 subjects (48%) developed PU at different levels of severity. The results showed that age, Braden scale (subscales of mobility and friction/shear), Barthel scale, Mini Nutritional Assessment, hemoglobin, and albumin are predictors associated with the development of PU (AUC 85%). The result is an improvement over the use of the Braden scale alone (AUC 75%). Regarding the identification of predictive factors for PU severity, 4AT also emerges as potentially relevant. Conclusion: Assessing the subject's nutritional status, physical performance, and functional autonomies enables the effective integration of the Braden scale in identifying patients most susceptible to developing PU. Our findings support the integration of a comprehensive set of methodologically robust frailty determinants into traditional risk assessment tools. This integration reflects the mutual interplay between patients' frailty, skin frailty, and PU development in very old hospitalized patients.

Effects of Virtual Reality Motor-Cognitive Training for Older People With Cognitive Frailty: Multicentered Randomized Controlled Trial.

BACKGROUND: Cognitive frailty refers to a clinical syndrome in which physical frailty and mild cognitive impairment coexist. Motor-cognitive training and virtual reality (VR) have been used to launch various therapeutic modalities to promote health in older people. The literature advocates that motor-cognitive training and VR are effective in promoting the cognitive and physical function of older people. However, the effects on older people with cognitive frailty are unclear. OBJECTIVE: This study examined the effects of VR motor-cognitive training (VRMCT) on global cognitive function, physical frailty, walking speed, visual short-term memory, inhibition of cognitive interference, and executive function in older people with cognitive frailty. METHODS: This study used a multicentered, assessor-blinded, 2-parallel-group randomized controlled trial design. Participants were recruited face-to-face in 8 older adult community centers. Eligible participants were aged ≥60 years, were community dwelling, lived with cognitive frailty, had no dementia, and were not mobility restricted. In the intervention group, participants received VRMCT led by interventionists with 16 one-hour training sessions delivered twice per week for 8 weeks. In the control group, participants received the usual care provided by the older adult community centers that the investigators did not interfere with. The primary outcome was global cognitive function. The secondary outcomes included physical frailty, walking speed, verbal short-term memory, inhibition of cognitive interference, and executive function. Data were collected at baseline (T0) and the week after the intervention (T1). Generalized estimating equations were used to examine the group, time, and interaction (time × group) effects on the outcomes. RESULTS: In total, 293 eligible participants enrolled in the study. The mean age of the participants was 74.5 (SD 6.8) years. Most participants were female (229/293, 78.2%), had completed primary education (152/293, 52.1%), were married (167/293, 57.2%), lived with friends (127/293, 43.3%), and had no VR experience (232/293, 79.5%). In the intervention group, 81.6% (119/146) of participants attended >80% (13/16, 81%) of the total number of sessions. A negligible number of participants experienced VR sickness symptoms (1/146, 0.7% to 5/146, 3%). VRMCT was effective in promoting global cognitive function (interaction effect: P=.03), marginally promoting executive function (interaction effect: P=.07), and reducing frailty (interaction effect: P=.03). The effects were not statistically significant on other outcomes. CONCLUSIONS: VRMCT is effective in promoting cognitive functions and reducing physical frailty and is well tolerated and accepted by older people with cognitive frailty, as evidenced by its high attendance rate and negligible VR sickness symptoms. Further studies should examine the efficacy of the intervention components (eg, VR vs non-VR or dual task vs single task) on health outcomes, the effect of using technology on intervention adherence, and the long-term effects of the intervention on older people with cognitive frailty at the level of daily living. TRIAL REGISTRATION: ClinicalTrials.gov NCT04730817; https://clinicaltrials.gov/study/NCT04730817.

[Factors contributing to frailty in institutionalized older adults: a multi-institutional cross-sectional study].

AIM: To reveal the characteristics and the oral function of institutionalized frail older adults and the factors contributing to frailty. METHODS: This multicenter, cross-sectional study included 214 patients. A questionnaire was administered to registered dietitians from these institutions. Sex, age, height, weight, grip strength, calf circumference, level of care need, FRAIL-NH, MNA® -SF, dysphagia, food form and water thickening, number of medications, major diseases, comorbidities, independence in daily living of older people with dementia, use of medication with dry mouth, nutritional care issues (malnutrition-related problems) by multiple occupations in Nutrition and Eating Swallowing Screening, Assessment and Monitoring, and nine oral-related items were evaluated. RESULTS: One hundred six patients (49.5%) were classified as frail, 75% of the patients were women, and the mean BMI was 19.7 kg/m2. Older adults with frailty were characterized by high care needs, malnutrition, multiple comorbidities, multiple medications, eating and swallowing disorders, the requirement of feeding assistance, and the need to adjust the shape of meals and fluids. The multivariable OR (95%CI) for "choking and residue problems" was 1.81 (1.20-2.73), while that for "dietary concentration problems" was 4.28 (2.10-8.74). CONCLUSION: Caregivers must maintain posture and provide meal assistance. Professionals in various occupations must adjust the proper food form and medication content. Meal times must be examined in consideration of the times at which drugs will be most effective. Oral care must be provided, and an environment must be created to help the subject concentrate. Focusing on problems of choking, residue, and concentration on meals is expected to improve frailty, aspiration pneumonia, and the prognosis of institutionalized older adults.

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis.

Background: Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. Objectives: To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. Review design: Systematic review and network meta-analysis. Eligibility criteria: Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention. Main outcomes: Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year. Data sources: We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Review methods: Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). Results: We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive. Limitations: High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts. Conclusions: Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence. Future work: Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further. Study registration: This study is registered as PROSPERO CRD42019162195. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Due to a lack of robust evidence, the benefits and risks of most types of community services for older people are unclear. Individualised care planning, where medication is adjusted and there are regular follow-ups, probably helps people stay living at home. There are many kinds of community services for older people. For example, in some services, everyone is given exercise and dietary advice or an individualised care plan. These often aim to help older people age independently. Maintaining independence is important in later life. We wanted to find out which community services work best: to help people stay living at home, and to do day-to-day activities independently. We reviewed findings from previous studies that have tested different community services for older people. We combined these findings and compared different types of service with one another. We rated our confidence in the evidence. We found 129 studies with 74,946 people. We found 63 different kinds of service have been studied. The studies were carried out in diverse populations around the world. Individualised care planning, where medication is adjusted and there are regular follow-ups, may help people age independently. It probably increases the chance of staying at home slightly. It may also help with doing day-to-day activities very slightly. Exercise and dietary advice may also help people stay living at home. However, there was some evidence that some services may reduce independence. We do not know what effect most services have. We generally had little confidence in the evidence because studies were small, and information was missing. The evidence is up to date to August 2021.

Urban-Rural Differences in the Association of eHealth Literacy With Medication Adherence Among Older People With Frailty and Prefrailty: Cross-Sectional Study.

Background: With advances in science and technology and improvements in health literacy, more studies have focused on frailty prevention by promoting medication adherence, emphasizing the role of eHealth literacy. However, the association between eHealth literacy and medication adherence in frail older adults has not been well studied, and it is unknown whether urban-rural differences exist in this relationship. Objective: This study aims to examine the relationship between eHealth literacy and medication adherence in older people with different frailty statuses, emphasizing variations between rural and urban areas. Methods: Between November and December 2020, a total of 4218 urban and rural community members (aged ≥60 years) in China were recruited as participants using a multistage random sampling method. A face-to-face structured questionnaire survey was conducted to collect information on demographic characteristics, eHealth literacy (consisting of application, evaluation, and decision dimensions), and medication adherence. eHealth literacy was assessed using the Chinese version of the eHealth Literacy Scale developed by Norman and Skinner, and medication adherence was measured using the 4-item Morisky scale. We used a general descriptive analysis and stratified logistic regression models to examine how eHealth literacy is linked to medication adherence and urban-rural differences. Results: There were 4218 respondents, of which 2316 (54.9%) lived in urban areas and 1902 (45.1%) in rural areas, respectively. After adjusting for potential confounders, among participants with prefrailty, eHealth literacy was associated with medication adherence in urban areas in terms of less application (adjusted odds ratio [AOR] 1.16, 95% CI 0.82-1.63), less evaluation (AOR 1.29, 95% CI 0.92-1.81), and less decision ability (AOR 1.20, 95% CI 0.86-1.68); eHealth literacy was linked with medication adherence in the rural areas in terms of less application (AOR 1.10, 95% CI 0.56-2.13), less evaluation (AOR 1.05, 95% CI 0.61-1.79), and less decision ability (AOR 1.10, 95% CI 0.64-1.90). Among frail participants, less eHealth literacy (AOR 0.85, 95% CI 0.48-1.51), along with its dimensions, including less application (AOR 0.85, 95% CI 0.47-1.54), evaluation (AOR 0.89, 95% CI 0.50-1.57), and decision ability (AOR 0.99, 95% CI 0.55-1.76), were associated with medication adherence in urban areas; less eHealth literacy (AOR 0.89, 95% CI 0.48-1.65), along with its dimensions, including less application (AOR 1.23, 95% CI 0.62-2.44), evaluation (AOR 0.98, 95% CI 0.53-1.82), and decision ability (AOR 0.90, 95% CI 0.49-1.67), were associated with medication adherence in rural areas. Conclusions: The results of this study suggest that there is an association between eHealth literacy and medication adherence among older people with frailty and prefrailty. To promote medication adherence, eHealth literacy can be helpful in tailoring interventions.

Research Progress on Frailty in Elderly People.

Global aging is rapidly accelerating, which significantly influences the health systems worldwide. Frailty emerges as the most conspicuous hallmark of aging, imposing novel global health challenges. Characterized by a multifaceted decline across physiological system, frailty diminishes an individual's capacity to maintain equilibrium in the presence of stressors, which leads to adverse outcomes such as falls, delirium, and disability. Several screening tools and interventions have been developed to mitigate the harm caused by frailty to human health, but research on frailty in mainland China commences belatedly with scant studies conducted. Therefore, it is imperative to explore screening methods and treatment modalities tailored to the Chinese context, thereby enhancing the older adults' quality of life and advancing social medicine. This review aims to elucidate the evolution, diagnosis, and management of frailty, alongside the challenges it poses, with the overarching goal of guiding future diagnostic and therapeutic endeavors. Specifically, we summarized the mechanisms of frailty and intervention strategies in elderly people, and meanwhile, we evaluated the advantages and disadvantages of different measurement tools.

Mediterranean Diet and Ultra-Processed Food Intake in Older Australian Adults-Associations with Frailty and Cardiometabolic Conditions.

Dietary patterns contribute to overall health and diseases of ageing but are understudied in older adults. As such, we first aimed to develop dietary indices to quantify Mediterranean Diet Score (MDS) utilisation and Ultra-processed Food (UPF) intake in a well-characterised cohort of relatively healthy community-dwelling older Australian adults. Second, we aimed to understand the relationship between these scores and the association of these scores with prevalent cardiometabolic disease and frailty. Our major findings are that in this population of older adults, (a) pre-frailty and frailty are associated with reduced MDS and increased UPF intake; (b) adherence to MDS eating patterns does not preclude relatively high intake of UPF (and vice versa); and (c) high utilisation of an MDS eating pattern does not prevent an increased risk of frailty with higher UPF intakes. As such, the Mediterranean Diet pattern should be encouraged in older adults to potentially reduce the risk of frailty, while the impact of UPF intake should be further explored given the convenience these foods provide to a population whose access to unprocessed food may be limited due to socioeconomic, health, and lifestyle factors.

Prospective Monitoring of New Drugs in Older Adults with and without Frailty: Near-Real-Time Assessment of Effectiveness and Safety of Oral Anticoagulants in Medicare Data.

BACKGROUND AND OBJECTIVE: Prospective sequential analyses after a new drug approval allow proactive surveillance of new drugs. In the current study, we demonstrate feasibility of frailty-specific sequential analyses for dabigatran, rivaroxaban, and apixaban versus warfarin. METHODS: We partitioned Medicare data from 2011 to 2020 into datasets based on calendar year following the date of drug approval. Each calendar year of data was added sequentially for analysis. We used a new-user, active comparative design by comparing the initiators of dabigatran versus warfarin, rivaroxaban versus warfarin, and apixaban versus warfarin. Patients aged ≥ 65 years with atrial fibrillation without contraindication to the anticoagulants were included. Claims-based frailty index ≥ 0.25 was used to define frailty. The initiators of each direct oral anticoagulant were propensity-score matched to the initiators of warfarin within each frailty status. The effectiveness outcome was ischemic stroke or systemic thromboembolism, and the safety outcome was major bleeding. For each calendar year, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) from Cox proportional hazards models using all data available up to that year. RESULTS: As an example of the results, in the 2020 dataset, compared with warfarin, apixaban was associated with a reduced risk of ischemic stroke or systemic thromboembolism (frail: HR 0.73, 95% CI 0.63-0.85; non-frail: HR 0.65, 95% CI 0.59-0.72) and major bleeding (frail: HR 0.63, 95% CI 0.57-0.69; non-frail: HR 0.59, 95% CI 0.56-0.63) in both frail and non-frail patients. We found evidence for apixaban's effectiveness and safety within 1-2 years after the drug approval in frail older patients. CONCLUSION: Our frailty-specific sequential analyses can be applied to future near-real-time monitoring of newly approved drugs.