A decline in exercise capacity (EC) is a characteristic of frailty. We hypothesized that decline is the effect of decrements in several physiological systems. We assessed whether the relationship of three main physiological systems—cardiac, pulmonary, and musculoskeletal—to EC is independent or interactive and whether their effect on EC varies with respect to frailty status.
Observational study of 547 disabled women aged 65 years and older (Women’s Health and Aging Study I) including 131 frail who participated in a test of EC. EC (seated step test), cardiac function (chronotropic index), pulmonary function (forced vital capacity, FVC), musculoskeletal function (quadriceps strength, QS), and frailty status were measured and interactive effects were modeled using linear regression and differentiation.
Each physiological system had a direct relationship with EC, which was lower in frail compared with nonfrail. The relationship between FVC and EC was positive and increased with increasing QS in nonfrail subjects. The effect of QS on EC was positive and increased with increasing FVC regardless of frailty. In subjects with low QS, frailty status was associated with lower EC and this effect became stronger with increasing FVC.
Findings suggest but do not show that frailty status modifies the effects of physiological function in several systems on EC. Approaches to understanding emergent properties such as vulnerability to illness and death and clinical efforts to prevent and treat frailty should evaluate and possibly intervene on several physiological systems to be maximally effective.
Frailty; Exercise capacity
Frailty is characterized by vulnerability to acute stressors and is a consequence of decline in overall function and physiologic reserves. An estimated 7% of the US population older than 65 years and 30% of octogenarians are frail. The domains to define frailty include mobility, strength, balance, motor processing, cognition, nutrition, endurance, and physical activity. Pathophysiologic pathways leading to frailty involve a multisystem cascade that includes neuroendocrine dysfunction with lower insulinlike growth factor and dehydroepiandrosterone sulfate and an altered inflammatory milieu with increased levels of C-reactive protein, interleukins, tumor necrosis factor α, and abnormal coagulation. Frailty predicts death and heralds the transition to disability in general populations. As the population with coronary artery disease shifts toward older patients, physicians must consider the role of frailty in their patients. This review will enable clinicians to recognize frailty and consider its relevance in their daily practice. We also elaborate on reasons to consider frailty in older adults with cardiovascular disease and focus on its early identification, on referral to specialists, and on care after serious cardiac events.
Ageing of the population in western societies and the rising costs of health and social care are refocusing health policy on health promotion and disability prevention among older people. However, efforts to identify at-risk groups of older people and to alter the trajectory of avoidable problems associated with ageing by early intervention or multidisciplinary case management have been largely unsuccessful. This paper argues that this failure arises from the dominance in primary care of a managerial perspective on health care for older people, and proposes instead the adoption of a clinical paradigm based on the concept of frailty. Frailty, in its simplest definition, is vulnerability to adverse outcomes. It is a dynamic concept that is different from disability and easy to overlook, but also easy to identify using heuristics (rules of thumb) and to measure using simple scales. Conceptually, frailty fits well with the biopsychosocial model of general practice, offers practitioners useful tools for patient care, and provides commissioners of health care with a clinical focus for targeting resources at an ageing population.
disability; frail elderly; general practice
Our aim was to examine whether engagement in productive activities, including volunteering, paid work, and childcare, protects older adults against the development of geriatric frailty.
Data from the first (1988) and second (1991) waves of the MacArthur Study of Successful Aging, a prospective cohort study of high-functioning older adults aged 70–79 years (n = 1,072), was used to examine the hypothesis that engagement in productive activities is associated with lower levels of frailty 3 years later.
Engagement in productive activities at baseline was associated with a lower cumulative odds of frailty 3 years later in unadjusted models (odds ratio [OR] = 0.74, 95% confidence interval [CI] = 0.58–0.96) but not after adjusting for age, disability, and cognitive function (adjusted OR = 0.78, 95% CI = 0.60–1.01). Examination of productive activity domains showed that volunteering (but neither paid work nor childcare) was associated with a lower cumulative odds of frailty after adjusting for age, disability, and cognitive function. This relationship diminished and was no longer statistically significant after adjusting for personal mastery and religious service attendance.
Though high-functioning older adults who participate in productive activities are less likely to become frail, after adjusting for age, disability, and cognitive function, only volunteering is associated with a lower cumulative odds of frailty.
Productive activities; Volunteering; Frailty
Frailty is a relatively new geriatric concept referring to an increased vulnerability to stressors. Various definitions have been proposed, as well as a range of multidimensional instruments for its measurement. More recently, a frailty phenotype that predicts a range of adverse outcomes has been described. Understanding frailty is a particular challenge both from a clinical and a public health perspective because it may be a reversible precursor of functional dependence. The Lausanne cohort Lc65+ is a longitudinal study specifically designed to investigate the manifestations of frailty from its first signs in the youngest old, identify medical and psychosocial determinants, and describe its evolution and related outcomes.
The Lc65+ cohort was launched in 2004 with the random selection of 3054 eligible individuals aged 65 to 70 (birth year 1934–1938) in the non-institutionalized population of Lausanne (Switzerland). The baseline data collection was completed among 1422 participants in 2004–2005 through questionnaires, examination and performance tests. It comprised a wide range of medical and psychosocial dimensions, including a life course history of adverse events. Outcomes measures comprise subjective health, limitations in activities of daily living, mobility impairments, development of medical conditions or chronic health problems, falls, institutionalization, health services utilization, and death. Two additional random samples of 65–70 years old subjects will be surveyed in 2009 (birth year 1939–1943) and in 2014 (birth year 1944–1948).
The Lc65+ study focuses on the sequence "Determinants → Components → Consequences" of frailty. It currently provides information on health in the youngest old and will allow comparisons to be made between the profiles of aging individuals born before, during and at the end of the Second World War.
To validate two established frailty indexes and compare their ability to predict adverse outcomes in a diverse elderly community-dwelling sample of men and women.
Prospective observational study.
A diverse defined geographic area of Boston.
765 community-dwelling participants in the MOBILIZE Boston Study.
Two published frailty indexes, recurrent falls, disability, overnight hospitalization, emergency room visits, chronic medical conditions, self-reported health, physical function, cognitive ability (including executive function) and depression. One index was developed from the Study of Osteoporotic Fractures (SOF) and the other from the Cardiovascular Health Study (CHS).
The SOF frailty index classified 77.1% as robust, 18.7% as pre-frail and 4.2% as frail. The CHS frailty index classified 51.2% as robust, 38.8% as pre-frail and 10.0% as frail. Both measures of frailty (SOF; CHS) were similar in their ability to predict key geriatric outcomes such as recurrent falls (HRfrail=2.2 [1.2-4.0]; HRfrail=1.9 [1.2-3.1]), overnight hospitalization (ORfrail=3.5 [1.5,8.0]); ORfrail=4.4 [2.4-8.2]), emergency room visits (ORfrail=3.5 [1.4,8.8]); ORfrail=3.1 [1.6-5.9]) and disability (ORfrail=5.4[2.3,12.3]); ORfrail=7.7 [4.0,14.7]), as well as chronic medical conditions, physical function, cognitive ability and depression.
We validated two established frailty indexes using an independent elderly sample of diverse men and women and showed that both indexes are good at distinguishing relevant geriatric conditions and predicting recurrent falls, overnight hospitalization and emergency room visits by level of frailty. Though both indexes are good measures of frailty, the simpler SOF index may prove easier and more practical in a clinical setting.
Frailty; community-dwelling; MOBILIZE Boston Study; Study of Osteoporotic Fracture; Cardiovascular Health Study
In 2002, an EC study reported that different European countries define disability differently, and this is one of the primary reasons why no common Europe-wide policies on disability exist. The EU-MHADIE project was funded with the aim of producing recommendations and guidelines for future common disability policies. The WHO’s ICF classification and its bio-psycho-social model of disability was the theoretical reference to ground existing and survey data on.
Description of care and policy practice
MHADIE project demonstrated the feasibility and utility of the ICF, as a model of disability and functioning, for the harmonisation of data across populations and sectors in Europe, and for the development of realistic, evidence-based and effective social policies for persons with disabilities that will achieve equality of opportunities and full participation, according to the UN Convention on the Rights of Persons with Disabilities.
Disability is an ever-changing experience, and so data that recognize its dynamic nature must be gathered, through longitudinal studies that use a consistent definition of disability. The research performed within MHADIE has demonstrated the feasibility, utility and value of ICF classification and model in harmonising data across populations and sectors in Europe. MHADIE researchers have demonstrated that it is possible to develop realistic, evidence-based and effective social policies for persons with disabilities and that it is essential to share the same disability definition. By providing a common framework for defining and measuring functioning and disability, MHADIE’s results help to improve the accuracy and comparability estimates of prevalence of impairments and disability Europe-wide. MHADIE results show, among other, that family and transportation policies are key factors for all persons with disabilities, and dedicated European policies are needed to improve and emphasize their role.
A definition of disability underlying ICF’s principles was produced, together with policy recommendation divided into statistical, clinical and education sections that have been presented at the European Parliament and are available at http://www.mhadie.it.
ICF classification; disability; UN Convention on the Rights of Persons with Disabilities
We examined frailty, particularly how diabetes and obesity impact disability and morbidity in Mexican American older adults.
We studied the trajectory of frailty over 10 years in 2,049 Mexican Americans participating in the Hispanic Established Populations Epidemiologic Studies of the Elderly. A frailty index based on weight loss, exhaustion, grip strength, walking speed, and physical activity was computed and data were collected on sociodemographic and health status, comorbidities and performance-based functional measures.
The sample was 58% female with a mean age of 74.43 (sd = 6.04) at baseline. Analyses at 10 year follow-up revealed 75% of the surviving sample (N = 777) were classified as pre-frail or frail compared to 55% at baseline. 84% of persons identified as frail at baseline died by the end of follow-up. Baseline age, diabetes, arthritis, smoking status, body mass index, cognition, negative affect, and number of comorbid conditions were predictors of frailty at follow-up (R2 = 0.29, p <.05).
Research is needed to reduce the number of Mexican American older adults who become frail and transition to disability and loss of independence.
Frail elderly; Mexican Americans; health status; activities of daily living
Frailty among older people is related to an increased risk of adverse health outcomes such as acute and chronic diseases, disability and mortality. Although many intervention studies for frail older people have been reported, only a few have shown positive effects regarding disability prevention. This article presents the design of a two-arm cluster randomized controlled trial on the effectiveness, cost-effectiveness and feasibility of a primary care intervention that combines the most promising elements of disability prevention in community-dwelling frail older people.
In this study twelve general practitioner practices were randomly allocated to the intervention group (6 practices) or to the control group (6 practices). Three thousand four hundred ninety-eight screening questionnaires including the Groningen Frailty Indicator (GFI) were sent out to identify frail older people. Based on their GFI score (≥5), 360 participants will be included in the study. The intervention will receive an interdisciplinary primary care intervention. After a comprehensive assessment by a practice nurse and additional assessments by other professionals, if needed, an individual action plan will be defined. The action plan is related to a flexible toolbox of interventions, which will be conducted by an interdisciplinary team. Effects of the intervention, both for the frail older people and their informal caregivers, will be measured after 6, 12 and 24 months using postal questionnaires and telephone interviews. Data for the process evaluation and economic evaluation will be gathered continuously over a 24-month period.
The proposed study will provide information about the usefulness of an interdisciplinary primary care intervention. The postal screening procedure was conducted in two cycles between December 2009 and April 2010 and turned out to be a feasible method. The response rate was 79.7%. According to GFI scores 29.3% of the respondents can be considered as frail (GFI ≥ 5). Nearly half of them (48.1%) were willing to participate. The baseline measurements started in January 2010. In February 2010 the first older people were approached by the practice nurse for a comprehensive assessment. Data on the effect, process, and economic evaluation will be available in 2012.
To compare how well frailty measures based on a phenotypic frailty approach proposed in the Cardiovascular Health Study (CHS) and a cumulative deficits approach predict mortality.
The main cohort of the Cardiovascular Health Study (CHS).
A phenotypic frailty index (PFI) was defined in the same way as proposed in the CHS: assessing weight loss, exhaustion, low physical activity, slowness, and poor grip strength. A cumulative deficit index (DI) was defined based on 48 elderly deficits (signs, symptoms, impairments, diseases) included in the index, with equal weights.
Of the 1,073 frailest individuals with the lowest survival, the PFI, categorized as proposed in the CHS into robust, prefrail, and frail categories, underestimated the risk of death for 720 persons, whereas the DI categorized into the same three frailty categories underestimated the mortality risk for 134 persons. The higher power of the DI for discriminating frail individuals in their susceptibility to death also followed from comparison of quasi-instantaneous values of both indices. The three-level DI identified 219 individuals as frail of 361 individuals identified as frail according to the three-level PFI.
The DI can more precisely evaluate chances of death because it assesses a broader spectrum of disorders than the PFI. Both indices appear to be frailty related. Integration of both approaches is highly promising for increasing the precision of discrimination of the risk of death and especially for identification of the most vulnerable elderly people.
Frailty; mortality; aging and well-being; health; survival
The concept of frailty has been defined as a multidimensional syndrome characterized by the loss of physical and cognitive reserve that predisposes to the accumulation of deficits and increased vulnerability to adverse events. Frailty is strongly correlated with age, and overlaps with and extends aspects of a patient's disability status (that is, functional limitation) and/or burden of comorbid disease. The frail phenotype has more specifically been characterized by adverse changes to a patient's mobility, muscle mass, nutritional status, strength and endurance. We contend that, in selected circumstances, the critically ill patient may be analogous to the frail geriatric patient. The prevalence of frailty amongst critically ill patients is currently unknown; however, it is probably increasing, based on data showing that the utilization of intensive care unit (ICU) resources by older people is rising. Owing to the theoretical similarities in frailty between geriatric and critically ill patients, this concept may have clinical relevance and may be predictive of outcomes, along with showing important interaction with several factors including illness severity, comorbid disease, and the social and structural environment. We believe studies of frailty in critically ill patients are needed to evaluate how it correlates with outcomes such as survival and quality of life, and how it relates to resource utilization, such as length of mechanical ventilation, ICU stay and duration of hospitalization. We hypothesize that the objective measurement of frailty may provide additional support and reinforcement to clinicians confronted with end-of-life decisions on the appropriateness of ICU support and/or withholding of life-sustaining therapies.
Frailty is a common condition in elders and identifies a state of vulnerability for adverse health outcomes.
Our objective was to provide a biological face validity to the well-established definition of frailty proposed by Fried et al.
Data are from the baseline evaluation of 923 participants aged ≥65 y enrolled in the Invecchiare in Chianti study. Frailty was defined by the presence of ≥3 of the following criteria: weight loss, exhaustion, low walking speed, low hand grip strength, and physical inactivity. Muscle density and the ratios of muscle area and fat area to total calf area were measured by using a peripheral quantitative computerized tomography (pQCT) scan. Analyses of covariance and logistic regressions were performed to evaluate the relations between frailty and pQCT measures.
The mean age (±SD) of the study sample was 74.8 ± 6.8 y, and 81 participants (8.8%) had ≥3 frailty criteria. Participants with no frailty criteria had significantly higher muscle density (71.1 mg/cm3, SE = 0.2) and muscle area (71.2%, SE = 0.4) than did frail participants (69.8 mg/cm3, SE = 0.4; and 68.7%, SE = 1.1, respectively). Fat area was significantly higher in frail participants (22.0%, SE = 0.9) than in participants with no frailty criteria (20.3%, SE = 0.4). Physical inactivity and low walking speed were the frailty criteria that showed the strongest associations with pQCT measures.
Frail subjects, identified by an easy and inexpensive frailty score, have lower muscle density and muscle mass and higher fat mass than do nonfrail persons.
Frailty; skeletal muscle; body composition; fat mass; inflammation; muscle mass; muscle density; aging; epidemiology
Leprosy-related disability is a challenge to public health, and social and rehabilitation services in endemic countries. Disability is more than a mere physical dysfunction, and includes activity limitations, stigma, discrimination, and social participation restrictions. We assessed the extent of disability and its determinants among persons with leprosy-related disabilities after release from multi drug treatment.
We conducted a survey on disability among persons affected by leprosy in Indonesia, using a Rapid Disability Appraisal toolkit based on the International Classification of Functioning, Disability and Health. The toolkit included the Screening of Activity Limitation and Safety Awareness (SALSA) scale, Participation Scale, Jacoby Stigma Scale (anticipated stigma), Explanatory Model Interview Catalogue (EMIC) stigma scale and Discrimination assessment. Community members were interviewed using a community version of the stigma scale. Multivariate linear regression was done to identify factors associated with social participation.
Overall 1,358 persons with leprosy-related disability (PLD) and 931 community members were included. Seventy-seven percent of PLD had physical impairments. Impairment status deteriorated significantly after release from treatment (from 59% to 77%). Around 60% of people reported activity limitations and participation restrictions and 36% anticipated stigma. As for participation restrictions and stigma, shame, problems related to marriage and difficulties in employment were the most frequently reported problems. Major determinants of participation were severity of impairment and level of education, activity and stigma. Reported severity of community stigma correlated with severity of participation restrictions in the same districts.
The majority of respondents reported problems in all components of disability. The reported physical impairment after release from treatment justifies ongoing monitoring to facilitate early prevention. Stigma was a major determinant of social participation, and therefore disability. Stigma reduction activities and socio-economic rehabilitation are urgently needed in addition to strategies to reduce the development of further physical impairment after release from treatment.
leprosy; disability; impairment; activity; participation; ICF; stigma; discrimination
Dramatic advances in understanding mechanisms of aging have recently been made in model systems. Interventions have been devised that successfully enhance survival. Major issues still in need of resolution include whether these interventions not only increase survival but also enhance function, delay frailty, and can be translated into clinical application. It seems there are basic biologic findings close to being ready for translation. However, a number of barriers exist to translating these findings into realistic clinical interventions. Steps and resources needed include measuring not only survival but also impact of interventions on age-related disability, frailty, and onset of disease in model systems; development of clinically relevant measures of disability, frailty, and disease for each animal model and genetically tractable animal models of frailty; training and career-long funding mechanisms for geriatricians in basic science research and for basic scientists in geriatric issues; translationally capable review and funding mechanisms; emphasis on studies of interventions that can be initiated in later life for preventing or reversing disability; genetic association studies in humans to identify new candidate genes and pathways that correlate with disability, frailty, and age-related disease onset as well as longevity; study of exposure to environmental agents or toxins early in life on survival, disability, frailty, and disease in later life.
Healthspan; Translation; Animal studies of aging
In coming decades the proportion of very elderly people living in the Western world will dramatically increase. This forthcoming "grey epidemic" will lead to an explosion of chronic diseases. In order to anticipate booming health care expenditures and to assure that social security is funded in the future, research focusing on the relationship between chronic diseases, frailty and disability is needed. The general aim of the BELFRAIL cohort study (BFC80+) is to study the dynamic interaction between health, frailty and disability in a multi-system approach focusing on cardiac dysfunction and chronic heart failure, lung function, sarcopenia, renal insufficiency and immunosenescence.
The BFC80+ is a prospective, observational, population-based cohort study of subjects aged 80 years and older in three well-circumscribed areas of Belgium. In total, 29 general practitioner (GP) centres were asked to include patients aged 80 and older. Only three exclusion criteria were used: severe dementia, in palliative care and medical emergency. Two sampling methods for the recruitment of patients were used. Between November 2, 2008 and September 15, 2009, 567 subjects were included in the BFC80+ study. Every study participant was invited to undergo four study visits. The GP recorded background variables and medical history and performed a detailed anamnesis and clinical examination. The clinical research assistant performed an extensive examination including performance testing, questionnaires and technical examinations. Echocardiography was performed at home by a cardiologist. A blood sample was collected in the morning. Follow-up reporting of hard outcome measures including mortality, hospitalization and morbidity was organized. A second data collection is planned after 18 months.
The BFC80+ was designed to acquire a better understanding of the epidemiology and pathophysiology of chronic diseases in the very elderly and to study the dynamic interaction between health, frailty and disability in a multi-system approach. The wide variety of dimensions investigated in the BFC80+ will enable us not only to investigate in depth the relationship between the different physiological systems but also to initiate new research questions based on this unique database of community-dwelling elderly.
Disability carries negative social meaning, and little is known about when (or if), in the process of health decline, persons identify themselves as “disabled” We examine the social and health criteria that older adults use to subjectively rate their own disability status. Using a panel study of older adults (ages 72+), we estimate ordered probit and growth curve models of perceived disability over time. Total prevalent morbidity, functional limitations, and cognitive impairment are predictors of perceived disability. Cessation of driving and receipt of home health care also influence older adults’ perceptions of their own disability. A dense social network slowed the rate of labeling oneself disabled, while health anxiety accelerated the process over time, independent of health status. When considering perceived disability, the oldest old use multidimensional criteria capturing function, recent changes in health status and social networks, and anxiety about their health.
Frailty is a state of health signified by an increased vulnerability to adverse health outcomes in the face of stressors (e.g. infection). There is emerging consensus that research on both the theory and measurement of frailty must focus on the dynamic interactions within and across systems underlying the frailty syndrome. In this paper, we propose a dynamical systems modeling approach, based on the stimulus-response experimental paradigm, to propel future advances in the study of frailty. Our proposal is novel in that it provides a quantitative framework to operationalize and test the core notion underlying frailty that it signifies a loss of resilience in homeostatic regulation. The proposed framework offers many important benefits, including (a) insights into whether and how homeostatic regulation differs between frail and non-frail older adults, (b) identification of critical regulatory systems, if they exist, that could function as sentinel systems for screening and early detection of frailty, (c) establishment of the value of provocative tests that can provide maximal information on the integrity of systems identified in (b), and (d) evaluation and unification of diverse empirical descriptions of frailty by providing a mathematical framework anchored in quantifying the loss of resilience, an essential property of frailty.
frailty; dynamical systems; homeostasis; stimulus-response; provocative testing
Interventions that enhance mobility in frail older people are needed to maintain health and independence, yet definitive evidence of effective interventions is lacking. Our objective was to assess the impact of a multifactorial intervention on mobility-related disability in frail older people.
We conducted a randomised, controlled trial with 241 frail community-dwelling older people in Sydney, Australia. Participants were classified as frail using the Cardiovascular Health Study definition, did not have severe cognitive impairment and were recently discharged from an aged care and rehabilitation service. The experimental group received a 12 month multifactorial, interdisciplinary intervention targeting identified frailty components. Two physiotherapists delivered a home exercise program targeting mobility, and coordinated management of psychological and medical conditions with other health professionals. The control group received usual care. Disability in the mobility domain was measured at baseline and at 3 and 12 months using the International Classification of Functioning, Disability and Health framework. Participation (involvement in life situations) was assessed using the Life Space Assessment and the Goal Attainment Scale. Activity (execution of mobility tasks) was measured using the 4-metre walk and self-report measures.
The mean age of participants was 83.3 years (SD: 5.9 years). Of the participants recruited, 216 (90%) were followed-up at 12 months. At this time point, the intervention group had significantly better scores than the control group on the Goal Attainment Scale (odds ratio 2.1; 95% confidence interval (CI) 1.3 to 3.3, P = 0.004) and Life Space Assessment (4.68 points, 95% CI 1.4 to 9.9, P = 0.005). There was no difference between groups on the global measure of participation or satisfaction with ability to get out of the house. At the activity level, the intervention group walked 0.05 m/s faster over 4 m (95% CI 0.0004 to 0.1, P = 0.048) than the control group, and scored higher on the Activity Measure for Post Acute Care (P < 0.001).
The intervention reduced mobility-related disability in frail older people. The benefit was evident at both the participation and activity levels of mobility-related disability.
Australia and New Zealand Clinical Trials Register (ANZCTR): ANZCTRN12608000507381.
exercise; frail elderly; International Classification of Functioning, Disability and Health; RCT
The term “frailty” is used loosely to describe a range of conditions in older people, including general debility and cognitive impairment. There is no clear consensus on the definition of frailty; however, it is proposed that frailty comprises a collection of biomedical factors which influences an individual's physiological state in a way that reduces his or her capacity to withstand environmental stresses. Only a subset of older people are at risk of becoming frail; these are vulnerable, prone to dependency and have reduced life expectancy. These health outcomes contribute to an increased demand for medical and social care, and are associated with increased economic costs. As demographic trends indicate a rise in the older population, this healthcare burden will increase. This review aims to encapsulate the current debate surrounding the concept of frailty, with emphasis on proposed definitions of frailty which may be relevant to its identification in the clinical setting.
Sarcopenia, the age associated loss of skeletal muscle mass and function, has considerable societal consequences for the development of frailty, disability and health care planning. A group of geriatricians and scientists from academia and industry met in Rome, Italy on November 18, 2009 to arrive at a consensus definition of sarcopenia. The current consensus definition was approved unanimously by the meeting participants and is as follows: Sarcopenia is defined as the age-associated loss of skeletal muscle mass and function. The causes of sarcopenia are multi-factorial and can include disuse, altered endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies. While cachexia may be a component of sarcopenia, the two conditions are not the same. The diagnosis of sarcopenia should be considered in all older patients who present with observed declines in physical function, strength, or overall health. Sarcopenia should specifically be considered in patients who are bedridden, cannot independently rise from a chair, or who have a measured gait speed less that 1.0 m·s−1. Patients who meet these criteria should further undergo body composition assessment using dual energy x-ray absorptiometry (DXA) with sarcopenia being defined using currently validated definitions. A diagnosis of sarcopenia is consistent with a gait speed of less than 1 m·s−1 and an objectively measured low muscle mass (eg: appendicular mass relative to ht2 that is ≤ 7.23 kg/ m2 in men ≤ 5.67 kg/ m2 in men). Sarcopenia is a highly prevalent condition in older persons that leads to disability, hospitalization and death.
muscle; aging; body composition; function; disability
Disability in Activities of Daily Living (ADL) is an adverse outcome of frailty that places a burden on frail elderly people, care providers and the care system. Knowing which physical frailty indicators predict ADL disability is useful in identifying elderly people who might benefit from an intervention that prevents disability or increases functioning in daily life. The objective of this study was to systematically review the literature on the predictive value of physical frailty indicators on ADL disability in community-dwelling elderly people.
A systematic search was performed in 3 databases (PubMed, CINAHL, EMBASE) from January 1975 until April 2010. Prospective, longitudinal studies that assessed the predictive value of individual physical frailty indicators on ADL disability in community-dwelling elderly people aged 65 years and older were eligible for inclusion. Articles were reviewed by two independent reviewers who also assessed the quality of the included studies.
After initial screening of 3081 titles, 360 abstracts were scrutinized, leaving 64 full text articles for final review. Eventually, 28 studies were included in the review. The methodological quality of these studies was rated by both reviewers on a scale from 0 to 27. All included studies were of high quality with a mean quality score of 22.5 (SD 1.6). Findings indicated that individual physical frailty indicators, such as weight loss, gait speed, grip strength, physical activity, balance, and lower extremity function are predictors of future ADL disability in community-dwelling elderly people.
This review shows that physical frailty indicators can predict ADL disability in community-dwelling elderly people. Slow gait speed and low physical activity/exercise seem to be the most powerful predictors followed by weight loss, lower extremity function, balance, muscle strength, and other indicators. These findings should be interpreted with caution because the data of the different studies could not be pooled due to large variations in operationalization of the indicators and ADL disability across the included studies. Nevertheless, our study suggests that monitoring physical frailty indicators in community-dwelling elderly people might be useful to identify elderly people who could benefit from disability prevention programs.
Frailty is a complex and dynamic condition associated with aging. This condition is characterised by the difficult adaptation of an old subject to new challenges occurring during life. Frailty is supposed to be due to the progressive decrease of physiological reserves and multiorgan and multisystem change. It coincides with a reduced or absent resilience. In general comorbidities like hypertension, heart disease, inflammation and infectious diseases are potential risk factors for and psychophysical decline. The aim of this work is to highlight the importance of impaired cognition as factor predisposing to frailty. The authors are convinced and suggest that the presence of neurobehavioral disturbance like apathy associated to impaired executive function could be the major predisposing factor for frailty and unsuccessful aging. Unfortunately available literature largely underestimates the presence of these factors. Thus to better identify markers of frailty, a good neuropsychological assessment and the evaluation of behavioural disturbances are suggested.
In order to adapt oral care and treatment to the demands of the growing group of frail dentulous older people, it is important to understand how and to which extent having natural teeth contributes to the quality of life (QoL) of frail older people and how frailty influences their perspective.
A qualitative approach was used. Interviews with 38 Dutch frail older dentulous people were tape-recorded, transcribed, coded for content and analyzed. Additional information was collected which included age, gender, living situation, use of dental prostheses, self-reported oral health status, chronic disorders, and an index for frailty.
Seven themes were identified in the relationship between natural teeth and the QoL of the participants: pride and achievement; intactness; sense of control; oral function; appearance; comfort; along with coping and adapting to disabilities. Having natural teeth generally had a positive effect on QoL. Positive effects through pride and achievement, intactness, and sense of control were most apparent for the most severely frail. They compared themselves with peers who are more often edentate, and valued the good state of their teeth against the background of their declining health, especially those with disabilities causing severe chronic pain or impaired fine-motor skills. The effect of coping with and adaptation to tooth loss was also most apparent for the most severely frail. There was a gender effect in that the men generally cared less about having natural teeth than women, regardless of their level of frailty.
QoL of frail older people is positively influenced by natural teeth, and this effect seems to increase with increasing frailty. Preservation of teeth contributes to a positive body image and self-worth. Oral care for frail people should aim to preserve natural teeth if possible.
Aged; Oral health; Frailty; Quality of life; Natural teeth; Body image; Self-worth
To identify frailty subdimensions.
Longitudinal cohort (MacArthur Study).
Three U.S. urban centers.
One thousand one hundred eighteen high-functioning subjects aged 70 to 79 in 1988.
Participants with three or more of five Cardiovascular Health Study (CHS) frailty criteria (weight loss, weak grip, exhaustion, slow gait, and low physical activity) in 1991 were classified as having the CHS frailty phenotype. To identify frailty subdimensions, factor analysis was conducted using the CHS variables and an expanded set including the CHS variables, cognitive impairment, interleukin-6 (IL-6), C-reactive protein (CRP), subjective weakness, and anorexia. Participants with four or more of 10 criteria were classified as having an expanded frailty phenotype. Predictive validity of each identified frailty subdimension was assessed using regression models for 4-year disability and 9-year mortality.
Two subdimensions of the CHS phenotype and four subdimensions of the expanded frailty phenotype were identified. Cognitive function was consistently part of a subdimension including slower gait, weaker grip, and lower physical activity. The CHS subdimension of slower gait, weaker grip, and lower physical activity predicted disability (adjusted odds ratio (AOR) =1.7, 95% confidence interval (CI) =1.3–2.2) and mortality (AOR =1.5, 95% CI =1.3–1.8). Subdimensions of the expanded model with predictive validity were higher IL-6 and CRP (AOR =1.2 for mortality); slower gait, weaker grip, lower physical activity, and lower cognitive function (AOR =1.8 for disability; AOR =1.5 for mortality), and anorexia and weight loss (AOR =1.2 for disability).
This study provides preliminary empirical support for subdimensions of geriatric frailty, suggesting that pathways to frailty differ and that subdimension-adapted care might enhance care of frail seniors.
frailty; disability; aged; comorbidity
Identify standard self-report questions about functioning suitable for measuring disability across integrated health and social services.
Functional activities can be validly grouped according to the International Classification of Functioning, Disability and Health (ICF) chapters of mobility, self-care, and domestic life.
Cross-sectional analysis using information on 112,601 persons interviewed as part of the United States National Health Interview Survey on Disability. We combined related sets of questions and tested the appropriateness of their groupings through confirmatory factor analyses. Construct validity was addressed by seeking to confirm clinically logical relationships between the resulting functional scales and related health concepts, including number of physician contacts, number of bed days, perception of illness, and perception of disability.
Internal consistency for the summed scales ranged from 0.78 to 0.92. Correlations between the functional scales and related concepts ranged from 0.12 to 0.52 in directions consistent with expectations.
Analyses supported the 3 ICF chapters.
The routine collection of this core set of functions could enhance decision-making at the client, professional, organizational, and policy levels encouraging cooperation among the medical and social service sectors when caring for people with disabilities.
disabled persons; integrated delivery system; computer communication health plan; computerized medical records systems; functional review of systems; international classification of functioning; disability and health (ICF)