Frailty Indices and Nutritional Screening Tools as Predictors of Adverse Outcomes in Hospitalised Older People

Frailty and malnutrition are two major medical issues influencing the health of older people. This doctoral thesis investigated the predictive ability and discriminatory power of clinically applicable frailty instruments and their malnutrition counterparts - nutritional screening tools (NSTs). The study was prospective and observational by design, and included patients aged ≤ 70 years consecutively admitted to the Geriatric Evaluation and Management Unit (GEMU) at The Queen Elizabeth Hospital, South Australia. Thesis aims were to: (i) identify the prevalence rates of malnutrition and frailty in hospitalised older people and (ii) determine the predictive ability and accuracy of these measurements. The mean (standard deviation) age of patients was 85.2 (6.4) years; 123 (72 %) were female, n = 172. Malnutrition and frailty prevalence rates were high: malnutrition was found in 53 (31 %) of patients using the Mini Nutritional Assessment (MNA) for classification; and frailty was found in 107 patients (62 %) by the Cardiovascular Health Study (CHS) frailty index. When looking at nutritional screening tools as predictors of hospital discharge outcomes: the MNA and the MNA-short form (MNA-SF) were associated with length of stay (LOS); the Geriatric Nutritional Risk Index (GNRI) and calf circumference (CC) were associated with functional decline; and mid arm circumference (MAC) was associated with a higher level of care on discharge. At six months post-hospitalisation, malnutrition by the MNA (OR = 3.29) and GNRI (OR = 2.84) was predictive of poor outcome (defined as mortality or admission to high level care). However the discriminative ability of this prediction was inadequate (area under Receiver Operating Characteristic curve (auROC) values were < 0.7). iii Regarding frailty, almost all frailty and functional decline indices were predictive of poor outcome (mortality or high level care admission) at both hospital discharge and at six month post-hospitalisation. However when discriminative ability was considered, only the Frailty Index of Cumulative Deficits (FI-CD) and the adapted Katz score of Activities of Daily Living showed adequate values (auROC values of 0.735 and 0.704 respectively). The FI-CD was the only instrument to show adequate discriminatory power in predicting poor six month outcome (auROC = 0.702, P < 0.001). Malnutrition shares many characteristics with frailty; however the overlap between these two conditions lacks a quantitative foundation. Therefore, this doctoral project also looked at the efficacy of nutritional screening tools as frailty indices in hospitalised older people. An additional focus of this thesis was the association between appetite, body composition and inflammation in healthy people of all ages. This thesis illustrated the high prevalence rate of both malnutrition and frailty in hospitalised older people. Results highlight the importance of research into the predictive ability of both NSTs and frailty instruments in hospitalised older people. Such knowledge will be of assistance in the areas of gerontology research, clinical practice and public health policy, particularly in the wake of the global expansion of the number of older people. Thesis results may also assist in standardising definitions for both frailty and malnutrition, definitions which are greatly needed in clinical practice and research.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 201

Sarcopenia and post-hospital outcomes in older adults: a longitudinal study

Introduction Sarcopenia poses a significant problem for older adults, yet very little is known about this medical condition in the hospital setting. The aims of this hospital-based study were to determine: (i) the prevalence of sarcopenia; (ii) factors associated with sarcopenia; and (iii) the association of sarcopenia with adverse clinical outcomes post-hospitalisation. Methods This is a longitudinal analysis of consecutive patients aged ≥70 years admitted to a Geriatric Management and Evaluation Unit (GEMU) ward. Sarcopenia was classified using the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm, which included: handgrip strength, gait speed, and muscle mass using Bioelectrical Impedance Analysis (BIA). Outcomes were assessed at 12-months post-hospital discharge, and included both mortality and admission to a hospital Emergency Department (ED). Kaplan-Meier methods were used to estimate survival, with Cox proportion hazard models then applied. All regression analyses controlled for age, sex, and co-morbidity. Results 172 patients (72% female) with a mean (SD) age of 85.2 (6.4) years were included. Sarcopenia was present in 69 (40.1%) of patients. Patients with sarcopenia were twice as likely to die in the 12-months post-hospitalisation (HR, 95% CI = 2.23, 1.15–4.34), but did not have an increased likelihood of ED admission. Conclusions Sarcopenia showed an independent association with 12-month post-hospital mortality in older adults. With the new recognition of sarcopenia as a medical condition with its own unique ICD-10-CM code, awareness and diagnosis of sarcopenia in clinical settings is paramount

Frailty increases the long-term risk for fall and fracture-related hospitalizations and all-cause mortality in community-dwelling older women

Frailty is associated with declines in physiological capacity across sensory, neurological, and musculoskeletal systems. An underlying assumption is that the frailer an individual, the more likely they are to experience falls and fractures. We examined whether grades of frailty can assess the long-term risk of hospitalized falls, fractures, and all-cause mortality in 1261 community-dwelling older women (mean age [SD] of 75.1 [2.7] yr) over 14.5 yr. Frailty was operationalized using a frailty index (FI) of cumulative deficits from 33 variables across multiple health domains (physical, mental, comorbidities) at baseline. The total score across these variables was summed and divided by 33 to obtain the FI. Participants were graded as fit (FI ≤ 0.12), mildly frail (FI \u3e 0.12-0.24), moderately frail (FI \u3e 0.24-0.36), or severely frail (FI \u3e 0.36). Fall-related (n = 498), any fracture-related (n = 347), and hip fracture-related hospitalizations (n = 137) and deaths (n = 482) were obtained from linked health records. Associations between FI grades and clinical outcomes were analyzed using multivariable-adjusted Cox-proportional hazard models including age, treatment (calcium/placebo), BMI, smoking history, socioeconomic status, plasma vitamin D (25OHD) status plus season obtained, physical activity, self-reported prevalent falls in the last 3 mo, and self-reported fractures since the age of 50 yr. At baseline, 713 (56.5%), 350 (27.8%), 163 (12.9%), and 35 (2.8%) of women were classified as fit, mildly frail, moderately frail, and severely frail, respectively. Women with mild, moderate, and severe frailty had significantly higher hazards (all P \u3c .05) for a fall-related (46%, 104%, 168%), any fracture-related (88% for moderate, 193% for severe frailty), hip fracture-related hospitalizations (93%, 127%, 129%), and all-cause mortality (47%, 126%, 242%). The FI identified community-dwelling older women at risk for the most serious falls and fractures and may be incorporated into risk assessment tools to identify individuals with poorer clinical prognosis

Higher plant-derived nitrate intake is associated with lower odds of frailty in a cross-sectional study of community-dwelling older women

Purpose: Dietary nitrate intake is inversely related to numerous contributors towards frailty, including cardiovascular disease and poor physical function. Whether these findings extend to frailty remain unknown. We investigated if habitual nitrate intake, derived from plants or animal-based foods, was cross-sectionally associated with frailty in women. Methods: Community-dwelling older Australian women (n = 1390, mean age 75.1 ± 2.7 years) completed a validated semi-quantitative food frequency questionnaire (FFQ). Nitrate concentrations in food were obtained from international nitrate databases. We adopted the Rockwood frailty index (FI) of cumulative deficits comprising 33 variables across multiple health domains (scored 0 to 1), which predicts increased hospitalisation and mortality risk. A FI ≥ 0.25 indicated frailty. Cross-sectional associations between nitrate intake (total plant and animal nitrate, separately) and frailty were analysed using multivariable-adjusted logistic regression models (including lifestyle factors), as part of restricted cubic splines. Results: A non-linear inverse relationship was observed between total plant nitrate intake and frailty. Compared to women with the lowest plant nitrate intake (Quartile [Q]1), women with greater intakes in Q2 (OR 0.69 95%CI 0.56–0.84), Q3 (OR 0.67 95%CI 0.50–0.90) and Q4 (OR 0.66 95%CI 0.45–0.98) had lower odds for frailty. A nadir in the inverse association was observed once intakes reached ~ 64 mg/d (median Q2). No relationship was observed between total animal nitrate and frailty. Conclusion: Community-dwelling older women consuming low amounts of plant-derived nitrate were more likely to present with frailty. Consuming at least one daily serving (~ 75 g) of nitrate-rich green leafy vegetables may be beneficial in preventing frailty

The relationship between frailty and social vulnerability: a systematic review

Both frailty (reduced physiological reserve) and social vulnerability (scarcity of adequate social connections, support, or interaction) become more common as people age and are associated with adverse consequences. Analyses of the relationships between these constructs can be limited by the wide range of measures used to assess them. In this systematic review, we synthesised 130 observational studies assessing the association between frailty and social vulnerability, the bidirectional longitudinal relationships between constructs, and their joint associations with adverse health outcomes. Frailty, across assessment type, was associated with increased loneliness and social isolation, perceived inadequacy of social support, and reduced social participation. Each of these social vulnerability components was also associated with more rapid progression of frailty and lower odds of improvement compared with the absence of that social vulnerability component (eg, more rapid frailty progression in people with social isolation vs those who were not socially isolated). Combinations of frailty and social vulnerability were associated with increased mortality, decline in physical function, and cognitive impairment. Clinical and public health measures targeting frailty or social vulnerability should, therefore, account for both frailty and social vulnerability

Recent developments in frailty identification, management, risk factors and prevention : A narrative review of leading journals in geriatrics and gerontology

Funding The Frailty Epidemiology Research Network (EPI-FRAIL) is an international collaborative project aimed at filling knowledge gaps in the field of frailty epidemiology. The network was established as part of a NWO/ZonMw Veni fellowship awarded to E.O. Hoogendijk (Grant no. 91618067). P. Hanlon is funded through a Clinical Research Training Fellowship from the Medical Research Council (Grant reference: MR/S021949/1). Z. Liu was supported by the Soft Science Research Program of Zhejiang Province (2023KXCX-KT011). J. Jylhävä has received grant support from the Swedish Research Council (grant no. 2018-02077), the Academy of Finland (grant no. 349335), the Sigrid Jusélius Foundation, the Yrjö Jahnsson Foundation and the Instrumentarium Science Foundation. M. Sim is supported by a Royal Perth Hospital Research Foundation Career Advancement Fellowship and an Emerging Leader Fellowship from the Future Health Research and Innovation Fund (Department of Health, Western Australia). R. Ambagtsheer receives funding from the Australian Medical Research Future Fund (grant #MRF2016140). D. L. Vetrano receives financial support from the Swedish Research Council (2021-03324). S. Shi reports funding from the National Institute of Aging, R03AG078894-01. None of the funding agencies had any role in the conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.Peer reviewedPublisher PD

Sarcopenia: A Time for Action. An SCWD Position Paper

The term sarcopenia was introduced in 1988. The original definition was a "muscle loss" of the appendicular muscle mass in the older people as measured by dual energy x-ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC-F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease-related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age-related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age-related and disease-related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life-long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia

An expert opinion on the management of frailty in heart failure from the Australian Cardiovascular Alliance National Taskforce

Approximately 50% of all adults with heart failure (HF) are classified as frail. Frailty is a clinical state of \u27accelerated ageing\u27 that complicates management and results in adverse health outcomes. Despite recommendations for frailty assessment in HF guidelines, its implementation into routine clinical practice has been slow. Further, evidence to inform models of care and pharmacological treatment for individuals with HF who are classified as frail is lacking. The complexity of management underscores the importance of tailoring models of care that can improve the focus on frailty through multidisciplinary care teams. Frailty can be reduced in some cases through the comprehensive geriatric assessment model of care, integrating treatment pillars such as exercise, nutrition, social engagement and support networks, and optimised medication use. A national agenda for action on frailty in the context of HF is needed to advance policy, practice, education, and research improve health outcomes for individuals affected. In November 2023 the Australian Cardiovascular Alliance (ACvA) facilitated a national workshop on frailty and HF with key experts. This has led to the development of a frailty and HF national taskforce with the aim to address major priorities and unmet needs. This statement is first step for the taskforce in implementing a national agenda for the management of frailty in HF. Here we outline key considerations for policy, practice, education, and research in Australia

Consensus guidelines for sarcopenia prevention, diagnosis and management in Australia and New Zealand

Background: Sarcopenia is an age-associated skeletal muscle condition characterized by low muscle mass, strength, and physical performance. There is no international consensus on a sarcopenia definition and no contemporaneous clinical and research guidelines specific to Australia and New Zealand. The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force aimed to develop consensus guidelines for sarcopenia prevention, assessment, management and research, informed by evidence, consumer opinion, and expert consensus, for use by health professionals and researchers in Australia and New Zealand. Methods: A four-phase modified Delphi process involving topic experts and informed by consumers, was undertaken between July 2020 and August 2021. Phase 1 involved a structured meeting of 29 Task Force members and a systematic literature search from which the Phase 2 online survey was developed (Qualtrics). Topic experts responded to 18 statements, using 11-point Likert scales with agreement threshold set a priori at >80%, and five multiple-choice questions. Statements with moderate agreement (70%–80%) were revised and re-introduced in Phase 3, and statements with low agreement (80%) were confirmed by the Task Force in Phase 4. Conclusions: The ANZSSFR Task Force present 17 sarcopenia management and research recommendations for use by health professionals and researchers which includes the recommendation to adopt the EWGSOP2 sarcopenia definition in Australia and New Zealand. This rigorous Delphi process that combined evidence, consumer expert opinion and topic expert consensus can inform similar initiatives in countries/regions lacking consensus on sarcopenia