Frailty syndrome: implications and challenges for health care policy

Older adults are a highly heterogeneous group with variable health and functional life courses. Frailty has received increasing scientific attention as a potential explanation of the health diversity of older adults. The frailty phenotype and the Frailty Index are the most frequently used frailty definitions, but recently new frailty definitions that are more practical have been advocated. Prevalence of frailty among the community-dwelling population aged 65 years and older is ~10% but varies depending on which frailty definitions are used. The mean prevalence of frailty gradually increases with age, but the individual’s frailty level can be improved. Older adults, especially frail older adults, form the main users of medical and social care services. However, current health care systems are not well prepared to deal with the chronic and complex medical needs of frail older patients. In this context, frailty is potentially a perfect fit as a risk stratification paradigm. The evidence from frailty studies has not yet been fully translated into clinical practice and health care policy making. Successful implementation would improve quality of care and promote healthy aging as well as diminish the impact of aging on health care systems and strengthen their sustainability. At present, however, there is no effective treatment for frailty and the most effective intervention is not yet known. Based on currently available evidence, multi-domain intervention trials, including exercise component, especially multicomponent exercise, which includes resistance training, seem to be promising. The current challenges in frailty research include the lack of an international standard definition of frailty, further understanding of interventions to reverse frailty, the best timing for intervention, and education/training of health care professionals. The hazards of stigmatization should also be considered. If these concerns are properly addressed, widespread application of public health approaches will be possible, including screening, identification, and treatment of frailty, resulting in better care and healthier aging for older people

Prevalence of Frailty in Mild to Moderate Alzheimer's Disease: A Systematic Review and Meta-analysis

BACKGROUND: Frailty is a state of increased vulnerability to poor resolution of homeostasis as a consequence of age-related decreased physiological reserves. Although physical frailty and cognitive impairment have been shown to be associated, evidence on the prevalence of frailty in Alzheimer’s disease is scarce. OBJECTIVE: To conduct a systematic review on the prevalence of frailty and to combine the data to synthesize the pooled prevalence of physical frailty among patients with Alzheimer’s disease. METHOD: Five electronic databases (Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library) were searched for studies providing cross-sectional data on physical frailty among patients with Alzheimer’s disease published from 2000 to January 2016. RESULTS: Of 2,564 studies identified through the systematic review, five studies incorporating 534 patients with Alzheimer’s disease were included for the meta-analysis. The prevalence of frailty varied with a wide range from 11.1% to 50.0% and the pooled prevalence was 31.9% (five studies, 95% confidence interval (CI)=15.7%-48.5%) . The high degree of heterogeneity was observed in all analyses publication bias was detected. CONCLUSION: The current study showed that frailty is highly prevalent in older patients with Alzheimer’s disease in the community with the pooled prevalence of 31.9%. The true prevalence may be much higher given that end-stage patients may not be included. This information is important for clinicians and researchers

Non-linear association between alcohol and incident frailty among community-dwelling older people: A dose-response meta-analysis

A recent systematic review and meta-analysis study suggested that higher alcohol consumption is associated with lower risks for frailty. However the apparent protective effect may not be true because of some limitations. Therefore we further explored potential linear and non-linear associations using a two-stage dose-response meta-analysis. Restricted cubic splines were applied with three fixed knots at percentiles (10%, 50%, and 90%). A two-stage dose-response meta-analysis showed a significant non-linear association (p for non-linearity < 0.001); incident frailty risk decreased until around 15 g/day of alcohol consumption and increased thereafter. This suggests that while moderate alcohol consumption is associated with a lower risk of frailty, at higher consumption levels this apparent protect effect is lost. Given these findings, non-linear associations should be considered in future research on alcohol and frailty

Does current smoking predict future frailty? The English longitudinal study of ageing

BACKGROUND: smoking is the single most preventable cause of morbidity and mortality. The evidence on independent associations between smoking in later life and incident frailty is scarce. OBJECTIVES: to examine the effect of current smoking in older people on the risk of developing frailty, controlling for important confounders. METHODS: we used data of 2,542 community-dwelling older people aged ≥60 years in England. Participants were classified as current smokers or non-smokers. Frailty was defined using modified Fried criteria. Multivariable logistic regression models were used to examine risk of 4-year incident frailty in current smokers compared with non-smokers, adjusted for demographic, socioeconomic and health variables. RESULTS: of 2,542 participants, 261 and 2,281 were current smokers and non-smokers, respectively. The current smokers were significantly frailer, younger, with lower BMI, less educated, less wealthy and lonelier compared with non-smokers at baseline. In multivariable logistic regression models adjusting for age and gender, current smokers were twice as likely to develop frailty compared with non-smokers (odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.39–3.39, P = 0.001). The association is attenuated largely by controlling for socioeconomic status. Smoking remains significantly associated with incident frailty in fully adjusted models including age, gender, socioeconomic status, alcohol use, cognitive function and loneliness (OR = 1.60, 95% CI = 1.02–2.51, P = 0.04). The relationship is however attenuated when taking account of non-response bias through multiple imputation. CONCLUSIONS: current smokers compared with non-smokers were significantly more likely to develop frailty over 4 years among community-dwelling older people. Given that smoking is a modifiable lifestyle factor, smoking cessation may potentially prevent or delay developing frailty, even in old age

A systematic review and meta-analysis of prospective associations between alcohol consumption and incident frailty

BACKGROUND: light-to-moderate alcohol consumption is protective against all-cause mortality and cardiovascular diseases. There is limited evidence in the literature on how alcohol consumption is related to frailty. METHODS: five databases (Embase, Scopus, MEDLINE, CINAHL, PsycINFO) were systematically searched in July 2016 for prospective studies published between 2000 and 2016 examining baseline alcohol consumption and subsequent frailty risk among middle-aged or older community-dwelling population. Odds ratios (ORs) for incident frailty were pooled using a random-effects model. Heterogeneity, methodological quality and publication bias were assessed. RESULTS: of 926 studies identified by the systematic search, four studies were included (total n = 44,051, ≥55 years, 66.2% alcohol users). OR of incident frailty for the highest (at least 24 g of alcohol/day for men, 12g of alcohol/day for women) or the most frequent (≥5 days of drinking/week) alcohol consumption compared with no drinking were used for a meta-analysis. Pooled OR among three studies measuring alcohol consumption quantitatively showed that the highest alcohol consumption was associated with lower frailty risk (3 studies:pooled OR = 0.44, 95%CI = 0.19-1.00, P = 0.05). Adding the other study measuring frequency of alcohol consumption made little change (4 studies:pooled OR = 0.61, 95%CI = 0.44-0.77, P < 0.001). Two of the included studies suggested a possible U-shaped association with lowest risks for moderate drinkers. Heterogeneity was moderate in both analyses (I2 = 52-67%). There was no evidence of publication bias. CONCLUSIONS: this systematic review and meta-analysis study provides the first pooled evidence suggesting that heavier alcohol consumption is associated with lower incident frailty compared with no alcohol consumption among community-dwelling middle-aged and older people. However, this association may be due to unadjusted effect measures, residual confounding, 'sick quitter' effect or survival bias

Health promotion for mild frailty based on behaviour change: Perceptions of older people and service providers.

Mild frailty is common among older people, but it is potentially reversible with health promotion interventions. Behaviour change may be a key to preventing progression of frailty; however, we know little about what interventions work best and how a behaviour change approach would be perceived by this group. The aim of this study was to explore how mildly frail older people perceive health promotion based on behaviour change and what factors affect engagement with this approach. We conducted semi-structured interviews with 16 older people with mild frailty who received a pilot home-based behaviour change health promotion service, including a dyad of older person/family carer, and two service providers delivering the service in two diverse areas of South England. Interviews were audio-recorded, transcribed and thematically analysed. The concept of goal setting was acceptable to most participants, though the process of goal setting needed time and consideration. Goals on maintaining independence, monitoring of progress and receiving feedback were reported to increase motivation. Physical/mental capability and knowledge/perception of own needs were main determinants of the type of goals chosen by participants as well as the approach used by the project workers. Older people with complex needs benefited from care coordination, with a combination of goal setting and elements of social, practical and emotional support in varying proportions. Mildly frail older people responded well to a behaviour change approach to promote health and well-being. Further consideration is needed of the most effective strategies based on complexity of needs, and how to overcome barriers among people with cognitive impairment

Hearing impairment and incident disability and all-cause mortality in older British community-dwelling men.

BACKGROUND AND OBJECTIVE: hearing impairment is common in older adults and has been implicated in the risk of disability and mortality. We examined the association between hearing impairment and risk of incident disability and all-cause mortality. DESIGN AND SETTING: prospective cohort of community-dwelling older men aged 63-85 followed up for disability over 2 years and for all-cause mortality for 10 years in the British Regional Heart Study. METHODS: data were collected on self-reported hearing impairment including hearing aid use, and disability assessed as mobility limitations (problems walking/taking stairs), difficulties with activities of daily living (ADL) and instrumental ADL (IADL). Mortality data were obtained from the National Health Service register. RESULTS: among 3,981 men, 1,074 (27%) reported hearing impairment. Compared with men with no hearing impairment, men who could hear and used a hearing aid, and men who could not hear despite a hearing aid had increased risks of IADL difficulties (age-adjusted OR 1.86, 95% CI 1.29-2.70; OR 2.74, 95% CI 1.53-4.93, respectively). The associations remained after further adjustment for covariates including social class, lifestyle factors, co-morbidities and social engagement. Associations of hearing impairment with incident mobility limitations, incident ADL difficulties and all-cause mortality were attenuated on adjustment for covariates. CONCLUSION: this study suggests that hearing problems in later life could increase the risk of having difficulties performing IADLs, which include more complex everyday tasks such as shopping and light housework. However, further studies are needed to determine the associations observed including the underlying pathways

Structure and tissue distribution of some retinoid-binding proteins

Vitamin A has, apart from its function in the visual pigments, general effects on several organs. Early signs of vitamin A deficiency include keratinization of epithelia and hyperkeratosis of the skin. To elucidate a generalized function for vitamin A, we have taken the approach of tracing the vitamin from its storage site in the liver via its blood transport by the retinol-binding protein (RBP) to its uptake by susceptible cells. We have also examined the intracellular occurrence of vitamin A as regards its binding to specific receptor proteins. Here we summarize data on the amino acid sequences of several vitamin A-binding proteins. The finding that CRBP and CRABP, the two intracellular proteins, are homologous to each other, to a myelin protein, and to a fatty acid-binding protein may shed light on the functions of these proteins. Retinoic acid, which binds to CRABP but not CRBP, induces differentiation of teratocarcinoma cells. This is accompanied by a lowering of the CRABP concentration, an increase of the CRBP level, and an increase in the uptake of retinol from RBP. The epidermis contains both CRBP and CRABP, and their distributions are rather similar. However, in contrast to CRBP, CRABP is most abundant in cells lining the hair follicles. CRBP occurs in greatest relative amounts in the outer layers of the epidermis. Since techniques have been developed to measure CRBP and CRABP, normal and disease-affected skin may now be explored as to quantity and cellular distribution of the retinoid-binding proteins