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Kenneth Rockwood - One of the best experts on this subject based on the ideXlab platform.
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what do we know about Frailty in the acute care setting a scoping review
2018Co-Authors: Olga Theou, Emma Squires, Kayla Mallery, Jacques S Lee, Sherri Fay, Judah Goldstein, Joshua J Armstrong, Kenneth RockwoodAbstract:The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing Frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in Frailty research. This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured Frailty. Among the 204 articles that did measure Frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-Frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used Frailty tools to predict adverse health outcomes. In 74% of the cases Frailty predicted the outcome examined, typically mortality and length of stay. Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring Frailty. There was great variability in tools used and more recently published studies were more likely to use established Frailty tools. Overall, Frailty appears to be a good predictor of adverse health outcomes. For Frailty to be implemented in clinical practice Frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined.
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Frailty, nutrition-related parameters, and mortality across the adult age spectrum
2018Co-Authors: Kulapong Jayanama, Olga Theou, Joanna M Blodgett, Leah Cahill, Kenneth RockwoodAbstract:Abstract Background Nutritional status and individual nutrients have been associated with Frailty in older adults. The extent to which these associations hold in younger people, by type of malnutrition or grades of Frailty, is unclear. Our objectives were to (1) evaluate the relationship between individual nutrition-related parameters and Frailty, (2) investigate the association between individual nutrition-related parameters and mortality across Frailty levels, and (3) examine whether combining nutrition-related parameters in an index predicts mortality risk across Frailty levels. Methods This observational study assembled 9030 participants aged ≥ 20 years from the 2003–2006 cohorts of the National Health and Nutrition Examination Survey who had complete Frailty data. A 36-item Frailty index (FI) was constructed excluding items related to nutritional status. We examined 62 nutrition-related parameters with established cut points: 34 nutrient intake items, 5 anthropometric measurements, and 23 relevant blood tests. The 41 nutrition-related parameters which were associated with Frailty were combined into a nutrition index (NI). All-cause mortality data until 2011 were identified from death certificates. Results All 5 anthropometric measurements, 21/23 blood tests, and 19/34 nutrient intake items were significantly related to Frailty. Although most nutrition-related parameters were directly related to Frailty, high alcohol consumption and high levels of serum alpha-carotene, beta-carotene, beta-cryptoxanthin, total cholesterol, and LDL-c were associated with lower Frailty scores. Only low vitamin D was associated with increased mortality risk across all Frailty levels. Seventeen nutrition-related parameters were associated with mortality in the 0.1–0.2 FI group, 11 in the 0.2–0.3 group, and 16 in the > 0.3 group. Overall, 393 (5.8%) of the participants had an NI score less than 0.1 (abnormality in ≤ 4 of the 41 parameters examined). Higher levels of NI were associated with higher mortality risk after adjusting for Frailty and other covariates (HR per 0.1: 1.19 [95%CI 1.133–1.257]). Conclusions Most nutrition-related parameters were correlated to Frailty, but only low vitamin D was associated with higher risk for mortality across levels of Frailty. As has been observed with other age-related phenomena, even though many nutrition-related parameters were not significantly associated with mortality individually, when combined in an index, they strongly predicted mortality risk
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operationalization of Frailty using eight commonly used scales and comparison of their ability to predict all cause mortality
2013Co-Authors: Olga Theou, Kenneth Rockwood, Arnold MitnitskiAbstract:Objectives: To operationalize Frailty using eight scales and to compare their content validity, feasibility, prevalence estimates of Frailty, and ability to predict all-cause mortality. Design: Secondary analysis of the Survey of Health, Ageing and Retirement in Europe (SHARE). Setting: Eleven European countries. Participants: Individuals aged 50 to 104 (mean age 65.3 ± 10.5, 54.8% female, N = 27,527). Measurements: Frailty was operationalized using SHARE data based on the Groningen Frailty Indicator, the Tilburg Frailty Indicator, a 70-item Frailty Index (FI), a 44-item FI based on a Comprehensive Geriatric Assessment (FI-CGA), the Clinical Frailty Scale, Frailty phenotype (weighted and unweighted versions), the Edmonton Frail Scale, and the FRAIL scale. Results: All scales had fewer than 6% of cases with at least one missing item, except the SHARE-Frailty phenotype (11.1%) and the SHARE-Tilburg (12.2%). In the SHARE-Groningen, SHARE-Tilburg, SHARE-Frailty phenotype, and SHARE-FRAIL scales, death rates were 3 to 5 times as high in excluded cases as in included ones. Frailty prevalence estimates ranged from 6% (SHARE-FRAIL) to 44% (SHARE-Groningen). All scales categorized 2.4% of participants as frail. Of unweighted scales, the SHARE-FI and SHARE-Edmonton scales most accurately predicted mortality at 2 (SHARE-FI area under the receiver operating characteristic curve (AUC) = 0.77, 95% confidence interval (CI) = 0.75�0.79); SHARE-Edmonton AUC = 0.76, 95% CI = 0.74�0.79) and 5 (both AUC = 0.75, 95% CI = 0.74�0.77) years. The continuous score of the weighted SHARE-Frailty phenotype (AUC = 0.77, 95% CI = 0.75�0.78) predicted 5-year mortality better than the unweighted SHARE-Frailty phenotype (AUC = 0.70, 95% CI = 0.68�0.71), but the categorical score of the weighted SHARE-Frailty phenotype did not (AUC = 0.70, 95% CI = 0.68�0.72). Conclusion: Substantive differences exist between scales in their content validity, feasibility, and ability to predict all-cause mortality. These Frailty scales capture related but distinct groups. Weighting items in Frailty scales can improve their predictive ability, but the trade-off between specificity, predictive power, and generalizability requires additional evaluation.
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psychological well being in relation to Frailty a Frailty identity crisis
2012Co-Authors: Melissa K Andrew, John D Fisk, Kenneth RockwoodAbstract:Background: Frailty can be defined as the presence of multiple, interacting medical and functional problems. Frailty is associated with psychiatric conditions but its relation to psychological well-being is unclear. A “Frailty identity crisis” has been proposed as a maladaptive response to the sense of self as health deficits accumulate. We evaluated this so-called identity crisis by investigating associations between well-being, Frailty, and mortality in community-dwelling older Canadians. Methods: In this secondary analysis of the Canadian Study of Health and Aging ( N = 5,703; age 70+), Frailty was defined by an index of 33 health deficits. Psychological well-being was measured using Ryff's 18-item scale, with six domains (autonomy, personal growth, environmental mastery, positive relations, purpose in life, and self-acceptance). Cognition was measured using the Modified Mini-Mental State Examination. Associations between well-being, Frailty, and mortality were measured using linear regression, adjusting for age, sex, education, cognition, and mental health. Results: For each additional Frailty-defining deficit, the psychological well-being score worsened by 0.3 points (0.29, 95% CI: 0.22–0.36, p Conclusions: Frailty was associated with low levels of well-being. Psychological well-being impaired by a Frailty identity crisis may play an important role in defining subjective health in older adults.
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prevalence and 10 year outcomes of Frailty in older adults in relation to deficit accumulation
2010Co-Authors: Xiaowei Song, Arnold Mitnitski, Kenneth RockwoodAbstract:OBJECTIVES: To evaluate the prevalence and 10-year outcomes of Frailty in older adults in relation to deficit accumulation. DESIGN: Prospective cohort study. SETTING: The National Population Health Survey of Canada, with Frailty estimated at baseline (1994/95) and mortality follow-up to 2004/05. PARTICIPANTS: Community-dwelling older adults (N=2,740, 60.8% women) aged 65 to 102 from 10 Canadian provinces. During the 10-year follow-up, 1,208 died. MEASUREMENTS: Self-reported health information was used to construct a Frailty index (Frailty Index) as a proportion of deficits accumulated in individuals. The main outcome measure was mortality. RESULTS: The prevalence of Frailty increased with age in men and women (correlation coefficient=0.955–0.994, P<.001). The Frailty Index estimated that 622 (22.7%, 95% confidence interval (CI)=21.0–24.4%) of the sample was frail. Frailty was more common in women (25.3%, 95% CI=23.2–27.5%) than in men (18.6%, 95% CI=15.9–21.3%). For those aged 85 and older, the Frailty Index identified 39.1% (95% CI=31.3–46.9%) of men as frail, compared with 45.1% (95% CI=39.7–50.5%) of women. Frailty significantly increased the risk of death, with an age- and sex-adjusted hazard ratio for the Frailty Index of 1.57 (95% CI=1.41–1.74). CONCLUSION: The prevalence of Frailty increases with age and at any age lessens survival. The Frailty Index approach readily identifies frail people at risk of death, presumably because of its use of multiple health deficits in multidimensional domains.
Philip Green - One of the best experts on this subject based on the ideXlab platform.
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Frailty assessment in the cardiovascular care of older adults
2014Co-Authors: Jonathan Afilalo, Luigi Ferrucci, Philip Green, Mathew S Maurer, Karen P Alexander, Larry A Allen, Michael J Mack, Jeffrey J Popma, Daniel E FormanAbstract:Due to the aging and increasingly complex nature of our patients, Frailty has become a high-priority theme in cardiovascular medicine. Despite the recognition of Frailty as a pivotal element in the evaluation of older adults with cardiovascular disease (CVD), there has yet to be a road map to facilitate its adoption in routine clinical practice. Thus, we sought to synthesize the existing body of evidence and offer a perspective on how to integrate Frailty into clinical practice. Frailty is a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors. Upward of 20 Frailty assessment tools have been developed, with most tools revolving around the core phenotypic domains of Frailty—slow walking speed, weakness, inactivity, exhaustion, and shrinking—as measured by physical performance tests and questionnaires. The prevalence of Frailty ranges from 10% to 60%, depending on the CVD burden, as well as the tool and cutoff chosen to define Frailty. Epidemiological studies have consistently demonstrated that Frailty carries a relative risk of >2 for mortality and morbidity across a spectrum of stable CVD, acute coronary syndromes, heart failure, and surgical and transcatheter interventions. Frailty contributes valuable prognostic insights incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients. Interventions designed to improve outcomes in frail elders with CVD such as multidisciplinary cardiac rehabilitation are being actively tested. Ultimately, Frailty should not be viewed as a reason to withhold care but rather as a means of delivering it in a more patient-centered fashion.
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tct 785 the eyeball test in aortic stenosis characterizing subjective Frailty with objective measures
2013Co-Authors: Tamim Nazif, Philip Green, Jeanmichel Paradis, Christopher W Hawk, Kishore J Harjai, Tiffany Wong, Rosa M Lazarte, Isaac George, Martin B Leon, Ajay J KirtaneAbstract:Assessment of Frailty complements traditional risk assessment in high-risk older adults with aortic stenosis (AS). Subjective Frailty assessment is widely used, but its associations with objective markers of Frailty are poorly characterized. Frailty was subjectively assessed by an interventional
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the impact of Frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis a single center experience
2012Co-Authors: Philip Green, Abigail Woglom, Philippe Genereux, Benoit Daneault, Jeanmichel Paradis, Susan Schnell, Marian Hawkey, Mathew S Maurer, Ajay J Kirtane, Susheel KodaliAbstract:Objectives This study sought to evaluate the impact of Frailty in older adults undergoing transcatheter aortic valve replacement (TAVR) for symptomatic aortic stenosis. Background Frailty status impacts prognosis in older adults with heart disease; however, the impact of Frailty on prognosis after TAVR is unknown. Methods Gait speed, grip strength, serum albumin, and activities of daily living status were collected at baseline and used to derive a Frailty score among patients who underwent TAVR procedures at a single large-volume institution. The cohort was dichotomized on the basis of median Frailty score into frail and not frail groups. The impact of Frailty on procedural outcomes (stroke, bleeding, vascular complications, acute kidney injury, and mortality at 30 days) and 1-year mortality was evaluated. Results Frailty status was assessed in 159 subjects who underwent TAVR (age 86 ± 8 years, Society of Thoracic Surgery Risk Score 12 ± 4). Baseline Frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score. Although high Frailty score was associated with a longer post-TAVR hospital stay when compared with lower Frailty score (9 ± 6 days vs. 6 ± 5 days, respectively, p = 0.004), there were no significant crude associations between Frailty status and procedural outcomes, suggesting adequacy of the standard selection process for identifying patients at risk for periprocedural complications after TAVR. Frailty status was independently associated with increased 1-year mortality (hazard ratio: 3.5, 95% confidence interval: 1.4 to 8.5, p = 0.007) after TAVR. Conclusions Frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR but was associated with increased 1-year mortality after TAVR. Further studies will evaluate the independent value of this Frailty composite in older adults with aortic stenosis.
Robert L Kane - One of the best experts on this subject based on the ideXlab platform.
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association of Frailty with survival a systematic literature review
2013Co-Authors: Tatyana Shamliyan, Kristine Mc Talley, Rema Ramakrishnan, Robert L KaneAbstract:Frailty is a known risk factor for those aged 65 and over, and its prevalence increases with age. Definitions of Frailty vary widely, and prevalence estimates are affected by the way Frailty is defined. Systematic reviews have yet to examine the literature on the association between definitions of Frailty and mortality. We examined the definitions and prevalence of Frailty and its association with survival in older community-dwelling adults. We conducted a systematic review of observational population-based studies published in English. We calculated pooled prevalence of Frailty with a random effects model. We identified 24 population-based studies that examined Frailty in community-dwelling older adults. The pooled prevalence was 14% when Frailty was defined as a phenotype exhibiting three or more of the following: weight loss, fatigue/exhaustion, weakness, low physical activity/slowness, and mobility impairment. The pooled prevalence was 24% when Frailty was defined by accumulation of deficits indices that included up to 75 diseases and impairments. The prevalence of Frailty increased with age and was greater in women and in African Americans. Frailty in older adults was associated with poor survival with a dose-responsive reduction in survival per increasing number of Frailty criteria. Taking into account population prevalence and multivariate adjusted relative risks, we estimated that 3-5% of deaths among older adults could be delayed if Frailty was prevented. Frailty is a prevalent and important geriatric syndrome associated with decreased survival. Geriatric assessment of Frailty provides clinically important information about functional status and survival of older adults.
Howard Bergman - One of the best experts on this subject based on the ideXlab platform.
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management of Frailty opportunities challenges and future directions
2019Co-Authors: Elsa Dent, Howard Bergman, Finbarr C Martin, Jean Woo, Roman Romeroortuno, Jeremy D WalstonAbstract:Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of Frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of Frailty severity. In clinical practice, we should do what works, starting with Frailty screening, case identification, and management of Frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage Frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of Frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.
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the identification of Frailty a systematic literature review
2011Co-Authors: Shelley A Sternberg, Sathya Karunananthan, Howard Bergman, Andrea Wershof Schwartz, Mark A ClarfieldAbstract:An operational definition of Frailty is important for clinical care, research, and policy planning. The literature on the clinical definitions, screening tools, and severity measures of Frailty were systematically reviewed as part of the Canadian Initiative on Frailty and Aging. Searches of MEDLINE from 1997 to 2009 were conducted, and reference lists of retrieved articles were pearled, to identify articles published in English and French on the identification of Frailty in community-dwelling people aged 65 and older. Two independent reviewers extracted descriptive information on study populations, Frailty criteria, and outcomes from the selected papers, and quality rankings were assigned. Of 4,334 articles retrieved from the searches and 70 articles retrieved from the pearling, 22 met study inclusion criteria. In the 22 articles, physical function, gait speed, and cognition were the most commonly used identifying components of Frailty, and death, disability, and institutionalization were common outcomes. The prevalence of Frailty ranged from 5% to 58%. Despite significant work over the past decade, a clear consensus definition of Frailty does not emerge from the literature. The definition and outcomes that best suit the unique needs of the researchers, clinicians, or policy-makers conducting the screening determine the choice of a screening tool for Frailty. Important areas for further research include whether disability should be considered a component or an outcome of Frailty. In addition, the role of cognitive and mood elements in the Frailty construct requires further clarification.
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role of Frailty in patients with cardiovascular disease
2009Co-Authors: Jonathan Afilalo, Sathya Karunananthan, Mark J Eisenberg, Karen P Alexander, Howard BergmanAbstract:Frailty is a geriatric syndrome of increased vulnerability to stressors that has been implicated as a causative and prognostic factor in patients with cardiovascular disease (CVD). The American Heart Association and the Society of Geriatric Cardiology have called for a better understanding of Frailty as it pertains to cardiac care in the elderly. The aim of this study was to systematically review studies of Frailty in patients with CVD. A search was conducted of Ovid MEDLINE, EMBASE, the Cochrane Database, and unpublished sources. Inclusion criteria were an assessment of Frailty using systematically defined criteria and a study population with prevalent or incident CVD. Nine studies were included, encompassing 54,250 elderly patients with a mean weighted follow-up of 6.2 years. In community-dwelling elders, CVD was associated with an odds ratio (OR) of 2.7 to 4.1 for prevalent Frailty and an OR of 1.5 for incident Frailty in those who were not frail at baseline. Gait velocity (a measure of Frailty) was associated with an OR of 1.6 for incident CVD. In elderly patients with documented severe coronary artery disease or heart failure, the prevalence of Frailty was 50% to 54%, and this was associated with an OR of 1.6 to 4.0 for all-cause mortality after adjusting for potential confounders. In conclusion, there exists a relation between Frailty and CVD; Frailty may lead to CVD, just as CVD may lead to Frailty. The presence of Frailty confers an incremental increase in mortality. The role of Frailty assessment in clinical practice may be to refine estimates of cardiovascular risk, which tend to be less accurate in the heterogenous elderly patient population.
Ajay J Kirtane - One of the best experts on this subject based on the ideXlab platform.
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tct 785 the eyeball test in aortic stenosis characterizing subjective Frailty with objective measures
2013Co-Authors: Tamim Nazif, Philip Green, Jeanmichel Paradis, Christopher W Hawk, Kishore J Harjai, Tiffany Wong, Rosa M Lazarte, Isaac George, Martin B Leon, Ajay J KirtaneAbstract:Assessment of Frailty complements traditional risk assessment in high-risk older adults with aortic stenosis (AS). Subjective Frailty assessment is widely used, but its associations with objective markers of Frailty are poorly characterized. Frailty was subjectively assessed by an interventional
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the impact of Frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis a single center experience
2012Co-Authors: Philip Green, Abigail Woglom, Philippe Genereux, Benoit Daneault, Jeanmichel Paradis, Susan Schnell, Marian Hawkey, Mathew S Maurer, Ajay J Kirtane, Susheel KodaliAbstract:Objectives This study sought to evaluate the impact of Frailty in older adults undergoing transcatheter aortic valve replacement (TAVR) for symptomatic aortic stenosis. Background Frailty status impacts prognosis in older adults with heart disease; however, the impact of Frailty on prognosis after TAVR is unknown. Methods Gait speed, grip strength, serum albumin, and activities of daily living status were collected at baseline and used to derive a Frailty score among patients who underwent TAVR procedures at a single large-volume institution. The cohort was dichotomized on the basis of median Frailty score into frail and not frail groups. The impact of Frailty on procedural outcomes (stroke, bleeding, vascular complications, acute kidney injury, and mortality at 30 days) and 1-year mortality was evaluated. Results Frailty status was assessed in 159 subjects who underwent TAVR (age 86 ± 8 years, Society of Thoracic Surgery Risk Score 12 ± 4). Baseline Frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score. Although high Frailty score was associated with a longer post-TAVR hospital stay when compared with lower Frailty score (9 ± 6 days vs. 6 ± 5 days, respectively, p = 0.004), there were no significant crude associations between Frailty status and procedural outcomes, suggesting adequacy of the standard selection process for identifying patients at risk for periprocedural complications after TAVR. Frailty status was independently associated with increased 1-year mortality (hazard ratio: 3.5, 95% confidence interval: 1.4 to 8.5, p = 0.007) after TAVR. Conclusions Frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR but was associated with increased 1-year mortality after TAVR. Further studies will evaluate the independent value of this Frailty composite in older adults with aortic stenosis.
