Critical methodological concerns regarding the secondary analysis of a low-carbohydrate diet trial on frailty in older diabetic patients.

The predictive value of preoperative frailty screening for postoperative outcomes in older patients undergoing surgery for non-metastatic colorectal cancer

IS FRAILTY STATUS A TRIGGER FOR GOALS OF CARE DOCUMENTATION IN OLDER PATIENTS ADMITTED TO THE HOSPITAL?

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Rigshospitalet Research Foundation Background The number of older patients is increasing world-wide. Older patients have a higher risk of complications related to acute coronary syndrome (ACS) treatment and are more often frail. Yet, they are often missing in clinical trials, which leads to a knowledge gap in current guidelines when treating older ACS patients. Frailty scoring may be a better tool than conventional risk scores to assess prognosis. Previous studies have proposed that a patient’s biological age instead of chronological age could be used to better guide the treatment strategy in older ACS patients. Potentially frailty scoring can be used to decide a patient’s biological age. Purpose We wanted to investigate the prevalence of frailty in a consecutive population of ACS patients ≥70 years referred to invasive angiography at a tertiary centre. Furthermore, we wanted to investigate whether frail patients had a worse 12-month outcome compared to non-frail patients. Methods From September 2020 to September 2021 all patients ≥70 years referred to our institution with ACS were, when logistically possible, undergoing bedside frailty scoring using the clinical frailty scale (CFS). The CFS scoring was performed at the time of admission by nurses at the department. Patients were divided into three frailty groups depending on their CFS score: Robust (1-3), Vulnerable (4) and Frail (5-9). Patients were followed for 12 months. Results During the study period, 691 patients ≥70 years old with ACS were admitted. Of the 451 (65%) patients who had a frailty assessment, 70 (16%) patients were frail, 77 (17%) were vulnerable and 304 (67%) were robust. Frail and vulnerable patients were older (frail: 80.9 (5.6) years, vulnerable: 78.5 (5.7) years and robust: 76.7 (4.8) years, p<0.001), had more comorbidities, defined as a higher Charlson index score (frail: 4.5 [4.0-5.0], vulnerable: 4.0 [4.0-6.0] and robust: 4.0 [3.0-4.0], p<0.001) and longer hospitalisation (frail: 5 [3-9.2] days, vulnerable: 8 [3.5-14.0] days and robust: 5 [3-7] days, p=0.021). Furthermore, frail and vulnerable patients less frequently underwent revascularisation during their first admission (frail: 58.9%, vulnerable: 65.1% and robust: 77.9%, p<0.001). In 12-month follow-up, frail and vulnerable patients had a higher cumulated incidence of all-cause mortality compared to robust patients (p<0.001), figure 1. Frail patients had more than four times the risk of 12-month all-cause mortality compared to robust patients (HR 4.16 (2.12-8.15), p<0.001). The association remained significant after adjustment for age and comorbidities (HR 2.71 (1.30-5.64), p=0.008), as well as for GRACE score (HR 2.98 (1.50-5.90), p=0.002), table 1. Conclusion In patients ≥70 years old with ACS and referred to invasive angiography, frailty according to the CFS score had a prevalence of 16%. Frail and vulnerable patients had more than four times the risk of all-cause mortality in 12-month follow-up.

BackgroundThe association between frailty and older patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) is unclear. Therefore, we conducted a systematic review and meta‐analysis to investigate the prevalence of frailty in older patients with AMI following PCI, and determine the relationship between frailty and adverse outcomes in these patients.HypothesisOlder patients with AMI have a higher prevalence of frailty after PCI, and the frailty in these patients increases the risk of adverse outcomes.MethodsA comprehensive search of the PubMed, Cochrane, Ovid (Medline), Ovid (Embase), and Web of Science databases was performed for articles published until October 2021. A meta‐analysis was performed using stata12.0 software. A random‐effects model was used when I2 was greater than 50%; otherwise, a fixed‐effects model was used.ResultsThere were a total of 274,976 older patients in the included studies. Nine studies investigated the prevalence of frailty in older patients with AMI after PCI, with an overall prevalence of 39% (95% confidence interval [CI]: 18%–60%, p < .001). Six studies included adverse outcomes of frailty in older patients with AMI after PCI, including all‐cause mortality (hazard ratio [HR] = 2.29, 95% CI: 1.65–3.16, p = .285), rehospitalization (HR = 2.53, 95% CI: 1.38–4.63), and in‐hospital major bleeding (HR = 1.93, 95% CI: 1.29–2.90, p = .825).ConclusionThe frailty prevalence is increased in older patients with AMI after PCI, especially in ST‐segment elevation myocardial infarction (STEMI). AMI with frailty after PCI is more likely to be associated with worse clinical outcomes, such as death, bleeding, and rehospitalization.

Frailty-Based Outcomes with Bispecific Antibodies in Older Patients with Multiple Myeloma

Background and aimsTo systematically evaluate the relevant literature to explore the prevalence and influencing factors of frailty in older patients with diabetes in China.MethodsCochrane Library, PubMed, Embase, Medline, CINAHL, Scopus, Proquest Central, Web of Science, SinoMed, CNKI, VIP and Wan fang Databases were searched to collect Chinese and English literatures about frailty in older diabetic patients. RevMan 5.4 software was used to extract data for systematic review.ResultsSeventeen studies involving 23,070 older patients with diabetes were included. The results showed that the prevalence of frailty in older Chinese diabetic patients was 30%. The main influencing factors were HbA1c level, number of complications, age, depression, exercise, and nutritional status.ConclusionThe prevalence of frailty in Chinese elderly diabetic patients is high and there are many influencing factors. However, the quality of relevant literature is general and the number is limited, so high-quality prospective studies should be carried out in the future to further verify the conclusions.

Frailty is associated with increased mortality and complications in older trauma patients. However, the impact of trauma on functional outcomes in older patients has not been well studied. We hypothesized that trauma would worsen an older person's function postinjury as measured using the Rockwood Clinical Frailty Scale (CFS), and that frail patients would experience poorer health outcomes compared with prefrail and nonfrail patients. This was a prospective cohort study including all trauma patients 65 years or older admitted to a Level 1 trauma center. CFS scores were recorded at baseline (pretrauma), 3, 6, and 12 months postinjury. This was compared between nonfrail (CFS scores 1-3), prefrail (CFS score 4), and frail (CFS score ≥5) patients using a linear mixed-effects model adjusted for age, sex, mechanism, comorbidities, injury severity, surgery during admission, and intensive care unit admission. In-hospital and 12-month health outcomes were recorded and compared. A total of 224 patients were included. Twelve-month mortality in frail patients (28%) was significantly higher than prefrail (20%) and nonfrail (5%) patients (p < 0.01). Increasing frailty was associated with higher rates of discharge into supported care (p < 0.01) and reinjury (p < 0.01), with over one in three frail patients experiencing reinjury within 12 months. Pretrauma frail patients demonstrated a prolonged deterioration in frailty and failed to recover by 12 months. Nonfrail and prefrail patients both became more frail, and although they made some recovery, neither group returned to their functional baseline by 12 months. Trauma produces significant frailty decline, resulting in a period of heightened vulnerability to mortality, morbidity, and reinjury. Pretrauma frailty influences the trajectory of functional decline and recovery, which is helpful for providing prognostic information, establishing goals of care, and selecting patients who may benefit from interventions aimed at reversing frailty. Prognostic and Epidemiological; Level I.

Chronic inflammation plays a pivotal role in the development of frailty in patients with cardiovascular diseases (CVD). Systemic inflammatory response index (SIRI) has been shown to reflect the overall inflammatory status. This study aimed toinvestigate the relationship between SIRI and frailty in older patients with CVD, and to develop a nomogram for predicting the risk of frailty in this population. A total of 234 older patientswith CVD were included. Inflammation markers were derived from routine blood tests, and frailty status was assessed using the FRAIL scale. Clinical and laboratory characteristics were compared between patients with or without frailty. Multivariate logistic regression was employed to identify significant variables for inclusion in the nomogram. The performance of the nomogram, including its discrimination and calibration, was rigorously evaluated. A total of 98 cases were assigned to the frailty group and 136 to the non-frailty group. Patients in the non-frailty group were generally younger, more likely to have normal kidney function, and better blood pressure control. Frail patients exhibited a higher degree of systemic inflammation compared to non-frail patients (P < 0.05). Age, LDL-C and SIRI were identified as three independent risk factors with significant potential for predicting frailty in CVD patients. Therefore, we constructed a clinical nomogram model for frailty based on age, LDL-C and SIRI. The nomogram for frailty had considerable discriminative and calibrating abilities. In summary, our study demonstrated a significant association between elevated levels of inflammation markers, particularly SIRI, and an increased risk of frailty. Furthermore, by integrating age, LDL-C and SIRI, we established a nomogram to predict the risk of frailty in older patients with CVD.

Colorectal cancer is a disease of the elderly. As older and frail patients are under-represented in clinical trials, most of the evidence available on treatment of older metastatic colorectal patients with cancer originates from pooled analyses of the older patients included in large prospective clinical trials and from community-based studies. The aging process is highly individual and cannot be based on the chronological age alone. It is characterised by a decline in organ function with an increased risk of comorbidity and polypharmacy. These issues can result in an increased susceptibility to the complications of both the disease and treatment. Therefore, evaluation of performance status and the chronological age alone is not sufficient, and additionally assessment must be included in the treatment decision process. In the present review, we will focus on clinical aspects of treating older and frail metastatic colorectal patients with cancer, but also on the present knowledge on how to select and tailor therapy for this particular group of patients.Trial registration numberEudraCT 2014-000394-39, pre-results.

The Brief Gah Scale (Geriatric Assessment in Hematology) Correlates Well with a Comprehensive Geriatric Assessment in Patients with Hematologic Malignancies

IntroductionBoth the prevalence of atrial fibrillation (AF) and its subsequent use of direct oral anticoagulants (DOACs) are rapidly increasing in patients of older age. In the absence of contra-indications, guidelines advocate anticoagulation based on the CHA2DS2-VASc score for all AF patients aged 75 and above. However, some practitioners are hesitant to prescribe anticoagulants to older and frail patients due to perceived elevated bleeding risks. This review delves into the comparative treatment outcomes of DOACs versus vitamin K antagonists (VKAs) in older patients with AF, particularly focusing on those of advanced age, frailty, increased risk of falling, chronic kidney disease (CKD), or with a history of major bleeding. Additionally, considerations on the use of off-label DOAC doses, the role of left atrial appendage (LAA) closure and future developments in factor XIa-inhibitors will be discussed.ResultsWhile strong evidence supports the use of DOACs in the vital older patients with nonvalvular AF, it remains scant in frail patient groups. There is some evidence from non-randomized studies suggesting that the effect of DOACs compared with VKAs is consistent between frail and nonfrail patients. However, recent findings from a single randomized trial showed increased bleeding risks but comparable thromboembolic outcomes in frail individuals switching from VKAs to DOACs. In patients with an increased risk of falling, data suggest no relevant interaction of increased risk of falling on the effectiveness and safety of DOACs compared with warfarin. Resuming oral anticoagulants in patients with Af after major bleeding seems to be beneficial. Off-label low-dose DOAC is often prescribed to patients who were underrepresented in larger randomized trails because of an elevated risk of bleeding or overexposure to DOACs, but its effect on clinical outcomes remains uncertain.ConclusionsDOACs are the recommended oral anticoagulant for vital older patients with AF. The scarcity of data backing DOAC use in frail individuals, those with renal impairments, or significant bleeding history underscores the necessity for further investigation. However, existing evidence suggests at least similar effectiveness and safety and potential benefits for DOACs in these patient subsets. Therefore, there is no reason to suggest these patients should be treated differently than the established guidelines regarding anticoagulation.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40266-024-01138-5.

Background:Frailty is a state that reflects reduced reserve and resistance to stressors among elderly persons. A preceding study showed that 38 out of 90 (42%) RA patients aged ≥ 55 years who visited our outpatient clinic were frail. Presence of frailty was not age-dependent. Patients were mainly classified as frail because of positive answers on single items that report on depressive feelings (73.7%), anxiety (57.9%), missing people around (65.8%) and emptiness (63.2%) [1]. It is unclear whether frailty is a cause, consequence or comorbidity of poor psycho-emotional health. Alternatively, they could also be congruent conditions. Exploring whether poor psycho-emotional health might be a longitudinal predictor of frailty, might shed light upon the relation between frailty and psycho-emotional health.Objectives:In this mixed qualitative / quantitative study, we assessed whether older frail RA patients were already more lonely, depressed, and/or anxious than non-frail RA patients at 40 years.Methods:All 90 RA patients who participated in our previous study on frailty in 2017 were invited for the current study. Participants were invited to rate validated multidimensional questionnaires on depression and anxiety (Geriatric Depression Scale (GDS) and Hospital Anxiety and Depression Scale (HADS)), loneliness (de Jong Gierveld loneliness scale) social support (Social Support List) for their current situation, but also retrospectively for their situation at the age of 40. Current frailty was assessed by the Groningen Frailty Indicator (GFI). Semi-structured interviews took place in an age-stratified sample to explore how the diagnosis of RA has influenced patients’ life. Items of questionnaires were compared using the chi-square test. Interviews were annotated by two independent readers. Codes were taxonomically organized and linked to themes using NVivo 12.Results:32 (36%) of the 90 invited patients participated and 28 completed all psycho-emotional questionnaires. Twelve out of 32 patients (37.5%) were classified as frail by the GFI. On the GDS at current age, 6/12 frail patients had signs of depression compared to 2/17 non-frail patients (p=0.04) (Table 1). More frail patients had signs of an anxiety disorder on the HADS, both at current age and age 40 (age 40: 7/11 frail patients versus 0/0 non-frail patients, p&lt;0.01; Table 1). Results on the individual level were more blurred: 3 (42%) out of 7 frail patients were anxious at age 40, but not at current age. The loneliness, social support and HADS depression questionnaires showed no difference between frail and non-frail patients, both at current age and age 40. A stratified sample of 10/32 (31%) patients were interviewed of which 5 (50%) were frail on the GFI. Frail patients more often expressed anxious feelings at current age. Since the diagnosis of RA, frail patients worried more about the future, i.e. about the progression of RA. Non-frail patients tended to be more optimistic. In the interviews, patients expressed not having feelings of depression and anxiety at age 40.Table 1.Number of frail and non-frail patients per questionnaire at current age and age 40.QuestionnaireFrailNon-frailTotalp-valueGDS nowNo depression615210.04Depression628GDS age 40No depression917260.06Depression303HADS anxiety nowNo indication anxiety617230.01Indication anxiety505HADS anxiety age 40No indication anxiety41721&lt;0.01Indication anxiety707Conclusion:Although it is difficult to disentangle the causal conundrum between psycho-emotional health and frailty, frail patients were on a group level more anxious at younger age on the HADS in our study. Psychiatric symptomatology might be misinterpreted for frailty at current age. Limitations of our study include a high chance on amplified memory bias.

Background There is limited research on the factors influencing frailty improvement and on whether exercise therapy is effective in the general population with heart failure. We aimed to examine the factors and interventions that affect the improvement of frailty in older patients with heart failure during hospitalization. Methods This multicentre prospective cohort study included patients with heart failure admitted and treated in the participating hospitals. Cox regression analysis was done to determine factors and interventions that affect improvement of frailty. After the Cox regression analysis, the receiver operating characteristic (ROC) curve was calculated for significant predictors to assess the cut-off point. Results The factors that affect improvement of frailty were the high short physical performance battery (SPPB) chair-stand test and hand grip strength values. The results of the ROC analysis revealed that the cut-off values of the SPPB chair-stand test and hand grip strength were 2 points and 13.7 kg, respectively. Interventions that affect frailty improvement were use of dobutamine, low resting heart rate, early days to start until aerobic exercise, and light intensity or higher of aerobic exercise. Moreover, the cut-off values of the resting heart rate, number of days to start until aerobic exercise, and intensity of aerobic exercise were 80 beats per minute, 7 days, and 31.6%, respectively. Conclusions Our results suggest that pharmacotherapy and exercise will be effective to improve frailty in patients with heart failure. In particular, early exercise therapy, including aerobic exercise, started within 7 days, may be effective to improve frailty in older patients with heart failure with low resting heart rate, depending on their condition on admission.

Influencing factors of frailty in older patients with chronic heart failure: Based on Bayesian network.

This study aimed to investigate the effects of glycaemic control and diabetes distress on frailty in older Chinese patients with diabetes, and to explore the mediating role of diabetes distress between glycaemic control and frailty. This is a descriptive, cross-sectional study. A total of 209 older patients with diabetes were recruited from a teaching hospital in Zhejiang Province. Data were collected from February to September 2022. A self-designed questionnaire was used to collect demographic and disease-related data. The Fried Scale and Diabetes Distress Scale were employed to assess frailty and diabetes distress, respectively The bootstrap method was used to examine the mediating effects of diabetes distress on glycaemic control and frailty. The STROBE checklist was adhered to in the reporting of this study (see details in File S1). The findings indicated a positive correlation between the level of glycaemic control and frailty, as well as between diabetes distress and frailty. Furthermore, diabetes distress was found to play a complete mediating role between glycaemic control and frailty. The study findings highlight the relationship between glycaemic control, diabetes distress and frailty offering a valuable reference for enhancing the management of frailty in older patients with diabetes. This study emphasizes the significance of managing glycaemic control and diabetes distress in older patients with diabetes to prevent frailty, and may contribute for healthcare professionals to developing effective measures to improve the frailty of older diabetic patients in clinical settings. This study was conducted with the participation of older patients with diabetes who contributed data by completing study questionnaires and undergoing physical assessments.