A New Functional Classification Based on Frailty and Disability Stratifies the Risk for Mortality Among Older Adults: The FRADEA Study.

OBJECTIVES: The aim of the current study was to investigate whether a new functional classification, based on basic (BADL) and instrumental (IADL) activities of daily living and frailty, is associated with mortality in older adults during 10 years of follow-up. DESIGN: Cohort study, with a follow-up of 10 years. SETTING AND PARTICIPANTS: A total of 924 participants aged 70 and older from the Frailty and Dependence in Albacete (FRADEA) study, a population-based sample of Spanish older adults. MEASURES: At baseline, a new functional classification of 8 categories was constructed with limitations in BADL using the Barthel Index, limitations in IADL using the Lawton IADL Index, and the criteria of the frailty phenotype. Associations with 10-year mortality were assessed using Kaplan-Meier curves and Cox proportional hazard models. RESULTS: The risk of mortality gradually increased toward the less functionally independent end of the classification. The presence of mild, moderate, or severe BADL impairment was associated with mortality, in models adjusted for age, sex, comorbidity and institutionalization. The analyses also revealed that those who were BADL independent, IADL dependent and prefrail [hazard ratio (HR) = 2.27, 95% confidence interval (CI) = 1.22-4.20], and those who were BADL independent and frail (HR = 3.74, 95% CI = 1.88-7.42) had an increased risk of mortality. CONCLUSIONS/IMPLICATIONS: A new functional classification composed of BADL, IADL, and frailty representing the functional continuum is effective in stratifying the risk for mortality in older adults. Frailty is a high-mortality-risk state close to subjects with mild disability in BADL, needing an intensive specialized approach. Prefrailty with any impairment in IADL has an intermediate mortality risk and should be offered primary care interventions.

Frailty, Polypharmacy, and Health Outcomes in Older Adults: The Frailty and Dependence in Albacete Study.

BACKGROUND/OBJECTIVES: To investigate if polypharmacy modifies the association between frailty and health outcomes in older adults. DESIGN: Ongoing cohort study. SETTING: Albacete City, Spain. PARTICIPANTS: A total for 773 participants, 457 women (59.1%), over age 70 years from the FRADEA Study. MEASUREMENTS: Frailty phenotype, polypharmacy considered as the chronic use of 5 or more drugs, and comorbidity were collected at the baseline visit. Participants were categorized in 6 groups according to frailty and polypharmacy, and were followed up for 5.5 years (mean 1057 days, range 1-2007). Mortality or incident disability in basic activities of daily living was considered the main outcome variable. Hospitalization and visits to the emergency department were also recorded. The adjusted association between combined frailty status and polypharmacy with outcome variables was analyzed. RESULTS: The mean age of study population was 78.5 years. In this population, we identified a 15.3% (n = 118) of frail with polypharmacy, 3.4% (n = 26) of frail without polypharmacy, 35.3% (n = 273) of prefrail with polypharmacy, 20.3% (n = 157) of prefrail without polypharmacy, 10.3% (n = 80) of nonfrail with polypharmacy, and 15.4% (n = 119) of nonfrail participants without polypharmacy. Participants with frailty and polypharmacy had a higher adjusted risk of mortality or incident disability [odds ratio (OR) 5.3; 95% confidence interval (CI) 2.3-12.5] and hospitalization (OR 2.3; 95% CI 1.2-4.4), compared with those without frailty and polypharmacy. Frail and prefrail participants with polypharmacy had a higher adjusted mortality risk compared with the nonfrail without polypharmacy, hazard ratio 5.8 (95% CI 1.9-17.5) and hazard ratio 3.1 (95% CI 1.1-9.1), respectively. CONCLUSIONS: Polypharmacy is associated with mortality, incident disability, hospitalization, and emergency department visits in frail and prefrail older adults, but not in nonfrail adults. Polypharmacy should be monitored in these patient subgroups to optimize health outcomes.

Energetics of Aging and Frailty: The FRADEA Study.

BACKGROUND: Resting metabolic rate (RMR) and total daily energy expenditure (TDEE) decrease with aging, but it is not known whether frailty modulates this association. We hypothesize that RMR and TDEE values are similar between younger and older nonfrail older adults, whereas they are lower in older prefrail and frail compared with younger adults. METHODS: A cross-sectional analysis of the FRADEA study, Albacete (Spain), including 402 participants (213 women) older than 70 years (mean age 76 years; range 70-91), was conducted. Estimated RMR (eRMR), oxygen consumption (VO2), expired volume (Ve), and respiratory frequency (RF) were determined using indirect calorimetry; TDEE was determined with the Calcumed instrument; and fat-free mass was determined by bioimpedanciometry. General linear models were used for analysis. RESULTS: Mean TDEE was 1,889 (SD 470) kcal and eRMR was 1,071 (SD 323) kcal. Both TDEE (B = -24 kcal/day; 95% confidence interval: -35.4 to -14.2; p < .001) and eRMR (B= -15.8 kcal/day; 95% confidence interval: -23.1 to -8.5; p < .001) diminished linearly with age, with lower values in frail and prefrail participants. There was a strong trend between frailty and lower eRMR (F = 2.9; p = .058), with a modifying effect between age and frailty (F = 3.6; p = .002). eRMR in prefrail and frail participants were on average 160 and 114 kcal/day less than that in the nonfrail participants, respectively, and taken together, 154 kcal/day less (F = 5.4; p = .020). Frail and prefrail participants also presented lower Ve and VO2 values that were partially compensated by an RF increase. CONCLUSION: Frailty status modulates the energy requirements of aging. Frail and prefrail older adults present lower eRMR than nonfrail adults.

Frailty and mortality, disability and mobility loss in a Spanish cohort of older adults: the FRADEA study.

BACKGROUND: Original Fried's frailty criteria have not demonstrated their prognostic validity of mortality, disability and mobility loss in European cohorts. OBJECTIVES: To analyze whether frailty implies increased risk of death, incident disability in basic (BADL) or instrumental (IADL) activities of daily living, or mobility impairment. DESIGN: Concurrent cohort study. SETTING: Albacete City, Spain. PARTICIPANTS: 993 participants over age 70 from the FRADEA Study. MEASUREMENTS: Mortality, BADL and mobility using the Barthel Index, and IADL using the Lawton IADL Index, were recorded. BADL disability was defined as loss of the ability to perform bathing, grooming, dressing, toilet use, or feeding, while deterioration of mobility was defined as loss of ability to perform transfers, walk, or use stairs, and IADL disability as losing any of the activities included in the Lawton Index. The risk of presenting adverse events was determined by Cox and Kaplan-Meier proportional hazard analysis and logistic regression adjusted for age, sex, function, and comorbidity. RESULTS: Mean follow-up was 534 days (SD 153), during which 105 participants (10.6%) died. Mean time to death was 363 days (SD 218), while 192 (25.4%) lost at least one BADL, 492 (60%) at least one IADL, and 222 (28.9%) lost mobility. Frail subjects had a greater adjusted risk of death (HR 5.5, CI 95% 1.5-20.2), of losing BADL (HR 2.5, CI 95% 1.3-4.8), of losing mobility (HR 2.7, CI 95% 1.5-5.0), and of losing IADL (HR 1.9, CI 95% 1.1-3.3) than non-frail patients. CONCLUSION: Fried's frailty criteria are associated with death, incident disability, and mobility impairment in a Spanish cohort of older adults.

Effects of a short-term occupational therapy intervention in an acute geriatric unit. A randomized clinical trial.

OBJECTIVES: To compare the benefits of a short-term occupational therapy intervention (OTI) when added to the conventional treatment model (CTM) in the functional recovery of patients admitted to an acute geriatric unit (AGU). STUDY DESIGN: Non-pharmacological randomized clinical trial. 400 patients were randomized to OTI (n = 198) or CTM (n = 202) group. Mean age 83.5. Interventions included needs assessment, iatrogenic prevention, retraining in activities of daily living, and instructions for caregivers in three groups of patients defined a priori (cardiopulmonary disease, stroke, other conditions) 5 days a week, 30-45 min a day. MAIN OUTCOME MEASURE: Recovery of ≥ 10 Barthel index points by discharge. Secondary outcome was the reduction in confusional episodes. RESULTS: The adjusted relative risk (RR) of functional recovery in the OTI group was 1.16 (95%CI 0.91-1.47). In participants with cardiopulmonary disease was 1.57 (95%CI 1.06-2.32), number needed to treat (NNT) 5. Participants with other conditions assigned to OTI had a reduction in acute confusional episodes; RR 0.48 (95% CI 0.26-0.87), NNT 7. CONCLUSIONS: Although overall there were no significant differences, patients with cardiopulmonary disease or non-stroke pathologies admitted to an AGU, may benefit from a short-term OTI.

Upper extremity function, an independent predictor of adverse events in hospitalized elderly.

OBJECTIVE: To examine the relationships between upper extremity function (UEF) and mortality, need for social assistance and change of residence, at discharge from hospital and at 1 month following discharge. METHODS: Observational, cohort study. SETTING: Acute Geriatric Unit of a Tertiary Teaching Hospital. SUBJECTS: 356 Consecutive patients admitted over a 6-month period. Performance of 4 UEF tasks (UEFTs) was assessed by direct observation on admission, at discharge and at 1 month after discharge: picking up a full glass, touching the scapula, cutting with a knife and unfastening a button. UEF was correlated with measures of global physical and mental functioning, namely the Barthel index, the Lawton index, Holden's FAC scale and Pfeiffer's test. The association of UEF with adverse events such as mortality, need for social assistance and change of residence was also assessed. RESULTS: UEF was well-correlated with global functioning scales (p<0.001). Using multivariant models, the inability to perform 3 or 4 UEFTs on admission was an independent predictor of mortality at discharge (OR 15.2; CI 95% 5.2-44.4) and at 1 month (OR 3.3; CI 95% 1.8-6.2), of need for social assistance at discharge (OR 2.1; CI 95% 1.1-4.1) and at 1 month (OR 3.3; CI 95% 1.1-10.1), and of change of residence at discharge (OR 3.5; CI 95% 1.2-10.4). CONCLUSIONS: UEF, independently of global functioning, is a predictor of adverse events in the hospitalized elderly. Its determination by direct observation may be an indirect measure of global functioning during hospitalization, avoiding potentially biased data facilitated by caregivers.