Prognostic accuracy of 70 individual frailty biomarkers in predicting mortality in the Canadian Longitudinal Study on Aging.

The frailty index (FI) uses a deficit accumulation approach to derive a single, comprehensive, and replicable indicator of age-related health status. Yet, many researchers continue to seek a single "frailty biomarker" to facilitate clinical screening. We investigated the prognostic accuracy of 70 individual biomarkers in predicting mortality, comparing each with a composite FI. A total of 29,341 individuals from the comprehensive cohort of the Canadian Longitudinal Study on Aging were included (mean, 59.4 ± 9.9 years; 50.3% female). Twenty-three blood-based biomarkers and 47 test-based biomarkers (e.g., physical, cardiac, cardiology) were examined. Two composite FIs were derived: FI-Blood and FI-Examination. Mortality status was ascertained using provincial vital statistics linkages and contact with next of kin. Areas under the curve were calculated to compare prognostic accuracy across models (i.e., age, sex, biomarker, FI) in predicting mortality. Compared to an age-sex only model, the addition of individual biomarkers demonstrated improved model fit for 24/70 biomarkers (11 blood, 13 test-based). Inclusion of FI-Blood or FI-Examination improved mortality prediction when compared to any of the 70 biomarker-age-sex models. Individual addition of seven biomarkers (walking speed, chair rise, time up and go, pulse, red blood cell distribution width, C-reactive protein, white blood cells) demonstrated an improved fit when added to the age-sex-FI model. FI scores had better mortality risk prediction than any biomarker. Although seven biomarkers demonstrated improved prognostic accuracy when considered alongside an FI score, all biomarkers had worse prognostic accuracy on their own. Rather than a single biomarker test, implementation of routine FI assessment in clinical settings may provide a more accurate and reliable screening tool to identify those at increased risk of adverse outcomes.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial.

BACKGROUND: Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty. METHODS: Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels. DISCUSSION: This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful. TRIAL REGISTRATION: The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

Association of admission frailty and frailty changes during cardiac rehabilitation with 5-year outcomes.

AIMS: Examine the association between (1) admission frailty and (2) frailty changes during cardiac rehabilitation (CR) with 5-year outcomes (i.e. time to mortality, first hospitalization, first emergency department (ED) visit, and number of hospitalizations, hospital days, and ED visits). METHODS AND RESULTS: Data from patients admitted to a 12-week CR programme in Halifax, Nova Scotia, from May 2005 to April 2015 (n = 3371) were analysed. A 25-item frailty index (FI) estimated frailty levels at CR admission and completion. FI improvements were determined by calculating the difference between admission and discharge FI. CR data were linked to administrative health data to examine 5-year outcomes [due to all causes and cardiovascular diseases (CVDs)]. Cox regression, Fine-Gray models, and negative binomial hurdle models were used to determine the association between FI and outcomes. On average, patients were 61.9 (SD: 10.7) years old and 74% were male. Mean admission FI scores were 0.34 (SD: 0.13), which improved by 0.07 (SD: 0.09) by CR completion. Admission FI was associated with time to mortality [HRs/IRRs per 0.01 FI increase: all causes = 1.02(95% CI 1.01,1.04); CVD = 1.03(1.02,1.05)], hospitalization [all causes = 1.02(1.01,1.02); CVD = 1.02(1.01,1.02)], ED visit [all causes = 1.01(1.00,1.01)], and the number of hospitalizations [all causes = 1.02(95% CI 1.01,1.03); CVD = 1.02(1.00,1.04)], hospital days [all causes = 1.01(1.01,1.03)], and ED visits [all causes = 1.02(1.02,1.03)]. FI improvements during CR had a protective effect regarding time to all-cause hospitalization [0.99(0.98,0.99)] but were not associated with other outcomes. CONCLUSION: Frailty status at CR admission was related to long-term adverse outcomes. Frailty improvements during CR were associated with delayed all-cause hospitalization, in which a larger effect was associated with a greater chance of improved outcome.

This work improves our understanding of the relationship between admission frailty and frailty changes with mortality, hospitalization, and emergency department (ED) use in a cardiac rehabilitation (CR) setting. Frailty changes during CR were related with time to hospitalization due to any cause.Higher frailty levels at admission of CR were related to lower time to death, re-hospitalization, and ED visit and to a higher total number of hospitalizations and ED visits due to all causes or due to cardiovascular diseases.Overall, this work underscores the importance of considering the degree of frailty in the CR setting for the purpose of predicting adverse outcomes.

Comparing Virtual and Center-Based Cardiac Rehabilitation on Changes in Frailty.

Many patients with cardiovascular disease (CVD) are frail. Center-based cardiac rehabilitation (CR) can improve frailty; however, whether virtual CR provides similar frailty improvements has not been examined. To answer this question, we (1) compared the effect of virtual and accelerated center-based CR on frailty and (2) determined if admission frailty affected frailty change and CVD biomarkers. The virtual and accelerated center-based CR programs provided exercise and education on nutrition, medication, exercise safety, and CVD. Frailty was measured with a 65-item frailty index. The primary outcome, frailty change, was analyzed with a two-way mixed ANOVA. Simple slopes analysis determined whether admission frailty affected frailty and CVD biomarker change by CR model type. Our results showed that admission frailty was higher in center-based versus virtual participants. However, we observed no main effect of CR model on frailty change. Results also revealed that participants who were frailer at CR admission observed greater frailty improvements and reductions in triglyceride and cholesterol levels when completing virtual versus accelerated center-based CR. Even though both program models did not change frailty, higher admission frailty was associated with greater frailty reductions and change to some CVD biomarkers in virtual CR.

The impact of cardiovascular health and frailty on mortality for males and females across the life course.

BACKGROUND: The effect of frailty and poor cardiovascular health on mortality for males and females is not fully elucidated. We investigated whether the combined burden of frailty and poor cardiovascular health is associated with all-cause and cardiovascular disease (CVD) mortality by sex and age. METHODS: We analyzed data of 35,207 non-institutionalized US residents aged 20-85 years old (mean age [standard deviation]: 46.6 [16.7 years], 51.4% female, 70.8% White, 10.3% Black, 13.2% Hispanic) from the National Health and Nutrition Examination Survey (1999-2015). Cardiovascular health was measured with the American Heart Association's Life's Simple 7 score (LS7). A 33-item frailty index (FI) was constructed to exclude cardiovascular health deficits. We grouped the FI into 0.1 increments (non-frail: FI < 0.10, very mildly frail: 0.1 ≤ FI < 0.20, mildly frail: 0.20 ≤ FI < 0.30, and moderately/severely frail: FI ≥ 0.30) and LS7 into tertiles (T1[poor] = 0-7, T2[intermediate] = 8-9, T3[ideal] = 10-14). All-cause and CVD mortality data were analyzed up to 16 years. All regression models were stratified by sex. RESULTS: The average FI was 0.09 (SD 0.10); 29.6% were at least very mildly frail, and the average LS7 was 7.9 (2.3). Mortality from all-causes and CVD were 8.5% (4228/35,207) and 6.1% (2917/35,207), respectively. The median length of follow-up was 8.1 years. The combined burden of frailty and poor cardiovascular health on mortality risk varied according to age in males (FI*age interaction p = 0.01; LS7*age interaction p < 0.001) but not in females. In females, poor FI and LS7 combined to predict all-cause and CVD mortality in a dose-response manner. All-cause and CVD mortality risk was greater for older males (60 and 70 years old) who were at least mildly frail and had intermediate cardiovascular health or worse (hazard ratio [lower/higher confidence interval ranges] range: all-cause mortality = 2.02-5.30 [1.20-4.04, 3.15-6.94]; CVD-related mortality = 2.22-7.16 [1.03-4.46, 4.49-11.50]) but not for younger males (30, 40, and 50 years old). CONCLUSIONS: The combined burden of frailty and LS7 on mortality is similar across all ages in females. In males, this burden is greater among older people. Adding frailty to assessments of overall cardiovascular health may identify more individuals at risk for mortality and better inform decisions to implement preventative or treatment approaches.

The impact of an exercise intervention on frailty levels in hospitalised older adults: secondary analysis of a randomised controlled trial.

BACKGROUND: physical activity reduces frailty in community-dwelling older adults. How exercise influences frailty in hospitalised older adults requires additional investigation. OBJECTIVES: (i) to examine the impact of an exercise intervention on frailty in older adults admitted to an acute care ward, and (ii) to determine the impact of baseline frailty on the effectiveness of this intervention. SETTING/PARTICIPANTS: this is a secondary analysis of a randomised controlled clinical trial that tested an intensive exercise intervention in ≥75-year-old adults admitted to an acute care ward. METHODS: the intervention included two daily sessions of moderate-intensity exercises (control received usual care). A 63-item Frailty Index (FI) was constructed, and three groups were formed: <0.2, 0.2-0.29 and ≥0.3. Other outcomes included Short Physical Performance Battery (SPPB) and Barthel Index (BI). RESULTS: a total of 323 individuals were included. The mean age was 87.1 years (± 4.8 standard deviation [SD]) and 56.3% were females. The intervention group improved FI from 0.26 (± 0.10 SD) to 0.20 (± 0.10 SD), whereas the control group FI worsened from 0.25 (± 0.1 SD) to 0.27 (± 0.10 SD). After stratifying by baseline FI, SPPB and depression improved in the intervention group across all levels of frailty; FI, BI and quality of life only improved in individuals with a baseline FI ≥ 0.2. CONCLUSIONS: frailty improves with an intensive individualised exercise intervention, especially in those with high baseline levels of frailty. In addition, frailty is a useful outcome when examining the impact of an intervention of hospitalised older adults.

Self-Compassion, Adaptive Reactions and Health Behaviours Among Adults With Prediabetes and Type 1, Type 2 and Gestational Diabetes: A Scoping Review.

Engaging in health-promoting behaviours has health benefits for people with prediabetes or diabetes. People experience negative affect after diagnoses, which can impede self-regulation of health behaviours. Self-compassion, extending care to oneself in difficult times, can mitigate negative affect and promote self-regulation. This scoping review explored the relationship between self-compassion and adaptive affect, self-regulation and engagement in health-promoting/management behaviours among people with prediabetes or diabetes. We conducted a scoping literature search from 6 databases for studies and conference abstracts. Randomized controlled trials and cross-sectional, longitudinal, observational and qualitative designs focused on self-compassion were included. Eligible studies included adults with diabetes (prediabetes, type 1, type 2 and gestational), measured self-compassion using a validated Self-Compassion Scale (quantitative) or included the 3 components (qualitative) and investigated: negative affect, health promoting/management behaviours and/or self-regulation. After deduplication, 5,338 quantitative and 953 qualitative abstracts, and 18 conference proceedings were screened leaving 35 articles. Full-text screening retained 11 eligible studies (6 cross-sectional studies, 2 randomized controlled trials, 2 longitudinal studies and 1 qualitative study). Higher self-compassion was associated with decreased negative affect in 9 studies and was positively associated with well-being in 1 cross-sectional study. Self-compassion led to decreased negative affect and improved blood glucose in 2 interventions. Five studies found positive associations between self-compassion and health-promoting/management behaviours. One qualitative study found self-compassion to benefit affective reactions, health-promoting behaviours and self-regulation. This review shows that self-compassion is linked to adaptive behavioural and affective responding among people with prediabetes and diabetes, and the need for more research on self-compassion and self-regulation in these populations.

The impact of physical activity and sedentary behaviors on frailty levels.

Heterogeneity in aging can be explained by frailty. Lifestyle behaviors such as physical activity can help manage frailty levels. Conversely, sedentary behaviours are associated with frailty independently of physical activity. Here, we summarize epidemiological and clinical trial evidence concerning the impact of physical activity and sedentary behaviors on frailty levels. We also analysed the National Health and Nutrition Examination Survey (NHANES) data to describe physical activity and sedentary behavior accumulation patterns across frailty levels and their impact on mortality risk. The few prospective and intervention studies demonstrate that higher physical activity levels are associated with a lower incidence of frailty. There are no interventions published which limit sedentary behaviors to manage frailty. Using the NHANES data we demonstrate that individuals are less likely to meet physical activity guidelines and are more likely to accumulate sedentary time in prolonged bouts. Prolonged sedentary bouts and total sedentary time were associated with a higher mortality risk in frail individuals but not in the fit group. Non-bouted sedentary time was not associated with mortality risk. Our review and novel data suggest that there is a need for more intervention studies which focus on increasing physical activity or minimizing sedentary time to manage frailty levels.

The association between patterns of physical activity and sedentary time with frailty in relation to cardiovascular disease.

OBJECTIVE: The associations of moderate-vigorous physical activity (MVPA) bouts and patterns of sedentary time (ST) with frailty according to cardiovascular disease (CVD) status are unknown. METHODS: Accelerometry in adults ≥50 years old from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey were used. Bouted and sporadic MVPA in ≥10-minute or <1-minute bouts were assessed based on meeting a percentage of physical activity guidelines of 150 minutes/wk, respectively. ST patterns included: prolonged ST lasting ≥30 minutes, and the frequency, intensity, and duration of breaks from ST. A 46-item frailty index defined frailty. Multivariable linear regression was used. RESULTS: There were 827 and 1490 CVD-free and CVD participants, respectively. Meeting a higher percentage of the physical activity guidelines through bouted MVPA was associated with lower frailty in CVD-only participants (P < 0.05 for CVD interaction). Sporadic MVPA was associated with lower frailty levels in both groups. Prolonged ST was associated with worse frailty in CVD (P > 0.05 for CVD interaction). Frequency of ST breaks was not associated with frailty. Average ST break intensity was protective in both groups. The duration of breaks in ST was associated with lower frailty in CVD participants only (P > 0.05 for CVD interaction). CONCLUSION: Insufficient MVPA and prolonged ST are detrimental despite CVD status.

The impact of sedentary and physical activity behaviour on frailty in middle-aged and older adults.

Physical activity and sedentary behaviours are associated with frailty. However, it is unknown if different accumulation patterns of these behaviours are linked with frailty. Four studies were conducted: the first 3 determined if bouts of moderate-vigorous physical activity (MVPA) and patterns of sedentary behaviours were associated with frailty (study 1), and if sex (study 2) and cardiovascular disease (CVD) status (study 3) affected these associations. Study 4 systematically reviewed the evidence to determine if preoperative physical activity and sedentary behaviours were linked to postcardiac surgical outcomes. Studies 1-3 used accelerometer data from the 2003-2004/2005-2006 National Health and Nutrition Examination Survey. Bouted (≥10 min) and sporadic (<10 min) durations of MVPA were analyzed based on meeting a proportion of the physical activity guidelines of 150 min/week. Prolonged sedentary behaviours were measured in bouts lasting ≥30 min. Breaks from sedentary behaviour were any ≥1 min interruption in sedentary time. Average intensity and duration during breaks were analyzed. Frailty was measured with a 46-item frailty index (FI). Study 4 included investigations that linked preoperative physical activity behaviours to postoperative health outcomes. The first 3 studies revealed that sporadic and bouted MVPA were associated with a lower FI. Meeting 1%-49% of the physical activity guidelines had a protective association with frailty. Prolonged sedentary bouts had a more detrimental association with frailty in females than males. Bouted MVPA was associated with a lower FI in CVD participants but not in those without CVD. Average break intensity was associated with a lower FI across studies. Average break duration was associated with frailty in males and in those with CVD. Study 4 included 11 articles, which reported inconsistent findings in relation to self-reported physical activity behaviour and postoperative outcomes in cardiac surgery patients. No studies analyzed sedentary behaviour or frailty. Data from this thesis suggest that bouts of MVPA and patterns of sedentary behaviours are associated with frailty, and support the need to limit extended periods of sedentary time and promote a physically active lifestyle. Studies are needed to determine if preoperative physical activity and sedentary behaviours are associated with postcardiac surgical frailty.

Examining Patient Outcome Quality Indicators Based on Wait Time From Referral to Entry Into Cardiac Rehabilitation: A PILOT OBSERVATIONAL STUDY.

PURPOSE: The purpose of this study was to examine whether meeting the Canadian Cardiovascular Society (CCS) ≤60-day wait time from cardiac rehabilitation (CR) referral to enrollment is associated with CCS patient-level quality indicator outcomes. METHODS: This pilot observational study consisted of 69 participants entering CR separated into 2 groups based on wait time (≤60-day, n = 45; >60-day, n = 24). Data were collected at baseline, and 1, 4 (CR completion), 6, and 12 months after baseline. Quality indicators for achieving a 0.5 peak metabolic equivalent (MET) improvement at CR completion, physical activity of 150 min/wk of moderate-vigorous physical activity, and CR adherence were assessed. Depressive symptoms were assessed with the Patient Health Questionnaire. RESULTS: Sixty participants completed the study (≤60-day, n = 40; >60-day, n = 20). In the ≤60-day group, 92% of participants achieved the 0.5 MET improvement upon CR completion; whereas 60% of the >60-day group met this criteria (P ≤ .05). For the 150 min/wk of moderate-vigorous physical activity and CR adherence, both groups were not significantly different at any time. Elevated depressive symptoms were initially observed in 45% of participants in the ≤60-day group and 35% in the >60-day group (NS) and decreased to 8% in the ≤60-day group compared with 30% in the >60-day group at 12 months (P ≤ .05). CONCLUSIONS: Meeting the CCS 60-day acceptable wait time is associated with improvements in METs and depressive symptoms, but not with physical activity or CR adherence. A larger observational study is warranted to explore patient-level CCS quality indicators during and after CR.

Prevalence of frailty in Canadians 18-79 years old in the Canadian Health Measures Survey.

BACKGROUND: There is little certainty as to the prevalence of frailty in Canadians in younger adulthood. This study examines and compares the prevalence of frailty in Canadians 18-79 years old using the Accumulation of Deficits and Fried models of frailty. METHODS: The Canadian Health Measures Study data were used to estimate the prevalence of frailty in adults 18-79 years old. A 23-item Frailty Index using the Accumulation of Deficits Model (cycles 1-3; n = 10,995) was developed; frailty was defined as having the presence of 25% or more indices, including symptoms, chronic conditions, and laboratory variables. Fried frailty (cycles 1-2; n = 7,353) included the presence of ≥3 criteria: exhaustion, physical inactivity, poor mobility, unintentional weight loss, and poor grip strength. RESULTS: The prevalence of frailty was 8.6 and 6.6% with the Accumulation of Deficits and the Fried Model. Comparing the Fried vs. the Accumulation of Deficits Model, the prevalence of frailty was 5.3% vs. 1.8% in the 18-34 age group, 5.7% vs. 4.3% in the 35-49 age group, 6.9% vs. 11.6% in the 50-64 age group, and 7.8% vs. 20.2% in the 65+ age group. Some indices were higher in the younger age groups, including persistent cough, poor health compared to a year ago, and asthma for the accumulation of deficits model, and exhaustion, unintentional weight loss, and weak grip strength for the Fried model, compared to the older age groups. CONCLUSIONS: These data show that frailty is prevalent in younger adults, but varies depending on which frailty tool is used. Further research is needed to determine the health impact of frailty in younger adults.