Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established. 

Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality. 

Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline). 

Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

https://www.sharp.com/services/hospice/upload/phenotype5-13.pdf

Frailty in Older Adults Evidence for a Phenotype

Cardiovascular Health Study Collaborative Research Group : Frailty in older adults : evidence for a phenotype

http://lib.ajaums.ac.ir/booklist/archives%20of%20neurology_24%20Jan-2_17.pdf

The cardiovascular health study: Design and rationale

Distinguishing between depression and anxiety has been a matter of concern and controversy for some time. Studies in normal samples have suggested, however, that assessment of two broad mood factors—Negative Aflect (NA) and Positive Affect (PA)—may improve their differentiation. The present study extends these findings to a clinical sample. As part of an ongoing twin study, 90 inpatient probands and 60 cotwins were interviewed with the anxiety and depression sections of the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981). Respondents also completed trait NA and PA scales. Consistent with previous research, NA was broadly correlated with symptoms and diagnoses of both anxiety and depression, and acted as a general predictor of psychiatric disorder. In contrast, PA was consistently related (negatively) only to symptoms and diagnoses of depression, indicating that the loss of pleasurable engagement is a distinctive feature of depression. The results suggest that strengthening the PA component in depression measures may enhance their discriminative power.

/pdf/positive-and-negative-affectivity-and-their-relation-to-51ga4y6stk.pdf

Positive and negative affectivity and their relation to anxiety and depressive disorders.

Background and Purpose Our aim was to identify potential risk factors for and clinical manifestations of white matter findings on cranial MRI in elderly people. Methods Medicare eligibility lists were used to obtain a representative sample of 5888 community-dwelling people aged 65 years or older. Correlates of white matter findings were sought among 3301 participants who underwent MRI scanning and denied a history of stroke or transient ischemic attack. Participants underwent extensive standardized evaluations at baseline and on follow-up, including standard questionnaires, physical examination, multiple blood tests, electrocardiogram, pulmonary function tests, carotid sonography, and M-mode echocardiography. Neuroradiologists graded white matter findings from 0 (none) to 9 (maximal) without clinical information. Results Many potential risk factors were related to the white matter grade, but in the multivariate model the factors significantly (all P<.01) and independently associated with increased grade w...

Clinical Correlates of White Matter Findings on Cranial Magnetic Resonance Imaging of 3301 Elderly People: The Cardiovascular Health Study

The factorial and discriminant validity of the Center for Epidemiological Studies Depression (CES-D) scale was examined for a sample of 116 parents who were participating in family support programs designed to prevent child abuse and neglect. Participants' self-reports of depressive symptoms as measured by the CES-D were analyzed in relation to their self-esteem (measured with the Rosenberg Self-Esteem scale) and state and trait anxiety (measured with Spielberger's State-Trait Anxiety Inventory). Factorial validity was adequate, and results indicated a moderate correlation between the CES-D and self-esteem and state anxiety. However, a high correlation was obtained between the CES-D and trait anxiety, which suggests that the CES-D measures in large part the related conceptual psychological domain of predisposition for anxiousness.

Factorial and Discriminant Validity of the Center for Epidemiological Studies Depression (CES-D) Scale.

An ecological model of human development was used to assess the interrelationship between psychological determinants of parenting parental age and parenting skill for a sample of 210 parents. Parents race was found to be significantly related to attitudes toward childrearing knowledge of child development and perceived social support. Punitive attitudes toward childrearing and parental race were significant predictors of the quality of parenting with more punitive and younger parents having less supportive and less nurturant home environments. The subjects were recruited from 3 agencies in the Midwest. Data were collected between March 1984 and March 1985. Each subject was interviewed and a HOME instrument was administered to each one. The HOME is a 45 item interview/observation scale which contains 6 subscales: emotional and verbal responsivity avoidance of restriction and punishment organization of the environment provision of play materials maternal involvement and variety in daily stimulation. The apparent unimportance of parental age as a predictor of parenting raises doubts about the appropriateness of equating chronological age with poor caretaking. The results do not give an indication of the cause-effect relationship between depression knowledge expectations attitudes and perceived social support. Low income participants with relatively little education were high in reported levels of social support.

Ecological determinants of parenting.

In-depth structured interviews were conducted with spokespeople for 176 inner-city churches regarding perceptions of existing community problems, number of currently offered church-based social and health programs, and potential interest in church sponsorship of new maternal and child health programs. The sample of respondents represented 78% of the 227 churches located in a low-income, primarily black urban area with 150,000 residents. The typical church participating in the survey was Baptist with a congregation of 100 to 500 people, most of whom were not community residents. The leading community problems identified by the clergy were, in descending order: lack of jobs, teenage pregnancy, gang crime, school drop-outs, and hunger. The perception of community problems matched the church services offered as measured by the number of food and clothing pantries. Few churches had ongoing programs for neighborhood youths. Although many of these same churches expressed interest in expanding services for mothers, adolescents and children, few perceived themselves as having the necessary staff, funds, or technical expertise to conduct such programs.

The religious community as a partner in health care.

The effectiveness of public health nursing in promoting maternal and child health through home visits is summarized from empirical studies published between 1960 and 1984. Eight reports identified through a comprehensive reference search were first classified according to the components of nursing service studied (assessment, teaching, counseling or support, referral, and clinical services). The results of each study were then analyzed for study population characteristics, the research design and statistical methods employed, the reliability of the measures used, significant treatment effects, sample size, and statistical power. The research is evenly divided among studies employing an experimental design, a quasi-experimental design, and samples of low-income and middle-income mothers. The reliability of the measures was, with one exception, not reported. All but one study had final sample sizes for treatment and control or comparison groups of fewer than 100 subjects. Four of the studies thus had sample sizes sufficiently large to detect a medium treatment effect; power calculations showed that none could measure a small treatment impact. Within the methodological limitations of these studies, our review found that under certain circumstances public health nurses can effectively impart health knowledge to high-risk mothers and can effect positive change in maternal attitudes and parenting practices that in turn can be associated with positive changes in infant health and development. Cumulative knowledge from this body of research suggests that a priority for future evaluations of public health nursing is development of theoretical frameworks that maximize the fit between the needs of the population served and the services provided and between the outcomes measured and the nursing services being assessed.

Effectiveness of home visits by public health nurses in maternal and child health: an empirical review.

The structure of depression is presented for 100 young adolescent 278 older adolescent and 276 adult mothers at risk for depression by virtue of their unmarried status and low income. Depression is measured with the Center for Epidemiological Depression Scale a widely used tool established reliability and validity. Three different factorial structures are identified with the youngest mothers having the most complex structure and the highest level of depression. The findings are compared to the dimensions of depression for adult married women. Implications of the results for service providers working with adolescent mothers are discussed. (authors)

Janet Reis

Papers

Factorial and Discriminant Validity of the Center for Epidemiological Studies Depression (CES-D) Scale.

Ecological determinants of parenting.

The religious community as a partner in health care.

Effectiveness of home visits by public health nurses in maternal and child health: an empirical review.

The Structure of Depression in Community Based Young Adolescent, Older Adolescent, and Adult Mothers.