Instrumental Activities of Daily Living as a Potential Marker of Frailty A Study of 7364 Community-Dwelling Elderly Women (the EPIDOS Study)
01 Jul 2001-Journals of Gerontology Series A-biological Sciences and Medical Sciences (Oxford University Press)-Vol. 56, Iss: 7
TL;DR: The results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls.
Abstract: Background. A number of clinical conditions have been shown to be associated with frailty in elderly people. We hypothesized that incapacities on the Instrumental Activities of Daily Living (IADLs) scale could make it possible to identify this population. We investigated the associations between IADL incapacities and the various known correlates of frailty in a cohort of community-dwelling elderly women. Methods. Cross-sectional analysis was carried out on the data from 7364 women aged over 75 years (EPIDOS Study). The IADL was the dependent variable. Sociodemographic, medical, and psychological performance measures were obtained during an assessment visit. Falls in the previous 6 months and fear of falling were also ascertained. Body composition was measured by dual-energy x-ray absorptiometry. The factors associated with disability in at least one IADL were included in a logistic regression model. Results. Thirty-two percent of the population studied had disability in at least one IADL item. This group was significantly older (81.7 � 4.1 yr vs 79.8 � 3.4 yr), had more frequent histories of heart disease, stroke, depression or diabetes, and was socially less active ( p � .001). These associations persisted after multivariate analysis. Cognitive impairment as assessed by the Pfeiffer test (Pfeiffer score � 8) was closely associated with disabilities on the IADL (OR 3.101, 95% confidence interval [CI] 2.19‐4.38). Falls and fear of falling were also more frequent in the group of women with an abnormal IADL ( p � .001) but only fear of falling remained significantly associated with incapacities on at least one IADL item after logistic regression (OR 1.47, 95% CI 1.28‐1.69). Women with disability on at least one IADL item also had lower bone mineral density, this was independent of the other factors. Conclusion. Our results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls. Disabilities on this scale could be a good tool for identifying individuals at risk of frailty among elderly persons living at home and in apparent good health. This finding requires confirmation by longitudinal studies.
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TL;DR: The ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools are determined.
Abstract: Background: There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. Methods: We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. Results: The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%–30.6%) and entry into an institution (23.9%, 95% CI 8.8%–41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Interpretation: Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.
5,189 citations
TL;DR: The frailty definition developed in the CHS is applicable across diverse population samples and identifies a profile of high risk of multiple adverse outcomes and is consistent with the widely held theory that conceptualizes frailty as a syndrome.
Abstract: Background "Frailty" is an adverse, primarily gerontologic, health condition regarded as frequent with aging and having severe consequences. Although clinicians claim that the extremes of frailty can be easily recognized, a standardized definition of frailty has proved elusive until recently. This article evaluates the cross-validity, criterion validity, and internal validity in the Women's Health and Aging Studies (WHAS) of a discrete measure of frailty recently validated in the Cardiovascular Health Study (CHS). Methods The frailty measure developed in CHS was delineated in the WHAS data sets. Using latent class analysis, we evaluated whether criteria composing the measure aggregate into a syndrome. We verified the criterion validity of the measure by testing whether participants defined as frail were more likely than others to develop adverse geriatric outcomes or to die. Results The distributions of frailty in the WHAS and CHS were comparable. In latent class analyses, the measures demonstrated strong internal validity vis a vis stated theory characterizing frailty as a medical syndrome. In proportional hazards models, frail women had a higher risk of developing activities of daily living (ADL) and/or instrumental ADL disability, institutionalization, and death, independently of multiple potentially confounding factors. Conclusions The findings of this study are consistent with the widely held theory that conceptualizes frailty as a syndrome. The frailty definition developed in the CHS is applicable across diverse population samples and identifies a profile of high risk of multiple adverse outcomes.
1,077 citations
Cites background from "Instrumental Activities of Daily Li..."
...There have been proposals to identify older adults who are frail, or at risk for frailty, by their disability status (9), functional performance (10), or a combination of either with comorbidity, neurosensory problems, or adverse geriatric out-...
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TL;DR: A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke, and greater adherence to post–acute stroke rehabilitation guidelines was associated with improved patient outcomes.
Abstract: Stroke is a leading cause of disability in the United States.1 The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15 000 veterans are hospitalized for stroke each year (VA HSR&D, 1997).
Forty percent of stroke patients are left with moderate functional impairments and 15% to 30% with severe disability.2 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and reduce potential costly long-term care expenditures.
There are only 45 rehabilitation bed units (RBUs) in the VA today. Many veterans who have a stroke and are admitted to a VA Medical Center will find themselves in a facility that does not offer comprehensive, integrated, multidisciplinary care. In a VA rehabilitation field survey published in December 2000, more than half of the respondents reported that the “rehabilitative care of stroke patients was incomplete, fragmented, and not well coordinated” at sites lacking a RBU (VA Stroke Medical Rehabilitation Questionnaire Results, 2000).
In Department of Defense (DoD) medical treatment facilities, approximately 20 000 active-duty personnel and dependents were seen in 2002 for stroke and stroke-related diagnoses according to ICD-9 coding.3 Comprehensive treatment for stroke patients in DoD medical facilities is given primarily at medical centers. Smaller DoD community hospitals may have limited resources to see both inpatients and outpatients, relying more on the TRICARE network for ongoing stroke rehabilitation services.
A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke.4–6 The VA/DoD Stroke Rehabilitation Working Group only focused on the post–acute stroke rehabilitation care.
Duncan and colleagues7 found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded “compliance …
959 citations
TL;DR: A comprehensive review of the definitions and assessment tools on frailty in clinical practice and research was performed, combining evidence derived from a systematic review of literature along with an expert opinion of a European, Canadian and American Geriatric Advisory Panel (GAP).
Abstract: Frailty is a commonly used term indicating older persons at increased risk for adverse outcomes such as onset of disability, morbidity, institutionalisation or mortality or who experience a failure to integrate adequate responses in the face of stress. Although most physicians caring for older people recognize the importance of frailty, there is still a lack of both consensus definition and consensual clinical assessment tools. The aim of the present manuscript was to perform a comprehensive review of the definitions and assessment tools on frailty in clinical practice and research, combining evidence derived from a systematic review of literature along with an expert opinion of a European, Canadian and American Geriatric Advisory Panel (GAP). There was no consensus on a definition of frailty but there was agreement to consider frailty as a pre-disability stage. Being disability a consequence rather than the cause of frailty, frail older people do not necessary need to be disabled. The GAP considered that disability (as a consequence of frailty) should not be included in frailty definitions and assessment tools. Although no consensual assessment tool could be proposed, gait speed could represent the most suitable instrument to be implemented both in research and clinical evaluation of older people, as assessment of gait speed at usual pace is a quick, inexpensive and highly reliable measure of frailty.
842 citations
Cites methods from "Instrumental Activities of Daily Li..."
...(32) Blaum and colleagues evaluated baseline data from the WHAS of a subpopulation of 599 women with a BMI greater than 18....
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...(32) Purse, evaluated frailty following Fried and Rockwood’s diagnostic criteria, but added single item performances (gait speed, grip strength and repeated chair stands)....
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TL;DR: A better understanding of these clinical changes and their underlying mechanisms may confirm the impression held by many geriatricians that increasing frailty is distinguishable from ageing and in consequence is potentially reversible.
Abstract: Frailty has long been considered synonymous with disability and comorbidity, to be highly prevalent in old age and to confer a high risk for falls, hospitalization and mortality. However, it is becoming recognized that frailty may be a distinct clinical syndrome with a biological basis. The frailty process appears to be a transitional state in the dynamic progression from robustness to functional decline. During this process, total physiological reserves decrease and become less likely to be sufficient for the maintenance and repair of the ageing body. Central to the clinical concept of frailty is that no single altered system alone defines it, but that multiple systems are involved. Clinical consensus regarding the phenotype which constitutes frailty, drawing upon the opinions of numerous authors, shows the characteristics to include wasting (loss of both muscle mass and strength and weight loss), loss of endurance, decreased balance and mobility, slowed performance, relative inactivity and, potentially, decreased cognitive function. Frailty is a distinct entity easily recognized by clinicians, with multiple manifestations and with no single symptom being sufficient or essential in its presentation. Manifestations include appearance (consistent or not with age), nutritional status (thin, weight loss), subjective health rating (health perception), performance (cognition, fatigue), sensory/physical impairments (vision, hearing, strength) and current care (medication, hospital). Although the early stages of the frailty process may be clinically silent, when depleted reserves reach an aggregate threshold leading to serious vulnerability, the syndrome may become detectable by looking at clinical, functional, behavioral and biological markers. Thus, a better understanding of these clinical changes and their underlying mechanisms, beginning in the pre-frail state, may confirm the impression held by many geriatricians that increasing frailty is distinguishable from ageing and in consequence is potentially reversible. We therefore provide an update of the physiopathology and clinical and biological characteristics of the frailty process and speculate on possible preventative approaches.
511 citations
References
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TL;DR: Comprehensive geriatric assessment is effective in guiding the treatment of frail elderly patients and leads to significantly improved outcomes under appropriate conditions, including urinary incontinence.
Abstract: The rapid growth of the elderly population has increased the need for improved geriatric care and prevention of disability. For example, the prevalence and severity of osteoporosis can be reduced significantly by the use of estrogen, with or without added progestin, in postmenopausal women. A common and devastating problem of frail elderly persons is urinary incontinence, most cases of which can be classified without referral for urologic services. Appropriate treatment can improve nearly half of all cases of persistent incontinence. Comprehensive geriatric assessment is effective in guiding the treatment of frail elderly patients and leads to significantly improved outcomes under appropriate conditions. The advent of the teaching nursing home has shed light on the medical problems of elderly residents of nursing homes, including malnutrition, dysregulation of water and electrolyte balance, falling, cognitive and affective illnesses, behavior disturbances, infections, and pathogenic drug use. The future application of advanced technology may revolutionize nursing home care.
37 citations
TL;DR: In this article, factors relating to six-year mortality in a representative sample of seventy-year-old Jerusalem residents (N=605) were investigated using logistic regression techniques.
Abstract: Factors relating to six-year mortality in a representative sample of seventy-year-old Jerusalem residents (N=605) were investigated using logistic regression techniques. Around 16.3% of the study population died during the six-year post-interview period. Bivariate analysis found elevated mortality related to being male, having more than one IADL dysfunction, more than two ADL dysfunctions, financial problems, no social support in times of emergencies, bad self-rated health status, cognitive impairment, confinement to bed during the fortnight prior to interview, and lack of regular exercise. Logistic regression controlling for gender, various clinical diagnoses, financial state, social support and smoking status showed IADL (ROR=4.57, 95% CI 1.51, 13.90), cognitive impairment (ROR=3.99, 95% CI 1.85, 8.59) and having been bed-sick a week or more during the preceding fortnight (ROR=6.60, 95% CI 1.00, 43.86) to be independent predictors of mortality. All persons who had a cognitive problem and were dysfunctional in more than two IADL categories, and 93.8% of persons who had been bed-sick and had more than one IADL dysfunction died during the study period. Combined measures of these three easily obtainable variables could prove a cheap and efficient method of identifying at-risk elderly persons in order to provide them with specific programs aimed at decreasing functional decline, and hence mortality.
31 citations
Journal Article•
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TL;DR: The occurrence of failure to thrive following hip fracture is described and it is concluded that this progressive decline occurred in about 10% of patients following hip fractures and that it was associated with physical and cognitive impairment and increased health care utilization.
Abstract: I n the present issue, Fox et al. describe the occurrence of failure to thrive following hip fracture. I They used a functional definition of failure to thrive: decreasing ability to walk one block. They concluded that this progressive decline occurred in about 10% of patients following hip fracture and that it was associated with physical and cognitive impairment and increased health care utilization. Whereas some metabolic predictors could be inferred from their data, they concluded that the failure to thrive syndrome, as observed in their subjects, appeared to be a \"complex and multifaceted condition,\" with \"multiple causes and influences.\" People don't die of old age any more. Not that they ever did die of old age. At one time, however, \"old age\" was an acceptable cause of death. In the present era, older people die of specific diagnoses or, at least, failure of a specific organ system. Nonetheless, old age is associated with general and nearly universal changes in organs and metabolism that impair the response to physiological, metabolic, psychological, or other stress that precedes death. This state of impaired homeostatic reserve is the condition called \"frailty.\" The course from robust health to frailty is called \"failure to thrive.\" Failure to thrive is related to other age-associated changes that presage death. The change most commonly recognized is weight loss. An article published last year in the Journal of the American Geriatrics Society by Wallace et al. focused on weight loss in ourpatients.\" Similar to the 10% incidence of failure to thrive found by Fox et aI., Wallace et al. found that the incidence of unexplained weight loss was about 13% in outpatients. Because the amount of weight loss was 4%, it must have come primarily from fat or muscle. Loss of fat and muscle is commonly called malnutrition, and loss of muscle alone is called sarcopenia. Because muscle loss, with or without concomitant fat loss results in loss of strength, endurance, and ability to walk, these conditions and syndromes are interrelated: failure to thrive, malnutrition, sarcopenia, and frailty.
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