J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING©
AGE, FRAILTY, DISABILITY, INSTITUTIONALIZATION, MULTIMORBIDITY OR COMORBIDITY. WHICH ARE THE MAIN TARGETS IN OLDER ADULTS? P. ABIZANDA1, L. ROMERO2, P.M. SANCHEZ-JURADO2, M. MARTINEZ-REIG2, S.A. ALFONSO-SILGUERO2, L. RODRIGUEZ-MANAS3 1. Head of the Geriatrics Department, Complejo Hospitalario Universitario de Albacete; 2. Specialist in Geriatrics, Complejo Hospitalario Universitario de Albacete; 3. Head of the Geriatrics Department, Hospital General Universitario de Getafe, Madrid; Corresponding author: Pedro Abizanda, Hospital Perpetuo Socorro, C/ Seminario 4, 02006 Albacete, Spain, Tel.: +34967597651, Fax: +34967597635, Email: [email protected]
Abstract: Objectives: Age, frailty, disability, institutionalization, multimorbidity or comorbidity are main risk factors for serious health adverse outcomes in older adults. However, the adjusted relevance of each of them in order to determine which characteristics must be of importance for health policies in this population group, has not been established. Design: Concurrent population-based cohort study. Setting: Albacete city, Spain. Participants: 842 participants over age 70 from the FRADEA Study. Measurements: Age, gender, institutionalization, frailty (Fried´s criteria), previous disability in basic activities of daily living (BADL) (Barthel index), comorbidity (Charlson index), and multimorbidity (≥ 2 from 14 selected diseases) were recorded in the basal visit. The combined event of mortality or incident disability in BADL was determined in the follow-up visit. The risk of presenting adverse events was determined by Kaplan-Meier analysis and logistic regression adjusted for age, sex, and institutionalization. Results: Mean follow-up 520 days. 63 participants died (7.5%). Among the remaining 779, 191 lost at least one BADL (24.5%). The combined event of mortality or disability was present in 254 participants (30.2%). Age (OR 1.10, 95%CI 1.06-1.14), frailty (OR 3.07, 95%CI 1.63-5.77), disability (OR 2.19, 95%CI 1.43-3.36) and institutionalization (OR 2.73, 95%CI 1.68-4.44) were independently associated with the combined adverse event, but not comorbidity or multimorbidity. In subjects younger than 80, only frailty, disability and institutionalization were risk factors, and in those aged ≥ 80, only age, disability and institutionalization were. Conclusions Health policies for older adults must take into account mainly frailty and disability in subjects younger than 80 and disability in those older than 80. Key words: Frailty, multimorbidities, disablement process.
detectable, preventable, and treatable pre-disability state that develops in young older adults and progresses to disability as they grow older (9, 10). Frailty prevalence is also related to age, ranging from 3.2% among 65- to 70-year-olds to 23.1% among people aged 90 years and older (11, 12). Since 2001, frailty has been considered an important predictor of health outcomes in the elderly, such as death, institutionalization, falls, reduced mobility, hospitalization, and increased dependence in basic activities of daily living (BADL), and instrumental activities of daily living (IADL) (11, 13-15). Disability is the difficulty of coping with BADL or IADL, and it is usually measured with validated instruments as the Barthel index for BADL or the Lawton index for IADL. It increases with age, and has also been associated with mortality, incident disability, hospitalization, length of hospital stay and institutionalization (15, 17). Few studies have compared the adjusted association between disability, multimorbidity or comorbidity and adverse health outcomes (18-20), but none has included frailty in the analysis, or differentiated between youngest (aged 70 to 79) and oldest old (aged 80 or over). In the present study we analyze the longitudinal association between frailty, disability, multimorbidity or comorbidity and mortality or incident disability in a cohort of older adults over age 70 representative of the population in Albacete, Spain, to determine which of these characteristics better identifies high risk older adults.
Introduction Healthcare systems must be based on targeted populations at risk for adverse health outcomes (1). In older adults, main adverse health outcomes include mortality, incident disability, institutionalization and hospitalization. Age, disability, frailty, comorbidity or multimorbidity have all been related with adverse outcomes in older adults, but it is not well known neither the relative importance of each one as a predictor of these adverse outcomes, nor changes with age of these associations. Recently, multimorbidity is being presented as the cornerstone of health policies for older adults because it represents a shift from the traditional single disease paradigm to a more holistic patient centered approach (2-6). Multimorbidity is defined as the co-occurrence of two or more chronic diseases in a specific period of time, and is related to age (7), with a prevalence estimates of 65-98% in older adults (2, 3, 6). It has been associated with mortality, hospitalization and longer hospital stays, institutionalization, lower quality of life, loss of physical functioning, depression, multiple drug use and higher health care utilization and costs (3, 8). Frailty has been recently defined as a “A medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death” (9), and is a Received October 18, 2013 Accepted for publication November 25, 2013
1
J Nutr Health Aging
AGE, FRAILTY, DISABILITY, INSTITUTIONALIZATION, MULTIMORBIDITY OR COMORBIDITY Method
original study (21).
Subjects and Study Setting Our study presents data from the first and second waves of the FRADEA (Frailty and Dependence in Albacete) Study. The rationale, design, methodology, selection of subjects, and baseline characteristics have been previously described (21). Briefly, 1172 subjects were randomly selected from the population aged 70 years or more from the city of Albacete (n=18,137), of whom 993 (84.7%) agreed to participate. In the second cut, 958 participants agreed to continue (96.5% of the initial cohort). Study design Population based concurrent cohort study. The baseline interview was carried out in person by four trained nurses at the Geriatric facilities of the Hospital del Perpetuo Socorro in Albacete between November 2007 and November 2009. The nurses went to the homes of participants who could not come to the site to obtain the required information. The follow-up visit was conducted by telephone by the same four nurses 18 months after the baseline visit. Study Variables At the baseline visit, age, sex, institutionalization, previous disability in BADL using the Barthel Index, comorbidity using the Charlson index, multimorbidity and frailty with Fried´s criteria were recorded. The Barthel index is an ordinal scale that measures bathing, grooming, dressing, feeding, toilet use, urinary and fecal incontinence, transferring, walking 50 meters and stair use, ranging from 0 (dependence in all BADL) to 100 (independence in all BADL). Baseline BADL disability was considered when the participant required aid to perform the bathing, grooming, dressing, feeding, or toilet use activities from the Barthel Index. Chronic diseases were identified from the participant´s medical records. Diseases were coded according to the ICD-10 and thereafter classified within large homogeneous groups for later analysis. The Charlson Comorbidity Index was used to analyze comorbidity. A Charlson Comorbidity Index rating of 3 or higher represented high comorbidity. Multimorbidity was considered when the participant presented two or more of the following 14 selected chronic diseases: hypertension, dislipemia, diabetes, depression, coronary disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dementia, asthma/bronchial hypereactivity, stroke, non skin cancer (except melanoma), heart failure, anemia, and parkinsonism. During the baseline visit, the frailty criteria proposed by Fried (11) were recorded, with one small modification in the physical activity criteria. Subjects were classified as frail when three or more of the five criteria were present, and pre-frail when one or two were present. The methodology for application of all the assessment tools used as well as bibliographical references can be found in the 2
Outcome Variables The main outcome variable was the combined event of mortality or incident disability in BADL. During the telephone interview, death was recorded along with the date it occurred. When this was unknown, the death registry of the Complejo Hospitalario Universitario and that of the Albacete primary care facility were consulted. Incident disability in BADL was defined as presenting lower scores on the Barthel Index in bathing, grooming, dressing, feeding, or toilet use in the followup visit compared to the baseline visit. The combined event was considered when mortality or incident BADL disability were present. Ethical Aspects Our investigation complies with the standards of the Helsinki declaration concerning investigation with human subjects. The study was approved by the Albacete Health Region Independent Ethics Committee. All participants signed an informed consent form prior to inclusion in the study. Statistical Analysis A descriptive analysis of the characteristics of the sample was performed, and chi square and t-Student tests were used to analyze the association between each independent variable and the events recorded. The association between frailty, disability, comorbidity or multimorbidity and the combined event was analyzed with Kaplan-Meier curves with bivariate comparisons using log rank tests. The observations were independent and censoring was non-informative. The association between frailty, disability, comorbidity or multimorbidity and mortality, incident disability in BADL, or the combined event was analyzed adjusted for the study covariables (age, sex, and institutionalization) using logistic regression models. In model 1 high comorbidity was considered when the Charlson index score was ≥ 3, and in model 2 multimorbidity was considered when 2 or more of the 14 selected diseases were present. Finally, the same associations were determined for the combined event in participants younger or equal/older than 80 years. Interactions between all study covariates and the combined event were analyzed before selecting the final models. In models with only 2 independent variables, interaction between age-frailty, ageinstitutionalization, sex-frailty, sex-comorbidity, disabilityinstitutionalization and frailty-institutionalization were detected, but in models with all the variables, only the interactions between frailty-age, and disabilityinstitutionalization reached statistical significance. However, the inclusion of these interactions in the final models did not significantly change the adjusted association between covariates and the combined event. All data were stored and analyzed using the SPSS 17.0 program.
J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING© comorbidity, and multimorbidity, but not with sex. However, incident disability in BADL was associated with older age, female sex, institutionalization, frailty, disability in BADL and multimorbidity, but not with high comorbidity, and the combined event was associated with all the study covariables. Figure 1 presents the unadjusted probability of not presenting the combined event (mortality or incident disability in BADL) for frailty (panel A), disability in BADL (panel B), high comorbidity (panel C), and multimorbidity (panel D) using Kaplan-Meier analysis. Mean combined event-free time was 939 ± 43 days for the non-frail, 694 ± 15 among the prefrail, and 619 ± 20 for frail subjects( Log-rank χ2 57.1, p
THE JOURNAL OF NUTRITION, HEALTH & AGING©
AGE, FRAILTY, DISABILITY, INSTITUTIONALIZATION, MULTIMORBIDITY OR COMORBIDITY. WHICH ARE THE MAIN TARGETS IN OLDER ADULTS? P. ABIZANDA1, L. ROMERO2, P.M. SANCHEZ-JURADO2, M. MARTINEZ-REIG2, S.A. ALFONSO-SILGUERO2, L. RODRIGUEZ-MANAS3 1. Head of the Geriatrics Department, Complejo Hospitalario Universitario de Albacete; 2. Specialist in Geriatrics, Complejo Hospitalario Universitario de Albacete; 3. Head of the Geriatrics Department, Hospital General Universitario de Getafe, Madrid; Corresponding author: Pedro Abizanda, Hospital Perpetuo Socorro, C/ Seminario 4, 02006 Albacete, Spain, Tel.: +34967597651, Fax: +34967597635, Email: [email protected]
Abstract: Objectives: Age, frailty, disability, institutionalization, multimorbidity or comorbidity are main risk factors for serious health adverse outcomes in older adults. However, the adjusted relevance of each of them in order to determine which characteristics must be of importance for health policies in this population group, has not been established. Design: Concurrent population-based cohort study. Setting: Albacete city, Spain. Participants: 842 participants over age 70 from the FRADEA Study. Measurements: Age, gender, institutionalization, frailty (Fried´s criteria), previous disability in basic activities of daily living (BADL) (Barthel index), comorbidity (Charlson index), and multimorbidity (≥ 2 from 14 selected diseases) were recorded in the basal visit. The combined event of mortality or incident disability in BADL was determined in the follow-up visit. The risk of presenting adverse events was determined by Kaplan-Meier analysis and logistic regression adjusted for age, sex, and institutionalization. Results: Mean follow-up 520 days. 63 participants died (7.5%). Among the remaining 779, 191 lost at least one BADL (24.5%). The combined event of mortality or disability was present in 254 participants (30.2%). Age (OR 1.10, 95%CI 1.06-1.14), frailty (OR 3.07, 95%CI 1.63-5.77), disability (OR 2.19, 95%CI 1.43-3.36) and institutionalization (OR 2.73, 95%CI 1.68-4.44) were independently associated with the combined adverse event, but not comorbidity or multimorbidity. In subjects younger than 80, only frailty, disability and institutionalization were risk factors, and in those aged ≥ 80, only age, disability and institutionalization were. Conclusions Health policies for older adults must take into account mainly frailty and disability in subjects younger than 80 and disability in those older than 80. Key words: Frailty, multimorbidities, disablement process.
detectable, preventable, and treatable pre-disability state that develops in young older adults and progresses to disability as they grow older (9, 10). Frailty prevalence is also related to age, ranging from 3.2% among 65- to 70-year-olds to 23.1% among people aged 90 years and older (11, 12). Since 2001, frailty has been considered an important predictor of health outcomes in the elderly, such as death, institutionalization, falls, reduced mobility, hospitalization, and increased dependence in basic activities of daily living (BADL), and instrumental activities of daily living (IADL) (11, 13-15). Disability is the difficulty of coping with BADL or IADL, and it is usually measured with validated instruments as the Barthel index for BADL or the Lawton index for IADL. It increases with age, and has also been associated with mortality, incident disability, hospitalization, length of hospital stay and institutionalization (15, 17). Few studies have compared the adjusted association between disability, multimorbidity or comorbidity and adverse health outcomes (18-20), but none has included frailty in the analysis, or differentiated between youngest (aged 70 to 79) and oldest old (aged 80 or over). In the present study we analyze the longitudinal association between frailty, disability, multimorbidity or comorbidity and mortality or incident disability in a cohort of older adults over age 70 representative of the population in Albacete, Spain, to determine which of these characteristics better identifies high risk older adults.
Introduction Healthcare systems must be based on targeted populations at risk for adverse health outcomes (1). In older adults, main adverse health outcomes include mortality, incident disability, institutionalization and hospitalization. Age, disability, frailty, comorbidity or multimorbidity have all been related with adverse outcomes in older adults, but it is not well known neither the relative importance of each one as a predictor of these adverse outcomes, nor changes with age of these associations. Recently, multimorbidity is being presented as the cornerstone of health policies for older adults because it represents a shift from the traditional single disease paradigm to a more holistic patient centered approach (2-6). Multimorbidity is defined as the co-occurrence of two or more chronic diseases in a specific period of time, and is related to age (7), with a prevalence estimates of 65-98% in older adults (2, 3, 6). It has been associated with mortality, hospitalization and longer hospital stays, institutionalization, lower quality of life, loss of physical functioning, depression, multiple drug use and higher health care utilization and costs (3, 8). Frailty has been recently defined as a “A medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death” (9), and is a Received October 18, 2013 Accepted for publication November 25, 2013
1
J Nutr Health Aging
AGE, FRAILTY, DISABILITY, INSTITUTIONALIZATION, MULTIMORBIDITY OR COMORBIDITY Method
original study (21).
Subjects and Study Setting Our study presents data from the first and second waves of the FRADEA (Frailty and Dependence in Albacete) Study. The rationale, design, methodology, selection of subjects, and baseline characteristics have been previously described (21). Briefly, 1172 subjects were randomly selected from the population aged 70 years or more from the city of Albacete (n=18,137), of whom 993 (84.7%) agreed to participate. In the second cut, 958 participants agreed to continue (96.5% of the initial cohort). Study design Population based concurrent cohort study. The baseline interview was carried out in person by four trained nurses at the Geriatric facilities of the Hospital del Perpetuo Socorro in Albacete between November 2007 and November 2009. The nurses went to the homes of participants who could not come to the site to obtain the required information. The follow-up visit was conducted by telephone by the same four nurses 18 months after the baseline visit. Study Variables At the baseline visit, age, sex, institutionalization, previous disability in BADL using the Barthel Index, comorbidity using the Charlson index, multimorbidity and frailty with Fried´s criteria were recorded. The Barthel index is an ordinal scale that measures bathing, grooming, dressing, feeding, toilet use, urinary and fecal incontinence, transferring, walking 50 meters and stair use, ranging from 0 (dependence in all BADL) to 100 (independence in all BADL). Baseline BADL disability was considered when the participant required aid to perform the bathing, grooming, dressing, feeding, or toilet use activities from the Barthel Index. Chronic diseases were identified from the participant´s medical records. Diseases were coded according to the ICD-10 and thereafter classified within large homogeneous groups for later analysis. The Charlson Comorbidity Index was used to analyze comorbidity. A Charlson Comorbidity Index rating of 3 or higher represented high comorbidity. Multimorbidity was considered when the participant presented two or more of the following 14 selected chronic diseases: hypertension, dislipemia, diabetes, depression, coronary disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dementia, asthma/bronchial hypereactivity, stroke, non skin cancer (except melanoma), heart failure, anemia, and parkinsonism. During the baseline visit, the frailty criteria proposed by Fried (11) were recorded, with one small modification in the physical activity criteria. Subjects were classified as frail when three or more of the five criteria were present, and pre-frail when one or two were present. The methodology for application of all the assessment tools used as well as bibliographical references can be found in the 2
Outcome Variables The main outcome variable was the combined event of mortality or incident disability in BADL. During the telephone interview, death was recorded along with the date it occurred. When this was unknown, the death registry of the Complejo Hospitalario Universitario and that of the Albacete primary care facility were consulted. Incident disability in BADL was defined as presenting lower scores on the Barthel Index in bathing, grooming, dressing, feeding, or toilet use in the followup visit compared to the baseline visit. The combined event was considered when mortality or incident BADL disability were present. Ethical Aspects Our investigation complies with the standards of the Helsinki declaration concerning investigation with human subjects. The study was approved by the Albacete Health Region Independent Ethics Committee. All participants signed an informed consent form prior to inclusion in the study. Statistical Analysis A descriptive analysis of the characteristics of the sample was performed, and chi square and t-Student tests were used to analyze the association between each independent variable and the events recorded. The association between frailty, disability, comorbidity or multimorbidity and the combined event was analyzed with Kaplan-Meier curves with bivariate comparisons using log rank tests. The observations were independent and censoring was non-informative. The association between frailty, disability, comorbidity or multimorbidity and mortality, incident disability in BADL, or the combined event was analyzed adjusted for the study covariables (age, sex, and institutionalization) using logistic regression models. In model 1 high comorbidity was considered when the Charlson index score was ≥ 3, and in model 2 multimorbidity was considered when 2 or more of the 14 selected diseases were present. Finally, the same associations were determined for the combined event in participants younger or equal/older than 80 years. Interactions between all study covariates and the combined event were analyzed before selecting the final models. In models with only 2 independent variables, interaction between age-frailty, ageinstitutionalization, sex-frailty, sex-comorbidity, disabilityinstitutionalization and frailty-institutionalization were detected, but in models with all the variables, only the interactions between frailty-age, and disabilityinstitutionalization reached statistical significance. However, the inclusion of these interactions in the final models did not significantly change the adjusted association between covariates and the combined event. All data were stored and analyzed using the SPSS 17.0 program.
J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING© comorbidity, and multimorbidity, but not with sex. However, incident disability in BADL was associated with older age, female sex, institutionalization, frailty, disability in BADL and multimorbidity, but not with high comorbidity, and the combined event was associated with all the study covariables. Figure 1 presents the unadjusted probability of not presenting the combined event (mortality or incident disability in BADL) for frailty (panel A), disability in BADL (panel B), high comorbidity (panel C), and multimorbidity (panel D) using Kaplan-Meier analysis. Mean combined event-free time was 939 ± 43 days for the non-frail, 694 ± 15 among the prefrail, and 619 ± 20 for frail subjects( Log-rank χ2 57.1, p
