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PubMed2004

The predictive effect of episodes on the risk of recurrence in depressive and bipolar disorders - a life-long perspective.

OBJECTIVE: It is generally accepted that one of the most important predictors of recurrence in depressive and bipolar disorders is the number of previous episodes. However, very few studies have considered the individual tendency toward recurrence in analyses of the effect of the number of episodes on the risk of subsequent recurrence in affective disorder. METHOD: Frailty models were used to estimate the effect of the number of episodes on the rate of recurrence taking into account the individual frailty toward recurrence. The study base consisted of 406 patients, 186 patients with depressive disorder and 220 patients with bipolar disorder, who were admitted between 1959 and 1963 to the Psychiatric Hospital University of Zurich with an affective episode and followed up to 1997. RESULTS: The individual rate of subsequent recurrence was found to increase with the number of episodes even when the effect was adjusted for the individual frailty toward recurrence. The effect of episodes was the same in depressive and bipolar disorders and for men and women. CONCLUSION: It seems increasingly valid that in depressive and bipolar disorders, the risk of subsequent recurrence increases with the number of episodes.

Bipolar Disorder↗

PubMed1995

Survival of related individuals: an extension of some fundamental results of heterogeneity analysis.

"Many ideas in the analysis of heterogeneous mortality are based on the relationship between individual and observed hazard rates. This connection is established with the help of conditional averaging procedure: The observed risk of death at age x is calculated among those who survive this age. The analogy of this result for bivariate survival model with correlated individual hazards is derived. In the case of correlated frailty model the parametric specification of the mean, variance and correlation coefficient of the bivariate frailty distribution among survivors is obtained. The relationship between local association measure and the characteristics of the bivariate frailty distribution among survivors is established." (SUMMARY IN FRE)

Age Factors↗

PubMed2004

Spirituality and well-being in frail and nonfrail older adults.

Previous studies have identified that spiritual beliefs contribute to psychological well-being (PWB) in older people, but limited research has considered the effects of spirituality on PWB when physical health deteriorates and people become frail. We recruited 233 British participants from warden-controlled retirement housing to complete interviewer-administered questionnaires. Results showed that, after we controlled for marital status, age, education, other health problems, and gender, degree of frailty had a negative effect on PWB. Spirituality was also a significant predictor of PWB and moderated the negative effects of frailty on PWB. Therefore, this study suggests that spirituality is a resource in maintaining PWB, and that the use of this resource is more significant for individuals with greater levels of frailty.

Adaptation, Psychological↗

PubMed2003

Survival of hemodialysis patients: modeling differences in risk of dialysis centers.

OBJECTIVE: Dialysis is the most common renal replacement therapy for patients with end stage renal disease. This paper considers survival of dialysis patients, aiming to assess quality of renal replacement therapy at dialysis centers in Rio de Janeiro, Brazil, and to investigate differences in survival between health facilities. METHODS: A Cox proportional hazards model, allowing for time-varying covariates and prevalent data, was the basic method used to analyze the survival of 11,579 patients on hemodialysis in 67 health facilities in Rio de Janeiro State from January 1998 until August 2001, using data obtained from routine information systems. A frailty random effects model was applied to investigate differences in mortality between health centers not explained by measured characteristics. RESULTS: The individual variables associated with the outcome were age and underlying disease, with diabetes being the main isolated risk factor. Considering covariates of the health unit, two factors were associated with performance: bigger units had on average better survival times than smaller ones and units which offered cyclic peritoneal dialysis performed less well than those that did not. There were significant frailty effects among centers, with relative risks varying between 0.24 and 3.15, and an estimated variance of 0.43. CONCLUSIONS: Routine assessment based on health registries of the outcome of any high technology medical treatment is extremely important in maintaining quality of care and in estimating the impact of changes in therapies, units, and patient profiles. The frailty model allowed estimation of variation in risk between centers not attributable to any measured covariates. This can be used to guide more specific investigation and changes in health policies related to renal transplant therapies.

Ambulatory Care Facilities↗

PubMed2007

Heterogeneity in risk factors for cognitive impairment, no dementia: population-based longitudinal study from the Kungsholmen Project.

OBJECTIVES: The objectives of this study were to investigate the relation of vascular, neuropsychiatric, social, and frailty-related factors with "Cognitive impairment, no dementia" (CIND) and to verify their effect independently of future progression to Alzheimer disease (AD). METHODS: Seven hundred eighteen subjects aged 75+ years who attended baseline, 3- and 6-year follow-up examinations of the Kungsholmen Project, a Swedish prospective cohort study, were studied. CIND was defined according to the performance on the Mini-Mental State Examination. Potential risk factors were collected at baseline and clustered according to four research hypotheses (frailty, vascular, neuropsychiatric, and social hypothesis), each representing a possible pathophysiological mechanism of CIND independently of subsequent development of AD. RESULTS: Over a mean 3.4 years of follow up, 82 participants (11.4%) developed CIND. When the population was subsequently followed for a mean of 2.7 years, subjects with CIND had a threefold increased risk to progress to AD. After multiple adjustments, including adjustment for the development of AD at the 6-year follow up, risk factors for CIND were hip fracture, polypharmacy, and psychoses. CONCLUSIONS: The results suggest that not only the AD-type neurodegenerative process, but also neuropsychiatric- and frailty-related factors may induce cognitive impairment in nondemented elderly. These findings may have relevant preventive and therapeutic implications.

Activities of Daily Living↗

PubMed2001

Accumulation of deficits as a proxy measure of aging.

This paper develops a method for appraising health status in elderly people. A frailty index was defined as the proportion of accumulated deficits (symptoms, signs, functional impairments, and laboratory abnormalities). It serves as an individual state variable, reflecting severity of illness and proximity to death. In a representative database of elderly Canadians we found that deficits accumulated at 3% per year, and show a gamma distribution, typical for systems with redundant components that can be used in case of failure of a given subsystem. Of note, the slope of the index is insensitive to the individual nature of the deficits, and serves as an important prognostic factor for life expectancy. The formula for estimating an individual's life span given the frailty index value is presented. For different patterns of cognitive impairments the average within-group index value increases with the severity of the cognitive impairment, and the relative variability of the index is significantly reduced. Finally, the statistical distribution of the frailty index sharply differs between well groups (gamma distribution) and morbid groups (normal distribution). This pattern reflects an increase in uncompensated deficits in impaired organisms, which would lead to illness of various etiologies, and ultimately to increased mortality. The accumulation of deficits is as an example of a macroscopic variable, i.e., one that reflects general properties of aging at the level of the whole organism rather than any given functional deficiency. In consequence, we propose that it may be used as a proxy measure of aging.

Aged↗

PubMed1999

Modeling random effects for censored data by a multivariate normal regression model.

A normal distribution regression model with a frailty-like factor to account for statistical dependence between the observed survival times is introduced. This model, as opposed to standard hazard-based frailty models, has survival times that, conditional on the shared random effect, have an accelerated failure time representation. The dependence properties of this model are discussed and maximum likelihood estimation of the model's parameters is considered. A number of examples are considered to illustrate the approach. The estimated degree of dependence is comparable to other models, but the present approach has the advantage that the interpretation of the random effect is simpler than in the frailty model.

Animals↗

PubMed1993

Development of the common data base for the FICSIT trials.

The eight FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) sites test different intervention strategies in selected target groups of older adults. To compare the relative potential of these interventions to reduce frailty and fall-related injuries, all sites share certain descriptive (risk-adjustment) measures and outcome measures. This article describes the shared measures, which are referred to as the FICSIT Common Data Base (CDB). The description is divided into four sections according to the four FICSIT committees responsible for the CDB: (1) psychosocial health and demographic measures; (2) physical health measures; (3) fall-related measures; and (4) cost and cost-effectiveness measures. Because the structure of the FICSIT trial is unusual, the CDB should expedite secondary analyses of various research questions dealing with frailty and falls.

Accidental Falls↗

PubMed1997

The impact of aging and chronic disease on use of hospital and outpatient services in a large HMO: 1971-1991.

OBJECTIVES: To examine overall and diagnosis-specific trends in the use of inpatient and outpatient medical services (1970-1988) among older members of a large HMO. DESIGN: Two cohorts of approximately 3000 persons aged 65 or older in 1971 and 1980 were compared for hospital and outpatient utilization during 9-year follow-up periods (1971-79 and 1980-88). All subjects were evaluated for vital status throughout the follow-up period as well. PARTICIPANTS: All 6057 subjects were members of the Northern California Kaiser Permanente Medical Care Program in 1971 or 1980. The study sample was sex-age stratified (65-69,70-79,80+) at baseline. MEASUREMENTS: Data on demographics, outpatient health services utilization, categories of outpatient utilization and disease diagnoses were obtained from membership lists or medical chart review; inpatient utilization, including admitting and discharge diagnosis, length of stay, and number of hospital days was assessed from computerized hospitalization records. RESULTS: Hospital discharge rates (sex-age adjusted) increased by 12% between cohorts, with the largest increases at the oldest ages. There was a 25% increase among women and a 9% increase among men. Length of stay decreased by 20%. Hospitalization for ischemic heart disease decreased by 17%. Congestive heart failure (CHF) discharge rates (sex-age adjusted) were 92% higher in the 1980-88 cohort. For diagnoses related to nursing home institutionalization and frailty, discharge rates were significantly higher in the 1980-88 cohort: pneumonia (+34%), urinary tract infections (+104%), dehydration (+110%), osteoarthritis (+64%), syncope (+246%), leg cellulitis (+70%). In-hospital survival improved, but overall percent of readmissions also increased by 4%; readmissions for CHF increased by 13% and those for conditions of frailty by 120%. Overall outpatient visits increased by 17%. Use of laboratory tests (+57%) and outpatient surgeries (+99%) increased for all age strata in 1980-88 compared with 1971-79. CONCLUSIONS: While overall outpatient and inpatient utilization has largely decreased over the past 30 years, as a result of economic factors and improved treatments for some major diseases, there has been an increase in utilization among older people. Hospitalization for diagnoses associated with end-stage cardiovascular disease (CHF), musculoskeletal disease, frailty and iatrogenic aspects of institutionalization are clearly increasing substantially. The largest impact of aging on health care may be the result of institutionalization and its sequelae. Improved treatment for cardiovascular disease may also be leading to increased utilization at later stages in the disease process.

Aged↗

PubMed2006

Characteristics of frail older adult drivers.

OBJECTIVES: To determine the prevalence of driving in older adults with mild to moderate physical frailty and to compare characteristics of current frail older adult drivers with those of former drivers in the sample. DESIGN: Retrospective study of frail older adults enrolled in randomized trials of exercise and hormone replacement therapy. SETTING: Urban, academic medical center. PARTICIPANTS: One hundred eighty-three sedentary community-dwelling men and women aged 75 and older with mild to moderate physical frailty, as defined by two of the following three criteria: modified Physical Performance Test (PPT) score between 18 and 32, peak oxygen uptake (VO2) between 10 and 18 mL/kg per minute, and self-report of difficulty or assistance with one activity of daily living (ADL) or two instrumental ADLs. Participants were classified as current or former drivers. MEASUREMENTS: Demographic characteristics, medical diagnoses, medication use, modified PPT score, and psychometric tests. RESULTS: The majority (85%) of the participants were drivers. Former drivers were more likely to be older, be female, reside in congregate independent living for the elderly, have a higher incidence of arthritis and congestive heart failure, take sedating medications, have lower total ADL scores, have lower VO2 peak scores, and have more impairment on tests of cognition and physical strength, although only age, type of residence, and grip strength were independent predictors of driving cessation in the regression analysis. CONCLUSION: Despite the presence of physical frailty, many older adults choose to continue to drive. Further studies are needed to better understand the driving behaviors of frail older adults and explore opportunities for optimizing driving abilities.

Activities of Daily Living↗

PubMed2005

A semiparametric mixture model for analyzing clustered competing risks data.

A very general class of multivariate life distributions is considered for analyzing failure time clustered data that are subject to censoring and multiple modes of failure. Conditional on cluster-specific quantities, the joint distribution of the failure time and event indicator can be expressed as a mixture of the distribution of time to failure due to a certain type (or specific cause), and the failure type distribution. We assume here the marginal probabilities of various failure types are logistic functions of some covariates. The cluster-specific quantities are subject to some unknown distribution that causes frailty. The unknown frailty distribution is modeled nonparametrically using a Dirichlet process. In such a semiparametric setup, a hybrid method of estimation is proposed based on the i.i.d. Weighted Chinese Restaurant algorithm that helps us generate observations from the predictive distribution of the frailty. The Monte Carlo ECM algorithm plays a vital role for obtaining the estimates of the parameters that assess the extent of the effects of the causal factors for failures of a certain type. A simulation study is conducted to study the consistency of our methodology. The proposed methodology is used to analyze a real data set on HIV infection of a cohort of female prostitutes in Senegal.

AIDS Vaccines↗

PubMed2004

Oral mucosal and osseous disorders in frail elders.

OBJECTIVE: This paper reviews the implications of frailty for oral health in old age due to the incidence of oral pathoses following on mucosal atrophy, tooth loss, trauma from dentures, polypharmacy, malnutrition, salivary disorders, degeneration of jawbone and cancer. BACKGROUND: Frailty as a condition of old age occurs when elders have energy levels below a critical threshold, or when the social or cultural environment is limited. RESULTS: Frail elders are particularly vulnerable to pathoses, but not simply because of old age per se. Oral diseases accompanying frailty are due to a complicated mixture of biopsychosocial changes that accompany old age. CONCLUSIONS: Management of oral mucosal and osseous disorders in frail elders requires an understanding of the changes that occur with advancing age.

Aged↗

PubMed2005

Design and pilot results of a single blind randomized controlled trial of systematic demand-led home visits by nurses to frail elderly persons in primary care [ISRCTN05358495].

BACKGROUND: The objective of this article is to describe the design of an evaluation of the cost-effectiveness of systematic home visits by nurses to frail elderly primary care patients. Pilot objectives were: 1. To determine the feasibility of postal multidimensional frailty screening instruments; 2. to identify the need for home visits to elderly. METHODS: Main study: The main study concerns a randomized controlled in primary care practices (PCP) with 18 months follow-up and blinded PCPs. Frail persons aged 75 years or older and living at home but neither terminally ill nor demented from 33 PCPs were eligible. Trained community nurses (1) visit patients at home and assess the care needs with the Resident Assessment Instrument-Home Care, a multidimensional computerized geriatric assessment instrument, enabling direct identification of problem areas; (2) determine the care priorities together with the patient; (3) design and execute interventions according to protocols; (4) and visit patients at least five times during a year in order to execute and monitor the care-plan. Controls receive usual care. Outcome measures are Quality of life, and Quality Adjusted Life Years; time to nursing home admission; mortality; hospital admissions; health care utilization. Pilot 1: Three brief postal multidimensional screening measures to identify frail health among elderly persons were tested on percentage complete item response (selected after a literature search): 1) Vulnerable Elders Screen, 2) Strawbridge's frailty screen, and 3) COOP-WONCA charts. Pilot 2: Three nurses visited elderly frail patients as identified by PCPs in a health center of 5400 patients and used an assessment protocol to identify psychosocial and medical problems. The needs and experiences of all participants were gathered by semi-structured interviews. DISCUSSION: The design holds several unique elements such as early identification of frail persons combined with case-management by nurses. From two pilots we learned that of three potential postal frailty measures, the COOP-WONCA charts were completed best by elderly and that preventive home visits by nurses were positively evaluated to have potential for quality of care improvement.

Aged↗

PubMed2005

Incomplete functional recovery after delirium in elderly people: a prospective cohort study.

BACKGROUND: Delirium often has a poor outcome, but why some people have incomplete recovery is not well understood. Our objective was to identify factors associated with short-term (by discharge) and long-term (by 6 month) incomplete recovery of function following delirium. METHODS: In a prospective cohort study of elderly patients with delirium seen by geriatric medicine services, function was assessed at baseline, at hospital discharge and at six months. RESULTS: Of 77 patients, vital and functional status at 6 months was known for 71, of whom 21 (30%) had died. Incomplete functional recovery, defined as > or =10 point decline in the Barthel Index, compared to pre-morbid status, was present in 27 (54%) of the 50 survivors. Factors associated with death or loss of function at hospital discharge were frailty, absence of agitation (hypoactive delirium), a cardiac cause and poor recognition of delirium by the treating service. Frailty, causes other than medications, and poor recognition of delirium by the treating service were associated with death or poor functional recovery at 6 months. CONCLUSION: Pre-existing frailty, cardiac cause of delirium, and poor early recognition by treating physicians are associated with worse outcomes. Many physicians view the adverse outcomes of delirium as intractable. While in some measure this might be true, more skilled care is a potential remedy within their grasp.

Aged↗

PubMed1990

Survival models for familial aggregation of cancer.

It has recently been shown that the relative risks of the order of 2 to 4 that are frequently found for cancer among relatives of affected cases are unlikely to be explainable by shared environmental risk factors. Classical methods of epidemiological analysis are not well suited to such analysis because they assume that the outcomes of each individual are independent. Classical methods of genetic analysis, on the other hand, are limited in their handling of environmental factors and variable ages of onset. The recent development of random effects models for survival analysis, however, appears to bridge this gap. Specifically, a proportional hazards model is postulated for the effects of measured covariates and of one or more components of frailty that are unmeasured but assumed to have some common distribution and known covariance structure within each family. From these assumptions, the posterior expectation of the hazard for each individual can be derived, given the covariate value and the observed and expected disease history of the family. These are then treated as known in a standard partial likelihood analysis; this is essentially a form of expectation-maximization algorithm. However, this does not provide a valid estimate of the covariance matrix because it fails to take account of the variability in the estimates of the frailties; an alternative approach using the imputation-posterior algorithm is suggested. This paper describes extensions of this approach to multivariate frailty distributions, modifications for application to pedigree and case-control studies, some simulation results, and applications to studies of breast cancer in twins and of lung cancer in relation to family smoking habits.

Adenocarcinoma↗

PubMed1994

The prevalence and correlates of fear of falling in elderly persons living in the community.

OBJECTIVES: Fear of falling has been recognized as a potentially debilitating consequence of falling in elderly persons. However, the prevalence and the correlates of this fear are unknown. METHODS: Prevalence of fear of falling was calculated from the 1-year follow-up of an age- and gender-stratified random sample of community-dwelling elderly persons. Cross-sectional associations of fear of falling with quality of life, frailty, and falling were assessed. RESULTS: The prevalence of fear increased with age and was greater in women. After adjustment for age and gender, being moderately fearful of falling was associated with decreased satisfaction with life, increased frailty and depressed mood, and recent experience with falls. Being very fearful of falling was associated with all of the above plus decreased mobility and social activities. CONCLUSIONS: Fear of falling is common in elderly persons and is associated with decreased quality of life, increased frailty, and recent experience with falls.

Accidental Falls↗

PubMed1997

Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons.

BACKGROUND: The importance of total cholesterol level as a risk factor for coronary heart disease in older adults is controversial. OBJECTIVE: To determine whether findings showing that total cholesterol level is not an important risk factor for coronary heart disease in older adults are the result of inadequate adjustment for co-occurring diseases and frailty. DESIGN: Multicenter, longitudinal study with 5-year follow-up for death. PARTICIPANTS: 4066 men and women from East Boston, Massachusetts; Iowa and Washington counties, Iowa; and New Haven, Connecticut. MEASUREMENTS: In 1988, participants were interviewed about their health status and had blood samples taken. Mortality follow-up was through 1992. RESULTS: In analyses that included all fatal coronary heart disease events (252 deaths) and did not adjust for risk factors for coronary heart disease and measures of frailty, persons with the lowest total cholesterol levels (< or = 4.15 mmol/L [< or = 160 mg/dL]) had the highest rate of death from coronary heart disease, whereas those with elevated total cholesterol levels (> or = 6.20 mmol/L [> or = 240 mg/dL]) seemed to have a lower risk for death from coronary heart disease (P for trend = 0.04). After adjustment for established risk factors for coronary heart disease and markers of poor health (including chronic conditions, low serum iron and albumin levels) and exclusion of 44 deaths from coronary heart disease that occurred within the first year, elevated total cholesterol levels predicted increased risk for death from coronary heart disease, and the risk for death from coronary heart disease decreased as cholesterol levels decreased (P for trend = 0.005). CONCLUSIONS: Elevated total cholesterol level is a risk factor for death from coronary heart disease in older adults, and the apparent adverse effects associated with low cholesterol levels are secondary to comorbidity and frailty. This suggests that excluding older persons from cholesterol screening is inappropriate, but interpretation of screening results in older persons requires clinical judgment. Results from controlled clinical trials are needed to clarify this issue.

Aged↗

PubMed2001

The prevalence and psychosocial characteristics of the frail elderly in Japan: a community-based study.

There is insufficient epidemiological data about frail elders in Japan. Few studies concerning the relationship between psychosocial characteristics and frailty exist in the literature. The purpose of this study was to assess the prevalence and to explore the characteristics of the frail elderly in a community of Japan by cross-sectional and case-control studies. Data were collected from a total of 2,310 non-institutionalized persons aged 65 years or older, by mail survey and interview. We defined frailty as a precursor of disability. The prevalence of frail elders was estimated at 6.1%. After controlling for age and gender, multiple logistic regression analyses disclosed that frail elders displayed significantly higher emotional reliance on another person, worsening self-efficacy, fair or poor subjective health, and poor functional ability than independent elders, and significantly higher self-efficacy than bedridden elders. The most noticeable finding in this study was the significant association of psychosocial factors with frailty among the community-dwelling elderly. Based on our study results, we suggest that when controlling physical variables, psychosocial variables might strongly affect the frail status among elderly persons.

Aged↗