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      Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study

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          Abstract

          Background

          Frailty is an important clinical syndrome that is consistently associated with adverse outcomes in older people. The relevance of frailty to chronic respiratory disease and its management is unknown.

          Objectives

          To determine the prevalence of frailty among patients with stable COPD and examine whether frailty affects completion and outcomes of pulmonary rehabilitation.

          Methods

          816 outpatients with COPD (mean (SD) age 70 (10) years, FEV 1% predicted 48.9 (21.0)) were recruited between November 2011 and January 2015. Frailty was assessed using the Fried criteria (weight loss, exhaustion, low physical activity, slowness and weakness) before and after pulmonary rehabilitation. Predictors of programme non-completion were identified using multivariate logistic regression, and outcomes were compared using analysis of covariance, adjusting for age and sex.

          Results

          209/816 patients (25.6%, 95% CI 22.7 to 28.7) were frail. Prevalence of frailty increased with age, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) score and age-adjusted comorbidity burden (all p≤0.01). Patients who were frail had double the odds of programme non-completion (adjusted OR 2.20, 95% CI 1.39 to 3.46, p=0.001), often due to exacerbation and/or hospital admission. However, rehabilitation outcomes favoured frail completers, with consistently better responses in MRC score, exercise performance, physical activity level and health status (all p<0.001). After rehabilitation, 71/115 (61.3%) previously frail patients no longer met case criteria for frailty.

          Conclusions

          Frailty affects one in four patients with COPD referred for pulmonary rehabilitation and is an independent predictor of programme non-completion. However, patients who are frail respond favourably to rehabilitation and their frailty can be reversed in the short term.

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          Most cited references21

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          Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living.

          S. Katz (1983)
          The aging of the population of the United States and a concern for the well-being of older people have hastened the emergence of measures of functional health. Among these, measures of basic activities of daily living, mobility, and instrumental activities of daily living have been particularly useful and are now widely available. Many are defined in similar terms and are built into available comprehensive instruments. Although studies of reliability and validity continue to be needed, especially of predictive validity, there is documented evidence that these measures of self-maintaining function can be reliably used in clinical evaluations as well as in program evaluations and in planning. Current scientific evidence indicates that evaluation by these measures helps to identify problems that require treatment or care. Such evaluation also produces useful information about prognosis and is important in monitoring the health and illness of elderly people.
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            Estimation of skeletal muscle mass by bioelectrical impedance analysis.

            The purpose of this study was to develop and cross-validate predictive equations for estimating skeletal muscle (SM) mass using bioelectrical impedance analysis (BIA). Whole body SM mass, determined by magnetic resonance imaging, was compared with BIA measurements in a multiethnic sample of 388 men and women, aged 18-86 yr, at two different laboratories. Within each laboratory, equations for predicting SM mass from BIA measurements were derived using the data of the Caucasian subjects. These equations were then applied to the Caucasian subjects from the other laboratory to cross-validate the BIA method. Because the equations cross-validated (i.e., were not different), the data from both laboratories were pooled to generate the final regression equation SM mass (kg) = [(Ht 2 / R x 0.401) + (gender x 3.825) + (age x -0. 071)] + 5.102 where Ht is height in centimeters; R is BIA resistance in ohms; for gender, men = 1 and women = 0; and age is in years. The r(2) and SE of estimate of the regression equation were 0.86 and 2.7 kg (9%), respectively. The Caucasian-derived equation was applicable to Hispanics and African-Americans, but it underestimated SM mass in Asians. These results suggest that the BIA equation provides valid estimates of SM mass in healthy adults varying in age and adiposity.
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              Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.

              Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronic conditions, frailty, and disability. However, in geriatric medicine, there is a growing consensus that these are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions, including their clinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analyses in selected areas where no current published data exists. Overall, the goal of this article is to provide a basis for distinguishing between these three important clinical conditions in older adults and showing how use of separate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.
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                Author and article information

                Journal
                Thorax
                Thorax
                thoraxjnl
                thorax
                Thorax
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0040-6376
                1468-3296
                November 2016
                13 June 2016
                : 71
                : 11
                : 988-995
                Affiliations
                [1 ]King's College London, Cicely Saunders Institute , London, UK
                [2 ]NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College , London, UK
                [3 ]The Hillingdon Hospital NHS Foundation Trust , Middlesex, UK
                [4 ]Harefield Pulmonary Rehabilitation Unit, Harefield Hospital , Middlesex, UK
                Author notes
                [Correspondence to ]: Dr Matthew Maddocks, King's College London, Cicely Saunders Institute, London SE5 9PJ, UK; matthew.maddocks@ 123456kcl.ac.uk
                Article
                thoraxjnl-2016-208460
                10.1136/thoraxjnl-2016-208460
                5099190
                27293209
                156af76d-71bb-48fc-9018-7ccc85fcd6bc
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

                History
                : 8 February 2016
                : 27 April 2016
                : 6 May 2016
                Funding
                Funded by: National Institute for Health Research, http://dx.doi.org/10.13039/501100000272;
                Award ID: CLARHC North West and South London
                Categories
                1506
                Chronic Obstructive Pulmonary Disease
                Original article
                Custom metadata
                unlocked

                Surgery
                copd epidemiology,exercise,pulmonary rehabilitation
                Surgery
                copd epidemiology, exercise, pulmonary rehabilitation

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