Mortality Risk Along the Frailty Spectrum: Data from the National Health and Nutrition Examination Survey 1999 to 2004

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d15784630e228">OBJECTIVES</h5> <p id="P1">To determine the relationship between frailty and overall and cardiovascular mortality.</p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d15784630e233">DESIGN</h5> <p id="P2">Longitudinal mortality analysis.</p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d15784630e238">SETTING</h5> <p id="P3">National Health and Nutrition Examination Survey (NHANES) 1999–2004.</p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d15784630e243">PARTICIPANTS</h5> <p id="P4">Community-dwelling older adults aged 60 and older (N = 4,984; mean age 71.1 ± 0.19, 56% female). </p> </div><div class="section"> <a class="named-anchor" id="S5">  </a> <h5 class="section-title" id="d15784630e248">MEASUREMENTS</h5> <p id="P5">We used data from 1999–2004 cross-sectional NHANES and mortality data from the National Death Index, updated through December 2011. An adapted version of Fried’s frailty criteria was used (low body mass index, slow walking speed, weakness, exhaustion, low physical activity). Frailty was defined as persons meeting 3 or more criteria, prefrailty as meeting 1 or 2 criteria, and robust (reference) as not meeting any criteria. The primary outcome was to evaluate the association between frailty and overall and cardiovascular mortality. Cox proportional hazard models were used to evaluate the association between risk of death and frailty category adjusted for age, sex, race, smoking, education, coronary artery disease, heart failure, nonskin cancer, diabetes, and arthritis. </p> </div><div class="section"> <a class="named-anchor" id="S6">  </a> <h5 class="section-title" id="d15784630e253">RESULTS</h5> <p id="P6">Half (50.4%) of participants were classified as robust, 40.3% as prefrail, and 9.2% as frail. Fully adjusted models demonstrated that prefrail (hazard ratio (HR) = 1.64, 95% confidence interval (CI) = 1.45–1.85) and frail (HR = 2.79, 95% CI = 2.35–3.30) participants had a greater risk of death and of cardiovascular death (prefrail: HR = 1.84, 95% CI = 1.45–2.34; frail: HR = 3.39, 95% CI = 2.45–4.70). </p> </div><div class="section"> <a class="named-anchor" id="S7">  </a> <h5 class="section-title" id="d15784630e258">CONCLUSION</h5> <p id="P7">Frailty and prefrailty are associated with increased risk of death. Demonstrating the association between prefrail status and mortality is the first step to identifying potential targets of intervention in future studies. </p> </div>

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Frailty: emergence and consequences in women aged 65 and older in the Women's Health Initiative Observational Study.

Nancy Fugate Woods, Andrea LaCroix, Shelly Gray … (2005)

To define frailty using simple indicators; to identify risk factors for frailty as targets for prevention; and to investigate the predictive validity of this frailty classification for death, hospitalization, hip fracture, and activity of daily living (ADL) disability. Prospective study, the Women's Health Initiative Observational Study. Forty U.S. clinical centers. Forty thousand six hundred fifty-seven women aged 65 to 79 at baseline. Components of frailty included self-reported muscle weakness/impaired walking, exhaustion, low physical activity, and unintended weight loss between baseline and 3 years of follow-up. Death, hip fractures, ADL disability, and hospitalizations were ascertained during an average of 5.9 years of follow-up. Baseline frailty was classified in 16.3% of participants, and incident frailty at 3-years was 14.8%. Older age, chronic conditions, smoking, and depressive symptom score were positively associated with incident frailty, whereas income, moderate alcohol use, living alone, and self-reported health were inversely associated. Being underweight, overweight, or obese all carried significantly higher risk of frailty than normal weight. Baseline frailty independently predicted risk of death (hazard ratio (HR)=1.71, 95% confidence interval (CI)=1.48-1.97), hip fracture (HR=1.57, 95% CI=1.11-2.20), ADL disability (odds ratio (OR)=3.15, 95% CI=2.47-4.02), and hospitalizations (OR=1.95, 95% CI=1.72-2.22) after adjustment for demographic characteristics, health behaviors, disability, and comorbid conditions. These results support the robustness of the concept of frailty as a geriatric syndrome that predicts several poor outcomes in older women. Underweight, obesity, smoking, and depressive symptoms are strongly associated with the development of frailty and represent important targets for prevention.

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Decline in Cardiovascular Mortality: Possible Causes and Implications.

George Mensah, Gina Wei, Paul Sorlie … (2017)

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

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Frailty in older men: prevalence, progression, and relationship with mortality.

, Thuy-Tien Dam, P. Cawthon … (2007)

To describe the association between frailty and health status, the progression of frailty, and the relationship between frailty and mortality in older men. Cross-sectional and prospective cohort study. Six U.S. clinical centers. Five thousand nine hundred ninety-three community-dwelling men aged 65 and older. Frailty was defined as three or more of the following: sarcopenia (low appendicular skeletal mass adjusted for height and body fat), weakness (grip strength), self-reported exhaustion, low activity level, and slow walking speed. Prefrail men met one or two criteria; robust men had none. Follow-up averaged 4.7 years. At baseline, 240 subjects (4.0%) were frail, 2,395 (40.0%) were prefrail, and 3,358 were robust (56.0%). Frail men were less healthy in most measures of self-reported health than prefrail or robust men. Frailty was somewhat more common in African Americans (6.6%) and Asians (5.8%) than Caucasians (3.8%). At the second visit, men who were frail at baseline tended to remain frail (24.2%) or die (37.1%) or were unable to complete the follow-up visit (26.2%); robust men tended to remain robust (54.4%). Frail men were approximately twice as likely to die as robust men (multivariate hazard ratio (MHR)=2.05, 95% confidence interval (CI)=1.55-2.72). Mortality risk for frail men was greater in all weight categories than for nonfrail men but was highest for normal-weight frail men (MHR=2.39, 95% CI=1.51-3.79, P for interaction=.01). The relationship between frailty and mortality was somewhat stronger in younger men than older men (P for interaction=.01). Frailty in older men is associated with poorer health and a greater risk of mortality.