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Measuring Frailty A comparison of the frailty phenotype and frailty index for the prediction of all-cause mortality James Nazroo Alan Marshall, Kris Mekli and Neil Pendleton neil.pendleton@manchester.ac.uk
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Background Specific definitions and models of frailty are contested Broad agreement that frailty is a non-specific state reflecting age-related declines in multiple systems, which lead to adverse outcomes (mortality, hospitalisation) Two common approaches to characterise frailty: Frailty index (Rockwood and colleagues) Frailty phenotype (Fried and colleagues) Compare the two approaches and, in particular, their success in predicting all cause mortality And how well do they perform compared with other markers of risk?
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The English Longitudinal Study of Ageing (www.ifs.org.uk/elsa) A panel study of people aged 50 and older, recently finished our sixth wave of data collection, with additional wave 0 data available Sample at wave 1 (2002) was approximately 11,400 people born before 1 st March 1952 who were in the private household sector. Drawn from Health Survey for England (wave 0). Face to face interview every two years since 2002, with a biomedical assessment carried out by a nurse every four years. Those incapable of doing the interview have a proxy interview. End of life interviews are carried out with the partners or carers of people who died after wave 1. Detailed content on: demographics, health, performance, biomarkers, wellbeing, economics, housing, employment, social relationships, social civic and cultural participation, life history. Sister study to HRS, SHARE, KLOSA, CHARLS, etc.
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Frailty Index (FI) Based on accumulation of ‘deficits’ (from 30 items) Activities of Daily Living Cognitive function Chronic diseases CVD Depression/mental health Poor eyesight/hearing Falls, fractures and joint replacements 0-1 scale for each component Calculate the proportion of deficits held (so 0-1 scale) Can be divided into three categories Robust (0-0.12) Pre-frail (0.13-0.21) Frail (>0.21)
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Frailty Phenotype (FP): Fried et al. 2001 Aim: to establish a standardized definition of frailty 5 items: Sarcopenia: unintentional weight loss, > 8% bodyweight Exhaustion: had both ‘everything they did was an effort’ and ‘could not get going much of the time’, during the past week Low physical activity: no work and no other physical activities Slowness: timed walk in the slowest 20% of population Weakness: grip strength in the weakest 20% of population Outcome Robust phenotype: positive for 0 item Pre-frail phenotype: positive for 1-2 items Frail phenotype: positive for 3-5 items
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Analysis Those aged sixty or older (walking speed) Cumulative distribution of Frailty Index score for each Frailty Phenotype category (‘robust’, ‘pre-frail’ and ‘frail’) Kaplan-Meier survival plots Cox proportional hazard models Test association between Frailty Index and Frailty Phenotype (at wave 2) and all cause mortality Unadjusted model and then adjusted for demographics and then key risk factors (education, wealth, bmi, smoking) Compare goodness of fit of models, and compare fit with models using self-assessed health and wealth
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0.21 used as a cut-off for dichotomous frailty variable 30% frail in wave 1 Frailty index: distribution (wave 1)
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Descriptives P value compares the survived and died groups (t-test and chi squared test)
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Males Cumulative distribution Females Frailty index Frail Pre-frail Robust Frail Pre-frail Robust Frailty Index cumulative distribution by Frailty Phenotype
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Kaplan-Meier survival estimates - Males Blue = Robust group. Red = Pre-frail group. Green = Frail group Frailty IndexFrailty Phenotype
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Kaplan-Meier survival estimates - females Blue = Robust group. Red = Pre-frail group. Green = Frail group Frailty IndexFrailty Phenotype
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Cox survival model - results Model 1 controls for age and sex. Model 2 controls for age, sex, education, wealth, smoking, couple
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Cox survival model: Health and wealth Model 1 controls for age and sex. Model 2 controls for age, sex, education, (wealth), smoking, couple
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Conclusions Prediction of mortality over an eight year period for older people (aged 60+) living in the community: Comparable results for Frailty Index and Frailty Phenotype Comparable results for self-assessed health and wealth Choice of measure might reflect the particular setting Frailty Phenotype advantageous in clinical setting: detailed longitudinal ‘diagnostic’ measure Frailty index useful in community environment: checklist approach
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