Frailty can be broadly defined as the vulnerable health status that occurs in older adults. With the ageing population understanding frailty is becoming an increasingly important issue. While no consensus exists on the exact definition of frailty, two models have become prominent in geriatric research. These are the frailty phenotype, a model that measures frailty according to the syndromic aggregation of 5 physical criteria and the frailty index (FI), a broad index of age related health deficits. While recent years have seen a substantial increase in research into frailty, there remains a relative paucity of data from European studies and studies in men. Of the many mechanisms suggested to contribute to frailty there has been particular interest in the role of declining levels of anabolic hormones, partly because replacement of these hormones represents a potential strategy for managing this condition. The broad aim of this thesis was to explore the condition of frailty and its relationship to anabolic hormones, particularly testosterone (T) in ageing European Men. This project involved analysis of data from 2 studies: The European Male Ageing Study (EMAS), a longitudinal cohort study of 3369 men from 8 European centres and a trial of T treatment in 262 men with low testosterone and symptoms of frailty. A set of phenotypic frailty criteria were developed for use in the EMAS, using this model the prevalence of frailty was 2.6%. This increased with age from 0.1% in men aged 40-49 up to 6.7% in men aged 70-79. This model was compared against an FI, the correlation between the two models was moderate, r=0.41, and both models were related to incident falling at 2 year follow up; Ordinal OR (95% CI), 3.15 (1.75 to 5.66) for the frailty phenotype and 5.28 (3.35 to 8.32) for the FI in adjusted analyses. In the hormone analyses frailty was related to lower free T according to both models, Ordinal OR (95% CI); 1.19 (1.02 to 1.39) for the phenotype and β-coefficient (95% CI); 0.006 (0.003 to 0.009) for the FI (FI values range from 0-0.7). Free T was particularly related to the sarcopenia criteria OR (95% CI); 1.40 (1.09 to 1.80). Frailty was also related to LH, FSH and SHBG. Deficiency in multiple anabolic hormones was related to frailty, in adjusted analyses each additional deficiency was associated with an RRR (95% CI); 1.71 (1.38 to 2.13) increased risk of phenotypic frailty and a β-coefficient (95% CI); 0.016 (0.012 to 0.02) increase in FI score. The trial analyses focussed on a 6 month post treatment follow up phase. It was found that gains in lean mass and muscle strength were not maintained at 6 months post treatment. The adjusted difference between groups at 6 months post treatment for knee extensor strength was 4.0 (-3.9 to 11.9) Nm compared to 8.1 (-0.2 to 16.5) Nm at the end of treatment, similarly the difference in lean mass declined from 1.2 (0.8 to 1.7) kg at end of treatment to 0.3 (-0.1 to 0.8) kg at 6 months post treatment. In summary, the frailty phenotype was adapted and validated for use in the EMAS study. Analyses using this model and the trial follow up analyses are supportive of an influence of T on lean body mass in ageing men. The other hormone relationships seen suggest frailty may be broadly related to changes in the endocrine system in ageing men. The lack of sustained benefit from T treatment combined with the relationships with multiple endocrine markers suggests more complex management strategies may be required for this condition.

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The Canadian population is aging and issues related to the care of older adults are becoming increasingly common. The practice of general surgery is no stranger to this phenomenon, as older adults are increasingly presenting for surgery. Some 40% of these surgeries occur on a non-elective basis, which is associated with increased morbidity and mortality when compared to elective surgery. However, very little research has been done on prognostic factors for poor post-operative outcomes in older adults presenting for non-elective surgery. Thus, the purpose of this research is three-fold. First, to review the literature on prognostic factors for adverse outcomes in this patient population. Second, to examine prognostic factors associated with mortality in this patient population. Lastly, to examine prognostic factors associated with discharge to institution in this patient population.

Community case management services provide targeted care to patients with long term health conditions (LTCs) and complex needs, at high risk of adverse events such as emergency hospital admissions. However, there is no standardised evidence informed programme for providing such care, including for patient monitoring. The complexity of older patients, those most likely to have multiple LTCs, and who often present with frailty and atypical symptoms, enhance the difficulty of on-going monitoring and targeting of care. There is an established relationship between ageing and LTCs, frailty and muscle strength, and function and service use, suggesting that muscle strength may be a useful aid to monitoring. Whilst muscle strength is a known indicator for future health, it is not known whether monitoring it is feasible or useful as a short term indicator in older people, especially those at high risk of adverse events. Patients are initially identified for case management by predictive modelling and/or clinical judgement, but little is known about the patients who go on to receive such care. The feasibility and usefulness of routine measures of muscle strength to help clinicians provide timely interventions were investigated alongside case management patients’ health, functional and physical status. An initial pilot study in healthy older adults (n=21) investigated four portable measures of strength, grip strength, sniff nasal inspiratory pressure (SNIP), peak inspiratory flow (PIF) and peak expiratory flow (PEF), and confirmed, via the collection of repeated measures at two time points one week apart, the reliability and acceptability of all but SNIP. A follow on feasibility study explored the acceptability and stability of the three successfully piloted measures in case management patients (n=8) and clinicians (n=5) via researcher administered questionnaire, with the reliability and stability of the measures assessed using a variety of statistical tests including intra-class correlation coefficients and Bland-Altman plots, on data collected over a maximum 7 week period. Concurrently measures of physical and functional ability and health were conducted. A third study analysed routine primary and secondary care case management patient data (n=101), allowing the development of a health and demographic profile of patients, including an assessment of frailty. The pilot and feasibility studies confirmed the reliability and acceptability of three portable measures of strength, PIF, PEF and grip strength. The high level of muscle strength stability observed in patients over the short-medium term, despite adverse events, suggested that whilst monitoring muscle strength may be feasible it would not be useful over this time period. Analysis of routine primary and secondary care data, identified case management patients as predominately female, with age skewed towards the older old and experiencing high levels of deprivation. Multiple LTCs were commonly recorded, and a wide variety of conditions noted. Health service use varied greatly, with few patients recording frequent usage. A frailty index suggested that frailty was common, and highlighted the potential for the development of a useful frailty index using routine data to improve the targeting of case management services towards those who are most at risk.

Die Entscheidung für oder gegen eine elektive Versorgung abdomineller Aortenaneurysmen wird häufig anhand des Patientenalters getroffen. In dieser Arbeit soll untersucht werden ob sich die Frailty besser eignet als das alleinige Patientenalter um das postoperative Outcome abzuschätzen. / The decision for or against elective treatment of abdominal aortic aneurysms is often made on the basis of the patient's age. The aim of this thesis is to investigate whether frailty is more suitable than the patient's age alone to estimate the postoperative outcome.

Background: Frailty has an impact on outcomes in the acute care and in the community setting but there is minimal research that examines frailty in the geriatric rehabilitation setting. Purpose: The purpose of this thesis was to answer the question “What is the association between frailty status and rehabilitation outcomes among older adults?” Methods: A systematic review using the Cochrane Handbook’s guidelines and adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was completed. Four databases were searched as well as grey literature. Screening, extraction, and quality assessments were completed by two reviewers. Data synthesis was completed through vote counting. Results: Twelve studies met the inclusion criteria from which data were extracted. There is a negative association between frailty and discharge functional status, functional change, discharge to home, and a positive association between frailty and length of stay. Conclusion: Further research is needed on this topic to replicate these findings through meta-analyses. Frailty needs to be addressed in the geriatric rehabilitation setting to improve the functional status of frail patients and reduce extended stays in rehabilitation and decrease discharges to a new place of residence.

No / From the moment of birth, the human body plays host to a rich diversity of microbes. Body sites such as the skin, the gut and the mouth support communities of microorganisms (collectively known as the microbiome) that are both numerous and diverse. As our understanding of the microbiome advances, it is evident that these microbial populations participate in a multitude of symbiotic associations with us. The disruption of these associations can lead to a range of diseases beyond mere pathogenesis as microbial nutrition, signaling, and immune defense break down. It is known that changes in microbial composition occur as the human host ages and that diet and living conditions influence the microbiome of older individuals. However, the link between the microbiome and frailty is as yet mostly unexplored. Although the microbiome is likely to influence health factors that contribute to frailty, further work is needed to determine whether overall microbial signatures of frailty exist and, if so, what the diagnostic and therapeutic utility of these signatures might be.

A síndrome da fragilidade, definida como a redução da reserva energética e da resistência aos estressores, associada à indicação tardia de alguns procedimentos cirúrgicos, resulta em maior ocorrência de situações de risco para os pacientes cardiopatas, com maior predisposição para o desenvolvimento de complicações pós-operatórias, que estão relacionadas a um aumento nos casos de readmissão hospitalar e tempo prolongado de internação. Com o objetivo de melhorar o manejo pós-operatório e aperfeiçoar nossa avaliação da gravidade, prevenção e estratificação de risco, a fisioterapia pré-operatória utiliza testes funcionais que traduzem a real condição física e pulmonar do paciente, permitindo a identificação de fatores potencialmente de risco. Como forma de avaliar a prevalência de fragilidade na população candidata a cirurgia cardíaca, a associação dos testes funcionais com fragilidade e a morbidade e mortalidade peri e pósoperatória, avaliamos os candidatos à cirurgia cardíaca de acordo com os cinco critérios de propostos por Fried: perda de peso não intencional, sinais de depressão, redução da força de preensão palmar, baixo nível de atividade física e redução da velocidade da marcha, além da capacidade pulmonar (manovacuometria, ventilometria e peak flow), da tolerância ao esforço (TC6) e função cognitiva (MEEM). Após a cirurgia foram coletadas informações com relação ao procedimento cirúrgico e recuperação pós-operatória e então os indivíduos foram divididos em dois grupos: frágeis e não frágeis e subdivididos de acordo com a faixa etária em idosos e não idosos. Foram avaliados 100 indivíduos, sendo 59 valvopatas e 41 coronariopatas; 13% foram considerados não-frágeis, 70% pré-frágeis e 17% frágeis; a pressão inspiratória máxima foi significativamente menor nos indivíduos frágeis (52±21 contra 75±33 nos não-frágeis; p=0,044), assim como a força de preensão palmar (31±11 contra 22±8; p=0,007); 11 pacientes evoluíram com óbito após o procedimento, sendo 7,2% dos não frágeis contra 29,4% dos indivíduos frágeis (p=0,019). A partir dos resultados encontrados podemos concluir que a prevalência de fragilidade nos pacientes candidatos a cirurgia cardíaca foi alta, mesmo entre os indivíduos não considerados idosos e que além disso, os indivíduos frágeis apresentaram menor força de preensão palmar, menor capacidade vital e menores pressões inspiratórias e expiratórias que as observadas em pacientes não-frágeis, bem como maior mortalidade hospitalar. / Frailty syndrome, defined as the reduction of energy reserve and resistance to stressors, associated with late indication of some surgical procedures, results in a higher occurrence of risk situations for the patients with heart disease, with a greater predisposition to the development of postoperative complications, which are related to an increase in cases of hospital readmission and high length of stay. In order to improve postoperative management and our assessment of severity, prevention and risk stratification, preoperative physiotherapy uses functional tests that translate the patient\'s actual physical and pulmonary condition, allowing the identification of potentially risk factors. As a way of evaluating the prevalence of frailty in population for cardiac surgery, the association of functional tests with frailty, and peri and postoperative morbidity and mortality, we evaluated the candidates for cardiac surgery according to five criteria proposed by Fried: loss of weight, depression, low handgrip strength, low level of physical activity and reduction of walking speed, as well as lung capacity (manovacuometry, ventilometry and peak flow), effort tolerance (6MWT) and cognitive function (MMSE). After surgery, information was collected regarding the surgical procedure and postoperative recovery and then, subjects were divided into two groups: fragile and nonfragile and subdivided according to the age group in the elderly and not elderly. We evaluated 100 individuals, being 59 valvopaths and 41 coronary disease; 13% were considered nonfragile, 70% pre-fragile and 17% fragile; the maximum inspiratory pressure was significantly lower in the fragile individuals (52 ± 21 vs 75 ± 33 in non-fragile, p = 0.044), as well as the handgrip strength (31 ± 11 vs. 22 ± 8, p = 0.007); 11 patients died after the procedure (7.2% non-fragile versus 29.4% fragile individuals; p = 0.019). From the results found, we can conclude that the prevalence of frailty in cardiac surgery patients was high, even among individuals not considered elderly, and, in addition, fragile individuals had lower handgrip strength, lower vital capacity and lower inspiratory pressures and expiratory rates than those observed in non-fragile patients, as well as higher in-hospital mortality.

A síndrome da fragilidade, definida como a redução da reserva energética e da resistência aos estressores, associada à indicação tardia de alguns procedimentos cirúrgicos, resulta em maior ocorrência de situações de risco para os pacientes cardiopatas, com maior predisposição para o desenvolvimento de complicações pós-operatórias, que estão relacionadas a um aumento nos casos de readmissão hospitalar e tempo prolongado de internação. Com o objetivo de melhorar o manejo pós-operatório e aperfeiçoar nossa avaliação da gravidade, prevenção e estratificação de risco, a fisioterapia pré-operatória utiliza testes funcionais que traduzem a real condição física e pulmonar do paciente, permitindo a identificação de fatores potencialmente de risco. Como forma de avaliar a prevalência de fragilidade na população candidata a cirurgia cardíaca, a associação dos testes funcionais com fragilidade e a morbidade e mortalidade peri e pósoperatória, avaliamos os candidatos à cirurgia cardíaca de acordo com os cinco critérios de propostos por Fried: perda de peso não intencional, sinais de depressão, redução da força de preensão palmar, baixo nível de atividade física e redução da velocidade da marcha, além da capacidade pulmonar (manovacuometria, ventilometria e peak flow), da tolerância ao esforço (TC6) e função cognitiva (MEEM). Após a cirurgia foram coletadas informações com relação ao procedimento cirúrgico e recuperação pós-operatória e então os indivíduos foram divididos em dois grupos: frágeis e não frágeis e subdivididos de acordo com a faixa etária em idosos e não idosos. Foram avaliados 100 indivíduos, sendo 59 valvopatas e 41 coronariopatas; 13% foram considerados não-frágeis, 70% pré-frágeis e 17% frágeis; a pressão inspiratória máxima foi significativamente menor nos indivíduos frágeis (52±21 contra 75±33 nos não-frágeis; p=0,044), assim como a força de preensão palmar (31±11 contra 22±8; p=0,007); 11 pacientes evoluíram com óbito após o procedimento, sendo 7,2% dos não frágeis contra 29,4% dos indivíduos frágeis (p=0,019). A partir dos resultados encontrados podemos concluir que a prevalência de fragilidade nos pacientes candidatos a cirurgia cardíaca foi alta, mesmo entre os indivíduos não considerados idosos e que além disso, os indivíduos frágeis apresentaram menor força de preensão palmar, menor capacidade vital e menores pressões inspiratórias e expiratórias que as observadas em pacientes não-frágeis, bem como maior mortalidade hospitalar. / Frailty syndrome, defined as the reduction of energy reserve and resistance to stressors, associated with late indication of some surgical procedures, results in a higher occurrence of risk situations for the patients with heart disease, with a greater predisposition to the development of postoperative complications, which are related to an increase in cases of hospital readmission and high length of stay. In order to improve postoperative management and our assessment of severity, prevention and risk stratification, preoperative physiotherapy uses functional tests that translate the patient\'s actual physical and pulmonary condition, allowing the identification of potentially risk factors. As a way of evaluating the prevalence of frailty in population for cardiac surgery, the association of functional tests with frailty, and peri and postoperative morbidity and mortality, we evaluated the candidates for cardiac surgery according to five criteria proposed by Fried: loss of weight, depression, low handgrip strength, low level of physical activity and reduction of walking speed, as well as lung capacity (manovacuometry, ventilometry and peak flow), effort tolerance (6MWT) and cognitive function (MMSE). After surgery, information was collected regarding the surgical procedure and postoperative recovery and then, subjects were divided into two groups: fragile and nonfragile and subdivided according to the age group in the elderly and not elderly. We evaluated 100 individuals, being 59 valvopaths and 41 coronary disease; 13% were considered nonfragile, 70% pre-fragile and 17% fragile; the maximum inspiratory pressure was significantly lower in the fragile individuals (52 ± 21 vs 75 ± 33 in non-fragile, p = 0.044), as well as the handgrip strength (31 ± 11 vs. 22 ± 8, p = 0.007); 11 patients died after the procedure (7.2% non-fragile versus 29.4% fragile individuals; p = 0.019). From the results found, we can conclude that the prevalence of frailty in cardiac surgery patients was high, even among individuals not considered elderly, and, in addition, fragile individuals had lower handgrip strength, lower vital capacity and lower inspiratory pressures and expiratory rates than those observed in non-fragile patients, as well as higher in-hospital mortality.

Background: The exponential growth of the aging population makes research on reversing frailty increasingly important. Objective: To explore the concept of reversing frailty in older adults and identify existing interventions that achieve frailty reversal as an outcome. Methods: We used a five-stage scoping review methodology outlined by Arksey and O’Malley and enhanced by Joanna Briggs, Levac, and colleagues. We critically appraised all eligible studies and synthesized data using descriptive and narrative analyzes. We searched CINAHL, EMBASE, PubMed, and Web of Science. Results: The concept of reversing frailty seems complex, and no standard intervention exists.That notwithstanding, a few types of single- or multi-component intervention characteristics showed effectiveness in reversing frailty. Conclusion: Frailty can be reversed. However, concept analysis is needed to clarify and define reverse frailty. To ensure maximum effectiveness, the identified interventions, ranging from mostly physical activity to a combination of physical activity and nutrition, could be tailored to each individual’s needs.