No description available.

No description available.

The typical cardiac surgery patient is increasing in age and level of frailty. Frailty can be defined as an increased vulnerability to stressors due to decreased physiological reserve. Previous investigations have demonstrated the benefit of cardiac rehabilitation (CR) programming on surgical outcomes. However, the link between pre-operative frailty and post-operative CR completion is unclear. The purpose of this study was to determine if pre-operative frailty status impacts CR completion post-operatively. A total of 114 cardiac surgery patients with an average age of 71 years were included in the analysis. CR completers were significantly less frail than CR non-completers at baseline based on the Clinical Frailty Scale (CFS; p=0.01), Modified Fried Criteria (MFC; p=0.0005), Short Physical Performance Battery (SPPB; p=0.007) and the Functional Frailty Index (FFI; p=<0.0001). The change in frailty status from baseline to 1-year post-operatively was not statistically different between CR completers and non-completers; CFS (p=0.90), MFC (p=0.70), SPPB (p=0.06) and FFI (p=0.07). However, the MFC frailty domains of cognitive impairment (p=0.0005) and low physical activity (p=0.04), in addition to the FFI physical domain of frailty (p=0.009), did significantly improve among CR completers when compared to non-completers. CR attendance measured by swipe card access did not correlate with frailty modifications. Collectively, these data suggest that participants deemed to be frail at the pre-operative time point attend and complete CR less frequently than non-frail participants. Furthermore, CR completion does not appear to modify frailty status overall; although, some frailty domains appear to be more sensitive to change than others. / February 2017

Im Rahmen dieser Arbeit wurde ein Frailty-Screening mittels Clinical Frailty Scale (CFS) bei 246 Patienten im Alter ≥70 Jahren in die klinische Routine der Klinik und Poliklinik für Strahlentherapie des Universitätsklinikums Würzburg eingeführt. Die prospektive Erhebung der CFS erfolgte nach entsprechender Schulung innerhalb eines Zeitraums von 6 Monaten im Rahmen des Erstgespräches vor fraktioniert perkutaner Radiatio. In einem sekundären Projektabschnitt wurden innerhalb eines Nachbeobachtungszeitraumes von insgesamt 365 Tagen nach Bestrahlungsbeginn Komplikationen retrospektiv erfasst. Nach entsprechender Mitarbeiterschulung wurde eine erfolgreiche Implementierung des Frailty-Screenings in die klinische Routine erzielt. In der schließenden statistischen Auswertung zeigte sich ein höheres Ausmaß an Frailty prädiktiv für einen komplikationsreichen Therapieverlauf. Dabei wurden akute Toxizität, Therapieabbrüche, stationäre Notaufnahmen, sowie ein Versterben analysiert. Abschließend wurde analysiert, ob sich innerhalb des ECOG Performance Status Subgruppen mittels Frailty identifizieren ließen. Dabei wurde ein besonderes Augenmerk auf das Vorliegen gebrechlicher Patienten innerhalb der Patientengruppen mit verhältnismäßig guter Funktion (ECOG 0 bzw. 1) gelegt. In Zusammenschau der Befunde des PS (ECOG) und CFS zeigten sich innerhalb der ECOG Grad 0 und Grad 1 eine heterogene Aufteilung „fitter“ bis „gebrechlicher" Patienten. Die Ergebnisse dieser Arbeit zeigen, dass ein Frailty-Screening mittels CFS nach entsprechender Schulung im radioonkologischen Alltag umsetzbar ist und in ein Gesamtkonzept eingebettet werden sollte. Aufgrund des prädiktiven Wertes in Bezug auf ein negatives Outcome und dem Vorliegen von Gebrechlichkeit auch bei Patienten mit verhältnismäßig gutem PS (ECOG 0, 1), könnten ältere Patienten von einem zusätzlichen Frailty-Screening profitieren, dies insbesondere im Hinblick auf die zunehmende Inanspruchnahme radioonkologischer Therapien. / In this study, a frailty screening was implemented into the initial clinical outpatient examination at the Department of Radiation Oncology at the University Hospital in Würzburg using the Clinical Frailty Scale (CFS). Within a period of 6 months, 246 patients over the age of 70 were prospectively assessed prior to percutaneous fractionated radiotherapy. Up to 365 days after therapy, complications were retrospectively analyzed. After multiple training sessions, frailty screening was accurate. Statistical analysis indicated that frailty was a predictor of radiotherapy-associated complications, including acute toxicity, treatment interruption, emergency hospital admittance and death. Furthermore, subgroups were displayed within performance status (ECOG) using the CFS and frail patients were identified within those with better performance status (ECOG 0 and ECOG 1). This study succeeded in demonstrating successful implementation of frailty screening after training and underlines the predictive value of using frailty to identify patients with risk higher risk of negative outcome in radiotherapy. As frail patients may be concealed within groups with better performance status, patients may benefit from additional screening, especially when taking the rising age of patients undergoing radiotherapy into account.

PhD Thesis / Background: The home care population is a cohort of medically complex older adults at risk for cardiac arrest and poor post-cardiac arrest health outcomes. Research Question: What is the prognosis of cardiac arrest among patients receiving home care, and what pre-arrest features and geriatric syndromes (e.g., frailty) are prognostic of survival and post-cardiac arrest health? Methods: Following a systematic review and meta-analysis that evaluated the prognostic association between frailty and post-cardiac arrest outcomes, a population-based retrospective cohort was created of adults (≥18 years) who received cardiac arrest care at a hospital in Ontario, Canada, between 2006 and 2018. Patients receiving home care and nursing home residents were identified using the Home Care Dataset and the Continuing Care Reporting System. Arrests were analyzed overall and within distinct sub-groups of in-hospital (IHCA) and out-of-hospital cardiac arrests (OHCA). The primary outcome for this thesis was 30-day survival post-cardiac arrest. Frailty was measured using the Clinical Frailty Scale and a valid frailty index. The odds of survival from cardiac arrest were estimated using multivariable logistic regression. Prognostic models were internally validated using bootstrap resampling (n= 2000). Results: We found high certainty evidence for an association between the Clinical Frailty Scale and death prior to hospital discharge after IHCA (OR = 2.93; 95% CI = 2.43 – 3.53) after adjusting for age as a minimum confounder. Our retrospective cohort contained 86,836 unique adult cardiac arrests, of which 39,610 were OHCA and 47,226 were IHCA. Patients receiving home care represented 10.7% of the cohort and were less likely to survive to hospital discharge (RD = -6.4; 95%CI = -7.4– -5.2) and one-year (RD = -12.8; 95%CI = -14.6 – -10.9) post-cardiac arrest compared to community-dwelling individuals receiving no support in the community. Frail patients receiving home care had worse odds of 30-day survival when measured with the CFS (OR=0.78; 95%CI = 0.61-0.98) and a frailty index (OR=0.89; 95%CI = 0.85-0.95), after adjusting for age, sex, and arrest setting. My prognostic model out-performed the two valid frailty measures and demonstrated fair discriminative accuracy (AUROC = 0.66; 95%CI=0.65-0.65) and good calibration (Slope = 0.95) for group-level prognostication when internally validated among patients receiving home care. Conclusion:Patients receiving home care have a worse absolute risk of death when compared to community-dwelling individuals receiving no community-based support services. Frailty is associated with survival and post-cardiac arrest declines in cognition and function when evaluated in patients receiving home care. The prognostic model developed within my thesis outperformed the ability of frailty to predict 30-day survival and is suitable for group-level prognostication. / Dissertation / Doctor of Philosophy (PhD) / The proportion of older adults receiving home care is growing. The home care population is frail and medically complex, with a greater risk for cardiac arrest. This thesis aims to evaluate the prognosis and prognostic factors influencing survival and other health outcomes, to develop a statistical model that can predict 30-day survival post-cardiac arrest. Findings from my research demonstrate that patients receiving home care have worse survival outcomes post-cardiac arrest compared to well-being older adults living in the community. In my research, frailty was associated with survival and declines in post-cardiac arrest functional independence and cognitive performance among patients receiving home care. Our statistical model performed better than valid frailty measures and had respectable accuracy for group-level prognostication. The home care population is ideally positioned for proactive and shared decision-making about end-of-life care preferences, bearing in mind their receipt of detailed and routine health assessments.

Background Frailty is an aging-associated vulnerability to poor health comes when challenged by physiologic stressors. Frailty is a common problem amongst the elderly and is associated with increased mortality and health care resource utilization. Frailty is common in recipients of cardiac devices. What is not known is whether interventions will improve frailty and if this changes patient outcomes. Methods There are four chapters in this thesis. In chapter 1, a review of the current state of frailty research, methods of measurement, biomarkers, imaging modalities and interventions are presented. In chapter 2, a pilot randomized controlled trial is proposed to determine if a supervised exercise program and nutritional supplement improves physical frailty in cardiac device patients. Chapter 3 presents the results of the pilot study to date. In chapter 4, we discuss the challenges faced during the COVID-19 pandemic with respect to recruitment and conducting the trial and changes to the protocol that could have improved the study and adapted to the current state of research. Results There are two conceptual models of frailty which include the frailty phenotype and frailty index. Frailty instruments are abundant and there is no gold standard measurement. Frailty biomarkers, imaging techniques in their current state are complementary measures and are not yet ready for clinical practice. The DEFINIT P trial is single centre RCT involving 24 cardiac device patients randomized to 12 month supervised exercise program and nutritional supplement. Recruitment was halted due to COVID-19 pandemic. Conclusions Frailty is common in cardiac device recipients. A gold standard frailty instrument is not yet established though efforts are currently underway. The DEFINIT P study is feasible with respect to recruitment and consent targets but whether the adherence target to the exercise intervention and nutritional supplement is achieved remains unknown due to stopping the pilot trial as a result of the COVID 19 pandemic. / Thesis / Master of Science (MSc) / Frailty is a state of vulnerability in elderly that makes them susceptible to large declines in health from minor illnesses. Frail elderly are more likely to be admitted to the hospital, nursing homes and have higher chance of dying. Old age and frailty are not the same. Frailty is common in patients with a pacemakers and defibrillators. The purpose of this study is to test whether a supervised exercise program and a nutritional supplement will help improve frailty. We planned to recruit 24 patients into the randomized control trial and 100 patients in the registry and follow them for a period of one year. We aimed to understand how common is frailty in elderly with pacemakers and defibrillators and what factors contribute to developing frailty.

La dépression et la malnutrition ne sont pas des conditions inévitables du vieillissement et elles représentent des problèmes de santé très importants étant donné leur prévalence élevée et leurs effets néfastes sur les capacités fonctionnelles. Précédemment, aucun travail de recherche ne s'est intéressé à étudier l'effet explicatif de la nutrition dans la relation entre la dépression et la capacité fonctionnelle. Objectifs. 1) Déterminer l'effet du risque nutritionnel (RN) dans la relation entre les symptômes dépressifs (SD) et la capacité fonctionnelle (CF) des personnes âgées. Méthodologie. Les données de base (TI) des 1,793 hommes (48 %) et femmes (52 %) (74,4[plus ou moins]4,1 ans) de la cohorte NuAge ont été utilisées pour les analyses. La CF a été mesurée par le score global de 4 tests de performance physique selon la méthode proposée par Guralnik et coil. (Timed"up & go", vitesse de marche (4 m), levée de chaise (5X), équilibre unipodal). Un résultat [supérieur ou égal à] 11 ou [inférieur ou égal à] 20 à l'Échelle de dépression gériatrique indique la présence de SD et un score [supérieur ou égal à] 3 au Dépistage nutritionnel des aînés (DNA[copyright]), un RN. Des analyses de variance ont été utilisées pour comparer les groupes suivants sur leur CF : saris RN et sans SD, avec RN et sans SD, sans RN et avec SD, avec RN et avec SD. La régression linéaire multivariée a permis de tester l'effet modificateur du RN VII dans la relation SD/CF ainsi que les associations entre le score global de CF et plusieurs variables sociodémographiques et sanitaires. Résultats. Le RN est présent chez 51% des sujets et sa prévalence est plus élevée dans les groupes plus âgés dans les 2 sexes ([rhô][inférieur à]0,001). La prévalence des SD est plus élevée chez les femmes (12,7%) que chez les hommes (7,7%) ([rhô]=0,001) de même que le score de CF (H: 10,59[plus ou moins]3,41; F: 9,25[plus ou moins]3,40; [rhô][inférieur à]0,001). Chez les deux sexes, la meilleure performance a été observée chez les plus jeunes et chez ceux qui rapportaient plus d'activités physiques. Par contre, le score de CF est plus faible dans le groupe avec RN et avec SD (8,86[plus ou moins]3,42) en comparaison avec le groupe sans RN et sans SD (10,55[plus ou moins]3,28) ([rhô]=0,001). L'inclusion du RN dans un modèle comprenant l'âge, le sexe et les SD a montré que le RN a un effet additionnel indépendant sur la CF ([rhô][inférieur à]0,001), lequel persiste après l'ajustement selon la scolarité, le revenu, l'indice de masse corporelle, le fardeau de la maladie et l'activité physisque. Par contre, l'interaction (RN*SD) n'est pas significative indiquant que le RN ne modifie pas la relation entre les SD et le score de CF. Ce dernier modèle explique 34% de la variabilité observée dans le score de la CF. Conclusion. Le risque nutritionnel est associé, de façon indépendante, à une capacité fonctionnelle réduite, mais ne modifie pas la relation entre cette dernière et les symptômes dépressifs. Étant donné l'importance des capacités fonctionnelles pour le maintien de l'autonomie, le développement de programmes comprenant la prévention du risque nutritionnel est une voie plausible et raisonnable d'intervention. De plus, ces programmes devraient inclure des composantes psychosociales qui auraient le potentiel de soulager les symptômes dépressifs. Malgré leurs limites liées aux analyses transversales, nos résultats proposent des hypothèses pour identifier les personnes âgées les plus à risque de présenter des limites fonctionnelles.

Bakgrund: Forskning om att förebygga och motverka sköra tillstånd hos äldre är mer aktuellt idag än någonsin då befolkningsmängden i världen stiger och andelen äldre ökar. Frailty är den internationella benämningen på skörhet, som också används som diagnos. För att vara frail skall individen uppfylla två eller fler definierade kriterier. Dessa är ofrivillig viktminskning av cirka fem kilo eller mer under det senaste året, självupplevd utmattning, nedsatt greppstyrka, långsam gång samt låg fysisk aktivitet. Det är allmänt vedertaget att frailty ökar, att det är vanligare hos äldre med kroniska sjukdomar och vanligare bland kvinnor än bland män. Undernäring och sarkopeni kan vara en orsak till frailty. Både undernäring och sarkopeni kan motverkas och frailty bör därför kunna förebyggas och behandlas. Syfte: Syftet är att sammanställa litteratur om att behandla frailty med nutrition och fysisk aktivitet. Metod: Studiens design är en systematisk litteraturstudie med 13 kvantitativa RCT-studier.   Resultat: Resultatet indikerar att behandling med nutrition respektive fysisk aktivitet minskar frailty. Kombinerad individuellt anpassad, teambaserad behandling med personlig feedback ger bäst effekt.   Slutsats: Behandling med nutrition och fysisk aktivitet kan motverka frailty.   Nyckelord: Frailty, physical activity, nutrition

Although poor walking is the most common symptom of peripheral artery disease (PAD), reported results are inconsistent when comparing gait parameters between PAD patients and healthy controls. This inconsistency may be due to frailty, which is highly prevalent among PAD patients. To address this hypothesis, 41 participants, 17 PAD (74 +/- 8 years) and 24 aged-matched controls (76 +/- 7 years), were recruited. Gait was objectively assessed using validated wearable sensors. Analysis of covariate (ANCOVA) tests were used to compare gait parameters between PAD and non-PAD groups, considering age, gender, and body mass index as covariates, while stratified based on frailty status. According to the Fried frailty index, 47% of PAD and 50% of control participants were non-frail and the rest were classified as pre-frail. Within non-frail participants, gait speed, body sway during walking, stride length, gait cycle time, double-support, knee range of motion, speed variability, mid-swing speed, and gait initiation were significantly different between PAD and control groups (effect size d = 0.75 +/- 0.43). In the pre-frail group, however, most of the gait differences were diminished except for gait initiation and gait variability. Results suggest that gait initiation is the most sensitive parameter for detecting gait impairment in PAD participants when compared to controls, regardless of frailty status (d = 1.30-1.41; p<0.050). The observed interaction effect between frailty and PAD on gait parameters confirms the importance of assessing functionality in addition to age to provide more consistency in detecting motor performance impairments due to PAD.

O objetivo geral deste trabalho foi estudar a prevalência de quedas e fragilidade entre os idosos no ano de 2006, e a incidência de fragilidade no período de 2006 a 2010, tendo quedas como principal variável independente. Para tal objetivo foram utilizados os dados do Estudo SABE (Saúde, Bemestar e Envelhecimento), referentes aos idosos residentes no município de São Paulo em duas coletas (2006 e 2010). A amostra é representativa dos idosos residentes no município de São Paulo realizada por conglomerados com duplo estágio. Para a descrição das amostras em 2006 e 2010 foram realizadas análises bivariadas, cruzando-se as variáveis independentes e com as variáveis desfecho. Como se trata de amostra complexa, o teste para associação foi o de Rao-Scott que toma em conta os pesos amostrais. Os dados foram analisados através da técnica de Análise Multivariada, o que permitiu uma abordagem analítica, considerando o comportamento de cada variável per si e na presença das demais. Foi utilizado o modelo de regressão logística para prevalência de 2006 e os fatores associados à fragilidade. No período 2006-2010, para estudar os desfechos, foi empregado a regressão de Poisson para encontrar a Incidence Rate Ratio, ou seja, os fatores associados à incidência no período 2006- 2010. Neste último caso as categorias de fragilidade Pré-frágil e Frágil foram agrupadas em uma só. As incidências foram comparadas pelo teste de Cox baseado na regressão. Como resultado foi observado que a variável quedas foi significativa nas análises bivariada e na prevalência, mas não na análise de incidência. Na incidência da fragilidade no período de 2006 a 2010 temos associações significativas com as variáveis: idade, alteração da visão, dificuldade para cuidar próprio dinheiro, utilizar transporte e dificuldade para tomar seus remédios. Portanto, concluiu-se que muitas dessas variáveis são modificáveis, ou seja, é possível reabilitar ou adaptar para que o paciente possa ter uma melhor qualidade de vida e diminuir os riscos de fragilidade e/ou quedas. Assim, a importância de criação de grupos multidisciplinares de prevenção e promoção da saúde, além de novas pesquisas envolvendo quedas e fragilidade em idosos para que esses, mesmo frágeis, possam ter uma melhor qualidade de vida. / The objective of this work is to study the prevalence of falls and frailty among the elderly in 2006, and the incidence of frailty in the 2006-2010 period and falls as the main independent variable. For this objective will be used data from the SABE Study (Health, Wellbeing and Aging), relating to elderly people living in São Paulo in two collections (2006 and 2010). The sample is representative of the elderly in São Paulo carried out by conglomerates with dual stage. For a description of the samples in 2006 and 2010 bivariate analyzes will be carried out, crossing the independent variables and the outcome variables. As these are complex sample, the test for association will be the Rao-Scott that takes into account the sampling weight. Data were analyzed by multivariate analysis technique, which enabled an analytical approach, considering the behavior of each variable itself and in the presence of others. Was used the logistic regression model for 2006 prevalence and factors associated with fragility. In the period 2006-2010, to study the outcomes, was used Poisson regression to find the Incidence Rate Ratio, that is, factors associated with the incidence in 2006-2010. In the latter case the categories of Pre-frail and frail were grouped into one. The incidences were compared using Cox regression test based on. As a result it was observed that was significant in the variable falls bivariate analysis and the prevalence, incidence but not in the analysis. The incidence of frailty in the 2006-2010 period have significant association with age, abnormal vision, difficulty to look after their own money, using transport and difficult to take your medication. Therefore, it was concluded that many of these variables are modifiable, or it is possible to rehabilitate or adapt for the patient to get a better quality of life and reduce the risk of frailty and / or falls. Thus, the importance of creating multidisciplinary teams of prevention and health promotion, and new research involving falls and frailty in the elderly so that these, same fragile, can have a better quality of life.