Ahead of print articles
LETTER TO THE EDITOR: INTERGENERATIONAL CONFLICTS BETWEEN YOUNG AND OLDER ADULTS: MAY THE CINEMA OF PASOLINI HELP US?
H.J. Coelho-Júnior, E. Marzetti
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H.J. Coelho-Júnior ; E. Marzetti ; (2023): Letter to the Editor: Intergenerational Conflicts between Young and Older Adults: May the Cinema of Pasolini Help Us?. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.19
RELATIONSHIP OF FRAILTY, NUTRITIONAL STATUS AND ORAL HEALTH-RELATED QUALITY OF LIFE IN MEXICO CITY NURSING HOME RESIDENTS
M.E. Irigoyen-Camacho, M.C. Velazquez-Alva, M.A. Zepeda-Zepeda, M.F. Cabrer-Rosales, I. Rangel- Castillo, I. Lazarevich, F.R. Barroso-Villafuerte, A. Castaño-Seiquer, J. Flores-Fraile
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BACKGROUND: We aimed to identify the association among nutritional status, Oral Health-Related Quality of Life (OHRQoL) and frailty, and to estimate the mediation effect of these conditions between age and frailty in a group of Mexico City nursing home residents.
METHODS: We conducted a cross-sectional study. Fried’s phenotype criteria, Full Mini Nutritional Assessment, and General Oral Health Assessment Index was applied.
RESULTS: The participants (n = 286) mean age was 82.4 (± 9.2) years. The prevalence of frailty was 58%, and the prevalence of malnutrition and the risk of malnutrition were 22.7% and 59.5%, respectively. A higher risk of frailty was associated with older age (p = 0.015), sex (women) (p = 0.041), poor nutritional status (p <0.001) and compromised OHRQoL (p <0.001). Approximately 40% of the effect of age on frailty was mediated by nutritional status and OHRQoL (p <0.05).
CONCLUSION: A strong association between nutritional status and frailty was observed. Additionally, OHRQoL was associated with frailty. The effect of age on frailty was mediated by OHRQoL and nutritional status. Interventions targeted to improve nutritional status and oral health may contribute to preventing or delaying the onset of frailty.
M.E. Irigoyen-Camacho, ; M.C. Velazquez-Alva ; M.A. Zepeda-Zepeda ; M.F. Cabrer-Rosales ; I. Rangel- Castillo ; I. Lazarevich ; F.R. Barroso-Villafuerte ; A. Castaño-Seiquer ; J. Flores-Fraile (2023): Relationship of Frailty, Nutritional Status and Oral Health-Related Quality of Life in Mexico City Nursing Home Residents. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.29
LETTER TO THE EDITOR: INTERGENERATIONAL CONFLICTS BETWEEN YOUNG AND OLDER ADULTS: MAY THE CINEMA OF PASOLINI HELP US?
H.J. Coelho-Júnior, E. Marzetti
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H.J. Coelho-Júnior ; E. Marzetti ; (2023): Letter to the Editor: Association of Loneliness with Cognitive FunctionsIntergenerational Conflicts between Young and Older Adults: May the Cinema of Pasolini Help Us?. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.19
THE EFFECT OF FRAILTY ON INDEPENDENT LIVING AFTER SURGERY: A POPULATION-BASED RETROSPECTIVE COHORT STUDY
A. Garland, T. Mutter, O. Ekuma, C. Papadimitropolous
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BACKGROUND: Most people value quality of life over mere duration. At least 50% of people are extremely averse to ever living in a nursing home (NH).
OBJECTIVES: Assess whether pre-operative frailty is associated with new, post-operative NH placement.
DESIGN, SETTING: Retrospective, population-based cohort study in the Canadian province of Manitoba, 2000-2017.
PARTICIPANTS: 7408 persons ≥65 years undergoing any of 16 specific, elective, noncardiac surgeries of varying Operative Surgical Stress (OSS).
MEASUREMENTS: The primary outcome was new admission to a NH, or being placed on a waiting list for a NH, within 180 days of index hospital admission, among index hospital survivors. Frailty was assessed from administrative data by the Preoperative Frailty Index (pFI), which ranges 0-1. Other outcomes were 30-day and 90-180 day mortality, and post-hospital medical resource use to 180 days. Analyses used multivariable regression models, adjusted for age, sex, OSS, year of surgery, anesthetic technique, and socioeconomic status. P-values were adjusted for the six outcomes.
RESULTS: Subjects had mean age (±SD) of 74±7 yrs; 61% were male. pFI ranged 0-0.68, with a mean±SD of 0.21±0.09. All six outcomes were significantly associated with greater frailty. Each additional 0.1 unit increase in pFI was associated with a hazard ratio for new NH admission or wait-listing of 3.01 (p<0.0006).
CONCLUSIONS: While our study agrees with prior work indicating that greater frailty is associated with higher probability of post-operative discharge to a NH, it overcomes a number of limitations of all prior work. Strong arguments follow that prospective surgical candidates be evaluated for their degree of frailty, and that their informed consent include discussion of the possibility of survival with loss of independence.
A. Garland ; T. Mutter ; O. Ekuma ; C. Papadimitropolous ; (2023): The Effect of Frailty on Independent Living After Surgery: A Population-Based Retrospective Cohort Study. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.27
GERIATRIC SERVICES HUB – A COLLABORATIVE FRAILTY MANAGEMENT MODEL BETWEEN THE HOSPITAL AND COMMUNITY PROVIDERS
L.F. Tan, J. Teng, Z.J. Chew, A. Choong, L. Hong, R. Aroos, P.V. Menon, J. Sumner, K.C. Goh, S.K. Seetharaman
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Background: Frailty is an important geriatric syndrome especially with ageing populations. Frailty can be managed or even reversed with community-based interventions delivered by a multi-disciplinary team. Innovation is required to find community frailty models that can deliver cost-effective and feasible care to each local context.
Objectives: We share pilot data from our Geriatric Service Hub (GSH) which is a novel frailty care model in Singapore that identifies and manages frailty in the community, supported by a hospital-based multi-disciplinary team.
Methods: We describe in detail our GSH model and its implementation. We performed a retrospective data analysis on patient characteristics, uptake, prevalence of frailty and sarcopenia and referral rates for multi-component interventions.
Results: A total of 152 persons attended between January 2020 to May 2021. Majority (59.9%) were female and mean age was 81.0 ± 7.1 years old. One-fifth (21.1%) of persons live alone. Mean Charlson Co-morbidity Index was 5.2 ± 1.8. Based on the clinical frailty risk scale (CFS), 31.6% were vulnerable, 51.3% were mildly frail and 12.5% were moderately frail. Based on SARC-F screening, 45.3% were identified to be sarcopenic whilst 56.9% had a high concern about falling using the Falls-Efficacy Scale-International. BMD scans were done for 41.4% of participants, of which 58.7% were started on osteoporosis treatment. In terms of referrals to allied health professionals, 87.5% were referred for physiotherapy, 71.1% for occupational therapy and 50.7% to dieticians.
Conclusion: The GSH programme demonstrates a new local model of partnering with community service providers to bring comprehensive population level frailty screening and interventions to pre-frail and frail older adults. Our study found high rates of frailty, sarcopenia and fear of falling in community-dwelling older adults who were not presently known to geriatric care services.
L.F. Tan ; J. Teng ; Z.J. Chew ; A. Choong ; L. Hong ; R. Aroos ; P.V. Menon ; J. Sumner ; K.C. Goh ; S.K. Seetharaman (2023): Geriatric Services Hub – A Collaborative Frailty Management Model between The Hospital and Community Providers. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.23
IMPACT OF COHABITATION DURING CONFINEMENT ON OLDER ADULTS’ NEGATIVE AFFECT: WHAT SPECIFICITY OF LIFE AS A COUPLE?
S. Caillot-Ranjeva, V. Bergua, C. Meillon, H. Amieva
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Background: Social isolation is a risk factor for older adults’ physical and psychological health. The beneficial effect of social connections in times of major health events is undeniable. Nevertheless, it remains unclear whether the positive effect of social support depends on the relationship type.
Objectives: This study aimed to investigate the influence of older adults’ living conditions on the risk of experiencing negative affect during the first lockdown and post-lockdown.
Design: An epidemiological study conducted during the COVID-19 crisis, at the time of the first lockdown, and 2 to 3 months following the lockdown.
Setting: A subset sample of the PACOVID survey, a population-based survey of older adults. Participants: Altogether, 277 participants were included into three groups depending on their living conditions: Group 1 “living alone” (n = 141); Group 2 “living with their spouse” (n = 106); Group 3 “living in cohabitation with relatives” (n = 30). Measurements: Mixed logistic regression analyses were used to study the change in the risk of experiencing negative affects over time according to the living conditions. The presence of negative affects during lockdown was assessed using three items from the 20-item Center for Epidemiologic Studies Depression Scale : «Do you feel sad?»; «Do you feel depressed?; «Do you feel lonely?
Results: Participants living with their relatives or partner were significantly less likely to experience negative affect than those living alone during lockdown. Moreover, over time, only those living with their spouse had this lesser risk compared to those living alone. Conclusions: These findings highlight the protective effect of social support over time and more specifically of that provided by the spouse. Couple functioning ought to be given consideration when studying the impact of health crisis situation on the mental health of older adults.
S. Caillot-Ranjeva ; V. Bergua ; C. Meillon ; H. Amieva ; (2023): Impact of Cohabitation during Confinement on Older Adults’ Negative Affect: What Specificity of Life as a Couple?. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.25
A JUDO-BASED EXERCISE PROGRAM TO REDUCE FALLS AND FRAILTY RISK IN COMMUNITY-DWELLING OLDER ADULTS: A FEASIBILITY STUDY
A.D. Jadczak, M. Verma, M. Headland, G. Tucker, R. Visvanathan
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Objectives: This study aimed to explore the feasibility (including recruitment, safety and adherence) and the effects of a twice weekly supervised Judo-based exercise program over eight weeks on mobility, balance, physical performance, quality of life, fear of falling and physical activity (including by frailty status) in community-dwelling older people aged ≥65 years.
Design: Pre-post study.
Participants: A total of 17 participants (mean age 74.3±6.2; range 66-87 years; 76.5% female).
Intervention: A Judo-based exercise program conducted twice weekly for 60 minutes per session over eight weeks.
Measurements: Pre and post assessments included the Timed Up & Go (TUG); the Berg Balance Scale (BBS); the Short Physical Performance Battery (SPPB); the Short Form Health Survey-36 (SF-36); the Falls Efficiency Scale International (FES-I); and an ActivPal accelerometer to measure participants’ physical activity.
Results: Most participants had low (≤3) Charlson’s Comorbidity Index scores (n=17, 100%), were well nourished (n=16, 94.1%), not sarcopenic (n=16, 94.1%), and not cognitively impaired (n=13, 76.5%), anxious or depressed (n=14, 82.4%). Ten participants (58.8%) were non-frail and seven were pre-frail (41.2%). Significant improvements (p<0.05) were seen for mobility (TUG), balance (BBS) and physical performance (SPPB). Pre-frail participants showed greater improvement in mobility (TUG) than non-frail participants (p=0.020). No changes (p≥0.05) were seen in quality of life, fear of falling, or physical activity. Participants’ adherence (i.e., attending sessions) was high (i.e., ≥81.2%). No serious adverse events or withdrawals were reported.
Conclusion: Findings suggest that the eight week Judo-based exercise program can be delivered safely to older adults aged ≥65 years, including those at-risk of frailty, as long as there is close supervision with individualisation of the program in response to emergent health symptoms and the program is conducted on requisite Judo mats. This Judo-based exercise program is effective in improving physical function with potential to prevent falls and frailty risk.
A.D. Jadczak ; M. Verma ; M. Headland ; G. Tucker ; R. Visvanathan (2023): A Judo-Based Exercise Program to Reduce Falls and Frailty Risk in Community-Dwelling Older Adults: A Feasibility Study. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.17
REDUCED HANDGRIP STRENGTH IS ASSOCIATED WITH 1 YEARMORTALITY IN BRAZILIAN FRAIL NONAGENARIANS AND CENTENARIANS
M.L. Sáez de Asteasu, E.L. Cadore, T. Steffens, E. Blanco-Rambo, T.C. Schneider, M. Izquierdo, C. Pietta-Dias
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The aim of the present study was to investigate the association between handgrip strength and mortality in Brazilian frail nonagenarians and centenarians. Eighty-one oldest old were included (mean age [SD]: 94.2 [3.8] years). Data on strength was assessed by handgrip strength. Mortality rate of the participants was evaluated at 1-year follow-up after the functional assessment. A logistic regression analysis was used to assess differences in categories of handgrip strength between groups regarding the mortality rate. Forty-six participants (56.8%) had reduced handgrip strength. After 1 year, there were 16 deaths. Those older adults with a low handgrip strength had higher prevalence (28.3% vs. 8.6%) and increased risk of mortality than those with preserved handgrip strength (Odds ratio=4.4, confidence interval 95% 1.1, 18.4) (p=0.042). Reduced handgrip strength is associated with higher mortality rate at 1-year follow-up in Brazilian frail nonagenarians and centenarians.
M.L. Sáez de Asteasu ; E.L. Cadore ; T. Steffens ; E. Blanco-Rambo ; T.C. Schneider ; M. Izquierdo ; C. Pietta-Dias ; (2023): Reduced Handgrip Strength Is Associated with 1 Year-Mortality in Brazilian Frail Nonagenarians and Centenarians. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.21
PREOPERATIVE REHABILITATION IS FEASIBLE IN THE WEEKS PRIOR TO SURGERY AND SIGNIFICANTLY IMPROVES FUNCTIONAL PERFORMANCE
D.E. Hall, A. Youk, K. Allsup, K. Kennedy, T.D. Byard, R. Dhupar, D. Chu, A.M. Rahman, M. Wilson, L.P. Cahalin, J. Afilalo, D. Forman
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Background: Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength.
Objectives: Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery.
Design: Single arm clinical trial.
Setting: Veterans Affairs hospital.
Participants: Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30.
Intervention: Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant’s normally scheduled surgery.
Measurements: Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models.
Results: 43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041).
Conclusions: Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.
D.E. Hall ; A. Youk ; K. Allsup ; K. Kennedy ; T.D. Byard ; R. Dhupar ; D. Chu ; A.M. Rahman ; M. Wilson ; L.P. Cahalin ; J. Afilalo ; D. Forman ; (2022): Preoperative Rehabilitation Is Feasible in the Weeks Prior to Surgery and Significantly Improves Functional Performance. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2022.42
JFA N°03 - 2023
PHYSICAL FRAILTY AND COGNITIVE FUNCTION AMONG OLDER CHINESE ADULTS: THE MEDIATING ROLES OF ACTIVITIES OF DAILY LIVING LIMITATIONS AND DEPRESSION
C. Peng, J.A. Burr, Y. Yuan, K.L. Lapane
J Frailty Aging 2023;12(3)156-165Show summaryHide summary
BACKGROUND: Physical frailty and cognitive impairment are prevalent globally, particularly in China, which is experiencing an unprecedented aging of its large population.
OBJECTIVES: Examine the association between physical frailty and the level and rate of change of cognitive function, globally and by domain, among community-dwelling Chinese older adults, and quantify the mediation effects from activities of daily living (ADL) limitations and depressive symptoms.
SETTING: China Health and Retirement Longitudinal Study (2011-2018).
PARTICIPANTS: 5,431 eligible adults aged ≥ 60 years with valid information on physical frailty.
MEASUREMENTS: Physical frailty, cognitive function, ADL limitations, and depressive symptoms were respectively assessed by frailty phenotypes, the Telephone Interview for Cognitive Status (episodic memory, executive function, and orientation), performance in six daily tasks, and the eight-item Center for Epidemiological Studies Depression Scale. Latent growth curve models were used to address the objectives.
RESULTS: Compared to adults who were non-frail, those who were pre-frail (β = −0.06) and frail (β = −0.13) reported significantly worse global cognitive function and episodic memory (pre-frail: β = −0.05; frail: β = −0.14), executive function (pre-frail: β = −0.04, frail: β = −0.10), and orientation (pre-frail: β = −0.06; frail: β = −0.07) at baseline; those who were frail were more likely to experience faster decline in global cognitive function (β = 0.12) and episodic memory (β = 0.08). ADL limitations (β = −0.07) and depressive symptoms (β = −0.14) significantly mediated the association between physical frailty and the level of cognitive function, but not its rate of decline.
CONCLUSIONS: Intervention strategies that help maintain cognitive function may benefit from early screening and assessment of physical frailty. For pre-frail and frail older Chinese adults, programs designed to help improve or maintain activities of daily living and reduce number of depressive symptoms may contribute to better cognitive performance.
C. Peng ; J.A. Burr ; Y. Yuan ; K.L. Lapane ; (2023): Physical Frailty and Cognitive Function among Older Chinese Adults: The Mediating Roles of Activities of Daily Living Limitations and Depression. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.1
LONGITUDINAL MEASUREMENTS OF FGF23, SARCOPENIA, FRAILTY AND FRACTURE IN OLDER COMMUNITY DWELLING WOMEN
L. Egund, T.K. Paulin, H. Ekstubbe, P. Bartosch, L. Malmgren
J Frailty Aging 2023;12(3)166-174Show summaryHide summary
Background: FGF23 has been associated with frailty and functional performance in older individuals, but the association to sarcopenia is unknown.
Objectives: To investigate the association between FGF23, frailty, sarcopenia and fractures in older community dwelling women.
Design: Prospective longitudinal cohort study.
Setting: Malmö, Sweden.
Participants: 995 75-year-old women, followed prospectively for ten years, with re-investigations after five (n=667) and ten (n=324) years.
Measurements: C-terminal levels of FGF23 were measured and a frailty index of ‘deficits in health’ created. Sarcopenia was defined by low muscle mass and strength and “probable sarcopenia” by low muscle mass only. Incident fractures were continuously registered for 10-years. Based on tertiles of FGF23, odds ratio for frailty, sarcopenia and probable sarcopenia was investigated using logistic regression models adjusted for: eGFR, PTH, calcium, vitamin D and phosphate. Fracture-free survival during 10-year follow-up was depicted using Kaplan Meier curves.
Results: While fracture-free survival did not differ between tertiles, women in the highest tertile of FGF23 had lower muscle strength and gait speed, and higher proportion with impaired mobility at baseline. At age 75, these women had higher odds of also being frail (ORadj 1.6 (95% CI 1.1-2.4)) and suffering from probable sarcopenia (ORadj 1.8 (95% CI 1.1-3.1)), but not sarcopenia. At follow-up the association between FGF23 and probable sarcopenia was not evident. While the association with frailty was attenuated at age 80 after adjustment (ORadj 1.6 (95% CI 1.0-2.5)), women in the highest tertile had higher odds of being frail at age 85 (ORadj 3.4 (95% CI 1.7-6.6)).
Conclusions: FGF23 may be a promising clinical marker for muscle strength, functional performance, and frailty in older women, but not for future fragility fractures. Whether FGF23 is also associated with sarcopenia requires further investigation.
L. Egund ; T.K. Paulin ; H. Ekstubbe ; P. Bartosch ; L. Malmgren ; (2023): Longitudinal Measurements of FGF23, Sarcopenia, Frailty and Fracture in Older Community Dwelling Women. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.22
SENSITIVITY, SPECIFICITY, POSITIVE AND NEGATIVE PREDICTIVE VALUES OF A POSTAL MAIL SELF-SCREENING TOOL FOR FRAILTY IN FRENCH OLDER ADULTS
J. Shourick, P. Lucas, N. Tavassoli, M. Rego-Lopes, M.L. Seux, O. Hanon, S. Andrieu, B. Vellas, F. Forette
J Frailty Aging 2023;12(3)175-181Show summaryHide summary
Background: Frailty has emerged as one of the major risk factors of loss of autonomy and it can be reverted through early and appropriate interventions. A wide range of available frailty screening tools are administered, mainly in clinical settings. However, few frailty instruments are self-administered.
OBJECTIVES: The aim of this study was to determine the diagnostic test accuracy of a modified self-administered questionnaire derived from the Study of Osteoporotic Fractures (SOF) index against the Fried frailty phenotype in identifying frailty.
DESIGN: Observational, multicenter, diagnostic test accuracy study.
PARTICIPANTS: Participants aged 70 and over, living at home or in community-dwelling (n=5134) in two centers in France were contacted.
MEASUREMENTS: Participants were mailed self-administered questionnaires derived from the SOF index. Responders who accepted the home evaluation were assessed by trained nurses, blinded to results of the questionnaire, using the Fried frailty phenotype as the reference method.
RESULTS: The questionnaire was sent to 5134 participants, of which 1878 (36.6%) met inclusion criteria and returned the questionnaire. Fried frailty assessments were obtained in 691 (35.4%) participants. A total of 639 subjects had a complete evaluation on both the self-administered questionnaire and the Fried phenotype. Mean age was 78.9 (standard deviation [SD]: 5.95) years and 359 (56.2%) participants were women.
According to the questionnaire, 159 (24.9%) subjects were considered frail, 172 (26.9%) pre-frail, and 308 (48.2) robust. With the home evaluation, Fried frailty phenotype results were respectively, 114 (17.8%), 295 (46.2%) and 230 (36%). The self-administered questionnaire presented a sensitivity of 66.6% (95% CI: 57.2-75.2) and a specificity of 84.2% (95% CI: 80.8-87.2).
CONCLUSIONS: A self-administered questionnaire can be used in elders and represents an opportunity for empowering them in the management of their health in the context of frailty.
J. Shourick ; P. Lucas ; N. Tavassoli ; M. Rego-Lopes ; M.L. Seux ; O. Hanon ; S. Andrieu ; B. Vellas ; F. Forette ; (2023): Sensitivity, Specificity, Positive and Negative Predictive Values of a Postal Mail Self-Screening Tool for Frailty in French Older Adults. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.11
RELATIONSHIPS AMONG GRIP STRENGTH MEASUREMENT, RESPONSE TIME, AND FRAILTY CRITERIA
Y. Suzuki, Y. Matsui, Y. Hirano, I. Kondo, T. Nemoto, M. Tanimoto, H. Arai
J Frailty Aging 2023;12(3)182-188Show summaryHide summary
BACKGROUND: Muscle response in older adults is believed to decrease with maximal muscle strength, although it has not been adequately assessed; further, the relationship between frailty and muscle response remains unexamined.
OBJECTIVES: This study aimed to develop a practical method for measuring muscle response using grip strength in older adults and to clarify the relationship between frailty and grip strength response.
DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional, clinical, observational study. A total of 248 patients (94 men and 154 women, mean age: 78.2 years) who visited the outpatient unit in the Integrated Healthy Aging Clinic of our Hospital for the first time were enrolled.
MEASUREMENTS: Using a grip strength measuring device originally developed by us, we measured grip strength response indices, such as reaction time, time constant, rate of force development (response speed), and maximum grip strength. Grip strength response indices were compared among three groups (robust, pre-frail, and frail) according to the Fried and Kihon checklist assessments for frailty.
RESULTS: Based on Fried’s assessment, marked differences were found between groups not only in maximal grip strength but also in response time and response speed. Based on the Kihon checklist assessment, there was no significant difference in response time; however, a considerable difference in response speed for the left hand was observed. Moreover, according to the Kihon checklist assessment, some cases showed differences in muscle response although not in maximal muscle strength.
CONCLUSIONS: The response speed of grip strength was suggested to decrease with frailty. The results suggest that measurement of grip strength response in both hands is useful to examine the relationship between frailty and grip strength response.
Y. Suzuki ; Y. Matsui ; Y. Hirano ; I. Kondo ; T. Nemoto ; M. Tanimoto ; H. Arai (2023): Relationships among Grip Strength Measurement, Response Time, and Frailty Criteria. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.18
COGNITION IN PEOPLE AGED 80 YEARS AND OLDER: DETERMINANTS AND PREDICTORS OF CHANGE FROM A POPULATION-BASED REPRESENTATIVE STUDY IN GERMANY
A. Ophey, T. Brijoux, A. Conrad, A.-K. Folkerts, S. Zank, E. Kalbe
J Frailty Aging 2023;12(3)189-197Show summaryHide summary
BACKGROUND: The number of people aged 80 years and older (80+) will increase drastically in the upcoming decades. The preservation of cognitive functions will contribute to their quality of life and independence.
OBJECTIVES: To identify determinants of cognition and predictors of change in cognitive performance in the population 80+.
DESIGN: Cross-sectional and longitudinal population-based on the representative NRW80+ survey.
SETTING: Randomly drawn cases of people aged 80+ from the municipal registration offices, including people living in private homes and institutional settings.
PARTICIPANTS: The participants in the cross-sectional sample (N=1503, 65.5%female) were 84.7 years old (95%CI[84.5,85.0]) and had 12.3 years of education (95%CI[12.1,12.4]). The participants in the longitudinal sample (N=840, 62.5%female) were 84.9 years old (95%CI[84.6,85.2]) and had 12.3 years of education (95%CI[12.0,12.5]).
MEASUREMENTS: The cognitive screening DemTect, age, sex, education, and social, physical, and cognitive lifestyle activities, as well as subjective general health status and depressive symptoms, were assessed at baseline and 24-month follow-up.
RESULTS: Younger age, more years of education, and more cognitive lifestyle activities were identified as the most consistent determinants of both better cognitive performance and preservation of cognitive performance for both global cognition as well as the DemTect subtests on memory and executive functions.
CONCLUSIONS: Our findings reveal that commonly investigated determinants of, and change in, cognitive performance are valid for the people 80+ and highlight the importance of cognitive lifestyle activities for cognitive health. The maintenance of cognitive functions is a key aspect of healthy aging in terms of preserving independence in people 80+.
A. Ophey ; T. Brijoux ; A. Conrad ; A.-K. Folkerts ; S. Zank ; E. Kalbe ; (2023): Cognition in People Aged 80 Years and Older: Determinants and Predictors of Change from a Population-Based Representative Study in Germany. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.20
SUBJECTIVE COGNITIVE DECLINE AS A PREDICTOR OF FRAILTY IN OLDER ADULTS: HELLENIC LONGITUDINAL INVESTIGATION OF AGING AND DIET STUDY (HELIAD)
E. Margioti, N. Scarmeas, M. Yannakoulia, E. Dardiotis, G. Hadjigeorgiou, P. Sakka, E. Ntanasi, E. Aretouli, M.H. Kosmidis
J Frailty Aging 2023;12(3)198-207Show summaryHide summary
Background: Subjective cognitive decline (SCD) is a self-evaluation of cognitive impairment, in the absence of observed objective cognitive deficits on a neuropsychological assessment. Frailty refers to a multidimensional syndrome where the individual has poor health including falls, disabilities, hospitalization, and vulnerability. Both terms are associated with cognitive decline and increased incidence of dementia. The present longitudinal study explored whether the detection of SCD can predict the development of frailty over time.
Methods: The Hellenic Longitudinal Investigation of Aging and Diet (HELIAD) is an epidemiological, population-based study. From the original testing sample of 1,984 older Greek individuals (≥65 years old), 1,121 remained in the longitudinal analysis. Participants diagnosed with frailty, Mild Cognitive Impairment (MCI), dementia, severe depression, and anxiety, in the baseline assessment were excluded from the analysis (n=146), resulting in a total sample of 975 participants. The average follow-up interval was 3.1 years (SD=0.84 years). SCD was assessed in the baseline assessment with a series of eighteen questions. The questions regarding SCD were categorized according to cognitive domains. Frailty was assessed according to a phenotypic-physiologic (Fried’s definition) and a multidomain approach (Frailty Index). Univariate and multivariate Cox regression analyses were used for exploring the role of SCD in developing frailty.
Results: The proportion of individuals with frailty according to Fried’s definition was greater compared to the Frailty Index. At follow-up according to Fried’s definition, a greater proportion of cases with frailty was found in those who reported SCD complaints regarding orientation (OD) (HR=3.12 95% CI:1.45-6.73 p<0.004) or in those who reported at least three SCD complaints regarding their memory performance (SMC3) (HR=1.92 95% CI:1.05-3.52 p<0.035) at the baseline assessment. Subjective complaints regarding orientation were predictive of a greater hazard of frailty as defined by the Fried scale (HR=3.12 95% CI:1.45-6.73 p<0.004) and the Frailty Index (HR=3.59 95% CI:1.77-7.25 p<0.001).
Conclusion: Our findings demonstrate that healthy older adults who report SCD complaints regarding orientation or state that they have at least three memory complaints have a higher risk of developing frailty. Additionally, the number of participants with a clinical diagnosis of MCI or dementia, compared to individuals with normal aging, at follow-up was found to be significantly greater in cases with frailty according to both frailty definitions applied (p<0.001). Consequently, it is advisable to use screening questionnaires for SCD covering multiple cognitive domains in clinical practice for identifying and managing frailty, thus, implementing effective interventions to promote healthy aging.
E. Margioti ; N. Scarmeas ; M. Yannakoulia ; E. Dardiotis ; G. Hadjigeorgiou ; P. Sakka ; E. Ntanasi ; E. Aretouli ; M.H. Kosmidis ; (2023): Subjective Cognitive Decline as a predictor of Frailty in older adults: Hellenic Longitudinal Investigation of Aging and Diet study (HELIAD). The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.28
PREDICTING THE READMISSION AND MORTALITY IN OLDER PATIENTS HOSPITALIZED WITH PNEUMONIA WITH PREADMISSION FRAILTY
K. Yamada, K. Iwata, Y. Yoshimura, H. Ota, Y. Oki, Y. Mitani, Y. Oki, Y. Yamada, A. Yamamoto, K. Ono, A. Honda, T. Kitai, R. Tachikawa, N. Kohara, K. Tomii, A. Ishikawa
J Frailty Aging 2023;12(3)208-213Show summaryHide summary
Background: In older people, frailty has been recognized as an important prognostic factor. However, only a few studies have focused on multidimensional frailty as a predictor of mortality and readmission among inpatients with pneumonia.
Objective: The present study aimed to assess the association between preadmission frailty and clinical outcomes after the hospitalization of older patients with pneumonia.
Design: Single-center, retrospective case-control study.
Setting: Acute phase hospital at Kobe, Japan.
Participants: The present study included 654 consecutive older inpatients with pneumonia.
Measurements: Frailty status before admission was assessed using total Kihon Checklist (KCL) score, which has been used as a self-administered questionnaire to assess comprehensive frailty, including physical, social, and cognitive status. The primary outcome was a composited 6-month mortality and readmission after discharge.
Results: In total, 330 patients were analyzed (median age: 79 years, male: 70.4%, median total KCL score: 10 points), of which 68 were readmitted and 10 died within 6 months. After multivariate analysis, total KCL score was associated with a composited 6-month mortality and readmission (adjusted hazard ratio, 1.07; 95% confidence interval, 1.02–1.12; p = 0.006). The cutoff value for total KCL score determined by receiver operating characteristic curve analysis was 15 points (area under the curve = 0.610). The group with a total KCL score ≥ 15 points had significantly higher readmission or mortality rates than the groups with a total KCL score < 15 points (p < 0.001).
Conclusions: Preadmission frailty status in older patients with pneumonia was an independent risk factor for readmission and survival after hospitalization.
K. Yamada ; K. Iwata ; Y. Yoshimura ; H. Ota ; Y. Oki ; Y. Mitani ; Y. Oki ; Y. Yamada ; A. Yamamoto ; K. Ono ; A. Honda ; T. Kitai ; R. Tachikawa ; N. Kohara ; K. Tomii ; A. Ishikawa ; (2022): Predicting the Readmission and Mortality in Older Patients Hospitalized with Pneumonia with Preadmission Frailty. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2022.36
EVALUATING QUALITY-OF-LIFE, LENGTH OF STAY AND COSTEFFECTIVENESS OF A FRONT-DOOR GERIATRICS PROGRAM: AN EXPLORATORY PROOF-OF-CONCEPT STUDY
M.J. Pereira, E. Chong, J.A.D. Molina, S.H.X. Ng, E.F. Goh, B. Zhu, M. Chan, W.S. Lim
J Frailty Aging 2023;12(3)214-220Show summaryHide summary
Background: The Emergency Department Interventions for Frailty (EDIFY) program was developed to deliver early geriatric specialist interventions at the Emergency Department (ED). EDIFY has been successful in reducing acute admissions among older adults.
Objectives: We aimed to examine the effectiveness of EDIFY in improving health-related quality-of-life (HRQOL) and length of stay (LOS), and evaluate EDIFY’s cost-effectiveness.
Design: A quasi-experiment study.
Setting: The ED of a 1700-bed tertiary hospital.
Participants: Patients (≥85 years) pending acute hospital admission and screened by the EDIFY team to be potentially suitable for discharge or transfer to low-acuity care areas.
Intervention: EDIFY versus standard-care.
Measurements: Data on demographics, comorbidities, premorbid function, and frailty status were gathered. HRQOL was measured using EQ-5D-5L over 6 months. We used a crosswalk methodology to compute Singapore-specific index scores from EQ-5D-5L responses and calculated quality-adjusted life-years (QALYs) gained. LOS and bills in Singapore-dollars (SGD) before subsidy from ED attendances (including admissions, if applicable) were obtained. We estimated average programmatic EDIFY cost and performed multiple imputation (MI) for missing data. QALYs gained, LOS and cost were compared. Potential uncertainties were also examined.
Results: Among 100 participants (EDIFY=43; standard-care=57), 61 provided complete data. For complete cases, there were significant QALYs gained at 3-month (coefficient=0.032, p=0.004) and overall (coefficient=0.096, p=0.002) for EDIFY, whilst treatment cost was similar between-groups. For MI, we observed only overall QALYs gained for EDIFY (coefficient=0.102, p=0.001). EDIFY reduced LOS by 17% (Incident risk ratio=0.83, p=0.015). In a deterministic sensitivity analysis, EDIFY’s cost-threshold was SGD$2,500, and main conclusions were consistent in other uncertainty scenarios. Mean bills were: EDIFY=SGD$4562.70; standard-care=SGD$5530.90. EDIFY’s average programmatic cost approximated SGD$469.30.
Conclusions: This exploratory proof-of-concept study found that EDIFY benefits QALYs and LOS, with equivalent cost, and is potentially cost-effective. The program has now been established as standard-care for older adults attending the ED at our center.
M.J. Pereira ; E. Chong ; J.A.D. Molina ; S.H.X. Ng ; E.F. Goh ; B. Zhu ; M. Chan ; W.S. Lim (2022): Evaluating Quality-of-Life, Length of Stay and Cost-Effectiveness of a Front-Door Geriatrics Program: An Exploratory Proof-of-Concept Study. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2022.40
FRAILTY, QUALITY OF LIFE, AND LONELINESS OF AGING IN NATIVE AND DIASPORIC CHINESE ADULTS
S.L. Cheung, W.P. Krijnen, C.P. van der Schans, J.S.M. Hobbelen
J Frailty Aging 2023;12(3)221-230Show summaryHide summary
Background: Global migration has increased in the past century, and aging in a foreign country is relevant to the Chinese diaspora.
Objective: With regard to migration, this study focuses on the places of aging as the context of older Chinese adults. This study aimed to describe the general health and wellbeing of this population with respect to their location.
Design: This study has a cross sectional design.
Setting and participants: Participants were recruited who were “aging in place” from Tianjin, China (199 participants), and “aging out of place” from the Netherlands (134 participants). Data from April to May 2019 in China and November 2018 to March 2019 in the Netherlands were aggregated.
Measurements: frailty, QoL and loneliness were used in both samples.
Results: T-tests and regression analyses demonstrated that social domains of frailty and QoL, as well as loneliness and frailty prevalence characterized the major differences between both places of aging. A correlation analysis and visual correlation network revealed that frailty, quality of life (QoL), and loneliness were more closely related in the aging out of place sample. Social domains of frailty and QoL, as well as the prevalence of loneliness and frailty, characterized the major differences between both places of aging.
Conclusions: The findings indicate that frailty, QoL, and loneliness have a complex relationship, confirming that loneliness is a major detriment to the general wellbeing of older Chinese adults aging out of place. This study examined the places of aging of the larger Chinese population and allows a comprehensive understanding of health and wellbeing. The social components, especially loneliness, among the aging out of place Chinese community should receive more attention practice and clinical wise. On the other hand, frailty as well as its prevention is of more importance for the Chinese community aging in place.
S.L. Cheung ; W.P. Krijnen ; C.P. van der Schans ; J.S.M. Hobbelen ; (2022): Frailty, Quality of Life, and Loneliness of Aging in Native and Diasporic Chinese Adults. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2022.27
CLINICAL CHARACTERISTICS AND MORTALITY OF OLD AND VERY OLD PATIENTS HOSPITALIZED FOR HIP FRACTURE OR ACUTE MEDICAL CONDITIONS
D. Fluck, C.H. Fry, R. Lisk, K. Yeong, J. Robin, T.S. Han
J Frailty Aging 2023;12(3)231-235Show summaryHide summary
Background: There is increasing interest in healthcare quality and economic implications for hip fracture patients of very old age. However, results are limited by access to comparable control groups.
Objectives: We examined healthcare quality measures including mortality and length of stay (LOS) in hospital of adults aged 60-107 years undergoing hip operations, compared to an age-matched group admitted for acute general medical conditions.
Design: Monocentric cross-sectional study.
Setting: Ashford and St Peter’s Hospitals NHS Foundation Trust, Surrey, United Kingdom.
Participants: A total of 3972 consecutive admissions for hip operation from 1st April 2009 to 30th June 2019 (dataset-1) and 6979 for acute general medical conditions from 1st April 2019 to 29th February 2020 (dataset-2). Respective ages, mean (±standard deviation), were 83.5 years (±9.1) and 79.8 years (±9.8).
Measurements: Mortality and LOS were assessed with each group divided into five- year age bands and those ≥95 years.
Results: There were proportionally more (P <0.001) females admitted for hip operations (72.8%) than for acute general medical conditions (53.8%). Amongst patients admitted with general medical conditions, the frequency of the most serious recorded conditions - including congestive heart failure, stroke, and pneumonia - increased with age. Amongst patients undergoing hip operations, 5.7% died in hospital and 29.3% had a LOS ≥3 weeks. Corresponding values for acute general medical conditions were 10.4% and 11.8%. For those undergoing hip operations in all age categories, the risk of death was lower than for acute general medical group: sex-adjusted odds ratios ranged between 0.27 and 0.67, but the risk of LOS ≥3 weeks was greater: odds ratios ranged between 2.46 and 2.95.
Conclusions: Compared to those admitted with acute general medical conditions, patients admitted for hip operations had a lower risk of death, but a longer hospital LOS.
D. Fluck ; C.H. Fry ; R. Lisk ; K. Yeong ; J. Robin ; T.S. Han (2022): Clinical Characteristics and Mortality of Old and Very Old Patients Hospitalized for Hip Fracture or Acute Medical Conditions. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2022.34
REFERENCE STANDARD FOR THE MEASUREMENT OF LOSS OF AUTONOMY AND FUNCTIONAL CAPACITIES IN LONG-TERM CARE FACILITIES
F. Buckinx, E. Peyrusqué, M.J. Kergoat, M. Aubertin-Leheudre
J Frailty Aging 2023;12(3)236-243Show summaryHide summary
The vast majority of people living in long-term care facilities (LTCFs) are octogenarians (i.e., in Québec, 57.4% of the residents are age 85 or older, 26.2% are between age 75 and 84, 10.7% are between age 65 and 74, and 5.7% are below age 65 (1)), who are affected by a great loss of physical or cognitive autonomy due to illnesses and are unable to maintain their independence, safety and mobility at home. For the majority of them, their last living environment will be a LTCF. Moreover, the annual turnover in LTCFs is one-third of all residents (2) while the average length of stay is 823 days (1). Therefore the main challenges for caregivers in LTCFs are the maintenance of functional capacities and preventing patients from becoming bedridden and isolated. Measuring the level of autonomy and functional capacities is therefore a key element in the care of institutionalized people. Several validated tools are available to quantify the degree of dependence and the functional capacities of older people living in long-term care facilities. This narrative review aims to present the characteristics of the specific population living in long-term care facilities and describe the most widely used and validated tools to measure their level of autonomy and functional capacities.
F. Buckinx ; E. Peyrusqué ; M.J. Kergoat ; M. Aubertin-Leheudre ; (2023): Reference Standard for the Measurement of Loss of Autonomy and Functional Capacities in Long-Term Care Facilities. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.4
THE NUMBER OF MEDICATIONS IS ASSOCIATED WITH FRACTURES IN A POPULATION OF DIALYZED OLDER PATIENTS WITH FRAILTY
D. Azzolino, S. Vettoretti, M.M. Poggi, A. Soldati, M. Cesari
J Frailty Aging 2023;12(3)244-246Show summaryHide summary
Older persons with chronic kidney disease (CKD) undergoing hemodialysis represent a growing portion of patients characterized by high vulnerability but still marginally studied. This study aimed at exploring the relationship between the number of prescriptions and fractures in older patients with CKD undergoing hemodialysis. A 24-item Frailty Index (FI) based on sociodemographic, clinical and biological data was computed. Unadjusted and adjusted logistic regression models were performed to test the association of prescribed medications with history of fractures. A total of 107 older patients undergoing hemodialysis (38 [35.5%] women, mean age 79.1 standard deviation, SD=7.7) were included in the study. Mean number of prescribed medications was 9.9 (SD=3.9) and was significantly associated with fractures (OR 1.18, 95% CI 1.06-1.32, p=0.003), even after adjustment for potential confounders (OR 1.16, 95% CI 1.03-1.30, p=0.016). If these results will be confirmed, interventions based on deprescribing will become essential in older persons undergoing hemodialysis.
D. Azzolino ; S. Vettoretti ; M.M. Poggi ; A. Soldati ; M. Cesari (2023): The Number of Medications Is Associated with Fractures in a Population of Dialyzed Older Patients with Frailty. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.5
ASSOCIATION OF BASELINE FRAILTY WITH PATIENT-REPORTED OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS AT 1 YEAR
S.B. Lieber, M. Nahid, M. Rajan, M. Barbhaiya, L. Sammaritano, R.A. Lipschultz, M. Lin, M.C. Reid, L.A. Mandl
J Frailty Aging 2023;12(3)247-251Show summaryHide summary
The relationship of baseline frailty with subsequent patient-reported outcomes in systemic lupus erythematosus (SLE) remains unclear. We assessed these associations in a pilot prospective cohort study. Frailty based on the FRAIL scale and the Fried phenotype and patient-reported outcomes, namely Patient Reported Outcomes Measurement Information System computerized adaptive tests and Valued Life Activities disability, were measured at baseline and 1 year among women aged 18-70 years with SLE enrolled at a single center. Differences in Patient Reported Outcomes Measurement Information System computerized adaptive tests between frail and non-frail participants were evaluated using Wilcoxon rank sum tests, and the association of baseline frailty with self-report disability at 1 year was estimated using linear regression. Of 51 participants, 24% (FRAIL scale) and 16% (Fried phenotype) met criteria for frailty at baseline despite median age of 55.0 and 56.0 years, respectively. Women with (versus without) baseline frailty using either measure had worse 1-year Patient Reported Outcomes Measurement Information System computerized adaptive test scores across multiple domains and greater self-report disability. Baseline frailty was significantly associated with self-report disability at 1 year (FRAIL scale: parameter estimate 0.55, 95% confidence interval (CI) 0.21-0.89, p<0.01; Fried phenotype: parameter estimate 0.61, 95% CI 0.22-1.00, p<0.01), including only slight attenuation after adjustment for SLE cumulative organ damage (FRAIL scale: parameter estimate 0.45, 95% CI 0.09-0.81, p=0.02; Fried phenotype: parameter estimate 0.49, 95% CI 0.09-0.90, p=0.02). These preliminary findings support frailty as an independent risk factor for clinically relevant patient-reported outcomes, including disability onset, among women with SLE.
S.B. Lieber ; M. Nahid ; M. Rajan ; M. Barbhaiya ; L. Sammaritano ; R.A. Lipschultz ; M. Lin ; M.C. Reid ; L.A. Mandl ; (2023): Association of Baseline Frailty with Patient-Reported Outcomes in Systemic Lupus Erythematosus at 1 Year. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.24
ERRATUM TO: EFFECTS OF CURCUMIN C3 COMPLEX® ON PHYSICAL FUNCTION IN MODERATELY FUNCTIONING OLDER ADULTS WITH LOW-GRADE INFLAMMATION – A PILOT TRIAL
R.T. Mankowski, K.T. Sibille, C. Leeuwenburgh, Y. Lin, F.-C. Hsu, P. Qiu, B. Sandesara, S.D. Anton
J Frailty Aging 2023;12(3)252Show summaryHide summary
R.T. Mankowski ; K.T. Sibille1 ; C. Leeuwenburgh ; Y. Lin ; F.-C. Hsu ; P. Qiu ; B. Sandesara ; S.D. Anton ; (2023): Erratum to: Effects of Curcumin C3 Complex® on Physical Function in Moderately Functioning Older Adults with Low-Grade Inflammation – A Pilot Trial. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.26
ERRATUM TO: OPTIMIZING THE AGING BRAIN: THE BEAD STUDY ON THE ETHICS OF DEMENTIA PREVENTION
M. Andreoletti, C. Lazzaroni, N. Petersen, S. Segawa, A. Leibing, S. Schicktanz, A. Blasimme
J Frailty Aging 2023;12(3)253Show summaryHide summary
M. Andreoletti ; C. Lazzaroni ; N. Petersen ; S. Segawa ; A. Leibing ; S. Schicktanz ; A. Blasimme ; (2023): Erratum to: Optimizing the Aging Brain: The BEAD Study on the Ethics of Dementia Prevention. The Journal of Frailty and Aging (JFA). http://dx.doi.org/10.14283/jfa.2023.13