Review
Association of frailty with survival: A systematic literature review

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Abstract

Frailty is a known risk factor for those aged 65 and over, and its prevalence increases with age. Definitions of frailty vary widely, and prevalence estimates are affected by the way frailty is defined. Systematic reviews have yet to examine the literature on the association between definitions of frailty and mortality.

We examined the definitions and prevalence of frailty and its association with survival in older community-dwelling adults. We conducted a systematic review of observational population-based studies published in English. We calculated pooled prevalence of frailty with a random effects model.

We identified 24 population-based studies that examined frailty in community-dwelling older adults. The pooled prevalence was 14% when frailty was defined as a phenotype exhibiting three or more of the following: weight loss, fatigue/exhaustion, weakness, low physical activity/slowness, and mobility impairment. The pooled prevalence was 24% when frailty was defined by accumulation of deficits indices that included up to 75 diseases and impairments. The prevalence of frailty increased with age and was greater in women and in African Americans. Frailty in older adults was associated with poor survival with a dose–responsive reduction in survival per increasing number of frailty criteria. Taking into account population prevalence and multivariate adjusted relative risks, we estimated that 3–5% of deaths among older adults could be delayed if frailty was prevented.

Frailty is a prevalent and important geriatric syndrome associated with decreased survival. Geriatric assessment of frailty provides clinically important information about functional status and survival of older adults.

Highlights

► 24 population-based studies examining frailty in community-dwelling older adults demonstrated that prevalence was 14% when frailty was defined as a phenotype and 24% when frailty was defined by accumulation of deficits indexes. ► The prevalence of frailty increased with age and was greater in women and in African Americans. ► Frailty was associated with poor survival with a dose–responsive reduction in survival with greater numbers of phenotypic frailty components. ► When population prevalence and multivariate adjusted relative risks were taken into account, we estimated that 3–5% of deaths among older adults could be delayed if frailty was prevented.

Introduction

Frailty—the age-related decline in function and well-being—is a core concept of geriatric medicine (Fried et al., 2009). With increased age comes a higher prevalence of chronic diseases (National Center for Health Statistics, 2007) as well as functional declines across multiple physiologic systems (Fried et al., 2009, Markle-Reid and Browne, 2003). Geriatricians generally define frailty as a clinical syndrome resulting from increased vulnerability and decreased ability to maintain homeostasis (Bortz, 1993, Carlson et al., 1998, Markle-Reid and Browne, 2003). Conceptual definitions of frailty address physical, psychological, and social dimensions (de Vries et al., 2011). Operational definitions of frailty vary and can include nutritional status, physical activity, mobility, energy (Wolf et al., 1996), strength (Dayhoff et al., 1998, Fried et al., 2004, Ory et al., 1993), cognition (Burnside, 1990), mood (McDougall and Balyer, 1998, Tennstedt et al., 1992), and social relations and support (de Vries et al., 2011). Several authors define disability as an important frailty component (Chichin, 1988, Guralnik and Simonsick, 1993, MacAdam et al., 1989, Payette et al., 1999, Reichel, 1989, Winograd et al., 1988, Winograd et al., 1991).

How frailty is defined affects its presumed impact on patient-centered outcomes, including quality of life, institutionalization, and mortality (Avila-Funes et al., 2009, Rockwood et al., 2006, Rockwood et al., 2005). Systematic reviews have yet to examine how definitions of frailty affect its estimated prevalence and association with mortality. We systematically reviewed operational definitions of frailty, identified the prevalence of frailty based on these definitions, and examined the association between frailty and survival.

Section snippets

Literature search

We sought studies from a wide variety of sources, including MEDLINE® via Ovid and PubMed®, the Cochrane Reviews, manual searches of reference lists from systematic reviews and other relevant publications, and the Centers for Disease Control and Prevention website that lists all publications from the Longitudinal Studies of Aging. Search strategies are described elsewhere (Kane et al., 2011).

Eligibility criteria

We included original epidemiologic population-based surveys, cohort studies, systematic reviews, and

Results

We identified 24 population-based studies examining frailty in community-dwelling older adults (Table A.1). The studies enrolled predominantly Caucasian adults aged 65 years and over.

Discussion

The absence of frailty is a significant indicator of successful aging (Fedarko, 2011). However, the lack of consensus on the definition of frailty creates clinical and research challenges (Sternberg et al., 2011). Frailty occurs on a spectrum of severity, and defining the moment that frailty begins is difficult (Xue, 2011). Broad, multi-element frailty definitions are bound to be more inclusive (Rockwood and Mitnitski, 2011, Weiss, 2011, Yao et al., 2011). One key challenge is to develop

Grant support

This project was funded under Contract No. 290-2007-10064 1 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The authors of this report are responsible for its content. Statements in the paper should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. The Agency for Healthcare Research and Quality suggested the initial questions and provided copyright release for

Conflict of interest

The authors have no conflict of interest to disclose.

Acknowledgements

We would like to thank Dorothee Aeppli, Ph.D., for her calculations of life expectancy among populations with increased risk of death; Christopher A. Warlick, M.D., Ph.D., for his recommendation about models to predict mortality in elderly patients; the librarian Judith Stanke, M.A., for her contributions to the literature search; Jing Du, Warren Manyara, M.D., and Molly Moore, for their assistance with the literature search and data abstraction; Jeannine Ouellette for help in writing the

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    This report was commissioned by the U.S. Preventive Services Task Force (USPSTF) as background material to help them understand the role of geriatric syndromes in older adults’ well-being. It was funded by the Agency for Healthcare Research and Quality. The full report, including a detailed description of our methods, is available at http://www.uspreventiveservicestaskforce.org/uspstf11/es87.pdf

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