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Frailty begins in the forties

Background: There is little known about pre-frailty attributes or when changes which contribute to frailty might be detectable and amenable to change. This study explores pre-frailty and frailty in independent community-dwelling adults aged 40–75 years.

Methods: Participants were recruited through local council networks, a national bank and one university in Adelaide, Australia. Fried frailty phenotype scores were calculated from measures of unintentional weight loss, exhaustion, low physical activity levels, poor hand grip strength and slow walking speed. Participants were identified as not frail (no phenotypes), pre- frail (one or two phenotypes) or frail (three or more phenotypes). Factor analysis was applied to binary forms of 25 published frailty measures Differences were tested in mean factor scores between the three Fried frailty phenotypes and ROC curves estimated predictive capacity of factors.

Results: Of 656 participants (67% female; mean age 59.9 years, SD 10.6) 59.2% were classified as not frail, 39.0% pre-frail and 1.8% frail. There were no gender or age differences. Seven frailty factors were identified, incorporating all 25 frailty measures. Factors 1 and 7 significantly predicted progression from not-frail to pre-frail (Factor 1 AUC 0.64 (95%CI 0.60–0.68, combined dynamic trunk stability and lower limb functional strength, balance, foot sensation, hearing, lean muscle mass and low BMI; Factor 7 AUC 0.55 (95%CI 0.52–0.59) comprising continence and nutrition. Factors 3 and 4 significantly predicted progression from pre-frail to frail (Factor 3 AUC 0.65 (95% CI 0.59–0.70)), combining living alone, sleep quality, depression and anxiety, and lung function; Factor 4 AUC 0.60 (95%CI 0.54–0.66) comprising perceived exertion on exercise, and falls history.

Conclusions: This research identified pre-frailty and frailty states in people aged in their 40s and 50s. Pre-frailty in body systems performance can be detected by a range of mutable measures, and interventions to prevent progression to frailty could be commenced from the fourth decade of life.

Gordon et al BMC Geriatrics.

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Covid will impact all of our health

Homebound status is associated with poorer physical and mental health, as well as disability in the elderly. We aimed to examine the prevalence and the role of homebound status on mortality in a representative sample of the French non-institutionalized population. This study included 7497 people aged 65 and over who were interviewed in 1999 and 2001 about the consequences of health problems on activities of daily living. Homebound status was defined as staying permanently inside the home, excluding an accident or a temporary illness. The influence of the homebound status on two-year mortality was assessed in a logistic regression model adjusted for the main confounders (age, sex, living as a couple, physical and mental impairments). The prevalence of homebound status was 4.7% (95% CI: 3.9–5.4) in this study. The number of homebound elderly was estimated at 421 000 in France. The prevalence of homebound status increases with age and reaches 33.9% in people aged 95–99 years (95% CI: 13.1–54.6). Compared to non-homebound subjects, homebound elderly were more likely to be female, widower, to live alone and to have had a former low level job. Homebound status was associated with a number of physical and mental impairments. It increased the risk of dying within two years with an adjusted OR 3.45 (95% CI: 2.66–4.46). Homebound status should be considered as an indicator of frailty and used in the identification of old people likely to benefit from preventive interventions.

Herr et al. Homebound status increases death risk within two years in the elderly: Results from a national longitudinal survey

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The art of pitching in medicine

If you are a health professional a lot of what you say will be an attempt to pitch to the patient. I forgot to keep that in mind as I broke the news that Hilda had diabetes. Her husband sat bolt upright next to her looking concerned at the mention of ‘diabetes’. I casually asked:

Me: What do you like to eat?

There was silence.

Me: Do you like bread or potatoes?

Him: Yes! She likes lots of bread and potatoes!

Poor Hilda looked like Christmas was cancelled. I knew then that her devoted husband would make sure she didn’t get to enjoy any of her favorite meals and she looked like she just wanted this meeting to end.

A pitch is successful if your ideas get past the Amygdala and through to the neocortex where the information may then be classified as ‘new and interesting’ enough to warrant a second thought. In Hilda’s case the information would simply elicit a flight or fight reaction. When she got home she would argue bitterly that bread and potatoes were not the source of her trouble and that may be she’d prefer to see another doctor. Meanwhile her diabetes would remain problematic. If we don’t pitch effectively we don’t get the best outcomes. For people with coughs and colds we pitch for time, knowing that the symptoms (though horrible) will get completely better. For those like Hilda with a long term illness we pitch for them to make different choices and for those with a life limiting illness we might pitch for surgery and other invasive treatments.

I don’t remember being taught how to ‘pitch’ during my training decades ago. It is often assumed that simply giving people ‘information’ does the trick. But of course our words, when they don’t penetrate to the neocortex, are relayed and potentially reframed by family and friends, or dissected with reference to Dr. Google. That means we fall short repeatedly unless we consider what we say and how we say it in similar circumstances.

Hilda needs her bread and potatoes- I was determined that we would come to a shared understanding of her problem and that the ban would be lifted sometimes. Fortunately in primary care there is that option in most cases. It might also be worth learning the art of pitching from others who do it for a living in three minutes.

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