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Background: Survival predictors are not established for cystic fibrosis (CF) patients listed for lung transplantation (LT). Using the deficit accumulation approach, we developed a CF-specific frailty index (FI) to allow risk stratification for adverse waitlist and post-LT outcomes., Methods: We studied adult CF patients listed for LT in the Toronto LT Program (development cohort 2005-2015) and the Swiss LT centres (validation cohort 2008-2017). Comorbidities, treatment, laboratory results and social support at listing were utilized to develop a lung disease severity index (LI deficits, d = 18), a frailty index (FI, d = 66) and a lifestyle/social vulnerability index (LSVI, d = 10). We evaluated associations of the indices with worsening waitlist status, hospital and ICU length of stay, survival and graft failure., Results: We studied 188 (Toronto cohort, 176 [94%] transplanted) and 94 (Swiss cohort, 89 [95%] transplanted) patients. The median waitlist times were 69 and 284 days, respectively. The median follow-up post-transplant was 5.3 and 4.7 years. At listing, 44.7% of patients were frail (FI ≥ 0.25) in the Toronto and 21.3% in the Swiss cohort. The FI was significantly associated with all studied outcomes in the Toronto cohort (FI and post-LT mortality, multivariable HR 1.74 [95%CI:1.24-2.45] per 0.1 point of the FI). In the Swiss cohort, the FI was associated with worsening waitlist status, post-LT mortality and graft failure., Conclusions: In CF patients listed for LT, FI risk stratification was significantly associated with waitlist and post-LT outcomes. Studying frailty in young populations with advanced disease can provide insights on how frailty and deficit accumulation impacts survival., Competing Interests: Disclosure statement The authors have no conflicts of interest to disclose., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation., Objective: To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA., Design: Retrospective cohort study., Participants: Patients ≥ 65 years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail., Main Measures: In-hospital mortality after cardiopulmonary resuscitation., Key Results: Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001)., Conclusions: Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population., (© 2021. Society of General Internal Medicine.)

Background: Parallel to growth of aging and obese populations, the prevalence of metabolic diseases is rising. How body mass index (BMI) relates to frailty and mortality across frailty levels is controversial. We examined the associations of high BMI with frailty and mortality and explored the effects of percent body fat on these associations., Methods: We included 29,937 participants aged ≥50 years from the 2001-2006 National Health and Nutrition Examination Survey (NHANES) cohorts (N=6062; 53.7% females) and from wave 1 (2004) of Survey of Health, Ageing and Retirement in Europe (SHARE) (N=23,875; 54% females). BMI levels were categorized as: normal: 18.5-24.9 kg/m 2 , overweight: 25.0-29.9, obese grade 1: 30.0-34.9, and obese grade 2 or 3: >35.0. A frailty index (FI) was constructed excluding nutrition-related items: 36 items for NHANES and 57 items for SHARE. We categorized the FI using 0.1-point increments: FI ≤ 0.1 (non-frail), 0.1 < FI ≤ 0.2 (very mildly frail), 0.2 < FI ≤ 0.3 (mildly frail), and FI > 0.3 (moderately/severely frail). Percent body fat was measured using DXA for NHANES participants. All-cause mortality data were obtained until 2015 for NHANES and 2017 for SHARE to estimate 10-year mortality risk. All analyses were adjusted for age, sex, educational, marital, employment, and smoking statuses., Results: Mean age of participants was 63.3±10.2 years for NHANES and 65.0±10.0 years for SHARE. In both cohorts, BMI levels ≥25 kg/m 2 were associated with higher frailty, compared to normal BMI. In SHARE, having a BMI level greater than 35 kg/m 2 increased mortality risk in participants with FI≤0.1 (HR 1.31, 95%CI 1.02-1.69). Overweight participants with FI scores >0.3 were at lower risk for mortality compared to normal BMI [NHANES (0.79, 0.64-0.96); SHARE (0.71, 0.63-0.80)]. Higher percent body fat was associated with higher frailty. Percent body fat significantly mediated the relationship between BMI levels and frailty but did not mediate the relationship between BMI levels and mortality risk., Conclusions: Being overweight or obese is associated with higher frailty levels. In this study, we found that being overweight is a protective factor of mortality in moderately/severely frail people and obesity grade 1 may be protective for mortality for people with at least a mild level of frailty. In contrast, obesity grades 2 and 3 may be associated with higher mortality risk in non-frail people. The relationship between BMI and frailty is partially explained by body fat., (© 2022. The Author(s).)

Background: Physical activity (PA) interventions may reduce the burden of frailty and can prevent mobility disability for older adults. We explored whether a 2-year PA intervention would improve frailty trajectory, lead to clinically meaningful frailty changes (CMC), or impact major mobility disability (MMD) across baseline frailty levels., Methods: We analyzed data for 1635 community-dwelling participants who were 70-89 years old (mean baseline age [SD]: 78.9 [5.2] years, 67.2% female) from the Lifestyle Interventions and Independence Study. Participants were randomized to either PA or health education (HE) intervention. A 44-item frailty index (FI) was constructed at baseline and 0.5, 1, 1.5, and 2 years after baseline. CMC was defined as change in FI of ≥0.03. MMD was the inability to complete a 400 m-walk within 15 min without assistance. Mixed-effects models were used to estimate frailty trajectory and CMC. Cox regression models were used to determine whether the effect of PA on the composite of MMD or death differed by baseline FI., Results: Mean FI (SD) at baseline for both the PA and HE groups was 0.18 (0.10). Two years after baseline, mean FIs were 0.23 (0.12) for PA and 0.24 (0.12) for HE. The MMD rates were 30.1% (246/818) and 35.5% (290/817) for PA and HE, respectively. There was no time-by-intervention interaction for frailty trajectory or for CMC. Regarding the composite MMD and death, there was no FI-by-intervention interaction. Simple association analyses revealed that when baseline FI was centered at 0.15 or higher, the PA intervention was associated with lower risk of MMD or death compared to HE (HR [CI] range for FI ≥ 0.15: 0.65-0.81 [0.43-0.67, 0.90-0.98])., Conclusion: Participants in both groups showed similar frailty trajectories and CMC. Those who were frailer benefitted more from the PA intervention regarding MMD and death and may be a focus of recruitments for future PA program., (© 2022 The American Geriatrics Society.)

Background: No evidence-based recommendations regarding optimal breakfast frequency and timing and type 2 diabetes mellitus (T2DM) exist for older adults because of limited studies., Objectives: We sought to prospectively assess relations between breakfast frequency and timing and T2DM risk among older adults and determine whether these depended on sex or cardiometabolic risk factors., Methods: Weekly breakfast frequency and usual daily breakfast time were assessed by questionnaire at baseline in 3747 older adults (aged ≥ 65 y) from the Cardiovascular Health Study (CHS) who were free of cancer and T2DM and followed for 17.6 y. Multivariable-adjusted hazard ratios (aHRs) with 95% CIs estimated from Cox proportional hazards models were used to quantify associations with T2DM., Results: Most CHS participants (median age: 74 y; IQR: 71-78 y) consumed breakfast daily (85.5%), and 73% had their first daily eating occasion between 07:00 and 09:00, both of which were associated with higher socioeconomic status, factors that are indicative of a healthier lifestyle, and lower levels of cardiometabolic risk indicators at baseline. During follow-up, 547 T2DM cases were documented. No strong evidence was observed linking breakfast frequency and risk of T2DM. Compared with participants whose breakfast timing (first eating occasion of the day) was 07:00-09:00, those who broke fast after 09:00 had an aHR for T2DM of 0.71 (95% CI: 0.51, 0.99). This association was present in participants with impaired fasting glucose at baseline (aHR: 0.61; 95% CI: 0.39, 0.95) but not in those without (aHR: 0.83; 95% CI: 0.50, 1.38). No associations between eating frequency or timing and T2DM were observed within other prespecified subgroups., Conclusions: Eating breakfast daily was not associated with either higher or lower risk of T2DM in this cohort of older adults, whereas a later (after 09:00) daily first eating occasion time was associated with lower T2DM risk in participants with impaired fasting glucose at baseline.This trial was registered at clinicaltrials.gov as NCT00005133., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

The Canadian population is aging. With aging, biological and social changes occur increasing the risk of developing chronic conditions and functional loss leading to frailty. Older adults living with frailty are more vulnerable to minor stressors, take longer to recover from illness, and have difficulty participating in daily activities. The Canadian Frailty Network's (CFN) mission is to improve the lives of older adults living with frailty. In September 2019, CFN launched the Activity & Exercise, Vaccination, Optimization of medications, Interaction & Socialization, and Diet & Nutrition (AVOID) Frailty public health campaign to promote assessing and reducing risk factors leading to the development of frailty. As part of the campaign, CFN held an Enabling Healthy Aging Symposium with 36 stakeholders from across Canada. Stakeholders identified individual and community-level opportunities and challenges for the enablement of healthy aging and frailty mitigation, as part of a focused consultative process. Stakeholders ranked the three most important challenges and opportunities at the individual and community levels for implementing AVOID Frailty recommendations. Concrete actions, further research areas, policy changes, and existing resources/programs to enhance the AVOID Frailty campaign were identified. The results will help inform future priorities and behaviour change strategies for healthy aging in Canada., Competing Interests: CONFLICT OF INTEREST DISCLOSURES Dr. Megan Racey was supported by a Post-Doctoral Fellowship through the Canadian Frailty Network at the time of the Enabling Healthy Aging Symposium. Dr. Emily McDonald is co-owner of MedSafer, a medication deprescribing software. All remaining authors declare no conflicts of interest exist., (© 2022 Author(s). Published by the Canadian Geriatrics Society.)

Background: Frailty can be operationalised using the deficit accumulation approach, which considers health deficits across multiple domains. We aimed to develop, validate and compare three different frailty indices (FI) constructed from self-reported health measures (FI-Self Report), blood-based biomarkers (FI-Blood) and examination-based assessments (FI-Examination)., Methods: Up to 30,027 participants aged 45-85 years from the baseline (2011-2015) comprehensive cohort of the Canadian Longitudinal Study on Aging were included in the analyses. Following standard criteria, three FIs were created: a 48-item FI-Self Report, a 23-item FI-Blood and a 47-item FI-Examination. In addition a 118-item FI-Combined was constructed. Mortality status was ascertained in July 2019., Results: FI-Blood and FI-Examination demonstrated broader distributions than FI-Self Report. FI-Self Report and FI-Blood scores were higher in females, whereas FI-Examination scores were higher in males. All FI scores increased nonlinearly with age and were highest at lower education levels. In sex and age-adjusted models, a 0.01 increase in FI score was associated with a 1.08 [95% confidence interval (CI): 1.07,1.10], 1.05 (1.04,1.06), 1.07 (1.05,1.08) and a 1.13 (1.11,1.16) increased odds of mortality for FI-Self Report, FI-Blood, FI-Examination and FI-Combined, respectively. Inclusion of the three distinct FI types in a single model yielded the best prognostic accuracy and model fit, even compared to the FI-Combined, with all FIs remaining independently associated with mortality., Conclusion: Characteristics of all FIs were largely consistent with previously established FIs. To adequately capture frailty levels and to improve our understanding of the heterogeneity of ageing, FIs should consider multiple types of deficits including self-reported, blood and examination-based measures., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Coronary artery disease (CAD) is a major overlapping challenge in both clinical and public health realms due to high rates of hospitalization and mortality. Despite nutrition being a key risk factor for CAD, little is known about eating timing and frequency in Canadians or their relation to risk of hospitalization and/or mortality from CAD., Methods: Breakfast consumption, between-meal consumption, eating frequency, and established CAD risk factors were assessed at baseline in 13,328 adults free of cancer and CAD from the 2004 Canadian Community Health Survey, Cycle 2.2, Nutrition Focus and were linked to administrative health databases to determine incidence of hospitalization and/or mortality from CAD in the following 9 years. Multivariable-adjusted hazard ratios with 95% confidence intervals estimated from Cox proportional hazards models were computed to test for associations between eating timing/frequency and hospitalization and/or mortality from CAD (n = 746 cases)., Results: Skipping breakfast (12.0% of participants) and engaging in between-meal consumption (90.2%) were common practices, as was eating 4-5 times per day (55.2%). Skipping breakfast, between-meal consumption, and eating more or less than 4-5 times/day were strongly and bi-directionally associated with many sociodemographic, lifestyle, and metabolic risk factors at baseline. No associations were observed between skipping breakfast, between-meal consumption, or eating frequency and risk of hospitalization and/or mortality from CAD., Conclusions: Skipping breakfast, between-meal consumption, and eating frequency were associated with numerous established risk and preventative factors for CAD at baseline but were not directly associated with the risk of hospitalization and/or mortality from CAD in this cohort of Canadian adults., (© 2022 The Authors.)

Age-friendly cities are crucial to achieve the WHO goal of healthy aging. Such cities promote opportunities for health, participation, and security, thus enhancing quality of life as people age. Older people commonly experience psychosocial challenges such as anxiety, depression, substance abuse, loss of autonomy, grief, fear, and loneliness. Australian and Canadian cities continue to seek innovation to improve healthy urban aging and create more age-friendly environments for older adults. There is increasing evidence on the effectiveness and feasibility of mobile technology in health promotion and closing psychological treatment gaps. Older adults have been demonstrated to engage frequently with mobile devices, particularly text messaging. In this article, we conceptualize the Text4HealthyAging, an evidence-based text messaging innovation to support healthy urban aging in Canadian and Australian cities., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: VIOA and EE are board members of the GPEF, a not-for-profit organization involved with the design of Text4HealthyAging program. All other authors declare no conflicting interests., (© The Author(s) 2022.)

Background: physical activity reduces frailty in community-dwelling older adults. How exercise influences frailty in hospitalised older adults requires additional investigation., Objectives: (i) to examine the impact of an exercise intervention on frailty in older adults admitted to an acute care ward, and (ii) to determine the impact of baseline frailty on the effectiveness of this intervention., Setting/participants: this is a secondary analysis of a randomised controlled clinical trial that tested an intensive exercise intervention in ≥75-year-old adults admitted to an acute care ward., Methods: the intervention included two daily sessions of moderate-intensity exercises (control received usual care). A 63-item Frailty Index (FI) was constructed, and three groups were formed: <0.2, 0.2-0.29 and ≥0.3. Other outcomes included Short Physical Performance Battery (SPPB) and Barthel Index (BI)., Results: a total of 323 individuals were included. The mean age was 87.1 years (± 4.8 standard deviation [SD]) and 56.3% were females. The intervention group improved FI from 0.26 (± 0.10 SD) to 0.20 (± 0.10 SD), whereas the control group FI worsened from 0.25 (± 0.1 SD) to 0.27 (± 0.10 SD). After stratifying by baseline FI, SPPB and depression improved in the intervention group across all levels of frailty; FI, BI and quality of life only improved in individuals with a baseline FI ≥ 0.2., Conclusions: frailty improves with an intensive individualised exercise intervention, especially in those with high baseline levels of frailty. In addition, frailty is a useful outcome when examining the impact of an intervention of hospitalised older adults., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The comprehensive geriatric assessment (CGA) is the core tool used by geriatricians across diverse clinical settings to identify vulnerabilities and estimate physiologic reserve in older adults. In this paper, we demonstrate the iterative process at our institution to identify and develop a feasible, acceptable, and sustainable bedside CGA-based frailty index tool (FI-CGA) that not only quantifies and grades frailty but also provides a uniform way to efficiently communicate complex geriatric concepts such as reserve and vulnerability with other teams. We describe our incorporation of the FI-CGA into the electronic health record (EHR) and dissemination among clinical services. We demonstrate that an increasing number of patients have documented FI-CGA in their initial assessment from 2018 to 2020, while additional comanagement services were established (Figure 2). The acceptability and sustainability of the FI-CGA, and its routine use by geriatricians in our division, were demonstrated by a survey where the majority of clinicians report using the FI-CGA when assessing a new patient and that the FI-CGA informs their clinical management. Finally, we demonstrate how we refined and updated the FI-CGA, we provide examples of applications of the FI-CGA across the institution and describe areas of ongoing process improvement and challenges for the use of this tailored yet standardized tool across diverse inpatient and outpatient services. The process outlined can be used by other geriatric departments to introduce and incorporate an FI-CGA., (© 2021 The American Geriatrics Society.)

Background: The relationship between occupational physical activity and frailty is complex and understudied., Objective: We explore whether moderate-vigorous physical activity (MVPA) in retirement and main lifetime occupation physical demands (OPD) are associated with frailty in retirement., Methods: Retired adults aged 50 + who participated in waves 3-4 of the Survey of Health, Ageing and Retirement in Europe were included. We constructed a 65-item frailty index (FI; Wave 4). Linear regressions tested the independent associations between OPD (Wave 3) and retirement MVPA (Wave 4) with FI (B: 95% CI) controlling for occupation characteristics (Wave 3) and demographics (Wave 4). These models were repeated across country groups (Nordic; Mediterranean; Continental) and sexes., Results: We included 8,411 adults (51.1% male) aged 72.4 years (SD 8.0). Frequent MVPA was consistently associated with lower FI (-0.09 : 0.10--0.08, p < .001) while OPD was associated with higher FI (0.02 : 0.01-0.03, p < .001). The MVPA*OPD interaction (-0.02: -0.04--0.00, p = .043) was weakly associated with FI, but did not explain additional model variance or was significant among any country group or sex., Conclusions: For a sample of European community-dwelling retirees, a physically demanding main lifetime occupation independently predicts worse frailty, even in individuals who are physically active in retirement.

Main Problem: Frailty is an established risk factor for cognitive decline and Alzheimer's disease. Few studies have examined the longitudinal relationship between frailty and cognition., Methods: Participants of Rush Memory and Aging project ( n = 625, 67.5% female, 83.2 ± 5.9 years at baseline) underwent annual clinical evaluations (average follow-up 5.6 ± 3.7 years) followed by neuropathologic assessment after death. A frailty index was calculated from 41 health variables at each evaluation. Clinical diagnosis of MCI and/or dementia was ascertained by clinical data review (blinded to neuropathological data) after death. Age, sex, education, and neuropathological burden (10-item index) were evaluated as covariates. Frailty trajectories were calculated using a mixed effects model., Results: At baseline the mean frailty index = 0.24 ± 0.12 and increased at rate of 0.026 or ~1 deficit per year. At death, 27.7% of the sample had MCI, and 38.6% had dementia. Frailty trajectories were significantly steeper among those individuals who were ultimately diagnosed as clinically impaired prior to death, even after controlling for age, sex, education, and neuropathological index., Conclusions: Findings suggest a strong link between health status (frailty index) and dementia, even after considering neuropathology. Frailty trajectories were associated with risk for MCI and dementia, underscoring the importance of addressing frailty to manage dementia risk., Competing Interests: Melissa Andrew reports grants from GSK, Pfizer, and Sanofi unrelated to the current work. David Bennett reports grants from the National Institutes of Health (NIH). Kenneth Rockwood reports personal fees from Lundbeck for attending an advisory board meeting in 2017. Kenneth Rockwood is President and Chief Science Officer of DGI Clinical, which in the last 5 years has contracts with pharma and device manufacturers (Baxter, Baxalta, Shire, Hollister, Nutricia, Roche, Otsuka) on individualized outcome measurement. Otherwise, any personal fees are for invited guest lectures and academic symposia, received directly from event organizers, chiefly for presentations on frailty. He is Associate Director of the Canadian Consortium on Neurodegeneration in Aging, which is funded by the Canadian Institutes of Health Research, and with additional funding from the Alzheimer Society of Canada and several other charities, as well as, in its first phase (2013–2018), from Pfizer Canada and Sanofi Canada. He receives career support from the Dalhousie Medical Research Foundation as the Kathryn Allen Weldon Professor of Alzheimer Research, and research support from the Canadian Institutes of Health Research, the Nova Scotia Health Research Foundation, the Capital Health Research Fund, and the Fountain Family Innovation Fund of the Nova Scotia Health Authority Foundation., (© 2021 The Authors. Aging Medicine published by Beijing Hospital and John Wiley & Sons Australia, Ltd.)

Background: The extent to which the degree of baseline frailty, as measured using standardized multidimensional health assessments before hospital admission, predicts survival among older adults after admission to an ICU remains unclear., Research Question: Is baseline frailty an independent predictor of survival among older adults receiving care in an ICU?, Study Design and Methods: Retrospective cohort study of community-dwelling older adults (age, ≥ 65 years) receiving public home services who were admitted to any ICU in Ontario, Canada, between April 1, 2009, and March 31, 2015. All individuals underwent an interRAI Resident Assessment Instrument-Home Care (RAI-HC) assessment completed within 180 days of ICU admission. These assessments were linked to hospital discharge abstract records. Patients were categorized using frailty measures each calculated from the RAI-HC: a classification tree version of the Clinical Frailty Scale; the Frailty Index-Acute Care; and the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. One-year survival models were used to compare their performance. Patients were stratified based on the receipt of mechanical ventilation in the ICU., Results: Of 24,499 individuals admitted to an ICU within 180 days of a RAI-HC assessment, 26.4% (n = 6,467) received mechanical ventilation. Overall, 43.0% (95% CI, 42.4%-43.6%) survived 365 days after ICU admission. In general, among the overall cohort and both mechanical ventilation subgroups, mortality hazards increased with the severity of baseline frailty. Models predicting survival 30, 90, and 365 days after admission to an ICU that adjusted for one of the frailty measures were more discriminant than reference models that adjusted only for age, sex, major clinical category, and area income quintile., Interpretation: Severity of baseline frailty is independently associated with survival after ICU admission and should be considered when determining goals of care and treatment plans for people with critical illness., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the relative contributions of frailty and neuropathology to dementia expression in a population-based cohort study., Design: Cross-sectional analysis of observational data., Setting: Population-representative clinicopathological cohort study., Participants: Adults aged 75+ recruited from general practice registries in Cambridge, UK, in 1985., Measurements: A 39-item frailty index and 15-item neuropathological index were used to operationalize frailty and neuropathology, respectively. Dementia status was ascertained by clinical consensus at time of death. Relationships were evaluated using logistic regression models in participants with autopsy records (n = 183). Model fit was assessed using change in deviance. Population attributable fraction for frailty was evaluated in relation to dementia incidence in a representative sample of the survey participants (n = 542)., Results: Participants with autopsy were 92.3 ± 4.6 years at time of death, and mostly women (70%). Average frailty index value at last survey before death was 0.34 ± 0.16. People with dementia (63% of the sample) were frailer, had lower MMSE scores, and a higher burden of neuropathology. Frailty and neuropathological burden were significantly and independently associated with dementia status, without interaction; frailty explained an additional 3% of the variance in the model. Assuming a causal relationship and based on population-attributable fraction analyses, preventing severe frailty (Frailty Index ≥ 0.40) could have avoided 14.2% of dementia cases in this population-based cohort., Conclusions: In the very old, frailty contributes to the risk for dementia beyond its relationship with the burden of traditional dementia neuropathologies. Reducing frailty could have important implications for controlling the burden of dementia. Future research on frailty interventions should include dementia risk as a key outcome, public health interventions and policy decisions should consider frailty as a key risk factor for dementia, and biomedical research should focus on elucidating shared mechanisms of frailty and dementia development.

Background: Frailty is a state of increased vulnerability to stressors, and predicts risk of adverse outcomes, such as mortality. Frailty can be defined by a frailty index (FI) using an accumulation of deficits approach. An FI comprised of 20 items derived from our previously studied test-based frailty index (TBFI) and an additional 33 survey-based elements sourced from the standard CGA was developed to evaluate if predictive validity of survival was improved., Methods: One hundred eighty-nine cancer patients during acute hospitalization were consented between September 2018 and May 2019. Frailty scores were calculated, and patients were categorized into four groups: non-frail (0-0.2), mildly frail (0.2-0.3), moderately frail (0.3-0.4), and severely frail (>0.4). Patients were followed for 1-year to assess FI and TBFI prediction of survival. Area under the curve (AUC) statistics from ROC analyses were compared for the FI versus TBFI., Results: Increasing frailty was similarly associated with increased risk of mortality (HR, 4.5 [95% CI, 2.519-8.075] and HR, 4.1 [95%CI, 1.692-9.942]) and the likelihood of death at 6 months was about 11-fold (odds ratio, 10.9 [95% CI, 3.97-33.24]) and 9.73-fold (95% CI, 2.85-38.50) higher for severely frail patients compared to non-frail patients for FI and TBFI, respectively. This association was independent of age and type of cancer. The FI and TBFI were predictive of survival for older and younger cancer patients with no significant differences between models in discriminating survival (FI AUC, 0.747 [95% CI, 0.6772-0.8157] and TBFI AUC, 0.724 [95% CI, 0.6513-0.7957])., Conclusions: The TBFI was predictive of survival, and the addition of an in-person assessment (FI) did not greatly improve predictive validity. Increasing frailty, as measured by a TBFI, resulted in a meaningfully increased risk of mortality and may be well-suited for screening of hospitalized cancer patients., (© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: the Clinical Frailty Scale (CFS) was originally developed to summarise a Comprehensive Geriatric Assessment and yield a care plan. Especially since COVID-19, the CFS is being used widely by health care professionals without training in frailty care as a resource allocation tool and for care rationing. CFS scoring by inexperienced raters might not always reflect expert judgement. For these raters, we developed a new classification tree to assist with routine CFS scoring. Here, we test that tree against clinical scoring., Objective/methods: we examined agreement between the CFS classification tree and CFS scoring by novice raters (clerks/residents), and the CFS classification tree and CFS scoring by experienced raters (geriatricians) in 115 older adults (mean age 78.0 ± 7.3; 47% females) from a single centre., Results: the intraclass correlation coefficient (ICC) for the CFS classification tree was 0.833 (95% CI: 0.768-0.882) when compared with the geriatricians' CFS scoring. In 93%, the classification tree rating was the same or differed by at most one level with the expert geriatrician ratings. The ICC was 0.805 (0.685-0.883) when CFS scores from the classification tree were compared with the clerk/resident scores; 88.5% of the ratings were the same or ±1 level., Conclusions: a classification tree for scoring the CFS can help with reliable scoring by relatively inexperienced raters. Though an incomplete remedy, a classification tree is a useful support to decision-making and could be used to aid routine scoring of the CFS., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Skipping meals is an increasingly common practice to lose weight among North American adults. However, the long-term effect of this practice on incident type 2 diabetes mellitus (T2DM) remains unknown. We assessed whether skipping meals to lose weight is associated with T2DM risk and whether this association is modified by cardiometabolic risk factors., Methods: Skipping meals to lose weight was assessed by questionnaire in 2,288 adults from the 1995 Nova Scotia Health Survey and was linked to administrative health databases to determine T2DM incidence in the following 23 years. Multivariable-adjusted Cox proportional hazards models estimated hazard ratios (aHRs) and 95% confidence intervals (CIs) for T2DM., Results: During follow up, 378 T2DM cases were diagnosed. Compared with participants who did not skip meals to lose weight, those who did (2.2%) had a 125% higher risk of T2DM (aHR, 2.25; 95% CI, 1.31 to 3.86). This association was no longer present after further adjustment for baseline body mass index (BMI) (aHR, 1.66; 95% CI, 0.96 to 2.85). Skipping meals to lose weight was associated with T2DM among participants who were men (n=1,135; aHR, 2.09; 95% CI, 1.09 to 4.02) or had a BMI <30 kg/m 2 (n=1,676; aHR, 2.64, 95% CI, 1.15 to 6.06), elevated cholesterol (n=1,146; aHR, 2.11; 95% CI, 1.06 to 4.22), high blood pressure (n=1,133; aHR, 2.10; 95% CI, 1.10 to 4.01) and restless sleep (n=1,186; aHR, 2.19; 95% CI, 1.13 to 4.25), but not among women, those with a BMI of ≥30 kg/m 2 and those without elevated cholesterol, high blood pressure or restless sleep., Conclusions: Skipping meals to lose weight may be a predictive modifiable risk factor for developing T2DM over time, potentially working in connection with other T2DM risk factors., (Copyright © 2020 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Frailty is an important health issue in an aging population; it is a state of vulnerability that renders the elderly susceptible to adverse health outcomes, including disability, hospitalization, long-term care admission and death. Early frailty stages are recognizable through screening and are reversible with targeted interventions. To date, however, there is no screening tool for use in Malaysia. The English Pictorial Fit-Frail Scale (PFFS) is a visual tool that assesses a person's fitness-frailty level in 14 health domains, with higher scores indicating higher frailty., Objective: The aim was to translate and adapt the English PFFS for use in Malaysian clinical settings., Methods: The original English PFFS underwent forward and backward-translation by two bilingual translators to and from the Malay language. A finalized version, the PFFS-Malay (PFFS-M), was formed after expert reviewers' consensus and was pilot tested with 20 patients, 20 caregivers, 16 healthcare assistants, 17 nurses and 22 doctors. Score agreement between patients and their caregivers and among healthcare professionals were assessed. All participants rated their understanding of the scale using the feasibility survey forms., Results: A total of 95 participants were included. There were high percentages of scoring agreements among all participants on the scale (66.7% to 98.9%). Overall feedback from all respondents were positive and supported the face validity of the PFFS-M., Conclusion: The PFFS-M reflects an accurate translation for the Malaysian population. The scale is usable and feasible and has face validity. Reliability and predictive validity assessments of the PFFS-M are currently underway., (© Academy of Family Physicians of Malaysia.)

Introduction: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches., Methods and Analysis: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation., Ethics and Dissemination: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners., Trial Registration Number: NCT03442426;Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Multistate life tables are used to estimate life expected in three frailty states: frailty free, mild/moderate frailty, severe frailty. Estimates are provided for the combination of education and wealth by age, stratified by sex. Data consider 17,115 cases from the Health and Retirement Study, 2000-2014. Frailty is measured using a 59 item frailty index based on deficit accumulation. Estimates are derived using stochastic population analysis for complex events. Population-based and status-based results are reported. Findings confirm a hypothesis that the combination of higher education and wealth results in longer lives in more favorable degrees of frailty. Also, as hypothesized, wealth generally affords a greater advantage than does education among those with severe frailty at baseline. For instance, high wealth provides a 70-year-old woman with severe frailty at baseline 0.70 more total years and 0.81 more frailty free years then her counterpart with low wealth, compared to gains of 0.39 and 0.54, respectively, for those with high education. Unexpectedly, wealth also has a greater role among those frailty free at baseline. A 70-year-old woman frailty free at baseline with high wealth lives 3.19 more net years and 4.13 more years frailty free than her counterpart with low wealth, while the same comparison for high versus low education indicates advantages of 2.00 total and 1.96 frailty free years. Relative change ratios also indicate more robust results for wealth versus education. In sum, there is evidence that inequality in duration of life in degrees of frailty is socially patterned., Competing Interests: Conflict of interestThrough Dalhousie University, KR has asserted copyright of the Clinical Frailty Scale. It is free for use for education, research and not-for-profit care., (© Springer Nature B.V. 2021.)

Introduction: Frailty is a state of vulnerability characterized by multisystemic physiological decline. The Pictorial Fit Frail Scale (PFFS) is a practical, image-based assessment that may facilitate the assessment of frailty in individuals with inadequate health literacy (HL). Objective: Determine the concurrent validity and feasibility of the PFFS in older Veterans with different levels of HL and cognition. Methods: Cross-sectional study in a geriatric clinic at a Veteran Health Administration (VHA) medical center. Veterans ≥65 years old completed a HL evaluation, PFFS, FRAIL scale and cognitive screening. We assessed the associations between PFFS, FRAIL scale, and VA-Frailty Index (VA-FI), and compared PFFS and FRAIL scale accuracy with a Receiver Operating Characteristic curve, Area Under the Curve (AUC) analysis, using the VA-FI as reference. Results: Eighty-three Veterans, mean age 76.20 ( SD  = 6.02) years, 65.1% Caucasian, 69.9% had inadequate HL, 57.8% were frail and 20.5% had cognitive impairment. All participants completed the 43 PFFS items. There were positive correlations between PFFS and VA-FI, r  = .55 (95% CI: 0.365-0.735, p  < .001), and FRAIL scale, r  = .673 (95% CI: 0.509-0.836, p  < .001). Compared to the VA-FI, the PFFS (AUC = 0.737; 95% CI: 0.629-0.844) and FRAIL scale (AUC = 0.724;95% CI: 0.615-0.824; p  < .001) showed satisfactory diagnostic accuracy. Conclusions: The PFFS is valid and feasible in evaluating frailty in older Veterans with different levels of HL and cognition., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: Beyond intakes of total energy and individual nutrient, eating patterns may influence health, and thereby the risk of adverse outcomes. How different diet measures relate to frailty-a general measure of increased vulnerability to unfavorable health outcomes-and mortality risk, and how this might vary across the life course, is not known. We investigated the associations of five dietary indices (Nutrition Index (NI), the energy-density Dietary Inflammatory Index (E-DII™), Healthy Eating Index-2015 (HEI-2015), Mediterranean Diet Score (MDS), and Dietary Approaches to Stop Hypertension (DASH)) with frailty and mortality., Methods: We included 15,249 participants aged ≥ 20 years from the 2007-2012 cohorts of the National Health and Nutrition Examination Survey (NHANES). The NI combined 31 nutrition-related deficits. The E-DII is a literature-derived dietary index associated with inflammation. The HEI-2015 assesses adherence to the Dietary Guidelines of Americans. The MDS represents adherence to the traditional Mediterranean diet. DASH combines macronutrients and micronutrients to prevent hypertension. Frailty was evaluated using a 36-item frailty index. Mortality status was ascertained up to December 31, 2015., Results: Participants' mean age was 47.2 ± 16.7 years and 51.7% were women. After adjusting for age, sex, race, educational level, marital and employment status, smoking, BMI, and study cohort, higher NI and E-DII scores and lower HEI-2015, MDS, and DASH scores were individually significantly associated with frailty. All dietary scores were significantly associated with 8-year mortality risk after adjusting for basic covariates and frailty: NI (hazard ratio per 0.1 point, 1.15, 95%CI 1.10-1.21), E-DII (per 1 point, 1.05, 1.01-1.08), HEI-2015 (per 10 points, 0.93, 0.89-0.97), MDS (per 1 point, 0.94, 0.90-0.97), and DASH (per 1 point, 0.96, 0.93-0.99). The associations of E-DII, HEI-2015, and MDS scores with 8-year mortality risk persisted after additionally adjusting for NI., Conclusions: NI, E-DII, HEI-2015, MDS, and DASH scores are associated with frailty and 8-year mortality risk in adults across all ages. Nevertheless, their mechanisms and sensitivity to predict health outcomes may differ. Nutrition scores have the potential to include measures of both consumption and laboratory and physical measures of exposure.

The social vulnerability index (SVI) independently predicts mortality and others adverse outcomes across different populations. There is no evidence that the SVI can predict adverse outcomes in individuals living in countries with high social vulnerability such as Latin America. The aim of this study was to analyze the association of the SVI with mortality and disability in Mexican middle-aged and older adults. This is a longitudinal study with a follow-up of 47 months, the Mexican Health and Aging Study, including people over the age of 40 years. A SVI was calculated using 42 items stratified in three categories low (<0.36), medium (0.36-0.47), and high (>0.47) vulnerability. We examined the association of SVI with three-year mortality and incident disability. Cox and logistic regression models were fitted to test these associations. We included 14,217 participants (58.4% women) with a mean age of 63.9 years (±SD 10.1). The mean SVI was of 0.42 (±SD 0.12). Mortality rate at three years was 6% (n = 809) and incident disability was 13.2% (n = 1367). SVI was independently associated with mortality, with a HR of 1.4 (95% CI 1.1-1.8, p < 0.001) for the highest category of the SVI compared to the lowest. Regarding disability, the OR was 1.3 (95% CI 1.1-1.5, p = 0.026) when comparing the highest and the lowest levels of the SVI. The SVI was independently associated with mortality and disability. Our findings support previous evidence on the SVI and builds on how this association persists even in those individuals with underlying contextual social vulnerability.

Background: frailty is a public health priority now that the global population is ageing at a rapid rate. A scientifically sound tool to measure frailty and generate population-based reference values is a starting point., Objective: in this report, our objectives were to operationalize frailty as deficit accumulation using a standard frailty index (FI), describe levels of frailty in Canadians ≥45 years old and provide national normative data., Design: this is a secondary analysis of the Canadian Longitudinal Study on Aging (CLSA) baseline data., Setting/participants: about 51,338 individuals (weighted to represent 13,232,651 Canadians), aged 45-85 years, from the tracking and comprehensive cohorts of CLSA., Methods: after screening all available variables in the pooled dataset, 52 items were selected to construct an FI. Descriptive statistics for the FI and normative data derived from quantile regressions were developed., Results: the average age of the participants was 60.3 years (95% confidence interval [CI]: 60.2-60.5), and 51.5% were female (95% CI: 50.8-52.2). The mean FI score was 0.07 (95% CI: 0.07-0.08) with a standard deviation of 0.06. Frailty was higher among females and with increasing age, and scores >0.2 were present in 4.2% of the sample. National normative data were identified for each year of age for males and females., Conclusions: the standardized frailty tool and the population-based normative frailty values can help inform discussions about frailty, setting a new bar in the field. Such information can be used by clinicians, researchers, stakeholders and the general public to understand frailty, especially its relationship with age and sex., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: frailty is a dynamic condition for which a range of interventions are available. Health state utilities are values that represent the strength of an individual's preference for specific health states, and are used in economic evaluation. This is a topic yet to be examined in detail for frailty. Likewise, little has been reported on minimally important difference (MID), the extent of change in frailty status that individuals consider to be important., Objectives: to examine the relationship between frailty status, for both the frailty phenotype (FP) and frailty index (FI), and utility (preference-based health state), and to determine a MID for both frailty measures., Design and Setting: population-based cohort of community-dwelling Australians., Participant: in total, 874 adults aged ≥65 years (54% female), mean age 74.4 (6.2) years., Measurements: frailty was measured using the FP and FI. Utilities were calculated using the short-form 6D health survey, with Australian and UK weighting applied. MID was calculated cross-sectionally., Results: for both the FP and FI, frailty was significantly statistically associated (P < 0.001) with lower utility in an adjusted analysis using both Australian and UK weighting. Between-person MID for the FP was identified as 0.59 [standard deviation (SD) 0.31] (anchor-based) and 0.59 (distribution-based), whereas for the FI, MID was 0.11 (SD 0.05) (anchor-based) and 0.07 (distribution-based)., Conclusions: frailty is significantly associated with lower preference-based health state utility. Frailty MID can be used to inform design of clinical trials and economic evaluations, as well as providing useful clinical information on frailty differences that patients consider important., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Despite comprehensive multidisciplinary candidacy assessments to determine appropriateness for solid organ transplantation, limitations persist in identifying candidates at risk of adverse outcomes. Frailty measures may help inform candidacy evaluation. Our main objective was to create a solid organ transplant frailty index (FI), using the cumulative deficits model, from data routinely collected during candidacy assessments. Secondary objectives included creating a social vulnerability index (SVI) from assessment data and evaluating associations between the FI and assessment, waitlist, and posttransplant outcomes., Methods: In this retrospective cohort study of solid organ transplant candidates from Toronto General Hospital, cumulative deficits FI and SVI were created from data collected during candidacy evaluations for consecutive kidney, heart, liver, and lung transplant candidates. Regression modeling measured associations between the FI and transplant listing, death or removal from the transplant waitlist, and survival after waitlist placement., Results: For 794 patients, 40 variable FI and 10 variable SVI were created (258 lung, 222 kidney, 201 liver, and 113 heart transplant candidates). The FI correlated with assessment outcomes; patients with medical contraindications (mean FI 0.35 ± 0.10) had higher FI scores than those listed (0.29 ± 0.09), P < 0.001. For listed patients, adjusted for age, sex, transplant type, and SVI, higher FI was associated with an increased risk of death (pretransplant or posttransplant) or delisting (hazard ratio 1.03 per 0.01 FI score, 95% confidence interval, 1.01-1.05, P = 0.01)., Conclusions: A cumulative deficits FI can be derived from routine organ transplant candidacy evaluations and may identify candidates at higher risk of adverse outcomes., Competing Interests: K.R. is President and Chief Science Officer of DGI Clinical, which in the last 5 years has contracts with pharma and device manufacturers (Baxter, Baxalta, Shire, Hollister, Nutricia, Roche, Otsuka) on individualized outcome measurement. In 2017, he attended an advisory board meeting with Lundbeck. Otherwise any personal fees are for invited guest lectures and academic symposia, received directly from event organizers, chiefly for presentations on frailty. He is Associate Director of the Canadian Consortium on Neurodegeneration in Aging, which is funded by the Canadian Institutes of Health Research, and with additional funding from the Alzheimer Society of Canada and several other charities, as well as, in its first phase (2013–2018), from Pfizer Canada and Sanofi Canada. He receives career support from the Dalhousie Medical Research Foundation as the Kathryn Allen Weldon Professor of Alzheimer Research, and research support from the Canadian Institutes of Health Research, the Nova Scotia Health Research Foundation, the Capital Health Research Fund and the Fountain Family Innovation Fund of the Nova Scotia Health Authority Foundation. The other authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Background: With an ageing population, the number of people with frailty is increasing. Despite this trend, the extent to which the severity and lethality of frailty have changed over time is not well understood. We aimed to investigate how frailty severity and lethality have changed over an 18-year period in the USA., Methods: In this population-based observational study, we used data from the National Health and Nutrition Examination Survey (NHANES) to identify community-dwelling individuals (aged ≥20 years) in the USA between 1999 and 2018. We analysed data from a series of ten 2-year, nationally representative, cross-sectional, prospective studies (from 1999-2000 to 2017-18) from the NHANES. Frailty was measured by use of the deficit accumulation approach (ie, a 46-item frailty index). The proportion of individuals categorised as non-frail, or living with very mild frailty, mild frailty, moderate frailty, and severe frailty were compared across cohorts. Random-effects models were used to examine the association between frailty index score and sex, age, and cohort. Mortality status as of Dec 31, 2015, was ascertained by use of National Death Index data, and 5-year mortality was available in the first six cohorts (1999-2010). Cox regression models and Kaplan-Meier curves were used to estimate the association between frailty index scores and mortality., Findings: In total, 49 004 individuals were included in our study. Associations were mainly non-linear (quadratic), with frailty increasing at a faster rate in more recent cohorts. Between 1999 and 2018, the proportion of non-frail individuals decreased by 10·4% (from 2747 [63·8%; 95% CI 61·9-65·6] of 4307 to 2884 [53·4%; 51·3-55·5] of 5399), whereas the proportion of individuals with very mild frailty increased by 2·4% (from 987 [22·9%; 21·3-24·6] to 1365 [25·3%; 23·5-27·2]), by 2·7% (from 370 [8·6%; 7·7-9·6] to 609 [11·3%; 10·1-12·5]) in those with mild frailty, by 3·1% (from 140 [3·3%; 2·7-3·9] to 347 [6·4%; 5·6-7·4]) in those with moderate frailty, and by 2·1% (from 63 [1·5%; 1·1-1·9] to 195 [3·6%; 3·0-4·3]) in those with severe frailty. Being a woman, older, and from a more recent cohort were associated with higher frailty index scores (all p<0·0001). In more recent cohorts, mean frailty index scores increased more quickly with age (p<0·0001), and sex differences in mean frailty index scores decreased (p<0·0001). In men of all ages and in women aged 35 years or older, mean frailty index scores were higher in more recent cohorts, with larger increases in frailty in older age groups. In 28 692 individuals from the first six cohorts (1999-2000 to 2009-10) with linked mortality data, frailty index scores were significantly associated with mortality (hazard ratio 1·053 [95% CI 1·050-1·057] per 0·01 increase in frailty index score). The absence of an interaction between cohort and frailty index score (p=0·58) suggested that the association between frailty and mortality was similar for all cohorts., Interpretation: Increasing frailty levels in more recent cohorts of middle-aged and older adults combined with stable frailty lethality between 1999 and 2018, suggest a challenge to healthy longevity, with the proportion of individuals with a high degree of frailty continuing to increase., Funding: Supported in part by the Canadian Institutes of Health Research., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Frailty and sarcopenia are age-related conditions with shared features and are both associated with adverse health outcomes. Relatively little is known about outcomes of these conditions in combination. The aim of this study was to examine the predictive ability of combined frailty and sarcopenia classification on mortality., Methods: Frailty was measured in 716 community-dwelling adults aged ≥65 years from the North West Adelaide Health Study (mean age 74.1(6.1) years, 55.5 % female) using the frailty phenotype (FP) and sarcopenia using the revised consensus definition from the European Working Group on Sarcopenia. Participants were classified as: neither frail nor sarcopenic, frail-only, sarcopenic-only, or both frail and sarcopenic. All participants had a minimum of 10 years of mortality follow-up., Results: We identified 2.8 % of participants as both frail and sarcopenic, 15.5 % as frail-only, and 3.5 % as sarcopenic-only. Classification as both frail and sarcopenic, in a multivariable model, resulted in significantly elevated mortality risk (HR = 3.52, p < .001), which was over three times that of those neither frail nor sarcopenic. Frail-only was also a significant mortality predictor (HR = 2.03, p = .001), while classification as sarcopenic-only was not a significant predictor of mortality (HR = 1.65, p = .141). There was no significant difference in severity of frailty (mean number of characteristics) or grip strength between frail-only and those with both conditions when stratified by sex., Conclusions: Individuals identified as frail would benefit from screening and assessment for sarcopenia, and vice versa for those identified as sarcopenic, as the mortality risk for individuals with these conditions in combination is nearly double that of each separately., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To test the hypothesis that degree of frailty and neuropathologic burden independently contribute to global cognition and odds of dementia., Methods: This was a secondary analysis of a prospective cohort study of older adults living in Illinois. Participants underwent an annual neuropsychological and clinical evaluation. We included 625 participants (mean age 89.7 ± 6.1 years; 67.5% female) who died and underwent autopsy. We quantified neuropathology using an index measure of 10 neuropathologic features: β-amyloid deposition, hippocampal sclerosis, Lewy bodies, tangle density, TDP-43, cerebral amyloid angiopathy, arteriolosclerosis, atherosclerosis, and gross and chronic cerebral infarcts. Clinical consensus determined dementia status, which we coded as no cognitive impairment, mild cognitive impairment, or dementia. A battery of 19 tests spanning multiple domains quantified global cognition. We operationalized frailty using a 41-item frailty index. We employed regression analyses to model relationships between neuropathology, frailty, and dementia., Results: Both frailty and a neuropathology index were independently associated with global cognition and dementia status. These results held after controlling for traditional pathologic measures in a sample of participants with Alzheimer clinical syndrome. Frailty improved the fit of the model for dementia status (χ 2 [2] 72.64; p < 0.0001) and explained an additional 11%-12% of the variance in the outcomes., Conclusion: Dementia is a multiply determined condition, to which both general health, as captured by frailty, and neuropathology significantly contribute. This integrative view of dementia and health has implications for prevention and therapy; specifically, future research should evaluate frailty as a means of dementia risk reduction., (© 2020 American Academy of Neurology.)

Objective: To examine the predictive validity of the FRAIL scale for mortality, and diagnostic test accuracy (DTA) against the frailty phenotype (FP)., Measurement: Frailty was measured in 846 community-dwelling adults (mean age 74.3 [SD 6.3] years, 54.8% female) using a modified FRAIL scale and modified FP. Mortality was matched to death records., Results: The FRAIL scale demonstrated significant predictive validity for mortality up to 10 years (Frail adjHR: 2.60, P < .001). DTA findings were acceptable for specificity (86.8%) and Youden index (0.50), but not sensitivity (63.6%), or area under the receiver operator curve (auROC) (0.75). DTA estimates were more acceptable when a cut-point of ≥2 characteristics was used rather than ≥3 in the primary DTA analysis., Conclusion: The FRAIL scale is a valid predictor of mortality. DTA estimates depend on FRAIL scale cut-point used. This instrument is a potentially useful frailty screening tool., (© 2020 AJA Inc.)

Purpose: The aim of this study was to identify lifestyle factors in males and females that are associated with a greater degree of frailty in a Canadian cohort., Methods: Cross-sectional data analysis from participants aged 30-74 yrs of the Atlantic PATH cohort. Inclusion criteria included completion of mental health questionnaires and ≥1 vital measure (n = 9133, 70% female, mean age 55 yrs). A frailty index was created based on 38 items with higher values indicating increasing frailty. The association between lifestyle factors and frailty was assessed by logistic regression., Results: 805 participants had a high level of frailty (frailty index ≥0.30). There was a significant interaction among sex, age, and lifestyle factors such as smoking status (P < 0.001), alcohol consumption (P < 0.001), physical activity level (P = 0.005), time spent sitting (P < 0.001) and sleeping (P < 0.001) on frailty. Smoking was harmful whereas sleep was protective for both males and females (<60 yrs). Females (<60yrs) that sat for ≥4 h/day were more likely to be highly frail whereas females (all ages) that consumed alcohol at least occasionally were less likely to be highly frail. Males, but not females, that engaged in a high level of physical activity were less likely to have a high level of frailty., Conclusions: Higher frailty is more prevalent among participants with unhealthy lifestyle behaviors related to smoking, alcohol consumption, sedentary and physical activity level, diet, and sleep. Differences in lifestyle behaviors of males and females of specific ages should be considered for managing frailty levels., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: we investigated whether two frailty tools predicted mortality among emergency department (ED) patients referred to internal medicine and how the level of illness acuity influenced any association between frailty and mortality., Methods: two tools, embedded in a Comprehensive Geriatric Assessment (CGA), were the clinical frailty scale (CFS) and a 57-item deficit accumulation frailty index (FI-CGA). Illness acuity was assessed using the Canadian Triage and Acuity Scale (CTAS). We examined all-cause 30-day and 6-month mortality and time to death., Results: in 808 ED patients (mean age ± SD 80.8 ± 8.8, 54.4% female), the mean FI-CGA score was 0.44 ± 0.14, and the CFS was 5.6 ± 1.6. A minority (307; 38%) were classified as having high acuity (CTAS: 1-2). The 30-day mortality rate was 17%; this increased to 34% at 6 months. Compared to well patients with low acuity, the risk of 30-day mortality was 22.5 times (95% CI: 9.35-62.12) higher for severely frail patients with high acuity; 53% of people with very severe frailty (CFS = 8) and high acuity died within 30 days. When acuity was low, the risk for 30-day mortality was significantly higher only among those with very high levels of frailty (CFS 7-9, FI-CGA > 0.5). When acuity was high, even lower levels of frailty (CFS 5-6, FI-CGA 0.4-0.5) were associated with higher 30-day mortality., Conclusions: across levels of frailty, higher acuity increased mortality risk. When acuity was low, the risk was significant only when the degree of frailty was high, whereas when acuity was high, even lower levels of frailty were associated with greater mortality risk., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Introduction: Cognitive impairment is the hallmark of Alzheimer's disease (AD) and related dementias. However, motor decline has been recently described as a prodromal state that can help to detect at-risk individuals. Similarly, sensory changes, sleep and behavior disturbances, and frailty have been associated with higher risk of developing dementia. These clinical findings, together with the recognition that AD pathology precedes the diagnosis by many years, raises the possibility that non-cognitive changes may be early and non-invasive markers for AD or, even more provocatively, that treating non-cognitive aspects may help to prevent or treat AD and related dementias., Methods: A subcommittee of the Canadian Consensus Conference on Diagnosis and Treatment of Dementia reviewed areas of emerging evidence for non-cognitive markers of dementia. We examined the literature for five non-cognitive domains associated with future dementia: motor, sensory (hearing, vision, olfaction), neuro-behavioral, frailty, and sleep. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assign the strength of the evidence and quality of the recommendations. We provide recommendations to primary care clinics and to specialized memory clinics, answering the following main questions: (1) What are the non-cognitive and functional changes associated with risk of developing dementia? and (2) What is the evidence that sensory, motor, behavioral, sleep, and frailty markers can serve as potential predictors of dementia?, Results: Evidence supported that gait speed, dual-task gait speed, grip strength, frailty, neuropsychiatric symptoms, sleep measures, and hearing loss are predictors of dementia. There was insufficient evidence for recommending assessing olfactory and vision impairments as a predictor of dementia., Conclusions: Non-cognitive markers can assist in identifying people at risk for cognitive decline or dementia. These non-cognitive markers may represent prodromal symptoms and several of them are potentially amenable to treatment that might delay the onset of cognitive decline., Competing Interests: The authors have no conflicts of interest to disclose.The authors have no conflicts of interest to disclose., (© 2020 The Authors. Alzheimer's & Dementia: Translational Research & Clinical Interventions published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Background: Frailty is increasingly recognized as an important construct which has health implications for older adults. The Clinical Frailty Scale (CFS) is a judgement-based frailty tool that evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill). The aim of this scoping review is to identify and document the nature and extent of research evidence related to the CFS., Methods: We performed a comprehensive literature search to identify original studies that used the Clinical Frailty Scale. Medline OVID, Scopus, Web of Science, CINAHL, PsycINFO, Cochrane Library and Embase were searched from January 2005 to March 2017. Articles were screened by two independent reviewers. Data extracted included publication date, setting, demographics, purpose of CFS assessment, and outcomes associated with CFS score., Results: Our search yielded 1688 articles of which 183 studies were included. Overall, 62% of studies were conducted after 2015 and 63% of the studies measured the CFS in hospitalized patients. The association of the CFS with an outcome was examined 526 times; CFS was predictive in 74% of the cases. Mortality was the most common outcome examined with CFS being predictive 87% of the time. CFS was associated with comorbidity 73% of the time, complications 100%, length of stay 75%, falls 71%, cognition 94%, and function 91%. The CFS was associated with other frailty scores 94% of the time., Conclusions: This scoping review revealed that the CFS has been widely used in multiple settings. The association of CFS score with clinical outcomes highlights its utility in the care of the aging population.

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data., Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA)., Participants: 903 996 non-Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003-2013., Main Outcome Measures: 44-item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment., Results: The mean frailty index score during 2003-2013 was 0.20 (SD, 0.07; range, 0-0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003-2005 to 75.0% in 2012-2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69-6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32-9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63-0.64) for death and 0.63 (95% CI, 0.62-0.63) for entry into permanent residential aged care within one year of assessment., Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation., (© 2020 AMPCo Pty Ltd.)

Objectives: To describe the association of frailty level on admittance to the Emergency Department (ED) with various hospital complications including delirium, low phase angle, and low handgrip strength. Design: Prospective cohort. Setting: ED rooms of two public general hospitals in Mexico City. Participants: A total of 548 persons 60 years or older who were admitted to the ED and who were alive during follow-up testing at home were included. Measurements: A 32-item frailty index (FI) was measured on admission to the ED. Outcome measures included delirium, phase angle, and hand grip strength measured during different stages of the hospitalization (i.e., from admission to the ED through to follow-up at home). Results: From this final sample, mean age was 76 years (± SD 7.2) and 58.4% ( n = 320) were women. Mean waiting time in the ED was 5.1 h (± SD 6.2), the average stay in the ED was 99.9 (±68.2) h, and 274 subjects (50%) were admitted to a general ward after ED admission. FI was not associated with phase angle and was negatively associated with handgrip strength at admission to ED (β = -3.97, confidence interval [CI] 95% -5.56 -2.38, p < 0.001), discharge from ED (β = -3.94, CI 95% -5.97 -1.90, p < 0.001), and discharge from hospital (β = -4.93, CI 95% -7.68 -2.18, p = 0.01). FI was positively associated with delirium (β = 3.68, CI 95% 1.53-5.83, p < 0.01). Conclusion: Higher frailty at ED admission was associated with lower hand grip strength and delirium during hospitalization in Mexican older adults., (Copyright © 2020 Pérez-Zepeda, Carrillo-Vega, Theou, Jácome-Maldonado and García-Peña.)

Background: Clinically meaningful change (CMC) for frailty index (FI) scores is little studied. We estimated the CMC by associating changes in FI scores with changes in the Clinical Frailty Scale (CFS) in hospitalized patients., Methods: The Serious Outcomes Surveillance Network of the Canadian Immunization Research Network enrolled older adults (65+ years) admitted to hospital with acute respiratory illness (mean age = 79.6 ± 8.4 years; 52.7% female). Patients were assigned CFS and 39-item FI scores in-person at admission and via telephone at 1-month postdischarge. Baseline frailty state was assessed at admission using health status 2 weeks before admission. We classified those whose CFS scores remained unchanged (n = 1,534) or increased (n = 4,390) from baseline to hospital admission, and whose CFS scores remained unchanged (n = 1,565) or decreased (n = 2,546) from admission to postdischarge. For each group, the CMC was represented as the FI score change value that best predicted one level CFS change, having the largest Youden J value in comparison to no change., Results: From baseline to admission, 74.1% increased CFS by ≥1 level. From admission to postdischarge, 61.9% decreased CFS by ≥1 levels. A change in FI score of 0.03 best predicted both one-level CFS increase (sensitivity = 70%; specificity = 69%) and decrease (sensitivity = 66%; specificity = 61%) in comparison to no change. Of those who changed CFS by ≥1 levels, 70.9% (baseline to admission) and 72.4% (admission to postdischarge) changed their FI score by at least 0.03., Conclusions: A clinically meaningful change of 0.03 in the frailty index score holds promise as a benchmark for assessing the meaningfulness of frailty interventions., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To review medication-related criteria within validated frailty tools., Methods: Narrative review of validated frailty assessment tools. Frailty tools were identified from recently published reviews; each tool was reviewed to determine whether any medication-related criteria were included and how these criteria contributed to the scoring/assessment of frailty., Results: Eight out of 16 validated frailty tools included medication-related criteria. The majority of criteria were a numerical cut-off of number of medications taken; however, the specific cut-off was not consistent., Conclusion: Inclusion of medication-related criteria in frailty tools is highly variable. Future research is required to determine whether incorporation of medication use into frailty assessment can impact outcomes in terms of frailty prevention and treatment., (© 2020 AJA Inc.)

Objective: To assess the feasibility, reliability, and validity of the Pictorial Fit-Frail Scale (PFFS) among patients, caregivers, nurses, and geriatricians in an outpatient memory clinic., Design: Observational study., Setting: A Canadian referral-based outpatient memory clinic., Participants: Fifty-one consecutive patients and/or their caregivers, as well as attending nurses and geriatricians., Measurements: Participants (patients, caregivers, nurses, and geriatricians) were asked to complete the PFFS based on the patient's current level of functioning. Time-to-complete and level of assistance required was recorded. Participants also completed a demographic survey and patients' medical history (including the Mini-Mental State Examination [MMSE], and Comprehensive Geriatric Assessment [CGA]) was obtained via chart review., Results: Patient participants had a mean age of 77.3±10.1 years, and average MMSE of 22.0±7.0, and 53% were female. Participants were able to complete the PFFS with minimal assistance, and their average times to completion were 4:38±2:09, 3:11±1:16, 1:05±0:19, and 0:57±0:30 (mins:sec) for patients, caregivers, nurses, and geriatricians, respectively. Mean PFFS scores as rated by patients, caregivers, nurses, and geriatricians were 9.0±5.7, 13.1±6.6, 11.2±4.5, 11.9±5.9, respectively. Patients with low MMSE scores (0-24) took significantly longer to complete the scale and had higher PFFS scores. Inter-rater reliability between nurses and geriatricians was 0.74, but it was lower when assessments were done for patients with low MMSE scores (0.47, p<0.05). The correlation between PFFS and a Frailty Index based on the CGA was moderately high and statistically significant for caregivers, nurses, and geriatricians (r=0.66, r=0.59, r=0.64, respectively), but not patients., Conclusions: The PFFS is feasible, even among people with some slight cognitive impairment, though it may be less useful when patients with severe dementia administer it to themselves. Further, the PFFS may help inform clinicians about areas of concern as identified by patients, enabling them to contribute more to diagnostic and treatment decisions or helping with health tracking and care planning.

The key idea behind the Clinical Frailty Scale (CFS) is that, as people age, they are more likely to have things wrong with them. Those things they have wrong (health deficits) can, as they accumulate, erode their ability to do the high order functions which define their overall health. These high order functions include being able to: think and do as they please; look after themselves; interact with other people; and move about without falling. The Clinical Frailty Scale brings that information together in one place. This paper is a guide for people new to the Clinical Frailty Scale. It also introduces an updated version (CFS version 2.0), with revised level names (e.g., "vulnerable" becomes "living with very mild frailty") and minor edits to level descriptions. The key points discussed are that the Clinical Frailty Scale assays the baseline state, it is not widely validated in younger people or those with stable single-system disabilities, and it requires clinical judgement. The Clinical Frailty Scale is now commonly used as a triage tool to make important clinical decisions such as allocating scarce health care resources for COVID-19 management; therefore, it is important that the scale is used appropriately., Competing Interests: Olga Theou declares that no conflicts of interest exist. CONFLICT OF INTEREST DISCLOSURES Kenneth Rockwood has asserted copyright of the Clinical Frailty Scale through Dalhousie University. Use is free for research, education, or not-for-profit care. (Users are asked not to change it or charge for its use.) In addition to academic and hospital appointments, he is President and Chief Science Officer of DGI Clinical, which in the last five years has contracts with pharma and device manufacturers (Baxter, Baxalta, Biogen, Shire, Hollister, Nutricia, Roche, Otsuka) on individualized outcome measurement. In 2017 he attended an advisory board meeting with Lundbeck. He is Associate Director of the Canadian Consortium on Neurodegeneration in Aging, which is funded by the Canadian Institutes of Health Research (CAN-137794), with additional funding from the Alzheimer Society of Canada and several other charities. He receives research support through grants from the Canadian Institutes of Health Research, the Canadian Frailty Network, the Nova Scotia Health Research Foundation, the Nova Scotia Health Authority Research Fund, the Dalhousie Medical Research Fund as the Kathryn Allen Weldon Professor of Alzheimer Research, and the Fountain Family Innovation Fund of the QEII Health Science Centre Foundation., (© 2020 Author(s). Published by the Canadian Geriatrics Society.)

Background: Cardiac rehabilitation is a mainstay treatment for patients experiencing an adverse cardiovascular event. Heart disease is important in frailty, but the impact of cardiac rehabilitation on frailty is unclear., Methods: Patients were referred to a 12-week group-based exercise and education cardiac rehabilitation program performed twice weekly. Frailty was measured with the use of a 25-item accumulation of deficits frailty index (range 0-1; higher values indicate greater frailty) at cardiac rehabilitation admission and completion. Patients were categorized by the degree of frailty in 0.1 increments., Results: Of the 4004 patients who enrolled, 2322 (58.0%) completed cardiac rehabilitation with complete data at admission and completion. There were 414 (17.8%), 642 (27.6%), 690 (29.7%), 401 (17.3%), and 175 (7.5%) patients with admission frailty levels of < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50, respectively. Frailty levels improved from cardiac rehabilitation admission (mean 0.34 [95% CI 0.32-0.35]) to completion (0.26 [0.25-0.28]) for those who completed the program (P < 0.001). After adjusting for age, sex, and number of exercise sessions attended, frailty improved in all frailty groups by mean differences of 0.03 (0.02-0.03), 0.05 (0.05-0.06), 0.08 (0.08-0.09), 0.10 (0.09-0.11), and 0.11 (0.10-0.13) in the < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50 frailty groups, respectively. The minimal improvement in frailty scores (≥ 0.03 reduction) was achieved by 48%, 65%, 72%, 76%, and 79% of patients in the the 5 frailty groups, respectively., Conclusions: Although higher frailty levels were associated with cardiac rehabilitation drop-out, finishing the program was related to improving frailty levels, especially in patients who were the frailest., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: Diabetes is common among older hospitalized adults; however, the effect of a diabetes diagnosis, frailty and blood glucose on mortality and hospital length of stay (LOS) has not been well described, nor is frailty routinely assessed in inpatients., Methods: This study included patients ≥65 years of age consulted to internal medicine through the emergency department at a Canadian tertiary care hospital. An internist-geriatrician determined their frailty status using the Clinical Frailty Scale. Inpatient mortality rates and LOS were obtained from a hospital administrative database. Admission glucose (fasting or random) and hemoglobin A1C were performed within 1 and 92 days of the comprehensive geriatric assessment., Results: This study included 400 patients (mean age, 81.4±8.1 years), 79.3% were frail (Clinical Frailty Scale score ≥5) and 35.3% had diabetes. The inpatient mortality rate was 19.7%, and among those who were discharged from the hospital, mean LOS was 23.7±36.5 days. Patients with diabetes were more likely to be frail than patients without diabetes. Diabetes status was not associated with LOS or mortality, but frailty was associated with both outcomes in multivariate regression analysis adjusted for age, sex and admission glucose. In patients with diabetes, mean admission glucose decreased with increasing frailty., Conclusions: Frailty was more common in patients with diabetes. Frailty, not diabetes, was associated with increased mortality and LOS in multivariate analysis. In patients with diabetes, admission glucose was lower with higher frailty. Frailty should be routinely assessed in all inpatients with diabetes because it is associated with hospital outcomes., (Copyright © 2019 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Little is known about symptoms associated with frailty in institutionalized Portuguese older adults. This study aimed to investigate the association of frailty with diverse geriatric health characteristics. Cross-sectional data from 140 women aged between 75 and 85 years were analyzed. Data were collected between March and June, 2016. Fried's definition of physical frailty, psychological, sex hormones, disability and physical fitness outcomes were examined. The prevalence of frailty was 40%. Frail women had lower scores in cognitive and physical fitness, and higher scores for depressive symptoms and comorbidities. Significant correlations emerged between frailty and disability, fear of falling, aerobic resistance and cognition. Regression analyses and Receiver Operating Only aerobic resistance (sensitivity [93-96%]; specificity [74-77%], p = .001) and cognition (sensitivity [77-88%]; specificity [65-71%], p < .001) remained in the equation as independently related to physical frailty. A trend of significant differences in lower systolic blood pressure may reflect being less physically active and/or having more systemic comorbidity. Fried's model can be considered applicable. The 2-minute step test and the Mini Mental State Examination could better identify frail populations. The role of blood pressure and level of education in physical frailty status needs to be further explored.

Objectives: Despite their role in health and disease, the relationship between fatty acids (FAs) and frailty and mortality remains unclear. The aim of this study was to explore how FA intake is associated with frailty and mortality., Methods: This observational study included 4062 participants ≥50 y of age from the 2003-2006 cohorts of the National Health and Nutrition Examination Survey. A 36-item frailty index (FI) and a 14-item nutrition index (NI) were constructed. We analyzed 29 dietary FA variables., Results: After adjustment for potential covariates and the NI, higher total FAs, saturated FAs (SFAs), and butanoic acid intake were associated with a higher degree of frailty. After an additional adjustment for the FI, higher SFA intake (total, hexanoic acid, octanoic acid, decanoic acid, tetradecanoic acid, hexadecanoic acid, and octadecanoic acid) was associated with higher mortality risk, whereas higher polyunsaturated FAs (total and octadecadienoic acid), ω-3 FAs (total, octadecatrienoic acid, and docosapentaenoic acid), and eicosenoic acid intake was associated with lower mortality risk., Conclusions: Only a higher percentage of SFA intake was associated with both higher frailty and mortality even after considering the degree of nutritional deficits. The effect of SFAs on mortality was evident across levels of frailty. FAs were associated with long-term mortality more often than they with degree of frailty., (Copyright © 2019 Elsevier Inc. All rights reserved.)