Research Article: Comparative analysis of the association between 35 frailty scores and cardiovascular events, cancer, and total mortality in an elderly general population in England: An observational study

Date Published: March 27, 2018

Publisher: Public Library of Science

Author(s): Gloria A. Aguayo, Michel T. Vaillant, Anne-Françoise Donneau, Anna Schritz, Saverio Stranges, Laurent Malisoux, Anna Chioti, Michèle Guillaume, Majon Muller, Daniel R. Witte, Kazem Rahimi

Abstract: BackgroundFrail elderly people experience elevated mortality. However, no consensus exists on the definition of frailty, and many frailty scores have been developed. The main aim of this study was to compare the association between 35 frailty scores and incident cardiovascular disease (CVD), incident cancer, and all-cause mortality. Also, we aimed to assess whether frailty scores added predictive value to basic and adjusted models for these outcomes.Methods and findingsThrough a structured literature search, we identified 35 frailty scores that could be calculated at wave 2 of the English Longitudinal Study of Ageing (ELSA), an observational cohort study. We analysed data from 5,294 participants, 44.9% men, aged 60 years and over. We studied the association between each of the scores and the incidence of CVD, cancer, and all-cause mortality during a 7-year follow-up using Cox proportional hazard models at progressive levels of adjustment. We also examined the added predictive performance of each score on top of basic models using Harrell’s C statistic. Using age of the participant as a timescale, in sex-adjusted models, hazard ratios (HRs) (95% confidence intervals) for all-cause mortality ranged from 2.4 (95% CI: 1.7–3.3) to 26.2 (95% CI: 15.4–44.5). In further adjusted models including smoking status and alcohol consumption, HR ranged from 2.3 (95% CI: 1.6–3.1) to 20.2 (95% CI: 11.8–34.5). In fully adjusted models including lifestyle and comorbidity, HR ranged from 0.9 (95% CI: 0.5–1.7) to 8.4 (95% CI: 4.9–14.4). HRs for CVD and cancer incidence in sex-adjusted models ranged from 1.2 (95% CI: 0.5–3.2) to 16.5 (95% CI: 7.8–35.0) and from 0.7 (95% CI: 0.4–1.2) to 2.4 (95% CI: 1.0–5.7), respectively. In sex- and age-adjusted models, all frailty scores showed significant added predictive performance for all-cause mortality, increasing the C statistic by up to 3%. None of the scores significantly improved basic prediction models for CVD or cancer. A source of bias could be the differences in mortality follow-up time compared to CVD/cancer, because the existence of informative censoring cannot be excluded.ConclusionThere is high variability in the strength of the association between frailty scores and 7-year all-cause mortality, incident CVD, and cancer. With regard to all-cause mortality, some scores give a modest improvement to the predictive ability. Our results show that certain scores clearly outperform others with regard to three important health outcomes in later life. Finally, we think that despite their limitations, the use of frailty scores to identify the elderly population at risk is still a useful measure, and the choice of a frailty score should balance feasibility with performance.

Partial Text: Although chronological age is the strongest determinant of disease occurrence and mortality, it is increasingly recognised that the process of ageing is heterogeneous [1] due to a combination of differences in lifetime cumulative exposure to determinants of chronic disease and differences in individual susceptibility. The concept of frailty was introduced as a way of identifying individuals who, at a given age, have a particularly fragile health balance and are therefore more vulnerable to rapid health deterioration and early mortality [2]. However, the operationalization of the concept of frailty has been fraught with difficulties, as different groups of researchers and clinicians have expressed diverging views on which characteristics make up frailty and on how these should be assessed individually and in unison.

Table 2 shows the baseline characteristics of the participants included in the analysis.

Our direct comparison of the association between 35 published frailty scores and three major health outcomes in later life demonstrates that there is great variability in the strength of the prospective association with CVD, cancer, and total mortality. Moreover, the strength of the association also differed between each of the three outcomes. While most scores added predictive ability to both simple and more complex underlying models for total mortality, this was not the case for CVD or cancer.



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