Julie Whitney

Background: The increasing life expectancy provides an opportunity for healthy longevity, but frailty is a potential challenge. Existing studies of frailty prevalence in England are largely cross-sectional, use heterogeneous frailty definitions, and rarely break down population-level drivers or project future burden, limiting their use for health and social care planning. Objective: This study aimed to explore temporal trends of frailty prevalence and project scenario-based future prevalence up to 2040 for the community-dwelling population aged 50 years and older in England. Methods: Prevalence of frailty (measured using a frailty index) in the overall sample and subgroups of age, sex, educational level, and marital status from 2002 to 2022 was estimated among the community-dwelling population aged 50 years and older using 10 waves of nationally representative data from the English Longitudinal Study of Ageing (ELSA; n=6226 to 11,218 across waves). The number of individuals with frailty was also derived in each year. Joinpoint regression models were used to explore temporal trends of frailty prevalence. A linear probability regression model was performed using pooled data from 10 waves of the ELSA to explore driving factors and project future prevalence. Decomposition analysis was used to estimate the contribution of individual factors to the change in prevalence. Results: A statistically nonsignificant ( P =.61) increase of 2.3 percentage points from 15.5% (1738/11,218) in 2002 to 17.8% (1108/6226) in 2022 was observed, with the number of individuals with frailty growing from 2,560,122 to 3,791,038 among community-dwelling adults aged 50 years and older in England. Those with advanced age, who were female, had a lower educational level, and/or were single had a consistently higher prevalence of frailty. Opposing contributions netted to this overall change: improvements in sociodemographic conditions and educational attainment and healthier lifestyle behaviors offset 222.5%, 94.9%, and 51.6% of the observed increase, respectively. Under scenario-based projections, prevalence was estimated at 20.5% (95% CI 19.2%-21.9%) in 2040, corresponding to 5,213,689 people with frailty. Conclusions: Despite a modest increase in prevalence among the community-dwelling population aged 50 years and older, the substantial growth in the absolute number of individuals with frailty indicates a likely rise in future care demands. The study contributes a 20-year trend, decomposition, and forecast framework for community-dwelling older adults. Findings support prioritizing broader sociodemographic development alongside educational attainment and healthy lifestyles, with potential policy approaches including income and social protection, housing improvements, access to health care, and prevention. Key limitations include self-reported measures, exclusion of care home residents, and potential influence of unmeasured effects.

BACKGROUND: Hypertension and frailty frequently coexist in older adults. However, relationships between their trajectories are unclear. This study aims to examine whether frailty progressed differently between individuals with and without hypertension before and after diagnosis. METHODS: Data were drawn from 3 nationally representative cohorts across 14 countries, including 21 418 participants (mean baseline age 63.2±10.2 years) followed for 16 to 18 years. Individuals with hypertension at baseline were excluded. Hypertension was defined by self-reported physician diagnosis and antihypertensive medication use by self-report of taking any medication. Diagnosis timing was based on the first survey wave at which hypertension was reported. Coarsened exact matching matched participants who developed hypertension with those who did not. Piecewise linear mixed models estimated frailty trajectories before and after diagnosis. RESULTS: Among 10 709 participants who developed hypertension (median diagnosis age 70 years), frailty index rescaled to a 0 to 100 scale (0–100) increased by 0.63 points/y (95% CI, 0.57–0.70) before diagnosis and 1.09 points/y (95% CI, 0.97–1.21) after diagnosis. During the 8 years preceding diagnosis, participants who developed hypertension experienced greater increases in frailty index rescaled to a 0 to 100 scale than matched controls without hypertension (difference, 2.69 [95% CI, 2.43–2.95]). The corresponding difference during the 8 years after diagnosis was 1.51 (95% CI, 1.01–2.01). Among individuals with hypertension, antihypertensive medication use was associated with a nonsignificant reduction in frailty progression after diagnosis. Findings remained robust after excluding participants with cardiovascular conditions. CONCLUSIONS: Participants with hypertension experienced faster frailty progression before and after diagnosis. Studies using objective blood pressure measurement are needed to confirm this association.

Background: Walking frame users are at increased risk of falls due to gait and balance impairments and restrictions caused by the frame itself. While exercise is an effective fall prevention intervention in the general population, there are no programmes specific to walking frame users. Adaptations may be required for walking frame users to achieve an appropriate intensity and dose of fall prevention exercise without increasing the propensity to fall while exercising. The Frame Fit intervention is a home exercise programme adapted for the needs of frame users. The aim of this study was to evaluate safety, acceptability and effectiveness of the Frame Fit intervention. Methods: Community dwelling older people (aged ≥ 65) who use a walking frame were recruited to the randomised controlled trial and allocated to the 6-month Frame Fit intervention, a programme of home exercises prescribed and progressed by a physiotherapist, or to usual care. Falls (primary outcome) were recorded using diaries for 12 months from randomisation. Physical performance (grip strength, balance, gait speed and sit-to-stand), timed up and go, physical activity, fear of falling and health-related quality of life was measured at baseline and after six months. Secondary healthcare use and mortality was collected from electronic records for 12 months from randomisation. Results: Of 117 participants randomised, (59 to intervention, 58 to usual care), 86 were followed up at six months and 83 provided 12 month falls data. There were two intervention-related adverse events. There were more falls reported by the intervention group than control group at six months (adj, IRR: 2.10, 95%CI 1.06–3.98) but no difference in falls at 12 months (adj.IRR:1.76, 95%CI 0.93–3.33). Adherence was satisfactory but there was low uptake to the trial. There were no differences found in the secondary outcome measures. Conclusions: Frame Fit intervention offered a satisfactory safety profile, was acceptable to those who participated and feasible. Due to low recruitment rates, the study was underpowered to detect a difference in falls or other outcomes. Further research is needed to optimally tailor fall prevention interventions to walking frame users. Trial registration: The protocol was prospectively registered as a clinical trial with the ISRCTN (clinical trial number: 57645734) on 11/09/2014.

Background: Laboratory-based frailty indices (FI-Labs) offer potential adjuncts and alternatives to clinical assessments. Still, their optimal configuration and construct validity compared with nurse-assessed Clinical Frailty Scale (CFS) scores remain unclear. Methods: In this retrospective cohort study, we evaluated five FI-Lab configurations against nurse-assessed CFS scores using data from 74 493 emergency department visits. We examined their association with clinical outcomes and assessed measurement reliability using mixed effects models. Results: While nurse assessments demonstrated superior outcome discrimination (c-statistic 0.726 for 90-day mortality versus 0.718 for best FI-Lab), automated FI-Lab measures showed significantly greater between-visit reliability [intraclass correlation coefficient (ICC) = 0.51–0.76 versus 0.37 for nurse CFS]. The drug-adjusted FI-Lab demonstrated highest reliability (ICC = 0.76) but weaker age associations (β = 0.002, P = .08) compared to other configurations (β = 0.006–0.013, P < .001). In complex models adjusting for illness severity, nurse CFS scores showed stronger mortality associations (HR 1.55, 95% CI 1.45–1.66 per standard deviation) compared to FI-Lab configurations (HR range 1.19–1.29). Notably, all frailty measures showed effect sizes comparable to age (HR range 1.37–1.55 per SD). Conclusions: Automated FI-Lab measures offer a reliability advantage over nurse-assessed CFS scores despite slightly lower predictive validity for mortality. Their comparable effect sizes to age suggest these automated measures capture clinically meaningful patient characteristics. This trade-off between reliability and predictive validity suggests that integrated approaches combining automated screening with targeted clinical assessment may provide optimal frailty identification in emergency settings.

Background: Emergency departments (EDs) in England are under significant strain, with increasing attendances and extended wait times, affecting frail older adults. The clinical frailty scale (CFS) has been implemented as a tool to assess frailty in ED settings, but its reliability and predictive accuracy as a screening tool remain debated. Objective: To evaluate the use and variability of the CFS in EDs and its association with patient outcomes, including discharge rates, length of stay, readmission and mortality. Methods: A retrospective cohort study of ED attendances at two London (UK) hospitals from 2017 to 2021. Data included CFS scores, demographics, clinical observations and outcomes. Comparative statistics, logistic regression, Cox proportional hazards models and competing risk regression were applied to examine CFS predictive validity. Results: In a sample of 123 324 ED visits, CFS scores strongly correlated with adverse outcomes: e.g. for long-term mortality (n = 33 475, events = 8871), each CFS single-point increase was associated with a 25% increase in mortality risk (95% CI 1.23–1.26). CFS scores varied significantly between raters and across visits, median difference two levels (interquartile range 1–3). Intraclass correlation coefficient analysis showed that 33.1% of CFS score differences was attributable to between-patient differences, 15.4% to inter-rater differences, with 51.5% residual variance from non-frailty factors, such as acute illness severity. Conclusion: The CFS is associated with crucial patient outcomes in the ED. Inter-rater variability and potentially confounding factors can limit its consistency. Automation to enhance CFS score reliability should be explored as a means to support proactive management.

Conducted physically, supervised group-based falls prevention exercise programs have demonstrated effectiveness in reducing the risk of falls among older adults. In this study, we aimed to assess the acceptability, feasibility, and effectiveness of a virtual supervised group-based falls prevention exercise program (WE-SURF™) for community-dwelling older adults at risk of falls. Method: A preliminary study utilizing virtual discussions was conducted to assess the acceptability of the program among six older adults. Effectiveness was evaluated in a randomized controlled feasibility study design, comprising 52 participants (mean age: 66.54; SD: 5.16), divided into experimental (n = 26) and control (n = 26) groups. The experimental group engaged in a 6-month WE-SURF™ program, while the control group received standard care along with a fall’s prevention education session. Feasibility of the intervention was measured using attendance records, engagement rates from recorded videos, dropouts, attrition reasons, and adverse events. Results: Preliminary findings suggested that WE-SURF™ was acceptable, with further refinements. The study revealed significant intervention effects on timed up and go (TUG) (η2p:0.08; p < 0.05), single leg stance (SLS) (η2p:0.10; p < 0.05), and lower limb muscle strength (η2p:0.09; p < 0.05) tests. No adverse events occurred during the program sessions, and both attendance and engagement rates were high (> 80% and 8/10, respectively) with minimal dropouts (4%). The WE-SURF™ program demonstrated effectiveness in reducing the risk of falls while enhancing muscle strength and balance. Conclusion: In conclusion, WE-SURF™ was demonstrated to be an acceptable, feasible, and effective virtual supervised group-based exercise program for fall prevention in community-dwelling older adults at risk of falls. With positive outcomes and favourable participant engagement, WE-SURF™ holds the potential for wider implementation. Further research and scaling-up efforts are recommended to explore its broader applicability. (Registration number: ACTRN 12621001620819).

Exercise and physical activity can improve bone strength and the risk of falls, which may offer benefits in the prevention and management of osteoporosis. However, uncertainty about the types of exercise that are safe and effective instigates lack of confidence in people with osteoporosis and health professionals. Existing guidelines leave some questions unresolved. This consensus statement aimed to determine the physical activity and exercise needed to optimise bone strength, reduce fall and fracture risk, improve posture and manage vertebral fracture symptoms, while minimising potential risks in people with osteoporosis. The scope of this statement was developed following stakeholder consultation. Meta-analyses were reviewed and where evidence was lacking, individual studies or expert opinion were used to develop recommendations. A multidisciplinary expert group reviewed evidence to make recommendations, by consensus when evidence was not available. Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. For safety, we recommend avoiding postures involving a high degree of spinal flexion during exercise or daily life. People with vertebral fracture or multiple low trauma fractures should usually exercise only up to an impact equivalent to brisk walking. Those at risk of falls should start with targeted strength and balance training. Vertebral fracture symptoms may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with specialist advice to encourage return to normal activities. Everyone with osteoporosis may benefit from guidance on adapting postures and movements. There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks.