Abstract
Background and Aims
Frailty is an all-embracing syndrome of diminished physiological reserve to stressors resulting in reduced physical ability and increased vulnerability to hospitalization and mortality. There is data on cross-sectional frailty assessments and its subsequent relationship to mobility, quality of life, depression, cognitive decline, nursing home admissions, and disability. The most widely used definition in the literature is known as the Fried Frailty Phenotype. It is based on five physical domains that can be assessed by self-report (weight loss, low physical activity, and exhaustion) and objective measures (weakness and slow gait speed). Based on the number of deficits, individuals are characterized as robust (0), pre-frail (1-2/5) and frail (≥ 3/5). The prevalence of frailty is disproportionately increased in patients with chronic kidney disease (CKD) in comparison to non-CKD counterparts and is the highest in patients on hemodialysis. While the cross-sectional measurement of frailty on hemodialysis patients has been associated with adverse clinical events, there is a paucity of data on longitudinal assessment of frailty and its relationship to outcomes. The primary objective of the study was to evaluate the change in frailty status in patients on hemodialysis over 12 months in relation to the level of independence. The secondary objective was to determine the changes in frailty and explore a relationship with mood, quality of life, and cognition.
Method
We conducted a prospective cohort study amongst 100 prevalent hemodialysis patients at the Regina General Hospital, Saskatchewan, Canada between January 2015 and January 2017. The patients underwent frailty assessments at baseline and one year later. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for (physical activity and self-perceived exhaustion). Cognition, mood and quality of life were measured using questionnaires [Montreal Cognitive Assessment (MoCA), Geriatric Depression Score (GDS), and EuroQol (EQ-5D) utility scores and Visual Analogue Scores (VAS) respectively]. Differences across baseline and 1-year groups were assessed using McNemar‘s test or Wilcoxon signed-rank test, as appropriate. We assessed the differences between frail and non-frail (composite of robust and pre-frail) of groups using Mann–Whitney test or Chi-square test/ Fisher’s exact test where appropriate.
Results
97/100 had complete initial assessments. The median (Interquartile Range=IQR) duration of dialysis at baseline was 35.5 (13.75-71.75 months). One year later, 22 had died, 10 refused assessments and 3 relocated. 18/22 (82%) who died were frail. At baseline, 68% were frail, 27% were pre-frail and 5% were robust. At baseline, 69% had MoCA score≥ 24, 53% had GDS score≥ 2, median EQ-5D utility score was 0.80 (0.70-0.85), median EQ-VAS was 60 (44-80). 82% of the patients were independent, 17% were independent with support, and 1% required support from home care. Even though death was not a pre-specified endpoint, we found that a fifth of our patients (22/100) patients had died by the time of the next assessment in 12 months. 18/22 (82%) had been identified as frail suggesting majority of the deaths had occurred in frail patients.
Conclusion
To our knowledge, this is the first Canadian study that explores the relationship between longitudinal changes in frailty with the level of independence, mood, cognition, and quality of life. We show high prevalence (95%) of frail and pre-frail status at baseline which remained unchanged one year later. Frail patients on dialysis were older, had challenges with mobility and self-care in comparison to their non-frail counterparts. Frailty and pre-frailty is near-ubiquitous in our dialysis patients and will need to be proactively addressed to improve subsequent healthcare outcomes.
Decreased Self Report Physical Activity One Year after an Acute Ankle Sprain
