Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
Center on Aging and Health, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
J Am Geriatr Soc. 2021 Apr;69(4):908-915. doi: 10.1111/jgs.16976. Epub 2020 Dec 24.
To investigate the rate and patterns of accumulation of frailty manifestations in relationship to all-cause mortality and whether there is a point in the progression of frailty beyond which the process becomes irreversible and death becomes imminent (a.k.a. point of no return).
Longitudinal observational study.
Community or a non-nursing home residential care setting.
Two thousand five hundred and fifty seven robust older adults identified at baseline in 2011 with follow-up for all-cause mortality between 2011 and 2018.
Frailty was measured by the physical frailty phenotype. Cox models were used to study the relationships of the number of frailty criteria (0-5) at each point in time and its accumulation patterns with all-cause mortality. Markov state-transition models were used to study annual transitions between health states (i.e., frailty, recovery, and death) after becoming frail among those with frailty onset (n = 373).
There was a nonlinear association between greater number of frailty criteria and increasing risk of mortality, with a notable risk acceleration after having accumulated all five criteria (hazard ratio (HR) = 32.6 vs none, 95% confidence interval (CI) = 15.7-67.5). In addition, the risk of one-year mortality tripled, and the likelihood of recovery (i.e., reverting to be robust or pre-frail) halved among those with five frailty criteria compared to those with three or four criteria. A 50% increase in mortality risk was also associated with frailty onset without (vs with) a prior history of pre-frailty (HR = 1.51, 95% CI = 1.20-1.90).
Both the number and rate of accumulation of frailty criteria were associated with mortality risk. Although there was insufficient evidence to declare a point of no return, having all five-frailty criteria signals the beginning of a transition toward a point of no return. Ongoing monitoring of frailty progression could aid clinical and personal decision-making regarding timing of intervention and eventual transition from curative to palliative care.
调查衰弱表现的累积率和模式与全因死亡率的关系，以及衰弱进程是否存在一个不可逆且死亡迫在眉睫的转折点（即不归点）。
纵向观察性研究。
社区或非养老院居住护理环境。
2011 年基线时确定的 2557 名健壮老年人，2011 年至 2018 年期间进行全因死亡率随访。
衰弱采用身体衰弱表型进行测量。Cox 模型用于研究各时间点的衰弱标准数量（0-5）及其累积模式与全因死亡率的关系。马尔可夫状态转移模型用于研究在出现衰弱（n=373）的情况下，那些进入衰弱状态的人在一年内从健康状态（即衰弱、恢复和死亡）之间的转移情况。
随着衰弱标准数量的增加，死亡率的风险呈非线性增加，在累积了所有五个标准后，风险显著加速（风险比（HR）=32.6 比无，95%置信区间（CI）=15.7-67.5）。此外，与有三或四个标准的人相比，有五个衰弱标准的人在一年内死亡的风险增加了两倍，恢复的可能性（即恢复为健壮或衰弱前期）减半。与有衰弱前期病史的人相比，无衰弱前期病史的人出现衰弱时，死亡率风险增加 50%（HR=1.51，95%CI=1.20-1.90）。
衰弱标准的数量和累积速度都与死亡率风险相关。尽管没有足够的证据宣布一个不归点，但所有五个衰弱标准都标志着向不归点转变的开始。对衰弱进展的持续监测可以帮助临床和个人决策，确定干预的时机以及从治疗性护理向姑息性护理的最终转变。
