The accumulation of deficits approach to describe frailty

Autoři: Raskit Lachmann aff001;  Marta Stelmach-Mardas aff001;  Manuela M. Bergmann aff001;  Wolfgang Bernigau aff001;  Daniela Weber aff003;  Tobias Pischon aff004;  Heiner Boeing aff001
Působiště autorů: Department of Epidemiology, German Institute of Human Nutrition, Potsdam-Rehbruecke, Germany aff001;  Department of Biophysics, Poznan University of Medical Sciences, Poznan, Poland aff002;  Department of Molecular Toxicology, German Institute of Human Nutrition, Potsdam-Rehbruecke, Germany aff003;  Molecular Epidemiology Research Group, Max-Delbrueck Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin-Buch, Germany aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223449


The advancing age of the participants of the European Prospective Investigation into Cancer and Nutrition (EPIC)—Potsdam study was the incentive to investigate frailty as a major parameter of ageing. The aim of this study was to develop a multidimensional tool to measure frailty in an ageing, free-living study population. The “accumulation of deficits approach” was used to develop a frailty index (FI) to characterize a sub-sample (N = 815) of the EPIC-Potsdam (EPIC-P) study population regarding the aging phenomenon. The EPIC-P frailty index (EPIC-P-FI) included 32 variables from the following domains: health, physical ability, psychosocial and physiological aspects. P–values were calculated for the linear trend between sociodemographic and life style variables and the EPIC-P-FI was calculated using regression analysis adjusted for age. The relationship between the EPIC-P-FI and age was investigated using fractional polynomials. Some characteristics such as age, education, time spent watching TV, cycling and a biomarker of inflammation (C-reactive protein) were associated with frailty in men and women. Interestingly, living alone, having no partner and smoking status were only associated with frailty in men, and alcohol use and physical fitness (VO2max) only in women. The generated, multidimensional FI, adapted to the EPIC-P study, showed that this cohort is a valuable source for further exploration of factors that promote healthy ageing.

Klíčová slova:

Aging – Elderly – Frailty – Hand strength – Mental health and psychiatry – Physical activity – Professions – Aging and cancer


1. Romero-Ortuno R, Kenny RA. The frailty index in Europeans: association with age and mortality. Age Ageing. 2012; 41:684–689. doi: 10.1093/ageing/afs051 22522775

2. Shamliyan T, Talley KM, Ramakrishnan R, Kane RL. Association of frailty with survival: a systematic literature review. Ageing Res Rev. 2013; 12:719–736. doi: 10.1016/j.arr.2012.03.001 22426304

3. Saum KU, Dieffenbach AK, Muller H, Holleczek B, Hauer K, Brenner H. Frailty prevalence and 10-year survival in community-dwelling older adults: results from the ESTHER cohort study. Eur J Epidemiol. 2014; 29:171–179 doi: 10.1007/s10654-014-9891-6 24671603

4. Dorner TE, Luger E, Tschinderle J, Stein KV, Haider S, Kapan A, et al. Association between Nutritional Status (MNA(R)-SF) and Frailty (SHARE-FI) in Acute Hospitalised Elderly Patients. J Nutr Health Aging 2014; 18:264–269. doi: 10.1007/s12603-013-0406-z 24626753

5. Bergman H, Ferrucci L, Guralnik J, Hogan DB, Hummel S, Karunananthan S. et al. Frailty: an emerging research and clinical paradigm—issues and controversies. J Gerontol A Biol Sci Med Sci 2007; 62: 731–737. doi: 10.1093/gerona/62.7.731 17634320

6. Rodriguez-Manas L, Feart C, Mann G, Viña J, Chatterji S, Chodzko-Zajko W. et al. Searching for an operational definition of frailty: a Delphi method based consensus statement: the frailty operative definition-consensus conference project. J Gerontol A Biol Sci Med Sci 2013; 68: 62–67. doi: 10.1093/gerona/gls119 22511289

7. Bouillon K, Kivimaki M, Hamer M, Sabia S, Fransson EI, Singh-Manoux A. et al. Measures of frailty in population-based studies: an overview. BMC Geriatr 2013;13: 64. doi: 10.1186/1471-2318-13-64 23786540

8. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J. et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56: 146–156.

9. Kane RL, Shamliyan T, Talley K, Pacala J. The association between geriatric syndromes and survival. J Am Geriatr Soc. 2012; 60: 896–904. doi: 10.1111/j.1532-5415.2012.03942.x 22568483

10. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I. et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173: 489–495. doi: 10.1503/cmaj.050051 16129869

11. Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr 2008; 8:24. doi: 10.1186/1471-2318-8-24 18826625

12. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci 2007; 62: 738–743. doi: 10.1093/gerona/62.7.738 17634321

13. Boeing H, Korfmann A, Bergmann MM. Recruitment procedures of EPIC-Germany. European Investigation into Cancer and Nutrition. Ann Nutr Metab 1999; 43: 205–215. doi: 10.1159/000012787 10592369

14. Riboli E, Kaaks R. The EPIC Project: rationale and study design. European Prospective Investigation into Cancer and Nutrition. Int J Epidemiol 1997; 26 Suppl 1:S6–14.

15. Boeing H, Wahrendorf J, Becker N. EPIC-Germany-A source for studies into diet and risk of chronic diseases. European Investigation into Cancer and Nutrition. Ann Nutr Metab 1999; 43: 195–204. doi: 10.1159/000012786 10592368

16. Kroke A, Bergmann MM, Lotze G, Jeckel A, Klipstein-Grobusch K, Boeing H. Measures of quality control in the German component of the EPIC study. European Prospective Investigation into Cancer and Nutrition. Ann Nutr Metab 1999; 43: 216–224. doi: 10.1159/000012788 10592370

17. Wientzek A, Tormo Diaz MJ, Castano JM, Amiano P, Arriola L, Overvad K. et al. Cross-sectional associations of objectively measured physical activity, cardiorespiratory fitness and anthropometry in European adults. Obesity 2014; 22: 127–134.

18. Mitnitski AB, Song X, Rockwood K. The estimation of relative fitness and frailty in community-dwelling older adults using self-report data. J Gerontol A Biol Sci Med Sci 2004; 59: 627–632.

19. Hoover M, Rotermann M, Sanmartin C, Bernier J. Validation of an index to estimate the prevalence of frailty among community-dwelling seniors. Health Rep 2013; 24: 10–17.

20. Hubbard RE, Lang IA, Llewellyn DJ, Rockwood K. Frailty, body mass index, and abdominal obesity in older people. J Gerontol A Biol Sci Med Sci 2010; 65: 377–381. doi: 10.1093/gerona/glp186 19942592

21. Martinez-Gonzalez MA, Garcia-Arellano A, Toledo E, Bes-Rastrollo M, Bulló M, Corella D. et al. Obesity indexes and total mortality among elderly subjects at high cardiovascular risk: the PREDIMED study. PloS One 2014; 9: e103246. doi: 10.1371/journal.pone.0103246 25072784

22. Bartali B, Frongillo EA, Bandinelli S, Lauretani F, Semba RD, Fried LP. et al. Low nutrient intake is an essential component of frailty in older persons. J Gerontol A Biol Sci Med Sci 2006; 61: 589–593. doi: 10.1093/gerona/61.6.589 16799141

23. FAO/WHO/UNU. Human energy requirements: Report of a Joint FAO/WHO/UNU Expert Consultation. Rome, 2001.

24. Clegg A, Rogers L, Young J. Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review. Age Ageing 2015; 44: 148–152 doi: 10.1093/ageing/afu157 25355618

25. Eeles E, Low Choy N. Frailty and Mobility. Interdiscip Top Gerontol Geriatr 2015; 41: 107–120. doi: 10.1159/000381200 26301984

26. Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology 2009; 55: 539–549. doi: 10.1159/000211949 19346741

27. Hubbard RE. Sex Differences in Frailty Interdiscip Top Gerontol Geriatr. 2015; 41: 41–53.

28. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorld Journal 2001; 1: 323–336. doi: 10.1100/tsw.2001.58 12806071

29. Kulminski AM, Ukraintseva SV, Kulminskaya IV, Arbeev KG, Land K, Yashin AI. Cumulative deficits better characterize susceptibility to death in elderly people than phenotypic frailty: lessons from the Cardiovascular Health Study. J Am Geriatr Soc 2008; 56: 898–903. doi: 10.1111/j.1532-5415.2008.01656.x 18363679

30. Mitnitski AB, Graham JE, Mogilner AJ, Rockwood K. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr 2002; 2: 1. doi: 10.1186/1471-2318-2-1 11897015

31. Abete P, Basile C, Bulli G, Curcio F, Liguori I, Della-Morte D, et al. The Italian version of the "frailty index" based on deficits in health: a validation study. Aging Clin Exp Res. 2017;29:913–926. doi: 10.1007/s40520-017-0793-9 28688080

32. Testa G, Liguori I, Curcio F, Russo G, Bulli G, Galizia G, et al. Multidimensional frailty evaluation in elderly outpatients with chronic heart failure: A prospective study. Eur J Prev Cardiol. 2019;26:1115–1117. doi: 10.1177/2047487319827460 30722680

33. Dapp U, Minder CE, Anders J, Golgert S, von Renteln-Kruse W. Long-term prediction of changes in health status, frailty, nursing care and mortality in community-dwelling senior citizens—results from the longitudinal urban cohort ageing study (LUCAS). BMC Geriatr 2014; 14: 141. doi: 10.1186/1471-2318-14-141 25522653

34. Pialoux T, Goyard J, Lesourd B. Screening tools for frailty in primary health care: a systematic review. Geriatr Gerontol Int 2012; 12: 189–197. doi: 10.1111/j.1447-0594.2011.00797.x 22233158

35. Garcia-Garcia FJ, Carcaillon L, Fernandez-Tresguerres J, Alfaro A, Larrion JL, Castillo Ce. t al. A new operational definition of frailty: the frailty trait scale. J Am Med Dir Assoc 2014; 15: 371 e7– e13.

36. Sourial N, Wolfson C, Bergman H, Zhu B, Karunananthan S, Quail J. et al. A correspondence analysis revealed frailty deficits aggregate and are multidimensional. J Clin Epidemiol 2010; 63: 647–654. doi: 10.1016/j.jclinepi.2009.08.007 19880286

37. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing 2006; 35: 526–529. doi: 10.1093/ageing/afl041 16757522

38. Jung HW, Kim SW, Ahn S, Lim JY, Han JW, Kim TH. et al. Prevalence and outcomes of frailty in Korean elderly population: comparisons of a multidimensional frailty index with two phenotype models. PloS one 2014; 9: e87958. doi: 10.1371/journal.pone.0087958 24505338

39. Tocchi C, Dixon J, Naylor M, Jeon S, McCorkle R. Development of a frailty measure for older adults: the frailty index for elders. J Nurs Meas 2014; 22: 223–240. 25255675

40. Goggins WB, Woo J, Sham A, Ho SC. Frailty index as a measure of biological age in a Chinese population. J Gerontol A Biol Sci Med Sci 2005; 60: 1046–1051. doi: 10.1093/gerona/60.8.1046 16127111

41. Bielderman A, van der Schans CP, van Lieshout MR, de Greef MH, Boersma F, Krijnen WP. et al. Multidimensional structure of the Groningen Frailty Indicator in community-dwelling older people. BMC Geriatr 2013; 13: 86 doi: 10.1186/1471-2318-13-86 23968433

42. Drubbel I, de Wit NJ, Bleijenberg N, Eijkemans RJ, Schuurmans MJ, Numans ME. Prediction of adverse health outcomes in older people using a frailty index based on routine primary care data. J Gerontol A Biol Sci Med Sci 2013; 68: 301–308. doi: 10.1093/gerona/gls161 22843671

43. Romero-Ortuno R. Frailty Index in Europeans: Association with determinants of health. Geriatr Gerontol Int 2014; 14: 420–429. doi: 10.1111/ggi.12122 23879634

44. Jones D, Song X, Mitnitski A, Rockwood K. Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians. Aging Clin Exp Res 2005; 17: 465–471. 16485864

45. Drubbel I, Bleijenberg N, Kranenburg G, Eijkemans RJ, Schuurmans MJ, de Wit NJ. et al. Identifying frailty: do the Frailty Index and Groningen Frailty Indicator cover different clinical perspectives? a cross-sectional study. BMC Family Practice 2013; 14: 64. doi: 10.1186/1471-2296-14-64 23692735

46. Shi J, Yang Z, Song X, Yu P, Fang X, Tang Z et al. Sex Differences in the Limit to Deficit Accumulation in Late Middle-Aged and Older Chinese People: Results From the Beijing Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci 2008; 69: 702–709.

47. Rockwood K, Mitnitski A. Limits to deficit accumulation in elderly people. Mech Ageing Dev. 2006; 127: 494–496. doi: 10.1016/j.mad.2006.01.002 16487992

48. Armstrong JJ, Mitnitski A, Launer LJ, White LR, Rockwood K. Frailty in the Honolulu-Asia Aging Study: Deficit Accumulation in a Male Cohort Followed to 90% Mortality. J Gerontol A Biol Sci Med Sci. 2015; 70: 125–131. doi: 10.1093/gerona/glu089 24973228

49. Li G, Ioannidis G, Pickard L, Kennedy C, Papaioannou A, Thabane L. et al. Frailty index of deficit accumulation and falls: data from the Global Longitudinal Study of Osteoporosis in Women (GLOW) Hamilton cohort. BMC Musculoskelet Disord 2014; 15: 185. doi: 10.1186/1471-2474-15-185 24885323

50. Harttgen K, Kowal P, Strulik H, Chatterji S, Vollmer S. Patterns of frailty in older adults: comparing results from higher and lower income countries using the Survey of Health, Ageing and Retirement in Europe (SHARE) and the Study on Global AGEing and Adult Health (SAGE). PloS One 2013; 8: e75847. doi: 10.1371/journal.pone.0075847 24204581

51. Bennett S, Song X, Mitnitski A, Rockwood K. A limit to frailty in very old, community-dwelling people: a secondary analysis of the Chinese longitudinal health and longevity study. Age Ageing 2013; 42: 372–377. doi: 10.1093/ageing/afs180 23232936

52. Buchman AS, Wilson RS, Bienias JL, Bennett DA. Change in frailty and risk of death in older persons. Exp Aging Res 2009; 35: 61–82. doi: 10.1080/03610730802545051 19173102

53. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc 2012; 60: 1487–1492. doi: 10.1111/j.1532-5415.2012.04054.x 22881367

54. Ravaglia G, Forti P, Lucicesare A, Pisacane N, Rietti E, Patterson C. Development of an easy prognostic score for frailty outcomes in the aged. Age Ageing 2008; 37: 161–166. doi: 10.1093/ageing/afm195 18238805

55. Wang C, Song X, Mitnitski A, Yu P, Fang X, Tang Z. et al. Gender differences in the relationship between smoking and frailty: results from the Beijing Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci. 2013; 68: 338–346. doi: 10.1093/gerona/gls166 22843672

56. Mello Ade C, Engstrom EM, Alves LC. Health-related and socio-demographic factors associated with frailty in the elderly: a systematic literature review. Cad Saude Publica 2014; 30: 1143–1168. doi: 10.1590/0102-311x00148213 25099040

57. Shi J, Song X, Yu P, Tang Z, Mitnitski A, Fang X, Rockwood K. Analysis of frailty and survival from late middle age in the Beijing Longitudinal Study of Aging. BMC Geriatr 2011; 11: 17. doi: 10.1186/1471-2318-11-17 21507234

58. Guessous I, Luthi JC, Bowling CB, Theler JM, Paccaud F, Gaspoz JM. et al. Prevalence of frailty indicators and association with socioeconomic status in middle-aged and older adults in a swiss region with universal health insurance coverage: a population-based cross-sectional study. J Aging Res 2014:198603. doi: 10.1155/2014/198603 25405033

59. Pegorari MS, Tavares DM. Factors associated with the frailty syndrome in elderly individuals living in the urban area. Rev Lat Am Enfermagem 2014; 22: 874–882. doi: 10.1590/0104-1169.0213.2493 25493685

60. Hoogendijk EO, van Hout HP, Heymans MW, van der Horst HE, Frijters DH, Broese van Groenou MI. et al. Explaining the association between educational level and frailty in older adults: results from a 13-year longitudinal study in the Netherlands. Ann Epidemiol 2014; 24: 538–544. doi: 10.1016/j.annepidem.2014.05.002 24935466

61. Ng TP, Feng L, Nyunt MS, Larbi A, Yap KB. Frailty in older persons: multisystem risk factors and the Frailty Risk Index (FRI). J Am Med Dir Assoc 2014; 15: 635–642. doi: 10.1016/j.jamda.2014.03.008 24746590

62. Woo J, Goggins W, Sham A, Sham A, Ho SC. Social determinants of frailty. Gerontology 2005; 51: 402–408. doi: 10.1159/000088705 16299422

63. Etman A, Kamphuis CB, van der Cammen TJ, Burdorf A, van Lenthe FJ. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Eur J Public Health 2015; 25: 345–350. doi: 10.1093/eurpub/cku093 25061232

64. Lee JS, Auyeung TW, Leung J, Buyssed DJ, Kaneita Y. Long sleep duration is associated with higher mortality in older people independent of frailty: a 5-year cohort study. J Am Med Dir Assoc 2014; 15: 649–654. doi: 10.1016/j.jamda.2014.05.006 24973244

65. Nobrega PV, Maciel AC, de Almeida Holanda CM, Oliveira Guerra R, Araújo JF. Sleep and frailty syndrome in elderly residents of long-stay institutions: a cross-sectional study. Geriatr Gerontol Int 2014; 14: 605–612. doi: 10.1111/ggi.12144 24020502

66. Healy GN, Dunstan DW, Salmon J, Shaw JE, Zimmet PZ, Owen N. Television time and continuous metabolic risk in physically active adults. Med Sci Sports Exerc 2008; 40: 639–645. doi: 10.1249/MSS.0b013e3181607421 18317383

67. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc 2009; 41: 998–1005. doi: 10.1249/MSS.0b013e3181930355 19346988

68. Blodgett J, Theou O, Kirkland S, Andreou P, Rockwood K. The association between sedentary behaviour, moderate-vigorous physical activity and frailty in NHANES cohorts. Maturitas 2015; 80: 187–191. doi: 10.1016/j.maturitas.2014.11.010 25542406

69. Wientzek A, Vigl M, Steindorf K, Brühmann B, Bergmann MM, Harttig U. et al. The improved physical activity index for measuring physical activity in EPIC Germany. PloS One 2014; 9: e92005. doi: 10.1371/journal.pone.0092005 24642812

70. Puts MT, Visser M, Twisk JW, Deeg DJ, Lips P. Endocrine and inflammatory markers as predictors of frailty. Clin Endocrinol (Oxf) 2005; 63: 403–411.

71. Hubbard RE, O'Mahony MS, Savva GM, Calver BL, Woodhouse KW. Inflammation and frailty measures in older people. J Cell Mol Med 2009; 13: 3103–3109. doi: 10.1111/j.1582-4934.2009.00733.x 19438806

72. Theou O, O'Connell MD, King-Kallimanis BL, O'Halloran AM, Rockwood K, Kenny RA. Measuring frailty using self-report and test-based health measures. Age Ageing 2015; 44:471–477 doi: 10.1093/ageing/afv010 25687601

Článek vyšel v časopise


2019 Číslo 10