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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 194-198

A prospective study for the assessment of frailty in elderly chronic kidney disease patients


1 Department of Medicine, Faculty of Medicine and Health Sciences, SGT Medical College Hospital and Research Institute, SGT University, Gurugram, Haryana, India
2 Department of Medicine, Lal Bahadur Shastri Hospital, New Delhi, India
3 Department of Internal Medicine, Max Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India
4 Department of Clinical Psychology, Faculty of Behavioral Sciences, SGT Medical College Hospital and Research Institute, SGT University, Gurugram, Haryana, India

Date of Submission10-Mar-2021
Date of Decision21-Mar-2021
Date of Acceptance29-Mar-2021
Date of Web Publication23-Oct-2021

Correspondence Address:
Prof. Narinder Pal Singh
Department of Medicine, Faculty of Medicine and Health Sciences, SGT Medical College Hospital and Research Institute, SGT University, Gurugram, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_35_21

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  Abstract 


Background: Frailty is a common clinical syndrome in the elderly that may be associated with increased risk of health complications and decreased physical functioning. Early screening of individuals who are at high risk of frailty is required to allow timely intervention for the prevention and reversal of frailty. There is a paucity of information on frailty among the Indian elderly population and especially among the elderly chronic kidney disease (CKD) population. Hence, the aim of the present study was to find out the occurrence of frailty in elderly patients with CKD. Methods: The present prospective cross-sectional study was conducted from an outpatient clinic of a tertiary care hospital. We enrolled 200 participants aged 60 years or above, dividing them into two groups as case (included those with CKD stage 3 and above who were not on dialysis with or without any coexisting comorbidities) and control groups (included those non-CKD patients with or without any coexisting comorbidities). Exclusion criteria were patients with prior history of stroke with neurological complications, dementia or cognitive deficit, severe Parkinson's disease, and nonambulatory. Assessment of frailty was done using the short physical performance battery test (SPPBT) and handgrip strength (HGS). Assessment of HGS was done using a JAMAR hand dynamometer. The data were analyzed using SPSS V 20.0. Results: Majority of the participants were male in the case group (58%), while they were almost equal in the control group (51%). Most of the participants belonged to the age groups of 60–70 years with a mean age of 68.8 ± 5.90 years and 67.99 ± 5.93 years in case and control groups, respectively. In the case group, more than half of the patients had CKD stage 4 (57%), followed by CKD stage 5 (36%). There was no significant difference in diabetes mellitus (P = 0.41), hypertension (P = 0.63), malignancy (P = 1.0), CLD (P = 0.097), and thyroid disorder (P = 0.85) among the groups. Using SPPBT, frailty was found to be significantly higher in CKD patients in comparison to control (78% vs. 62%, P = 0.014). Using the HGS criteria, frailty was detected almost similar in both the groups (CKD vs. non-CKD; 77% vs. 78%, P = 0.866). Frailty was found to be high (78.5%) in CKD patients who had estimated glomerular filtration rate of <30 ml/min. Moreover, frailty was significantly higher in those with diabetes with CKD than diabetic alone (P = 0.009). Conclusion: Frailty was found to be high in elderly patients with CKD as compared to the non-CKD population. This indicates a need for continuous assessment of frailty and timely tailored intervention for prevention and reversal of frailty in the elderly CKD population.

Keywords: Chronic kidney disease, elderly, frailty, handgrip strength, short physical performance battery test


How to cite this article:
Singh NP, Khan MQ, Choudhary PN, Gupta AK, Kaul S. A prospective study for the assessment of frailty in elderly chronic kidney disease patients. Indian J Med Spec 2021;12:194-8

How to cite this URL:
Singh NP, Khan MQ, Choudhary PN, Gupta AK, Kaul S. A prospective study for the assessment of frailty in elderly chronic kidney disease patients. Indian J Med Spec [serial online] 2021 [cited 2022 Nov 30];12:194-8. Available from: http://www.ijms.in/text.asp?2021/12/4/194/329032




  Introduction Top


Frailty is a state of transit between aging and disability, attributable to hormonal changes, diminished muscle strength, anorexia, depression, and degeneration in multiple physiological functions.[1],[2] Frailty is associated with an increased risk of poor outcomes such as fall, disability, long-term care, hospitalization, and mortality.[3] Studies have shown an association between frailty and comorbid conditions such as diabetes, hypertension, chronic kidney disease (CKD), and coronary artery disease.[4] CKD is associated with a higher risk of frailty or diminished physical function. Frailty may lead to an increase in the risk of mortality in patients with CKD.[5] Frailty is highly prevalent among patients undergoing dialysis and is a strong independent predictor of falls regardless of age.[6],[7] Therefore, it is necessary to do an early screening of individuals who are at high risk of frailty and also to identify the component of frailty affecting them. This may lead to timely intervention for the prevention and reversal of frailty. There have been more than twenty-five separate frailty scales described.[8] Short physical performance battery test (SPPBT) is a feasible and standardized tool to assess frailty in geriatric outpatient department (OPD) clinics. Moreover, handgrip strength (HGS) has been used widely to diagnose frailty taking into account gender and body mass index (BMI).[9] HGS testing is a quick assessment tool for frailty and has the potential to be used during common OPD visits. Muscle strength is measured using a JAMAR hand dynamometer.[10] Both tests focus primarily on physical component, so may not be able to assess multidimensional components of frailty. There is a paucity of information on frailty in CKD and non-CKD population in India. Hence, we conducted the study to find out the occurrence of frailty among CKD and non-CKD elderly population.


  Methods Top


Study population

The present prospective cross-sectional study was conducted from an outpatient clinic of a tertiary care hospital. We enrolled 200 participants aged 60 years or above, dividing them into two arms as case and control. Elderly participants with CKD Stage 3 and above (estimated glomerular filtration rate [eGFR]: <60 ml/min/1.73 m2) not on dialysis at screening with or without any comorbidities were considered as case, while elderly non-CKD with or without any coexisting comorbidities were considered as control. Patients with prior medical history of stroke with neurological complications, dementia or cognitive deficit, severe Parkinson's disease, and nonambulatory and patients who underwent dialysis were excluded from the study.

Study procedure

Study participants were assessed and enrolled in the study based on inclusion and exclusion criteria. Informed consent was taken before enrolling the subject in the study. The study was initiated after approval from the ethics committee of the institution. Patient details were incorporated based on the proforma, thereby including demographic details and history of comorbidities. Blood samples for serum creatinine were obtained in each participant and eGFR was calculated (using MDRD equation). SPPBT and HGS were used for the assessment of the frailty and the data were recorded.

Measurement

Short physical performance battery test

SPPB test score was calculated by adding scores obtained individually in its three parameters, each ranging from 0 to 4. These were balance test (side by side, semi tandem, and tandem), 4-m gait speed test, and chair stand test. The scoring system for diagnosing frailty[11],[12] is depicted in [Table 1]. A score of <10 was considered as frail and a score more than and equal to 10 was considered as nonfrail.
Table 1: Short Physical Performance Battery Test

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Handgrip strength

Handgrip analysis was done using the JAMAR hand dynamometer and the HGS was measured and noted. The cutoffs defined according to BMI and gender by Fried et al.[9] were used to classify the participants as frail and nonfrail [Table 2].
Table 2: Handgrip strength (kg) cutoff for frailty stratified by gender and body mass index (Fried et al.)

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Statistical analysis

All the statistical analyses were performed using SPSS (version 20.0, Armonk, NY, USA: IBM Corp.). Continuous variables were reported as mean and standard deviation and categorical variables were illustrated in percentage. The relationship between the comorbidities and frailty was established using statistical inference Chi-square test. 5% probability level was considered as statistically significant, i.e., P < 0.05.


  Results Top


The majority of the participants were male in both case (58%) and control groups (51%). Most of the participants belonged to the age groups of 60–70 years. In the case group, more than half of patients had CKD stage 4 (57%), followed by CKD stage 5 (36%). Demographic details and various comorbidities of study participants are illustrated in [Table 3].
Table 3: Descriptive statistics

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Frailty detected by short physical performance battery test

By applying SPPBT in the case group, frailty was observed in more than three-fourth of participants (78%), while in the control group, less than two-third (62%) were frail. The difference was statistically significant (0.014). Frailty was found to be high (78.5%) in CKD patients who had eGFR <30 ml/min [Figure 1]. Among patients with CKD (case group), the majority of women were frail (76.1%) than men (64.8%); however, the difference was nonsignificant (P = 0.852). There was a significant relationship between the comorbidities and frailty. It was observed that the frailty was significantly higher in those with diabetes with CKD than diabetic alone (P = 0.0098) [Table 4].
Figure 1: Frailty in chronic kidney disease stages

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Table 4: Frailty distribution diagnosed with Short Physical Performance Battery Test

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Frailty detected by handgrip strength (JAMAR dynamometer)

By applying HGS, in the case group, frailty was observed in similar number of cases (77%) and controls (78%) (P = 0.866).


  Discussion Top


Frailty is a common clinical syndrome in the elderly CKD population that may be associated with an increased risk of poor health outcomes. Hence, it is necessary to do an early screening of individuals who are at high risk of becoming frail. It may allow timely intervention for the prevention and reversal of frailty. There is a paucity of study to find out frailty in the geriatric population in the tertiary care setting. Thus, the present study was one such attempt in a cohort of older adults at an outpatient clinic of a tertiary care hospital.

As per the WHO estimation, India has 112 million elderly people (8.2% of the total population of the world) with multiple physical, social-psychological, and economic problems. Worldwide prevalence of frailty has been found to vary from 5% to 20% in the elderly population. The prevalence of frailty has been reported to be >50% in the elderly predialysis CKD population and more than 70% reported in dialysis-dependent elderly CKD patients.[13],[14],[15] In India, community-based observational studies demonstrated that the proportion of frailty was 35%–78% among elderly aged 60 years.[16],[17]

The present study was based on two methods (SPPBT and HGS) for the detection of frailty. SPPBT seems to be a better method because it is not only based on one parameter but also includes an extensive scoring system. In the present study, we found significantly higher frailty by applying SPPBT in the participants with CKD (as compared to the control group), whereas the HGS, it was equal in both groups.

By applying SPPBT, the prevalence of frailty was found to be significantly high in CKD patients (78%) than the control group (62%), suggesting that CKD patients were at increased risk of frailty. Using HGS method, 77% of CKD patients were found to be frail. This was contrary to the findings by the SPPBT method. We observed the prevalence of frailty to be higher than previously reported studies from India. There could be various possibilities explaining this difference including study limitation of small sample size, different comorbidity status among patients, different scales being used in previous studies, or observation of different settings of patient care such as Khandelwal et al. found 33.2% frailty among hospitalized patients.[18] A Canadian study did a comparative study between SPPBT and Fried's phenotype method for the assessment of frailty in older people. They observed that frailty was 50% and 35% according to SPPBT and Fried's phenotype method.[19]

Comorbidities also play an important role in the development of frailty among patients with CKD.[20] Thus, comorbid conditions such as diabetes, hypertension, coronary artery disease, thyroid disorder, malignancy, and chronic liver disease could accelerate frailty progression in patients even without CKD.[21],[22] There is an overlapping relationship between comorbidity and frailty. The present study observed that the frailty was higher in those with diabetes with CKD. This indicates a significant contribution of diabetes in the impairment of physical functioning in patients with CKD. It has been shown that diabetes makes individuals prone to frailty by increasing the risk of sarcopenia;[23],[24] therefore, diabetes could be the main cause for frailty in CKD patients. Moreover, studies have reported that the risk of reduced physical function was correlated with comorbidities and frailty risk was 8-fold higher in diabetic patients.[20],[25] Hence, the patients with CKD having diabetes have more chance of increased frailty compared with those with other comorbidity. That is why endocrinologists and nephrologists both should have awareness of frailty and its simple methods that can be done in OPD. Older patients with comorbidities especially diabetes mellitus should be screened for frailty during OPD visits.

In the present study, frailty (78.5%) was found to be high in CKD patients who had eGFR <30 ml/min, while it was 57.1% in CKD patients with eGFR >30 ml/min. Thus, as the eGFR reduces, frailty worsens. The results are consistent with other recent studies.[20],[26],[27],[28],[29]

There are a few limitations in our study. The present study is a small observational one, conducted at a single center; therefore, a conclusion regarding the association between HGS and SPPBT for diagnosing frailty among CKD patients could not be made. Therefore, further studies may be needed to correlate both methods and establishing a quicker way to screen frailty among CKD patients in OPDs.

Conclusion

Hence, the present study reported a significantly high prevalence of frailty in elderly patients with CKD compared to the non-CKD population. There is a need for continued assessment of frailty and tailored intervention for prevention and reversal of frailty. Early identification of individuals who are at high risk of becoming frail with appropriate intervention is a cornerstone of quality care in the elderly population.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
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