title: Frailty and the prediction of dependence and mortality in low- and middle-income countries: a 10/66 population-based cohort study.
abstract: BACKGROUND
  In countries with high incomes, frailty indicators predict adverse outcomes in older people, despite a lack of consensus on definition or measurement. We tested the predictive validity of physical and multidimensional frailty phenotypes in settings in Latin America, India, and China.
  
  
  METHODS
  Population-based cohort studies were conducted in catchment area sites in Cuba, Dominican Republic, Venezuela, Mexico, Peru, India, and China. Seven frailty indicators, namely gait speed, self-reported exhaustion, weight loss, low energy expenditure, undernutrition, cognitive, and sensory impairment were assessed to estimate frailty phenotypes. Mortality and onset of dependence were ascertained after a median of 3.9 years.
  
  
  RESULTS
  Overall, 13,924 older people were assessed at baseline, with 47,438 person-years follow-up for mortality and 30,689 for dependence. Both frailty phenotypes predicted the onset of dependence and mortality, even adjusting for chronic diseases and disability, with little heterogeneity of effect among sites. However, population attributable fractions (PAF) summarising etiologic force were highest for the aggregate effect of the individual indicators, as opposed to either the number of indicators or the dichotomised frailty phenotypes. The aggregate of all seven indicators provided the best overall prediction (weighted mean PAF 41.8 % for dependence and 38.3 % for mortality). While weight loss, underactivity, slow walking speed, and cognitive impairment predicted both outcomes, whereas undernutrition predicted only mortality and sensory impairment only dependence. Exhaustion predicted neither outcome.
  
  
  CONCLUSIONS
  Simply assessed frailty indicators identify older people at risk of dependence and mortality, beyond information provided by chronic disease diagnoses and disability. Frailty is likely to be multidimensional. A better understanding of the construct and pathways to adverse outcomes could inform multidimensional assessment and intervention to prevent or manage dependence in frail older people, with potential to add life to years, and years to life.
authors.affiliation: Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King's College, De Crespigny Park, London, SE5 8AF, UK. jothees.at@iiphh.org.|Indian Institute of Public Health Hyderabad, Public Health Foundation of India, Plot no 1, ANV Arcade, Amar Co-operative society, Kavuri Hills, Madhapur, Hyderabad -, 500033, , Telangana, India. jothees.at@iiphh.org.
authors.forename: Jotheeswaran
authors.initials: J
authors.lastname: At
authors.affiliation: Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King's College, De Crespigny Park, London, SE5 8AF, UK. renata@firstinfo.com.
authors.forename: Renata
authors.initials: R
authors.lastname: Bryce
authors.affiliation: Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King's College, De Crespigny Park, London, SE5 8AF, UK. matthew.prina@kcl.ac.uk.
authors.forename: Matthew
authors.initials: M
authors.lastname: Prina
authors.affiliation: Universidad Nacional Pedro Henriquez Ureña (UNPHU), Internal Medicine Department, Geriatric Section, Km 7 1/2, Av. John F. Kennedy, Santo Domingo, 1423, Dominican Republic. daisyacosta@claro.net.do.
authors.forename: Daisy
authors.initials: D
authors.lastname: Acosta
authors.affiliation: Universidade Federal de Sao Paulo, Department of Psychobiology, Rua Napoleão de Barros, 925, 3rd floor, São Paulo, SP,, 04024-002, Brazil. ferricleusa@gmail.com.|Institute of Education and Health Sciences at the Hospital Alemao Oswaldo Cruz, Rua João Juliao, 245, First floor, Sao Paulo, SP,, 01323-903, Brazil. ferricleusa@gmail.com.
authors.forename: Cleusa P
authors.initials: CP
authors.lastname: Ferri
authors.affiliation: Instituto de la Memoria y Desordenes Relacionados, Av. Constructores 1230, La Molina, Lima, Perú. mariella.guerra.1066@gmail.com.
authors.forename: Mariella
authors.initials: M
authors.lastname: Guerra
authors.affiliation: Peking University, Institute of Mental Health, 51 Huayuan N Rd, Haidian, Beijing, 100083, China. dengy@mail.tsinghua.edu.cn.
authors.forename: Yueqin
authors.initials: Y
authors.lastname: Huang
authors.affiliation: Facultad de Medicina Finley-Albarran, Medical University of Havana, Calle 146 No. 2504, Playa municipality, Havana, Cuba. mguerra@infomed.sld.cu.
authors.forename: Juan J Llibre
authors.initials: JJ
authors.lastname: Rodriguez
authors.affiliation: Medicine Department, Caracas University Hospital; Faculty of Medicine, Universidad Central de Venezuela, Edif. Decanato de Medicina, Los Chaguaramos, Caracas-9995, Venezuela. aquiles@cantv.net.
authors.forename: Aquiles
authors.initials: A
authors.lastname: Salas
authors.affiliation: National Institute of Neurology and Neurosurgery of Mexico, Autonomous National University of Mexico, Delegacion Tlalpan, Coyoacán -, 4510, Mexico. drasosa@hotmail.com.
authors.forename: Ana Luisa
authors.initials: AL
authors.lastname: Sosa
authors.affiliation: Voluntary Health Services, Taramani, Chennai-, 6000113, India. jdw@vsnl.com.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Williams
authors.affiliation: Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King's College, De Crespigny Park, London, SE5 8AF, UK. michael.dewey@kcl.ac.uk.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Dewey
authors.affiliation: National Institute of Neurology and Neurosurgery of Mexico, Autonomous National University of Mexico, Delegacion Tlalpan, Coyoacán -, 4510, Mexico. ixhuetzca@hotmail.com.
authors.forename: Isaac
authors.initials: I
authors.lastname: Acosta
authors.affiliation: Peking University, Institute of Mental Health, 51 Huayuan N Rd, Haidian, Beijing, 100083, China. zhaoruiliu@gmail.com.
authors.forename: Zhaorui
authors.initials: Z
authors.lastname: Liu
authors.affiliation: Department of Ageing and Life Course, World Health Organization, Avenue Appia 201211, Geneva 27, Switzerland. beardj@who.int.
authors.forename: John
authors.initials: J
authors.lastname: Beard
authors.affiliation: Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King's College, De Crespigny Park, London, SE5 8AF, UK. martin.prince@kcl.ac.uk.
authors.forename: Martin
authors.initials: M
authors.lastname: Prince
mesh_terms: D000368:Aged; D002681:China / Q000453:epidemiology; D002908:Chronic Disease / Q000453:epidemiology; D015331:Cohort Studies; D003906:Developing Countries / Q000706:statistics & numerical data*; D006233:Persons with Disabilities / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data*; D006801:Humans; D007194:India / Q000453:epidemiology; D007843:Latin America; D008297:Male; D008800:Mexico / Q000453:epidemiology; D012959:Socioeconomic Factors