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Kane RL, Talley KMC, Shamliyan T, et al. Common Syndromes in Older Adults Related to Primary and Secondary Prevention [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Jul. (Evidence Syntheses/Technology Assessments, No. 87.)

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Common Syndromes in Older Adults Related to Primary and Secondary Prevention [Internet].

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Geriatric syndromes can lead to age-related decline in well-being among elderly adults.1,2 The signs and symptoms encompassed by geriatric syndromes span multiple physiological systems related to functional dependency.3,4 A number of syndromes identified by longitudinal studies are associated with reduced function and quality of life and increased risk of institutionalization and mortality.5–8 However, variations in syndrome definitions make systematic discussion of their effects difficult.

Routine clinical practice includes assessment of age-related chronic diseases based on accepted diagnostic criteria. In contrast, comprehensive geriatric assessment goes beyond examination for chronic diseases and focuses on functional independence in daily activities and optimal interventions to improve functional status and quality of life.9 Indeed, comprehensive geriatric assessment emphasizes functional status as a major quality of life factor for older adults.10

Quality of life improvements for older adults require addressing geriatric syndromes in addition to managing chronic disease.11 A geriatric syndrome’s definition, along with its combination with any chronic disease, affects the syndrome’s association with patient-centered outcomes, including quality of life, institutionalization, and mortality.12–14 Certain factors are long known to affect patient-centered outcomes. For example, the persistently strong association between self-assessed health status and patient-centered outcomes remains a marvel.15 Similarly, dependency, defined as deficiencies in activities of daily living (ADLs), also associates strongly with patient-centered outcomes.16 Systematic reviews have yet to examine other syndromes, such as cognitive impairment, frailty, poor nutrition status, or chronic inflammation for prevalence or association with institutionalization and mortality.

This review examines what is known about common geriatric syndromes and their effect on the clinical course of older patients. Our analysis examines the extent to which varying definitions of each syndrome can affect determination of its prevalence and its association with patient-centered outcomes. In general, we anticipate a reciprocal relationship; the more inclusive the definition, the higher the prevalence. More encompassing definitions or those with lower thresholds will inevitably raise prevalence estimates and be less precise in their predictive power than more stringent definitions with higher cut scores. For example, Manton applied ADL- and instrumental activities of daily living (IADL)-related measures for disability to describe a pattern of decline in prevalence over two decades.17 Our review synthesizes the evidence for the following research questions.

Key Questions

Key Question 1. What is the definition and prevalence of common syndromes/conditions in older adults?

  • Multiple morbidities (using polypharmacy as a proxy)
  • Cognitive impairment
  • Frailty
  • Disability
  • Sarcopenia
  • Malnutrition
  • Homeostenosis
  • Chronic inflammation

Key Question 2. What is the prevalence of common syndromes/conditions in older adults in sex, age, race, ethnicity, and other subgroups?

  • Sex subgroups (men, women)
  • Age subgroups (>65 years, >85 years)
  • Race subgroups (European, African, Asian, American Native)
  • Ethnicity subgroups (white Hispanic, white non-Hispanic, African American, Asian, Arab, Oceanic, Jewish)
  • Comorbidity profile defined as a composite comorbidity measure rather than the presence of the specific disease

Key Question 3. What is the association between these common syndromes/conditions and mortality, institutionalization, hospitalization, and activities of daily living?

Key Question 4. What statistical and decisionmaking models report mortality based on these common geriatric syndromes/conditions?

Focus of the Review

This review examines selected geriatric syndromes for prevalence and potential impact on various outcomes. We do not address the suitability of preventing these syndromes or altering their courses.

Multiple operational definitions of the syndromes presented a challenge to summarizing the research on their prevalence and predictive power. Frailty, especially, persists as an elusive concept, despite efforts at consensus conferences on the topic.18–21 Frailty may be viewed as a specific phenotype or as an index of deficit accumulations.22,23 However, despite problems of definition and measurement, frailty demonstrates a potent association with outcomes. Different indices derived from frailty measures have shown association with adverse events.24 Likewise, increasing frailty is typically associated with adverse events.25 Frailty and related components (such as ADL dependency, delirium, malnutrition risk, and comorbidity) are linked to increased mortality risk.26 More deficit accumulation is associated with worse outcomes.13 Frailty predicts mortality even after consideration of the effects of clinical and subclinical disease.27 Frailty’s predictive capacity also seems to hold up among various populations in different countries.28

Syndromes are also not independent; definitions and prevalence estimates overlap considerably. For example, sarcopenia is associated with frailty, but some view the former as a dimension of the latter.29–31 Frailty is associated with comorbidity and disability, although efforts to distinguish the latter emphasize frailty’s multisystem dysfunction and instability.32,33 Various geriatric conditions (such as cognitive impairment, falls, and ADL dependency) are associated with disability.34 Polypharmacy may indicate multiple morbidities, but overzealous prescription may also be a factor.35 Research suggests that inflammatory cytokines play a substantial role in age-related disease.36 Thus, separating the syndromes presents another challenge.

This report was commissioned by the U.S. Preventive Services Task Force (USPSTF) as background material to help them understand the impact of geriatric syndromes on well-being. The USPSTF opted not to consider disease as a risk factor. Our review does not address the suitability of preventing the examined syndromes or altering their courses.

The Technical Expert Panel (TEP) selected geriatric syndromes (but not diseases) for this review according to how much each syndrome would affect the enthusiasm of clinicians for recommending prevention strategies. We addressed the eight syndromes that were most highly rated.

We included original epidemiologic studies that examined prevalence of the eligible syndromes in adults older than age 65 years. We defined young-old as ages 65–80 years, elderly as ages 80–90 years, and very old as ages 90 years and older. We defined age categories the same as they were defined in the original studies.

We retrieved 2,377 publications and excluded 1,865 that were not eligible for review. We included 509 publications of 123 studies. The majority of the studies were well designed prospective cohorts or national surveys conducted in the United States, including the National Health and Nutrition Examination Survey (NHANES), the National Health Interview Survey, and the National Survey of Self-Care and Aging (76 studies, 62 percent).


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