Frailty and social isolation exacerbate health risks

In a recent review published in the journal The Lancet Healthy Longevity, researchers pooled the results of 130 observational studies examining bidirectional associations between frailty and social vulnerability, a growing concern in today’s unnaturally long-lived human society.

Their findings show that both frailty (reduced physiological reserve) and social vulnerability (insufficient social interactions, support, or connections) worsen with age and are independently associated with adverse outcomes, including increased risk or intensity of the other. When present together, these conditions lead to significantly increased decline in physical and cognitive function and risk of mortality. This review aims to inform clinicians and public health policymakers to consider both frailty and social vulnerability when attempting to address both.

Study: The relationship between frailty and social vulnerability: a systematic review. Image credit: Paul Maguire / Shutterstock

What is frailty and how does it relate to social vulnerability?

Frailty is theoretically defined as a clinically recognizable state of increased vulnerability resulting from age-related declines in physiological reserve and function in multiple systems. This compromises the ability to cope with everyday or acute stressors. Frailty is a common condition among older people and is a growing global clinical and public concern. Advances in modern medicine have greatly extended human life expectancy beyond natural limits—1.5 billion people are expected to be 65 or older by 2050, leading to a corresponding increase in the prevalence of frailty.

Research shows that frailty can significantly increase the risks of mortality, functional decline (including loss of independence), and associated medical costs. Worryingly, frailty is increasingly seen as a co-morbidity alongside social vulnerability, the lack of adequate social interaction, connection or support. Like frailty, social vulnerability is age-related, giving the latter the same longevity-related disadvantages that plague the former.

Unfortunately, despite frailty and social vulnerability representing different constructs with different pathologies, most conventional diagnostic models (eg, the frailty index, the Fried frailty phenotype, and the social vulnerability index) operationalize both conditions, confounding studies of the associations between these comorbidities. diseases. Reviews aimed at interpreting these results suffer from the shared shortcoming of focusing on only one concept of social vulnerability (eg, loneliness or social isolation) and its relationship to frailty, thus reducing their holistic view and generalizability.

About the research

The present review has three main aims: 1. To investigate the prevalence of social vulnerability in individuals displaying frailty and vice versa; 2. To assess the longitudinal, potentially bidirectional relationship between frailty and social vulnerability; and 3. To evaluate the impacts and outcomes of combinations of these conditions. The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023425870) and its methodology was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Data (publications) for the study were obtained from six online scientific repositories (MEDLINE, Scopus, Web of Science Core Collection, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature) as of January 1, 2021 (due to this being the year in which the weakness was first qualitatively described) by 28 April 2023. Of the 4083 articles initially identified, 1413 were found to be duplicates and 2189 were removed during title and abstract screening, resulting in a full-text screening set of 481 posts. Application of study inclusion criteria (participant age >18 years; measured both frailty and social vulnerability; was longitudinal or cross-sectional) resulted in a further exclusion of 359 publications, leaving a final data set of 130 included studies.

A pilot template was used to extract data from the publication, and five independent reviewers manually performed the Joanna Briggs Institute Critical Appraisal Checklist for Risk of Bias Assessment and Quality Assessment. Results were generated and discussed in the form of a narrative synthesis, with crop charts used for descriptive data presentation.

Survey results

The 130 included studies consist of 100 sample datasets, with some sample cohorts such as the Study on Health, Aging and Retirement in Europe (SHARE), the China Longitudinal Study of Health and Retirement (CHARLS) and the English Longitudinal Study of Aging (ELSA ) cohort analyzes in multiple independent studies. Study-specific sample cohorts were found to range in size from 70 to 27,468 individuals, representing individuals from 27 countries aged between 40 and 85 years.

“Of the selected studies, 90 assessed the cross-sectional association between frailty and social vulnerability, 36 assessed longitudinal changes in these constructs, and 23 assessed the association between these constructs and clinical outcomes.”

Although quality assessment revealed generally high publication quality, some studies required substantial adjustments for confounding variables due to the lack of reporting of standardized variables. Analyzes of cross-sectional associations revealed that frailty may be associated with social vulnerability more often than expected – 23 of 24 studies linked frailty with increased loneliness, nine of 10 with decreased social participation, and all eight included studies with elevated values ​​on the social vulnerability index. vulnerability.

The adverse outcomes of frailty extend beyond these, with 20 of 23 studies finding that frailty was associated with increased social isolation, 19 of 28 with decreased perceived social support, and 12 of 14 with social vulnerability. Worryingly, some studies found a link between social and physical frailty (11 of 14).

Estimates of social vulnerability paint a similar picture, with each individual component of social vulnerability associated with increased risk of frailty and acceleration of condition progression in individuals with pre-existing frailty. Evaluating the results of the combined effects of frailty and social vulnerability revealed that, when present in combination, these conditions significantly increased patients’ risk of mortality and observed declines in their physical and cognitive functionality.

Conclusion

The present review collects and discusses data and results from 130 publications examining the links between frailty and social vulnerability. Their findings highlight that these conditions, although different in their symptoms and pathologies, are closely related. Having one of the two conditions dramatically increases the risk of acquiring the other. In individuals exhibiting both frailty and social vulnerability, persistence of one condition has been observed to accelerate the progression of the other. Alarmingly, individuals presenting with cubicle conditions showed a significantly higher risk of mortality and physical and cognitive functional declines than those with one of the conditions studied.

These findings will help clinicians and policymakers make more informed decisions when trying to target frailty or social vulnerability. Simultaneous interventions against both are expected to produce the best results for both.