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Associations Between Frailty, Retinal Microvascular Changes, and Cerebral White Matter Abnormalities in Korean Older Adults

2014; Wiley; Volume: 62; Issue: 11 Linguagem: Inglês

10.1111/jgs.13114

1532-5415

Hee‐Won Jung, Sun‐Wook Kim, Sol‐Ji Yoon, Jung‐Yeon Choi, Kwang‐Il Kim, Cheol‐Ho Kim,

Cardiovascular Health and Disease Prevention

Journal of the American Geriatrics SocietyVolume 62, Issue 11 p. 2209-2210 Letters to the EditorFree Access Associations Between Frailty, Retinal Microvascular Changes, and Cerebral White Matter Abnormalities in Korean Older Adults Hee-Won Jung MD, MSc, Hee-Won Jung MD, MSc Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorSun-Wook Kim MD, Sun-Wook Kim MD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorSol-Ji Yoon MD, Sol-Ji Yoon MD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorJung-Yeon Choi MD, Jung-Yeon Choi MD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorKwang-il Kim MD, PhD, Kwang-il Kim MD, PhD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorCheol-Ho Kim MD, PhD, Cheol-Ho Kim MD, PhD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this author Hee-Won Jung MD, MSc, Hee-Won Jung MD, MSc Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorSun-Wook Kim MD, Sun-Wook Kim MD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorSol-Ji Yoon MD, Sol-Ji Yoon MD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorJung-Yeon Choi MD, Jung-Yeon Choi MD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorKwang-il Kim MD, PhD, Kwang-il Kim MD, PhD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this authorCheol-Ho Kim MD, PhD, Cheol-Ho Kim MD, PhD Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea College of Medicine, Seoul National University, Seoul, KoreaSearch for more papers by this author First published: 21 November 2014 https://doi.org/10.1111/jgs.13114Citations: 22AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat To the Editor: Microvascular abnormalities occur before macrovascular diseases such as hypertension,1 and in older people, microvascular abnormities in the cerebral white matter and retinal vessels are associated with functional decline2 and cognitive impairment.3-5 Furthermore, a recent study showed that microvascular abnormalities were more closely associated with disability-free survival than macrovascular diseases.6 To the best of the knowledge of the authors of the current study, the effect of microvascular changes on the pathophysiology of frailty has been scarcely studied. Therefore, the goal of the current study was to elucidate cross-sectional associations between frailty, retinal microvascular changes, and cerebral white matter changes. The clinical records of 87 people aged 65 and older who had had a comprehensive geriatric assessment (CGA), funduscopy, and brain magnetic resonance imaging collected within a 2-year interval between each examination at Seoul National University Bundang Hospital from 2009 to 2013 were reviewed. Using components of the CGA that included activities of daily living, instrumental activities of daily living, cognitive function (Mini-Mental State Examination), physical performance (Timed Up and Go Test), and a laboratory examination (serum albumin level), a multidimensional frailty index (range 0 (not frail) to 1 (frail)) was calculated.7 Retinal vessel abnormality was quantified from the ratio of central retinal artery equivalent to central retinal vein equivalent (CRAE/CRVE),8 an index that showed an association with cognitive impairment in the Atherosclerosis Risk In Communities Study.3 Changes in cerebral white matter have been quantified using the modified Fazekas scale,2 which is associated with abnormalities in the volume of white matter and the probability of future independent living. Subjects were placed into Groups 1 (mild), 2 (moderate), or 3 (severe), according to severity of change in cerebral white matter. Clinical covariables included hypertension (diagnosis of or treatment for hypertension), diabetes mellitus (diagnosis of or treatment with medication), atrial fibrillation (diagnosed in medical record or detection on electrocardiogram review), and history of stroke. The median age of the population was 78 (interquartile range (IQR) 74–83), and 33 (37.9%) were male. The median frailty index was 0.28 (IQR 0.08–0.67). The median value of the modified Fazekas scale score was 2 (IQR 1–3, standard deviation 0.28), and that for the CRAE/CRVE was 0.61 (IQR 0.50–0.70). The Kruskal–Wallis test showed a significant difference in frailty index according to the modified Fazekas scale (P < .001, results of post hoc analysis using Mann–Whitney tests are shown, Figure 1A). Subjects in Groups 2 (0.09, 95% confidence interval (CI) = 0.08–0.10) and 3 (0.42, 95% CI = 0.46–0.20) had a higher frailty index than those in Group 1, according to the linear mixed effect model with covariables of age, sex, hypertension, diabetes mellitus, and history of stroke. In addition, as shown in Figure 1B, the frailty index was associated with CRAE/CRVE ratio, according to the linear regression analysis (P < .001, B = −1.29), and this significant association was maintained after adjustments with age, sex, hypertension, diabetes mellitus, and history of stroke (P < .001, B = −1.22). The CRAE/CRVE ratios were associated with the modified Fazekas scale, according to the linear regression analysis (P = .02, B = −0.037). Figure 1Open in figure viewerPowerPoint Relationship between the frailty index and (A) cerebral white matter changes according to the modified Fazekas scale and (B) retinal vessel abnormalities according to the ratio of the central retinal artery equivalent to the central retinal vein equivalent (CRAE/CRVE). The line denotes predicted association according to linear regression analysis (P < .001, B = −0.129). In this cross-sectional study, associations were observed between frailty status, retinal vessel abnormality, and cerebral white matter changes in Korean older adults. These results were obtained from the combined observations of in vivo retinal vessel and cerebral white matter abnormalities and their association with a multidimensional frailty index. Therefore, the results of this study have implications for further research on the possible role of microvascular aging on the pathophysiology of frailty. The concept of cognitive frailty, defined as minimal cognitive impairment and physical frailty without the definitive finding of dementia, including Alzheimer's disease, was recently suggested as a distinct clinical entity from dementia.9 Although the concept of cognitive frailty is yet to be widely accepted, results of the present study may have a possible role in the mechanism of cognitive frailty. This study has several limitations. Because the study was performed retrospectively with a small number of subjects treated in single university hospital, generalizability is limited. Furthermore, the causal effect of microvascular abnormality on frailty cannot be evaluated because of the cross-sectional nature of the study. In conclusion, frailty is associated with retinal microvascular changes and cerebral white matter changes in Korean older adults. Acknowledgments Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Hee-Won Jung: study concept, acquisition of data, interpretation of data, preparation of manuscript. Sun-Wook Kim, Sol-Ji Yoon, Jung-Yeon Choi: acquisition and interpretation of data. Kwang-il Kim, Cheol-Ho Kim: study concept and interpretation of data. Sponsor's Role: None. References 1Ding J, Wai KL, McGeechan K et al. Retinal vascular caliber and the development of hypertension: A meta-analysis of individual participant data. J Hypertens 2014; 32: 207– 215. 2Inzitari D, Pracucci G, Poggesi A et al. Changes in white matter as determinant of global functional decline in older independent outpatients: Three year follow-up of LADIS (leukoaraiosis and disability) study cohort. BMJ 2009; 339: b2477. 3Wong TY, Klein R, Sharrett AR et al. Retinal microvascular abnormalities and cognitive impairment in middle-aged persons: The Atherosclerosis Risk in Communities Study. Stroke 2002; 33: 1487– 1492. 4Prins ND, van Dijk EJ, den Heijer T et al. Cerebral small-vessel disease and decline in information processing speed, executive function and memory. Brain 2005; 128: 2034– 2041. 5Heringa SM, Bouvy WH, van den Berg E et al. Associations between retinal microvascular changes and dementia, cognitive functioning, and brain imaging abnormalities: A systematic review. J Cereb Blood Flow Metab 2013; 33: 983– 995. 6Kim DH, Grodstein F, Newman AB et al. Prognostic implications of microvascular and macrovascular abnormalities in older adults: Cardiovascular Health Study. J Gerontol A Biol Sci Med Sci 2014. doi: 10.1093/gerona/glu074. 7Jung HW, Kim SW, Ahn S 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. 8Knudtson MD, Lee KE, Hubbard LD et al. Revised formulas for summarizing retinal vessel diameters. Curr Eye Res 2003; 27: 143– 149. 9Kelaiditi E, Cesari M, Canevelli M et al. Cognitive frailty: Rational and definition from an (I.A.N.A./I.A.G.G.) international consensus group. J Nutr Health Aging 2013; 17: 726– 734. Citing Literature Volume62, Issue11November 2014Pages 2209-2210 FiguresReferencesRelatedInformation