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Hanna Falk Erhag,1– 3 Gudny Guðnadóttir,3 Joakim Alfredsson,4 Tommy Cederholm,5,6 Niklas Ekerstad,7,8 Dorota Religa,9,10 Bengt Nellgård,11 Katarina Wilhelmson2,3,12 1Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 2Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden; 3Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden; 4Department of Cardiology, and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden; 5Clinical Nutrition and Metabolism Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; 6Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden; 7Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden; 8The Research and Development Unit, NU Hospital Group, Trollhättan, Sweden; 9Department of Neurobiology, Care Sciences, and Society, Clinical Geriatrics, Karolinska Institute, Stockholm, Sweden; 10Division for Clinical Geriatrics, Karolinska University Hospital, Stockholm, Sweden; 11Department of Anesthesiology and Intensive Care, Institute of Clinical Studies, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 12Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenCorrespondence: Hanna Falk Erhag, Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Wallinsgatan 6, Gothenburg, SE 431 41, Sweden, Tel +46 760 476888, Fax +46 31 786 60 77, Email hanna.falk@gu.seBackground: Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill.Purpose: To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients > 65 years in acute clinical settings.Design: Systematic review with narrative synthesis.Methods: Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020.Results: Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review.Conclusion: A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients’ quality of life is warranted.Keywords: clinical frailty scale, risk stratification, acute clinical settings, literature review

Anne-Marie Boström,1 Tommy Cederholm,2 Gerd Faxén-Irving,3 Erika Franzén,4 Helena Grönstedt,5 Åke Seiger,3 Sofia Vikström,6 Anders Wimo7 1Division of Nursing, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Medical Unit Aging, Theme Inflammation and Aging, Karolinska University Hospital, Stockholm and R&D Unit, Stockholms Sjukhem, Stockholm, Sweden; 2Medical Unit Aging, Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Division of Clinical Geriatrics, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm and Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden; 3Division of Clinical Geriatrics, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden; 4Division of Physiotherapy, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Medical Unit Occupational Therapy and Physiotherapy, Theme Women’s Health and Allied Health Professionals, Karolinska University Hospital, Stockholm and Stockholms Sjukhem R&D Unit, Stockholm, Sweden; 5Medical Unit Occupational therapy and Physiotherapy, Women´s Health and Allied Health Professionals Theme, Karolinska University Hospital, Stockholm, Sweden; 6Division of Occupational Therapy, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden; 7Division of Neurogeriatrics, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, SwedenCorrespondence: Anne-Marie Boström, Division of Nursing, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Alfred Nobels allé 23, Huddinge, Stockholm, S 141 83, Sweden, Tel +468524 839 19, Email anne-marie.bostrom@ki.sePurpose: Health-related quality of life (HRQoL) is an important patient-related outcome for the assessment of interventions and treatments in older people. Understanding underlying mechanisms for HRQoL is crucial for improving care, rehabilitation and symptom relief. This study examined the associations between HRQoL and frailty, sarcopenia, dependence of ADL, physical function and nutritional status in older nursing home (NH) residents.Patients and Methods: This is a cross-sectional study employing baseline data from the Older Person’s Exercise and Nutrition (OPEN) study. Residents ≥ 75 years and able to stand up from seated position, residing in eight nursing homes in Sweden, were recruited. The EuroQoL 5-dimension Questionnaire (EQ-5D-5L, 0– 1) was used to assess HRQoL. For exposure, the FRAIL and SARC-F questionnaires, Bergs Balance Scale, Functional Independence Measure (FIM), and Mini Nutritional Assessment-Short Form (MNA-SF) were used, including chair-stand test, walking speed and some biochemical markers. Descriptive and inferential statistics including linear regression models were applied.Results: Data from 113 residents (59% women, mean age 85 years) revealed a mean EQ-5D index of 0.76. After relevant adjustments, factors associated with low HRQoL were sarcopenia (p< 0.001), cognitive function (p< 0.001), dependence in ADL (p=0.002), low plasma-albumin (p=0.002) and impaired nutritional status (p=0.038).Conclusion: This study displays evidence that modifiable conditions like sarcopenia and malnutrition are related to HRQoL in older NH residents. Such findings indicate a potential for physical exercise, including muscle training, and improved nutritional routines, including protein supplementation, to enhance nursing home care. Future studies, in larger NH populations, on exercise and nutrition for effects on HRQoL are needed.Keywords: quality of life, EQ5D-5L, sarcopenia, physical function, nutritional status

Wilhelmina Ekström,1 Bodil Samuelsson,2 Sari Ponzer,3 Tommy Cederholm,4,5 Karl-Göran Thorngren,6 Margareta Hedström7 1Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, 2Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 3Department of Clinical Science and Education, Section of Orthopaedics, Karolinska Institutet, Södersjukhuset, Stockholm, 4Department of Public Health and Caring Sciences, 5Department of Geriatrics, Uppsala University, Uppsala University Hospital, Uppsala, 6Department of Clinical Sciences, Lund, Orthopaedics, Lund University, Lund, 7Department of Orthopaedics, Institute of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Huddinge, Stockholm, Sweden Objectives: To evaluate potential sex differences and other factors associated with complications within 4 months after a hip fracture.Methods: A total of 1,915 patients ≥65 years (480 men) with hip fracture were consecutively included in a prospective multicenter cohort study. A review of medical records and patient interviews according to a study protocol based on the Standardized Audit of Hip Fractures in Europe (SAHFE, RIKSHÖFT) was performed. Sex differences in comorbidity according to the American Society of Anesthesiologists score and complications 4 months after a hip fracture were registered. Multivariate logistic regression analysis was performed to identify factors related to complications.Results: Male sex was associated with worse general health according to the American Society of Anesthesiologists classification (P=0.005) and with more comorbidities (P

Lena Flodin,1,2 Maria Sääf,3 Tommy Cederholm,4 Amer N Al-Ani,2,5 Paul W Ackermann,5,6 Eva Samnegård,7 Nils Dalen,7 Margareta Hedström2,51Department of Geriatric Medicine, Karolinska University Hospital Stockholm, Sweden; 2Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden; 3Department of Endocrinology, Metabolism, and Diabetes, Karolinska University Hospital, Stockholm, Sweden; 4Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden; 5Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden; 6Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; 7Department of Clinical Science, Division of Orthopedics, Karolinska Institutet, Danderyd Hospital, Stockholm, SwedenBackground: After a hip fracture, a catabolic state develops, with increased bone loss during the first year. The aim of this study was to evaluate the effects of postoperative treatment with calcium, vitamin D, and bisphosphonates (alone or together) with nutritional supplementation on total hip and total body bone mineral density (BMD).Methods: Seventy-nine patients (56 women), with a mean age of 79 years (range, 61–96 years) and with a recent hip fracture, who were ambulatory before fracture and without severe cognitive impairment, were included. Patients were randomized to treatment with bisphosphonates (risedronate 35 mg weekly) for 12 months (B; n=28), treatment with bisphosphonates along with nutritional supplementation (40 g protein, 600 kcal daily) for the first 6 months (BN; n=26), or to controls (C; n=25). All participants received calcium (1,000 mg) and vitamin D3 (800 IU) daily. Total hip and total body BMD were assessed with dual-energy X-ray absorptiometry at baseline, 6, and 12 months. Marker of bone resorption C-terminal telopeptide of collagen I and 25-hydroxy vitamin D were analyzed in serum.Results: Analysis of complete cases (70/79 at 6 months and 67/79 at 12 months) showed an increase in total hip BMD of 0.7% in the BN group, whereas the B and C groups lost 1.1% and 2.4% of BMD, respectively, between baseline and 6 months (P=0.071, between groups). There was no change in total body BMD between baseline and 12 months in the BN group, whereas the B group and C group both lost BMD, with C losing more than B (P=0.009). Intention-to-treat analysis was in concordance with the complete cases analyses.Conclusion: Protein-and energy-rich supplementation in addition to calcium, vitamin D, and bisphosphonate therapy had additive effects on total body BMD and total hip BMD among elderly hip fracture patients. Keywords: hip fracture, nutritional supplementation, bisphosphonates, bone mineral density