“Falls are a major health concern for people with MS, as more than 50% of individuals living with MS experience at least one fall every year,” says Tobia Zanotto, PhD. “Although the life expectancy of people with MS has increased, thanks to the increasing availability and effectiveness of disease-modifying therapies, one of the potential challenges brought about by this increased lifespan is that age-related conditions, such as frailty, may aggravate common MS symptoms. Frailty augments the vulnerability to many adverse outcomes like falls, hospitalizations, and mortality in older adults. To date, however, little is known about frailty in people with MS and there is a critical need to shed more light on the implications of this biological syndrome on the QOL of people with MS.”

For a paper published in Archives of Physical Medicine and Rehabilitation, Dr. Zanotto, Jacob J. Sosnoff, PhD, and colleagues aimed to explore the association between frailty and history of falls among people with MS. “We leveraged data collected as part of a randomized controlled trial, conducted in the United States and Israel, focusing on a novel rehabilitation intervention in people with MS,” Dr. Sosnoff says. “We set out to 1) design a frailty index based on multiple subjective and objective measures of physical function and activity, cognition, QOL, and comorbidities, and 2) to examine the association between the frailty index and the number of falls reported by participants in the previous 12 months.”

A total of 118 people with relapsing-remitting MS [mean age, 48.9±10.0; 74.6% female; Expanded Disability Status Scale (EDSS) range=1.0-6.0] were analyzed in a cross-sectional analysis. A frailty index was determined from 40 health deficits by following standard validated procedures. The number of falls during a period of 12-months was documented.

Frailty Significantly Linked With Fall History

“We observed that frailty was moderately correlated with disability,” Dr. Zanotto says. “However, our most important finding was that frailty was significantly associated with fall history, even after adjustment for demographics and disability. This seems to suggest that frailty is a syndrome related to, but independent of, disability in individuals with MS. Therefore, measuring frailty, alongside the conventional measures of disability, may provide distinct prognostic information that may be helpful in evaluating the risk for common MS-related adverse outcomes and to set therapeutic goals in disease and symptom management, including fall prevention strategies.”

The study team observed that the frailty index remained associated with a higher number of falls (based on 12-month history), even after adjustment for age, gender, and disability levels in the study sample of people with MS (Table).

Cross-Sectional Study Design Has Limitations

Drs. Zanotto, Sosnoff and colleagues acknowledge some limitations of their investigation. “While we observed a significant association between frailty and fall history in our patients, the cross-sectional study design does not allow us to speculate as to whether frailty may be a real predictor of falls in individuals with MS,” Dr. Zanotto points out. “In addition, fall history consisted of self-reported information, which may be subjected to recall bias.”

To address these limitations, the study team agreed that future research would be required to confirm these findings by using a prospective study design and by recording falls according to gold standard methods (eg, weekly fall diaries). “There is also a need to better understand to what extent frailty, disability, and comorbidity overlap in people with MS,” Dr. Sosnoff says. “Future studies should therefore address this knowledge gap which, in turn, would enable us to more critically identify the rehabilitation needs of the MS community.”

There is still a critical need to identify what conceptualization of frailty may be more relevant for the MS population, Dr. Sosnoff adds “Our frailty index was based on the deficit accumulation model developed by Kenneth Rockwood, MD, MPA, FRCPC, and colleagues at Dalhousie University. However, this operational definition alone does not necessarily capture the complexity of frailty, and further research is needed to untangle the pathogenesis of this biological syndrome in the context of MS.”