Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017

The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process.

To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017.

We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death).

The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code.

Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.