Leader: Patrizia Rovere-Querini (UNISR); Other collaborator(s): Licia Iacoviello (NEUROMED), Maria Benedetta Donati (NEUROMED)
Sarcopenia often leads to loss of independence and poor quality of life. Early identification, adequate diagnosis, follow-up and, possibly, mitigation of sarcopenia, will improve the management of elderly people. Aims: 1) to monitor sarcopenia by coupling body composition data to functional assessments and neuromuscular changes (high-density surface electromyography); 2) to improve sarcopenia and frailty by small-molecule epigenetic inhibitors. Data collected from an existing cohort of volunteers will be compared with those obtained in experimental ageing (spoke 2) and with subjects included in the EPIC study (spoke 10). A pilot feasibility study treating volunteers with the identified inhibitor(s) will be eventually set up.
Brief description of the activities and of the intermediate results
Main policy/industry/practice implications: Beginning of the training activities with the healthcare professionals of the House of Health (Casa della salute) “Le Piagge” and the dissemination activities with people living in this quarter.
We continue to perform multidimensional geriatric evaluations (including blood sample collection and biobanking) in a large cohort of geriatric and neurologic patients. We have now completed 222 visits of participants previously enrolled in the FRASNET study and 51 patients affected by cognitive impairment.
After identifying the most appropriate methodology for determining frailty through a literature review and a comparison among the participating Operating Units (UO) of the Spoke, we measured the frailty index within the Moli-sani study. The Moli-sani study is a large population cohort that includes 24,325 individuals over the age of 35 (5,831 subjects over the age of 65), residing in the Molise region and randomly recruited from municipal registers between 2005 and 2010 through multistage sampling. For this purpose, biometric and clinical data (electrocardiogram, spirometry tests, anthropometric measurements, and blood pressure), lifestyle factors (dietary habits, physical activity, smoking habits, socioeconomic status), and psycho-emotional variables (stress, depression, resilience) were analyzed through standardized procedures, along with samples (citrate plasma, EDTA plasma, serum, cell pellets, DNA, and urine stored in a liquid nitrogen biobank). For defining outcomes (survival status, mortality, cause-specific hospitalization, incidence of neurodegenerative diseases), we updated the study's follow-up to 2020 using hospital discharge records, pharmaceutical records, and regional mortality registries. To construct the frailty index, we used 36 variables including clinical predictors and biomarkers measured in the samples stored in the biobank.
We have completed the dosage (though the Ella method) of the biomarkers selected in the context of WP3 (GDF15, sRAGE, FGF21 and Nfl) in 288 individuals.
The article “Frailty Index, Frailty Phenotype and 6-year mortality trends in the FRASNET Cohort” is under review at Frontiers in Geriatric Medicine.
The revision on “Impact of epigenetic and mitochondrial alterations on frailty and related outcomes in adults’ population: a systematic review with meta-analysis” is ongoing.
The Frailty index obtained in the Moli-sani cohort has been used as a predictor of mortality and hospitalizations both in the general population (n= 23340) and in the subgroup aged over 65 (n=4700). A manuscript is in preparation.
A complementary method to evaluate frailty has been tested in the Moli-sani cohort in collaboration with the Mario Negri Research Institute, by using a hierarchical cluster analysis in 9570 subjects older than 50 years. Multivariable logistic regression was then used to analyse the association between clusters and outcomes (total and cause-specific mortality and hospitalizations). Moreover, life style determinants of frailty have been analysed. A manuscript is in preparation.
We continue to perform multidimensional geriatric evaluations (including blood sample collection and biobanking) in a large cohort of geriatric and neurologic patients.
The article “MUSCLE HEALTH & AGEING” is under review at Frontiers in Ageing.
The revision on “Impact of epigenetic and mitochondrial alterations on frailty and related outcomes in adults’ population: a systematic review with meta-analysis” is ongoing.
The abstract “Early recognition and prompt treatment of acute sarcopenia: impact on short- and long-term outcomes” was accepted as poster presenatation at at the 15th International Conference on Frailty and Sarcopenia Research (ICFSR).
The abstract “Biomarkers for sarcopenia: predicting muscle mass and function decline through GDF-15, FGF21, sRAGE, and Neurofilaments” was accepted as oral presenattion at the 15th International Conference on Frailty and Sarcopenia Research (ICFSR).
The two frailty indices developed by Partner Neuromed in the Moli-sani project, using complementary approaches, have both shown associations with mortality (total and cause specific), non-fatal events and hospitalizations due to common chronic conditions (cardiovascular disease, cancer, and neurodegenerative disorders), albeit with differing magnitudes of effect. We performed comprehensive analyses in older adults, assessed potential effect modification by including interaction terms between the frailty indices and selected covariates, and carried out mediation analyses to evaluate the explanatory role of possible mediators—especially inflammatory parameters.
Follow up visits were completed.
The abstract “GDF-15, sRAGE, FGF21, and NfL: Novel Biomarkers in Malnutrition” was submitted to the International Congressa of Sarcopenia, Cachexia and Waisting disorders.
The article “MUSCLE HEALTH & AGEING” is under review at Frontiers in Ageing.
The revision on “Impact of epigenetic and mitochondrial alterations on frailty and related outcomes in adults’ population: a systematic review with meta-analysis” is ongoing.
Partner Neuromed further explored the association between the two frailty indices and neurological outcomes, specifically Parkinson's disease, Alzheimer's disease, and major depressive disorders. Ongoing analyses combine traditional statistical approaches with machine learning techniques, including XGBoost models with feature importance and SHAP (SHapley Additive exPlanations) analysis to improve predictive accuracy and interpretability of results. In addition, mediation analyses are being conducted to evaluate the potential explanatory role of inflammatory parameters in these associations. Particular attention is being dedicated to the older adult population to better understand the interplay between frailty, neurodegenerative conditions, and inflammation-related biological pathways
Preliminary findings by partner Neuromed suggest that inflammation may partly account for the observed associations between frailty index and mortality, highlighting a complex interplay between frailty, chronic disease outcomes, and underlying biological pathways. Two manuscripts are currently in preparation, each focusing on data from the Moli-sani cohort but applying one of the two distinct frailty indices.
Partner Neuromed reached a major milestone with the completion and submission of the first manuscript on frailty in the Moli-sani cohort to a peer-reviewed journal. This study, based on 20,975 participants and 15 years of follow-up, demonstrated that a higher frailty index is associated with an increased risk of several major chronic conditions. The strongest associations emerged for cardiometabolic diseases, with hazard ratios of 1.82 for diabetes and 1.56 for coronary heart disease per 1-SD increase in the frailty index. Significant associations were also observed for neurodegenerative outcomes, including Parkinson’s disease (HR=1.24) and non-Alzheimer dementias (HR=1.31), as well as for hospitalizations and both all-cause and cause-specific mortality. The associations were consistent across sex-stratified analyses and robust to the exclusion of early events, with stronger effects seen in individuals younger than 65 years. These findings highlight the relevance of frailty assessment in predicting a broad range of age-related conditions and support its integration into preventive and risk stratification strategies.
Between April and July 2025, the activities focused on the integration and interpretation of biomarker data derived from the FRASNET cohort, contributing to the identification of molecular signatures associated with malnutrition, frailty, and sarcopenia in aging. In April 2025 the team contributed to the preparation of an abstract titled “GDF-15, sRAGE, FGF21, and NfL: Novel Biomarkers in Malnutrition”, submitted to the International Congress on Sarcopenia, Cachexia and Wasting Disorders. This work was grounded in the quantitative analysis of biomarker data and represents an important step toward the data-driven characterization of malnutrition risk in older populations. In May 2025, the team was actively involved in the statistical analysis and writing of the manuscript “Mitokine Signatures of Aging: GDF-15 and FGF21 Predict Frailty, Sarcopenia, and Malnutrition in the FRASNET Study”, submitted to Mechanisms of Ageing and Development. The article presents robust analytical evidence supporting the role of GDF-15 and FGF21 as predictive biomarkers of geriatric syndromes, based on multivariate modeling and population-level validation. In June 2025 results from the biomarker analyses were also shared with the clinical and scientific community during the 13th Congresso I.S.Mu.L.T. in Milan. The oral presentation “Biomarkers per la sarcopenia: come prevenire il declino della massa e della funzione muscolare” emphasized the translational value of WP2’s data interpretation work in identifying early indicators of muscle decline. In July 2025, the team provided a structured update on progress and key results as part of the Spoke 3 coordination activities. These efforts illustrate WP2’s central role in translating complex biological data into clinically meaningful insights, supporting the AGE-IT mission of precision aging research.
During this period, the following scientific papers were completed and published: Molecular constraints of sarcopenia in the ageing muscle. Frontiers in Aging, 2025 Jul 3;6:1588014. doi: 10.3389/fragi.2025.1588014. The association between CKD and frailty in the FRASNET study: a novel eGFR threshold as a key determinant of frailty in the elderly. Journal of Nephrology, 2025. In addition, three further manuscripts have been submitted and are currently under peer review, addressing complementary molecular and clinical aspects of frailty and sarcopenia in older adults.
The first manuscript on frailty in the Moli-sani cohort was enriched in response to co-authors comments. The main suggestion involved analyzing the frailty index not only as a continuous variable but also after categorization into three groups: fit, pre-frail, and frail. The manuscript was expanded with these additional analyses, which demonstrated a clear gradient of increasing risk across frailty categories.
When analysing the frailty index as a continuous variable, the strongest associations emerged for cardiometabolic diseases, with hazard ratios of 1.82 for diabetes and 1.56 for coronary heart disease per 1-SD increase in the frailty index. Significant associations were also observed for neurodegenerative outcomes, including Parkinson's disease (HR=1.24) and non-Alzheimer dementias (HR=1.31), as well as for hospitalizations and both all-cause and cause-specific mortality.
The categorical analysis comparing frail versus fit individuals revealed even stronger associations for several key outcomes. Specifically, frail participants showed markedly elevated risks compared to fit individuals: Parkinson's disease (HR=2.70, 95% CI 1.20 to 4.95), lung cancer (HR=3.10, 95% CI 1.90 to 5.95), diabetes (HR=5.20, 95% CI 3.40 to 5.95), and all-cause mortality (HR=1.95, 95% CI 1.70 to 2.25). These associations were particularly pronounced for these outcomes, highlighting the clinical relevance of frailty categorization in risk stratification. The findings remained consistent across sex-stratified analyses and were robust to the exclusion of early events, with stronger effects observed in individuals younger than 65 years. The revised version of the manuscript has been resubmitted to the international peer-reviewed journal Age and Ageing.
A reverse sarcopenia index (RSI) was also computed in the cohort, as the ratio between creatinine and cystatin C and is currently being tested for association with several outcomes.The analysis revealed a strong protective association with all-cause mortality (3,583 deaths, median (IQR) follow-up 15.0 (2.2) years; HR [95% CI] = 0.33 [0.25-0.44] per unit increase in RSI). The analysis of cause-specific deaths revealed a protective association for cardiovascular disease (CVD: 0.30 [0.18-0.50]; 1,294 deaths, median (IQR) follow-up 15.0 (2.2) years) but not for cancer and Covid-19-related deaths. Further analyses are ongoing to untangle these associations (e.g. investigating linearity and potential modifications of effect) and to replicate these associations in independent cohorts.
During the reporting period (September–December 2025), the activities of Spoke 3, WP2 focused on the epidemiological characterization of frailty and multimorbidity in Italian community-dwelling older adults, as well as on the validation of circulating biomarkers associated with geriatric syndromes using large population-based cohorts.
Partner Neuromed submitted the manuscript “Frailty Index Predicts the Risk of 17 Health Outcomes in Distinct Ways: Prospective Findings from the Moli-sani Study” to the international peer-reviewed journal Age and Ageing. Following editorial evaluation, the journal issued a request for revision. We provided a complete and detailed response to all reviewer and Associate Editor comments. The revision involved both clarifications and targeted expansions of the manuscript, without altering the core results. All reviewer comments were fully addressed, and the revised manuscript, together with a detailed response document, has been resubmitted. We are currently awaiting the editorial decision with confidence in the robustness of the revised version.
In parallel, preliminary work has started on a second manuscript within the same project framework, focusing on the relationship between frailty and comorbidity burden in the Moli-sani cohort. This ongoing analysis examines the cross-sectional association between the Frailty Index and the Charlson Comorbidity Index, with the aim of evaluating the degree of overlap and divergence between these two widely used measures of health vulnerability. While the frailty index captures the accumulation of multidimensional deficits, the Charlson index reflects clinically diagnosed comorbid conditions weighted by prognostic severity. Initial descriptive and analytical steps have been completed, including the harmonization of variables, construction of both indices within the same baseline population, and preliminary modeling of their association across age and sex strata. These analyses will allow assessment of whether frailty provides information beyond comorbidity alone, and to what extent the two indices identify overlapping or distinct risk profiles within the general adult population.
The drafting of the manuscript entitled
“A Nationwide Picture of Frailty and Comorbidities in Community-Dwelling Older Adults in Italy: Data from the FRASNET (North) and Moli-sani (South) Cohorts” is currently ongoing.
This study aims to provide a comprehensive national estimate of frailty prevalence, assessed using the Frailty Index, and of comorbidity burden across Northern and Southern Italy, leveraging harmonized data from two large population-based cohorts. The manuscript will represent the first nationwide comparison of frailty and multimorbidity patterns across different Italian geographical areas.
Significant progress has been achieved in terms of scientific dissemination, with multiple high-impact manuscripts published, accepted, or under review:
Accepted / Published
“Unmasking Malnutrition Through soluble RAGE: A Biomarker-Guided Insight from FRASNET” – Experimental Gerontology (accepted).
“Circulating mitokines GDF-15 and FGF21 are associated with frailty, sarcopenia, and malnutrition in older adults: Evidence from the FRASNET study” – Mechanisms of Ageing and Development (published).
These two papers provide strong evidence supporting the role of circulating biomarkers in identifying frailty-related phenotypes, malnutrition, and sarcopenia in older adults, directly contributing to the objectives of WP2.
Submitted
3. “FGF21 levels predict depressive symptoms in older adults: Evidence from the FRASNET cohort” – submitted to the American Journal of Geriatric Psychiatry.
This manuscript expands the scope of WP2 by exploring the relationship between metabolic stress biomarkers and neuropsychiatric outcomes in ageing.
Under review
4. “Plasma Neurofilaments as Biomarkers of Frailty, Sarcopenia, and Malnutrition: Insights from the FRASNET Study” – currently under peer review.
This study evaluates neurofilament light chain (NfL) as a novel biomarker linking neurodegeneration and geriatric syndromes, further strengthening the translational impact of the project.