Background Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality. Methods Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002–2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality. Results A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0–0.10), 32.6% were pre-frail (FI = 0.11–0.20), 18.9% were mildly frail (FI = 0.21–0.30), 8.7% were moderately frail (FI = 0.31–0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years’ hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97–2.04), 3.49 (3.44–3.55), 5.88 (5.79–5.97), and 10.39 (10.23–10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49–1.53), 2.36 (2.33–2.39), 3.68 (3.63–3.73), 6.62 (6.53–6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites. Conclusions Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.

Background The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty. Methods ICD-9 codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by two geriatricians. Using nationals cohort of Veterans ≥65 years old, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined. Results The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97-98% were male, 78-79% were white, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI ≥0.2) consistently had a hazard of death more than two-times higher than non-frail patients (VA-FI <0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits. Conclusions The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans ≥65 years old, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.

The aim of the current research was to provide a new method for mapping the developmental sequences of serial killers' life histories. The role of early childhood abuse, leading to types of serial murder and behaviours involved in the murders, was analysed using Behaviour Sequence Analysis. A large database (n ¼ 233) of male serial killers with known childhood abuse (physical, sexual, or psychological) was analysed according to typologies and crime scene behaviours. Behaviour Sequence Analysis was used to show significant links between behaviours and events across their lifetime. Sexual, physical, and psychological abuse often led to distinct crime scene behaviours. The results provide individual accounts of abuse types and behaviours. The present research highlights the importance of childhood abuse as a risk factor for serial killers' behaviours, and provides a novel and important advance in profiling serial killers and understanding the sequential progression of their life histories.

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The aim of the current research was to provide a novel method for mapping the developmental sequences of serial killers' life histories. An in-depth biographical account of serial killers' lives, from birth through to conviction, was gained and analyzed using Behavior Sequence Analysis. The analyses highlight similarities in behavioral events across the serial killers' lives, indicating not only which risk factors occur, but the temporal order of these factors. Results focused on early childhood environment, indicating the role of parental abuse; behaviors and events surrounding criminal histories of serial killers, showing that many had previous convictions and were known to police for other crimes; behaviors surrounding their murders, highlighting differences in victim choice and modus operandi; and, finally, trial pleas and convictions. The present research, therefore, provides a novel approach to synthesizing large volumes of data on criminals and presenting results in accessible, understandable outcomes.