Retrospective older-adult study links red cell size variation-to-albumin ratio to frailty

A higher red blood cell distribution width-to-albumin ratio was strongly associated with frailty, sarcopenia risk and malnutrition in a retrospective cross-sectional study of 1,948 older adults attending a university hospital geriatrics clinic. The researchers reported that these associations remained robust after fuller adjustment for potential confounding factors, while the ratio’s ability to distinguish individual outcomes was modest. Their findings support considering the measure as a low-cost triage signal for comprehensive geriatric assessment, not as a definitive diagnostic test.

The primary analysis used each patient’s first visit between January 2020 and September 2025. Participants were 60 years of age or older, and the cohort was predominantly female, with 64.3% women and a median age of 73. The investigators assessed frailty, functional independence, nutritional status, mood, cognition, sarcopenia risk, handgrip strength, falls and urinary incontinence using validated instruments.

Logistic regression estimated the odds of each outcome for a one-standard-deviation increase in the red blood cell distribution width-to-albumin ratio, abbreviated RAR. The primary models adjusted for age and sex; later models additionally accounted for body mass index, polypharmacy, anaemia, renal function and comorbidities. After adjustment for age and sex, a one-standard-deviation increase in RAR was most strongly associated with frailty, for which the odds were 1.86 times higher, with a 95% confidence interval of 1.62–2.13.

The corresponding odds ratio for sarcopenia risk was 1.80, with a 95% confidence interval of 1.60–2.02, while the odds ratio for malnutrition was 1.63, with a 95% confidence interval of 1.43–1.86. These three associations persisted after the researchers added body mass index, polypharmacy, anaemia, renal function and comorbid illnesses to the models. In contrast, the age- and sex-adjusted associations with cognitive impairment, depressive symptoms, falls and urinary incontinence were weaker: their odds ratios were 1.31, 1.25, 1.22 and 1.15, respectively, with all reported P values at or below .01.

Those associations attenuated after fuller adjustment, and the urinary-incontinence association was no longer statistically significant. Rank correlations between RAR and the measured outcomes were significant but weak to moderate, with absolute ρ values ranging from 0.11 to 0.33. Diagnostic discrimination was limited across the outcomes examined.

Areas under the receiver operating characteristic curve ranged from 0.54 to 0.70. The researchers also identified exploratory cut-points of 3.32 to 3.51 for the three most strongly associated outcomes—frailty, sarcopenia risk and malnutrition—at which sensitivity ranged from 0.49 to 0.60 and specificity from 0.71 to 0.77. These figures show that the proposed thresholds would not reliably capture every affected patient and should not be interpreted as established diagnostic boundaries.

The study reported that the cut-points had not been externally validated, and their performance in other populations or clinical settings was therefore not established by this analysis. The study was designed around the need for simple triage markers in a system where comprehensive geriatric assessment can identify multidimensional vulnerability but requires substantial resources. In that context, the authors positioned RAR as a potential signal for helping clinics prioritize older adults for fuller assessment.

The outpatient population may also limit how broadly the findings can be applied. Taken together, the evidence identifies a low-cost candidate that warrants further validation, but the modest discrimination, attenuation of several adjusted associations and lack of external threshold validation make RAR an adjunctive triage indicator rather than a replacement for clinical evaluation.

Subject of Research: Association of the red blood cell distribution width-to-albumin ratio with geriatric syndromes in older outpatients

Article Title: Association of the red blood cell distribution width-to-albumin ratio with major geriatric syndromes: a retrospective cross-sectional single-centre study

Article References: Levent, M., & Akın, S. (2026). Association of the red blood cell distribution width-to-albumin ratio with major geriatric syndromes: a retrospective cross-sectional single-centre study. BMC Geriatrics. https://doi.org/10.1186/s12877-026-08520-5

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08520-5

Keywords: red blood cell distribution width, albumin ratio, frailty, sarcopenia, malnutrition, geriatric assessment, older adults, retrospective study, diagnostic discrimination, Association, blood, cell