Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale

First-line Treatment With Bendamustine and Rituximab for Old and Frail Patients With Aggressive Lymphoma: Results of the B-R-ENDA Trial

The incidence of aggressive B-cell lymphomas increases with age, but for elderly or frail patients not eligible for doxorubicin-containing treatment standard therapy remains to be defined. In this prospective, multicenter, phase-2 B-R-ENDA trial, we investigated the feasibility, toxicity, and efficacy of 8 cycles rituximab combined with 6 cycles bendamustine (BR) in elderly or frail aggressive B-cell lymphoma patients: 39 patients aged >80 years and 29 patients aged 61-80 years with elevated Cumulative Illness Rating Scalescore >6 were included. Progression-free survival (PFS) and overall survival (OS) at 2 years were 45% (95% confidence interval [CI], 28%-61%) and 46% (28%-63%) for the patients age >80, as well 32% (13%-51%) and 37% (17%-57%) for frail patients age 64-80, respectively. In a preplanned retrospective analysis, we found no significant differences in PFS and OS comparing the outcome of the 39 patients age >80 years with 40 patients aged 76-80 years treated with 6xR-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) and 2 x rituximab in the RICOVER-60 trial (DSHNHL 1999-1, NCT00052936, EU-20243), yet we detected lower rates of infections and treatment-related deaths in the BR-treated patients. We demonstrate that older and frail patients with aggressive B-cell lymphoma who are not able to receive standard CHOP-based therapy can benefit from anthracycline-free therapy as a feasible and effective therapeutic option.

Clinical complexity and diabetes: a multidimensional approach for the management of cardiorenal metabolic syndrome

Diabetes mellitus (DM) is one of the fastest-growing health emergencies of the 21st century, and one of the chronic diseases with the highest socio-economic impact on health care systems. DM is the main cause of chronic kidney disease, and is associated with a significant increase in cardiovascular risk and clinical and care complexity. The presence of a constellation of cardiac, metabolic, and renal diseases, in a complex patient with DM, constitutes the CardioRenal Metabolic Syndrome (CRMS). The management of these patients should include a paradigm shift from a reactive strategy to a proactive approach, and the integration of territorial, hospital and social assistance services according to the Chronic Care Model (CCM). Complexity science suggests an alternative model in which disease and health arise from complex, dynamic, and unique interactions among the different components of the overall system. The hospital should be viewed as a highly specialized hub of the chronic care system, which interacts with the outpatient specialist and primary care. In order to create effective communication among territorial care units and highly specialized hospitals, levels of clinical complexity are here proposed and included in a multidimensional management model for the complex patient with diabetes and cardiorenal comorbidity.

Cardiovascular Comorbidities in Relation to the Functional Status and Vitamin D Levels in Elderly Patients with Dementia

(1) Background: As dementia is an incurable, multifactorial neurodegenerative disease, we gathered and analyzed a number of patient characteristics, assessing possible correlations that may support early diagnosis and a more accurate prognosis for cognitively impaired patients. (2) Methods: We used standard clinical parameters (cognitive and functional status, comorbidities, and plasma vitamin D levels) in a study group of 162 patients aged above 55 years old. (3) Results: We reported a higher incidence of cardiovascular and metabolic comorbidities in patients with severe or moderate cognitive impairment; a validated correlation between functional status, cognitive status, and serum vitamin D levels; and a more frequently associated profile of neurologic comorbidities in patients with a more significant cognitive deficiency. (4) Conclusions: The present research adds data on the significant correlations of cognitive deficits with cardiovascular, metabolic, and neurologic diseases (and the lack of correlation with osteoarticular illness). Clinicians should make the best use of the current screening and assessment tools (such as the functional scoring of daily activities, cognitive evaluation, and the screening of risk factors). Our data may offer starting points for future in-depth analysis of dementia-modifiable risk factors.

Rehabilitation of Post-COVID-19 Musculoskeletal Sequelae in Geriatric Patients: A Case Series Study

The musculoskeletal system is affected in over 40% of patients with Coronavirus disease 2019 (COVID-19). There is an increased need for post-acute rehabilitation after COVID-19, especially in elderly people with underlying health problems. The aim of this study was to evaluate the benefits of an early and goal-orientated rehabilitation program using combined approaches, robotic medical devices together with other rehabilitation techniques and therapies, in elderly people after acute COVID-19. Ninety-one patients (62.64 ± 14.21 years) previously diagnosed with severe SARS-CoV-2 infection were admitted to the Medical Rehabilitation Clinical Hospital Baile Felix, Romania, for medical rehabilitation, but only six patients (85.33 ± 3.07 years) met the inclusion criteria and participated in the study. The rehabilitation treatment was complex, performed over 4 weeks, and included combined approaches: exercise therapy, robotic gait training, occupational therapy, and massages. Activity and participation evaluation were performed using the Barthel Index and Functional Independence Measure for activities of daily living (ADLs). Assessments were performed at admission and discharge from the rehabilitation clinic. Lokomat patients' reports revealed that the patients had improved motor control (with one exception). The measurement of functional ability revealed an improvement in most cases. This study presents some of the first data on outcomes of COVID-19 patients' musculoskeletal rehabilitation in our country. Early complex medical rehabilitation improved functional independence and autonomy in ADLs in very old patients, post-COVID-19.

Handgrip strength rather than chair stand test should be used to diagnose sarcopenia in geriatric rehabilitation inpatients: REStORing health of acutely unwell adulTs (RESORT)

BACKGROUND

according to the revised sarcopenia definition proposed by the European Working Group on Sarcopenia in Older People (EWGSOP2) and revised definition of the Asian Working Group for Sarcopenia (AWGS2019), handgrip strength (HGS) and chair stand test (CST) can be used interchangeably as initial diagnostic measures.

OBJECTIVE

to assess the agreement between sarcopenia prevalence, using either HGS or CST, and their association with adverse outcomes in geriatric rehabilitation inpatients.

METHODS

REStORing health of acutely unwell adulTs is an observational, longitudinal cohort of geriatric rehabilitation inpatients. Cohen's kappa (κ) was used to assess the agreement between sarcopenia prevalence (no, probable and confirmed and severe sarcopenia) according to EWGSOP2 and AWGS2019 using either HGS or CST. Associations between HGS and CST and readmission, institutionalisation and mortality were assessed by binomial regression.

RESULTS

patients (n = 1,250, 57% females) had a median age of 83.1 years (interquartile range: [77.5-88.3]). There was no agreement between probable sarcopenia prevalence using HGS or CST for EWGSOP2 and AWGS2019, respectively (HGS: 70.9% and 76.2%; CST: 95.5% and 98.4%; κ = 0.08 and 0.02). Agreement between confirmed and severe sarcopenia prevalence using either HGS or CST was strong to almost perfect. HGS was associated with 3-month institutionalisation and 3-month and 1-year mortality, whereas CST was not associated.

CONCLUSIONS

HGS and CST cannot be used interchangeably as diagnostic measures for probable sarcopenia in geriatric rehabilitation inpatients. CST is not useful to predict adverse outcomes in geriatric rehabilitation inpatients.

Multimorbidity, Frailty and Diabetes in Older People-Identifying Interrelationships and Outcomes

Multimorbidity and frailty are highly prevalent in older people with diabetes. This high prevalence is likely due to a combination of ageing and diabetes-related complications and other diabetes-associated comorbidities. Both multimorbidity and frailty are associated with a wide range of adverse outcomes in older people with diabetes, which are proportionally related to the number of morbidities and to the severity of frailty. Although, the multimorbidity pattern or cluster of morbidities that have the most adverse effect are not yet well defined, it appears that mental health disorders enhance the multimorbidity-related adverse outcomes. Therefore, comprehensive diabetes guidelines that incorporate a holistic approach that includes screening and management of mental health disorders such as depression is required. The adverse outcomes predicted by multimorbidity and frailty appear to be similar and include an increased risk of health care utilisation, disability and mortality. The differential effect of one condition on outcomes, independent of the other, still needs future exploration. In addition, prospective clinical trials are required to investigate whether interventions to reduce multimorbidity and frailty both separately and in combination would improve clinical outcomes.

Effectiveness of Standard Sequential Bilateral Repetitive Transcranial Magnetic Stimulation vs Bilateral Theta Burst Stimulation in Older Adults With Depression: The FOUR-D Randomized Noninferiority Clinical Trial

IMPORTANCE

Treatment-resistant depression (TRD) is common in older adults. Bilateral repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex for 48 minutes has demonstrated efficacy in TRD. Theta burst stimulation (TBS), a newer form of rTMS, can also be delivered bilaterally using left intermittent TBS and right continuous TBS for only 4 minutes.

OBJECTIVE

To establish the effectiveness and tolerability of TBS compared with standard rTMS in older adults with TRD.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized noninferiority trial with open treatment and blinded assessors, recruitment occurred between December 2016 and March 2020. The trial was conducted at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada and included outpatients 60 years and older with a diagnosis of depression, moderate severity, and nonresponse to 1 or more antidepressant trial of adequate dosage and duration or intolerance of 2 or more trials.

INTERVENTIONS

Participants were randomized to receive a course of 4 to 6 weeks of either bilateral standard rTMS or TBS.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was change in Montgomery-Åsberg Depression Rating Scale; secondary outcome measures included the 17-item Hamilton Rating Scale for Depression, Quick Inventory of Depressive Symptomatology (16-item) (self-report), and dropout rates. A noninferiority margin of 2.75 points was used for the primary outcome. All participants who attained the primary completion point of 4 weeks were analyzed.

RESULTS

A total of 87 participants (mean [SD] age, 67.1 [6.7] years; 47 [54.0%] female) were randomized to standard bilateral rTMS and 85 (mean [SD] age, 66.3 [5.3] years; 45 [52.9%] female) to TBS, of whom 85 (98%) and 79 (93%) were assessed for the primary outcome, respectively, whereas tolerability was assessed in all randomized participants. In the rTMS group, 4 (4.6%) were American Indian, reported other, or preferred not to answer; 5 (5.8%) were Asian; and 78 (89.7%) were White. In the TBS group, 6 (7.1%) were Asian, 2 (2.4%) were Black or reported other, and 77 (90.3%) were White. Mean (SD) Montgomery-Åsberg Depression Rating Scale total scores improved from 25.6 (4.0) to 17.3 (8.9) for rTMS and 25.7 (4.7) to 15.8 (9.1) for TBS (adjusted difference, 1.55; lower 95% CI -0.67), establishing noninferiority for TBS. The all-cause dropout rates were relatively similar between groups (rTMS: 2 of 87 [2.3%]; TBS: 6 of 85 [7.1%]; P = .14; χ2 = 2.2).

CONCLUSIONS AND RELEVANCE

In older adults with TRD, bilateral TBS compared with standard bilateral rTMS achieved noninferior reduction in depression symptoms. Both treatments had low and similar dropout rates. Using TBS rather than rTMS could increase access to treatment several-fold for older adults with TRD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02998580.

Venlafaxine XR treatment for older patients with major depressive disorder: decision trees for when to change treatment

BACKGROUND

Predictors of antidepressant response in older patients with major depressive disorder (MDD) need to be confirmed before they can guide treatment.

OBJECTIVE

To create decision trees for early identification of older patients with MDD who are unlikely to respond to 12 weeks of antidepressant treatment, we analysed data from 454 older participants treated with venlafaxine XR (150-300 mg/day) for up to 12 weeks in the Incomplete Response in Late-Life Depression: Getting to Remission study.

METHODS

We selected the earliest decision point when we could detect participants who had not yet responded (defined as >50% symptom improvement) but would do so after 12 weeks of treatment. Using receiver operating characteristic models, we created two decision trees to minimise either false identification of future responders (false positives) or false identification of future non-responders (false negatives). These decision trees integrated baseline characteristics and treatment response at the early decision point as predictors.

FINDING

We selected week 4 as the optimal early decision point. Both decision trees shared minimal symptom reduction at week 4, longer episode duration and not having responded to an antidepressant previously as predictors of non-response. Test negative predictive values of the leftmost terminal node of the two trees were 77.4% and 76.6%, respectively.

CONCLUSION

Our decision trees have the potential to guide treatment in older patients with MDD but they require to be validated in other larger samples.

CLINICAL IMPLICATIONS

Once confirmed, our findings may be used to guide changes in antidepressant treatment in older patients with poor early response.

Ventriculoatrial Shunt Under Locoregional Anesthesia: A Technical Note

BACKGROUND

Ventriculoatrial shunt is routinely performed under general anesthesia and is used to treat various kinds of hydrocephalus. Idiopathic normal pressure hydrocephalus patients are generally elderly and can have high comorbidities; in such patients, avoiding general anesthesia and limiting opioid administration could be beneficial. We started to perform ventriculoatrial shunt under locoregional anesthesia, in order to make this procedure more truly "minimally invasive".

METHODS

Demographic data, American Society of Anesthesiologists (ASA) score and vital signs, Ramsay sedation scale, and procedural duration were collected. All procedures were performed combining sedation with cervical plexus and scalp block. After internal jugular vein cannulation, a catheter was inserted and connected with a programmable valve and then with the ventricular catheter. Outcome was assessed by the Idiopathic Normal Pressure Hydrocephalus Grading Scale and complications were recorded at 3-month follow-up.

RESULTS

Ten consecutive patients were enrolled; the mean age was 74 years, 8 were male, ASA score median value was 3. Opioids were administered only in 4 patients, in 6 patients the value of Ramsay scale was 5. The average duration of surgery was 59.5 minutes. No procedure was converted to general anesthesia.

CONCLUSIONS

Our preliminary experience with ventriculoatrial shunt under locoregional anesthesia demonstrates that this technique is feasible, is not associated with an increase in operating times or complications, can avoid general anesthesia, and helps to limit opioid administration in the elderly. It can therefore represent a valid option in order to improve treatment quality in these complex patients.

Neuropsychological Impairments and Their Cognitive Architecture in Mild Cognitive Impairment (MCI) with Lewy Bodies and MCI-Alzheimer's Disease

OBJECTIVE

The present study aimed to clarify the neuropsychological profile of the emergent diagnostic category of Mild Cognitive Impairment with Lewy bodies (MCI-LB) and determine whether domain-specific impairments such as in memory were related to deficits in domain-general cognitive processes (executive function or processing speed).

METHOD

Patients (n = 83) and healthy age- and sex-matched controls (n = 34) underwent clinical and imaging assessments. Probable MCI-LB (n = 44) and MCI-Alzheimer's disease (AD) (n = 39) were diagnosed following National Institute on Aging-Alzheimer's Association (NIA-AA) and dementia with Lewy bodies (DLB) consortium criteria. Neuropsychological measures included cognitive and psychomotor speed, executive function, working memory, and verbal and visuospatial recall.

RESULTS

MCI-LB scored significantly lower than MCI-AD on processing speed [Trail Making Test B: p = .03, g = .45; Digit Symbol Substitution Test (DSST): p = .04, g = .47; DSST Error Check: p < .001, g = .68] and executive function [Trail Making Test Ratio (A/B): p = .04, g = .52] tasks. MCI-AD performed worse than MCI-LB on memory tasks, specifically visuospatial (Modified Taylor Complex Figure: p = .01, g = .46) and verbal (Rey Auditory Verbal Learning Test: p = .04, g = .42) delayed recall measures. Stepwise discriminant analysis correctly classified the subtype in 65.1% of MCI patients (72.7% specificity, 56.4% sensitivity). Processing speed accounted for more group-associated variance in visuospatial and verbal memory in both MCI subtypes than executive function, while no significant relationships between measures were observed in controls (all ps > .05).

CONCLUSIONS

MCI-LB was characterized by executive dysfunction and slowed processing speed but did not show the visuospatial dysfunction expected, while MCI-AD displayed an amnestic profile. However, there was considerable neuropsychological profile overlap and processing speed mediated performance in both MCI subtypes.

Hypnosis for pain and anxiety management in cognitively impaired older adults undergoing scheduled lumbar punctures: a randomized controlled pilot study

BACKGROUND

Core cerebrospinal fluid (CSF) amyloid and tau biomarker assessment has been recommended to refine the diagnostic accuracy of Alzheimer's disease. Lumbar punctures (LP) are invasive procedures that might induce anxiety and pain. The use of non-pharmacological techniques must be considered to reduce the patient's discomfort, in this setting. The objective of this study was to examine the efficacy of hypnosis on anxiety and pain associated with LP.

METHODS

A monocentric interventional randomized-controlled pilot study is conducted in a university geriatric day hospital. Cognitively impaired patients aged over 70 were referred for scheduled LP for the diagnostic purpose (CSF biomarkers). The participants were randomly assigned either to a hypnosis intervention group or usual care. Pain and anxiety were both self-assessed by the patient and hetero-evaluated by the operator.

RESULTS

We included 50 cognitively impaired elderly outpatients (women 54%, mean age 77.2 ± 5.0, mean Mini-Mental State Examination score 23.2 ± 3.5). Hypnosis was significantly associated with reduced self-assessed (p < 0.05) and hetero-assessed anxiety (p < 0.01). Hetero-evaluated pain was significantly lower in the hypnosis group (p < 0.05). The overall perception of hypnosis was safe, well-accepted, and feasible in all the participants of the intervention group with 68% perceiving the procedure as better or much better than expected.

CONCLUSIONS

This pilot study suggested that hypnosis was feasible and may be used to reduce the symptoms of discomfort due to invasive procedures in older cognitively impaired patients. Our results also confirmed the overall good acceptance of LP in this population, despite the usual negative perception.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04368572. Registered on April 30, 2020.

Predicting Medication Nonadherence in Older Adults With Difficult-to-Treat Depression in the IRL-GRey Randomized Controlled Trial

OBJECTIVE

Nonadherence to antidepressants interferes with optimal treatment of late-life depression. This analysis examines clinical and treatment factors predicting medication nonadherence in difficult-to-treat late-life depression.

METHODS

Secondary analysis of data from a clinical trial of antidepressant pharmacotherapy for Major Depressive Disorder in 468 adults aged 60+ years. All participants received venlafaxine XR for 12 weeks. Nonremitters were randomized to augmentation with either aripiprazole or placebo for 12 additional weeks. Medication adherence was assessed 14 times over 24 weeks. The analyses examined sociodemographic, clinical, and treatment factors that may predict antidepressant nonadherence during early (weeks 1-6), late (weeks 7-12), and augmentation (weeks 13--24) treatment.

RESULTS

Poor cognitive function and early response were predictive of early nonadherence. Poor cognitive function and prior nonadherence were predictive of late nonadherence. Living alone was associated with nonadherence both late and during augmentation treatment.

CONCLUSION

Future studies should consider the role of early response and cognitive function to improve antidepressant adherence, particularly among older adults who live alone.

Assessment of the external validity of the National Comprehensive Cancer Network (NCCN) guidelines for pancreatic ductal adenocarcinoma in a population of older patients aged 70 years and older

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) mainly occurs in older adults. Since randomized clinical trials (RCTs) provide the highest-quality evidence incorporated in NCCN recommendations, the underrepresentation of older patients in RCTs challenges guidelines' external validity and limits the solidity of evidence in this specific population.

MATERIALS AND METHODS

The study aimed to investigate external validity of NCCN guidelines for PDCA and the impact of reference studies eligibility on overall survival (OS) in a real-world older population. We retrieved RCTs supporting NCCN recommendations for management of PDAC and identified ten topics. We matched a cohort of 707 PDAC patients aged ≥70 years from the Moffitt Cancer Center database with eligibility criteria of 96 reference RCTs to check the proportion of patients eligible for at least two RCTs. Eligibility >60% was rated full validity, 30%-60% partial validity and < 30% limited validity. We also performed log-rank test to assessed whether "eligibility" status affects OS, stratifying by age (70-74; 75-79; ≥80).

RESULTS AND DISCUSSION

We found full validity for neoadjuvant (57/73 patients; 69.86%), locally advanced (28/39; 71.79%) and second line (88/110; 80%) treatment, while lowest validity was found for adjuvant chemotherapy (37/86; 43%). Eligible status was correlated with a significant OS benefit for adjuvant chemoradiation (p = 0.002) in all-comers and for first-line polychemotherapy in patients aged ≥80 (p = 0.01). Our analysis supports the limitation of guidelines' external validity in older patients, and hints at possible correlations with survival, although no definitive conclusions can be drawn at this stage. Renewing RCT design with broader eligibility criteria might help increase inclusion of older and thus strengthen the evidence.

Predictors of Postoperative Delirium in Older Patients Undergoing Elective Spine Surgery

Introduction

This prospective study was conducted to investigate the prevalence and predictors of postoperative delirium (POD) in a cohort of patients aged ≥65 years who were scheduled to undergo elective spine surgery.

Methods

Patients aged ≥65 years who were scheduled to undergo elective spine surgery from February 2018 to May 2019 were prospectively recruited for this study. Delirium was diagnosed according to the Confusion Assessment Method algorithm. Candidate predictors included patient characteristics, comorbidities, surgical time, blood loss, preoperative laboratory parameters, and preoperative cognitive function, as assessed by the Mini-Cog test. These variables were compared between patients with and without POD. Multivariate logistic regression was performed to identify the independent predictors of POD. For the continuous variables, a receiver operating characteristic curve was used to determine the optimal cutoff value for predicting POD.

Results

Of the 106 patients included in the study, 12 (11.3%) patients developed POD, with a median time to onset of 3 d and median duration of 2 d. After adjusting for confounders, the occurrence of POD was independently associated with older age, a higher blood urea nitrogen (BUN) concentration, and a lower Mini-Cog score. The optimal cutoff point of the Mini-Cog score for predicting the occurrence of POD was ≤3.

Conclusions

POD was a common complication after spine surgery, showing an incidence of 11.3% in this study. Older age, a higher BUN concentration, and impaired cognition, as defined by the Mini-Cog, were independent predictors of POD. The current results may be useful for early identification of patients at risk of POD and facilitation of targeted interventions for preventing POD or mitigating its severity.

Rest-activity rhythms and tract specific white matter lesions in older adults at risk for cognitive decline

White matter lesions (WMLs) are common in older adults and represent an important predictor of negative long-term outcomes. Rest-activity rhythm disturbance is also common, however, few studies have investigated associations between these factors. We employed a novel AI-based automatic WML segmentation tool and diffusion-weighted tractography to investigate associations between tract specific WML volumes and non-parametric actigraphy measures in older adults at risk for cognitive decline. The primary non-parametric measures of interest were inter-daily stability (IS), intra-daily variability and relative amplitude, with the anterior thalamic radiation (ATR), superior longitudinal fasciculus (SLF) and inferior longitudinal fasciculus (ILF) selected as tracts of interest. One hundred and eight participants at risk for cognitive decline (classified as experiencing subjective or objective cognitive decline) were included (mean age = 68.85 years, SD = 8.91). Of the primary non-parametric measures of interest, results showed that lower IS was associated with a greater likelihood of higher WML burden in the ATR (OR = 1.82, 95% CI [1.12,3.15]). Analysis of secondary non-parametric measures revealed later onset of the least active period to be associated with greater likelihood of high WML burden in the SLF (OR = 1.55, 95% CI [1.00,2.53]) and increased activity during the least active 5-h period to be associated with a greater likelihood of high whole-brain WML burden (OR = 1.83, 95% CI [1.06,3.47]). This study shows integrity of the ATR and SLF, and overall WML burden is linked to altered rest-activity rhythms in older adults at risk for cognitive decline, with those demonstrating altered rest-activity rhythms showing 50%-80% higher odds of having high WML burden.

Association of Low Emotional and Tangible Support With Risk of Dementia Among Adults 60 Years and Older in South Korea

IMPORTANCE

The association between social support and dementia risk has been debated. Most previous prospective studies have not differentiated the subtypes of social support.

OBJECTIVE

To examine whether the association between social support and risk of dementia differs by subtype of social support and by sex.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide prospective cohort study included randomly sampled South Korean adults 60 years or older. The study was launched November 1, 2010, with follow-up every 2 years until November 30, 2020. The 5852 participants who completed the assessment for social support and were not diagnosed as having dementia, severe psychiatric disorders including major depressive disorder, or major neurological disorders at the baseline assessment were included in the analysis.

EXPOSURES

Geriatric psychiatrists administered the structured diagnostic interviews and physical examinations to every participant based on the Korean version of the Consortium to Establish a Registry for Alzheimer Disease (CERAD-K) Assessment Packet Clinical Assessment Battery.

MAIN OUTCOMES AND MEASURES

Baseline levels of emotional and tangible support using the Medical Outcomes Survey Social Support Survey.

RESULTS

Among the 5852 participants (mean [SD] age, 69.8 [6.6] years; 3315 women [56.6%]; mean [SD] follow-up duration, 5.9 [2.4] years), 237 (4.0%) had incident all-cause dementia and 160 (2.7%) had incident Alzheimer disease (AD) subtype of dementia. Compared with women who reported having emotional support, those with low emotional support had almost a 2-fold higher incidence of all-cause dementia (18.4 [95% CI, 13.6-23.2] vs 10.7 [95% CI, 9.0-12.5] per 1000 person-years) and AD (14.4 [95% CI, 10.2-18.6] vs 7.8 [95% CI, 6.3-9.3] per 1000 person-years). Adjusted Cox proportional hazard analysis revealed that low emotional support was associated with increased risk of all-cause dementia (hazard ratio, 1.61 [95% CI, 1.10-2.36]; P = .02) and AD (hazard ratio, 1.66 [95% CI, 1.07-2.57]; P = .02) only in women. Low tangible support was not associated with a risk of all-cause dementia or AD regardless of sex.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that older women with low emotional support constitute a population at risk for dementia. The level of emotional support should be included in risk assessments of dementia.

Handgrip Strength as a Predictor of Successful Rehabilitation After Hip Fracture in Patients 65 Years of Age and Above

Purpose

It is important to identify factors associated with the outcome of rehabilitation after hip fracture as an aid to planning the rehabilitation framework and the future discharge of patients. Previous studies have shown that handgrip strength (HGS) is one of the factors associated with the success of rehabilitation.

Materials and Methods

A retrospective study among patients 65 years of age and above who underwent surgical repair of a hip fracture followed by rehabilitation in the Geriatrics ward between September 2019 and December 2021. Successful rehabilitation was determined as Montebello Rehabilitation Factor Score Revised (MRFS-R) ≥50%. Associations were assessed between various sociodemographic and clinical variables, including HGS, and rehabilitation success. HGS was tested as a continuous and dichotomous variable, in accordance with various definitions of low muscle strength.

Results

Data were collected for 173 patients. The mean age was 81.2 ± 7.2 years and 68.2% were women. In a logistic regression model only HGS, as a continuous variable, was independently associated with rehabilitation success, with each increase of 1 kg increasing the chance for successful rehabilitation by 6.8%.

Conclusion

HGS is a simple tool for the planning of the rehabilitation process among patients with hip fracture.

Mood disorders increase mortality mainly through dementia: A community-based prospective cohort study

OBJECTIVE

The effects of mood disorders on mortality may be mediated by their effects on the risk of dementia, and interventions to reduce the occurrence of dementia may reduce their overall mortality. This study aimed to investigate the direct effects of depressive and bipolar disorders on the 6-year risk of mortality and also their indirect effects on mortality due to their effect on the risk of dementia.

METHODS

A total of 5101 Koreans were selected from a community-based prospective cohort study, and 6-year risks of mortality and dementia in participants with depressive and bipolar disorders were estimated by Cox proportional hazard analysis. The direct and indirect effects of depressive and bipolar disorders on the risk of mortality were estimated using structural equation modeling.

RESULTS

The depressive and bipolar disorder groups showed 51% and 85% higher 6-year mortality, and 82% and 127% higher risk of dementia, respectively, compared to euthymic controls. The effects of depressive and bipolar disorders on mortality were mainly mediated by their effects on the risk of dementia in a structural equation model. The direct effects of each mood disorder on mortality were not significant.

CONCLUSION

Both depressive and bipolar disorders increased the risks of mortality and dementia, and the effects of mood disorders on mortality were mainly mediated through dementia. As dementia occurs later in life than mood disorders, measures to prevent it may effectively reduce mortality in individuals with a history of mood disorders, as well as being more feasible than attempting to control other causes of death.

Characteristics of geriatric rehabilitation inpatients based on their frailty severity and change in frailty severity during admission: RESORT

BACKGROUND

Frailty is prevalent amongst geriatric inpatients and worsens clinical outcomes. Determinants of admission frailty and changes in frailty severity are potential targets for intervention.

OBJECTIVE

To identify characteristics associated with frailty severity at admission and change in frailty severity during geriatric rehabilitation.

METHODS

The observational, prospective, longitudinal inception cohort REStORing health of acutely unwell adulTs (RESORT) includes geriatric rehabilitation inpatients. Demographic, medical, nutritional, functional, and psychological characteristics were analysed according to admission Clinical Frailty Scale. Linear and multinomial logistic regression prediction models identified admission characteristics predicting change in frailty severity during rehabilitation.

RESULTS

A total 1716 inpatients (median age [IQR] 83.4 [77.7-88.6] years, 56.4 % females) were included. Poorer admission medical, nutritional, functional, and psychological status was associated with more severe frailty. Cardiac admissions, higher Cumulative Illness Rating Scale, greater number of medications, and better Short Physical Performance Battery at admission predicted improved frailty severity. Admission cognitive impairment, delirium, higher Charlson Comorbidity Index, and Hospital Anxiety and Depression Scale anxiety predicted worsened frailty severity. Explained variation was low.

CONCLUSIONS

Frailer geriatric rehabilitation inpatients have more complicated disease and impaired nutritional, physical, and psychological markers. Admission cognitive impairment, delirium, comorbidity, and anxiety predict worsening frailty during rehabilitation, and require prompt management.

Validation of clinical frailty scale in Chinese translation

BACKGROUND

Identification of frailty is crucial to guide patient care for the elderly. The Clinical Frailty Scale (CFS) is a reliable, synthesis and clinical judgment-based tool. However, a validated Chinese version of CFS (CFS-C) is lacking. The aim of this study is to describe the translation process of CFS into traditional Chinese and to evaluate its reliability and validity in a geriatric study population in Taiwan.

METHODS

This cross-sectional study recruited 221 geriatric outpatients aged 65 years or older at a medical center in Taipei, Taiwan. The Chinese version of CFS was produced following Brislin's translation model. Weighted kappa for agreement and Kendall's tau for correlation were used to assess inter-rater reliability (a subgroup of 52 outpatients) between geriatricians and one research assistant, and validity tests (221 outpatients) by comparing CFS-C with Fried frailty phenotype and Frailty Index based on Comprehensive Geriatric Assessment (FI-CGA). Correlation between CFS-C and other geriatric conditions were also assessed.

RESULTS

The inter-rater reliability revealed moderate agreement (weighted kappa = 0.60) and strong correlation (Kendall's tau = 0.67). For criterion validity, CFS-C categorisation showed fair agreement (weighted kappa = 0.37) and significant correlation (Kendall's tau = 0.46) with Fried frailty phenotype, and higher agreement (weighted kappa = 0.51) and correlation (Kendall's tau = 0.63) with FI-CGA categorisation. CFS-C was significantly correlated with various geriatric assessments, including functional disability, physical performance, hand grip, comorbidity, cognition, depression, and nutrition status. No significant correlation was found between CFS-C and appendicular muscle mass.

CONCLUSIONS

The CFS-C demonstrated acceptable validity and reliability in Chinese older adults in Taiwan. Development of CFS-C enhanced consistency and accuracy of frailty assessment, both in research and clinical practice.

Patterns of Alcohol Consumption and Associated Factors in a Population-Based Sample of 70-Year-Olds: Data from the Gothenburg H70 Birth Cohort Study 2014-16

Older adults of today consume more alcohol, yet knowledge about the factors associated with different consumption levels is limited in this age group. Based on the data from a population-based sample (n = 1156, 539 men and 617 women) in The Gothenburg H70 Birth Cohort Study 2014−16, we examined sociodemographic, social, and health-related factors associated with alcohol consumption levels in 70-year-olds, using logistic regression. Total weekly alcohol intake was calculated based on the self-reported amount of alcohol consumed. Alcohol consumption was categorized as lifetime abstention, former drinking, moderate consumption (≤98 g/week), and at-risk consumption (>98 g/week). At-risk consumption was further categorized into lower at-risk (98−196 g/week), medium at-risk (196−350 g/week), and higher at-risk (≥350 g/week). We found that among the 1156 participants, 3% were lifetime abstainers, 3% were former drinkers, 64% were moderate drinkers, and 30% were at-risk drinkers (20% lower, 8% medium, 2% higher). Among several factors, former drinking was associated with worse general self-rated health (OR 1.65, 95% CI 1.08−2.51) and lower health-related quality of life (measured by physical component score) (OR 0.94, 95% CI 0.91−0.97), higher illness burden (OR 1.16, 95% CI 1.07−1.27), and weaker grip strength (OR 0.96, 95% CI 0.94−0.98). Higher at-risk drinkers more often had liver disease (OR 11.41, 95% CI 3.48−37.37) and minor depression (OR 4.57, 95% CI 1.40−14.95), but less contacts with health care (OR 0.32, 95% CI 0.11−0.92). Our findings demonstrate the importance of classifications beyond abstinence and at-risk consumption, with implications for both the prevention and clinical management of unhealthy consumption patterns in older adults.

Incidence of Revision Surgery After Decompression With vs Without Fusion Among Patients With Degenerative Lumbar Spinal Stenosis

Importance

Only limited data derived from large prospective cohort studies exist on the incidence of revision surgery among patients who undergo operations for degenerative lumbar spinal stenosis (DLSS).

Objective

To assess the cumulative incidence of revision surgery after 2 types of index operations-decompression alone or decompression with fusion-among patients with DLSS.

Design, Setting, and Participants

This cohort study analyzed data from a multicenter, prospective cohort study, the Lumbar Stenosis Outcome Study, which included patients aged 50 years or older with DLSS at 8 spine surgery and rheumatology units in Switzerland between December 2010 and December 2015. The follow-up period was 3 years. Data for this study were analyzed between October and November 2021.

Exposures

All patients underwent either decompression surgery alone or decompression with fusion surgery for DLSS.

Main Outcomes and Measures

The primary outcome was the cumulative incidence of revision operations. Secondary outcomes included changes in the following patient-reported outcome measures: Spinal Stenosis Measure (SSM) symptom severity (higher scores indicate more pain) and physical function (higher scores indicate more disability) subscale scores and the EuroQol Health-Related Quality of Life 5-Dimension 3-Level questionnaire (EQ-5D-3L) summary index score (lower scores indicate worse quality of life).

Results

A total of 328 patients (165 [50.3%] men; median age, 73.0 years [IQR, 66.0-78.0 years]) were included in the analysis. Of these, 256 (78.0%) underwent decompression alone and 72 (22.0%) underwent decompression with fusion. The cumulative incidence of revisions after 3 years of follow-up was 11.3% (95% CI, 7.4%-15.1%) for the decompression alone group and 13.9% (95% CI, 5.5%-21.5%) for the fusion group (log-rank P = .60). There was no significant difference in the need for revision between the 2 groups over time (unadjusted absolute risk difference, 2.6% [95% CI, -6.3% to 11.4%]; adjusted absolute risk difference, 3.9% [95% CI, -5.2% to 17.0%]; adjusted hazard ratio, 1.40 [95% CI, 0.63-3.13]). The number of revisions was significantly associated with higher SSM symptom severity scores (β, 0.171; 95% CI, 0.047-0.295; P = .007) and lower EQ-5D-3L summary index scores (β, -0.061; 95% CI, -0.105 to -0.017; P = .007) but not with higher SSM physical function scores (β, 0.068; 95% CI, -0.036 to 0.172; P = .20). The type of index operation was not significantly associated with the corresponding outcomes.

Conclusions and Relevance

This cohort study showed no significant association between the type of index operation for DLSS-decompression alone or fusion-and the need for revision surgery or the outcomes of pain, disability, and quality of life among patients after 3 years. Number of revision operations was associated with more pain and worse quality of life.

An Internet-Based Self-Management Intervention to Reduce Fatigue Among People With Traumatic Brain Injury: A Pilot Randomized Controlled Trial

IMPORTANCE

Fatigue is a chronic and distressing sequela of traumatic brain injury (TBI). Little evidence exists for the efficacy of interventions that address post-TBI fatigue.

OBJECTIVE

To evaluate the preliminary efficacy of a self-management intervention (Maximizing Energy; MAX) for reducing the impact (primary outcome) and severity of fatigue on daily life, improving fatigue experience, and increasing participation compared with a health education (HE) intervention.

DESIGN

Pilot randomized controlled trial (RCT).

SETTING

Community.

PARTICIPANTS

Forty-one participants randomly assigned to the MAX (n = 20) or HE (n = 21) intervention.

INTERVENTIONS

The MAX intervention included problem-solving therapy with energy conservation education to teach participants fatigue management. The HE intervention included diet, exercise, and energy conservation education. Both interventions (30 min/day, 2 days/wk for 8 wk) were delivered online by occupational therapists.

OUTCOME AND MEASURES

The primary outcome was the modified Fatigue Impact Scale (mFIS). Outcome measures were collected at baseline, postintervention, and 4- and 8-wk postintervention.

RESULTS

At 8 wk postintervention, participants in the MAX group reported significantly lower levels of fatigue impact (mFIS) than those in the HE group, F(1, 107) = 29.54, p = .01; Cohen's d = 0.87; 95% confidence interval [0.18, 1.55].

CONCLUSIONS AND RELEVANCE

These findings provide preliminary evidence that the MAX intervention may decrease the impact of fatigue on daily life among people with post-TBI fatigue. What This Article Adds: An internet-based, self-management intervention combining occupational therapy- delivered energy conservation education with cognitive-behavioral therapy seems to reduce fatigue impact and severity among people with post-TBI fatigue. Future appropriately powered RCTs could positively contribute to the evidence available to occupational therapy practitioners for this chronic, debilitating, and often overlooked symptom.

Thinking of Me or Thinking of You? Behavioral Correlates of Self vs. Other Centered Worry and Reappraisal in Late-Life

Psychotherapeutic approaches in late-life anxiety have limited effect on reducing worry severity. The self-referential processing of worry contents (self- vs. other-focused worry) and reappraisal styles (internal vs. external locus of control) are important elements in psychotherapy, but little is known about these processes in late-life. We aimed to characterize severe worry from a self-referential processing perspective. We recruited 104 older adults with various levels of worry and used a personalized task to induce and reappraise worry. We analyzed the association between (1) worry severity/frequency for worry content (self- or other-focused) and (2) for reappraisal style (internal vs. external locus of control) with clinical inventories measuring anxiety, worry, depression, rumination, neuroticism, emotion regulation strategies, perceived stress, and physical illness burden. Higher self-worry severity was associated with higher scores of clinical inventories of worry, depression, perceived stress, and neuroticism, whereas other-worry severity did not show any association. Greater self-worry frequency was associated with higher medical burden. External locus of control in reappraisal statements was associated with lower worry severity in men. Overall, more severe and frequent self-focused worry was associated with a greater psychological and physiological burden. These results are useful in tailoring psychotherapy for older adults with severe worry.

Psycho-cognitive assessment and quality of life in older adults with chronic obstructive pulmonary disease-carrying the rs4713916 gene polymorphism (G/A) of gene FKBP5 and response to pulmonary rehabilitation: a proof of concept study

PURPOSE

Chronic obstructive pulmonary disease (COPD) is characterized by pulmonary and extra-pulmonary multi-morbidity including depression, anxiety and cognitive disorders. Several studies investigated the association of the FKBP5 gene polymorphisms with susceptibility to anxiety, depression, and behavioral disorders. The FKBP5 gene codifies the FKBP51 protein which modulates the glucocorticoid receptor in the adaptive stress response. Genetic variants of the FKBP5 gene have been associated to a higher risk of developing mental disorders. We analyzed the association of genetic variants and stress exposure investigating the susceptibility to psychological distress and the impact on cognitive balance and quality of life (QoL) of COPD patients carrying the rs4713916 polymorphism (G/A) and we examined its association, with COPD rehabilitative outcomes.

MATERIALS AND METHODS

A pilot study evaluated cognitive, psychological, clinical alterations/disorders, QoL, and coping strategies in 70 older adults with COPD, undergoing pulmonary rehabilitation, stratified according to the FKBP5 rs4713916 genotype (GG or GA).

RESULTS

Carriers of rs4713916 polymorphisms (G/A) show better cognitive performances, a higher degree of independence in the daily living activities, better QoL, no presence of depressive mood and anxiety symptoms, no family history of psychiatric disorders, more ability to cope with stressors by avoiding emotions but demanding emotional support, and lesser use of anti-anxiety, anti-depressant, anti-psychotic, hypnotic-sedative drugs. No difference was found in the number of comorbidities.

CONCLUSION

These results offer valuable insights into the role of FKBP5 in the complex network of mechanisms associated to clinical, psychological and behavioral features of COPD patients.

Association of Molecular Senescence Markers in Late-Life Depression With Clinical Characteristics and Treatment Outcome

IMPORTANCE

Many older adults with depression do not experience remission with antidepressant treatment, and markers of cellular senescence in late-life depression (LLD) are associated with greater severity of depression, greater executive dysfunction, and higher medical illness burden. Since these clinical characteristics are associated with remission in LLD, molecular and cellular senescence abnormalities could be a possible biological mechanism underlying poor treatment response in this population.

OBJECTIVE

To examine whether the senescence-associated secretory phenotype (SASP) index was associated with the likelihood of remission from a depressive episode in older adults.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized, open-label clinical trial was conducted between August 2009 and August 2014 in Pittsburgh, Pennsylvania; St Louis, Missouri; and Toronto, Ontario, Canada, with older adults in a current major depressive episode according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) diagnostic criteria. Data from biomarker analyses were reported according to the clinical trial archived plasma samples run in March 2021. Data were analyzed from June to November 2021.

EXPOSURE

Venlafaxine extended release (dose ranging from 37.5 mg to 300 mg daily) for up to 12 weeks.

MAIN OUTCOMES AND MEASURES

The association between a composite biomarker-based index (SASP index) and treatment remission in older adults with major depression was measured using clinical data and blood samples.

RESULTS

There were 416 participants with a mean (SD) age of 60.02 (7.13) years; 64% (265 participants) were self-reported female, and the mean (SD) Montgomery-Asberg Depression Rating Scale score was 26.6 (5.7). Higher SASP index scores were independently associated with higher rates of nonremission, with an increase of 1 unit in the SASP index score increasing the odds of nonremission by 19% (adjusted odds ratio, 1.19; 95% CI, 1.05-1.35; P = .006). In contrast, no individual SASP factors were associated with remission in LLD.

CONCLUSIONS AND RELEVANCE

Using clinical data and blood samples from a nonrandomized clinical trial, the results of this study suggest that molecular and cellular senescence, as measured with the SASP index, is associated with worse treatment outcomes in LLD. Combining this index score reflecting interrelated biological processes with other molecular, clinical, and neuroimaging markers may be useful in evaluating antidepressant treatment outcomes. These findings inform a path forward for geroscience-guided interventions targeting senescence to improve remission rates in LLD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00892047.

Decision-support systems for managing polypharmacy in the elderly: A scoping review

Polypharmacy, the consuming of more than five drugs, is a public health problem. It can lead to many interactions and adverse drug reactions and is very expensive. Therapeutic guidelines for managing polypharmacy in the elderly have been issued, but are highly complex, limiting their use. Decision-support systems have therefore been developed to automate the execution of these guidelines, or to provide information about drugs adapted to the context of polypharmacy. These systems differ widely in terms of their technical design, knowledge sources and evaluation methods. We present here a scoping review of electronic systems for supporting the management, by healthcare providers, of polypharmacy in elderly patients. Most existing reviews have focused mainly on evaluation results, whereas the present review also describes the technical design of these systems and the methodologies for developing and evaluating them. A systematic bibliographic search identified 19 systems differing considerably in terms of their technical design (rule-based systems, documentary approach, mixed); outputs (textual report, alerts and/or visual approaches); and evaluations (impact on clinical practices, impact on patient outcomes, efficiency and/or user satisfaction). The evaluations performed are minimal (among all the systems identified, only one system has been evaluated according to all the criteria mentioned above) and no machine learning systems and/or conflict management systems were retrieved. This review highlights the need to develop new methodologies, combining various approaches for decision support system in polypharmacy.

A Public Health Perspective of Post-Traumatic Stress Disorder

Trauma exposure is one of the most important and prevalent risk factors for mental and physical ill-health. Prolonged or excessive stress exposure increases the risk of a wide variety of mental and physical symptoms, resulting in a condition known as post-traumatic stress disorder (PTSD). The diagnosis might be challenging due to the complex pathophysiology and co-existence with other mental disorders. The prime factor for PTSD development is exposure to a stressor, which variably, along with peritraumatic conditions, affects disease progression and severity. Additionally, many factors are thought to influence the response to the stressor, and hence reshape the natural history and course of the disease. With sufficient knowledge about the disease, preventive and intervenient methods can be implemented to improve the quality of life of the patients and to limit both the medical and economic burden of the disease. This literature review provides a highlight of up-to-date literature on traumatic stress, with a focus on causes or triggers of stress, factors that influence response to stress, disease burden, and the application of the social-ecological public health model of disease prevention. In addition, it addresses therapeutic aspects, ethnic differences in traumatic stress, and future perspectives, including potential biomarkers.

Is there a relationship between intensity of occupational therapy and functional outcomes in hospitalised older patients? A prospective cohort study

INTRODUCTION

Delivering high-intensity occupational therapy can improve functional outcomes for patients and reduce length of stay. However, there is little published evidence of this in the aged rehabilitation setting. This study aims to explore the association between intensity of occupational therapy interventions and functional outcomes in geriatric rehabilitation inpatients.

METHODS

A prospective cohort study was conducted with adult inpatients admitted to a geriatric rehabilitation program. The intervention was the intensity of occupational therapy measured as high (≥30 minutes per day) versus low (<30 minutes per day). The primary outcome measured was change in functional performance, defined as a minimum of half a point improvement in the Katz Index of Activities of Daily Living (ADL) and/or the Lawton and Brody Scale of Instrumental ADL (IADL) at admission to rehabilitation, discharge and 3months post-discharge.

RESULTS

A total of 693 patients were included in the analysis. The mean age was 82.2 years (standard deviation [SD] = 7.9), 57% were females, and 64% had cognitive impairment. Patients (n = 210) who received greater than or equal to 30 minutes of occupational therapy daily were more likely to have clinically relevant functional improvements.; for both ADL (odds ratio [OR] = 1.87, 95% confidence interval [CI]: 1.24-2.83) and IADL (OR = 3.00, 95% CI: 1.96-4.61), after adjusting for age, sex, severity of function (ADL ≤ 2) at admission, frailty and cognitive impairment. Improvements in ADL and IADL were maintained for at least 3 months following discharge.

CONCLUSION

This study found that geriatric rehabilitation inpatients who received higher intensity of occupational therapy interventions were more likely to functionally improve than those who received lower intensity. Further research is required to determine if other factors, such as therapy type, influence functional outcomes.

A comparison of two approaches for modeling dementia progression in a changing patient context

OBJECTIVES

To explain the heterogeneity in dementia disease trajectory, we studied the influence of changing patient characteristics on disease course by comparing the association of dementia progression with baseline comorbidity and frailty, and with time-varying comorbidity and frailty.

METHODS

We used individual growth models to study baseline and time-varying associations in newly diagnosed dementia patients (n = 331) followed for 3 years. We measured cognition using the Mini-Mental State Examination (MMSE), daily functioning using the Disability Assessment for Dementia (DAD), frailty using the Fried criteria and comorbidity using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G).

RESULTS

Although baseline comorbidity and frailty were associated with decreased daily functioning at diagnosis, their effects clearly diminished over time. In contrast, when incorporating comorbidity and frailty as time-varying covariates, comorbidity was associated with lower daily functioning, and frailty with both lower cognition and daily functioning. Being frail was associated with a 0.9-point lower MMSE score (p = 0.03) and a 14.9-point lower DAD score (p < 0.01). A 1-point increase in CIRS-G score was associated with a 1.1-point lower DAD score (p < 0.01).

CONCLUSIONS

Time-varying comorbidity and frailty were more consistently associated with dementia disease course than baseline comorbidity and frailty. Therefore, modeling only baseline predictors is insufficient for understanding the course of dementia in a changing patient context.

Accuracy of 12 short versions of the Geriatric Depression Scale to detect depression in a prospective study of a high-risk population with different levels of cognition

OBJECTIVES

To determine the accuracy of 12 previously validated short versions of the Geriatric Depression Scale (GDS) to detect major depressive disorder (MDD) in a high-risk population with and without global cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

Five hospitals, Western Sweden.

PARTICIPANTS

Older adults (age ≥70 years, n = 60) assessed at a home visit 1 year after hospital care in connection with suicide attempt.

MEASUREMENTS

Depression symptoms were rated using the established 15-item GDS. Eleven short GDS versions identified by a recent systematic review were derived from this administered version. Receiver operating characteristic curves and area under the curve (AUC) for the identification of MDD diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were obtained for each version. The Youden Index optimal criterion was used to determine the appropriate cutoffs. Analyses were repeated after stratification by cognitive status (Mini Mental State Examination score ≤24 and >24) for the best performing GDS short versions and the established 15-item GDS.

RESULTS

The 7-item GDS according to Broekman et al. (), with a cutoff 3, was the most accurate among the 12 short versions (AUC 0.90, 95% confidence interval 0.80-1.00), identifying MDD with sensitivity 88% and specificity 81%. The cutoff score remained consistent in the presence of global cognitive impairment, which was not the case for the standardized 15-item GDS.

CONCLUSION

The Broekman 7-item GDS had high accuracy to detect MDD in this prospective clinical cohort at high risk for MDD. Further testing of GDS short versions in diverse settings is required.

The Prognostic Value of Eight Comorbidity Indices in Older Patients with Cancer: The ELCAPA Cohort Study

Background: A prognostic assessment is crucial for making cancer treatment decisions in older patients. We assessed the prognostic performance (relative to one-year mortality) of eight comorbidity indices in a cohort of older patients with cancer. Methods: We studied patients with cancer aged ≥70 included in the Elderly Cancer Patient (ELCAPA) cohort between 2007 and 2010. We assessed seven nonspecific indices (Charlson Comorbidity Index (CCI), three modified versions of the CCI, the Elixhauser Comorbidity Index, the Gagne index, and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G)) and the National Cancer Institute Comorbidity Index. Results: Overall, 510 patients were included. Among patients with nonmetastatic cancer, all the comorbidity indices were independently associated with 1-year mortality (adjusted hazard ratios (aHRs) of 1.44 to 2.51 for one standard deviation increment; p < 0.05 for all) and had very good discriminant ability (Harrell’s C > 0.8 for the eight indices), but were poorly calibrated. Among patients with metastatic cancer, only the CIRS-G was independently associated with 1-year mortality (aHR (95% confidence interval): 1.26 [1.06−1.50]). Discriminant ability was moderate (0.61 to 0.70) for the subsets of patients with metastatic cancer and colorectal cancer. Conclusion: Comorbidity indices had strong prognostic value and discriminative ability for one-year mortality in older patients with nonmetastatic cancer, although calibration was poor. In older patients with metastatic cancer, only the CIRS-G was predictive of one-year mortality.

Long-term use of pharmacological treatment in Alzheimer's disease: a retrospective cohort study in real-world clinical practice

PURPOSE

To assess the impact of long-term use of different drugs commonly prescribed in Alzheimer's disease (AD) on its clinical course and to identify clinical and therapeutic factors associated with a delay in AD progression.

METHODS

We retrospectively enrolled 50 patients visited at the Neurology Unit, Careggi University Hospital (Florence), followed for at least 24 months. AD diagnosis was made according to clinical diagnostic criteria for probable/possible AD dementia, always supported at least by one biomarker. Clinical features, MMSE scores evaluated at diagnosis and every 6 months, and AD drugs used for at least 6 months, were recorded. Cox regression analysis was performed to estimate the hazard ratio (HR) for AD progression, assuming as the "final event," the progression to a more severe disease stage, defined as the achievement of an MMSE score less than 10.

RESULTS

At baseline, the median MMSE score was 22. During follow-up (median of 41 months), 56% of patients progressed to a more severe disease stage. The use of memantine, either alone (HR 0.24; 95% CI 0.09-0.60) or combined with acetylcholinesterase inhibitors (HR 0.35; 95% CI 0.14-0.88) and a higher MMSE score at baseline (HR 0.82; 95% CI 0.70-0.96) were associated with a significantly lower risk of AD progression.

CONCLUSION

Nowadays, effective disease-modifying therapy for AD is missing. Nevertheless, when the diagnosis is established, our results support the advantage of long-term use of available pharmacological treatments, especially in combination, in delaying AD progression to its more severe disease stage.

Diabetes, sarcopenia and chronic kidney disease; the Screening for CKD among Older People across Europe (SCOPE) study

BACKGROUND

Sarcopenia may be more present in older adults with diabetes (DM). Accordingly, we evaluated the prevalence of sarcopenia and its associated risk factors among community-dwelling older adults with DM.

METHODS

A cross-sectional analysis of older people living in the community was carried out. Participants (aged 75 years and more) came from an European multicenter prospective cohort (SCOPE study). Global geriatric assessment including short physical performance battery, handgrip strength test and bioelectrical impedance analysis was performed. Sarcopenia was defined by the updated criteria of the European Working Group on Sarcopenia in Older People (EWGSOP2). Estimated glomerular filtration rate (eGFR) was calculated using Berlin Initiative Study (BIS) to define the stages of chronic kidney disease (CKD). Previous known DM was defined as physician-diagnosed DM registered in the patient's medical record or the use of DM-related medications. Hemoglobin A1c levels and specific DM therapies administered were collected. Time elapsed from the first diagnosis of DM was not collected and, therefore, was not included in the analyses.

RESULTS

A total of 1,420 subjects were evaluated with a median age of 79.0 (6.0) years, of which 804 (56.6%) were women and 615 (43.3%) men; 315 (22.2%) participants had prior DM diagnosis, with a median age of 80.0 (6.0), 146 (46.3%) were women. Using EWGSOP2 definition, 150 (10.6%) participants in the SCOPE study met diagnostic criteria for sarcopenia. Participants without diabetes had more often normal results in the 3 sarcopenia components than participants with diabetes [887 (80.31%) vs. 227 (72.1%), p = 0.002], highlighting higher percentages of severe sarcopenia in participants with diabetes [27 (8.6%) vs. 58 (5.2%), p = 0.028]. Confirmed or severe sarcopenia was detected in 41 (13%) participants with diabetes and 109 (9.8%) participants without diabetes (p = 0.108). According to BIS equation, sarcopenia was not significantly more prevalent in the more advanced stages of CKD (p = 0.845). In multivariate analyses, older age (odds ratios [OR], 1.17; 95% confidence interval [CI], 1.08-1.27), and lower body mass index (OR, 0.79; 95% CI, 0.71-0.89 were associated with the presence of sarcopenia.

CONCLUSIONS

One tenth of all older community-dwelling subjects have sarcopenia. Older age and being thinner, but not worse renal function, were associated with higher prevalence of sarcopenia in older older adults with diabetes.

Impact of involvement of relatives in early home visits by a hospital-led geriatric team

OBJECTIVES

To evaluate whether the involvement of relatives in home visits by a geriatric team post-discharge is associated with unplanned readmissions in severely frail patients living alone.

METHODS

A quality improvement project evaluating outcomes from routine care of patients who were severely frail, 65+ years, living alone, and visited at home by a geriatric team after discharge from acute hospital admission. We compared patients who did and did not have relatives attending the visit. Data were analyzed by logistic regression.

RESULTS

Of 437 patients with a mean age of 85.0 (±7.8) years 73% had severe comorbidity, 68% had a low functional ability, and 100 patients (23%) had relatives attending. Attendance of relatives was associated with a lower unplanned 30-day readmission rate (10% vs. 18%, adjusted odds ratio: 0.48 (0.23-1.00) p=0.05).

CONCLUSION

Results highlights the importance of involvement of relatives in care planning in the severely frail older patients living alone.

How to Improve the Drafting of Health Profiles

Delineating patients' health profiles is essential to allow for a proper comparison between medical care and its results in patients with comorbidities. The aim of this work was to evaluate the concordance of health profiles outlined by ward doctors and by epidemiologists and the effectiveness of training interventions in improving the concordance. Between 2018 and 2021, we analyzed the concordance between the health profiles outlined by ward doctors in a private hospital and those outlined by epidemiologists on the same patients' medical records. The checks were repeated after training interventions. The agreement test (Cohen's kappa) was used for comparisons through STATA. The initial concordance was poor for most categories. After our project, the concordance improved for all categories of CIRS. Subsequently, we noted a decline in concordance between ward doctors and epidemiologists for CIRS, so a new training intervention was needed to improve the CIRS profile again. Initially, we found a low concordance, which increased significantly after the training interventions, proving its effectiveness.

Combating sarcopenia in geriatric rehabilitation patients: study protocol of the EMPOWER-GR observational cohort, sarcopenia awareness survey and randomised controlled feasibility trial

INTRODUCTION

Sarcopenia is highly prevalent in geriatric rehabilitation patients. Resistance exercise training (RET) combined with protein supplementation is recommended to increase muscle mass and strength in older adults. However, sarcopenia awareness, feasibility to diagnose and treat sarcopenia, and efficacy of treatment in geriatric rehabilitation patients remain to be established.

METHODS AND ANALYSIS

Enhancing Muscle POWER in Geriatric Rehabilitation (EMPOWER-GR) encompasses four pillars: (1) an observational cohort study of 200 geriatric rehabilitation inpatients determining sarcopenia prevalence, functional and nutritional status at admission; (2) a survey among these 200 patients and 500 healthcare professionals and semistructured interviews in 30 patients and 15 carers determining sarcopenia awareness and barriers/enablers regarding diagnostics and treatment; (3) a feasibility, single-centre, randomised, controlled, open-label, two parallel-group trial in 80 geriatric rehabilitation patients with sarcopenia. The active group (n=40) receives three RET sessions per week and a leucine and vitamin D-enriched whey protein-based oral nutritional supplement two times per day in combination with usual care for 13 weeks. The control group (n=40) receives usual care. Primary outcomes are feasibility (adherence to the intervention, dropout rate, overall feasibility) and change from baseline in absolute muscle mass at discharge and week 13. Secondary outcomes are feasibility (participation rate) and change from baseline at discharge and week 13 in relative muscle mass, muscle strength, physical and functional performance, mobility, nutritional status, dietary intake, quality of life and length of stay; institutionalisation and hospitalisation at 6 months and mortality at 6 months and 2 years; (4) knowledge sharing on sarcopenia diagnosis and treatment.

ETHICS AND DISSEMINATION

Ethical exemption was received for the observational cohort study, ethics approval was received for the randomised controlled trial. Results will be disseminated through publications in scientific peer-reviewed journals, conferences and social media.

TRIAL REGISTRATION NUMBER

NL9444.

The Relationship between Size of Core Network and Frequency of Contacts with Agitation and Positive Affect in Older Adults with Dementia

BACKGROUND

Few studies have explored the associations of agitation symptoms among older adults with core network size and with frequency of contact with core network care providers. The present study aimed to investigate the associations of agitation and affect among older adult people with dementia (PWD) with core network size and frequency of contact with core network care providers.

METHODS

A convenience sample of 98 Omani older adult PWD residing in their homes was recruited. Most of the participants (63.3%) were female, and the mean age of the participants was 80 years (standard deviation = 9.0). A total of 77 participants suffered from severe dementia, while the remaining 21 had mild to moderate dementia levels. Valid and reliable instruments completed by either the participating PWD or their caregivers were used to measure the study variables.

RESULTS

The main hypothesis of the study was not supported, whereby core network size and frequency of contact with the core network were not found to be significantly associated with activities of daily living (ADL) and instrumental ADL (IADL) core networks or agitation and affect. Further, the findings indicated no significant associations between core network size or closeness between PWD and their IADL and ADL caregivers and the amount of ADL and IADL care provided. The level of care provided by the caregivers and the participants' frequency of contact with the core network remained consistent throughout the progress of the dementia patients' conditions.

DISCUSSION/CONCLUSION

The findings of this study are incongruent with the findings of studies conducted in Western countries, which have reported that older adults prefer to have meaningful interactions with small, close social networks as opposed to large networks. Our findings may be explained by the strong cultural values in Oman which place great emphasis on caring for elderly family members. It is essential to understand these relationships in order to develop effective home care interventions for older adult PWD in Oman.

Positive effects on activities of daily living one year after receiving comprehensive geriatric assessment - results from the randomised controlled study CGA-Swed

BACKGROUND

Today's acute hospital care is poorly adapted to the complex needs of frail older people. This exposes them to avoidable risks, such as loss of functional capacities, leading to unnecessary health and social care needs. Being frail and in need of acute hospital care often leads to higher dependence in Activities of Daily Living (ADL), especially if one's needs are not acknowledged. Comprehensive Geriatric Assessment (CGA) is one way to meet frail older people's complex needs. The study's aim was to investigate the effects on frail older people's ADL 12 months after receiving CGA.

METHODS

This is a two-armed randomised controlled intervention study. Participants were frail older people (75+) who sought the emergency department and needed admission to a medical ward. The intervention was CGA performed at a geriatric management unit during the hospital stay. The CGA included comprehensive assessment of medical, functional, psychological, social, and environmental status as well as treatment, rehabilitation, discharge planning, and follow-up. Multidisciplinary teamwork and a person-centred approach were used. The control was care at an ordinary medical hospital ward. The primary outcome was change in dependence in ADL from 2 weeks before admission to the 12-month follow-up.

RESULTS

At admission, 155 people participated (77 in the control, 78 in the intervention). At the 12-month follow-up, 78 participated (40 in the control, 38 in the intervention). Attrition was mainly due to mortality. Four participants in the control (5.2%) and twelve in the intervention group (15.4%) had improved in their ADL 1 year after discharge (OR = 3.32; 95% CI = 1.02-10.79).

CONCLUSIONS

In-hospital CGA performed at a geriatric management unit improves frail older people's ADL. Being less dependent in ADL increases frail older people's ability to remain in their own housing, which is important for both the individual and society.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02773914 . Retrospectively registered 16 May 2016.

Delirium and Delirium Severity Predict the Trajectory of the Hierarchical Assessment of Balance and Mobility in Hospitalized Older People: Findings From the DECIDE Study

BACKGROUND

Delirium is common, distressing, and associated with poor outcomes. Despite this, delirium remains poorly recognized, resulting in worse outcomes. There is an urgent need for methods to objectively assess for delirium. Physical function has been proposed as a potential surrogate marker, but few studies have monitored physical function in the context of delirium. We examined if trajectories of physical function are affected by the presence and severity of delirium in a representative sample of hospitalized participants older than 65 years.

METHOD

During hospital admissions in 2016, we assessed participants from the Delirium and Cognitive Impact in Dementia study daily for delirium and physical function, using the Hierarchical Assessment of Balance and Mobility (HABAM). We used linear mixed models to assess the effect of delirium and delirium severity during admission on HABAM trajectory.

RESULTS

Of 178 participants, 58 experienced delirium during admission. Median HABAM scores in those with delirium were significantly higher (indicating worse mobility) than those without delirium. Modeling HABAM trajectories, HABAM scores at first assessment were worse in those with delirium than those without, by 0.76 (95% CI: 0.49-1.04) points. Participants with severe delirium experienced a much greater perturbance in their physical function, with an even lower value at first assessment and slower subsequent improvement.

CONCLUSIONS

Physical function was worse in those with delirium compared to without. This supports the assertion that motor disturbances are a core feature of delirium and monitoring physical function, using a tool such as the HABAM, may have clinical utility as a surrogate marker for delirium and its resolution.

Bipolar symptoms, somatic burden, and functioning in older-age bipolar disorder: Analyses from the Global Aging & Geriatric Experiments in Bipolar Disorder Database project

OBJECTIVE

Literature on older-age bipolar disorder (OABD) is limited. This first-ever analysis of the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) investigated associations among age, BD symptoms, comorbidity, and functioning.

METHODS

This analysis used harmonized, baseline, cross-sectional data from 19 international studies (N = 1377). Standardized measures included the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Depression Rating Scale (MADRS), and Global Assessment of Functioning (GAF).

RESULTS

Mean sample age was 60.8 years (standard deviation [SD] 12.2 years), 55% female, 72% BD I. Mood symptom severity was low: mean total YMRS score of 4.3 (SD 5.4) and moderate-to-severe depression in only 22%. Controlled for sample effects, both manic and depressive symptom severity appeared lower among older individuals (p's < 0.0001). The negative relationship between older age and symptom severity was similar across sexes, but was stronger among those with lower education levels. GAF was mildly impaired (mean =62.0, SD = 13.3) and somatic burden was high (mean =2.42, SD = 1.97). Comorbidity burden was not associated with GAF. However, higher depressive (p < 0.0001) and manic (p < 0.0001) symptoms were associated with lower GAF, most strongly among older individuals.

CONCLUSIONS

Findings suggest an attenuation of BD symptoms in OABD, despite extensive somatic burden. Depressive symptom severity was strongly associated with worse functioning in older individuals, underscoring the need for effective treatments of BD depression in older people. This international collaboration lays a path for the development of a better understanding of aging in BD.

Thalamic abnormalities in older adults with remitted early-onset depression using structural magnetic resonance imaging

BACKGROUND

The thalamus is a key diencephalic structure involved in major depressive disorder (MDD). Studies have consistently revealed abnormalities in thalamic volumes in older adults with late-onset depression (LOD), however abnormalities in older adults with early-onset depression (EOD) have not yet been well-studied.

METHODS

Fifty-nine euthymic participants with a history of EOD and fifty-nine matched comparison participants without a lifetime history of depression underwent neuroimaging, medical and neuropsychological assessments. Thalamic volumes were compared between groups. To investigate the previously-proposed right hemispheric (RH) dominance theory of MDD, we explored the bilateral, right and left hemispheric (LH) thalamic volumes. Multiple regression analyses were used to evaluate between-group and within-group effects. Correlational analyses examined associations between group and cognitive performance.

RESULTS

Relative to the comparison group, those with EOD had significantly larger bilateral, LH and RH thalamic volumes. Those with EOD, those who were younger, and those who had fewer years of education demonstrated larger bilateral and LH thalamic volumes. For RH thalamic volumes, those with EOD and those who were younger demonstrated larger RH thalamic volumes. EOD within-group models were also run to assess associations between relevant depression variables. The results showed that only age was significant for bilateral and RH thalamic volumes. For the LH thalamic volumes, the model was not significant. No significant correlations were found between cognitive performance and EOD groups.

CONCLUSION

Older adults with a history of EOD showed significantly larger bilateral, RH and LH thalamic volumes. Further research is needed to delineate potential underlying mechanisms of this change.

A Randomized Controlled Trial of Tai Chi Chih or Health Education for Geriatric Depression

OBJECTIVES

Geriatric depression is difficult to treat and frequently accompanied by treatment resistance, suicidal ideations and polypharmacy. New adjunctive mind-body treatment strategies can improve clinical outcomes in geriatric depression and reduce risk for side-effects of pharmacological treatments.

METHODS

We conducted a 3-month randomized controlled trial to assess the efficacy and tolerability of combining Tai Chi Chih (TCC) or Health Education and Wellness training (HEW) with the stable standard antidepressant treatment on mood and cognitive functioning in depressed older adults (NCT02460666). Primary outcome was change in depression as assessed by the Hamilton Rating Scale for Depression (HAM-D) post-treatment. Remission was defined as HAM-D ≤ 6; naturalistic follow-up continued for 6 months. We also assessed psychological resilience, health-related quality of life and cognition.

RESULTS

Of the 178 randomized participants, 125 completed the 3-month assessment and 117 completed the 6-month assessment. Dropout and tolerability did not differ between groups. Remission rate within TCC was 35.5% and 33.3%, compared to 27.0% and 45.8% in HEW, at 3 and 6 months respectively (χ²(1) = 1.0, p = 0.3; χ²(1) = 1.9, p =0.2). Both groups improved significantly on the HAM-D at 3 and 6 months. TCC demonstrated a greater improvement in general health compared to HEW.

CONCLUSIONS

Both TCC and HEW combined with a standard antidepressant treatment improved symptoms of depression in older adults. While TCC was superior to HEW in improving general health, we did not find group differences in improvement in mood and cognition.

Association between serum free hemoglobin level and cerebral white matter hyperintensity volume in older adults

The association between serum free hemoglobin (sfHb) level and white matter hyperintensity (WMH) volume is controversial. This study is to examine this association considering nonlinearity, sex dimorphism, and WMH type. We enrolled 704 older adults among the participants of the Korean Longitudinal Study on Cognitive Aging and Dementia and visitors to the Dementia Clinic of Seoul National University Bundang Hospital. We measured sfHb level in the venous blood and WMH volume (V_WMH) using fluid-attenuated inversion recovery magnetic resonance images. The association between sfHb level and periventricular V_WMH was linear in men (linear regression; β =  - 0.18, p = 0.006) and U-shaped in women (restricted cubic spline; F = 6.82, p < 0.001). sfHb level was not associated with deep V_WMH in either sex. These findings were also observed in participants without anemia. To conclude, sfHb level is associated with periventricular V_WMH in older adults of both sexes. Maintaining an optimal sfHb level may contribute to the prevention of WMH.

Pediatric Sleep Disturbances and Symptoms of Depression in Older Adults

We investigated the association between retrospectively reported sleep disturbances during childhood and adolescence and current symptoms of depression and anxiety in older adults. Participants included 116 older adults (M age  =  68 years [SD  =  6.4 years]) who completed a battery of sleep and psychological assessments. We tested two multivariate regression models using age, sex, race, physical illness burden, insomnia status, and pediatric sleep disturbances as correlates of depressive symptoms and anxiety symptoms. Pediatric sleep disturbances were significantly associated with greater depressive symptomatology (β  =  0.247, p  =  .010), independent of current insomnia status. Medium effect sizes were reported. Our results suggest that pediatric sleep disturbances may be a biobehavioral signal for the development of poor emotional health across the lifespan. Future research should identify critical windows of development when sleep disturbances might be most impactful on emotional health trajectories.