Mini-Nutritional Assessment Short-Form as a useful method of predicting poor 1-year outcome in elderly patients undergoing orthopedic surgery

AIM

The present study aimed to determine whether the Mini-Nutritional Assessment Short-Form (MNA-SF) can predict the 1-year outcome of orthopedic fracture surgery in elderly patients.

METHODS

This 1-year prospective study assessed nutrition using the MNA-SF at baseline, and postoperatively at 6 and 12 months. Repeated measures analysis of covariance was used to examine functional change over time for two MNA-SF categories. Multivariable logistic regression analysis with forward stepwise modeling was carried out to identify risk factors of functional decline, emergency department visit, hospital readmission and mortality at follow up.

RESULTS

There were 312 participants, 11 of whom died (3.53%) during 1-year follow up. The mean age was 74.04 ± 7.65 years. A total of 88.1% and 11.9% of the participants were well nourished (MNA-SF 12-14 points) or at risk of undernutrition (0-11 points), respectively. For MNA-SF as a continuous variable, lower MNA-SF scores were associated with a significantly higher risk of emergency department visit at 6-month follow up, and mortality at 12-month follow up (emergency room visit, adjusted odds ratio 0.78, 95% CI 0.63-0.96, P < 0.05; mortality, adjusted odds ratio 0.73, 95% CI 0.57-0.94, P < 0.05). No association was found between functional decline and hospital readmission, and MNA-SF scores. For MNA-SF categories, functional decline was more profound in patients at risk of undernutrition than in well-nourished patients, especially 6-12 months postoperatively.

CONCLUSIONS

The MNA-SF could be an effective and non-invasive preoperative screening tool to predict functional decline, emergency department visit and mortality during the year after surgery. Geriatr Gerontol Int 2017; 17: 2361-2368.

Total Hip and Knee Arthroplasty in Patients Older Than Age 80 Years

A rapidly aging population is currently reshaping the demographic profile of the United States. Among older patients, the cohort aged >80 years is not only living longer but also is electing to undergo more total hip and knee arthroplasties. To improve perioperative safety, orthopaedic surgeons should understand the risks and clinical outcomes of arthroplasty in patients of advanced age. Although morbidity and mortality rates are higher for patients aged >80 years than for younger patients undergoing total hip and knee arthroplasties and revision surgeries, functional outcomes, pain relief, and patient satisfaction are consistent between groups. In addition, geriatric co-management before total hip and total knee arthroplasty has reduced the rate of minor complications and the length of hospital stays in elderly patients. Surgeons should inform older patients and their families of the increased risks of morbidity and mortality before these procedures are undertaken.

Health, frailty and disability after ninety: Results of an observational study in France

BACKGROUND

In spite of their increasing demographic weight, health characteristics of the oldest old remain poorly described in epidemiological studies.

OBJECTIVE

To describe the health of people aged 70 years and over included in the SIPAF study, and to compare the prevalence of health indicators including successful aging, frailty, and disability between three age groups including the oldest old.

METHODS

The study population is composed of 2350 retired people recruited between 2008 and 2010, of whom 512 are aged 90 and over (21.8%). A comprehensive geriatric assessment was performed at home by trained nurses. The prevalence of health and functional indicators, as well as the distribution of people among successful ageing, frailty, and disability, were described by age group (70-79, 80-89, 90+) and sex.

RESULTS

Compared to their younger counterparts, people aged 90 years and over were more likely to experience functional limitations, sensory impairment, cognitive impairment, poor mood, and frailty. One third of the nonagenarians needed help in at least one basic activity of daily living and 25% met the frailty criteria. In contrast, the prevalence of most chronic diseases did not increase after ninety. Successful ageing concerned 9% of the oldest old. Women were less likely to experience successful ageing and more likely to be frail or dependent.

CONCLUSION

This study shows the diversity of health states in very old age and points out that one quarter of the people aged 90 and over said frail are likely to take advantage of preventive actions of disability.

Prevalence and Severity of Dementia in Nursing Home Residents

BACKGROUND/AIMS

The aim of this study was to compare the presence and severity of dementia in two large cross-sectional samples of nursing home residents from 2004/2005 and 2010/2011.

METHODS

Demographic information as well as data on the type of nursing home unit, length of stay before assessment, physical health, regularly used prescribed drugs and Clinical Dementia Rating scale scores were used in the analyses. Logistic and linear regression models for hierarchical data were estimated.

RESULTS

The odds of the occurrence and of a greater severity of dementia were higher in 2010/2011 than in 2004/2005. Independent of the time of study, married men had more severe dementia than single men, and single women had more severe dementia than single men.

CONCLUSION

The findings may reflect the increase in the need for more nursing home beds designed for people with dementia between 2004/2005 and 2010/2011.

[The NonaSantfeliu study. Baseline assessment and ten years of follow-up]

NonaSantfeliu study: A review is presented of the studies that are part of the initial overall assessment and the studies performed during the 10 years of follow-up of a cohort of nonagenarians. It is a population-based study of 186 subjects, 76.5% women, mean age at baseline of 93.06 years, a quarter (26%) being institutionalized. The mean of baseline Barthel index was 60.8, and the mean for the Lobo's cognitive minimental was 21. Nonagenarian males with low comorbidity had more successful aging criteria than women with high comorbidity quantified with the Charlson Index. The survival rate at 10 years follow-up was very low, and 95.6% of the population had died. This represented an annual mortality rate of 9.5%. A common denominator on assessing all different annual cuts, is that the most important factors associated with mortality are those related to geriatric assessment, such as a function, cognition, dementia, and cumulative comorbidity and multiple medications, compared to more traditional risk factors described in younger populations.

Inverted CD4:CD8 ratio is not associated with three-year mortality in a sample of community-dwelling oldest old: the OCTABAIX immune study

BACKGROUND

The presence of an immune risk phenotype (IRP) has been correlated with survival rates in elderly people.

OBJECTIVE

To determine whether an inverted CD4:CD8 ratio might be a marker of IRP in a sample of oldest old by assessing its relationship with mortality.

DESIGN

Prospective cohort study.

SETTING

Community-based survey study of seven primary healthcare centres.

PARTICIPANTS

328 people born in 1924 and registered with primary healthcare centres.

MEASUREMENTS

Chronic drug prescription, functional status (Barthel and Lawton indexes) and cognitive status (Spanish version of the Mini-Mental State Examination) were recorded. CD4:CD8 ratios were determined, with a ratio of 1.00 or less being used to define IRP.

RESULTS

The CD4:CD8 ratio was 1.00 or less in 47 subjects (15.6%). After three years, 51 subjects had died (16.3%); 9 were from among the 47 (19.1%) with an inverted CD4:CD8 ratio and 42 (15.8%) from the remainder (P=0.52). Multivariate analysis identified two significant clinical variables (Lawton Index scores and the number of chronic drugs prescribed) as being independent predictors of three-year mortality risk in this cohort of octogenarians. This risk profile did not change when introducing the CD4:CD8 ratio into the calculation.

CONCLUSION

In this community-dwelling population of oldest old (85 years old at baseline) an inverted CD4:CD8 ratio was not associated with three-year mortality.

Characteristics and outcome in nonagenarians admitted in general internal medicine and other specialties

To describe the characteristics of nonagenarians admitted to the surgical and medical divisions at a tertiary hospital and compare them with nonagenarians admitted to other hospital care services.

METHODS

A retrospective study of all hospital discharge episodes via the registry of the Basic Minimum Data Set at the Hospital General Universitario de Alicante from January 2007 until December 2011.

RESULTS

Of the 165,870 hospitalizations, 2461 (1.5%) were nonagenarians. The highest number of admitted nonagenarians was in the Division of General Internal Medicine (DGIM) (n=751), followed by the short stay unit (SSU) (n=633). The rate of nonagenarians per 100 admissions to the DGIM was 10.2, significantly higher than that of those admitted to the SSU (6.2) (p<0.001), the service of orthopedic and trauma surgery (2.2) (p<0.001), and other specialties. Females comprised 64.8% of the nonagenarians. Mortality was 17% for the nonagenarians admitted, while for those admitted to the DGIM it was 27.7%. Those hospitalized in the SSU had a lower risk of death during hospitalization (8.1%) (odds ratio [OR] 0.23, 95% confidence interval [CI] 0.16-0.32) and a greater risk of being admitted for diseases and disorders of the circulatory system (OR: 1.58, 95% CI: 1.22-2.05), particularly for heart failure and shock (OR: 1.82, 95% CI: 1.30-2.53), and being discharged with home hospitalization (OR: 8.05, 95% CI: 5.5-11.8).

CONCLUSIONS

Nonagenarian patients represent a tenth of those admitted to the DGIM. The profile of nonagenarians admitted to the DGIM is different from other hospital services. Hospital mortality for nonagenarians admitted to the DGIM is high and superior to other hospital services.

Functional decline over 2 years in older Spanish adults: evidence from the Survey of Health, Ageing and Retirement in Europe

AIM

To evaluate the social, educational, health and behavioral predictors of physical functional decline in older Spanish adults.

METHODS

A 2-year longitudinal study based on 699 community-dwelling Spanish adults aged over 65 years participating in the Survey of Health, Ageing and Retirement in Europe was carried out. Several predictors of a combined measure of functional disability were examined using logistic regressions.

RESULTS

A decline in function was experienced by 166 individuals. Functional decline in men was associated with an increased number of chronic diseases (OR 2.25, 95% CI 1.21-4.19) and depressive symptoms (OR 5.05, 95% CI 2.42-10.54) over a 2-year period, whereas among women it was associated with decreased numeracy score (OR 1.88, 95%CI 1.05-3.34).

CONCLUSIONS

Longitudinal changes in predictors are strongly associated with longitudinal changes in function between baseline and a 2-year follow up, most clearly among men. A decrease in cognitive functioning and increased depressive symptoms are associated with a decline in physical functioning, and can serve as useful clinical predictors to prevent disability in older Spanish adults.

Cognitive decline one year after hospitalization in older adults without dementia

BACKGROUND/AIMS

We studied cognitive functioning 1 year after hospitalization (T2) in patients at least 65 years old without cognitive impairment at baseline (T1).

METHODS

Cognition was assessed using the Mini-Mental State Examination (MMSE) at both time points. We included 211 (114 women) patients with a mean age of 78.3 (SD 7.0) years and an MMSE score of 24 and above.

RESULTS

At T2, 69 (32.7%) patients had an MMSE score below 24. In participants with MMSE 24-26 at T1, cognitive decline was related to impaired physical self-maintenance, a decline in the performance of the instrumental activities of daily living, impaired hearing and less reading ability. In participants with MMSE 27-30, cognitive decline was associated with higher comorbidity (Charlson Index) and impaired physical self-maintenance and hearing.

CONCLUSION

A reduced functioning level and increased comorbidity predicted a decline in cognitive functioning.

Challenges of diagnosing dementia in the oldest old population

People aged 90 and older are the fastest growing age group in most parts of the world. Since the prevalence of dementia has been shown to increase exponentially after the age of 65, there is an acceptance that the oldest old population has a high burden of dementia; however, there is a lack of consensus on how best to diagnose dementia in this population. This review summarizes the various approaches to diagnosing dementia and the prevalence and incidence rates of dementia that have been reported. We also summarize the literature on cognitive and functional performance and biomarkers for dementia and discuss the limitations to interpretation of these data. Finally, we make recommendations for both researchers and clinicians who intend to diagnose dementia in the oldest old population.

Impact of Geriatric Conditions Versus Medical Diagnoses on ADL Disability Among Nonagenarians and Centenarians

Objective: The authors investigated the relationship of activities of daily living (ADL) disability with medical diseases and geriatric conditions among nonagenarians and centenarians. Method: Cross-sectional, n = 870 Chinese (age range: 90-108 years). Self-reported medical diseases and geriatric-specific conditions were obtained by face-to-face interviews. Biomedical measurements included systolic/diastolic blood pressure, BMI (body mass index), albumin, fasting glucose, creatinine clearance, hemoglobin, and lipid panel. Results: In bivariate analyses, 4 of 7 geriatric conditions (hearing problems, falls, cognitive impairment, fracture), and 6 of 11 biomedical measurements (fasting glucose, cholesterol, LDL, creatinine clearance, hemoglobin, albumin), but none of 10 medical diseases and no degree of comorbidities, were associated with ADL disability. In four different multivariate logistic regression models, two geriatric conditions (impaired cognition, fracture) were significant in three models, respiratory disease in one model, and fasting glucose in two models. Discussion: This study emphasizes the importance of geriatric conditions and their association with ADL disability among the oldest-old adult population.

Nutritional screening tools as predictors of mortality, functional decline, and move to higher level care in older people: a systematic review

This systematic review assessed whether nutritional screening tools (NSTs) predict mortality, functional decline, and move to higher level care in older adults residing in the community or in institutions. In total, 37 prospective studies published between 1999 and 2012 met inclusion criteria and were included in this review. The most commonly used NST in these studies was the Mini Nutritional Assessment (MNA). Comparison of NSTs was limited by variation in follow-up time, lack of uniform definition of functional decline, and biases in many studies. Results of MNA, MNA-Short Form (MNA-SF), and Geriatric Nutrition Risk Index (GNRI) assessments were significantly associated with subsequent mortality, with good negative predictive power (∼0.83), but only modest positive predictive power (PPV∼0.32). MNA-SF and MNA results had a low to moderate association with functional decline (PPV∼0.34). Move to higher level care was less strongly associated with NST scores (PPV∼0.25). Overall, there is evidence that NSTs can predict those at low risk of mortality, functional decline, and, to a lesser extent, move to higher level care in older people.

Body mass index, waist circumference, and waist-to-hip ratio as predictors of mortality in nonagenarians: the Vitality 90+ Study

BACKGROUND

The associations of body mass index (BMI) and abdominal obesity with mortality among very old people are poorly known. The purpose of this study was to investigate the association of BMI, waist circumference (WC), and waist-to-hip ratio with mortality in nonagenarians.

METHODS

This study is part of a prospective population-based study, Vitality 90+, including both community-dwelling and institutionalized persons from Tampere, Finland. Altogether 192 women and 65 men aged 90 years were subjected to anthropometric measurements, a baseline interview, and a 4-year mortality follow-up. Cox proportional hazards models were used in the statistical analyses.

RESULTS

In men, normal weight indicated a three times higher mortality risk (hazard ratio [HR] 3.09, 95% confidence interval [CI] 1.35-7.06) compared with overweight, and WC was inversely associated with mortality (HR 0.96, 95% CI 0.93-1.00) after adjustment for covariates. In women, the univariate waist-to-hip ratio (HR 1.43, 95% CI 1.06-1.92) and BMI-adjusted waist-to-hip ratio (HR 1.45, 95% CI 1.07-1.97) were positively associated with mortality. Also, overweight women whose WC was <86 cm had lower mortality than normal weight women with similar WC (HR 0.34, 95% CI 0.12-0.97).

CONCLUSIONS

In nonagenarian men, low BMI and low WC predict increased mortality. In nonagenarian women, waist-to-hip ratio alone and adjusted for BMI is positively associated with mortality. The potential positive effects of overweight combined with WC warrant more detailed analyses in larger data. In all, future studies are needed to better understand the health and functional consequences of body composition among the oldest old.

Differences according to gender and health status in CD4:CD8 ratio in a sample of community-dwelling oldest old. The OCTABAIX immune study

BACKGROUND AND AIMS

The presence of an immune-risk phenotype (IRP) has been correlated with survival rates in elderly people. The aim of this study is to characterize the inverted CD4:CD8 ratio as a possible marker of IRP in a sample of oldest old (85 years) by assessing differences in gender and health status.

METHODS

Comorbidity, functional status (Barthel Index), and cognitive status with the Spanish version of the Mini-Mental State Examination were evaluated. Non-disabled subjects were defined as those with better health status, with scores of >90 on the Barthel Index and >23 points on the Spanish version of the Mini-Mental State Examination. CD4:CD8 ratios were recorded, and a ratio of 1.00 or less was used to define IRF.

RESULTS

Three hundred and twelve subjects aged 85 years old were studied, 190 women (60.9%) and 122 men. The CD4:CD8 ratio was 1.00 or less in 47 subjects (15.6%) and higher than 2.2 in 115 (36.8%). There were no differences in CD4:CD8 ratio according to health status. The inverted CD4:CD8 ratio was more frequent in men (55.3%).

CONCLUSION

In this community-dwelling, single year birth cohort study, the subgroup with poor health status did not have a lower CD4:CD8 ratio. The inverted CD4:CD8 ratio was more frequent in men.

Mortality and complications in very old patients (90+) admitted to departments of internal medicine in Spain

SUMMARY

Patients over 90 years of age (the "very elderly") account for an increasing number of admissions to departments of internal medicine (IM). The aim of this study was to analyse the demographic data, hospitalization characteristics, medical complications, and predictors of mortality in patients over 90 admitted to IM departments.

MATERIAL AND METHODS

All patients admitted to IM departments in Spain between the years 2005 and 2007 were analysed. Clinical and demographic data were compared with records from "younger elderly" patients (65-90).

RESULTS

During the study period, there were 1,567,659 patient admissions to IM departments in Spain, and 90,679 (5.8%) were older than 90. Hospital mortality occurred in 22.3% of very elderly patients. The main predictors for hospital death were pressure ulcer (Odds Ratio [OR] 1.55, CI95% 1.45-1.66), thromboembolic disease (OR 1.83, CI95% 1.61-2.09), nosocomial pneumonia (OR 2.53, CI95% 2.39-2.69), hip fracture (OR 2.20, CI95% 1.53-3.18), male gender (OR 1.06, CI95% 1.03-1.10), age (OR 1.05, CI95% 1.04-1.06), dementia (OR 1.13, CI95% 1.08-1.18), cancer (OR 1.60, CI95% 1.51-1.71), acute respiratory failure (OR 1.83, CI95% 1.76-1.89), acute infectious disease (OR 2.30, IC95% 2.11-2.52), and Charlson comorbidity index (OR 1.21, CI95% 1.16-1.26).

CONCLUSIONS

Very elderly patients represent a large and growing fraction of the total admissions to IM departments in Spain. They are at higher risk for complications during their hospital stay and mortality rate is double that of the younger elderly.

Predictors of 3-year mortality in subjects over 95 years of age. The NonaSantfeliu study

OBJECTIVES

To examine the survival rates of subjects aged 95 or over after a follow-up period of 3 years, and to determine predictive factors for mortality risk.

DESIGN

A prospective cohort study.

SETTING

A community-based study.

PARTICIPANTS

Forty-eight subjects aged 95 or over.

MEASUREMENTS

Sociodemographic data, Barthel Index, Lawton-Brody Index, Spanish version of the Mini-Mental State Examination, short version of the Mini Nutritional Assessment, comorbidity (Charlson Index), and prevalent chronic diseases were evaluated. Patients who died were compared with the rest.

RESULTS

Thirty-six deaths (75%) were recorded during follow-up. The Cox multivariate analysis showed that lower Barthel Index scores and a history of heart failure were independently associated with long-term mortality.

CONCLUSIONS

In subjects aged 95 or over, poor functional status and history of heart failure were the two independent risk factors for 3-year mortality.

BMI, waist circumference, and mortality according to health status in the older adult population of Spain

Among the explanations proposed for the weak and inconsistent association between BMI and mortality in the elderly are the lack of adjustment for waist circumference (WC) and that the association varies with health status. This work examines the independent association of BMI and WC with mortality in older adults, and the influence of health status on this association. A cohort of 3,536 persons representative of the Spanish population aged >or=60 years was selected in 2000 and 2001, and followed prospectively until 2007. The analyses were performed with Cox models and adjusted for the main confounders. During follow-up, 659 persons died (18.6% of the cohort). Before adjusting for WC, mortality in the upper quartile of BMI was 15% lower than in the lower quartile (hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.66-1.08; P for linear trend = 0.076). After adjusting for WC, the association was even stronger, so that mortality in the upper quartile of BMI was 37% lower than in the lower quartile (HR: 0.63; 95% CI: 0.45-0.88; P for linear trend < 0.003). Before adjusting for BMI, no association was observed between WC and mortality. After adjusting for BMI, WC was positively associated with mortality (HR for upper vs. lower quartile of WC: 1.48; 95% CI: 1.07-2.05; P for linear trend = 0.008). These associations were mainly observed in those with limitations in mobility and agility. BMI has an inverse, and WC has a direct, independent association with mortality in older adults, particularly in those with worse health status.