Validation study of Charlson Comorbidity Index in predicting mortality in Chinese older adults

External Validation of the Charlson Comorbidity Index-based Model for Survival Prediction in Thai Patients Diagnosed with Dementia

BACKGROUND

The Charlson Comorbidity Index (CCI) is commonly employed for predicting mortality. Nonetheless, its performance has rarely been evaluated in patients with dementia. This study aimed to examine the predictive capability of the CCI-based model for survival prediction in Thai patients diagnosed with dementia.

METHODS

An external validation study was conducted using retrospective data from adults with dementia who had visited the outpatient departments at Maharaj Nakorn Chiang Mai Hospital between 2006 and 2012. The data obtained from electronic medical records included age, gender, date of dementia diagnosis and death, types of dementia, and comorbidities at the time of dementia diagnosis. The discriminative ability and calibration of the CCI-based model were estimated using Harrell's C Discrimination Index and visualized with calibration plot. As the initial performance did not meet satisfaction, model updating and recalibration were performed.

RESULTS

Of 702 patients, 56.9% were female. The mean age at dementia diagnosis was 75.22 (SD 9.75) year-old. During external validation, Harrell's C-statistic of the CCI-based model was 0.58 (95% CI, 0.54-0.61). The model showed poor external calibration. Model updating was subsequently performed. All updated models demonstrated a modest increase in Harrell's C-statistic. Temporal recalibration did not significantly improve the calibration of any of the updated models.

CONCLUSION

The CCI-based model exhibited fair discriminative ability and poor calibration for predicting survival in Thai patients diagnosed with dementia. Despite attempts at model updating, significant improvements were not achieved. Therefore, it is important to consider the incorporation of other influential prognostic factors.

Biopsychosocial determinants of sexual health in older age: the role of health-related, relationship, and psychosexual factors

BACKGROUND

Given the unprecedented aging of the population and the increased focus on overall well-being in older age, investigating the determining factors of sexual well-being in older adults becomes essential as it offers insights into promoting healthy aging and overall quality of life.

AIM

By applying the biopsychosocial model of sexuality in older age, we aimed to identify the role of biomedical and psychosocial factors in predicting sexual well-being in partnered older adults (≥55 years old).

METHODS

A total of 111 participants (mean [SD], 63.2 [5.96]) completed a self-report questionnaire assessing biopsychosocial dimensions. Bivariate correlational analyses and hierarchical multiple regression were conducted to investigate factors associated with sexual well-being. Health-related factors were entered into the first regression model. The second model included factors pertaining to relationship dimensions. Sexual beliefs were introduced in the third regression model.

OUTCOMES

Self-rated health, psychological distress, subjective cognitive decline, sexual beliefs, duration of the relationship, relationship satisfaction, and sexual well-being were assessed.

RESULTS

Findings from the hierarchical regression revealed that duration of relationship [t(104) = -3.07, P < .01], relationship satisfaction [t(104) = 8.49, P < .001], and age-related sexual beliefs [t(104) = -2.75, P < .01] were significant predictors of sexual well-being of partnered older adults [F(6, 104) = 22.77, P < .001, R2 = .57], after controlling for health-related factors. These findings suggest that relationship factors and sexual beliefs play a significant role in predicting sexual well-being of older adults, above and beyond health-related dimensions.

CLINICAL IMPLICATIONS

Interventional approaches aimed at promoting sexual well-being in older age might benefit from incorporating exercises that demystify age-related sexual beliefs, by normalizing changes that occur with aging and fostering positive attitudes toward sexual expression in older age; particularly for older adults in long-term relationships, relationship satisfaction must also be considered as an important intervention target.

STRENGTHS AND LIMITATIONS

Further investigation using longitudinal designs is required to examine the causal links between these factors and sexual well-being in older age.

CONCLUSION

Findings from this study underscore the role of relationship dimensions and age-related sexual beliefs for the sexual well-being of partnered older adults.

Association of nutritional status and comorbidity with long-term survival among community-dwelling older males

BACKGROUND

Estimates of survival in the older can be of benefit in various facets, particularly in medical and individual decision-making. We aim to validate the value of a combination of nutrition status evaluation and comorbidity assessment in predicting long-term survival among community-dwelling older.

METHODS

The Charlson Comorbidity Index (CCI) was applied for comprehensive evaluation of comorbidities. Participants were classified into CCI score ≤ 2 and ≥ 3 subgroups. Nutritional status was assessed by using Mini Nutritional Assessment-Short Form (MNA-SF) and Geriatric Nutritional Risk Index (GNRI) evaluations. Mortality rates and survival curves over a 5-year period were compared among subgroups classified by CCI and/or MNA-SF/GNRI evaluations.

RESULTS

A total of 1033 elderly male participants were enrolled in this study, with an average age of 79.44 ± 8.61 years. 108 deceased participants (10.5%) were identified during a follow-up of 5 years. Cox proportional hazards regression analysis showed that age, CCI, MNA-SF and GNRI were independent predictors of 5-year all-cause death in this cohort. Compared to those with normal nutrition status and CCI ≤ 2, the subgroup at risk of malnutrition and CCI ≥ 3 had a significantly higher 5-year all-cause mortality rate (HR = 4.671; 95% CI:2.613-8.351 for MNA-SF and HR = 7.268; 95% CI:3.401-15.530 for GNRI; P < 0.001 for both). Receiver operating characteristic curve analysis demonstrated that a combination of either MNA-SF or GNRI with CCI had significantly better performance than CCI, MNA-SF or GNRI alone in predicting all-cause death.

CONCLUSION

The combination of nutritional assessment (MNA-SF or GNRI) with CCI can significantly improve the predictive accuracy of long-term mortality outcomes among community-dwelling older males.

Geriatric syndromes in the population older than 90 years: The prevalence and association with chronic diseases

OBJECTIVE

The aim of this study was to explore the prevalence of geriatric syndromes and comorbid conditions, as well as their interrelationships, in individuals aged 90 years and over.

METHODS

This study included participants aged 90 years and older who underwent a comprehensive geriatric assessment in a tertiary geriatric outpatient clinic. Demographic and clinical characteristics were obtained using the electronic medical records. The geriatric syndrome burden was calculated by adding each syndrome, which was then stratified into one of two groups based on the median value: no or low burden (<4) and high burden (≥4). The modified Charlson comorbidity index was used to determine chronic disease burden.

RESULTS

A total of 235 participants (93.2 ± 2.7 years) were recruited in this study. The mean index score was 7.3, and 46% (n = 107) of participants had a high geriatric syndrome burden. The most common geriatric syndrome was incontinence (69%), followed by polypharmacy (60%) and depression (43%). When compared to patients without such a diagnosis, the prevalence of polypharmacy was significantly higher in patients diagnosed with hypertension, chronic kidney disease, cardiovascular disease, diabetes mellitus and chronic obstructive pulmonary disease (p = 0.02, p = 0.02, p < 0.001, p = 0.008, p = 0.007, respectively). However, no chronic disease was associated with geriatric syndrome burden.

CONCLUSIONS

We found that the burden of medical conditions in the older population over 90 years of age could influence general health status significantly, with a high prevalence of chronic diseases and geriatric syndromes.

The Influence of Healthy Habits on Cognitive Functions in a Group of Hemodialysis Patients

(1) Background: Cognitive impairment (CI) is more prevalent in hemodialysis (HD) patients than in the general population. The purpose of this study was to examine if behavioral, clinical, and vascular variables are linked with CI in individuals with HD. (2) Methods: Initially, 47 individuals with chronic HD volunteered to participate in the trial, but only 27 patients ultimately completed the Montreal Cognitive Assessment (MoCA) and the Computerized Cognitive Assessment Tool (CompBased-CAT). We collected information on smoking, mental activities, physical activity (Rapid Assessment of Physical Activity, RAPA), and comorbidity. The oxygen saturation (rSO2) and pulse wave velocity (PWV; IEM Mobil-O-Graph) of the frontal lobes were measured. (3) Results: Significant associations were discovered between MoCA and rSO2 (r = 0.44, p = 0.02 and r = 0.62, p = 0.001, right/left, respectively), PWV (r = -0.69, p = 0.0001), CCI (r = 0.59, p = 0.001), and RAPA (r = 0.72, p = 0.0001). Those who actively occupied their time during dialysis and non-smokers achieved higher cognitive exam results. A multivariate regression study demonstrated that physical activity (RAPA) and PWV had separate effects on cognitive performance. (4) Conclusions: Cognitive skills are related to inter-dialysis healthy habits (physical activity, smoking) and intra-dialysis activities (tasks and mind games). Arterial stiffness, oxygenation of the frontal lobes, and CCI were linked with CI.

Age-specific associations between the number of co-morbidities, all-cause mortality and public direct medical costs in patients with type 2 diabetes: A retrospective cohort study

AIM

To evaluate the association between the number of co-morbidities, all-cause mortality and public health system expenditure in patients with type 2 diabetes (T2D) across different age groups.

MATERIALS AND METHODS

A retrospective observational study of T2D patients using electronic health records in Hong Kong was conducted. Patients were stratified by age (< 50, 50-64, 65-79, ≥ 80 years) and the number of co-morbidities (0, 1, 2, 3, ≥ 4), defined using the Charlson Comorbidity Index and prevalent chronic diseases identified in local surveys. The association between the number of co-morbidities, all-cause mortality and direct medical costs was examined using Cox proportional hazard regression and the gamma generalized linear model with log link function.

RESULTS

A total of 262 212 T2D patients with a median follow-up of 10 years were included. Hypertension and dyslipidaemia were the most common co-morbidities in all age groups. After age stratification, cardiovascular diseases dominated the top pair of co-morbidities in the older age groups (65-79 and ≥ 80 years), while inflammatory and liver disease were predominant among younger individuals. Compared with co-morbidity-free T2D patients, the hazard ratios (95% CI) of death for patients aged younger than 50 and 80 years or older with two co-morbidities were 1.31 (1.08-1.59) and 1.25 (1.15-1.36), respectively, and increased to 3.08 (2.25-4.21) and 1.98 (1.82-2.16), respectively, as the number of co-morbidities increased to four or more. Similar trends were observed for medical costs.

CONCLUSIONS

Age-specific co-morbidity patterns were observed for patients with T2D. A greater number of co-morbidities was associated with increased mortality and healthcare costs, with stronger relationships observed among younger patients.

Predictivity of the comorbidity indices for geriatric syndromes

Background

The aging population and increasing chronic diseases make a tremendous burden on the health care system. The study evaluated the relationship between comorbidity indices and common geriatric syndromes.

Methods

A total of 366 patients who were hospitalized in a university geriatric inpatient service were included in the study. Sociodemographic characteristics, laboratory findings, and comprehensive geriatric assessment(CGA) parameters were recorded. Malnutrition, urinary incontinence, frailty, polypharmacy, falls, orthostatic hypotension, depression, and cognitive performance were evaluated. Comorbidities were ranked using the Charlson Comorbidity Index(CCI), Elixhauser Comorbidity Index(ECM), Geriatric Index of Comorbidity(GIC), and Medicine Comorbidity Index(MCI). Because, the CCI is a valid and reliable tool used in different clinical settings and diseases, patients with CCI score higher than four was accepted as multimorbid. Additionally, the relationship between geriatric syndromes and comorbidity indices was assessed with regression analysis.

Results

Patients’ mean age was 76.2 ± 7.25 years(67.8% female). The age and sex of multimorbid patients according to the CCI were not different compared to others. The multimorbid group had a higher rate of dementia and polypharmacy among geriatric syndromes. All four indices were associated with frailty and polypharmacy(p < 0.05). CCI and ECM scores were related to dementia, polypharmacy, and frailty. Moreover, CCI was also associated with separately slow walking speed and low muscle strength. On the other hand, unlike CCI, ECM was associated with malnutrition.

Conclusions

In the study comparing the four comorbidity indices, it is revealed that none of the indices is sufficient to use alone in geriatric practice. New indices should be developed considering the complexity of the geriatric cases and the limitations of the existing indices.

Effectiveness of Partially Hydrolyzed Guar Gum in Reducing Constipation in Long Term Care Facility Residents: A Randomized Single-Blinded Placebo-Controlled Trial

OBJECTIVES

To assess the effectiveness of partially hydrolyzed guar gum (PHGG) in improving constipation and reducing the use of laxatives among long term care facility (LTCF) residents.

DESIGN

A single-center, prospective, randomized, placebo-controlled, single-blinded parallel-group trial from September 2021 to November 2021.

SETTING

Four LTCF in Hong Kong.

PARTICIPANTS

Fifty-two LTCF residents with chronic constipation (mean age: 83.9±7.6 years, male 38%).

INTERVENTION

5g PHGG mixed with 200ml water per day for 4 weeks was given to intervention group participants. Control group received 200ml water for 4 weeks. Participants continued their usual as-needed laxative (lactulose, senna or dulcolax) on their own initiative.

MEASUREMENTS

Baseline measurements included age, gender, Charlson comorbidity index, Roackwood's Clinical Frailty Scale, body mass index and daily dietary fiber intake. Outcome measures were fecal characteristics assessed by Bristol Stool Form Scale, bowel opening frequency and laxative use frequency at baseline, first, second, third and fourth week of trial. Adverse events were measured. The study was registered on ClinicalTrial.gov; identifier: NCT05037565.

RESULTS

There was no significant difference in bowel frequency and stool characteristics between the treatment group and control group. However, there was a significantly lower frequency of lactulose, senna, and total laxative use in the treatment group compared with controls in the third and fourth week. There was no significant difference in adverse effects between the two groups.

CONCLUSION

This study showed that daily dietary fibre supplementation by using PHGG for 4 weeks in LTCF residents results in significantly less laxative use than placebo. It may be an effective way to reduce laxative dependence among older people living in LTCFs.

Developing and validating a Chinese multimorbidity-weighted index for middle-aged and older community-dwelling individuals

OBJECTIVE

To develop and validate an index to quantify the multimorbidity burden in Chinese middle-aged and older community-dwelling individuals.

METHODS

We included 20,035 individuals aged 45 and older from the China Health and Retirement Longitudinal Study (CHARLS) and 19,297 individuals aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Health outcomes of physical functioning (PF), basic and instrumental activities of daily living (ADL and IADL) and mortality were obtained. Based on self-reported disease status, we calculated five commonly used western multimorbidity indexes for CHARLS baseline participants. The one that predicted the health outcomes the best was selected and then modified through a linear mixed model using the repeated individual data in CHARLS. The performance of the modified index was internally and externally evaluated with CHARLS and CLHLS data.

RESULTS

The multimorbidity-weighted index (MWI) performed the best among the five indexes. In the modified Chinese multimorbidity-weighted index (CMWI), the weights of the diseases varied greatly (range 0.2-5.1). The top three diseases with the highest impact were stroke, memory-related diseases and cancer, corresponding to weights of 5.1, 4.3 and 3.4, respectively. Compared with the MWI, the CMWI showed better model fits for PF and IADL with larger R2 and smaller Akaike information criterion, and comparable prediction performances for ADL, IADL and mortality (e.g. the same predictive accuracy of 0.80 for ADL disability).

CONCLUSION

The CMWI is an adequate index to quantify the multimorbidity burden for Chinese middle-aged and older community-dwelling individuals. It can be directly computed via disease status examined in regular community health check-ups to facilitate health management.

Association Between Caregiver Depression and Elder Mistreatment-Examining the Moderating Effect of Care Recipient Neuropsychiatric Symptoms and Caregiver-Perceived Burden

OBJECTIVES

To examine the association between caregiver (CG) depression and increase in elder mistreatment and to investigate whether change in care recipient (CR) neuropsychiatric symptoms (NPS) and change in CG-perceived burden influence this association.

METHODS

Using 2-year longitudinal data, we analyzed a consecutive sample of 800 Chinese primary family CGs and their CRs with mild cognitive impairment or mild-to-moderate dementia recruited from the geriatric and neurological departments of 3 Grade-A hospitals in the People's Republic of China. Participatory dyads were assessed between September 2015 and February 2016 and followed for 2 years.

RESULTS

CG depression at baseline was associated with a sharper increase in psychological abuse and neglect. For CRs with increased NPS, having a depressed CG predicted a higher level of psychological abuse than for those CRs without NPS. For CGs with decreased burden, the level of depression was associated with a slower increase in neglect than for CGs who remained low burden.

DISCUSSION

This study showed the differential impact of CG depression on the increase in elder mistreatment depending on the change in CR NPS and CG-perceived burden. The present findings provide valuable insights into the design of a systematic and integrative intervention protocol for elder mistreatment that simultaneously focuses on treating CG depression and perceived burden and CR NPS.

Overall mortality in older people receiving physician-led home visits: a multicentre prospective study in Japan

BACKGROUND

Japan has the most rapidly ageing population in the world. The Japanese government has, therefore, promoted physician-led home health care for frail and disabled people.

OBJECTIVES

To describe mortality among older people receiving physician-led health care at home or at a nursing home in Japan and to identify risk factors.

METHODS

This was a multicentre prospective cohort study. Participants were aged ≥65 years and had started to receive regular physician-led health care at home or at nursing homes from 13 facilities between 1 February 2013 and 31 January 2016. The observation period ended on 31 January 2017. We used a biopsychosocial approach for exploratory analysis of 13 variables to identify mortality risk factors.

RESULTS

The median (25th to 75th percentile) observation time was 417 (121-744) days. Of 825 participants, 380 died. The total cumulative survival for 180, 360, 720 and 1440 days was 73.4% (95% confidence interval: 70.2-76.3), 64.2% (60.8-67.5), 52.6% (48.8-56.3) and 34.6% (23.5-46.0). The Kaplan-Meier cumulative survival curve showed a steep drop during the first 6 months of observation. A multivariate Cox proportional hazard model showed that sex (male), high Charlson Comorbidity Index score, low serum albumin level, low Barthel Index score, receipt of oxygen therapy, high Cornell Scale for Depression in Dementia score and non-receipt of public assistance were associated with mortality.

CONCLUSIONS

Overall mortality in physician-led home visits in Japan was described and mortality risk factors identified. Public assistance receipt was associated with lower mortality.

Potentially Inappropriate Medication and Associated Factors Among Older Patients with Chronic Coronary Syndrome at Hospital Discharge in Beijing, China

Purpose

Medication therapy is crucial in the management of chronic coronary syndrome (CCS). The use of potentially inappropriate medications (PIMs) contributes to poor outcomes in older patients, making it a major public health concern. However, few studies are available on PIMs use in older Chinese CCS patients. To investigate the frequency of prescribed PIMs at discharge and explore risk factors in older adults with CCS.

Patients and Methods

The cross-sectional study was conducted in a tertiary hospital in China over three months, from 1st October to 31st December, 2019. CCS patients aged over 60 years who were discharged alive were recruited. Information on demographics and medications at discharge was collected. Clinical data including diagnoses, frailty status, New York Heart Association (NYHA) class and age-adjusted Charlson Comorbidity Index (ACCI) were evaluated in each patient. PIMs were identified using the 2019 Beers criteria. Binary logistic regression was performed to recognize variables related to PIMs.

Results

A total of 447 eligible patients with 2947 medications were included. The prevalence of PIMs use was 38%. Medications to be avoided, to be used with caution, and with drug–drug interactions were 38.4%, 48.9% and 12.7% of the PIMs, respectively. Medications with drug–disease/syndrome interactions and those adjusted for kidney function were not identified. The common PIMs were diuretics (37.1%), benzodiazepines and benzodiazepine receptor agonist hypnotics (15.2%), glimepiride (13.1%), and co-prescription of potassium-sparing diuretics and renin-angiotensin system (RAS) inhibitors (9.7%). Individuals with frailty syndrome, polypharmacy, multiple comorbidities, atrial fibrillation, psychiatric disorders and greater NYHA class severity were more likely to receive PIMs.

Conclusion

Prescription of PIMs was a common burden in older adults. A CCS multidisciplinary team is needed to control PIMs, especially in vulnerable older patients.

Ceftazidime-avibactam in the treatment of infections from carbapenem-resistant Klebsiella pneumoniae: Ceftazidime-avibactam against CR-KP infections

OBJECTIVES

Clinical experience with ceftazidime-avibactam (CAZ-AVI) for the treatment of carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections is not well evaluated. The aim of this study was to assess its efficacy in a single-centre cohort of patients infected with CR-KP.

METHODS

We conducted a retrospective observational study of consecutive patients treated for >72 h with CAZ-AVI or other active antibiotics (OAAs) for CR-KP infections. The primary outcome was 30-d mortality. The secondary outcomes were 14-d clinical failure and 14-d microbiological failure. Multivariate regression and propensity score matching were used to evaluate the relationship between CAZ-AVI treatment and outcomes.

RESULTS

Ninety infections caused by CR-KP were documented in our study. Forty-two patients were treated with CAZ-AVI and 48 with OAAs. The crude 30-d mortality (8/42 vs. 22/48, P=0.007), 14-d clinical failure (14/42 vs. 24/48, P=0.046) and 14-d microbiological failure (11/42 vs. 15/48, P=0.034) were significantly lower in patients with CAZ-AVI treatment. The Kaplan-Meier survival curves of 30-d mortality confirmed the findings (logrank=0.004). In the multivariable models, the odds ratio (OR) of 30-d mortality (OR 0.23 95% CI 0.10-0.51, P<0.000), 14-d clinical failure (OR 0.37, 95% CI 0.14-0.95, P=0.039) and 14-d microbiological failure (OR 0.17, 95% CI 0.08-0.93, P=0.038) remain consistently significant. In the subgroup analysis, CAZ-AVI was associated with decreased 30-d mortality in the positive blood culture (OR 0.23, 95% CI 0.08-0.63, P=0.004), septic shock (OR 0.23, 95% CI 0.07-0.78, P=0.019), SOFA score (>5, OR 0.13, 95% CI 0.04-0.36, P<0.000), mechanical ventilation (OR 0.13, 95% CI 0.04-0.36, p<0.000) and Charlson comorbidity index (>3, OR 0.15, 95% CI 0.04-0.55, P=0.004). After propensity score matching, 29 cases from each group were well matched. The 30-d mortality remained significantly lower in the CAZ-AVI group (6/29 vs. 13/29, P=0.05).

CONCLUSION

CAZ-AVI may be a more valuable therapeutic option for severe CR-KP infections than for mild cases and further randomized controlled trials are needed to evaluate the efficacy.

Plasma N-Terminal Pro-B-Type Natriuretic Peptide Is Associated with Intrinsic Capacity Decline in an Older Population

OBJECTIVES

To determine the association between plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) and intrinsic capacity in an older population.

METHOD

We recruited 283 participants aged 60-97 years (mean 77.42±4.08 years). Intrinsic capacity was assessed with the World Health Organization Integrated Care for Older People (ICOPE) screening tool including six domains: cognition, locomotion, vitality, hearing, vision, and psychology. Multimorbidity, polypharmacy, gait speed, physical activity, lifestyles, and chronic inflammation were assessed. We used multivariate logistic regression and the Spearman's correlation to assess the association between plasma NT-proBNP and intrinsic capacity.

RESULTS

The average intrinsic capacity score was 4.53±1.34. The percentage of decreased intrinsic capacity was 75.3%. Participants with decreased intrinsic capacity were older, with more cardiovascular and cerebrovascular diseases and polypharmacy, and had lower gait speed and higher C-reactive protein. Plasma NT-proBNP was significantly higher in the decreased intrinsic capacity group (128.0[56.8-280.8] pg/mL vs. 72.6[39.7-120.0] pg/mL, p<0.001). Multivariate logistic regression analysis revealed that NT-proBNP was the only independent risk factor for decreased intrinsic capacity among multiple covariates (odds ratio=1.005, p=0.038). Elevated NT-proBNP levels were associated with abnormal locomotion, hearing, vision, and psychology domains. Additionally, NT-proBNP levels were inversely correlated with the intrinsic capacity score adjusted for both age and coronary artery disease (r=-0.371, p< 0.001).

CONCLUSION

Elevated NT-proBNP levels were associated with decreased intrinsic capacity in older persons, independent of age, multimorbidity, polypharmacy, and chronic inflammation. Further longitudinal studies are required to explore the predictive role of NT-proBNP on declines in intrinsic capacity.

Integrated Care for Older People Screening Tool for Measuring Intrinsic Capacity: Preliminary Findings From ICOPE Pilot in China

Objectives: The World Health Organization (WHO) proposed the Integrated Care for Older People (ICOPE) screening tool to identify older people with priority conditions associated with declines in intrinsic capacity (IC). We aimed to determine the clinical utility of the WHO ICOPE screening tool in a Chinese population. Method: A total of 376 adults aged 68.65 ± 11.41 years participated in the study. IC was assessed with the WHO ICOPE screening tool, covering five domains: cognitive, locomotor, sensory, vision, and psychological capacity. We assessed the activities of daily living (ADL); instrumental activities of daily living (IADL); the Fried frailty phenotype; FRAIL scale; Strength, Assistance With Walking, Rising From chair, Climbing Stairs, and Falls (SARC-F) scale; Mini-mental State Examination (MMSE); Geriatric Depression Scale (GDS); social frailty; and quality of life. Results: There were 260 (69.1%) participants who showed declines in one or more IC dimensions. The percentages of decline in mobility, cognition, vitality, hearing, vision, and psychological capacity were 25.3, 46.8, 16.2, 15.4, 11.7, and 12.0%, respectively. IC decreased with increasing age. After adjusting for age, sex, and multimorbidity, participants with declines in IC were more likely to be older, frail, and disabled. They also had worse physical, mental, and overall health. There was a higher prevalence of declines in IC in participants with frailty. After adjusting for age, IC was positively correlated with walking speed, resilience score, and MMSE score and negatively correlated with frailty, SARC-F score, IADL score, GDS score, and physical and mental fatigue. The IC score was not associated with body composition variables such as fat-free mass, body fat percentage, or visceral fat area. Higher IC was associated with better quality of life. The area under the curve of the receiver operating characteristic (AUC-ROC) for the ICOPE screening tool vs. Fried phenotype, FRAIL, ADL disability, IADL disability, and SARC-F were 0.817, 0.843, 0.954, 0.912, and 0.909, respectively. Conclusion: Our research affirms that the ICOPE screening tool is useful to identify adults with poor physical and mental function in a Chinese sample. This tool may assist in identifying declines in IC in an integrative care model and help slow down function decline and onset of care dependence.

PM2.5 air pollution contributes to the burden of frailty

Frailty is common among older people and results in adverse health outcomes. We investigated whether exposure to PM_2.5 is associated with frailty. This cross-sectional study involved 20,606 community-dwelling participants aged ≥ 65 years, residing in New Taipei City, Taiwan. Analytic data included phenotypic frailty, disease burden by Charlson Comorbidity Index (CCI), urban or rural residence, and household income. PM_2.5 exposure was calculated from air quality monitoring records, with low exposure defined as the lowest quartile of the study population. 1,080 frail participants (5.2%) were older, predominantly female, had more comorbidities, lived rurally, and had low PM_2.5 exposure (all p < 0.001). In multinomial logistic regression analyses, the likelihood of high PM_2.5 exposure was higher in prefrail (OR 1.4, 95% CI 1.3–1.5) and frail adults (OR 1.5, 95% CI 1.2–1.9) than in robust individuals, with stronger associations in those who were male (frail: OR 2.1, 95% CI 1.5–3.1; prefrail: OR 2.2, 95% CI 1.9–2.6), ≥ 75 years old (frail: OR 1.8, 95% CI 1.3–2.4; prefrail: OR 1.5, 95% CI 1.3–1.8), non-smokers (frail: OR 1.6, 95% CI 1.3–2.0; prefrail: OR 1.4, 95% CI 1.2–1.5), had CCI ≥ 2 (frail: OR 5.1, 95% CI 2.1–12.6; prefrail: OR 2.1, 95% CI 1.2–3.8), and with low household income (frail: OR 4.0, 95% CI 2.8–5.8; prefrail: OR 2.7, 95% CI 2.2–3.3). This study revealed a significant association between PM_2.5 exposure and frailty, with a stronger effect in vulnerable groups.

The use of functional performance tests and simple anthropomorphic measures to screen for comorbidity in primary care

BACKGROUND

Many older adults are unaware that they have comorbid diseases. Increased adiposity and reduced muscle mass are identified as key contributors to many chronic diseases in older adults. Understanding the role they play in the development of comorbidities in older populations is of prime importance.

OBJECTIVES

To identify the optimal body shape associated with three common functional performance tests and to determine which anthropometric and functional performance test best explains comorbidity in a sample of older adults in Hong Kong.

METHODS

A total of 432 older adults participated in this cross-sectional study. Researchers assessed their body height, body mass index, waist circumference, waist-to-hip ratio, handgrip strength (kg), functional reach (cm) and results in the timed-up-and-go (TUG) test (seconds). The Charlson Comorbidity Index was used to assess comorbidity.

RESULTS

Allometric modelling indicated that the optimal body shape associated with all functional performance tests would have required the participants to be taller and leaner. The only variable that predicted comorbidity was the TUG test. The inclusion of body size/shape variables did not improve the prediction model.

CONCLUSION

Performance in the TUG test alone was found to be capable of identifying participants at risk of developing comorbidities. The TUG test has potential as a screening tool for the early detection of chronic diseases in older adults.

IMPLICATIONS FOR PRACTICE

Many older people are unaware of their own co-existing illnesses when they consult physicians for a medical condition. TUG can be a quick and useful screening measure to alert nurses in primary care to the need to proceed with more detailed assessments. It is an especially useful screening measure in settings with high patient volumes and fiscal constraints. TUG is low cost and easy to learn and is therefore also relevant for nurses and health workers in low-resource, low-income countries.

The effects of a transitional care program on discharge readiness, transitional care quality, health services utilization and satisfaction among Chinese kidney transplant recipients: A randomized controlled trial

BACKGROUND

Kidney transplantation is the major treatment for end-stage renal disease (ESRD). However, kidney transplant recipients (KTRs) face severe challenges during the transition period from hospital discharge to home, increasing the risk of early hospital readmission (EHR) and affecting patient safety. Nevertheless, knowledge of effective transitional care for KTRs is limited in China.

OBJECTIVE

To evaluate the effectiveness of an innovative transitional care program in improving discharge readiness, transitional care quality, health services utilization and patient satisfaction among KTRs in China.

DESIGN

A prospective randomized controlled trial.

SETTINGS AND PARTICIPANTS

Patients admitted to undergo kidney transplantation were recruited in a general tertiary hospital in Chengdu, China.

METHODS

A total of 220 eligible patients were recruited and randomly assigned to the intervention and control groups. Participants in the intervention group received a transitional care intervention developed by the research team, including a risk assessment for early readmission, health education from admission to predischarge, individualized discharge planning, and a telephone follow-up once per week for one month and WeChat follow-up postdischarge. The control group received routine care of comparable length and follow-up contact. A trained research assistant collected all patients' baseline data on admission (T0), evaluated the discharge readiness (by the Readiness for Hospital Discharge Scale) on the day of discharge (T1), collected data on transitional care quality (by the Care Transition Measure-15) and patients' satisfaction with transitional care services (by a self-developed patient satisfaction scale) on the 30th day postdischarge (T2), and collected data on hospital readmission, unscheduled outpatient department visits, and emergency room visits on the 30th and 90th days (by a self-developed health services utilization record table) (T3) postdischarge. Intervention effects were analyzed using independent samples t-tests, Wilcoxon-Mann-Whitney U tests, Chi-square tests or Fisher's exact test.

RESULTS

Compared with the control group, the intervention group showed significantly better discharge readiness (personal status, P<0.001; knowledge, P = 0.010; coping ability, P<0.001; expected support, P = 0.007; total score, P<0.001), better transitional care quality (importance of preferences, P<0.001; management preparation, P<0.001; critical understanding, P = 0.003; written and understandable care plan, P = 0.012; total score, P<0.001), lower readmission rate at T2 (P = 0.033) and at T3 (P = 0.013), lower emergency room visit rate at T3 (P = 0.014), and better satisfaction with transitional care services (P<0.001).

CONCLUSIONS

This study provides evidence that an innovative transitional care program is effective in promoting KTRs' discharge readiness, transitional care quality, reducing hospital readmission and emergency room visits, and improving their satisfaction with transitional care services.

TRIAL REGISTRATION

Clinical Trials ChiCTR1800014971.

A national study on long-term osteoporosis therapy and risk of recurrent fractures in patients with hip fracture

OBJECTIVE

The study aimed to evaluate the impact of osteoporosis (OP) medication persistence on subsequent fractures and all-cause mortality in patients with hip fracture.

METHODS

In this retrospective cohort study, we included patients aged ≥ 40 years with fragility hip fracture from the Taiwan's National Health Insurance Research Database. OP medication persistence was categorized as yes (≥ 12 months) or no (< 12 months). A multivariate Cox proportional hazard model was used to evaluate the association between OP medication persistence and recurrent fractures (including hip, vertebral, and upper and lower limb fractures) and all-cause mortality.

RESULTS

A total of 946 patients were included in the study (86.5 % of them aged ≥ 65 years) and 210 patients persistently received OP medications. Persistent OP medication use was associated with lower fracture risk (adjusted hazard ratio [aHR] = 0.64; 95 % CI = 0.41-0.99; P = .043) in the follow-up period. The strongest predictors for all-cause mortality were age ≥ 80 years (HR = 5.68, 95 % CI = 1.36-23.64, P = .017), male sex (HR = 1.55; 95 % CI = 1.18-2.03; P = .002), and Charlson Comorbidity Index ≥ 3 (aHR = 1.56; 95 % CI = 1.07-2.27; P = .022). Kaplan-Meier curves showed a lower cumulative incidence of recurrent fractures in the persistent group than that in the non-persistent group (P = .028).

CONCLUSION

Persistent OP medication use was associated with a lower risk of recurrent fractures but not with mortality in patients with hip fracture.

Factors associated with death in bedridden patients in China: A longitudinal study

BACKGROUND

Immobility is common and associated with adverse outcomes in hospitalized patients, especially older people. However, the factors contributing to mortality in bedridden patients are not well known. This study aimed to estimate short-term mortality and analyze risk factors that affect the prognosis of bedridden patients.

METHODS

This was a multicenter study in China involving 23,738 patients admitted to 25 hospitals between November 2015 and June 2016. All-cause mortality was recorded for 90 days after enrollment regardless of whether death occurred before or after discharge. Socio-demographic and clinical information was obtained from an electronic database. Univariate and multivariate Cox regression analysis was used to identify factors associated with mortality.

RESULTS

In total, 23,738 hospitalized bedridden patients, there were 1,114 (4.7%) observed deaths. The overall mortality rate was therefore 4.7%. Of these, 318 (1.4%) died while hospitalized and 796 (3.4%) after discharge. The univariate Cox regression analysis showed that variables significantly associated with 90-day mortality included total time spent bedridden, urinary tract infection and pulmonary infection (p<0.05). The multivariate Cox regression analysis showed that the independent risk factors for death were age (adjusted hazard ratio [aHR] 1.006, 95% CI 1.000-1.011), and pulmonary infection (aHR 1.439, 95% CI 1.266-1.635). The hazard ratios for mortality were reduced with urinary tract infection and more time spent bedridden.

CONCLUSIONS

The mortality after discharge was significantly higher than mortality in hospital. The factors affecting short-term mortality in bedridden patients included age, time spent bedridden, urinary tract infection and pulmonary infection. This suggests these factors may be potential predictors of mortality in bedridden patients. It is essential for medical staff to improve health education of patients and family members, pay more attention to follow up after discharge and meet care needs at home.

Malnutrition risks and their associated factors among home-living older Chinese adults in Hong Kong: hidden problems in an affluent Chinese community

Background

Although China is undergoing rapid economic development, it is facing an ageing population. No data exists on malnutrition risks of older adults in an affluent Chinese society. The aim of this study is to examine these risks and identify their associated factors among home-living older Chinese adults in Hong Kong.

Methods

This is a cross-sectional study, to which home-living subjects aged 60 or above were recruited, between May and September 2017, from a non-governmental community organisation located in three different districts of Hong Kong. Nutritional status was assessed by the Mini Nutritional Assessment (MNA), and its associated factors examined included socio-demographic characteristics, lifestyle, health status and diet. Multivariable logistic regression analysis was performed to identify factors associated with malnutrition risks (MNA < 24).

Results

Six hundred thirteen subjects (mean age: 78.5 ± 7.4; 54.0% females) completed the survey. Nearly 30% (n = 179) were at risk of malnutrition. By multivariable logistic regression, subjects (1) whose vision was only fair or unclear, (2) with poor usual appetite and (3) with main meal skipping behaviour had significantly higher malnutrition risk (all p < 0.05).

Conclusions

In this affluent Chinese society, the malnutrition risk in older adults is close to the global average, which is a matter for much concern. Interventions are therefore warranted that target vulnerable groups with poor vision, appetite, and meal skipping behaviour.

Trial registration

Not applicable.

Short- and long-term outcomes in elderly patients with locally advanced non-small-cell lung cancer treated using video-assisted thoracic surgery lobectomy

BACKGROUND

In recent years, video-assisted thoracic surgery (VATS) lobectomy has been used to treat locally advanced non-small-cell lung cancer (LA-NSCLC). However, VATS has not been reported in elderly patients (≥70 years) with LA-NSCLC. The purpose of this study was to compare short- and long-term outcomes of patients with LA-NSCLC aged ≥70 years and 55-69 years treated with VATS.

PATIENTS AND METHODS

From January 2012 to January 2018, a total of 83 patients with LA-NSCLC who were ≥55 years of age underwent VATS. Patients were divided into ≥70 years group (37 cases) and 55-69 years group (46 cases), based on their age at the time of VATS. Short- and long-term outcomes of these two groups of patients were compared.

RESULTS

American Society of Anesthesiologists scores of ≥70 years patients were higher than those of 55-69 years patients. No significant differences were observed when comparing the general preoperative data. For short-term outcomes, there was no significant difference between the two groups of patients in length of surgery, intraoperative blood loss, conversion to thoracotomy, postoperative 30-day complication rate and severity, postoperative 30-day mortality, pathological results, compliance with adjuvant chemotherapy, or other factors. Long-term follow-up results showed that recurrence, overall survival, and disease-free survival were similar in both groups. Furthermore, multivariate analysis showed that age was not an independent predictor of overall and disease-free survival.

CONCLUSIONS

VATS in elderly patients (≥70 years) with LA-NSCLC can result in short- and long-term outcomes similar to those of 55-69 years patients with LA-NSCLC.

High comorbidity, measured by the Charlson Comorbidity Index, associates with higher 1-year mortality risks in elderly patients experiencing a first acute heart failure hospitalization

BACKGROUND

Comorbidity is related to poor health results in chronic heart failure (HF).

AIMS

The purpose of the study was to assess whether a high Charlson Comorbidity Index score (CCI) relates to 1 year mortality after a first hospitalization for acute HF (AHF).

METHODS

We reviewed the medical records of 897 patients > 65 years of age admitted within a two-year period because of a first episode of AHF. We analyzed two groups: low (CCI ≤ 2) and high (CCI > 2) comorbidity.

RESULTS

Patients' mean CCI was 2.2 ± 1.7; 344 patients (38.35%) had a CCI > 2. 1-year all-cause mortality rate in the high comorbidity group was 32.6%, worse than that among low comorbidity group patients (23.7%, p = 0.002). Cox multivariate analysis identified a CCI > 2 as an independent risk factor for 1-year mortality (p = 0.002; HR: 1.525; CI 95% 1.161-2.003), along with older age, history of arterial hypertension, and higher admission heart rate and serum potassium values. Analyzing CCI as a continuous variable, the association remained is also significant (p = 0.0001; HR 1.145; CI 95% 1.069-1.854).

CONCLUSIONS

Higher global comorbidity (CCI > 2) at the time of a first hospitalization because of AHF is an independent predictor of mid-term post-discharge mortality among elderly HF patients.

Effects of a hospital-community partnership transitional program in patients with coronary heart disease in Chengdu, China: A randomized controlled trial

AIM

To evaluate the effects of a hospital-community partnership transitional program among patients with coronary heart disease.

METHODS

This was a randomized controlled trial with 236 patients who were randomized into two groups. The patients in the control group received the usual care. In contrast, the patients in the study group received the transitional care program. The data were collected at the baseline, 30 days, and 90 days after discharge. The primary outcomes were the 30 and 90 day readmission rates after discharge. The secondary outcomes included the quality-of-care transitions, medicine adherence, and chronic disease self-efficacy.

RESULTS

The findings indicated that: (i) the patients in the study group reported significantly lower 30 and 90 day readmission rates after their discharge than those in the control group; (ii) statistically significant differences were found in the quality-of-care transitions at 30 days postdischarge between the two groups as the patients in the study group reported significantly higher quality-of-care transitions, compared to those in the control group; and (iii) the patients in the study group reported significantly higher scores in medication adherence and chronic disease self-efficacy at 30 and 90 days after discharge than those in the control group.

CONCLUSION

This study is an original effort to establish and evaluate a hospital-community partnership transitional care program in patients with coronary heart disease in China and the findings have demonstrated its effects.

Multimorbidity and mortality in older adults: A systematic review and meta-analysis

OBJECTIVE

To review literature and provide a pooled effect for the association between multimorbidity and mortality in older adults.

METHODS

A systematic review was performed of articles held on the PUBMED database published up until January 2015. Studies which used different diseases and other conditions to define frailty, evaluated multimorbidity related only to mental health or which presented disease homogeneity were not included. A meta-analysis using random effect to obtain a pooled effect of multimorbidity on mortality in older adults was conducted only with studies which reported hazard ratio (HR). Stratified analysis and univariate meta-regression were performed to evaluate sources of heterogeneity.

RESULTS

Out of 5806 identified articles, 26 were included in meta-analysis. Overall, positive association between multimorbidity and mortality [HR: 1.44 (95%CI: 1.34; 1.55)] was detected. The number of morbidities was positively related to risk of death [HR: 1.20 (95%CI: 1.10; 1.30)]. Compared to individuals without multimorbidity, the risk of death was 1.73 (95%CI: 1.41; 2.13) and 2.72 (95%CI: 1.81; 4.08) for people with 2 or more and 3 or more morbidities, respectively. Heterogeneity between studies was high (96.5%). The sample, adjustment and follow-up modified the associations. Only nine estimates performed adjustment which included demographic, socioeconomic and behaviour variables. Disabilities appear to mediate the effect of multimorbidity on mortality.

CONCLUSIONS

Multimorbidity was associated with an increase in risk of death. Multimorbidity measurement standardization is needed to produce more comparable estimates. Adjusted analysis which includes potential confounders might contribute to better understanding of causal relationships between multimorbidity and mortality.

Comorbidity burden assessment in older people admitted to a Portuguese University Hospital

PURPOSE

To determine the most valuable comorbidity index to apply in a clinical context and its prospective association with 1-year mortality and 3-month readmission. The authors also intend to gauge the evolution of older patients' admission profile over 13 years, in the same clinical setting.

SUBJECTS/MATERIALS AND METHODS

The authors analyzed data from 100 consecutive patients admitted in 2012. The Charlson Comorbidity Index (CCI), the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and the Medication-Based Disease Burden Index (MDBI) were used to evaluate comorbidity. Length of stay, number of diagnoses and of medications, readmission and mortality were assessed. A p value <0.05 was considered significant.

RESULTS

Mean age was 80.6 years, mean length of stay was 8.8 days, and mean number of diagnosis per patient was 7.9. Mean values of score were of 3.6 for the CCI, 11.3 for the CIRS-G and 0.552 for the MDBI. Three-month readmission and 1-year mortality rates related to higher CCI and CIRS-G scores. No association was found between MDBI and the outcomes evaluated. One-year mortality reached 24 % and 3-month readmission was of 43 %. Comparing the two samples, mean age increased in 2.1 years and the number of diagnosis by 2.2. Length of stay decreased 2 days.

DISCUSSION AND CONCLUSION

CCI was easier to use but the CIRS-G was better at evaluating comorbidity. MDBI did not seem to be a trustworthy tool. Despite an older population with high comorbidity, length of stay decreased over 13 years. However, readmission was high. Introduction of geriatric care standards is required to improve health outcomes for older patients.

Immunogenicity and safety of intradermal trivalent influenza vaccination in nursing home older adults: a randomized controlled trial

OBJECTIVE

To compare the immunogenicity and safety between full-dose (15 μg) intramuscular (i.m.) and full-dose (15 μg) intradermal (i.d.) immunization of the trivalent influenza vaccine in nursing home older adults.

DESIGN

A single-center, randomized, controlled, open-label, parallel group trial from October 2013 to April 2014.

SETTING

Nine nursing homes in Hong Kong.

PARTICIPANTS

Hundred nursing home older adults (mean age: 82.9 ± 7.4 years).

INTERVENTION

Fifty received i.d. (Intanza) and 50 received i.m. (Vaxigrip) vaccination.

MEASUREMENTS

Baseline measurements included demographics, comorbidity, frailty and nutritional status. Day 21 and day 180 immunogenicity (seroconversion rate, seroprotection rate, geometric mean titer [GMT] fold increase in antibody titer) using hemagglutination-inhibition and adverse events were measured. Noninferiority and superiority of i.d. compared with i.m. vaccination in immunogenicity were analyzed. The study was registered on ClinicalTrials.gov; identifier: NCT 01967368.

RESULTS

At day 21, noninferiority in immunogenicity of the i.d. vaccination was demonstrated. The seroconversion rate of the H1N1 strain was significantly higher in the i.d. group. At day 180, immunogenicity of both groups fell but the GMT of all strains in i.d. group was higher and the difference was significant for H3N2 strain. The seroconversion rate and GMT fold increase of H3N2 strain was significantly higher in the i.d. group. Local adverse events was significantly more in i.d. group, but they were mild and resolved in 72 hours.

CONCLUSIONS

I.d. vaccination is noninferior, and even superior in some parts of immunogenicity assessment, to i.m. vaccination without compromising safety in nursing home older adults. I.d. vaccination is a good alternative to i.m. vaccination in this population.

Association between body mass index and cause-specific mortality as well as hospitalization in frail Chinese older adults

AIM

A U-shaped relationship between body mass index (BMI) and all-cause mortality has been reported, but there are few studies examining the association between BMI and cause-specific mortality and hospitalization. We carried out a longitudinal study to examine these associations in Chinese older adults with multiple comorbidities, which could provide a reference for the recommended BMI in this population.

METHODS

From 2004 to 2013, a retrospective cohort of Chinese older adults was selected from a geriatric day hospital in Hong Kong. They were divided into groups according to their BMI: BMI <16; BMI 16-18; BMI 18.1-20; BMI 20.1-22; BMI 22.1-24; BMI 24.1-26; BMI 26.1-28; BMI 28.1-30 and BMI >30. Other assessments included medical, functional, cognitive, social and nutritional assessment.

RESULTS

A total of 1747 older adults (mean age 80.8 ± 7.1 years, 44.1% male, 46.1% living in nursing homes, Charlson Comorbidity Index 2.0 ± 1.6) with a median follow up of 3.5 years were included. Older adults with BMI 24-28 had the lowest all-cause, infection-related and cardiovascular mortality (P < 0.001). Multivariate analysis showed that there was an inverted J-shaped association between BMI and hazard ratio for all-cause and infection-related mortality in both nursing home and community-dwelling older adults. The rate of all-cause hospitalization was lower in older adults with BMI 22-28 (P = 0.002). Multivariate analysis showed that there was an inverted J-shaped association between the odds ratio of recurrent hospitalization and BMI.

CONCLUSION

Chinese older adults with BMI 24-28 had lower all-cause mortality, infection-related mortality, cardiovascular-related mortality and all-cause hospitalization. This study provides a reference for the recommended BMI in this population.