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Garcez FB, Garcia de Alencar JC, Fernandez SSM, Avelino-Silva VI, Sabino EC, Martins RCR, Franco LAM, Lima Ribeiro SM, Possolo de Souza H, Avelino-Silva TJ. Association Between Gut Microbiota and Delirium in Acutely Ill Older Adults. J Gerontol A Biol Sci Med Sci 2023; 78:1320-1327. [PMID: 36869725 PMCID: PMC10395556 DOI: 10.1093/gerona/glad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Indexed: 03/05/2023] Open
Abstract
Our aim was to investigate the association between gut microbiota and delirium occurrence in acutely ill older adults. We included 133 participants 65+ years consecutively admitted to the emergency department of a tertiary university hospital, between September 2019 and March 2020. We excluded candidates with ≥24-hour antibiotic utilization on admission, recent prebiotic or probiotic utilization, artificial nutrition, acute gastrointestinal disorders, severe traumatic brain injury, recent hospitalization, institutionalization, expected discharge ≤48 hours, or admission for end-of-life care. A trained research team followed a standardized interview protocol to collect sociodemographic, clinical, and laboratory data on admission and throughout the hospital stay. Our exposure measures were gut microbiota alpha and beta diversities, taxa relative abundance, and core microbiome. Our primary outcome was delirium, assessed twice daily using the Confusion Assessment Method. Delirium was detected in 38 participants (29%). We analyzed 257 swab samples. After adjusting for potential confounders, we observed that a greater alpha diversity (higher abundance and richness of microorganisms) was associated with a lower risk of delirium, as measured by the Shannon (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.60-0.99; p = .042) and Pielou indexes (OR = 0.69; 95% CI = 0.51-0.87; p = .005). Bacterial taxa associated with pro-inflammatory pathways (Enterobacteriaceae) and modulation of relevant neurotransmitters (Serratia: dopamine; Bacteroides, Parabacteroides: GABA) were more common in participants with delirium. Gut microbiota diversity and composition were significantly different in acutely ill hospitalized older adults who experienced delirium. Our work is an original proof-of-concept investigation that lays a foundation for future biomarker studies and potential therapeutic targets for delirium prevention and treatment.
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Affiliation(s)
- Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM 66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Departamento de Medicina, Hospital Universitario, Universidade Federal de Sergipe, São Cristóvão, Brazil
| | - Júlio César Garcia de Alencar
- Laboratorio de Investigacao Medica em Emergencias Clinicas (LIM 51), Departamento de Clínica Médica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Vivian Iida Avelino-Silva
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ester Cerdeira Sabino
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Parasitologia Medica (LIM 46), Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberta Cristina Ruedas Martins
- Laboratório de Parasitologia Medica (LIM 46), Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Augusto Moysés Franco
- Laboratório de Parasitologia Medica (LIM 46), Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Heraldo Possolo de Souza
- Laboratorio de Investigacao Medica em Emergencias Clinicas (LIM 51), Departamento de Clínica Médica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM 66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Avelino-Silva TJ, Garcez FB, Campora F, Curiati JAE, Jacob-Filho W. Finding the Goldilocks zone: Effects of ambient temperature on mortality of hospitalized older adults. J Am Geriatr Soc 2023. [PMID: 37010701 DOI: 10.1111/jgs.18354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/11/2023] [Accepted: 03/07/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Thiago J Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, and Trinity College Dublin, Dublin, Ireland
| | - Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Hospital Universitario, Universidade Federal de Sergipe, Aracaju, Brazil
| | - Flavia Campora
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jose A E Curiati
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Wilson Jacob-Filho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Lopes BNA, Garcez FB, Suemoto CK, Morillo LS. Accuracy of two prognostic indexes to predict mortality in older adults with advanced dementia. Dement Neuropsychol 2022; 16:52-60. [PMID: 35719252 PMCID: PMC9170258 DOI: 10.1590/1980-5764-dn-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/05/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Dementia is a cause of disability among older adults. Accessing advanced dementia prognosis is a challenge.
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Affiliation(s)
| | - Flavia Barreto Garcez
- Universidade de São Paulo, Faculdade de Medicina, Divisão de Geriatria, São Paulo SP, Brazil
| | - Claudia Kimie Suemoto
- Universidade de São Paulo, Faculdade de Medicina, Divisão de Geriatria, São Paulo SP, Brazil
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Muñoz Fernandez SS, Garcez FB, Alencar JCGD, Cederholm T, Aprahamian I, Morley JE, de Souza HP, Avelino da Silva TJ, Ribeiro SML. Applicability of the GLIM criteria for the diagnosis of malnutrition in older adults in the emergency ward: A pilot validation study. Clin Nutr 2021; 40:5447-5456. [PMID: 34653825 DOI: 10.1016/j.clnu.2021.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/02/2021] [Accepted: 09/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Acutely ill older adults are at higher risk of malnutrition. This study aimed to explore the applicability and accuracy of the GLIM criteria to diagnose malnutrition in acutely ill older adults in the emergency ward (EW). METHODS We performed a retrospective secondary analysis, of an ongoing cohort study, in 165 participants over 65 years of age admitted to the EW of a Brazilian university hospital. Nutrition assessment included anthropometry, the Simplified Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool (MST), and the Mini-Nutritional Assessment (MNA). We diagnosed malnutrition using GLIM criteria, defined by the parallel presence of at least one phenotypic [nonvolitional weight loss (WL), low BMI, low muscle mass (MM)] and one etiologic criterion [reduced food intake or assimilation (RFI), disease burden/inflammation]. We used the receiver operating characteristic (ROC) curves and Cox and logistic regression for data analyses. RESULTS GLIM criteria, following the MNA-SF screening, classified 50.3% of participants as malnourished, 29.1% of them in a severe stage. Validation of the diagnosis using MNA-FF as a reference showed good accuracy (AUC = 0.84), and moderate sensitivity (76%) and specificity (75.1%). All phenotypic criteria combined with RFI showed the best metrics. Malnutrition showed a trend for an increased risk of transference to intensive care unit (OR = 2.08, 95% CI 0.99, 4.35), and severe malnutrition for in-hospital mortality (HR = 4.23, 95% CI 1.2, 14.9). CONCLUSION GLIM criteria, following MNA-SF screening, appear to be a feasible approach to diagnose malnutrition in acutely ill older adults in the EW. Nonvolitional WL combined with RFI or acute inflammation were the best components identified and are easily accessible, allowing their potential use in clinical practice.
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Affiliation(s)
| | - Flavia Barreto Garcez
- Geriatrics Division, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Julio César García de Alencar
- Disciplina de Emergencias Clínicas, Departamento de Clínica Médica, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Tommy Cederholm
- Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Karolinska University Hospital, Stockholm, Sweden
| | - Ivan Aprahamian
- Geriatrics Division, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - John Edward Morley
- Division of Geriatric Medicine, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Heraldo Possolo de Souza
- Disciplina de Emergencias Clínicas, Departamento de Clínica Médica, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | - Sandra Maria Lima Ribeiro
- Nutrition Department, School of Public Health, University of Sao Paulo, São Paulo, Brazil; School of Arts, Science, and Humanity, University of Sao Paulo, São Paulo, Brazil
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Barreto-Filho JA, Seabra-Garcez JD, Garcez FB, Moreira TS, Drager LF. Reply to Nuschke and Haouzi. J Appl Physiol (1985) 2021; 131:1136-1137. [PMID: 34520282 PMCID: PMC8453353 DOI: 10.1152/japplphysiol.00556.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- José Augusto Barreto-Filho
- Division of Cardiology, Federal University of Sergipe, Aracaju, Brazil.,Division of Cardiology, Hospital São Lucas Rede São Luiz D'Or, Sergipe, Brazil
| | - Juliane Dantas Seabra-Garcez
- Division of Cardiology, Federal University of Sergipe, Aracaju, Brazil.,Division of Cardiology, Hospital São Lucas Rede São Luiz D'Or, Sergipe, Brazil
| | - Flavia Barreto Garcez
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Division of Geriatrics, Federal University of Sergipe, Aracaju, Brazil
| | - Thiago S Moreira
- Department of Physiology and Biophysics, Institute of Biomedical Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Luciano F Drager
- Hypertension Unit, Renal Division, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Berjeaut EJBK, de Carvalho BM, Aliberti MJR, Avelino-Silva TJ, Campora F, Jacob-Filho W, Garcez FB. "Part of a great team": Perceptions of geriatrics fellows on doing research during a pandemic. J Am Geriatr Soc 2021; 69:3058-3061. [PMID: 34343345 DOI: 10.1111/jgs.17397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/11/2021] [Accepted: 07/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Eugênia Jatene Bou Khazaal Berjeaut
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruna Macêdo de Carvalho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Thiago J Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Faculdade Israelita de Ciencias da Saude Albert Einstein, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Flavia Campora
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Wilson Jacob-Filho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Aliberti MJR, Szlejf C, Avelino-Silva VI, Suemoto CK, Apolinario D, Dias MB, Garcez FB, Trindade CB, Amaral JRDG, de Melo LR, de Aguiar RC, Coelho PHL, Hojaij NHSDL, Saraiva MD, da Silva NOT, Jacob-Filho W, Avelino-Silva TJ. COVID-19 is not over and age is not enough: Using frailty for prognostication in hospitalized patients. J Am Geriatr Soc 2021; 69:1116-1127. [PMID: 33818759 PMCID: PMC8251205 DOI: 10.1111/jgs.17146] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 12/29/2022]
Abstract
Background Frailty screening using the Clinical Frailty Scale (CFS) has been proposed to guide resource allocation in acute care settings during the pandemic. However, the association between frailty and coronavirus disease 2019 (COVID‐19) prognosis remains unclear. Objectives To investigate the association between frailty and mortality over 6 months in middle‐aged and older patients hospitalized with COVID‐19 and the association between acute morbidity severity and mortality across frailty strata. Design Observational cohort study. Setting Large academic medical center in Brazil. Participants A total of 1830 patients aged ≥50 years hospitalized with COVID‐19 (March–July 2020). Measurements We screened baseline frailty using the CFS (1–9) and classified patients as fit to managing well (1–3), vulnerable (4), mildly (5), moderately (6), or severely frail to terminally ill (7–9). We also computed a frailty index (0–1; frail >0.25), a well‐known frailty measure. We used Cox proportional hazards models to estimate the association between frailty and time to death within 30 days and 6 months of admission. We also examined whether frailty identified different mortality risk levels within strata of similar age and acute morbidity as measured by the Sequential Organ Failure Assessment (SOFA) score. Results Median age was 66 years, 58% were male, and 27% were frail to some degree. Compared with fit‐to‐managing‐well patients, the adjusted hazard ratios (95% confidence interval [CI]) for 30‐day and 6‐month mortality were, respectively, 1.4 (1.1–1.7) and 1.4 (1.1–1.7) for vulnerable patients; 1.5 (1.1–1.9) and 1.5 (1.1–1.8) for mild frailty; 1.8 (1.4–2.3) and 1.9 (1.5–2.4) for moderate frailty; and 2.1 (1.6–2.7) and 2.3 (1.8–2.9) for severe frailty to terminally ill. The CFS achieved outstanding accuracy to identify frailty compared with the Frailty Index (area under the curve = 0.94; 95% CI = 0.93–0.95) and predicted different mortality risks within age and acute morbidity groups. Conclusions Our results encourage the use of frailty, alongside measures of acute morbidity, to guide clinicians in prognostication and resource allocation in hospitalized patients with COVID‐19.
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Affiliation(s)
- Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Claudia Szlejf
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Department of Big Data, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Vivian I Avelino-Silva
- Department of Infectious Diseases, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Faculdade Israelita de Ciencias da Saúde Albert Einstein, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Claudia Kimie Suemoto
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Daniel Apolinario
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Hospital do Coracao (HCor), Associacao Beneficente Siria, Sao Paulo, Brazil
| | - Murilo Bacchini Dias
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Carolina B Trindade
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - José Renato das Graças Amaral
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Leonardo Rabelo de Melo
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Renata Cunha de Aguiar
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Paulo Henrique Lazzaris Coelho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Naira Hossepian Salles de Lima Hojaij
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcos Daniel Saraiva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Natalia Oliveira Trajano da Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Wilson Jacob-Filho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Thiago J Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Faculdade Israelita de Ciencias da Saúde Albert Einstein, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Poco PCE, Aliberti MJR, Dias MB, Takahashi SDF, Leonel FC, Altona M, Venys AL, Shin-Ike IA, Garcia BA, Sumita LH, Lima LMDO, Garcez FB, Avelino-Silva TJ. Divergent: Age, Frailty, and Atypical Presentations of COVID-19 in Hospitalized Patients. J Gerontol A Biol Sci Med Sci 2021; 76:e46-e51. [PMID: 33151305 PMCID: PMC7665317 DOI: 10.1093/gerona/glaa280] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 12/04/2022] Open
Abstract
Background Although frailty has been associated with atypical manifestations of infections, little is known about COVID-19 presentations in hospitalized frail patients. We aimed to investigate the association between age, frailty, and clinical characteristics of COVID-19 in hospitalized middle-aged and older adults. Methods Longitudinal observational study comprising 711 patients aged ≥50 years consecutively admitted to a university hospital dedicated to COVID-19 severe cases, between March and May 2020. We reviewed electronic medical records to collect data on demographics, comorbidities, COVID-19 signs/symptoms, and laboratory findings on admission. We defined frailty using the Clinical Frailty Scale (CFS=1-9; frail ≥5). We also documented in-hospital mortality. We used logistic regressions to explore associations between age, frailty, and COVID-19 signs/symptoms; and between typical symptoms (fever, cough, dyspnea) and mortality. Results Participants had a mean age of 66±11 years, and 43% were female. Overall, 25% were frail, and 37% died. The most common COVID-19 presentations were dyspnea (79%), cough (74%), and fever (62%), but patients aged ≥65 years were less likely to have a co-occurrence of typical symptoms, both in the absence (OR=0.56; 95%CI=0.39-0.79) and in the presence of frailty (OR=0.52; 95%CI=0.34-0.81). In contrast, older age and frailty were associated with unspecific presentations, including functional decline, acute mental change, and hypotension. After adjusting for age, sex, and frailty, reporting fever was associated with lower odds of mortality (OR=0.70; 95%CI=0.50-0.97). Conclusions Atypical COVID-19 presentations are common in frail and older hospitalized patients. Providers should be aware of unspecific disease manifestations during the management and follow-up of this population.
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Affiliation(s)
- Paula Cristina Eiras Poco
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil.,Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Murilo Bacchini Dias
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Silvia de Fatima Takahashi
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Fabio Campos Leonel
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Marcelo Altona
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Amanda Lagreca Venys
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Isabela Akie Shin-Ike
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Bianca Aparecida Garcia
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Leticia Harumi Sumita
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Lara Mune de Oliveira Lima
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
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Moreira TS, Barreto-Filho JA, Seabra-Garcez JD, Barreto Garcez F, Drager LF. Last Word on Viewpoint: Nondyspnogenic acute hypoxemic respiratory failure in COVID-19 pneumonia-Breathing pattern in patients with SARS-CoV-2. J Appl Physiol (1985) 2021; 130:900. [PMID: 33724891 PMCID: PMC7984239 DOI: 10.1152/japplphysiol.01080.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thiago S Moreira
- Department of Physiology and Biophysics, Institute of Biomedical Science, University of Sao Paulo, Sao Paulo, Brazil
| | - José A Barreto-Filho
- Division of Cardiology, Federal University of Sergipe, Sergipe, Brazil.,Division of Cardiology, Hospital São Lucas Rede São Luiz D'Or, Sergipe, Brazil
| | - Juliane D Seabra-Garcez
- Division of Cardiology, Federal University of Sergipe, Sergipe, Brazil.,Division of Cardiology, Hospital São Lucas Rede São Luiz D'Or, Sergipe, Brazil
| | | | - Luciano F Drager
- Hypertension Unit, Renal Division, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Aliberti MJR, Covinsky KE, Garcez FB, Smith AK, Curiati PK, Lee SJ, Dias MB, Melo VJD, Rego-Júnior OFD, Richinho VDP, Jacob-Filho W, Avelino-Silva TJ. A fuller picture of COVID-19 prognosis: the added value of vulnerability measures to predict mortality in hospitalised older adults. Age Ageing 2021; 50:32-39. [PMID: 33068099 PMCID: PMC7665299 DOI: 10.1093/ageing/afaa240] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 10/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although coronavirus disease 2019 (COVID-19) disproportionally affects older adults, the use of conventional triage tools in acute care settings ignores the key aspects of vulnerability. OBJECTIVE This study aimed to determine the usefulness of adding a rapid vulnerability screening to an illness acuity tool to predict mortality in hospitalised COVID-19 patients. DESIGN Cohort study. SETTING Large university hospital dedicated to providing COVID-19 care. PARTICIPANTS Participants included are 1,428 consecutive inpatients aged ≥50 years. METHODS Vulnerability was assessed using the modified version of PRO-AGE score (0-7; higher = worse), a validated and easy-to-administer tool that rates physical impairment, recent hospitalisation, acute mental change, weight loss and fatigue. The baseline covariates included age, sex, Charlson comorbidity score and the National Early Warning Score (NEWS), a well-known illness acuity tool. Our outcome was time-to-death within 60 days of admission. RESULTS The patients had a median age of 66 years, and 58% were male. The incidence of 60-day mortality ranged from 22% to 69% across the quartiles of modified PRO-AGE. In adjusted analysis, compared with modified PRO-AGE scores 0-1 ('lowest quartile'), the hazard ratios (95% confidence interval) for 60-day mortality for modified PRO-AGE scores 2-3, 4 and 5-7 were 1.4 (1.1-1.9), 2.0 (1.5-2.7) and 2.8 (2.1-3.8), respectively. The modified PRO-AGE predicted different mortality risk levels within each stratum of NEWS and improved the discrimination of mortality prediction models. CONCLUSIONS Adding vulnerability to illness acuity improved accuracy of predicting mortality in hospitalised COVID-19 patients. Combining tools such as PRO-AGE and NEWS may help stratify the risk of mortality from COVID-19.
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Affiliation(s)
- Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Alexander K Smith
- Division of Geriatrics, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Pedro Kallas Curiati
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Sei J Lee
- Division of Geriatrics, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Murilo Bacchini Dias
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Victor José Dornelas Melo
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Otávio Fortes do Rego-Júnior
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Valéria de Paula Richinho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Wilson Jacob-Filho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Thiago J Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
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Abstract
This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.
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Barreto-Filho JA, Seabra-Garcez JD, Garcez FB, Moreira TS, Drager LF. Nondyspnogenic acute hypoxemic respiratory failure in COVID-19 pneumonia. J Appl Physiol (1985) 2020; 130:892-897. [PMID: 33031016 PMCID: PMC7984237 DOI: 10.1152/japplphysiol.00522.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- José Augusto Barreto-Filho
- Division of Cardiology, Federal University of Sergipe, São Cristóvão, Brazil.,Division of Cardiology, Hospital São Lucas Rede São Luiz D'Or, Aracaju, Brazil
| | - Juliane Dantas Seabra-Garcez
- Division of Cardiology, Federal University of Sergipe, São Cristóvão, Brazil.,Division of Cardiology, Hospital São Lucas Rede São Luiz D'Or, Aracaju, Brazil
| | | | - Thiago S Moreira
- Department of Physiology and Biophysics, Institute of Biomedical Science, University of Sao Paulo, São Paulo, Brazil
| | - Luciano F Drager
- Hypertension Unit, Renal Division, University of Sao Paulo Medical School, São Paulo, Brazil.,Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
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Garcez FB, Jacob-Filho W, Avelino-Silva TJ. Association Between Level of Arousal and 30-Day Survival in Acutely Ill Older Adults. J Am Med Dir Assoc 2020; 21:493-499. [PMID: 31974062 DOI: 10.1016/j.jamda.2019.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/29/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the association between impaired arousal on admission and 30-day mortality in acutely ill older adults. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Patients age +65 years admitted to the geriatric ward of a tertiary university hospital from 2010 to 2018 in Sao Paulo, Brazil. METHODS Participants were evaluated on admission according to a standardized comprehensive geriatric assessment model. Delirium was detected using the short version of the Confusion Assessment Method (Short-CAM). We used 2 alternative criteria to define impaired arousal: lethargy, stupor, or coma according to the Short-CAM; and a Glasgow Coma Scale (GCS) score of ≤13. Our primary outcome was time-to-death in 30 days, and we used Cox proportional hazards models to explore the association between impaired arousal and decreased survival. RESULTS We included 1554 admissions with a mean age of 81 years and of whom 61% were women. Overall, prevalent delirium was observed in 28% of the cases. We found that in 33% of admissions, patients were lethargic, stuporous, or comatose, and that in 23%, they had GCS scores of ≤13. General 30-day mortality was 19% but reached 32% in patients with GCS scores of ≤13. Impaired arousal was independently associated with lower survival in 30 days, both when defined using Short-CAM criteria [lethargy + stupor + coma: hazard ratio (HR) 2.33, 95% confidence interval (CI) 1.66‒3.27] and GCS scores (GCS 12‒13: HR 1.62, 95% CI 1.13‒2.33; GCS ≤ 11: HR 2.53, 95% CI 1.68‒3.80). In interaction analyses, we confirmed our results in patients who had impaired arousal but were neither delirious (lethargy + stupor + coma: HR 2.16, 95% CI 1.44‒3.24; GCS ≤ 11: HR 3.07; 95% CI 1.50‒6.29) nor demented (lethargy + stupor + coma: HR 1.95, 95% CI 1.15‒3.28). CONCLUSIONS AND IMPLICATIONS Level of arousal on admission was an independent predictor of 30-day survival in acutely ill older adults, regardless of delirium or baseline dementia. Clinicians should be aware that even if unsure of whether a patient has delirium, arousal assessment can provide crucial clinical and prognostic insight.
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Affiliation(s)
| | - Wilson Jacob-Filho
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil; Medical Research Laboratory (LIM-66), Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil; Medical Research Laboratory (LIM-66), Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil; School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, Brazil
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14
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Garcez FB, Apolinario D, Campora F, Curiati JAE, Jacob-Filho W, Avelino-Silva TJ. Delirium and post-discharge dementia: results from a cohort of older adults without baseline cognitive impairment. Age Ageing 2019; 48:845-851. [PMID: 31566669 DOI: 10.1093/ageing/afz107] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/04/2019] [Accepted: 07/05/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES to investigate the association between delirium occurrence in acutely ill older adults and incident dementia after hospital discharge. METHODS retrospective cohort study examining acutely ill older adults aged +60 years and consecutively admitted to the geriatric ward of a tertiary university hospital from 2010 to 2016. Inclusion criteria were absence of baseline cognitive decline on admission and documented clinical follow-up of +12 months after discharge. Admission data were collected from our local database, including results from a standardized comprehensive geriatric assessment completed for every patient. Pre-existing cognitive decline was identified based on clinical history, CDR and IQCODE-16. Delirium was diagnosed using short-CAM criteria, while post-discharge dementia after 12 months was identified based on medical records' review. We used competing-risk proportional-hazard models to explore the association between delirium and post-discharge dementia. RESULTS we included 309 patients. Mean age was 78 years, and 186 (60%) were women. Delirium was detected in 66 (21%) cases. After a median follow-up of 24 months, 21 (32%) patients who had experienced delirium progressed with dementia, while only 38 (16%) of those without delirium had the same outcome (P = 0.003). After adjusting for possible confounders, delirium was independently associated with post-discharge dementia with a sub-hazard ratio of 1.94 (95%CI = 1.10-3.44; P = 0.022). CONCLUSION one in three acutely ill older adults who experienced delirium in the hospital developed post-discharge dementia during follow-up. Further understanding of delirium as an independent and potentially preventable risk factor for cognitive decline emphasizes the importance of systematic initiatives to fight it.
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Affiliation(s)
| | - Daniel Apolinario
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Flavia Campora
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Wilson Jacob-Filho
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, Brazil
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