Post-COVID-19 patients in geriatric rehabilitation substantially recover in daily functioning and quality of life

BACKGROUND

After an acute infection, older persons may benefit from geriatric rehabilitation (GR).

OBJECTIVES

This study describes the recovery trajectories of post-COVID-19 patients undergoing GR and explores whether frailty is associated with recovery.

DESIGN

Multicentre prospective cohort study.

SETTING

59 GR facilities in 10 European countries.

PARTICIPANTS

Post-COVID-19 patients admitted to GR between October 2020 and October 2021.

METHODS

Patients' characteristics, daily functioning (Barthel index; BI), quality of life (QoL; EQ-5D-5L) and frailty (Clinical Frailty Scale; CFS) were collected at admission, discharge, 6 weeks and 6 months after discharge. We used linear mixed models to examine the trajectories of daily functioning and QoL.

RESULTS

723 participants were included with a mean age of 75 (SD: 9.91) years. Most participants were pre-frail to frail (median [interquartile range] CFS 6.0 [5.0-7.0]) at admission. After admission, the BI first steeply increased from 11.31 with 2.51 (SE 0.15, P < 0.001) points per month and stabilised around 17.0 (quadratic slope: -0.26, SE 0.02, P < 0.001). Similarly, EQ-5D-5L first steeply increased from 0.569 with 0.126 points per month (SE 0.008, P < 0.001) and stabilised around 0.8 (quadratic slope: -0.014, SE 0.001, P < 0.001). Functional recovery rates were independent of frailty level at admission. QoL was lower at admission for frailer participants, but increased faster, stabilising at almost equal QoL values for frail, pre-frail and fit patients.

CONCLUSIONS

Post-COVID-19 patients admitted to GR showed substantial recovery in daily functioning and QoL. Frailty at GR admission was not associated with recovery and should not be a reason to exclude patients from GR.

The Impact of Delirium on Recovery in Geriatric Rehabilitation after Acute Infection

OBJECTIVES

Delirium is common during acute infection in older patients and is associated with functional decline. Geriatric rehabilitation (GR) can help older patients to return to their premorbid functional level. It is unknown whether delirium affects GR outcomes in patients with acute infection. We evaluated whether delirium affects trajectories of activities of daily living (ADL) and quality of life (QoL) recovery in GR after COVID-19 infection.

DESIGN

This study was part of the EU-COGER study, a multicenter cohort study conducted between October 2020 and October 2021.

SETTING AND PARTICIPANTS

Participants were recruited after COVID-19 infection from 59 GR centers in 10 European countries.

METHODS

Data were collected at GR admission, discharge, and at the 6-week and 6-month follow-ups. Trajectories of ADL [using the Barthel index (BI)] and QoL [using the EuroQol-5 Dimensions-5 Level (EQ-5D-5L)] recovery were examined using linear mixed models.

RESULTS

Of the 723 patients included (mean age 75.5 ± 9.9 years; 52.4% male), 28.9% had delirium before or during GR admission. Participants with delirium recovered in ADL at approximately the same rate as those without (linear slope effect = -0.13, SE 0.16, P = .427) up to an estimated BI score of 16.1 at 6 months. Similarly, participants with delirium recovered in QoL at approximately the same rate as those without (linear slope effect = -0.017, SE 0.015, P = .248), up to an estimated EQ-5D-5L score of 0.8 at 6 months.

CONCLUSIONS AND IMPLICATIONS

Presence of delirium during the acute phase of infection or subsequent GR did not influence the recovery trajectory of ADL functioning and QoL.

Effects of Nutrition and Exercise Interventions on Persons with Sarcopenic Obesity: An Umbrella Review of Meta-Analyses of Randomised Controlled Trials

BACKGROUND

Sarcopenic obesity (SO) is an increasing phenomenon and has been linked to several negative health consequences. The aim of this umbrella review is the assessment of effectiveness and certainty of evidence of nutrition and exercise interventions in persons with SO.

METHOD

We searched for meta-analyses of RCTs in PubMed, EMBASE and CENTRAL that had been conducted in the last five years, focusing on studies on the treatment and prevention of SO. The primary endpoints were parameters for SO, such as body fat in %, skeletal muscle mass index (SMMI), gait speed, leg strength and grip strength. The methodological quality was evaluated using AMSTAR and the certainty of evidence was assessed using GRADE.

RESULTS

Four systematic reviews with between 30 to 225 participants were included in the umbrella review. These examined four exercise interventions, two nutrition interventions and four interventions that combined nutrition and exercise. Resistance training was the most frequently studied intervention and was found to improve gait speed by 0.14 m/s to 0.17 m/s and lower leg strength by 9.97 kg. Resistance, aerobic, mixed exercise and hypocaloric diet combined with protein supplementation is not significantly effective on selected outcomes for persons with SO compared to no intervention. The low number of primary studies included in the reviews resulted in moderate to very low certainty of evidence.

CONCLUSION

Despite the lack in certainty of evidence, resistance training may be a suitable intervention for persons with SO, in particular for improving muscle function. Nevertheless, further research is necessary to strengthen the evidence.

Management of use of urinary antimuscarinics and alpha blockers for benign prostatic hyperplasia in older adults at risk of falls: a clinical review

PURPOSE

We aimed to outline the existing information and the underlying mechanisms of risk of falls associated with the use of urinary antimuscarinics for overactive bladder (OAB) or alpha-blockers for benign prostatic hyperplasia (BPH) in older adults. In addition, we aimed to provide assistance to clinicians in decision-making about (de-)prescribing these drugs in older adults.

METHODOLOGY

Based on a literature search in PubMed and Google Scholar, we reviewed the literature, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in OAB and BPH in older patients. We discussed the use of bladder antimuscarinics and alpha-blockers, their potential side effects related to falls, and the deprescribing of these drugs in older adults.

RESULTS

Urinary urgency or incontinence and lower urinary tract symptoms due to untreated OAB and BPH contribute to fall risk. On the other hand, the use of bladder antimuscarinics and alpha-blockers is also related to fall risk. They contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in their side-effect profiles regarding these problems. Falls are common and can cause a remarkable amount of morbidity and mortality. Thus, preventive measures should be taken to lower the risk. If the clinical condition allows, withdrawal of bladder antimuscarinics and alpha-blockers is recommended in fall-prone older adults. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups.

CONCLUSIONS

The decision to prescribe or deprescribe these treatments in patients at high risk of falls should be individualized. In addition to explicit tools that are helpful for clinical decision-making in (de-)prescribing these drugs, STOPPFall (a recently developed expert-based decision aid specifically aiming to prevent falls) is present to assist prescribers in attaining decisions.

Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project)

OBJECTIVE

To determine whether a multicomponent intervention based on physical activity with technological support and nutritional counselling prevents mobility disability in older adults with physical frailty and sarcopenia.

DESIGN

Evaluator blinded, randomised controlled trial.

SETTING

16 clinical sites across 11 European countries, January 2016 to 31 October 2019.

PARTICIPANTS

1519 community dwelling men and women aged 70 years or older with physical frailty and sarcopenia, operationalised as the co-occurrence of low functional status, defined as a short physical performance battery (SPPB) score of 3 to 9, low appendicular lean mass, and ability to independently walk 400 m. 760 participants were randomised to a multicomponent intervention and 759 received education on healthy ageing (controls).

INTERVENTIONS

The multicomponent intervention comprised moderate intensity physical activity twice weekly at a centre and up to four times weekly at home. Actimetry data were used to tailor the intervention. Participants also received personalised nutritional counselling. Control participants received education on healthy ageing once a month. Interventions and follow-up lasted for up to 36 months.

MAIN OUTCOME MEASURES

The primary outcome was mobility disability (inability to independently walk 400 m in <15 minutes). Persistent mobility disability (inability to walk 400 m on two consecutive occasions) and changes from baseline to 24 and 36 months in physical performance, muscle strength, and appendicular lean mass were analysed as pre-planned secondary outcomes. Primary comparisons were conducted in participants with baseline SPPB scores of 3-7 (n=1205). Those with SPPB scores of 8 or 9 (n=314) were analysed separately for exploratory purposes.

RESULTS

Mean age of the 1519 participants (1088 women) was 78.9 (standard deviation 5.8) years. The average follow-up was 26.4 (SD 9.5) months. Among participants with SPPB scores of 3-7, mobility disability occurred in 283/605 (46.8%) assigned to the multicomponent intervention and 316/600 (52.7%) controls (hazard ratio 0.78, 95% confidence interval 0.67 to 0.92; P=0.005). Persistent mobility disability occurred in 127/605 (21.0%) participants assigned to the multicomponent intervention and 150/600 (25.0%) controls (0.79, 0.62 to 1.01; P=0.06). The between group difference in SPPB score was 0.8 points (95% confidence interval 0.5 to 1.1 points; P<0.001) and 1.0 point (95% confidence interval 0.5 to 1.6 points; P<0.001) in favour of the multicomponent intervention at 24 and 36 months, respectively. The decline in handgrip strength at 24 months was smaller in women assigned to the multicomponent intervention than to control (0.9 kg, 95% confidence interval 0.1 to 1.6 kg; P=0.028). Women in the multicomponent intervention arm lost 0.24 kg and 0.49 kg less appendicular lean mass than controls at 24 months (95% confidence interval 0.10 to 0.39 kg; P<0.001) and 36 months (0.26 to 0.73 kg; P<0.001), respectively. Serious adverse events occurred in 237/605 (39.2%) participants assigned to the multicomponent intervention and 216/600 (36.0%) controls (risk ratio 1.09, 95% confidence interval 0.94 to 1.26). In participants with SPPB scores of 8 or 9, mobility disability occurred in 46/155 (29.7%) in the multicomponent intervention and 38/159 (23.9%) controls (hazard ratio 1.25, 95% confidence interval 0.79 to 1.95; P=0.34).

CONCLUSIONS

A multicomponent intervention was associated with a reduction in the incidence of mobility disability in older adults with physical frailty and sarcopenia and SPPB scores of 3-7. Physical frailty and sarcopenia may be targeted to preserve mobility in vulnerable older people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02582138.

Comparison between EWGSOP1 and EWGSOP2 criteria and modelling of diagnostic algorithm for sarcopenic obesity in over 70 years old patients

PURPOSE

Sarcopenic obesity (SO) as a new diagnostic entity defined by presence of obesity in combination with sarcopenia represents serious health condition negatively affecting quality of life in old age. Despite the rapidly increasing incidence of SO associated with demographic aging, clear diagnostic criteria for SO have not yet been established. We describe here the applicability of the EWGSOP2 and EWGSOP1 diagnostic criteria in identifying sarcopenia and SO and the development of a refinement algorithm for SO detection.

METHODS

In total 156 subjects were pre-screened, 126 had a complete dataset and were included, 20.6% (n = 26) were men and 79.4% (n = 100) women, mean age 81 ± 6.3 years in tertiary hospital, Prague, Czech Republic. Testing of physical performance (hand-grip test, 400 m walk test, chair stand test, gait speed), anthropometric measures and SARC-F, SPPB and MNA-SF were used to determine physical, functional, and nutritional status, while muscle mass and fat mass were measured by DXA scans to confirm sarcopenia and SO diagnosis.

RESULTS

The prevalence of sarcopenia (BMI adjusted ALM < 0.789 for men, < 0.512 for women) was 26.2% (n = 33), SO in 20.6% (n = 26). 78.8% of all sarcopenic subjects fulfilled the criteria of SO (FM > 27% for men and > 38% for women; waist circumference > 90 cm for men and > 85 cm for women). EWGSOP1 criteria for diagnosing sarcopenia showed better sensitivity of 97.0% than the EWGSOP2 66.7%, while specificity reached 100% for both criteria. According to DXA measurement, EWGSOP1 identified 3.0% cases (1 out of 33) as false negative meanwhile EWGSOP2 identified 33.3% cases as false negative and this difference was statistically significant (McNemar's test, p < 0.001). An algorithm for SO was developed (which uses sex, BMI, height, waist circumference and SPPB) with sensitivity and specificity of 88.5 and 91.0%, respectively.

CONCLUSION

High prevalence of obesity among elderly people and rather low sensitivity of current diagnostic criteria for SO call for ongoing research. Broader international consensus for SO diagnostic criteria, screening and diagnosis algorithm are crucial for early detection of SO in older people in clinical practice so that optimal multi-component therapy can be initiated.

The Association of Anticholinergic Drugs and Delirium in Nursing Home Patients With Dementia: Results From the SHELTER Study

OBJECTIVES

Drugs with anticholinergic properties are associated with an increased prevalence of delirium, especially in older persons. The aim of this study was to evaluate the association between the use of this class of drugs in nursing home (NH) patients and prevalence of delirium, particularly in people with dementia.

DESIGN

Cross-sectional multicenter study.

SETTING AND PARTICIPANTS

3924 nursing home patients of 57 nursing homes in 7 European countries participating in the Services and Health for Elderly in Long TERmcare (SHELTER) project.

METHODS

Descriptive statistics, calculation of percentage, and multivariable logistic analysis were applied to describe the relationship between anticholinergic drug use and prevalence of delirium in NH patients. The Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB) were used to calculate the anticholinergic load.

RESULTS

54% of patients with dementia and 60% without dementia received at least 1 anticholinergic drug according to the ACB. The prevalence of delirium was higher in the dementia group (21%) compared with the nondementia group (11%). Overall, anticholinergic burden according to the ACB and ARS was associated with delirium both in patients with and without dementia, with odds ratios ranging from 1.07 [95% confidence interval (CI) 0.94-1.21] to 1.26 (95% CI 1.11-1.44). These associations reached statistical significance only in the group of patients with dementia. Among patients with dementia, delirium prevalence increased only modestly with increasing anticholinergic burden according to the ACB, from 20% (with none or minimal anticholinergic burden) to 25% (with moderate burden) and 27% delirium (with strong burden scores).

CONCLUSIONS AND IMPLICATIONS

The ACB scale is relatively capable to detect anticholinergic side effects, which are positively associated with prevalence of delirium in NH patients. Given the modest nature of this association, strong recommendations are currently not warranted, and more longitudinal studies are needed.

The Relevance of Diet, Physical Activity, Exercise, and Persuasive Technology in the Prevention and Treatment of Sarcopenic Obesity in Older Adults

The aging population faces two conditions that threaten healthy aging: high fat mass (obesity) and low muscle mass and function (sarcopenia). The combination of both-referred to as sarcopenic obesity-synergistically increases the risk of adverse health outcomes. The two conditions often co-occur because they reinforce each other and share common etiologies, including poor nutrition and inactivity. All aging people are at risk of gaining weight and losing muscle mass and could benefit from improvements in physical activity, exercise and dietary intake. one specific window of opportunity is during the transient time of retirement, as older adults already need to restructure their daily activities. It is key to change lifestyle behavior in a sustainable manner, providing scientifically proven, personalized, and acceptable principles that can be integrated in daily life. Health technologies (e.g., applications) can provide promising tools to deliver personalized and appealing lifestyle interventions to a large group of people while keeping health care costs low. Several studies show that health technologies have a strong positive effect on physical activity, exercise and dietary intake. Specifically, health technology is increasingly applied to older people, although strong evidence for long term effects in changing lifestyle behavior is generally lacking. Concluding, technology could play an important role in the highly warranted prevention of sarcopenic obesity in older adults. Although health technology seems to be a promising tool to stimulate changes in physical activity, exercise and dietary intake, studies on long lasting effects and specifically targeted on older people around the time of retirement are warranted.

Pharmacological management of osteoporosis in nursing home residents: the Shelter study

OBJECTIVE

To prevent osteoporotic fractures in nursing home residents a combination of bisphosphonates, calcium and vitamin D is recommended. This study assessed the prevalence of pharmacological osteoporosis prevention in nursing home residents from eight countries, and assessed its association with patient characteristics.

DESIGN

Cross-sectional analyses of the SHELTER study data. We assessed the overall prevalence of osteoporosis medication (OM) use (vitamin D, calcium and bisphosphonates) in residents stratified for falls and fractures over last 30 days, health instability with high mortality risk, cognitive impairment, and dependence in walking.

SETTING AND PARTICIPANTS

Nursing home residents in the Czech Republic, England, Finland, France, Germany, Italy, The Netherlands and Israel.

RESULTS

Of 3832 eligible residents, vitamin D, calcium and bisphosphonates were used by 16.2%, 10.4%, and 4.5% respectively. All 3 classes of OM together were used by 1.5% of all residents. Of residents with a recent fracture, 9.5% used a bisphosphonate (2.7% all 3 OMs). In patients with recent falls, 20.8% used vitamin D and 15.3% calcium. In residents with severe cognitive impairment, 15.5% used vitamin D and 9.3% used calcium. Of the bisphosphonate users, 33.7% also used both vitamin D and calcium, 25.8% used only calcium in addition and 17.4% only vitamin D in addition. The use of any OM varied widely across countries, from 66.8% in Finland to 3.0% in Israel.

CONCLUSIONS AND IMPLICATIONS

We found substantial pharmacological under-treatment of prevention of osteoporosis in residents with recent falls, fractures and dependence in walking. Only two-thirds of bisphosphonate users also took a vitamin D-calcium combination, despite guideline recommendations. On the other hand, possible over-treatment was found in residents with high mortality risk in whom preventive pharmacotherapy might not have still been appropriate. The prevalence of pharmacological prevention of osteoporosis differed substantially between countries. Efforts are needed to improve pharmacotherapy in residents.

Standard error of measurement and smallest detectable change of the Sarcopenia Quality of Life (SarQoL) questionnaire: An analysis of subjects from 9 validation studies

Objectives

The Sarcopenia Quality of Life (SarQoL) questionnaire, a sarcopenia-specific patient-reported outcome measure, evaluates quality of life with 55 items. It produces 7 domain scores and 1 overall quality of life score, all between 0 and 100 points. This study aims to contribute to the interpretation of the SarQoL scores by calculating the standard error of measurement (SEM) and smallest detectable change (SDC) in a sample of subjects from 9 studies.

Methods

Subjects from 9 studies (conducted in Belgium, Brazil, Czech Republic, England, Greece, Lithuania, Poland and Spain) were included. The SEM, a measure of the error in the scores that is not due to true changes, was calculated by dividing the standard deviation of the difference between test and retest scores (SDdiff) by √2. The SDC, defined as change beyond measurement error, was calculated by multiplying SDdiff by 1.96. Bland-Altman plots were assessed for the presence of systematic errors.

Results

A total of 278 sarcopenic subjects, aged 77.67 ± 7.64 years and 61.5% women, were included. The SEM for the overall SarQoL score ranged from 0.18 to 4.20 points for the individual studies, and was 2.65 points when all subjects were analyzed together. The SDC for the overall score ranged from 0.49 to 11.65 points for the individual studies, and was 7.35 points for all subjects. The Bland-Altman plots revealed no systematic errors in the questionnaire.

Conclusion

This study shows that, for individual subjects, a change in overall quality of life of at least 7.35 points (on a scale from 0 to 100) would have to be observed to confirm that a true change, beyond measurement error, has occurred. It also demonstrated that the SarQoL questionnaire is a precise instrument, with the observed scores within less than 3 points of the theoretical “true score”.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Overactive urinary bladder in elderly female patients: treatment specificities and drug interactions

Aging is an inevitable process in the life of each organism and it is no different in the human world. According to the world statistics and demographic data, an ever increasing group in our population live to a ripe old age. The paper deals with pharmacological therapy for overactive bladder (OAB) in older women while also considering frequent comorbidities in older age. The prevalence of OAB at this life stage is greater as compared to other, more serious diseases. There are less clinical studies on geriatric patients than those focusing on younger age categories. The effect of pharmacotherapy with antimuscarinics against placebo is demonstrable within all age groups including people aged over 75. With regard to polypharmacotherapy in older adults, antimuscarinics may intervene in drug interactions. Therefore the authors draw attention to these risk factors and the ways to prevent them. Key words: drug interactions - geriatry - overactive bladder - urinary incontinence.

Sarcopenia as a severe organ failure, its diagnosing and present therapeutic possibilities

Sarcopenia is defined as generalized and progressive age-related loss of skeletal muscle mass, muscle strength and physical performance below a defined threshold. In sarcopenia skeletal muscle mass - the largest body organ - is failing in its function and the term "muscle failure" was suggested. Sarcopeniat is now recognized as a serious clinical problem compromising healthy aging concept and quality of life of affected older people. Sarcopenia has a complex multifactorial pathogenesis, which involves not only age-related changes in neuromuscular function, muscle protein turnover, and hormone levels and sensitivity, but also a chronic pro-inflammatory state, oxidative stress, and behavioral factors - particularly nutritional status and degree of physical activity. The paper provides detailed review of screening and diagnostic methods and consensus-based cut off values and biomarkers of potential patophysiologic mechanisms involved in sarcopenia development in individual patient. Further, detailed description of current preventive and therapeutic strategies for sarcopenia is included. These involve structured physical activities, namely progressive resistance training and aerobic activities which prevent muscle loss and improve muscle performance. The effect of exercise is enhanced by nutritional supplementation, particularly through proteoanabolic effect of proteins and some amino acids. There are no currently registered drugs with indication of sarcopenia but there are promising substances in higher phases of clinical trials (such as antimyostatin human monoclonal antibodies, selective androgen receptor modulators) which have the potential to be introduced into clinical practice soon. Conclusions Sarcopenia is a new clinical diagnosis of organ failure of the skeletal muscle function leading to multiple adverse health outcomes. Physicians should be aware of clinical symptoms and diagnostic algorithm and target treatment according to sarcopenia leading causes. Key words: clinical diagnosis and treatment - muscle failure - muscle mass, strength and function - sarcopenia.

Statin therapy in elderly patients

Cardiovascular events occur most frequently in patients at higher age groups. The elderly suffer not only more advanced and complex changes of cardiovascular system but, also, other chronic conditions. Moreover, compared to middle-age, different therapeutic response is often observed due to changes of pharmaco-kinetics and -dynamics; these patients use other medications, which may trigger drug interactions. The situation is further complicated by non-adherence related to frequent cognitive impairment. On one hand the elderly enjoy the greatest absolute benefit from adequate cardiovascular treatment while on the other they might be more susceptible to adverse reactions. In spite of the fact statins represent preventative medications, they must be indicated cautiously taken into consideration comorbidities, frailty and disability occurring in advanced age. Frail and disabled patients have greater risk of statin adverse effects, however, even these patients have lower mortality rates while being on statins. In seniors with life expectancy exceeding 5 years statins, when indicated, bring unambiguously proven benefit and should be considered high-priority medications. Key words: atherosclerosis - cardiovascular disease - dyslipidemia - elderly - frailty - management - statins.

Delivery of Care to Nursing Home Residents With Diabetes: Results From the SHELTER Study

OBJECTIVES

To describe health care and preventive service provision to nursing home (NH) residents with diabetes mellitus (DM) and to analyze factors determining use of selected services.

DESIGN

In the period between 2009 and 2011, the Services and Health for Elderly in Long TERm care (SHELTER) project, a 12-month prospective cohort study, was conducted to assess 4037 NH residents aged 60 years and older residing in 59 NHs in 7 European countries and Israel.

METHODS

The InterRAI tool for long-term care facilities was used to assess care needs and provided health care services. Descriptive statistics and multivariate logistic regression were applied to describe differences between NH residents with (DR) and without DM (non-DR), and to find factors determining use of services and care provided to both groups.

RESULTS

DR more often than non-DR were hospitalized (18.2% vs 14.3%) and required rehabilitation (23.8% vs 18.2%) or clinically complex care (15.9% vs 13.7%). They also more frequently received a repositioning program (26.8% vs 22.7%), a wound care (15.1% vs 9.8%), and some preventive services as yearly eye examination (41.0% vs 35.9%), pneumococcal vaccination (33.5% vs 26.6%), mammography in women (12.1% vs 7.4%), and colonoscopy (5.6% vs 3.6%). Yet, rates of some of them (mammography, colonoscopy, hearing and dental examinations) were very low in both study cohorts with exception of annual influenza vaccination (82.1%) and yearly blood pressure checkup (95.0%). Interestingly, DM enhanced odds only for mammography [odds ratio (OR) 1.55, 95% confidence interval [CI] 1.15-2.09, P = .004) and eye examination (OR 1.21, 95% CI 1.03-1.42; P = .018).

CONCLUSIONS

DR more frequently receive care related to DM clinical complexity; nevertheless, the recommended frequency of preventive procedures is not met both in DR and non-DR.

[The "Short Physical Performance Battery" in the Czech Republic - the pilot and validation study in older persons]

INTRODUCTION

Population ageing increases number of seniors with decline of physical capabilities and functional deficits. Targeted interventions to maintain or increase physical performance are most effective before the development of full frailty, in so-called "prefrail" period. One of the assessment tools for evaluation of the physical performance and/ or frailty in older persons is the "Short Physical Performance Battery" -  SPPB. The aim of the study was to introduce the assessment battery to clinical practice in the CR and to evaluate its selected psychometric properties.

METHOD

Original English SPPB was translated into Czech language and back translated to ensure linguistic accuracy. SPPB was applied in the selected sample of older persons and validated against other performance tools for cognition, self- care and nutrition status used in CR and selected psychometric properties evaluated.

RESULTS

We examined 145 older persons (108 women, i.e. 74.48 % and 37 men, i.e. 25.52 %) mean age 80.38 years (54- 101 years, SD ± 8,47). We found good physical performance in 35 (24.1 %) older persons (SPPB 10- 12 points), 21 (14.5 %) were identified as prefrail (SPPB 7- 9 points) and 89 (61.4 %) as frail in high risk of future disability or already disabled (SPPB 6 points). We found statistically significant correlation of global SPPB score with nutritional status (MNA- Short Form), activities of daily living performance (ADL) and cognitive performance (MMSE) -  (Spearman correlation ρ = 0.51; 0.53 and 0.38 respectively). The Cronbachs a for SPPB variables scored 0.821, which is consistent with good internal consistency of SPPB battery. When evaluating 3 age groups [ 75 years (n = 41), 76- 85 (n = 62) and 86- 101 years (n = 42)] the most significant correlations were found between SPPB and MNA, ADL and MMSE in the young elderly (ρ = 0.74, 0.79 and 0.64 respectively) and they diminished with increasing age.

CONCLUSION

We confirmed significant correlations between SPPB and self care activities, cognitive performance and nutritional status and good internal consistency of the battery. SPPB test is simple, easy to perform, with low time and cost requirements. It could be recommended for clinical practice in both community and hospitalized older patients to evaluate their overall physical performance and identify persons at risk of frailty and disability who may profit from targeted interventions.

Evidence-based strategies for the optimization of pharmacotherapy in older people

Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention's success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape 'age-attuned' health and drug policy.

End products of lipid peroxidation in erythrocyte membranes in Alzheimer's disease

Alzheimer's disease (AD) is accompanied by oxidative stress in the brain. Because the brain tissue is rich in polyunsaturated fatty acids, it is prone to the free radical attack resulting in lipid peroxidation. Intermediates of lipid peroxidation may diffuse from the primary site, cross the blood-brain barrier and modify erythrocyte membranes in the bloodstream. We exposed isolated erythrocyte membranes from patients with AD and the control group to in vitro free radical damage and monitored the accumulation of the end products of lipid peroxidation, lipofuscin-like pigments (LFPs), by fluorescence spectroscopy. LFPs were analyzed by means of tridimensional and synchronous fluorescence spectroscopy. The levels of LFP formed during in vitro peroxidation were significantly higher in erythrocyte membranes from patients with AD compared with the control group. Furthermore, the chemical composition of LFP in AD was different from the control group. The analysis of the specific modifications of erythrocyte membranes in AD is of great medical importance regarding the need of a diagnostic blood biomarker.

Understanding sarcopenia as a geriatric syndrome

PURPOSE OF REVIEW

Highly prevalent in the population older than 65 years and leading to poor outcomes (functional decline and its related consequences), sarcopenia does not benefit yet either of a clear understanding of its pathophysiology or of precise clinical or biological markers allowing its identification.

RECENT FINDINGS

The new scientific definition of 'geriatric syndromes' challenges the authors to review the current sarcopenia literature, allowing them to affirm that sarcopenia cannot be considered as an age-related disease but as a true 'geriatric syndrome'. More than 50% of the population older than 80 years suffer from this medical condition, which is linked to multiple causations: the ageing process itself, genetic susceptibility, certain life habits, changes in living conditions and a number of chronic diseases. Moreover, sarcopenia favours poor outcomes such as mobility disorders, disability, poor quality of life and death.

SUMMARY

Considering sarcopenia as a geriatric syndrome allows us to request its recognition and assess its multiple risk factors, to implement a clinical and public health approach to the management of sarcopenic patients and population at risk and to disentangle the links among sarcopenia, frailty, disability and mortality.

[New evidence-based criteria for evaluating the appropriateness of drug regimen in seniors. Criteria STOPP (screening tool of older person's prescriptions) and START (screening tool to alert doctors to right treatment)]

Drug prescribing in the old age is burdened by a significant number of prescribing errors often resulting in high rate of adverse drug events associated with increased morbidity, health care utilization and health costs. The revised 2003 Beers' Criteria represent the most widely used method for identification of high risk ("potentially inappropriate") medication in elderly persons. A standardized method for evaluating omission of potentially beneficial drugs has been lacking. The Beers' Criteria consist of the list of selected drugs with high potential of adverse drug events in old age and clinical conditions with relative contraindications of selected drugs (drug-disease interactions). Prescribing of these drugs should be avoided in older patients. However, several limitations prevent wider use of Beers' Criteria: several outdated drugs or drugs unavailable in Europe are listed, some controversial drugs with specific indications are on the list, drug-drug interaction and drug class duplications are not mentioned, and last but not least low user friendliness was criticized. To overcome these limitations, new STOPP and START Criteria were developed in 2007 to serve as a screening tool for comprehensive assessment of safety and quality of prescription in patients 65 years and older. In the current review article Czech version of both criteria are presented for the first time in the Czech literature. Using STOPP Criteria potentially inappropriate drugs are identified in drug regimen which could be stopped altogether or replaced by a safer drug alternative. Concomitant use of START Criteria will help the prescribing physician to consider the benefit of starting new drugs in selected clinical situations. Both screening tools represent a new method for improving quality of geriatric prescribing in clinical practice.

Aging, disability and frailty

Despite multiple and often overlapping definitions of disability and frailty, both are common clinical characteristics of aged individuals though not identical. The geriatric syndrome of frailty is described as status of global impairment of physiological reserves involving multiple organ systems. The clinical correlate of frailty manifests as increased vulnerability, impaired capability to withstand intrinsic and environmental stressors, and limited capacity to maintain physiological and psychosocial homeostasis. Geriatric frailty is found in 20-30% of the elderly population over 75 years and increases with advancing age. It was reported to be associated with long-term adverse health-related outcomes - increased risk of geriatric syndromes, dependency, disability, hospitalization, institutional placement, and mortality. The clinical phenotype of frailty manifests as multi-system pathologies characterized by low physical activity, global weakness with low muscle strength, fatigability/exhaustion, overall slowness particularly of gait, loss of weight among others. These above-mentioned clinical symptoms could be explained by (or related to) some 'preclinical' diagnoses such as sarcopenia, osteopenia, nonspecific balance disorders, nutritional problems, and overall deconditioning. More recent studies found the frailty clinical phenotype to be associated with pathologic laboratory markers (IL-6, CRP, 25-hydroxyvitamin D, IGF-1, D-dimers), which suggest possible pathogenesis involving hormonal dysregulation, immuno-aging, pro-coagulation and pro-inflammatory status. In the article, current recommendations for future research strategies of frailty syndrome will be discussed.

Indicators of elder abuse: a crossnational comparison of psychiatric morbidity and other determinants in the Ad-HOC study

OBJECTIVE

The objective of this study was to determine crossnationally the prevalence of indicators of elder abuse and their relationship to putative risk factors, particularly depression, dementia, and lack of service provision.

METHOD

Nearly 4,000 people aged 65+ receiving health or social community services in 11 European countries were interviewed using the minimum dataset homecare (MDS-HC) interview, which includes an abuse screen used previously in elder abuse studies and questions about demographic, physical, psychiatric, cognitive, and service factors.

RESULTS

One hundred seventy-nine (4.6%) people assessed had at least one indicator of abuse. The proportion screening positive increased with severity of cognitive impairment, presence of depression, delusions, pressure ulcers, actively resisting care, less informal care, expressed conflict with family or friends, or living in Italy or Germany, but not with having a known psychiatric diagnosis.

CONCLUSION

Severity of cognitive impairment, depression, and delusions predicted screening positive for abuse in older adults, but having a known psychiatric diagnosis did not, indicating that screening for psychiatric morbidity might be rational strategies to combat elder abuse. People in Italy and Germany were most likely to screen positive for indicators of abuse, and the authors suggest that this might relate to higher levels of dependency in the participants looked after at home in these countries as a result of cultural and service provision differences.

[Cross-national comparison of drug compliance and non-compliance associated factors in the elderly with polypharmacotherapy]

BACKGROUND

Population of seniors in the Czech Republic consumes more than 35 % of all prescribed medications. Currently, Czech seniors take on the average 4-5 prescribed drugs. However, our knowledge about factors influencing drug compliance is scarce particularly in seniors with polypharmacotherapy. Non-compliance can contribute to treatment failure and increases the risk of adverse drug reactions. The aim of the study is to compare drug compliance in the elderly in 11 European countries and to assess the impact of demographic and drug-related factors on non-compliance to medication.

METHODS AND RESULTS

Cross-sectional comparative study in 3881 elderly subjects living in the community receiving home-care services in 11 European countries participating in ADHOC (Aged in Home Care) study. In the sample of Czech subjects we performed in-depth analysis of causes and factors associated with non-compliance in patients with polypharmacotherapy. 12.5% (n=456) of European seniors were non-compliant with prescribed medication with significantly higher prevalence of non-compliance in the CR (33.5 %) and Germany (17.0 %). In the Czech sample following non-compliance risk factors have been identified: taking > or = 7 drugs per os (OR= 2.2), 10 single applications/day (OR= 2.5), more than twice daily dosing (OR= 2.4), problems with drug preparation (OR= 4.6), polypharmacotherapy 5 years and longer (OR= 5.5) and drug preparation without supervision or help (OR= 2.8). The highest prevalence of non-compliance was found for antidepressants (80 %), antiasthmatics (68 %), fibrates (60 %), nonsteroidal antiinflammatory drugs, vasodilatators, anticoagulants/antiplatelet drugs and nootropics (50 %). Among the most common causes, patients reported forgetting to take the drug (74.3 % patients), mistrust in drug effect (10.6%) and fear of taking "too many drugs" (8.6 %).

CONCLUSIONS

Non-compliance to prescribed drug regimen is a prevalent problem in one third of the Czech seniors and was found to be the highest among 11 European countries. Doctors prescribing to older people have to monitor purposefully compliance and strenghten co-operation and motivation of the patient to adhere with prescribed drug regimen. Particularly in seniors with polypharmacotherapy it seems necessary to simplify drug regimen as much as possible. In elderly patients with physical disability, cognitive impairment or depression supervision and/or help of another person with drug preparation and application may improve drug compliance.

[Effectiveness of teaching gerontology and geriatrics in students of the 1st Faculty of Medicine, Charles University in Prague]

BACKGROUND

Increasing number of seniors in the society requires more university-degree educated professionals--health care professionals, social care workers and managers with basic exposure to and knowledge of gerontology and geriatrics. The aim of our paper was to evaluate the effectiveness of undergraduate training of gerontology and geriatrics among students of the 1st Faculty of Medicine, Charles University in Prague.

METHODS AND RESULTS

To get information about knowledge of medical students and students of ergotherapy and physiotherapy and about their attitudes towards senior citizens we conducted a survey using two anonymous questionnaires prepared in our department and piloted earlier. The survey ran during the academic year 2004/2005. Students completed identical questionnaires twice, first time before the start of the clinical rotation and second time after the training end (n=134). Evaluation of knowledge and attitudes confirmed that one to two weeks clinical rotation at Department of Geriatrics was effective and increased knowledge of students in the topic trained. The percentage of correct answers in all three evaluated training programmes increased after the completion of the clinical rotation and reached 83% and more. From 134 participating students, 54.5 % appreciated life experience and wisdom of seniors they met, 98.4 % of students were satisfied with the training programme and 67.2 % of students reported that after training they changed their attitude towards senior population.

CONCLUSIONS

Our survey confirmed that clinical training in geriatric medicine at 1st Faculty of Medicine, Charles University in Prague, prepared in agreement with current European recommendations is sufficiently effective and well accepted by the students. Therefore we recommend introduction of formal geriatric training for students in all medical faculties in the Czech Republic.

Indwelling catheter use in home care: elderly, aged 65+, in 11 different countries in Europe

OBJECTIVE

To describe possible differences/patterns in the use of indwelling urinary catheters (IUC) in Europe.

DESIGN

A prospective, population-based, assessment study.

SETTING

The target population was 4,455 (random sample of 405 from each of 11 countries) aged 65+ receiving home care.

METHODS

The clients were assessed by using the Resident Assessment Instrument MDS-HC; epidemiological and medical characteristics of clients and service utilisation were recorded.

MEASUREMENTS

The frequency of use of IUC related to the patients' activities of daily living (ADL) and cognitive functioning.

RESULTS

The sample consisted of 4,010 informants: 74% female, with mean age 82.3 +/-7.3 years; men 80.9 +/-7.5 years and female 82.8 +/-7.3 years. A total of 216 (5.4%) clients were using IUC. In Italy 23% were using a catheter compared with 0% in The Netherlands. Catheter use was more common in men than in women (11.5% versus 3.3%). Use of IUC was significantly correlated to certain diseases and symptoms and increase in care burden and formal services. Twenty-six per cent of the informants with indwelling catheters scored three or more on a hierarchical ADL scale (0-6). The clients using IUC in the Nordic countries were less dependent on care than in the other European countries. Models built on multivariate analysis explained 37% of the use of IUC. Tradition and attitudes may explain the differences between the sites.

CONCLUSIONS

Catheter use is associated with formal or family care burden. The need for nursing home placement ought to be considered in some cases. A stricter criterion for using IUC may be considered in the southern European countries.

Potentially inappropriate medication use among elderly home care patients in Europe

CONTEXT

Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability.

OBJECTIVE

To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument.

MAIN OUTCOME MEASURES

Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model.

RESULTS

Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001).

CONCLUSIONS

Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

[Atypical pyoderma gangrenosum in 92-year-old patient]

Pyoderma gangrenosum (PG) is rather rare chronic dermatosis presenting as cutaneous necrosis followed by development of expanding chronic ulcer with well-demarcated, undermined, violaceous borders. Diagnosis of PG is predominantly based on the clinical presentation and course. Histopathologic findings may be non-specific. Half of patients suffer from a somatic systemic disease. We describe 92-year-old lady presenting with large non-healing ulcer of the anterolateral calf with the diagnosis of atypical PG. In a discussion differential diagnosis of cutaneous ulcers mimicking PG is reviewed and the treatment possibilities summarised.

The RAI-PC: an assessment instrument for palliative care in all settings

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

[Case-mix classification in post-acute and long-term care. Validation of Resource Utilization Groups III (RUG-III) in the Czech Republic]

BACKGROUND

Czech facilities for non-acute, continuing care provide care for very heterogeneous group of residents with different clinical characteristics, care needs and resource use. The rate based funding of LTC doesn't reflect patient case-mix. Therefore, a case mix system RUG based on per diem resource use is being used abroad for rational and fair LTC funding.

METHODS

The validity of RUG-III has been evaluated and its use for financing of LTC and geriatric care in CR examined. In a sample of 1162 residents from 18 institutions patients were assigned to one of 44 RUG-III groups regarding their clinical characteristics. Data were analyzed using analysis of variance with individual care time per patient per day as independent and RUG-III groups as dependent variables. Weighted means for each group (case-mix indexes, CMI) were calculated.

RESULTS

The RUG-III system achieved 59% variance explanation of total per diem costs of nursing and therapy/rehabilitation care and meets criteria of clinical validity. The CMIs for individual groups span from 0.39 to 2.70 i.e. differences in resource use between groups were sevenfold. Resource use within groups was relatively homogeneous.

CONCLUSIONS

The RUG-III represent a suitable case-mix system for nonacute institutional care in the Czech health care. Besides its use for payment incentives, RUG-III can be used in facility management, quality assurance process and for comparative analyses on national and international level.

Culture, Economics, and Alzheimer's Disease: Social Determinants of Resource Allocation

Although the United States and the Czech Republic have approximately the same proportion of people older than ages 65 and 80, there are striking differences in the response to Alzheimer's disease. In the United States, there is considerable public interest, openness about the problem, and a vigorous research effort to cope with the disease. In the Czech Republic, by contrast, there is little government, media, or public interest. The disease is treated as a natural result of aging and thought to be a matter offate and acceptance rather than calling for a medical response. The cultural and historical reasons for this difference are explored, noting that a change in Czech attitudes and practices, important and necessary, will nonetheless come at a price. Both coun tries will in the future face new and daunting problems in caring for those with the disease.

[Urinary incontinence in patients in long-term institutional care. Results of an international study in 8 countries]

BACKGROUND

Urinary incontinence (UI) represents a prevalent nursing problem in geriatric facilities. Yet, comparison of the Czech Republic with countries using different chronic care system has not been conducted.

METHODS AND RESULTS

Data from INTERRAI international database from 8 countries: Czech Republic, Denmark, France, Iceland, Italy, Japan, Sweden and USA have been evaluated in the sample of 280,271 nursing home residents. Prevalence of bladder and bowel incontinence and correlates with selected clinical factors have been determined and national samples compared with the results of 1080 patients in the Czech Republic. Prevalence of UI reached from 42.9% in Japan to 65.2% in France. France and CR belong to countries with the highest prevalence of both bladder and bowel incontinence. Cognitive impairment and dependency in ambulation are factors significantly associated with UI in all countries (p < 0.001). Immobility, age, gender and urinary tract infection reached the statistical significance only in some countries.

CONCLUSIONS

High prevalence of bladder and bowel incontinence has been demonstrated in an extended sample of nursing home residents. Common protocol Resident Assessment Instrument-Minimum Data Set (RAI-MDS) and creation of a large cross-national database are opening up possibilities for a new level of clinical research in geriatrics.

[Urinary and fecal incontinence in geriatric facilities in the Czech Republic]

BACKGROUND

Incontinence represents one of the common problems in long-term care geriatric facilities and nursing homes. However, in the Czech Republic data on prevalence, severity and incontinence-associated factors for nursing home residents are not available. The aim of the study was to report the prevalence of urinary (UI) and bowel incontinence (BI) in different geriatric facilities and to identify factors positively associated with incontinence.

METHODS AND RESULTS

In a sample of 1162 residents of 18 long-term care facilities UI has been found in 684 residents (63.3%). Health and social care facilities did not differ significantly (60.7 vs 65.6%). Of the incontinent 294 residents (27.2%) suffered from permanent/daily incontinence, 390 (36.1%) from occasional transitory UI. Prevalence of BI reached 54.4%, as well as double incontinence (45.9%). Cognitive impairment, self-care ADL and/or mobility dependency and bed rest are factors significantly associated with UI (for all P < 0.001). However, age, gender and urinary tract infection did not reach the statistical significance (P = 0.280-0.069). Risk adjustment/stratification for UI revealed the prevalence of 33.0% in the low risk group. In the high risk group (high ADL dependency and severe cognitive impairment) the prevalence came up to 96.0%.

CONCLUSIONS

Our study presents the first results focused on incontinence problem in long-term care geriatric institutions in the Czech Republic. High prevalence of this condition makes incontinence an important medical, nursing and economical yet neglected problem.

Urinary incontinence in nursing home residents: a cross-national comparison

BACKGROUND

using data from a cross-national data base we report the prevalence of urinary incontinence in nursing home residents, describe the main factors associated with bladder incontinence, and compare the usage of incontinence-related tests and care practices across countries.

RESULTS

urinary incontinence is highly prevalent (43-65%) in the seven countries studied. Dependency in ambulating, cognitive impairment and urinary tract infections are significantly associated with urinary incontinence in nursing home populations in most countries. Large cross-country differences are observed in the percentage of elderly undergoing incontinence-related testing and in the percentage of residents using appliances and programmes to treat or prevent incontinence.

CONCLUSION

this study of different cultural approaches and strategies to evaluate and treat urinary incontinence may stimulate a public debate on the quality of care in nursing homes and promote the sharing of care practices designed to reduce urinary incontinence.

Nursing homes in 10 nations: a comparison between countries and settings

AIM

to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA).

METHOD

data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues.

RESULTS

All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades. Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the 'youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country' (Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly.

CONCLUSIONS

no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibility assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC

OBJECTIVE

To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC.

DESIGN

Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients.

SETTING AND PARTICIPANTS

Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States.

MEASUREMENTS

The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications.

RESULTS

Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels.

CONCLUSION

Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

[The effect of disability of the aged patient on the level of caregiving burden by the family]

BACKGROUND

A growing number of dependent elderly people is cared for at home by family members. However, long-term caregiving may become an intolerable strain for some families and lead to failure of family care. The aim of the study was to examine if level of physical and mental disability of the patient influences the extent of perceived caregiver burden representing risk factor for negative outcome.

METHODS AND RESULTS

128 elderly patients with disability and dependency (37 men, 91 women, average age 79.9 +/- 6.9 yrs) and 128 their primary caregivers, mostly family members (28.9% men, 71.1% women) were evaluated. Functional status of care recipient was assessed by means of Barthel ADL Index (mean = 70.9 +/- 26.5), IADL Test (mean = 31.4 +/- 23.5) and Mini-Mental State Exam, MMSE (mean = 20.4 +/- 6.5). Average score of Caregiver Burden Interview (CBI) was 34.7 +/- 18.8. According to CBI, 40.6% of caregivers were found under high or even extremely hig level of stress. Level of perceived burden correlated significantly with physical and mental disability level, in decreasing order for IADL, ADL and MMSE (rs = 0.582-0.708, p < 0.001).

CONCLUSIONS

Caregiver burden of family caregivers is significantly related to the level of functioning and cognitive impairment of care recipient, particularly to his/her ability to perform instrumental activities. Functional decline of elderly patient represents a risk factor which contributes to negative caregiving outcome and institutional placement.

Health care services for the elderly in Czech Republic: new trends and future development

Old people over 65 are now the most rapidly growing segment of the population and represent 13% of all Czech inhabitants. Because of the high prevalence of morbidity and disability among the elderly they are the most important consumers of health care services, both extramural and intramural. They consume about 1/3 of the total expenditures on the health care, 40-50% of the general practitioner's time, 40% of prescribed drugs, and over 30% of all hospital days. An important additional consequence of population aging are the increasing needs and costs of long-term care. During the past 30 years, health services for the elderly have been developed and geriatric and chronic care medicine have become an integral part of the contemporary medical enterprise. The past few years of political and economical transformation have brought about significant changes in health and social care and they are having a great impact on the provision of services. In light of the demographic projections and steadily increasing costs of health care, what are the contemporary changes and what should be the future development of health care services for the elderly?

[Transformation of health care, the aged patient and the aging society]

Ageing of the population is associated with historically new social conflicts which have an immediate impact on the health services. The advances of the health care reform depend also on the fact whether the social and health policy will be able to foresee these conflicts and tackle them in advance. The most serious conflict is the increasing number of old people who require health and/or social care with recent medical advances as regards old age, and are confronted with final and restricted nation-wide and health resources resp. The author discusses possible solutions which in addition to a technical, organizational and economic aspect have a significant, although frequently omitted, moral, ethical and philosophical dimension.