Age-Adjusted Modified Frailty Index: Association With Hip Fracture Discharge Functional Dependence

INTRODUCTION

Hip fractures are a common traumatic injury that carry significant morbidity and mortality, and prognostication of functional outcome is becoming increasingly salient. Across multiple surgical specialties, the five-item and 11-item Modified Frailty Index (mFI-5 and mFI-11) have been found to be convenient, quick, and sensitive tools for identifying patients at risk for perioperative complications. A prior study described the superiority of an Age-Adjusted Modified Frailty Index (aamFI) for predicting perioperative complications compared to the mFI-5 in an elective hip surgery. We sought to externally validate the aamFI in a multicenter hip fracture cohort and hypothesize that these risk scores would not only predict functional dependence (FD) at discharge, but that the aamFI would outperform the mFI-5 and mFI-11.

METHODS

The Pennsylvania Trauma Systems Foundation registry was queried from 2010 to 2020 for CPT codes, ICD-9 and ICD-10 codes pertaining to hip fracture patients. Patients with missing locomotion and transfer mobility data were excluded. FD status was determined by discharge locomotion and transfer mobility scores per existing methodology. Univariable and Multivariable analysis as well as receiver operator characteristic curves were used to evaluate and compare the three indices for prediction of functional status at discharge. P value < 0.05 was considered significant.

RESULTS

Twelve thousand seven hundred and forty patients met inclusion criteria (FD: 8183; functional independent 4557). On univariable logistic regression analysis, the mFI-11 (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.47-1.58, P < 0.05), mFI-5 (OR 1.57, 95% CI 1.51-1.63), and aamFI (OR 1.57, 95% CI 1.52-1.62, P < 0.05) were associated with FD. On multivariable logistic regression analysis for predictors of FD, when controlling for age (for the mFI-11 and mFI-5), sex, injury severity score, and admission vitals (systolic blood pressure and respiratory rate), higher mFI-11 and mFI-5 scores independently predicted FD at discharge (OR 1.23, 95% CI 1.18-1.28, P < 0.05 and OR 1.23, 95% CI 1.18-1.29P < 0.05 respectively). Higher aaMFI scores had superior association with functional dependence (OR 1.59, 95% CI 1.54-1.64, P < 0.05). Receiver operator characteristic curves for the mFI-11, mFI-5, and aaMFI showed comparable diagnostic strength (area under curve [AUC] = 0.63 95% CI 0.62-0.64, P < 0.05; AUC = 0.63 95% CI 0.62-0.64, P < 0.05; and AUC = 0.67 95% CI 0.65-0.67, P < 0.05 respectively).

CONCLUSIONS

The mFI-11, mFI-5, and aamFI are predictive of functional outcome following hip fracture. By including age, the aamFI retains the ease of use of the mFI-5 while improving its prognostic utility for functional outcome.

[Impacto de la dependencia funcional de los pacientes mayores atendidos en los servicios de Urgencias españoles durante la primera ola pandémica de la COVID-19 sobre la mortalidad a 30, 180 y 365 días en función del diagnóstico (COVID versus no COVID).]

OBJECTIVE

Functional assessment is part of geriatric assessment. How it is performed in hospital Emergency Departments (ED) is poorly understood, let alone its prognostic value. The aim of this paper was to investigate whether baseline disability to perform basic activities of daily living (BADL) was an independent prognostic factor for death after the index visit to the ED during the first wave of the COVID-19 pandemic and whether it had a different impact on patients with and without diagnosis of COVID-19.

METHODS

A retrospective observational study of the EDEN-Covid (Emergency Department and Elder Needs during COVID) cohort was carried out, consisting of all patients aged ≥65 years seen in 52 Spanish EDs selected by chance during 7 consecutive days (30/3/2020 to 5/4/2020). Demographic, clinical, functional, mental and social variables were analyzed. Dependence was categorized with the Barthel index (BI) as independent (BI=100), mild-moderate dependence (100>BI>60) and severe-total dependence (BI<60), and their crude and adjusted association was evaluated with mortality at 30, 180 and 365 days using COX proportional hazards models.

RESULTS

Of 9,770 enrolled patients with a mean age of 79 years, 51% were men, 6,305 (64.53%) were independent, 2,340 (24%) had mild-moderate dependence, and 1,125 (11.5%) severe-total dependence. The number of deaths at 30 days in these three groups was 500 (7.9%), 521 (22.3%) and 378 (33.6%), respectively; at 180 days it was 757 (12%), 725 (30.9%) and 526 (46.8%); and at 365 days 954 (15.1%), 891 (38.1%) and 611 (54.3%). In relation to independent patients, the adjusted risks (hazard ratio) of dying within 30 days associated with mild-moderate and severe-total dependency were 1.91 (95% CI: 1.66-2.19) and 2.51. (2.11-2.98); at 180 days they were 1.88 (1.68-2.11) and 2.64 (2.28-3.05); and at 365 days they were 1.82 (1.64-2.02) and 2.47 (2.17-2.82). This negative impact of dependency on mortality was greater in patients diagnosed with COVID-19 than in non-COVID-19 (p interaction at 30, 180 and 365 days of 0.36, 0.05 and 0.04).

CONCLUSIONS

The functional dependence of older patients who attend Spanish EDs during the first wave of the pandemic is associated with mortality at 30, 180 and 365 days, and this risk is significantly higher in patients treated for COVID-19.

Incidence of preoperative instrumental activities of daily living (IADL) dependence and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

Instrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022.

PATIENTS

Patients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale.

INTERVENTIONS

Preoperative assessment.

MEASUREMENT

The primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition.

MAIN RESULTS

Twenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I2: 0%; P = 0.0005).

CONCLUSIONS

There is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes.

Risk Factors for Suicidality in Individuals With Spinal Cord Injury: A Focus on Physical and Functional Characteristics

OBJECTIVE

: To demonstrate the association between the physical and functional characteristics of individuals with spinal cord injury (SCI) and suicidality, an area of research that is less understood than the association with demographic, social, and psychological characteristics.

METHODS

: A retrospective cross-sectional study was conducted with 259 patients with SCI admitted for rehabilitation at the National Rehabilitation Center, Seoul, between January 2019 and December 2021. Demographic, SCI-related, physical, and functional data were collected from their medical records. Suicide risk was assessed using the Mini International Neuropsychiatric Interview.

RESULTS

: The 259 participants had an average age of 49.1 years, and 75.7% were male. The analysis revealed a statistically significant negative correlation between age and suicidality. No significant differences were found for sex, education, occupation, or SCI-related factors. Lower upper extremity motor score (UEMS) was significantly associated with higher suicide risk. Regarding functional factors, the inability to perform independent rolling, come to sit, wheelchair propelling, and self-driving were associated with increased suicidality. In the multiple linear regression analysis, lower UEMS, limited shoulder joint motion, upper extremity spasticity, and dependent wheelchair propulsion were predictors of higher suicide risk.

CONCLUSION

: This study highlights the associations among physical status, functional dependency, and suicide risk in individuals with SCI. These findings emphasize the need to address psychological aspects and physical and functional factors in the management of individuals with SCI who are at a high risk of suicide.

Long-term care need, loneliness, and perceived social isolation during the COVID-19 pandemic: evidence from the German Ageing Survey

BACKGROUND

There is a complete lack of studies focusing on the association between care degree (reflecting the long-term care need) and loneliness or social isolation in Germany.

AIMS

To investigate the association between care degree and loneliness as well as perceived social isolation during the COVID-19 pandemic.

METHODS

We used data from the nationally representative German Ageing Survey, which covers community-dwelling middle-aged and older individuals aged 40 years or over. We used wave 8 of the German Ageing Survey (analytical sample: n = 4334 individuals, mean age was 68.9 years, SD: 10.2 years; range 46-100 years). To assess loneliness, the De Jong Gierveld instrument was used. To assess perceived social isolation, the Bude and Lantermann instrument was used. Moreover, the level of care was used as a key independent variable (absence of care degree (0); care degree 1-5).

RESULTS

After adjusting for various covariates, regressions showed that there were no significant differences between individuals without a care degree and individuals with a care degree of 1 or 2 in terms of loneliness and perceived social isolation. In contrast, individuals with a care degree of 3 or 4 had higher loneliness (β = 0.23, p = 0.034) and higher perceived social isolation scores (β = 0.38, p < 0.01) compared to individuals without a care degree.

DISCUSSION/CONCLUSIONS

Care degrees of 3 or 4 are associated with higher levels of both loneliness and perceived social isolation. Longitudinal studies are required to confirm this association.

Persisting cognitive impairment predicts functional dependence at 1 year after stroke and transient ischemic attack: a longitudinal, cohort study

OBJECTIVE

Minor stroke or transient ischemic attack (TIA) usually have mild and nondisabling symptoms, and these functional deficits may recover fully e.g., TIA, however, part of them still suffer from cognitive impairment and poor outcomes. We conducted a study to determine the relationship between cognition evaluated by Montreal Cognitive Assessment (MoCA) and poor functional outcomes assessed by the Modified Rankin Scale (mRS) (mRS ≥ 2) and Stroke Impact Scale (SIS)-16(SIS-16<25%).

METHODS

The data of this study come from the impairment of cognition and Sleep (ICONS) after acute ischemic stroke or transient ischemic attack in Chinese patients study. A total of 1675 minor stroke patients and TIA patients were finally recruited. Patients' cognition were evaluated by Montreal Cognitive Assessment (MoCA) scale at 2-week (2w), 3 months (3 m) and 1 year(1y). Cognitive impairment (CI) was defined as MoCA score ≤ 22. According to MoCA score, patients were divided into 4 groups: no PSCI group: with MoCA-2w>22 and MoCA-3 m>22; improved PSCI group: with MoCA-2w ≤ 2 and MoCA-3 m>22;delayed PSCI group: MoCA-2w>22 and MoCA-3 m ≤ 22; persisting PSCI group: with MoCA-2w ≤ 22 and MoCA-3 m ≤ 22.

RESULTS

A total of 1675 stroke patients were recruited in this study. There were 818 patients (48.84%) who had PSCI at baseline. Of these, 123 patients (15%) had mRS ≥2 at 3 months. The persisting PSCI group was a significant predictor of functional dependence at 3 months and 1 year after stroke and when adjusted for covariates such as gender, age, history of stroke, depression and intracranial atherosclerotic stenosis, stroke subtype and acute infarction type.

CONCLUSION

Persisting PSCI increased the risk of poor functional outcome after 3 months and 1 year follow-up. These high-risk individuals should be identified for targeted rehabilitation and counseling to improve longer-term post-stroke outcome.

Cognitive Dependence in Physically Independent Patients at Discharge From Acute Traumatic Brain Injury Rehabilitation

OBJECTIVE

To determine the incidence of cognitive dependence in adults who are physically independent at discharge from acute traumatic brain injury (TBI) rehabilitation.

DESIGN

Analysis of historical clinical and demographic data obtained from inpatient stay.

SETTING

Inpatient rehabilitation unit in a large, metropolitan university hospital.

PARTICIPANTS

Adult inpatients with moderate to severe TBI (N=226) who were physically independent at discharge from acute rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM Motor and Cognitive subscales, discharge destination, and care plan.

RESULTS

Approximately 69% (n=155) of the physically independent inpatients were cognitively dependent at discharge from acute rehabilitation, with the highest proportions of dependence found in the domains of problem solving and memory. Most (82.6%; n=128) of these physically independent, yet cognitively dependent, patients were discharged home. Of those discharged home, 82% (n=105) were discharged to the care of family members, and 11% (n=15) were discharged home alone. Patients from racial and ethnic minority backgrounds were significantly more likely than White patients to be discharged while cognitively dependent.

CONCLUSIONS

The majority of physically independent patients with TBI were cognitively dependent at the time of discharge from acute inpatient rehabilitation. Further research is needed to understand the effect of cognitive dependence on caregiver stress and strain and the disproportionate burden on racial and ethnic minority patients and families. Given the potential functional and safety limitations imposed by cognitive deficits, health care policy and practice should facilitate delivery of cognitive rehabilitation services in acute TBI rehabilitation.

The Elderly Nutritional Index for Geriatric Malnutrition Assessment (ENIGMA): concurrent, construct and predictive validity in an external evaluation cohort of community-dwelling older persons

We previously developed a malnutrition risk index, the Elderly Nutritional Index for Geriatric Malnutrition Assessment (ENIGMA) with good predictive accuracy for mortality risk in an original population cohort (SLAS1). Herein, we further evaluate the concurrent and predictive validity of the ENIGMA construct in an external validation cohort (SLAS-2) of 2824 community-dwelling older adults aged 55+ years. They were assessed on the ENIGMA index, Mini Nutritional Assessment-Short Form (MNA-SF) and the Geriatric Nutritional Risk Index (GNRI), known correlates of malnutrition, and baseline and follow-up functional dependency and 10-year mortality risk. Higher ENIGMA risk categories were significantly associated (P < 0·001) with lower education, living alone, smoking, low physical activity, BMI < 18·5 kg/m², poorer muscle strength and functional mobility, exhaustion, physical frailty, homocysteine, glomerular filtration rate, Hb, red and white blood cell counts, platelets, systemic inflammation indexes, metabolic syndrome, CVD, cognitive impairment and depressive symptoms (Geriatric Depression Scale ≥ 5). ENIGMA scores showed statistically significant (P < 0·001) correlations but low-to-moderate concordance with MNA-SF (r = 0·148, agreement = 45·9 %, kappa = 0·085) and GNRI scores (r = 0·156, agreement = 45·8 %, kappa = 0·096). Controlling for known correlates of malnutrition, only high-risk ENIGMA among the indexes significantly predicted baseline functional dependency (OR = 1·64, 95 % CI 1·01, 2·65) and mortality (hazard ratio = 1·65 (95 % CI 1·04, 2·62). ENIGMA marginally out-performed MNA-SF and GNRI in predicting baseline functional dependency (AUC: 0·625 v. 0·584 v. 0·526), follow-up functional dependency (AUC: 0·594 v. 0·525 v. 0·479) and 10-year mortality risk (AUC: 0·641 v. 0·596 v. 0·595). The concurrent and predictive validity of the ENIGMA construct is replicated in an external evaluation study of community-dwelling older persons.

Do older adults with multimorbidity prefer institutional care than those without multimorbidity? The role of functional limitation

Background

Population ageing and social transformation present tremendous challenges to the informal support system of older adults, which engendered institutional care in China. This study aimed to examine the association between multimorbidity and institutional care willingness, and investigate whether there is an interaction effects between multimorbidity and functional limitations on institutional care willingness among Chinese older adults.

Methods

Data were obtained from the sixth National Health Service Survey of Shandong province, China. The sample included 8583 older adults (age ≥ 60 years; 51.7% women), 44.8% without chronic diseases, 34.8% and 20.4% with one chronic condition and multimorbidity, respectively. Multivariable logistic regression models and marginal effects analysis were used to the interaction effects analysis.

Results

A total of 666 (7.8%) participants had institutional care willingness in Shandong, China. Participants with multimorbidity were more likely to have institutional care willingness than their peers without chronic condition (OR = 1.25, 95% CI = 1.06, 1.55) after adjusted for confounders. Marginal effect analysis showed that under the condition that other variables remain unchanged, the probability of them with multimorbidity choosing institutional care for older adults with functional limitations was 6.9% lower than those without multimorbidity (95% CI = -0.128, -0.010, P = 0.023). The interaction effect between chronic health conditions and functional limitation for older adults to choose institutional care was statistically significant, and the average interaction effect was 4.83% (Z = -2.70, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${S}_{\overline{x} }$$\end{document}Sx¯ = 0.0189, P < 0.05).

Conclusions

This relationship between multimorbidity and institutional care willingness varied by functional limitations. To better meet the care needs among older adults with multimorbidity and functional limitations, more resources and incentives should be provided to encourage the building-up of eldercare institutions. The governments should also establish long-term care system and to provide better home-based care for older adults, as older adults who prefer home care remain the majority.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02812-2.

Effectiveness of dyadic psychoeducational intervention for stroke survivors and family caregivers on functional and psychosocial health: A systematic review and meta-analysis

OBJECTIVES

Stroke is the third leading cause of disability worldwide, influencing the whole family's health and well-being. Dyadic (i.e., stroke survivor and family caregiver) psychoeducational intervention is a potential alternative to disease management and support, targeting at the dyads of stroke survivors and their caregivers as active participants in partnership. This review aimed to evaluate the current evidence on supporting the dyadic psychoeducational intervention for the functional and psychosocial health of stroke survivors' and their family caregivers.

DESIGN

Systematic review and meta-analysis DATA SOURCES: Nine English databases (Cochrane Library, Medline, CINAHL, PsycINFO, EMBASE, British Nursing Index, PubMed, Web of Science and Digital Dissertation Consortium) and two Chinese databases (CNKI and Wanfang) were searched to identify eligible studies published from their inception to April 2020. Additional relevant studies were identified from the reference lists and bibliographies of the identified articles and a manual search of relevant journals.

REVIEW METHODS

Studies were searched using keywords based on the 'PICOS' framework. The eligibility of individual full-text articles was independently assessed by two reviewers in accordance with the selection criteria. The risk of bias of the included studies was assessed using Cochrane RoB 2.0. The main outcomes were subjected to meta-analysis whenever possible; otherwise, narrative syntheses were conducted.

RESULTS

Eleven studies with 1769 stroke survivors and 1578 family caregivers were identified. The meta-analysis of pooled data suggested that the dyadic psychoeducational intervention had a significant immediate (<1 month) effect on family caregivers' burden (SMD = -0.25, 95% CI: -0.50 to -0.01, p = 0.04) and a long-term (≥6 months) effect on survivors' quality of life (SMD = -0.30, 95% CI: -0.53 to -0.07, p = 0.01). Subgroup pooled analyses indicated that the interventions initiated in hospitals could significantly improve the survivors' functional independence immediately after intervention (SMD = 0.40, 95% CI: 0.08 to 0.72, p = 0.01). Conversely, the interventions initiated at home did not significantly affect this functional outcome.

CONCLUSIONS

This review supports the notion that the dyadic psychoeducational intervention can be effective in improving the stroke survivors' functional independence and their family caregivers' burden for a short period and the survivors' quality of life in the long run. However, its effectiveness is not conclusive because other psychosocial health outcomes for the stroke survivors and their family caregivers have not yet been found to significantly improve after intervention. Therefore, further large-scale randomised controlled trials with a high-quality design are warranted to evaluate their effectiveness in diverse functional and psychosocial health outcomes for stroke survivors and their family caregivers.

The relationship between lead and cadmium levels and functional dependence among elderly participants

The adverse impacts of lead and cadmium exposure on health outcomes have been reported in the past. Few studies have been conducted on the relationship between lead and cadmium exposures and disability. We evaluated whether lead and cadmium exposures were associated with functional dependence including the total number of disabilities, activities of daily living (ADL), instrumental activities of daily living (IADL), leisure and social activities (LSA), lower extremity mobility (LEM), and general physical activities (GPA) in an elderly population. A total of 5513 eligible subjects were enrolled in the study from the National Health and Nutrition Examination Survey 2001-2006. Serum lead and cadmium exposure assessments were performed using atomic absorption spectrometry. Functional dependence was assessed by 19 structured questions. The relationships between lead and cadmium exposures and functional dependence were investigated using by multivariable linear regression models. Q2, Q3, and Q4 of lead exposure were significantly associated with the total number of disabilities, with β coefficients of - 0.62 (95% CI - 0.99, - 0.24), - 0.64 (95% CI - 1.02, - 0.26), and - 0.81 (95% CI - 1.19, - 0.42), respectively. This relationship remained significant in males. Furthermore, we analyzed the relationships between lead and cadmium exposure quartiles and various functional dependence metrics, and we determined that lead content was significantly associated with decreased ADL, LEM, and GPA (p < 0.05) and cadmium content was inversely associated with ADL (p < 0.05). Our study demonstrated a strong relationship between exposure to lead and cadmium and functional dependence in an elderly population.

Trends in stroke outcomes at hospital discharge in first-ever stroke patients: Observations from the Malaysia National Stroke Registry (2009-2017)

BACKGROUND

Stroke outcomes could be a quality indicator across the continuum of care and inform stroke management policymaking. However, this topic has rarely to date been studied directly.

AIMS

We sought to investigate recent trends in stroke outcomes at hospital discharge among first-ever stroke patients.

METHODS

This was an analysis of data from the Malaysia National Stroke Registry. Patients aged 18 years or older documented as having a first episode of stroke in the registry were recruited. Subsequently, the comparison of proportions for overall and sex-specific stroke outcomes between years (from 2009 to 2017) was conducted. The primary outcome was modified Rankin Scale score, which was assessed at hospital discharge, and each patient was categorized as follows: 1) functional independence, 2) functional dependence, or 3) death for analysis.

RESULTS

This study included 9361 first-ever stroke patients. Approximately 36.2% (3369) were discharged in an independence state, 53.1% (4945) experienced functional dependence, and 10.8% (1006) patients died at the time of hospital discharge. The percentage of patients who were discharged independently increased from 23.3% in 2009 to 46.5% in 2017, while that of patients discharged in a disabled state fell from 56.0% in 2009 to 45.6% in 2017. The percentage of death at discharge was reduced from 20.7% in 2009 to 7.8% in 2017. These findings suggest that the proportions of stroke outcomes at hospital discharge have changed significantly over time (p < 0.001), and there was a significant sex-related difference in stroke outcomes at hospital discharge following first stroke episode (p < 0.001).

CONCLUSIONS

Our data indicate there has been a significant change in stroke outcomes over the past nine years in Malaysia. This information ought to be considered in ongoing efforts of tertiary stroke prevention.

Exposure to polycyclic aromatic hydrocarbons and risk of disability among an elderly population

Polycyclic aromatic hydrocarbons (PAHs) are environmental pollutants. Exposure to PAHs is associated with several adverse health outcomes. However, no previous study has examined the relationship between PAH exposure and functional dependence in an elderly population. Our aim was to examine whether PAH exposure was associated with functional dependence including total disability, activities of daily living (ADL), instrumental activities of daily living (IADL), leisure and social activities (LSA), lower extremity mobility (LEM), and general physical activities (GPA) in an elderly population. A total of 5816 elderly adults from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2006 were examined. PAH exposure was measured by urinary biomarkers. Functional dependence was assessed by 19 structured questions. The association between PAH exposures with functional dependence was performed by using a multivariable linear regression model. After adjusting for pertinent variables, positive associations were observed between the total number of disabilities and 2-naphthalene and 1-pyrene quartiles (all P_trend < 0.05). There was a dose-dependent relationship between 1-pyrene quartiles and all functional dependence domains, and the higher quartile of 1-pyrene was more closely associated with functional impairment (all P_trend < 0.05). PAH exposure is associated with functional dependence in American elderly adults. Future research is needed to bring to light the pathophysiological underlying mechanisms related to these findings.

Perioperative Understanding of Geriatric Patients

Surgical treatment of the elderly can be a very difficult and complex endeavor. Appropriate and thorough evaluation of this group of patients is essential to identify surgical candidates who may be at increased risk for developing age-related problems, such as cognitive impairment or postoperative delirium. Involvement of family members and ancillary caregivers is ideal. In order to optimize surgical results, communication of goals of surgery and expectations of patients in order to achieve these goals is paramount. Physical therapy assessment of the elderly will give input on patients' capacity to perform needed changes in ambulatory status after surgery.

Grit and Ambition are Associated with Better Neurocognitive and Everyday Functioning Among Adults Living with HIV

Grit and ambition are psychological factors that may protect neurocognitive function among persons living with HIV (PLWH). We examined associations between grit, ambition, premorbid verbal intellectual function, and current neurocognitive and everyday functioning among PLWH and persons without HIV (HIV-). 120 PLWH and 94 HIV- adults completed the Grit Scale (includes total score and consistency of interests and perseverance of effort subscales), ambition scale, and a comprehensive neurobehavioral battery. PLWH had lower grit scores than HIV- adults. The two groups did not differ on ambition. No relationship was observed between grit and cognition among HIV- adults. Among PLWH, however, higher perseverance of effort and more ambition was related to better global neurocognitive functioning, and higher grit, but not ambition, was related to independence in daily functioning. Longitudinal studies are needed to elucidate these relationships over time and examine whether grit or ambition have protective effects on cognitive outcomes among PLWH.

Disability, support and long-term social care of an elderly Spanish population, 2008-2009: an epidemiologic analysis

BACKGROUND

Though poorly known, relationships between disability, need of help (dependency) and use of social services are crucial aspects of public health. The objective of this study was to describe the links between disability, officially assessed dependency, and social service use by an industrial population, and identify areas of inequity.

METHODS

We took advantage of a door-to-door survey conducted in the Cinco Villas district, Spain, in 2008-2009, which provided data on disability, morbidity, and service use among 1216 residents aged ≥50 years, and officially assessed dependency under the 2006 Dependency Act (OAD). Using logistic regression, we combined data collected at homes/residences on 625 disability screened-positive participants, and administrative information on degree of OAD and benefits at date of visit.

RESULTS

Based on 163 disabled persons, the prevalence of residential/community-care users was 13.4% overall, with 6.0% being market-provided, 2.5% supported by the 2006 Act, and 4.9% supported by other public funds. Of 111 OAD applicants, 30 had been assigned an OAD degree; in 29 cases this was the highest OAD degree, with 12 receiving direct support for residential care and 17 receiving home care. Compared to unassessed dependency, the highest OAD degree was linked to residential care (OR and 95% CI) 12.13 (3.86-38.16), declared non-professional care 10.99 (1.28-94.53), and publicly-funded, non-professional care 26.30 (3.36-205.88). In contrast, 43 persons, 58% of the severely/extremely disabled, community-dwelling sample population, 81% of whom were homebound, including 10 persons with OAD but no implemented service plan, made no use of any service, and of these, 40% lacked a non-professional carer.

CONCLUSIONS

Formal service use in the Cinco Villas district attained ratios observed for established welfare systems but the publicly-funded proportion was lower. The 2006 Act had a modest, albeit significant, impact on support for non-professional carers and residential care, coexisting with a high prevalence of non-use of social services by severely disabled persons.

Race-based disparities in loss of functional independence after hysterectomy for uterine cancer

PURPOSE

Racial disparities in uterine cancer-related outcomes have been reported. The goal of this study was to determine if race, pre-operative body mass index (BMI), and medical comorbidities are predictors of loss of functional independence after hysterectomy for uterine cancer.

METHODS

Loss of independence was defined as a change from pre-operative functional independence, to a post-operative requirement of discharge to a post-care facility, or death within the first 30 days following uterine cancer surgery. Demographic factors, comorbidities, BMI, intra-operative and post-operative outcomes, and discharge status were abstracted from the 2011 and 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Statistical analyses included multivariable logistic regression and Wald tests for interaction.

RESULTS

A total of 4005 patients had uterine cancer and were functionally independent pre-operatively. After adjusting for clinical features and comorbidities, Black women were not significantly more likely to lose functional independence than non-Black women. However, a significant interaction (OR = 1.17, p < 0.001) was found between race and BMI for loss of functional independence. Interaction plots revealed worsening functional outcomes for Black women with BMI >40 but not in non-Blacks.

CONCLUSIONS

The interaction suggests a 17 % increased odds of losing independence for each unit of BMI difference for Black uterine cancer patients, or 170 % increased odds of losing independence for a 10-point increase in BMI, given a linear association. To reduce the likelihood of losing post-operative functional independence, Black, high-BMI patients with or at risk for uterine cancer may especially benefit from weight loss or interventions to optimize physical function.

Hospital-acquired functional decline in older patients cared for in acute medical wards and predictors: Findings from a multicentre longitudinal study

Describing the trajectories of hospital-associated functional decline in older patients admitted to acute medical units and identifying predictors at the individual, nursing, and hospital levels, were the aims of the study. A longitudinal survey among 12 acute medical units in which 1464 patients were consecutively enrolled and evaluated using the Barthel Index (BI), was performed. Functional decline was defined as a decrease in the BI of at least 5 points from admission to discharge. In all, 17.1% participants (n = 251) demonstrated functional decline. In accordance with multiple logistic regression analysis, 28.8% (R(2)) of the variance in the functional decline was explained by: confusion/disorientation (RR = 4.684; 95% CI = 3.144-6.978), admission from nursing homes (RR = 2.464; 95% CI = 1.642-3.697), daily care expressed in minutes offered by nursing aides (RR = 1.535; 95% CI = 1.275-1.849), higher workforce skill-mix (RR = 2.221; 95% CI = 1.763-2.797), bladder catheter insertion (RR = 1.599; 95% CI = 1.128-2.268), and higher BI score at admission (RR = 1.019; 95% CI = 1.014-1.024). Increasing the amount of care delivered by competent nurses-having a bachelors degree-providing and supervising direct-care activities, may reduce the occurrence of functional decline in older patients admitted to medical units.

Short-term prognostic factors in the elderly patients seen in emergency departments due to infections

OBJECTIVES

To analyse factors associated with short-term mortality in elderly patients seen in emergency departments (ED) for an episode of infectious disease.

MATERIALS AND METHODS

A prospective, observational, multicentre, analytical study was carried out on patients aged 75years and older who were treated in the ED of one of the eight participating hospitals. An assessment was made of 26 independent variables that could influence mortality at 30days. They covered epidemiological, comorbidity, functional, clinical and analytical factors. Multivariate logistic regression analysis was performed.

RESULTS

The study included 488 consecutive patients, 92 (18.9%) of whom died within 30days of visiting the ED. Three variables were significantly associated with higher mortality: severe functional dependence, with Barthel index ≤60 [odds ratio (OR) 8,92; 95% confidence interval (CI): 4.98-15.98, P=.003], systolic blood pressure <90mmHg [OR 7.34; 95%CI: 4.39-12.26, P=.005] and serum lactate >4mmol/l [OR 21.14; 95%CI: 8.94-49.97, P=.001]. The area under the curve for the model was 0.971 (95%CI: 0.951-0.991; P<.001).

CONCLUSIONS

Several factors evaluated in an initial assessment in the ED, including the level of functional dependence, systolic blood pressure and, especially, serum lactate, were found to determine a poor short-term prognosis in the elderly patients who presented with an episode of an infectious disease.

Prevalence and correlates of functional dependence among maintenance dialysis patients

Functional dependence is an important determinant of longevity and quality of life. The purpose of the current study was to determine the prevalence and correlates of functional dependence among patients with end-stage renal disease (ESRD) receiving maintenance dialysis. We enrolled 148 participants with ESRD from five clinics. Functional status, as measured by basic and instrumental activities of daily living (ADL, IADL), was ascertained by validated questionnaires. Functional dependence was defined as needing assistance in at least one of seven IADLs or at least one of four ADLs. Demographic characteristics, chronic health conditions, anthropometric measurements, and laboratories were assessed by a combination of self-report and chart review. Cognitive function was assessed with a neurocognitive battery, and depressive symptoms were assessed by questionnaire. Mean age of the sample was 56.2 ± 14.6 years. Eighty-seven participants (58.8%) demonstrated dependence in ADLs or IADLs, 70 (47.2%) exhibited IADL dependence alone, and 17 (11.5%) exhibited combined IADL and ADL dependence. In a multivariable-adjusted model, stroke, cognitive impairment, and higher systolic blood pressure were independent correlates of functional dependence. We found no significant association between demographic characteristics, chronic health conditions, depressive symptoms or laboratory measurements, and functional dependence. Impairment in executive function was more strongly associated with functional dependence than memory impairment. Functional dependence is common among ESRD patients and independently associated with stroke, systolic blood pressure, and executive function impairment.

[Spanish short-stay-units: results according to department designated to manage the unit]

OBJECTIVES

To compare the efficiency of short-stay units (SSUs) managed by different departments within hospitals.

MATERIAL AND METHODS

Cross-sectional study in 40 hospitals with SSUs. From June 1 to December 31, 2012,we gathered data on clinical caseloads and management. Variables directly related to efficiency were mean length of stay, bed rotation index, and weekend discharge rate.

RESULTS

Forty SSUs were studied; 25 (62.5%) were managed by the hospital's emergency department (ED), 9 (22.5%) were managed by the internal medicine department (IMD), 5 (12.5%) were independent, and 1 was jointly managed by the hospital's ED and the IMD. A total of 45 140 patients were discharged from the SSUs. The most common diagnoses were exacerbation of chronic heart or respiratory disease, urinary tract infection, and respiratory infection. Age was the only variable that was related to the hospital department designated to manage these SSUs. The mean ages by management type were as follows: independent SSUs (75.6 years) vs ED-managed SSUs (67.2 years) vs IMD-managed SSUs (57.8 years) (P=.02). Group-by-group comparisons showed that the mean length of stay was shorter in ED-managed SSUs than in IMD-managed units (2.65 vs 3.73 respectively; P=.047), and overall mortality was lower in IMD-managed SSUs than in ED-managed SSUs (0.64% vs 3%; P=.033). However, unforeseen mortality (after excluding patients under palliative care or judged to be in the final hours of life) did not differ significantly between groups.

CONCLUSION

We did not detect important differences between SSUs managed by different departments in the hospitals in this series. However, mean length of stay was found to be shorter in ED-managed SSUs than in IMD-managed units.

Analysis of disability using WHODAS 2.0 among the middle-aged and elderly in Cinco Villas, Spain

BACKGROUND

The prevalence of disability, as defined by the International Classification of Functioning, Disability and Health (ICF), among the middle-aged and elderly population is poorly known.

OBJECTIVE

To determine disability prevalence in a resident population sample aged ≥50 years, in the Cinco Villas district, Spain, from June 2008 through June 2009.

METHODS

We used the WHODAS 2.0 36-item questionnaire to quantify the prevalence of disability, globally and by domain, together with a 13-item combined measure of three domains, Getting around, Self-care and Life activities, claimed to reflect the need of integrated services. In addition, we performed exploratory analyses of the relationship between disability and different variables using ordinal logistic regression.

RESULTS

Disability was detected by global WHODAS score in 604 of a total of 1214 persons, i.e., a prevalence of 49.8% 95% CI (46.9-52.5), with the corresponding figures for mild, moderate, severe, and extreme disability being 26.8%, 16.0%, 7.6% and 0.1%, respectively. Disability increased with age, was higher among women, and for specific domains. Prevalence of severe/extreme disability among women vs. men was as follows: Getting around, 26.8% vs. 12.1%; Life activities, 25.2% vs. 6.8%; and Self-care, 9.5% vs. 6.0%. Disability was more frequent among subjects diagnosed with dementia, chronic liver disease, severe mental disease, and stroke. The abovementioned 13-item measure yielded prevalence figures for disability levels quite similar to those obtained using 36-item scores.

CONCLUSIONS

For the first time, this study furnishes detailed disability prevalence figures and data on associated variables in a middle-aged and elderly Western population.

Nutrition risk, functional dependence, and co-morbidities affect depressive symptoms in Taiwanese aged 53 years and over: a population-based longitudinal study

OBJECTIVE

This study examined cross-sectional and longitudinal associations of nutritional risk, functional dependence and co-morbidities with depressive symptoms in people aged 53 years and over in Taiwan.

METHODS

Study data were obtained from a population-based longitudinal study, the Taiwan Longitudinal Study of Aging (TLSA), with a nationally representative sample of nearly-old and old Taiwanese.

RESULTS

The prevalence of having depressive symptoms and being at risk of malnutrition/malnourishment in 1999 was 23% and 21%. Mini-Nutritional Assessment (MNA) score, being at risk of malnutrition/malnourishment, number of self-reported co-morbidities, and activities of daily living (ADL) score were all cross-sectionally correlated with depressive symptoms (all p<.05). Being at risk of malnutrition/malnourishment and number of co-morbidities were also longitudinally associated with increased risk of subsequent depressive symptoms over four and eight years (all p<.05). The relationship between nutritional risk and subsequent depressive symptoms was stronger than the relationship between co-morbidities and ADL score and subsequent depressive symptoms.

CONCLUSIONS

These results suggested that nutritional risk, co-morbidities and functional dependence are all associated with increased risks of depressive symptoms in people aged 53 years and above. Nutritional risk contributes significantly to subsequent depressive symptoms and is a strong and consistent predictor of subsequent depressive symptoms in nearly-old and old Taiwanese.