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Hosts recent articles from research based journals. Pinboard started in August 2016.
This board collates published research on older people in prehospital care.
The board is aimed at those working in the area of prehospital care.
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This board is maintained and run by Matt Holland, Librarian LKS ASE Matt.Holland@nwas.nhs.uk.
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Abstract: This article is based on the M. Powell Lawton Award Lecture that I delivered at the 2016 Gerontological Society of America Annual Meeting. I provide an overview of my journey in geriatric medicine and delirium research. I created new measures, including the Confusion Assessment Method, for identification of delirium; conceptualized a multifactorial risk model; and developed and tested intervention strategies for delirium prevention. The Hospital Elder Life Program arose from this work. In addition, like Dr. Lawton, I am working to apply my work to the policy arena. As the population ages, we face an unprecedented opportunity to realize the full benefit of aging in our society, an untapped resource. The field of aging is facing innumerable challenges in terms of continued stigma and funding shortfalls for clinical care and research. I issue a call to action to clinicians, researchers, and leaders in aging to seize this opportunity to use our know-how and expertise to transform the experience of aging for all.
Pub.: 23 Feb '18, Pinned: 09 Mar '18
Abstract: Publication date: Available online 13 February 2018 Source:Archives of Gerontology and Geriatrics Author(s): Jane Andreasen, Mette Aadahl, Erik Elgaard Sørensen, Helle Højmark Eriksen, Hans Lund, Kim Overvad OBJECTIVE To assess whether frailty in acutely admitted older medical patients, assessed by a self-report questionnaire and evaluation of functional level at discharge, was associated with readmission or death within 6 months after discharge. A second objective was to assess the predictive performance of models including frailty, functional level, and known risk factors. METHODS A cohort study including acutely admitted older patients 65+ from seven medical and two acute medical units. The Tilburg Frailty Indicator (TFI), Timed-Up-and-Go (TUG), and grip strength (GS) exposure variables were measured. Associations were assessed using Cox regression with first unplanned readmission or death (all-causes) as the outcome. Prediction models including the three exposure variables and known risk factors were modelled using logistic regression and C-statistics. RESULTS Of 1,328 included patients, 50% were readmitted or died within 6 months. When adjusted for gender and age, there was an 88% higher risk of readmission or death if the TFI scores were 8–13 points compared to 0–1 points (HR 1.88, CI 1.38;2.58). Likewise, higher TUG and lower GS scores were associated with higher risk of readmission or death. The area under the curve for the prediction models ranged from 0.64 (0.60;0.68) to 0.72 (0.68;0.76). CONCLUSION In acutely admitted older medical patients, higher frailty assessed by TFI, TUG, and GS was associated with a higher risk of readmission or death within 6 months after discharge. The performance of the prediction models was mediocre, and the models cannot stand alone as risk stratification tools in clinical practice.
Pub.: 15 Feb '18, Pinned: 09 Mar '18
Abstract: Predicting case types that are unlikely to be treated by paramedics can aid in managing demand for emergency ambulances by identifying cases suitable for alternative management pathways. The aim of this study was to identify the patient characteristics and triage outcomes associated with ‘no paramedic treatment’ for cases referred for emergency ambulance dispatch following secondary telephone triage.A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch following secondary telephone triage between September 2009 and June 2012. Multivariable logistic regression modelling was used to identify explanatory variables associated with ‘no paramedic treatment’.There were 19,041 cases eligible for inclusion in this study over almost three years, of which 8510 (44.7%) were not treated after being sent an emergency ambulance following secondary triage. Age, time of day, pain, triage guideline group, and comorbidities were associated with ‘no paramedic treatment’. In particular, cases 0–4 years of age or those with psychiatric conditions were significantly less likely to be treated by paramedics, and increasing pain resulted in higher rates of paramedic treatment.This study highlights that case characteristics can be used to identify particular case types that may benefit from care pathways other than emergency ambulance dispatch. This process is also useful to identify gaps in the alternative care pathways currently available. These findings offer the opportunity to optimise secondary telephone triage services to support their strategic purpose of minimising unnecessary emergency ambulance demand and to match the right case with the right care pathway.
Pub.: 10 Jan '18, Pinned: 14 Jan '18
Abstract: To summarize the best available evidence regarding the effectiveness of interventions for preventing frailty progression in older adults.Frailty is an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. Evidence supporting the malleability of frailty, its prevention and treatment, has been presented.The review considered studies on older adults aged 65 and over, explicitly identified as pre-frail or frail, who had been undergoing interventions focusing on the prevention of frailty progression. Participants selected on the basis of specific illness or with a terminal diagnosis were excluded. The comparator was usual care, alternative therapeutic interventions or no intervention. The primary outcome was frailty. Secondary outcomes included: (i) cognition, quality of life, activities of daily living, caregiver burden, functional capacity, depression and other mental health-related outcomes, self-perceived health and social engagement; (ii) drugs and prescriptions, analytical parameters, adverse outcomes and comorbidities; (iii) costs, and/or costs relative to benefits and/or savings associated with implementing the interventions for frailty. Experimental study designs, cost effectiveness, cost benefit, cost minimization and cost utility studies were considered for inclusion.Databases for published and unpublished studies, available in English, Portuguese, Spanish, Italian and Dutch, from January 2001 to November 2015, were searched. Critical appraisal was conducted using standardized instruments from the Joanna Briggs Institute. Data was extracted using the standardized tools designed for quantitative and economic studies. Data was presented in a narrative form due to the heterogeneity of included studies.Twenty-one studies, all randomized controlled trials, with a total of 5275 older adults and describing 33 interventions, met the criteria for inclusion. Economic analyses were conducted in two studies. Physical exercise programs were shown to be generally effective for reducing or postponing frailty but only when conducted in groups. Favorable effects on frailty indicators were also observed after the interventions, based on physical exercise with supplementation, supplementation alone, cognitive training and combined treatment. Group meetings and home visits were not found to be universally effective. Lack of efficacy was evidenced for physical exercise performed individually or delivered one-to-one, hormone supplementation and problem solving therapy. Individually tailored management programs for clinical conditions had inconsistent effects on frailty prevalence. Economic studies demonstrated that this type of intervention, as compared to usual care, provided better value for money, particularly for very frail community-dwelling participants, and had favorable effects in some of the frailty-related outcomes in inpatient and outpatient management, without increasing costs.This review found mixed results regarding the effectiveness of frailty interventions. However, there is clear evidence on the usefulness of such interventions in carefully chosen evidence-based circumstances, both for frailty itself and for secondary outcomes, supporting clinical investment of resources in frailty intervention. Further research is required to reinforce current evidence and examine the impact of the initial level of frailty on the benefits of different interventions. There is also a need for economic evaluation of frailty interventions.
Pub.: 13 Jan '18, Pinned: 14 Jan '18
Abstract: To understand the influence of prehospital physical function and strength on clinical outcomes of critically ill older adults.Secondary analysis of prospective cohort study.Health, Aging and Body Composition (Health ABC) Study.Of 3,075 older adult Health ABC participants, we identified 575 (60% white, 61% male, mean age 79) with prehospital function or grip strength measurements within 2 years of an intensive care unit stay.The primary analysis evaluated the association between prehospital walk speed and mortality, and secondary analyses focused on associations between function or grip strength and mortality or hospital length of stay. Function and grip strength were analyzed as continuous and categorical predictors.Slower prehospital walk speed was associated with greater risk of 30-day mortality (for each 0.1 m/s slower, odds ratio = 1.13, 95% confidence interval (CI) = 1.04–1.23, P = .004). Grip strength, chair stands, and balance had weaker, non-statistically significant associations with 30-day mortality. Participants with slower prehospital walk speed (hazard ratio (HR) = 0.94, 95% CI = 0.90–0.98, P = .005) and weak grip strength (HR = 0.85, 95% CI = 0.73–0.99, P = .03) were less likely to be discharged from the hospital alive. All function and strength measures were significantly associated with 1-year mortality.Slow prehospital walk speed was strongly associated with greater 30-day mortality and longer hospital stay in critically ill older adults, and measures of function and strength were associated with 1-year mortality. These data add to the accumulating evidence on the relationship between physical function and critical care outcomes.
Pub.: 11 Jan '18, Pinned: 12 Jan '18
Abstract: Objective and importance of study: To describe characteristics and temporal trends of fall-related ambulance service use and hospital admission in older adults in New South Wales (NSW), Australia. Such information will facilitate a more targeted approach to planning and delivery of health services to prevent falls and their adverse sequelae in different groups of older adults.Retrospective population-based descriptive study.Fall-related ambulance use and hospital admissions for all falls and injurious falls in NSW residents aged ≥65 years between 2006 and 2013 were obtained from two discrete sources of routinely collected data. Rates of use are presented descriptively.There were 314 041 occasions of fall-related ambulance use by older adults and 331 311 fall-related hospitalisations, of which 69% (n = 227 753) were for injurious falls. Fractures accounted for 57% of injurious hospitalisations. Slips and trips were the most common mechanism of falls requiring hospitalisation (52%). Residents of aged care facilities had a greater proportion of fall injury hospitalisations compared with people living in the community (85% and 65%, respectively).Rates of fall-related ambulance use and hospitalisation were similar and continued to increase over time. Increased effort is needed to prevent falls and associated injury among older people in NSW, particularly among people living in aged care facilities. Ongoing monitoring of rates and the characteristics of people who fall are needed to determine the long-term impact of fall prevention interventions.
Pub.: 09 Nov '17, Pinned: 24 Dec '17
Abstract: The study aimed to evaluate the predictive validity of the Brody self-report frailty index among older people. Design, setting and measurements: A longitudinal cohort study (2-years) conducted in Sweden, which included 1141 respondents, aged 65-103 years. Data were collected during 2011-2013 through a postal questionnaire with questions about demographic data, living conditions, self-reported health, ADL dependency (ADL-staircase) and frailty (the Brody frailty index).The total sample was comprised of 53 percent women and the mean age was 74.5 years (SD 7.0). The mean frailty index score at baseline was 0.12 and increased with higher age (rs= 0.819) as well as with increased ADL dependency (rs = 0.740). The analyses showed high percentage of correctly classified cases (97.1-98.2), high specificity (98.1-98.4) but low sensitivity (22.2-66.7).The self-report frailty index seems to be a valid measure of current frailty, but its predictive validity was found to be non-acceptable especially regarding the instrument's sensitivity. Such instrument can be useful to predict frailty and allocate resources in the care of older people.
Pub.: 23 Nov '17, Pinned: 24 Dec '17
Abstract: frailty is a central concept in geriatric medicine, yet its utility in the Emergency Department (ED) is not well understood nor well utilised. Our objectives were to develop an ED frailty index (FI-ED), using the Rockwood cumulative deficits model and to evaluate its association with adverse outcomes.this was a large multinational prospective cohort study using data from the interRAI Multinational Emergency Department Study. The FI-ED was developed from the Canadian cohort and validated in the multinational cohort. All patients aged ≥75 years presenting to an ED were included. The FI-ED was created using 24 variables included in the interRAI ED-Contact Assessment tool.there were 2,153 participants in the Canadian cohort and 1,750 in the multinational cohort. The distribution of the FI-ED was similar to previous frailty indices. The mean FI-ED was 0.26 (Canadian cohort) and 0.32 (multinational cohort) and the 99th percentile was 0.71 and 0.81, respectively. In the Canadian cohort, a 0.1 unit increase in the FI-ED was significantly associated with admission (odds ratio (OR) = 1.43 [95% CI: 1.34-1.52]); death at 28 days (OR = 1.55 [1.38-1.73]); prolonged hospital stay (OR = 1.37 [1.22-1.54]); discharge to long-term care (OR = 1.30 [1.16-1.47]); and need for comprehensive geriatric assessment (OR = 1.51 [1.41-1.60]). The multinational cohort showed similar associations.the FI-ED conformed to characteristics previously reported. A FI, developed and validated from a brief geriatric assessment tool could be used to identify ED patients at higher risk of adverse events.
Pub.: 23 Nov '17, Pinned: 24 Dec '17
Abstract: Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The SHARE-FI (Survey of Health, Ageing and Retirement in Europe Frailty Instrument) frailty measure, developed for use in the community, has also been used in the emergency department (ED).To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts.A prospective cohort study was completed of those aged ≥70 presenting to ED over 24 hours, seven days a week.Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and six and twelve month outcomes were reviewed.Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR0.89, 95% CI0.58-1.38, p = 0.614) or being alive at home at twelve months (OR1.07, 95% CI0.72-1.57, p = 0.745. Older patients were more likely to die (OR2.34, 95% CI1.30-4.21, p = 0.004) and less likely to be alive at home at twelve months (OR0.49, 95% CI0.23-0.83, p = 0.009). Patients with dementia (OR0.24, p = 0.005) and on ≥ 5 medications (OR0.37, 95% CI0.16-0.87, p = 0.022) had a lower likelihood of being alive at home at twelve months.Almost half of the sample cohort were frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED.
Pub.: 14 Dec '17, Pinned: 24 Dec '17
Abstract: Delirium is a geriatric syndrome, characterized by acutely altered mental status with inattention, fluctuating course and global cognitive dysfunction, which is associated with a significant burden in terms of negative outcomes and costs of care. Delirium is frequently undetected despite its prevalence and incidence are relevant. In this brief report, we report the state of the art in terms of prevention for both medical and surgical patients. A non-pharmacological approach seems to be the more promising method to prevent delirium and improve quality of care for people at risk.
Pub.: 03 Nov '17, Pinned: 24 Dec '17
Abstract: To investigate the effectiveness and cost of an 18-month multi-disciplinary Comprehensive Fragility Fracture Management Program (CFFMP) for fragility hip fracture patients.Prospective cohort study.Elderly patients with hip fracture were recruited at their first postoperative follow-up in 2 district hospitals. The intervention group comprised patients from the hospital undergoing CFFMP, and the control group comprised patients from another hospital undergoing conventional care. CFFMP provided geri-orthopaedic co-management, physician consultations, group-exercise and vibration-therapy. Timed-up-and-go test (TUG), Elderly Mobility Scale (EMS), Berg Balance Scale (BBS) and fall risk screening (FS) were used to assess functional performance. Incidences of falls and secondary fractures, the cost of the programme and related healthcare resources were recorded.A total of 76 patients were included in the intervention group (mean age 77.9 years ((standard deviation; SD) 6.1) ) and 77 in the control group (79.9 (SD 7.2)), respectively. The re-fracture rate in the control group (10.39%) was significantly higher than in the intervention group (1.32%) (p = 0.034). The intervention group improved significantly in TUG, EMS and FS after a 1-year programme. The overall healthcare costs per patient in the intervention and control groups were US$22,450 and US$25,313, respectively.Multi-disciplinary CFFMP is effective, with reduced overall cost, reduced length of hospital stay and reduced secondary fracture rate. The rehabilitation community service favours rehabilitation and improved quality of life of hip fracture patients.
Pub.: 21 Dec '17, Pinned: 22 Dec '17
Abstract: Existing operational definitions of frailty are personnel-costly and time-consuming, resulting in estimates with a small sample size that cannot be generalized to the population level. The objectives were to develop a multimorbidity frailty index using Taiwan's claim database, and to understand its ability to predict adverse event.This is a retrospective cohort study. Subjects aged 65 to 100 years who have full National Health Insurance coverage in 2005 were included. We constructed the multimorbidity frailty index using cumulative deficit approach and categorized study population according to the multimorbidity frailty index quartiles: fit, mild frailty, moderate frailty and severe frailty. The multimorbidity frailty index included deficits from outpatient and inpatient diagnosis. Associations with all-cause mortality, unplanned hospitalization and intensive care unit admission were assessed using Kaplan-Meier curves and Cox regression analyses.The multimorbidity frailty index incorporated 32 deficits, with mean multimorbidity frailty index score of 0.052 (standard deviation = 0.060) among 86,133 subjects included. Compared to subjects in fit category, subjects with severe frailty were associated with a 5.0-fold (adjusted hazard ratio, aHR 4.97; 95% confidence interval, 95% CI 4.49-5.50) increased risk of death at 1 year after adjusting for age and gender. Subjects with moderate frailty or mild frailty was associated with 3.1- (adjusted HR 3.08; 95% CI 2.80-3.39) or 1.9- (adjusted HR 1.86; 95% CI 1.71-2.01) folds increased risk, respectively.4.49-5.50). The risk trend of unplanned hospitalization and intensive care unit admission is similar among the study population. Besides, the association between the frailty categories and all three outcomes was slightly stronger among women.The multimorbidity frailty index was highly associated with all-cause mortality, unplanned hospitalization and ICU admission. It could serve as an efficient tool for stratifying older adults into different risk groups for planning care management programs.
Pub.: 18 Nov '17, Pinned: 04 Dec '17
Abstract: Coronary spastic angina (CSA) is relatively more common in young people than in elderly people. Here, we present three cases of elderly male patients who experienced out-of-hospital cardiac arrest (OHCA) likely due to coronary spasm-induced ventricular fibrillation (Vf) from 2013 to 2016. After defibrillation, emergency coronary arteriography demonstrated severe coronary vasospasm that resolved following intracoronary infusion of nitroglycerin in the right coronary arteries in all three patients, with no organic obstructive lesion in the coronary arteries after nitroglycerin infusion. Case 1 was a 74-year-old patient with a past history of unstable angina and no organic obstructive lesion on coronary arteriography. He was administered oral amlodipine, isosorbide mononitrate, and nicorandil. He survived an OHCA and underwent implantable cardioverter defibrillator (ICD) implantation on day 57. Case 2 was a 71-year-old patient without prior CSA, who suddenly lost consciousness during a break after tennis. Vf was reversed to sinus rhythm by defibrillation in the ambulance. He died of multi-organ failure on day 7. Case 3 was a 66-year-old patient diagnosed with multi-vessel CSA by coronary arteriography with acetylcholine provocation test. He survived an OHCA associated with inferior acute myocardial infarction, rejected ICD implantation, and has not had a chest pain attack or syncope since discharge.
Pub.: 01 Nov '17, Pinned: 06 Nov '17
Abstract: It is unknown if the association between delirium and mortality is consistent for individuals across the whole range of health states. A bimodal relationship has been proposed, where delirium is particularly adverse for those with underlying frailty, but may have a smaller effect (perhaps even protective) if it is an early indicator of acute illness in fitter people. We investigated the impact of delirium on mortality in a cohort simultaneously evaluated for frailty.We undertook an exploratory analysis of a cohort of consecutive acute medical admissions aged ≥70. Delirium on admission was ascertained by psychiatrists. A Frailty Index (FI) was derived according to a standard approach. Deaths were notified from linked national mortality statistics. Cox regression was used to estimate associations between delirium, frailty and their interactions on mortality.The sample consisted of 710 individuals. Both delirium and frailty were independently associated with increased mortality rates (delirium: HR 2.4, 95%CI 1.8-3.3, p<0.01; frailty (per SD): HR 3.5, 95%CI 1.2-9.9, p=0.02). Estimating the effect of delirium in tertiles of FI, mortality was greatest in the lowest tertile: tertile 1 HR 3.4 (95%CI 2.1-5.6); tertile 2 HR 2.7 (95%CI 1.5-4.6); tertile 3 HR 1.9 (95% CI 1.2-3.0).While delirium and frailty contribute to mortality, the overall impact of delirium on admission appears to be greater at lower levels of frailty. In contrast to the hypothesis that there is a bimodal distribution for mortality, delirium appears to be particularly adverse when precipitated in fitter individuals.
Pub.: 04 Nov '17, Pinned: 06 Nov '17
Abstract: A growing number of older adults use in-home Medicaid Waiver Home and Community Based services (HCBS) to facilitate aging-in-place. A primary service of this program is Home Care Aide assistance with activities of daily living and homemaker needs. Despite the known benefits of exercise, exercise programs are currently not offered to clients in the Medicaid Waiver system. Thus, the purpose of this paper is to describe a six-month Home Care Aide-led resistance exercise intervention protocol for frail older adults receiving Medicaid waiver services.
Pub.: 01 Sep '17, Pinned: 06 Nov '17
Abstract: To describe the natural history of frailty transitions in a large cohort of community-dwelling older men and identify predictors associated with progression to or improvement from states of greater frailty.Prospective cohort study.Six U.S. sites.Community-dwelling men aged 65 and older (N = 5,086).Frailty was measured at baseline and an average of 4.6 years later. Frailty was defined as having three or more of the following components (low lean mass, weakness, self-reported exhaustion, low activity level, and slow walking speed); prefrailty was defined as having one or two components. Separate multivariable logistic regression models were analyzed for progression and improvement in frailty status.Of the 5,086 men, 8% were frail, 46% were prefrail, and 46% were robust at baseline. Between baseline and follow-up, 35% progressed in frailty status or died, 56% had no change in frailty status, and 15% of prefrail or frail participants improved, although only 0.5% improved across two levels, from frail to robust. In multivariable models, factors associated with improvement in frailty status included greater leg power, being married, and good or excellent self-reported health, whereas presence of any instrumental activity of daily living (IADL) limitations, low albumin levels, high interleukin-6 levels, and presence of chronic obstructive pulmonary disease or diabetes mellitus were associated with lower likelihood of improvement in frailty status.Improvement in frailty status was possible in this cohort of community-dwelling older men, but improvement from frail to robust was rare. Several predictors were identified as possible targets for intervention, including prevention and management of comorbid medical conditions, prevention of IADL disability, physical exercise, and nutritional and social support.
Pub.: 05 Sep '17, Pinned: 29 Oct '17
Abstract: Type 2 diabetes mellitus (T2DM) is a major risk factor for falls and frailty in older adults. The purpose of this review was to survey, the current literature on risk factors and interventions for prevention of falls and frailty in older adults with T2DM.Screening for falls and frailty in the clinical setting is recommended. Exercise to improve balance, strength, and mobility; health education; and diabetes self-management are potential interventions for falls and frailty in older adults with T2DM. Pharmacologic agents are the focus of current studies which may lead to potential future interventions for both falls and frailty.Evidence-based guidelines and tools for prevention and management of falls and frailty have been developed for clinicians caring for older adults. Because of the reciprocal relationship between falls and frailty, interventions to prevent one may also improve the other geriatric syndrome.
Pub.: 22 Jul '17, Pinned: 26 Oct '17
Abstract: Frailty is an important risk factor for adverse outcomes in older people. Substantial variation in frailty prevalence between socioeconomic groups exists, but longitudinal evidence for the association between socioeconomic position (SEP) and frailty is scarce.To investigate the course of socioeconomic inequalities in frailty among older adults during 10 years of follow-up.Data were used from the Longitudinal Aging Study Amsterdam (n = 1,509). Frailty was measured with the functional domains approach, based on deficiencies in four domains: physical, nutritive, cognitive, and sensory. Mixed-model analyses were performed to estimate the course of frailty and its association with SEP during a 10-year follow-up. We investigated whether similar patterns of associations held in different scenarios, comparing results of survivor analyses with those based on two imputation methods accounting for dropout due to death (substitution of first missing value and missing values imputed with a prediction model).All scenarios showed a linear increase in frailty with aging (survivor analyses OR = 1.87, 95% CI = 1.66-2.11) and associations of low education and low income with frailty (adjusted OR for low education = 1.76, 95% CI = 1.05-2.97; adjusted OR for low income = 1.90, 95% CI = 1.20-3.01; both for survivor analyses). Sex-stratified analyses indicated that socioeconomic inequalities were mainly present in men, not in women. Similar patterns of associations of SEP with frailty were observed in all scenarios, but the increase in frailty prevalence over time differed substantially between the scenarios. There were no statistically significant interactions between time and SEP on frailty (all scenarios), suggesting that inequalities in frailty did not increase or decrease during follow-up.SEP inequalities in frailty among older adults were observed, mainly among men, and persisted during 10 years of follow-up.
Pub.: 23 Oct '17, Pinned: 24 Oct '17
Abstract: Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.
Pub.: 04 Oct '17, Pinned: 21 Oct '17
Abstract: screening for cognitive impairment in Emergency Department (ED) requires short, reliable tools.to validate the 4AT and 6-Item Cognitive Impairment Test (6-CIT) for ED dementia and delirium screening.diagnostic accuracy study.attendees aged ≥70 years in a tertiary care hospital's ED.trained researchers assessed participants using the Standardised Mini Mental State Examination, Delirium Rating Scale-Revised 98 and Informant Questionnaire on Cognitive Decline in the Elderly, informing ultimate expert diagnosis using Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for dementia and delirium (reference standards). Another researcher blindly screened each participant, within 3 h, using index tests 4AT and 6-CIT.of 419 participants (median age 77 years), 15.2% had delirium and 21.5% had dementia. For delirium detection, 4AT had positive predictive value (PPV) 0.68 (95% confidence intervals: 0.58-0.79) and negative predictive value (NPV) 0.99 (0.97-1.00). At a pre-specified 9/10 cut-off (9 is normal), 6-CIT had PPV 0.35 (0.27-0.44) and NPV 0.98 (0.95-0.99). Importantly, 52% of participants had no family present. A novel algorithm for scoring 4AT item 4 where collateral history is unavailable (score 4 if items 2-3 score ≥1; score 0 if items 1-3 score is 0) proved reliable; PPV 0.65 (0.54-0.76) and NPV 0.99 (0.97-1.00). For dementia detection, 4AT had PPV 0.39 (0.32-0.46) and NPV 0.94 (0.89-0.96); 6-CIT had PPV 0.46 (0.37-0.55) and NPV 0.94 (0.90-0.97).6-CIT and 4AT accurately exclude delirium and dementia in older ED attendees. 6-CIT does not require collateral history but has lower PPV for delirium.
Pub.: 07 Oct '17, Pinned: 21 Oct '17
Abstract: To explore how older people with complex health problems experience frailty in their daily lives.A better understanding of the personal experience of frailty in the context of fluctuating ill-health has the potential to contribute to the development of personalised approaches to care planning and delivery.An ethnographic study of older people, living at home, receiving support from a community matron service in a large city in the North of England.Up to six care encounters with each of ten older people, and their community matron, were observed at monthly intervals, over a period of time ranging from 4 to 11 months. Semi-structured interviews were conducted with the older participants in their own homes. Fieldwork took place over a 4-year period. Data analysis was undertaken using the constant comparative method.The experience of frailty was understood through the construction of four themes: Fluctuating ill-health and the disruption of daily living; Changes to the management of daily living; Frailty as fear, anxiety and uncertainty; Making sense of changes to health and daily living.Older people work hard to shape and maintain daily routines in the context of complicated and enduring transitions in health and illness. However, they experience episodic moments of frailty, often articulated as uncertainty, where daily living becomes precarious and their resilience is threatened. Developing an understanding of the personal experiences of frail older people in the context of transition has the potential to inform nursing practice in person-centred care .Nurses need to support frail older people to maintain independence and continuity of personhood in the context of daily routines.
Pub.: 11 Oct '17, Pinned: 21 Oct '17
Abstract: The question of this systematic review is: What is the diagnostic test accuracy of self-reported frailty screening instruments among community-dwelling older people against any of the following reference standard tests: the frailty phenotype, frailty index and comprehensive geriatric assessment?
Pub.: 17 Oct '17, Pinned: 21 Oct '17
Abstract: There are some older patients who are 'at the decision margin' of admission. This systematic review sought to explore this issue with the following objective: what admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear.Systematic review of controlled studies (April 2005-December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed.Primary and secondary healthcare interface.People aged over 65 years at risk of an unplanned admission.Any community-based intervention offered as an alternative to admission to an acute hospital.Reduction in secondary care use, patient-related outcomes, safety and costs.Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities.This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking.
Pub.: 03 Aug '17, Pinned: 02 Oct '17
Abstract: Frailty is one of the most challenging aspects of population ageing due to its association with increased risk of poor health outcomes and quality of life. General practice provides an ideal setting for the prevention and management of frailty via the implementation of preventive measures such as early identification through screening.Our study will evaluate the feasibility, acceptability and diagnostic test accuracy of several screening instruments in diagnosing frailty among community-dwelling Australians aged 75+ years who have recently made an appointment to see their general practitioner (GP). We will recruit 240 participants across 2 general practice sites within South Australia. We will invite eligible patients to participate and consent to the study via mail. Consenting participants will attend a screening appointment to undertake the index tests: 2 self-reported (Reported Edmonton Frail Scale and Kihon Checklist) and 5 (Frail Scale, Groningen Frailty Index, Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA-7), Edmonton Frail Scale and Gait Speed Test) administered by a practice nurse (a Registered Nurse working in general practice). We will randomise test order to reduce bias. Psychosocial measures will also be collected via questionnaire at the appointment. A blinded researcher will then administer two reference standards (the Frailty Phenotype and Adelaide Frailty Index). We will determine frailty by a cut-point of 3 of 5 criteria for the Phenotype and 9 of 42 items for the AFI. We will determine accuracy by analysis of sensitivity, specificity, predictive values and likelihood ratios. We will assess feasibility and acceptability by: 1) collecting data about the instruments prior to collection; 2) interviewing screeners after data collection; 3) conducting a pilot survey with a 10% sample of participants.The Torrens University Higher Research Ethics Committee has approved this study. We will disseminate findings via publication in peer-reviewed journals and presentation at relevant conferences.
Pub.: 05 Aug '17, Pinned: 02 Oct '17
Abstract: Both frailty and falls occur at earlier than expected ages among HIV-infected individuals, but the contribution of frailty to fall risk in this population is not well understood. We examined this association among participants enrolled in AIDS Clinical Trials Group (ACTG) A5322.A prospective, multi-center cohort study of HIV-infected men and women ≥40 years.Frailty assessment included a 4-meter walk, grip strength, and self-reported weight loss, exhaustion, and low physical activity. Multinomial logistic regression assessed the association between baseline frailty, grip, and 4-meter walk and single and recurrent (2+) falls over the next 12 months; logistic regression assessed effect modification by several factors on association between frailty and any (1+) falls.Of 967 individuals, 6% were frail, 39% pre-frail, and 55% non-frail. Eighteen percent had ≥1 fall, and 7% had recurrent falls. In multivariable models, recurrent falls were more likely among frail (OR = 17.3; 95% CI = 7.03-42.6) and pre-frail (OR = 3.80; 95% CI = 1.87-7.72) than non-frail individuals. Significant associations were also seen with recurrent falls and slow walk and weak grip. The association between frailty and any falls was substantially stronger among individuals with peripheral neuropathy.Aging HIV-infected pre-frail and frail individuals are at significantly increased risk of falls. Incorporation of frailty assessments or simple evaluations of walk speed or grip strength in clinical care may help identify individuals at greatest risk for falls. Peripheral neuropathy further increases fall risk among frail persons, defining a potential target population for closer fall surveillance, prevention, and treatment.
Pub.: 15 Aug '17, Pinned: 02 Oct '17
Abstract: The association between frailty and malnutrition is widely noted, but the common and distinct aspects of this relationship are not well understood. We investigated the prevalence of prefrailty/frailty and malnutrition/nutritional risk; their overlapping prevalence; compared their sociodemographic, physical, and mental health risk factors; and assessed their association, independently of other risk factors.Cross-sectional study of population-based cohort (Singapore Longitudinal Ageing Study [SLAS]-1 [enrolled 2003-2005] and SLAS-2 [enrolled 2010-2013]) of community-dwelling older Singaporeans aged ≥55 (n = 6045).Mini Nutritional Assessment (MNA)-Short Form (SF), Nutritional Screening Initiative (NSI) Determine Checklist, Fried physical frailty phenotype.The overall prevalence of MNA malnutrition was 2.8%, and at risk of malnutrition was 27.6%; the prevalence of frailty and prefrailty were 4.5%, and 46.0% respectively. Only 26.5% of participants who were malnourished were frail, but 64.2% were prefrail (totally 90.7% prefrail or frail). The prevalence of malnutrition among frail participants was 16.1%, higher than in other studies (10%); nearly one-third of the whole population sample had normal nutrition while being prefrail (27.7%) or frail (1.5%). The prevalence of risk factors for prefrailty/frailty and malnutrition/nutritional risk were remarkably similar. MNA at risk of malnutrition and malnutrition were highly significantly associated with prefrailty (odds ratio [OR] 2.11 and 6.71) and frailty (OR 2.72 and 17.4), after adjusting for many other risk factors. The OR estimates were substantially lower with NSI moderate and high nutritional risk for prefrailty (OR 1.39 and 1.74) and frailty (OR 1.27 and 1.93), but remain significantly elevated.Frailty and malnutrition are related but distinct conditions in community-dwelling older adults. The contribution of poor nutrition to frailty in this population is notably greater. Both frail/prefrail elderly and those who are malnourished/at nutritional risk should be identified early and offered suitable interventions.
Pub.: 15 Aug '17, Pinned: 02 Oct '17
Abstract: Higher levels of frailty result in higher risks of adverse frailty outcomes such as hospitalisation and mortality. There are, however, indications that more factors than solely frailty play a role in the development of these outcomes. The presence of resources, e.g. sufficient income and good self-management abilities, might slow down the pathway from level of frailty to adverse outcomes (e.g. mortality). In the present paper we studied whether resources (i.e. educational level, income, availability of informal care, living situation, sense of mastery and self-management abilities) moderate the impact of the level of frailty on the adverse outcomes mortality, hospitalisation and the development of disability over a two-year period.Longitudinal data on a sample of 2420 community-dwelling pre-frail and frail older people were collected. Participants filled out a questionnaire every six months, including measures of frailty, resources and outcomes. To study the moderating effects of the selected resources their interaction effects with levels of frailty on outcomes were studied by means of multiple logistics and linear regression models.Frail older participants had increased odds of mortality and hospitalisation, and had more deteriorating disability scores compared to their pre-frail counterparts. No moderating effects of the studied resources were found for the outcomes mortality and hospitalisation. Only for the outcome disability statistically significant moderating effects were present for the resources income and living situation, yet these effects were in the opposite direction to what we expected. Overall, the studied resources showed hardly any statistically significant moderating effects and the directions of the trends were inconsistent.Frail participants were more at risk of mortality, hospitalisation, and an increase in disability. However, we were unable to demonstrate a clear moderating effect of the studied resources on the adverse outcomes associated with frailty (among pre-frail and frail participants). More research is needed to increase insight into the role of moderating factors. Other resources or outcome measures should be considered.
Pub.: 19 Aug '17, Pinned: 02 Oct '17
Abstract: The hypothesis of reverse epidemiology holds that, obesity may reduce the risk of clinical adverse events in older subjects. However, this association is controversial and rarely explored according to the underlying health status. We tested this phenomenon by assessing the association between body mass index (BMI) and clinical adverse events in community dwelling older women according to their frailty status.EPIDOS is a multicenter prospective cohort of community-dwelling women aged 75 and older recruited between 1992 and 1994. At baseline, we collected demographics, BMI (<21 kg/m(2): underweight; 21-24.9: normal weight; 25-29.9: overweight and ≥30: obesity), frailty through Fried model, and clinical characteristics. All-cause mortality, falls, hip fractures, and hospital admission were collected within 5 years of follow-up and were analyzed using univariate and multivariate survival analysis by using Kaplan-Meier methods and Cox Hazard Proportional models.Of 6662 women (mean age, 80.4 years), 11.6%; 95% Confidence Interval (95% CI) CI [10.8%-12.3%] were frail. By multivariate analysis, the risk of death in frail women (compared to not-frail normal weight women) decreases with increase of BMI: adjusted Hazard Ratio (aHR)frail-underweight = 2.04 [1.23-3.39]; aHRfrail-normal weight = 3.07 [2.21-4.26]; aHRfrail-overweight = 1.83 [1.31-2.56]; aHRfrail-obese = 1.76 [1.15-2.70]; p < 0.001. Frail overweight and obese women had a significant lower risk of death than frail normal-weight women (p = 0.004). Similar features were found for fall risk and hip fracture and for not-frail women. The relative risks of hospital admission for normal weight, overweight and obese frail women were similar (aHRfrail-normal weight = 1.50 [1.22-1.84], aHR frail-overweight =1.48 [1.26-1.74] and aHR frail-obese =1.53 [1.24-1.89], respectively).Our results suggest that overweight and obesity reduce the risks of clinical adverse events in frail community-dwelling older women and that frailty definition through Fried model had to be re-calibrated for overweight and obese individuals.
Pub.: 29 Aug '17, Pinned: 02 Oct '17
Abstract: Physical frailty increases the risk of future activity limitation, which in turn, compromises independent living of older people and limits their healthspan. Thus, we seek to identify moderators and mediators of the effect of physical frailty on activity limitation change in older people, including gender- and age-specific effects. In a longitudinal study using data from waves 2, 4, and 6 of the English Longitudinal Study of Ageing, unique physical frailty factor scores of 4638 respondents aged 65 to 89years are obtained from confirmatory factor analysis of physical frailty, which is specified by three indicators, namely slowness, weakness, and exhaustion. Using a series of autoregressive cross-lagged models, we estimate the effect of physical frailty factor score on activity limitation change, including its moderation by social conditions, and indirect effects through physical and psychological conditions. We find that the effect of physical frailty on activity limitation change is significantly stronger with older age, while it has significant indirect effects through low physical activity, depressive symptoms, and cognitive impairment. In turn, indirect effects of physical frailty through low physical activity and cognitive impairment are stronger with older age. Sensitivity analyses suggest that these effects vary in their robustness to unmeasured confounding. We conclude that low physical activity, depressive symptoms, and cognitive impairment are potentially modifiable mediators on pathways from physical frailty to activity limitation in older people, including those who are very old. This evidence offers support for population-level interventions that target these conditions, to mitigate the effect of physical frailty on activity limitation, and thereby enhance healthspan.
Pub.: 29 Aug '17, Pinned: 02 Oct '17
Abstract: The aim of this study was to examine the association of sedentary behaviour patterns with frailty in older people.Clinical setting.Cross-sectional, observational study.A triaxial accelerometer was used in a subsample from the Toledo Study for Healthy Aging (519 participants, 67-97 years) to assess several sedentary behaviour patterns including sedentary time per day, the number and duration (min) of breaks in sedentary time per day, and the proportion of the day spent in sedentary bouts of 10 minutes or more. Frailty was assessed using the Frailty Trait Scale (FTS). Regression analysis was used to ascertain the associations between sedentary behaviour patterns and frailty.Sedentary time per day and the proportion of the day spent in sedentary bouts of 10 minutes or more, were positively associated with frailty in the study sample. Conversely, the time spent in breaks in sedentary time was negatively associated with frailty.In summary, breaking up sedentary time and time spent in sedentary behaviour are associated with frailty in older people.
Pub.: 12 Sep '17, Pinned: 02 Oct '17
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