Failure to complete performance-based measures is associated with poor health status and an increased risk of death
TL;DR: The aim of the study was to establish whether the use of antipsychotic medication in elderly people with dementia is aversive to their quality of life and promote well-being.
Abstract: design, execution, analysis and interpretation of data, or preparation of the study. ALASTAIR MACDONALD1∗, DIMITRIOS ADAMIS2, ADRIAN TRELOAR2, FINBARR MARTIN3 1Institute of Psychiatry, Psychological Medicine, London, UK Email: alastair.macdonald@iop.kcl.ac.uk 2Oxleas NHS Trust, Old Age Psychiatry, London, UK 3Guy’s and St Thomas’ NHS Foundation Trust, Elderly Care Unit, London, UK ∗To whom correspondence should be addressed
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TL;DR: Frailty status correlated significantly with length of stay and was a predictor of poor functional gain, suggesting the FI may have clinical utility, augmenting clinical judgement in the management of older inpatients.
Abstract: Background: multidisciplinary rehabilitation is of proven benefit in the management of older inpatients. However, the identification of patients who will do well with rehabilitation currently lacks a strong evidence base.
Objectives: the aims of this study were to compare the importance of chorological age, gender, co-morbidities and frailty in the prediction of adverse outcomes for patients admitted to an acute geriatric rehabilitation ward.
Design: prospective observational cohort study.
Subjects and setting: two hundred and sixty-five patients admitted consecutively to an acute geriatric rehabilitation ward at a tertiary care teaching hospital.
Methods: frailty status was measured by an index of accumulated deficits, giving a potential score from 0 (no deficits) to 1.0 (all 40 deficits present). Patients were stratified into three outcomes: good (discharged to original residence within 28 days), intermediate (discharged to original residence but longer hospital stay) and poor (newly institutionalised or died).
Results: patients were old (82.6 ± 8.6 years) and frail (mean frailty index (FI) 0.34 ± 0.09). Frailty status correlated significantly with length of stay and was a predictor of poor functional gain. The odds ratio of intermediate and poor outcome relative to a good outcome was 4.95 (95% CI = 3.21, 7.59; P < 0.001) per unit increase in FI. Chronological age, gender and co-morbidity showed no significant association with outcomes.
Conclusion: frailty is associated with adverse rehabilitation outcomes. The FI may have clinical utility, augmenting clinical judgement in the management of older inpatients.
97 citations
Cites background from "Failure to complete performance-bas..."
...Since those unable to complete cognitive [13] or performance-based measures [14] have a worse outcome, inability to complete each test also counted as a deficit....
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TL;DR: Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes, and could optimise clinical utility and minimise costs.
Abstract: Background: A better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care. Methods: 1418 patients aged ≥70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis. Results: Variables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data. Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0–1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0. In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70 – 2.48]). Conclusions: Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs. The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.
96 citations
Cites background from "Failure to complete performance-bas..."
...This is defined as restlessness, lethargy, being difficult to arouse or displaying altered environmental perception [26]....
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...To complete coding of functional domains, in view of the association between failure to complete performancebased measures and adverse outcomes [26], an interRAI score of 8 was also coded as 1 full deficit....
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TL;DR: The relationship between impaired balance, mobility and frailty, and relate these to risk of death is described and a subsample of 1295 community-dwelling non-demented adults from the second wave of the Canadian Study of Health and Aging is examined.
93 citations
TL;DR: Investigation of how two specific tests of postural control, LOS and postural stability, relate to ankle muscle strength and foot sensation in older adults may lead to a better understanding of the mechanisms underlying falls that occur during reaching and bending movements.
Abstract: SIR—Loss of balance and falls in the elderly constitute a major problem associated with human suffering as well as high costs for society [1]. Falls might occur during various daily activities, such as tripping or tangling the feet, reaching movements or bending [2]. Many of these activities are constrained by limits of stability (LOS). LOS can be described as the maximum distance a person can intentionally displace his/her centre of gravity, and lean his/her body in a given direction without losing balance, stepping or grasping. Accordingly, one's LOS capacity is likely to be an important prerequisite for the successful planning and execution of movements such as using a step stool to reach into a high cabinet as well as bending over from standing position to pick up an object from the floor.
Ageing is associated with decreased LOS [3–5], muscle strength [6] and foot sensation [7]. Investigators have reported significant correlations between postural stability, quadriceps, ankle dorsiflexion and hand-grip strength [8–11], tibialis anterior latency [8] and functional clinical balance testing [12] among older adults. However, the relationships between lower-limb muscle strength and falls are unclear. Several studies show minimal or no differences in strength between fallers and non-fallers [13, 14] while others show no strength–falls relationships [15].
Cutaneous mechanoreceptors at the soles of the feet contribute to postural stability when standing [16]. Those with reduced feet sensation have a higher risk of falling [17] and greater instability [18]. Reduced foot sensation may contribute to reduced LOS, since older adults might not properly detect when the centre of gravity approaches the LOS.
To our knowledge, no one has studied how postural control during LOS relates to ankle strength and foot sensation among older adults.
The aims of this study are to investigate how two specific tests of postural control, LOS and postural stability, relate to ankle muscle strength and foot sensation in older adults. Identification of sensorimotor factors associated with both types of balance control can help us to understand better the balance problems facing older adults. Given that LOS likely requires highly active muscular control and that postural stability requires careful sensory monitoring of stance, we hypothesised that ankle muscle strength (and not foot sensation) will be significantly correlated with LOS and that foot sensation (and not ankle muscle strength) will be significantly correlated with postural stability. Data from this study may lead to a better understanding of the mechanisms underlying falls that occur during reaching and bending movements.
92 citations
TL;DR: A review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization is presented.
Abstract: There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.
88 citations
Cites background from "Failure to complete performance-bas..."
...Other concerns include the relatively high proportion of older adults with significant cognitive and functional limitations (who many would argue are frail) unable to complete these measures(25,26) and the limited specificity of some of these measures....
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TL;DR: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition, and finds that there is an intermediate stage identifying those at high risk of frailty.
Abstract: Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.
Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.
Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).
Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
16,255 citations
"Failure to complete performance-bas..." refers background in this paper
...Sir—Mobility impairment is common in elderly people, often leads to adverse outcomes [1–4] and is intertwined with frailty [5, 6]....
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TL;DR: A new Geriatric Depression Scale (GDS) designed specifically for rating depression in the elderly was tested for reliability and validity and compared with the Hamilton Rating Scale for Depression (HRS-D) and the Zung Self-Rating Depression Scale(SDS) as discussed by the authors.
13,014 citations
TL;DR: This study evaluated a modified, timed version of the “Get‐Up and Go” Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital and suggested that the timed “Up & Go’ test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time.
Abstract: This study evaluated a modified, timed version of the "Get-Up and Go" Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital (mean age 79.5 years). The patient is observed and timed while he rises from an arm chair, walks 3 meters, turns, walks back, and sits down again. The results indicate that the time score is (1) reliable (inter-rater and intra-rater); (2) correlates well with log-transformed scores on the Berg Balance Scale (r = -0.81), gait speed (r = -0.61) and Barthel Index of ADL (r = -0.78); and (3) appears to predict the patient's ability to go outside alone safely. These data suggest that the timed "Up & Go" test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time. The test is quick, requires no special equipment or training, and is easily included as part of the routine medical examination.
12,004 citations
"Failure to complete performance-bas..." refers background or methods in this paper
...We did not use the original cutpoints for the TUG, but rather used the performance tertiles....
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...Here, those with missing data on either one of the TUG or FR had worse outcomes than those with poor performance, and those with missing data for both had the worst outcomes....
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...As with those whose performance on both the FR and TUG was impaired, patients with missing data on either or both the FR/TUG were more likely to be older women and to have worse scores for mood, cognition, function and co-morbidity (Table 1)....
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...Kaplan-Meier curves of survival over 5 years for each of the FR (Panel A) and TUG (Panel B) ability and inability groups....
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...However, in three recent investigations of mobility in the elderly, the proportion with missing data varied widely from 1.0 to 19.5% for the FR and 0.7 to 51% for the TUG [10, 13, 23]....
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TL;DR: A large number of changes, distant from the site or sites of inflammation and involving many organ systems, may accompany inflammation, and the mechanisms mediating them are becoming better understood.
Abstract: A large number of changes, distant from the site or sites of inflammation and involving many organ systems, may accompany inflammation. In 1930 interest was focused on these changes by the discovery of C-reactive protein (so named because it reacted with the pneumococcal C-polysaccharide) in the plasma of patients during the acute phase of pneumococcal pneumonia.1 Accordingly, these systemic changes have since been referred to as the acute-phase response,2 even though they accompany both acute and chronic inflammatory disorders. New acute-phase phenomena continue to be recognized, and the mechanisms mediating them are becoming better understood. This review summarizes much of . . .
6,157 citations