Antoni Salvà

COGNITIVE FRAILTY: RATIONAL AND DEFINITION FROM AN (I.A.N.A./I.A.G.G.) INTERNATIONAL CONSENSUS GROUP

The frailty syndrome has recently attracted attention of the scientific community and public health organizations as precursor and contributor of age-related conditions (particularly disability) in older persons. In parallel, dementia and cognitive disorders also represent major healthcare and social priorities. Although physical frailty and cognitive impairment have shown to be related in epidemiological studies, their pathophysiological mechanisms have been usually studied separately. An International Consensus Group on “Cognitive Frailty” was organized by the International Academy on Nutrition and Aging (I.A.N.A) and the International Association of Gerontology and Geriatrics (I.A.G.G) on April 16th, 2013 in Toulouse (France). The present report describes the results of the Consensus Group and provides the first definition of a “Cognitive Frailty” condition in older adults. Specific aim of this approach was to facilitate the design of future personalized preventive interventions in older persons. Finally, the Group discussed the use of multidomain interventions focused on the physical, nutritional, cognitive and psychological domains for improving the well-being and quality of life in the elderly. The consensus panel proposed the identification of the so-called “cognitive frailty” as an heterogeneous clinical manifestation characterized by the simultaneous presence of both physical frailty and cognitive impairment. In particular, the key factors defining such a condition include: 1) presence of physical frailty and cognitive impairment (CDR=0.5); and 2) exclusion of concurrent AD dementia or other dementias. Under different circumstances, cognitive frailty may represent a precursor of neurodegenerative processes. A potential for reversibility may also characterize this entity. A psychological component of the condition is evident and concurs at increasing the vulnerability of the individual to stressors.

International Association of Gerontology and Geriatrics: A Global Agenda for Clinical Research and Quality of Care in Nursing Homes

A workshop charged with identifying the main clinical concerns and quality of care issues within nursing homes was convened by the International Association of Gerontology and Geriatrics, with input from the World Health Organization. The workshop met in Toulouse, France, during June 2010. Drawing on the latest evidence and mindful of the international development agenda and specific regional challenges, consensus was sought on priority actions and future research. The impetus for this work was the known variation in the quality of nursing home care experiences of older people around the world. The resulting Task Force recommendations include instigation of sustainable strategies designed to enhance confidence among older people and their relatives that the care provided within nursing homes is safe, mindful of their preferences, clinically appropriate, and delivered with respect and compassion by appropriately prepared expert doctors, registered nurses, administrators, and other staff. The proposals extend across 4 domains (Reputational Enhancement and Leadership, Clinical Essentials and Care Quality Indicators, Practitioner Education, and Research) that, in concert, will enhance the reputation and status of nursing home careers among practitioners, promote effective evidence-informed quality improvements, and develop practice leadership and research capabilities.

Physical Exercise Interventions for Improving Performance-Based Measures of Physical Function in Community-Dwelling, Frail Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVE To conduct a systematic review to determine the efficacy of exercise-based interventions on improving performance-based measures of physical function and markers of physical frailty in community-dwelling, frail older people. DATA SOURCES Comprehensive bibliographic searches in MEDLINE, the Cochrane Library, PEDro, and CINAHL databases were conducted (April 2013). STUDY SELECTION Randomized controlled trials of community-dwelling older adults, defined as frail according to physical function and physical difficulties in activities of daily living (ADL). Included trials had to compare an exercise intervention with a control or another exercise intervention, and assess performance-based measures of physical function such as mobility and gait, or disability in ADL. DATA EXTRACTION Two review authors independently screened the search results and performed data extraction and risk of bias assessment. Nineteen trials were included, 12 of them comparing exercise with an inactive control. Most exercise programs were multicomponent. DATA SYNTHESIS Meta-analysis was performed for the comparison of exercise versus control with the inverse variance method under the random-effects models. When compared with control interventions, exercise was shown to improve normal gait speed (mean difference [MD]=.07m/s; 95% confidence interval [CI], .04-.09), fast gait speed (MD=.08m/s; 95% CI, .02-.14), and the Short Physical Performance Battery (MD=2.18; 95% CI, 1.56-2.80). Results are inconclusive for endurance outcomes, and no consistent effect was observed on balance and the ADL functional mobility. The evidence comparing different modalities of exercise is scarce and heterogeneous. CONCLUSIONS Exercise has some benefits in frail older people, although uncertainty still exists with regard to which exercise characteristics (type, frequency, duration) are most effective.

Incidence and consequences of falls among elderly people living in the community.

BACKGROUND AND OBJECTIVES To evaluate the incidence of falls according to socio-demographic and health factors, and to determine their physical, psychological and social consequences. SUBJETS AND METHOD: Population-based prospective study, which included a representative cohort of 448 elderly community-dwellers, aged 65 or more living in the city of Mataró (Spain). We made a baseline evaluation, which was repeated after a one-year follow up, consisting of a standardized questionnaire on socio-demographic characteristics, physical activity, tests of physical and cognitive function, history of falls during the previous year, the Falls Efficacy Scale, and associated chronic conditions. Follow-up interviews at intervals of one month over 12 months, consisting of a standardized questionnaire aimed at detecting and describing any fall occurred during the previous month. RESULTS 25.1% (95% CI, 18.8-31.4) of males and 37.0% (95% CI, 31.2-42.8) of females fell. Multiple falls were observed in 3.8% of men and 10.9% of women. 203 falls were reported, providing a crude incidence rate of 30.9 falls per 100 men-years (95% CI, 23.3-41.0) and 56.5 falls per 100 women-years (95% CI, 46.5-68.8). A positive association with falls was found with age, reduced physical and cognitive function, associated chronic conditions and previous falls. 71.1% of falls had physical consequences, with 7.7% of fractures, and 21.7% needed medical aid. 64.4% of fallers feared of falling again. CONCLUSIONS Our study shows a pattern of high incidence of falls among the elderly living in the Spanish non-institutionalized community. Our data confirm that adverse consequences derived from the falls are frequent and often severe, which makes falls one of the major problems of elderly people.

Malnutrition in community-dwelling adults with dementia (Nutrialz Trial)

ObjectivesThe objective of this study is to assess the nutritional status, measured by the MNA, in community-dwelling elderly individuals with dementia and to identify clinical risk factors for nutritional risk or malnutrition.DesignCross-sectional analysis of a cluster randomized clinical trial (Nutrialz).SettingCommunity-dwelling individuals attending dementia clinics.Participants940 individuals.MeasurementsThe clinical scales assessed were Mini Nutritional Assessment (MNA), Eating Behaviour Scale (EBS), Charlson comorbidity index, Clinical Dementia Rating (CDR), Mini-Mental State Examination (MMSE), Basic Activities of Daily Living (BADL) score, Instrumental Activities of Daily Living (IADL) score, Neuropsychiatric Inventory Questionnaire (NPI-Q), Cornell depression scale and Zarit Caregiver Burden Interview.Results5.2% of participants were classified as being malnourished, 42.6% as being at risk of malnutrition and 52.2% as well nourished. Malnutrition by type of dementia was more frequent in Lewy bodies dementia (18.2%) than in the other types. Worse nutritional status is significantly related to more advanced age and worse cognitive, functional and behavioural profile, as well as increased burden for caregivers. Presence of behavioural symptoms is significantly related to worse nutritional level for all NPI-Q symptoms but depression, exaltation, lack of inhibition and irritability. The items more strongly related to malnutrition are appetite/feeding and hallucinations. Dependence in any basic or instrumental ADL is significantly related to higher risk of malnutrition. Dependence on feeding is a strongly related risk factor, while food preparation is only a moderate one. A logistic regression model to predict at risk/malnutrition kept as significant risk factors EBS (Odds Ratio (OR) 0.84, 95%CI 0.78 to 0.91), Cornell (OR 1.12, 95%CI 1.09 to 1.16), the number of dependent BADL (OR 1.29, 95%CI 1.17 to 1.42), age (OR 1.04, 95%CI 1.02–1.06), MMSE (OR 0.95, 95%CI 0.92 to 0.98) and Charlson (OR 1.18, 95%CI 1.05 to 1.34). A similar model built for prediction of malnutrition retained as significant covariables only EBS, Cornell and the number of dependent BADL.ConclusionThese results will allow a better understanding of the clinical stage previous to malnutrition. An adequate diagnosis and treatment of identified modifiable factors like functional impairment, eating behaviours and depression could delay or avoid malnutrition.

Changes in whole-brain functional networks and memory performance in aging

We used resting-functional magnetic resonance imaging data from 98 healthy older adults to analyze how local and global measures of functional brain connectivity are affected by age, and whether they are related to differences in memory performance. Whole-brain networks were created individually by parcellating the brain into 90 cerebral regions and obtaining pairwise connectivity. First, we studied age-associations in interregional connectivity and their relationship with the length of the connections. Aging was associated with less connectivity in the long-range connections of fronto-parietal and fronto-occipital systems and with higher connectivity of the short-range connections within frontal, parietal, and occipital lobes. We also used the graph theory to measure functional integration and segregation. The pattern of the overall age-related correlations presented positive correlations of average minimum path length (r = 0.380, p = 0.008) and of global clustering coefficients (r = 0.454, p < 0.001), leading to less integrated and more segregated global networks. Main correlations in clustering coefficients were located in the frontal and parietal lobes. Higher clustering coefficients of some areas were related to lower performance in verbal and visual memory functions. In conclusion, we found that older participants showed lower connectivity of long-range connections together with higher functional segregation of these same connections, which appeared to indicate a more local clustering of information processing. Higher local clustering in older participants was negatively related to memory performance.

Health and nutritional promotion program for patients with dementia (Nutrialz Study): Design and baseline data

BackgroundThere is a lack of data on global weight loss prevention programs for patients with dementia or clear evidence about their impact on a functional level, caregiver burden or the use of healthcare and social resources. “NutriAlz” is a socio-educative and nutritional intervention program to prevent weight loss and loss of function in dementia patients.Study Design and MethodsA cluster randomized multi-centre study, which will allow the comparison of a group benefiting from the intervention with a control group after a year of monitoring. Patients were recruited from 11 hospitals in the ambulatory diagnostic units and day care centres. The baseline interview include: sociodemographic and socioeconomic variables (age, gender, educational level, marital status); diagnostic, treatments, MMS, a list of comorbid conditions; activities of daily living (ADL, IADL), Zarit Scale, brief-NPI, Cornell scale and nutritional status as measured by the Mini Nutritional Assessment. All participants or their family signed the inform consent form.Baseline characteristicsTotal of 946 patients were included, with a mean (± SD) of 79 ± 7.3 year of age; 68,1 % were women; 44,9% lives with their partner, only 3% lives alone; 79.8% had Alzheimer’s dementia, 5.25 ± 3.0 years since symptoms of dementia and 2.8 ± 2.11 years since diagnosis. Mean MMSE score was 15.4 ± 6.2; mean weight was 64.4 ± 12.5 kg; mean BMI was 27.0 ± 4.5 (with 3% below 19, 5% between 19–21, 10% between 21–23, and 82% above 23). Mean ADL without difficulties was 3.2± 2.1; mean IADL without difficulties was 0.7± 1.6; mean number of symptoms in the NPI was 4.4 ± 2.59, with severity score of 7.9 ± 5.9 and distress score of 11.3 ± 9.0; mean Zarit scale was 27.4 ± 15.5; mean MNA was 23.2 ± 3.5 with 5 % as malnourished, 32 % at risk of malnutrition, and 63 % with adequate nutritional status.

Falls and risk factors for falls in community-dwelling adults with dementia (NutriAlz trial).

To estimate the number of fallers and risk factors for falls in a cohort with dementia, we did a secondary analysis of a cluster-randomized controlled trial (NutriAlz) in 11 outpatient and day care centers in Catalonia (Spain) including 626 community-dwelling patients with dementia, followed for 12 months. Participants’ characteristics were assessed at baseline, at 6 and 12 months [fall in the earlier 6 mo, anthropometric data, comorbidities, Mini-Mental State Examination, Clinical Dementia Rating, Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living, Neuropsychiatric Inventory Questionnaire, Zarit Caregiver Burden Interview and Mini-Nutritional Assessment]. Multivariate logistic regression models and generalized linear models were used to explore risk factors for falls and changes in health and function. Two hundred twenty-three participants fell during the 12 months follow-up (35.62%). Risk factors identified for falls were age (odds ratio (OR)=1.03, 95% confidence interval (CI), 1.00-1.05), BADL (OR=1.18, 95% CI, 1.05-1.32), and earlier fall (OR=2.30, 95% CI, 1.57-3.35). Fallers had worse health than nonfallers, and their dependence increased significantly more in BADL during the study, compared with nonfallers. Dependence in BADL is a risk factor and a consequence of falls; interventions aimed at preventing falls in dementia patients could promote autonomy in BADL and slow its decline.

Evaluation of a urinary incontinence unit for community-dwelling older adults in Barcelona: implementation and improvement of the perceived impact on daily life, frequency and severity of urinary incontinence.

BackgroundUrinary incontinence >(UI) is one of the most important and frequent geriatric syndromes. It is considered a silent but great social problem. Conservative management of UI, in a multidisciplinary and comprehensive approach, has been successful in previous studies, leading to a partial or total remission of the syndrome.AimsTo investigate the acceptance of a geriatric incontinence unit and the effect of a multidimensional intervention on the improvement of UI regarding frequency, severity and perceived impact on daily life of community-dwelling older adults.MethodologyProspective study with a multifactorial intervention with pre-post analyses. 92 patients aged 60 years and over were assessed for UI at an outpatient geriatric unit. They received an individualized conservative treatment and were followed up for 3 months. The International Consultation on Incontinence modular Questionnaire-Short Form (ICIQ-SF) was translated into Catalan. The difference of the perceived impact on the daily life before and 3 months after treatment was used as a primary outcome. The global score and the subscores on frequency and severity were used as secondary outcomes.Results77.2% patients had an improvement in their perceived impact of UI on daily life. Concerning the ICIQ-SF global score, 82.6% improved. There was a significant improvement of about 30% in all dimensions measured. Many patients pointed out that being able to talk about the problem with a healthcare professional, in some cases for the first time, was very important to them.ConclusionsA conservative and multidisciplinary management of UI improved the impact of UI on daily life among comorbid geriatric patients. The Catalan ICIQ-SF was successfully implemented. Outpatient geriatric incontinence units seem to be effective and should be implemented to improve detection and management of this important geriatric syndrome.ZusammenfassungHintergrundDie Harninkontinenz ist eines der wichtigsten und häufigsten geriatrischen Syndrome. Sie wird als stilles, dabei jedoch großes soziales Problem betrachtet. Dennoch hat die konservative Behandlung der Harninkontinenz in einem multidisziplinären und globalen Ansatz, bereits erfolgreiche Ergebnisse aufzuweisen und in vorausgegangenen Studien zu einer partiellen oder sogar totalen Remission der Syndrome geführt.Ziele der StudieUntersuchung der Akzeptanz einer geriatrischen Inkontinenz-Ambulanz und des Effektes eines multidimensionalen Therapieansatzes auf die Verbesserung der Harninkontinenz hinsichtlich der Häufigkeit, des Schweregrades und der Wahrnehmung der Beeinträchtigung des Alltagslebens bei zu Hause lebenden älteren Menschen.MethodenProspektive Studie mit einer multifaktoriellen Intervention und Vorher-Nachher-Analyse. 92 Patienten, älter als 60 Jahre, wurden in einer geriatrischen Ambulanz für Harninkontinenz gezielt untersucht. Es wurde eine individualisierte konservative Behandlung und eine Nachbeobachtung von drei Monaten durchgeführt. Der „International Consultation on Incontinence modular Questionnaire-Short Form“ (ICIQ-SF) wurde ins Katalanische übersetzt. Als primärer Outcome wurde der Unterschied der subjektiven Wahrnehmung der Beeinträchtigung des Alltagslebens vor und nach dreimonatiger Behandlung gewählt. Der globale Score und die Subscores Häufigkeit und Schweregrad wurden als sekundäre Outcomes benutzt.Ergebnisse:Bei 77,2% der Patienten wurde eine Verbesserung der subjektiven Wahrnehmung der Beeinträchtigung des Alltagslebens durch die Harninkontinenz erreicht. Bezüglich des globalen Scores verbesserten sich sogar 82,6%. In allen untersuchten Dimensionen konnte eine signifikante Verbesserung um etwa 30% nachgewiesen werden. Viele Patienten betonten, dass Sie es als sehr positiv empfunden hätten, in einigen Fällen sogar zum ersten Mal, über dieses Problem mit ausgebildetem Gesundheitspersonal sprechen zu können.SchlussfolgerungEin konservatives und multidimensionelles Behandlungskonzept der Harninkontinenz verbesserte die Wahrnehmung der Alltagsbeeinträchtigung bei komorbiden, geriatrischen Patienten. Die katalanische Übersetzung des ICIQ-SF konnte erfolgreich eingesetzt werden. Geriatrische Ambulanzen für Harninkontinenz scheinen wirksam zu sein und sollten in Zukunft vermehrt eingerichtet werden, um die Erkennung und Behandlung dieses wichtigen geriatrischen Syndroms zu verbessern.

Biomarkers associated with sedentary behaviour in older adults: A systematic review

OBJECTIVE Pathomechanisms of sedentary behaviour (SB) are unclear. We conducted a systematic review to investigate the associations between SB and various biomarkers in older adults. METHODS Electronic databases were searched (MEDLINE, EMBASE, CINAHL, AMED) up to July 2015 to identify studies with objective or subjective measures of SB, sample size ≥50, mean age ≥60years and accelerometer wear time ≥3days. Methodological quality was appraised with the CASP tool. The protocol was pre-specified (PROSPERO CRD42015023731). RESULTS 12701 abstracts were retrieved, 275 full text articles further explored, from which 249 were excluded. In the final sample (26 articles) a total of 63 biomarkers were detected. Most investigated markers were: body mass index (BMI, n=15), waist circumference (WC, n=15), blood pressure (n=11), triglycerides (n=12) and high density lipoprotein (HDL, n=15). Some inflammation markers were identified such as interleukin-6, C-reactive protein or tumor necrosis factor alpha. There was a lack of renal, muscle or bone biomarkers. Randomized controlled trials found a positive correlation for SB with BMI, neck circumference, fat mass, HbA1C, cholesterol and insulin levels, cohort studies additionally for WC, leptin, C-peptide, ApoA1 and Low density lipoprotein and a negative correlation for HDL. CONCLUSION Most studied biomarkers associated with SB were of cardiovascular or metabolic origin. There is a suggestion of a negative impact of SB on biomarkers but still a paucity of high quality investigations exist. Longitudinal studies with objectively measured SB are needed to further elucidate the pathophysiological pathways and possible associations of unexplored biomarkers.