Claudio Bilotta

Older People's Quality of Life (OPQOL) scores and adverse health outcomes at a one-year follow-up. A prospective cohort study on older outpatients living in the community in Italy

BackgroundThere is limited knowledge on the ability of a poor quality of life (QOL) and health-related QOL (HRQOL) to predict mortality and other adverse health events, independently of the frailty syndrome and other confounders, in older people living in the community and not selected on the basis of specific chronic conditions. Aim of this study was to evaluate the ability of the overall QOL and of the HRQOL to predict several adverse health outcomes at a one-year follow-up in an older outpatient population living in the community.MethodsWe carried out a prospective cohort study on 210 community-dwelling outpatients aged 65+ (mean age 81.2 yrs) consecutively referred to a geriatric clinic in Milan, Italy. At baseline participants underwent a comprehensive geriatric assessment including evaluation of overall QOL and HRQOL by means of the Older Peoples Quality of Life (OPQOL) questionnaire. At a one-year follow-up, between June and December 2010, we investigated nursing home placement and death in all 210 participants as well as any fall, any admission to the emergency department (ED), any hospitalisation and greater functional dependence among the subset of subjects still living at home.ResultsOne year after the visit 187 subjects were still living at home (89%) while 7 had been placed in a nursing home (3.3%) and 16 had died (7.7%). At multiple logistic regression analyses the lowest score-based quartile of the OPQOL total score at baseline was independently associated with a greater risk of any fall and any ED admission. Also, the lowest score-based quartile of the health-related OPQOL sub-score was associated with a greater risk of any fall as well as of nursing home placement (odds ratio [OR] 10.03, 95% confidence interval [CI] 1.25-80.54, P = 0.030) and death (OR 4.23, 95% CI 1.06-16.81, P = 0.041). The correlation with the latter two health outcomes was found after correction for age, sex, education, income, living conditions, comorbidity, disability and the frailty syndrome.ConclusionsIn an older outpatient population in Italy the OPQOL total score and its health-related sub-score were independent predictors of several adverse health outcomes at one year. Notably, poor HRQOL predicted both nursing home placement and death even after correction for the frailty syndrome. These findings support and enhance the prognostic relevance of QOL measures.

A short measure of quality of life in older age: The performance of the brief Older People's Quality of Life questionnaire (OPQOL-brief)

Promoting quality of life in older age is an internationally recognized priority, requiring valid measurement. We present a short version of the established Older Peoples Quality of Life questionnaire (OPQOL-brief). The full OPQOL-35 was original in being developed from the perspectives of older people, assessed conceptually, and validated with a population sample using gold-standard psychometric assessment. The OPQOL-brief was also developed by asking older people to prioritize the most important items from the OPQOL-35, next assessed psychometrically with a population sample, and also statistically against the discarded 22 items. The aim was to assess the psychometric properties of the short, 13-item version of the OPQOL (OPQOL-brief), and to compare the performance of included and discarded items. The method was a national population survey of people aged 65+ living at home. The measures were OPQOL-brief, WHOQOL-QOL and CASP-19. The OPQOL-brief was found to be a highly reliable and valid, short measure of quality of life in older age. The OPQOL-brief is of value in assessment of interventions where a rigorously tested, short measure is required. The grounded development of the instrument is consistent with international policy emphasis on user involvement in shaping policy and research.

Frailty syndrome diagnosed according to the Study of Osteoporotic Fractures (SOF) criteria and adverse health outcomes among community-dwelling older outpatients in Italy. A one-year prospective cohort study

The easy-to-apply SOF criteria for frailty were recently validated in studies conducted in the U.S. only. In order to determine the ability of the SOF criteria to predict adverse health outcomes at a one-year follow-up in a sample of older outpatients in Italy we carried out a prospective cohort study on 265 community-dwelling outpatients aged 65+ (mean age 81.5 years) consecutively referred to a geriatric clinic. At baseline participants underwent a comprehensive geriatric assessment (CGA) including evaluation of their frailty status according to the SOF criteria. At a one-year follow-up, between June and December 2010, we investigated nursing home placement and death in all participants as well as any fall, any admission to the emergency department (ED), any hospitalization and a greater disability among the subset of subjects still living at home. One year after the visit 231 subjects were still living at home (87.2%), 9 had been placed in a nursing home (3.4%) and 25 had died (9.4%). Frailty was associated with a greater risk of falls (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.05-3.83, p=0.035), hospitalization (OR 2.08, 95% CI 1.02-4.24, p=0.045) and death (OR 3.07, 95% 1.02-4.24, p=0.045) after correction for demographic characteristics, comorbidity including dementia and depression, socioeconomic position and severe disability. Thus, in an older outpatient population in Italy the frailty syndrome diagnosed according to the SOF criteria was an independent predictor of several adverse health outcomes.

Frailty syndrome diagnosed according to the Study of Osteoporotic Fractures criteria and mortality in older outpatients suffering from Alzheimer's disease: A one-year prospective cohort study

Objective: The frailty syndrome is associated with adverse clinical outcomes independently of cognitive impairment. The recent easy-to-apply Study of Osteoporotic Fractures (SOF) criteria for frailty could be useful to diagnose such syndrome also in Alzheimers disease (AD) patients. The aim of this study was to apply these criteria among AD outpatients in order to determine: (i) the prevalence and correlates of frailty and (ii) the one-year predictors of death in this population. Method: This prospective cohort study enrolled 109 community-dwelling outpatients aged 65+ (median age 84 years) consecutively diagnosed with AD at a geriatric outpatient service in Italy in 2009. At baseline, participants underwent a comprehensive geriatric assessment including the evaluation of frailty status by means of the SOF criteria. Multiple logistic regression analysis was performed to find correlates of frailty. At a one-year follow-up, data on mortality were available for 95 participants and predictors of death were evaluated by means of multiple logistic regression analysis. Results: Most participants had mild (52%) or moderate (29%) dementia. Frailty status was defined for all subjects at baseline: 25 (22%) were robust, 30 (28%) pre-frail and 54 (50%) frail. Independent correlates of frailty were age and dependence in the basic activities of daily living, and in particular in dressing. One year after enrolment, frailty was an independent predictor of death (odds ratio 11.27, 95% confidence interval 1.64–77.72, p = 0.014) after correction for age, sex, dependence in the basic activities of daily living, severity of cognitive impairment and comorbidity. Conclusion: Frailty status was diagnosed according to the SOF criteria in all AD outpatients and it was an independent one-year predictor of death. In order to provide them with appropriate prognostic evaluation and therapeutic advice all AD outpatients, especially those with specific disabilities, could be screened by means of the SOF criteria for frailty.

Caregiver burden as a short-term predictor of weight loss in older outpatients suffering from mild to moderate Alzheimer's disease: A three months follow-up study

Objective: To determine if caregiver burden (CB) can be an independent predictive factor of weight loss at three months in older outpatients suffering from mild to moderate Alzheimers disease (AD) and living at home. Method: Prospective cohort study involving 105 subjects aged 70 years or more, affected by mild to moderate AD and living at home with the assistance of at least one informal caregiver, who consecutively underwent a multidimensional geriatric assessment. Body weight was re-evaluated at a three month follow-up, from December 2008 to April 2009. Those who experienced a weight loss greater than 3% of the baseline weight constituted the ‘weight loss’ group. Results: Out of the 97 older participants attending follow-up, 22 (23%) had experienced a weight loss > 3%. At a multivariate logistic regression analysis, a greater CB at baseline, defined by a score of the caregiver burden inventory scale in the highest tertile (i.e. 36+ out of 96), turned out to predict weight loss at three months (odds ratio (OR) 13.93, 95% confidence interval (CI) 1.91–101.33, p = 0.009), independently of other factors associated with the ‘weight loss’ group such as age, functional dependence and the risk of malnutrition estimated by means of the Mini Nutritional Assessment Short Form (MNA-SF). Conclusion: For older outpatients affected by mild to moderate AD and living at home, CB constitutes a risk factor for weight loss even in the short-term, independently of other factors such as the risk of malnutrition assessed by means of the MNA-SF.

Social vulnerability, mental health and correlates of frailty in older outpatients living alone in the community in Italy.

Objective: To determine the main social, functional and clinical characteristics of community-dwelling older outpatients living alone and to find correlates of frailty in this population. Method: Cross-sectional survey of 302 community-dwelling outpatients aged 65+ (median age 82 years) consecutively referred to a geriatric medicine clinic in Italy from June to November 2009. Participants underwent a comprehensive geriatric assessment including frailty status evaluated by means of the study of osteoporotic fractures (SOF) criteria. Students t-test and the chi-squared test were used to compare subjects ‘living alone’ and ‘not living alone’ as well as ‘frail’ and ‘not frail’ subjects among the participants living alone. Multiple logistic regression analyses were performed to find independent correlates of frailty among participants living alone. Results: Participants ‘living alone’ were 124 (41%). Compared to subjects ‘not living alone’ (n = 178), they were older, received less assistance from informal and formal caregivers, had poorer living and financial conditions, a better cognitive status and functional self-sufficiency but a worse emotional status. One-third of them (n = 41) were frail. Among frail elders (n = 116), subjects living alone also showed a higher prevalence of unexpected new diagnoses of dementia than those not living alone. Independent correlates of frailty among participants living alone were: having experienced a severe acute disease in the past year (odds ratio [OR] 303.9; 95% confidence interval [CI] 13–7091; p < 0.001), dependence in the bathing BADL ability (OR 62.74; 95% CI 12.17–323.32; p < 0.001), depression (OR 10.43; 95% CI 2.31–47.13; p = 0.002) and incontinence (OR 3.98; 95% CI 1.01–15.66; p = 0.048). Conclusion: In older outpatients living alone, including those who were frail, we found a lower availability of personal assistance, significantly more social and financial vulnerability and a higher risk of depression. In frail elders there was also a higher prevalence of underdiagnosed dementia. In order to better recognise frail subjects in this specific population, four independent correlates of frailty were identified.

One-year predictors of turnover among personal-care workers for older adults living at home in Italy

ABSTRACT This paper reports a study that aimed to identify the predictors of the turnover of privately-employed personal-care staff that provide community-dwelling older adults in Italy with assistance in the activities of daily living. The prospective cohort study enrolled 121 older adults (mean age 85.6 years) living at home, along with their personal-care workers and 107 informal carers. The older participants underwent a comprehensive geriatric assessment. At a one-year follow-up between May 2006 and June 2008, 12 of the older participants had been placed in a nursing home and 26 had died. Of the 83 still living at home, 22 had changed their personal-care staff (26.5% turnover). Multivariate logistic regression analysis identified one characteristic of the personal-care staff, living far away from their families (odds ratio (OR) 16.30, p=0.01), and two characteristics of the elders, namely being widowed (OR 0.09, p=0.01) and having cognitive impairment (OR 0.10, p=0.01), as one-year predictors of turnover and of the retention of personal-care workers, respectively. Further studies are needed both to evaluate whether immigration politics that enable family reconjunction would reduce the turnover of personal-care workers, and to investigate the lower turnover among personal-care staff caring for widowed elders and older adults with cognitive impairment.

An easy intervention to improve short-term adherence to medications in community-dwelling older outpatients. A pilot non-randomised controlled trial

BackgroundComplex interventions to improve compliance to pharmacological treatment in older people have given mixed results and are not easily applicable in clinical practice. The aim of this study was to test the short-term efficacy on self-reported medication adherence of an easy intervention in which the patient or caregiver was asked to transcribe the pharmacological treatment while it was dictated to him/her by the doctor.MethodsPilot non-randomised controlled trial involving 108 community-dwelling outpatients aged 65+ (54 in the intervention arm, 54 controls) referred to a geriatric service from May to July 2009 and prescribed by the geriatrician a change in therapy. The intervention was applied at the end of the visit to the person managing the medications, be it the elder or his/her caregiver. Outcome of the study was the occurrence of any adherence error, assessed at a one-month follow-up by means of a semi-structured interview.ResultsThe socio-demographic, functional and clinical characteristics of the two compared groups were similar at baseline. At a one-month follow-up 43 subjects (40%) had made at least one adherence error, whether unintentional or intentional. In the intervention group the prevalence of adherence errors was lower than in controls (20% vs 59%; adjusted odds ratio 0.16, 95% confidence interval 0.07 - 0.39; p < 0.001) after adjusting for the person managing the medications, the adherence errors at baseline and for the number of prescribed drugs.ConclusionsIn an older outpatient population the intervention considered was effective in reducing the prevalence of adherence errors in the month following the visit.Trial registrationAustralian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12611000347965

Predictors of clinical events occurring during hospital stay among elderly patients admitted to medical wards in Italy

BACKGROUND Clinical events occurring during hospital stay are independent predictors of prolonged hospitalization, in-hospital mortality and readmission among elderly patients admitted to medical wards. PURPOSE To identify predictors of intercurrent clinical events (ICE) during hospital stay among the main demographic, functional and clinical characteristics assessed at hospital admission in a multicenter sample of elderly inpatients in Italy. METHODS This observational prospective cohort study was conducted in 66 internal and geriatric medicine hospital wards in 2010. It enrolled 1267 inpatients aged 65years or older living at home before hospitalization. Multivariable Poisson regression analyses were employed to identify the most common ICEs as well as their independent predictors. RESULTS During the hospital stay 427 patients (33.7%) experienced at least one ICE. The most common ICEs were urinary tract infections, pneumonia, anemia, arrhythmias and fluid electrolyte disorders. After correction for age, sex, comorbidity, cognitive impairment and functional dependence, independent predictors of any ICE were: being a bladder catheter holder (RR [risk ratio] 1.86, 95% CI 1.52-2.27), being on treatment at home with a proton pump inhibitor (PPI) (RR 1.25, 95% CI 1.03-1.53), with immunosuppressant therapy (RR 2.10, 95% CI 1.24-3.56), and body temperature at admission (RR 1.19, 95% CI 1.06-1.33). CONCLUSION Four clinical characteristics, easily assessable at admission, may be useful to identify elderly inpatients at a higher risk for developing ICEs during hospital stay. Furthermore three of these predictors are modifiable factors, thus interventions reducing the use of catheter, PPI and immunosuppressants may result in reduction of ICEs.

AGE AND TIME SPENT IN THE EMERGENCY DEPARTMENT OF AN URBAN TEACHING HOSPITAL IN ITALY

different between the control and treatment arms. This study demonstrates that a cranberry UTI prevention study is feasible to conduct in long-term care. Although the incidence of contaminated urine specimens was high, negative or positive clean-catch samples were obtained in 68% of attempts. Because maintaining oral hydration is challenging, and many residents dislike the acrid flavor and volume of cranberry juice necessary, it is not an optimal UTI preventive strategy. Cranberry tablets reduce UTI in patients with spinal cord injury with neurogenic bladder. In this small sample, efficacy of cranberry capsules was not demonstrated in long-term care residents, but the primary goal of this study was to determine feasibility. The results of this pilot study have implications for designing a definitive trial. The inability to follow all participants for the full 6 months reflects the vulnerability of the population. Future studies will require unique recruitment strategies because loss to follow-up is common in this population. In addition, because there was no trend toward efficacy of cranberry capsules, it is possible that the cranberry capsules were underdosed. Escalating doses of proanthocyanidins (up to 108 mg) were increasingly effective at inhibiting E. coli adherence to uroepithelium. Additional clinical studies of higher doses of proanthocyanidins are warranted to identify the optimal dose of cranberry capsules for prevention of bacteriuria and UTI in long-term care residents. Such a preventive strategy could be well tolerated with few side effects and have a major effect on long-term care.