Davide L. Vetrano

Association of Sarcopenia With Short- and Long-term Mortality in Older Adults Admitted to Acute Care Wards: Results From the CRIME Study

BACKGROUND Sarcopenia is a common condition in older and frail populations, and it has been associated with adverse health outcomes. However, impact of sarcopenia on mortality in hospitalized older adults has rarely been evaluated. Aim of the present study was to investigate the association between sarcopenia and mortality during hospital stay and at 1 year after discharge in older individuals admitted to acute care wards. METHODS This is a multicentre observational study involving 770 in-hospital patients. Muscle mass was quantified with the bioelectrical impedance analysis. The diagnosis of sarcopenia was based on the algorithm proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). After discharge, participants were followed for 1 year. Mortality was assessed during hospital stay and during 1-year follow-up. RESULTS Within the 770 participants (mean age: 81 ± 7 years, 56% women), sarcopenia was present in 214 (28%) of them, 22 participants died during hospital stay, and 113 in the year after discharge. Participants with sarcopenia had a significantly higher in-hospital (6% vs 2%; p = .007) and 1-year mortality (26% vs 14%; p < .001) as compared with participants without sarcopenia. After adjusting for potential confounders, sarcopenia resulted significantly associated with in-hospital (hazard ratio: 3.45; 95% CI: 1.35-8.86) and 1-year mortality (hazard ratio: 1.59; 95% CI: 1.10-2.41). CONCLUSIONS Sarcopenia is a prevalent condition among older adults admitted to acute care wards and it is associated with increased short- and long-term mortality in hospitalized older adults.

Anorexia of Aging: A Modifiable Risk Factor for Frailty

Anorexia of aging, defined as a loss of appetite and/or reduced food intake, affects a significant number of elderly people and is far more prevalent among frail individuals. Anorexia recognizes a multifactorial origin characterized by various combinations of medical, environmental and social factors. Given the interconnection between weight loss, sarcopenia and frailty, anorexia is a powerful, independent predictor of poor quality of life, morbidity and mortality in older persons. One of the most important goals in the management of older, frail people is to optimize their nutritional status. To achieve this objective it is important to identify subjects at risk of anorexia and to provide multi-stimulus interventions that ensure an adequate amount of food to limit and/or reverse weight loss and functional decline. Here, we provide a brief overview on the relevance of anorexia in the context of sarcopenia and frailty. Major pathways supposedly involved in the pathogenesis of anorexia are also illustrated. Finally, the importance of treating anorexia to achieve health benefits in frail elders is highlighted.

Polypharmacy in nursing home residents with severe cognitive impairment: Results from the SHELTER Study

Pharmacological treatment of older adults with cognitive impairment represents a challenge for prescribing physicians, and polypharmacy is common in these complex patients. The aim of the current study is to assess prevalence and factors related to polypharmacy in a sample of nursing home (nursing home) residents with advanced cognitive impairment.

Polypharmacy and health outcomes among older adults discharged from hospital: Results from the CRIME study

To investigate if older adults using multiple drugs have an increased risk of rehospitalization and mortality after hospital discharge.

Inappropriate drugs in elderly patients with severe cognitive impairment: results from the shelter study.

Background It has been estimated that Nursing Home (NH) residents with impaired cognitive status receive an average of seven to eight drugs daily. The aim of this study was to determine prevalence and factors associated with use of inappropriate drugs in elderly patients with severe cognitive impairment living in NH in Europe. Methods Cross-sectional data from a sample of 1449 NH residents with severe cognitive impairment, participating in the Services and Health for Elderly in Long TERm care (SHELTER) study were analysed. Inappropriate drug use was defined as the use of drugs classified as rarely or never appropriate in patients with severe cognitive impairment based on the Holmes criteria published in 2008. Results Mean age of participating residents was 84.2±8.9 years, 1087 (75.0%) were women. Inappropriate drug use was observed in 643 (44.9%) residents. Most commonly used inappropriate drugs were lipid-lowering agents (9.9%), antiplatelet agents (excluding Acetylsalicylic Acid – ASA –) (9.9%), acetylcholinesterase, inhibitors (7.2%) and antispasmodics (6.9%). Inappropriate drug use was directly associated with specific diseases including diabetes (OR 1.64; 95% CI 1.21–2.24), heart failure (OR 1.48; 95% CI 1.04–2.09), stroke (OR 1.43; 95% CI 1.06–1.93), and recent hospitalization (OR 1.69; 95% CI 1.20–2.39). An inverse relation was shown between inappropriate drug use and presence of a geriatrician in the facility (OR 0.55; 95% CI 0.39–0.77). Conclusion Use of inappropriate drugs is common among older EU NH residents. Determinants of inappropriate drug use include comorbidities and recent hospitalization. Presence of a geriatrician in the facility staff is associated with a reduced rate of use of these medications.

Assessing and Measuring Chronic Multimorbidity in the Older Population: A Proposal for Its Operationalization

Abstract Background Although the definition of multimorbidity as “the simultaneous presence of two or more chronic diseases” is well established, its operationalization is not yet agreed. This study aims to provide a clinically driven comprehensive list of chronic conditions to be included when measuring multimorbidity. Methods Based on a consensus definition of chronic disease, all four-digit level codes from the International Classification of Diseases, 10th revision (ICD-10) were classified as chronic or not by an international and multidisciplinary team. Chronic ICD-10 codes were subsequently grouped into broader categories according to clinical criteria. Last, we showed proof of concept by applying the classification to older adults from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K) using also inpatient data from the Swedish National Patient Register. Results A disease or condition was considered to be chronic if it had a prolonged duration and either (a) left residual disability or worsening quality of life or (b) required a long period of care, treatment, or rehabilitation. After applying this definition in relation to populations of older adults, 918 chronic ICD-10 codes were identified and grouped into 60 chronic disease categories. In SNAC-K, 88.6% had ≥2 of these 60 disease categories, 73.2% had ≥3, and 55.8% had ≥4. Conclusions This operational measure of multimorbidity, which can be implemented using either or both clinical and administrative data, may facilitate its monitoring and international comparison. Once validated, it may enable the advancement and evolution of conceptual and theoretical aspects of multimorbidity that will eventually lead to better care.

Prevalence of the seven cardiovascular health metrics in a Mediterranean country: results from a cross-sectional study

AIM Primordial prevention is essential for reaching cardiovascular (CV) health. This is defined by seven health metrics identified by the American Heart Association. Aim of the present study was to assess prevalence and distribution of these seven CV health metrics within an unselected population. METHODS All the 1110 consecutive individuals (mean age 56 ± 13 years; 56% women) who agreed to be screened within the context of a national campaign of CV prevention were included. The following findings have been considered as ideal: never/former smoker, regular participation in physical activity, body mass index lower than 25.0, healthy diet, cholesterol lower than 200 mg/dl, diabetes absence and a blood pressure lower than 120/80 mmHg. RESULTS Participants presented, on average, 4.1 ± 1.2 ideal CV health metrics, with a decreasing number across age-groups. Only 10.4% covered more than five ideal CV health metrics and 8.3% covered less than three ideal health metrics. Only 1.9% of the study population met all the seven ideal metrics. In particular, only 34% (379 subjects) in our population presented an ideal level of cholesterol. The higher prevalence was observed in younger subjects (45%) and the lower (28%) in people older than 62 years (P < 0.001). CONCLUSION Prevalence of the seven CV health metrics was low in our population and just 1 in 10 met more than five ideal CV health metrics. Social initiatives and awareness policies from governments are mandatory to promote CV health. Further studies should address the impact of such CV metrics on several outcomes in European countries.

Predictors of length of hospital stay among older adults admitted to acute care wards: a multicentre observational study

BACKGROUND Reduction in length of hospital stay (LOS) is considered as a potential strategy to optimize resource consumption and reduce health care costs. We analysed predictors of increased LOS among older patients admitted to acute care wards according to type of admission (through the Emergency Room [ER] or elective). METHODS We analysed data of 1123 older patients, aged 65years or older, consecutively admitted to seven acute care wards. LOS was defined as the number of days from admission to discharge (or death) and categorized according to its median value (10days). RESULTS Mean age of participants was 81±7years and 56% were women. Patients admitted through ER had a shorter LOS compared with those elective (10.4±6.7 vs. 12.0±6.7days; p<0.0001). Factors associated with LOS >10days, for patients admitted through ER, were female gender (OR 0.58; 95% C.I. 0.37-0.90), erythrocyte sedimentation rate (OR 1.02; 95% C.I. 1.01-1.03), and excessive polypharmacy (use of ≥10 drugs during stay) (OR 3.60; 95% C.I. 1.40-9.25). Predictors for elective patients were chronic alcohol consumption (OR 0.54; 95% C.I. 0.32-0.93), walking speed ≥0.8m/s (OR 0.31; 95% C.I. 0.14-0.72), excessive polypharmacy (OR 4.78; 95% C.I. 1.92-11.90), pressure ulcers (OR 2.60; 95% C.I. 1.01-6.79), cerebrovascular disease (OR 0.49; 95% C.I. 0.24-0.99) and dementia (OR 0.18; 95% C.I. 0.08-0.39). CONCLUSIONS LOS differed between patients admitted through emergency and through elective admission. Demographic and clinical parameters can affect LOS and polypharmacy was the strongest and the only common risk factor in both groups.

Chronic diseases and geriatric syndromes: The different weight of comorbidity

BACKGROUND Comorbidity is a relevant health determinant in older adults. Co-occurrence of several diseases and other age-associated conditions generates new clinical phenotypes (geriatric syndromes [GS] as falls, delirium etc.). We investigated the association of chronic diseases, alone or in combination, and GS in older adults receiving home care services in 11 European countries and one Canadian province. METHODS Participants were cross-sectionally evaluated with the multidimensional assessment instrument RAI HC. We assessed 14 different diagnoses and 8 GS (pain, urinary incontinence, falls, disability, dizziness, weight loss, pressure ulcers and delirium). Adjusted mean number of GS per participant was calculated for groups of participants with each disease when occurring alone or with comorbidity. RESULTS The mean age of the 6903 participants was 82.2±7.4 years and 4750 (69%) were women. Participants presented with an average of 2.6 diseases and 2.0 GS: pain (48%), urinary incontinence (47%) and falls (33%) were the most prevalent. Parkinsons disease, cerebrovascular disease and peripheral artery disease were associated with the highest number of GS (2.5, 2.3 and 2.2, respectively). Conversely, hypertension, diabetes, dementia, cancer and thyroid dysfunction were associated with the lowest number of GS (2.0 on average). For 9/14 examined diseases (hypertension, diabetes, dementia, COPD, heart failure, ischemic heart disease, atrial fibrillation, cancer and thyroid dysfunction) the number of GS increased with the degree of comorbidity. CONCLUSIONS Comorbidity and GS are prevalent in older adults receiving home care. Different diseases have a variable impact on occurrence of GS. Comorbidity is not always associated with an increased number of GS.

A Multicomponent Approach to Identify Predictors of Hospital Outcomes in Older In-Patients: A Multicentre, Observational Study

Background The identification of older patients at risk of poor hospital outcomes (e.g. longer hospital stay, in-hospital mortality, and institutionalisation) is important to provide an effective healthcare service. Objective To identify factors related to older patients’ clinical, nutritional, functional and socio-demographic profiles at admission to an acute care ward that can predict poor hospital outcomes. Design and Setting The CRiteria to assess appropriate Medication use among Elderly complex patients project was a multicentre, observational study performed in geriatric and internal medicine acute care wards of seven Italian hospitals. Subjects One thousand one hundred twenty-three consecutively admitted patients aged 65 years or older. Methods Hospital outcomes were length of stay, in-hospital mortality, and institutionalisation. Results Mean age of participants was 81 years, 56% were women. Median length of stay was 10 (7–14) days, 41 patients died during hospital stay and 37 were newly institutionalised. Number of drugs before admission, metastasized cancer, renal failure or dialysis, infection, falls at home during the last year, pain, and walking speed were independent predictors of LoS. Total dependency in activities of daily living and inability to perform grip strength test were independent predictors of in-hospital mortality. Malnutrition and total dependency in activities of daily living were independent predictors of institutionalisation. Conclusions Our results confirm that not only diseases, but also multifaceted aspects of ageing such as physical function and malnutrition are strong predictors of hospital outcomes and suggest that these variables should be systematically recorded.