Jan Szewieczek

Fried frailty phenotype assessment components as applied to geriatric inpatients

Background Management of geriatric patients would be simplified if a universally accepted definition of frailty for clinical use was defined. Among definitions of frailty, Fried frailty phenotype criteria constitute a common reference frame for many geriatric studies. However, this reference frame has been tested primarily in elderly patients presenting with relatively good health status. Objective The aim of this article was to assess the usefulness and limitations of Fried frailty phenotype criteria in geriatric inpatients, characterized by comorbidity and functional impairments, and to estimate the frailty phenotype prevalence in this group. Patients and methods: Five hundred consecutive patients of the university hospital subacute geriatric ward, aged 79.0±8.4 years (67% women and 33% men), participated in this cross-sectional study. Comprehensive geriatric assessment and Fried frailty phenotype component evaluation were performed in all patients. Results Multimorbidity (6.0±2.8 diseases) characterized our study group, with a wide range of clinical conditions and functional states (Barthel Index of Activities of Daily Living 72.2±28.2 and Mini-Mental State Examination 23.6±7.1 scores). All five Fried frailty components were assessed in 65% of patients (95% confidence interval [CI] =60.8–69.2) (diagnostic group). One or more components were not feasible to be assessed in 35% of the remaining patients (nondiagnostic group) because of lack of past patient’s body mass control and/or cognitive or physical impairment. Patients from the nondiagnostic group, as compared to patients from the diagnostic group, presented with more advanced age, higher prevalence of dementia, lower prevalence of hypertension, lower systolic and diastolic blood pressure, body mass index, Mini-Mental State Examination and Barthel Index of Activities of Daily Living. Despite diagnostic limitations, we found ≥3 positive criteria (thus, frailty diagnosis) in 54.2% of the study group (95% CI =49.8–58.6), with prevalence from 31.7% in sexagenarians to 67.6% in nonagenarians. Conclusion Fried frailty phenotype criteria seem useful for geriatric inpatient assessment, despite diagnostic limitations. High prevalence of frailty among geriatric inpatients suggests that evaluation for frailty should be considered a part of the comprehensive geriatric assessment.

ICC-dementia (International Centenarian Consortium - dementia): An international consortium to determine the prevalence and incidence of dementia in centenarians across diverse ethnoracial and sociocultural groups

BackgroundConsiderable variability exists in international prevalence and incidence estimates of dementia. The accuracy of estimates of dementia in the oldest-old and the controversial question of whether dementia incidence and prevalence decline at very old age will be crucial for better understanding the dynamics between survival to extreme old age and the occurrence and risk for various types of dementia and comorbidities. International Centenarian Consortium – Dementia (ICC-Dementia) seeks to harmonise centenarian and near-centenarian studies internationally to describe the cognitive and functional profiles of exceptionally old individuals, and ascertain the trajectories of decline and thereby the age-standardised prevalence and incidence of dementia in this population. The primary goal of the ICC-Dementia is to establish a large and thorough heterogeneous sample that has the power to answer epidemiological questions that small, separate studies cannot. A secondary aim is to examine cohort-specific effects and differential survivorship into very old age. We hope to lay the foundation for further investigation into risk and protective factors for dementia and healthy exceptional brain ageing in centenarians across diverse ethnoracial and sociocultural groups.MethodsStudies focusing on individuals aged ≥95 years (approximately the oldest 1 percentile for men, oldest 5th percentile for women), with a minimum sample of 80 individuals, including assessment of cognition and functional status, are invited to participate. There are currently seventeen member or potential member studies from Asia, Europe, the Americas, and Oceania. Initial attempts at harmonising key variables are in progress.DiscussionGeneral challenges facing large, international consortia like ICC-Dementia include timely and effective communication among member studies, ethical and practical issues relating to human subject studies and data sharing, and the challenges related to data harmonisation. A specific challenge for ICC-Dementia relates to the concept and definition of’abnormal’ in this exceptional group of individuals who are rarely free of physical, sensory and/or cognitive impairments.

Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors

Background Inpatient geriatric falls are a frequent complication of hospital care that results in significant morbidity and mortality. Objective Evaluate factors associated with falls in geriatric inpatients after implementation of the fall prevention program. Methods Prospective observational study comprised of 788 consecutive patients aged 79.5±7.6 years ( χ¯ ± standard deviation) (66% women and 34% men) admitted to the subacute geriatric ward. Comprehensive geriatric assessment (including Mini-Mental State Examination, Barthel Index of Activities of Daily Living, and modified Get-up and Go Test) was performed. Confusion Assessment Method was used for diagnosis of delirium. Patients were categorized into low, moderate, or high fall risk groups after clinical and functional assessment. Results About 15.9%, 21.1%, and 63.1% of participants were classified into low, moderate, and high fall risk groups, respectively. Twenty-seven falls were recorded in 26 patients. Increased fall probability was associated with age ≥76 years (P<0.001), body mass index (BMI) <23.5 (P=0.007), Mini-Mental State Examination <20 (P=0.004), Barthel Index <65 (P=0.002), hemoglobin <7.69 mmol/L (P=0.017), serum protein <70 g/L (P=0.008), albumin <32 g/L (P=0.001), and calcium level <2.27 mmol/L. Four independent factors associated with fall risk were included in the multivariate logistic regression model: delirium (odds ratio [OR] =7.33; 95% confidence interval [95% CI] =2.76–19.49; P<0.001), history of falls (OR =2.55; 95% CI =1.05–6.19; P=0.039), age (OR =1.14; 95% CI =1.05–1.23; P=0.001), and BMI (OR =0.91; 95% CI =0.83–0.99; P=0.034). Conclusion Delirium, history of falls, and advanced age seem to be the primary risk factors for geriatric falls in the context of a hospital fall prevention program. Higher BMI appears to be associated with protection against inpatient geriatric falls.

Delirium in the geriatric unit: proton-pump inhibitors and other risk factors.

Background Delirium remains a major nosocomial complication of hospitalized elderly. Predictive models for delirium may be useful for identification of high-risk patients for implementation of preventive strategies. Objective Evaluate specific factors for development of delirium in a geriatric ward setting. Methods Prospective cross-sectional study comprised 675 consecutive patients aged 79.2±7.7 years (66% women and 34% men), admitted to the subacute geriatric ward of a multiprofile university hospital after exclusion of 113 patients treated with antipsychotic medication because of behavioral disorders before admission. Comprehensive geriatric assessments including a structured interview, physical examination, geriatric functional assessment, blood sampling, ECG, abdominal ultrasound, chest X-ray, Confusion Assessment Method for diagnosis of delirium, Delirium-O-Meter to assess delirium severity, Richmond Agitation-Sedation Scale to assess sedation or agitation, visual analog scale and Doloplus-2 scale to assess pain level were performed. Results Multivariate logistic regression analysis revealed five independent factors associated with development of delirium in geriatric inpatients: transfer between hospital wards (odds ratio [OR] =2.78; confidence interval [CI] =1.54–5.01; P=0.001), preexisting dementia (OR =2.29; CI =1.44–3.65; P<0.001), previous delirium incidents (OR =2.23; CI =1.47–3.38; P<0.001), previous fall incidents (OR =1.76; CI =1.17–2.64; P=0.006), and use of proton-pump inhibitors (OR =1.67; CI =1.11–2.53; P=0.014). Conclusion Transfer between hospital wards, preexisting dementia, previous delirium incidents, previous fall incidents, and use of proton-pump inhibitors are predictive of development of delirium in the geriatric inpatient setting.

Normal insulin response to short-term intense exercise is abolished in Type 2 diabetic patients treated with gliclazide

BACKGROUND Physical activity is an essential component of diabetes management; however, exercise is associated with the risk for metabolic decompensation. The aim of the study was to analyze insulin response to the short-term intense exercise in middle-aged Type 2 diabetic patients treated with gliclazide. MATERIALS AND METHODS Fourteen Type 2 diabetic patients (47.9+/-1.6 years, mean+/-S.E.M.), treated with gliclazide, and 14 healthy controls (45.1+/-1.0 years) were submitted to standard graduated submaximal (90% HR(max)) exercise treadmill testing at 2 h after standardized breakfast. Serum glucose, insulin, proinsulin, C peptide, growth hormone, insulin-like growth factor-1, and cortisol concentrations; and plasma lactate, glucagon, epinephrine, and norepinephrine concentrations were measured during the periexercise period up to the 60th min of the recovery period. RESULTS Significant hemodynamic (heart rate, systolic, and diastolic blood pressure), metabolic (lactate concentration), and hormonal (epinephrine and norepinephrine levels) responses to the exercise were similar in patients and healthy subjects. Glucose, insulin, and proinsulin levels were higher in the diabetic group at the preexercise and at all the next analyzed time points. The insulin concentration increased during the postprandial period in both groups and decreased subsequently during the exercise only in the control group, without concurrent C peptide decline. The C peptide-to-insulin ratio increased during the exercise and decreased immediately postexercise only in the control group. CONCLUSIONS The initial decrease of the insulin serum concentration during short-term intense exercise in normal middle-aged men is primarily related to the increased clearance of the hormone. Normal insulin response to the exercise was abolished in Type 2 diabetic patients treated with gliclazide.

Grip strength as a frailty diagnostic component in geriatric inpatients

Background Frailty has emerged as a key medical syndrome predictive of comorbidity, disability, institutionalization and death. As a component of the five frailty phenotype diagnostic criteria, patient grip strength deserves attention as a simple and objective measure of the frailty syndrome. The aim of this study was to assess conditions that influence grip strength in geriatric inpatients. Patients and methods The study group consisted of 80 patients aged 78.6±7.0 years (X¯±SD), with 68.8% women, admitted to the Department of Geriatrics. A comprehensive geriatric assessment was complemented with assessment for the frailty phenotype as described by Fried et al for all patients in the study group. Functional assessment included Barthel Index of Activities of Daily Living (Barthel Index), Instrumental Activities of Daily Living Scale and Mini-Mental State Examination. Results Three or more frailty criteria were positive in 32 patients (40%), while 56 subjects (70%) fulfilled the frailty criterion of weakness (grip strength test). Multivariate linear regression analysis revealed that two independent measures showed positive association with grip strength – Mini-Mental State Examination score (β=0.239; P=0.001) and statin use (β=0.213; P=0.002) – and four independent measures were negatively associated with grip strength – female sex (β=−0.671; P<0.001), C-reactive protein (β=−0.253; P<0.001), prior myocardial infarction (β=−0.190; P=0.006) and use of an antidepressant (β=−0.163; P=0.018). Low physical activity was identified as the only independent qualitative frailty component associated with 2-year mortality in multivariate logistic regression analysis after adjustment for age and sex (odds ratio =6.000; 95% CI =1.357–26.536; P=0.018). Conclusion Cognitive function, somatic comorbidity and medical treatment affect grip strength as a measure of physical frailty in geriatric inpatients. Grip strength was not predictive of 2-year mortality in this group.

Pressure ulcers in palliative ward patients: hyponatremia and low blood pressure as indicators of risk

Background Prevention strategies for pressure ulcer formation remain critical in patients with an advanced illness. We analyzed factors associated with the development of pressure ulcers in patients hospitalized in a palliative care ward setting. Patients and methods This study was a retrospective analysis of 329 consecutive patients with a mean age (± standard deviation) of 70.4±11.8 years (range: 30–96 years, median 70.0 years; 55.3% women), who were admitted to the Palliative Care Department between July 2012 and May 2014. Results Patients were hospitalized for mean of 24.8±31.4 days (1–310 days, median 14 days). A total of 256 patients (77.8%) died in the ward and 73 patients (22.2%) were discharged. Two hundred and six patients (62.6%) did not develop pressure ulcers during their stay in the ward, 84 patients (25.5%) were admitted with pressure ulcers, and 39 patients (11.9%) developed pressure ulcers in the ward. Four factors assessed at admission appear to predict the development of pressure ulcers in the multivariate logistic regression model: Waterlow score (odds ratio [OR] =1.140, 95% confidence interval [CI] =1.057–1.229, P=0.001), transfer from other hospital wards (OR =2.938, 95% CI =1.339–6.448, P=0.007), hemoglobin level (OR =0.814, 95% CI =0.693–0.956, P=0.012), and systolic blood pressure (OR =0.976, 95% CI =0.955–0.997, P=0.023). Five other factors assessed during hospitalization appear to be associated with pressure ulcer development: mean evening body temperature (OR =3.830, 95% CI =1.729–8.486, P=0.001), mean Waterlow score (OR =1.194, 95% CI =1.092–1.306, P<0.001), the lowest recorded sodium concentration (OR =0.880, 95% CI =0.814–0.951, P=0.001), mean systolic blood pressure (OR =0.956, 95% CI =0.929–0.984, P=0.003), and the lowest recorded hemoglobin level (OR =0.803, 95% CI =0.672–0.960, P=0.016). Conclusion Hyponatremia and low blood pressure may contribute to the formation of pressure ulcers in patients with an advanced illness.

The Body Mass Index and Waist Circumference as Predictors Of Body Composition in Post CSCI Wheelchair Rugby Players (Preliminary Investigations)

Abstract The enforced sedentary lifestyle and muscle paresis below the level of injury are associated with adipose tissue accumulation in the trunk. The value of anthropometric indicators of obesity in patients with spinal cord injuries has also been called into question. We hypothesized that the Body Mass Index recommended by the WHO to diagnose obesity in general population has too low sensitivity in case of wheelchair rugby players. The study group comprised 14 wheelchair rugby players, aged 32.6 ± 5.1 years, who had sustained CSCI (paralysis of lower limbs and upper extremities). The research tool was the Tanita Viscan visceral and trunk fat analyzer AB140 using the abdominal bioelectrical impedance analysis (BIA) to estimate the visceral fat level (Vfat) and trunk fat percentage (Tfat). The AB140 analyzer also allowed the measurement of body composition of those individuals who could not assume an upright position. Our analyses revealed high and very high correlation coefficients between Vfat and WC (r=0.9), WHtR (r=0.7) and Tfat (r=0.9) whereas the correlation between Vfat and the BMI was weak, especially in the subgroup with Vfat < 13.5% ( r=0.2). The subgroup with Vfat>13.5 exhibited a moderate-level relationship between the BMI and visceral fat increase. It was concluded that the BMI had a low sensitivity for predicting obesity risk in wheelchair rugby players after CSCI. The sensitivity of WC measurement was higher and thus, it may be stated that it constitutes an objective tool for predicting obesity risk in post-CSCI wheelchair rugby players.