Mindy J. Fain

Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis

IMPORTANCE The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.

The Older HIV-Positive Adult: A Critical Review of the Medical Literature

Older adults make up an ever-growing proportion of human immunodeficiency virus (HIV) cases in the United States, with approximately 25% of infections occurring in adults over the age of 50 years. Although there is a preliminary body of literature addressing the socioeconomic and prognostic issues of HIV infection in older adults, very little rigorous scientific research has looked at the significant clinical issues relevant to this growing population. Treatment of older adults is complicated by an increased prevalence of medical comorbidities, but little is known about the effects of complicated medication regimens in this group, as they are routinely excluded from clinical trials of newer HIV medications. The delay in diagnosis and treatment of HIV in older adults has led to poorer outcomes, including lower baseline CD4 counts, decreased time to acquired immune deficiency syndrome diagnosis, and increased mortality. Despite these facts, there is mounting evidence that timely diagnosis and treatment of HIV in older adults leads to improved outcomes, similar to younger patients. This review evaluates the literature focusing on HIV and older adults.

Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis.

BACKGROUND The rate of mortality and factors predicting worst outcomes in the geriatric population presenting with trauma are not well established. This study aimed to examine mortality rates in severe and extremely severe injured individuals 65 years or older and to identify the predictors of mortality based on available evidence in the literature. METHODS We performed a systematic literature search on studies reporting mortality and severity of injury in geriatric trauma patients using MEDLINE, PubMed, and Web of Science. RESULTS An overall mortality rate of 14.8% (95% confidence interval [CI], 9.8–21.7%) in geriatric trauma patients was observed. Increasing age and severity of injury were found to be associated with higher mortality rates in this patient population. Combined odds of dying in those older than 74 years was 1.67 (95% CI, 1.34–2.08) compared with the elderly population aged 65 years to 74 years. However, the odds of dying in patients 85 years and older compared with those of 75 years to 84 years was not different (odds ratio, 1.23; 95% CI, 0.99–1.52). A pooled mortality rate of 26.5% (95% CI, 23.4–29.8%) was observed in the severely injured (Injury Severity Score [ISS] ≥ 16) geriatric trauma patients. Compared with those with mild or moderate injury, the odds of mortality in severe and extremely severe injuries were 9.5 (95% CI, 6.3–14.5) and 52.3 (95% CI, 32.0–85.5; p ⩽ 0.0001), respectively. Low systolic blood pressure had a pooled odds of 2.16 (95% CI, 1.59–2.94) for mortality. CONCLUSION Overall mortality rate among the geriatric population presenting with trauma is higher than among the adult trauma population. Patients older than 74 years experiencing traumatic injuries are at a higher risk for mortality than the younger geriatric group. However, the trauma-related mortality sustains the same rate after the age of 74 years without any further increase. Moreover, severe and extremely severe injuries and low systolic blood pressure at the presentation among geriatric trauma patients are significant risk factors for mortality. LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.

Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer?

BACKGROUND The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients. METHODS We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient’s discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome. RESULTS A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9–18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2–3), and median Glasgow Coma Scale (GCS) score of 13 (12–15). Of the patients, 69% had favorable outcome, and 31% had unfavorable outcome. On univariate analysis, FI was found to be a significant predictor for unfavorable outcome (odds ratio, 1.8; 95% confidence interval, 1.2–2.3). After adjusting for age, ISS, and GCS score in a multivariate regression model, FI remained a strong predictor for unfavorable discharge disposition (odds ratio, 1.3; 95% confidence interval, 1.1–1.8). CONCLUSION The concept of frailty can be implemented in geriatric trauma patients with similar results as those of nontrauma and nonsurgical patients. FI is a significant predictor of unfavorable discharge disposition and should be an integral part of the assessment tools to determine discharge disposition for geriatric trauma patients. LEVEL OF EVIDENCE Prognostic study, level II.

The Frailty Syndrome: Clinical measurements and basic underpinnings in humans and animals

Frailty is an increasingly recognized syndrome resulting in age-related decline in function and reserve across multiple physiologic systems. It presents as a hyperinflammable state, characterized by high vulnerability for adverse health outcomes, such as disability, falls, hospitalization, institutionalization, and mortality. The prevalence of Frailty Syndrome (FS) is of potentially enormous significance, as it potentially affects 20-30% of adults older than 75. Cellular and molecular basis of frailty has not been elucidated. The objective of this review is to discuss recent advances in: (i) the potential cellular and molecular basis of Frailty Syndrome, including development of new models to study it; (ii) the human and animal measures of Frailty Syndrome; and (iii) the development of objective cross-species correlates to aid the basic understanding, diagnosis, treatment and rehabilitation of Frailty Syndrome in older adults.

Wearable sensor-based in-home assessment of gait, balance, and physical activity for discrimination of frailty status: baseline results of the Arizona frailty cohort study.

Background: Frailty is a geriatric syndrome resulting from age-related cumulative decline across multiple physiologic systems, impaired homeostatic reserve, and reduced capacity to resist stress. Based on recent estimates, 10% of community-dwelling older individuals are frail and another 41.6% are prefrail. Frail elders account for the highest health care costs in industrialized nations. Impaired physical function is a major indicator of frailty, and functional performance tests are useful for the identification of frailty. Objective instrumented assessments of physical functioning that are feasible for home frailty screening have not been adequately developed. Objective: To examine the ability of wearable sensor-based in-home assessment of gait, balance, and physical activity (PA) to discriminate between frailty levels (nonfrail, prefrail, and frail). Methods: In an observational cross-sectional study, in-home visits were completed in 125 older adults (nonfrail: n = 44, prefrail: n = 60, frail: n = 21) living in Tucson, Ariz., USA, between September 2012 and November 2013. Temporal-spatial gait parameters (speed, stride length, stride time, double support, and variability of stride velocity), postural balance (sway of hip, ankle, and center of mass), and PA (percentage of walking, standing, sitting, and lying; mean duration and variability of single walking, standing, sitting, and lying bouts) were measured in the participants home using validated wearable sensor technology. Logistic regression was used to assess the most sensitive gait, balance, and PA variables for identifying prefrail participants (vs. nonfrail). Multinomial logistic regression was used to identify variables sensitive to discriminate between three frailty levels. Results: Gait speed (area under the curve, AUC = 0.802), hip sway (AUC = 0.734), and steps/day (AUC = 0.736) were the most sensitive parameters for the identification of prefrailty. Multinomial regression revealed that stride length (AUC = 0.857) and double support (AUC = 0.841) were the most sensitive gait parameters for discriminating between three frailty levels. Interestingly, walking bout duration variability was the most sensitive PA parameter for discriminating between three frailty levels (AUC = 0.818). No balance parameter discriminated between three frailty levels. Conclusion: Our results indicate that unique parameters derived from objective assessment of gait, balance, and PA are sensitive for the identification of prefrailty and the classification of a subjects frailty level. The present findings highlight the potential of wearable sensor technology for in-home assessment of frailty status.

Inflammatory bowel disease and the elderly: a review.

Inflammatory bowel disease among the elderly is common, with growing incident and prevalence rates. Compared with younger IBD patients, genetics contribute less to the pathogenesis of older-onset IBD, with dysbiosis and dysregulation of the immune system playing a more significant role. Diagnosis may be difficult in older individuals, as multiple other common diseases can mimic IBD in this population. The clinical manifestations in older-onset IBD are distinct, and patients tend to have less of a disease trajectory. Despite multiple effective medical and surgical treatment strategies for adults with Crohns disease and ulcerative colitis, efficacy studies typically have excluded older subjects. A rapidly ageing population and increasing rates of Crohns and ulcerative colitis make the paucity of data in older adults with IBD an increasingly important clinical issue.

Cardiocerebral Resuscitation Improves Out‐of‐Hospital Survival in Older Adults

OBJECTIVES: To compare the survival and neurological status of people aged 65 and older receiving cardiocerebral resuscitation (CCR) with that of those receiving standard advanced life support (Std‐ALS), as well as predictors of survival.

Preparing for an Aging World: Engaging Biogerontologists, Geriatricians, and the Society

Although the demographic revolution has produced hundreds of millions people aged 65 and older, a substantial segment of that population is not enjoying the benefits of extended healthspan. Many live with multiple chronic conditions and disabilities that erode the quality of life. The consequences are also costly for society. In the United States, the most costly 5% of Medicare beneficiaries account for approximately 50% of Medicares expenditures. This perspective summarizes a recent workshop on biomedical approaches to best extend healthspan as way to reduce age-related dysfunction and disability. We further specify the action items necessary to unite health professionals, scientists, and the society to partner around the exciting and palpable opportunities to extend healthspan.

Managing older adults with ground-level falls admitted to a trauma service: the effect of frailty

To determine whether frail elderly adults are at greater risk of fracture after a ground‐level fall (GLF) than those who are not frail.