Nadia Sourial

A correspondence analysis revealed frailty deficits aggregate and are multidimensional.

OBJECTIVE To examine the relationships among seven frailty domains: nutrition, physical activity, mobility, strength, energy, cognition, and mood, using data from three studies. STUDY DESIGN AND SETTING Data from three studies were separately analyzed using multiple correspondence analysis (MCA). The graphical output of MCA was used to assess (1) if the presence of deficits in the frailty domains separate from the absence of deficits on the graph, (2) the dimensionality of the domains, (3) the clustering of domains within each dimension, and (4) their relationship with age, sex, and disability. Results were compared across the studies. RESULTS In two studies, presence of deficits for all domains separated from absence of deficits. In the third study, there was separation in all domains except cognition. Three main dimensions were retained in each study; however, assigned dimensionality of domains differed. The clustering of mobility with energy and/or strength was consistent across studies. Deficits were associated with older age, female sex, and disability. CONCLUSION Our results suggest that frailty is a multidimensional concept for which the relationships among domains differ according to the population characteristics. These domains, with the possible exception of cognition, appear to aggregate together and share a common underlying construct.

Contribution of Frailty Markers in Explaining Differences Among Individuals in Five Samples of Older Persons

BACKGROUND There has been little research on the relative importance of frailty markers. The objective was to investigate the association among seven frailty domains (nutrition, physical activity, mobility, strength, energy, cognition, and mood) and their relative contribution in explaining differences among individuals in five samples of older persons. METHODS Data from five studies of aging were analyzed using multiple correspondence analysis. Aggregation of frailty markers was evaluated using graphical output. Decomposition of variability was used to assess the relative contribution of each marker in each sample. Results were combined across the samples to assess the average contribution. RESULTS Frailty markers were found to consistently aggregate in each sample, suggesting a possible underlying construct. Physical strength had the highest contribution on average in explaining differences among individuals. Mobility and energy also had large contributions. Nutrition and cognition had the smallest contributions. CONCLUSIONS Our results provide further evidence supporting the notion that frailty domains may belong to a common construct. Physical strength may be the most important discriminating characteristic.

Identifying mobility heterogeneity in very frail older adults. Are frail people all the same

Frail older adults sustain mobility limitations; however, clinical experience suggests that their mobility characteristics are far from being homogeneous. We conducted a prospective analysis to identify mobility heterogeneity in 1160 very frail older adults and we investigated the associations between mobility limitation profiles and further institutionalization and death. A cluster analysis using 11 self-reported mobility indicators was used to identify mobility profiles (MPs). At baseline, MPs varies from having mild limitations (n=370), moderate limitations (n=470), to severe limitations (n=320). Mild MP did not have mobility disability. Moderate MP had upper limb task limitations and mild lower limb task difficulties. Severe MP portrayed more deficits in lower limbs tasks functions with important mobility disability. After 2 years of follow up, the Severe MP group had a higher risk of mortality and nursing home placement when compared with Mild MP. Higher incidences of hip fracture and hospitalization were associated with the severity of MP. Even among very frail elderly, we identified different levels of mobility, cautioning against to treat them as a homogeneous group. Mobility heterogeneity predicted mortality and nursing home placement in a dose response manner. None of the mobility indicators individually predicted the outcomes as strongly as the profiles. Identification of this mobility heterogeneity may assist on planning of health programs in very frail elderly.

Frailty Markers Predicting Emergency Department Visits in a Community-Dwelling Sample of Vulnerable Seniors in Montreal

La fragilité met les individus à un risque accru de mauvaise santé. Les personnes âgées consomment une quantité disproportionnée des ressources du service des urgence [SU]. Afin d’étudier la relation entre les marqueurs de fragilité et l’effet sur l’utilisation des services des urgence par les personnes âgées vivant dans les communautés, nous avons mené une analyse secondaire d’un essai prospectif randomisé contrôlé de 22 mois à Montreal, au Canada, en utilisant la base de données du Système de services intégrés pour personnes âgées en perte d’autonomie (SIPA). Nous avons evalué un échantillon de 565 individus, avec cinq marqueurs de fragilité : l’activité physique, la force, la cognition, l’énérgie et la mobilité. Une régression logistique univariée et multivariée a été réalisée afin d’évaluer la relation potentielle entre les marqueurs de fragilité et les visites aux urgences. Les résultats ont révelé que 70 pour cent des participants avaient au moins trois marqueurs de fragilité. Cependant, aucune relation n’a été trouvée entre les marqueurs de fragilité et les visites aux urgences. Ces résultats suggèrent, donc, que parmi les personnes âgées fonctionellement sévèrement handicapés au sein des communautés, la présence de marqueurs de fragilité ne semble pas prévoir les visites aux urgences.

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self‐management, discharge planning, structured follow‐up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995–2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane “Risk of Bias”). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random‐effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: −0.02 [−0.05, 0.00]; NNT: 50), 6, 12 and 18 months post‐discharge, a lower rate of ED visits at 3 months (RD: −0.08 [−0.15, −0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: −0.08 [−0.14, −0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: −1.33; [−2.15, −0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.

Effect of an interdisciplinary educational program on antipsychotic prescribing among residents with dementia in two long-term care centers.

The effect of an educational program on antipsychotic prescribing was assessed in two Canadian long-term care centers (LTCC). In each center (Center A residents, n = 258 and Center B residents, n = 191, with dementia at program inception), the rate of change in the odds of using antipsychotics in residents was estimated using mixed-effects logistic regression during a 6-month program period and a 4-month postprogram period, with baseline proportions of use estimated during the 6 months prior to the program. Preprogram proportions of antipsychotic use were 41.6% and 46.2%, respectively. Antipsychotic use decreased during the program in both centers: (odds ratio with 95% CI: 0.943 per week [0.921, 0.965] and 0.969 per week [0.944, 0.994], respectively). During the postprogram period, antipsychotic use increased in Center A (1.039 per week [1.007, 1.072]) but decreased progressively in Center B. The study results suggest the need to implement an ongoing educational program in LTCC.

The relationship of self-rated health with functional status, toxicity and mortality: Results of a prospective pilot study of older patients with newly-diagnosed cancer

OBJECTIVES To determine the association between self-rated health (SRH) and functional status, comorbidity, toxicity of treatment and mortality in older patients with newly-diagnosed cancer. MATERIALS AND METHODS Patients aged 65 and over, newly diagnosed were recruited at the Jewish General Hospital, Montreal, Canada. SRH and functional status [instrumental activities of daily living (IADL), basic activities of daily living (ADL), Eastern Cooperative Oncology Group performance status (ECOG PS), frailty markers and number of comorbid conditions] were evaluated prior to the start of treatment, and at 3, 6 and 12 months (SRH only). Treatment toxicity and mortality data were abstracted from the chart. Logistic regression was also used to examine the relationship between functional status, comorbidity and SRH at baseline. Logistic and Cox regression were used to examine the association between baseline SRH and treatment toxicity/time to death. RESULTS There were 112 participants enrolled on this study (median age 74.1). At baseline, 74 patients (66.1%) had a good SRH and 38 patients (33.9%) had poor SRH. Only an increasing number of comorbid conditions was associated with poor SRH at baseline in both univariate and multivariable analysis. We found no association between SRH and toxicity or mortality. CONCLUSION A substantial proportion had poor SRH prior to and during cancer treatment. An increasing number of comorbidities was associated with poor SRH at baseline. SRH did not predict toxicity or mortality. Attention to comorbid conditions in older patients with cancer is warranted considering their impact on SRH in this population.

Assessing the Effect of Preoperative Nutrition on Upper Body Function in Elderly Patients Undergoing Elective Abdominal Surgery

BACKGROUND Malnutrition among elderly surgical patients has been associated with poor postoperative outcomes and reduced functional status. Although previous studies have shown that nutrition contributes to patient outcomes, its long-term impact on functional status requires better characterization. This study examines the effect of nutrition on postoperative upper body function over time in elderly patients undergoing elective surgery. METHODS This is a 2-year prospective study of elderly patients (≥70 years) undergoing elective abdominal surgery. Preoperative nutrition status was determined with the Subjective Global Assessment (SGA). The primary outcome was handgrip strength (HGS) at 1, 4, 12, and 24 weeks postsurgery. Repeated measures analysis was used to determine whether SGA status affects the trajectory of postoperative HGS. RESULTS The cohort included 144 patients with a mean age of 77.8 ± 5.0 years and a mean body mass index of 27.7 ± 5.1 kg/m2 . The median (interquartile range) Charlson Comorbidity Index was 3 (2-6). Participants were categorized as well-nourished (86%) and mildly to moderately malnourished (14%), with mean preoperative HGS of 25.8 ± 9.2 kg and 19.6 ± 7.0 kg, respectively. At 24 weeks, 64% of well-nourished patients had recovered to baseline HGS, compared with 44% of mildly to moderately malnourished patients. Controlling for relevant covariates, SGA did not significantly affect the trajectory of postoperative HGS. CONCLUSION While HGS values over the 24 weeks were consistently higher in the well-nourished SGA group than the mildly to moderately malnourished SGA group, no difference in the trajectories of HGS was detected between the groups.