Nele Van Den Noortgate

Serum cystatin C concentration compared with other markers of glomerular filtration rate in the old old.

OBJECTIVES: To assess serum cystatin C, compared with other markers of renal function, as a marker of renal function in the old old (aged 85 and older).

The Physical Performance Test as a predictor of frequent fallers: a prospective community-based cohort study

Objective: To construct a risk model in order to identify elderly individuals at risk of frequent falling. Design: Prospective community-based cohort study over 12 months. Setting: Baseline measures were performed at a local community centre. Subjects: Two hundred and sixty-three community-dwelling elderly people (mean age 72 years). Measurements: A variety of variables were evaluated, including medical, psychological, sensory, physical and postural control measurements. Fall incidence was monitored retrospectively and during one-year follow-up. Results: Logistic regression analysis showed that polypharmacia was the most prominent medical fall predictor with an odds ratio (OR) of 1.29 (P =0.005), poor visual acuity the best sensory predictor (OR=0.84; P =0.009) and general fear of falling the most crucial psychological predictor (OR=3.25; P B=0.001). Increased postural sway in near-tandem stance with eyes open was selected as the best balance predictor for falls (OR=5.60; P =0.010), followed by delayed anteroposterior movement velocity during rhythmic weight shifts (OR=0.42; P =0.004). The best physical predictor was a low score on the Physical Performance Test (OR=4.16; P <0.001), followed by decreased maximal handgrip strength (OR=0.87; P <0.001) and increased timed chair-stands (OR=1.13; P <0.003). Step-by-step regression analysis revealed a risk model for the prediction of future falls, as a combination of the Physical Performance Test and maximal handgrip strength. Conclusion: This study confirms the multicausality of falls, since medical, psychological, sensory, postural control as well as physical variables provides a predictive value. The composed fall risk model was mainly physically oriented.

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients

Background:We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients. Methods:In a single-center, historical cohort study (1992–2006), we compared middle-aged (45–64 years; n = 524), old (65–74 years; n = 326), and very old ICU patients (≥75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay. Results:Although the total number of ICU admissions (patients aged ≥45 years) decreased by ∼10%, the number of very old patients increased by 33% between the periods 1992–1996 and 2002–2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992–1996) to 13.5% (1997–2001) and 17.4% (2002–2006) (p < 0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4‰ in middle-aged, 5.5‰ in old, and 4.6‰ in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0–1.5) and significant for very old age (hazard ratio, 1.8; 95% confidence interval, 1.4–2.4). Conclusion:Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

Reevaluation of Formulas for Predicting Creatinine Clearance in Adults and Children, Using Compensated Creatinine Methods

In clinical practice, glomerular filtration rate (GFR) is the most important marker for evaluation of renal function (1). Dosages of drugs that are eliminated by glomerular filtration are often based on GFR. At present, the most reliable methods for accurate assessment of overall GFR require intravenous administration of exogenous compounds and are both cumbersome and expensive. In clinical practice, creatinine clearance (CrCl) is widely accepted as a simple measure of GFR. However, CrCl systematically overestimates GFR because creatinine is freely filtered by the glomerulus and is also secreted by the proximal tubule. In the earliest methods, serum creatinine was assayed by the Jaffe reaction after deproteinization, eliminating the pseudo-chromogen effect of proteins (2). Similarly, the first automated methods used dialysis membranes to prevent interference from plasma proteins. Today, however, analyzers use undiluted serum and plasma, making them subject to the so-called “protein error” (3). This produces a positive difference of ∼27 μmol/L creatinine compared with HPLC methods (4)(5)(6)(7). Because urine contains relatively little or no protein, the protein error affects only creatinine determinations in serum. Therefore, CrCl is underestimated when creatinine methods affected by protein error are used. This underestimation has been stated to be compensated by the overestimation attributable to tubular secretion of creatinine. However, studies confirming this statement are lacking. In compensated Jaffe methods, the values assigned to the calibrator set point are adjusted to minimize the pseudo-creatinine contribution of proteins. The result is that compensated methods produce lower creatinine values. Alternatively, the protein error can be avoided by use of enzymatic creatinine methods. Collection of timed urine for CrCl is often a major source of error; therefore, simple formulas have been introduced to estimate GFR based on serum creatinine concentration, age, gender, body weight, and body length (8)(9) …

The risk of being fearful or fearless of falls in older people: an empirical validation.

Purpose. To investigate the risk of being fearful or fearless of falls in older people. Methods. Using a force plate, postural control in different sensory and rhythmic conditions was measured in 263 community-dwelling older people. Other assessments included fear of falling, and handgrip strength. Fall incidence was assessed at baseline and during a one-year follow-up period. Results. Logistic regression analysis revealed that increased lateral sway in near-tandem stance with eyes open (OR = 5.33; p < 0.01) and a worse performance on anteroposterior rhythmic weight shifts (OR = 0.65; p < 0.05) were related to falls. Univariate analyses revealed that older people with inappropriate high fear of falling according to their fall incidence had worse balance capacities on the rhythmic weight shifts (p < 0.05) but had similar static balance and physical capacities. Older people with inappropriate low fear of falling had a better hand grip (p < 0.05) but equally worse balance capacities than the comparison group. Conclusions. The results indicate the importance of lateral stability in relation to falls. They also suggest a substantial impact of inappropriate fear of falling on physical performance. Inappropriate high fear of falling may result in worse performance during dynamic balance tests, whereas older people with inappropriate low fear seem to overrate their capacities because of higher strength.

The appropriate use of non-steroidal anti-inflammatory drugs in rheumatic disease: opinions of a multidisciplinary European expert panel

Introduction Given the safety issues of non-steroidal anti-inflammatory drugs (NSAID) and the robustness of guidelines, making treatment choices in daily clinical practice is increasingly difficult. This study aimed systematically to analyse the opinions of a multidisciplinary European expert panel on the appropriateness of different NSAID, with or without the use of a proton pump inhibitor (PPI), in individual patients with chronic rheumatic disease. Methods Using the Research and Development/University of California at Los Angeles appropriateness method, the appropriateness of five (non-)selective NSAID with or without a PPI was assessed for 144 hypothetical patient profiles, ie, unique combinations of cardiovascular and gastrointestinal risk factors. Appropriateness statements were calculated for all indications. Results All options without PPI were considered appropriate in patients with no gastrointestinal/cardiovascular risk factors. Cyclooxygenase-2 selective inhibitors (C2SI) alone and non-selective NSAID plus PPI were preferred for patients with elevated gastrointestinal risk and low cardiovascular risk. Naproxen plus PPI was favoured in patients with high cardiovascular risk. For the combination of high gastrointestinal/high cardiovascular risk the use of any NSAID was discouraged; if needed, naproxen plus PPI or a C2SI plus PPI could be considered. Discussion The panel results may support treatment considerations at the level of individual patients, according to their gastrointestinal/cardiovascular risk profile.

Actual and preferred place of death of home-dwelling patients in four European countries: making sense of quality indicators.

Background Dying at home and dying at the preferred place of death are advocated to be desirable outcomes of palliative care. More insight is needed in their usefulness as quality indicators. Our objective is to describe whether “the percentage of patients dying at home” and “the percentage of patients who died in their place of preference” are feasible and informative quality indicators. Methods and Findings A mortality follow-back study was conducted, based on data recorded by representative GP networks regarding home-dwelling patients who died non-suddenly in Belgium (n = 1036), the Netherlands (n = 512), Italy (n = 1639) or Spain (n = 565). “The percentage of patients dying at home” ranged between 35.3% (Belgium) and 50.6% (the Netherlands) in the four countries, while “the percentage of patients dying at their preferred place of death” ranged between 67.8% (Italy) and 86.0% (Spain). Both indicators were strongly associated with palliative care provision by the GP (odds ratios of 1.55–13.23 and 2.30–6.63, respectively). The quality indicator concerning the preferred place of death offers a broader view than the indicator concerning home deaths, as it takes into account all preferences met in all locations. However, GPs did not know the preferences for place of death in 39.6% (the Netherlands) to 70.3% (Italy), whereas the actual place of death was known in almost all cases. Conclusion GPs know their patients’ actual place of death, making the percentage of home deaths a feasible indicator for collection by GPs. However, patients’ preferred place of death was often unknown to the GP. We therefore recommend using information from relatives as long as information from GPs on the preferred place of death is lacking. Timely communication about the place where patients want to be cared for at the end of life remains a challenge for GPs.

Prevalence of Symptoms in Older Cancer Patients Receiving Palliative Care: A Systematic Review and Meta-Analysis

CONTEXT Symptom control is an essential part of palliative care and important to achieve optimal quality of life. Studies showed that patients with all types of advanced cancer suffer from diverse and often severe symptoms. Research focusing on older persons is scarce because this group is often excluded from studies. Consequently, it is unclear which symptoms older palliative care patients with cancer experience and what is the prevalence of these symptoms. To date, no systematic review has been performed on the prevalence of symptoms in older cancer patients receiving palliative care. OBJECTIVES The objective of this systematic review was to search and synthesize the prevalence figures of symptoms in older palliative care patients with cancer. METHODS A systematic search through multiple databases and other sources was conducted from 2002 until April 2012. The methodological quality was evaluated. All steps were performed by two independent reviewers. A meta-analysis was performed to pool the prevalence of symptoms. RESULTS Seventeen studies were included in this systematic review. Thirty-two symptoms were identified. The prevalence of these symptoms ranged from 3.5% to 77.8%. The most prevalent symptoms were fatigue, excretory symptoms, urinary incontinence, asthenia, pain, constipation, and anxiety and occurred in at least 50% of patients. CONCLUSION There is a high degree of uncertainty about the reported symptom prevalence because of small sample sizes, high heterogeneity among studies, and the extent of instrument validation. Research based on rigorous methods is needed to allow more conclusive results.

Understanding the relationship between type 2 diabetes mellitus and falls in older adults: a prospective cohort study.

Background Older adults with type 2 Diabetes Mellitus are at increased risk of falling. The current study aims to identify risk factors that mediate the relationship between diabetes and falls. Methods 199 older adults (104 with diabetes and 95 healthy controls) underwent a medical screening. Gait (GAITRite®), balance (AccuGait® force plate), grip strength (Jamar®), and cognitive status (Mini-Mental State Examination and Clock Drawing Test) were assessed. Falls were prospectively recorded during a 12-month follow-up period using monthly calendars. Results Compared to controls, diabetes participants scored worse on all physical and cognitive measures. Sixty-four participants (42 diabetes vs. 22 controls) reported at least one injurious fall or two non-injurious falls (“fallers”). Univariate logistic regression identified diabetes as a risk factor for future falls (Odds Ratio 2.25, 95%CI 1.21–4.15, p = 0.010). Stepwise multiple regressions defined diabetes and poor balance as independent risk factors for falling. Taking more medications, slower walking speed, shorter stride length and poor cognitive performance were mediators that reduced the Odds Ratio of the relationship between diabetes and faller status relationship the most followed by reduced grip strength and increased stride length variability. Conclusions Diabetes is a major risk factor for falling, even after controlling for poor balance. Taking more medications, poorer walking performance and reduced cognitive functioning were mediators of the relationship between diabetes and falls. Tailored preventive programs including systematic medication reviews, specific balance exercises and cognitive training might be beneficial in reducing fall risk in older adults suffering from diabetes.

Advance Care Planning in terminally ill and frail older persons

OBJECTIVE Advance Care Planning (ACP) - the communication process by which patients establish goals and preferences for future care - is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients. METHODS We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis. RESULTS The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control. CONCLUSIONS ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patients power of imagination. This may result in end-of-life decisions not reflecting the patients true wishes. PRACTICE IMPLICATIONS Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.