Torgeir Bruun Wyller

Risk factors for serious fall related injury in elderly women living at home.

Objectives: To study whether balance, function, and other health status indicators can predict serious fall related injury in elderly women living at home. Methods: In this prospective study, the authors took a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%), living in the community. Serious fall injuries which occurred over a period of during one year were recorded, together with baseline registrations of health, function, and tests of walking and balance. Results: In all, 155 women (50.5%) fell one or more times. One hundred and fifty six (51%) of the 308 falls resulted in a fall related injury, 74 (24%) in a serious fall related injury, and 40 falls (13%) resulted in fractures. The presence of rheumatic disorders, inability to rise from the floor, arthrosis of the hip, having had more than one fall during the one year follow up period, and an increased tendency to sway in the frontal plane when doing a calculation task were independent and significant predictors for serious fall related injury (fractures included). The independent predictors of fall induced fractures were experiencing more than one fall in the follow up period, cognitive impairment, and receiving care from professional or other. Conclusion: The study suggests that rheumatic disorders and the inability to get up from lying on the floor were the strongest independent risk factors for serious fall related injury. Experiencing more than one fall in the follow up period and cognitive impairment are the strongest independent predictors for fall induced fractures. Age was not a significant predictor of serious fall related injury. Assessment of these markers is feasible in a clinical setting and is a useful way of identifying those who are at risk of serious fall related injuries.

Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: A prospective observational cohort study

OBJECTIVE To examine the association between the outcomes of a pre-operative comprehensive geriatric assessment (CGA) and the risk of severe post-operative complications in elderly patients electively operated for colorectal cancer. METHODS One hundred seventy-eight consecutive patients ≥ 70 years electively operated for all stages of colorectal cancer were prospectively examined. A pre-operative CGA was performed, and patients were categorized as fit, intermediate, or frail. The main outcome measure was severe complications within 30 days of surgery. RESULTS Twenty-one patients (12%) were categorized as fit, 81 (46%) as intermediate, and 76 (43%) as frail. Eighty-three patients experienced severe complications, including three deaths; 7/21 (33%) of fit patients, 29/81 (36%) of intermediate patients and 47/76 (62%) of frail patients (p=0.002). Increasing age and ASA classification were not associated with complications in this series. CONCLUSION CGA can identify frail patients who have a significantly increased risk of severe complications after elective surgery for colorectal cancer.

The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients: A modified Delphi study

Objective. To establish a clinically relevant list with explicit criteria for pharmacologically inappropriate prescriptions in general practice for elderly people ≥70 years. Design. A three-round Delphi process for validating the clinical relevance of suggested criteria (n = 37) for inappropriate prescriptions to elderly patients. Setting. A postal consensus process undertaken by a panel of specialists in general practice, clinical pharmacology, and geriatrics. Main outcome measures. The Norwegian General Practice (NORGEP) criteria, a relevance-validated list of drugs, drug dosages, and drug combinations to be avoided in the elderly (≤70 years) patients. Results. Of the 140 invited panellists, 57 accepted to participate and 47 completed all three rounds of the Delphi process. The panellists reached consensus that 36 of the 37 suggested criteria were clinically relevant for general practice. Relevance of three of the criteria was rated significantly higher in Round 3 than in Round 1. At the end of the Delphi process, a significant difference between the different specialist groups’ scores was seen for only one of the 36 criteria. Conclusion. The NORGEP criteria may serve as rules of thumb for general practitioners (GPs) related to their prescribing practice for elderly patients, and as a tool for evaluating the quality of GPs’ prescribing in settings where access to clinical information for individual patients is limited, e.g. in prescription databases and quality improvement interventions.

Risk Factors for Preoperative and Postoperative Delirium in Elderly Patients with Hip Fracture

OBJECTIVES: To evaluate risk factors for preoperative and postoperative delirium.

Are there gender differences in functional outcome after stroke

Purpose: To study gender differences in functional outcome unexpectedly observed in a follow-up study of stroke patients. Design: Prospective study of hospitalized stroke patients, with evaluations in the subacute phase and after one year. Setting: Geriatric and general medical wards, and geriatric outpatient clinic of a university hospital serving as general hospital for a defined population. Subjects: All stroke patients admitted during a six-month period (n = 165) were considered for inclusion, of whom 87 could be assessed in the subacute phase and 65 after one year. Main outcome measures: Motor function assessed by the Sodring Motor Evaluation of Stroke Patients; cognitive function by the Assessment of Stroke and other Brain Damage; and activities of daily living (ADL) function by the Barthel Index. Nursing-home residency registered after one year. Results: Men achieved a significantly better score than women on most of the scales used. The age-adjusted odds for a man to have a higher Barthel score than a woman was 3.1 (95% confidence interval (CI) 1.3-7.0) in the subacute phase and 3.3 (95% CI 1.2-9.0) after one year. Differences of the same magnitude were seen on the subscales of the motor and cognitive tests. The same trend was observed on all items of the Barthel Index. The males had a lower likelihood to be permanent nursing-home residents after one year, the age-adjusted odds ratio for nursing-home residency for females versus males being 6.3 (95% CI 1.2-65.3). Conclusion: Women seem to be functionally more impaired by stroke than men.

Prediction of long-term functional outcome after stroke rehabilitation

Objective: To ”nd patient characteristics in the early post stroke phase that could predict three years functional outcome. Design: Prospective study. Setting: In-hospital rehabilitation department (admission and discharge). Outpatient department one and three years post stroke. Subjects: One hundred and forty-two stroke patients (56% women), median age 75 years. Main outcome measures: Barthel Index (BI) score; BI score change; accommodation status; Rankin scale score; and Frenchay Activities Index (FAI) score, all registered three years post stroke. Results: The percentages of patients still living at home after one and three years were 88% and 83%, respectively. Twenty per cent of the patients had deteriorated according to the BI after three years, mostly due to recurrent strokes (odds ratio (OR) 10.3; 95% con”dence interval (CI) 3.0–35.5) and co-morbidity with other disabling disorders (OR 3.9; CI 1.1–13.5). Co-morbidity also emerged as an important risk factor for dependency according to BI score (OR 8.8; CI 2.4–32.1) as well as for a poor FAI score (OR 4.9; CI 1.9–13.0). BI in the early phase was the strongest predictor for long-term functional outcome. Urinary incontinence emerged as a risk factor for nursing home placement after three years (OR 3.2; CI 0.9–11.3). Cognitive dysfunction was a risk factor for poor FAI scoring (OR 2.7; CI 1.0–7.0). Conclusions: After stroke rehabilitation, concomitant chronic disabling disorders and recurrent strokes seem to play an important role regarding dependency, handicap and long-term functional decline.

Well-being and instrumental activities of daily living after stroke

Objective: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke. Design: Cross-sectional with evaluation at six months post stroke. Subjects: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. Main outcome measures: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named ‘coping’, ‘anxiety’ and ‘satisfaction’ that served as main outcomes. Results: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension ‘satisfaction’ related significantly to the Nottingham subscale ‘leisure activities’ (β = -0.38, p= 0.01), whereas ‘coping’ was indirectly associated with ‘leisure activities’ by its correlation with ‘satisfaction’ (R= 0.26, p= 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables. Conclusion: ‘Leisure activities’ demonstrated the strongest association to subjective well-being as expressed by the ‘satisfaction’ dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial).

BackgroundDelirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline.MethodsThis was a single-center, prospective, randomized controlled trial in which patients with hip fracture were randomized to treatment in an acute geriatric ward or standard orthopedic ward. Inclusion and randomization took place in the Emergency Department at Oslo University hospital. The key intervention in the acute geriatric ward was Comprehensive Geriatric Assessment including daily interdisciplinary meetings. Primary outcome was cognitive function four months after surgery measured using a composite outcome incorporating the Clinical Dementia Rating Scale (CDR) and the 10 words learning and recalls tasks from the Consortium to Establish a Registry for Alzheimer’s Disease battery (CERAD). Secondary outcomes were pre- and postoperative delirium, delirium severity and duration, mortality and mobility (measured by the Short Physical Performance Battery (SPPB)). Patients were assessed four and twelve months after surgery by evaluators blind to allocation.ResultsA total of 329 patients were included. There was no significant difference in cognitive function four months after surgery between patients treated in the acute geriatric and the orthopedic wards (mean 54.7 versus 52.9, 95% confidence interval for the difference -5.9 to 9.5; P = 0.65). There was also no significant difference in delirium rates (49% versus 53%, P = 0.51) or four month mortality (17% versus 15%, P = 0.50) between the intervention and the control group. In a pre-planned sub-group analysis, participants living in their own home at baseline who were randomized to orthogeriatric care had better mobility four months after surgery compared with patients randomized to the orthopedic ward, measured with SPPB (median 6 versus 4, 95% confidence interval for the median difference 0 to 2; P = 0.04).ConclusionsPre- and postoperative orthogeriatric care given in an acute geriatric ward was not effective in reducing delirium or long-term cognitive impairment in patients with hip fracture. The intervention had, however, a positive effect on mobility in patients not admitted from nursing homes.Trial registrationClinicalTrials.gov NCT01009268 Registered November 5, 2009

Prognostic significance of micturition disturbances after acute stroke.

OBJECTIVES: To investigate the prevalence, incidence, clinical types, and prognostic effect of micturition disturbances in acute stroke.

Acute phase predictors of subsequent psychosocial burden in carers of elderly stroke patients.

The objective was to describe the psychosocial burden experienced by informal carers of elderly stroke victims, and to identify its predictors among baseline characteristics of the patients. From a prospective study of 171 elderly stroke patients admitted to a geriatric ward for rehabilitation in the acute phase, 68 patients living at home with a primary caregiver were identified 6 months after the stroke. At baseline, all the patients were assessed with respect to motor function, cognitive function, global handicap and activities of daily living, and after 6 months the caregivers were assessed, using the Relatives’ Stress Scale. According to this, the most frequent impacts were worries that an accident might befall their relatives, that they had to reorganise their household routines and further, that their social life and ability to take holidays had been reduced. Impaired cognitive function was the only baseline patient characteristic that predicted a subsequent psychosocial burden on the carer. Special attention should be paid to elderly stroke patients initially assessed with impaired cognitive function and their caregivers.