Differing trends in fall-related fracture and non-fracture injuries in older people with and without dementia

ObjectivesTo explore the impact of dementia on the trends in fall-related fracture and non-fracture injuries for older people.MethodsIndividuals aged ≥65 years who were admitted to a NSW hospital for at least an over-night stay for a fall-related injury from 2003 to 2012 were identified. Age-standardised hospitalisation rates, length of stay, access to in-hospital rehabilitation, 30-day and 1-year mortality were examined. Annual percentage change (PAC) over time was calculated using negative binomial regression.ResultsOf the 228,628 fall-related injury hospitalisations, 20.6% were for people with dementia. People with dementia were more likely to be admitted with a hip fracture, and less likely to be admitted with a fracture of the forearm/wrist, and received less in-hospital rehabilitation than people without dementia. Fall-related hip-fracture rates for people with dementia decreased by 4.2% (95%CI −5.6 to −2.7, p < 0.001) per annum; there was no change over time for people without dementia (PAC-0.2%; 95%CI −0.8 to 0.5, p = 0.643). Rates for other fractures decreased by 1.2% (95%CI −1.9 to −0.5, p < 0.001) per annum in people with dementia, while rates increased by 2.2% (95%CI 1.9–2.5, p < 0.001) for people without dementia. By contrast, non-fracture injuries including traumatic brain injury increased significantly for both people with and without dementia.ConclusionRates of fall-related fracture and non-fracture hospitalisations for people with dementia remain higher than for those without dementia. However, fall-related fracture hospitalisation rates have decreased for people with dementia, while there has not been a corresponding decrease in people without dementia.     

Mild cognitive impairment: epidemiology and dementia risk in an elderly Italian population

OBJECTIVES: To investigate prevalence and incidence of mild cognitive impairment (MCI) and its risk of progression to dementia in an elderly Italian population.
DESIGN: Longitudinal.
SETTING: Population-based cohort aged 65 and older resident in an Italian municipality.
PARTICIPANTS: A total of 1,016 subjects underwent baseline evaluation in 1999/2000. In 2003/04, information about cognitive outcome was collected for 745 participants who were free of dementia at baseline.
MEASUREMENTS: MCI (classified as with or without impairment of the memory domain), dementia, Alzheimer's dementia (AD), and vascular dementia (VaD) diagnosed according to current international criteria.
RESULTS: Overall prevalence of MCI was 7.7% (95% confidence interval (CI)=6.1–9.7 %) and was greater with older age and poor education. During 4 years of follow-up, 155 incident MCI cases were diagnosed, with an incidence rate of 76.8 (95% CI=66.8–88.4) per 1,000 person-years. Approximately half of prevalent and incident MCI cases had memory impairment. Compared with normal cognition, multivariable-adjusted risk for progression from MCI with memory impairment to dementia was 4.78 (95% CI=2.78–8.07) for any dementia, 5.92 (95% CI=3.20–10.91) for AD, and 1.61 (95% CI=0.37–7.00) for VaD. No association with dementia risk was found for MCI without memory impairment. Approximately one-third of MCI cases with memory impairment did not progress to dementia.
CONCLUSION: MCI occurs often in this elderly Italian cohort and is associated with greater risk of AD, but only when the impairment involves the memory domain. However, a substantial proportion of MCI cases with memory impairment do not progress to dementia.     

Atrial fibrillation and risk of dementia in non-demented elderly subjects with and without mild cognitive impairment (MCI)

MCI is regarded as a precursor of dementia, but not all patients with MCI actually develop dementia. As Alzheimer and vascular dementia (AD and VD, respectively) are thought to share many common etiopathogenetic mechanisms, we investigated whether the vascular risk factor atrial fibrillation affect the risk of conversion to dementia for different MCI subtypes diagnosed according to international criteria. One-hundred-eighty elderly outpatients with MCI and 431 elderly outpatients with a normal cognition were followed-up for a mean of 3 and 4 years, respectively. The risk of conversion to dementia associated with atrial fibrillation was studied in both samples using a Cox proportional-hazards model adjusted for sociodemographic and medical variables. Overall conversion rate to dementia was 10.5 (8.0-13.8) per 100 person-years in the MCI group and 2.2 (1.5-3.1) per 100 person-years in the normal cognition group. Atrial fibrillation was significantly associated with conversion to dementia (hazard ratio=HR=4.63, 95% confidence interval=Cl=1.72-12.46) in the MCI group, but not in the cognitively normal group (HR=1.10, 95% Cl=0.40-3.03). Current diagnostic criteria for MCI subtypes define heterogeneous populations, but atrial fibrillation can be useful in identifying people with increased risk of conversion to dementia.     

One-year mortality after hip fracture in older individuals: the effects of delirium and dementia

BackgroundDelirium is common in older hip fracture patients, yet its association with mortality after hip fracture remains uncertain. This study aimed to determine whether delirium was associated with all-cause one-year mortality after hip fracture in older patients and whether the effect of delirium was independent of dementia status.MethodA retrospective analysis of linked hospitalisation and mortality data for patients aged ≥65 years with a hip fracture during 1 January 2010 to 30 June 2014 in New South Wales, Australia. The association between delirium and mortality after a hip fracture was assessed using Cox proportional hazard regression.ResultsThere were 4,065 (14.6%) of 27,888 hip fracture hospitalisations identified with delirium during hospitalisation. Individuals with delirium had a higher age-adjusted rate of all-cause one-year mortality after hip fracture compared to individuals without delirium (35.3% versus 23.9%). After adjusting for covariates, the risk of all-cause mortality was increased at one-year post-admission for older individuals compared to those aged 65-69 years, for individuals with multiple comorbidities, dementia (Hazard Ratio (HR): 1.14; 95%CI:1.08-1.20), delirium (HR: 1.19; 95%CI:1.12-1.26), and who had an Intensive Care Unit admission (HR: 1.44; 95%CI:1.31-1.59). Comorbid delirium did not add additional mortality risk for individuals with a hip fracture who have dementia.ConclusionsDelirium identified in hospital was associated with all-cause one-year mortality after hip fracture in older Australians without dementia. As delirium is potentially preventable, better systematic assessment and documentation of a hip fracture patient’s cognitive state is warranted to select the most effective strategies to prevent and manage delirium.     

Characteristic Profiles of Activities of Daily Living and Relationship with Cognitive Performance in Thai Elderly with Different Stages from Normal Cognitive Function,Mild Cognitive Impairment to Dementia

ABSTRACT

Objective: The objectives were twofold—first, to evaluate the functional difference among normal cognitive elderly, mild cognitive impairment (MCI), and people with dementia; and second, to investigate the relationship between cognitive performance and functional abilities. Method: The Disability Assessment for Dementia (DAD) was administered to 90 participants: 20 normal controls (NC), 20 with MCI, 25 with mild dementia, 15 with moderate dementia and 10 with severe dementia patients. Results: The mean (SD) scores on instrumental activities of daily living (IADL) were 94.8 (6.4) for NC, 89.1 (9.9) for MCI, 33.6 (21.7) for mild dementia, 13 (12.2) for moderate dementia and 1.7 (4.2) for severe dementia. MCI participants presented slightly noticeable deficit in one IADL domain: ‘finance and correspondence’, whereas mild dementia presented deficit in all six IADL domains. Scores of basic activities of daily living (BADL) of the NC and MCI groups were equal at a perfect 100. The scores were slightly reduced in mild dementia patients (92.7 [12.3]) and were decreased in moderate (68.6 [26.4]) and severe dementia participants (10 [14.4]). Conclusions: Our studies demonstrated that IADL can be subtly impaired in people with MCI, but markedly impaired in those with mild dementia. BADL begin to decline in moderate dementia and then reach a level of severe impairment in severe dementia.     

Parathormone,vitamin D and the risk of atrial fibrillation in older adults: A prospective study

Background & aimsVitamin D and parathormone (PTH) have been associated with cardiovascular outcomes, but their impact on atrial fibrillation (AF) onset is still unclear. We explored the influence of serum 25-hydroxyvitamin D (25[OH]D) and PTH on AF risk in older adults.Methods and resultsData come from 2418 participants enrolled in the Progetto Veneto Anziani study. Serum 25(OH)D and intact PTH were measured using radioimmunoassay and two-site immunoassay, respectively. The associations between 25(OH)D, PTH and adjudicated AF cases over 4-years were explored by Cox regression.Over the follow-up, 134 incident cases of AF were assessed. The incidence rate of the sample was 13.5 (95%CI 11.4–15.9) per 1000 person-years, and was higher among those with high PTH levels (high: 16.4 [95%CI 11.3–24.0] per 1000 person-years), especially when associated to low 25(OH)D (20.3 [95%CI 12.9–32.3] per 1000 person-years). At Cox regression, only high PTH was significantly associated to an increased risk of AF (HR = 1.90, 95%CI 1.27–2.84). A marginal significant interaction (p = 0.06) was found between 25[OH]D and PTH concentrations in influencing AF risk. When exploring the risk of AF for combined categories of 25(OH)D and PTH, we found that those with high PTH and low 25(OH)D levels had an AF risk twice as high as that of people with normal values (HR = 2.09, 95%CI 1.28–3.42).ConclusionThe risk of AF may be increased by high PTH levels, especially when associated with 25(OH)D deficiency. The identification and treatment of high PTH or vitamin D deficiency may thus contribute to lower the risk of AF.     

Conversion pattern and predictive factor of mild cognitive impairment in elderly Koreans

ObjectiveWe aimed to understand conversion characteristics of mild cognitive impairment (MCI) in elderly Koreans.MethodsWe analyzed clinical data of 760 individuals who participated in a two-year follow-up study. Neuropsychological assessments and clinical examination were conducted in the follow-ups. Logistic regression model was used to estimate predictive risk factors of MCI conversion.ResultThe participants at baseline (n = 760) represented 462 cognitively normal individuals (60.8%), 286 individuals with MCI (37.6%), and 12 individuals with dementia (1.6%). Among the cognitively normal individuals (n = 462), 108 (23.4%) progressed to MCI during the two-year follow-up period, including 92 with amnestic mild cognitive impairment (aMCI; 19.9%) and 16 with non-amnestic mild cognitive impairment (non-aMCI; 3.5%). Interestingly, 3.7% of participants with aMCI converted to non-aMCI, while 45.5% of participants with non-aMCI converted to aMCI. Moreover, a higher proportion of non-aMCI (27.3%) reverted to a cognitively normal state, compared to aMCI participants (18.6%), indicating that non-amnestic cognitive impairment is more unstable than amnestic cognitive impairment, and probably converges toward aMCI. Additionally, we found that weight loss was associated with incident MCI and future MCI. Weight loss was negatively correlated with Clinical Dementia Rating (p = 0.005), and significantly associated with a higher risk of MCI conversion from a cognitively normal state (OR = 1.10, 95% CI: 1.00–1.21, p = 0.042).ConclusionThis study supports that non-amnestic MCI is prone to converge toward amnestic MCI, and the elderly people with weight loss are at risk for developing cognitive decline.     

Effects of physical exercise on cognitive function of older adults with mild cognitive impairment: A systematic review and meta-analysis

Background and PurposeMild Cognitive Impairment (MCI) is associated with a greater risk of dementia for older adults. However, systematic reviews have shown that some physical exercise (PE) seems to improve MCI symptoms and signs. Those reviews and meta-analysis could not explain what possible moderator influenced their results. This meta-analysis aims to identify the effect of PE over older people’s cognition with MCI and explore sources of heterogeneity.MethodsDatabases were searched from inception January 2020 for randomized clinical trials that evaluated the effects of PE over cognition of older persons with MCI. Random effect meta-analyses were performed for each cognitive outcome. Subgroup analyses and meta-regressions models explored the potential sources of heterogeneity.ResultsA total of 2077 participants (mean age = 71.8 years) from 27 studies were included. PE improves global cognitive function (SMD = 0.348 [95 % CI 0.166 to 0.529]; p = 0.0001), executive function (SMD = 0.213 [95 % CI 0.026 to 0.400]; p = 0.026) and delayed recall (SMD = 0.180 [95 % CI 0.002 to 0.358]; p = 0.047). A trend towards beneficial effects of PE on verbal fluency (SMD = 0.270 [95 %, CI -0.021 to 0.561]; p = 0.069) and attention (SMD = 0.170 [CI -0.016 to 0.357]; p = 0.073) were also observed. Subgroup analyses showed a relationship between modality and intensity of physical exercise and changes observed in global cognitive function, executive function, delayed recall, verbal fluency and working memory.Discussion and ConclusionPE can ameliorate cognitive deficts of older adults with MCI. The most pronounced effects appear to arise from other types of exercise that included mind-body exercises and moderate intensity.     

Low-grade systemic inflammation is associated with functional disability in elderly people affected by dementia

The decline in basic and instrumental activities of daily living (BADLs and IADLs, respectively) is a well-established clinical hallmark of dementia. Growing evidence has shown that systemic subclinical inflammation may be related to functional impairment. We evaluated the possible association between low-grade systemic inflammation and functional disability in older individuals affected by dementia. We explored the association between high-sensitivity C-reactive protein (hs-CRP) levels and BADLs/IADLs in older individuals affected by late onset Alzheimer’s disease (LOAD; n 110), “mixed” dementia (n 135), or mild cognitive impairment (MCI; n 258), and compared them with 75 normal Controls. Independent of age, gender, comorbidity, and other potential confounders, higher hs-CRP was significantly associated with poorer BADLs (loss ≥?1 function) in people with LOAD (odds ratio [OR] 3.14, 95% confidence interval [CI], 1.33–7.33) and mixed dementia (OR 2.48, 95%CI 1.12–5.55), but not in those with MCI (OR 1.38, 95%CI 0.83–2.45) or Controls (OR 2.98, 95%CI 0.54–10.10). No association emerged between hs-CRP and IADLs in any of the sub-group. Our data suggest that systemic low-grade inflammation may contribute to functional disability in older patients with dementia.     

Association between risk,duration and cause of hospitalisations in people with rheumatoid arthritis and multimorbidity in the UK Biobank and Scottish Early Rheumatoid Arthritis (SERA) cohorts: Longitudinal observational study

ObjectivesTo investigate association between presence of multimorbidity in people with established and early rheumatoid arthritis (RA) and risk, duration and cause of hospitalisations.DesignLongitudinal observational study.SettingUK Biobank, population-based cohort recruited between 2006 and 2010, and the Scottish Early Rheumatoid Arthritis (SERA), inception cohort recruited between 2011 and 2015. Both linked to mortality and hospitalisation data.Participants4757 UK Biobank participants self-reporting established RA; 825 SERA participants with early RA meeting the 2010 ACR/EULAR classification criteria. Participants stratified by number of long-term conditions (LTCs) in addition to RA (RA only, RA + 1 LTC and RA + ≥ 2 LTCs) and matched to five non-RA controls.Main outcome measuresNumber and duration of hospitalisations and their causes. Incidence rate ratios (IRR) and 95% confidence intervals (CI) calculated using negative binomial regression models.ResultsParticipants with RA + ≥ 2 LTCs experienced higher hospitalisation rates compared to those with RA alone (UK Biobank: IRR 2.10, 95% CI 1.91 to 2.30; SERA: IRR 1.74, 95% CI 1.23 to 2.48). Total duration of hospitalisation in RA + ≥ 2 LTCs was also higher (UK Biobank: IRR 2.48, 95% CI 2.17 to 2.84; SERA: IRR 1.90, 95% CI 1.07 to 3.38) than with RA alone. Rate and total duration of hospitalisations was higher in UK Biobank RA participants than non-RA controls with equivalent number of LTCs. Hospitalisations for respiratory infection were higher in early RA than established RA and were the commonest cause of hospital admission in early RA.ConclusionsParticipants with established or early RA with multimorbidity experienced a higher rate and duration of hospitalisations than those with RA alone and with non-RA matched controls.     

Accelerated weight loss and incident dementia in an elderly African-American cohort

OBJECTIVES: To examine the association between changes in body mass index (BMI), dementia, and mild cognitive impairment (MCI). DESIGN: Prospective observational study. SETTING: Urban community in Indianapolis, Indiana. PARTICIPANTS: Participants were African Americans aged 65 and older enrolled in the Indianapolis Dementia Project and followed through 2007. This analysis included 1,331 participants who did not have dementia at their first BMI measurement. MEASUREMENTS: Cognitive assessment and clinical evaluations were conducted every other year to identify participants with dementia or MCI during 12 years of follow‐up (mean follow‐up 6.4 years). BMI measures; alcohol and smoking history; and medical conditions including history of cancer, hypertension, diabetes mellitus, heart attack, stroke; and depression were collected at each follow‐up evaluation. Mixed‐effect models were used to examine the differences in BMI between participants who developed dementia or MCI and those who did not, adjusting for covariates. RESULTS: Mean BMI at baseline was 29.8 ± 5.7 for women and 28.3 ± 4.8 for men. Participants with incident dementia or MCI had greater decline in BMI than those without (P=.02 for dementia, P=.04 for MCI). BMI in participants with incident dementia, MCI, and normal cognition did not differ 12 or 9 years before diagnosis, but 6 years before diagnosis, participants with incident dementia had significantly lower BMI than participants with normal cognition (P=.03), as did participants with MCI (P=.006). CONCLUSION: Decline in BMI appears to be an early marker for dementia. There is a need for the close monitoring of weight loss in older adults.     

简易认知量表和8条目痴呆筛查问卷在高龄老年人群早期认知功能下降筛查中的应用

目的探讨简易认知量表（Mini-Cog）和8条目痴呆筛查问卷（8-item ascertain dementia, AD8）对80岁以上老年人群早期轻度认知功能障碍（mild cognitive impairment, MCI）的筛查价值。 方法选取杭州市某福利中心的2014年10月前已入住的908名高龄老年人进行Mini-Cog和AD8筛查,随访5年后对仍然健在且能配合完成检查者进行二次认知功能评估。计算Mini-Cog和AD8初筛的敏感度和特异度,并分析随访5年后AD8的ROC曲线结果以及两种量表的一致性检验结果。 结果908例高龄老年人中523例确诊为痴呆（不计入后续筛查及随访调查）,余385例筛查结果显示：Mini-Cog、AD8诊断MCI的敏感度分别为54.88%、57.32%,特异度分别为85.52%、86.43%。随访5年后仍健在且接受二次评估的老年人共167名,其中认知功能正常106例（54例出现认知功能下降）,MCI 61例（36例出现认知功能进一步下降）。对于随访5年的认知功能正常者及MCI者,AD8诊断的AUC分别为0.572（95%CI=0.486-0.658）、0.723（95%CI=0.611-0.835）,Mini-Cog和AD8（以得分>3为分界线）诊断的一致性Kappa值分别为0.105、0.018和0.225、0.524。 结论AD8和Mini-Cog均具有一定的MCI评估效能,尤其适用于养老机构及社区高龄老年群体的认知功能筛查。     

Development and validation of the Montreal cognitive assessment for people with hearing impairment (MoCA-H)

Background

Hearing impairment is common among older adults and affects cognitive assessments for identification of dementia which rely on good hearing function. We developed and validated a version of the Montreal Cognitive Assessment (MoCA) for people with hearing impairment.

Methods

We adapted existing MoCA 8.1 items for people with hearing impairment by presenting instructions and stimuli in written rather than spoken format. One Attention domain and two Language domain items required substitution by alternative items. Three and four candidate items respectively were constructed and field-tested along with the items adapted to written form. We used a combination of individual item analysis and item substitution to select the set of alternative items to be included in the final form of the MoCA-H in place of the excluded original items. We then evaluated the performance and reliability of the final tool, including making any required adjustments for demographic factors.

Results

One hundred and fifty-nine hearing-impaired participants, including 76 with normal cognition and 83 with dementia, completed the adapted version of the MoCA. A further 97 participants with normal hearing completed the standard MoCA as well as the novel items developed for the MoCA-H to assess score equivalence between the existing and alternative MoCA items and for independence from hearing impairment. Twenty-eight participants were retested between 2–4 weeks after initial testing. After the selection of optimal item set, the final MoCA-H had an area under the curve of 0.973 (95% CI 0.952–0.994). At a cut-point of 24 points or less sensitivity and specificity for dementia was 92.8% and 90.8%, respectively. The intraclass correlation for test–retest reliability was 0.92 (95%CI 0.78–0.97).

Conclusion

The MoCA-H is a sensitive and reliable means of identifying dementia among adults with acquired hearing impairment.     

Serum uric acid level and association with cognitive impairment and dementia: systematic review and meta-analysis

Serum uric acid (sUA) level may be associated with cognitive impairment/dementia. It is possible this relationship varies with dementia subtype, particularly between vascular dementias (VaD) and Alzheimer’s (AD) or Parkinson’s disease (PDD)-related dementia. We aimed to present a synthesis of all published data on sUA and relationship with dementia/cognition through systematic review and meta-analysis. We included studies that assessed the association between sUA and any measure of cognitive function or a clinical diagnosis of dementia. We pre-defined subgroup analyses for patients with AD, VaD, PDD, mild cognitive impairment (MCI), and mixed or undifferentiated. We assessed risk of bias/generalizability, and where data allowed, we performed meta-analysis to describe pooled measures of association across studies. From 4811 titles, 46 papers (n?=?16,688 participants) met our selection criteria. Compared to controls, sUA was lower in dementia (SDM ?0.33 (95%CI)). There were differences in association by dementia type with apparent association for AD (SDM ?0.33 (95%CI)) and PDD (SDM ?0.67 (95%CI)) but not in cases of mixed dementia (SDM 0.19 (95%CI)) or VaD (SDM ?0.05 (95%CI)). There was no correlation between scores on Mini-Mental State Examination and sUA level (summary r 0.08, p?=?0.27), except in patients with PDD (r 0.16, p?=?0.003). Our conclusions are limited by clinical heterogeneity and risk of bias in studies. Accepting this caveat, the relationship between sUA and dementia/cognitive impairment is not consistent across all dementia groups and in particular may differ in patients with VaD compared to other dementia subtypes.     

Mild Cognitive Impairment,Screening, and Patient Perceptions in Heart Failure Patients

ObjectiveCognitive impairments are prevalent in heart failure (HF) patients, worsening outcomes but often undetected.The aim of this study was to screen HF outpatients for mild cognitive impairment (MCI), determine the areas of cognition affected, patient awareness of cognitive change, and associated factors.Method and ResultsHF patients (n = 128) newly registered for the Management of Cardiac Function program, free from neurocognitive disorder, and with sufficient visual acuity were assessed with the use of the Montreal Cognitive Assessment tool (MoCA). MCI was classified as MoCA score ≤22. The sample was elderly (mean, 80.65 years; SD, 11.52). Mean MoCA score was 24.58 (SD 3.45), 22% were classified as impaired, 45% had noticed a change in cognition, and 15% reported that they were affected in their daily lives. Patients noticing this impact had lower MoCA scores (22.74, SD 3.0) than those who did not (25.17, SD 2.96; P ≤ .02). Most impairments occurred for delayed recall, visuospatial/executive function, and abstraction. The odds of impairment increased by the presence of ischemic heart disease (odds ratio, 4.18; 95% confidence interval, 1.15–15.69).ConclusionsIn HF outpatients without a dementia diagnosis, MCI is prevalent. Screening for MCI and incorporation of compensatory strategies are essential.     

上海部分城乡地区血管性痴呆的发病率及危险因素研究

目的　调查上海部分城乡地区血管性痴呆 (VaD)的发病率及相关危险因素。方法　在上海地区基线患病率调查的基础上选择 5个居委会和 4个村委会的居民作为研究对象。通过简易精神状态量表 (MMSE) ,根据文化程度划分的分界值进行初筛 ,在分界值以下的对象和正常人群中随机选择 4 %进入细查。细查项目有体格检查、详细病史记录以及成套的神经心理学测试 ,包括 :Pfeffer功能活动、Fuld物体记忆、快速物体回忆、韦氏儿童智力量表积木测验和韦氏成人智力量表数字广度、日常生活功能量表 (ADL)、HachisKi缺血量表、汉密顿抑郁量表 (HAMD)等。以精神障碍诊断和统计手册作为痴呆的诊断标准。 6个月后对所有进入细查的对象进行复查 ,根据美国神经病学、语言障碍和卒中 老年性痴呆和相关疾病学会的标准诊断阿尔茨海默病 (AD) ;根据美国国立神经病卒中研究所和瑞士神经科学研究国际协会的标准诊断VaD。结果　在实际完成初筛的 35 4 5例中 ,确诊新发痴呆病例 112例 ,其中VaD 2 8例 ,发病率是 2 .5 4 3 千人年 (标化率为 2 .4 0 3 千人年 )。VaD与年龄呈正相关 ,其OR =1.12 7(95 %CI :1.0 76～ 1.179,P =0 .0 0 0 ) ,与教育呈负相关 ,其OR =0 .6 5 4 (95 %CI:0 .4 5 1～ 0 .94 3,P =0 .0 2 3)。结论　上海部分城乡地区     

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study

ObjectiveTo investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation.MethodsConsecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units.ResultsWe included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4–11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6–10 days, 1287 (15.0%) 11–15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0–64.9) when LOH was 11–15 days, and by 72.0% (95%CI = 42.6–107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4–36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk.ConclusionsShort hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments.     

Physical performance across the cognitive spectrum and between dementia subtypes in a population-based sample of older adults: The HUNT study

BackgroundLiterature on physical performance in older adults across the cognitive spectrum remains inconclusive, and knowledge on differences between dementia subtypes is lacking. We aim to identify distinct physical-performance deficits across the cognitive spectrum and between dementia subtypes.Methods11,466 persons were included from the 70-year-and-older cohort in the fourth wave of the Trøndelag Health Study (HUNT4 70+). Physical performance was assessed with the Short Physical Performance Battery (SPPB), 4-meter gait speed, five-times-sit-to-stand (FTSS), grip strength and one-leg-standing (OLS). Clinical experts diagnosed dementia per DSM-5 criteria. Multiple linear and logistic regression were performed to analyze differences between groups. Age, sex, education, somatic comorbidity, physical activity and smoking status were used as covariates.ResultsGait speed declined across the cognitive spectrum, beginning in people with subjective cognitive decline (SCD). Participants with mild cognitive impairment (MCI) additionally showed reduced lower-limb muscle strength, balance and grip strength. Those with dementia scored lowest on all physical-performance measures. Participants with Alzheimer's disease (AD) had a higher SPPB sum score and faster gait speed than participants with vascular dementia (VaD) and Lewy body dementia (LBD); participants with VaD and LBD had lower odds of being able to perform FTSS and OLS than participants with AD.ConclusionsPhysical performance declined across the spectrum from cognitively healthy to SCD to MCI and to dementia. Participants with AD performed better on all assessments except grip strength than participants with VaD and LBD. Stage of cognitive impairment and dementia subtype should guide exercise interventions to prevent mobility decline and dependency.     

Frailty and cognitive status evaluation can better predict mortality in older adults?

Objectivesto evaluate the improvement in one-year mortality prediction after adding a 2-min cognitive screening to a simple 1-min frailty detection instrument. Secondary outcomes were new activities of daily living (ADL) disability and falls.DesignProspective cohort study.SettingA geriatric day-hospital for intermediate care.ParticipantsA total of 701 older adults with an acute or decompensated disease (79.5 (8.3) years, 64% female).MeasurementsA rapid and simple frailty evaluation was performed using the FRAIL questionnaire. The presence of cognitive impairment was defined by previous diagnosis of dementia or a score of five or less on an education-corrected 10-point cognitive screening tool.ResultsFrail participants with normal (hazard risk [HR] 4.0, 95% confidence interval [CI], 1.73–9.25) and impaired cognition had a higher risk of death (HR 4.38, 95% CI, 1.95–9.87) than robust participants. The presence of cognitive impairment increased the risk of death in prefrail (HR 3.60, 95% CI, 1.55–8.34) and robust participants (HR 3.49, 95% CI, 1.22–9.96). Cognitive impairment was associated with an increased risk of incident ADL disability in all frailty categories. The presence of cognitive impairment was associated with a significantly higher risk of fall in robust seniors. The predictive accuracy of the FRAIL scale was lower than expected (between 0.58 and 0.69), and a small improvement was observed after adding the cognitive screening (between 0.61 and 0.72).ConclusionDespite of significant results in predicting relevant clinical events, the present combination of the FRAIL and 10-CS scales may not be ideal in clinical practice.     

Opioid treatment and hypoalbuminemia are associated with increased hospitalisation rates in chronic pancreatitis outpatients

Background/objectivesChronic pancreatitis (CP) is a complex and debilitating disease with high resource utilisation. Prospective data on hospital admission rates and associated risk factors are scarce. We investigated hospitalisation rates, causes of hospitalisations and associated risk factors in CP outpatients.MethodsThis was a prospective cohort study comprising 170 patients with CP. The primary outcome was time to first pancreatitis related hospitalisation and secondary outcomes were the annual hospitalisation frequency (hospitalisation burden) and causes of hospitalisations. A number of clinical and demographic parameters, including pain pattern and severity, opioid use and parameters related to the nutritional state, were analysed for their association with hospitalisation rates.ResultsOf the 170 patients, 57 (33.5%) were hospitalised during the follow-up period (median 11.4 months [IQR 3.8–26.4]). The cumulative hospitalisation incidence was 7.6% (95% CI; 4.5–12.2) after 30 days and 28.8% (95% CI; 22.2–35.7) after 1 year. Eighteen of the hospitalised patients (32%) had three or more admissions per year. High dose opioid treatment (>100 mg per day) (Hazard Ratio 3.1 [95% CI; 1.1–8.5]; P = 0.03) and hypoalbuminemia (<36 g/l) (Hazard Ratio 3.8 [95% CI; 2.0–7.8]; P < 0.001) were identified as independent risk factors for hospitalisation. The most frequent causes of hospitalisations were pain exacerbation (40%) and common bile duct stenosis (28%).ConclusionsOne-third of CP outpatients account for the majority of hospital admissions and associated risk factors are high dose opioid treatment and hypoalbuminemia. This information should be implemented in outpatient monitoring strategies to identify risk patients and improve treatment.