Lack of Association Between Perioperative Medication and Postoperative Delirium in Hip Fracture Patients in an Orthogeriatric Care Pathway

ObjectivesUnits for perioperative geriatric care are playing a growing role in the care of older patients after hip fracture surgery. Postoperative delirium is one of the most common complications after hip fracture, but no study has assessed the impact of therapeutics received during a dedicated orthogeriatric care pathway on its incidence. Our main objective was to assess the association between drugs used in emergency, operating, and recovery departments and postoperative delirium during the acute stay.DesignRetrospective cohort study.Setting and ParticipantsAll patients ≥70 years old admitted for hip fracture to the emergency department and hospitalized in our unit for perioperative geriatric care after hip fracture surgery under general anesthesia between July 2009 and December 2019 in an academic hospital in Paris.MethodsDemographic, clinical, and biological data and all medications administered pre-, peri-, and postoperatively were prospectively collected by 3 geriatricians. Postoperative delirium in the unit for perioperative geriatric care was assessed by using the confusion assessment method scale. Logistic regression analysis was used to assess variables independently associated with postoperative delirium.ResultsA total of 490 patients were included [mean (SD) age 87 (6) years]; 215 (44%) had postoperative delirium. The occurrence was not associated with therapeutics administered during the dedicated orthogeriatric care pathway. Probability of postoperative delirium was associated with advanced age [>90 years, odds ratio (OR) 2.03, 95% confidence interval (CI) 1.07–3.89], dementia (OR 3.51, 95% CI 2.14-–5.82), depression (OR 1.85, 95% CI 1.14–3.01), and preoperative use of beta-blockers (OR 1.75, 95% CI 1.10–2.79).Conclusions and implicationsNo emergency or anesthetic drugs were significantly associated with postoperative delirium. Further studies are needed to demonstrate a possible causal link between preoperative use of beta-blockers and postoperative delirium.     

The Association Between Psychological Resilience and Physical Function Among Older Adults With Hip Fracture Surgery

ObjectivesTo examine the associations of prefracture psychological resilience and prefracture general mental health with physical function among older adults with hip fracture surgery.DesignSingle-center observational study.InterventionNone.Setting and participantsPatients aged ≥50 years who underwent first hip fracture surgery between January 2017 and December 2017 (N = 152).MethodsWe used data collected prospectively from the hospital's hip fracture registry. We performed generalized estimating equations to examine the associations of prefracture psychological resilience (10-item Connor-Davidson Resilience Scale) and prefracture general mental health (Short Form–36 mental health subscale) with physical function (Short Form–36 physical functioning subscale) at 4 time points—prefracture (based on recall), and 1.5, 3, and 6 months after surgery.ResultsPrefracture psychological resilience had an association with physical function; a 1-unit increase in psychological resilience score was associated with 1.15 units [95% confidence interval (CI) 0.71, 1.59] higher physical function score across 4 time points. In contrast, the association between general mental health and physical function varied over time; a 1-unit increase in general mental health score was associated with 0.42 units (95% CI 0.18, 0.66) higher physical function score at prefracture, 0.02 units (95% CI –0.18, 0.22) lower at 1.5 months, 0.23 units (95% CI –0.03, 0.49) higher at 3 months, and 0.39 units (95% CI 0.09, 0.68) higher at 6 months after surgery.Conclusions and implicationsPsychological resilience is associated with physical function among older adults with hip fracture surgery, independent from general mental health. Our findings suggest the potential for interventions targeting psychological resilience for these patients and call for more studies on psychological factors affecting physical function recovery after hip fracture surgery.     

Risk Factors and 120-Day Functional Outcomes of Delirium After Hip Fracture Surgery: A Prospective Cohort Study Using the UK National Hip Fracture Database (NHFD)

ObjectivesTo identify risk factors of postoperative delirium among hip fracture patients with normal preoperative cognition, and examine associations with returning home or recovery of mobility.DesignProspective cohort study.Setting and ParticipantsWe used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018–2019), but excluded those with abnormal cognition [abbreviated mental test score (AMTS) < 8] on presentation.MethodsWe examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1–3 being an intermediate score not excluding delirium.ResultsOverall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home [odds ratio (OR), 0.46; 95% CI, 0.38–0.55] or regain outdoor mobility (OR, 0.63; 95% CI, 0.53–0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81–0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1–3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance.Conclusion and ImplicationsDelirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.     

Timed Up and Go (TUG) Reference Values and Predictive Cutoffs for Fall Risk and Disability in Singaporean Community-Dwelling Adults: Yishun Cross-Sectional Study and Singapore Longitudinal Aging Study

ObjectivesThe “timed up and go” (TUG) test is a simple and widely used test of overall functional mobility. There is a paucity of TUG normative data among Asian individuals who differ in habitual gait speed and fall risk from Western population. The objectives of this study were to determine TUG reference values and optimum cutoffs predicting prevalent and incident disability for community-dwelling adults.DesignOne cross-sectional (Study 1–Yishun Study) and one longitudinal (Study 2–Singapore Longitudinal Aging Study) study in Singapore.Setting and ParticipantsStudy 1 comprised 538 nondisabled, community-dwelling adults aged between 21 and 90 years. Study 2 comprised 1356 community-dwelling older adults aged ≥55 years followed for 3 years.MethodsStudy 1 collected TUG reference values and assessed physiological fall risk (PFR) using the Physiological Profile Assessment (PPA). Study 2 assessed association of TUG with disability with the Barthel Index and the Lawton scale at baseline and follow-up.ResultsFrom Study 1, mean TUG time for individuals aged 60 to 74 years was 9.80 seconds, shorter than values reported for Westerners of 12.30 seconds. It was significantly associated with high PFR [odds ratio (OR) 1.14, 95% confidence interval (CI) 1.03–1.27], 74.0% agreement, Cohen's kappa = 0.314 (95% CI 0.238–0.390); area under the curve = 0.85 (95% CI 0.80–0.90). A TUG cutoff of 10.2 seconds discriminated high PFR from low PFR with 84.4% sensitivity and 72.6% specificity. In Study 2, the threshold for observing significantly increased risk of disability was ≥9.45 seconds for prevalent disability (OR 2.98, 95% CI 1.41–6.78), functional decline (OR 2.68, 95% CI 1.33–5.80), and incidental disability (OR 2.25, 95% CI 1.08–4.97).Conclusions and ImplicationsTUG reference values and cutoff predicting disability for community-dwelling older adults in Singapore are consistent with Asian data and lower than for Western individuals. TUG could be used to guide development and evaluation of risk screening of adverse health outcomes across the life span in Singapore.     

Proton-pump inhibitor use and hip fractures in men: a population-based case-control study

PurposeTo estimate the association between proton-pump inhibitor (PPI) use and hip fracture.MethodsWe conducted a case-control study of 6774 pairs of men aged 45 years or older, matched on age, race, and medical center. Cases sustained incident hip fractures in 1997–2006. Fracture date was index date for each case-control pair. PPI exposure was identified from electronic pharmacy records, 1991–2006. PPI use was measured as (1) ever versus never; (2) adherence; (3) duration; and (4) recentness. Omeprazole and pantoprazole were analyzed separately using conditional logistic regression, adjusted for comorbidities. Nonusers were the referent group.ResultsEight hundred ninety-six (13.2%) cases and 713 (10.5%) controls used omeprazole before index date (matched odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01–1.27). Greatest adherence (medication possession ratio > 80%) (OR, 1.33; 95% CI, 1.09–1.62), highest tertile of duration (OR, 1.23; 95% CI, 1.02–1.48), and recent use (OR, 1.22; 95% CI, 1.02–1.47) were associated with hip fracture. Six hundred ninety-four (10.2%) cases and 576 (8.5%) controls had used pantoprazole (OR, 1.10; 95% CI, 0.97–1.24). Longest duration (OR, 1.25; 95% CI, 1.02–1.53) and most recent use (OR, 1.38; 95% CI, 1.12–1.71) were associated with hip fracture. Our study suggests that PPI use and hip fractures are associated, with risk increasing with longer duration and more recent use.     

Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis

ObjectiveOlder adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring.DesignRetrospective observational cohort study using EHRs.Setting and ParticipantsA cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia.MethodsLogistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling.ResultsDementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19–3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20–2.38], 1-year mortality (HR = 1.78, 95% CI 1.33–2.38), 180-day readmission (HR = 1.62, 95% CI 1.39–1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21–1.58).Conclusions and ImplicationsDementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.     

Dementia and Poor Continuity of Primary Care Delay Hospital Discharge in Older Adults: A Population-Based Study From 2001 to 2016

ObjectivesDelayed discharge, remaining in acute care longer than medically necessary, reflects less than optimal use of hospital care resources and can have negative implications for patients. We studied (1) the change over time in delayed discharge in people with and without dementia, and (2) the association of delayed discharge with discharge destination and with the continuity of primary care prior to urgent admission.DesignA retrospective population-based study.Setting and ParticipantsDelayed discharge after urgent admission and length of delayed discharge were studied in all hospital users aged ≥70 years with at least 1 urgent admission in British Columbia, Canada, in years 2001/02, 2005/06, 2010/11, and 2015/16 (N = 276,299).MethodsLinked administrative data provided by Population Data BC were analyzed using generalized estimating equations (GEE), logistic regression analysis, and negative binomial regression analyses.ResultsDelayed discharge increased among people with dementia and decreased among people without dementia, whereas the length of delay decreased among both. Dementia was the strongest predictor of delayed discharge [odds ratio 4.76; 95% confidence interval (CI) 4.59–4.93], whereas waiting for long-term care placement [incidence rate ratio (IRR) 1.56; 95% CI 1.50–1.62] and dementia (IRR 1.50; 95% CI 1.45–1.54) predicted a higher number of days of delay. Continuity and quantity of care with the same physician before urgent admission was associated with a decreased risk of delayed discharge, especially in people with dementia.Conclusions and ImplicationsThis study demonstrates the need for better system integration and patient-centered care especially for people with dementia. Population aging will likely increase the number of patients at risk of delayed discharge. Delayed discharge is associated with both the patient's complex needs and the inability of the system to meet these needs during and after urgent care. Sufficient investments are needed in both primary care and long-term care resources to reduce delayed discharges.     

Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities

ObjectiveTo compare 30-day mortality in long-term care facility (LTCF) residents with and without COVID-19 and to investigate the impact of 31 potential risk factors for mortality in COVID-19 cases.DesignRetrospective cohort study.Setting and ParticipantsAll residents of LTCFs registered in Senior Alert, a Swedish national database of health examinations in older adults, during 2019-2020.MethodsWe selected residents with confirmed COVID-19 until September 15, 2020, along with time-dependent propensity score–matched controls without COVID-19. Exposures were COVID-19, age, sex, comorbidities, medications, and other patient characteristics. The outcome was all-cause 30-day mortality.ResultsA total of 3731 residents (median age 87 years, 64.5% female) with COVID-19 were matched to 3731 controls without COVID-19. Thirty-day mortality was 39.9% in COVID-19 cases and 5.7% in controls [relative risk 7.05, 95% confidence interval (CI) 6.10-8.14]. In COVID-19 cases, the odds ratio (OR) for 30-day mortality was 2.44 (95% CI 1.57-3.81) in cases aged 80-84 years, 2.99 (95% CI 1.93-4.65) in cases aged 85-89 years, and 3.28 (95% CI 2.11-5.10) in cases aged ≥90 years, as compared with cases aged <70 years. Other risk factors for mortality among COVID-19 cases included male sex (OR, 2.60, 95% CI 2.22-3.05), neuropsychological conditions (OR, 2.18; 95% CI 1.76-2.71), impaired walking ability (OR, 1.45, 95% CI 1.17-1.78), urinary and bowel incontinence (OR 1.51, 95% CI 1.22-1.85), diabetes (OR 1.36, 95% CI 1.14-1.62), chronic kidney disease (OR 1.37, 95% CI 1.11-1.68) and previous pneumonia (OR 1.57, 95% CI 1.32-1.85). Nutritional factors, cardiovascular diseases, and antihypertensive medications were not significantly associated with mortality.Conclusions and ImplicationsIn Swedish LTCFs, COVID-19 was associated with a large excess in mortality after controlling for an extensive number of risk factors. Beyond older age and male sex, several prevalent clinical risk factors independently contributed to higher mortality. These findings suggest that reducing transmission of COVID-19 in LTCFs will likely prevent a considerable number of deaths.     

Sarcopenia Combined With FRAX Probabilities Improves Fracture Risk Prediction in Older Chinese Men

ObjectivesTo examine whether the inclusion of sarcopenia in prediction models adds any incremental value to fracture risk assessment tool (FRAX).Design, Setting, and ParticipantsData from a prospective cohort of 4000 community-dwelling Chinese men and women aged 65 years and older with adjudicated fracture outcomes were analyzed.MeasurementsAt baseline, femoral neck bone mineral density (BMD) was assessed, as were the clinical risk factors included in FRAX, along with additional appendicular skeletal muscle mass, grip strength, and gait speed. Sarcopenia was defined according to the Asian Working Group for Sarcopenia algorithm. Incident fractures were documented during the follow-up period from 2001 to 2013.ResultsOf 4000 participants, 565 experienced at least 1 type of incident fracture and 132 experienced a hip fracture during a follow-up of 10.2 years. Hazard ratios (HRs) for 1-unit increase in FRAX score without BMD in men were 1.12 [95% confidence interval (CI) 1.08–1.16] for all fractures combined and 1.19 (95% CI 1.13–1.27) for hip fracture, and in women were 1.04 (95% CI 1.03–1.06) for all fractures combined and 1.08 (95% CI 1.06–1.11) for hip fracture. Similar to results of the FRAX score without BMD, HRs for 1-unit increase in FRAX score with BMD in men were 1.04 (95% CI 1.03–1.06) for all fractures combined and 1.19 (95% CI 1.13–1.25) for hip fracture, and in women were 1.04 (95% CI 1.03–1.05) for all fractures combined and 1.06 (95% CI 1.05–1.08) for hip fracture. Sarcopenia was significantly associated with all fractures combined (Adjusted HR 1.87; 95% CI 1.30–2.68) and hip fracture (Adjusted HR 2.67; 95% CI 1.46–4.90) in men but not in women. The discriminative values for fracture, as measured by the area under the receiver operating characteristic curve, were 0.60–0.73 and 0.62–0.76 for FRAX without and with BMD, respectively. Adding sarcopenia did not significantly improve the discriminatory capacity over FRAX (P > .05). Using reclassification techniques, sarcopenia significantly enhanced the integrated discrimination improvement by 0.6% to 1.2% and the net reclassification improvement by 7.2% to 20.8% in men, but it did not contribute to predictive accuracy in women.ConclusionsSarcopenia added incremental value to FRAX in predicting incident fracture in older Chinese men.     

The Relationship of Oral Health with Progression of Physical Frailty among Older Adults: A Longitudinal Study Composed of Two Cohorts of Older Adults from the United Kingdom and United States

ObjectiveTo investigate the prospective associations between oral health and progression of physical frailty in older adults.DesignProspective analysis.Setting and ParticipantsData are from the British Regional Heart Study (BRHS) comprising 2137 men aged 71 to 92 years from 24 British towns and the Health, Aging, and Body Composition (HABC) Study of 3075 men and women aged 70 to 79 years.MethodsOral health markers included denture use, tooth count, periodontal disease, self-rated oral health, dry mouth, and perceived difficulty eating. Physical frailty progression after ∼8 years follow-up was determined based on 2 scoring tools: the Fried frailty phenotype (for physical frailty) and the Gill index (for severe frailty). Logistic regression models were conducted to examine the associations between oral health markers and progression to frailty and severe frailty, adjusted for sociodemographic, behavioral, and health-related factors.ResultsAfter full adjustment, progression to frailty was associated with dentition [per each additional tooth, odds ratio (OR) 0.97; 95% CI: 0.95–1.00], <21 teeth with (OR 1.74; 95% CI: 1.02–2.96) or without denture use (OR 2.45; 95% CI 1.15–5.21), and symptoms of dry mouth (OR ≥1.8; 95% CI ≥ 1.06–3.10) in the BRHS cohort. In the HABC Study, progression to frailty was associated with dry mouth (OR 2.62; 95% CI 1.05–6.55), self-reported difficulty eating (OR 2.12; 95% CI 1.28–3.50) and ≥2 cumulative oral health problems (OR 2.29; 95% CI 1.17–4.50). Progression to severe frailty was associated with edentulism (OR 4.44; 95% CI 1.39–14.15) and <21 teeth without dentures after full adjustment.Conclusions and ImplicationsThese findings indicate that oral health problems, particularly tooth loss and dry mouth, in older adults are associated with progression to frailty in later life. Additional research is needed to determine if interventions aimed at maintaining (or improving) oral health can contribute to reducing the risk, and worsening, of physical frailty in older adults.     

Identifying Key Risk Factors for Dizziness Handicap in Middle-Aged and Older People

ObjectivesMore than 10% of people aged 50 years and older report dizziness. Despite available treatments, dizziness remains unresolved for many people due in part to suboptimal assessment. We aimed to identify factors associated with dizziness handicap in middle-aged and older people to identify targets for intervention to address this debilitating problem. A secondary aim was to determine whether factors associated with dizziness differed between middle-aged (<70 years) and older people (≥ 70 years).DesignSecondary analysis of baseline and prospective data from a randomized controlled trial.Setting and participantsIn total, 305 individuals aged 50 to 92 years reporting significant dizziness in the past year were recruited from the community.MethodsParticipants were classified as having either mild or no dizziness handicap (score <31) or moderate/severe dizziness handicap (score: 31‒100) based on the Dizziness Handicap Inventory. Participants completed health questionnaires and underwent assessments of psychological well-being, lying and standing blood pressure, vestibular function, strength, vision, proprioception, processing speed, balance, stepping, and gait. Participants reported dizziness episodes in monthly diaries for 6 months following baseline assessment.ResultsDizziness Handicap Inventory scores ranged from 0 to 86 with 95 participants (31%) reporting moderate/severe dizziness handicap. Many vestibular, cardiovascular, psychological, balance-related, and medical/medications measures were significantly associated with dizziness handicap severity and dizziness episode frequency. Binary logistic regression identified a positive Dix Hallpike/head-roll test for benign paroxysmal positional vertigo [odds ratio (OR) 2.09, 95% confidence interval (CI) (1.11‒3.97)], cardiovascular medication use [OR 1.90, 95% CI (1.09‒3.32)], high postural sway when standing on the floor with eyes closed (sway path ≥160 mm) [OR 2.97, 95% CI (1.73‒5.10)], and anxiety (Generalized Anxiety Disorder Scale 7-item Scale score ≥8) [OR 3.08, 95% CI (1.36‒6.94)], as significant and independent predictors of moderate/severe dizziness handicap. Participants aged 70 years and over were significantly more likely to report cardiovascular conditions than those aged less than 70 years old.Conclusions and implicationsAssessments of cardiovascular conditions and cardiovascular medication use, benign paroxysmal positional vertigo, anxiety, and postural sway identify middle-aged and older people with significant dizziness handicap. A multifactorial assessment including these factors may assist in tailoring evidence-based therapies to alleviate dizziness handicap in this group.     

Evaluación sobre historia clínica electrónica. Asociación entre indicadores de proceso medidos sobre historia electrónica y resultados intermedios en salud,en pacientes con hipertensión

ObjectiveTo study relationship between institutional process indicators (measured using electronic records) and intermediate outcomes of patients with hypertension.DesignCross-sectional epidemiological study.SettingPrimary Care Health District 1. Madrid. 2010.PatientsAll patients with hypertension. n = 80,306.Main measurementsVariables. Independent. Institutional process indicators. Dependent. Intermediate outcomes: blood pressure within target limits, LDL-cholesterol, tobacco and weight and detected complications. Confounding. Age, gender, co-morbidity, drugs and professional variables.ResultsThe BP of 55.1% (SE 0.2%) of patients was within target limits. Bivariate analysis and multivariate logistic regression showed that the recording of some process indicators was associated with an increase in the probability to achieve targets in intermediate outcomes: smoking advice (OR: 1.69, 95% CI: 1.61 - 1.77), reviewing personal history (OR: 1.54, 95% CI:1.42-1.68), increase was less or biased: BP (OR: 1.19, 95% CI:1.14-1.25), sodium and potassium (OR: 1.14, 95% CI:1.09-1.19), BMI (OR 1.08, 95% CI:1.04-1.12); also diabetes, edema, and creatinine, but there was timing bias. The relationship between other indicators (those oriented to lifestyle, family history, classification, urine examination, reviewing of drug therapy, LDL, electrocardiogram and cardiac auscultation) and a higher probability to achieve targets was not found.ConclusionsIn hypertension, some institutional process indicators measured on electronic records were associated with an increase in the probability to achieve targets in intermediate outcomes. No relationship was found between other indicators. This suggests maintaining process and outcome measurement, to include the impact of interventions, to prioritize improvements in process indicators that show low performance and high impact and to remove or to change process indicators where no relationship is found.     

Factores asociados a mala calidad de sueño en población brasilera a partir de los 40 años de edad: estudio VIGICARDIO

ObjectiveThe prevalence of poor sleep quality in men and women ≥ 40 years old from the VIGICARDIO Study was determined, and sociodemographic, health, lifestyle and social capital factors associated with poor sleep quality were identified.MethodsA population-based study conducted in 2011 among 1,058 non-institutionalised individuals randomly selected from Cambé, Paraná State, Brazil. Logistic regression was used to evaluate the association between sleep quality and sociodemographic, health, lifestyle and social capital factors in men and women.ResultsThe prevalence of poor sleep quality was 34% in men and 44% in women. Having bad/regular self-rated health status was a factor associated with poor sleep quality in men (OR: 1.79; 95% CI: 1.17-2.72) and women (OR: 2.43; 95% CI: 1.68-3.53). Being obese (OR: 1.67; 95% CI: 1.13-2.46), having depression (OR: 2.09; 95% CI: 1.41-3.13) and presenting temporal orientation difficulties (OR: 1.95; 95% CI: 1.08-3.52) were associated factors in women. Difficulty to understand what is explained (OR: 2.18; 95% CI: 1.16-4.09) and alcohol abuse (OR: 1.85; 95% CI: 1.21-2.83) were associated factors in men.ConclusionFactors affecting sleep quality are different for men and for women. These factors should be taken into consideration when devising activities that promote good sleep quality, with a view to improving their effectiveness.     

Factors and Outcomes Associated With Dysphagia in Hospitalized Persons With Dementia

ObjectivesDysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia.DesignA retrospective study of hospitalized adults (aged ≥65 years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area.Setting and ParticipantsData were obtained from the inpatient EHR with the following inclusion criteria: age ≥65 years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision).MethodsA diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of “difficulty swallowing” as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis.ResultsOf adults with dementia (N = 8637), the average age was 84.5 years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n = 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B = 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55).Conclusions and ImplicationsGiven its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.     

High Prevalence of Oropharyngeal Dysphagia in Acutely Hospitalized Patients Aged 80 Years and Older

ObjectivesOropharyngeal dysphagia is a geriatric syndrome that is usually underdiagnosed in older patients. The aim of this study was to determine the prevalence and identify the main risk factors of dysphagia in the oldest old patients admitted to an acute geriatric unit.DesignObservational prospective study.Setting and ParticipantsOlder patients admitted to an acute geriatric unit of a university hospital.Measures329 patients (mean age 93.5 years, range 81-106) were assessed for oropharyngeal dysphagia within 48 hours of hospital admission using the Volume-Viscosity Swallow Test. Demographic characteristics, geriatric assessment, geriatric syndromes, comorbidities, drug treatment, and complications were examined to determine their association with the presence of dysphagia.ResultsOropharyngeal dysphagia was present in 271 (82.4%) of the participants. Multivariate logistic regression showed that malnutrition [odds ratio (OR) 3.62, 95% confidence interval (CI) 1.01-12.93; P = .048], admission for respiratory infection (OR 2.89, 95% CI 1.40-5.94; P = .004), delirium (OR 2.89, 95% CI 1.40-5.94; P = .004), severe dependency (OR 3.23, 95% CI 1.23-8.87; P = .017), and age (OR 1.11, 95% CI 1.01-1.21; P = .03) were significantly associated with dysphagia. The use of a calcium antagonist at the time of admission was associated with a reduced risk of dysphagia (OR 0.39, 95% CI 0.16-0.92; P = .03).Conclusions and ImplicationsThe prevalence of oropharyngeal dysphagia is high in the oldest old patients admitted to an acute geriatric unit when assessed with an objective diagnostic method. Our findings suggest that objective swallowing assessment should be routinely performed on admission in order to start early interventions to avoid complications of dysphagia in this complex population.     

The Association of Changes in Physical Performance During Geriatric Inpatient Rehabilitation With Short-Term Hospital Readmission,Institutionalization, and Mortality: RESORT

ObjectivesGeriatric inpatient rehabilitation aims to restore function, marked by physical performance, to enable patients to return and remain home after hospitalization. However, after discharge some patients are soon readmitted, institutionalized, or may die. Whether changes in physical performance during geriatric rehabilitation are associated with these short-term adverse outcomes is unknown. This study aimed to determine the association of changes in physical performance during geriatric inpatient rehabilitation with short-term adverse outcomes.DesignObservational longitudinal study.Setting and ParticipantsGeriatric rehabilitation inpatients of the REStORing health of acutely unwell adulTs (RESORT) cohort study of the Royal Melbourne Hospital (Melbourne, Australia) were included.MethodsThe change from admission to discharge in the Short Physical Performance Battery (SPPB) score, balance, gait speed (GS), chair stand test (CST), and hand grip strength (HGS) were calculated and analyzed using logistic regression analysis with readmission, incidence of institutionalization, and mortality, and ≥1 adverse outcome within 3 months postdischarge.ResultsOf 693 inpatients, 11 died during hospitalization and 572 patients (mean age 82.6 ± 7.6 years, 57.9% female) had available physical performance data. Within 3 months postdischarge, 47.3% of patients had ≥1 adverse outcome: readmission was 20.8%, institutionalization was 26.6%, and mortality was 7.9%. Improved SPPB score, balance, GS, CST, and HGS were associated with lower odds of institutionalization and mortality. Improved GS was additionally associated with lower odds of readmission [odds ratio (OR) 0.35, 95% CI 0.16-0.79]. CST score had the largest effect, with a 1-point increase associating with 40% lower odds of being institutionalized (OR 0.60, 95% CI 0.42-0.86), 52% lower odds of mortality (OR 0.48, 95% CI 0.29-0.81), and a 24% lower odds of ≥1 adverse outcome (OR 0.76, 95% CI 0.59-0.97).Conclusions and ImplicationsImprovement in physical performance was associated with lower odds of short-term institutionalization and mortality indicating the prognostic value of physical performance improvement during geriatric inpatient rehabilitation.     

A simple validated questionnaire predicted functional decline in community-dwelling older persons: prospective cohort studies

ObjectivesTo modify and validate in primary health care the Identification of Seniors At Risk (ISAR) screening questionnaire to identify older persons at increased risk of functional decline and to compare this strategy with risk stratification by age alone.Study Design and SettingProspective development (n = 790) and validation cohorts (n = 2,573) of community-dwelling persons aged ≥70 years. Functional decline at 12 months was defined as an increase of at least one point on the modified Katz–activities of daily living index score compared with baseline or death.ResultsThree items were independently associated with functional decline: age (odds ratio [OR]: 1.06 per year; 95% confidence interval [CI]: 1.02, 1.10), dependence in instrumental activities of daily living (OR: 2.17; 95% CI: 1.46, 3.22), and impaired memory (OR: 2.22; 95% CI: 1.41, 3.51). The area under the receiver operating characteristics curve (AUC) range of the ISAR-primary care model was 0.67–0.70, and 40.6% was identified at increased risk. Validation yielded an AUC range of 0.63–0.64. Age ≥75 years alone yielded an AUC range of 0.56–0.57 and identified 55.4% at increased risk in the development cohort.ConclusionAlthough the ISAR–Primary Care (ISAR-PC) has moderate predictive value, application of the ISAR-PC is more efficient than selection based on age alone in identifying persons at increased risk of functional decline.     

Malnutrition According to GLIM Criteria and Adverse Outcomes in Community-Dwelling Chinese Older Adults: A Prospective Analysis

ObjectivesThe Global Leadership Initiative on Malnutrition (GLIM) has proposed a consensus scheme for classifying malnutrition. This study examined the prevalence of malnutrition according to GLIM criteria and evaluated if these criteria were associated with adverse outcomes in community-dwelling older adults.DesignThis was a prospective cohort study.Setting and ParticipantsCommunity-dwelling Chinese men and women aged ≥65 years in Hong Kong.MethodsA health check including questionnaire interviews and physical measurements was conducted at baseline and 14-year follow-up. Participants were classified as malnourished at baseline according to the GLIM criteria based on 2 phenotypic components (low body mass index and reduced muscle mass) and 1 etiologic component (inflammation). Adverse outcomes including sarcopenia, frailty, falls, mobility limitation, hospitalization, and mortality were assessed at 14-year follow-up. Adjusted multiple logistic regression and Cox proportional hazards model were performed to examine the associations between malnutrition and adverse outcomes and presented as odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI).ResultsData of 3702 participants [median age: 72 years (IQR 68–76)] were available at baseline. Malnutrition was present in 397 participants (10.7%). Malnutrition was significantly associated with higher risk of sarcopenia (n = 898, OR 2.25; 95% CI 1.04–4.86), frailty (Fried (n = 971, OR 2.83; 95% CI 1.47–5.43), FRAIL scale (n = 985, OR 2.30; 95% CI 1.06–4.98)) and all-cause mortality (n = 3702, HR: 1.62; 95% CI 1.39–1.89). There was no significant association between malnutrition and falls (n = 987, OR 1.09; 95% CI 0.52–2.31), mobility limitation (n = 989, OR 0.98; 95% CI 0.36–2.67), and hospitalization (n = 989, OR 1.37; 95% CI 0.67–2.77).Conclusions and ImplicationsAmong community-dwelling Chinese older adults, malnutrition according to selected GLIM criteria was a predictor of sarcopenia, frailty, and mortality at 14-year follow-up; whereas no association was found for falls, mobility limitation, and hospitalization. Clinicians may consider applying the GLIM criteria to identify malnourished community-dwelling older adults.