Failure to regain function at 3 months after acute hospital admission predicts institutionalization within 12 months in older patients

ObjectivesTo study the effects of functional decline on admission to long-term institutionalized care within 12 months from acute hospital admission.DesignPooled analyses of 3 longitudinal cohorts.SettingTertiary and secondary hospital.ParticipantsA total of 1085 community-dwelling patients older than 65 years acutely admitted to an internal medicine or orthopedic ward.MeasurementsDemographic data and medical data were collected within 2 days from hospital admission. Functional status (activities of daily living [ADL]) was assessed at baseline (reflecting preadmission status 2 weeks before admission) and 3 months after admission, and function loss (change between preadmission and 3 months) was calculated. Living situation was assessed 3 and 12 months after hospitalization. Cox regression analysis was used to predict institutionalization (living in a long-term assisted care or nursing home facility) within 12 months.ResultsADL function loss in the 3 months following hospital admission increased the risk of institutionalization also in patients without preadmission impairment (loss of function in 1 item HR = 5.3, 95% CI 2.2–12.6, p < .001; ≥2 items HR = 7.3, 95% CI 3.4–15.7, p < .001) compared with patients without impairment and function loss. The risk progressively increased with higher preadmission impairment. Patients with preadmission ADL impairment in 2 or more items without additional loss of function had an increased risk (HR = 6.4, 95% CI 3.1–13.3, p < .001) for institutionalization. This model was adjusted for age, gender, cognitive impairment, social situation, use of health care services, length of hospital stay, and comorbidity.ConclusionLoss of function in ADL tasks following hospitalization increased the risk for institutionalization, irrespective of preadmission ADL impairment. Potentially, counteracting loss of function in ADLs after acute hospital admission by more intensive rehabilitation may partly reduce the need for institutionalization.     

Predictors for the Transitions of Poor Clinical Outcomes Among Geriatric Rehabilitation Inpatients

ObjectiveTo investigate the associations of morbidity burden and frailty with the transitions between functional decline, institutionalization, and mortality.DesignREStORing health of acutely unwell adulTs (RESORT) is an ongoing observational, longitudinal inception cohort and commenced on October 15, 2017. Consented patients were followed for 3 months postdischarge.Setting and ParticipantsConsecutive geriatric rehabilitation inpatients admitted to geriatric rehabilitation wards.MethodsPatients’ morbidity burden was assessed at admission using the Charlson Comorbidity Index (CCI) and Cumulative Illness Rating Scale (CIRS). Frailty was assessed using the Clinical Frailty Scale (CFS) and modified Frailty Index based on laboratory tests (mFI-lab). A multistate model was applied at 4 time points: 2 weeks preadmission, admission, and discharge from geriatric rehabilitation and 3 months postdischarge, with the following outcomes: functional decline, institutionalization, and mortality. Cox proportional hazards regression was applied to investigate the associations of morbidity burden and frailty with the transitions between outcomes.ResultsThe 1890 included inpatients had a median age of 83.4 (77.6-88.4) years, and 56.3% were female. A higher CCI score was associated with a greater risk of transitions from preadmission and declined functional performance to mortality [hazard ratio (HR) 1.28, 95% CI 1.03-1.59; HR 1.32, 95% CI 1.04-1.67]. A higher CIRS score was associated with a higher risk of not recovering from functional decline (HR 0.80, 95% CI 0.69-0.93). A higher CFS score was associated with a greater risk of transitions from preadmission and declined functional performance to institutionalization (HR 1.28, 95% CI 1.10-1.49; HR 1.23, 95% CI 1.04-1.44) and mortality (HR 1.12, 95% CI 1.01-1.33; HR 1.11, 95% CI 1.003-1.31). The mFI-lab was not associated with any of the transitions. None of the morbidity measures or frailty assessment tools were associated with the transitions from institutionalization to other outcomes.Conclusions and ImplicationsThis study demonstrates that greater frailty severity, assessed using the CFS, is a significant risk factor for poor clinical outcomes and demonstrates the importance of implementing it in the geriatric rehabilitation setting.     

Predictors of herpes zoster vaccination among Australian adults aged 65 and over

Objective(s)To estimate HZ vaccine coverage in Australia among older Australians and to identify potential barriers to vaccination.DesignAnalysis of data from three cross-sectional surveys administered online between 2019 and 2020.Setting and participantsAdults aged 65 and over residing in Australia.Main outcome measuresSelf-reported herpes zoster vaccination.ResultsAmong the 744 adults aged 65 and over in this sample, 32% reported being vaccinated for HZ, including 23% of participants aged 65–74, 55% of participants aged 75–84, and 0% for participants aged 85 and above. Those who are vaccinated with other immunisations are more likely to have received HZ vaccine, including seasonal influenza (OR = 4.41, 95 % CI: 2.44–7.98) and pneumococcal vaccines (OR = 4.43, 95 % CI: 2.92 – 6.75). Participants with a history of certain conditions, such as stroke (OR = 2.26, 95 % CI: 1.13–4.49), were more likely to be vaccinated against HZ. Participants that reported smoking tobacco daily were less likely to be vaccinated against HZ (OR = 0.48, 95 % CI: 0.26–0.89). Participants were less likely to be vaccinated against HZ if they preferred to develop immunity ‘naturally’ (OR = 0.29, 95 % CI: 0.15 – 0.57) or expressed distrust of vaccines (OR = 0.34, 95 % CI: 0.13–0.91).Conclusion(s)Further research is required to understand the barriers to HZ vaccine uptake. Increasing the funding eligibility for those who are at risk of complications from shingles, or lowering the age of eligibility, may increase vaccine coverage.     

Factors Associated with Step Numbers in Acutely Hospitalized Older Adults: The Hospital-Activities of Daily Living Study

ObjectivesTo determine the number of steps taken by older patients in hospital and 1 week after discharge; to identify factors associated with step numbers after discharge; and to examine the association between functional decline and step numbers after discharge.DesignProspective observational cohort study conducted in 2015–2017.Setting and ParticipantsOlder adults (≥70 years of age) acutely hospitalized for at least 48 hours at internal, cardiology, or geriatric wards in 6 Dutch hospitals.MethodsSteps were counted using the Fitbit Flex accelerometer during hospitalization and 1 week after discharge. Demographic, somatic, physical, and psychosocial factors were assessed during hospitalization. Functional decline was determined 1 month after discharge using the Katz activities of daily living index.ResultsThe analytic sample included 188 participants [mean age (standard deviation) 79.1 (6.7)]. One month postdischarge, 33 out of 174 participants (19%) experienced functional decline. The median number of steps was 656 [interquartile range (IQR), 250–1146] at the last day of hospitalization. This increased to 1750 (IQR 675–4114) steps 1 day postdischarge, and to 1997 (IQR 938–4098) steps 7 days postdischarge. Age [β = ?57.93; 95% confidence interval (CI) ?111.15 to ?4.71], physical performance (β = 224.95; 95% CI 117.79–332.11), and steps in hospital (β = 0.76; 95% CI 0.46–1.06) were associated with steps postdischarge. There was a significant association between step numbers after discharge and functional decline 1 month after discharge (β = ?1400; 95% CI –2380 to ?420; P = .005).Conclusions and ImplicationsAmong acutely hospitalized older adults, step numbers double 1 day postdischarge, indicating that their capacity is underutilized during hospitalization. Physical performance and physical activity during hospitalization are key to increasing the number of steps postdischarge. The number of steps 1 week after discharge is a promising indicator of functional decline 1 month after discharge.     

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.     

Subjective Cognitive Decline,Cognitive Reserve Indicators,and the Incidence of Dementia

ObjectiveBoth cognitive reserve and subjective cognitive decline are closely related to the risk of dementia. We investigated whether cognitive reserve can modify the risk of dementia developing from subjective cognitive decline.DesignLongitudinal population-based study.Setting and ParticipantsThe prospective study analyzed data from 2099 participants aged 65 or over from the Cognitive Function and Ageing Study–Wales (CFAS-Wales).MethodsDementia was ascertained through the comprehensive judgment symptoms of geriatric mental state automated geriatric examination for computer assisted taxonomy (GMS-AGECAT). Subjective cognitive decline was evaluated by 2 questions in the baseline interview. Cognitive reserve indicators were derived from 3 previously identified factors: early life education, mid-life occupational complexity, and late-life cognitive activities. We used logistic regression models to estimate dementia risk in relation to subjective cognitive decline and indicators of cognitive reserve. The interaction between subjective cognitive decline and cognitive reserve were evaluated by additive and multiplicative scales.ResultsBaseline subjective cognitive decline and low cognitive reserve significantly increased the risk of dementia, after 2 years of follow-up. There was an additive interaction between subjective cognitive decline and cognitive reserve [the relative excess risk due to interaction = −0.63, 95% confidence interval (CI) = −0.89 to −0.36, P for additive interaction <0.001]. There was no multiplicative interaction between subjective cognitive decline and cognitive reserve indicator (P = .138). Statistically significant association between subjective cognitive decline and dementia was found only in the low-level and medium-level cognitive reserve group (OR = 3.78, 95% CI = 1.50–9.55 and OR = 3.64, 95% CI = 1.09–12.2, respectively), but not in the high-level groups.Conclusion and ImplicationsCognitive reserve attenuated subjective cognitive decline associated risk of developing dementia. This finding suggests the need for greater emphasis on detecting prodromal dementia when older patients having lower cognitive reserve present with subjective cognitive decline.     

Knowledge,attitude, and perception regarding HPV-related diseases and vaccination among the general public in Guizhou Province of China

BackgroundThe rising prevalence of high-risk human papillomavirus (HR-HPV) type-related diseases pose an ongoing health challenge in China. In this study, we assessed the current views of the general public of the Guizhou Province on HPV and HPV vaccinations to provide recommendations for future directions regarding the rollout of HPV vaccination in the area.MethodsAn online questionnaire survey was conducted that included 3412 (2532 females and 880 males) native adult residents of the Guizhou Province. Data on the socio-demographic characteristics, knowledge of HPV, and perceptions of HPV vaccinations were collected. Data comparisons were made between students and non-students and between participants with and without medical backgrounds. All statistical analyses were performed using SPSS 26.0.ResultsThe self-reported HPV infection rates were 5.85% in women and 0.86% in men. A total of 46.29% of women and 34.43% of men achieved acceptable knowledge levels of HPV and 47.54% of women possessed an acceptable knowledge level of HPV vaccines. Non-students and medical participants performed significantly better in the knowledge tests than their respective opposing groups. Online media was the most popular HPV information source for all the participants. A total of 93.58% of women and 87.88% of men expressed willingness toward HPV vaccination. The major facilitators of vaccination acceptance were females (OR = 1.932, 95% CI: 1.390–2.685, p < 0.001) or students (OR = 2.276, 95% CI: 1.207–4.291, p = 0.011), and participants with higher HPV knowledge level (OR = 1.796, 95% CI: 1.300–2.481, p < 0.001). Ages 41–50 (OR = 0.255, 95% CI: 0.121–0.538, p = 0.001) or > 50 (OR = 0.141, 95% CI: 0.059–0.337, p < 0.001) were significant predictors of a negative attitude towards HPV vaccination.ConclusionGuizhou residents had poor knowledge of HPV-related issues. The percentage of healthcare workers who achieved acceptable knowledge levels was one-half or less. The increasing HPV prevalence and cervical cancer incidence can be contained if more affordable vaccines are developed and the low knowledge levels pervading young adults and medical staff is eliminated.     

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

ObjectivesTo determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.DesignWeb-based discrete choice experiment with 19 clinical scenarios.Setting and ParticipantsOnline survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.MethodsClinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non–evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.ResultsFor all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16–5.65], obvious blood in urine (OR 4.66, 95% CI 3.99–5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28–4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53–7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53–5.47) had highest odds for the forced-deliberation group.Conclusions and ImplicationsThis study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.     

Concurrent and Predictive Validity of FRAIL-NH in Hospitalized Older Persons: An Exploratory Study

ObjectivesThe FRAIL-NH was originally developed for frailty assessment of nursing home (NH) residents. We aimed to compare concurrent, predictive, and known-groups validity between FRAIL-NH and FRAIL, using the Frailty Index (FI) as gold standard reference. We also examined for ceiling effect of both measures in the detection of severe frailty.DesignA secondary analysis of a prospective cohort study.Setting & ParticipantsOlder adults (mean age 89.4 years) hospitalized for an acute medical illness in a 1300-bed tertiary hospital.MeasurementsBaseline data on demographics, comorbidities, severity of illness, functional status, and cognitive status were gathered. We also captured outcomes of mortality, length of stay (LOS), institutionalization, and functional decline. For concurrent validity, we compared areas under the operating characteristic curves (AUCs) for both measures against the FI. For predictive validity, univariate analyses and multiple logistic regression were used to compare both measures against the adverse outcomes of interest. For known-groups validity, we compared both measures against comorbidities and functional status via 1-way analysis of variance, and dementia diagnosis via independent t test. Box plots were also derived to investigate for possible ceiling effect.ResultsBoth measures had good concurrent validity (both AUC > 0.8 and P < .001), with FRAIL-NH detecting more frailty cases (79.5% vs 50.0%). Although FRAIL-frail was superior for in-hospital mortality [6.7% vs 1.0%, P = .031, odds ratio (OR) 9.29, 95% confidence interval (CI) 1.09-79.20, P < .042] and LOS (10 vs 8 days, P = .043), FRAIL-NH-frail better predicted mortality (OR 6.62, 95% CI 1.91-22.94, P = .003) and institutionalization (OR 6.03, 95% CI 2.01-18.09, P = .001) up to 12 months postenrollment. Known-groups validity was good for both measures with FRAIL-NH yielding greater F values for functional status and dementia. Lastly, box plots revealed a ceiling effect for FRAIL in the severely frail group.Conclusions and ImplicationsThis exploratory study highlights the potential for expanding the role of FRAIL-NH beyond NH to acute care settings. Contrasted to FRAIL, FRAIL-NH had better overall validity with less ceiling effect in discrimination of severe frailty.     

Patient and clinician factors associated with uptake of the human papillomavirus (HPV) vaccine among adolescent patients of a primary care network

BackgroundHuman papillomavirus (HPV) vaccination rates for adolescents remain relatively low. The purpose of this study is to examine patient and clinician factors associated with HPV vaccination among patients, ages 11–17, of a large community-based primary care network.MethodsElectronic health records and administrative data from a large primary care network from January 2017 – June 2018 for patients ages 11–17 (n = 10,682) and the 198 primary care clinicians that saw them were analyzed. Mixed effects logistic regression models examined the association of patient and clinician factors with HPV vaccine uptake.ResultsMost patients (63.0%) had at least one dose of the HPV vaccine, and 37.7% were up to date. In adjusted analyses, patients who received the tetanus, diphtheria, and pertussis (Tdap) vaccine (OR = 2.8, 95% CI: 2.1–3.9) compared to those who did not receive the vaccine and patients with five or more medical visits (OR = 1.9, 95% CI: 1.6–2.2) had the greatest odds of being up to date with the HPV vaccine series. Compared to White patients, African American/Black (OR = 0.8, 95% CI: 0.6 – 1.0) and Alaskan Native/American Indian (OR = 0.5, 95% CI: 0.3–0.9) patients were less likely to be up to date. Boys were also less likely to be up to date with the HPV vaccine series compared to girls (OR = 0.7, 95% CI: 0.7–0.8). Additionally, patients with family/general practice primary care clinicians were less likely to have their patients up to date than those with pediatricians (OR = 0.8, 95% CI: 0.6 – 1.0).ConclusionHPV vaccine uptake varied by patient characteristics, heath care utilization and primary care clinician specialty. These findings may inform future evidence-based interventions aimed at increasing HPV vaccine uptake among adolescents by targeting patient sub-groups and reducing missed opportunities for vaccination.     

Usage of community services and domestic helpers predicted institutionalization of elders having functional or cognitive impairments: a 12-month longitudinal study in Hong Kong

ObjectivesTo estimate the 12-month institutionalization rate and to identify the associated predictors among functionally impaired elders with or without cognitive impairment.MethodsA cohort of Hong Kong community-dwelling elders aged 65 or older with functional and/or cognitive impairments was recruited and interviewed from 2007 to 2008. Twelve months after the baseline interview, the family caregivers or elders were interviewed to update the residence status of the elders. Logistic regressions were used to examine the association between institutionalization and the baseline variables.ResultsEighty elders (of 749 respondents) had been institutionalized within 12 months from baseline. The institutionalization rates were 6.2% (95% confidence interval (CI): 4.0%–8.5%) for elders with functional impairment only and 17.3% (95% CI: 13.0%–21.6%) for elders with both functional and cognitive impairments. Stepwise multiple logistic regressions found that more usage of community services was the single predictor to institutionalization in 1 year for the elders with functional impairment only. The risk was doubled (odd ratio = 2.166, 95% CI: 1.286–3.647) for usage in 1 more community service. For elders with both functional and cognitive impairments, the institutionalization risk was reduced by about 70% with employment of a domestic helper (odd ratio = 0.268, 95% CI: 0.120–0.598), despite increased risk being associated with advancing age of caregiver, caregiver being male, and deteriorating functional status of the elder.ConclusionAmong the functionally impaired elders, more usage of community services predicted increased institutionalization, whereas among the functionally and cognitively impaired elders, employment of a domestic helper predicted reduced institutionalization. Innovative services and care models are needed to prevent unnecessary institutionalization and to postpone premature institutionalization. Further research needs to be conducted to investigate the long term care needs of the elders from the perspective of both the elders and their caregivers.     

Prognosis of an abnormal one-leg balance in community-dwelling patients with Alzheimer's disease: a 2-year prospective study in 686 patients of the REAL.FR study

ObjectivesThe aim of this study was to explore the predictive value of an abnormal one-leg balance (OLB) test for functional decline, nursing home admission, and mortality in community-dwelling patients affected with Alzheimer’s disease (AD).DesignA 2-year prospective, observational cohort study.SettingNineteen memory centers across France.ParticipantsA total of 686 community-dwelling patients with AD.MeasurementsMini-mental state examination, Activity of Daily Living scale, and balance (ability to stand unassisted for 5 seconds on 1 leg) were reported every 6 months. Functional decline was defined as a loss of 0.5 or more points at a 5-point Activity of Daily Living score (bathing, dressing, toileting, continence, and feeding). Nursing home admission and mortality were recorded. Neuropsychiatric symptoms, medication, and caregiver’s burden were assessed every 6 months. Time-to-event analyses were used.ResultsAt baseline, 632 patients with AD had a balance measurement (mean age = 77.8 years, SD = 6.9; 72.2% were women) and 15.2% had an abnormal OLB test: these patients were older, had lower mini-mental state examination and Activity of Daily Living scores, and more neuropsychiatric symptoms, osteoarthritis, comorbidities and medications (all P < .05). After adjustment for age and sex, the risk of functional decline (hazard ratio [HR]: 1.69; 95% confidence interval [CI], 1.26–2.26), nursing home admission (HR: 2.51; 95% CI, 1.69–3.73), and death (HR: 2.42; 95% CI, 1.43–4.11) was higher in patients with an abnormal OLB. After adjustment for other potential confounders, the presence of an abnormal OLB was significantly associated only with nursing home admission (HR: 1.73, 95% CI, 1.09–2.75).ConclusionIn the present study, an abnormal OLB predicts nursing home admission in patients with AD. Although statistically significant when solely adjusted for age and sex, an abnormal OLB test failed to predict functional decline and mortality when adjusted for multiple confounders.     

Influencia de la duración de la estancia hospitalaria sobre la mortalidad tras el alta en pacientes mayores con patología médica aguda

ObjectiveTo analyse whether hospital length of stay is associated with mortality at six months after discharge in the elderly.MethodsAn observational longitudinal study of patients surviving at hospital discharge. A binary logistic regression analysis was performed to study factors related to extended stay (> 12 days). The relationship between mortality at 6 months and length-of-stay quartiles was studied using a Cox regression analysis.Results1180 patients were studied with a mean age of 86.6 years (standard deviation: 6.9). The median length of stay was 8 days (interquartile range: 5-12). Six-month mortality was 26.1%. After adjusting for age, gender, main diagnosis, comorbidity, albumin at admission, functional deterioration at admission and functional and mental status at discharge, hospital stay above the median was associated with mortality at 6 months: 9-12 days, HR = 1.79, 95% CI: 1.01-3.14; and > 12 days, HR = 2.04, 95% CI: 1.19-3.53.ConclusionsProlonged hospital stay is an independent risk factor for mortality at 6 months after discharge.     

Factors Associated With Remaining in a Skilled Nursing Facility for Over 90 Days from Admission: Residents' Participation in Therapy and Desire to Return to the Community

BackgroundTo identify the factors associated with stay in a skilled nursing facility (SNF) among new enrollees who did not fully participate in therapy sessions.MethodsData (n = 36,133) were obtained from the Minimum Data Set version 2.0 in the state of Michigan in 2009. Study participants were new SNF enrollees (n = 699) who did not fully participate in therapy sessions despite their desire to return to the community. Multivariate logistic regressions were performed to identify factors contributing to remaining in a nursing home for 91 days or longer.ResultsNew SNF enrollees were more likely to remain in nursing home when they were depressed (odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.09–2.08; P = .01), experiencing delirium (OR = 3.20; 95% CI, 1.48–5.92; P < .001), were not in pain (OR = 0.83; 95% CI, 0.60–0.95; P = .03), or in less complex care (OR = 0.57; 95% CI, 0.44–0.81; P < .01).ConclusionsA higher number of new SNF enrollees than previously reported were likely to stay in nursing homes (28.0%). Depression and delirium were associated with stay in an SNF, while pain and higher complexity of care were associated with returning to the community.     

Social and demographic patterns of influenza vaccination coverage in Norway,influenza seasons 2014/15 to 2020/21

AimsTo examine influenza vaccination coverage among risk groups (RG) and health care workers (HCW), and study social and demographic patterns of vaccination coverage over time.MethodsVaccination coverage was estimated by self-report in a nationally representative telephone survey among 14 919 individuals aged 18–79 years over seven influenza seasons from 2014/15 to 2020/21. We explored whether belonging to an influenza RG (being >=65 years of age and/or having >=1 medical risk factor), being a HCW or educational attainment was associated with vaccination status using logistic regression.ResultsVaccination coverage increased from 27 % to 66 % among individuals 65–79 years, from 13 % to 33 % among individuals 18–64 years with >=1 risk factor, and from 9 % to 51 % among HCWs during the study period. Being older, having a risk factor or being a HCW were significantly associated with higher coverage in all multivariable logistic regression analyses. Higher education was also consistently associated with higher coverage, but the difference did not reach significance in all influenza seasons. Educational attainment was not significantly associated with coverage while coverage was at its lowest (2014/15–2017/18), but as coverage increased, so did the differences. Individuals with intermediate or lower education were less likely to report vaccination than those with higher education in season 2018/19, OR = 0.61 (95 % CI 0.46–0.80) and OR = 0.58 (95 % CI 0.41–0.83), respectively, and in season 2019/20, OR = 0.69 (95 % CI 0.55–0.88) and OR = 0.71 (95 % CI 0.53–0.95), respectively. When the vaccine was funded in the COVID-19 pandemic winter of 2020/21, educational differences diminished again and were no longer significant.ConclusionsWe observed widening educational differences in influenza vaccination coverage as coverage increased from 2014/15 to 2019/20. When influenza vaccination was funded in 2020/21, differences in coverage by educational attainment diminished. These findings indicate that economic barriers influence influenza vaccination decisions among risk groups in Norway.     

Risk factors of ICU or high dependency requirements amongst hospitalized pediatric pertussis cases: A 10 year retrospective series,Singapore

IntroductionPertussis causes the highest complication rates and deaths in the infant group. Our study explored risk factors for ICU/high dependency (HD) admissions and intubation/non-invasive ventilation (NIV).MethodsA retrospective review of pertussis admissions over 10 years from 2007 to 2016 was done at KK Women's and Children's Hospital, Singapore. To understand risk factors for severe pertussis infection, we compared cases requiring ICU/HD care with controls admitted to the general ward. Risk factors for intubation/NIV were also studied. Vaccine efficacy for protection against ICU/HD admission or intubation/NIV was also calculated.ResultsThere were 200 pertussis patients with a median age of 2.75 months. Sixty-one % were ≤3 months and 14.5% were <6 weeks old. Majority of patients (77%) had no prior pertussis vaccination. After removing 3 patients with missing vaccination records, 20 cases were compared with 177 controls. On univariate analysis, risk factors for ICU/HD admission comprised: Age ≤3 months, contact history, underlying co-morbidity, prematurity, absent DTaP vaccination, lymphocytosis, hyperleukocytosis (wbc ≥50 × 10⁹/L), thrombocytosis (platelet ≥500 × 10⁹/L), and pneumonia. Multivariate analysis revealed that age ≤3 months (OR 40, 95% CI 4.57–1111.11, p = .007), co-morbidity (OR 8.46 (95% CI 1.47–56.89, p = .019), pneumonia (OR 18.08, 95% CI 3.22–132.15, p = .002), white cell count (OR 1.07, 95% CI 1.01–1.14, p = .023) and cyanosis (OR 5.09, 95% CI 1.31–24.71, p = .026) were risk factors for ICU/HD admission. Prior DTaP vaccination had a vaccine effectiveness of 86.5% in preventing ICU/HD admission and 82.1% in preventing intubation/NIV.ConclusionsAs the majority of pertussis patients were infants ≤3 months old who are at high risk for ICU/HD admission and intubation/NIV, prevention is key to reducing pertussis morbidity. Even though not statistically significant, DTaP vaccination had a role in preventing ICU/HD admission and intubation/NIV.     

Effect of a Simple Exercise Program on Hospitalization-Associated Disability in Older Patients: A Randomized Controlled Trial

ObjectiveHospitalization-associated disability [HAD, ie, the loss of ability to perform ≥1 basic activities of daily living (ADLs) independently at discharge] is a frequent condition among older patients. The present study assessed whether a simple inpatient exercise program decreases HAD incidence in acutely hospitalized very old patients.DesignIn this randomized controlled trial (Activity in Geriatric Acute Care) participants were assigned to a control or intervention group and were assessed at baseline, admission, discharge, and 3 months thereafter.Setting and ParticipantsIn total, 268 patients (mean age 88 years, range 75–102) admitted to an acute care for older patients unit of a public hospital were randomized to a control (n = 125) or intervention (exercise) group (n = 143).MethodsBoth groups received usual care, and patients in the intervention group also performed simple supervised exercises (walking and rising from a chair, for a total duration of ∼20 minutes/day). We measured ADL function (Katz index) and incident HAD at discharge and after 3 months (primary outcome) and Short Physical Performance Battery, ambulatory capacity, number of falls, rehospitalization, and death during a 3-month follow-up (secondary outcomes).ResultsMedian duration of hospitalization was 7 days (interquartile range 4 days). The intervention group had a lower risk of HAD with reference to both baseline [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17–0.76, P = .007] and admission (OR 0.29; 95% CI 0.10–0.89, P = .030). A trend toward an improved ADL function at discharge vs admission was found in the intervention group compared with controls (OR 0.32; 95% CI ‒0.04 to 0.68; P = .083). No between-group differences were noted for the other endpoints (all P > .05).Conclusion and ImplicationsA simple inpatient exercise program decreases risk of HAD in acutely hospitalized, very old patients.     

Delirium Superimposed on Dementia Strongly Predicts Worse Outcomes in Older Rehabilitation Inpatients

ObjectiveDelirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation.DesignProspective cohort study.SettingHospital rehabilitation unit.ParticipantsA total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006.MeasurementsDementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations.ResultsThe median age was 77 years (interquartile range: 71–83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6–42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8–8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1–2.8; P = .01).ConclusionsDSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.