Fecal Incontinence Is Associated With Mortality Among Older Adults With Complex Needs: An Observational Cohort Study

Exploring the association between cardiovascular health and bowel health

Chronic constipation, diarrhea, and fecal incontinence have high incidence, potential disability, and socioeconomic impact, imposing a heavy burden on the quality of life. We aim to explore the association between cardiovascular health (CVH) and bowel health from National Health and Nutrition Survey 2005-2010. CVH is assessed using Life's Essential 8 (LE8). Chronic constipation, chronic diarrhea, and fecal incontinence are assessed based on Bristol Stool Form Scale classification, bowel movements, and bowel leakage. Better health behaviors (odds ratio [OR]: 0.71, 95% confidence interval [CI] 0.53-0.94, p = 0.02) and worse health factors (OR: 1.45, CI 1.03-2.04, p = 0.04) were associated with less chronic constipation. Less chronic diarrhea is correlated with better CVH (OR: 0.53, 95% CI 0.35-0.79, p = 0.003) and health factors (OR: 0.61, CI 0.46-0.81, p = 0.001). Meanwhile, the proportion of chronic diarrhea significantly decreases when the health behaviors score exceeds 59.42. Lower fecal incontinence was associated with better health behaviors (OR: 0.63, CI 0.44-0.90, p = 0.01) CVH. Better CVH and health behaviors are both linked to lower all-cause mortality in participants with chronic constipation and chronic diarrhea. A higher health behaviors score is also associated with less all-cause mortality in patients with fecal incontinence. Maintaining CVH at the population level contributes to intestinal health, achieving the dual management of both while saving on healthcare costs. However, further prospective research is needed to confirm these associations.

Resident Factors Associated With Breakthrough SARS-CoV-2 Infections

OBJECTIVE

To examine incidence of and resident characteristics associated with breakthrough infections (BTIs) and severe illness among residents with 2 messenger RNA (mRNA) vaccinations.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Nursing home (NH) residents who completed their primary series of mRNA COVID-19 vaccination by March 31, 2021.

METHODS

Electronic health records and Minimum Data Set assessments from a multistate NH data consortium were used to identify BTI and severe illness (a composite measure of hospitalization and/or death within 30 days of BTI) occurring prior to November 24, 2021. A t test for differences in means was used to compare covariates for residents with and without BTI. Finally, we estimated incidence rate ratios (IRRs) for BTI with 95% CIs using a modified Poisson regression approach, comparing residents with BTI vs residents without. We adjusted for facility fixed effects in our model.

RESULTS

Our sample included 23,172 residents from 984 NHs who were at least 14 days past their second mRNA vaccine dose. Of those, 1173 (5%) developed an incident COVID-19 BTI (mean follow-up time: 250 days). Among residents with BTI, 8.6% were hospitalized or died within 30 days of BTI diagnosis. Factors associated with severe illness included age ≥85 years (IRR 2.08, 95% CI 1.08-4.02, reference age <65 years), bowel incontinence (IRR 1.73, 95% CI 1.01-2.99), coronary artery disease (IRR 1.96, 95% CI 1.31-2.94), chronic kidney disease (IRR 1.65, 95% CI 1.07-2.54), and schizophrenia (IRR 2.38, 95% CI 1.19-4.75).

CONCLUSIONS AND IMPLICATIONS

Among vaccinated NH residents, BTIs and associated severe illness are rare. Residents aged ≥85 years and with certain comorbidities appear to be the most vulnerable. Given that the pandemic continues and testing policies have relaxed, these data provide prognostic information for NH facilities faced with continued outbreaks.

Navigating through incontinence: A qualitative systematic review and meta-aggregation of the experiences of family caregivers

BACKGROUND

Community dwelling older adults who are care dependent are highly affected by incontinence, resulting in substantial informal caregiver burden. Understanding the experiences of these caregivers is needed to develop supportive programs that reduce caregiver burden and rates of institutionalization for care recipients.

OBJECTIVES

This systematic review aimed to critically appraise and synthesize the qualitative literature on the perceptions, experiences, and consequences of informal caregivers managing incontinence in community dwelling older adults.

DESIGN

A qualitative evidence synthesis using meta-aggregation.

DATA SOURCES

CINAHL, Embase, Ovid Medline, PsycInfo, Scopus, and ProQuest Dissertations and Theses.

REVIEW METHODS

A comprehensive search was conducted to identify qualitative studies of all designs, published in English from January 1970 to November 2020, reporting on the experiences of unpaid adult family members or friends providing care at home to an adult aged 60 or older with urinary and/or fecal incontinence. Screening, data extraction, and quality appraisal were conducted independently by two reviewers, with disagreements resolved by consensus with all team members. Joanna Briggs Institute (JBI) processes were used to assess study quality, and the dependability and credibility of both study findings and synthesized findings. All articles included met predetermined criteria.

RESULTS

Database searches yielded 1165 references, of which 117 full-text documents were screened. Seven articles of moderate to high methodological quality met eligibility criteria and were included. Studies occurred in nine countries with 134 participants who were mostly female spouses of the care recipient. From these eligible studies, 49 findings were extracted with 35 equivocal or credible findings eligible for meta-aggregation. Findings were synthesized into the following four categories: 1) emotional responses, 2) physical, financial, and social consequences, 3) family roles and caregiver support, and 4) management and coping strategies.

CONCLUSIONS

Informal caregivers experience many physical, psychosocial, and financial challenges in caring for an older family member with incontinence. Educational and supportive programs for managing incontinence should be multi-component and tailored to meet the individual needs of informal caregivers. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing incontinence.

PROSPERO REGISTRATION

CRD42017069185.

Rectal Prolapse: Age-Related Differences in Clinical Presentation and What Bothers Women Most

BACKGROUND

Rectal prolapse has a diverse symptom profile that affects patients of all ages.

OBJECTIVE

We sought to identify bothersome symptoms and clinical presentation that motivated patients who have rectal prolapse to seek care, characterize differences in symptom severity with age, and determine factors associated with bothersome symptoms.

DESIGN

This study is a retrospective analysis of a prospectively maintained registry.

SETTINGS

This study was conducted at a tertiary referral academic center.

PATIENTS

Included were 129 consecutive women with full-thickness rectal prolapse.

MAIN OUTCOME MEASURES

The main outcomes measured were primary bothersome symptoms, 5-item Cleveland Clinic/Wexner Fecal Incontinence questionnaire, and the 5-item Obstructed Defecation Syndrome questionnaire. Patients were categorized by age <65 vs age ≥65 years.

RESULTS

Cleveland Clinic/Wexner Fecal Incontinence score >9 was more common in older patients (87% vs 60%, p = 0.002). Obstructed Defecation Syndrome score >8 was more common in younger patients (57% vs 28%, p < 0.001). Older patients were more likely than younger patients to report bothersome symptoms of pain (38% vs 19%, p = 0.021) and bleeding (12% vs 2%, p = 0.046). Mucus discharge was reported by most patients (older, 72% vs younger, 66%, p = 0.54) but was bothersome for only 18%, regardless of age. Older patients had more severe prolapse expression than younger patients (at rest, 33% vs 11%; during activity, 26% vs 19%; only with defecation, 40% vs 64%, p = 0.006). Older patients were more likely to seek care within 6 months of prolapse onset (29% vs 11%, p = 0.056). On multivariable regression, increasing age, narcotic use, and nonprotracting prolapse at rest were associated with reporting pain as a primary concern.

LIMITATIONS

This was a single-center study with a small sample size.

CONCLUSIONS

Rectal prolapse-related bothersome symptoms and health care utilization differ by age. Although rectal pain is often not commonly associated with prolapse, it bothers many women and motivates older women to undergo evaluation. Patient-reported functional questionnaires may not reflect patients' primary concerns regarding specific symptoms and could benefit from supplementation with questionnaires to elicit individualized symptom priorities. See Video Abstract at http://links.lww.com/DCR/B492.

PROLAPSO DE RECTO

INFLUENCIA DE LA EDAD EN DIFERENCIAS VINCULADAS CON LA PRESENTACIÓN CLÍNICA Y LOS SÍNTOMAS MAS DESAGRADABLES: El prolapso de recto tiene una gran variedad de síntomas que afectan a pacientes con edades diferentes.Identificar los síntomas mas molestos y la presentación clínica que motivaron a los pacientes con un prolapso de recto a consultar por atención médica, caracterizar las diferencias de gravedad de los síntomas con relación a la edad y determinar los factores asociados con los síntomas mas molestos.Análisis retrospectivo de un registro prospectivo.Centro académico de referencia terciaria.Consecutivamente 129 mujeres que presentaban un prolapso rectal completo.Síntomas y molestias primarias, cuestionario de incontinencia fecal de la Cleveland Clinic / Wexner de 5 ítems, cuestionario de síndrome de defecación obstruida de 5 ítems. Los pacientes fueron categorizados en < 65 años versus ≥ 65 años.El puntaje de incontinencia fecal de la Cleveland Clinic / Wexner > 9 fue más común en pacientes mayores (87% vs 60%, p = 0.002). La puntuación del síndrome de defecación obstructiva > 8 fue más común en pacientes más jóvenes (57% vs 28%, p <0,001). Los pacientes mayores fueron más propensos que los pacientes jóvenes a informar síntomas y molestias de dolor (38% vs 19%, p = 0.021) y sangrado (12% vs 2%, p = 0.046). La mayoría de los pacientes informaron secresión de moco (mayores, 72% frente a más jóvenes, 66%, p = 0,54), pero sólo el 18% tuvo molestias, independientemente de la edad. Los pacientes mayores tenían una exteriorización de prolapso más grave que los pacientes jóvenes (en reposo, 33% frente a 11%; durante la actividad, 26% frente a 19%; solo con defecación, 40% frente a 64%, p = 0,006). Los pacientes mayores tenían más probabilidades de buscar atención médica dentro de los 6 meses posteriores al inicio del prolapso (29% frente a 11%, p = 0.056). Tras la regresión multivariable, el aumento de la edad, el uso de narcóticos y el prolapso no prolongado en reposo se asociaron con la notificación de dolor como queja principal.Centro único; tamaño de muestra pequeño.Los síntomas y molestias relacionadas con el prolapso rectal y la solicitud de atención médica difieren según la edad. Aunque el dolor rectal a menudo no se asocia comúnmente con el prolapso, incomoda a muchas pacientes y motiva a las mujeres mayores a someterse a un examen médico. Los cuestionarios funcionales con las respuestas de las pacientes pueden no reflejar las preocupaciones principales de éstos con respecto a los síntomas específicos y podrían requerir cuestionarios complementarios para así obtener prioridades individualizadas con relación a los síntomas identificados. Consulte Video Resumen en http://links.lww.com/DCR/B492. (Traducción-Dr. Xavier Delgadillo).

Fecal Incontinence in the Elderly

Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.

Risk factors of readmission after geriatric hospital care: An interRAI-based cohort study in Finland

PURPOSE

To identify risk factors for readmission after geriatric hospital care.

METHODS

A retrospective cohort study of 1,167 community-dwelling patients aged ≥70 years who were hospitalised in two geriatric hospitals and discharged to their homes over a three-year period. We combined the results of the interRAI-post acute care instrument (interRAI-PAC) with hospital discharge records. Factors associated with readmissions within 90 days following discharge were analysed using logistic regression analysis.

RESULTS

The patients' mean age was 84.5 (SD 6.2) years, and 71% (n = 827) were women. The 90-day readmission rate was 29.5%. The risk factors associated with readmission in the univariate analysis were as follows: age, admission from home vs. acute care hospital, Alzheimer's disease, unsteady gait, fatigue, unstable conditions, Activities of Daily Living Hierarchy Scale (ADLH) score, Cognitive Performance Scale (CPS) score, body mass index (BMI), frailty index, bowel incontinence, hearing difficulties, and poor self-rated health. In the multivariable analysis, age of ≥90 years, ADLH ≥1, unsteady gait, BMI <25 or ≥30 kg/m 2 , and frailty remained as risk factors for readmission. Surgical operation during the treatment period was associated with a lower readmission risk.

CONCLUSIONS AND IMPLICATIONS

InterRAI-PAC performed upon admission to geriatric hospitals revealed patient-related risk factors for readmission. Based on the identified risk factors, we recommend that the patient's functional ability, activities of daily living (ADL) needs, and individual factors underlying ADL disability, as well as nutritional and mobility problems should be carefully addressed and managed during hospitalization to diminish the risk for readmission.

Development and validation of multivariable mortality risk-prediction models in older people undergoing an interRAI home-care assessment (RiskOP)

BACKGROUND

Currently, one-year survival of older people with complex co-morbidities is unpredictable. Identifying older adults with a reduced life expectancy will lead to more targeted care and better healthcare resource allocation.

METHODS

Development and validation of one-year and three-month mortality risks in people aged ≥65 years who had completed an International Resident Assessment Instrument-Home Care (interRAI-HC) assessment between July 2012 and March 2018. Data was split into development (90%) and validation data sets (10%). A multivariable logistic regression model using data from 108 interRAI questions across multiple domains was developed and validated using discrimination metrics and calibration curves. Variables each explaining at least 1% of the model were then used to develop and validate a parsimonious model. Subgroups by sex, age, ethnicity, and comorbidities were evaluated.

FINDINGS

There were 104,436 persons (60.2% female; mean age 82.1 years) in the study cohort of whom 20,972 (20.1%) died within one year. The full multivariable model had area under the curves (AUCs) of 0.778 to 0.795 in the 5 validation datasets and was well calibrated. After variable reduction a parsimonious model consisted of 16 variables and was well calibrated and the AUC remained high: 0.773 (0.769 to 0.777). The three-month parsimonious model comprised 22 variables and was well calibrated with an AUC of 0.843 (95%CI: 0.839 to 0.848).

INTERPRETATION

These community-based risk prediction models accurately predict mortality in older people with complex co-morbidities. They may contribute to both forecasting for policy making and clinical decision making regarding an individual's needs.

FUNDING

The New Zealand Health Research Council.

Hospital adverse outcomes of the elderly in a tertiary referral hospital: A prospective cohort study of 9,586 admissions

OBJECTIVE

This study aimed to evaluate the hospital adverse outcomes (HAO) of admitted older adult patients in a large prospective cohort and investigate the demographic, economic, and health-related characteristics at risk of HAO in all older adult patients admitted in the general ward of a tertiary referral hospital.

MATERIALS AND METHODS

We recruited admission episodes of older adult patients aged over 65 years who were admitted at the general ward of Konkuk University Medical Center, which is a tertiary referral hospital, from September 2016 to October 2017. Out of 9,586 admission episodes, 8,263 were included. Modified from the Geriatric Screening for Care-10, six common geriatric health issues, namely, dysphagia, polypharmacy, fecal incontinence, functional mobility, depression, and dementia, were evaluated. Fall, hospital-acquired pressure ulcer (HPU), and mortality were checked daily by experienced nurses during the patients' hospital stay. A logistic regression model was used, and P < 0.05 was the threshold of significance.

RESULTS

The incidence rates of fall and HPU were 1.3 % and 4.0 %, respectively. The hospital mortality was 6.1 %. Older adult patients with dysphagia or dementia upon admission were significantly associated with an increased likelihood of falls. Furthermore, age, ER admission, low income, fecal incontinence, or functional immobility increased the HPU incidence. Meanwhile, age, male, ER admission, fecal incontinence, or functional immobility significantly increased the hospital mortality.

CONCLUSION

All demographic, economic, and health-related characteristics, except for polypharmacy and depression, affect the incidence of HAO. Intervention to vulnerable older adult patients with HAO risk could improve the treatment outcome.

Constipation and Fecal Incontinence in the Elderly

PURPOSE OF REVIEW

To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly.

RECENT FINDINGS

Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Risk of cancer in patients with fecal incontinence

BACKGROUND

Fecal incontinence may be an early symptom of cancer, but its association with cancer remains unclear. We examined the risk of selected cancers, including colorectal cancer, other gastrointestinal cancers, hormone-related cancers, and lymphoma, in patients with fecal incontinence.

METHODS

Using Danish population-based registries, all patients with hospital-based diagnoses of fecal incontinence during 1995-2013 were identified. We calculated cumulative incidences of cancers. As a measure of relative risks, we computed standardized incidence ratios (SIRs), that is, the observed number of cancers relative to the expected number based on national incidence rates by sex, age, and calendar year.

RESULTS

Among 16 556 patients with fecal incontinence, the cumulative incidence of colorectal cancers, other gastrointestinal cancers, hormone-related cancers, and lymphoma each was less than 0.4% after 1 year. It increased to under 3% after 10 years. The SIR for any cancer during 19 years of follow-up was 1.12 [95% confidence interval (CI), 1.06-1.19]. The SIRs during the first year were 2.31 (95% CI, 1.65-3.13) for colorectal cancer, 1.56 (95% CI, 0.89-2.54) for other gastrointestinal cancers, 1.00 (95% CI, 0.72-1.35) for hormone-related cancers, and 2.02 (95% CI, 1.01-3.61) for lymphoma. Beyond 1 year, the SIR reached unity for other gastrointestinal cancers, hormone-related cancers, and lymphoma, while a reduced risk was observed for colorectal cancer (SIR = 0.77, 95% CI, 0.59-0.98).

CONCLUSIONS

Fecal incontinence was a marker of cancer, especially gastrointestinal cancers and lymphoma within 1 year, which presumably is driven partly by reverse causation. However, the absolute risks were low. Heightened diagnostic efforts may explain in part the increased short-term risk of colorectal cancers.

Fecal Incontinence Symptoms and Impact in Older Versus Younger Women Seeking Care

BACKGROUND

The differential impact of aging on fecal incontinence symptom severity and condition-specific quality of life remains unclear.

OBJECTIVE

The purpose of this study was to characterize differences in symptom distress, quality of life, and anorectal physiology assessments in older versus younger women with fecal incontinence.

DESIGN

This was a cross-sectional study.

SETTINGS

This study was conducted at a tertiary genitorectal disorder clinic.

PATIENTS

Women presenting for fecal incontinence evaluation between 2003 and 2016 were classified as older or younger based on age ≥65 or <65 years.

MAIN OUTCOME MEASURES

The main outcomes were symptom-specific quality of life and distress measured by validated questionnaires (the Modified Manchester Health Questionnaire containing the Fecal Incontinence Severity Index); anorectal physiology and anatomy were assessed by manometry and endoanal ultrasound.

RESULTS

Of 879 subjects, 286 and 593 were classified as older and younger (mean ages, 71.4 ± 5.3 y and 51.3 ± 10.5 y). Solid stool leakage was more frequent in older women (83.2% vs 76.7%; p = 0.03), whereas liquid stool leakage (83.2% vs 82.8%; p = 0.88) and fecal urgency (76.9% vs 78.8%; p = 0.54) did not differ between groups. Mean symptom severity scores were similar between groups (28.0 ± 11.9 and 27.6 ± 13.5; p = 0.69); however, there was greater negative impact on quality of life among younger women (46.3 ± 22.0 vs 51.8 ± 21.8; p < 0.01). Multivariable linear regression controlling for pertinent covariates revealed younger age as an independent predictor for worse condition-specific quality-of-life scores (p < 0.01). Squeeze pressures were similar between groups, whereas younger women had greater resting pressures and higher rates of sphincter defects (external, 7.7% vs 20.2%; internal, 12.2% vs 26.8%; both p < 0.01).

LIMITATIONS

This study was limited by its lack of patient obstetric history and the duration of their incontinence symptoms.

CONCLUSIONS

Characteristics differ between older and younger women seeking care for fecal incontinence. The differential impact and age-related phenotypes may provide useful information for patient counseling and developing management algorithms for women with fecal incontinence. See Video Abstract at http://links.lww.com/DCR/A910.

High delayed mortality after the first episode of Clostridium difficile infection

Clostridium difficile infection (CDI) is characterized by a high delayed and unrelated mortality. Predicting delayed mortality in CDI patients could allow the implementation of interventions that could reduce these events. A prospective multicentric study was carried out to investigate prognostic factors associated with mortality. It was based on a cohort (July 2015 to February 2016) of 295 patients presenting with CDI. Logistic regression was used and the model was calibrated using the Hosmer-Lemeshow test. The mortality rate at 75 days in our series was 18%. Age (>65 years), comorbidity (defined by heart failure, diabetes mellitus with any organ lesion, renal failure, active neoplasia or immunosuppression) and fecal incontinence at clinical presentation were associated with delayed (75-day) mortality. When present, each of the aforementioned variables added one point to the score. Mortalities with 0, 1, 2 and 3 points were 0%, 9.4%, 18.5% and 38.2%, respectively. The area under the ROC curve was 0.743, and the Hosmer-Lemeshow goodness-of-fit test p value was 0.875. Therefore, the prediction of high delayed mortality in CDI patients by our scoring system could promote measures for increasing survival in suitable cases.

Home visits: A new screening tool for frailty? A retrospective exploratory study

Background

In the United Kingdom, the new NHS contract for primary care mandates that practices use the Electronic Frailty Index (EFI) to screen for frailty and apply clinical judgment, based on knowledge of the patient, to decide whether they have a diagnosis of frailty. EFI has not yet been validated for this purpose. Many primary care clinicians would agree that although not formally investigated, there seems to be a strong association between being housebound or in institutional care and having a diagnosis of frailty. Although being housebound or in institutional care is not commonly coded in primary care computer record systems (IT), this cohort of patients do require home visits if they become unwell. Home visits are coded and it is simple to run a search on primary care IT to generate a list of older people who have received a home over given period.

Aim

This study assessed whether being housebound and requiring home visits could form a new screening tool for frailty.

Design and Setting

Retrospective cohort study from 1/3/15 to 29/2/16. Primary care, South Devon.

Method

Medical records of 154 patients over 65 years of age were evaluated. Patients were divided into two groups: a group (n = 82) that had received a home visit and a second group consisting of a randomized sample of patients (n = 72) with similar baseline characteristics who had not. Patient records were analyzed by two clinicians to determine whether a frailty syndrome was present. Researchers were blinded to each other's results. An arbitrator determined the frailty status on disagreement.

Results

Home visits have a sensitivity of 87.23% [95% confidence interval (CI): 74.35%-95.17%] and specificity of 61.68% (95% CI: 51.78%-70.92%). For frailty, Cohen's Kappa showed fair interobserver reliability.

Conclusion

This study suggests that home visits are a good screen for frailty; the data are easy to retrieve from primary care IT and could be used as a valid screening tool to assist with identifying frailty in primary care.

Reduced Pain Reports With Increasing Cognitive Impairment in Older Persons in New Zealand

BACKGROUND

Conflicting findings prevail about pain in older persons with cognitive impairment. There is evidence of changed pain perception; however, pain is also underrecognized. Pain and cognitive impairment were examined in a national cohort of older persons assessed using the Home Care International Residential Assessment Instrument (interRAI-HC).

METHODS

Participants were 41 459 aged 65+ years receiving a mandated needs assessment to access publicly funded services. InterRAI-HC pain severity and Cognitive Performance Scale analyses covaried for age, gender, and ethnicity.

RESULTS

Milder pain prevalence increased with age, whereas daily severe-excruciating pain prevalence decreased with age. Daily severe-excruciating pain was reported by 18% of cognitively intact individuals decreasing to 8% in the severe cognitive impairment group. This relationship remained after covarying for age, sex, and ethnicity. Differences among dementia subtypes were found.

CONCLUSION

Although severe pain reports decrease with increasing age and cognitive impairment, more nuanced research covarying for dementia severity and subtype is required.

Ageing, loneliness, and the geographic distribution of New Zealand's interRAI-HC cohort

Loneliness is a significant negative predictor of ageing well and a contra-indicator for resilience against requiring long-term residential care. Health geographers can contribute to the loneliness and ageing literature through examining how exposures in the physical and social landscape can affect positive and negative health outcomes. As well as improving individual experiences of ageing, spatial analysis may help to contribute to better understandings of loneliness and help reduce the $1.7 billion per annum New Zealand currently spends on publicly-funded aged residential care. Using New Zealand Home Care International Residential Assessment Instrument data from 2012 to 2016, the spatial distribution of the interRAI-HC cohort was examined. Urban and rural distribution, socioeconomic status, and ethnicity within the interRAI-HC cohort was compared against total population and population aged 65 plus. Relative to the socioeconomic status of the 65 plus cohort, those being interRAI-HC assessed were more likely to live in socially deprived areas. Socioeconomic deprivation also positively correlated with loneliness (OR = 1.002). Carer stress was negatively correlated with socioeconomic status (OR = 0.99). Those in rural areas were predicted to be less lonely than urban dwellers (OR = 0.98), and this observation remained similar and significant when socioeconomic status, the experience of negative social interactions or carer stress, and whether they lived alone were included. Living in rural areas had a protective effect against loneliness for all ethnic groups apart from Pasifika. 'Hot' and 'cold' clusters of loneliness were identified, with the distribution of interRAI-HC assessments in hot clusters less likely to be rural areas (OR = 0.71). Our findings did not diverge greatly from prior research on older people and loneliness in rural areas. Observations of regional differences regarding rurality and socioeconomic status did not show large differences, and this research will benefit in future from analysis at finer geographic scale.

A High-yield Fall Risk and Adverse Events Screening Questions From the Stopping Elderly Accidents, Death, and Injuries (STEADI) Guideline for Older Emergency Department Fall Patients

OBJECTIVES

The objectives were to examine whether responses to the Stopping Elderly Accidents, Death, and Injuries (STEADI) questions responses predicted adverse events after an older adult emergency department (ED) fall visits and to identify factors associated with such recurrent fall.

METHODS

We conducted a prospective study at two urban, teaching hospitals. We included patients aged ≥ 65 years who presented to the ED for an accidental fall. Data were gathered for fall-relevant comorbidities, high-risk medications for falls, and the responses to 12 questions from the STEADI guideline recommendation. Our outcomes were the number of 6-month adverse events that were defined as mortality, ED revisit, subsequent hospitalization, recurrent falls, and a composite outcome.

RESULTS

There were 548 (86.3%) patients who completed follow-up and 243 (44.3%) patients experienced an adverse event after a fall within 6 months. In multivariate analysis, seven questions from the STEADI guideline predicted various outcomes. The question "Had previous fall" predicted recurrent falls (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.52 to 3.97), the question "Feels unsteady when walking sometimes" (OR = 2.34, 95% CI = 1.44 to 3.81), and "Lost some feeling in their feet" predicted recurrent falls. In addition to recurrent falls risk, the supplemental questions "Use or have been advised to use a cane or walker," "Take medication that sometimes makes them feel light-headed or more tired than usual," "Take medication to help sleep or improve mood," and "Have to rush to a toilet" predicted other outcomes.

CONCLUSION

A STEADI score of ≥4 did not predict adverse outcomes although seven individual questions from the STEADI guidelines were associated with increased adverse outcomes within 6 months. These may be organized into three categories (previous falls, physical activity, and high-risk medications) and may assist emergency physicians to evaluate and refer high-risk fall patients for a comprehensive falls evaluation.