Prognosis of hospitalised older people with different levels of functioning: a prospective cohort study

Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts

Background

Guidelines recommend routine frailty screening for all hospitalised older adults to inform care decisions, based mainly on studies in elective or speciality-specific settings. However, most hospital bed days are accounted for by acute non-elective admissions, in which the prevalence and prognostic value of frailty might differ, and uptake of screening is limited. We therefore did a systematic review and meta-analysis of frailty prevalence and outcomes in unplanned hospital admissions.

Methods

We searched MEDLINE, EMBASE and CINAHL up to 31/01/2023 and included observational studies using validated frailty measures in adult hospital-wide or general medicine admissions. Summary data on the prevalence of frailty and associated outcomes, measurement tools, study setting (hospital-wide vs general medicine), and design (prospective vs retrospective) were extracted and risk of bias assessed (modified Joanna Briggs Institute checklists). Unadjusted relative risks (RR; moderate/severe frailty vs no/mild) for mortality (within one year), length of stay (LOS), discharge destination and readmission were calculated and pooled, where appropriate, using random-effects models. PROSPERO CRD42021235663.

Findings

Among 45 cohorts (median/SD age = 80/5 years; n = 39,041,266 admissions, n = 22 measurement tools) moderate/severe frailty ranged from 14.3% to 79.6% overall (and in the 26 cohorts with low-moderate risk of bias) with considerable heterogeneity between studies (phet < 0.001) preventing pooling of results but with rates <25% in only 3 cohorts. Moderate/severe vs no/mild frailty was associated with increased mortality (n = 19 cohorts; RR range = 1.08-3.70), more consistently among cohorts using clinically administered tools (n = 11; RR range = 1.63-3.70; phet = 0.08; pooled RR = 2.53, 95% CI = 2.15-2.97) vs cohorts using (retrospective) administrative coding data (n = 8; RR range = 1.08-3.02; phet < 0.001). Clinically administered tools also predicted increasing mortality across the full range of frailty severity in each of the six cohorts that allowed ordinal analysis (all p < 0.05). Moderate/severe vs no/mild frailty was also associated with a LOS >8 days (RR range = 2.14-3.04; n = 6) and discharge to a location other than home (RR range = 1.97-2.82; n = 4) but was inconsistently related to 30-day readmission (RR range = 0.83-1.94; n = 12). Associations remained clinically significant after adjustment for age, sex and comorbidity where reported.

Interpretation

Frailty is common in older patients with acute, non-elective hospital admission and remains predictive of mortality, LOS and discharge home with more severe frailty associated with greater risk, justifying more widespread implementation of screening using clinically administered tools.

Funding

None.

Is hospitalization a risk factor for cognitive decline in older age adults?

OBJECTIVES

Many studies document cognitive decline following specific types of acute illness hospitalizations (AIH) such as surgery, critical care, or those complicated by delirium. However, cognitive decline may be a complication following all types of AIH. This systematic review will summarize longitudinal observational studies documenting cognitive changes following AIH in the majority admitted population and conduct meta-analysis (MA) to assess the quantitative effect of AIH on post-hospitalization cognitive decline (PHCD).

METHODS

We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Selection criteria were defined to identify studies of older age adults exposed to AIH with cognitive measures. 6566 titles were screened. 46 reports were reviewed qualitatively, of which seven contributed data to the MA. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

The qualitative review suggested increased cognitive decline following AIH, but several reports were particularly vulnerable to bias. Domain-specific outcomes following AIH included declines in memory and processing speed. Increasing age and the severity of illness were the most consistent risk factors for PHCD. PHCD was supported by MA of seven eligible studies with 41,453 participants (Cohen's d = -0.25, 95% CI [-0.02, -0.49] I² 35%).

CONCLUSIONS

There is preliminary evidence that AIH exposure accelerates or triggers cognitive decline in the elderly patient. PHCD reported in specific contexts could be subsets of a larger phenomenon and caused by overlapping mechanisms. Future research must clarify the trajectory, clinical significance, and etiology of PHCD: a priority in the face of an aging population with increasing rates of both cognitive impairment and hospitalization.

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017-18

BACKGROUND

The purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure.

METHODS

We analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017-2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households.

RESULTS

Results suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674-46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359-63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest.

CONCLUSIONS

Multimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.

Associations between health-related quality of life and physical function in older adults with or at risk of mobility disability after discharge from the hospital

Aim

To investigate if health-related quality of life (HRQOL) is associated with physical function in older adults with or at risk of mobility disability after hospital discharge.

Findings

Better physical function (SPPB) was significantly associated with a higher level of physical HRQOL (SF-36 subscales physical functioning, role physical, bodily pain and general health).

Message

The positive associations between physical function and physical HRQOL might indicate that the exercise interventions aiming to improve physical function might also improve physical HRQOL in this group of older adults.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00525-0.

Purpose

To optimise the treatment for older adults after hospitalisation, thorough health status information is needed. Therefore, we aimed to investigate the associations between health-related quality of life (HRQOL) and physical function in older adults with or at risk of mobility disability after hospital discharge.

Methods

This cross-sectional study recruited 89 home-dwelling older people while inpatients within medical wards at a general hospital in Oslo, Norway. HRQOL [the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36)] and physical function [the Short Physical Performance Battery (SPPB)] were measured a median of 49 [interquartile range (IQR) 26–116] days after discharge. Simple linear regression analyses were conducted, and multivariable regression models were fitted.

Results

The mean age of the patients was 78.3 years; 43 (48.9 %) were females. Multivariable regressions showed positive associations between SPPB and the physical subscales {physical functioning [B (95% CI) 4.51 (2.35–6.68)], role physical [B (95% CI) 5.21 (2.75–7.67)], bodily pain [B (95% CI) 3.40 (0.73–6.10)] and general health [B (95% CI) 3.12 (1.13–5.12)]}. Univariable regressions showed no significant associations between SPPB and the mental subscales {vitality [B (95% CI) 1.54 (− 0.10–3.18)], social functioning [B (95% CI) 2.34 (− 0.28–4.96)], role emotional [B (95% CI) 1.28 (− 0.96–3.52)] and mental health [B (95% CI) 1.00 (− 0.37–2.36)]}.

Conclusion

The results reinforce that physical function and physical HRQOL are strongly linked, and interventions improving physical function might improve physical HRQOL. However, this hypothesis would have to be tested in a randomised controlled trial.

Trial registration

ClinicalTrials.gov. Registered 19 September 2016 (NCT02905383).

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00525-0.

Effects of a multicomponent high intensity exercise program on physical function and health-related quality of life in older adults with or at risk of mobility disability after discharge from hospital: a randomised controlled trial

Background

Many older people suffer from mobility limitations and reduced health-related quality of life (HRQOL) after discharge from hospital. A consensus regarding the most effective exercise-program to optimize physical function and HRQOL after discharge is lacking. This study investigates the effects of a group-based multicomponent high intensity exercise program on physical function and HRQOL in older adults with or at risk of mobility disability after discharge from hospital.

Methods

This single blinded parallel group randomised controlled trial recruited eighty-nine home dwelling older people (65–89 years) while inpatient at medical wards at a general hospital in Oslo, Norway. Baseline testing was conducted median 49 (25 percentile, 75 percentile) (26, 116) days after discharge, before randomisation to an intervention group or a control group. The intervention group performed a group-based exercise program led by a physiotherapist twice a week for 4 months. Both groups were instructed in a home-based exercise program and were encouraged to exercise according to World Health Organisation’s recommendations for physical activity in older people. The primary outcome, physical performance, was measured by the Short Physical Performance Battery (SPPB). Secondary outcomes were 6-min walk test (6MWT), Berg Balance Scale (BBS), grip strength, Body Mass Index (BMI), and HRQOL (the Short-Form 36 Health Survey (SF-36)). Data were analysed according to the intention-to-treat principle. Between-group differences were assessed using independent samples t-test.

Results

The groups were comparable at baseline. Intention-to-treat analysis showed that the intervention group improved their functional capacity (6MWT) and the physical component summary of SF-36 significantly compared to the control group. No further between group differences in change from baseline to 4 months follow-up were found.

Conclusions

A high intensity multicomponent exercise program significantly improved functional capacity and physical HRQOL in older adults with or at risk of mobility disability after discharge from hospital. The study suggests that this population can benefit from systematic group exercise after hospital-initial rehabilitation has ended.

Trial registration

ClinicalTrials.gov. NCT02905383. September 19, 2016.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12877-020-01829-9.

Association of Access to Healthcare with Self-Assessed Health and Quality of Life among Old Adults with Chronic Disease in China: Urban Versus Rural Populations

This study examined urban-rural differences in the association of access to healthcare with self-assessed health and quality of life (QOL) among old adults with chronic diseases (CDs) in China. The data of 5796 older adults (≥60) with self-reported CDs were collected from the Study on Global Ageing and Adult Health in China, including indicators of self-assessed health and QOL and information on access to healthcare. Associations of access to healthcare with self-assessed health and QOL at the 10th, 50th, and 90th conditional quantiles were determined after controlling individual and household factors, showing that urban patients who received healthcare within two weeks gave higher ratings on self-assessed health scores at the 10th and 50th quantiles. In rural areas, one-year and two-week access to healthcare was found to be associated with QOL scores at the 10th and 90th quantiles, respectively. Marginal effects of using needed health service decreased with a growth in QOL and self-assessed health scores in both urban and rural locations despite these effects being significant across the whole distribution. Overall, access to healthcare affects the self-assessed health and QOL of the elderly with CDs in China, especially in patients with poor health, though differently for urban and rural patients. Policy actions targeted at vulnerable and rural populations should give priority to reducing barriers to seeking health services.

[Prognostic indices for older adults during the year following hospitalization in an acute medical ward: An update]

CONTEXT

As population grow older, chronic diseases are more prevalent. It leads to an increase of hospitalization for acute decompensation, sometimes iterative. Management of these patients is not always clear, and care provided is not always proportional to life expectancy. Making decisions in acute situations is not easy.

OBJECTIVE

This review aims to list and describe mortality scores within a year following hospitalization of patients of 65 years or older.

SOURCES

Following keywords were searched in title and abstract of articles via an advanced search in PudMed, and by searching Mesh terms: "aged", "aged, 80 and over", "mortality", "prognosis", "hospitalized", "models, statistical", "acute geriatric ward", "frailty", "outcome".

STUDIES SELECTION

Studies published in English between 1985 and 2015 were selected. Last article was published in June 2015. Articles that described prognostic factors of mortality without a scoring system were excluded. Articles that focus either on patients in the Emergency Department and in Intensive Care Unit, or living in institution were excluded.

RESULTS

Twenty-two scores are described in 17 articles. These scores use items that refer to functional status, comorbidities, cognitive status and frailty. Scores of mortality 3 or 6 months after hospitalization are not discriminative. Few of the 1-year mortality prognostic score are discriminative with AUC≥0.7.

LIMITS

This review is not systematic.

CONCLUSION

Practical use of these scores might help management of these patients, in order to initiate appropriate reflexion and palliative care if necessary.

Discriminative value of frailty screening instruments in end-stage renal disease

BACKGROUND

Numerous frailty screening instruments are available, but their applicability for identifying frailty in patients with end-stage renal disease (ESRD) is unknown. We aimed to investigate the diagnostic accuracy of three instruments used for frailty screening in an ESRD population.

METHODS

The study was conducted in 2013 in a teaching hospital in The Netherlands and included patients receiving haemodialysis, peritoneal dialysis and pre-dialysis care. We determined the sensitivity and specificity of three screening instruments: the Groningen Frailty Indicator (GFI), the Identification of Seniors at Risk-Hospitalized Patients (ISAR-HP) and the Veiligheidsmanagementsysteem (VMS), which is a safety management system for vulnerable elderly patients. The Frailty Index was the gold standard used.

RESULTS

The prevalence of frailty was 37% in a total of 95 participants with ESRD [mean age 65.2 years (SD 12.0), 57% male]. Frailty prevalence in participants ≥65 years of age and <65 years of age was 44% and 28%, respectively (P = 0.11). Sensitivity and specificity for frailty of the GFI were 89% and 57%, respectively; ISAR-HP 83% and 77%, respectively; and VMS 77% and 67%, respectively.

CONCLUSIONS

Although the GFI showed the highest sensitivity, it is not yet possible to propose a firm choice for one of these screening instruments or specific items due to the small scale of the study. Since there is a high prevalence of frailty in ESRD patients, translation and testing of the effectiveness of screening using the GFI in the prognostication and prevention of development or deterioration of frailty in this population should be the next step.

Physical activity in non-frail and frail older adults

Introduction

Physical activity (PA) is important for healthy ageing. Better insight into objectively measured PA levels in older adults is needed, since most previous studies employed self-report measures for PA assessment, which are associated with overestimation of PA.

Aim

This study aimed to provide insight in objectively measured indoor and outdoor PA of older adults, and in PA differences by frailty levels.

Methods

Data were collected among non-frail (N = 74) and frail (N = 10) subjects, aged 65 to 89 years. PA, measured for seven days with accelerometers and GPS-devices, was categorized into three levels of intensity (sedentary, light, and moderate-to-vigorous PA).

Results

Older adults spent most time in sedentary and light PA. Subjects spent 84.7%, 15.1% and 0.2% per day in sedentary, light and moderate-to-vigorous PA respectively. On average, older adults spent 9.8 (SD 23.7) minutes per week in moderate-to-vigorous activity, and 747.0 (SD 389.6) minutes per week in light activity. None of the subjects met the WHO recommendations of 150 weekly minutes of moderate-to-vigorous PA. Age-, sex- and health status-adjusted results revealed no differences in PA between non-frail and frail older adults. Subjects spent significantly more sedentary time at home, than not at home. Non-frail subjects spent significantly more time not at home during moderate-to-vigorous activities, than at home.

Conclusions

Objective assessment of PA in older adults revealed that most PA was of light intensity, and time spent in moderate-to-vigorous PA was very low. None of the older adults met the World Health Organization recommendations for PA. These levels of MVPA are much lower than generally reported based on self-reported PA. Future studies should employ objective methods, and age specific thresholds for healthy PA levels in older adults are needed. These results emphasize the need for effective strategies for healthy PA levels for the growing proportion of older adults.

Evaluation of the Prevention and Reactivation Care Program (PreCaP) for the hospitalized elderly: a prospective nonrandomized controlled trial

Background

The hospitalized elderly are at risk of functional decline. We evaluated the effects and care costs of a specialized geriatric rehabilitation program aimed at preventing functional decline among at-risk hospitalized elderly.

Methods

The prospective nonrandomized controlled trial reported here was performed in three hospitals in the Netherlands. One hospital implemented the Prevention and Reactivation Care Program (PReCaP), while two other hospitals providing usual care served as control settings. Within the PReCaP hospital we compared patients pre-implementation with patients post-implementation of the PReCaP (“within-hospital analysis”), while our nonrandomized controlled trial compared patients of the PReCaP hospital post-implementation with patients from the two control hospitals providing usual care (“between-hospital analysis”). Hospitalized patients 65 years or older and at risk of functional decline were interviewed at baseline and at 3 and 12 months using validated questionnaires to score functioning, depression, and health-related quality of life (HRQoL). We estimated costs per unit of care from hospital information systems and national data sources. We used adjusted general linear mixed models to analyze functioning and HRQoL.

Results

Between-hospital analysis showed no difference in activities of daily living (ADL) or instrumental activities of daily living (IADL) between PReCaP patients and control groups. PReCaP patients did have slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2–0.6]), lower depression (Geriatric Depression Scale 15; −0.9 [95% −1.1 to −0.6]) and higher perceived health (Short-Form 20; 5.6 [95% CI 2.8–8.4]) than control patients. Analyses within the PReCaP hospital comparing patients pre-and post-implementation of the PReCaP showed no improvement over time in functioning, depression, and HRQoL. One-year health care costs were higher for PReCaP patients, both for the within-hospital analysis (+€7,000) and the between-hospital analysis (+€2,500).

Conclusion

We did not find any effect of the PReCaP on ADL and IADL. The PReCaP may possibly provide some benefits to hospitalized patients at risk of functional decline with respect to cognitive functioning, depression, and perceived health. Further evaluations of integrated intervention programs to limit functional decline are therefore required.

Characteristics of residential areas and transportational walking among frail and non-frail Dutch elderly: does the size of the area matter?

Background

A residential area supportive for walking may facilitate elderly to live longer independently. However, current evidence on area characteristics potentially important for walking among older persons is mixed. This study hypothesized that the importance of area characteristics for transportational walking depends on the size of the area characteristics measured, and older person’s frailty level.

Methods

The study population consisted of 408 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighborhood (ELANE) study in 2011–2012. Characteristics (aesthetics, functional features, safety, and destinations) of areas surrounding participants’ residences ranging from a buffer of 400 meters up to 1600 meters (based on walking path networks) were linked with self-reported transportational walking using linear regression analyses. In addition, interaction effects between frailty level and area characteristics were tested.

Results

An increase in functional features (e.g. presence of sidewalks and benches) within a 400 meter buffer, in aesthetics (e.g. absence of litter and graffiti) within 800 and 1200 meter buffers, and an increase of one destination per buffer of 400 and 800 meters were associated with more transportational walking, up to 2.89 minutes per two weeks (CI 1.07-7.32; p < 0.05). No differences were found between frail and non-frail elderly.

Conclusions

Better functional and aesthetic features, and more destinations in the residential area of community-dwelling older persons were associated with more transportational walking. The importance of area characteristics for transportational walking differs by area size, but not by frailty level. Neighbourhood improvements may increase transportational walking among older persons, thereby contributing to living longer independently.