Frailty and hospitalization-associated disability after pneumonia: A prospective cohort study

Extremely Poor Post-discharge Prognosis in Aspiration Pneumonia and Its Prognostic Factors: A Retrospective Cohort Study

There is little evidence regarding the long-term prognosis of patients with aspiration pneumonia. This study aimed to investigate post-discharge survival time and prognostic factors in older patients hospitalized for aspiration pneumonia. This retrospective cohort study included patients aged ≥ 65 years hospitalized for aspiration pneumonia and discharged alive from a tertiary care hospital in Japan between April 2009 and September 2014. Candidate prognostic factors were patient's age, sex, body mass index (BMI), performance status, chronic conditions, CURB-65 score, serum albumin level, hematocrit concentration, nutritional pathway at discharge, and discharge location. Kaplan-Meier curves were determined and multivariable survival analysis using Cox regression model was performed to analyze the effect of each factor on mortality. In total, 209 patients were included in this study. The median age was 85 years, 58% of the patients were males, 33% had a performance status of 4 and 34% were discharged home. Among the patients, 65% received oral intake, 23% received tube feeding, and 21% received parenteral nutrition at discharge. During the follow-up period, 77% of the patients died, and the median post-discharge survival time was 369 days. Besides male sex and low BMI, tube feeding (adjusted hazard ratio (aHR) = 1.70, 95% confidence interval (CI) 1.11-2.59) and parenteral nutrition (aHR = 4.42, 95% CI 2.57-7.60) were strongly associated with mortality. Long-term prognosis of patients hospitalized for aspiration pneumonia was extremely poor. The nutritional pathway at discharge was a major prognostic factor. These results may be useful for future care and research.

Steroids in severe community-acquired pneumonia

There is conflicting evidence regarding the use of steroids in severe community-acquired pneumonia (CAP), with previous randomised controlled trials limited by small sample sizes. ESCAPe and CAPE COD are two recently published large trials on steroids in severe CAP. ESCAPe assessed the initiation of methylprednisolone within 72-96 h of hospital admission, while CAPE COD studied the use of hydrocortisone within 24 h of the development of severe CAP. ESCAPe did not show any differences in all-cause 60-day mortality or any of its secondary outcomes. CAPE COD showed that hydrocortisone improved all-cause 28-day mortality and reduced the risk of intubation or vasopressor-dependent shock. Important differences between the trials included the steroid regimens used, timing of steroid administration and baseline characteristics, with more diabetic patients included in ESCAPe. The results of CAPE COD support the initiation of hydrocortisone within 24 h of developing severe CAP, but more research is needed to evaluate long-term outcomes and optimum dosing regimens for steroids in severe CAP.

Ideal Postdischarge Follow-Up After Severe Pneumonia or Acute Respiratory Failure: A Qualitative Study of Primary Care Clinicians in Diverse Settings

BACKGROUND

Most patients discharged after hospitalization for severe pneumonia or acute respiratory failure receive follow-up care from primary care clinicians, yet guidelines are sparse.

RESEARCH QUESTION

What do primary care clinicians consider to be ideal follow-up care after hospitalization for severe pneumonia or acute respiratory failure and what do they perceive to be barriers and facilitators to providing ideal follow-up?

STUDY DESIGN AND METHODS

We conducted, via videoconferencing, semistructured interviews of 20 primary care clinicians working in diverse settings from five US states and Washington, DC. Participants described postdischarge visits, ongoing follow-up, and referrals for patients recovering from hospitalizations for pneumonia or respiratory failure bad enough to be hospitalized and to require significant oxygen support or seeking treatment at the ICU. Barriers and facilitators were probed using the capability, opportunity, motivation, behavior framework. Interview summaries and rigorous and accelerated data reduction analysis techniques were used.

RESULTS

Core elements of primary care follow-up after severe pneumonia or acute respiratory failure included safety assessment, medication management, medical specialty follow-up, integrating the hospitalization into the primary care relationship, assessing mental and physical well-being, rehabilitation follow-up, and social context of recovery. Clinicians described specific practices as well as barriers and facilitators at multiple levels to optimal care.

INTERPRETATION

Our findings suggest that at least seven core elements are common in follow-up care after severe pneumonia or acute respiratory failure, and conventional systems include barriers and facilitators to delivering what primary care clinicians consider to be optimal follow-up care. Future research could leverage identified barriers and facilitators to develop implementation tools that enhance the delivery of robust follow-up care for severe pneumonia or acute respiratory failure.

Association between dietary supplements and frailty: a cross-sectional study using national survey data in South Korea

We aimed to examine the association between the use of specific types of dietary supplements and frailty using cross-sectional, nationally representative survey data. Adults aged ≥50 years in the Korea National Health and Nutrition Examination Survey 2018-2020 were included. We calculated a 46-item frailty index to assess frailty. In total, 27,384 older adults were included (mean age: 62.47 years; median frailty index: 0.12). Among them, 72% used at least one dietary supplement. The prevalence of dietary supplement use was higher among women than among men and in participants with higher socioeconomic status. Compared to non-users, users of dietary supplements had a healthier diet and nutrient intake, and lower levels of frailty. After adjusting for socioeconomic and dietary factors, users of vitamin C, red ginseng or calcium were found to be significantly less frail. Our findings indicate promising results concerning dietary supplement intake in managing frailty among older Korean adults.

Impact of frailty on pneumonia outcomes in older patients: a systematic review and meta-analysis

PURPOSE

The ideal method for identifying frailty remains unclear, but the condition is associated with poor prognoses in many illnesses. Despite the availability of studies, the prognostic implications of frailty on older patients with pneumonia remains unexplored. To determine the burden and effect of frailty on selected clinical outcomes among older patients with pneumonia.

METHODS

We searched Medline, Google Scholar, and Science Direct databases for articles published in English following the PRISMA framework to guide our review. We included studies conducted on patients (> 60 years) with frailty and pneumonia, and reporting the effect of frailty on mortality, hospital stay, length readmission, and ICU admission. We performed a meta-analysis using STATA 14.2, calculating pooled odds ratios and 95% confidence intervals.

RESULTS

We analysed data from 16 studies and calculated a pooled frailty prevalence of 49% (95% CI 37-60%) in older patients with pneumonia. Unadjusted analyses revealed an odds ratio (OR) of 2.50 (95% CI 1.88-3.32) for the intermediate risk group, and an OR of 3.51 (95% CI 3.05-4.05) for the high risk group regarding mortality. The high risk frailty group also exhibited significant elevations in the risk of readmissions and extended hospital stay lengths. Substantial heterogeneity was observed in both adjusted and unadjusted analyses.

CONCLUSIONS

Our systematic review and meta-analysis results show that one in every two older individuals with pneumonia present frailty, a condition that significantly influences their rates of mortality and readmission, and their hospital stay length.

Association of Frailty With Risk of Incident Hospital-Treated Infections in Middle-Aged and Older Adults: A Large-Scale Prospective Cohort Study

BACKGROUND

Although frailty is associated with a range of adverse health outcomes, its association with the risk of hospital-treated infections is uncertain.

METHODS

A total of 416 220 participants from the UK Biobank were included in this prospective cohort study. Fried phenotype was adopted to evaluate frailty, which included 5 aspects (gait speed, physical activity, grip strength, exhaustion, and weight). More than 800 infectious diseases were identified based on electronic health records. Cox proportional models were used to estimate the associations.

RESULTS

During a median 12.3 years (interquartile range 11.4-13.2) of follow-up (4 747 345 person-years), there occurred 77 988 (18.7%) hospital-treated infections cases. In the fully adjusted model, compared with participants with nonfrail, the hazard ratios (HRs) (95% confidence intervals [CIs]) of those with prefrail and frail for overall hospital-treated infections were 1.22 (1.20, 1.24) and 1.78 (1.72-1.84), respectively. The attributable risk proportion of prefrail and frail were 18.03% and 43.82%. Similarly, compared to those without frailty, the HRs (95% CIs) of those with frailty for bacterial infections were 1.76 (1.70-1.83), for viral infections were 1.62 (1.44-1.82), and for fungal infections were 1.75 (1.47-2.08). No association was found between frailty and parasitic infections (HR: 1.17; 95% CI: 0.62-2.20).

CONCLUSIONS

Frailty was significantly associated with a higher risk of hospital-treated infections, except for parasitic infections. Studies evaluating the effectiveness of implementing frailty assessments are needed to confirm our results.

Risk factors associated with functional decline in older hospital survivors with acute lower respiratory tract infections: a prospective cohort study

OBJECTIVE

To evaluate the dynamics of basic activity of daily living (BADL) in older patients with acute lower respiratory tract infections (LRTIs) during acute phase and to investigate risk factors associated with decreased physical function at discharge.

METHODS

We conducted a prospective cohort study of patients aged 65 years and older who were hospitalized for acute LRTIs between April 15, 2020 and January 15, 2023. All patients received geriatric assessment at admission, including emotion, cognition, frailty, physical function status and so on. The BADL was also evaluated by the Barthel Index (BI) at two weeks before admission by recall (baseline status), at admission and at discharge. Based on the BI grades at baseline and at discharge, patients were classified into two groups: ADL decline and no ADL decline. Multivariable adjusted logistic regression models were used to evaluate the risk factors of decreased physical function.

RESULTS

A total of 364 older survivors with LRTIs were included in the analysis. The median age was 74 years (IQR 61.0-82.0), 231 (62.6%) were male, the median length of stay was 10 days. In the geriatric assessment, 139 patients (38.2%) were classified as frailty, 137 patients (37.6%) experienced insomnia, 60 patients (16.5%) exhibited cognitive impairments, and 37 patients (10.2%) were defined as malnutrition. Additionally, 30 patients (8.2%) dealt with emotional disorders. On average, patients were taking 3 medications, and Charlson Comorbidity Index score was 4. 72 patients (19.8%) had function decline at discharge. In the multivariable analysis, frailty status had an odds ratio of 4.25 (95% CI 1.31-19.26) for decreased physical function and cognitive impairment had an odds ratio of 2.58 (95% CI 1.27-5.19).

CONCLUSIONS

About 20% older patients with LRTIs experienced functional decline at discharge. Compared to age, severity of diseases and length of stay, frailty and cognitive impairment performed better at predicting the function decline. The apply of geriatric assessment may contribute to enhance the quality of management and treatment for patients with the older with LRTIs.

Clinical implementation of partial oral treatment in infective endocarditis: the Danish POETry study

BACKGROUND AND AIMS

In the Partial Oral Treatment of Endocarditis (POET) trial, stabilized patients with left-sided infective endocarditis (IE) were randomized to oral step-down antibiotic therapy (PO) or conventional continued intravenous antibiotic treatment (IV), showing non-inferiority after 6 months. In this study, the first guideline-driven clinical implementation of the oral step-down POET regimen was examined.

METHODS

Patients with IE, caused by Staphylococcus aureus, Enterococcus faecalis, Streptococcus spp. or coagulase-negative staphylococci diagnosed between May 2019 and December 2020 were possible candidates for initiation of oral step-down antibiotic therapy, at the discretion of the treating physician. The composite primary outcome in patients finalizing antibiotic treatment consisted of embolic events, unplanned cardiac surgery, relapse of bacteraemia and all-cause mortality within 6 months.

RESULTS

A total of 562 patients [median age 74 years (IQR, interquartile range, 65-80), 70% males] with IE were possible candidates; PO was given to 240 (43%) patients and IV to 322 (57%) patients. More patients in the IV group had IE caused by S. aureus, or had an intra-cardiac abscess, or a pacemaker and more were surgically treated. The primary outcome occurred in 30 (13%) patients in the PO group and in 59 (18%) patients in the IV group (P = .051); in the PO group, 20 (8%) patients died vs. 46 (14%) patients in the IV group (P = .024). PO-treated patients had a shorter median length of stay [PO 24 days (IQR 17-36) vs. IV 43 days (IQR 32-51), P < .001].

CONCLUSIONS

After clinical implementation of the POET regimen almost half of the possible candidates with IE received oral step-down antibiotic therapy. Patients in the IV group had more serious risk factors for negative outcomes. At 6-month follow-up, there was a numerically but not statistically significant difference towards a lower incidence of the primary outcome, a lower incidence of all-cause mortality and a reduced length of stay in the PO group. Due to the observational design of the study, the lower mortality may to some extent reflect selection bias and unmeasured confounding. Clinical implementation of PO regimens seemed feasible and safe.

Geriatric Medicine in South Korea: A Stagnant Reality amidst an Aging Population

In the face of an ever-increasing wave of an aging population, this paper provides an update on the current status of geriatric medicine in Korea, comparing it with global initiatives and suggesting future directions. Older adults require a multifaceted approach, addressing not only comorbidity management but also unmet complex medical needs, nutrition, and exercise to prevent functional decline. In this regard, the World Health Organization's Integrated Care for Older People guidelines underscore the importance of patient-centered primary care in preventing a decline in intrinsic capacity. Despite these societal needs and the ongoing aging process, the healthcare system in Korea has yet to show significant movement or a shift toward geriatric medicine, further complicated by the absence of a primary care system. We further explore global efforts in establishing age-integrative patient-centered medical systems in Singapore, Australia, Canada, the United Kingdom, and Japan. Additionally, we review the unmet needs and social issues that Korean society is currently facing, and local efforts by both government and a private tertiary hospital in Korea. In conclusion, considering the current situation, we propose that the framework of geriatric medicine should form the foundation of the future healthcare system.

Frailty and Adverse Outcomes After SARS-CoV-2 Infection in Elderly Patients on Maintenance Hemodialysis: A Cohort Study

Purpose

Frailty is an important geriatric syndrome associated with aging and adverse events, especially in patients with severe infection. To help guide prognosis for elderly patients undergoing maintenance hemodialysis (MHD) who experience acute infection, this study investigated whether baseline (pre-infection) frailty may be associated with adverse outcomes in elderly patients undergoing MHD who suffer SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection.

Patients and Methods

Patients (aged ≥60 y) receiving MHD had been assessed for overall frailty and the 5 frailty components based on the Fried Frailty Phenotype scale within 3 months prior to SARS-CoV-2 infection.

Results

There were 59 and 98 patients in the frail and non-frail groups, respectively. Three months after SARS-CoV-2 infection, 21 (13.4%) and 45 (28.7%) patients had died or were in hospital. The multivariate COX proportional risk model suggested that the all-cause mortality rate in patients judged overall frail or with low activity was significantly higher compared with that of the non-frail (P = 0.049; 0.003). The multivariate logistic regression analysis showed that hospitalization 3 months after SARS-CoV-2 infection was associated with both overall frailty and low activity (OR 2.276, 95% CI: 1.034-5.010, P = 0.041; OR 2.809, 95% CI: 1.311-6.020, P = 0.008, respectively).

Conclusion

Overall frailty and specifically low activity were significantly associated with all-cause mortality and hospitalization in this elderly MHD population after SARS-CoV-2 infection. Early assessment of frailty and effective interventions are recommended to improve the prognosis of patients receiving MHD who are at higher risk of acute infection.

Assessment tools and incidence of hospital-associated disability in older adults: a rapid systematic review

Background

During hospitalization older adults have a high risk of developing functional impairments unrelated to the reasons for their admission. This is termed hospital-associated disability (HAD). This systematic review aimed to assess the incidence of HAD in older adults admitted to acute care with two outcomes: firstly in at least one activity of daily living from a set of functional tasks (e.g., Katz Index) and secondly the incidence of functional decline in an individual functional task (e.g., bathing), and to identify any tools or functional tasks used to assess activities of daily living (ADL) in hospitalized older patients.

Methods

A rapid systematic review was performed according to the recommendations of the Cochrane Rapid Reviews Methods Group and reported the data according the PRISMA statement. A literature search was performed in Medline (via Ovid), EMBASE, and Cochrane Central Register of Controlled Trials databases on 26 August 2021. Inclusion criteria: older adults (≥65 years), assessment of individual items of activities of daily living at baseline and discharge. Exclusion criterion: studies investigating a specific condition that could affect functional decline and studies that primarily examined a population with cognitive impairment. The protocol was registered on OSF registries (https://osf.io/9jez4/) identifier: DOI 10.17605/OSF.IO/9JEZ4.

Results

Ten studies were included in the final review. Incidence of HAD (overall score) was 37% (95% CI 0.30-0.43). Insufficient data prevented meta-analysis of the individual items. One study provided sufficient data to calculate incidence, with the following values for patients' self-reported dependencies: 32% for bathing, 27% for dressing, 27% for toileting, 30% for eating and 27% for transferring. The proxy reported the following values for patients' dependencies: 70% for bathing, 66% for dressing, 70% for toileting, 61% for eating and 59% for transferring. The review identified four assessment tools, two sets of tasks, and individual items assessing activities of daily living in such patients.

Conclusions

Incidence of hospital-associated disability in older patients might be overestimated, due to the combination of disease-related disability and hospital-associated disability. The tools used to assess these patients presented some limitations. These results should be interpreted with caution as only one study reported adequate information to assess the HAD incidence. At the item level, the latter was higher when disability was reported by the proxies than when it was reported by patients. This review highlights the lack of systematic reporting of data used to calculate HAD incidence. The methodological quality and the risk of bias in the included studies raised some concerns.

Efficacy and Safety of Vaccinations in Geriatric Patients: A Literature Review

With the progressive lengthening of the average age of the population, especially in some countries such as Italy, vaccination of the elderly is a fixed point on which most of the public health efforts are concentrating as epidemic infectious diseases, especially those of the winter, have a major impact on the progression of severe disease, hospitalization, and death. The protection of the elderly against acute infectious diseases should not only limit mortality but also have a positive impact on the fragility of these people in terms of less disability and fewer care needs. However, vaccination of the elderly population differs in efficacy and safety compared to that of other population categories since aging and the consequent loss of efficiency of the immune system lead to a reduction in the immunogenicity of vaccines without achieving a lasting antibody coverage. There are various strategies to avoid the failure of immunization by vaccines such as resorting to supplementary doses with adjuvant vaccines, increasing the dosage of the antigen used, or choosing to inoculate the serum relying on various routes of administration of the vaccine. Vaccination in the elderly is also an important factor in light of growing antibiotic resistance because it can indirectly contribute to combating antibiotic resistance, reducing theoretically the use of those agents. Furthermore, vaccination in old age reduces mortality from infectious diseases preventable with vaccines and reduces the same rate of resistance to antibiotics. Given the importance and complexity of the topic, in this review, we will deal with the main aspects of vaccination in the elderly and how it can influence mortality and healthcare costs, especially in those countries where population aging is more evident. Therefore, we conducted a systematic literature search in PubMed to identify all types of studies published up to 31 May 2023 that examined the association between vaccination and the elderly. Data extraction and quality assessment were conducted by two reviewers (PC and TC) who independently extracted the following data and assessed the quality of each study.

Exploring the Frailty Components Related to Hospitalization-Associated Disability in Older Patients After Cardiac Surgery Using a Comprehensive Frailty Assessment

BACKGROUND

We investigated the components of frailty associated with hospitalization-associated disability (HAD) after cardiac surgery.

METHODS AND RESULTS

This retrospective, observational study evaluated 1,446 older patients after elective cardiac surgery at the Sakakibara Heart Institute. We examined the association between HAD and 7 domains of frailty assessed by the Kihon Checklist. HAD was defined as a decline in the ability to perform activities of daily living (ADL) between admission and discharge, as assessed by the Barthel Index. Logistic regression and decision tree analysis were used to identify associations between the number and type of frailty components and HAD. Of the 1,446 patients, 190 were excluded, and 90 (7%) developed HAD. An increase in the number of frailty components was a risk factor for HAD (odds ratio: 1.88, 95% confidence interval: 1.62-2.17). Decision tree analysis identified physical functional decline, depression, and cognitive dysfunction as factors associated with HAD. The incidence of HAD was highest in cases of physical functional decline (21%) and lowest for cases in which the 3 aforementioned factors were absent (2.8%).

CONCLUSIONS

An increased number of frailty factors increased the risk of HAD and the findings also reaffirmed the importance of a comprehensive assessment to evaluate the risk of HAD, including evaluation of physical function, cognitive function, and depression.

A model for predicting physical function upon discharge of hospitalized older adults in Taiwan-a machine learning approach based on both electronic health records and comprehensive geriatric assessment

Background

Predicting physical function upon discharge among hospitalized older adults is important. This study has aimed to develop a prediction model of physical function upon discharge through use of a machine learning algorithm using electronic health records (EHRs) and comprehensive geriatrics assessments (CGAs) among hospitalized older adults in Taiwan.

Methods

Data was retrieved from the clinical database of a tertiary medical center in central Taiwan. Older adults admitted to the acute geriatric unit during the period from January 2012 to December 2018 were included for analysis, while those with missing data were excluded. From data of the EHRs and CGAs, a total of 52 clinical features were input for model building. We used 3 different machine learning algorithms, XGBoost, random forest and logistic regression.

Results

In total, 1,755 older adults were included in final analysis, with a mean age of 80.68 years. For linear models on physical function upon discharge, the accuracy of prediction was 87% for XGBoost, 85% for random forest, and 32% for logistic regression. For classification models on physical function upon discharge, the accuracy for random forest, logistic regression and XGBoost were 94, 92 and 92%, respectively. The auROC reached 98% for XGBoost and random forest, while logistic regression had an auROC of 97%. The top 3 features of importance were activity of daily living (ADL) at baseline, ADL during admission, and mini nutritional status (MNA) during admission.

Conclusion

The results showed that physical function upon discharge among hospitalized older adults can be predicted accurately during admission through use of a machine learning model with data taken from EHRs and CGAs.

The relationship between frailty and community-acquired pneumonia in older patients

PURPOSES

To explore the relationship between frailty and community-acquired pneumonia (CAP) in older patients.

METHODS

A prospective observational study included 109 older patients(≥ 65 years) hospitalized with CAP in respiratory department of Fuxing hospital, Capital Medical University from June 2018 to December 2020. Frailty scores(Frail Scale, range 0-5) and pneumonia severity CURB-65 scale(mild = 1, modest = 2, and severe ≥ 3) were measured. We extracted clinical variables including white blood cell(WBC), neutrophil-to-lymphocyte ratio (NLR), C-reactive protein(CRP), hemoglobin, and albumin. Charlson Comorbidity Index(CCI) was calculated as well. The correlations between the variables and frailty scores were investigated, respectively. After adjusting for covariates, binomial logistic regression analysis was used to assess independent effect of frailty scores on the outcome(discharge or death/progression) in older CAP patients.

RESULTS

The subjects had a median age 87(interquartile range,8.5) years, 60.6% male, 45.9% pre-frail, and 32.1% frail. There were positive correlations between frailty scores and CURB-65 scale (p = 0.000, r = 0.542), CCI(p = 0.000, r = 0.359) and NLR(p = 0.005, r = 0.268). Negative correlations were observed between frailty scores and hemoglobin (p = 0.002, r = - 0.298), albumin (p = 0.000, r = - 0.465). In multivariable logistic regression analysis, the factors associated with discharge or death/progression of CAP were frailty scores (OR = 1.623, p = 0.037), NLR (OR = 1.086, p = 0.008) and albumin (OR = 0.869, p = 0.034).

CONCLUSIONS

Frailty is correlated with CURB-65 scale, CCI and hemoglobin, and albumin in older patients with CAP. Frailty is also a correlate of increased risk for death or progression in these older people.

Early physical rehabilitation effectiveness in frail older patients hospitalized for community-acquired pneumonia: analysis of a nationwide database in Japan

BACKGROUND

Frailty is a significant predictor of prognosis in older patients with community-acquired pneumonia (CAP). No effective therapy has been reported in frail patients with CAP, with frailty determined using the Hospital Frailty Risk Score (HFRS).

AIMS

To investigate whether early physical rehabilitation intervention would effectively minimize adverse outcomes in frail older patients (determined using the HFRS) hospitalized for CAP.

METHODS

This retrospective cohort analysis involved patients with CAP aged ≥ 65 years enrolled in the Japanese Diagnostic Procedure Combination Database between 2014 and 2020 and assessed as being frail. We compared 30-day mortality and readmission rates for patients who did and who did not receive physical rehabilitation within three days of admission and evaluated the association between outcomes and receiving early physical rehabilitation using Cox regression models and inverse probability weighting (IPW) for sensitivity analysis.

RESULTS

The analysis involved 31,133 frail older patients hospitalized for CAP (mean age 84.3 ± 6.3 years; females, 49.1%), including 11,515 (37.0%) who received early physical rehabilitation. Cox regression analysis showed that early physical rehabilitation intervention was inversely associated with 30-day mortality and readmission rates. The IPW model also showed similar results.

DISCUSSION

Early physical rehabilitation was associated with reduced risks of 30-day mortality, overall in-hospital mortality, and 30-day readmission rates in frail older patients with CAP.

CONCLUSIONS

Early physical rehabilitation in frail older patients hospitalized for CAP may improve outcomes. This finding highlights the importance of simultaneously introducing the HFRS and early physical rehabilitation intervention into clinical practice for frail older patients with CAP.

Frailty and the risk of infection-related hospitalizations in older age: Differences by sex

OBJECTIVES

To investigate the extent to which frailty is associated with infection-related hospitalizations in older men and women, and to explore whether, among women, previous exposure to endogenous estrogens in terms of age at menopause and number of pregnancies modify such a relationship.

STUDY DESIGN

The sample comprised 2784 participants in the Progetto Veneto Anziani aged ≥65 years. At baseline and after 4.4 years, frailty was identified according to the presence of three or more of the following: weakness, exhaustion, weight loss, low physical activity, and low walking speed. A passive follow-up on infection-related hospitalizations and mortality was performed for 10 years of observation through linkage with regional registers.

MAIN OUTCOME MEASURES

The association between frailty and infection-related hospitalizations was assessed through mixed-effects Cox regressions.

RESULTS

Frailty was significantly associated with a 78 % higher risk of infection-related hospitalization, with stronger results in men (hazard ratio = 2.32, 95 % confidence interval 1.63-3.30) than in women (hazard ratio = 1.54, 95 % confidence interval 1.18-2.02). Focusing on women, we found a possible modifying effect for the number of pregnancies but not menopausal age. Women who had experienced one or no pregnancy demonstrated a higher hazard of infection-related hospitalization as a function of frailty (hazard ratio = 3.00, 95 % confidence interval 1.58-5.71) than women who had experienced two or more pregnancies (hazard ratio = 1.68, 95 % confidence interval 1.18-2.39).

CONCLUSION

Frailty in older age increases the risk of infection-related hospitalizations, especially in men. The "immunologic advantage" of the female sex in younger age seems to persist also after menopause as a function of the number of pregnancies a woman has experienced.

Post-acute care for frail older people decreases 90-day emergency room visits, readmissions and mortality: An interventional study

BACKGROUND

To evaluate the effects of post-acute care (PAC) on frail older adults after acute hospitalization in Taiwan.

METHODS

This was a multicenter interventional study. Frail patients aged ≥ 75 were recruited and divided into PAC or control group. The PAC group received comprehensive geriatric assessment (CGA) and multifactorial intervention including exercise, nutrition education, and medicinal adjustments for two to four weeks, while the control group received only CGA. Outcome measures included emergency room (ER) visits, readmissions, and mortality within 90 days after PAC.

RESULTS

Among 254 participants, 205 (87.6±6.0 years) were in the PAC and 49 (85.2±6.0 years) in the control group. PAC for more than two weeks significantly decreased 90-day ER visits (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.10-0.43; p = 0.024), readmissions (OR 0.30, 95% CI 0.16-0.56; p < 0.001), and mortality (OR 0.20, 95% CI 0.04-0.87; p = 0.032). Having problems in self-care was an independent risk factor for 90-day ER visits (OR 2.11, 95% CI 1.17-3.78; p = 0.012), and having problems in usual activities was an independent risk factor for 90-day readmissions (OR 2.69, 95% CI 1.53-4.72; p = 0.001) and mortality (OR 3.16, 95% CI 1.16-8.63; p = 0.024).

CONCLUSION

PAC program for more than two weeks could have beneficial effects on decreasing ER visits, readmissions, and mortality after an acute illness in frail older patients. Those who perceived severe problems in self-care and usual activities had a higher risk of subsequent adverse outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT Identifier: NCT05452395.

Impact of Frailty Risk on Oral Intake and Length of Hospital Stay in Older Patients with Pneumonia: A Historical Cohort Study

The aim of this study was to examine the association between frailty risk and outcomes in older patients with pneumonia. For this purpose, the JMDC multi-center database was used, and a historical cohort study was conducted to examine the association between the Hospital Frailty Risk Score (HFRS) and oral intake prognosis and length of hospital stay in older patients hospitalized with pneumonia. Patients were classified into low-risk (HFRS < 5), intermediate-risk (HFRS = 5−15), and high-risk (HFRS > 15) groups based on their HFRS scores, and outcomes were defined as the number of days from admission to the start of oral intake and length of hospital stay. A total of 98,420 patients with pneumonia (mean age 82.2 ± 7.2) were finally included. Of these patients, 72,207 (73.4%) were in the low-risk group, 23,136 (23.5%) were in the intermediate-risk group, and 3077 (3.1%) were in the high-risk group. The intermediate- and high-risk groups had a higher number of days to the start of oral intake than the low-risk group (intermediate-risk group: coefficient 0.705, 95% confidence interval [CI] 0.642−0.769; high-risk group: coefficient 0.889, 95% CI 0.740−1.038). In addition, the intermediate- and high-risk groups also had longer hospital stays than the low-risk group (intermediate-risk group: coefficient 5.743, 95% CI 5.305−6.180; high-risk group: coefficient 7.738, 95% CI 6.709−8.766). Overall, we found that HFRS is associated with delayed initiation of oral intake and prolonged hospital stay in older patients with pneumonia. Therefore, evaluation based on HFRS could be helpful in making clinical decisions regarding the selection of feeding strategies and when to discharge older patients with pneumonia.

Impact of nutrition and physical activity on outcomes of hospital-acquired pneumonia

Frailty is an important risk factor for adverse health-related outcomes. It is classified into several phenotypes according to nutritional state and physical activity. In this context, we investigated whether frailty phenotypes were related to clinical outcome of hospital-acquired pneumonia (HAP). During the study period, a total of 526 patients were screened for HAP and 480 of whom were analyzed. The patients were divided into four groups according to physical inactivity and malnutrition: nutritional frailty (Geriatric Nutritional Risk Index [GNRI] < 82 and Clinical Frailty Scale [CFS] ≥ 4), malnutrition (GNRI < 82 and CFS < 4), physical frailty (GNRI ≥ 82 and CFS ≥ 4), and normal (GNRI ≥ 82 and CFS < 4). Among the phenotypes, physical frailty without malnutrition was the most common (39.4%), followed by nutritional frailty (30.2%), normal (20.6%), and malnutrition (9.8%). There was a significant difference in hospital survival and home discharge among the four phenotypes (p = 0.009), and the nutritional frailty group had the poorest in-hospital survival and home discharge (64.8% and 34.6%, respectively). In conclusion, there were differences in clinical outcomes according to the four phenotypes of HAP. Assessment of frailty phenotypes during hospitalization may improve outcomes through adequate nutrition and rehabilitation treatment of patients with HAP.

Functional status recovery trajectories in hospitalised older adults with pneumonia

BACKGROUND AND OBJECTIVES

Pneumonia is associated with significant mortality and morbidity in older adults. We investigated changes in functional status over 6 months after pneumonia hospitalisation by frailty status.

METHODS AND MEASUREMENTS

This single-centre prospective cohort study enrolled 201 patients (mean age 79.4, 37.3% women) who were hospitalised with pneumonia. A deficit-accumulation frailty index (range: 0-1; robust <0.15, pre-frail 0.15-0.24, mild-to-moderately frail 0.25-0.44, severely frail ≥0.45) was calculated on admission. Functional status, defined as self-reported ability to perform 21 activities and physical tasks independently, was measured by telephone at 1, 3 and 6 months after discharge. Group-based trajectory model was used to identify functional trajectories. We examined the probability of each trajectory based on frailty levels.

RESULTS

On admission, 51 (25.4%) were robust, 43 (21.4%) pre-frail, 40 (20.0%) mild-to-moderately frail and 67 (33.3%) severely frail patients. Four trajectories were identified: excellent (14.4%), good (25.4%), poor (28.9%) and very poor (31.3%). The trajectory was more strongly correlated with frailty level on admission than pneumonia severity. The most common trajectory was excellent trajectory (59.9%) in robust patients, good trajectory (74.4%) in pre-frail patients, poor trajectory (85.0%) in mild-to-moderately frail patients and very poor trajectory (89.6%) in severely frail patients. The risk of poor or very poor trajectory from robust to severely frail patients was 11.8%, 25.6%, 92.5% and 100%, respectively.

CONCLUSIONS

Frailty was a strong determinant of lack of functional recovery over 6 months after pneumonia hospitalisation in older adults. Our results call for hospital-based and post-acute care interventions for frail patients.

A focus group interview with health professionals: establishing efficient transition care plan for older adult patients in Korea

Background

Although transition care planning can affect the functional status and quality of life after acute hospitalization in older adults, little is known on problems associated with discharge planning in acute care hospitals in Korea. We aimed to investigate barriers and possible solutions on transfer planning of complex older patients in this study.

Methods

We used focus group interviews with the application of framework analysis. Twelve physicians providing inpatient care from 6 different institutions in Korea participated in the interview. Facilitating questions were extracted from 2 roundtable meetings prior to the primary interview. From transcribed verbatim, themes were constructed from corresponding remarks by participants.

Results

We revealed two main domains of the barrier, which included multiple subdomains for each of them. The first domain was a patient factor barrier, a composite of misperception of medical providers’ intentions, incomprehension of the healthcare system, and communication failure between the caregivers or decision-makers. The second domain, institutional factors included different fee structures across the different levels of care, high barrier to accessing health service in tertiary hospitals or to be referred to, the hardship of communication between institutions, and insufficient subacute rehabilitation service across the country.

Conclusions

Through the interview, physicians in the field recognized barriers to a smooth transition care process from tertiary level hospitals to community care, especially for older adults. Participants emphasized both the patients and hospital sides of adjustment on behaviors, communication, and greater attention for the individuals during the transition period.

Frailty and mortality associations in patients with COVID ‐19: A Systematic Review and Meta‐analysis

Background

Observational data during the pandemic have demonstrated mixed associations between frailty and mortality.

Aim

To examine associations between frailty and short‐term mortality in patients hospitalised with coronavirus disease 2019 (COVID‐19).

Methods

In this systematic review and meta‐analysis, we searched PubMed, Embase and the COVID‐19 living systematic review from 1 December 2019 to 15 July 2021. Studies reporting mortality and frailty scores in hospitalised patients with COVID‐19 (age ≥18 years) were included. Data on patient demographics, short‐term mortality (in hospital or within 30 days), intensive care unit (ICU) admission and need for invasive mechanical ventilation (IMV) were extracted. The quality of studies was assessed using the Newcastle−Ottawa Scale.

Results

Twenty‐five studies reporting 34 628 patients were included. Overall, 26.2% (n = 9061) died. Patients who died were older (76.7 ± 9.6 vs 69.2 ± 13.4), more likely male (risk ratio (RR) = 1.08; 95% confidence interval (CI): 1.06–1.11) and had more comorbidities. Fifty‐eight percent of patients were frail. Adjusting for age, there was no difference in short‐term mortality between frail and non‐frail patients (RR = 1.04; 95% CI: 0.84–1.28). The non‐frail patients were commonly admitted to ICU (27.2% (4256/15639) vs 29.1% (3567/12274); P = 0.011) and had a higher mortality risk (RR = 1.63; 95% CI: 1.30–2.03) than frail patients. Among patients receiving IMV, there was no difference in mortality between frail and non‐frail (RR = 1.62; 95% CI 0.93–2.77).

Conclusion

This systematic review did not demonstrate an independent association between frailty status and short‐term mortality in patients with COVID‐19. Patients with frailty were less commonly admitted to ICU and non‐frail patients were more likely to receive IMV and had higher mortality risk. This finding may be related to allocation decisions for patients with frailty amidst the pandemic.

Hospitalization costs of adult community-acquired pneumonia in England

OBJECTIVE

Accurate and up-to-date figures of the cost of community-acquired pneumonia (CAP) hospitalization are needed to understand the associated economic burden for public health decision-makers. Recent estimates are lacking, and previously published estimates differ markedly. Our objective was to estimate the current mean cost to the UK National Health Service (NHS) for adult hospitalized CAP.

METHODS

All CAP hospitalizations in 2019 for those aged ≥18 years were identified from English Hospital Episode Statistics (HES). Each hospitalization was mapped to the tariff cost paid to the care provider within the NHS, including critical care costs and accounting for length of stay and complexity of the case. Mean hospitalization costs were estimated in total and in individuals with defined underlying comorbidities.

RESULTS

A mean cost of £3,904 was estimated for 187,251 CAP admissions providing a total cost of approximately £731 million per annum. The mean cost was £3,402, excluding critical care costs, and £11,654 for critical care episodes in the 4.4% of admissions receiving this care. Groups at high risk of CAP had higher mean costs, ranging from £4,458 for people with diabetes to £5,215 for those with heart disease aged <65 years and £4,356 for those with heart disease to £4,751 for those with liver disease aged >65 years who comprised 74.3% of admissions overall.

CONCLUSION

This estimate of the cost of hospitalization for CAP from the total population and in those with certain underlying comorbidities will allow a valid understanding of the cost-benefit of vaccination and evidence-based prioritization of pneumococcal vaccination to those at highest risk.

Comparison of Frailty Index to Pneumonia Severity Measures in Older Patients With Pneumonia

OBJECTIVES

Risk stratification tools are useful to provide appropriate clinical care for older patients with pneumonia. This study aimed to compare a Frailty Index (FI) with pneumonia severity measures, CURB-65, and the Pneumonia Severity Index (PSI), for predicting mortality and persistent disability after pneumonia.

DESIGN

Single-center prospective cohort study.

SETTING AND PARTICIPANTS

The study included 190 patients aged ≥65 years who were hospitalized with pneumonia at a university hospital in Korea between October 2019 and September 2020.

METHODS

At admission, a 50-item deficit-accumulation FI (range: 0-1), CURB-65 (range: 0-5), and PSI (range: 0-395) scores were calculated. The outcomes were death and a composite outcome of death or decline in ability to perform daily activities and physical task 6 months later.

RESULTS

The median age was 79 years (interquartile range: 74-85), and 70 (36.8%) patients were women. The patients who died (n = 53) had higher FI (median, 0.46 vs 0.20; P < .011), CURB-65 score (median, 3 vs 2; P = .001), and PSI score (median, 149 vs 116; P < .001) than those who did not. The C-statistics (95% confidence intervals) for 6-month mortality were 0.69 (0.61-0.77) for the FI, 0.62 (0.53-0.71) for CURB-65, and 0.71 (0.62-0.79) for the PSI (P = .019). The C-statistics for the 6-month composite outcome were 0.73 (0.65-0.81) for the FI, 0.64 (0.55-0.73) for CURB-65, and 0.69 (0.60-0.77) for the PSI (P = .096). The C-statistics improved when the FI was added to CURB-65 (from 0.64 to 0.74; P = .003) and to the PSI (from 0.69 to 0.75; P = .044) for the composite outcome.

CONCLUSIONS AND IMPLICATIONS

Measuring frailty provides additive value to widely used pneumonia severity measures in predicting death or persistent hospitalization-associated disability in older adults after pneumonia hospitalization. Early recognition of frailty may be useful to identify those who require in-hospital and post-acute care interventions for functional recovery.

Impact of physical frailty on the clinical outcomes of older patients hospitalized for pneumonia

AIM

This study aimed to assess the association between physical frailty and clinical outcomes among older patients hospitalized for pneumonia.

METHODS

This study examined 852 consecutive patients hospitalized for pneumonia between October 2018 and September 2020. Patients who were <65 years old, scheduled for admission, did not receive inpatient rehabilitation, or died during admission were excluded. A short physical performance battery (SPPB) test was performed by physical therapists upon discharge. The primary outcome measure was a composite endpoint of readmission or mortality due to any cause within 6 months of discharge.

RESULTS

In total, 521 patients (median age, 80 years; interquartile range, 74-86 years) were included in the analyses, and were divided into the following two groups: robust group with SPPB scores >9 (n = 150), and physical frailty group with SPPB scores ≤9 (n = 371). Of these, 346 (66.4%) patients were men; and the median SPPB score was 6 (interquartile range, 1-10). During the median follow-up period of 53 days (interquartile range, 4-180 days), 92 (17.6%) patients were readmitted and 25 (4.8%) patients died. Patients with physical frailty were at an increased risk for the primary endpoint (hazard ratio, 2.21; 95% confidence interval, 1.44-3.41; P < 0.001); the risk remained significant after adjusting for multiple variables (adjusted hazard ratio, 1.70; 95% confidence interval, 1.05-2.74; P = 0.028).

CONCLUSIONS

Among older patients with pneumonia, physical frailty status at discharge was an independent risk factor for readmission and mortality within 6 months after initial discharge. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.