Barthel Index at hospital admission is associated with mortality in geriatric patients: a Danish nationwide population-based cohort study

The influence of nationwide COVID-19 lockdown on the functional impairment and long-term survival of dependent people for carrying out basic activities of daily living in a neighborhood of the city of Madrid, Spain: Orcasitas Cohort Longitudinal Study

Background

Prolonged confinement can lead to personal deterioration at various levels. We studied this phenomenon during the nationwide COVID-19 lockdown in a functionally dependent population of the Orcasitas neighborhood of Madrid, Spain, by measuring their ability to perform basic activities of daily living and their mortality rate.

Methods

A total of 127 patients were included in the Orcasitas cohort. Of this cohort, 78.7% were female, 21.3% were male, and their mean age was 86 years. All participants had a Barthel index of ≤ 60. Changes from pre- to post-confinement and 3 years afterward were analyzed, and the effect of these changes on survival was assessed (2020-2023).

Results

The post-confinement functional assessment showed significant improvement in independence over pre-confinement for both the Barthel score (t = -5.823; p < 0.001) and the classification level (z = -2.988; p < 0.003). This improvement progressively disappeared in the following 3 years, and 40.9% of the patients in this cohort died during this period. These outcomes were associated with the Barthel index (z = -3.646; p < 0.001) and the level of dependence (hazard ratio 2.227; CI 1.514-3.276). Higher mortality was observed among men (HR 1.745; CI 1.045-2.915) and those with severe dependence (HR 2.169; CI 1.469-3.201). Setting the cutoff point of the Barthel index at 40 provided the best detection of the risk of death associated with dependence.

Conclusions

Home confinement and the risk of death due to the COVID-19 pandemic awakened a form of resilience in the face of adversity among the population of functionally dependent adults. The Barthel index is a good predictor of medium- and long-term mortality and is a useful method for detecting populations at risk in health planning. A cutoff score of 40 is useful for this purpose. To a certain extent, the non-institutionalized dependent population is an invisible population. Future studies should analyze the causes of the high mortality observed.

Cross-Sectional Study Comparing Activities of Daily Living Using Barthel Index Within a Geriatric Population Having Non-Communicable Diseases

Introduction Disabilities and non-communicable diseases (NCDs) are prevalent among the elderly, significantly affecting their quality of life. Comprehensive population-based data are essential for effective healthcare planning and rehabilitation. This study aims to determine the prevalence of self-reported disabilities and compare Barthel Index scores among elderly individuals with and without NCDs. Methods A cross-sectional study was conducted at Dr. D. Y. Patil Medical College, Pune, involving 102 patients aged 60 years and above. Patients with a history of strokes or limb amputations were excluded. Data on demographics, comorbidities, and functional status were collected using a structured questionnaire designed based on Barthel Index scoring to assess the activities of daily living (ADL). Results The study included 102 participants: 58 males (56.9%) and 44 females (43.1%). Age distribution showed 73.5% in the 60-74 age group, 22.5% in the 75-84 age group, and 3.9% in the 85+ age group. Comorbidity data revealed that 37.3% had no comorbidities, 26.4% had one comorbidity, and 36.3% had two or more comorbidities. The mean Barthel Index scores were 87.11 for those without comorbidities, 83.89 for those with one comorbidity, and 82.30 for those with two or more comorbidities. The most affected activities were stair climbing (75.7%), bowel control (48.5%), and mobility (47.1%). Conclusion NCDs significantly impact daily activities in the elderly, underscoring the need for targeted healthcare interventions to improve their quality of life. This study highlights the importance of comprehensive care strategies to address the specific needs of elderly patients with comorbidities.

The De Morton Mobility Index (DEMMI) in hospitalized geriatric patients is associated with risk of readmission, mortality, and discharge to a post-acute care facility: A nationwide register-based cohort study

OBJECTIVE

To examine the association between the de Morton Mobility Index (DEMMI) score on admission in geriatric patients and readmission and mortality within 30, 180, and 365 days after discharge, and discharge to a post-acute care facility.

METHODS

A nationwide register-based cohort study including 23,941 geriatric in-patients aged ≥65 years admitted to a geriatric ward between 2014 and 2017 and included in the Danish National Database for Geriatrics. The DEMMI score was categorized into four subcategories: very low mobility (DEMMI=0-24), low mobility (DEMMI=27-39), moderately reduced mobility (DEMMI=41-57), and independent mobility (DEMMI=62-100). Patients were followed 30, 180 and 365 days after discharge for readmission and mortality. Their risk of being discharged to a post-acute care facility was examined. Adjusted hazard ratios (HRs) and odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated.

RESULTS

HRs for readmission within 30-days were 1.36 (1.24-1.48) for very low mobility, 1.30 (1.20-1.42) for low mobility and 1.17 (1.08-1.28) for moderately reduced compared with independent mobility. Similar results were seen for readmission within 180- and 365-days. For mortality, HR for 30-day mortality ranged from1.93 and 5.66, 180-day mortality between 1.62 and 3.19, and 365-day mortality between 1.54 and 2.81 compared with patients with independent mobility. OR for discharge to a post-acute care facility was 8.76 (7.29-10.53) for lowest compared with the highest DEMMI mobility subcategory.

CONCLUSION

In geriatric in-patients, lower DEMMI scores on hospital admission are associated with increased rates of discharge to a post-acute care facility, and for readmission, and mortality within one year.

Association of cancer with functional decline at old age: a longitudinal study in Danish twins

INTRODUCTION

There is evidence that older adults with cancer have a higher risk of functional decline than cancer-free older adults. However, few studies are longitudinal, and none are twin studies. Thus, we aimed to investigate the relationship between cancer and functional decline in older adult (aged 70+ years) twins.

MATERIALS AND METHODS

Cancer cases in the Longitudinal Study of Aging Danish Twins were identified through the Danish Cancer Registry. Functional status was assessed using hand grip strength (6 years follow-up), and self-reported questions on mobility (10 years follow-up), and cut-offs were defined to assess functional decline. Cox regression models were performed for all the individual twins. In addition, we extended the analysis to discordant twin pairs (twin pairs with one having cancer and the other being cancer-free), to control to a certain extent for (unmeasured) shared confounders (genetic and environmental factors).

RESULTS

The analysis based on individual twins showed that individual twins with cancer are at increased hazard of worsening hand grip strength (hazard ratio (HR) 1.37, 95% confidence interval (CI) 1.04, 1.80) than cancer-free twins. Among the discordant twin pairs, twins with cancer had a higher hazard of worsening hand grip strength (HR 3.50, 95% CI 1.15, 10.63) than cancer-free cotwins. In contrast, there was no evidence of a difference between the hazard of experiencing mobility decline for twins with cancer compared with cancer-free twins, in both individual twins and discordant twin pairs analyses.

DISCUSSION

Cancer was associated with hand grip strength functional decline in old individual twins and discordant pairs. Our results strengthen the importance of comprehensive geriatric assessment in older adults with cancer, as well as the importance of routine assessment of functional status. Promoting physical activity through exercise training programmes could enable the prevention of functional decline in older adults with cancer.

Effects of general and spinal anesthesia on postoperative rehabilitation in older adults after lower limb surgery: a retrospective cohort study

Objective

To investigate the effects of perioperative general anesthesia (GA) and spinal anesthesia (SA) on postoperative rehabilitation in elderly patients with lower limb surgery.

Methods

This retrospective propensity score-matched cohort study included patients aged 65 years or older who underwent lower limb surgery between January 1, 2020, and May 31, 2023. The GA and SA were selected at the request of the orthopedic surgeon, patient, and their family members. The main outcomes included the incidence of the patient's inability to self-care at discharge, postoperative complications including pulmonary infection, thrombus of lower extremity veins, infection of incisional wound and delirium, length of hospital stay, and incidence of severe pain in the first 2 days postoperatively.

Results

In total, 697 patients met the inclusion criteria, and 456 were included in the final analysis after propensity score matching. In the GA and SA groups, 27 (11.84%) and 26 (11.40%) patients, respectively, could not care for themselves at discharge. The incidence rates did not differ between the groups (p = 0.884). In contrast, the incidence of postoperative complications (GA: 10.53% and SA: 4.39%; p = 0.013) and the length of hospital stay (GA: 16.92 ± 10.65 days and SA: 12.75 ± 9.15 days; p < 0.001) significantly differed between the groups.

Conclusion

The choice of anesthesia is independent of the loss of postoperative self-care ability in older patients (>65 years) and is not a key factor affecting postoperative rehabilitation after lower limb surgery. However, compared with GA, SA reduces the incidence of postoperative complications and a prolonged hospital stay. Thus, SA as the primary anesthetic method is a protective factor against a prolonged hospital stay.

A Higher Postoperative Barthel Index at Discharge is Associated with a Lower One-Year Mortality After Hip Fracture Surgery for Geriatric Patients: A Retrospective Case‒Control Study

Purpose

To evaluate the relationship between the postoperative Barthel index assessing activities of daily living at discharge and the one-year mortality after hip fracture surgery.

Methods

Patients with hip fracture admitted to Peking University First Hospital from January 2015 to January 2020 were enrolled retrospectively according to the inclusion and exclusion criteria. The Barthel index and other related confounding variables were collected. Logistic regression and Kaplan‒Meier survival curves were constructed to explore the relationship between the postoperative Barthel index at discharge and the one-year mortality of geriatric patients after hip fracture surgery.

Results

A total of 444 patients with a mean age of 81.61±6.14 years were included. A significant difference was not observed in the preoperative Barthel index at admission between the deceased group and the surviving group (38.90±15.83 vs 36.96±10.74, p=0.446). However, the difference in the postoperative Barthel index at discharge between these two groups was statistically significant (43.08±14.40 vs 53.18±13.43, P<0.001). The multivariable logistic regression analysis revealed that the postoperative Barthel index at discharge was an independent risk factor for one-year mortality after adjustment for confounding variables (adjusted OR 0.73, 95% CI 0.55-0.98, p˂0.05). The Kaplan‒Meier survival curve showed that patients who had a high Barthel index (≥50) at discharge had a significantly lower mortality in the long term than patients with a low Barthel index (<50) at discharge (P< 0.001).

Conclusion

The postoperative Barthel index at discharge was independently associated with the one-year mortality of geriatric patients after hip fracture surgery. A higher postoperative Barthel index at discharge indicated a lower mortality after hip fracture surgery. The Barthel index at discharge has the potential to provide essential prognostic information for early risk stratification and directing future care.

Development and usability of a hospital standardized ADL ratio (HSAR) for elderly patients with cerebral infarction: a retrospective observational study using administrative claim data from 2012 to 2019 in Japan

BACKGROUND

Maintenance of activities of daily living (ADL) during acute hospitalization is an important treatment goal, especially for elderly inpatients with diseases that often leave disabilities, such as cerebral infarction. However, studies assessing risk-adjusted ADL changes are limited. In this study, we developed and calculated a hospital standardized ADL ratio (HSAR) using Japanese administrative claims data to measure the quality of hospitalization care for patients with cerebral infarction.

METHODS

This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of cerebral infarction (ICD-10, I63) were used. The HSAR was defined as the ratio of the observed number of ADL maintenance patients to the expected number of ADL maintenance patients multiplied by 100, and ratio of ADL maintenance patients was risk-adjusted using multivariable logistic regression analyses. The c-statistic was used to evaluate the predictive accuracy of the logistic models. Changes in HSARs in each consecutive period were assessed using Spearman's correlation coefficient.

RESULTS

A total of 36,401 patients from 22 hospitals were included in this study. All variables used in the analyses were associated with ADL maintenance, and evaluations using the HSAR model showed predictive ability with c-statistics (area under the curve, 0.89; 95% confidence interval, 0.88-0.89).

CONCLUSIONS

The findings indicated a need to support hospitals with a low HSAR because hospitals with high/low HSAR were likely to produce the same results in the subsequent periods. HSAR can be used as a new quality indicator of in-hospital care and may contribute to the assessment and improvement of the quality of care.

Nosocomial COVID-19: A Nationwide Spanish Study

INTRODUCTION

SARS-CoV-2 is a highly contagious virus, and despite professionals' best efforts, nosocomial COVID-19 (NC) infections have been reported. This work aimed to describe differences in symptoms and outcomes between patients with NC and community-acquired COVID-19 (CAC) and to identify risk factors for severe outcomes among NC patients.

METHODS

This is a nationwide, retrospective, multicenter, observational study that analyzed patients hospitalized with confirmed COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry) from March 1, 2020, to April 30, 2021. NC was defined as patients admitted for non-COVID-19 diseases with a positive SARS-CoV-2 test on the fifth day of hospitalization or later. The primary outcome was 30-day in-hospital mortality (IHM). The secondary outcome was other COVID-19-related complications. A multivariable logistic regression analysis was performed.

RESULTS

Of the 23,219 patients hospitalized with COVID-19, 1,104 (4.8%) were NC. Compared to CAC patients, NC patients were older (median 76 vs. 69 years; p < 0.001), had more comorbidities (median Charlson Comorbidity Index 5 vs. 3; p < 0.001), were less symptomatic (p < 0.001), and had normal chest X-rays more frequently (30.8% vs. 12.5%, p < 0.001). After adjusting for sex, age, dependence, COVID-19 wave, and comorbidities, NC was associated with lower risk of moderate/severe acute respiratory distress syndrome (ARDS) (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.59-0.87; p < 0.001) and higher risk of acute heart failure (aOR: 1.40; 1.12-1.72; p = 0.003), sepsis (aOR: 1.73; 1.33-2.54; p < 0.001), and readmission (aOR: 1.35; 1.03-1.83; p = 0.028). NC was associated with a higher case fatality rate (39.1% vs. 19.2%) in all age groups. IHM was significantly higher among NC patients (aOR: 2.07; 1.81-2.68; p < 0.001). Risk factors for increased IHM in NC patients were age, moderate/severe dependence, malignancy, dyspnea, moderate/severe ARDS, multiple organ dysfunction syndrome, and shock; odynophagia was associated with lower IHM.

CONCLUSIONS

NC is associated with greater mortality and complications compared to CAC. Hospital strategies to prevent NC must be strengthened.

Study on Risk Factors of Primary Non-traumatic OVCF in Chinese Elderly and a Novel Prediction Model

Objective

Prevention of fragility fractures is one of the public health priorities worldwide, whilst the incidence of osteoporotic vertebral compression fractures (OVCF) continues to rise and lacks the corresponding accurate prediction model. This study aimed to screen potential causes and risk factors for primary non‐traumatic osteoporotic vertebral compression fractures (NTOVCF) in the elderly by characterizing a patient population with NTOVCF and comparing it with a population of osteoporotic patients.

Methods

Between January 2013 and January 2022, 208 elderly patients with unequivocal evidence of bone fragility manifested as painful NTOVCF were enrolled, and compared with 220 patients with osteoporosis and no fractures. The demographic data, bone turnover markers, blood routine, serum biochemical values, and radiological findings were investigated. Differences between the fracture and non‐fracture groups were analyzed, and variables significant in univariate analysis and correlation analysis were included in the logistic analysis to build the risk prediction model for osteoporotic vertebral fractures. Univariate analysis using student's t‐tests for continuous variables or a chi‐squared test for categorical variables was conducted to identify risk factors.

Results

No significant differences were revealed regarding age, gender, BMI, smoking, alcohol consumption, blood glucose, propeptide of type I procollagen (P1NP), and N‐terminal middle segment osteocalcin (N‐MID) (P > 0.05). Parathyroid Hormone (PTH), 25(OH)D, serum albumin (ALB), hemoglobin (HB), bone mineral density (BMD), and cross‐sectional area (CSA) of the paraspinal muscle in the fracture group were significantly lower than those in the control group; however, b‐C‐terminal telopeptide of type I collagen (β‐CTX), total cholesterol (TC), high‐density lipoprotein cholesterol (HDL‐C), non‐prostatic acid phosphatase (NACP), and fatty degeneration ratio (FDR) were significantly higher than those in the control group (P < 0.05). Logistic regression analysis showed that ALB, HB, CSA, and BMD were negatively correlated with NTOVCF, while β‐CTX, HDL‐C, NACP, and FDR were positively correlated with NTOVCF.

Conclusion

Decreased physical activity, anemia, hypoproteinemia, imbalances in bone metabolism, abnormal lipid metabolism, and degenerative and decreased muscle mass, were all risk factors for OVCF in the elderly, spontaneous fractures may be the consequence of cumulative declines in multiple physiological systems over the lifespan. Based on this risk model, timely detection of patients with high OVCF risk and implementation of targeted preventive measures is expected to improve the effect of fracture prevention.

The “Diabetes Comorbidome”: A Different Way for Health Professionals to Approach the Comorbidity Burden of Diabetes

(1) Background: The disease burden related to diabetes is increasing greatly, particularly in older subjects. A more comprehensive approach towards the assessment and management of diabetes’ comorbidities is necessary. The aim of this study was to implement our previous data identifying and representing the prevalence of the comorbidities, their association with mortality, and the strength of their relationship in hospitalized elderly patients with diabetes, developing, at the same time, a new graphic representation model of the comorbidome called “Diabetes Comorbidome”. (2) Methods: Data were collected from the RePoSi register. Comorbidities, socio-demographic data, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), and functional status (Barthel Index), were recorded. Mortality rates were assessed in hospital and 3 and 12 months after discharge. (3) Results: Of the 4714 hospitalized elderly patients, 1378 had diabetes. The comorbidities distribution showed that arterial hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and COPD (22.7%), were the more frequent in subjects with diabetes. The graphic comorbidome showed that the strongest predictors of death at in hospital and at the 3-month follow-up were dementia and cancer. At the 1-year follow-up, cancer was the first comorbidity independently associated with mortality. (4) Conclusions: The “Diabetes Comorbidome” represents the perfect instrument for determining the prevalence of comorbidities and the strength of their relationship with risk of death, as well as the need for an effective treatment for improving clinical outcomes.

The Definition of the Term "Orthogeriatric Infection" for Periprosthetic Joint Infections

Introduction

In the background of the aging population, an increase of geriatric patients with specific age-related co-morbidities has already been seen over the years for proximal femur fractures in orthopaedic surgery as well as other medical disciplines. However, the geriatric aspect has not been well recognized in periprosthetic joint infection (PJI) patients so far. Therefore, this paper seeks to provide an overview on the co-morbidities of PJI patients with respect to the definition of geriatric patients.

Material and methods

In this single-center retrospective study, patients treated between 2007 and 2020 for PJI were included (n = 255). Patients were defined as geriatric according to the consensus definition criteria of the Federal Working Group of Clinical Geriatric Facilities e.V., the German Society for Geriatrics e.V. and the German Society for Gerontology and Geriatrics e.V. based on age (≤70 years), geriatric multimorbidity and the Barthel index (≤30).

Results

Applying the criteria defined 184 of the 255 (72.2%) PJI patients as geriatric infection patients. Regarding geriatric comorbidity, incontinence was most prevalent (38.1%), followed by immobility (25.6%). Comparing the geriatric infection patients with those classified as non-geriatric (n = 71) revealed that geriatric patients had a longer hospital stay and spent more days in the intensive care unit (ICU). Also, the amputation rate and the 5-year mortality rate was significantly increased (n = 15, 8.2% vs n = 1, 1.4%, P = .007 and n = 24, 13.0% vs n = 5, 7.0%, P = .005). The Barthel index showed a significant correlation with mortality (r = -.22, P = .011).

Discussion

We propose to use the term orthogeriatric infection patients in those cases in order to focus treatment not only on the orthopaedic infections but also on the important geriatric aspects.

Conclusion

The inclusion of geriatric physicians into the multidisciplinary team approach for PJI patients might be beneficial.

The effect of coupled inhibitory-facilitatory repetitive transcranial magnetic stimulation on shaping early reorganization of the motor network after stroke

Neural plasticity is a major factor driving cortical reorganization after stroke. This study aimed to evaluate functional connectivity (FC) changes in the cortical motor network after coupled inhibitory-facilitatory repetitive transcranial magnetic stimulation (rTMS) treatment and to assess the correlation between FC changes and functional recovery, further characterizing the neural mechanisms underlying the beneficial effects of rTMS. We randomly divided 63 patients with acute stroke into four groups: (1) Group A received coupled inhibitory-facilitatory rTMS [1 Hz over the contralesional primary motor cortex (M1) and 10 Hz over ipsilesional M1]; (2) Group B received a contralesional sham stimulation and ipsilesional 10 Hz stimulation; (3) Group C received a contralesional 1 Hz rTMS and ipsilesional sham stimulation; and (4) Group D received bilateral sham stimulation only. Standardized rehabilitation therapy was performed immediately after rTMS, and each group was treated with their respective treatment modalities for 4 weeks. Twenty-four hours before and after the intervention, participants underwent resting-state functional magnetic resonance imaging. Additional functional assessments were conducted at baseline, after treatment, and at the 3 month follow-up. The rTMS treatment significantly changed the FCs of intra- and inter-hemispheric cortical motor networks in the rTMS groups (A and B) compared with the sham group (Group D). This effect was more pronounced in Group A, which displayed a changed FC between the contralesional postcentral gyrus and contralesional superior parietal gyrus, between the contralesional precentral gyrus and contralesional postcentral gyrus, and between the ipsilesional postcentral gyrus and contralesional superior parietal gyrus, when compared with Groups B and C. Importantly, FC changes were significantly correlated with improvement of motor function. In the early stages of ischemic stroke, coupled rTMS was more conducive to motor recovery by modulating the FCs of intra-hemispheric and inter-hemispheric motor networks. Our results suggested that FC changes were related to motor function recovery for early-stage cerebral stroke patients treated with coupled rTMS. These findings could help to understand the mechanism of coupled rTMS and further the use of this therapy as an adjunct rehabilitation technique in motor recovery.

The Short-Term Changes of the Sagittal Spinal Alignments After Acute Vertebral Compression Fracture Receiving Vertebroplasty and Their Relationship With the Change of Bathel Index in the Elderly

Introduction

Fragility vertebral compression fractures (VCFs) are of major concern due to aging populations worldwide, which may occur after a fall from standing or due to severe osteoporosis, impacting greatly the life quality of the elderly. This study thus determined the factors independently associated with poor functional recovery from a new VCF and changes in sagittal spinal alignment after vertebroplasty in elderly patients with osteoporosis.

Materials and Methods

The data were collected from patients older than 70 years and diagnosed with a new VCF. Logistic regression analysis was performed to determine factors independently associated with function and radiographic status.

Results

We enrolled 8 male and 34 female patients with a mean age of 80.74 ± 8.31 years between January and July 2020. Compared with preoperative data, post-vertebroplasty lumbar sagittal alignments and functional scores improved significantly, and function recovered gradually over 12 weeks. Climbing stairs was the most influential performance indicator at the beginning of the recovery process. At each postoperative follow-up, changes in the C7-sacrum sagittal vertical axis exhibited an influence on functional recovery. Male patients were better able to move from a chair to a bed at the 2-week postoperative follow-up, and positive changes in the spino-sacral angle led to improved function in terms of stair climbing at the 6-week postoperative follow-up.

Conclusions

Vertebroplasty seemed to be effective for functional recovery related to sagittal spinal alignment improvement of the elderly with VCFs during postoperative 12 weeks, which may be a critical stage for the recovery for their life activities. The recovery rate for stair climbing after vertebroplasty was slower than for the other functional performance indicators in our study. In addition, if a patient was unable to demonstrate a marked improvement in sagittal alignment, they were likely to have ongoing impaired function and a poor prognosis after surgery.

Nosocomial COVID-19 Infection in a Long-Term Hospital in Spain: Retrospective Observational Study

Background and Objectives. The aim of this study is to compare clinical and epidemiological characteristics and outcomes in patients with versus without nosocomial COVID-19 after exposure to SARS-CoV-2 and to analyze the risk factors for severe outcomes of COVID-19 in a long-term hospital in Spain. Materials and methods. This retrospective, single-center observational study included all inpatients in a long-term hospital during a COVID-19 outbreak from 21 January to 15 March 2021. Results. Of 108 admitted patients, 65 (60.2%) were diagnosed with nosocomial COVID-19 disease (n = 34 women (52.3%), median age 77 years). In the univariable analysis, risk factors associated with nosocomial COVID-19 were dementia (OR 4.98 95% CI 1.58–15.75), dyspnea (OR 5.34 95% CI 1.69–16.82), asthenia (OR 5.10, 95% CI 1.40–18.60) and NECesidades PALiativas (NECPAL) (OR 1.28 95% CI 1.10–1.48). In the multivariable analysis, risk factors independently associated with nosocomial COVID-19 infection were dyspnea (aOR 7.39; 95% CI 1.27–43.11) and NECPAL (aOR 1.25; 95% CI 1.03–1.52). Of the 65 patients diagnosed with nosocomial COVID-19, 29 (44.6%) died, compared to 7/43 (16.2%) non-infected patients (OR 4.14, 95% CI 1.61–10.67). Factors associated with mortality in nosocomial COVID-19 were confusion (aOR 3.83; 95% CI 1.03–14.27) and dyspnea (aOR 7.47; 95% CI 1.87–29.82). The NECPAL tool played an important predictive role in both nosocomial COVID-19 infection and mortality (aOR 1.19, 95% CI: 1.00–1.41). Conclusions. In a long-term hospital, nosocomial COVID-19 main clinical characteristics associated with infection were dyspnea and NECPAL. Mortality was higher in the group with nosocomial COVID-19; risk factors were confusion and dyspnea. The NECPAL tool may help to predict progression and death in COVID-19.

The utility of the Barthel index as an outcome predictor in older patients with acute infection attending the emergency department

BACKGROUND

Functional decline and frailty are common in older adults and influence the risk of adverse outcomes. We aimed to assess the value of a Barthel index at the Emergency Department (ED-BI) score in predicting 30-day mortality and ED reconsultation among older patients with acute infection.

METHODS

We performed a prospective multicentre cohort study of older patients (≥75 years) diagnosed with acute infection in 69 Spanish EDs. Demographic, comorbidities, functional status, clinical and analytical data were collected. Unadjusted and adjusted logistic regression models were used to assess the association between ED-BI score, mortality and ED reconsultation.

RESULTS

In total 1596 patients with a mean age of 84.7 years were included in the study and 51.7% female. The most frequent focus of infection was respiratory in 918 patients (57.5%). Patients with an ED-BI< 60 points were significantly older, predominantly female, more likely institutionalized and more urinary infections. When comparing patients with an ED-BI score ≥ 60 points with those< 60 points no differences were found in ED reconsultation but in the latter group mortality at 30-days was higher (p < 0.001).

CONCLUSION

An ED-BI score< 60 points appears to be a strong predictor of mortality at the 30-day follow up in older patients with acute infection.

DATA AVAILABILITY

The data used to support the findings of this study are included within the article.

Haplotypes in the GC, CYP2R1 and CYP24A1 Genes and Biomarkers of Bone Mineral Metabolism in Older Adults

Candidate gene studies have analyzed the effect of specific vitamin D pathway genes on vitamin D availability; however, it is not clear whether genetic variants also affect overall bone metabolism. This study evaluated the association between genetic polymorphisms in GC, CYP2R1 and CYP24A1 and serum levels of total 25(OH)D, iPTH and other mineral metabolism biomarkers (albumin, total calcium and phosphorus) in a sample of 273 older Spanish adults. We observed a significant difference between CYP2R1 rs10741657 codominant model and total 25(OH)D levels after adjusting them by gender (p = 0.024). In addition, the two SNPs in the GC gene (rs4588 and rs2282679) were identified significantly associated with iPTH and creatinine serum levels. In the case of phosphorus, we observed an association with GC SNPs in dominant model. We found a relationship between haplotype 2 and 25(OH)D levels, haplotype 4 and iPTH serum levels and haplotype 7 and phosphorus levels. In conclusion, genetic variants in CYP2R1 and GC could be predictive of 25(OH)D and iPTH serum levels, respectively, in older Caucasian adults. The current study confirmed the role of iPTH as one of the most sensitive biomarkers of vitamin D activity in vivo.

Impact of Diabetes Mellitus and Its Comorbidities on Elderly Patients Hospitalized in Internal Medicine Wards: Data from the RePoSi Registry

BACKGROUND

Currently, diabetes represents the seventh leading cause of death worldwide, with a significant economic burden. The number and severity of comorbidities increase with age, and are identified as important determinants that influence the prognosis. We aimed to investigate comorbidities and outcomes in a cohort of hospitalized elderly patients affected by diabetes.

METHODS

In this observational study, we retrospectively analyzed data collected from the REgistro dei pazienti per lo studio delle POlipatologie e politerapie in reparti della rete Simi (RePoSi) registry. Socio-demographic, clinical characteristics, and laboratory findings were considered. The association between variables and in-hospital and 1-year follow-up were analyzed.

RESULTS

Among 4708 in-patients, 1378 (29.3%) had a diagnosis of diabetes. Patients with diabetes had more previous hospitalization, a clinically significant disability, and more need for a urinary catheter in comparison with subjects without diabetes. Patients affected by diabetes took more drugs, both at admission, at in-hospital stay, at discharge, and at 1-year follow-up. Thirty-five comorbidities were more frequent in patients with diabetes, and the first five were hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and chronic obstructive pulmonary disease (22.7%). Heart rate was an independent predictor of in-hospital mortality. At 1-year follow-up, cancer and male sex were strongly independently associated with mortality.

CONCLUSIONS

Our findings showed the severity of the impact of diabetes and its comorbidities in the real life of internal medicine and geriatric wards, and provide data to be used for a better tailored management of elderly in-patients with diabetes.

Combining inhibitory and facilitatory repetitive transcranial magnetic stimulation (rTMS) treatment improves motor function by modulating GABA in acute ischemic stroke patients

BACKGROUND

The combination of inhibitory and facilitatory repetitive transcranial magnetic stimulation (rTMS) can improve motor function of stroke patients with undefined mechanism. It has been demonstrated that rTMS exhibits a neuro-modulatory effect by regulating the major inhibitory neurotransmitter γ-aminobutyric acid (GABA) in other diseases.

OBJECTIVES

To evaluate the effect of combined inhibitory and facilitatory rTMS on GABA in the primary motor cortex (M1) for treating motor dysfunction after acute ischemic stroke.

METHODS

44 ischemic stroke patients with motor dysfunction were randomly divided into two groups. The treatment group was stimulated with 10 Hz rTMS at the ipsilesional M1 and 1 Hz rTMS at the contralesional M1. The sham group received bilateral sham stimulation at the motor cortices. The GABA level in the bilateral M1 was measured by proton magnetic resonance spectroscopy (1H-MRS) at 24 hours before and after rTMS stimulation. Motor function was measured using the Fugl-Meyer Assessment (FMA). The clinical assessments were performed before and after rTMS and after 3 months.

RESULTS

The treatment group exhibited a greater improvement in motor function 24 hours after rTMS compared to the sham group. The increased improvement in motor function lasted for at least 3 months after treatment. Following 4 weeks of rTMS, the GABA level in the ipsilesional M1 of the treatment group was significantly decreased compared to the sham group. Furthermore, the change of FMA score for motor function was negatively correlated to the change of the GABA:Cr ratio. Finally, the effect of rTMS on motor function outcome was partially mediated by GABA level change in response to the treatment (27.7%).

CONCLUSIONS

Combining inhibitory and facilitatory rTMS can decrease the GABA level in M1, which is correlated to the improvement of motor function. Thus, the GABA level in M1 may be a potential biomarker for treatment strategy decisions regarding rTMS neuromodulatory interventions.

Clinical features and risk factors for mortality among long-term care facility residents hospitalized due to COVID-19 in Spain

BACKGROUND

COVID-19 severely impacted older adults and long-term care facility (LTCF) residents. Our primary aim was to describe differences in clinical and epidemiological variables, in-hospital management, and outcomes between LTCF residents and community-dwelling older adults hospitalized with COVID-19. The secondary aim was to identify risk factors for mortality due to COVID-19 in hospitalized LTCF residents.

METHODS

This is a cross-sectional analysis within a retrospective cohort of hospitalized patients≥75 years with confirmed COVID-19 admitted to 160 Spanish hospitals. Differences between groups and factors associated with mortality among LTCF residents were assessed through comparisons and logistic regression analysis.

RESULTS

Of 6,189 patients≥75 years, 1,185 (19.1%) were LTCF residents and 4,548 (73.5%) were community-dwelling. LTCF residents were older (median: 87.4 vs. 82.1 years), mostly female (61.6% vs. 43.2%), had more severe functional dependence (47.0% vs 7.8%), more comorbidities (Charlson Comorbidity Index: 6 vs 5), had dementia more often (59.1% vs. 14.4%), and had shorter duration of symptoms (median: 3 vs 6 days) than community-dwelling patients (all, p<.001). Mortality risk factors in LTCF residents were severe functional dependence (aOR:1.79;95%CI:1.13-2.83;p=.012), dyspnea (1.66;1.16-2.39;p=.004), SatO2<94% (1.73;1.27-2.37;p=.001), temperature≥37.8ºC (1.62;1.11-2.38; p=.013); qSOFA index≥2 (1.62;1.11-2.38;p=.013), bilateral infiltrates (1.98;1.24-2.98;p<.001), and high C-reactive protein (1.005;1.003-1.007;p<.001). In-hospital mortality was initially higher among LTCF residents (43.3% vs 39.7%), but lower after adjusting for sex, age, functional dependence, and comorbidities (aOR:0.74,95%CI:0.62-0.87;p<.001).

CONCLUSION

Basal functional status and COVID-19 severity are risk factors of mortality in LTCF residents. The lower adjusted mortality rate in LTCF residents may be explained by earlier identification, treatment, and hospitalization for COVID-19.

Clinical Frailty Score vs Hospital Frailty Risk Score for predicting mortality and other adverse outcome in hospitalised patients with COVID-19: Spanish case series

OBJECTIVES

Frailty can be used as a predictor of adverse outcomes in people with coronavirus disease 2019 (COVID-19). The aim of the study was to analyse the prognostic value of two different frailty scores in patients hospitalised for COVID-19.

MATERIAL AND METHODS

This retrospective cohort study included adult (≥18 years) inpatients with COVID-19 and took place from 3 March to 2 May 2020. Patients were categorised by Clinical Frailty Score (CFS) and Hospital Frailty Risk Score (HFRS). The primary outcome was in-hospital mortality, and secondary outcomes were tocilizumab treatment, length of hospital stay, admission in intensive care unit (ICU) and need for invasive mechanical ventilation. Results were analysed by multivariable logistic regression and expressed as odds ratios (ORs), adjusting for age, sex, kidney function and comorbidity.

RESULTS

Of the 290 included patients, 54 were frail according to the CFS (≥5 points; prevalence 18.6%, 95% confidence interval [CI]: 14.4-23.7) vs 65 by HFRS (≥5 points; prevalence: 22.4%, 95% CI 17.8-27.7). Prevalence of frailty increased with age according to both measures: 50-64 years, CFS 1.9% vs HFRS 12.3%; 65-79 years, CFS 31.5% vs HFRS 40.0%; and ≥80 years, CFS 66.7% vs HFRS 40.0% (P < .001). CFS-defined frailty was independently associated with risk of death (OR 3.67, 95% CI 1.49-9.04) and less treatment with tocilizumab (OR 0.28, 95% CI 0.08-0.93). HFRS-defined frailty was independently associated with length of hospital stay over 10 days (OR 2.89, 95% CI 1.53-5.44), ICU admission (OR 4.18, 95% CI 1.84-9.52) and invasive mechanical ventilation (OR 5.93, 95% CI 2.33-15.10).

CONCLUSION

In the spring 2020 wave of the COVID-19 pandemic in Spain, CFS-defined frailty was an independent predictor for death, while frailty as measured by the HFRS was associated with length of hospital stay over 10 days, ICU admission and use of invasive mechanical ventilation.

Influencing factors of Barthel index scores among the community-dwelling elderly in Hong Kong: a random intercept model

Background

Barthel Index (BI) is one of the most widely utilized tools for assessing functional independence in activities of daily living. Most existing BI studies used populations with specific diseases (e.g., Alzheimer’s and stroke) to test prognostic factors of BI scores; however, the generalization of these findings was limited when the target populations varied.

Objectives

The aim of the present study was to utilize electronic health records (EHRs) and data mining techniques to develop a generic procedure for identifying prognostic factors that influence BI score changes among community-dwelling elderly.

Methods

Longitudinal data were collected from 113 older adults (81 females; mean age = 84 years, SD = 6.9 years) in Hong Kong elderly care centers. Visualization technologies were used to align annual BI scores with individual EHRs chronologically. Linear mixed-effects (LME) regression was conducted to model longitudinal BI scores based on socio-demographics, disease conditions, and features extracted from EHRs.

Results

The visualization presented a decline in BI scores changed by time and health history events. The LME model yielded a conditional R² of 84%, a marginal R² of 75%, and a Cohen’s f² of 0.68 in the design of random intercepts for individual heterogeneity. Changes in BI scores were significantly influenced by a set of socio-demographics (i.e., sex, education, living arrangement, and hobbies), disease conditions (i.e., dementia and diabetes mellitus), and EHRs features (i.e., event counts in allergies, diagnoses, accidents, wounds, hospital admissions, injections, etc.).

Conclusions

The proposed visualization approach and the LME model estimation can help to trace older adults’ BI score changes and identify the influencing factors. The constructed long-term surveillance system provides reference data in clinical practice and help healthcare providers manage the time, cost, data and human resources in community-dwelling settings.

Use of Drugs with Anticholinergic Properties at Hospital Admission Associated with Mortality in Older Patients: A Danish Nationwide Register-Based Cohort Study

BACKGROUND

Use of drugs with anticholinergic properties (DAP) has a negative impact on older people.

OBJECTIVE

Our aim was to examine the association between DAP at hospital admission and mortality in older patients.

PATIENTS AND METHODS

We performed a nationwide population-based cohort study including patients aged ≥ 65 years admitted to Danish geriatric medicine departments during 2005-2014. National health registers were used to link with individual-level data. Patients were followed to emigration, death, or study termination (31 December 2015). DAP was defined as medications included in the anticholinergic cognitive burden (ACB) scale, which assigns each DAP a score between 1 and 3. The individual ACB score was calculated and the number of DAP counted. We used Cox proportional-hazard regressions to estimate the crude and adjusted hazard ratios adjusting for age, activities of daily living, marital status, index admission period, BMI, and prior hospitalizations (model 1), and additionally Charlson Comorbidity Index (model 2).

RESULTS

We included 74,589 patients aged (median [IQR]) 83 (77-88) years. Use of one or more DAP (62.5%) was associated with increased mortality compared with those with no use (p < 0.001). In the fully adjusted model 2, compared with no use, higher mortality risks (HR [95% CI]) were seen with ACB score of 2 and number of DAP ≥ 5 for 30-day (1.46 [1.32-1.61] and 1.46 [1.09-1.95]), 1-year (1.34 [1.28-1.41] and 1.48 [1.29-1.70]), and overall mortality (1.27 [1.23-1.31] and 1.44 [1.31-1.59]), respectively.

CONCLUSIONS

Use of DAP at hospital admission is associated with short- and long-term mortality in geriatric patients. Deprescribing studies are warranted to study whether the impact on mortality can be attenuated.

Does geriatric follow-up visits reduce hospital readmission among older patients discharged to temporary care at a skilled nursing facility: a before-and-after cohort study

INTRODUCTION

Hospital readmission is a burden to patients, relatives and society. Older patients with frailty are at highest risk of readmission and its negative outcomes.

OBJECTIVE

We aimed at examining whether follow-up visits by an outgoing multidisciplinary geriatric team (OGT) reduces unplanned hospital readmission in patients discharged to a skilled nursing facility (SNF).

DESIGN

A retrospective single-centre before-and-after cohort study.

SETTING AND PARTICIPANTS

Study population included all hospitalised patients discharged from a Danish geriatric department to an SNF during 1 January 2016-25 February 2020. To address potential changes in discharge and readmission patterns during the study period, patients discharged from the same geriatric department to own home were also assessed.

INTERVENTION

OGT visits at SNF within 7 days following discharge. Patients discharged to SNF before 12 March 2018 did not receive OGT (-OGT). Patients discharged to SNF on or after 12 March 2018 received the intervention (+OGT).

MAIN OUTCOME MEASURES

Unplanned hospital readmission between 4 hours and 30 days following initial discharge.

RESULTS

Totally 847 patients were included (440 -OGT; 407 +OGT). No differences were seen between the two groups regarding age, sex, activities of daily living (ADLs), Charlson Comorbidity Index (CCI) or 30-day mortality. The cumulative incidence of readmission was 39.8% (95% CI 35.2% to 44.8%, n=162) in -OGT and 30.2% (95% CI 25.8% to 35.2%, n=113) in +OGT. The unadjusted risk (HR (95% CI)) of readmission was 0.68 (0.54 to 0.87, p=0.002) in +OGT compared with -OGT, and remained significantly lower (0.72 (0.57 to 0.93, p=0.011)) adjusting for age, length of stay, sex, ADL and CCI. For patients discharged to own home the risk of readmission remained unchanged during the study period.

CONCLUSION

Follow-up visits by OGT to patients discharged to temporary care at an SNF significantly reduced 30-day readmission in older patients.

Association of Body Mass Index With All-Cause Mortality in Acutely Hospitalized Older Patients

OBJECTIVES

The aim was to examine the relationship between body mass index (BMI) and mortality in older hospitalized patients taking activities of daily living (ADLs) into account.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Nationwide population-based study of all patients aged ≥65 years admitted to Danish geriatric medical departments during 2005 to 2014 and included in the National Danish Geriatric Database.

METHODS

Patients were followed until death, emigration, or study termination (December 31, 2015). Primary outcome was all-cause mortality. BMI and ADLs were routinely assessed on admission and linked at an individual level to the Danish national health registers. Kaplan-Meier analysis was used to estimate crude survival according to each BMI subcategory and Cox regression to examine the association with mortality adjusting for age, comorbidity, polypharmacy, ADLs, marital status, prior hospitalizations, and admission year.

RESULTS

In total, 74,589 patients (63% women) were included aged [mean (SD)] 82.5 (7.5) years with BMI [mean (SD)] of 23.9 (5.1) kg/m². During follow-up 51,188 died. Follow-up time was 191,972 person-years. Unadjusted and adjusted hazard ratio (HR) for overall, 30-day, and 1-year mortality decreased significantly with increasing BMI. In women, the highest adjusted HR (95% confidence interval) for overall mortality was seen for underweight patients (BMI <16) 1.83 (1.72-1.95) and the lowest for obesity grade II patients (BMI = 35.0-39.9) 0.66 (0.60-0.73) when using normal weight (BMI = 18.5-24.9) as reference. In men, the HR for BMI <16 and BMI = 35.0-39.9 were 1.98 (1.76-2.23) and 0.56 (0.49-0.65), respectively.

CONCLUSIONS AND IMPLICATIONS

In hospitalized older patients, association between mortality and BMI did not show a U-shaped or J-shaped curve after adjustment of multiple confounders, including ADLs. Instead, mortality was highest in patients with low BMI and decreased with increasing BMI before leveling off in the obese range. Our study highlights the need for a debate and reassessment of what should be the ideal BMI in this vulnerable patient group.

Increased Mortality in Elderly Patients Admitted with Hyponatremia: A Prospective Cohort Study

Hyponatremia is the most common electrolyte disorder, commonly affecting older hospitalized individuals; however, the literature is not clear regarding its effect on mortality. The aim of this 2-year observational prospective cohort study was to evaluate the mortality and re-admission rates, the clinical and laboratory characteristics and the causes of hyponatremia in patients older than 65 years admitted with a corrected serum sodium of 130 mEq/L or less in an internal medicine ward of a tertiary Greek university hospital. During the observation period, 138 patients (mean age 80.5 years, 36.2% male) fulfilled the inclusion criteria and were prospectively followed for 1 year after admission. Symptoms of hyponatremia were present in 59.4% of patients. Hypovolemia was the main sole cause of hyponatremia, but in about one third of patients, hyponatremia was multifactorial. Only a low proportion of patients (12.3%) fulfilled the criteria of the syndrome of inappropriate antidiuresis (SIAD) at admission according to the current guidelines. The re-admission rates at 3- and 12-months following discharge was 34.2% and 51.8%, respectively. Mortality during hospitalization was 17.4% and was higher compared to non-hyponatremic admitted older patients, while the total mortality at 1 year after admission was 28.3%, indicating that hyponatremia at admission is a marker of significant mortality during and after hospitalization in elderly patients.

Predicting Mortality Risk in Older Hospitalized Persons With COVID-19: A Comparison of the COVID-19 Mortality Risk Score with Frailty and Disability

Objectives

To assess the association of pre-morbid functional status [Barthel Index (BI)] and frailty [modified Frailty Index (mFI)] with in-hospital mortality and a risk scoring system developed for COVID-19 in patients ≥75 years diagnosed with COVID-19.

Design

Retrospective bicentric observational study.

Setting and Participants

Data on consecutive patients aged ≥75 years admitted with COVID-19 at 2 Italian tertiary care centers were collected from February 22 to May 30, 2020.

Methods

Overall, 221 consecutive patients with COVID-19 aged ≥75 years were admitted to 2 hospitals in the study period and were included in the analysis. Clinical, functional (BI), frailty (mFI), laboratory, and imaging data were collected. Mortality risk on admission was assessed with the COVID-19 Mortality Risk Score (COVID-19 MRS), a dedicated score developed for hospital triage.

Results

Ninety-seven (43.9%) patients died. BI, frailty, age, dementia, respiratory rate, Pao₂/Fio₂ ratio, creatinine, and platelet count were associated with mortality. Analysis of the area under the receiver operating characteristic (AUC) indicated that the predictivity of age was modest and the combination of BI, mFI, and COVID-19 MRS yielded the highest prediction accuracy (AUC_{COVID-19MRS+BI+mFI} vs AUC_Age: 0.87 vs 0.59; difference: +0.28, lower bound–upper bound: 0.17-0.34, P < .001).

Conclusions and Implications

Premorbid BI and mFI are associated with mortality and improved the accuracy of the COVID-19 MRS. Functional status may prove useful to guide clinical management of older individuals.

Activities of daily living at hospital admission and estimated survival time of older patients

BACKGROUND

Predicting expected survival time in acutely hospitalised older patients is a clinical challenge.

OBJECTIVE

To examine if activities of daily living (ADL) assessed by Barthel-Index-100 (Barthel-Index) at hospital admission adds useful information to clinicians on expected survival time in older patients.

METHODS

A nationwide population-based cohort study was used. All patients aged ≥65 years in the National Danish Geriatric Database from 2005 to 2014 were followed up until death, emigration or study termination (31 December 2015). Individual data were linked to national health registers. Barthel-Index was categorised into five-point subcategories with a separate category of Barthel-Index = 0. Kaplan-Meier analysis was used to assess crude survival proportions (95% CI) and Cox regression to examine association of Barthel-Index and mortality adjusting for age, Charlson comorbidity index, medication use, BMI, marital status, prior hospitalisations and admission year.

RESULTS

In total, 74,589 patients (63% women) aged (mean (SD)) 82.5(7.5) years with Barthel-Index (median (IQR)) 54(29-77) were included. In patients with Barthel-Index = 100-96 crude survival was 0.96(0.95-0.97) after 90-days, 0.88(0.87-0.89) after 1-year, and 0.79(0.78-0.80) after 2-years. Corresponding survival in patients with Barthel-Index = 0 was 0.49(0.47-0.51), 0.35(0.34-0.37) and 0.26(0.24-0.27). Decreasing Barthel-Index was associated with increasing mortality in the multivariable analysis. In women with Barthel-Index = 0, the mortality risk (HR (95% CI)) was 14.74(11.33-19.18) after 90-days, 8.40(7.13-9.90) after 1-year and 6.22(5.47-7.07) after 2-years using Barthel-Index = 100-96 as reference. In men, the corresponding risks were 11.36(8.81-14.66), 6.22(5.29-7.31) and 5.22(4.56-5.98).

CONCLUSIONS

ADL measured by Barthel-Index provides useful, easily accessible and independent information to clinicians on expected survival time in patients admitted to a geriatric department.

Effects of coupling inhibitory and facilitatory repetitive transcranial magnetic stimulation on motor recovery in patients following acute cerebral infarction

BACKGROUND

The treatment for patients suffering from motor dysfunction following stroke using continuous repetitive transcranial magnetic stimulation (rTMS) has the potential to be beneficial for recovery. However, the impact of explicit results on the coupling of various rTMS protocols on motor treatment in patients following acute cerebral infarction remain unexplored.

OBJECTIVE

The current study aims to design a sham-controlled randomized report to explore the capability of consecutive suppressive-facilitatory rTMS method to increase the motor results following acute stroke.

METHODS

A hundred ischemic stroke patients suffering from motor disorder were randomly assigned to obtain 4 week sessions of (1)10 Hz over the ipsilesional primary motor cortex (M1) and next 1 Hz over the contralesional M1; (2) contralesional sham stimulation and next ipsilesional real 10 Hz; (3) contralesional real 1 Hz rTMS and next ipsilesional sham stimulation; or (4) bilateral sham-control procedures. At 24 hours before and after the intervention, we obtained cortical excitability data from study subjects. At baseline, after treatment and 3 months follow up, we additionally evaluated patients with the clinical assessments.

RESULTS

At post-intervention, group A showed greater motor improvements in FMA, FMA-UL, NIHSS, ADL and mRS values than group B, group C and group D, that were continued for at least 3 months after the completion of the treatment time. Specifically, it is shown in the cortical excitability study that the motor-evoked potential (MEP) amplitude and resting motor threshold (rMT) more significantly improved in group A than other groups. The improvement in motor function and change in motor cortex excitability exhibit a significant correlation in the affected hemisphere. The combined 1 Hz and 10 Hz stimulation treatment showed a synergistic effect.

CONCLUSIONS

Facilitatory rTMS and coupling inhibitory produced extra satisfactory results in facilitating the motor's recovery in the subacute and acute phase following stroke compared to that acquired from alone single-course modulation.

Clinical Characteristics and Risk Factors for Mortality in Very Old Patients Hospitalized With COVID-19 in Spain

BACKGROUND

Advanced age is a well-known risk factor for poor prognosis in COVID-19. However, few studies have specifically focused on very old inpatients with COVID-19. This study aims to describe the clinical characteristics of very old inpatients with COVID-19 and identify risk factors for in-hospital mortality at admission.

METHODS

We conducted a nationwide, multicenter, retrospective, observational study in patients ≥ 80 years hospitalized with COVID-19 in 150 Spanish hospitals (SEMI-COVID-19) Registry (March 1-May 29, 2020). The primary outcome was in-hospital mortality. A uni- and multivariate logistic regression was performed to assess predictors of mortality at admission.

RESULTS

A total of 2772 consecutive patients (49.4% men, median age 86.3 years) were analyzed. Rates of atherosclerotic cardiovascular disease, diabetes mellitus, dementia, and Barthel Index < 60 were 30.8%, 25.6%, 30.5%, and 21.0%, respectively. The overall case-fatality rate was 46.9% (n: 1301) and increased with age (80-84 years: 41.6%; 85-90 years: 47.3%; 90-94 years: 52.7%; ≥95 years: 54.2%). After analysis, male sex and moderate-to-severe dependence were independently associated with in-hospital mortality; comorbidities were not predictive. At admission, independent risk factors for death were: oxygen saturation < 90%; temperature ≥ 37.8°C; quick sequential organ failure assessment (qSOFA) score ≥ 2; and unilateral-bilateral infiltrates on chest x-rays. Some analytical findings were independent risk factors for death, including estimated glomerular filtration rate < 45 mL/min/1.73 m2; lactate dehydrogenase ≥ 500 U/L; C-reactive protein ≥ 80 mg/L; neutrophils ≥ 7.5 × 103/μL; lymphocytes < 0.8 × 103/μL; and monocytes < 0.5 × 103/μL.

CONCLUSIONS

This first large, multicenter cohort of very old inpatients with COVID-19 shows that age, male sex, and poor preadmission functional status-not comorbidities-are independently associated with in-hospital mortality. Severe COVID-19 at admission is related to poor prognosis.

Attitudes towards deprescribing: The perspectives of geriatric patients and nursing home residents

BACKGROUND/OBJECTIVES

Successful deprescribing requires insight into patients' thoughts about deprescribing. We described attitudes towards deprescribing in a large sample of geriatric patients and nursing home residents.

DESIGN

Interview-based questionnaire study.

SETTING

Denmark.

PARTICIPANTS

Geriatric inpatients (n = 44), geriatric outpatients (n = 94), and nursing home residents (n = 162) with an Orientation-Memory-Concentration score of ≥8.

MEASUREMENTS

Participants completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire by interview. Attitudes were reported descriptively, and rPATD factor scores were compared between participant groups and across participant characteristics.

RESULTS

Participants had a median age of 82 years (interquartile range [IQR] 76-89) and used a median of 8 medications (IQR 5-10). Thirty-three percent of participants would like to try stopping one of their medications on their own, while 87% were willing to stop one on their physician's advice. Geriatric inpatients reported slightly greater perceived burden of taking medication compared to geriatric outpatients and nursing home residents (median "burden" score 50 vs 42, p = 0.11), while geriatric outpatients reported slightly more involvement in their medication use compared to nursing home residents (median "involvement" score 80 vs 75, p < 0.05) and geriatric inpatients (median "involvement" score 80 vs 70, p < 0.01). An increasing number of medications was associated with an increased "burden" score (p_trend = 0.001): Those using 1-4 medications daily had a median score of 25 (IQR 17-33) compared to 58 (IQR 42-75) among those using ≥10 medications daily. Similarly, an increasing number of medications was associated with a higher "concerns about stopping" score (p_trend  = 0.001) and a lower "appropriateness" score (p_trend  < 0.001), respectively.

CONCLUSION

Geriatric patients and nursing home residents are generally open towards deprescribing, particularly if proposed by their physician. Some differences exist between populations and across individual patient characteristics. Clinicians should increase awareness of deprescribing as a possibility in these populations and tailor their deprescribing approach to the individual patient.

Activities of daily living at hospital admission associated with mortality in geriatric patients with dementia: a Danish nationwide population-based cohort study

PURPOSE

Determining life expectancy in patients with dementia are challenging. We aimed at studying the association between basic activities of daily living as measured by the Barthel Index at hospital admission and mortality among older patients with dementia.

METHODS

All patients aged ≥ 65 years with diagnosed dementia in the population-based National Danish Geriatric Database from 2005 to 2014 were included and followed until death, emigration, or study termination (31.12.2015). Data on Barthel Index (BI) were used to assess ADL. Patients were categorized into four predefined standard BI subcategories according to the national Danish version of the statistical classification of diseases [BI = 0-24 (very low ADL), BI = 25-49 (low ADL), BI = 50-79 (moderate reduced ADL), and BI = 80-100 (independent ADL)]. Association with mortality was assessed using multivariable Cox regression analysis adjusting for age, marital status, Charlson Comorbidity Index, BMI, prior hospitalizations, year of admission and polypharmacy.

RESULTS

In total, 6550 patients (women 62%) were included, median (IQR) age 84 (79-88) years and BI 37 (13-63). Mortality increased significantly with decreasing BI in both the crude and multivariable analysis. In subcategories BI = (80-100) and BI = (0-24), survival time (median (95%)) was 3.6 (3.4-3.9) years and 0.8 (0.7-0.9) years, respectively. Also, in patients with BI = (0-24), the overall mortality risk (HR (95% CI)) was 2.5 (2.2-2.8), 30-day risk 11.8 (5.8-23.9), and 1-year risk 4.4 (3.6-5.5) when using BI = (80-100) as reference.

CONCLUSION

Barthel Index is independently associated with all-cause mortality among older patients with dementia admitted to hospital. BI may be a helpful tool for clinicians when discussing treatment and care strategies with patients and their families.

GABA-induced motor improvement following acute cerebral infarction

γ-Aminobutyric acid (GABA) plays a key role in motor learning. In the aftermath of stroke, we monitored GABA+ content of primary motor cortex by magnetic resonance spectroscopy (MRS), assessing its relation to functional motor recovery following a standardized 4-week program of rehabilitation. The cohort included 20 patients, each experiencing stroke within 2 weeks of symptom onset. Twenty age-matched healthy subjects were also recruited as controls. GABA+ levels were determined at baseline and following rehabilitation, performed only once in sex- and age-matched control subjects. Motor functions were then measured via Fugl-Meyer Assessment (FMA). Processing of MRS data was driven by open-source Gannet software. Because GABA, macromolecules, and homocarnosine jointly contribute to MEscher-Garwood Point RESolved Spectroscopy (MEGA-PRESS) signals, the designation GABA+ (rather than GABA) was applied. Baseline GABA+/creatine (Cr) ratios proved significantly lower in patients with strokes than in control subjects (P<0.05). Following the 4-week rehabilitative regimen, significant improvement in FMA indices was evident across the test group. FMA scores and GABA+/Cr ratios correlated significantly at baseline, the GABA+/Cr ratio displaying a significant association with motor function (P=0.025). In the setting of acute stroke, GABA+/Cr ratios of primary motor cortex fell significantly below levels found in healthy subjects. The observed association between GABA+/Cr ratio and motor recovery underscores the utility of MRS-measured GABA as a key motor recuperative biomarker.

The Barthel index as an indicator of hospital outcomes: A retrospective cross-sectional study with healthcare data from older people

AIMS

The assessment of functional status is a more appropriate measure in the older people than traditional healthcare outcomes. The present study aimed to analyse the association between functional status assessed using the Barthel Index and length of stay, in-hospital mortality, discharge destination, and Diagnosis-Related Groups-based cost.

DESIGN

This study was a retrospective study that used administrative data from patients older than 65 discharged from the University Hospital of Padua (Italy) in 2016.

METHODS

A logistic regression model for categorical variables (length of stay, in-hospital mortality, and discharge destination) and a generalized linear model with gamma distributions and log links for continuous variables (cost of hospitalization) were used to evaluate associations with the Barthel Index.

RESULTS

A total of 13,484 admissions were included in the analysis. In-hospital mortality, safe discharge, and length of stay were higher in patients with severe dependence than in patients with mild/no dependence with a 12-fold increased risk of death (OR = 12.81; 95% CI 9.22-18.14), a 4 times greater likelihood of safe discharge (OR = 4.64; 95% CI 3.96-5.45), and a 2-fold increase in length of stay (OR = 2.56; 95% CI 2.34-2.81). On the other hand, no significant association was found between the cost of hospitalization and the Barthel Index.

CONCLUSIONS

Barthel Index was strongly associated with in-hospital mortality, discharge destination, and length of stay. The costs of hospitalization, however, were not related to patients' functional impairment.

IMPACT

The study considers functional status as an indicator of hospital outcomes. Better comprehension of the relationship between functional status and healthcare outcomes may help with early and adequate healthcare planning and resource management.

Projection of the Number of Elderly in Different Health States in Thailand in the Next Ten Years, 2020-2030

The objective of this study is to predict the volume of the elderly in different health status categories in Thailand in the next ten years (2020–2030). Multistate modelling was performed. We defined four states of elderly patients (aged ≥ 60 years) according to four different levels of Activities of Daily Living (ADL): social group; home group; bedridden group; and dead group. The volume of newcomers was projected by trend extrapolation methods with exponential growth. The transition probabilities from one state to another was obtained by literature review and model optimization. The mortality rate was obtained by literature review. Sensitivity analysis was conducted. By 2030, the number of social, home, and bedridden groups was 15,593,054, 321,511, and 152,749, respectively. The model prediction error was 1.75%. Sensitivity analysis with the change of transition probabilities by 20% caused the number of bedridden patients to vary from between 150,249 and 155,596. In conclusion, the number of bedridden elders will reach 153,000 in the next decade (3 times larger than the status quo). Policy makers may consider using this finding as an input for future resource planning and allocation. Further studies should be conducted to identify the parameters that better reflect the transition of people from one health state to another.

[Length of hospital stay and functional status in patients with delayed start of physical therapy]

OBJECTIVE

To evaluate the association between hospital stay, functional status and physical therapy delay (PT delay) in patients admitted to a surgery unit of a high complexity hospital.

MATERIALS AND METHODS

Observational, analytic and cross-sectional study. We included 279 patients (124 women). Days of PT delay (calculated as the difference between hospital admission and start of PT), days of bed rest, prolonged hospital stay (75^th percentile of bed rest days), and functional status were registered to investigate the influence of PT delay on these variables.

RESULTS

The number of days of PT delay was strongly associated with the number of bed rest days (r2 = 0.74, p < 0.05). Moreover, a PT delay of five days or more was associated with extended lengths of stay in our sample (p < 0.05). However, physical therapy had similar effects on functional status, even when there were PT delays (p > 0.05).

CONCLUSIONS

PT delay is associated with extended length of stay in patients admitted to a surgery unit of a high complexity hospital. Future studies should investigate the associated factors that could explain the occurrence of PT delays in surgical patients.

Comparison of platelet-rich plasma gel in the care of the pressure ulcers with the dressing with serum physiology in terms of healing process and dressing costs

This research was carried out with the aim of comparing the effects of platelet-rich plasma (PRP) gel and gas dressing with serum physiologic applied to stage II pressure ulcer in coccyx of patients for 2 months on healing process and dressing costs. This prospective randomised controlled experimental study was conducted with 60 patients hospitalised in the palliative care unit after surgery. The experimental group (n = 30) was dressed with platelet-rich plasma gel. The control group (n = 30) was treated with serum physiologic dressing. At the end of the 20th observation of the patients in the experimental group, it was found that the mean scores of area, exudate, and tissue type in pressure sores decreased statistically (P < .001). In the control group, no significant difference was found between the mean PUSH score at the end of the 20th observation (P > .05). The study showed that PRP gel had a positive effect on healing of stage II pressure ulcers with platelet-rich plasma gel dressings. In addition, when evaluated in the long term, it was concluded that platelet-rich plasma gel is easily accessible and less costly than serum physiological dressing.

Frailty is associated with hospital readmission in geriatric patients: a prognostic study

PURPOSE

Targeting health care interventions requires valid measurements when predicting unplanned hospital readmission. The Multidimensional Prognostic Index (MPI) based on Comprehensive Geriatric Assessment (CGA) enables the prediction of mortality and length of stay (LOS) in older hospitalized patients. Our aim was to validate if the MPI as a frailty tool could predict unplanned hospital readmission in geriatric patients.

METHODS

This prognostic study was conducted in geriatric wards. The target population was 65 + -year-old patients hospitalized with acute illness. The MPI tool is derived from eight CGA domains by an interdisciplinary team: social aspects, number of drugs, activities of daily living (ADL), instrumental-ADL, cognitive status, severity of morbidity, risk of developing pressure sores, and nutritional status. Patients assessed were categorized into three groups: non-frail (MPI-1), moderate frail (MPI-2) or severe frail (MPI-3). Primary outcome was 30-day unplanned readmission and secondary LOS and 90-day mortality.

RESULTS

In total 1467 patients were included from January 1, 2018, to October 1, 2019. Mean age was 84.2 years (± 7.4) and 59% were women. 15.7% were readmitted. Hazard ratio (HR) for readmission in the MPI-2 group (n = 635) was 2.57; 95% confidence interval (CI) 1.25-5.29 (p = 0.01), and 2.60; 95% CI 1.27-5.33 (p = 0.009) in the MPI-3 group (n = 711) compared to the MPI-1 group (n = 121). MPI was a predictor of LOS and mortality.

CONCLUSION

Using the MPI tool to identify the frail and non-frail patients is applicable to predict unplanned hospital readmission in geriatric patients. The MPI is superior to the prognostic value of each single domain. MPI will be of great value to health professionals' decision-making.

Main Risk Factors Related to Activities of Daily Living in Non-Dialysis Patients with Chronic Kidney Disease Stage 3-5: A Case-Control Study

Introduction

Elderly people are at increased risk of falls, disability and death due to reduced functional reserve, decline in multiple systems functions, which affects their activities of daily living (ADL) and eventually develop into frailty. The ADL assessment is conducive to early detection to avoid further serious situations. Previous studies on patients’ activities of daily living with chronic kidney disease (CKD) are mainly focused on dialysis patients. Little information is available on non-dialysis patients.

Patients and Methods

A total of 303 elderly patients with CKD stage 3–5 who were admitted to our hospital were selected. ADL evaluation was performed on patients at admission, with Barthel index (BI) as the evaluation tool. They were divided into two groups based on BI (≥60 and <60). Demographic information, lifestyle and clinical profile were collected. The risk factors related to ADL were analyzed by univariate and multivariate models.

Results

The data of 303 patients enrolled in this study were analyzed. The average age of patients was 84.48± 7.14 years and 62.05% were male. There were 88 patients (29.04%) in BI <60 group and 215 patients (70.96%) in the BI ≥60 group. The average age of subjects in the two groups was 87.47 ± 5.85 years and 83.26± 7.28 years, respectively. On univariate analysis, ADL impairment was associated with many factors, such as age, body mass index, blood lipid, heart rate, smoking history, Charlson comorbidity index (CCI), hemoglobin, serum albumin, BNP, eGFR, etc. Multivariate logistic regression showed that age (OR 1.08, 95% CI 1.00–1.17, P=0.0390), Charlson comorbidity index (OR 4.75, 95% CI 1.17–19.30, P=0.0295), and serum albumin (OR 0.80, 95% CI 0.70–0.92, P=0.0012) were the independent risk factors of ADL impairment.

Conclusion

Decline of ADL in CKD patients was independently correlated with age, Charlson comorbidity index and serum albumin. ADL and its influential factors in the elderly CKD patients deserve further attention.

The functional status, rehospitalization, and hospital cost reduction in geriatric patients after the implementation of the universal health coverage program in the national referral hospital Indonesia

BACKGROUND Universal health coverage program (UHCP) might implicate negatively toward geriatric care with its impact on higher cost. The evaluation had to be made, especially in functional status, rehospitalization, and cost-effectiveness. METHODS Retrospective cohort study with historical control was done. Seventy two geriatric inpatients in the pre-UHCP group and 86 in the UHCP group were recruited from Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Subjects with geriatric syndromes admitted from July to December 2013 (pre-UHCP era) and January to June 2014 (UHCP era). Functional status changes, rehospitalization, and process indicators were observed. Cost reduction was calculated using the incremental cost-effectiveness ratio (ICER), whereby costs, functional status changes, and rehospitalization of both groups were used to identify the differences. RESULTS Proportions of functional status increase were 35.3% and 34.8% in the pre- UHCP and UHCP groups, respectively (p = 1.00) and the decrease were 5.9% and 4.5% in the pre-UHCP and UHCP group, respectively (p = 1.00). Rehospitalization rates were 21.7% and 18.1% (p = 0.603) in the pre-UHCP and UHCP groups, respectively. Mean hospital expenses were between 17.1 million IDR (1,221 USD; 1 USD = 14,000 IDR) for the pre-UHCP group and 20.8 million IDR (1,486 USD) for the UHCP group. ICER showed that hospitalization cost was 3.7 million IDR (264 USD) higher to increase 1 activity of daily living score in the UHCP era. As for rehospitalization, the cost was 600,000 IDR (43 USD) less, with 3.6% smaller in readmission. CONCLUSIONS There was no changes in patients’ functional status after the UHCP implementation. There was a reduction in rehospitalization with lower cost in the UHCP era.