Nutritional Status and Potentially Inappropriate Medications in Elderly

Assessment of frailty, daily life activities, and nutrition of elderly immigrants: A household based cross-sectional study

With the global migrant population on the rise, it's imperative to focus on the health status of more vulnerable groups within these communities. The elderly immigrants face myriad physical and psychosocial challenges that significantly impact their health and quality of life. This study aims to investigate the nutrition, daily life activities, and clinical frailty status of elderly immigrants residing in Türkiye. A cross-sectional design was employed in the Sultanbeyli District, focusing on Syrian immigrants aged 65 and over. Participants were surveyed face-to-face by interpreters proficient in Arabic. The questionnaire comprised sociodemographic details, health status, and scales like Katz Daily Life Activities, Clinical Frailty, and Mini Nutritional Assessment. The data analysis was executed using SPSS 22. Continuous variables were presented as mean ± standard deviation (SD) and median, while categorical ones were expressed in numbers and percentages (%). A significance level of P < .05 was considered for the analyses. The average age of the participants was determined as 71.64 ± 6.20 years. In the study group, 49.7% were female, 75.5% were younger than 75 years old, 47.7% had less than primary school education, 56.3% were married, 42.4% had a low income level, and 56.9% lived in the same household with 5 or more people. Among the participants in the study group, 47% had walking and balance problems, 29.1% had a history of falls in the last year, 10.6% were disabled, 69.5% complained of pain, 82.8% had a chronic illness, and 43% had polypharmacy. The median value of the KATZ Daily Living Activities scale was 6, the mean score of the Clinical Frailty Score scale was 3.25 ± 1.25, and the mean score of the Mini Nutritional Assessment scale was 12.40 ± 2.15. Among immigrant elderly individuals, 88.1% were able to sustain their lives independently, 13.9% were clinically frail, and 3.3% were at risk of malnutrition. Factors such as age, level of education, socioeconomic status, marital status, number of cohabitants in the household, BMI, neurological problems, walking-balance disorders, disability, and presence of chronic diseases are associated with daily life activities, frailty, and malnutrition status. It is believed that broader field research with greater participation would be beneficial for evaluating the nutritional status of immigrant elderly individuals.

The multidimensional prognostic index (MPI) predicts long-term mortality in old type 2 diabetes mellitus patients: a 13-year follow-up study

PURPOSE

The Multidimensional Prognostic Index (MPI) is a tool capable of holistically frame older patients in different settings and affected by different pathologies, establishing a risk of adverse events. Among them, type 2 diabetes mellitus (T2DM), a common metabolic disease in the elderly, is responsible for complications and deaths. Few previous works have focused specifically on MPI and DM, and none have followed up the patients for more than 3 years. The aim of the present study is to analyze MPI accuracy in predicting mortality in a cohort of T2DM patients followed-up for 13 years.

METHODS

The enrolled subjects were evaluated with MPI, identifying three levels of risk: MPI1 (low risk, 0.0-0.33), MPI2 (moderate risk, 0.34-0.66), and MPI3 (severe risk, 0.67-1.0), and with glycated hemoglobin, and years since T2DM diagnosis.

RESULTS

One hundred and seven patients met the inclusion criteria. MPI3 was excluded by further analysis since it was made up of only three patients. Overall, cognitive performances, autonomies in daily living, nutritional status, risk of pressure injuries, comorbidities, and taken drugs were better (p ≤ 0.0077) in MPI1 than MPI2; moreover, the story of T2DM was shorter (p = 0.0026). Cox model showed an overall 13-year survival of 51.9%, and survival rates were significantly smaller in MPI2 (HR: 4.71, p = 0.0007). Finally, increased age (HR: 1.15), poorer cognitive abilities (HR: 1.26), vascular (HR: 2.15), and kidney (HR: 2.17) diseases were independently associated with death.

CONCLUSION

Our results prove that MPI predicts short-, mid-, and even long-term mortality in T2DM patients, whose death seems to be related to age and cognitive status, and even more to vascular and kidney diseases.

Polypharmacy and malnutrition in older people: A narrative review

Polypharmacy is the simultaneous use of multiple medicines, usually more than five. Polypharmacy is highly prevalent among older individuals and is associated with several adverse health outcomes, including frailty. The role of polypharmacy in nutritional status seems to be crucial: although a clear association between polypharmacy and malnutrition has been widely reported in older people, the magnitude of the effect of increased number of drugs in combination with their type on the risk for malnutrition remains to be largely explored. Therefore, this review aims to discuss the association between polypharmacy and malnutrition in older people and to provide suggestions for its management. Polypharmacy is prevalent among malnourished frail patients, and the relative contribution of comorbidities and polypharmacy to malnutrition is difficult to be determined. Several mechanisms by which commonly used medications have the potential to affect nutritional status have been identified and described. Deprescribing (i.e., a systematic process of identification and discontinuation of drugs or a reduction of drug regimens) could be an essential step for minimizing the effects of polypharmacy on malnutrition. In this regard, the literature suggests that in older patients taking several medications, the best method to solve this problem is the comprehensive geriatric assessment, based on a holistic approach, including drug review, to find potential unnecessary and inappropriate medications. Nutritional and deprescribing interventions must be tailored to patient needs and to the local context to overcome barriers when applied in different settings.

Diabetes mellitus, malnutrition, and sarcopenia: The bond is not explained by bioelectrical impedance analysis in older adults

As people age, their risk of diabetes mellitus (DM) and sarcopenia increases due to the decline in muscle mass and strength. Bioelectrical impedance analysis (BIA) is a method used to detect changes in body composition. The primary aim of the study was to determine the distribution of BIA variables among a group of non-DM people and two groups of patients with controlled and uncontrolled DM. The secondary aim was to establish the independent association between BIA-derived data, lipidic assets, and the prevalence of metabolic syndromes with DM. This study included a total of 235 participants who were categorized into three groups based on the presence of diabetes mellitus (DM) and their glycated hemoglobin (HbA1c) levels: non-DM, controlled DM (HbA1c≤7.0%), and uncontrolled DM (HbA1c>7.0%). Waist circumference (p=0.005), bone (p<0.001), muscular (p<0.001), and appendicular skeletal mass (p<0.001) were lower in the non-DM group, while sarcopenic risk (p<0.001), total cholesterol (p<0.001), and LDL (p<0.001), were higher. Grip strength (p<0.001), visceral fat (p=0.01), and phase angle (p=0.04) were significantly lower in non-DM than uncontrolled DM patients, as well as the number of drugs taken (p=0.014). A multivariate analysis highlighted that LDL (coefficient -0.006, p=0.01) was negatively associated, while bone mass (coefficient 0.498, p=0.0042) was positively associated with DM uncontrol. Our study shows that BIA may not be the ideal tool for distinguishing between elderly individuals with and without DM, as it can be affected by numerous covariates, including potential differences in glucometabolic and cardiovascular control.

Six-item cognitive impairment test (6-CIT)'s accuracy as a cognitive screening tool: best cut-off levels in emergency department setting

Background

Nowadays, elderly patients represent a significant number of accesses to the Emergency Department (ED). Working rhythms do not allow to perform complete cognitive analysis, which would, however, be useful for the health care. This study aims to define the optimal cut-off values of the six-item Cognitive Impairment Test (6-CIT) as a cognitive screening tool in ED.

Methods

This study included 215 subjects, evaluated at the Emergency Department of the University Hospital of Monserrato, Cagliari, Italy, from July to December 2021. The accuracy of 6-CIT as a cognitive screening tool was assessed by comparison with Mini Mental State Examination (MMSE).

Results

The correlation coefficient between the two tests was -0.836 (CI: -0.87 to -0.79; p < 0.0001), and 6-CIT showed AUC = 0.947 (CI: 0.908-0.973; p < 0.0001). The 8/9 6-CIT cut-off score presented 86.76% sensitivity (CI: 76.4-93.8) and 91.84% specificity (CI: 86.2-95.7), and Youden index for this score was 0.786.

Conclusion

Our study demonstrates that 6-CIT is a reliable cognitive screening tool in ED, offering excellent sensitivity and specificity with a 8/9 points cut-off score.

Orthogeriatric Assessment of the Elderly Patient with Fragility Hip Fracture: Preliminary Results of a Prospective Study

Nowadays, more studies deal with "OrthoGeriatrics", for the co-management of elderly patients suffering fractures, from the admission to the discharge and beyond. For the first time at Cagliari University Hospital, we introduced an orthogeriatric service, in which trained geriatricians stay in orthopedic unit alongside trained orthopedics. The primary aim of the study was to analyze the rate of death and rehospitalization in elderly femur-fractured people of 65 or more years of age, identifying possible predictive factors. The secondary aim of the study was to analyze the recovery of daily living autonomies during the months following surgery. To reach the aim, we designed a prospective study, which is currently ongoing. We evaluated femur-fractured patients aged 65 years or more with a comprehensive geriatric assessment before surgery. The most common fractures were lateral hip ones, treated with osteosynthesis. Cognitive-affective, functional, and nutritional status, mood, and comorbidities were less impaired than in the outpatient service of the same hospital devoted to frail elderly. Pain control was excellent. A significantly low delirium incidence was found. More than a third of the sample were recognized as frail (according to the Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI)), and over a third of the sample were identified as a moderate-high risk of hospitalization and death (according to Multidimensional Prognostic Index (MPI)). Overall mortality rate was 13.87%, and rehospitalization rate was 11.84%. Frail people were more likely to die than non-frail (HR: 5.64), and pre-frail ones (HR: 3.97); similarly, high-risk patients were more likely to die than low-risk (HR: 8.04), and moderate-risk ones (HR: 5.46). Conversely, neither SHARE-FI nor MPI predicted rehospitalization. Creatinine (OR: 2.66, p = 0.003) and folate (OR: 0.75, p = 0.03) levels were independently associated with death and rehospitalization, respectively. Finally, the patients did recover the lost autonomies later, 6 months after surgery. Our study demonstrated that SHARE-FI and MPI are reliable tools to predict mortality in an orthogeriatric setting, and that creatinine and folate levels should also be measured given their independent association with negative outcomes.

Physical Performance and Falling Risk Are Associated with Five-Year Mortality in Older Adults: An Observational Cohort Study

Background: Falls in older people have a significant impact on public health. The scientific literature has provided evidence about the necessity for older adults to be physically active, since it reduces the incidence of falls, several diseases, and deaths, and can even slow down some effects of aging. The primary aim of our study is to identify if physical performances and risk of falling are related to 1-, 2-, 3-, 4-, and 5-year mortality. Its secondary aim is to establish if people with both severely impaired physical performance and a high risk of falling also present impairment in other geriatric domains. Methods: In this prospective study, we enrolled subjects aged 65 years or more, subjected them to comprehensive assessment (including assessment of risk of falling, physical capacities, comorbidities, autonomies in daily living, cognitive abilities, mood, and nutritional status), and followed them for 5 years. Results: We included 384 subjects, 280 of whom were women (72.7%), with a median age of 81 years. Our results showed that physical performances and risk of falling are highly correlated to each other (rho = 0.828). After divided the sample into three groups (people without augmented risk of falling and able to perform adequate physical activity; people with moderate risk of falling and/or disability; people with severe risk of falling and/or disability), we found that the more severe the disability and risk of falling were, the more compromised the other geriatric domains were. Moreover, the survival probability progressively increased following the same trend, amounting to only 41% in severely compromised people, 51.1% in moderately compromised people, and 62.8% in people without physical compromise nor an augmented falling risk (p = 0.0124). Conclusions: Poor physical performance combined with a high risk of falling, correlated with each other, are associated with higher mortality and impairment in multiple domains in older adults.

Frailty and comorbidity burden in Atrial Fibrillation

Background

With the aging of the population, the characterization of frailty and comorbidity burden is increasingly taking on particular importance. The aims of the present study are to analyze such conditions in a population affected by Atrial Fibrillation (AF), matching it with a population without AF, and to recognize potential independent factors associated with such common cardiovascular disease.

Methods

This study included subjects consecutively evaluated over 5 years at the Geriatric Outpatient Service, University Hospital of Monserrato, Cagliari, Italy. A sum of 1981 subjects met the inclusion criteria. The AF-group was made up of 330 people, and another 330 people were randomly selected to made up the non-AF-group. The sample was subjected to Comprehensive Geriatric Assessment (CGA).

Results

In our sample, severe comorbidity burden (p = 0.01) and frailty status (p = 0.04) were significantly more common in patients with AF than without AF, independently on gender and age. Furthermore, the 5-years follow-up demonstrated that survival probability was significantly higher in AF-group (p = 0.03). The multivariate analysis (AUC: 0.808) showed that the presence of AF was independently positively associated with a history of coronary heart disease (OR: 2.12) and cerebrovascular disease (OR: 1.64), with the assumption of Beta Blockers (OR: 3.39), and with the number of drugs taken (OR: 1.12), and negatively associated with the assumption of antiplatelets (OR: 0.09).

Conclusions

Elderly people with AF are frailer, have more severe comorbidities, and take more drugs, in particular beta blockers, than people without AF, who conversely have a higher survival probability. Furthermore, it is necessary to pay attention to antiplatelets, especially in AF-group, in order to avoid dangerous under- or over-prescriptions.

Mini-Mental State Examination: Optimal Cut-Off Levels for Mild and Severe Cognitive Impairment

Considering the need to intercept neurocognitive damage as soon as possible, it would be useful to extend cognitive test screening throughout the population. Here, we propose differential cut-off levels that can be used to identify mild and severe cognitive impairment with a simple and widely used first-level neurocognitive screening test: the Mini-Mental State Examination (MMSE). We studied a population of 262 patients referred for cognitive impairment testing using the MMSE and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), a neuropsychological battery. The sample consisted of 262 participants with mean age 73.8 years (60-87), of whom 154 (58.8%) women. No significant gender-related differences in cognitive ability were identified. The two tests (MMSE and RBANS) showed a moderate correlation in identifying cognitive deficit. We used RBANS as a categorial variable to identify different degrees of cognitive impairment. Youden's J indexes were used to consider the better sensitivity/specificity balance in the 24-point cut-off score for severe cognitive deficit, 29.7-point score for mild cognitive deficit, and 26.1-point score for both mild and severe cognitive deficit. The study shows that the MMSE does not identify early cognitive impairment. Though different cut-offs are needed to discriminate different impairment degrees, the 26.1-point score seems to be preferable to the others.

Anemia in Elderly Patients-The Impact of Hemoglobin Cut-Off Levels on Geriatric Domains

Background: The primary aim of this study was to evaluate the impact of anemia—according to the WHO criteria—on cognitive performances, mood, functional and nutritional status, and comorbidities in a population of subjects aged 65 years or older. The secondary aim of this study was to understand if different hemoglobin cut-off levels are associated with a variation of the mentioned domains’ impairment. Methods: We designed a cross-sectional study, including subjects aged 65 or more consecutively evaluated in an outpatient setting from July 2013 to December 2019. A sum of 1698 subjects met the inclusion criteria. They were evaluated with: MMSE and CDT (cognitive assessment), GDS (mood), BADL, IADL, PPT, and POMA (autonomies), MNA (nutritional status), and CIRS (comorbidities). Results: According to the WHO criteria, non-anemic patients reported significantly better performances than the anemics in BADL (p < 0.0001), IADL (p = 0.0007), PPT (p = 0.0278), POMA (p = 0.0235), MNA, CIRS TOT, CIRS ICC, and CIRS ISC (p < 0.0001). The same tendency has been found by considering the 12 g/dL- and the 13 g/dL-cut-off level in the whole population. The multivariate analysis showed that, considering the 12 g/dL-cut-off level, age (OR: 1.03, p = 0.0072), CIRS (OR: 1.08, p < 0.0001), and gender (OR: 0.57, p = 0.0007) were significant regressors of anemia, while considering the 13 g/dL-cut-off level, age (OR: 1.04, p = 0.0001), POMA (OR: 1.03, p = 0.0172), MNA (OR = 0.95, p = 0.0036), CIRS (OR: 1.17, p < 0.0001), ICC (OR = 0.83, p = 0.018), and gender (OR = 0.48, p < 0.0001) were significant regressors of anemia, while the other CGA variables were excluded by the model (p > 0.01). Conclusions: Our study showed that anemia negatively impact on geriatric people’s general status, regardless of which hemoglobin cut-off level is considered. It also highlighted that hemoglobin concentrations < 13 g/dL, regardless of gender, have an association with the impairment of the affective-functional-nutritional state as well as an increase in comorbidities; therefore, it should be pursuable to consider the elderly person “anemic” if Hb < 13 g/dL regardless of gender.

Comprehensive Geriatric Assessment: Application and correlations in a real-life cross-sectional study

Background

The assessment process of elderly people considers all aspects of an individual's life, including physical, mental, and social aspects. Frailty refers to a decline in physiological functions or strengths leading to increased vulnerability to stressors and decreased ability to cope with them. Comprehensive Geriatric Assessment (CGA) is a validated and useful tool in this context to holistically study elderly people. The primary aim of this study was to determine the prevalence of impaired health status in a large geriatric population turning to outpatient service, based on the components of the CGA, and thus to describe its usefulness in real-life clinical practice. The secondary aim of this study was the evaluation of the association between nutritional status, assessed with Mini Nutritional Assessment (MNA)-within the CGA-and cognitive-affective and functional capacities, and multimorbidity.

Materials and methods

This real-life, retrospective cross-sectional study included subjects consecutively evaluated from January 2009 to December 2020 at the Geriatric Outpatient Service, University Hospital of Monserrato, Cagliari, Italy. A sum of 3,260 patients were subjected to CGA.

Results

Only a small proportion of the sample (2.24%) showed an absence of impairment in cognitive-affective, functional, and nutritional domains. Moderate correlations were found between MNA and several other CGA variables, namely, Geriatric Depression Scale (GDS; ϱ = -0.41, p < 0.0001), Barthel Index of Independence in Activities of Daily Living (ADL) (ϱ = 0.51, p < 0.0001), Instrumental Activities of Daily Living (IADL) (ϱ = 0.43, p < 0.0001), and Performance-Oriented Mobility Assessment (ϱ = 0.44, p < 0.0001). A multiple regression also highlighted these variables as significant regressors of MNA. Finally, malnutrition showed a significant association with depression (odds ratio [OR]: 4.97), dependence on ADL (OR: 19.8) and IADL (OR: 7.04), and falling risk (OR: 5.16).

Conclusion

This study has figured out the complex situation in which geriatric care finds itself the complexity and severe impairment of elderly people. The possibilities of intervention are often limited, but the literature confirms the benefits of good nutritional status on the general health status. The data that emerged from our study fit into this assumption, highlighting the close association between the nutritional domain and the other CGA domains.