The evaluation of frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults'

BACKGROUND

Delirium is a common complication in hospitalized older adults with multifactorial etiology and poor health outcomes.

AIM

To determine the frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults.

METHODS

A prospective observational study was performed in patients aged ≥60 years consecutively admitted to geriatric ward. Potential risk factors were assessed within 24 hours of hospital admission. Delirium screening was performed on admission and daily thereafter throughout the hospital stay using Confusion Assessment Method (CAM). Patients were followed up at 1-year post-discharge.

RESULTS

The study included 200 patients with mean age 73.1 ± 8.83 years. Incidence and prevalence rate of delirium were 5% and 20% respectively. Multivariable regression analysis revealed emergency admission (OR= 5.12 (1.94-13.57), p=0.001), functional dependency (Katz index of Independence in Activities of Daily Living (Katz-ADL) score <5) 2 weeks before admission (OR= 3.08 (1.30-7.33), p=0.011) and more psychopathological symptoms (higher Brief Psychiatric Rating Scale (BPRS) total score) (OR=1.12 (1.06-1.18), p=0.001) to be independently associated with delirium. Patients in delirium group had significantly high in-hospital mortality (OR= 5.02 (2.12-11.8), p=0.001) and post-discharge mortality (HR= 2.02 (1.13-3.61), p=0.017) and functional dependency (Katz-ADL score <5) (OR= 5.45 (1.49-19.31), p=0.01) at 1-year follow up.

CONCLUSION

Delirium is quite frequent in geriatric inpatients and is associated with high in-hospital and post-discharge mortality risk and long-term functional dependency. Emergency admission, pre-hospitalization functional dependency, and more general psychopathological symptoms are independently associated factors. Hence, earliest identification and treatment with early implementation of rehabilitation services is warranted.

Performance of the Informant Questionnaire on Cognitive Decline for the Elderly (IQCODE) in a nationally representative study in India: the LASI-DAD study

BACKGROUND

Low and middle-income countries like India anticipate rapid population aging and increases in dementia burden. In India, dementia screening scales originally developed in other contexts need to be assessed for feasibility and validity, given the number of different languages and varying levels of literacy and education.

METHOD

Using data from the Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (N = 4,028), we characterize the performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We described patterns and correlates of missingness, evaluated the psychometric properties of the scale, and assessed criterion validity against the Hindi Mental State Examination (HMSE) using linear regression.

RESULTS

Several IQCODE items had high levels of missingness, which was associated with urbanicity, respondent's gender, and informant's generation (same vs. younger generation). Full IQCODE scores showed strong criterion validity against the HMSE; each 1-point increase in IQCODE score was associated with a 3.03-point lower score on the HMSE, controlling for age, gender, and urbanicity. The statistically significant association between IQCODE and HMSE was stronger in urban than rural settings (p-value for interaction = 0.04). Associations between IQCODE and HMSE remained unchanged after removing the three items with the highest levels of differential missingness (remembering addresses and telephone numbers, ability to work with familiar machines, ability to learn to use new gadget or machine).

CONCLUSION

Findings raise questions about the value of including items with high proportions of missingness, which may signal cultural irrelevance, while removing them did not affect criterion validity.

50,000 years of Evolutionary History of India: Insights from ~2,700 Whole Genome Sequences

India has been underrepresented in whole genome sequencing studies. We generated 2,762 high coverage genomes from India-including individuals from most geographic regions, speakers of all major languages, and tribal and caste groups-providing a comprehensive survey of genetic variation in India. With these data, we reconstruct the evolutionary history of India through space and time at fine scales. We show that most Indians derive ancestry from three ancestral groups related to ancient Iranian farmers, Eurasian Steppe pastoralists and South Asian hunter-gatherers. We uncover a common source of Iranian-related ancestry from early Neolithic cultures of Central Asia into the ancestors of Ancestral South Indians (ASI), Ancestral North Indians (ANI), Austro-asiatic-related and East Asian-related groups in India. Following these admixtures, India experienced a major demographic shift towards endogamy, resulting in extensive homozygosity and identity-by-descent sharing among individuals. At deep time scales, Indians derive around 1-2% of their ancestry from gene flow from archaic hominins, Neanderthals and Denisovans. By assembling the surviving fragments of archaic ancestry in modern Indians, we recover ~1.5 Gb (or 50%) of the introgressing Neanderthal and ~0.6 Gb (or 20%) of the introgressing Denisovan genomes, more than any other previous archaic ancestry study. Moreover, Indians have the largest variation in Neanderthal ancestry, as well as the highest amount of population-specific Neanderthal segments among worldwide groups. Finally, we demonstrate that most of the genetic variation in Indians stems from a single major migration out of Africa that occurred around 50,000 years ago, with minimal contribution from earlier migration waves. Together, these analyses provide a detailed view of the population history of India and underscore the value of expanding genomic surveys to diverse groups outside Europe.

Defining anthropometric thresholds (mid-arm circumference and calf circumference) in older adults residing in the community: a cross-sectional analysis using data from the population representative Longitudinal Aging Study in India (LASI DAD)

OBJECTIVES

To identify factors associated with malnutrition (undernutrition and overnutrition) and determine appropriate cut-off values for mid-arm circumference (MAC) and calf circumference (CC) among community-dwelling Indian older adults.

DESIGN

Data from the first wave of harmonised diagnostic assessment of dementia for Longitudinal Ageing Study in India (LASI-DAD) were used. Various sociodemographic factors, comorbidities, geriatric syndromes, childhood financial and health status were included. Anthropometric measurements included body mass index (BMI), MAC and CC.

SETTING

Nationally representative cohort study including 36 Indian states and union territories.

PARTICIPANTS

4096 older adults aged >60 years from LASI DAD.

OUTCOME MEASURES

The outcome variable was BMI, categorised as low (<18.5 kg/m2), normal (18.5-22.9 kg/m2) and high (>23 kg/m2). The cut-off values of MAC and CC were derived using ROC curve with BMI as the gold standard.

RESULTS

902 (weighted percentage 20.55%) had low BMI, 1742 (44.25%) had high BMI. Undernutrition was associated with age, wealth-quintile and impaired cognition, while overnutrition was associated with higher education, urban living and comorbidities such as hypertension, diabetes and chronic heart disease. For CC, the optimal lower and upper cut-offs for males were 28.1 cm and >31.5 cm, respectively, while for females, the corresponding values were 26 cm and >29 cm. Similarly, the optimal lower and upper cut-offs for MAC in males were 23.9 cm and >26.9 cm, and for females, they were 22.5 cm and >25 cm.

CONCLUSION

Our study identifies a high BMI prevalence, especially among females, individuals with higher education, urban residents and those with comorbidities. We establish gender-specific MAC and CC cut-off values with significant implications for healthcare, policy and research. Tailored interventions can address undernutrition and overnutrition in older adults, enhancing standardised nutritional assessment and well-being.

Trajectories and correlates of poor mental health in India over the course of the COVID-19 pandemic: a nation-wide survey

Introduction

The COVID-19 pandemic had large impacts on mental health; however, most existing evidence is focused on the initial lockdown period and high-income contexts. By assessing trajectories of mental health symptoms in India over two years, we aim to understand the effect of later time periods and pandemic characteristics on mental health in a lower-middle income context.

Methods

We used data from the Real-Time Insights of COVID-19 in India (RTI COVID-India) cohort study (N=3,662). We used covariate-adjusted linear regression models with generalized estimating equations to assess associations between mental health (PHQ-4 score) and pandemic periods as well as pandemic characteristics (COVID-19 cases and deaths, government stringency, self-reported financial impact, COVID-19 infection in the household) and explored effect modification by age, gender, and rural/urban residence.

Results

Mental health symptoms dropped immediately following the lockdown period but rose again during the delta and omicron waves. Associations between mental health and later pandemic stages were stronger for adults 45 years of age and older (p<0.001). PHQ-4 scores were significantly and independently associated with all pandemic characteristics considered, including estimated COVID-19 deaths (PHQ-4 difference of 0.041 SD units; 95% Confidence Interval 0.030 - 0.053), government stringency index (0.060 SD units; 0.048 - 0.072), self-reported major financial impacts (0.45 SD units; 0.41-0.49), and COVID-19 infection in the household (0.11 SD units; 0.07-0.16).

Conclusion

While the lockdown period and associated financial stress had the largest mental health impacts on Indian adults, the effects of the pandemic on mental health persisted over time, especially among middle-age and older adults. Results highlight the importance of investments in mental health supports and services to address the consequences of cyclical waves of infections and disease burden due to COVID-19 or other emerging pandemics.

The prevalence of frailty and its relationship with sociodemographic factors, regional healthcare disparities, and healthcare utilization in the aging population across India

Objective

To estimate frailty prevalence and its relationship with the socio-economic and regional factors and health care outcomes.

Methods

In this study, participants from the harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) were included. The frailty index (FI) was calculated using a 32-variable deficit model, with a value of ≥ 25% considered as frail. Data on demographic (including caste and religion) and socioeconomic profiles and health care utilization were obtained. The state-wise health index maintained by the government based on various health-related parameters was used to group the participants' residential states into high-, intermediate-, and low-performing states. Multivariable and zero-inflated negative binomial regression was used to assess the relationship of frailty index with sociodemographic characteristics, health index, and health care expenditure or hospitalization.

Results

Among the 3953 eligible participants, the prevalence of frailty was 42.34% (men = 34.99% and women = 49.35%). Compared to high-performing states, intermediate- and low-performing states had a higher proportion of frail individuals (49.7% vs. 46.8% vs. 34.5%, P < 0.001). In the adjusted analysis, frailty was positively associated with age, female sex, rural locality, lower education level, and caste (scheduled caste and other backward classes). After adjusting for the socio-economic profile, FI was inversely associated with the composite health index of a state (P < 0.001). FI was also significantly correlated with total 1-year health care expenditure and hospitalization (P < 0.001 and 0.020, respectively).

Conclusion

There is a high prevalence of frailty among older Indian adults that is associated with sociodemographic factors and regional health care performance. Furthermore, frailty is associated with increased health care utilization and expenditure.

Prevalence of dementia in India: National and state estimates from a nationwide study

INTRODUCTION

Prior estimates of dementia prevalence in India were based on samples from selected communities, inadequately representing the national and state populations.

METHODS

From the Longitudinal Aging Study in India (LASI) we recruited a sample of adults ages 60+ and administered a rich battery of neuropsychological tests and an informant interview in 2018 through 2020. We obtained a clinical consensus rating of dementia status for a subsample (N = 2528), fitted a logistic model for dementia status on this subsample, and then imputed dementia status for all other LASI respondents aged 60+ (N = 28,949).

RESULTS

The estimated dementia prevalence for adults ages 60+ in India is 7.4%, with significant age and education gradients, sex and urban/rural differences, and cross-state variation.

DISCUSSION

An estimated 8.8 million Indians older than 60 years have dementia. The burden of dementia cases is unevenly distributed across states and subpopulations and may therefore require different levels of local planning and support.

HIGHLIGHTS

The estimated dementia prevalence for adults ages 60+ in India is 7.4%. About 8.8 million Indians older than 60 years live with dementia. Dementia is more prevalent among females than males and in rural than urban areas. Significant cross-state variation exists in dementia prevalence.

Recurrent syncope in long survivors and its association with geriatric syndromes

Objective

Syncope is a common clinical condition in the elderly, associated with significant morbidity and risk of recurrence. Recurrent syncope causing a repeated reduction in the cerebral blood flow can predispose to progressive neurodegeneration, a decline in overall health and functionality. Hence, this study was conducted to study the common causes of recurrent syncope and its association with various geriatric syndromes.

Methodology

This case-control study recruited 50 cases of recurrent syncope and 50 controls, aged 75 years and older. A detailed history and sequential evaluation for aetiologies of recurrent syncope were done. Cognition, frailty, activities of daily living, depression, and nutrition were assessed using various scales.

Results

Most (80%, 80/100) of the participants were males and the mean age was 80.04 ± 4.3 years. In the syncope group, 42% (21/50) of patients had arrhythmia, and 30% (15/30) had valvular heart disease. Recurrent syncope was significantly associated with lower scores on Montreal cognitive assessment scale (OR: 6.47 P < 0.001), four or more comorbidities (OR: 6.29 P < 0.001), and hearing impairment (OR: 6.21 P < 0.004) on multivariate logistic regression analysis.

Conclusion

Recurrent syncope is significantly associated with cognitive impairment, the presence of four or more comorbidities, and hearing impairment. Conduction abnormality was the most common etiology of recurrent cardiovascular syncope. Structured evaluation and appropriate management of recurrent syncope might reduce the decline in physical, cognitive, and psychological reserve. A follow-up longitudinal study is needed to establish this.

Investigating the factors that explain white matter hyperintensity load in older Indians

White matter hyperintensities are areas of hyperintense signal on MRI that typically represent cerebrovascular pathology. While focal white matter hyperintensities are common among older individuals, extensive white matter hyperintensities have been found to accelerate the progression of dementia. However, little is currently known about how various socioeconomic, health, lifestyle and environmental factors affect the severity of these lesions, particularly in low- and middle-income countries such as India. We investigated this question using cross-sectional MRI data (n = 126) from a pilot neuroimaging sub-study of an ongoing, nationally representative epidemiological study of late-life cognition in India. As a screening step, we estimated white matter hyperintensity load from fluid-attenuated inversion recovery MRI using a fully automated technique and tested for associations with each factor separately, controlling for age, sex and estimated total intracranial volume in each case. A combined model of white matter hyperintensity load included five factors which were significant after multiple comparisons correction: systolic blood pressure, body mass index, urbanicity status (urban versus rural living), daily chore hours and the frequency of store trips. This model explained an additional 27% of the variance in white matter hyperintensity load (54 versus 27% for the baseline model with only age, sex and estimated total intracranial volume). We accounted for the possibility of reverse causality by additionally controlling for concurrent markers of neurodegeneration and cognitive impairment, with no substantial change in our findings. Overall, our findings suggest that controlling high blood pressure and maintaining both a healthy body mass index and high levels of physical activity may reduce white matter hyperintensity load in older Indian adults, helping to prevent or delay dementia.

Predictors of Survival Among the Oldest Old Following Acute Hospital Admission: Insights From Clinical and Biochemical Factors

Understanding the factors influencing survival in oldest old population is crucial for providing appropriate care and improving outcomes. This prospective observational study aimed to investigate the determinants of survival in acutely ill oldest old patients during acute hospitalization and 1-month follow-up. Various geriatric domains and biochemical markers were assessed. Among the 70 included patients with a median age of 87 (Inter quartile range: 85-90), the presence of diabetes, delirium, tachypnea, and high sirtuin-5 levels were associated with reduced in-hospital survival. Non-survivors had raised levels of Sirtuin 1 and Sirtuin 5, with an increase of 43% and 70%, respectively. At 1 month, delirium and diabetes were still associated with reduced survival. These findings suggest that type-2 diabetes, delirium, tachypnea, and high sirtuin-5 levels could serve as predictors of reduced survival in acutely ill, hospitalized oldest old patients.

Association Between Cognitive Performance and Nutritional Status: Analysis From LASI-DAD

Malnutrition in low- and middle-income countries causes cognitive decline and other health problems. Harmonized Diagnostic Assessment of Dementia for Longitudinal Aging Study in India (LASI DAD) is an extensive study on late-life cognition and dementia. This study examines the link between nutrition and cognitive abilities in older adults using data from the LASI DAD. We conducted descriptive statistics on nutritional parameters (body-mass index, waist-hip ratio, and Mini-Nutritional Assessment), cognitive functions, and socio-demographic variables in 2,892 adults aged ≥60 years. Cognitive domains assessed included delayed recall, orientation, language, executive function, abstract reasoning, and attention. Cognitive impairment was defined as impaired performance in two or more domains. Mean age was 69.3 ± 7.1 years, 52.9% were female, and 57.5% were illiterate. Low body-mass index (adjusted OR: 1.88, p < .001), at risk of malnutrition (adjusted OR: 1.89, p < .001) and malnourished (adjusted OR: 2.86, p < .001) on Mini-Nutritional Assessment were associated with the presence of cognitive impairment. Better cognitive performance was associated with increased body mass index (adjusted OR: 0.74, p-.03), hemoglobin (adjusted OR: 0.91, p-.006), and serum albumin (adjusted OR: 0.38, p < .001). This study shows that nutritional status assessed by anthropometric measures and blood markers is strongly linked to cognitive performance in older adults.

Establishment of Clinical Construct of Intrinsic Capacity in Older Adults and Its Prediction of Functional Decline

Background

The World Health Organization has conceptualised the health and healthcare of older adults around the concept of healthy ageing. Healthy ageing is defined as “the process of developing and maintaining the functional ability that enables well-being in older age”. This functional ability is the sum of two key factors: intrinsic capacity and interacting environment. This concept of intrinsic capacity encompasses a wide spectrum of health characteristics including the physiological and psychological changes associated with the ageing process. In general, IC declines from a high and stable state to an impaired status as people age. Monitoring individuals for changes in intrinsic capacity in the context of their environment will provide a holistic method of tracking the functioning of older adults at both a population and individual level, providing an opportunity to address any reversible factors of decline. However, this would require a clear and objective conceptualisation of the concept of intrinsic capacity.

Methodology

One hundred subjects were recruited via invitation by advertisement on the institute campus. Study participants underwent detailed physical examination and measurement of various physical and chemical biomarkers which were likely to represent intrinsic capacity as evidenced by the literature review. Outcomes measured were a decline in ADL, IADL, mortality and hospitalisation over a follow-up period of six months. Exploratory factor analysis (EFA) was done to obtain a clinical construct of the proposed entity of intrinsic capacity. Unpaired t-test and univariate logistic regression were used to check for the association between the composite score (IC) and its domains with the decline in ADL, IADL, mortality and hospitalisation.

Results

One composite score (composite IC score) and eight subfactors emerged. The composite score and subfactor domains showed good construct validity. Composite intrinsic capacity score and subdomains of strength and cognition were significantly different among subjects with and without ADL and IADL decline. Univariate logistic regression showed that composite intrinsic capacity score was a predictor of decline in ADL and IADL even after adjusting for age, sex, comorbidity status and education level of the subject with an adjusted odds ratio of 0.99 and 0.98, respectively. Subdomains of strength and cognition also predicted a decline in ADL and IADL independently.

Conclusion

The development of an objective construct of the concept of intrinsic capacity, using commonly measured clinical and biochemical parameters, is feasible and predictive of the subsequent functionality of an individual.

Association of geriatric syndromes in older adults with chronic obstructive pulmonary disease

Background

Geriatric syndromes (GS) are multi‐factorial conditions that make older adults vulnerable to morbidities and poor outcomes. The main objective was to observe the frequency of GS in older patients with COPD.

Methods

A case‐control study was conducted in the Geriatric department of a tertiary care hospital in India to evaluate geriatric syndromes including falls, cognitive impairment, frailty, functional impairment, urinary incontinence, malnutrition, and depression in patients with COPD and controls without COPD. The factors having a significant association with the occurrence of these GS in COPD patients were observed.

Results

In this study, 150 cases and 150 controls were included. The mean age of the participant was 65.85±5.54, with 76% males. Functional impairment, cognitive impairment, frailty, urinary incontinence, and malnutrition were significantly higher in COPD patients. The independent variables which increased the odds of geriatric syndromes were dyspnoea (≥2 mMRC grade) (AOR:3.54,95% CI:1.06‐11.8) and low socioeconomic status (AOR: 4.14, 95% CI: 1.03‐16.54), while male gender showed inverse association (AOR: 0.08,95% CI: 0.01‐0.99).

Conclusion

Geriatric syndromes are common in older COPD patients, and assessment for them should be done routinely in these patients.

Discrepancy in Fluid and Crystallized Intelligence: An Early Cognitive Marker of Dementia from the LASI-DAD Cohort

Background

Cognitive aging is a complex phenomenon, which comprises various cognitive skills, broadly categorized into fluid and crystallized intelligence. Crystallized intelligence (gc) tends to be maintained, as opposed to fluid intelligence (gf), which tends to decline rapidly with age. The association of the two with cognitive decline remains a matter of conjecture requiring further research.

Aim

The aim of the study was to identify the variables of gc and gf from a population data of Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD) study and investigate its relationship with the onset of cognitive impairment using discrepancy analysis against neuropsychological tests.

Methods

This analysis of data from LASI-DAD study was carried out on a sample of 3,223 participants. They were assessed on extensive thirteen cognitive tests and one subjective test of cognition. Standardized score was used for discrepancy analysis. Fluid ability minus crystallized ability was used to assess the cognitive impairment. Any statistical significance with the score difference >0.99 SD was defined as a presence of cognitive decline. Hindi Mental Status Examination (HMSE) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were used as gold standard.

Results

With increased discrepancy score, each cognitive parameter score declined which was found to be statistically significant. In HMSE (Normal = 25.81 ± 3.39; Impaired = 23.17 ± 3.54; p = <0.001), there was a drop of 2 point scores in identifying cognitive impairment in the population sample as per the gold standard. A similar trend was evident in other neurocognitive domains as well.

Conclusion

Crystallized-fluid intelligence discrepancy analysis has a strong potential in predicting the onset of cognitive decline ahead of time, facilitating early intervention.

Characterization of potentially inappropriate medications use in Indian elderly population and their impact on quality of life using Beers criteria

Background

Methods

Results

Conclusion

Six-minute walk test and its predictability in outcome of COVID-19 patients

BACKGROUND

The world is worsely hit by the COVID-19 pandemic resulting in increased morbidity and mortality. Increased mortality has been observed in older adults with multiple comorbidities. Six-minute walk distance (6MWD) at admission can help us to guide the requirement of oxygen during hospital stay that can be used to determine which patient can be managed at home.

MATERIALS AND METHODS

This study was a prospective observational study conducted on COVID-19 patients admitted at AIIMS, New Delhi, from October to December 2020. Patients aged more than 60 years were included in the study and underwent 6-min walk tests. Polypharmacy and multimorbidity were also assessed along with dyspnea which was measured on BORG scale. P < 0.05 was considered statistically significant. Statistical software STATA (version 14.2) was used for all the analyses.

RESULTS

The mean age of the study population was 68.76 (7.4). Oxygen saturation prior to the 6-MWT was normal and has significantly higher than the post test (P ≤ 0.001). 6MWD was significantly correlated with pre values of oxygen saturation. 6MWD was observed more in patients who did not require oxygen during hospital stay. Self-reported dyspnea, pulse rate, oxygen saturation, and systolic blood pressure were significantly associated with the patients who had an oxygen requirement during the hospital stay.

CONCLUSION

Self-reported dyspnea after 6MWT was found to be associated with oxygen requirement during hospital stay. Patients who have covered more distance in 6-min walk test have less oxygen requirement during hospital stay hence can be managed at home. This will reduce the health-care burden and will help to tackle the outburst during the ongoing pandemic.

Adherence to COVID-19 protective behaviours in India from May to December 2020: evidence from a nationally representative longitudinal survey

OBJECTIVES

Since the onset of the COVID-19 pandemic, behavioural interventions to reduce disease transmission have been central to public health policy worldwide. Sustaining individual protective behaviour is especially important in low-income and middle-income settings, where health systems have fewer resources and access to vaccination is limited. This study seeks to assess time trends in COVID-19 protective behaviour in India.

DESIGN

Nationally representative, panel-based, longitudinal study.

SETTING

We conducted a panel survey of Indian households to understand how the adoption of COVID-19 protective behaviours has changed over time. Our data span peaks and valleys of disease transmission over May-December 2020.

PARTICIPANTS

Respondents included 3719 adults from 1766 Indian households enrolled in the Harmonised Diagnostic Assessment of Dementia for the Longitudinal Ageing Study in India.

ANALYSIS

We used ordinary least squares regression analysis to quantify time trends in protective behaviours.

RESULTS

We find a 30.6 percentage point (95% CI (26.7 to 34.5); p<0.01) decline in protective behaviours related to social distancing over the observation period. Mask wearing and handwashing, in contrast, decreased by only 4.3 percentage points (95% CI (0.97 to 7.6); p<0.05) from a high base. Our conclusions are unchanged after adjusting for recorded COVID-19 caseload and nationwide COVID-19 containment policy; we also observe significant declines across socioeconomic strata spanning age, gender, education and urbanicity.

CONCLUSION

We argue that these changes reflect, at least in part, 'COVID-19 fatigue,' where adherence to social distancing becomes more difficult over time irrespective of the surrounding disease environment.

Blood Circulatory Level of Seven Sirtuins in Alzheimer's Disease: Potent Biomarker Based on Translational Research

Alzheimer's disease (AD) is an accelerating neurodegenerative disorder. Dysfunction of mitochondria and oxidative stress contributes to the pathogenesis of AD. Sirtuins play a role in this pathway and can be a potential marker to study neurodegenerative changes. This study evaluated serum levels of all seven sirtuin (SIRT1-SIRT7) proteins in three study groups: AD, mild cognitive impairment (MCI) and geriatric control (GC) by surface plasmon resonance (SPR) technique. Further, it was validated by the Western blot experiment. ROC analysis was performed to differentiate the study group based on the concentration of serum SIRT proteins. Out of seven sirtuins, serum SIRT1, SIRT3 and SIRT6 levels (mean ± SD) were significantly decreased in AD (1.65 ± 0.56, 3.15 ± 0.28, 3.36 ± 0.32 ng/µl), compared to MCI (2.17 ± 0.39, 3.60 ± 0.51, 3.73 ± 0.48 ng/µl) and GC (2.84 ± 0.47, 4.55 ± 0.48, 4.65 ± 0.55 ng/µl). ROC analysis showed the cut-off value with high sensitivity and specificity for cognitive impairment (AD and MCI). The concentration declined significantly with the disease progression. No specific difference was observed in the case of other SIRTs between the study groups. This study reveals an inverse relation of serum SIRT1, SIRT3 and SIRT6 concentration with AD. ROC analysis showed that these serum proteins have greater accuracy in diagnosing of AD. This is the first report of estimation of all seven serum sirtuins and the clinical relevance of SIRT3 and SIRT6 as serum protein markers for AD.

Outcome of older adults at risk of frailty

BACKGROUND

The integral part of the definition of frailty is the outcome associated with it. Older adults at risk of frailty are in the process of becoming frail. This study looked at the clinical characteristics and outcomes of older adults at risk of frailty.

METHODOLOGY

The study population was selected from outpatient department of the geriatric medicine department in a tertiary care hospital. Older adults identified as at risk of frailty were assessed at baseline and then followed up after 1 year for the composite primary outcome of death, falls, hospitalization, and self-rated poor quality of life in the follow-up period.

RESULTS

The study included 324 older adults who had completed 1-year follow up. Mean (SD) age was 74.49 (4.58) years, and males were 241 (74.15%). Frail and pre-frail at baseline among the study population were 31.17% and 61.11%, respectively. The primary outcome occurred in 43 (13.27%) patients. Poor baseline IADL was significantly associated with primary outcome at the end of 1 year.

CONCLUSION

An unfavorable outcome in older adults at risk of frailty was significantly higher and independent of their baseline frailty status. Poor baseline IADL value may be considered as a predictor for primary outcome at 1 year of follow up.

Assessment of mental health issues among geriatric population during COVID19 pandemic, Indian perspective

OBJECTIVES

Study was aimed to assess magnitude of mental health problems among geriatric population during COVID19 pandemic.

METHODOLOGY

Study was a cross-sectional observational study, total of 106 participants (Age ≥60 years) of either gender included in study. Mental health variables depressive and anxiety were assessed using GDS and HAM-A.

RESULTS

On GDS, 20(18.87%) patients had depressive symptoms and on HAM-A, 24(22.6%) patients were having anxiety symptoms.

CONCLUSION

Study highlight that Geriatric population have significant mental health issues during COVID19 pandemic, it should not be overlooked. It's necessary to provide elderly psychological intervention measures to improve their wellbeing.

Circulatory GSK-3β: Blood-Based Biomarker and Therapeutic Target for Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) is the progressive brain disorder which degenerates brain cells connection and causes memory loss. Although AD is irreversible, it is not impossible to arrest or slow down the progression of the disease. However, this would only be possible if the disease is diagnosed at an early stage, and early diagnosis requires clear understanding of the pathogenesis at molecular level. Overactivity of GSK-3β and p53 accounts for tau hyperphosphorylation and the formation of amyloid-β plaques.

OBJECTIVE

Here, we explored GSK-3β and p53 as blood-based biomarkers for early detection of AD.

METHODS

The levels of GSK-3β, p53, and their phosphorylated states were measured using surface plasmon resonance and verified using western blot in serum from AD, mild cognitive impairment (MCI), and geriatric-control (GC) subjects. The neurotoxic SH-SY5Y cell line was treated with antioxidant Emblica Officinalis (EO) for rescue effect.

RESULTS

GSK-3β, p53, and their phosphorylated states were significantly over expressed (p >  0.001) in AD and MCI compared to GC and can differentiate AD and MCI from GC. The expression level of GSK-3β and p53 proteins were found to be downregulated in a dose-dependent manner after the treatment with EO in amyloid-b-induced neurotoxic cells.

CONCLUSION

These proteins can serve as potential blood markers for the diagnosis of AD and EO can suppress their level. This work has translational value and clinical utility in the future.

Clinical features and outcomes of COVID-19 in older adults: a systematic review and meta-analysis

Background

Few studies have focused on exploring the clinical characteristics and outcomes of COVID-19 in older patients. We conducted this systematic review and meta-analysis to have a better understanding of the clinical characteristics of older COVID-19 patients.

Methods

A systematic search of PubMed and Scopus was performed from December 2019 to May 3rd, 2020. Observational studies including older adults (age ≥ 60 years) with COVID-19 infection and reporting clinical characteristics or outcome were included. Primary outcome was assessing weighted pooled prevalence (WPP) of severity and outcomes. Secondary outcomes were clinical features including comorbidities and need of respiratory support.

Result

Forty-six studies with 13,624 older patients were included. Severe infection was seen in 51% (95% CI– 36-65%, I²–95%) patients while 22% (95% CI– 16-28%, I²–88%) were critically ill. Overall, 11% (95% CI– 5-21%, I²–98%) patients died. The common comorbidities were hypertension (48, 95% CI– 36-60% I²–92%), diabetes mellitus (22, 95% CI– 13-32%, I²–86%) and cardiovascular disease (19, 95% CI – 11-28%, I²–85%). Common symptoms were fever (83, 95% CI– 66-97%, I²–91%), cough (60, 95% CI– 50-70%, I²–71%) and dyspnoea (42, 95% CI– 19-67%, I²–94%). Overall, 84% (95% CI– 60-100%, I²–81%) required oxygen support and 21% (95% CI– 0-49%, I²–91%) required mechanical ventilation. Majority of studies had medium to high risk of bias and overall quality of evidence was low for all outcomes.

Conclusion

Approximately half of older patients with COVID-19 have severe infection, one in five are critically ill and one in ten die. More high-quality evidence is needed to study outcomes in this vulnerable patient population and factors affecting these outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02261-3.

Incidence, risk factors, and viral etiology of community-acquired acute lower respiratory tract infection among older adults in rural north India

BACKGROUND

There are limited data on incidence, risk factors and etiology of acute lower respiratory tract infection (LRTI) among older adults in low- and middle-income countries.

METHODS

We established a cohort of community dwelling older adults ≥60 years and conducted weekly follow-up for acute respiratory infections (ARI) during 2015-2017. Nurses assessed ARI cases for LRTI, collecting combined nasal/throat swabs from all LRTI cases and an equal number of age- and sex-matched asymptomatic neighbourhood controls. Swabs were tested for influenza viruses, respiratory syncytial virus (RSV), human metapneumovirus (hMPV), and parainfluenza viruses (PIV) using polymerase chain reaction. LRTI and virus-specific LRTI incidence was calculated per 1000 person-years. We estimated adjusted incidence rate ratios (IRR) for risk factors using Poisson regression and calculated etiologic fractions (EF) using adjusted odds ratios for detection of viral pathogens in LRTI cases vs controls.

RESULTS

We followed 1403 older adults for 2441 person-years. LRTI and LRTI-associated hospitalization incidences were 248.3 (95% confidence interval (CI) = 229.3-268.8) and 12.7 (95% CI = 8.9-18.1) per 1000 person-years. Persons with pre-existing chronic bronchitis as compared to those without (incidence rate ratio (IRR) = 4.7, 95% CI = 3.9-5.6); aged 65-74 years (IRR = 1.6, 95% CI = 1.3-2.0) and ≥75 years (IRR = 1.8, 95% CI = 1.4-2.4) as compared to 60-64 years; and persons in poorest wealth quintile (IRR = 1.4, 95% CI = 1.1-1.8); as compared to those in wealthiest quintile were at higher risk for LRTI. Virus was detected in 10.1% of LRTI cases, most commonly influenza (3.8%) and RSV (3.0%). EF for RSV and influenza virus was 83.9% and 83.6%, respectively.

CONCLUSION

In this rural cohort of older adults, the incidence of LRTI was substantial. Chronic bronchitis was an important risk factor; influenza virus and RSV were major viral pathogens.

The changing perspective of clinical trial designs

Maintaining health and well-being of the population is a universal priority. Governments around the globe are therefore seeking greater efficiency and better outcomes from researches being held. Although large randomized trials or systematic review of several large trials provides the highest level of evidence, the intricate cost, time, and difficulties of conventional trials have led to questions about their sustainability commanding search for alternative approaches. Demands for improved competences in medical research have led to mounting interest in newer clinical trial designs. This article provides an insight into newer clinical trial designs, including cluster trials, adaptive designs, the master protocols along with their strengths, weaknesses, and which trials design should be opted for in different clinical scenarios.

Sestrin2 as Serum Protein Marker and Potential Therapeutic Target for Parkinson's Disease

Sestrin2 (Sesn2) appears to mediate neuroprotection against Parkinson's disease (PD)-associated pathophysiology, however, the mechanism is unknown. This pilot study examines serum Sesn2 level in PD patients and older adult control and also interrogates the rescue effect of Syzygium aromaticum extract on the neurotoxicity by paraquat in neuroblastoma cells. The blood sample was collected from 36 PD patients and 54 older adult control and concentration of serum Sesn2 was measured by surface plasmon resonance and western blot. A significantly elevated level of Sesn2 (p < .0001) was observed in sera of PD group (15.96 ± 2.428 ng/μL) than the control (13.65 ± 2.125 ng/μL) which was further confirmed by western blotting. The receiver operating characteristic (ROC) curve (0.76) determined the threshold value of ≥14.58 ng/μL for differentiating PD from control. The S aromaticum extract exhibited the rescue effect from paraquat induced toxicity in SH-SY5Y cells. Further, these cells showed dose-dependent downregulation of p53, Sesn2, and phosphorylated-AMPK with concomitant increase in phosphorylated-p70S6K level than paraquat-treated cells. The differential level of Sesn2 in study subjects proposes its utility as one of the potential serum markers in PD. The ethanolic extract of S aromaticum may serve as a novel platform for management of PD-associated neurotoxicity.

Legionella pneumophila in Patients with Pneumonia at a Referral Hospital, New Delhi, India, 2015-2020

Legionnaires' disease (LD) is an established cause of pneumonia, and the disease remains largely underdiagnosed. Even though LD has been reported from many parts of the world, only sporadic cases have been reported in India. During February 2015-January 2020, we enrolled 597 patients with radiographically confirmed pneumonia and tested respiratory secretions for Legionella spp. by using real-time PCR, and culture. A commercial urinary antigen test (UAT) was also used to detect the Legionella pneumophila (Lp) serogroup 1 antigen in urine. An LD case was defined as a patient with pneumonia and positive results for Legionella spp. infections determined by real-time PCR (from any respiratory specimen) or culture or UAT. Demographic data, risk factors, clinical, radiological, and outcome data of Lp-positive and Lp-negative patients were compared using logistic regression. Over the study period, 14 (2.3%) patients were positive for Legionella spp. infections by real-time PCR and UAT; eight (57%) were admitted to the intensive care unit, and four (28.6%) in-hospital deaths occurred. Bivariate analysis showed that renal disease, neurological conditions, confusion, leukocytosis, and requirement of oxygen support were more common in the Lp-positive group than in the Lp-negative group. However, multivariate analysis failed to confirm most of these differences; renal disease was the only independent variable remaining significant. All test methods have intrinsic limitations in identifying Legionella; therefore, more than one testing method should be used. Application of molecular assays including real-time PCR has great value because of its high sensitivity, specificity, and rapid diagnostic potency. Increased awareness and improved diagnostic testing could facilitate early detection of cases, pathogen-directed therapy, and improved outcomes for patients.

Case Report: Hypercalcemia in an Older Patient with Type I Lepra Reaction

Leprosy is a rare, chronic granulomatous disease, and India accounts for two-thirds of the new cases reported worldwide. Hypercalcemia is a rare complication of granulomatous disease. Here, we report a case of an older adult patient with leprosy and type I lepra reaction presenting with severe hypercalcemia.

Distribution of Virulence Genes and Sequence-Based Types Among Legionella pneumophila Isolated From the Water Systems of a Tertiary Care Hospital in India

Background: Legionnaires' disease (LD) is a potentially fatal pneumonia predominantly caused by infection due to Legionella pneumophila although more than 50 other Legionella species are described. Water systems contaminated with Legionella spp. are the implicated sources of Legionnaires' disease. In this study, we aimed to assess Legionella contamination in the water sources of a tertiary care hospital and to determine the virulence properties and molecular characteristics of L. pneumophila environmental isolates.

Methods: During May 2015 through August 2018, a total of 201 hospital water samples were tested for L. pneumophila by standardized culture procedures; environmental isolates were examined for the presence of two virulence genes: Legionella vir homolog (lvh) and repeats in structural toxin (rtxA) by PCR. The genotyping of isolates was performed by sequence-based typing (SBT) according to the protocol of the European Study Group for Legionella Infections (ESGLI).

Results:L. pneumophila was isolated from 38/201 (18.9%) water samples; among the 46 isolates, the lvh locus was present in 45 (97.8%), the rtxA locus was found in 45 (97.8%), and both loci were found in 44 (95.7%) isolates. A total of 23 sequence types (STs) were identified among the 44 isolates (index of discrimination [IOD] of 0.929), and 11/23 (47.8%) STs were new to the ESGLI database.

Conclusions: The study results showed genetic diversity in L. pneumophila isolates from the hospital environment along with a high percentage of pathogenicity loci. Besides, certain STs may have an increased ability to cause legionellosis, thus requires specific infection control and prevention strategies whenever identified.

A novel approach to correlate the salivary exosomes and their protein cargo in the progression of cognitive impairment into Alzheimer's disease

BACKGROUND

Cognition is the ability of a person to think, remember, and interconnect ideas from various dimensions to strive for solutions. Cognitive defects accompany all forms of dementia and the decline in cognition is a most feared aspect. Mild cognitive impairment is considered as a transitional phase and the progressive loss in cognition can finally lead to Alzheimer's disease.

NEW METHOD

In this study, we demonstrated a novel method based on nanoparticle tracking analysis (NTA) technique to directly correlate salivary exosomes concentration with the progression of cognitive impairment (CI) in Alzheimer's disease (AD).This could open up the possibility for an early and cost-effective screening of Alzheimer's disease.

RESULTS

Using our novel method, the total salivary exosomes concentration was measured by NTA technique, followed by validation of key exosomal cargo proteins through an automated western blot analyzer. We observed significant differences in salivary exosomes concentration among the groups of cognitively impaired and Alzheimer's disease patients (p = 0.0023) compared to the healthy control cohort. The method was validated through CD63 (exosomes surface marker) fluorescent antibody based quantification, which yielded a similar outcome (p = 0.0286). We further corroborated our findings with the expression level of oligomeric amyloid-beta, phosphorylated-tau protein from salivary exosomes. The Aβ oligomer/fibril abundance (p = 0.0291), phospho-tau (p = 0.0325) and Aβ protein abundance (p = 0.0198) was significantly higher in Alzheimer's and cognitively impaired patients in comparison to the healthy controls.

COMPARISON WITH EXISTING METHOD(S)

There are few molecular biomarkers available to differentiate between various stages of cognitive impairment. Moreover, the current methodologies utilizing the few biomarkers available are either invasive or expensive; also, for a patient with mild cognitive complains, it is impractical to use these as a screening tool.

CONCLUSION

Our initial results indicate that the salivary exosomes concentration based on the nano-tracking technique has the potential to be used as a cost-effective screening method for early disease detection.

Drooping shoulders: A rare manifestation of an uncommon disease

Primary systemic amyloidosis is an uncommon disease which presents with involvement of the kidney, heart, peripheral nervous system and liver. The involvement of skeletal muscles called amyloid myopathy is uncommon. We report a 74-year-old male who presented with progressively drooping shoulders followed by other muscular involvement without other organ involvement as a manifestation of amyloidosis. The patient was managed with melphalan, prednisolone and thalidomide with clinical improvement.

Hypertension and Cognitive Health Among Older Adults in India

OBJECTIVES

To assess the prevalence of diagnosed and undiagnosed hypertension and their relationship to cognitive function in older adults in India.

DESIGN

Longitudinal Aging Study in India-Diagnostic Assessment of Dementia (LASI-DAD), an in-depth national study of late-life cognition and dementia.

SETTING

Geriatric hospitals and respondents' homes across 14 states in India.

PARTICIPANTS

N = 2,874 individuals aged 60 years and older from LASI-DAD.

MEASUREMENTS

Hypertension was identified by self-report of physician diagnosis or measured blood pressure (BP) of 140/90 mmHg or higher. Undiagnosed hypertension was defined as hypertensive BP measurements, but no physician diagnosis. Controlled hypertension was defined as BP lower than 140/90 mmHg among those with a physician diagnosis. Total hypertension included both diagnosed and undiagnosed hypertension. A summary cognition score, derived from the sum of 18 cognitive tests administered in the LASI-DAD (range = 0-360) was used to assess cognitive function.

RESULTS

Total hypertension prevalence was 63.2% (41.5% diagnosed and 21.6% undiagnosed). Among those with hypertension, 34.5% were undiagnosed, 34.2% were diagnosed but uncontrolled, and 31.3% were diagnosed and controlled. Neither diagnosed nor undiagnosed hypertension was related to cognitive function in fully adjusted models. Older age, female sex, less education, being widowed, rural residence, residing in the north or central regions, being in a scheduled caste or tribe, low consumption, being underweight, and history of stroke were all independently associated with worse cognitive test performance.

CONCLUSION

Two-thirds of older Indian adults had hypertension, with the majority being undiagnosed or diagnosed but not adequately controlled. Hypertension was not independently associated with cognitive function, whereas sociodemographic factors were independently related to cognitive function. J Am Geriatr Soc 68:S29-S35, 2020.

Methodological considerations in designing and implementing the harmonized diagnostic assessment of dementia for longitudinal aging study in India (LASI-DAD)

The Harmonized Diagnostic Assessment of Dementia for Longitudinal Aging Study in India (LASI-DAD) is a population-representative, prospective cohort study of late-life cognition and dementia. It is part of an ongoing international research collaboration that aims to measure and understand cognitive impairment and dementia risk by collecting a set of cognitive and neuropsychological assessments and informant reports, referred to as the Harmonized Cognitive Assessment Protocol (HCAP). LASI-DAD provides nationally representative data drawn from a subsample of the ongoing Longitudinal Aging Study in India (LASI). One of LASI-DAD's distinctive features is its rich geriatric assessment, including the collection of venous blood samples and brain imaging data for a subsample of respondents. In this paper, we discuss the methodological considerations of developing and implementing the HCAP protocol in India. The lessons we learned from translating and applying the HCAP protocol in an environment where illiteracy and innumeracy are high will provide important insights to researchers interested in measuring and collecting data on late-life cognition and dementia in developing countries. We further developed an innovative blood management system that enables us to follow the collection, transportation, assay, and storage of samples. Such innovation can benefit other population surveys collecting biomarker data.

Behavioural issues in late life may be the precursor of dementia- A cross sectional evidence from memory clinic of AIIMS, India

Background

Mild Behavioural Impairment (MBI), an “at risk” state for incident cognitive declin, is characterized by late onset, sustained neuropsychiatric symptoms of any severity which cannot be accounted for by other formal medical and psychiatric nosology. There is no study related to MBI from India.

Methods and findings

In this cross-sectional observational study 124 subjects 60 years and above were recruited between March 2017 to October 2018, from memory clinic of department of Geriatric medicine with memory or behavioural complains. Subjects with major neurocognitive impairment (CDR score of 1 or more), major depressive disorder, generalized anxiety disorder and impaired activities of daily living (ADL) were excluded. Subjects with Mild Cognitive impairment (MCI) (CDR- 0.5), and Subjective cognitive impairment (SCI) (CDR- 0) were included. Neuropsychiatric Inventory Questionnaire (NPI-Q) was used to identify the presence of NPS. The ISTAART-MBI (International Society of Advance Alzheimer’s Research and Treatment-Alzheimer’s Association) diagnostic criteria was used to diagnose MBI. All the participants underwent a geriatric assessment using standardised screening. The objectives of this study was to determine the frequency of mild behavioural impairment (MBI), and its domains, in MCI or SCI and its association with comorbidities and geriatric syndromes. The mean age of the participants was 69.21, 71.77% (89) were male and 28.23% (35) were female. 41.13% (51) of these individuals were diagnosed with MBI. The MBI and non MBI group differed significantly in marital status, cognitive status and MCI subtype. The proportion of domains involved are as follows: decreased motivation 60.78%(31), emotional dysregulation 54.90% (28), impulse dyscontrol 68.63% (35), social inappropriateness 21.57%(11), abnormal perception 2 (3.93%). Presence of multi-morbidity, and diabetes, were statistically significant between the groups.

Conclusion

This study presents the first clinic-based prevalence estimates of MBI from Asia. Findings indicate a relatively high prevalence of MBI in predementia clinical states, impulse dyscontrol was the most commonly involved MBI domain. Multimorbidity, diabetes, urinary incontinence were other determinants of MBI.

Old age-associated enrichment of peripheral T regulatory cells and altered redox status in pulmonary tuberculosis patients

Aging influences the susceptibility and prognosis to various infectious diseases including tuberculosis (TB). Despite the impairment of T-cell function and immunity in older individuals, the mechanism for the higher incidence of TB in the elderly remains largely unknown. Here, we evaluated the age-associated immune alterations, particularly in effector and Treg responses in pulmonary TB patients. We also evaluated the impact of redox status and its modulation with N-acetyl-cysteine (NAC) in elderly TB. Higher frequency of Treg cells and reduced IFN-γ positive T cells were observed among older TB patients. The elevated number of Treg cells correlated tightly with bacillary load (i.e. disease severity); which declined significantly in response to successful anti-tubercular treatment. We could rescue Myobacterium tuberculosis-specific effector T cell (Th1) responses through various in vitro approaches, for example, Treg cell depletion and co-culture experiments, blocking experiments using antibodies against IL-10, TGF-β, and programmed death-1 (PD-1) as well as NAC supplementation. We report old age-associated enrichment of Treg cells and suppression of M. tuberculosis-specific effector T (Th1) cell immune responses. Monitoring these immune imbalances in older patients may assist in immune potentiation through selectively targeting Treg cells and/or optimizing redox status by NAC supplementation.

Low one-repetition-maximum knee extension is significantly associated with poor grip strength, female sex, and various aging-related syndromes

OBJECTIVE

Muscle strength in older adults is usually measured according to grip strength, which demonstrates upper muscle strength only. In this study, we used one-repetition-maximum (1-RM) knee extension as a measure of lower limb strength and assessed its relationship with grip strength and various geriatric syndromes.

METHODS

One hundred outpatients over the age of 65 years were recruited from a geriatric medicine center in India. The 1-RM knee extension was measured along with grip strength. Various geriatric conditions were measured, such as: nutrition (using the Mini Nutritional Assessment), cognition (Hindi Mental State Questionnaire), depression (5-item Geriatric Depression Scale), frailty (Fried and Rockwood models), and osteoporosis (dual-energy X-ray absorptiometry scan). Sarcopenia was diagnosed using the Asian Working Group for Sarcopenia criteria.

RESULTS

The mean age of participants was 72.5 years with 69% of them male. Median values of 1-RM knee extension and grip strength were 2.29 (0.5-10.0) and 17.5 (0-78), respectively. The 1-RM knee extension had moderate correlation with grip strength (r = 0.491, P < 0.001). Among demographic details, only female sex (P < 0.001) was significantly associated with lower 1-RM values. Further, after adjusting for age and sex, lower value of log10 1-RM knee extension was found to be significantly associated with malnutrition (P = 0.001), dementia (P = 0.016), depression (P = 0.047), frailty (Rockwood: P = 0.049; Fried: P = 0.011), and sarcopenia (P < 0.001).

CONCLUSION

The 1-RM knee extension has only moderate correlation with grip strength. A lower 1-RM knee extension value is significantly associated with female sex and various geriatric conditions, such as malnutrition, dementia, depression, frailty, and sarcopenia.

Scrub typhus in patients with acute febrile illness: a 5-year study from India

BACKGROUND

Scrub typhus was once thought to be a disease of rural origin and was confined to specific pockets in South Asia. Early diagnosis and treatment is extremely important as it is associated with high mortality if left untreated.

AIM

To delineate the clinical and molecular epidemiology of scrub typhus in patients presenting with acute febrile illness from various parts of India.

METHODS

During the study period of 5 years (October 2013 to October 2018), a total of 1742 patients with acute febrile illness <15 days were enrolled after taking informed consent. Patients were diagnosed using IgM Enzyme-linked immunosorbent assay (ELISA) based on the pre-determined region specific cut offs. Patients with positive IgM ELISA were also subjected to IgM Immunofluorescence assay and nested polymerase chain reaction (PCR) assay. The demographic and relevant clinical details of the patients were documented and analyzed.

RESULTS

A total of 210 (12.1%) patients were diagnosed with scrub typhus. Of these, nested PCR was positive in only 85 patients. Sequencing and phylogenetic analysis showed that the predominant circulating genotypes were Gilliam and Karp. On multivariate analysis, acute respiratory distress syndrome, myocarditis, encephalitis/encephalopathy, jaundice and splenomegaly were significantly more common in those patients who were diagnosed with scrub typhus. A total of 14 patients diagnosed with scrub typhus succumbed to the illness.

CONCLUSION

Patients with fever, headache, pulmonary manifestations, CNS manifestations, myocarditis, transaminitis or thrombocytopenia presenting in the monsoon and post-monsoon season should be evaluated for scrub typhus irrespective of the geographical location in India.

Hindi Version of Addenbrooke's Cognitive Examination III: Distinguishing Cognitive Impairment Among Older Indians at the Lower Cut-Offs

Background

Screening and diagnostic tests provide an objective measure of cognitive performance and also aid in distinguishing mild cognitive impairment (MCI) from major neurocognitive disorder (MNCD). Further, when such tests are culturally and educationally unbiased, it strengthens their diagnostic utility. This study aimed to validate the Hindi version of Addenbrooke’s Cognitive Examination III (ACE-III) in Indian older adults and compare its validity with the Hindi Mini-Mental State Examination (HMSE).

Methods

A sample of 412 consenting older adults visiting a memory clinic was recruited into the study. They were categorized into three groups: healthy controls (n=222), MCI (n=70), and MNCD (n=120). The complete clinical protocol was followed. Hindi ACE-III and HMSE were administered and were statistically analyzed.

Results

The optimal cut-off values to detect MCI and MNCD with ACE-III were 71 and 62 (AUC: 0.849 and 0.884), respectively, which were slightly higher than with HMSE (AUC: 0.822, 0.861). Education- and age-stratified cut-offs were also computed.

Conclusion

Hindi ACE-III has good discriminating power at lower cut-offs than the standard scores in differentiating between MCI and MNCD.

Prevalence and predictors of falls in a health-seeking older population: An outpatient-based study

BACKGROUND

Falls are one of the major causes of disability in older people. A wide range of risk factors for falls are described according to setting - inpatient, nursing homes and community. The aim of this study was to identify the risk factors for falls in an outpatient setting.

METHODS

In this cross-sectional observational study, 160 consenting subjects were enrolled randomly, from the Geriatric Medicine outpatient department, All India Institute of Medical Sciences, New Delhi, India. Non-ambulatory, seriously ill subjects were excluded. The subjects underwent brief evaluation including falls and geriatric assessment. They were grouped into fallers and non-fallers. A multivariable logistic regression analysis was used to identify the factors associated with falls.

RESULTS

The prevalence of falls was 23.75% (38/160). Women were proportionately higher (26.31%) in the fallers group vis-à-vis 19.67% in the non-fallers group. After multivariate analysis, opioids (odds ratio [OR] 5.24 [95% CI, 2.0 18-13.611]), vision impairment (OR 2.71 [95% CI, 1.050-07.011]), fear of falling (OR 3.17 [95% CI, 1.167-08.629]), instrumental activity of daily living (IADL) impairment (OR 3.41 [95% CI, 1.251-09.301]), anti-anginal medications (OR 8.90 [95% CI, 0.997-79.564]) and self-employment (OR 5.37 [95% CI, 1.058-27.329]) were associated with falls. Adequate nutrition (OR 0.82 [95% CI, 0.688-00.976]) and caregiver support (OR 0.46 [95% CI, 0.275-00.801]) were protective of falls.

CONCLUSION

We identified the multi-factorial etiology of falls. Patients having any of the above risk factors should undergo detailed fall risk assessment and preventive measures afterwards.

Frequency and predictors of compliance among patients taking antihypertensive medicines

INTRODUCTION

Medication compliance, an important aspect in the treatment of chronic disease research, is often assessed using pill count method. The patient perception is usually not addressed objectively. The present study was conducted to assess patient cognizance, prevalence and predictors of compliance towards antihypertensive therapy in Indian patients.

METHODS

Adult patients taking antihypertensive medicines were included from the cardiology and geriatric OPDs of a tertiary care hospital in India. Socio-demographic data and disease awareness information was collected. Hill-Bone high blood pressure compliance scale was administered for compliance score.

RESULTS

For the 452 participants, mean age was 54.6 ± 13.7 years with approximate 2:1 ratio of males to females. Cronbach's alpha value of 0.7 for Hill Bone compliance scale showed good internal consistency. More than 80% participants had a score of ≥80%, showing good compliance among Indian patients. Factors that were significantly associated with uncontrolled blood pressure with correlation analysis were age, gender and awareness regarding disease.

CONCLUSION

The study suggests that Hill-Bone high blood pressure compliance scale may be useful for assessing compliance in Indian population. An age appropriate intervention for continued compliance should be considered to improve compliance and hence, reduce long term sequelae of hypertension.

Clinical spectrum and diagnostic yields of Mycoplasma pneumoniae as a causative agent of community-acquired pneumonia

INTRODUCTION:

Infection with Mycoplasma pneumoniae (M. pneumonia) occurs worldwide which accounts for 15%–20% of cases of community-acquired pneumonia and indistinguishable clinically from other infectious causes of pneumonia.

AIM:

The aim of this study was to evaluate the real-time polymerase chain reaction (PCR) and to correlate it with other diagnostic methods such as culture, serology (ELISA), and conventional PCR along with the clinical signs and symptoms produced by M. pneumonia.

MATERIALS AND METHODS:

A total of 130 patients of all age groups presenting with clinical features of lower respiratory tract infections were enrolled over a period of 1 year and 2 months in a tertiary care hospital in Delhi. M. pneumoniae in throat swab samples was detected by real-time PCR, compared with culture, serology, conventional PCR, and clinical signs and symptoms. Univariate analyses were conducted to determine the association of M. pneumoniae infection among different categories of patients.

RESULTS:

Out of a total of 130 patients, 18 patients (14%) were positive for M. pneumoniae by any test; culture was positive in nine patients (50%), serology (IgM) in eight patients (44.4%), PCR in five patients (27.7%), and real-time PCR was positive in six patients (33.3%). Clinical signs and symptoms were higher in incidence in M. pneumoniae-positive patients. Age-matched healthy controls (30) were included in the study, and all were negative for any diagnostic test performed (P = 0.026).

CONCLUSION:

It was concluded that combination of M. pneumoniae-specific testing modalities is required for the diagnosis of this etiological agent rather than a single diagnostic method.

1622. Clinical and Environmental Surveillance of Legionella pneumophila in a Tertiary Healthcare Center in India

Background

Legionellosis is a form of pneumonia caused by Gram-negative bacilli belonging to the Legionella genus. In India, sporadic cases of legionellosis have been reported, but the incidence of this infection is still believed to be underestimated. We conducted a proactive clinical–environmental surveillance in a tertiary healthcare center to determine the frequency of legionellosis, and to identify the pathogen in the hospital water systems.

Methods

During February 2015–February 2019, we enrolled 533 cases (310 males, 223 females) with a diagnosis of pneumonia; a respiratory secretion was collected from each patient and tested for L.pneumophila by using a real-time PCR targeting mip gene. To identify Legionella spp. present in hospital water systems, we collected 201 hospital water samples and were analyzed by cultivation in BCYE agar. Legionella speciation and identification of Lp1 was done by real-time PCR assay.

Results

Among 533 cases, 11(2.1%) [6 male, 5 female] tested positive for L.pneumophila by real-time PCR. Of these, all were community-acquired sporadic cases not associated with a cluster or outbreak. Risk factors including smoking, alcohol use, malignancy, underlying respiratory disease, hypertension were identified in 8 (72.7%) cases. The duration of hospitalization for Legionella patients was 8–24 days; 5/11 (45.5%) patients were admitted to intensive care units. Of 11 patients 8 (72.7%) survived, and 3(27.3%) died. Among the 201 water samples tested, 38 (18.9%) tested positive for L.pneumophila by culture. The presence of Lp1 was detected in 25 (12.4%) water samples. Legionella spp. was recurrently isolated from patient areas, cooling towers, residential areas, and other areas inside the hospital campus.

Conclusion

The study indicates a low prevalence of legionellosis in this region. Even though Legionella colonization was detected in the hospital water system, no cases of hospital-acquired legionellosis were discovered during the study period. However, considering the risk of nosocomial legionellosis to patients we formulated Legionella control strategies in this hospital. Point-of-use filters were installed to the potable water units from where Legionella was isolated and repeat sampling from these sites were found to be negative for the contagion.

Disclosures

All authors: No reported disclosures.

Ethnic differences in the prevalence of frailty in the United Kingdom assessed using the electronic Frailty Index

OBJECTIVE

There have been few studies in which the prevalence of frailty of different ethnic groups has been assessed in multiethnic countries. The aim of this study was to evaluate the prevalence of frailty in different ethnic groups in the United Kingdom.

METHODS

Anonymized electronic health records (EHR) of 13 510 people aged 65 years and over were extracted from the database of a network of general practitioners, covering 16 clinical commissioning groups in London. Frailty was determined using the electronic Frailty Index (eFI), which was automatically calculated using EHR data. The eFI was used as a categorical variable with fit and mild frailty grouped together, and moderate and severe frailty grouped as frail.

RESULTS

The overall prevalence of frailty was 18.1% (95% confidence interval [CI], 17.4%-18.9%). The prevalence of frailty increased with age (odds ratio [OR], 1.11; 95% CI, 1.10-1.12) and body mass index (BMI; OR, 1.05; 95% CI, 1.04-1.06). The highest prevalence of frailty was observed for Bangladeshis, with 32.9% classified as frail (95% CI, 29.2-36.7); and the lowest prevalence of 14.0% (95% CI, 12.6-15.5) was observed for the Black ethnic group. Stepwise logistic regression retained ethnicity, age, and BMI as predictors of frailty.

CONCLUSION

This pilot study identified differences in the prevalence of frailty between ethnic groups in a sample of older people living in London. Additional studies are warranted to determine the causes of such differences, including migration and socioeconomic status. It would be worthwhile carrying out a validation study of the eFI in different ethnic populations.

LASI-DAD study: a protocol for a prospective cohort study of late-life cognition and dementia in India

INTRODUCTION

Alzheimer's disease and related dementias can be considered the epidemic of the 21st century. Particularly, the predicted growth in the size of elderly populations in low-income and middle-income countries is expected to produce a dramatic surge in dementia prevalence and incidence. Although a rising burden of dementia presents an urgent challenge for India, previous efforts to study dementia in the country have relied on non-representative samples in geographically restricted regions. The Harmonised Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) will provide rich, population-representative data on late-life cognition and dementia and their risk factors for the first time in India.

METHODS

The LASI-DAD will recruit a sample of 3000 people aged 60+ years. Their family members or friends, whom respondents nominate as informants, participate in the computer-assisted personal interview. The study sample is drawn from the ongoing, nationally representative Longitudinal Aging Study in India, a multipurpose panel survey of aging. We aim to collect rich data on cognitive and neuropsychological tests, informant reports, and epidemiological data through a comprehensive geriatric assessment, and venous blood collection and assays. For a subsample, we collect neuroimaging data. Data collection is currently in progress in 14 States and Union Territories of India. Clinicians will provide clinical consensus diagnosis based on the Clinical Dementia Rating.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Indian Council of Medical Research and all collaborating institutions. Anonymised data will be available for the larger research community through a secured website hosted by the Gateway to Global Aging Data platform. Research findings from the LASI-DAD team will be disseminated through journal publications and presentations at professional conferences.

Elevated Serum SIRT 2 May Differentiate Parkinson's Disease From Atypical Parkinsonian Syndromes

Atypical Parkinson syndromes (APSs) often have symptoms that overlap with those of Parkinson's disease (PD), especially early in the disease, making these disorders difficult to diagnose. Previous studies have demonstrated an association of oligomeric α-synuclein (α-Syn), a key element in the pathogenesis of PD, with Sirtuin (SIRT)2 proteins for modulating PD. We aimed to evaluate SIRT protein expression in serum of PD patients and compare it with APSs and normal elderly control (GC) and to correlate this with α-Syn. SIRT protein expression was evaluated in sera of 68 PD; 34 APS and 68 GC without any neuro-psychiatric illness as controls by surface plasmon resonance (SPR). SIRT2 expression was correlated with α-Syn in PD and GC. Significant (p < 0.0001) differences were observed between serum SIRT2 concentration in PD and APS and GC as well as between APS and GC. Receiver operating characteristic (ROC) analysis revealed the strong cut-off value to differentiate PD from APS and GC and also APS from GC. Significant correlation was observed among SIRT2 levels in early PD patients with Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn & Yahr (H & Y) and increased duration of disease. In addition, a strong positive correlation of SIRT2 with α-Syn (p < 0.0001) was observed. However, no such difference was detected for serum SIRT1 in cases of PD and APS or for GC. The present study is the first to report elevated serum SIRT2 in PD. The study also provided a simple test to distinguish PD from APS and may have translational utility for diagnosis.