Human Resources for Care in Latin America and the Caribbean: Current Needs and Future Demands

OBJECTIVES

To estimate the current gap and the necessary supply of human resources for care (HRC) for older people experiencing severe care dependence in Latin America and the Caribbean (LAC).

DESIGN

Simulation study using previous estimations of severe care dependence for LAC countries.

SETTING AND PARTICIPANTS

Older people (aged 65+) experiencing severe care dependence in 26 countries of LAC.

METHODS

We calculated the current gap and the necessary supply of HRC in 2020, 2035, and 2050 assuming a mix of complementary human resources, in line with regional standards for long-term care (LTC) schemes, and differing levels of care coverage.

RESULTS

Considering 100% coverage of LTC services for the population aged 65+ experiencing severe care dependence, the region will need almost 5 million people working full-time in the sector. This figure is expected to increase to more than 14 million by 2050. Nurse assistants and nurses will be the professional profiles in highest demand. In addition, the region requires 2 million rehabilitation professionals in 2020, and this figure will increase to more than 6 million in 2050.

CONCLUSIONS AND IMPLICATIONS

The rapid aging process in LAC will bring several challenges and opportunities to the region. Countries should start designing strategies to reduce the current gaps of HRC to meet older people's care needs in the coming years, in terms of both quantity and competencies, to help ensure that their human rights are met.

Comparison between the General Assessment of Hospitalised Patient Tool and the Barthel Index: A Retrospective Study

Among hospitalised patients, functional decline and increased dependence on others are common health problems. Identifying critical needs is an important starting point to empower patients to improve their own health and behaviour. Once these needs are determined, the most relevant goals for addressing patients' needs and health potential can be established. This study aimed to test a model for profiling patients using the General Assessment of Hospitalised Patients (ASGO) compared to the Barthel Index (BI) as the gold standard. A retrospective approach was conducted by reviewing administrative data recorded between 2017 and 2020 at the University of Padova, Italy. Data from patients (a) older than 18 years, (b) admitted to a local hospital, and (c) with a stay of at least three days were included in the study. The ASGO and the BI were both used on patients' admission and discharge from the ward. Data were analysed using STATA software (v.16) (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC). The database used for the analysis consisted of 842 patient records, with more than 50% over 75 years of age and consisting mainly of men. The results of the ASGO and the BI were more correlated at discharge (rho = -0.79) than at admission (rho = -0.59). Furthermore, sensitivity and specificity, calculated with reference to the optimal cut-off point (Youden index), demonstrated the highest reliability of the test at discharge (sensitivity: 0.87; specificity: 0.78) compared to admission (sensitivity: 0.77; specificity: 0.72). This result was confirmed by the analysis of the ROC curve: The area under the curve was greater at discharge (89%) than at admission (82%). Analysis of the results obtained from assessments created with the ASGO demonstrates the applicability of this model in the context of hospital care and how well it can represent functional dependence. This study was not registered.

Neuropsychological Characterization of Autosomal Recessive Intellectual Developmental Disorder 59 Associated with IMPA1 (MRT59)

Biallelic loss of function of IMPA1 causes autosomal recessive intellectual developmental disorder 59 (MRT59, OMIM #617323). MRT59 has been reported to present with significant intellectual disability and disruptive behavior, but little is known about the neurocognitive pattern of those patients. Thus, the aims of this study were: (1) to assess the cognitive profile of these patients, and (2) to evaluate their functional dependence levels. Eighteen adults, aged 37 to 89 years, participated in this study: nine MRT59 patients, five heterozygous carriers and four non-carrier family members. All of them were from a consanguineous family living in Northeast Brazil. All IMPA1 patients had the (c.489_493dupGGGCT) pathogenic variant in homozygosis. For cognitive assessment, the WASI battery was applied in nine MRT59 patients and compared to heterozygous carriers and non-carrier family members. Functional dependence was evaluated using the functional independence measure (FIM). Patients showed moderate to severe intellectual disability and severe functional disabilities. Heterozygous carriers did not differ from non-carriers. MRT59 patients should be followed up by health professionals in an interdisciplinary way to understand their cognitive disabilities and functional needs properly.

Contributing Factors to the Burden on Primary Family Caregivers of Stroke Survivors in South Korea

The purpose of this study is to identify the factors associated with the burden on primary family caregivers of stroke patients at home without care services. For this study, the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) data were used. Of the total 8010 caregivers, 1133 family caregiver burden was assessed with the shortened Caregiver Burden Inventory (CBI) 3 months after stroke. Patient and caregiver-related factors affecting the heavier burden of caregivers were identified by comparing the heavier caregiver burden group and the lighter caregiver burden group, which divided according to the CBI scores. The 719 (63.5%) family caregiver cared for patients at home without care services. Logistic regression analysis showed that four or more comorbidities (p = 0.002), neurological impairment at early onset (p < 0.001), dependence on daily life (p < 0.001), aphasia (p = 0.024), and depression(p < 0.001) were associated with a heavier burden of care. According to the shortened CBI, caregivers tended to be concerned more about psychological stress than physical strain. The findings suggest the importance of proactively guiding the emotional support services to caregivers who are at high risk of the heavier burden of patient care.

Functional dependence among stroke survivors: A concept analysis

AIM

To report an analysis of the concept of functional dependence among stroke survivors.

BACKGROUND

Functional dependence among stroke survivors is a focal stimulus that leads to caregiver burden and can be measured and applied to research and theory in different ways depending on the researcher's interpretation of the concept.

DESIGN

A concept analysis was conducted using the method described by Walker and Avant.

DATA SOURCE

A review of the literature was conducted using the CINAHL and PubMed databases. Lay literature, such as the Merriam-Webster dictionary was included.

RESULTS

Through the identification and analysis of definitions and uses of the concept, the defining attributes were found to be (1) inability to perform regular functions and (2) dependence on a caregiver to perform regular functions which form the conceptual and operational definitions. A model, borderline, and the related case of the conceptual definition are provided. One antecedent, two consequences, and four empirical referents are identified, alongside the instruments used to measure the empirical referents.

CONCLUSIONS

With functional dependence being so closely tied to caregiver burden, researchers and clinicians should take a dyadic approach to caring for this patient population to ensure both perspectives are considered, and optimal patient outcomes are achieved.

Predicting 30-Day Perioperative Outcomes in Adult Spinal Deformity Patients With Baseline Paralysis or Functional Dependence

BACKGROUND

Patients undergoing surgical treatment of adult spinal deformity (ASD) are often preoperatively risk stratified using standardized instruments to assess for perioperative complications. Many ASD instruments account for medical comorbidity and radiographic parameters, but few consider a patient's ability to independently accomplish necessary activities of daily living (ADLs).

METHODS

Patients ≥18 years undergoing ASD corrective surgery were identified in National Surgical Quality Improvement Program. Patients were grouped by (1) plegic status and (2) dependence in completing ADLs ("totally dependent" = requires total assistance in ADLs, "partially dependent" = uses prosthetics/devices but still requires help, "independent" = requires no help). Quadriplegics and totally dependent patients comprised "severe functional dependence," paraplegics/hemiplegics who are "partially dependent" comprised "moderate functional dependence," and "independent" nonplegics comprised "independent." Analysis of variance with post hoc testing and Kruskal-Wallis tests compared demographics and perioperative outcomes across groups. Logistic regression found predictors of inferior outcomes, controlling for age, sex, body mass index (BMI), and invasiveness. Subanalysis correlated functional dependence with other established metrics such as the modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI).

RESULTS

A total of 40,990 ASD patients (mean age 57.1 years, 53% women, mean BMI 29.8 kg/m²) were included. Mean invasiveness score was 6.9 ± 4.0; 95.2% were independent (Indep), 4.3% moderate (Mod), and 0.5% severe (Sev). Sev had higher baseline invasiveness than Mod or Indep groups (9.0, 8.3, and 6.8, respectively, P < 0.001). Compared with the Indep patients, Sev and Mod had significantly longer inpatient length of stay (LOS; 10.9, 8.4, 3.8 days, P < 0.001), higher rates of surgical site infection (2.2%, 2.9%, 1.5%, P < 0.001), and more never events (17.7%, 9.9%, 4.0%, P < 0.001). Mod had higher readmission rates than either the Sev or Indep groups (30.2%, 2.7%, 10.3%, P < 0.001). No differences in implant failure were observed (P > 0.05). Controlling for age, sex, BMI, CCI, invasiveness, and frailty, regression equations showed increasing functional dependence significantly increased odds of never events (OR, 1.82 [95% CI 1.57-2.10], P < 0.001), specifically urinary tract infection (OR, 2.03 [95% CI 1.66-2.50], P < 0.001) and deep venous thrombosis (OR, 2.04 [95% CI 1.61-2.57], P < 0.001). Increasing functional dependence also predicted longer LOS (OR, 3.16 [95% CI 2.85-3.46], P < 0.001) and readmission (OR, 2.73 [95% CI 2.47-3.02], P < 0.001). Subanalysis showed functional dependence correlated more strongly with mFI (r = 0.270, P < 0.001) than modified CCI (mCCI; r = 0.108, P < 0.001), while mFI and mCCI correlated most with one another (r = 0.346, P < 0.001).

CONCLUSIONS

Severe functional dependence had significantly longer LOS and more never-event complications than moderate or independent groups. Overall, functional dependence may show superiority to traditional metrics in predicting poor perioperative outcomes, such as increased LOS, readmission rate, and risk of surgical site infection and never events.

LEVEL OF EVIDENCE: 3

One-Year Functional, Cognitive, and Psychological Outcomes Following the Use of Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019: A Prospective Study

To prospectively describe 1-year outcomes, with a focus on functional outcome, cognitive outcome, and the burden of anxiety, depression, and post-traumatic stress disorder, in coronavirus disease 2019 patients managed with extracorporeal membrane oxygenation.

Design

Prospective case series.

Setting

Tertiary extracorporeal membrane oxygenation center in the United States.

Patients

Adult coronavirus disease 2019 acute respiratory distress syndrome patients managed with extracorporeal membrane oxygenation March 1, 2020, to July 31, 2020.

Interventions

Baseline variables, treatment measures, and short-term outcomes were obtained from the medical record. Survivors were interviewed by telephone, a year following the index intensive care admission. Functional outcome was assessed using the modified Rankin Scale and the World Health Organization Disability Assessment Scale 2.0. Cognitive status was assessed with the 5-minute Montreal Cognitive Assessment. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression. Screening for post-traumatic stress disorder was performed with the Posttraumatic Stress Disorder Checklist 5 instrument.

Measurements and Main Results

Twenty-three patients were managed with extracorporeal membrane oxygenation, 14 (61%) survived to hospital discharge. Thirteen (57%) were alive at 1 year. One patient was dependent on mechanical ventilation, another intermittently required supplemental oxygen at 1 year. The median modified Rankin Scale score was 2 (interquartile range, 1-2), median World Health Organization Disability Assessment Scale 2.0 impairment score was 21% (interquartile range, 6-42%). Six of 12 previously employed individuals (50%) had returned to work, and 10 of 12 (83%) were entirely independent in activities of daily living. The median Montreal Cognitive Assessment score was 14 (interquartile range, 13-14). Of 10 patients assessed with Hospital Anxiety and Depression Scale, 4 (40%) screened positive for depression and 6 (60%) for anxiety. Four of 10 (40%) screened positive for post-traumatic stress disorder.

Conclusions

Functional impairment was common a year following the use of extracorporeal membrane oxygenation in coronavirus disease 2019, although the majority achieved independence in daily living and about half returned to work. Long-term anxiety, depression, and post-traumatic stress disorder were common, but cognitive impairment was not.

Leukoaraiosis is associated with clinical symptom severity, poor neurological function prognosis and stroke recurrence in mild intracerebral hemorrhage: a prospective multi-center cohort study

Leukoaraiosis (LA) results from ischemic injury in small cerebral vessels, which may be attributable to decreased vascular density, reduced cerebrovascular angiogenesis, decreased cerebral blood flow, or microcirculatory dysfunction in the brain. In this study, we enrolled 357 patients with mild intracerebral hemorrhage (ICH) from five hospitals in China and analyzed the relationships between LA and clinical symptom severity at admission, neurological function prognosis at 3 months, and 1-year stroke recurrence. Patients were divided into groups based on Fazekas scale scores: no LA (n = 83), mild LA (n = 64), moderate LA (n = 98) and severe LA (n = 112). More severe LA, larger hematoma volume, and higher blood glucose level at admission were associated with more severe neurological deficit. More severe LA, older age and larger hematoma volume were associated with worse neurological function prognosis at 3 months. In addition, moderate-to-severe LA, admission glucose and symptom-free cerebral infarction were associated with 1-year stroke recurrence. These findings suggest that LA severity may be a potential marker of individual ICH vulnerability, which can be characterized by poor tolerance to intracerebral attack or poor recovery ability after ICH. Evaluating LA severity in patients with mild ICH may help neurologists to optimize treatment protocols. This study was approved by the Ethics Committee of Ruijin Hospital Affiliated to Shanghai Jiao Tong University (approval No. 12) on March 10, 2011.

[Clinical and pharmacological data in COVID-19 hospitalized nonagenarian patients]

Introducción

A pesar del impacto del SARS-CoV-2 en geriatría, disponemos de escasa información en pacientes nonagenarios. Nuestro objetivo es describir características clínicas, respuesta al tratamiento y factores de riesgo de mortalidad en nonagenarios con COVID-19.

Material y métodos

Estudio retrospectivo observacional de pacientes nonagenarios hospitalizados por COVID-19. Se registraron variables sociodemográficas, clínicas y polifarmacia previa, parámetros analíticos y tratamiento específico.

Resultados

Se incluyeron 79 pacientes. No se relacionó con mortalidad ninguna de las comorbilidades. La mortalidad fue del 50,6%, siendo mayor en pacientes con dependencia funcional moderada/grave respecto aquéllos independientes/ dependientes leves (59,5% vs 40,5%; p=0,015). Los fármacos específicos más prescritos fueron hidroxicloroquina/cloroquina y azitromicina. Los pacientes fallecidos presentaron más leucocitos y neutrófilos, y mayor linfopenia.

Conclusión

En nuestra cohorte, el estado funcional es el principal factor de riesgo de mortalidad, independientemente de las comorbilidades y el tratamiento recibido. Implementar la valoración geriátrica integral permitiría individualizar las estrategias terapéuticas en nonagenarios.

Influence of social support on limitation in daily living among older persons in Malaysia

AIM

Studies on the influence of social support on activity limitation among older persons remain limited. A better understanding of this relationship will help with resource planning and policy making aimed to reduce burden of care. The objective of this study was to assess the influence of social support on limitation in daily living among older persons in Malaysia.

METHODS

Data from the National Health and Morbidity Survey 2018, a nation-wide, cross-sectional survey using a two-stage stratified sampling design, were analyzed. A representative sample of individuals aged ≥60 years identified through national sampling frames throughout Malaysia was included. Face-to-face interviews were conducted using validated questionnaires on activities of daily living (ADL) and instrumental ADL (IADL). Social support was measured using the Duke Social Support Index.

RESULTS

The overall prevalence of the presence of any limitations in ADL and IADL was 17.0% and 42.9% respectively. Overall prevalence of the older persons with low to fair social support was 30.8% and high to very high social support was 69.2%. Logistic regression analysis identified the following factors as being associated with limitations in ADL and IADL: being female, of older age, having a monthly income <RM 1000 and reporting low to fair social support.

CONCLUSION

Low social support was associated with limitation in daily living among older persons in Malaysia. Future studies should consider evaluating the potential benefits of increasing social support on the activity limitation of our older population. Geriatr Gerontol Int 2020; 20: 26-32.

Functional dependence among older adults: a cross-sectional study with a rural population of southern Brazil

INTRODUCTION

Brazil has a rapidly aging population, yet little is known about the occurrence of functional dependence in the rural older adult population. The objective of this study was to estimate the prevalence of functional dependence and its associated factors among community-dwelling older adults in the rural area of the municipality of Rio Grande, Rio Grande do Sul state, Brazil.

METHODS

This was a cross-sectional, population-based study. A systematic random sampling of households was used. Eighty percent of households in the rural area were selected, which included 1131 older adults. The outcome analyzed in this study was functional dependence. This was measured by and data were collected using the Katz Index for Activities of Daily Living (ADL) and Lawton and Brody's Scale for Instrumental Activities of Daily Living (IADL). Descriptive analysis was used to estimate the prevalence of functional dependence in ADL and IADL and to describe the sample. Crude and adjusted analysis was performed by Poisson regression with robust adjustment of variance. Prevalence ratios (PRs) and 95% confidence intervals (95%CIs) were reported.

RESULTS

A total of 1029 older adults took part in this study, corresponding to an 8.9% rate of losses and refusals. Prevalence of functional dependence in ADL was 8.1% (95%CI 6.4-9.7), while prevalence of functional dependence in IADL was 32.4% (95%CI 29.5-35.2). The occurrence of functional dependence in one or more of ADL or IADL was 6.7% (95%CI 5.2-8.2). The following categories were associated with functional dependence in ADL: female sex (PR=1.70; 95%CI 1.10-2.62), age group 80 years or more (PR=3.68; 95%CI 2.20-6.16), no schooling (PR=2.61; 95%CI 1.26-5.37) and 1-4 years of schooling (PR=2.49; 95%CI 1.28-4.84), having diabetes (PR=1.85; 95%CI 1.21-2.83), depression in the previous year (PR=1.90; 95%CI 1.09-3.31), urinary incontinence (PR=3.26; 95%CI 2.06-5.16), history of stroke (PR=2.26; 95%CI 1.35-3.76) and poor/very poor self-rated health (PR=2.36; 95%CI 1.29-4.32). The following categories were associated with functional dependence in IADL: female sex (PR=1.40; 95%CI 1.19-1.65), age groups of 70-79 years (PR=1.92; 95%CI 1.51-2.43) and 80 years or more (PR=3.80; 95%CI 3.07-4.72), no schooling (PR=1.87; 95%CI 1.46-2.41) and 1-4 years of schooling (PR=1.55; 95%CI 1.22-1.96), medical diagnosis of diabetes (PR=1.33; 95%CI 1.10-1.60), urinary incontinence (PR=1.40; 95%CI 1.17-1.68), history of stroke (PR=1.41; 95%CI 1.10-1.81) and regular self-rated health (PR=1.27; 95%CI 1.06-1.52) or poor/very poor self-rated health (PR=1.80; 95%CI 1.41-2.30).

CONCLUSION

Older adults in rural areas have a high prevalence of functional dependence. Knowledge of functional dependence and associated factors in rural populations is necessary for the planning and developing actions, especially in the routine of primary care, which promote health and prevent or postpone the decline in functional capacity.

Cognitive Function, Access to Kidney Transplantation, and Waitlist Mortality Among Kidney Transplant Candidates With or Without Diabetes

RATIONALE & OBJECTIVE

Intact cognition is generally a prerequisite for navigating through and completing evaluation for kidney transplantation. Despite kidney transplantation being contraindicated for those with severe dementia, screening for more mild forms of cognitive impairment before referral is rare. Candidates may have unrecognized cognitive impairment, which may prolong evaluation, elevate mortality risk, and hinder access to kidney transplantation. We estimated the burden of cognitive impairment and its association with access to kidney transplantation and waitlist mortality.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

3,630 participants (January 2009 to June 2018) with cognitive function measured (by the Modified Mini-Mental State Examination [3MS]) at kidney transplantation evaluation at 1 of 2 transplantation centers.

PREDICTORS

Cognitive impairment (3MS score<80).

OUTCOMES

Listing, waitlist mortality, and kidney transplantation.

ANALYTICAL APPROACH

We estimated the adjusted chance of listing (Cox regression), risk for waitlist mortality (competing-risks regression), and kidney transplantation rate (Poisson regression) by cognitive impairment. Given potential differences in cause of cognitive impairment among those with and without diabetes, we tested whether these associations differed by diabetes status using a Wald test.

RESULTS

At evaluation, 6.4% of participants had cognitive impairment, which was independently associated with 25% lower chance of listing (adjusted HR, 0.75; 95% CI, 0.61-0.91); this association did not differ by diabetes status (Pinteraction=0.07). There was a nominal difference by diabetes status for the association between cognitive impairment and kidney transplantation rate (Pinteraction=0.05), while the association between cognitive impairment and waitlist mortality differed by diabetes status kidney transplantation rates (Pinteraction=0.02). Among candidates without diabetes, those with cognitive impairment were at 2.47 (95% CI, 1.31-4.66) times greater risk for waitlist mortality; cognitive impairment was not associated with this outcome among candidates with diabetes.

LIMITATIONS

Single measure of cognitive impairment.

CONCLUSIONS

Cognitive impairment is associated with a lower chance of being placed on the waitlist, and among patients without diabetes, with increased mortality on the waitlist. Future studies should investigate whether implementation of screening for cognitive impairment improves these outcomes.

Improved Outcomes after Reperfusion Therapies for Ischemic Stroke: A "Real-world" Study in a Developing Country

BACKGROUND

It is unknown if improvements in ischemic stroke (IS) outcomes reported after cerebral reperfusion therapies (CRT) in developed countries are also applicable to the "real world" scenario of low and middle-income countries. We aimed to measure the long-term outcomes of severe IS treated or not with CRT in Brazil.

METHODS

Patients from a stroke center of a state-run hospital were included. We compared the survival probability and functional status at 3 and 12 months in patients with severe IS treated or not with CRT. From 2010 to 2011, we performed intravenous reperfusion when patients arrived within 4.5 h time-window (IVT group) and after 2011, mechanical thrombectomy (MT) combined or not with intravenous alteplase (IAT group). Those who arrived >4.5 h in 2010-2011 and >6 h in 2012-2017 did not undergo CRT (NCRT group).

RESULTS

From 2010 to 2017, we registered 917 patients: 74% (677/917) in the NCRT group, 19% (178/917) in the IVT group and 7% (62/917) in the IAT group. Compared to the NCRT group, IVT patients had a 28% higher (HR: 0.72; 95% CI 0.53-0.96) 3-month adjusted probability of survival and risk of functional dependence was 19% lower (adjusted RR: 0.81; 95% CI 0.73-0.91). For those who underwent MT, the adjusted probability of survival was 59 % higher (HR: 0.41; 95% CI 0.21-0.77) and the risk of functional dependence was 21% lower (adjusted RR: 0.79; 95% CI 0.66-094). These outcomes remained significantly better throughout the first year.

CONCLUSION

CRT led to better outcomes in patients with severe IS in Brazil.

Relative Handgrip Strength Diminishes the Negative Effects of Excess Adiposity on Dependence in Older Adults: A Moderation Analysis

The adverse effects of fat mass on functional dependence might be attenuated or worsened, depending on the level of muscular strength. The aim of this study was to determine (i) the detrimental effect of excess adiposity on dependence in activities of daily living (ADL), and (ii) whether relative handgrip strength (HGS) moderates the adverse effect of excess adiposity on dependence, and to provide the threshold of relative HGS from which the adverse effect could be improved or worsened. A total of 4169 participants (69.3 ± 7.0 years old) from 244 municipalities were selected following a multistage area probability sampling design. Measurements included anthropometric/adiposity markers (weight, height, body mass index, waist circumference, and waist-to-height ratio (WHtR)), HGS, sarcopenia “proxy” (calf circumference), and ADL (Barthel Index scale). Moderation analyses were performed to identify associations between the independent variable (WHtR) and outcomes (dependence), as well as to determine whether relative HGS moderates the relationship between excess adiposity and dependence. The present study demonstrated that (i) the adverse effect of having a higher WHtR level on dependence in ADL was moderated by relative HGS, and (ii) two moderation thresholds of relative HGS were estimated: 0.35, below which the adverse effect of WHtR levels on dependency is aggravated, and 0.62, above which the adverse effect of fat on dependency could be improved. Because muscular strength represents a critically important and modifiable predictor of ADL, and the increase in adiposity is inherent in aging, our results underscore the importance of an optimal level of relative HGS in the older adult population.

To Treat or Not to Treat: Importance of Functional Dependence in Deciding Intravenous Thrombolysis of "Mild Stroke" Patients

Intravenous thrombolysis (IVT) in patients with a low National Institutes of Health Stroke Scale (NIHSS) score of 0–5 remains controversial. IVT should be used in patients with mild but nevertheless disabling symptoms. We hypothesize that response to IVT of patients with “mild stroke” may depend on their level of functional dependence (FD) at hospital admission. The aims of our study were to investigate the effect of IVT and to explore the role of FD in influencing the response to IVT. This study was a retrospective analysis of a prospectively collected database, including 389 patients stratified into patients receiving IVT (IVT⁺) and not receiving IVT (IVT ⁻) just because of mild symptoms. Barthel index (BI) at admission was used to assess FD, dividing subjects with BI score < 80 (FD⁺) and with BI score ≥ 80 (FD⁻). The efficacy endpoints were the rate of positive disability outcome (DO⁺) (3-month mRS score of 0 or 1), and the rate of positive functional outcome (FO⁺) (mRS score of zero or one, plus BI score of 95 or 100 at 3 months). At the multivariate analysis, IVT treatment was an independent predictor of DO⁺ (OR 3.12, 95% CI 1.34−7.27, p = 0.008) and FO⁺ (OR: 4.70, 95% CI 2.38−9.26, p = 0.001). However, FD⁺ IVT⁺ patients had a significantly higher prevalence of DO⁺ and FO⁺ than those FD⁺ IVT^–. Differently, IVT treatment did not influence DO⁺ and FO⁺ in FD^– patients. In FD⁺ patients, IVT treatment represented the strongest independent predictor of DO⁺ (OR 6.01, 95% CI 2.59–13.92, p = 0.001) and FO⁺ (OR 4.73, 95% CI 2.29–9.76, p = 0.001). In conclusion, alteplase seems to improve functional outcome in patients with “mild stroke”. However, in our experience, this beneficial effect is strongly influenced by FD at admission.

Dependent Functional Status is a Risk Factor for Perioperative and Postoperative Complications After Total Hip Arthroplasty

BACKGROUND

As the population ages, the need for total hip arthroplasty (THA) will increase. However, this will be associated with an increase in comorbidities and a decrease in the ability to independently perform activities of daily living (ADLs). This study was designed to evaluate the impact preoperative functional status has on short-term outcomes after THA.

METHODS

Primary THAs performed from 2012 to 2016 were identified in the National Surgical Quality Improvement Program database. Final analysis included 115,590 cases. Patients who could perform all ADLs were classified as independent functional status (n = 113,436), and patients requiring assistance with ADLs were classified as dependent functional status (n = 2154). Univariate analysis was used to compare perioperative outcomes and 30-day complication rates. Multivariate regression was then applied to determine if preoperative dependent functional status was an independent risk factor for adverse outcomes.

RESULTS

Functionally dependent patients were more likely to experience operative times >120 minutes (odds ratio [OR] = 1.39; P < .001), hospital stays >10 days (OR = 2.96; P < .001), and nonhome discharge (OR = 2.53; P < .001). Dependent functional status was also an independent risk factor for mortality (OR = 3.00; P = .001), reoperation (OR = 1.39; P = .015), readmission (OR = 1.75; P < .001), superficial surgical site infection (OR = 1.96; P = .002), wound dehiscence (OR = 2.72; P = .034), pneumonia (OR = 2.16; P = .001), reintubation (OR = 2.31; P = .007), prolonged ventilator use (OR = 3.01; P = .009), renal failure necessitating dialysis (OR = 3.94; P = .002), urinary tract infection (OR = 1.78; P = .001), blood transfusion (OR = 1.75; P < .001), and sepsis (OR = 2.38; P = .001).

CONCLUSIONS

Functionally dependent patients undergoing THA are at higher risk of mortality, adverse perioperative outcomes, and complications. These data may aid for patient counseling and risk stratification.

PD Assistance and Relationship to Co-Existing Geriatric Syndromes in Incident Peritoneal Dialysis Therapy Patients

Background:Home dialysis therapies, including peritoneal dialysis (PD), are preferred treatment strategies, offering flexibility and improved wellbeing. However, patients with complex disease and comorbidity may require assistance with personal care and healthcare-related tasks. The study objective was to formally assess the type and frequency of PD assistance received by patients over 50, and the relationship to observed frailty, functional status, and cognitive ability at the time of PD therapy initiation.Methods:Using a multicentered, prospective observational study design, patients aged ≥ 50 years were recruited from those starting PD. Patients underwent formal evaluation using validated components of a Comprehensive Geriatric Assessment. The receipt and nature of assistance with PD tasks were assessed 1 month after dialysis start by questionnaire.Results:A total of 121 patients (age 69 ± 10 years, 67% male, 54% diabetic) were recruited. A total of 75 (62%) patients received assistance for a variety of tasks from friends or family (n = 41, 34%) or a paid caregiver (n = 34, 28%) 1 month after starting dialysis. At baseline, there was a high prevalence of functional dependency (79/120, 66%), frailty (71/110, 65%), and impaired cognition (68/115, 59%). Only 5% were fully independent, clinically robust, and scored within the normal range on cognitive testing. Factors associated with PD assistance included comorbidity (p < 0.03), cognitive impairment (p < 0.0001), and functional dependence (p < 0.02).Conclusion:Older patients initiating PD in the outpatient setting have high rates of frailty, functional dependence, and cognitive changes at the time they initiate dialysis. More research is required to better understand how those factors contribute to the use of PD assistance.

The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia

This paper examines the healthcare needs of community-dwelling older people living in Porto, Portugal, diagnosed with moderate or severe dementia, linked to functional dependency, cognitive decline, limitations in the activities of daily life, and frailty levels. A sample of 83 participants was recruited. Data were collected between 2013 and 2017. A sociodemographic questionnaire, the Clinical Dementia Rating (CDR), the Barthel Index (BI), the Lawton and Brody Instrumental Activities of Daily Living (IADL) Scale, and the Edmonton Frail Scale (EFS) were used. A set of 26 healthcare needs was defined to support the assessment. The Pearson chi-square or Fisher's exact test (as appropriate) was used to examine the association of the needs (unmet and met) with the levels of dementia and frailty. Participants were diagnosed previously with moderate or severe dementia and benefited from a structured home-care program. There was a high number rated as "severe dementia," "fully dependent," "severely or fully dependent in the activities of daily living (ADL)," and "severe frailty." There were statistically significant differences among needs identified in people with moderate or severe dementia and moderate or severe frailty. The most prevalent healthcare needs in the sample were food preparation, medication/taking pills, looking after their home, toilet use, sensory problems, communication/interaction, bladder, bowels, eating and drinking, memory, sleeping, and falls prevention. In particular, the study identifies a set of needs that are present simultaneously in both frailty and dementia stages. This study underlines that despite well-structured home-care programs for people with dementia, unmet health needs remain. Timely healthcare needs assessment may help professionals to avoid fragmented care and to tailor quality-integrated interventions, including the emotional and psychological balance of the caregiver.

Association Between Total Cholesterol and 5 year Mortality in Patients with Carotid Artery Stenosis and Poststroke Functional Dependence

BACKGROUND

Aggressive lipid-lowering treatment reduces the risk of cardiovascular events, but remains controversial in stroke patients. We investigate the influence of total cholesterol level on 5-year outcomes of ischemic stroke patients with high-grade internal carotid artery (ICA) stenosis and poststroke functional dependence.

METHODS

One-hundred and ninety-six acute ischemic stroke patients with high-grade ICA stenosis and modified Rankin Scale score ≥ 3 upon discharge were enrolled and prospectively observed for 5 years. Patients were divided into 2 groups according to total cholesterol level at admission: ≥200 mg/dL or <200 mg/dL. Demographic features, vascular risk factors, co-morbidities, and outcomes were compared between the 2 groups.

RESULTS

117 (59.7%) patients had higher and 79 (40.3%) patients had lower total cholesterol levels. The prevalence of older age and atrial fibrillation was significantly higher in patients with lower total cholesterol; the prevalence of diabetes mellitus was higher in patients with higher total cholesterol. After adjusting for the established clinical predictors of adverse outcomes, the multivariate Cox regression revealed that lower total cholesterol level is a significant predictor of 5-year mortality (HR (hazard ratio) = 1.88, 95% CI (confidence interval) = 1.09-3.23, P = .023).

CONCLUSIONS

Lower total cholesterol level is associated with increased risk of 5-year mortality in ischemic stroke patients with high-grade ICA stenosis and post-stroke functional dependence. Aggressive treatment of hyperlipidemia should be carefully considered in these patients although it could reduce the risk of atherosclerotic cardiovascular diseases and stroke recurrence in some stroke patients.

Prevalence of functional dependence in Chinese centenarians and its relationship with serum vitamin D status

Background

Functional dependence (FD) and vitamin D deficiency are common conditions in older adults. However, little is known about the relationship between FD and serum vitamin D status in centenarians. The current study was designed to evaluate the prevalence of FD and examine its relationship with serum vitamin D status among centenarians in China.

Subjects and methods

A cross-sectional study of a large sample of Chinese centenarians including 180 men and 822 women was conducted from June 2014 to December 2016. Home interviews, physical examinations, and blood analyses were performed in 958 centenarians following standard procedures. FD was evaluated using the Barthel index of activities of daily living (ADL). Serum 25-hydroxyvitamin D (25OHD) concentrations were measured as a marker of vitamin D status.

Results

The prevalence of centenarians with FD was 71.2%. Vitamin D deficiency, lack of tea consumption, lack of outdoor activities, visual impairment, and fracture were predictors of FD. Centenarians in the lowest quartile of serum 25OHD concentration had an approximately threefold greater likelihood of FD than those in the highest quartile in multiple logistic regression models (OR =2.88; 95% CI 1.75–4.73; P<0.001). The multivariable OR with a 1 ng/mL decrease in serum 25OHD concentration was 1.06 (95% CI 1.04–1.08; P<0.001) for FD.

Conclusion

Serum 25OHD levels have important associations with FD in Chinese centenarians. Future research could focus on the value of intervening in the case of low serum 25OHD levels through vitamin D supplementation and improving ADL in the older population.

Entropy Inequalities for Lattices

We study entropy inequalities for variables that are related by functional dependencies. Although the powerset on four variables is the smallest Boolean lattice with non-Shannon inequalities, there exist lattices with many more variables where the Shannon inequalities are sufficient. We search for conditions that exclude the existence of non-Shannon inequalities. The existence of non-Shannon inequalities is related to the question of whether a lattice is isomorphic to a lattice of subgroups of a group. In order to formulate and prove the results, one has to bridge lattice theory, group theory, the theory of functional dependences and the theory of conditional independence. It is demonstrated that the Shannon inequalities are sufficient for planar modular lattices. The proof applies a gluing technique that uses that if the Shannon inequalities are sufficient for the pieces, then they are also sufficient for the whole lattice. It is conjectured that the Shannon inequalities are sufficient if and only if the lattice does not contain a special lattice as a sub-semilattice.

Urinary Incontinence in a National Cohort of Older Women: Implications for Caregiving and Care Dependence

BACKGROUND

Urinary incontinence (UI) can interfere with older women's ability to perform activities of daily living (ADLs), but little is known about factors that predispose incontinent women to become functionally dependent or compromise their ability to serve as caregivers to others.

STUDY DESIGN

UI, caregiving, and care-receiving behaviors were assessed by questionnaire in a national sample of community-dwelling older women. Multivariable models evaluated associations between incontinence and care dependence, assessed factors associated with care dependence among incontinent women, and compared health among female caregivers with and without incontinence.

RESULTS

Of the 1703 women, 27% reported weekly or more incontinence and 13% monthly incontinence. Women with weekly or more incontinence were more likely than women without incontinence to report receiving care for ADLs (AOR = 2.39, CI = 1.61-3.56) or instrumental ADLs (AOR = 1.94, CI = 1.42-2.63). Compared to 46% of women without incontinence, 60% of women with monthly or weekly incontinence reported unmet care needs (p = 0.0002). Factors associated with care dependence included more frequent incontinence, older age, marital status, and fair/poor health (p < 0.05 for all). Overall, 15% of women served as a caregiver for another adult, which did not differ by incontinence status (p = 0.84), but female caregivers with incontinence reported worse health than those without incontinence (p = 0.0004).

CONCLUSIONS

In this national cohort, older women with incontinence were more likely to be functionally dependent and have unmet care needs than those without incontinence, after adjustment for other factors. At least one in ten incontinent women served as caregivers, despite having worse health than female caregivers without incontinence.

A Longitudinal Study Examining the Change in Functional Independence Over Time in Elderly Individuals With a Functioning Kidney Transplant

Background:

Functional disability is defined as the need for assistance with self-care tasks.

Objective:

To document changes in functional status over time among older prevalent renal transplant recipients.

Design:

Single center, prospective, follow-up study.

Setting:

Single center, tertiary care transplant center.

Patients:

Patients, with a functioning kidney transplant, aged 65 years or older who underwent assessment of functional status approximately 12 months previously.

Measurements:

Validated tools used included Barthel Index, the Lawton-Brody Scale of Instrumental Activities of Daily Living, the Timed Up and Go test, the Veterans Specific Activity Questionnaire, the Mini-Cog, and dynamometer handgrip strength.

Methods:

Outpatient assessment by a trained observer.

Results:

Of the 82 patients previously studied, 64 (78%) patients participated in the follow-up study (mean age 70.5 ± 4.4 years, 58% male, 55% diabetic). Among those completing functional status measures, 32 (50%) had functional disability at baseline. Over the 1-year period, 11 (17%) of these patients experienced progressive functional decline, 6 (9%) exhibited no change, and 15 (23%) had functional recovery. Eleven patients (17%) initially independent, developed new-onset disability. One of the strongest predictors of progressive functional decline was having 1 or more falls in the previous year.

Limitations:

Assessments were performed only on 2 occasions separated by approximately 1 year.

Conclusions:

Fluctuations in disability states are common among older adults living with renal transplants. Episodes of functional disability may place individuals at higher risk of persistent and/or progressive disability.

[Seven questions for elderly in the practice of primary care physicians]

Although geriatric syndromes are widespread, they often remain undiagnosed leading to the development of adverse outcomes. For the prompt detection of the most common geriatric syndromes in primary care we have created seven issues related to weight loss, vision and hearing impairments, falls, mood disorder, cognitive impairment, urinary incontinence, and the difficulties in walking. We believe that using of these questions will allow physicians to focus on addressing the important health problems associated with age and will produce the selection of patients for comprehensive geriatric assessment.

Coexisting with dependence and well-being: the results of a pilot study intervention on 75-99-year-old individuals

BACKGROUND

The objective of this study is to design and implement an intervention program centered on preventing functional dependence.

METHODS

A pre/post quasi-experimental (typical case) design study with a control group was conducted on a group of 75-90-year-old individuals with functional dependence (n = 59) at three nursing homes in Madrid (Spain). The intervention program consists of two types of activities developed simultaneously. Some focused on emotional well-being (nine 90-minute sessions, once per week), whereas others focused on improving participants' physical condition (two 30-minute sessions, twice per week). The simple randomized participants included 59 elderly individuals (Intervention Group = 30, Control Group = 29) (mean age 86.80) [SD, 5. 19].

RESULTS

Fifty-nine participants were analyzed. The results indicate that the program is effective in improving mood, lowering anxiety levels (d = 0.81), and increasing both self-esteem (d = 0.65) and the perception of self-efficacy (d = 1.04). There are improvements in systolic pressure and functional dependence levels are maintained. Linear simple regression (independent variable pre-Barthel) shows that the pre-intervention dependence level can predict self-esteem after the intervention.

CONCLUSION

We have demonstrated that the program is innovative with regard to bio-psychosocial care in elderly individuals, is based on actual practice, and is effective in increasing both self-esteem and self-efficacy. These variables positively affect functional capabilities and delay functional dependence.

Ability of preoperative falls to predict postsurgical outcomes in non-selected patients undergoing elective surgery at an academic medical centre: protocol for a prospective cohort study

INTRODUCTION

Falls are increasingly recognised for their ability to herald impending health decline. Despite the likely susceptibility of postsurgical patients to falls, a detailed description of postoperative falls in an unselected surgical population has never been performed. One study suggests that preoperative falls may forecast postoperative complications. However, a larger study with non-selected surgical patients and patient-centred outcomes is needed to provide the generalisability and justification necessary to implement preoperative falls assessment into routine clinical practice. The aims of this study are therefore twofold. First, we aim to describe the main features of postoperative falls in a population of unselected surgical patients. Second, we aim to test the hypothesis that a history of falls in the 6 months prior to surgery predicts postoperative falls, poor quality of life, functional dependence, complications and readmission.

METHODS AND ANALYSIS

To achieve these goals, we study adult patients who underwent elective surgery at our academic medical centre and were recruited to participate in a prospective, survey-based cohort study called Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) (NCT02032030). Patients who reported falling in the 6 months prior to surgery will be considered 'exposed.' The primary outcome of interest is postoperative falls within 30 days of surgery. Secondary outcomes include postoperative functional dependence, quality of life (both physical and mental), in-hospital complications and readmission. Regression models will permit controlling for important confounders.

ETHICS AND DISSEMINATION

The home institution's Institutional Review Board approved this study (IRB ID number 201505035). The authors will publish the findings, regardless of the results.

Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND

Patients receiving long-term dialysis have among the highest mortality and hospitalization rates. In the nonrenal literature, functional dependence is recognized as a contributor to subsequent disability, recurrent hospitalization, and increased mortality. A higher burden of functional dependence with progressive worsening of kidney function has been observed in several studies, suggesting that functional dependence may contribute to both morbidity and mortality in dialysis patients.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

7,226 hemodialysis patients from 12 countries in the DOPPS (Dialysis Outcomes and Practice Patterns Study) phase 4 (2009-2011) with self-reported data for functional status.

PREDICTOR

Patients' ability to perform 13 basic and instrumental activities of daily living was summarized to create an overall functional status score (range, 1.25 [most dependent] to 13 [functionally independent]).

OUTCOME

Cox regression was used to estimate the association between functional status and all-cause mortality, adjusting for several demographic and clinical risk factors for mortality. Median follow-up was 17.2 months.

RESULTS

The proportion of patients who could perform each activity of daily living task without assistance ranged from 97% (eating) to 47% (doing housework). 36% of patients could perform all 13 tasks without assistance (functional status = 13), and 14% of patients had high functional dependence (functional status < 8). Functionally independent patients were younger and had many indicators of better health status, including higher quality of life. Compared with functionally independent patients, the adjusted HR for mortality was 2.37 (95% CI, 1.92-2.94) for patients with functional status < 8.

LIMITATIONS

Possible nonresponse bias and residual confounding.

CONCLUSIONS

We found a high burden of functional dependence across all age groups and across all DOPPS countries. When adjusting for several known mortality risk factors, including age, access type, cachexia, and multimorbidity, functional dependence was a strong consistent predictor of mortality.

Use of medications and functional dependence among Chinese older adults in a rural community: A population-based study

AIM

To investigate the associations between medication use and functional dependence in Chinese older people living in a rural community.

METHODS

The cross-sectional study included 1538 participants (age ≥60 years, 59.1% women) in the Confucius Hometown Aging Project in Shandong, China. In June 2010 to July 2011, data on demographics, lifestyle factors, health history, basic activities of daily living (ADL), instrumental ADL, and use of medications were collected through interviews and clinical examinations. Functional status was categorized into no dependence, dependence only in instrumental ADL and dependence in basic ADL. Data were analyzed with multinomial logistic models controlling for potential confounders.

RESULTS

Dependence in instrumental or basic ADL was significantly associated with use of antihypertensives and hypolipidemic agents, and basic ADL dependence was also associated with use of sedatives or tranquilizers and cardiac glycosides. An increased number of concurrently used medications was significantly associated with an increased likelihood of dependence in basic ADL (P for trend = 0.016). Compared with non-users of any medication, individuals who concurrently used three or more classes of medications had a multi-adjusted odds ratio of 2.91 (95% confidence interval 1.02-8.28) for dependence in basic ADL.

CONCLUSIONS

Use of antihypertensives, hypolipidemic drugs, cardiac glycosides and sedatives or tranquilizers, especially use of multiple classes of medications, is correlated with functional dependence among older people in rural China. Geriatr Gerontol Int 2015; 15: 1242-1248.

Trajectories of the multidimensional dying experience for terminally ill cancer patients

CONTEXT

Studies exploring the trajectories of physical-psychological-social-spiritual dying experiences frequently treat changes in these experiences as consistent across different domains and over time.

OBJECTIVE

This prospective, longitudinal investigation was designed to characterize trajectories of the multidimensional dying experience for cancer patients in their last year of life.

METHODS

Trajectories of physical-psychological-social-spiritual/existential dimensions and overall quality of life (QOL) were identified among 313 cancer patients using mixed-effects models to test for linear, quadratic, or cubic changes. Changes in each variable were evaluated for clinical significance using minimal important difference.

RESULTS

When patients transitioned to their end of life, symptom distress, functional dependence, anxiety, and depressive symptoms slightly increased, followed by a stable status for approximately four to six months, and accelerated dramatically to the first clinically significant changes at three to four months before death. Perceived social support and post-traumatic growth declined gradually to clinically significant changes at one and four months before death, respectively. Perceived sense of burden to others increased steadily in the last year of life, with no clinically significant changes identified. Overall QOL deteriorated gradually in the last year but did not reach a clinically significant change until 2.5 months before death.

CONCLUSION

All dimensions deteriorated in the last year of life but with distinctive physical-psychological-social-spiritual/existential and overall QOL trajectories. Recognizing trajectory patterns and tipping points of accelerating deterioration in each dimension can help clinicians anticipate times of increased distress, initiate timely, effective interventions to relieve patient suffering, and facilitate high-quality end-of-life care tailored to patients' needs and preferences.