Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes

OBJECTIVE

Older adults at the Emergency Department (ED) often present with nonspecific complaints (NSC) such as 'weakness' or 'feeling unwell'. Health care workers may underestimate illness in patients with NSC, leading to adverse health outcomes. This study compares characteristics and outcomes of NSC-patients versus specific complaints (SC) patients.

METHODS

Cohort study in patients ≥ 70 years in two Dutch EDs. NSC was classified according to the BANC-study-framework based on the medical history in the ED letter, before additional diagnostics took place. A second classification was performed at the end of the ED visit/hospital admission. Primary outcomes were functional decline, institutionalization, and mortality at 30 days.

RESULTS

26% (n = 228) of a total of 888 included patients presented with NSC. Compared with SC-patients, NSC-patients were older, more frail, and more frequently female. NSC-patients had a higher risk of functional decline and institutionalization at 30 days (adjusted ORs 1.84, 95% CI 1.27 - 2.72, and 2.46, 95% CI 1.51-4.00, respectively), but not mortality (adjusted OR 1.26, 95% CI 0.58 - 2.73). Reclassification to a specific complaint after the ED visit or hospital admission occurred in 54% of NSC-patients.

CONCLUSION

NSC occur especially in older, frail female patients and are associated with an increased risk of functional decline and institutionalization, even after adjustment for worse baseline status. In half of the patients, a specific complaint revealed during ED or hospital stay. Physicians at the ED should consider NSC as a red flag needing appropriate observation and evaluation of underlying serious conditions and needs of this vulnerable patient group.

Exploring the conceptual framework and measurement model of intrinsic capacity defined by the World Health Organization: A scoping review

WHO has defined intrinsic capacity (IC) as the composite of all physical and mental capacities of an individual covering five subdomains: cognition, locomotion, sensory, vitality, and psychological. Despite this well accepted definition, the conceptual and measurement model of IC remains unclear, which hampers a standardized operationalization of the construct. We performed a scoping review to give a comprehensive overview of the extent to which the current literature of IC addresses and assumes the conceptual framework and measurement model of IC as reflective or formative. For inclusion, we considered all types of articles that were published in peer-reviewed journals except for protocol articles. A systematic search of 6 databases from different disciplines led to the inclusion of 31 papers. We found inconsistency and gaps in the descriptions of IC. Most of the papers did not define the measurement model. In the conceptual background and validation articles, we identified descriptions of both reflective and formative measurement models while in empirical studies applying IC measurements the underlying assumptions remained mainly unclear. Defining a measurement model is not merely a theoretical matter but influences the operationalization and validation processes of the construct. This study raised questions about the most fundamental features of the IC construct and discusses whether IC should be considered as an underlying latent trait of all capacities (reflective construct) or an aggregate summary measure of the subdomain capacities (formative construct).

Excess mortality in depressive and anxiety disorders: The Lifelines Cohort Study

Background

To examine the mortality risk of current and life-time depressive as well as anxiety disorders, whether this risk is moderated by sex or age, and whether this risk can be explained by lifestyle and/or somatic health status.

Methods

A cohort study (Lifelines) including 141,377 participants (18–93 years) which were followed-up regarding mortality for 8.6 years (range 3.0–13.7). Baseline depressive and anxiety disorders according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria were assessed with the Mini International Neuropsychiatric Interview and lifetime diagnoses by self-report. All-cause mortality was retrieved from Statistics Netherlands. Cox-regression was applied to calculate proportional hazard ratios, adjusted for lifestyle (physical activity, alcohol use, smoking, and body mass index) and somatic health status (multimorbidity and frailty) in different models.

Results

The mortality rate of depressive and anxiety disorders was conditional upon age but not on sex. Only in people below 60 years, current depressive and anxiety disorders were associated with mortality. Only depressive disorder and panic disorder independently predicted mortality when all mental disorders were included simultaneously in one overall model (hazard ratio [HR] = 2.18 [95% confidence intervals (CI): 1.56–3.05], p < 0.001 and HR = 2.39 [95% CI: 1.15–4.98], p = 0.020). Life-time depressive and anxiety disorders, however, were independent of each other associated with mortality. Associations hardly changed when adjusted for lifestyle characteristics but decreased substantially when adjusted for somatic health status (in particular physical frailty).

Conclusions

In particular, depressive disorder is associated with excess mortality in people below 60 years, independent of their lifestyle. This effect seems partly explained by multimorbidity and frailty, which suggest that chronic disease management of depression-associated somatic morbidity needs to be (further) improved.

Course of frailty stratified by physical and mental multimorbidity patterns: a 5-year follow-up of 92,640 participants of the LifeLines cohort study

BACKGROUND

The frailty index (FI) is a well-recognized measurement for risk stratification in older people. Among middle-aged and older people, we examined the prospective association between the FI and mortality as well as its course over time in relation to multimorbidity and specific disease clusters.

METHODS

A frailty index (FI) was constructed based on either 64 (baseline only) or 35 health deficits (baseline and follow-up) among people aged ≥ 40 years who participated in LifeLines, a prospective population-based cohort living in the Northern Netherlands. Among 92,640 participants, multivariable Cox proportional hazard models were fitted to study the hazard ratio (HR) of the FI at baseline, as well as for 10 chronic disease clusters for all-cause mortality over a 10-year follow-up. Among 55,426 participants, linear regression analyses were applied to study the impact of multimorbidity and of specific chronic disease clusters (independent variables) on the change of frailty over a 5-year follow-up, adjusted for demographic and lifestyle characteristics.

RESULTS

The FI predicted mortality independent of multimorbidity and specific disease clusters, with the highest impact in people with either endocrine, lung, or heart diseases. Adjusted for demographic and lifestyle characteristics, all chronic disease clusters remained independently associated with an accelerated increase of frailty over time.

CONCLUSIONS

Frailty may be seen as a final common pathway for premature death due to chronic diseases. Our results suggest that initiating frailty prevention at middle age, when the first chronic diseases emerge, might be relevant from a public health perspective.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

OBJECTIVE

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.

METHODS

These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Malnutrition Screening and Assessment in Hospitalised Older People: a Review

Malnutrition (undernutrition) remains one of the most serious health problems for older people worldwide. Many factors contribute to malnutrition in older people, including: loss of appetite, polypharmacy, dementia, frailty, poor dentition, swallowing difficulties, social isolation, and poverty. Malnutrition is common in the hospital setting, yet often remains undetected by medical staff. The objective of this review is to compare the validity and reliability of Nutritional Screening Tools (NSTs) for older adults in the hospital setting. We also provide an overview of the various nutritional screening and assessment tools used to identify malnutrition in hospitalised older adults. These include: Subjective Global Assessment (SGA), the Mini Nutritional Assessment (MNA), MNA-short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Simplified Nutritional Appetite Questionnaire (SNAQ), Geriatric Nutrition Risk Index (GNRI) and anthropometric measurements. The prevalence and outcomes of malnutrition in hospitalised older adults are also addressed.

Socioeconomic Position and Malnutrition among Older Adults: Results from the FRADEA Study

OBJECTIVES

Low socioeconomic position (SEP) is related to many health-related conditions in older adults. However, there is a lack of knowledge on the association between SEP and malnutrition, a condition with serious consequences for older people in terms of quality of life and adverse health events. In the current study, we investigated socioeconomic inequalities in malnutrition and sub-domains of malnutrition in a sample of Spanish older adults.

DESIGN

Cross-sectional population-based study.

SETTING

Urban area of Albacete, Spain.

PARTICIPANTS

836 participants over age 70 from the first measurement wave (2007-2009) of the Frailty and Dependence in Albacete (FRADEA) study, a population-based cohort study.

MEASUREMENTS

Educational level and occupational level were the indicators of SEP. Nutritional risk was measured with the Mini Nutrition Assessment® Short Form (MNA®-SF). Logistic regression analyses were performed.

RESULTS

For both socioeconomic indicators there was a statistically significant association with nutritional risk (OR low education=1.99, 95% CI=1.18-3.35; OR low occupational level=1.71, 95% CI=1.08-2.72). However, these associations disappeared after adjusting for age and sex (OR low education=1.51, 95% CI=0.88-2.60 ; OR low occupational level=1.32, 95% CI=0.80-2.17). In adjusted models, statistically significant associations between SEP and sub-domains of the MNA®-SF were observed, but these associations were not consistent across socioeconomic indicators.

CONCLUSIONS

This study found that malnutrition is a condition that can appear in any older adult, regardless of their socioeconomic group. These findings suggest that interventions to prevent malnutrition in older adults can be targeted at a general older population, and do not have to be SEP specific.

Letter to the Editor: How Useful Are Multidomain Frailty Measures in Research and Clinical Practice?

To the Editor: There is increasing attention for the conceptof frailty in research and clinical practice. However, there arestill issues with regard to the conceptualization of frailty thatneed to be solved. Recently, international experts havemanaged to formulate a consensus definition of physical frailty:“A medical syndrome with multiple causes and contributorsthat is characterized by diminished strength, endurance, andreduced physiologic function that increases an individual’svulnerability for developing increased dependency and/ordeath” (1). This definition is in line with some commonly usedfrailty assessment tools, such as the frailty phenotype, theFRAIL questionnaire, and the Frailty Index (1). At the sametime, this frailty definition does not fully cover multidomainfrailty measures. These are frailty measures consisting ofsubscores for different frailty domains, such as thepsychological and social domain (Table 1). The Tilburg FrailtyIndicator (TFI) and the Groningen Frailty Indicator (GFI) areexamples of multidomain frailty measures (the Frailty Indexmay not be considered a multidomain frailty measure, butmultidimensional, since the global score derived from theFrailty Index does not distinguish different domains). Thequestion arises how multidomain frailty measures relate to thephysical frailty concept, and how they should be used inresearch and clinical practice. For what concerns the feasibilityof implementing multidomain frailty measures in the researchand clinical se