Assessing Neutrophil-to-Lymphocyte Ratio as a Nutritional Indicator in Community-Dwelling Older Adults

BACKGROUND

In an aging population, there is an increasing need for easily accessible nutritional markers.

AIMS

To determine whether the neutrophil-to-lymphocyte ratio (NLR) can serve as an effective nutritional indicator compared to the Mini-Nutritional Assessment Short Form (MNA-SF) or other common markers such as albumin and body mass index (BMI).

METHODS

Data were obtained from the SABE study in Ecuador, which included participants aged 60 years or older. This cross-sectional study collected comprehensive data, including demographics, health-related factors, and physical assessments. Neutrophil and lymphocyte counts were measured by complete blood count. Nutritional status was assessed by MNA-SF, and BMI was calculated. Several physical tests were performed to evaluate the participants' functional status. Confounding variables such as age, sex, and comorbidities were considered.

RESULTS

The final sample consisted of 1790 subjects (48.9% male). The overall median age was 68 years (IQR 64,76). BMI and lymphocytes were higher in females, while NLR was higher in males. MNA-SF showed a negative association with NLR. Similarly, lymphocyte count shows a positive association with MNA-SF. Physical tests, such as the Romberg test and the Five Times Sit-to-Stand test, also showed correlations with NLR and lymphocyte count, respectively.

CONCLUSION

The study results suggest a significant relationship between NLR and lymphocytes, and nutritional status. The correlation with albumin is stronger with NLR than with BMI. The simplicity and affordability of NLR may make it suitable for routine use in several medical fields, improving our understanding of the complex relationship between nutrition, inflammation, and overall health.

Neutrophil-to-lymphocyte ratio and lymphocyte count as an alternative to body mass index for screening malnutrition in older adults living in the community

PURPOSE

Accurate height and weight measurement can be challenging in older adults and complicates nutritional status assessment. Other parameters like the neutrophil-to-lymphocyte ratio (NLR) and the lymphocyte count (LC) could be an option to these measurements. We aimed to test these variables as subrogates of body mass index (BMI) or calf-circumference (CC) for malnutrition screening in community-dwelling older adults.

METHODS

This is a secondary analysis from the Salud, Bienestar y Envejecimiento (SABE) survey from Ecuador (2009). Includes data on demographics, health-related factors, physical assessments, and complete blood count, allowing to calculate NLR and LC to be used as part of the Mini Nutritional Assessment (MNA), instead of the BMI. Consequently, 4 models were included: standard MNA, MNA-CC, MNA-NLR and MNA-LC. Finally, age, sex, and comorbidities were considered as confounding variables.

RESULTS

In our analysis of 1,663 subjects, 50.81% were women. Positive correlations with standard MNA were found for MNA-NLR (Estimate = 0.654, p < 0.001) MNA-CC (Estimate = 0.875, p value < 0.001) and MNA-LC (Estimate = 0.679, p < 0.001). Bland-Altman plots showed the smallest bias in MNA-CC. Linear association models revealed varying associations between MNA variants and different parameters, being MNA-NLR strongly associated with all of them (e.g. Estimate = 0.014, p = 0.001 for albumin), except BMI.

CONCLUSION

The newly proposed model classified a greater number of subjects at risk of malnutrition and fewer with normal nutrition compared to the standard MNA. Additionally, it demonstrated a strong correlation and concordance with the standard MNA. This suggests that hematological parameters may offer an accurate alternative and important insights into malnutrition.

Diabetic Sarcopenia. A proposed muscle screening protocol in people with diabetes : Expert document

OBJECTIVES

To propose the grounds for "diabetic sarcopenia" as a new comorbidity of diabetes, and to establish a muscle screening algorithm proposal to facilitate its diagnosis and staging in clinical practice.

METHOD

A qualitative expert opinion study was carried out using the nominal technique. A literature search was performed with the terms "screening" or "diagnostic criteria" and "muscle loss" or "sarcopenia" and "diabetes" that was sent to a multidisciplinary group of 7 experts who, in a face-to-face meeting, discussed various aspects of the screening algorithm.

RESULTS

The hallmark of diabetic sarcopenia (DS) is muscle mass atrophy characteristic of people with diabetes mellitus (DM) in contrast to the histological and physiological normality of muscle mass. The target population to be screened was defined as patients with DM with a SARC-F questionnaire > 4, glycosylated haemoglobin (HbA1C) ≥ 8.0%, more than 5 years since onset of DM, taking sulfonylureas, glinides and sodium/glucose cotransporter inhibitors (SGLT2), as well as presence of chronic complications of diabetes or clinical suspicion of sarcopenia. Diagnosis was based on the presence of criteria of low muscle strength (probable sarcopenia) and low muscle mass (confirmed sarcopenia) using methods available in any clinical consultation room, such as dynamometry, the chair stand test, and Body Mass Index (BMI)-adjusted calf circumference. DS was classified into 4 stages: Stage I corresponds to sarcopenic patients with no other diabetes complication, and Stage II corresponds to patients with some type of involvement. Within Stage II are three sublevels (a, b and c). Stage IIa refers to individuals with sarcopenic diabetes and some diabetes-specific impairment, IIb to sarcopenia with functional impairment, and IIc to sarcopenia with diabetes complications and changes in function measured using standard tests Conclusion: Diabetic sarcopenia has a significant impact on function and quality of life in people with type 2 diabetes mellitus (T2DM), and it is important to give it the same attention as all other traditionally described complications of T2DM. This document aims to establish the foundation for protocolising the screening and diagnosis of diabetic sarcopenia in a manner that is simple and accessible for all levels of healthcare.

Is Frailty Diagnosis Important in Patients with COPD? A Narrative Review of the Literature

Frailty is prevalent in older adults and is related to a worsening functionality, quality of life, and health outcomes. Though there is an increasing interest in this field, the relationship between frailty and worsening COPD outcomes remains unknown. A narrative review of the literature with studies published between 2018 and 2022 was carried out to address three questions: the prevalence of frailty and other geriatric syndromes in COPD patients, the link between frailty and worsening health outcomes in COPD patients, and the non-pharmacological interventions performed in order to reverse frailty in these patients. A total of 25 articles were selected. Frailty prevalence ranged from 6% and 85.9%, depending on the COPD severity and the frailty measurement tool used. Frailty in COPD patients was related to a high prevalence of geriatric syndromes and to a high incidence of adverse events such as exacerbations, admissions, readmissions, and mortality. One study showed improvements in functionality after physical intervention. In conclusion, the prevalence of frailty is associated with a high incidence of geriatric syndromes and adverse events in COPD patients. The use of frailty screenings and a comprehensive geriatric assessment of COPD patients is advisable in order to detect associated problems and to establish individualized approaches for better outcomes.

Effect of Familial Longevity on Frailty and Sarcopenia: A Case-Control Study

Familial longevity confers advantages in terms of health, functionality, and longevity. We sought to assess potential differences in frailty and sarcopenia in older adults according to a parental history of extraordinary longevity. A total of 176 community-dwelling subjects aged 65-80 years were recruited in this observational case-control study, pair-matched 1:1 for gender, age, and place of birth and residence: 88 centenarians' offspring (case group) and 88 non-centenarians' offspring (control group). The main variables were frailty and sarcopenia based on Fried's phenotype and the European Working Group on Sarcopenia in Older People (EWGSOP) definitions, respectively. Sociodemographics, comorbidities, clinical and functional variables, the presence of geriatric syndromes, and laboratory parameters were also collected. Related sample tests were applied, and conditional logistic regression was performed. Cases had a higher percentage of robust patients (31.8% vs. 15.9%), lower percentages of frailty (9.1% vs. 21.6%) and pre-frailty (59.1% vs. 62.5%) (p = 0.001), and lower levels of IL-6 (p = 0.044) than controls. The robust adjusted OR for cases was 3.00 (95% CI = 1.06-8.47, p = 0.038). No significant differences in muscle mass were found. Familial longevity was also associated with less obesity, insomnia, pain, and polypharmacy and a higher education level and total and low-density lipoprotein cholesterol. The results suggest an inherited genetic component in the frailty phenotype, while the sarcopenia association with familial longevity remains challenging.

Genistein effect on cognition in prodromal Alzheimer's disease patients. The GENIAL clinical trial

BACKGROUND

Delaying the transition from minimal cognitive impairment to Alzheimer's dementia is a major concern in Alzheimer's disease (AD) therapeutics. Pathological signs of AD occur years before the onset of clinical dementia. Thus, long-term therapeutic approaches, with safe, minimally invasive, and yet effective substances are recommended. There is a need to develop new drugs to delay Alzheimer's dementia. We have taken a nutritional supplement approach with genistein, a chemically defined polyphenol that acts by multimodal specific mechanisms. Our group previously showed that genistein supplementation is effective to treat the double transgenic (APP/PS1) AD animal model.

METHODS

In this double-blind, placebo-controlled, bicentric clinical trial, we evaluated the effect of daily oral supplementation with 120 mg of genistein for 12 months on 24 prodromal Alzheimer's disease patients. The amyloid-beta deposition was analyzed using 18F-flutemetamol uptake. We used a battery of validated neurocognitive tests: Mini-Mental State Exam (MMSE), Memory Alteration Test (M@T), Clock Drawing Test, Complutense Verbal Learning Test (TAVEC), Barcelona Test-Revised (TBR), and Rey Complex Figure Test.

RESULTS

We report that genistein treatment results in a significant improvement in two of the tests used (dichotomized direct TAVEC, p = 0.031; dichotomized delayed Centil REY copy p = 0.002 and a tendency to improve in all the rest of them. The amyloid-beta deposition analysis showed that genistein-treated patients did not increase their uptake in the anterior cingulate gyrus after treatment (p = 0.878), while placebo-treated did increase it (p = 0.036). We did not observe significant changes in other brain areas studied.

CONCLUSIONS

This study shows that genistein may have a role in therapeutics to delay the onset of Alzheimer's dementia in patients with prodromal Alzheimer's disease. These encouraging results indicate that this should be followed up by a new study with more patients to further validate the conclusion that arises from this study.

TRIAL REGISTRATION

NCT01982578, registered on November 13, 2013.

Study of a Quasi-Experimental Trial to Compare Two Models of Home Care for the Elderly in an Urban Primary Care Setting in Spain: Results of Intermediate Analysis

Functional dependence is associated with an increase in need for resources, mortality, and institutionalization. Different models of home care have been developed to improve these results, but very few studies contain relevant information. This quasi-experimental study was conducted to evaluate two models of home care (HC) in a Primary Care setting: an Integrated Model (IM) (control model) and a Functional Model (FM) (study model).

MATERIAL AND METHODS

Two years follow-up of patients 65 years old and older from two Primary Health Care Centres (58 IM, 68 FM) was carried out, recruited between June-October 2018 in Badalona (Barcelona, Spain). Results of the mid-term evaluation are presented in this article. Health status, quality of care, and resource utilization have been evaluated through comprehensive geriatric assessment, quality of life and perception of health care scales, consumption of resources and complementary tests.

RESULTS

A significant difference was detected in the number of hospital admissions (FM/IM 0.71 (1.24)/1.35 (1.90), p: 0.031) in the Accident and Emergency department (FM/IM 2.01 (2.12)/3.53 (3.59), p: 0.006) and cumulative days of admission per year (FM/IM 5.43 (10.92)/14.69 (20.90), p: 0.003).

CONCLUSIONS

FM offers greater continuity of care at home for the patient and reduces hospital admissions, as well as admission time, thereby saving on costs.

Frailty Assessment in a Stable COPD Cohort: Is There a COPD-Frail Phenotype?

The frailty syndrome increases the morbidity/mortality in older adults, and several studies have shown a higher prevalence of this syndrome in patients with Chronic Obstructive Pulmonary Disease (COPD). The aim of this study was to identify the characteristics of frail patients with COPD to define a new phenotype called "COPD-frail." We conducted a cross-sectional study in a cohort of patients with stable COPD, classified as either frail, pre-frail, or non-frail. Sociodemographic, clinical, and biochemical variables were compared between the three groups of patients. The study included 127 patients, of which 31 were frail, 64 were pre-frail, and 32 non-frail. All subjects had FEV1/FVC below the lower limit of normal (range Z-score: -1.66 and -5.32). Patients in the frail group showed significantly higher scores in the mMRC (modified Medical Research Council) scale, the CAT (COPD Assessment Test), and the BODE (Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity) index. They also showed differences in symptoms according to GOLD (Global Initiative for Chronic Obstructive Lung Disease), as well as more COPD exacerbations, less physical activity, more anxiety and depression symptoms based on HADS (Hospital Anxiety and Depression Scale), and lower hemoglobin, hematocrit, and 25-hydroxycholecalciferol levels. Variables with independent association with frailty included the mMRC score, the HAD index for depression and age. In summary, differential characteristics of frail patients with COPD encourage the definition of a "COPD-frail" phenotype that-if identified early-would allow performing interventions to prevent a negative impact on the morbidity/mortality of these patients.

Healthcare for Older Adults, Where Are We Moving towards?

Since the end of World War II, science has not stopped progressing [...].

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.

Implementing Precision Medicine in Human Frailty through Epigenetic Biomarkers

The main epigenetic features in aging are: reduced bulk levels of core histones, altered pattern of histone post-translational modifications, changes in the pattern of DNA methylation, replacement of canonical histones with histone variants, and altered expression of non-coding RNA. The identification of epigenetic mechanisms may contribute to the early detection of age-associated subclinical changes or deficits at the molecular and/or cellular level, to predict the development of frailty, or even more interestingly, to improve health trajectories in older adults. Frailty reflects a state of increased vulnerability to stressors as a result of decreased physiologic reserves, and even dysregulation of multiple physiologic systems leading to adverse health outcomes for individuals of the same chronological age. A key approach to overcome the challenges of frailty is the development of biomarkers to improve early diagnostic accuracy and to predict trajectories in older individuals. The identification of epigenetic biomarkers of frailty could provide important support for the clinical diagnosis of frailty, or more specifically, to the evaluation of its associated risks. Interventional studies aimed at delaying the onset of frailty and the functional alterations associated with it, would also undoubtedly benefit from the identification of frailty biomarkers. Specific to the article yet reasonably common within the subject discipline.

[Coronavirus disease 2019 (COVID-19) and ageism: a narrative review of the literature]

Ageism is defined as stereotypes, prejudices and discrimination towards people due to their age. The present review analyzed the age-related attitudes, and the responses to them, produced during the COVID-19 pandemic. We searched for publications related to ageism during the COVID-19 pandemic in Pubmed, Medline, and Embase. Fourteen manuscripts were included. The works highlighted the civic and social sense of older adults, their capacity for help community, despite the risk of infection. This attitude contrasted with her vulnerability to illness and ageism. Specific interventions are necessary to support older adults during the pandemic, guaranteeing financial support, protection in the residential environment, access to information, and solving barriers to accessing health services. Likewise, chronological age should not be an independent criterion for clinical decision making.

[Coronavirus: the geriatric emergency of 2020. Joint document of the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology]

SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.

Study protocol of a quasi-experimental trial to compare two models of home care for older people in the primary setting

BACKGROUND

Preventive home visits are suited for patients with reduced mobility, such as older people. Healthcare needs for older patients are expected to increase due to the extended life expectancy estimated in coming years. The implementation of low-cost, patient-centered methodologies may buffer this rise in health care costs without affecting the quality of service. In order to find the best home care model with less investment, this paper describes a study protocol comparing two models of home care for older people.

METHODS

We describe a quasi-experimental study that compares the outcome of two different home care models already implemented in two primary care centers in Badalona (Barcelona, Spain). The traditional model (control model) is integrated in the sense that is continuous, the same primary care center team looks after its assigned patients both at the center and in preventive home visits. The new functional home care model (study model), consisting of a highly trained team, is specifically designed to meet patient needs and give total attention to preventive home interventions. The study will start and end on the expected dates, June 2018 to October 2020, and include all patients over 65 years old already enrolled in the home care programs of the primary care centers selected. The primary endpoint assessed will be the difference in hospitalization days between patients included in both home care programs. Other variables regarding health status, quality of care and resource utilization will also be compared between the two models.

DISCUSSION

The study in progress will assess whether a functional and highly trained home care team will meet the ever-aging population needs in terms of cost and health outcomes better than a traditional, integrated one. Lessons learned from this pilot study will provide guidelines for a future model of home care based on the IHI Triple Aim: better care, better health, and lower costs.

TRIAL REGISTRATION

Registered in ClinicalTrials.gov (Identifier: NCT03461315; March 12, 2018).

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Oxidative stress and exceptional human longevity: Systematic review

OBJECTIVE

Oxidative stress (OS) has been previously linked to the aging process, as have some diseases and geriatric syndromes as frailty and sarcopenia. The aim of the present study was to perform a systematic review on oxidative stress activity and extreme longevity in humans.

METHODS

We conducted a systematic literature review following the PRISMA guidelines. Observational studies assessing OS-biomarkers and/or antioxidants in long-lived individuals (97 years old or over) comparing them to those of one or more age groups, (at least one of which from comprising elderly subjects) were considered for inclusion. A narrative synthesis was planned. Quality of selected studies was assessed using the Newcastle-Ottawa quality assessment scale (NOS).

RESULTS

After screening and eligibility phases, 12 articles were finally selected, with 646 long-lived participants and 1052 controls, 447 adults (20-60 years old) and 605 elderly individuals (over 60 years old). The average score on NOS scale of studies was 4,8 out of 9. Centenarians showed significantly less (p<0,05) oxidative damage to lipids in different samples, lower levels of oxidized proteins in plasma and lower superoxide anion levels in neutrophils than elderly groups. Centenarian presented significantly lower superoxide dismutase and higher glutathione reductase activities, higher levels of vitamins A and E, lower of coenzyme Q10, and lower susceptibility to lipid peroxidation than elderly controls.

CONCLUSION

Based on studies of medium-low quality, available evidence suggests that long-lived individuals display less oxidative damage, particularly lower plasma lipid peroxidation biomarkers, than controls. More studies with better experimental designs are needed.

[Spanish National Hip Fracture Registry (RNFC): First-year results and comparison with other registries and prospective multi-centric studies from Spain]

OBJECTIVE

The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi- centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain.

METHODS

We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies.

RESULTS

The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%).

CONCLUSIONS

The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences.

A Community Program of Integrated Care for Frail Older Adults: +AGIL Barcelona

OBJECTIVES

To assess the 3-month impact on physical function of a program for community-dwelling frail older adults, based on the integration of primary care, geriatric medicine, and community resources, implemented in "real life".

DESIGN

Interventional cohort study.

SETTING

Primary care in Barcelona, Spain.

PARTICIPANTS

Individuals aged ≥80 years (n=134), presenting at least one sign of frailty (i.e., slow gait speed, weakness, memory complaints, involuntary weight loss, poor social support).

INTERVENTION

After frailty screening by the primary care team, candidates were referred to a geriatric team (geriatrician + physical therapist), who performed a comprehensive geriatric assessment and designed a tailored multidisciplinary intervention in the community, including a) multi-modal physical activity (PA) sessions, b) promotion of adherence to a Mediterranean diet c) health education and d) medication review.

MEASUREMENTS

Participants were assessed based on a comprehensive geriatric assessment including physical performance (Short Physical Performance Battery -SPPB- and gait speed), at baseline and at a three month follow-up.

RESULTS

A total of 112 (83.6%) participants (mean age=80.8 years, 67.9% women) were included in this research. Despite being independent in daily life, participants' physical performance was impaired (SPPB=7.5, SD=2.1, gait speed=0.71, SD=0.20 m/sec). After three months, 90.2% of participants completed ≥7.5 physical activity sessions. The mean improvements were +1.47 (SD 1.64) points (p<0.001) for SPPB, +0.08 (SD 0.13) m/sec (p<0.001) for gait speed, -5.5 (SD 12.10) sec (p<0.001) for chair stand test, and 53% (p<0.001) improved their balance. Results remained substantially unchanged after stratifying the analyses according to the severity of frailty.

CONCLUSIONS

Our results suggested that a "real-world" multidisciplinary intervention, integrating primary care, geriatric care, and community services may improve physical function, a marker of frailty, within 3 months. Further studies are needed to address the long-term impact and scalability of this implementation program.

The complexity of loneliness

Loneliness is a prevalent and global problem for adult populations, and a number of different studies have linked it to multiple chronic conditions, including: heart disease, lung disease, cardiovascular disease, hypertension, atherosclerosis, stroke, and metabolic disorders, such as obesity and metabolic disease. Is a major predictor of psychological problems, such as depression, psychological stress, and anxiety. Loneliness is linked to overall morbidity and mortality in adult populations. But limited interventions have demonstrated long-term effectiveness in reducing loneliness in adults with these same chronic conditions. Our research of the extant literature addresses the following question: What evidence exists regarding the relationships between loneliness and health? We focus on recent findings with respect to the links between loneliness and health.

Exercise: the lifelong supplement for healthy ageing and slowing down the onset of frailty

The beneficial effects of exercise have been well recognized for over half a century. Dr Jeremy Morris's pioneering studies in the fifties showed a striking difference in cardiovascular disease between the drivers and conductors on the double-decker buses in London. These studies sparked off a vast amount of research on the effects of exercise in health, and the general consensus is that exercise contributes to improved outcomes and treatment for several diseases including osteoporosis, diabetes, depression and atherosclerosis. Evidence of the beneficial effects of exercise is reviewed here. One way of highlighting the impact of exercise on disease is to consider it from the perspective of good practice. However, the intensity, duration, frequency (dosage) and counter indications of the exercise should be taken into consideration to individually tailor the exercise programme. An important case of the beneficial effect of exercise is that of ageing. Ageing is characterized by a loss of homeostatic mechanisms, on many occasions leading to the development of frailty, and hence frailty is one of the major geriatric syndromes and exercise is very useful to mitigate, or at least delay, it. Since exercise is so effective in reducing frailty, we would like to propose that exercise be considered as a supplement to other treatments. People all over the world have been taking nutritional supplements in the hopes of improving their health. We would like to think of exercise as a physiological supplement not only for treating diseases, but also for improving healthy ageing.

Orthogeriatric care: improving patient outcomes

Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard.

Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture

AIM

To identify how the severity of dementia influences functional recovery and mortality in elderly patients hospitalized for hip fracture.

METHODS

An observational retrospective study of 1258 patients aged older than 69 years and diagnosed with hip fracture who received care within an orthogeriatrics unit from 2004 to 2008 was carried out. During a 12-month follow-up period, functional recovery and mortality outcomes were measured.

RESULTS

Dementia was present in 383 (28.1%) patients: it was mild in 183 (48%), moderate in 102 (26.5%) and severe in 98 (25.5%). Compared with patients with preserved cognitive status, patients with dementia had the following statistically significant differences (means [standard deviation] or percentage): older age (preserved, 82.29 years [6.5 years]; mild, 83.63 years [6.1 years]; moderate, 83.47 years [5.9 years]; severe, 84.46 years [6.1 years]; P < 0.001); lower Barthel Index (89.7 [21.6], 72.7 [24.6], 58.9 [28.6], 38.0 [28.1]; P < 0.001); delirium (11.7%, 25.6%, 37.6%, 44.7%; P < 0.001); less ambulation at 6 months postdischarge (83.9%, 72.8%, 56.9%, 41.7%; P < 0.001); and higher mortality at discharge (4%, 5.7%, 8.2%, 10.6%; P < 0.001) and 12 months after discharge (21.2%, 32.3%, 46.3%, 53.5%; P < 0.001). Patients with severe dementia had lower probability of functional recovery at discharge (OR 0.272, 95% CI 0.140-0.526, P < 0.001) and 6 months after discharge (OR 0.439, 95% CI 0.197-0.979, P = 0.04), as well as a greater probability of dying (HR 1.640, 95% CI 1.020-2.635, P = 0.04).

CONCLUSIONS

We observed higher 12-month mortality and less functional recovery with increasing severity of dementia.

[Preliminary results of a community fall prevention programme: Precan study (falls prevention in La Ribera)]

OBJECTIVE

To evaluate the results of a fall prevention programme designed to be applied to the elderly living in the community.

MATERIAL AND METHODS

The sample consisted of 249 participants ≥70 years of age, who were randomly assigned to one of three groups. The monthly intervention group (GIM): instructions on fall prevention and healthy exercises to improve physical function and balance at beginning of the study, and a monthly theoretical and practical refresher session. The quarterly intervention group (GIT), with the same beginning intervention and a refresher session every three months. The control group (GC), the same beginning intervention but no refresher sessions.

RESULTS

The mean age of the sample was 74.47 years (SD 5.33), with 64% women. The incidence of falls was reduced from 0.64 per patient year in the previous year to 0.39 in the post-intervention year in GIM, from 0.49 to 0.47 in GIT, and in the GC it remained at 0.47 before and twelve months after, but with no significant differences in the reduction between groups (P=.062). At the end of the study there was a decrease in Rizzo scale of 0.72 points (95% CI: 0.57-0.88, P<.001).

CONCLUSION

An interdisciplinary community intervention programme can contribute to reducing the incidence of falls. Further studies are required to continue research into the incidence of falls in the elderly living in the community.

Early interdisciplinary hospital intervention for elderly patients with hip fractures : functional outcome and mortality

OBJECTIVES

Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge.

METHODS

This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years.

RESULTS

On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay.

CONCLUSIONS

Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery.