Impact of Hospitalization on Patients Ability to Perform Basic Activities of Daily Living

Functional independence is dictated by the ability to perform basic activities of daily living (ADLs). Although hospitalization is associated with impairments in function, we know less about patients' functional trajectory following hospitalization. We examined patients' ability to do basic ADLs across pre-admission, admission, and follow-up (discharge or two-weeks post-admission) and determined which factors predicted changes in ADLs at follow-up. A secondary analysis of a small prospective cohort study of older patients (n=83, 50 females, 81 ± 8 years) from the Emergency Department and a Geriatric Unit were included. ADL scores (dressing, walking, bathing, eating, in and out of bed, and using the toilet) and frailty level (via the Clinical Frailty Scale) were measured. Comparing follow-up to pre-admission, patients reported worse ADL scores for dressing (36% of patients), walking (31%), bathing (34%), eating (25%), in and out of bed (37%), and using the toilet (35%). Most patients (59%) had more difficulty with 1+ ADL at follow-up versus pre-admission, with one-fourth of patients having greater difficulty with 3+ ADLs. Older age and higher frailty level were associated with (all, p < .04) worse functional scores for eating, getting in and out of bed, and using the toilet (frailty only) at follow-up versus pre-admission. Here, most inpatients experienced worse difficulty performing multiple basic ADLs after hospital admission, potentially predisposing them for re-hospitalization and functional dependence. Older and frailer patients generally were less likely to recover to pre-admission levels. Hospitalization challenges patients' ability to perform ADLs in the short-term, post-discharge. Strategies to improve patients' functional trajectory are needed.

Evaluating the Safety and Outcomes of Oesophagogastroduodenoscopy in Elderly Patients Presenting With Acute Upper Gastrointestinal Bleeding

AIMS

In the absence of evidence-based guidelines regarding the safety and appropriateness of emergency endoscopy in elderly, co-morbid and frail patients, we aimed to find clinical outcomes in elderly patients who have undergone gastroscopy following an acute upper gastrointestinal bleeding (UGIB).

METHODS

We carried out a retrospective observational study of patients aged 70 years and older who had undergone emergency oesophagogastroduodenoscopy (OGD) at the Royal Sussex County Hospital, Brighton, United Kingdom, between May 2020 and January 2022. Data collected for analysis included Glasgow-Blatchford score, age, gender, endoscopic findings, endoscopic treatments, immediate complications, 90-day complications, 30-day and 90-day survival, length of hospital stay and re-bleeding.

RESULTS

A total of 248 study participants were categorised into two groups: age 70-79 years (n=102) and ≥80 years (n=146). Melaena (n=226, 91%, p=0.0001) was the commonest indication for emergency OGD in both groups, with the majority of patients presenting with a Glasgow-Blatchford score of ≥1 (n=200, 80.6%, p=0.2). Endoscopy findings were normal in 26.4% (n=27) of those 70-79 years and 32% (n=47) of those ≥80 years (p=0.01). Duodenal ulcer, oesophagitis and gastric ulcer were the commonest abnormal findings (n=50, 20%; n=29, 11.7%; and n=28, 11.3%, respectively). Of the participants, 93.8% (n=212) had no immediate complications. Bleeding and hypotension occurred in 2.7% (n=6) and 2% (n=5) of patients, respectively. At 90 days post-procedure, 83.3% (n=85) of those 70-79 years and 67.8% (n=99) of those ≥80 years had survived (p=0.180).

CONCLUSIONS

We conclude that OGD is largely a safe procedure in older adults with acute UGIB; however, the high proportion of OGDs with normal findings reinforces the importance of careful selection of patients.

Predictive Value of Comprehensive Geriatric Assessment Scores for Mortality in Patients With Hip Fracture: A Retrospective Cohort Study

Objective To assess the predictive value of three scoring systems, namely the American Society of Anesthesiologists (ASA) classification, the Clinical Frailty Scale (CFS), and the Nottingham Hip Fracture Score (NHFS), in predicting mortality among patients with hip fractures. Materials and methods This retrospective cohort study included 628 participants aged 60 years and above who sought treatment at a UK hospital between January 2018 and December 2018. Data on age, gender, mortality, and assessment scores were collected. The area under the curve was calculated for each receiver operator characteristic (ROC). Cross-tabulation was performed to examine the association between various assessment scores and mortality using the chi-square test. Results The mean age was 80.80±11.18 years. Females were 408 (64.97%). Higher CFS (p<0.001) and NHFS (p<0.001) scores were significantly associated with mortality, while the ASA score did not show a significant association (p=0.225). The calculated area under the curve (AUC) values were as follows: 0.71 (95% CI: 0.65 to 0.76) for CFS, 0.46 (95% CI: 0.39 to 0.53) for NHFS, and 0.41 (95% CI: 0.34 to 0.48) for the ASA score. Utilizing a cut-off of ≥6 for CFS, 57 individuals (98.3%) in the 30-day mortality group were correctly identified. Similarly, the ROC analysis determined a ≥5 cut-off for NHFS accurately predicting 50 patients (86.2%) who deceased within 30 days. Applying an ASA ≥3 cut-off resulted in a predictive mortality rate of 56 (96.6%). The NHFS score demonstrated the highest predictive capability for mortality, with patients scoring ≥5 having a significantly higher risk of mortality compared to those with a score <5. Conclusion This study showed robust correlations between high CFS (≥6) and NHFS (≥5), and mortality within the hip fracture patient cohort.

The Limitations of Frailty Assessment Tools in ANCA-Associated Vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) can be associated with a high burden of morbidity and mortality in an ageing population. It is increasingly recognised that individualised management is needed. Few studies have looked specifically at frailty related outcomes in AAV and a gap remains in understanding the application of frailty assessment tools in these patients. We carried out a single centre, cohort study between 2017 to 2022. Forty-one patients who had newly diagnosed or relapsing AAV and aged ≥65 years were included. The Clinical Frailty Scale (CFS) score at presentation was assessed by health care practitioners and interval CFS scores were carried out a minimum of 6 weeks from diagnosis. The aim was to determine if patients living with frailty had worse outcomes or if their perceived frailty improved with immunosuppressive treatment. The median CFS at diagnosis was 4 (vulnerable) and this remained at follow up. There was no significant interval change in CFS (P=0.16) suggesting that the patients did not become frailer and instead there was a tendency towards improved frailty scores at re-assessment. There was no significant difference in end stage kidney disease between those with higher (>5) or lower (≤5) CFS (P=1.0), although crude mortality was higher among those with an initial CFS >5 (P=0.03). Overall, we demonstrated that CFS has limitations in determining patients that may be frail as a result of disease burden with the potential to improve with treatment and clinicians should be mindful of this when making decisions relating to management.

Emergency General Surgery: Predicting Morbidity and Mortality in the Geriatric Population

Introduction  Numerous scoring systems have been created to predict the risk of morbidity and mortality in patients undergoing emergency general surgery (EGS). In this article, we compared the different scoring systems utilized at Humanitas Research Hospital and analyzed which one performed the best when assessing geriatric patients (>65 years of age). The scoring systems that were utilized were the APACHE II (Acute Physiology and Chronic Health Evaluation II), ASA (American Society of Anesthesiologists), ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program), Clinical Frailty Score, and the Clavien-Dindo classification as control. Materials and Methods  We compiled a database consisting of all patients over the age of 65 who underwent EGS in a consecutive 24-month period between January 1, 2017 and December 31, 2018. We used the biostatistical program "Stata Version 15" to analyze our results. Results  We found 213 patients who matched our inclusion criteria. Regarding death, we found that the ACS-NSQIP death calculator performed the best with an area under the curve of 0.9017 (odds ratio: 1.09; 95% confidence interval: 1.06-1.12). The APACHE II score had the lowest discriminator when predicting death. Considering short-term complications, the Clavien-Dindo classification scored highly, while both the APACHE II score and Clinical Frailty Score produced the lowest results. Conclusion  The results obtained from our research showed that scoring systems and classifications produced different results depending on whether they were used to predict deaths or short-term complications among geriatric patients undergoing EGS.

Site of care and factors associated with mortality in unvaccinated Australian aged care residents during COVID-19 outbreaks

BACKGROUND

Residential InReach presents an alternative to hospital admission for aged care residents swabbed for COVID-19, though relative outcomes remain unknown.

AIMS

To compare rates and predictors of 28-day mortality for aged care residents seen by InReach with COVID-19, or 'suspected COVID-19' ('sCOVID'), including hospital vs InReach-based care.

METHODS

Prospective observational study of consecutive patients referred to a Victorian InReach service meeting COVID-19 testing criteria between April-October 2020 (pre-vaccine availability). COVID-19 was determined by positive polymerase chain reaction testing on nasopharyngeal swab. sCOVID-19 was defined as meeting symptomatic Victorian Government testing criteria but persistently swab negative.

RESULTS

There were no significant differences in age, gender, Clinical Frailty Score (CFS) or Charlson Comorbidity Index (CCI) between 152 patients with COVID-19 and 118 patients with sCOVID. 28-day mortality was similar between patients with COVID-19 (35/152, 23%) and sCOVID (32/118, 27%) (p=0.4). For the combined cohort, 28-day mortality was associated with initial oxygen saturation (p<0.001), delirium (p<0.001), hospital transfer for acuity (p=0.02; but not public health/facility reasons), CFS (p=0.04), prior ischaemic heart disease (p=0.01) and dementia (p=0.02). For COVID-19 patients, 28-day mortality was associated with initial oxygen saturation (p=0.02), delirium (p<0.001), and hospital transfer for acuity (p=0.01), but not public health/facility reasons.

CONCLUSION

Unvaccinated aged care residents meeting COVID-19 testing criteria seen by InReach during a pandemic experience high mortality rates, including with negative swab result. Residents remaining within-facility (with InReach) experienced similar adjusted mortality odds to residents transferred to hospital for public health/facility-based reasons, and lower than those transferred for clinical acuity. This article is protected by copyright. All rights reserved.

Muscle Quantity at C3 and/or L3 on Routine Trauma Series Computed Tomography Correlate With Brain Frailty and Clinical Frailty Scale: A Cross-Sectional Study

Background

Sarcopenia (low muscle mass and function) is increasingly recognised to impact the quality of life and patient outcomes. The relationship with brain frailty is unknown.

Objectives

Assess if muscle mass at C3 correlates with muscle mass at L3 on routine trauma imaging. Assess for associations between muscle mass, brain frailty, and Clinical Frailty Scale (CFS) on routine trauma imaging.

Methods

Routine trauma-series computed tomography (CT) scans were retrospectively analysed for patients aged ≥16-years-old admitted to Queen Elizabeth Hospital in January 2020. Paravertebral, sternocleidomastoid, and total muscle cross-sectional area (CSA) at C3 (C3-SMM), and total psoas muscle CSA (TPA), total muscle CSA (L3-SMM), and total adipose CSA at L3 were calculated. Brain frailty scores were calculated assessing for leukoaraiosis, cerebral atrophy, and old vascular lesions/infarcts. CFS was calculated retrospectively from clinical notes. We assessed for correlation against age, CFS, muscle mass, and brain frailty using Pearson’s correlations.

Results

We included 111 patients in this study (mean age 49, SD 25.6; 65.8% female). C3-SMM strongly correlated with L3-SMM (r=0.746, p<0.001). Paravertebral and sternocleidomastoid CSA correlated with C3-SMM (paravertebral: r=0.814, p<0.001; sternocleidomastoid: r=0.814, p<0.001). TPA strongly correlated with L3-SMM (r=0.800, p<0.001). Sternocleidomastoid CSA and TPA both negatively correlated moderately with age (sternocleidomastoid: r=−0.460, p<0.001; TPA: r=−0.468, p<0.001), CFS (sternocleidomastoid: r=−0.414, p<0.001; TPA: r=−0.431, p<0.001), and brain frailty (sternocleidomastoid: r=−0.395, p<0.001; TPA: r=−0.436, p<0.001). Adipose CSA at L3 did not correlate with age, CFS, brain frailty, or muscle mass.

Conclusion

Muscle mass at C3 relates to muscle mass at L3. Muscle mass on routine trauma imaging is negatively associated with age, CFS, and brain frailty.

Clinical Characteristics, Frailty, and Mortality of Residents With COVID-19 in Nursing Homes of a Region of Madrid

Objectives

To describe the clinical characteristics, 30-day mortality, and associated factors of patients living in nursing homes (NH) with COVID-19, from March 20 to June 1, 2020.

Design

This is a retrospective study. A geriatric hospital-based team acted as a consultant and coordinated the care of older people living in NHs from the hospital.

Setting and Participants

A total of 630 patients aged 70 and older with Coronavirus Disease 2019 COVID-19 living in 55 NHs.

Methods

A logistic regression was performed to analyze the factors associated with mortality. In addition, Kaplan-Meier curves were applied according to mortality and its associated factors using the log-rank Mantel-Cox test.

Results

The diagnosis of COVID-19 was mainly made by clinical compatibility (N = 430). Median age was 87 years, 64.6% were women and 45.9% were transferred to be cared for at the hospital. A total of 282 patients died (44.7%) within the 30 days of first attention by the team. A severe form of COVID-19 occurred in 473 patients, and the most frequent symptoms were dyspnea (n = 332) and altered level of consciousness (n = 301). According to multiple logistic regression, male sex (P = .019), the Clinical Frailty Score (CFS) ≥6 (P = .004), dementia (P = .012), dyspnea (P < .001), and having a severe form of COVID-19 (P = .001), were associated with mortality, whereas age and care setting were not.

Conclusions and Implications

Mortality of the residents living in NHs with COVID-19 was almost 45%. The altered level of consciousness as an atypical presentation of COVID-19 should be considered in this population. A severe form of the disease, present in more than three-quarters of patients, was associated with mortality, apart from the male sex, CFS ≥6, dementia, and dyspnea, whereas age and care setting were not. These findings may also help to recognize patients in which the Advance Care Planning process is especially urgent to assist in the decisions about their care.

The Clinical Frailty Scale: Do Staff Agree?

The term frailty is being increasingly used by clinicians, however there is no strict consensus on the best screening method. The expectation in England is that all older patients should have the Clinical Frailty Scale (CFS) completed on admission. This will frequently rely on junior medical staff and nurses, raising the question as to whether there is consistency. We asked 124 members of a multidisciplinary team (consultants, junior doctors, nurses, and allied health professionals; physiotherapists, occupational therapists, dietitians, speech and language therapists) to complete the CFS for seven case scenarios. The majority of the participants, 91/124 (72%), were trainee medical staff, 16 were senior medical staff, 12 were allied health professions, and 6 were nurses. There was broad agreement both between the professions and within the professions, with median CFS scores varying by a maximum of only one point, except in case scenario G, where there was a two-point difference between the most junior trainees (FY1) and the nursing staff. No difference (using the Mann–Whitney U test) was found between the different staff groups, with the median scores and range of scores being similar. This study has confirmed there is agreement between different staff members when calculating the CFS with no specific preceding training.