Background. Frailty and fitness are important attributes of older persons, but population samples of their prevalence, attributes, and outcomes are limited. Methods. The authors report data from the ...community-dwelling sample (n = 9008) of the Canadian Study of Health and Aging, a representative, 5-year prospective cohort study. Fitness and frailty were determined by self-reported exercise and function level and testing of cognition. Results. Among the community-dwelling elderly population, 171 per 1000 were very fit and 12 per 1000 were very frail. Frailty increased with age, so that by age 85 years and older, 44 per 1000 were very frail. The risk for adverse health outcomes increased markedly with frailty: Compared with older adults who exercise, those who were moderately or severely frail had a relative risk for institutionalization of 8.6 (95% confidence interval, 4.9 to 15.2) and for death of 7.3 (95% confidence interval, 4.7 to 11.4). These risks persist after adjustments for age, sex, comorbid conditions, and poor self-rated health. At all ages, men reported higher levels of exercise and less frailty compared with women. Decreased fitness and increased frailty were also associated with poor self-ratings of health (42% in the most frail vs 7% in the most fit), more comorbid illnesses (6 vs 3), and more social isolation (34% vs 29%). Conclusions. Fitness and frailty form a continuum and predict survival. Exercise influences survival, even in old age. Relative fitness and frailty can be determined quickly in a clinical setting, are potentially useful markers of the risk for adverse health outcomes, and add value to traditional medical assessments that focus on diagnoses.
Background: Conflicting results have been reported about the status of diabetes mellitus as a risk for Alzheimer’s disease. We investigated the relationship between diabetes and incident dementia ...(including Alzheimer’s disease and vascular cognitive impairment) in a 5-year longitudinal study. Methods: Secondary analysis of the Canadian Study of Health and Aging, a representative cohort study of dementia in older Canadians. Results: 5,574 subjects without cognitive impairment at baseline participated in 5-year follow-up. Diabetes mellitus at baseline was associated with incident vascular cognitive impairment (RR: 1.62; 95% CI: 1.12–2.33) and its subtypes, vascular dementia (RR: 2.03; 95% CI: 1.15–3.57), and vascular cognitive impairment not dementia (RR: 1.68; 95% CI: 1.01–2.78). Diabetes was not associated with mixed Alzheimer’s/vascular dementia (RR: 0.87; 95% CI: 0.34–2.21), incident Alzheimer’s disease (RR: 1.30; 95% CI: 0.83–2.03) or all dementias (RR: 1.26; 95% CI: 0.90–1.76). Conclusions: Despite increased recognition of the role of vascular factors in Alzheimer’s disease, we did not find an association between diabetes and incident Alzheimer’s disease, even though diabetes was associated with incident vascular cognitive impairment.
Objectives To assess whether the core symptoms of Alzheimer disease (AD) consistently predict patient self-rated quality of life (QOL) as assessed by a variety of QOL measures in a large national ...sample of AD patients. Design Cross-sectional. Setting Fifteen dementia and geriatric clinics across Canada. Participants Community-living patients with AD (n = 370) with Mini-Mental State Exam (MMSE) scores greater than 10. Measurements Patients rated their QOL by using two utility indexes, the European QOL-5 Dimensions and the Quality of Well-Being Scale, a global QOL Visual Analog Scale, and the disease-specific QOL–AD instrument. Cognition was assessed with the AD Assessment Scale–Cognitive subscale and MMSE, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale (GDS). One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between core dementia symptoms and QOL ratings. Results The QOL measures had only small-to-moderate correlations with each other. For all QOL measures, patient ratings were significantly lower among patients with more depressive symptoms. In multivariable analyses, the GDS score was the only significant independent predictor of patient self-ratings for all four QOL measures. Conclusions Self-rated symptoms of depression were a consistent independent predictor of patient-rated QOL across diverse QOL measures, while performance-based measures of cognition and informant-based functional status were not. These findings confirm the importance of identifying and treating depression in patients with AD and endorse the use of measures of self-rated depressive symptoms and QOL as outcomes in AD clinical trials.
In a representative Canadian population survey (
n=66 589) the proportion of accumulated deficits in a frailty index showed a linear relationship with mortality in a log–log plot, such that the ...mortality rate was a power-law function of the frailty index. Represented in this way, the frailty index readily summarizes individual differences in health status. The exponent and amplitude parameters of the power function are gender specific, reflecting that while, on average, women accumulate more deficits than men of the same age, their risk of mortality is lower. The dependence of the mortality rate on the frailty index points to the merit of the index as a simple and accessible tool for estimating individual risks of mortality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Relatively little is known about how region of residence influences frailty of seniors. Frailty indexes can be used to investigate these effects. We constructed and validated a frailty index, to ...investigate the differences in health status between rural and urban seniors.
We studied rural (n=949) and urban (n=7598) older adults in the Canadian Study of Health and Aging, of whom 22% died over 72 months. The frailty index was generated from 40 self-reported health deficits (symptoms, diseases, disabilities, unfavourable living conditions).
The average value of the frailty index increased exponentially with age in both groups (rural: r=0.94; urban: r=0.97, p<0.01) and was highly correlated with mortality (r=0.96 for rural, r=0.97 for urban, p<0.01). Up to age 80, there were few rural-urban differences in frailty. After age 80, the rural sample showed higher mortality than the urban sample. The hazard ratio for death for each increment in the frailty index was 1.38 (1.14-1.72) in rural participants vs 1.18 (1.11-1.26) in urban participants. Women lived longer than men at any index value.
Frailty index analysis readily summarizes health and mortality differences between very old rural and urban dwellers, which reflect differences in deficit accumulation, and in the impact of gender on survival. The frailty index provides efficient dimensionality reduction for studying group differences in the health of older adults.
Objectives To assess whether the core symptoms of Alzheimer disease (AD) and caregiver factors consistently predict family caregiver ratings of patient quality of life (QOL) as assessed by a variety ...of QOL measures in a large national sample. Design Cross-sectional. Setting Fifteen dementia and geriatric clinics across Canada. Participants Family caregivers (n = 412) of community-living patients with AD of all severities. Measurements Caregiver ratings of patient QOL using three utility indexes, the European Quality of Life-5 Dimensions, Quality of Well-Being Scale and Health Utilities Index; a global QOL visual analogue scale; a disease-specific measure, the Quality of Life-Alzheimer's Disease; and a generic health status measure, the Short Form-36. Patient cognition was assessed with the cognitive subscale of the Alzheimer's Disease Assessment Scale and Mini-Mental State Examination, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale. Caregiver burden was assessed with the Zarit Burden Interview and caregiver depression with the Center for Epidemiologic Studies Depression scale. One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between patient dementia symptom and caregiver variables with QOL ratings. Results In multivariable analyses, caregiver ratings of patient function and depressive symptoms were the only consistent independent predictors of caregiver-rated QOL across the QOL measures. Conclusions Caregiver ratings of patient function and depression were consistent independent predictors of caregiver-rated QOL, using a spectrum of QOL measures, while measures of patient cognition and caregiver burden and depression were not. These findings support the continued use of caregiver ratings as an important source of information about patient QOL and endorse the inclusion in AD clinical trials of caregiver-rated measures of patient function, depression, and QOL.
Objectives
To compare the feasibility (adherence) and effectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium‐friendly preprinted postoperative orders (PPOs) for ...individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders.
Design
Pragmatic clinical trial to evaluate a quality improvement intervention.
Setting
Tertiary care hospital.
Participants
Individuals aged 65 and older admitted for hip fracture repair (N = 283).
Intervention
PPOs with delirium‐friendly options and doses for nighttime sedation, analgesia, and nausea and attention to catheter removal and bowel movements.
Measurements
Adherence to PPO was compared with adherence to routine orders. Drug doses were recorded. Presence of delirium was documented using the Confusion Assessment Method and the Mini‐Mental State Examination on postoperative Days 1, 3, and 5. Length of stay, discharge site, and in‐hospital mortality were recorded.
Results
Orthopedic nurses adhered reasonably well with delirium‐friendly PPOs. Of 283 participants, 42% developed postoperative delirium, with significantly less delirium in the intervention group (intervention 33%, control 51%, P = .001). The effect of the intervention was stronger in individuals with preexisting dementia (intervention 60%, control 97%, P < .001). Participants with postoperative delirium had longer hospital stays and were more likely to die or be discharged to a nursing home, but there was no significant between‐group difference in these outcomes.
Conclusion
It is possible to introduce delirium‐friendly PPOs into routine post‐hip fracture care in a representative elderly population including individuals with dementia. Delirium‐friendly PPOs executed by regular nursing staff resulted in a significant reduction in postoperative delirium but no difference in other outcomes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
This paper extends a method of apprising health status to a broad range of ages from adolescence to old age. The "frailty index" is based on the accumulation of deficits (symptoms, signs, disease ...classifications) as analyzed in the National Population Health Survey, a representative Canadian population sample (n = 81,859). The accumulation of deficits has both an age-independent (background) component and an age-dependent (exponential) component, akin to the well-known Gompertz-Makeham model for the risk of mortality. While women accumulate more deficits than men of the same age, on average, their rate of accumulation is lower, so the difference in the level of deficits between men and women decreases with age. Two possible invariants of the process of accumulation of deficits were found: (1) the age at which the average proportion of deficits coincides for men and women is 94 years, which closely matches the species-specific lifespan in humans (95 +/- 2); (2) the value of the frailty index (proportion of deficits), which corresponds to that age (0.18). The similarity between mortality kinetics and the accumulation of deficits (frailty kinetics), and the coincidence of the time parameters in the frailty and mortality models make it possible to express mortality risk in terms of accumulated deficits. This provides a simple and accessible tool that might have potential in a number of biomedical applications.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction: Timely, precise, and relevant communication between hospital-based clinicians and primary care physicians post-discharge (DC) ensures quality transitions, thereby reducing patient ...safety incidents and preventing readmission. At the present time there is limited knowledge of elements of quality or methods to score the quality criteria in the context of DC summaries. The Nova Scotia Health Authority, a provincial health system responsible for the delivery of services in a small Canadian province, embarked on a system-level approach to the standardization of DC summaries in an effort to improve quality and safety at care transitions from hospital to primary care. Materials and Methods: A comprehensive literature review to retrieve items relevant to quality in DC summaries, retrospective audit of charts, a consensus development process, and, finally, validation of a scoring tool were conducted in order to develop a quality scoring tool for DC summaries. Results: Relevant items were identified through the literature review and consensus development process. Corresponding definitions that were established assisted the development of the quality criteria, which were subsequently used to score the quality of DC summaries in our organization. Conclusion: The scoring tool developed through this work will be applied to help us gain a more in-depth understanding of quality in DC summaries and support the development of suitable education and quality processes in the health authority that can best support safe care transitions for patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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