Abstract
Background
Readmission in older adults is typically complex with multiple contributing factors. We aim to examine how two prevalent and potentially modifiable geriatric conditions – ...depressive symptoms and malnutrition – relate to other geriatric syndromes and 30-day readmission in hospitalized older adults.
Methods
Consecutive admissions of patients ≥ 65 years to a general medical department were recruited over 16 months. Patients were screened for depression, malnutrition, delirium, cognitive impairment, and frailty at admission. Medical records were reviewed for poor oral intake and functional decline during hospitalization. Unplanned readmission within 30-days of discharge was tracked through the hospital’s electronic health records and follow-up telephone interviews. We use directed acyclic graphs (DAGs) to depict the relationship of depressive symptoms and malnutrition with geriatric syndromes that constitute covariates of interest and 30-day readmission outcome. Multiple logistic regression was performed for the independent associations of depressive symptoms and malnutrition with 30-day readmission, adjusting for variables based on DAG-identified minimal adjustment set.
Results
We recruited 1619 consecutive admissions, with mean age 76.4 (7.9) years and 51.3% females. 30-day readmission occurred in 331 (22.0%) of 1,507 patients with follow-up data. Depressive symptoms, malnutrition, higher comorbidity burden, hospitalization in the one-year preceding index admission, frailty, delirium, as well as functional decline and poor oral intake during the index admission, were more commonly observed among patients who were readmitted within 30 days of discharge (
P
< 0.05). Patients with active depressive symptoms were significantly more likely to be frail (OR = 1.62, 95% CI 1.22–2.16), had poor oral intake (OR = 1.35, 95% CI 1.02–1.79) and functional decline during admission (OR = 1.58, 95% CI 1.11–2.23). Malnutrition at admission was significantly associated with frailty (OR = 1.53, 95% CI 1.07–2.19), delirium (OR = 2.33, 95% CI 1.60–3.39) cognitive impairment (OR = 1.88, 95% CI 1.39–2.54) and poor oral intake during hospitalization (OR = 2.70, 95% CI 2.01–3.64). In minimal adjustment set identified by DAG, depressive symptoms (OR = 1.38, 95% CI 1.02–1.86) remained significantly associated with 30-day readmission. The association of malnutrition with 30-day readmission was no longer statistically significant after adjusting for age, ethnicity and depressive symptoms in the minimal adjustment set (OR = 1.40, 95% CI 0.99–1.98).
Conclusion
The observed causal associations support screening and targeted interventions for depressive symptoms and malnutrition during admission and in the post-acute period.
The sit-to-stand (STS) test has been deployed as surrogate measures of strength or physical performance in sarcopenia diagnosis. This study examines the relationship of two common STS variants - Five ...Times Sit-to-Stand Test (5TSTS) and 30 s Chair Stand Test (30CST) - with grip strength, muscle mass and functional measures, and their impact on sarcopenia prevalence in community-dwelling older adults.
This is a cross-sectional analysis of 887 community-dwelling adults aged ≥50 years. Participants completed a battery of physical fitness tests - 5TSTS, 30CST, grip strength, gait speed, Timed-Up-and-Go (TUG) for dynamic balance and six-minute walk test (6MWT) for cardiorespiratory endurance. Muscle mass was measured using multi-frequency segmental bioelectrical impedance analysis (BIA). We performed correlation analysis between STS performance and other fitness measures and muscle mass, followed by multiple linear regression for the independent determinants of STS performance.
Mean participant age was 67.3±7 years, with female predominance (72.9%). STS tests exhibited weak correlations with grip strength (30CST, r = 0.290; 5TSTS, r = - 0.242; both p< 0.01), and stronger correlations with gait speed (30CST, r = 0.517; 5TSTS, r = - 0.533; both p< 0.01), endurance (30CST, r = 0.558; 5TSTS, r = - 0.531; both p < 0.01) and dynamic balance (30CST, r = - 0.501; 5TSTS, r = 0.646; both p< 0.01). Muscle mass correlated with grip strength but not STS. In multiple regression analysis, all fitness measures were independently associated with 30CST performance. Performance in both STS tests remained independent of muscle mass. There was no significant difference in prevalence of possible sarcopenia diagnosis using grip strength or STS (30CST, 25.0%; 5TSTS, 22.1%; grip strength, 22.3%; p = 0.276). When both measures are used, prevalence is significantly higher (42.0%; p = 0.276). Prevalence of confirmed sarcopenia with inclusion of muscle mass was significantly lower using STS compared with grip strength (30CST, 4.6%; 5TSTS, 4.1% vs. grip strength, 7.1%; p< 0.05).
In the sarcopenia construct, STS tests better represents muscle physical performance rather than muscle strength. Different subsets of population with possible sarcopenia are identified depending on the test used. The lack of association of STS performance with muscle mass results in a lower prevalence of confirmed sarcopenia compared with grip strength, but may better reflect changes in muscle quality.
There is a paucity of data for the assessment of frailty in acutely ill hospitalized older adults. We aim to (1) compare the performance of frailty measures 5-item scale of fatigue, resistance, ...ambulation, illnesses, and loss of weight) (FRAIL), Tilburg Frailty Indicator (TFI), and Clinical Frailty Scale (CFS) in identifying frailty, using the widely adopted Frailty Index (FI) as "gold standard," and (2) compare their ability to predict negative outcomes among hospitalized older adults.
Prospective cohort study.
Acute inpatient care.
A total of 210 patients (mean age 89.4 ± 4.6 years, 69.5% female) admitted to the Department of Geriatric Medicine.
Premorbid frailty status was assessed by FI, FRAIL, TFI, and CFS. We collected data on comorbidities, severity of illness, functional status, and cognitive status. We compared area under receiver operator characteristic curves for FRAIL, TFI, and CFS against the reference FI. Multiple logistic regression was performed to examine the association between frailty and the primary outcome of in-hospital mortality.
Frailty prevalence estimates were 87.1% (FI), 50% (FRAIL), 80% (TFI), and 81% (CFS). Area under receiver operator characteristics against FI ranged from 0.81 95% confidence interval (CI) 0.72-0.90: FRAIL to 0.91 (95% CI 0.87-0.95: CFS), with no significant difference on receiver operating characteristic curve contrast. Frailty, as defined by FRAIL score ≥3, was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031) and length of hospitalization 10 days (6.0-17.5) vs 8 days (5.0-14.0), P = .043. FI odds ratio (OR) = 1.15, 95% CI 1.00-1.33, P = .05, FRAIL (OR = 3.31, 95% CI 1.43-7.67, P = .005), and CFS (OR = 2.57, 95% CI 1.14-5.83, P = .023) independently predicted in-hospital mortality adjusted for age, sex, and severity of illness.
FRAIL and CFS are simple frailty measures that may identify older adults at highest risk of adverse outcomes of hospitalization. FRAIL performed better in predicting in-hospital mortality.
Frailty begins in middle life and manifests as a decline in functional fitness. We described a model for community frailty screening and factors associated with prefrailty and frailty and fitness ...measures to distinguish prefrail/frail from robust older adults. We also compared the Fatigue, Resistance, Ambulation, Illnesses and Loss of weight (FRAIL) scale against Fried frailty phenotype and Frailty Index (FI).
Community-dwelling adults ≥55 years old were designated robust, prefrail or frail using FRAIL. The multidomain geriatric screen included social profiling and cognitive, psychological and nutritional assessments. Physical fitness assessments included flexibility, grip strength, upper limb dexterity, lower body strength and power, tandem and dynamic balance and cardiorespiratory endurance.
In 135 subjects, 99 (73.3%) were robust, 34 (25.2%) were prefrail and 2 (1.5%) were frail. After adjusting for age and sex, depression (odds ratio OR, 2.90; 95% confidence interval CI, 1.05-7.90;
= 0.040) and malnutrition (OR, 6.07; 95% CI, 2.52-14.64;
<0.001) were independently associated with prefrailty/frailty. Prefrail/frail participants had significantly poorer performance in upper limb dexterity (
= 0.030), lower limb power (
= 0.003), tandem and dynamic balance (
= 0.031) and endurance (
= 0.006). Except for balance and flexibility, all fitness measures differentiated prefrail/frail from robust women. In men, only lower body strength was significantly associated with frailty. Area under receiver operating characteristic curves for FRAIL against FI and Fried were 0.808 (0.688-0.927,
<0.001) and 0.645 (0.546-0.744,
= 0.005), respectively.
Mood and nutrition are targets in frailty prevention. Physical fitness declines early in frailty and manifests differentially in both genders.
Background
The differential risk profiles associated with prefrailty may be attributable to underlying intrinsic capacity (IC).
Objectives
We examine (i) effect of a multi-domain physical exercise ...and nutrition intervention on pre-frailty reversal in community-dwelling older adults at 1-year, and (ii) whether IC contributes to pre-frailty reversal.
Methods
Prefrail participants in this non-randomized study were invited to attend a 4-month exercise and nutritional intervention following a frailty screen in the community. Prefrailty was operationalized as (i) FRAIL score 1–2 or (ii) 0 positive response on FRAIL but with weak grip strength or slow gait speed based on the Asian Working Group for Sarcopenia cut-offs. Participants who fulfilled operational criteria for prefrailty but declined enrolment in the intervention programme served as the control group. All participants completed baseline IC assessment: locomotion (Short Physical Performance Battery, 6-minute walk test), vitality (nutritional status, muscle mass), sensory (self-reported hearing and vision), cognition (self-reported memory, age- and education adjusted cognitive performance), psychological (Geriatric Depression Scale-15, self-reported anxiety/ depression). Reversal of prefrailty was defined as achieving a FRAIL score of 0, with unimpaired grip strength and gait speed at 1-year follow-up.
Results
Of 81 participants (70.0 ± 6.6 years, 79.0% female), 52 participants (64.2%) were enrolled in the multi-domain intervention, and 29 participants (35.8%) who declined intervention constituted the control group. There was no difference in age, gender and baseline composite IC between groups. Reversal to robustness at 1-year was similar between intervention and control groups (30.8% vs. 44.8% respectively,
p
= 0.206). Reduced prevalence of depression was observed among participants in the intervention group at 1-year relative to baseline (7.8% vs. 23.1%,
p
= 0.022). In multiple logistic regression, intervention had no effect on prefrailty reversal, while higher composite IC exhibited reduced likelihood of remaining prefrail at 1-year (OR = 0.67, 95% CI 0.45–1.00,
p
= 0.049).
Conclusion
Focusing only on the locomotion and vitality domains through a combined exercise and nutritional intervention may not adequately address component domain losses to optimize prefrailty reversal. Future studies should examine whether an IC-guided approach to target identified domain declines may be more effective in preventing frailty progression.
Aim
In order to account for the variability in gait speed due to demographic factors, an observed gait speed value can be compared with its predicted value based on age, sex, and body height ...(observed gait speed divided by predicted gait speed, termed “GS%predicted” henceforth). This study aimed to examine the screening accuracy of an optimal GS%predicted threshold for prefrailty/frailty.
Methods
This cross‐sectional study included 998 community‐dwelling ambulant participants aged >50 years (mean age = 68 years). Participants completed a multi‐domain geriatric screen and a physical fitness assessment, from which the 10‐m habitual gait speed, GS%predicted, Physical Frailty Phenotype (PFP) index, and 36‐item Frailty Index (FI) were computed.
Results
Based on the FI, ~49% of participants had pre‐frailty or frailty. The optimal threshold of GS%predicted (0.93) had greater screening accuracy than the 1.0 m/s fixed threshold for gait speed (AUC, 0.65 vs. 0.60; DeLong's P < 0.001). Replacing gait speed with GS%predicted in the PFP improved its overall discrimination (AUC, 0.70 vs. 0.67 of original PFP; DeLong's P < 0.001).
Conclusions
Defining a “slow” gait speed by a GS%predicted value of <0.93 provided greater screening accuracy than the traditional 1.0 m/s threshold for gait speed. Our results also support the use of GS%predicted‐derived PFP to identify older adults at risk of prefrailty/frailty. Geriatr Gerontol Int 2022; 22: 575–580.
To account for the variability in habitual gait speed due to demographic factors, an observed gait speed value can be compared with its predicted value based on age, sex, and body height (observed gait speed divided by predicted gait speed, termed “GS%predicted” henceforth). In a large sample of 998 community‐dwelling older adults, we found that defining a “slow” gait speed by a GS%predicted value of <0.93 provided greater prefrailty/frailty screening accuracy than the traditional 1.0 m/s threshold for gait speed.
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Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background: Disruption of Wnt signaling has been implicated in dysfunctional synaptic plasticity, the degree of which correlates with Alzheimer’s disease severity. We sought to examine whether serum ...Dickkopf-1 (Dkk-1), a Wnt antagonist, is associated with global disease progression in older adults with mild cognitive impairment (MCI) and mild-to-moderate AD. Methods: We prospectively followed 88 older adults with MCI and mild-to-moderate AD attending a Memory Clinic. Cognitive, functional performance and neuropsychological symptoms were assessed at baseline and 1-year. We reviewed neuroimaging and performed ApoE genotyping at baseline. Serum Dkk-1 was assayed at baseline and 1-year, along with blood biomarkers of inflammation and endocrine dysfunction. We defined global disease progression (“progressors”) as increase in Clinical Dementia Rating Sum-of-Boxes (CDR-SB) score by >2 points at 1-year. Results: Fifteen (17.0%) participants had global disease progression. At baseline, there was no difference in cognitive performance and neuropsychiatric symptoms, although progressors were more impaired in instrumental activities of daily living (p=0.008). Progressors had significantly greater deterioration in cognitive performance (p=0.002), with significantly worse functional performance and more severe neuropsychiatric symptoms (p=0.042) at follow-up. Serum inflammatory and endocrine biomarkers at baseline and 1-year were similar between groups. Serum Dkk-1 had increased significantly from baseline amongst progressors, while non-progressors exhibited decremental Dkk-1 (Dkk-1change: 354.304+670.467 vs -173.582+535.676ng/ml, p=0.001). Adjusting for age, gender and baseline cognitive performance, incremental Dkk-1 independently predicted global cognitive decline (p=0.012) Conclusion: Our results suggest progressively dysfunctional Wnt signaling through Dkk-1 antagonism in contributing to disease progression amongst older adults with MCI and mild-moderate AD.
Objectives
To develop and validate a machine learning based automated segmentation method that jointly analyzes the four contrasts provided by Dixon MRI technique for improved thigh composition ...segmentation accuracy.
Materials and methods
The automatic detection of body composition is formulized as a three-class classification issue. Each image voxel in the training dataset is assigned with a correct label. A voxel classifier is trained and subsequently used to predict unseen data. Morphological operations are finally applied to generate volumetric segmented images for different structures. We applied this algorithm on datasets of (1) four contrast images, (2) water and fat images, and (3) unsuppressed images acquired from 190 subjects.
Results
The proposed method using four contrasts achieved most accurate and robust segmentation compared to the use of combined fat and water images and the use of unsuppressed image, average Dice coefficients of 0.94 ± 0.03, 0.96 ± 0.03, 0.80 ± 0.03, and 0.97 ± 0.01 has been achieved to bone region, subcutaneous adipose tissue (SAT), inter-muscular adipose tissue (IMAT), and muscle respectively.
Conclusion
Our proposed method based on machine learning produces accurate tissue quantification and showed an effective use of large information provided by the four contrast images from Dixon MRI.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
To examine diagnostic agreement between Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) Neurocognitive Disorders (NCDs) criteria and DSM, Fourth Edition (DSM-IV) criteria ...for dementia and International Working Group (IWG) criteria for mild cognitive impairment (MCI) and DSM-V's impact on diagnostic classifications of NCDs. The authors further examined clinical factors for discrepancy in diagnostic classifications between the different operational definitions.
Using a cross-sectional study in tertiary memory clinic, the authors studied consecutive new patients aged 55 years or older who presented with cognitive symptoms. Dementia severity was scored based on the Clinical Dementia Rating scale (CDR). All patients completed neuropsychological evaluation. Agreement in diagnostic classifications between DSM-IV/IWG and DSM-V was examined using the kappa test and AC1 statistic, with multinomial logistic regression for factors contributing to MCI reclassification as major NCDs as opposed to diagnostically concordant MCI and dementia groups.
Of 234 patients studied, 166 patients achieved concordant diagnostic classifications, with overall kappa of 0.41. Eighty-six patients (36.7%) were diagnosed with MCI and 131 (56.0%) with DSM-IV-defined dementia. With DSM-V, 40 patients (17.1%) were classified as mild NCDs and 183 (78.2%) as major NCDs, representing a 39.7% increase in frequency of dementia diagnoses. CDR sum-of-boxes score contributed independently to differentiation of MCI patients reclassified as mild versus major NCDs (OR: 0.01; 95% CI: 0-0.09). CDR sum-of-boxes score (OR: 5.18; 95% CI: 2.04-13.15), performance in amnestic (OR: 0.14; 95% CI: 0.06-0.34) and language (Boston naming: OR: 0.52; 95% CI: 0.29-0.94) tests, were independent determinants of diagnostically concordant dementia diagnosis.
The authors observed moderate agreement between the different operational definitions and a 40% increase in dementia diagnoses with operationalization of the DSM-V criteria.
Objectives
Compare the diagnostic performance of FRAIL against Fried Phenotype and Frailty Index (FI), and identify clinical factors associated with pre-frailty/frailty.
Design
Cross-sectional ...analysis.
Setting
Community-based screenings in Senior Activity Centres, Residents’ Corners and Community Centres in northeast Singapore.
Participants
517 community dwelling participants aged >55 years and ambulant independently (with/ without walking aids) were included in this study. Residents of sheltered or nursing homes, and seniors unable to ambulate at least four meters independently were excluded.
Measurements
The multidomain geriatric screen included assessments for social vulnerability, mood, cognition, sarcopenia and nutrition. Participants completed a battery of physical fitness tests for grip strength, gait speed, lower limb strength and power, flexibility, balance and endurance, with overall physical performance represented by Short Physical Performance Battery (SPPB). Frailty status was assigned on FRAIL, Fried and 35-item FI.
Results
Prevalence of frailty was 1.3% (FRAIL) to 3.1% (FI). Pre-frailty prevalence ranged from 17.0% (FRAIL) to 51.2% (FI). FRAIL demonstrated poor agreement with FI (kappa=0.171, p<0.0001), and Fried (kappa=0.194, p<0.0001). A lower FRAIL cut-off ≥1 yielded significantly improved AUC of 0.70 (95%CI 0.55 to 0.86, p=0.009) against Fried, and 0.71 (95%CI 0.55 to 0.86, p=0.008) against FI. All 3 frailty measures were diagnostic of impaired physical performance on SPPB, with AUCs ranging from 0.69 on FRAIL to 0.77 on Fried (all p values <0.01). Prevalence of low socio-economic status, depression, malnutrition and sarcopenia increased significantly, while fitness measures of gait speed, balance, and endurance declined progressively across robust, pre-frail and frail on all 3 frailty instruments (p <0.05).
Conclusions
Our results suggest that different frailty instruments may capture over-lapping albeit distinct constructs, and thus may not be used interchangeably. FRAIL has utility for quick screening, and any positive response should trigger further assessment, including evaluation for depression, social vulnerability and malnutrition.
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