Prevalence and population characteristics associated with frailty in a rural low socioeconomic area in Denmark: the Lolland-Falster Health Study.

BACKGROUND: Frailty is a major geriatric syndrome that predicts increased vulnerability to minor stressor events and adverse outcomes such as falls, fractures, disability and death. The prevalence of frailty among individuals above the age of 65 varies widely with an overall weighted prevalence of 10.7%. OBJECTIVES: The purpose of this study was to examine the prevalence of prefrailty and frailty in community-dwelling older adults from the regions of Lolland-Falster, which is one of the most socioeconomically disadvantaged areas of Denmark with lower income and lower life expectancy compared with the general Danish population. Moreover, the objective was to find selected individual characteristics associated with frailty. DESIGN: An observational, cross-sectional registry-based population study with data from the regions of Lolland-Falster collected between February 2016 and February 2020. RESULTS: The study included 19 000 individuals. There were 10 154 above the age of 50 included for analysis. Prevalence of frailty in the age group of 50-64 years was 4.7% and 8.7% in the age group of 65 years and above.The study demonstrates associations between frailty and high age, female gender, low education level, low income, smoking, living alone, frequency of seeing one's children and getting help when needed. These associations are comparable with findings from other studies. CONCLUSION: The syndrome of frailty consists of not only physiological and medical issues but also education, life conditions such as living alone and living in poverty and how you evaluate your own health.

Dementia in Women Using Estrogen-Only Therapy.

This study examines the association between use of estrogen-only therapy for perimenopausal and menopausal women and risk of dementia.

Categorisation and assessment of medication discontinuation tools in elderly, frail patients.

Older frail patients with multiple diagnoses and comprehensive medication lists are at risk of drug interaction, adverse events, and unnecessary medication. The aim of this review is to evaluate existing tools for deprescribing in older frail patients. The identified eight tools can be organised in three levels. They all contribute to the understanding and execution of deprescribing. Further studies increasing the current evidence of the deprescribing tools are needed. Further studies concerning patient barriers and clinical outcomes are needed.

Self-reported dizziness, falls, and self-rated health in a rural population in Denmark.

PURPOSE: To investigate associations between dizziness, hearing loss, medication, and self-perceived health in the region of Lolland-Falster in Denmark. METHODS: A cross-sectional population-based study using data from questionnaires and physical examinations between February 8th, 2016, and February 13th, 2020. Individuals aged 50 years or above in the region of Lolland-Falster were randomly invited to participate. RESULTS: Of 10,092 individuals (52% female), the mean age was 64.7 and 65.7 years for females and males, respectively. 20% reported dizziness during the past 30 days, and prevalence increased with age. 24% of dizzy females suffered from falls compared to 21% of males. 43% sought treatment for dizziness. Logistic regression revealed a higher odds ratio of dizziness in groups with poor self-perceived health (OR = 2.15, 95% CI [1.71, 2.72]) and very poor self-perceived health (OR = 3.62 [1.75, 7.93]) compared to moderate self-perceived health. A higher OR was found for seeking treatment for dizziness in the group that had experienced falls (OR = 3.21 [2.54, 4.07]). 40% reported hearing loss. Logistic regression revealed a higher OR for dizziness in the group with severe hearing loss (OR = 2.40 [1.77, 3.26]) and moderate hearing loss (OR = 1.63 [1.37, 1.94]) compared to no hearing loss. CONCLUSION: One of five participants reported dizziness during the last month. Dizziness was negatively associated with self-perception of good health also after adjusting for comorbidities. Almost half of the dizzy participants sought treatment for dizziness and 21% experienced falls. Identification and treatment of dizziness are important to prevent falls from happening. CLINICAL TRIAL REGISTRATION: http://www. CLINICALTRIALS: gov (NCT02482896).

Menopausal hormone therapy and dementia: nationwide, nested case-control study.

OBJECTIVES: To assess the association between use of menopausal hormone therapy and development of dementia according to type of hormone treatment, duration of use, and age at usage. DESIGN: Nationwide, nested case-control study. SETTING: Denmark through national registries. PARTICIPANTS: 5589 incident cases of dementia and 55 890 age matched controls were identified between 2000 and 2018 from a population of all Danish women aged 50-60 years in 2000 with no history of dementia or contraindications for use of menopausal hormone therapy. MAIN OUTCOME MEASURES: Adjusted hazard ratios with 95% confidence intervals for all cause dementia defined by a first time diagnosis or first time use of dementia specific medication. RESULTS: Compared with people who had never used treatment, people who had received oestrogen-progestogen therapy had an increased rate of all cause dementia (hazard ratio 1.24 (95% confidence interval 1.17 to 1.33)). Increasing durations of use yielded higher hazard ratios, ranging from 1.21 (1.09 to 1.35) for one year or less of use to 1.74 (1.45 to 2.10) for more than 12 years of use. Oestrogen-progestogen therapy was positively associated with development of dementia for both continuous (1.31 (1.18 to 1.46)) and cyclic (1.24 (1.13 to 1.35)) regimens. Associations persisted in women who received treatment at the age 55 years or younger (1.24 (1.11 to 1.40)). Findings persisted when restricted to late onset dementia (1.21 (1.12 to 1.30)) and Alzheimer's disease (1.22 (1.07 to 1.39)). CONCLUSIONS: Menopausal hormone therapy was positively associated with development of all cause dementia and Alzheimer's disease, even in women who received treatment at the age of 55 years or younger. The increased rate of dementia was similar between continuous and cyclic treatment. Further studies are warranted to determine whether these findings represent an actual effect of menopausal hormone therapy on dementia risk, or whether they reflect an underlying predisposition in women in need of these treatments.

Perspective of geriatric patients on advance care planning in Denmark: a qualitative study.

OBJECTIVE: Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations. DESIGN: Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method. SETTING: Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark. PARTICIPANTS: We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview. RESULTS: This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will. CONCLUSION: Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Treatment with glucagon-like peptide-1 receptor agonists and incidence of dementia: Data from pooled double-blind randomized controlled trials and nationwide disease and prescription registers.

INTRODUCTION: People with type 2 diabetes have increased risk of dementia. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are among the promising therapies for repurposing as a treatment for Alzheimer's disease; a key unanswered question is whether they reduce dementia incidence in people with type 2 diabetes. METHODS: We assessed exposure to GLP-1 RAs in patients with type 2 diabetes and subsequent diagnosis of dementia in two large data sources with long-term follow-up: pooled data from three randomized double-blind placebo-controlled cardiovascular outcome trials (15,820 patients) and a nationwide Danish registry-based cohort (120,054 patients). RESULTS: Dementia rate was lower both in patients randomized to GLP-1 RAs versus placebo (hazard ratio [HR]: 0.47 (95% confidence interval [CI]: 0.25-0.86) and in the nationwide cohort (HR: 0.89; 95% CI: 0.86-0.93 with yearly increased exposure to GLP-1 RAs). DISCUSSION: Treatment with GLP-1 RAs may provide a new opportunity to reduce the incidence of dementia in patients with type 2 diabetes.

Frequency of missed or delayed diagnosis in dementia is associated with neighborhood socioeconomic status.

Introduction: Underdetection of dementia in areas with low socioeconomic status (SES) may interfere with findings concerning associations between SES and dementia. Methods: Using administrative registers we assessed the associations between age- and sex-adjusted dementia incidence and neighborhood socioeconomic status (nSES) in 94 Danish municipalities. Wealth was divided into income quartiles and other nSES variables were dichotomized into high versus low according to the median. Results: High population density (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.18-1.24), higher proportion of inhabitants in higher income quartiles (P for trend < .0001), and high educational level (OR 1.19, 95% CI 1.15-1.22) were associated with higher incidence of dementia. High proportion of residents above 65 years was associated with lower age-adjusted dementia incidence (OR 0.86, 95% CI 0.84-0.89). Discussion: Low nSES municipalities have a lower age-adjusted incidence of dementia diagnosis. These findings corroborate prior concerns that a large number of dementia diagnoses may be missed in municipalities characterized by low SES.

Vaginal estrogen and association with dementia: A nationwide population-based study.

INTRODUCTION: Use of systemic hormone therapy has been positively associated with development of dementia. Little is known about the dose-dependent effect of vaginal estradiol on dementia risk. METHODS: We assessed associations between cumulative dose of vaginal estradiol tablets and dementia in a case-control study nested in a nationwide Danish cohort of women aged 50 to 60 years at study initiation, who did not use systemic hormone therapy. Each case was age-matched to 10 female controls. RESULTS: A total of 4574 dementia cases were matched to 45,740 controls. Cumulative use of vaginal estradiol tablets was not associated with all-cause dementia; adjusted hazard ratio 1.02 (95% confidence interval [CI] 0.89-1.18) for low dose (< 750 mcg), 1.07 (0.94-1.21) for medium dose (750-2000 mcg), and 0.93 (0.84-1.03) for high dose (> 2000 mcg). Similarly, Alzheimer's disease (AD) only was not associated with vaginal estradiol. DISCUSSION: Exposure to vaginal estradiol tablets was not associated with all-cause dementia or AD only.

Feasibility, quality and validity of narrative multisource feedback in postgraduate training: a mixed-method study.

OBJECTIVES: To examine a narrative multisource feedback (MSF) instrument concerning feasibility, quality of narrative comments, perceptions of users (face validity), consequential validity, discriminating capacity and number of assessors needed. DESIGN: Qualitative text analysis supplemented by quantitative descriptive analysis. SETTING: Internal Medicine Departments in Zealand, Denmark. PARTICIPANTS: 48 postgraduate trainees in internal medicine specialties, 1 clinical supervisor for each trainee and 376 feedback givers (respondents). INTERVENTION: This study examines the use of an electronic, purely narrative MSF instrument. After the MSF process, the trainee and the supervisor answered a postquestionnaire concerning their perception of the process. The authors coded the comments in the MSF reports for valence (positive or negative), specificity, relation to behaviour and whether the comment suggested a strategy for improvement. Four of the authors independently classified the MSF reports as either 'no reasons for concern' or 'possibly some concern', thereby examining discriminating capacity. Through iterative readings, the authors furthermore tried to identify how many respondents were needed in order to get a reliable impression of a trainee. RESULTS: Out of all comments coded for valence (n=1935), 89% were positive and 11% negative. Out of all coded comments (n=4684), 3.8% were suggesting ways to improve. 92% of trainees and supervisors preferred a narrative MSF to a numerical MSF, and 82% of the trainees discovered performance in need of development, but only 53% had made a specific plan for development. Kappa coefficients for inter-rater correlations between four authors were 0.7-1. There was a significant association (p<0.001) between the number of negative comments and the qualitative judgement by the four authors. It was not possible to define a specific number of respondents needed. CONCLUSIONS: A purely narrative MSF contributes with educational value and experienced supervisors can discriminate between trainees' performances based on the MSF reports.

[The chronically dizzy patient].

Many medical, neurologic and psychiatric conditions as well as drugs can give chronic dizziness, and a systematic diagnostic workup is essential. Chronic vestibular syndrome is a clinical syndrome of chronic vertigo, dizziness or unsteadiness lasting months to years. There is generally a persistent unilateral or bilateral vestibular loss. Treatment depends on the aetiology, but in general, treatment with vestibular rehabilitation is effective, which is summarised in this review. Betahistin or other anti-vertigo-drugs are not indicated in the treatment of chronic vertigo.

Predictive validity of PRISMA-7 as a screening instrument for frailty in a hospital setting.

OBJECTIVES: Frailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study the associations between frailty defined as Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7) score ≥3 and use of healthcare resources in hospital and in the municipality as well as association between frailty and mortality. DESIGN: Register-based retrospective study. SETTING: The target population consists of patients aged 75 years or above who, during hospital stay, were assessed by a physiotherapist, and at discharge from hospital were prescribed further physical training in the community. PARTICIPANTS: 973 individuals aged 75+ years were included. OUTCOME MEASURES: We examined associations between frailty and use of healthcare resources in hospital and in the municipality as well as the association between frailty and mortality. RESULTS: 973 individuals aged 75+ years were included. Of these, 63.9% had a PRISMA-7 score ≥3 and were thus defined as frail. Frail individuals were older compared with non-frail with mean ages of 84.6 and 80.4 years, respectively, p>0.001. Age and gender-adjusted mortality after 1 year was higher among the frail (OR 2.46, 95% CI 1.53 to 3.97). Use of healthcare services in the municipality as well as hospital admissions was significantly higher among frail individuals. CONCLUSIONS: Based on these findings we consider PRISMA-7 to be useful in an in-hospital setting as a screening tool to identify frail elderly patients who may profit from further geriatric assessment during hospital stay. TRIAL REGISTRATION NUMBER: ID REG-070-2017.

Effect of single follow-up home visit on readmission in a group of frail elderly patients - a Danish randomized clinical trial.

BACKGROUND: Unplanned hospital admissions are costly and prevention of these has been a focus for research for decades. With this study we aimed to determine whether discharge planning including a single follow-up home visit reduces readmission rate. The intervention is not representing a new method but contributes to the evidence concerning intensity of the intervention in this patient group. METHODS: This study was a centrally randomized single-center controlled trial comparing intervention to usual care with investigator-blinded outcome assessment. Patients above the age of 65 were discharged from a single Danish hospital during 2013-2014 serving a rural and low socioeconomic area. For intervention patients study and department nurses reviewed discharge planning the day before discharge. On the day of discharge, study nurses accompanied the patient to their home, where they met with the municipal nurse. Together with the patient they reviewed cognitive skills, medicine, nutrition, mobility, functional status, and future appointments in the health care sector and intervened if appropriate. Readmission at any hospital in Denmark within 8, 30, and 180 days after discharge is reported. Secondary outcomes were time to first readmission, number of readmissions, length of stay, and readmission with Ambulatory Care Sensitive Conditions, visits to general practitioners, municipal services, and mortality. RESULTS: One thousand forty-nine patients aged > 65 years discharged from medical, geriatric, emergency, surgical or orthopedic departments met inclusion criteria characteristic of frailty, e.g. low functional status, need of more personal help and multiple medications. Among 945 eligible patients, 544 were randomized. Seven patients died before discharge. 56% in the intervention group and 54% in the control group were readmitted (p = 0.71) and 23% from the intervention group and 22% from the control group died within 180 days. There were no significant differences between intervention and control groups concerning other secondary outcomes. CONCLUSIONS: There was no effect of a single follow-up home visit on readmission in a group of frail elderly patients discharged from hospital. TRIAL REGISTRATION: https://clinicaltrials.gov (identifier NCT02318680), retrospectively registered December 11, 2014.

Associations between the SHARE frailty phenotype and common frailty characteristics: evidence from a large Danish population study.

OBJECTIVES: Frailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study associations between a frailty phenotype and frailty characteristics well known from the literature. DESIGN: Registry-based cross-sectional study. SETTING: The target population consists of inhabitants above the age of 50 living in the Danish municipalities of Lolland and Guldborgsund. Excluded are incapacitated people, inhabitants unable to understand Danish or English and inhabitants without a permanent residence. PARTICIPANTS: 7327 individuals aged 50+ years were included. OUTCOME MEASURES: We examined associations between the frailty measurement and factors known to be associated with frailty: sex, age, income insufficiency, education, comorbidity, self-assessed health, morbidity and mortality. RESULTS: 7327 individuals aged 50+ years were included. Of these, 6.5% had ≥3 frailty components (frail), 46.7% had 1-2 components (prefrail) and 46.9% had none (non-frail). Those who were frail were older and more likely female than those who were non-frail or prefrail. There was a stepwise decrease in educational level, and in self-assessed health with increasing frailty status, and a stepwise increase in difficulty in making ends meet, number of hospital contacts and mortality with increasing frailty status, p<0.0001 for each comparison. Compared with individuals who were non-frail, mortality was higher among those who were prefrail (HR: 2.90; 95% CI: 1.30 to 6.43) or frail (HR: 8.21; 95% CI: 3.37 to 20.0). CONCLUSIONS: Based on these findings, we consider the Lolland-Falster Health Study frailty assessment a valid instrument demonstrating the same characteristics as other validated frailty measures concerning associations with sex, age, income insufficiency, education, comorbidity, self-assessed health, morbidity and mortality. TRIAL REGISTRATION NUMBER: NCT02482896.

Risk of post-discharge fall-related injuries among adult patients with syncope: A nationwide cohort study.

BACKGROUND: Syncope could be related to high risk of falls and injury in adults, but documentation is sparse. We examined the association between syncope and subsequent fall-related injuries in a nationwide cohort. METHODS: By cross-linkage of nationwide registers, all residents ≥18 years with a first-time diagnosis of syncope were identified between 1997-2012. Syncope patients were matched 1:1 with individuals from the general population. The absolute one-year risk of fall-related injuries, defined as fractures and traumatic head injuries requiring hospitalization, was calculated using Aalen-Johansen estimator. Ratios of the absolute one-year risk of fall-related injuries (ARR) were assessed by absolute risk regression analysis. RESULTS: We identified 125,763 patients with syncope: median age 65 years (interquartile range 46-78). At one year, follow-up was complete for 99.8% where a total of 8394 (6.7%) patients sustained a fall-related injury requiring hospitalization, of which 1606 (19.1%) suffered hip fracture. In the reference group, 4049 (3.2%) persons had a fall-related injury. The one-year ARR of a fall-related injury was 1.79 (95% confidence interval 1.72-1.87, P<0.001) in patients with syncope compared with the reference group; however, increased ARR was not exclusively in older patients. Factors independently associated with increased ARR of fall-related injuries in the syncope population were: injury in past 12 months, 2.39 (2.26-2.53, P<0.001), injury in relation to the syncope episode, 1.62 (1.49-1.77, P<0.001), and depression, 1.37 (1.30-1.45, P<0.001). CONCLUSION: Patients with syncope were at 80% increased risk of severe fall-related injuries within the year following discharge. Notably, increased risk was not exclusively in older patients.

Resumption of oral anticoagulation following traumatic injury and risk of stroke and bleeding in patients with atrial fibrillation: a nationwide cohort study.

Aims: We examined the risks of all-cause mortality, stroke, major bleeding, and recurrent traumatic injury associated with resumption of vitamin K antagonists (VKAs) and non-VKAs oral anticoagulants (NOACs) following traumatic injury in atrial fibrillation (AF) patients. Methods and results: This was a Danish nationwide registry-based study (2005-16), including 4541 oral anticoagulant (OAC)-treated AF patients experiencing traumatic injury (defined as traumatic brain injury, hip fracture, or traumatic torso or abdominal injury). Within 90 days following discharge from traumatic injury, 60.6% resumed VKA (median age = 80, CHA2DS2-VASc = 4, HAS-BLED = 2), 16.7% resumed NOAC (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 2), and 22.7% did not resume OAC treatment (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 3). Switch from VKA to NOAC occurred among 9.5%. Since 2009, the trend in OAC resumption increased (P-value <0.0001), in particular with NOACs (P-value <0.0001). Follow-up started 90 days after discharge, and time-varying multiple Cox regression analyses were used for comparisons. Compared with non-resumption, VKA and NOAC resumption were associated with lower hazard [95% confidence interval (CI)] of all-cause mortality [hazard ratio (HR) 0.48 (0.42-0.53) and HR 0.55 (0.47-0.66), respectively] and ischaemic stroke [HR 0.56 (0.43-0.72) and HR 0.54 (0.35-0.82), respectively], increased major bleeding hazard [HR 1.30 (1.03-1.64) and HR 1.15 (0.81-1.63), respectively], and similar hazard of recurrent traumatic injury [HR 0.93 (0.73-1.18) and HR 0.87 (0.60-1.27), respectively]. Conclusion: AF patients resuming VKA and NOAC treatment following traumatic injury have lower hazard of all-cause mortality and ischaemic stroke, increased hazard of major bleeding but without additional hazards of recurrent traumatic injury. Withholding OAC following a traumatic injury in AF patients may not be warranted.

Falls in elderly patients are not treated according to national recommendations.

INTRODUCTION: The aim of this study was to evaluate health professionals' compliance with recommendations from the Danish Health Authority (DHA) concerning falls, to study the prevalence of acute hospital visits due to falls, and to compare characteristics of fall patients in two geographically and socioeconomically different areas of Denmark. METHODS: The study was conducted in the emergency departments (ED) of Slagelse Hospital (SH) and Nykøbing Falster Hospital (NFH), both located in Denmark. Included were individuals > 50 years visiting the EDs from January 1 to March 31, 2014 who reported a fall. Information concerning demographic data and comorbidity in fall patients was retrieved from the medical records of the patients. RESULTS: A total of 2,664 individuals > 50 years visited the EDs during the study period. In all, 1,100 individuals (41.2%) reported a fall. In the NFH 236 (44%) and in the SH 223 (39%) of the fall patients had a fracture (p = 0.049). Patients in the more socioeconomically deprived area covered by the NFH were younger and had higher fracture and heart failure rates. Only 2% of the medical records contained answers to all four questions recommended by the DHA for risk screening in fall patients. The number of medical records containing answers to any of the four questions ranged from 17.5% to 25.8%. CONCLUSIONS: Only few fall patients were screened according to DHA recommendations. ED staff´s adherence to guidelines concerning fall risk assessment is poor. Fall patients in a socioeconomically deprived area were younger and had higher fracture and heart failure incidences. FUNDING: This study received funding from the public Regional Research Foundation, Region Zealand, Denmark. TRIAL REGISTRATION: not relevant.

[The correlation between motivation, emotions land learning].

This article explores the importance of emotions as conditional for motivation in medical education. The main principles in self-determination theory and in control-value theory are outlined, and practical consequences which may be drawn from these theories are discussed. Based on the literature we hypothesize that human need for autonomy and competence may be violated by strict regulations and detailed plans for medical education, and that constructive feedback may modify these potential negative effects and support feelings of competence and autonomy.