The assessment and detection rate of intrinsic capacity deficits among older adults: a systematic review and meta-analysis.

BACKGROUND: Assessing and monitoring intrinsic capacity (IC) is an effective strategy to promote healthy ageing by intervening early in high-risk populations. This review systematically analyzed the global detection rates of IC deficits and explored variations across diverse populations and data collection methods. METHODS: This study was preregistered with PROSPERO, CRD42023477315. In this systematic review and meta-analysis, we systematically searched ten databases from January 2015 to October 2023, for peer-reviewed, observational studies or baseline survey of trials that assessed IC deficits among older adults aged 50 and above globally following the condition, context and population approach. The main outcome was intrinsic capacity deficits which could be assessed by any tools. Meta-analyses were performed by a random-effect model to pool the detection rates across studies and subgroup analyses were conducted by populations and data collection methods. RESULTS: Fifty-six studies conducted in 13 countries were included in the review and 44 studies with detection rates of IC were included in the meta-analysis. The pooled detection rate of IC deficits was 72.0% (65.2%-78.8%) and deficits were most detected in sensory (49.3%), followed by locomotion (40.0%), cognition (33.1%), psychology (21.9%), and vitality (20.1%). Variations in detection rates of IC deficits were observed across studies, with higher rates observed in low- and middle-income countries (74.0%) and hyper-aged societies (85.0%). Study population and measurement tools also explained the high heterogeneity across studies. CONCLUSION: IC deficits are common among older adults, while heterogeneity exists across populations and by measurement. Early monitoring with standardized tools and early intervention on specific subdomains of IC deficits are greatly needed for effective strategies to promote healthy ageing.

Factors associated with mortality in hospitalised, non-severe, older COVID-19 patients - the role of sarcopenia and frailty assessment.

BACKGROUND: COVID-19 has affected older persons the most. The propensity to have severe COVID-19 or die of the infection was especially prevalent among older subjects with multimorbidity, frailty and sarcopenia. The aim of our study was to check which of the simple clinical biomarkers, including the assessment of muscle and frailty, would associate with the survival and the length of hospital stay in older patients with COVID-19. An additional aim was to report the influence of chronic diseases, chronic medication use, and COVID-19 signs and symptoms on the aforementioned outcome measures. METHODS: The CRACoV study was a prospective single-center (University Hospital in Krakow, Krakow, Poland) observational study of clinical outcomes in symptomatic COVID-19 patients that required hospital treatment. We analysed data of persons aged ≥ 65 years. We assessed muscular parameters in accordance with EWGSOP2, frailty with the Rockwood Clinical Frailty Scale. We used the data of the initial and 3-month assessment. Demographic characteristics, past medical history, and baseline laboratory values were gathered as a part of routine care. We calculated sex and age, and additionally number-of-diseases adjusted odds ratios of mortality associated with studied factors and betas of the relation with these factors and the length of hospital stay. RESULTS: The mean (standard deviation, SD) age of 163 participants (44.8% women, 14.8% died) was 71.8 (5.6) years, age range 65-89 years. One score greater SARC-F was associated with 34% (p = 0.003) greater risk of death, and 16.8 h longer hospital stay (p = 0.01). One score greater Rockwood was associated with 86% (p = 0.002) greater risk of death, but was unrelated to the length of hospital stay. Hand grip strength and dynapenia were unrelated to mortality, but dynapenia was related to longer hospital stay. Probable sarcopenia was associated with 441% (p = 0.01) greater risk of death. CONCLUSIONS: In conclusion, the patient assessment with SARC-F and the Rockwood Clinical Frailty Scale may significantly improve the prediction of outcomes in older patients with COVID-19 and by extension might be of use in other acute severe infections. This, however, requires further research to confirm.

Strategies to Improve Vaccine Uptake throughout Adulthood.

Vaccine-preventable diseases represent a considerable burden on world health, and can have long-lasting consequences in those infected, especially in older adults, who can suffer functional decline, disability, and death. Vaccine uptake across the life course is desirable, but often suboptimal. A number of factors have been identified as contributors to low vaccine coverage, including sociodemographic characteristics, logistic factors such as ease of access and convenience, cultural attitudes including health literacy, and vaccine hesitancy. Strategies to improve vaccine uptake can target all the components underpinning low coverage, and include technology and communication-based strategies, physician-centered approaches, targeting healthcare workers for influenza vaccination, system-based factors, improved vaccine efficacy, and above all, political will and leadership.

Taking action against malnutrition in Asian healthcare settings: an initiative of a Northeast Asia Study Group.

Malnutrition is common in Asia, especially among people who are critically ill and/or older. Study results from China, Japan, and Taiwan show that malnutrition or risk of malnutrition is found in up to 30% of communitydwelling people and as much as 50% of patients admitted to hospitals-with prevalence even higher among those older than 70 years. In Asia, malnutrition takes substantial tolls on health, physical function, and wellbeing of people affected, and it adds huge financial burdens to healthcare systems. Attention to nutrition, including protein intake, can help prevent or delay disease- and age-related disabilities and can speed recovery from illness or surgery. Despite compelling evidence and professional guidelines on appropriate nutrition care in hospital and community settings, patients' malnutrition is often overlooked and under-treated in Asian healthcare, as it is worldwide. Since the problem of malnutrition continues to grow as many Asian populations become increasingly "gray", it is important to take action now. A medical education (feedM.E.) Global Study Group developed a strategy to facilitate best-practice hospital nutrition care: screen-intervene-supervene. As members of a newly formed feedM.E. Northeast Asia Study Group, we endorse this care strategy, guiding clinicians to screen each patient's nutritional status upon hospital admission or at initiation of care, intervene promptly when nutrition care is needed, and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans, including post-discharge. To encourage best-practice nutrition in Asian patient care settings, our paper includes a simple, stepwise Nutrition Care Pathway (NCP) in multiple languages.

Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective.

Herpes zoster (HZ) is primarily a disease of nerve tissue but the acute and longer-term manifestations require multidisciplinary knowledge and involvement in their management. Complications may be dermatological (e.g. secondary bacterial infection), neurological (e.g. long-term pain, segmental paresis, stroke), ophthalmological (e.g. keratitis, iridocyclitis, secondary glaucoma) or visceral (e.g. pneumonia, hepatitis). The age-related increased incidence of HZ and its complications is thought to be a result of the decline in cell-mediated immunity (immunosenescence), higher incidence of comorbidities with age and social-environmental changes. Individuals who are immunocompromised as a result of disease or therapy are also at increased risk, independent of age. HZ and its complications (particularly postherpetic neuralgia) create a significant burden for the patient, carers, healthcare systems and employers. Prevention and treatment of HZ complications remain a therapeutic challenge despite recent advances. This is an overview of the multidisciplinary implications and management of HZ in which the potential contribution of vaccination to reducing the incidence HZ and its complications are also discussed.

[Is it possible to reduce health inequalities in old age?]. / Est-il possible de réduire les inégalités de santé au grand âge?

Analysis of prospective data collected between 1984 and 2008 by the CERN medical team (European Centre of Nuclear Research, Geneva) concerning 2040 former employees who were retired or had died stimulated our interest on the impact of inequalities in socioeconomic conditions, employment, lifestyle and classical risk factors on health and life expectancy. Such inequalities explain differences in life expectancy, potentially reaching several decades, between rich and poor countries (France vs Swaziland), but also within a given country (USA), a given city (Glasgow) or even a given enterprise (CERN) where all employees have the same level of healthcare insurance and access to treatment. Classical cardiovascular and neurovascular risk factors (smoking, arterial hypertension and lipid disorders) interact with socioeconomic status, intelligence, education, emotions and job responsibility/complexity, precipitating or preventing cardiovascular events. The same is true of dementia, for which midlife risk factors (obesity, arterial hypertension and hypercholesterolemia) should be considered in the psychosocioeconomic context, which influences cognitive reserves and thus affects the risk and severity of dementia in old age. Thus, in addition to lifestyle and classical risk factors, socioeconomic status appears as a major health determinant, by imposing behaviors and habits and by determining access to healthcare.

Evidence-based strategies for the optimization of pharmacotherapy in older people.

Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention's success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape 'age-attuned' health and drug policy.

Economic evaluation of a vaccine for the prevention of herpes zoster and post-herpetic neuralgia in older adults in Switzerland.

BACKGROUND: A life-attenuated vaccine aimed at preventing herpes zoster (HZ) and its main complication, post-herpetic neuralgia (PHN), will soon be available in Europe. The study's objective was to assess the clinical and economic impact of a vaccination program for adults aged 70-79 years in Switzerland. RESULTS: A vaccination strategy compared to a no-vaccination resulted in lifetime incremental cost-effectiveness ratios (ICERs) of 25,538 CHF (23,646 USD) per QALY gained, 6,625 CHF (6,134 USD) per HZ case avoided, and 15,487 CHF (14,340 USD) per PHN3 case avoided under the third-party payer perspective. Sensitivity analyses showed that the model was most sensitive to the discount rates, HZ epidemiological data and vaccine price used. METHODS: A Markov model, simulating the natural history of HZ and PHN and the lifetime effects of vaccination, previously developed for the UK was adapted to the Swiss context. The model includes several health states including good health, HZ, PHN, and death. HZ and PHN states reflected pain severity. CONCLUSION: The model predicts clinical and economic benefits of vaccination in the form of fewer HZ and PHN cases and reductions in healthcare resource use. ICERs were within the commonly accepted thresholds in Switzerland, indicating that a HZ vaccination program would be considered a cost-effective strategy in the Swiss setting.

Efficiency and applicability of comprehensive geriatric assessment in the emergency department: a systematic review.

BACKGROUND AND AIMS: Comprehensive geriatric assessment (CGA) may benefit frail or chronically ill patients in the emergency department (ED), but take too much time to be performed routinely in ED. An alternative approach is to use first a screening tool to detect high-risk patients and then perform CGA in these patients only. This systematic review focuses on the use and value of CGA in ED for evaluation of older patients and its influence on adverse outcomes. This approach is compared with an alternative one using existing screening tools, validated in ED, to detect high-risk patients needing subsequent CGA. This review ends by suggesting a short assessment of CGA to be used in ED and ways to improve home discharge management from ED. METHODS: A systematic English Medline literature search was conducted in December 2009, with no date limit with the following Medical Subject Heading (MeSH) terms: "Frail Elderly", "Health Services for Aged", "Community Health Nursing", "Emergency Service, Hospital", "Geriatric Assessment", "Patient Discharge", "Risk Assessment" and "Triage". RESULTS: We selected 8 studies on CGA efficiency and 14 on screening tools. CGA in ED is efficient for decreasing functional decline, ED readmission and possibly nursing home admission in high-risk patients. As CGA takes too much time to be performed routinely in ED, validated screening tools can be applied to detect high-risk patients who will benefit most from CGA. CONCLUSIONS: The selected studies demonstrated that screening of high-risk patients is more efficient than age-based screening, and that CGA performed in ED, followed by appropriate interventions, improves outcomes.

Europe-wide survey of teaching in geriatric medicine.

By 2050, the European population of 720 million will include 187 million (one quarter) octogenarians. Although living longer is a true privilege, care for the graying population suffering from chronic and disabling diseases will raise enormous challenges to healthcare systems and geriatric education. Are European countries ready to cope with these challenges? An extensive 2006 survey of geriatric education in thirty-one of 33 European countries testifies that geriatrics is a recognized medical specialty in 16 countries and a subspecialty in nine of them. Six European countries have an established chair of geriatric medicine in each of their medical schools. Undergraduate teaching activities are organized in 25 of the surveyed countries and postgraduate teaching in 22 countries under the leadership of geriatricians (n=16) or general internists (n=6). A comparison with data collected in the 1990s shows important progresses: the number of established chairs increased by 45%, the undergraduate and postgraduate teaching activities increased respectively by 23% and 19%. However, these changes are very heterogeneously organized from country to country and within each country. In most European countries, there remains a huge need for reinforcing and harmonizing geriatric teaching activities to prepare the next generation of medical doctors to address the projected increase in chronic and disabled older patients. Several different innovative strategies are proposed.

Pain in severe dementia: self-assessment or observational scales?

OBJECTIVES: To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data. DESIGN: Prospective clinical study. SETTING: Geriatrics hospital and a geriatric psychiatry service. PARTICIPANTS: All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3. MEASUREMENTS: Three self-assessment tools--the verbal, horizontal visual, and faces pain scales--were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales. RESULTS: Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88-0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45-0.94; P<.001). Observational rating correlated at least moderately with self-assessment (r=0.25-0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales. CONCLUSION: Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

Upper extremity fractures in the elderly: consequences on utilization of rehabilitation care.

BACKGROUND AND AIMS: While hip fractures represent the most dramatic consequence of osteoporosis, fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures due to osteoporosis in the older population. The aim of this retrospective cohort study was to evaluate rehabilitation care utilization and associated factors in elderly individuals with upper limb fracture. METHODS: Over two years, 667 patients 65 years of age or older were studied, who presented to the emergency department either from their private homes or nursing homes with an upper extremity fracture. The following outcome variables were collected: gender; age; residence; location of fracture; treatment; discharge destination; length of hospitalization; length of stay in a rehabilitation facility; and ultimate place of habitation after the event. RESULTS: The most frequent sites of fracture were distal radius (37.2%) and proximal humerus (29.1%). Two-thirds of the patients were treated non-operatively. Inpatient rehabilitation care was necessary for 248 patients (37.2%; length of stay, 46 days). Factors associated with increased care included older age (> or = 80 years), coming from private home, sustaining two fractures, fractures of the humerus, and operative treatment. Six percent of the patients required permanent nursing home care. CONCLUSIONS: Upper extremity fractures in older people often require prolonged hospitalization and therefore account for considerable health care costs. Reasons are more related to advanced age and living conditions than to particular injury or treatment.

Feasibility and reliability of four pain self-assessment scales and correlation with an observational rating scale in hospitalized elderly demented patients.

BACKGROUND: Acute and chronic pain is common in hospitalized demented elderly people, yet there are limited data about the performance of pain assessment tools in this population. The aim of this study was to evaluate the feasibility and reliability of four pain self-assessment scales in this population and compare their performance to an observational pain rating scale. METHODS: Our prospective clinical study was conducted in an acute-care and intermediate-care geriatric hospital on 160 consecutive inpatient referrals to the dementia consultation who met Diagnostic and Statistical Manual of Mental Disorders-IV criteria for dementia. Exclusion criteria were delirium, terminal care, and severe sensory impairment. Four unidimensional self-assessment tools--the verbal, horizontal visual, vertical visual, and faces pain scales--were administered in randomized order to mild, moderate, and severely demented patients. An observational pain rating scale was independently completed by the nursing team. RESULTS: Only 12% of the 160 patients (mean age 85 years, 71% women) understood no scale. Respectively, 97%, 90%, and 40% of patients with mild, moderate, and severe dementia understood at least one scale (p <.05). There was a nonsignificant trend toward poorer comprehension of the faces scale. Test-retest reliability was high for all four self-assessment scales, and the correlation between these scales was very strong (Spearman's r(s) = 0.81-0.95; p <.001). Observational rating correlated moderately with self-assessment and tended to underestimate pain intensity (r(s) = 0.31-0.40; p <.05). CONCLUSIONS: Self-assessment pain scales can be used reliably in the vast majority of older hospitalized patients with mild to moderate dementia and in nearly half of those with severe dementia. Observational pain rating scales correlate only moderately with self-assessment and should be reserved for those few patients who have demonstrated that they cannot complete a self-assessment.

[The economical impact of dementia]. / Impact économique de la démence.

An epidemiology closely linked with the increase in life span. In most countries, the prevalence of dementia varies between 6 and 8% for individuals aged 65 years or more. It then dramatically increases with each subsequent decade, reaching around 30% of the population aged over 85. The costs associated with dementia are correlated with the increase in age and are of increasing concern for politicians, healthcare professionals and family members of demented patients. Current estimations are approximate, but dementia appears to be the most costly disease for society after the age of 65 years in France, the Netherlands, Sweden, or the United States. Detailed cost analyses have distinguished the direct medical,direct non-medical and intangible costs. The most important contribution in costs for society is the long-term care by health care professionals (institutionalization corresponding to 2/3 of the total costs for society!), but the care provided by the helpers and the families is even greater, even though difficult to quantify. The current question is to know whether present and future medical treatments will be able to reduce the tremendous financial costs of this chronic disease.

Hip fracture surgery: is the pre-operative American Society of Anesthesiologists (ASA) score a predictor of functional outcome?

BACKGROUND AND AIMS: Many studies have identified specific demographic, social, health or life-style pre-operative indicators of long-term outcome among older hip fracture patients who underwent surgical treatment. The purpose of this study was to determine the predictive value of peri- and intra-operative factors, and more specifically of the pre-operative American Society of Anesthesiologists (ASA) score on functional outcome in these patients. METHODS: A questionnaire designed to assess pre-fracture functional and health status was administered to surgically treated hip fracture patients. Post-fracture functional and health status was further ascertained by in-home interview one year after the operation. Among 140 consecutive eligible patients older than 65 years, 10 either refused subsequent interviews or could not be contacted; an additional 16 patients died during the year of follow-up, leaving 114 patients available for this study. RESULTS: The average age of the patients was 82.4 years. Almost two-thirds of them suffered from severe systemic disease, whether or not incapacitating (ASA grades III-IV). Subjects classified in these categories presented more frequently with cardiovascular disorders, were more frequently disoriented, and already had some pre-fracture difficulty with ambulation. The mortality at one year was almost nine times higher in severely impaired patients (grades III-IV) than in healthy or mildly affected patients (grades I-II). Functional outcome and/or ambulatory ability assessed at one year did not reveal any statistically significant difference between the ASA I-II and III-IV groups. The most pronounced difference was noticed for the functional independence measured by the ADL score (p = 0.236). Better prognoses were consistently recorded for patients with an intracapsular fracture, for those who were operated within 24 hours, for those treated with a prosthesis as opposed to internal fixation, and for those whose operating time was less than 1 1/2 hours. CONCLUSIONS: Although the ASA classification is a good predictor of long-term mortality, the findings of the present investigation do not conclusively associate ASA score with post-operative restoration of mobility and functional independence.