Prognostic Implications of Predischarge Assessment of Gait Speed After Hip Fracture Surgery.

BACKGROUND AND PURPOSES: Hip fracture represents one of the most severe injuries in the older adults. In long-term survivors, disability is common and walking ability may be considered an important predictor of functional recovery. We investigated whether 4-m gait speed, assessed in older persons early after surgical repair of hip fracture, could predict functional recovery and subsequent development of major clinical outcomes. METHODS: This was a prospective cohort study. We included adults older than 65 years, admitted to a community acute care hospital with hip fracture, undergoing surgical repair. As soon as the participant was able to stand and walk, using walking aids as needed but with no person's help, the 4-m walking speed was tested as the main predictive variable. The outcome variables included the change in the Barthel Index (BI) from prehospital through 1 year postoperative as a continuous variable and 2 dichotomous outcomes, that is, (1) a decrease in BI greater than 5 points in 1 year and (2) a composite endpoint, combining 5+ points BI decline, death, falls, institutionalization, and need for 24-hour home assistance in 1 year. RESULTS: Sixty-two participants (mean age = 85 years) were enrolled and evaluated, on average 6 days (standard error of the mean [SEM] = 0.2) after hip fracture surgery. Compared with prefracture (mean = 96.3; SEM = 0.9), BI decreased 1 month after surgery (mean = 76.5; SEM = 2.1) and recovered only partially at 2 (mean = 84.1; SEM = 2.2) and 12 months (mean = 87.2; SEM = 2.8). A predischarge value of the walking speed below the median (20.5 cm/s) predicted a substantial BI reduction throughout the 12 months. Furthermore, the adjusted risk of a decline in functional status was reduced by 5% (odds ratio = 0.95; 95% confidence interval, 0.91-0.997; P = .038) and that of the combined outcome by 7% (odds ratio = 0.93; 95% confidence interval, 0.88-0.99; P = .013) for each centimeter per second of predischarge walking speed. DISCUSSION AND CONCLUSION: The 4-m walking speed, measured early after surgical repair of hip fracture, has profound long-term prognostic implications. This assessment approach might prove helpful in clinical decision-making on the postoperative management of older hip fracture persons.

The "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) randomized controlled trial: Case finding, screening and characteristics of eligible participants.

BACKGROUND: The ongoing "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies (SPRINTT)" randomized controlled trial (RCT) is testing the efficacy of a multicomponent intervention in the prevention of mobility disability in older adults with physical frailty & sarcopenia (PF&S). Here, we describe the procedures followed for PF&S case finding and screening of candidate participants for the SPRINTT RCT. We also illustrate the main demographic and clinical characteristics of eligible screenees. METHODS: The identification of PF&S was based on the co-occurrence of three defining elements: (1) reduced physical performance (defined as a score on the Short Physical Performance Battery between 3 and 9); (2) low muscle mass according to the criteria released by the Foundation for the National Institutes of Health; and (3) absence of mobility disability (defined as ability to complete the 400-m walk test in 15 min). SPRINTT was advertised through a variety of means. Site-specific case finding strategies were developed to accommodate the variability across centers in catchment area characteristics and access to the target population. A quick "participant profiling" questionnaire was devised to facilitate PF&S case finding. RESULTS: During approximately 22 months, 12,358 prescreening interviews were completed in 17 SPRINTT sites resulting in 6710 clinic screening visits. Eventually, 1566 candidates were found to be eligible for participating in the SPRINTT RCT. Eligible screenees showed substantial physical function impairment and comorbidity burden. In most centers, project advertisement through mass media was the most rewarding case finding strategy. CONCLUSION: PF&S case finding in the community is a challenging, but feasible task. Although largely autonomous in daily life activities, older adults with PF&S suffer from significant functional impairment and comorbidity. This subset of the older population is therefore at high risk for disability and other negative health-related events. Key strategies to consider for successfully intercepting at-risk older adults should focus on mass communication methods.

The "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) randomized controlled trial: design and methods.

The sustainability of health and social care systems is threatened by a growing population of older persons with heterogeneous needs related to multimorbidity, frailty, and increased risk of functional impairment. Since disability is difficult to reverse in old age and is extremely burdensome for individuals and society, novel strategies should be devised to preserve adequate levels of function and independence in late life. The development of mobility disability, an early event in the disablement process, precedes and predicts more severe forms of inability. Its prevention is, therefore, critical to impede the transition to overt disability. For this reason, the Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies (SPRINTT) project is conducting a randomized controlled trial (RCT) to test a multicomponent intervention (MCI) specifically designed to prevent mobility disability in high-risk older persons. SPRINTT is a phase III, multicenter RCT aimed at comparing the efficacy of a MCI, based on long-term structured physical activity, nutritional counseling/dietary intervention, and an information and communication technology intervention, versus a healthy aging lifestyle education program designed to prevent mobility disability in 1500 older persons with physical frailty and sarcopenia who will be followed for up to 36 months. The primary outcome of the SPRINTT trial is mobility disability, operationalized as the inability to walk for 400 m within 15 min, without sitting, help of another person, or the use of a walker. Secondary outcomes include changes in muscle mass and strength, persistent mobility disability, falls and injurious falls, disability in activities of daily living, nutritional status, cognition, mood, the use of healthcare resources, cost-effectiveness analysis, quality of life, and mortality rate. SPRINTT results are expected to promote significant advancements in the management of frail older persons at high risk of disability from both clinical and regulatory perspectives. The findings are also projected to pave the way for major investments in the field of disability prevention in old age.

Short Physical Performance Battery and all-cause mortality: systematic review and meta-analysis.

BACKGROUND: The Short Physical Performance Battery (SPPB) is a well-established tool to assess lower extremity physical performance status. Its predictive ability for all-cause mortality has been sparsely reported, but with conflicting results in different subsets of participants. The aim of this study was to perform a meta-analysis investigating the relationship between SPPB score and all-cause mortality. METHODS: Articles were searched in MEDLINE, the Cochrane Library, Google Scholar, and BioMed Central between July and September 2015 and updated in January 2016. Inclusion criteria were observational studies; >50 participants; stratification of population according to SPPB value; data on all-cause mortality; English language publications. Twenty-four articles were selected from available evidence. Data of interest (i.e., clinical characteristics, information after stratification of the sample into four SPPB groups [0-3, 4-6, 7-9, 10-12]) were retrieved from the articles and/or obtained by the study authors. The odds ratio (OR) and/or hazard ratio (HR) was obtained for all-cause mortality according to SPPB category (with SPPB scores 10-12 considered as reference) with adjustment for age, sex, and body mass index. RESULTS: Standardized data were obtained for 17 studies (n = 16,534, mean age 76 ± 3 years). As compared to SPPB scores 10-12, values of 0-3 (OR 3.25, 95%CI 2.86-3.79), 4-6 (OR 2.14, 95%CI 1.92-2.39), and 7-9 (OR 1.50, 95%CI 1.32-1.71) were each associated with an increased risk of all-cause mortality. The association between poor performance on SPPB and all-cause mortality remained highly consistent independent of follow-up length, subsets of participants, geographic area, and age of the population. Random effects meta-regression showed that OR for all-cause mortality with SPPB values 7-9 was higher in the younger population, diabetics, and men. CONCLUSIONS: An SPPB score lower than 10 is predictive of all-cause mortality. The systematic implementation of the SPPB in clinical practice settings may provide useful prognostic information about the risk of all-cause mortality. Moreover, the SPPB could be used as a surrogate endpoint of all-cause mortality in trials needing to quantify benefit and health improvements of specific treatments or rehabilitation programs. The study protocol was published on PROSPERO (CRD42015024916).

Does comprehensive geriatric assessment improve the estimate of surgical risk in elderly patients? An Italian multicenter observational study.

BACKGROUND: The evaluation of surgical risk is crucial in elderly patients. At present, there is little evidence of the usefulness of comprehensive geriatric assessment (CGA) as a part of the overall assessment of surgical elderly patients. METHODS: We verified whether CGA associated with established surgical risk assessment tools is able to improve the prediction of postoperative morbidity and mortality in 377 elderly patients undergoing elective surgery. RESULTS: Overall mortality and morbidity were 2.4% and 19.9%, respectively. Multivariate analysis showed that impaired cognitive function (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.15 to 4.22; P < .02) and higher Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (OR, 1.11; 95% CI, 1.00 to 1.23; P < .04) are predictive of mortality. Higher comorbidity is predictive of morbidity (OR, 2.12; 95% CI, 1.06 to 4.22; P < .03) and higher American Society of Anesthesiologists (OR, 2.18; 95% CI, 1.31 to 3.63; P < .001) and National Confidential Enquiry into Patient Outcome of Death score (OR, 2.03; 95% CI, 1.03 to 4.00; P < .04). CONCLUSIONS: In elective surgical elderly patients, the morbidity and mortality are low. The use of CGA improves the identification of elderly patients at higher risk of adverse events, independent of the surgical prognostic indices.

Sertraline treatment for depression associated with acute coronary syndromes: a cost analysis from the viewpoint of the Italian Healthcare System.

BACKGROUND AND AIMS: Depressive disorders (DD) are independent risk factors for rehospitalization after acute coronary syndromes (ACS) and, hence, for increased healthcare costs. A placebo-controlled safety trial of 24 weeks of treatment with sertraline after ACS (Sertraline Anti-Depressant Heart Attack Randomized Trial, SADHART) suggested that active treatment was associated with reduced rehospitalization due to coronary and non-coronary events. With the SADHART database, a cost analysis was carried out to determine the economic consequences of treating DD after ACS in the perspective of the Italian Healthcare System. METHODS: Clinical information on medical events and rehospitalizations recorded over the study period was drawn from the original SADHART database, which did not contain information necessary for estimating indirect costs. Analysis was therefore limited to direct medical costs due to rehospitalizations, emergency room visits and hospital procedures, and the average Italian Diagnosis-Related Group (DRG) tariffs were applied. RESULTS: With the exclusion of the cost of sertraline treatment, the average direct cost per patient over the study period was 3,418+/-8,290 euro in the active treatment group and 4,409+/-9,439 euro in the placebo group (p=0.3). After including the cost of 24 weeks of sertraline treatment, the average cost in sertraline-treated patients was only modestly increased, to 3,524+/-8,290 euro. CONCLUSIONS: Treatment of major DD in patients with recent ACS can improve patient care without additional costs, and possibly with some savings, to the healthcare system.

Screening of older community-dwelling people at risk for death and hospitalization: the Assistenza Socio-Sanitaria in Italia project.

OBJECTIVES: To develop and validate mortality and hospitalization prognostic tools based upon information readily available to primary care physicians (PCPs). DESIGN: Population-based cohort study. Baseline predictors were patient demographics, a seven-item questionnaire on functional status and general health, use of five or more drugs, and previous hospitalization. SETTING: Community-based study. PARTICIPANTS: Prognostic indexes were developed in 2,470 subjects and validated in 2,926 subjects, all community-dwelling, aged 65 and older, and randomly sampled from the rosters of 98 PCPs in Florence, Italy. MEASUREMENTS: Fifteen-month mortality and hospitalization. RESULTS: Two scores were derived from logistic regression models and used to stratify participants into four groups. With Model 1, based upon the seven-item questionnaire, mortality rate ranged from 0.8% in the lowest-risk group (0-1 point) to 9.4% in the highest risk group (> or = 3 points), and hospitalization rate ranged from 12.4% to 29.3%; area under the receiver operating characteristic curves (AUC) was 0.75 and 0.60, respectively. With Model 2, considering also drug use and previous hospitalization, mortality and hospitalization rates ranged from 0.3% to 8.2% and from 8.1% to 29.7%, for the lowest-risk to the highest-risk group; the AUC increased significantly only for hospitalization (0.67). CONCLUSION: Prediction of death and hospitalization in older community-dwelling people can be easily obtained with two indexes using information promptly available to PCPs. These tools might be useful for guiding clinical care and targeting interventions to reduce the need for hospital care in older persons.