Delirium and frailty in older adults: Clinical overlap and biological underpinnings.

Frailty and delirium are two common geriatric syndromes sharing several clinical characteristics, risk factors, and negative outcomes. Understanding their interdependency is crucial to identify shared mechanisms and implement initiatives to reduce the associated burden. This literature review summarizes scientific evidence on the complex interplay between frailty and delirium; clinical, epidemiological, and pathophysiological commonalities; and current knowledge gaps. We conducted a PubMed systematic search in June 2023, which yielded 118 eligible articles out of 991. The synthesis of the results-carried out by content experts-highlights overlapping risk factors, clinical phenotypes, and outcomes and explores the influence of one syndrome on the onset of the other. Common pathophysiological mechanisms identified include inflammation, neurodegeneration, metabolic insufficiency, and vascular burden. The review suggests that frailty is a risk factor for delirium, with some support for delirium associated with accelerated frailty. The proposed unifying framework supports the integration and measurement of both constructs in research and clinical practice, identifying the geroscience approach as a potential avenue to develop strategies for both conditions. In conclusion, we suggest that frailty and delirium might be alternative-sometimes coexisting-manifestations of accelerated biological aging. Clinically, the concepts addressed in this review can help approach older adults with either frailty or delirium from a different perspective. From a research standpoint, longitudinal studies are needed to explore the hypothesis that specific pathways within the biology of aging may underlie the clinical manifestations of frailty and delirium. Such research will pave the way for future understanding of other geriatric syndromes as well.

Association Between Accelerometer-Assessed Physical Activity and Cognitive Function in Older Adults: A Cross-Sectional Study.

OBJECTIVE: Research suggests that physical activity (PA) improves cognitive function across various domains. However, the specific role of different PA measures, including step count, remains to be explored. Our aim was to assess the correlation between objectively measured PA and cognitive function. METHODS: We included 663 adults, aged ≥66 years, from the Swedish SNAC-K study (2016-2019). Global cognition and three cognitive domains (processing speed, executive function, and episodic memory) were assessed with validated tests. PA was measured through ActivPAL3 accelerometers. We applied age-stratified (<70 vs. ≥80 years), multi-adjusted, quantile regression to examine the cross-sectional associations between cognitive function and PA, considering steps/day and time spent in moderate-to-vigorous PA (MVPA). RESULTS: Each 1000-step increment (ß = 0.04; 95% CI: 0.01, 0.07) and each additional hour of MVPA per day (ß = 0.28; 95% CI: 0.02, 0.54) were correlated with better processing speed in the youngest-old, but not in the oldest-old. When further stratifying by MVPA (<60 min vs. ≥60 min/week), each 1000-step increment was associated with better processing speed in the youngest-old, regardless of their MVPA levels. CONCLUSION: Our study links accelerometer-assessed PA (steps and MVPA) with better processing speed in the youngest-old adults. Step count correlated with processing speed regardless of intensity. Further research is needed to determine the directionality of these associations.

Sustained improvement of intrinsic capacity in community-dwelling older adults: The +AGIL Barcelona multidomain program.

BACKGROUND: Different programs promote healthy ageing through the optimization of intrinsic capacity. However, a major challenge is to assess their sustained effects over time. +AGIL Barcelona, a consolidated multidomain program, aims to optimize older adults' intrinsic capacity through a coordinated approach among primary care, geriatrics and community resources, in agreement with the integrated care for older people (ICOPE) guidelines. We aimed to evaluate the +AGIL Barcelona longitudinal effect on older adults' physical performance. METHODS: All +AGIL Barcelona consecutive participants since 2016 were enrolled. After a comprehensive geriatric assessment, a tailored, multidisciplinary intervention aligned with the ICOPE guidelines is offered. It includes a 10-week boost multicomponent exercise program, nutritional and sleep-hygiene counselling, revision and optimization of pharmacological treatments and screening for cognitive impairment, depression and loneliness. Changes in physical performance after 3 and 6 months were assessed using mixed models including baseline frailty degree, time and all potential significant confounders. RESULTS: We included 194 participants in the analysis (mean age = 81.6 [standard deviation = 5.8], 68% women). An independent, clinically and statistically significant improvement in physical performance (Short Physical Performance Battery [SPPB] test, combining gait speed, strength and balance) was found at 3 months (SPPB mean change: 1.4; 95% CI: 1.1-1.6) and 6 months (SPPB mean change: 1.1; 95% CI 0.8-1.5). Equivalent results were observed for all the SPPB sub-tests. CONCLUSIONS: A coordinated, multidisciplinary and integrated program can benefit older adults' intrinsic capacity. The participants' empowerment and the connection with the available community resources are critical points for a successful intervention.

Mobile applications to prescribe physical exercise in frail older adults: review of the available tools in app stores.

INTRODUCTION: Different remote interventions, such as applications (apps), have been used to continue promoting healthy ageing and preventing disability during the COVID-19 pandemic. The growing trend of apps in health is exponential and may facilitate scaling up physical activity prescription. Numerous tools are available, but little is known regarding their appropriateness, validation and recommendation, especially for frail older adults. METHODS: In-house, we developed an application that makes both the Apple app Store and the Google Play Store searchable using topic-related keywords and facilitates the extraction of basic app-information of the search results. The study was aimed at apps available to an English-speaking market. The resulting apps were filtered using various inclusion and exclusion criteria. The resultant apps underwent a more in-depth characterisation and searches for scientific publications on each app website and PubMed. RESULTS: From an initial search result of >2,800 apps, 459 met the initial inclusion criteria. After a more in-depth review of their features, 39 apps remained for possible app in older frail patients. After testing them, 22 apps were excluded. Seventeen apps fit the inclusion and exclusion criteria and were deemed appropriate after peer review. Of these, only one app, Vivifrail, had any type of publication/published evidence. CONCLUSION: Apps can be valuable tool in prescribing exercise for frail older adults living in the community. However, few apps seem useful on a large scale, and there is limited evidence to support their effectiveness. It is important to invest in adapting Information and Communication Technologies to this population group.

Impact on physical function of the +AGIL Barcelona program in community-dwelling older adults with cognitive impairment: an interventional cohort study.

BACKGROUND: Older adults with cognitive impairment (CI) have higher multimorbidity and frailty prevalence, lower functional status and an increased likelihood to develop dementia, non-cognitive deficits, and adverse health-related events. +AGIL, a real-world program for frail older adults in a primary care area of Barcelona, is a pragmatic, multi-component and integrated intervention implemented since 2016. It includes physical activity, nutrition, sleep hygiene, revision and adequacy of pharmacological treatment, detection of undesired loneliness and screening for CI; to improve physical function in community-dwelling older adults. We aimed to assess the + AGIL longitudinal impact on physical function among community-dwelling frail older persons with CI. METHODS: An interventional cohort study included data from all the + AGIL consecutive participants from July 2016 until March 2020. Based on the comprehensive geriatric assessment, participants were offered a tailored multi-component community intervention, including a 10-week physical activity program led by an expert physical therapist. Physical performance was measured at baseline, three and six months follow-up. The pre-post impact on physical function was assessed by paired sample t-test for repeated samples. Linear mixed models were applied to analyze the + AGIL longitudinal impact. P-values < 0.05 were considered statistically significant. RESULTS: 194 participants were included (82 with CI, based on previous diagnosis or the Mini-COG screening tool), 68% women, mean age 81.6 (SD = 5.8) yo. Participants were mostly independent in Activities of Daily Living (mean Barthel = 92.4, SD = 11.1). The physical activity program showed high adherence (87.6% attended ≥ 75% sessions). At three months, there was a clinically and statistically significant improvement in the Short Physical Performance Battery (SPPB) and its subcomponents in the whole sample and after stratification for CI [CI group improvements: SPPB = 1.1 (SD = 1.8) points, gait speed (GS) = 0.05 (SD = 0.13) m/s, Chair stand test (CST)=-2.6 (SD = 11.4) s. Non-CI group improvements: SPPB = 1.6 (SD = 1.8) points, GS = 0.08 (SD = 0.13) m/s, CST=-6.4 (SD = 12.1) seg]. SPPB and gait speed remained stable at six months in the study sample and subgroups. CI had no significant impact on SPPB or GS improvements. CONCLUSION: Our results suggest that older adults with CI can benefit from a multidisciplinary integrated and comprehensive geriatric intervention to improve physical function, a component of frailty.

Geriatric syndromes and functions in older adults with COVID-19 hospitalized in sub-acute care: a multicenter study.

OBJECTIVE: Alternatives to conventional acute hospitalizations have been particularly useful during the COVID-19 pandemic. However, little is known on the management and outcomes of COVID-19 in older patient admitted to non-acute settings. The main aim of this study was to determine the effect of geriatrics syndromes on functional outcomes in older COVID-19 patients cared in sub-acute units. METHODS: Prospective multicenter observational cohort study of patients aged 65 years and older with COVID-19, admitted to sub-acute units in Italy and Spain. Multivariable logistic regression models were used to test the association between geriatric syndromes and other clinical variables, and the functional status at discharge, defined by a Barthel Index > = 80. RESULTS: A total of 158 patients were included in the study with a median age of 82 [Interquartile Range 81, 83]; of these 102 (65%) patients had a Barthel Index ≥ 80 at discharge. In the main multivariable logistic regression model a higher severity of frailty-measured with the Clinical Frailty Scale-(OR 0.30; CI 0.18-0.47), and the presence of delirium (OR 0.04; CI 0.00-0.35) at admission were associated with lower odds of a higher functional status at discharge. Other variables associated with lower functional status were female gender (OR 0.36; CI 0.13-0.96), and a higher number of comorbidities (OR 0.48; CI 0.26-0.82). CONCLUSION: The study reports a relatively high prevalence of functional recovery for older COVID-19 patients admitted to sub-acute units. Additionally, it underlines the importance of targeting geriatrics syndromes, in particular frailty and delirium, for their possible effects on functional recovery.

Impact of supplementation with vitamins B6 , B12 , and/or folic acid on the reduction of homocysteine levels in patients with mild cognitive impairment: A systematic review.

Hyperhomocysteinemia is an independent predictor of the risk for cognitive decline and may be a result of low levels of vitamins B12 , B6 , and folate. Previous findings suggest that adequate intake of these vitamins may reduce homocysteine levels. This review aimed to assess the effects of treatment with vitamins B6, B12 , and/or folic acid in the homocysteine levels in patients with mild cognitive impairment (MCI). A systematic literature review was conducted in EMBASE, MEDLINE®, PsycINFO, and Cochrane Central Register of Controlled Trials. The research question was formulated using the Population, Intervention, Comparison, and Outcome (PICO) framework: in patients with MCI (P); what is the efficacy of vitamins B6 , B12 , and/or folic acid intake (I); compared with baseline values, and/or compared with controls (C); in reducing homocysteine levels from baseline (O). A total of eight primary studies with a total of 1,140 participants were included in the review. Four were randomized controlled trials, one was a quasi-controlled trial, and three were observational studies. All studies included folic acid in their intervention, seven vitamin B12 , and four vitamin B6 . Mean (SD) length of the intervention period was 18.8 (19.3) months, ranging from 1 to 60 months. All studies showed a statistically significant decrease in homocysteine levels in groups treated with vitamins B6, B12 , and/or folic acid compared to controls, with a mean decline of homocysteine concentration of 31.9% in the intervention arms whereas it increased by 0.7% in the control arm. This review identified evidence of a reduction of plasma homocysteine levels in MCI patients taking vitamins B6, B12 , and/or folic acid supplements, with statistically significant declines being observed after 1 month of supplementation. Findings support that supplementation with these vitamins might be an option to reduce homocysteine levels in people with MCI and elevated plasma homocysteine.

Correlates to psychological distress in frail older community-dwellers undergoing lockdown during the COVID-19 pandemic.

BACKGROUND: This study identifies correlates of the lockdown's psychological distress in frail older community-dwellers (Catalonia, Spain). METHODS: Participants from a community frailty intervention program, with a comprehensive geriatric assessment within the 12-months pre-lockdown and COVID-19 free during the first pandemic wave (March-May 2020), underwent a phone assessment past the lockdown to assess COVID-19-related emotional distress (DME) as well as other sociodemograhic, clinical and psychosocial factors. RESULTS: Of the 94 frail older adults (age = 82,34 ± 6,12 years; 68,1% women; 38,3% living alone), 84,9% were at risk of experiencing moderate-to-high psychological distress, according to the backward stepwise logistic regression model obtained (χ2 = 47,007, p < 0,001, Nagelkerke R2 = 0,528), based on the following factors: absence of depressive symptoms before lockdown (OR = 0,12, p = 0,014, 95%CI[0,023-0,647]), not carrying out leisure activities during lockdown (OR = 0,257, p = 0,023, 95%CI[0,079-0,832]) and currently experiencing high malaise due to COVID-19 situation (OR = 1,504, p < 0,001, 95%CI[1,241-1,822]). DISCUSSION: These findings suggest that it is necessary to favour a prior overall health status and to empower frail older community-dwellers in the use of a broad repertoire of coping strategies in the face of adversity to foster mental health and keep at bay the potential emotional impact of the situation generated by the COVID pandemic.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study.

BACKGROUND: Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation. AIM: We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project". METHODS: We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale. RESULTS: Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001). CONCLUSION: This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

A retrospective multicentre cohort study of the performances on attention tests in outpatients with cognitive dysfunctions without delirium.

OBJECTIVE: Attention is the cardinal feature of delirium, but attentional domains may also be affected by dementia and its severity. It is, therefore, of interest to study the correlation between the severity of cognitive impairment in non-delirious patients and different measurements of attentional performance, to identify attention subdomains less affected by severity of cognitive impairment. METHODS: Neuropsychological data from non-delirious outpatients (age ≥ 65 years), presenting at two memory clinics were analysed retrospectively. Scores for selective, divided, and sustained attention were correlated with cognitive impairment as defined by the score of the Mini-Mental State Examination. RESULTS: A total of 1658 outpatients were included. The mean age was 77.15 (± 8.17) years, with a mean MMSE score of 22.67 (± 4.91). Compared to the type of attention, the tests that are less influenced by the severity of cognitive impairment are those of selective attention, in particular the Digit Span Forward (DSF). CONCLUSIONS: This is the first study to correlate deficits in attention subdomains with the degree of cognitive impairment in non-delirious patients. The results suggest that measurements of selective attention (i.e. DSF) might be better suited to discriminate delirium from dementia. Indeed, a lower score on these tests might be indicative of an acute change and worsening of the baseline inattention and a longitudinal monitoring of these changes might be used to determine the delirium resolution.

The relationship between frailty and delirium: insights from the 2017 Delirium Day study.

BACKGROUND: although frailty and delirium are among the most frequent and burdensome geriatric syndromes, little is known about their association and impact on short-term mortality. OBJECTIVE: to examine, in hospitalized older persons, whether frailty is associated with delirium, and whether these two conditions, alone or in combination, affect these patients' 30-day survival. DESIGN: observational study nested in the Delirium Day project, with 30-day follow-up. SETTING: acute medical wards (n = 118) and rehabilitation wards (n = 46) in Italy. SUBJECTS: a total of 2,065 individuals aged 65+ years hospitalized in acute medical (1,484 patients, 71.9%) or rehabilitation (581 patients, 28.1%) wards. METHODS: a 25-item Frailty Index (FI) was created. Delirium was assessed using the 4AT test. Vital status was ascertained at 30 days. RESULTS: overall, 469 (22.7%) patients experienced delirium on the index day and 82 (4.0%) died during follow-up. After adjustment for potential confounders, each FI score increase of 0.1 significantly increased the odds of delirium (odds ratio, OR: 1.66 [95% CI: 1.45-1.90]), with no difference between the acute (OR: 1.65 [95% CI: 1.41-1.93]) and rehabilitation ward patients (OR: 1.71 [95% CI: 1.27-2.30]). The risk of dying during follow-up also increased significantly for every FI increase of 0.1 in the overall population (OR: 1.65 [95% CI: 1.33-2.05]) and in the acute medical ward patients (OR: 1.61 [95% CI: 1.28-2.04]), but not in the rehabilitation patients. Delirium was not significantly associated with 30-day mortality in either hospital setting. CONCLUSIONS: in hospitalized older patients, frailty is associated with delirium and with an increased risk of short-term mortality.

Prevalence and management of delirium in community dwelling older people with dementia referred to a memory clinic.

OBJECTIVE: Our aim was to measure the prevalence of delirium, its clinical features, and outcomes in older patients referred to a memory clinic. METHODS: A retrospective cohort study of 109 older outpatients with delirium referred to a memory clinic with a home care service. Delirium was diagnosed using the confusion assessment method and dementia with the DSM-5 criteria. We collected information on cognitive and functional status, mortality, institutionalization, and hospitalization during 6 months following the delirium episode. RESULTS: Delirium prevalence was 3.6%, mostly of hyperactive type. Delirium worsened functional (ADL 2.95 ± 1.95 vs. 2.16 ± 1.84) and cognitive (MMSE 13.88 ± 8.96 vs.11.0 ± 9.49) status after 6 months compared to the baseline. The mortality rate was 29.4%, and 28.3% were admitted to a long-term facility after the episode of delirium. Of these patients, more than half were hospitalized during the follow-up. Of the 109 patients with delirium, 85 were managed at home and 24 were hospitalized. Patients who were hospitalized had more severe behavioral symptoms during the delirium episode. There was no difference in mortality and institutionalization according to the home or hospital management. CONCLUSIONS: This retrospective cohort study adds novel information to the existing literature of an understudied setting and population. The study supports the need to further investigate the feasibility and efficacy of the hospital at home models for the prevention and management of delirium in a high-risk population.

Sleep disturbances and the speed of multimorbidity development in old age: results from a longitudinal population-based study.

BACKGROUND: Sleep disturbances are prevalent among older adults and are associated with various individual diseases. The aim of this study was to investigate whether sleep disturbances are associated with the speed of multimorbidity development among older adults. METHODS: Data were gathered from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K), an ongoing population-based study of subjects aged 60+ (N = 3363). The study included a subsample (n = 1189) without multimorbidity at baseline (< 2 chronic diseases). Baseline sleep disturbances were derived from the Comprehensive Psychiatric Rating Scale and categorized as none, mild, and moderate-severe. The number of chronic conditions throughout the 9-year follow-up was obtained from clinical examinations. Linear mixed models were used to study the association between sleep disturbances and the speed of chronic disease accumulation, adjusting for sex, age, education, physical activity, smoking, alcohol consumption, depression, pain, and psychotropic drug use. We repeated the analyses including only cardiovascular, neuropsychiatric, or musculoskeletal diseases as the outcome. RESULTS: Moderate-severe sleep disturbances were associated with a higher speed of chronic disease accumulation (ß/year = 0.142, p = 0.008), regardless of potential confounders. Significant positive associations were also found between moderate-severe sleep disturbances and neuropsychiatric (ß/year = 0.041, p = 0.016) and musculoskeletal (ß/year = 0.038, p = 0.025) disease accumulation, but not with cardiovascular diseases. Results remained stable when participants with baseline dementia, cognitive impairment, or depression were excluded. CONCLUSION: The finding that sleep disturbances are associated with faster chronic disease accumulation points towards the importance of early detection and treatment of sleep disturbances as a possible strategy to reduce chronic multimorbidity among older adults.

IMAGINE study protocol of a clinical trial: a multi-center, investigator-blinded, randomized, 36-month, parallel-group to compare the effectiveness of motivational interview in rehabilitation of older stroke survivors.

BACKGROUND: Rehabilitation pathways are crucial to reduce stroke-related disability. Motivational Interviewing (MI), as a person-centered complex intervention, aimed to empower and motivate, and could be a resource to improve rehabilitation outcomes for older stroke survivors. The IMAGINE project aims to assess the impact of MI, as a complement to standard geriatric rehabilitation, on functional improvement at 30 days after admission, compared to standard geriatric rehabilitation alone, in persons admitted to geriatric rehabilitation after a stroke. Secondary objectives include assessing the impact of MI on physical activity and performance, self-efficacy, safety, cost-utility, participants' experiences and functional status at 3 months. METHODS: We will conduct a multicenter randomized clinical trial in three geriatric rehabilitation hospitals in Spain. Older adults after mild-moderate stroke without previous severe cognitive impairment or disability will be randomized into the control or intervention group (136 per group, total N = 272). The intervention group will receive 4 sessions of MI by trained nurses, including the design of a personalized rehabilitation plan agreed between stroke survivors and nurses based on stroke survivors´ goals, needs, preferences and capabilities. Main outcome will be the Functional Independence Measure (FIM). In-hospital physical activity will be measured through accelerometers and secondary outcomes using validated scales. The study includes a process evaluation and cost-utility analysis. DISCUSSION: Final results are expected by end of 2020. This study will provide relevant information on the implementation of MI as a rehabilitation reinforcement tool in older stroke survivors. A potential reduction in post-stroke disability and dependence would increase person's health-related quality of life and well-being and reduce health and social care costs. IMAGINE has the potential to inform practice and policymakers on how to move forward towards shared decision-making and shared responsibilities in the vulnerable population of older stroke survivors. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03434938 , registered on January 2018.

Operationalization of a frailty index among older adults in the InCHIANTI study: predictive ability for all-cause and cardiovascular disease mortality.

BACKGROUND: The frailty index (FI) is a sensitive instrument to measure the degree of frailty in older adults, and is increasingly used in cohort studies on aging. AIMS: To operationalize an FI among older adults in the "Invecchiare in Chianti" (InCHIANTI) study, and to validate its predictive capacity for mortality. METHODS: Longitudinal data were used from 1129 InCHIANTI participants aged ≥ 65 years. A 42-item FI was operationalized following a standard procedure using baseline data (1998/2000). Associations of the FI with 3- and 6-year all-cause and cardiovascular disease (CVD) mortality were studied using Cox regression. Predictive accuracy was estimated by the area under the ROC curve (AUC), for a continuous FI score and for different cut-points. RESULTS: The median FI was 0.13 (IQR 0.08-0.21). Scores were higher in women, and at advanced age. The FI was associated with 3- and 6-year all-cause and CVD mortality (HR range per 0.01 FI increase = 1.03-1.07, all p < 0.001). The continuous FI score predicted the mortality outcomes with moderate-to-good accuracy (AUC range 0.72-0.83). When applying FI cut-offs between 0.15 and 0.35, the accuracy of this FI for predicting mortality was moderate (AUC range 0.61-0.76). Overall, the predictive accuracy of the FI was higher in women than in men. CONCLUSIONS: The FI operationalized in the InCHIANTI study is a good instrument to grade the risk of all-cause mortality and CVD mortality. More measurement properties, such as the responsiveness of this FI when used as outcome measure, should be investigated in future research.

Defining the characteristics of intermediate care models including transitional care: an international Delphi study.

BACKGROUND: Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions. AIM: To identify and define the characteristics of intermediate care models. METHODS: A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted. RESULTS: Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models. DISCUSSION: There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination. CONCLUSIONS: This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

Nutritional Status and Functional Outcomes in Older Adults Admitted to Geriatric Rehabilitations: The SAFARI Study.

Objective: Evidence about the role of nutritional status (NS) on functional outcomes (FO) after rehabilitation in older adults is scarce. Our aim was to analyze the association between NS and FO in older adults admitted to geriatric rehabilitation units. Methods: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) multicenter study enrolled patients aged ≥65 years admitted to geriatric rehabilitation units in Italy and Spain. FO were absolute and relative functional gain (AFG-RFG) in Barthel Index (BI) at 1 and 3 months after admission. The association between NS (Mini Nutritional Assessment-Short Form) and FO was explored using linear regression and mixed models, adjusted for potential confounders. Analyses were then stratified for diagnosis at admission. Results: We included 415 patients (mean age 81.4 years [SD: 7.7]; 67% female; 9.4% malnourished [MN], 42.7% at risk of malnutrition [RM], and 48% well nourished [WN]). Admission diagnoses were hip fracture (39.5%), elective orthopedic surgery (EOS) (29.5%), and stroke (31%). In an adjusted linear mixed model, MN and RM participants had lower BI compared to WN (MN: ß: -8.47, p = 0.023; RM: ß: -5.22, p = 0.031), and differences between groups remained stable over time. After stratification for admission diagnosis, only MN patients admitted after EOS had worse FO, both at 30 days (AFG: ß adjusted: -13.54, p < 0.001; RFG: ß: -32, p < 0.001) and 3 months (AFG: ß adjusted: -17.79, p < 0.001; RFG: ß: -26.77, p = 0.002). Conclusions: In our sample, poor NS is associated with worse BI in older adults admitted to geriatric rehabilitation units; in patients undergoing EOS, MN is associated with worse FO. Our results documented for the first time the importance of assessing nutritional status before EOS.

Impairments in balance and mobility identify delirium in patients with comorbid dementia.

ABSTRACTDiagnosing delirium superimposed on dementia (DSD) remains challenging because of a lack of specific tools, though motor dysfunction in delirium has been relatively under-explored. This study aimed to use dysfunction in balance and mobility (with the Hierarchical Assessment of Balance And Mobility: HABAM) to identify DSD. This is a cross-sectional multicenter study, recruiting consecutive patients ≥70 years admitted to five acute or rehabilitation hospitals in Ireland, Italy, Portugal, and Switzerland. Delirium was diagnosed using DSM-5 criteria; dementia was determined by the Mini-Mental State Examination and the Questionnaire of Cognitive Decline in the Elderly. HABAM score was recorded at admission. Out of 114 patients (mean age ± SD = 82 ± 7; 54% female), dementia alone was present in 24.6% (n = 28), delirium alone in 18.4% (n = 21) and DSD in 27.2% (n = 31). Patients with DSD had a mean HABAM score 7 points greater than those with dementia alone (19.8 ± 8.7 vs 12.5 ± 9.5; p < 0.001); 70% of participants with DSD were correctly identified using the HABAM at a cut off of 22 (sensitivity 61%, specificity 79%, AUC = 0.76). Individuals with delirium have worse motor function than those without delirium, even in the context of comorbid dementia. Measuring motor function using the HABAM in older people at admission may help to diagnose DSD.

Validation of the Spanish version of the Pittsburgh Fatigability Scale for older adults.

BACKGROUND: The Pittsburgh Fatigability Scale (PFS) is the only validated scale for measuring perceived fatigability in older adults. AIMS: We validated the PFS Spanish version by assessing convergent validity with respect to several measures of physical performance, physical activity, physical function and disability. METHODS: A cross-sectional validation study of 79 community-dwelling older adults aged 70 and older from Barcelona, Spain was included. Translation-retrotranslation was performed. Convergent validity was assessed in relation to physical activity and performance measurements, and analyzed with Spearman correlation coefficients, a linear trend test and non-linear regression. We also assessed the discriminant validity of the PFS physical score between participants with different physical activity and performance levels. RESULTS: Higher PFS physical scores were inversely associated with the Short Physical Performance Battery (r = - 0.5, p < 0.001) and weak to moderately correlated with gait speed (r = 0.38, p = 0.001), and self-reported weekly walking time (r = 0.24, p = 0.035). CONCLUSION: The PFS is a novel, brief instrument to assess fatigability in Spanish-speaking older adults, with good convergent validity against physical performance measurements. Thus, the PFS can be used in Spanish-speaking populations.

Delirium Subtypes and Associated Characteristics in Older Patients With Exacerbation of Chronic Conditions.

OBJECTIVE: The prevalence and prognosis of delirium motor subtypes are not yet well established. We analyzed the prevalence of motor subtypes of delirium, as well as their risk factors and outcomes, among older vulnerable patients admitted for short-term management of exacerbated chronic conditions. METHODS: Cohort study of patients aged 65 and older who developed delirium while admitted to a subacute care unit for 12 months (N = 352). Confusion Assessment Method was used to determine the presence of delirium and the Delirium Motor Subtype Scale was used to define the motor subtype. Outcomes included discharge destination, mortality, readmission, and functional trajectories. RESULTS: Out of 352 patients with delirium (mean age= 87.4, 73.6% with dementia), hyperactive delirium was the most prevalent subtype (40.6%), followed by mixed (31%), hypoactive (25.9%), and nonmotor (2.6%). In multivariate models, worse preadmission functional status (odds ratio [OR] [95% confidence interval {CI}] = 0.97 [0.96-0.98]) and higher comorbidity (OR [95% CI] = 1.3 [1.04-1.51]) were associated with an increased risk of hypoactive delirium. In multivariate models adjusted for different variables, including disability, hypoactive delirium was associated with mortality compared with hyperactive delirium (OR [95% CI] = 4.7 [1.6-14]) and mixed delirium (OR [95% CI] = 2.0 [1.02-3.9]) and with worse functional recovery (Beta[95% CI] = -0.2 [-12.0-(-0.4)]). CONCLUSION: Delirium motor subtypes were associated with different patient characteristics and outcomes. Hypoactive delirium seems to affect more vulnerable patients and to be associated with worse outcomes. More research on the different delirium subtypes could help develop better preventive and management strategies.