Frailty as a predictor of mortality in older adults within 5 years of psychiatric admission.

OBJECTIVES: Older adults with psychiatric disorders have a substantially lower life expectancy than age-matched controls. Knowledge of risk factors may lead to targeting treatment and interventions to reduce this gap in life expectancy. In this study, we investigated whether frailty independently predicts mortality in older patients following an acute admission to a geriatric psychiatry hospital. METHODS: Clinical cohort study with a 5-year follow-up of 120 older patients admitted to a psychiatric hospital between February 2009 and September 2010. On admission, we assessed frailty with a frailty index (FI). We applied Cox regression analyses with time to death as the dependent variable, to examine whether the FI was a predictor for mortality, adjusted for age, sex, level of education, multimorbidity (Cumulative Illness Rating Scale for Geriatrics, CIRS-G scores), functional status (Barthel Index), neuropsychiatric symptoms (NPS), and severity of psychiatric symptoms at admission (Clinical Global Impressions Scale of Severity). RESULTS: Of the 120 patients, 63 (53%) patients were frail (FI ≥ 0.25), and 59 (49%) had died within 5 years. The FI predicted mortality with a hazard ratio (HR) of 1.78 (95% CI, 1.06-2.98) per 0.1 point increase, independent of the covariates. Co-morbidity measured by the CIRS-G and functional status measured by the Barthel Index were not significantly associated. CONCLUSIONS: Frailty was a strong predictor of mortality, independent of age, gender, multimorbidity, and functional status. This implies that frailty may be helpful in targeting inpatient psychiatric treatment and aftercare according to patients' life expectancy.

Frailty, multimorbidity and functional status as predictors for health outcomes of acute psychiatric hospitalisation in older adults.

Objectives: Frailty, multimorbidity and functional decline predict adverse health outcomes in community dwelling older people and older patients in general hospitals. This study investigates whether these characteristics separately are independent predictors of health outcomes of acute psychiatric hospitalization.Methods: Observational study in a prospectively sampled cohort of older patients, consecutively admitted to a psychiatric hospital. On admission we assessed frailty (Frailty Index and walking speed); multimorbidity (Cumulative Index Rating Scale Geriatrics (CIRS-G)) and functional status (Barthel Index). We used the Clinical Global Impressions of Improvement scale (CGI-I) as the psychiatric outcome measure, and dichotomized discharge destination as overall outcome measure: favourable (able to return home or previous care level) or adverse (death, or move to higher level of residential care).Results: We included 120 patients, 74.6 years (±7.8). 52.5% of the patients was frail (FI ≥0.25). The mean level of the CIRS-G was 13.5 (5.4). Mean CGI-I at discharge was 2.8 (± 1.0), indicating moderate improvement in the psychiatric outcome. Neither FI, CIRS-G, nor Barthel scores were, independent of age, sex and diagnosis, associated with the CGI-I. FI was predictive for adverse discharge destination (OR 1.91, 95%CI 1.09-3.37 per 0.1), as were higher CIRS-G (OR 1.19 95%CI 1.06-1.34, per point) and lower walking speed (OR 1.35 95%CI 1.06-1.72 per 0.1 m/s).Conclusions: Half of our patients were frail and had a high level of multimorbidity. The FI, walking speed and multimorbidity did not predict improvement of psychiatric symptoms at discharge, but independently helped to predict adverse discharge destination.

Frailty and Somatic Comorbidity in Older Patients With Medically Unexplained Symptoms.

OBJECTIVES: To examine the level of frailty and somatic comorbidity in older patients with medically unexplained symptoms (MUS) and compare this to patients with medically explained symptoms (MES). DESIGN: Cross-sectional, comparative study. SETTING: Community, primary care, and secondary healthcare to recruit patients with MUS in various developmental and severity stages and primary care to recruit patients with MES. PARTICIPANTS: In total, 118 patients with MUS and 154 patients with MES, all aged ≥60 years. METHODS: Frailty was assessed according to the Fried criteria (gait speed, handgrip strength, unintentional weight loss, exhaustion, and low physical activity), somatic comorbidity according to the self-report Charlson comorbidity index, and the number of prescribed medications. RESULTS: Although patients with MUS had less physical comorbidity compared with patients with MES, they were prescribed the same number of medications. Moreover, patients with MUS were more often frail compared with patients with MES. Among patients with MUS, physical frailty was associated with the severity of unexplained symptoms, the level of hypochondriacal beliefs, and the level of somatisation. CONCLUSIONS AND IMPLICATIONS: Despite a lower prevalence of overt somatic diseases, patients with MUS are more frail compared with older patients with MES. These results suggest that at least in some patients age-related phenomena might be erroneously classified as MUS, which may affect treatment strategy.

Geriatric characteristics in randomised controlled trials on antidepressant drugs for older adults: a systematic review.

OBJECTIVE: Meta-analyses of antidepressant drug treatment trials have found that increasing age is associated with a less favourable outcome. Because the prevalence of geriatric characteristics, like disability, medical co-morbidity, malnutrition, cognitive (dys)function and frailty increase with age and are associated with depression, these characteristics are likely to modify the treatment outcome of antidepressant drugs in late-life depression. This review examines how these five characteristics are taken into account in randomised controlled trials (RCTs) with antidepressant drugs for major depressive disorder in patients aged 60 years or above. DESIGN: A systematic search in PubMED, PsychInfo and EMBASE, from the year 2000 onwards, yielded 27 RCTs, with a total of 6356 subjects with a median age of 71 years. Two reviewers independently assessed whether each characteristic was considered as inclusion or exclusion criterion, descriptive variable, stratification variable, co-variable, outcome measure, or in adverse effect monitoring. RESULTS: Malnutrition and frailty were not taken into account in any study. Disability was used as an outcome measure in five studies. Two studies explicitly included a population with possibly serious medical co-morbidity. Cognitive status was the only condition taken into account as co-variable (n = 3) or stratifying variable (n = 1) and was used as outcome measure in seven studies. CONCLUSIONS: We conclude that geriatric characteristics are rarely taken into account in RCTs on antidepressant drugs in late-life depression, and studies including the oldest adults are underrepresented. This warrants recruitment of the oldest adults and adjustment of treatment strategies in future studies. Copyright © 2016 John Wiley & Sons, Ltd.

Physical functioning in older persons with somatoform disorders: a pilot study.

OBJECTIVES: The primary objective of this study was to systematically examine the physical functioning of older persons with somatoform disorders, as this has never been carried out before. Second, we wanted to test our hypothesis that higher somatic disease burden in patients with somatoform disorders is associated with a higher level of somatisation. DESIGN AND SETTING: Observational study of patients referred for medically unexplained symptoms (MUS) to our outpatient mental health center for older adults. The patients were offered a standardized, multidisciplinary diagnostic procedure, including a comprehensive geriatric assessment. Inter-rater reliability between two geriatricians assessing the contribution of somatic pathology to the main somatic symptom was assessed. PARTICIPANTS: A total of 37 patients referred for MUS (mean age 75 ± 6 years). MEASUREMENTS: Timed up and go test (TUG) and hand grip strength were used as measures for frailty; the Cumulative Index Rating Scale for Geriatrics (CIRS-G) sum score and severity index measured the burden of cumulative somatic morbidity. The Groningen Activity Rating Scale (GARS) measured functional status. The Whitely Index was used as measure for somatisation. RESULTS: Patients' main symptom could be completely explained by a somatic disease in 3/37 (8%) patients (kappa between geriatricians = 0.72). A total of 32 patients met the criterion for a Somatoform Disorder according to DSM-IV-TR criteria, but somatic comorbidity partially explained the main symptom in 15/32 patients. These patients were older (P = .049), had more somatic comorbidity (P = .049), a slower gait speed (TUG, P = .035), a lower hand grip strength (P = .050), and a lower functional status (P = .30) compared with the 17 patients without any explanation for their main somatic symptom. In contrast to our hypothesis, a higher level of somatisation was associated with less somatic disease burden. CONCLUSION: Geriatric assessment has an important added value in older patients referred with medically unexplained symptoms because in half of these patients, symptoms can be partially or fully explicable following careful assessment of comorbidity and frailty.

Gait velocity and the Timed-Up-and-Go test were sensitive to changes in mobility in frail elderly patients.

OBJECTIVE: To estimate clinically relevant changes in functional mobility tests and quantitative gait measures at group and individual level in frail elderly patients. STUDY DESIGN AND SETTING: This study was a cohort study of consecutively admitted frail elderly patients. Gait velocity, Timed-Up-and-Go test (TUG), and other mobility tests were measured on admission and 2 weeks later. In between, patients received multidisciplinary treatment. Three experts decided from video recordings if patients had a clinically relevant change in gait, defined as change in the expected risk of falling. RESULTS: A total of 85 patients (mean age 75.8 years, 46 female) participated. Of whom, 45% had dementia; 59 patients were stable and 26 showed a clinically relevant change in gait. Gait velocity and TUG were most sensitive to change at group level. In individual patients, a 5% change from baseline in gait velocity and 9% change in TUG had a sensitivity of 92% and 93% for detection of clinically relevant change, but specificity of 27% and 34%, respectively. CONCLUSION: At group level, gait velocity and TUG were, from all investigated tests, most sensitive to change and in this perspective the best outcome variables. In individual patients, the high intraindividual variability makes these measures unsuitable as independent screening instruments for clinically relevant changes in gait.