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.

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).

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.

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.

Danish register-based study on the association between specific antipsychotic drugs and fractures in elderly individuals.

Background: antipsychotic drugs (APs) have been associated with falls and fractures in elderly individuals but limited knowledge on specific drugs exist. Objective: to investigate the association between individual APs and fractures in elderly persons. Design and setting: nationwide register-based cohort study. Subjects: all Danish individuals aged ≥65 who had not been in treatment with any AP in the year before inclusion. Methods: incidence rate ratios (IRRs) of fractures of hip, pelvis or upper extremities during treatment with commonly used APs were assessed in multivariable Poisson models. Exposure was divided into time periods from initiation of treatment: 0-30 days, 31-365 days or >365 days. Results: one year prior to inclusion, 1,540,915 individuals ≥65 years had not received APs and of these 93,298 initiated treatment with APs. Mean follow-up was 9.6 years. During follow-up, 246,057 (16%) experienced a fracture. Associations were for all APs highest in the initial treatment period (0-30 days) with IRRs for risperidone 1.97 (95% CI: 1.70-2.28), olanzapine 2.31 (95% CI: 1.96-2.73), quetiapine 2.09 (95% CI: 1.73-2.52), zuclopenthixol 2.19 (95% CI: 1.82-2.63), chlorprothixen 1.62 (95% CI: 1.18-2.24), flupenthixol 1.43 (95% CI: 1.06-1.93), levomepromazine 1.19 (95% CI 0.86-1.66), haloperidol 2.98 (95% CI 2.57-3.45), compared with the background population. Conclusions: use of APs is associated with fractures in elderly persons especially in the initial treatment period. If AP use in an elderly person is deemed necessary, individual falls prophylaxis should be considered.

Antidepressants and the risk of hyponatremia: a Danish register-based population study.

OBJECTIVE: To examine the association between classes of antidepressants and hyponatremia, and between specific antidepressants and hyponatremia. DESIGN: Retrospective register-based cohort study using nationwide registers from 1998 to 2012. SETTING: The North Denmark Region. PARTICIPANTS: In total, 638 352 individuals were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Plasma sodium was obtained from the LABKA database. The primary outcome was hyponatremia defined as plasma sodium (p-sodium) below 135 mmol/L and secondary outcome was severe hyponatremia defined as p-sodium below 130 mmol/L. The association between use of specific antidepressants and hyponatremia was analysed using multivariable Poisson regression models. RESULTS: An event of hyponatremia occurred in 72 509 individuals and 11.36% (n=6476) of these events happened during treatment with antidepressants. Incidence rate ratios and CIs for the association with hyponatremia in the first p-sodium measured after initiation of treatment were for citalopram 7.8 (CI 7.42 to 8.20); clomipramine 4.93 (CI 2.72 to 8.94); duloxetine 2.05 (CI 1.44 to 292); venlafaxine 2.90 (CI 2.43 to 3.46); mirtazapine 2.95 (CI 2.71 to 3.21); and mianserin 0.90 (CI 0.71 to 1.14). CONCLUSIONS: All antidepressants except mianserin are associated with hyponatremia. The association is strongest with citalopram and lowest with duloxetine, venlafaxine and mirtazapine.

European postgraduate training in geriatric medicine: data of a systematic international survey.

INTRODUCTION: High-quality education and training standards in geriatric medicine are important to develop the profession of geriatric medicine. The objective of the study was to give a structured update on postgraduate specialty training in geriatric medicine throughout Europe to assess the need for further developments in postgraduate education. METHODS: The study was performed as a cross-sectional structured quantitative online survey with qualitative comments. The survey content covered organization, content and educational aspects of specialty training in geriatric medicine in European countries. After piloting, the questionnaire was sent to experts in geriatric medicine with a special interest in postgraduate training who are members of one of the following organizations; European Union of Medical Specialists (UEMS), European Academy for the Medicine of Aging (EAMA), and European Union Geriatric Medicine Society (EUGMS). RESULTS: Respondents to the survey represented 31 European countries. Geriatric medicine is recognized as an independent postgraduate specialty in 61.3 % (19/31) and as a subspecialty in 29.0 % (9/31) of the countries. In 5 of the 31 countries geriatric medicine is not recognized at all. Nearly all countries offering postgraduate training in geriatric medicine have written, competence-based curricula covering different learning domains. 20/31 countries (64.5 %) have some kind of specialist assessment. DISCUSSION: The survey tries to give an actual condensed picture of postgraduate specialty training in geriatric medicine across Europe. Results show a consistent improvement in the recognition of geriatric medicine as independent specialty over the last decade. Continuous development of specialty training in geriatric medicine is required to medical address the public health needs of an aging population. Competence-based educational models including adequate forms of assessment should be targeted throughout Europe. To emphasize the importance of postgraduate geriatric training, it should be a mission to harmonize training standards across Europe.

[Working environment and educational environment are two sides of the same coin]. / Arbejdsmiljø og uddannelsesmiljø er to sider af samme sag.

Educational environment is of major importance for job satisfaction and it consists of several components including curriculum and values of the organization. Educational climate is the environment, as the individual physicians perceive it. Motivation is important for job satisfaction as well as for learning. Autonomy, responsibility, supervision, feedback are all important factors influencing motivation and learning. These factors must be supported through appropriate organization of work in hospital departments and in general practice.

[Evidence-based pedagogical principles used at medical specialist workshop]. / Evidensbaserede paedagogiske principper ved speciallaegekursus.

How should a theoretical postgraduate course be organized to obtain maximum effect? We report an example of a two-day course planned and implemented according to educational approaches previously shown to be effective. The theme of the course is "The old patient", and the course is compulsory for residents in internal medicine. This case study showed that the methods used were feasible, and the participants gained knowledge. A multiple-choice test before and after the course showed 44% (before) and 64% (after) correct answers, p < 0.001.

Diagnosis of the syndrome of inappropriate secretion of antidiuretic hormone.

BACKGROUND: Hyponatremia is a frequent condition in elderly patients. In diagnostic workup, a 24-hour urine sample is used to measure urinary osmolality and urinary sodium concentration necessary to confirm the diagnosis of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This study was undertaken to test the hypothesis that a spot urine sample would be sufficient for urinalysis. METHODS: In nine patients with SIADH, morning spot and 24-hour urine samples were examined for osmolality and sodium concentration. Levels of arginine vasopressin, atrial natriuretic and brain natriuretic peptides, renin, and aldosterone were measured in the supine and upright positions of patients and compared with nine healthy age-matched control patients. RESULTS: The patients had low plasma osmolality (median 266 mOsm/kg) and measurable levels of arginine vasopressin (median 1.8 pg/mL). Values of osmolality in the spot urine (median 298 mOsm/kg) and in the 24-hour urine (median 215 mOsm/kg) did not differ significantly; neither did sodium concentration (medians 80 mmol/L in the spot urine versus 45 mmol/L in the 24-hour urine). Patients had significantly elevated plasma levels of brain natriuretic peptide (P = 0.007), elevated mean arterial blood pressure (P = 0.03), and lower plasma levels of creatinine (P = 0.002) compared to the controls. CONCLUSION: A spot urine sample seems to be sufficient to confirm the diagnosis of SIADH.

[Fall or syncope?]. / Fald eller synkope?

Falls among older adults are a major health problem. When older adults fall, it is difficult to determine whether it is just a simple fall or is caused by syncope, as people often have amnesia for the loss of consciousness. We report three cases in which cardiac monitoring, for seven days or more, showed that falls had been caused by cardiac-related syncopes.

[Who should be admitted to a geriatric unit?]. / Hvem skal indlaegges på geriatrisk afdeling?

Potential geriatric patients are frail old persons characterized by the presence of one or several geriatric conditions: polypharmacy, socio-economic problems, vision/hearing impairment, confusion, impaired mobility, incontinence, weight loss, depression, falls, dementia, and prolonged bedrest. Admission of these frail old patients to a geriatric unit may reduce mortality, improve function, and decrease the risk of nursing home placement. These frail old patients may not all be able to profit from geriatric rehabilitation. The published randomized trials showing substantial effect of geriatric rehabilitation exclude patients with severe dementia, terminal disease or those with a single medical disease for which there is no further treatment. Careful selection of patients is necessary in order to achieve superior, clear-cut effect when compared to conventional treatment in general medical wards.