Demandas clínicas e intervenções de enfermagem em consultas gerontológicas: Revisão integrativa / Demandas Clínicas e intervenciones de Enfermería en consultas gerontológicas: Una revisión integrativa / Clinical demands and nursing interventions in gerontological consultations: An integrative review

Resumen Introdução: A criação de guias que unificam as demandas clínicas prevalentes em consultas de enfermagem gerontológica e, das suas respectivas intervenções, se faz presente, devido a heterogeneidade das patologias emergentes no processo de envelhecimento, que irão precisar de cuidados. Objetivo: Identificar as demandas clínicas em consultas de enfermagem gerontológica e, as intervenções implementadas pelos(as) enfermeiros(as). Método: Revisão integrativa de pesquisas originais, publicadas entre 2018 e 2022, em inglês, espanhol e português, disponíveis nas bases de dados Scopus, MEDLINE/PubMed, BIREME/LILACS/BDENF/IBECS/BVS, SciELO e Google Scholar, pelos descritores DeCS/MESH: "Idoso"; "Enfermagem no Consultório"; "Enfermagem Geriátrica" e "Geriatria". O Rating System for the Hierarchy of Evidence for Intervention foi usado para determinar o nível de evidência da amostra final. Foram excluídos editoriais, estudos de revisão e artigos duplicados. A análise dos dados se deu pela leitura analítica e interpretativa, guiadas por um checklist. Resultados: Oito artigos foram selecionados e trouxeram demandas clínica tais como: o déficit no autocuidado para banho; autonegligência; fadiga; risco de integridade da pele prejudicada; desesperança; tristeza e depressão. As intervenções se relacionaram ao incentivo ao autocuidado; otimização dos medicamentos; estímulo a atividade física; cuidados com a pele; aconselhamento; musicoterapia e reabilitação psicossocial. Conclusão: Demandas clínicas atendidas nas consultas de enfermagem gerontológica possuem grande variação, com prevalência no domínio atividade/repouso, tais como intervenções voltadas para o tratamento e prevenção de doenças e ações visando a promoção da saúde, tendo o domínio comportamental mais expressivo.

Resumen Introducción: La creación de guías que unifiquen las demandas clínicas prevalentes en las consultas de enfermería gerontológica y sus respectivas intervenciones es necesaria, debido a la heterogeneidad de patologías emergentes en el proceso de envejecimiento que requerirán cuidados. Objetivo: Identificar las demandas clínicas en las consultas de enfermería gerontológica y las intervenciones implementadas por el personal de enfermería. Método: Revisión integrativa de investigaciones originales, publicadas entre 2018 y 2022, en inglés, español y portugués, en las bases de datos Scopus, MEDLINE/PubMed, BIREME/LILACS/BDENF/IBECS/BVS, SciELO y Google Scholar. Se utilizaron los descriptores DeCS/MESH: "Idoso"; "Enfermagem no Consultório"; "Enfermagem Geriátrica" e "Geriatria". Para determinar el nivel de evidencia de la muestra final, se usó el Rating System for the Hierarchy of Evidence for Intervention. Además, se excluyeron los editoriales, los estudios de revisión y los artículos duplicados. Los datos se analizaron mediante lectura analítica e interpretativa, guiada por una lista de verificación. Resultados: Se seleccionaron ocho artículos que aportaron demandas clínicas como déficit en el autocuidado para el baño, autodescuido, fatiga, riesgo integridad de la piel perjudicada; desesperanza, tristeza y depresión. Las intervenciones estaban orientadas al fomento del autocuidado, la optimización de la medicación, el fomento de la actividad física, el cuidado de la piel, el asesoramiento, la musicoterapia y la rehabilitación psicosocial. Conclusión: Las demandas clínicas atendidas en las consultas de enfermería gerontológica son muy variadas, con predominio en el dominio actividad/reposo, como intervenciones dirigidas al tratamiento y prevención de enfermedades y acciones dirigidas a la promoción de la salud, siendo más expresivo el dominio conductual.

Abstract Introduction: The creation of guidelines that unify the prevalent clinical demands from gerontological nursing consultations and their corresponding interventions are necessary due to the heterogeneity of emerging pathologies in the aging process that will require nursing care. Objective: To identify clinical demands in gerontological nursing consultations and the interventions implemented by nurses. Method: An integrative review of original research published from 2018 and 2022, in English, Spanish, and Portuguese, in Scopus, MEDLINE/PubMed, BIREME/lilacs/BDENF/IBECS/VHL, SciELO, and Google Scholar databases, using the DeCS/MESH descriptors: "Elderly", "Nursing in the Office", "Geriatric Nursing", and "Geriatrics". The Rating System for the Hierarchy of Evidence for Intervention was used to determine the level of evidence of the final sample. Editorials, review studies, and duplicate articles were excluded. The data were analyzed by analytical and interpretative reading, guided by a checklist. Results: Eight articles were selected that showed clinical demands such as deficits in self-care for bathing, self-negligence, fatigue, risk of damaged skin integrity, hopelessness, sadness, and depression. Interventions were related to encouraging self-care, medication optimization, encouragement of exercise, skin care, counseling, music therapy, and psychosocial rehabilitation. Conclusion: There are many different clinical demands in gerontological nursing consultations, especially associated with the domain of activity/rest. These include interventions to treat and prevent diseases, and actions aimed at health promotion, in most cases associated with the behavioral domain.

Aging in Heart Failure: Embracing Biology Over Chronology: JACC Family Series.

Age is among the most potent risk factors for developing heart failure and is strongly associated with adverse outcomes. As the global population continues to age and the prevalence of heart failure rises, understanding the role of aging in the development and progression of this chronic disease is essential. Although chronologic age is on a fixed course, biological aging is more variable and potentially modifiable in patients with heart failure. This review describes the current knowledge on mechanisms of biological aging that contribute to the pathogenesis of heart failure. The discussion focuses on 3 hallmarks of aging-impaired proteostasis, mitochondrial dysfunction, and deregulated nutrient sensing-that are currently being targeted in therapeutic development for older adults with heart failure. In assessing existing and emerging therapeutic strategies, the review also enumerates the importance of incorporating geriatric conditions into the management of older adults with heart failure and in ongoing clinical trials.

Teaching Frailty to Medical Residents: A Needs Assessment Among Geriatrics Faculty.

BACKGROUND: Knowledge of frailty is essential for meeting the Accreditation Council for Graduate Medical Education core competencies for US trainees. The UK General Medical Council requires that frailty be included in undergraduate and graduate medical education curricula. Trainees are expected to appropriately modify care plans and help make patient-centered decisions, while incorporating diagnostic uncertainty, such as frailty, in older adults. Little is known about current needs for frailty instruction in graduate medical education in the US and beyond. OBJECTIVE: We sought to capture faculty perceptions on how frailty should be defined and identified, and what aspects and level of detail should be taught to residents. DESIGN: The authors developed a 4-item short response questionnaire, and faculty had the option to respond via electronic survey or via semi-structured interviews. SETTING AND SUBJECTS: Respondents included 24 fellowship-trained geriatricians based at 6 different academic medical centers in a single urban metropolitan area. METHODS: An invitation to participate in either an electronic survey or semi-structured virtual interview was e-mailed to 30 geriatricians affiliated with an academic multi-campus Geriatric Medicine fellowship. Responses were transcribed and coded independently by two authors. RESULTS: Responses were received from 24 geriatricians via a combination of digital questionnaires (n=18) and semi-structured online interviews (n=6), for a response rate of 80%. Responses revealed significant diversity of opinion on how to define and identify frailty and how these concepts should be taught. CONCLUSIONS: As frailty is increasingly incorporated into clinical practice, consensus is needed on how to define and teach frailty to residents.

Proton pump inhibitors and risk of severe COVID-19 in older people.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 is a viral respiratory infection that can cause systemic disorders and lead to death, particularly in older people. Proton pump inhibitors (PPIs) increase the risk of enteric and lung infections. Considering the broad use of PPIs in older people, the potential role of PPIs in COVID-19 could be of dramatic significance. The objective of our study was to evaluate the link between PPIs and severe COVID-19 in older people. METHOD: We performed a retrospective cohort study, including all patients aged ≥65, hospitalised for a diagnosis of COVID-19. Epidemiological, clinical and biological data were extracted and we performed an Inverse Probability of Treatment Weighing method based on a propensity score. RESULTS: From March 2020 to February 2021, a total of 834 patients were included, with a median age of 83 and 52.8% were male. A total of 410 patients had a PPIs prescription, 358 (87.3%) were long-term PPIs-users and 52 (12.7%) were recent PPIs-users. Among PPIs-users, 163 (39.8%) patients developed severe COVID-19 versus 113 (26.7%) in PPIs-non users (odds ratio (OR) = 1.59 [1.18-2.14]; P < 0.05). Moreover, the double dose PPI-users had a higher risk of developing severe COVID-19 (OR = 3.36 [1.17-9.66]; P < 0.05) than the full dose PPI-users (OR = 2.15 [1.22-3.76]; P < 0.05) and the half dose PPI-users (OR = 1.64 [1.13-2.37]; P < 0.05). CONCLUSION: Our study reports evidence that the use of PPIs was associated with an increased risk of severe COVID-19 in older people.

Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study.

BACKGROUND: comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce. OBJECTIVE: to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls. DESIGN: complementary mixed-methods pre-post study, based on an embedded quasi-experimental model. SETTING: geriatric fracture centre. METHODS: qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing. RESULTS: thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge. CONCLUSION: as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.

The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program.

OBJECTIVE: To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults. DATA SOURCES AND STUDY SETTING: This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA. STUDY DESIGN: This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty. DATA COLLECTION: Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation. PRINCIPAL FINDINGS: Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled. CONCLUSIONS: STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE. TRIAL REGISTRATION: ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

Usefulness of Clinical Frailty Scale for Comprehensive Geriatric Assessment of Older Heart Failure Patients.

Background: Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic process to identify the physical, psychological, and social functions of patients with frailty. The Clinical Frailty Scale (CFS) might aid in effectively identifying older patients with heart failure (HF) and frailty who would then reap maximum benefits from the CGA. Methods and Results: A single-centre prospective cohort study that enrolled consecutive hospitalised patients (age ≥75 years) with HF was conducted. The Barthel index (BI), Mini Mental State Examination (MMSE), the Charlson comorbidity index (CCI), and the COntrolling NUTritional (CONUT) for CGA was used. Among 190 enrolled patients (mean age, 85.4 years; 47.9% male), all-cause mortality (primary endpoint) occurred in 45 patients and HF-related rehospitalization (secondary endpoint) in 59 patients within 1 year. The cumulative incidence of all-cause mortality was significantly higher in the high CFS group (low 6.3%, high 30.5%, P<0.001). However, the cumulative incidence of HF-related rehospitalization was not significantly different (low 26.3%, high 32.0%, P=0.304). The multivariable analysis revealed that the CFS group was independently associated with the risk of all-cause mortality. CFS showed a strong correlation with the BI and moderate correlation with the MMSE. Conclusions: The CFS was associated with all-cause mortality within 1 year and was correlated with frailty domains of CGA.

Efficacy of Digital and Non-Digital Compensatory Strategies in Supporting Prospective Memory Task Completion among Community-Dwelling Mid-Life and Older Adults.

OBJECTIVE: Compensatory strategies can be used to help mid-life and older adults successfully manage instrumental activities of daily living that rely upon prospective memory. This study compared the quality of digital and non-digital compensatory strategies in supporting accurate completion of naturalistic, real-world prospective memory tasks. METHOD: Participants included 70 community-dwelling mid-life and older adults. In this cross-sectional study, participants were tested remotely via Zoom in their homes. They were tasked with completing four real-world prospective memory tasks and encouraged to use their typical compensatory strategies. Utilized strategies were categorized, counted, and assigned quality scores (rating of thoroughness and utility), and prospective memory performance was coded. RESULTS: Participants who used any digital strategies utilized significantly more (ηp2 = .17) and better quality (ηp2 = .12) strategies than participants who did not use any digital strategies. However, the groups demonstrated equivalent prospective memory performance (ηp2 = .006). Within the digital group, participants' digital and non-digital strategies were of similar quality (d = .14) and resulted in similar prospective memory task accuracy (d = .01). CONCLUSIONS: Digital and non-digital strategies led to similar performance on naturalistic prospective memory tasks. Findings suggest that many different types of strategies can provide adequate prospective memory support to healthy mid-life and older adults. To inform development of compensatory strategy interventions, future studies should explore other factors that lead to successful prospective memory, such as the specific strategy type and task type match, across the continuum of cognitive impairment.

Geriatrics and artificial intelligence in Spain (Ger-IA project): talking to ChatGPT, a nationwide survey.

PURPOSE: The purposes of the study was to describe the degree of agreement between geriatricians with the answers given by an AI tool (ChatGPT) in response to questions related to different areas in geriatrics, to study the differences between specialists and residents in geriatrics in terms of the degree of agreement with ChatGPT, and to analyse the mean scores obtained by areas of knowledge/domains. METHODS: An observational study was conducted involving 126 doctors from 41 geriatric medicine departments in Spain. Ten questions about geriatric medicine were posed to ChatGPT, and doctors evaluated the AI's answers using a Likert scale. Sociodemographic variables were included. Questions were categorized into five knowledge domains, and means and standard deviations were calculated for each. RESULTS: 130 doctors answered the questionnaire. 126 doctors (69.8% women, mean age 41.4 [9.8]) were included in the final analysis. The mean score obtained by ChatGPT was 3.1/5 [0.67]. Specialists rated ChatGPT lower than residents (3.0/5 vs. 3.3/5 points, respectively, P < 0.05). By domains, ChatGPT ​​scored better (M: 3.96; SD: 0.71) in general/theoretical questions rather than in complex decisions/end-of-life situations (M: 2.50; SD: 0.76) and answers related to diagnosis/performing of complementary tests obtained the lowest ones (M: 2.48; SD: 0.77). CONCLUSION: Scores presented big variability depending on the area of knowledge. Questions related to theoretical aspects of challenges/future in geriatrics obtained better scores. When it comes to complex decision-making, appropriateness of the therapeutic efforts or decisions about diagnostic tests, professionals indicated a poorer performance. AI is likely to be incorporated into some areas of medicine, but it would still present important limitations, mainly in complex medical decision-making.

Design of the Dutch multicentre study on opportunistic screening of geriatric patients for atrial fibrillation using a smartphone PPG app: the Dutch-GERAF study.

BACKGROUND: Screening of high-risk patients is advocated to achieve early detection and treatment of clinical atrial fibrillation (AF). The Dutch-GERAF study will address two major issues. Firstly, the effectiveness and feasibility of an opportunistic screening strategy for clinical AF will be assessed in frail older patients and, secondly, observational data will be gathered regarding the efficacy and safety of oral anticoagulation (OAC). METHODS: This is a multicentre study on opportunistic screening of geriatric patients for clinical AF using a smartphone photoplethysmography (PPG) application. Inclusion criteria are age ≥ 65 years and the ability to perform at least three PPG recordings within 6 months. Exclusion criteria are the presence of a cardiac implantable device, advanced dementia or a severe tremor. The PPG application records patients' pulse at their fingertip and determines the likelihood of clinical AF. If clinical AF is suspected after a positive PPG recording, a confirmatory electrocardiogram is performed. Patients undergo a comprehensive geriatric assessment and a frailty index is calculated. Risk scores for major bleeding (MB) are applied. Standard laboratory testing and additional laboratory analyses are performed to determine the ABC-bleeding risk score. Follow-up data will be collected at 6 months, 12 months and 3 years on the incidence of AF, MB, hospitalisation, stroke, progression of cognitive disorders and mortality. DISCUSSION: The Dutch-GERAF study will focus on frail older patients, who are underrepresented in randomised clinical trials. It will provide insight into the effectiveness of screening for clinical AF and the efficacy and safety of OAC in this high-risk population. TRIAL REGISTRATION: NCT05337202.

A Mediation Analysis Examining High Risk, Anticholinergic Medication Use, Delirium, and Dementia After Major Surgery.

INTRODUCTION: Anticholinergic medications are known to cause adverse cognitive effects in community-dwelling older adults and medical inpatients, including dementia. The prevalence with which such medications are prescribed in older adults undergoing major surgery is not well described nor is their mediating relationship with delirium and dementia. We sought to determine the prevalence of high-risk medication use in major surgery patients and their relationship with the subsequent development of dementia. METHODS: This was a retrospective cohort study which used data between January 2013 and December 2019, in a large midwestern health system, including sixteen hospitals. All patients over age 50 undergoing surgery requiring an inpatient stay were included. The primary exposure was the number of doses of anticholinergic medications delivered during the hospital stay. The primary outcome was a new diagnosis of Alzheimer's disease and related dementias at 1-y postsurgery. Regression methods and a mediation analysis were used to explore relationships between anticholinergic medication usage, delirium, and dementia. RESULTS: There were 39,665 patients included, with a median age of 66. Most patients were exposed to anticholinergic medications (35,957/39,665; 91%), and 7588/39,665 (19.1%) patients received six or more doses during their hospital stay. Patients with at least six doses of these medications were more likely to be female, black, and with a lower American Society of Anesthesiologists class. Upon adjusted analysis, high doses of anticholinergic medications were associated with increased odds of dementia at 1 y relative to those with no exposure (odds ratio 2.7; 95% confidence interval 2.2-3.3). On mediation analysis, postoperative delirium mediated the effect of anticholinergic medications on dementia, explaining an estimated 57.6% of their association. CONCLUSIONS: High doses of anticholinergic medications are common in major surgery patients and, in part via a mediating relationship with postoperative delirium, are associated with the development of dementia 1 y following surgery. Strategies to decrease the use of these medications and encourage the use of alternatives may improve long-term cognitive recovery.

Outpatient geriatric health care in the German federal state of Mecklenburg-Western Pomerania: a population-based spatial analysis of claims data.

BACKGROUND: Due to unidentified geriatric needs, elderly patients have a higher risk for developing chronic conditions and acute medical complications. Early geriatric screenings and assessments help to identify geriatric needs. Holistic and coordinated therapeutic approaches addressing those needs maintain the independence of elderly patients and avoid adverse effects. General practitioners are important for the timely identification of geriatric needs. The aims of this study are to examine the spatial distribution of the utilization of outpatient geriatric services in the very rural Federal State of Mecklenburg-Western Pomerania in the Northeast of Germany and to identify regional disparities. METHODS: Geographical analysis and cartographic visualization of the spatial distribution of outpatient geriatric services of patients who are eligible to receive basic geriatric care (BGC) or specialized geriatric care (SGC) were carried out. Claims data of the Association of Statutory Health Insurance Physicians in Mecklenburg-Western Pomerania were analysed on the level of postcode areas for the quarter periods between 01/2014 and 04/2017. A Moran's I analysis was carried out to identify clusters of utilization rates. RESULTS: Of all patients who were eligible for BGC in 2017, 58.3% (n = 129,283/221,654) received at least one BCG service. 77.2% (n = 73,442/95,171) of the patients who were eligible for SGC, received any geriatric service (BGC or SGC). 0.4% (n = 414/95,171) of the patients eligible for SGC, received SGC services. Among the postcode areas in the study region, the proportion of patients who received a basic geriatric assessment ranged from 3.4 to 86.7%. Several regions with statistically significant Clusters of utilization rates were identified. CONCLUSIONS: The widely varying utilization rates and the local segregation of high and low rates indicate that the provision of outpatient geriatric care may depend to a large extent on local structures (e.g., multiprofessional, integrated networks or innovative projects or initiatives). The great overall variation in the provision of BGC services implicates that the identification of geriatric needs in GPs' practices should be more standardized. In order to reduce regional disparities in the provision of BGC and SGC services, innovative solutions and a promotion of specialized geriatric networks or healthcare providers are necessary.

Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data.

BACKGROUND: Limited research has evaluated the validity of claims-based definitions for deprescribing. OBJECTIVES: Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization. METHODS: We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity. RESULTS: Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity. CONCLUSIONS: The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.

Association Between Sleep Efficiency Variability and Cognition Among Older Adults: Cross-Sectional Accelerometer Study.

Background: Sleep efficiency is often used as a measure of sleep quality. Getting sufficiently high-quality sleep has been associated with better cognitive function among older adults; however, the relationship between day-to-day sleep quality variability and cognition has not been well-established. Objective: We aimed to determine the relationship between day-to-day sleep efficiency variability and cognitive function among older adults, using accelerometer data and 3 cognitive tests. Methods: We included older adults aged >65 years with at least 5 days of accelerometer wear time from the National Health and Nutrition Examination Survey (NHANES) who completed the Digit Symbol Substitution Test (DSST), the Consortium to Establish a Registry for Alzheimer's Disease Word-Learning subtest (CERAD-WL), and the Animal Fluency Test (AFT). Sleep efficiency was derived using a data-driven machine learning algorithm. We examined associations between sleep efficiency variability and scores on each cognitive test adjusted for age, sex, education, household income, marital status, depressive symptoms, diabetes, smoking habits, alcohol consumption, arthritis, heart disease, prior heart attack, prior stroke, activities of daily living, and instrumental activities of daily living. Associations between average sleep efficiency and each cognitive test score were further examined for comparison purposes. Results: A total of 1074 older adults from the NHANES were included in this study. Older adults with low average sleep efficiency exhibited higher levels of sleep efficiency variability (Pearson r=-0.63). After adjusting for confounding factors, greater average sleep efficiency was associated with higher scores on the DSST (per 10% increase, ß=2.25, 95% CI 0.61 to 3.90) and AFT (per 10% increase, ß=.91, 95% CI 0.27 to 1.56). Greater sleep efficiency variability was univariably associated with worse cognitive function based on the DSST (per 10% increase, ß=-3.34, 95% CI -5.33 to -1.34), CERAD-WL (per 10% increase, ß=-1.00, 95% CI -1.79 to -0.21), and AFT (per 10% increase, ß=-1.02, 95% CI -1.68 to -0.36). In fully adjusted models, greater sleep efficiency variability remained associated with lower DSST (per 10% increase, ß=-2.01, 95% CI -3.62 to -0.40) and AFT (per 10% increase, ß=-.84, 95% CI -1.47 to -0.21) scores but not CERAD-WL (per 10% increase, ß=-.65, 95% CI -1.39 to 0.08) scores. Conclusions: Targeting consistency in sleep quality may be useful for interventions seeking to preserve cognitive function among older adults.

Predictors of 2-Year Post-Discharge Mortality in Hospitalized Older Patients.

BACKGROUND: Understanding prognostic factors for adverse health outcomes is clinically relevant for improving treatment decision-making processes, potentially leading to enhanced patient prognosis. This secondary analysis of a prospective observational study aimed to identify independent factors associated with 2-year post-discharge mortality in acutely hospitalized older patients. METHODS: All-cause mortality and date of death of 115 patients (83.3 ± 6.3 years, females: n = 75, 65.2%) admitted to acute geriatric wards were determined two years after hospital discharge through telephone interviews. Potential prognostic factors measured at hospital admission included demographic and clinical characteristics, nutritional, cognitive, and psychological status, Fried frailty phenotype, functioning in activities of daily living, locomotor capacity, and 24 h in-hospital mobility and objectively measured physical activity (PA) behaviors. RESULTS: The 2-year mortality rate was 36.7% (n = 41). Univariate and multivariate Cox proportional hazards regression models revealed that mean daily PA level (hazards ratio (HR) = 0.59, 95% confidence interval (CI) 0.90-1.00; p = 0.042), frailty (HR = 3.39, 95% CI 1.20-9.51; p = 0.020), and underweight, in contrast to overweight (HR = 3.10, 95% CI 1.07-9.01; p = 0.038), at hospital admission were independently predictive of post-discharge mortality. CONCLUSION: PA, frailty, and underweight at hospital admission should be considered when evaluating long-term survival prognosis, establishing risk profiles, and developing personalized care pathways in acute hospital care of older adults.

Appropriateness of antithrombotics in geriatric inpatients with atrial fibrillation: a retrospective, cross-sectional study.

BACKGROUND: Atrial fibrillation occurs in nearly half of geriatric inpatients and is a major cause of morbidity and mortality. Suboptimal anticoagulation use is an important concern in this population. This study aimed to evaluate the appropriateness of antithrombotic therapies in this patient cohort. METHODS: A retrospective analysis was conducted on the geriatric wards of a teaching hospital in Belgium, on a background of clinical pharmacy services. The first 90 atrial fibrillation patients from 2020 to 2022 were included if they received an oral anticoagulant. We assessed utilisation and appropriateness of antithrombotics at discharge, examined reasons for guideline deviations, and explored factors associated with underdosing. Temporal associations for appropriateness and type of anticoagulant (vitamin K antagonist (VKA) vs direct oral anticoagulant (DOAC)) were assessed. RESULTS: The mean age of patients was 86.5 (±5.3) years and the median CHA2DS2-VASc score was 5 (interquartile range (IQR) 4-6). At discharge, 256 (94.8%) patients used a DOAC; nine (3.3%) used a VKA; one (0.4%) a DOAC-antiplatelet combination, and in four patients (1.5%) all antithrombotics were discontinued. The majority (64.4%) of patients received reduced DOAC doses with apixaban prescribed in 40.7%. In 39 (14.4%) patients, antithrombotic use was considered inappropriate, mostly without a rationale (23/39). Year 2022 (odds ratio (OR) 0.104; 95% confidence interval (CI), 0.012-0.878) was the sole determinant for underdosing. No significant differences were found with respect to appropriateness (p=0.533) or anticoagulant class (p=0.479) over time. CONCLUSION: Most geriatric inpatients received a justified reduced DOAC dose. A significant proportion was managed inappropriately with underdosing (= unjustified reduced dose) being most common. Frequently no rationale was provided for deviating from trial-tested doses.

Aspectos epidemiológicos, manejo clínico y resultados a corto plazo en pacientes mayores diagnosticados de insuficiencia cardiaca aguda en urgencias en España: resultados del estudio EDEN-34 / Epidemiological aspects, clinical management and short-term outcomes in elderly patients diagnosed with acute heart failure in the emergency department in Spain: results of the EDEN-34 study

Objetivo: Estimar la incidencia de diagnóstico de insuficiencia cardiaca aguda (ICA) en pacientes mayores en los servicios de urgencias (SU), la confirmación diagnóstica de la ICA en pacientes hospitalizados y los eventos adversos a corto plazo. Método: Se incluyeron a todos los pacientes de ≥65 años atendidos en 52 SU españoles durante una semana y se seleccionaron los diagnosticados de ICA. En los hospitalizados se recogieron los diagnosticados de ICA al alta. Como eventos adversos, se recogió la mortalidad intrahospitalaria y a 30 días, y evento adverso combinado (muerte u hospitalización) a 30 días posalta. Se calcularon las odds ratio (OR) ajustadas de las características demográficas, de estado basal y a la llegada al SU asociadas con mortalidad y evento adverso posalta a 30 días. Resultados: Se incluyeron 1.155 pacientes con ICA (incidencia anual: 26,5 por 1.000 habitantes ≥65 años, IC95%: 25,0-28,1). En el 86%, el diagnóstico de ICA constaba al alta. La mortalidad global a 30 días fue del 10,7%, la intrahospitalaria del 7,9% y el evento combinado posalta del 15,6%. La mortalidad intrahospitalaria y a 30 días se asoció con hipotensión arterial (OR ajustada: 74,0, IC95%: 5,39-1.015.; y 42,6, 3,74-485, respectivamente) e hipoxemia (2,14, 1,27-3,61; y 1,87, 1,19-2,93) a la llegada a urgencias y con precisar ayuda en la deambulación (2,24, 1,04-4,83; y 2,48, 1,27-4,86) y la edad (por cada incremento de 10 años; 1,54, 1,04-2,29, y 1,60, 1,13-2,28). Conclusiones: La ICA es un diagnóstico frecuente en los pacientes mayores que consultan en los SU. El deterioro funcional, la edad, la hipotensión e hipoxemia son los factores que más se asocian a mortalidad.(AU)

Objective: To estimate the incidence of acute heart failure (AHF) diagnosis in elderly patients in emergency departments (ED), diagnostic confirmation in hospitalized patients, and short-term adverse events. Methods: All patients aged ≥65 years attended in 52 Spanish EDs during 1 week were included and those diagnosed with AHF were selected. In hospitalized patients, those diagnosed with AHF at discharge were collected. As adverse events, in-hospital and 30-day mortality, and combined adverse event (death or hospitalization) at 30 days post-discharge were collected. Adjusted odds ratios (OR) for association of demographic variables, baseline status and constants at ED arrival with mortality and 30-day post-discharge adverse event were calculated. Results: We included 1,155 patients with AHF (annual incidence: 26.5 per 1000 inhabitants ≥65 years, 95%CI: 25.0-28.1). In 86% the diagnosis of AHF was known at discharge. Overall 30-day mortality was 10.7% and in-hospital mortality was 7.9%, and the combined event in 15.6%. In-hospital and 30-day mortality was associated with arterial hypotension (adjusted OR: 74.0, 95%CI: 5.39-1015. and 42.6, 3.74-485, respectively and hypoxemia (2.14, 1.27-3.61; and 1.87, 1.19-2.93) on arrival at the ED and requiring assistance with ambulation (2.24, 1.04-4.83; and 2.48, 1.27-4.86) and age (per 10-year increment; 1.54, 1.04-2.29; and 1.60, 1.13-2.28). The combined post-discharge adverse event was not associated with any characteristic. Conclusions: AHF is a frequent diagnosis in elderly patients consulting in the ED. The functional impairment, age, hypotension and hypoxemia are the factors most associated with mortality.(AU)