Method for Assigning Priority Levels in Acute Care (MAPLe-AC) predicts outcomes of acute hospital care of older persons--a cross-national validation.

BACKGROUND: Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been : identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning. METHODS: Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses. RESULTS: Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models. CONCLUSION: MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.

Vision and hearing impairments and their associations with falling and loss of instrumental activities in daily living in acute hospitalized older persons in five Nordic hospitals.

BACKGROUND: Many older people believe sensory problems are inevitably, a part of growing old, and avoid assessment and help. Such problems are often also overlooked by health professionals. The aim of this study was to find the prevalence of hearing and vision impairment and their associations with loss of instrumental activities in daily living (IADL) and risk of falling in patients aged 75 years or older, admitted to a medical ward in an acute hospital in each of the five Nordic countries. METHOD: The Minimum Data Set for Acute Care was used for data collection in 770 patients. Premorbid data, admission data and history of falls over 3 months were obtained on admission by interview and observation. Hearing impairment was present if the patient required a quiet setting to be able to hear normal speech. Vision impairment was defined as unable to read regular print in a newspaper. RESULTS: Bivariate and logistic regression analyses were performed. Forty-eight per cent of the patients had a hearing impairment, 32.3% had vision impairment and 20.1% had both. Hearing impairment was associated with falling but not in the logistic regression model. Hearing and vision impairment were associated with loss of IADL but only combined impairment was independently. CONCLUSION: Hearing and vision impairments were frequent among older patients in the medical wards. Falling was associated with hearing loss and IADL loss with hearing, vision and combined impairments. Sensory loss was also associated with fear of falling. It is recommended routinely to screen sensory functions in older patients in a medical setting. Intervention studies are needed to determine whether improvements in hearing and vision can prevent falls and further loss of function in this patient population.

Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment.

AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. METHOD: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. FINDINGS: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases. CONCLUSIONS: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.

Tiredness and subsequent disability in older adults: The role of walking limitations.

BACKGROUND: The purposes of the present study are to analyze whether tiredness in daily activities is associated with subsequent disability among nondisabled older adults and whether this association is mediated by walking limitations. METHODS: The investigation is based on baseline and follow-up data on 419 nondisabled 75-year-old persons in Jyväskylä, Finland, and Glostrup, Denmark. Onset of disability was measured by a validated scale based on seven items: combing hair, washing upper body, washing lower body, using the toilet, dressing upper body, dressing lower body, and cutting fingernails. Tiredness was measured by a validated scale based on the following items: using the toilet, washing and dressing lower body, and cutting toenails. Maximal walking speed was assessed by a 10-meter test. RESULTS: Tiredness in daily activities was significantly associated with subsequent disability when adjusted for walking limitations. CONCLUSION: The present findings indicate that it is important to take it seriously when older persons complain about tiredness, as these people are at higher risk of onset of disability.

Depressive symptomatology at age 75 and subsequent use of health and social services.

It is well documented that elderly persons are the largest consumers of many health and social services. Consequently it is of interest to identify characteristics of users of those services. The purpose of this study is to examine whether depressive symptoms among men and women at age 75 are an independent determinant of incident hospitalization and use of home help 5 years later. Four hundred and ten men and women participated in a prospective study in Glostrup, Denmark, when they were 75 and 80 years old. Depressive symptoms were evaluated by the Center for Epidemiologic Studies Depression Scale (CES-D Scale). Use of health and social services was measured by asking the participants whether they had been hospitalized or used home help during the year before follow-up. Among women, depressive symptoms at age 75 were associated with subsequent use of home help at age 80 (odds ratio (OR) = 2.5; 95% confidence interval (CI): 1.2-5.0) and marginally associated with subsequent hospitalization (OR = 1.8; 95% CI: 0.96-3.5). None of these results were seen in men. Preventive services should take into account depressive symptoms among elderly women.

Potentially inappropriate medication use among elderly home care patients in Europe.

CONTEXT: Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability. OBJECTIVE: To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument. MAIN OUTCOME MEASURES: Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model. RESULTS: Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001). CONCLUSIONS: Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

The IL-6 -174G>C polymorphism is associated with cardiovascular diseases and mortality in 80-year-old humans.

Chronic low-grade elevations in circulating levels of interleukin (IL)-6 act as a marker of subclinical cardiovascular diseases (CVD) and provide an independent predictor of increased mortality in elderly populations. The purpose of the present study was to test the hypothesis that the IL-6 -174G>C promoter polymorphism was associated with a high prevalence of CVD and acted as an independent predictor of mortality in a longitudinal study of 324 relatively healthy 80-year-old people with a history of CVD in 18% of the cases. The C allele was associated with elevated serum levels of IL-6 at baseline and the CC genotype had a high prevalence of CVD. A Cox regression model was used to explore the effect of the polymorphism on survival in the following six years. A significant interaction was found between smoking status and the polymorphism. Thus, C allele carrier status was associated with increased all-cause mortality risk in non-smokers independently of sex, body mass index, co-morbidity, and low-grade elevations in serum levels of IL-6. This effect was not detected among smokers. We conclude that the IL-6 -174G>C polymorphism was an independent predictor of all-cause mortality in octogenarians but the effect was complex and interacted with the smoking status.

Functional decline from age 80 to 85: influence of preceding changes in tiredness in daily activities.

OBJECTIVE: To analyze whether functional decline from age 80 to 85 is influenced by changes in self-reported tiredness in daily activities in the preceding 5-year period. METHOD: A prospective study of 226 75-year-old men and women with 5- and 10-year follow-up in the Western part of Copenhagen County. Tiredness in daily activities was measured at age 75 and 80 by a validated scale. Changes in tiredness from age 75 to 80: 1) Sustained no tiredness, 2) not tired-tired, 3) tired-not tired, 4) sustained tiredness. Functional decline from age 80 to 85:1) Sustained no need of help; 2) need of help at age 85, alive; 3) need of help at age 85 or dead; 4) dead. RESULTS: The analyses among the survivors showed a slight tendency to an association between having sustained tiredness or development of tiredness from age 75 to 80 and functional decline from age 80 to 85. Persons with sustained tiredness from age 75 to 80 were at significantly larger risk of functional decline and mortality from age 80 to 85. These results were not attenuated when adjusted by the covariates. CONCLUSION: The results in the present study indicate that it is important to take continuous complaints about tiredness in daily activities seriously, because this is an early sign of functional decline.

Tiredness in daily activities among nondisabled old people as determinant of onset of disability.

The purpose of this article was to examine whether self-reported tiredness in daily activities at age 75 is an independent determinant of onset of disability at 5-year follow-up. The investigation is based on two subgroups of nondisabled participants of 75 year olds who survived and participated in the follow-up study 5 years later (n = 510 and 429). Persons who felt tired in their daily activities had a larger risk of becoming disabled in mobility (OR = 3.2, 95% CI = 1.4-7.6) and in daily activities (OR = 2.1, 95% CI = 1.0-4.2) compared to persons without tiredness. In addition, persons with poor cognitive function, little diversity in social relations and no physical activity had an independent risk of onset of disability. The results indicate that it is important to take it seriously when older people complain about tiredness in daily activities, as these people are at higher risk of becoming disabled than others.

Muscle strength after resistance training is inversely correlated with baseline levels of soluble tumor necrosis factor receptors in the oldest old.

OBJECTIVES: To test the hypothesis that physical exercise induces an antiinflammatory response that is associated with reduced chronic activation of the tumor necrosis factor (TNF)-alpha system in frail elders and that the increase in muscle strength after resistance training is limited by systemic low-grade inflammation. DESIGN: A 12-week controlled resistance-training study. SETTING: Nursing homes in Copenhagen, Denmark. PARTICIPANTS: Twenty-one frail nursing home residents aged 86 to 95 completed the study. INTERVENTION: Ten participants were randomized to a program of resistance training of knee extensors and flexors three times a week for 12 weeks; the remaining 11 participants served as a control group who joined social activities supervised by an occupation therapist. MEASUREMENTS: Muscle strength, plasma levels of TNF-alpha, soluble TNF receptor (sTNFR)-1, and interleukin (IL)-6 were measured before and at the end of the intervention period. RESULTS: The training program improved muscle strength but did not affect plasma levels of TNF-alpha and sTNFR-I or IL-6. However, plasma levels of sTNFR-I at baseline were inversely correlated with the increase in muscle strength. CONCLUSION: Low-grade activation of the TNF system could limit the increase in muscle strength after resistance training in the oldest old. Furthermore, data suggest that the antiinflammatory response induced by 12 weeks of resistance training is not sufficient to reduce chronic activation of the TNF system, but the small sample size limited this interpretation.

The tumor necrosis factor alpha -308G>A polymorphism is associated with dementia in the oldest old.

OBJECTIVES: To test the hypothesis that the tumor necrosis factor (TNF) -308 G>A promoter gene polymorphism is a risk factor in age-related dementia and longevity. DESIGN: A cross-sectional and a longitudinal study. SETTING: A population-based sample of Danish centenarians. PARTICIPANTS: One hundred-year-old Danes (n=122) from "The Longitudinal Study of Danish Centenarians." Octogenarians (n=174) and healthy volunteers aged 18 to 30 (n=47) served as reference groups. METHODS: Whether the distribution of TNF -308 GG/GA/AA genotypes were different in centenarians than in younger age groups was investigated (Fischer exact test). Furthermore, whether the TNF -308 G>A polymorphism was associated with the prevalence of dementia (logistic regression analysis), the plasma level of TNF-alpha (analysis of variance), and mortality in the following 5 years (Cox regression analysis) within the cohort of centenarians was tested. RESULTS: The distribution of TNF -308 genotypes was not different across the three different age groups, but the GA genotype was associated with decreased prevalence of dementia in centenarians. The few centenarians with AA carrier status had higher mortality risk and tended to show higher plasma levels of TNF-alpha, but the significance was questionable due to a low number of subjects with this genotype. CONCLUSION: It is possible that the TNF -308 A allele is maintained during aging because subjects who are heterozygous for this polymorphism possess the optimal inflammatory response with regard to protection against age-related neurodegeneration.

Lifestyle, nutritional status, health, and mortality in elderly people across Europe: a review of the longitudinal results of the SENECA study.

This article provides an overview of the longitudinal Survey in Europe on Nutrition and the Elderly: a Concerted Action (SENECA) study, which was designed to assess differences in dietary and lifestyle factors among elderly Europeans, and to identify the factors that contribute to healthy aging. Elderly people from Belgium, Denmark, France, Italy, Portugal, Spain, Switzerland, and The Netherlands participated in the SENECA study. Standardized measurements were conducted at baseline in 1988-1989 and were repeated in 1993 and 1999. Diet, physical activity, and smoking, as well as maintenance of health and survival, were assessed. At baseline, considerable differences in lifestyle factors existed among elderly people. Mealtime patterns as well as dietary intake varied across Europe, and geographical patterns were apparent. Similar results were found for engagement in sport or professional activities. The smoking prevalence among women was generally low. Distinct geographical differences were also observed in percentages of deaths during the SENECA study and in overall survival time. A healthy lifestyle was related to stable self-perceived health, a delay in functional dependence, and mortality. Inactivity and smoking, and to a lesser extent a low-quality diet, increased mortality risk. A combined effect of multiple unhealthy lifestyle factors was also observed. The SENECA study showed that a healthy lifestyle at older ages is related to a delay in the deterioration of health status and a reduced mortality risk. Improving and maintaining a healthy lifestyle in elderly people across Europe is a great challenge for the European Community.

[Microalbuminuria is associated with a fourfold increased risk of ischemic heart disease among hypertensive patients]. / Mikroalbuminuri er associeret med firedobbelt risiko for iskaemisk hjertesygdom blandt hypertensive.

INTRODUCTION: The urinary excretion of albumin is positively correlated to the presence of ischaemic heart disease and atherosclerotic risk factors in subjects with arterial hypertension. The aim of this population-based, follow-up study of hypertensive patients was to assess the predictive impact of a slightly elevated urinary excretion of albumin, i.e. microalbuminuria, on ischaemic heart disease. MATERIAL AND METHODS: In 1983-1984, blood pressure, the albumin/creatinine concentration ratio in a morning urine sample, total and HDL cholesterol in plasma, body mass index, and smoking habits were measured in a population of 2085 men and women aged 30-60 years. Exclusion criteria were ischaemic heart disease, diabetes mellitus, and renal or urinary tract disease. Untreated hypertension or borderline hypertension (a systolic blood pressure above 140 mmHg and/or a diastolic blood pressure above 90 mmHg) were found in 204 of the participants, who were followed up until 1993 with respect to the development of ischaemic heart disease through the Danish Hospital Register and Death Certificate Register. RESULTS: Over 1978 person-years, 18 participants (9%) developed ischaemic heart disease. Microalbuminuria, defined as a urinary albumin/creatinine ratio above the upper decile in the hypertensive population under study (1.07 mg/mmol), was the strongest predictor of ischaemic heart disease with a relative risk (95% confidence interval) of 4.2 (1.5-11.9) (p = 0.006). When adjusted for all other variables, including age and sex, the relative risk was 3.5 (1.0-12.1) (p = 0.05). DISCUSSION: Microalbuminuria is associated with a fourfold increased risk of ischaemic heart disease in subjects with untreated hypertension or borderline hypertension. Urinary excretion of albumin should perhaps be monitored regularly in the hypertension clinic, and rigorous control of blood pressure and other modifiable atherosclerotic risk factors is to be recommended in hypertensive patients with microalbuminuria.

Mobility-related fatigue, walking speed, and muscle strength in older people.

BACKGROUND: Fatigue is an important early marker of functional decline among older people, but the mechanisms underlying this association are not fully understood. The purpose of the present study was to examine the association between mobility-related fatigue and walking speed and to test the degree to which muscle strength accounts for this association. METHODS: The study is based on baseline (n = 523) and 5-year follow-up data (n = 292) from a cohort of 75-year-old persons. Standardized assessments include self-report measures of mobility-related fatigue (score range 0-6) and medical history, as well as performance-based assessment of walking speed and maximal isometric strength of knee extension, body extension, and handgrip. RESULTS: In the cross-sectional baseline analysis, one unit increase in fatigue score was associated with 0.03 m/s (ß = -.03, p < .001) and 0.05 m/s (ß = -.05, p < .001) slower maximum walking speed among women and men, respectively, while adjusting for important covariates. Among women, muscle strength accounted up to 21% and among men up to 24% for the association. In the prospective analysis, fatigue at baseline was predictive of change in walking speed among men (ß = -.04, p < .001) but not among women (ß = -.005, p = .64). Among men, muscle strength accounted up to 15% for the association between baseline fatigue and change in maximum walking speed. CONCLUSIONS: Mobility-related fatigue is associated with slower walking speed in older adults. The results suggest that muscle strength is one of the underlying factors explaining this association.