The Charlson Comorbidity and Barthel Index predict length of hospital stay, mortality, cardiovascular mortality and rehospitalization in unselected older patients admitted to the emergency department.

BACKGROUND AND AIMS: The Charlson Comorbidity Index (CCI) is the most widely used assessment tool to report the presence of comorbid conditions. The Barthel index (BI) is used to measure performance in activities of daily living. We prospectively investigated the performance of CCI or BI to predict length of hospital stay (LOS), mortality, cardiovascular (CV) mortality and rehospitalization in unselected older patients on admission to the emergency department (ED). We also studied the association of CCI or BI with costs. METHODS: We consecutively enrolled 307 non-surgical patients ≥ 68 years presenting to the ED with a wide range of comorbid conditions. Baseline characteristic, clinical presentation, laboratory data, echocardiographic parameters and hospital costs were compared among patients. All patients were followed up for mortality, CV mortality and rehospitalization within the following 12 months. A multivariate analysis was performed. RESULTS: Mortality was increased for patients having a higher CCI or BI with a hazard ratio around 1.17-1.26 or 0.75-0.81 (obtained for different models) for one or ten point increase in CCI or BI, respectively. The prognostic impact of a high CCI or BI on CV mortality and rehospitalization was also significant. In a multiple linear regression using the same independent variables, CCI and BI were identified as a predictor of LOS in days. Multiple linear regression analysis did not confirm an association between CCI and costs, but for BI after adjusting for multiple factors. CONCLUSION: CCI and BI independently predict LOS, mortality, CV mortality, and rehospitalization in unselected older patients admitted to ED.

Frailty and functional decline indices predict poor outcomes in hospitalised older people.

BACKGROUND: admission to a Geriatric Evaluation and Management Unit (GEMU) can optimise a patient's chance of functional recovery. OBJECTIVE: to evaluate the ability of several commonly used frailty and functional decline indices to predict GEMU outcomes, both at discharge and at 6 months. DESIGN: prospective, observational study. SETTING AND PARTICIPANTS: consecutive GEMU patients aged ≥70 years. METHODS: patients were classified as 'frail' or 'at high risk of functional decline' using several frailty and functional decline instruments. Predictive ability was evaulated using logistic regression and area under receiver operator characteristic (ROC) curves (auROC). RESULTS: a total of 172 patients were included. Frailty prevalence varied from 24 to 94% depending on the instrument used. Several instruments predicted patients at risk of poor outcome, including the Frailty Index of Accumulative Deficits (FI-CD), Fried's Cardiovascular Health Study index, the Study of Osteoporotic Fractures index, an adapted Katz score of activities of daily living (ADL), Instrumental ADL, the Score Hospitalier d'Evaluation du Risque de Perte d'Autonomie (SHERPA) and grip strength [odds ratio (OR) range of 2.06-6.47]. Adequate discriminatory power for discharge outcome was achieved by the FI-CD (auROC = 0.735, P < 0.001) and an adapted Katz score (auROC = 0.704, P = < 0.001). The FI-CD also showed adequate discriminatory power for a poor 6-month outcome (auROC = 0.702, P < 0.001). CONCLUSION: frailty and functional decline instruments can predict older patients at risk of poor outcome. However, only the FI-CD showed adequate discriminatory power for outcome prediction at both follow-up time-points.

Sarcopenia measurement in research and clinical practice.

Sarcopenia is a disease related to accelerated loss of skeletal muscle and subsequent decline in functional capacity. It affects approximately 13% of the world's population aged over 60 years. Sarcopenia is primarily managed and prevented through a combination of exercise prescription combined with appropriate nutritional strategies. This review outlines diagnostic and case finding/screening tools for age-related (primary) sarcopenia used in research and clinical practice. Diagnostic tools critically reviewed include those of the: European Workgroup for Sarcopenia (EWGSOP) versions 1 and 2; Asian Working Group for Sarcopenia (AWGS) versions 1 and 2; Foundation for the National Institutes of Health (FNIH); and the Sarcopenia Definition and Outcomes Consortium (SDOC). Criteria used by diagnostic tools (muscle mass, muscle strength and physical functioning/performance) are also detailed. Case-finding tools include the SARC-F questionnaire, Ishii's formula and Goodman's screening grid. Additionally, this review discusses the strengths and weaknesses of each diagnostic and case-finding tool, and examines their ability to reliably predict adverse clinical outcomes and patient responses to potential therapies.

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review.

Cognitive assessment is a cornerstone of geriatric care. Cognitive impairment has the potential to significantly impact multiple phases of a person's cancer care experience. Accurately identifying this vulnerability is a challenge for many cancer care clinicians, thus the use of validated cognitive assessment tools are recommended. As international cancer guidelines for older adults recommend Geriatric Assessment (GA) which includes an evaluation of cognition, clinicians need to be familiar with the overall interpretation of the commonly used cognitive assessment tools. This rapid review investigated the cognitive assessment tools that were most frequently recommended by Geriatric Oncology guidelines: Blessed Orientation-Memory-Concentration test (BOMC), Clock Drawing Test (CDT), Mini-Cog, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Short Portable Mental Status Questionnaire (SPMSQ). A detailed appraisal of the strengths and limitations of each tool was conducted, with a focus on practical aspects of implementing cognitive assessment tools into real-world clinical settings. Finally, recommendations on choosing an assessment tool and the additional considerations beyond screening are discussed.

Laying the foundation for a primary care core set of the International Classification of Functioning, Disability and Health (ICF) for community-dwelling older adults: A qualitative study.

OBJECTIVE: To explore relevant areas of functioning from the perspective of community-dwelling adults aged 75 years and over, in order to develop a Core Set of the International Classification of Functioning, Disability and Health (ICF) for community-dwelling older adults for use in primary care. DESIGN: Qualitative study using semi-structured interviews and focus groups. PARTICIPANTS: A total of 27 community-dwelling older adults participated in the interviews and 24 of them in the focus groups. METHODS: Following the proposed methodology of the ICF Research Branch, this is 1 of 4 preparatory studies in the Core Set development process. Within the transcripts, concepts of functioning were identified, based on Mayring's qualitative content analysis using deductive category assignment with the ICF being the category system. RESULTS: Overall 6,667 concepts were identified. Most were linked to the Activities and Participation component. The most frequently identified categories were "recreation and leisure" and "family relationships". CONCLUSION: Categories from all ICF chapters were identified, demonstrating the complexity and multidimensionality of the ageing process, with a special emphasis on the component Activities and Participation. This qualitative study provides a list of relevant categories from the perspective of community--dwelling elderly people, which will be used to develop a Core Set for older primary care patients.

Proposals for continued research to determine older adults' falls risk.

Early detection of older adults with an increased risk of falling could enable early onset of preventative measures. Currently used fall risk assessment tools have not proven sufficiently effective in differentiating between high and low fall risk in community-living older adults. There are a number of tests and measures available, but many timed and observation-based tools are performed on a flat floor without interaction with the surrounding. To improve falls prediction, measurements in other areas that challenge mobility in dynamic conditions and that take a persons' own perception of steadiness into account should be further developed and evaluated as single or combined measures. The tools should be easy to apply in clinical practice or used as a self-assessment by the older adults themselves.

Neither Timed Up and Go test nor Short Physical Performance Battery predict future falls among independent adults aged ≥75 years living in the community.

OBJECTIVES: Previous research has shown that balance and gait difficulties are predictors of falls. The aim of this study was to evaluate the predictive validity of two tools reporting on balance and gait among older community-living adults independent in personal activities of daily living (p-ADL). METHODS: Prospective study design. Baseline assessment included the Timed Up and Go test (TUG) and the Short Physical Performance Battery (SPPB). Following baseline, falls were recorded monthly for one year by 202 participants (70.1% women) who were independent in p-ADL, and at least 75 years old (79.2±3.5). ROC-curves were made and AUC were calculated. RESULTS: Forty-seven percent of the participants reported falls. AUCs calculated for TUG were 0.5 (95%CI: 0.5-0.6) for those with at least one fall, and 0.5 (95% CI: 0.5-0.6) for recurrent fallers. Corresponding figures for SPPB were 0.5 (95% CI: 0.5-0.6) and 0.5 (95% CI: 0.5-0.6). CONCLUSION: This study does not support a recommendation to use the Timed Up and Go test or the Short Physical Performance Battery as tools for the identification of fall-prone persons among older adults living in the community. These results reinforce the need for further research into appropriate tools for identifying independent but fall-prone older adults.

Nutritional screening and dietitian consultation rates in a geriatric evaluation and management unit.

AIM: Nutritional screening may not always lead to intervention. The present study aimed to determine: (i) the rate of nutritional screening in hospitalised older adults; (ii) whether nutritional screening led to dietitian consultation and (iii) factors associated with malnutrition. METHODS: In this prospective study of patients aged ≥70 years admitted to a Geriatric Evaluation and Management Unit (GEMU), malnutrition was screened for using the Mini Nutritional Assessment Short Form (MNA-SF) and identified using the Mini Nutritional Assessment (MNA). RESULTS: Of the 172 patients participating in the study, 53 (30.8%) patients were malnourished, and 84 (48.8%) were at risk of malnutrition. Mean (SD) age was 85.2 (6.4 years), with 131 patients (76.2%) female. Nutritional screening was performed for all patients; however, it was incomplete in 59 (34.3%) because of omission of the anthropometric measurement. Overall, 62 (36.0%) of the total number of patients were seen by the dietitian, which included 26 (49%) of malnourished patients, 27 (32%) of at-risk patients and 9 (26%) of the well-nourished patients. No patients lost >1% of body weight during GEMU stay. Malnourished patients were more likely to be frail, have poor appetite, depression, and have lower levels of: albumin, cognition, physical function, grip strength and quality of life. CONCLUSIONS: The full benefits of nutritional screening by MNA-SF may not be realised if it does not result in malnourished patients receiving a dietitian consultation. However, it is possible that enrichment of the foodservice with high protein/high-energy options minimised patient weight loss in the GEMU.

Recognising older frail patients near the end of life: What next?

Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor -pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.

Frailty measurement in research and clinical practice: A review.

One of the leading causes of morbidity and premature mortality in older people is frailty. Frailty occurs when multiple physiological systems decline, to the extent that an individual's cellular repair mechanisms cannot maintain system homeostasis. This review gives an overview of the definitions and measurement of frailty in research and clinical practice, including: Fried's frailty phenotype; Rockwood and Mitnitski's Frailty Index (FI); the Study of Osteoporotic Fractures (SOF) Index; Edmonton Frailty Scale (EFS); the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) Index; Clinical Frailty Scale (CFS); the Multidimensional Prognostic Index (MPI); Tilburg Frailty Indicator (TFI); PRISMA-7; Groningen Frailty Indicator (GFI), Sherbrooke Postal Questionnaire (SPQ); the Gérontopôle Frailty Screening Tool (GFST) and the Kihon Checklist (KCL), among others. We summarise the main strengths and limitations of existing frailty measurements, and examine how well these measurements operationalise frailty according to Clegg's guidelines for frailty classification - that is: their accuracy in identifying frailty; their basis on biological causative theory; and their ability to reliably predict patient outcomes and response to potential therapies.

Nutritional screening tools and anthropometric measures associate with hospital discharge outcomes in older people.

AIM: To examine the association of nutritional screening tools (NSTs) and anthropometric measures with hospital outcomes in older people. METHODS: In 172 patients aged ≥70 years admitted to a Geriatric Evaluation Management Unit (GEMU), nutritional status was measured using the Mini-Nutritional Assessment (MNA), MNA-short form (MNA-SF), Geriatric Nutritional Risk Index (GNRI), Simplified Nutritional Appetite Questionnaire, calf circumference (CC), mid-arm circumference (MAC) and BMI. RESULTS: Malnutrition according to the MNA occurred in 53 (31%) patients. Functional change was associated with GNRI (Beta coefficient (ß), 95% CI = 0.17, 0.001-0.33) and CC (ß, 95% CI = 0.17, 0.01-0.33); GEMU length of stay was associated with MNA-SF-BMI (ß, 95% CI = -0.02, -0.003 to -0.004) and MNA-SF-CC (ß, 95% CI = -0.02, -0.003 to -0.001). MAC was associated with discharge to higher level of care (OR, 95% CI = 0.88, 0.81-0.96). CONCLUSION: In hospitalised older people, admission NSTs and anthropometric measures associate with discharge outcomes.

Relationship between universal health outcome priorities and willingness to take medication for primary prevention of myocardial infarction.

OBJECTIVES: To determine how well universal health outcome priorities represent individuals' preferences in specific clinical situations. DESIGN: Observational cohort study. SETTING: Community. PARTICIPANTS: Community-dwelling adults aged 65 and older (N = 357). MEASUREMENTS: Participants used three tools assessing universal health outcome priorities related to two common trade-offs: quality versus quantity of life and future health versus present inconveniences and burdens of treatment. The tools' ability to identify participants who were unwilling to take a medication that reduced the risk of myocardial infarction but caused dizziness and fatigue was analyzed. RESULTS: There were consistent and significant associations between unwillingness to take the medication and prioritizing quality of life or future health for all three tools in the expected direction (P < .05). Despite these associations, the positive (PPV) and negative predictive values for the tools were generally modest (0.49-0.83). The tool with the most specific statements resembling the medication scenario had the best specificity (0.97) and PPV (0.83). CONCLUSION: Universal health outcome priorities only modestly identified older persons who would be unwilling to take a medication for primary prevention of myocardial infarction that causes adverse effects. Although tools that are the most general in their assessment of priorities have the benefit of being applicable across the widest range of scenarios, tools with greater specificity may be necessary to inform individual treatment decisions.