How strong is the will-to-live in frail older persons? A survey study in acute geriatric wards and nursing homes in Belgium.

INTRODUCTION: Will-to-live is defined as the psychological expression of one's commitment to life and the desire to continue living. It is an important indicator of subjective wellbeing. This study aimed to assess the will-to-live in frail older hospitalized patients and nursing home residents as well as to evaluate its association with physical frailty, tiredness of life, depression and wish-to-die. METHODS: Between March and September 2021, we interviewed 186 older adults in six nursing homes and two acute geriatric wards across Belgium. Will-to-live was assessed using a single-item numeric rating scale from 0 to 5. A linear regression analysis was performed to assess the association between will-to-live and frailty (Clinical Frailty Scale) with adjustment for age, gender and setting. Mann-Whitney U test was used to evaluate the association between will-to-live and depression, tiredness of life and wish-to-die. RESULTS: Mean age was 85 (± 6.2) years. Mean score on the Clinical Frailty Scale was five (± 1.5) and four on the will-to-live (± 1.3). No statistical significant association was found between will-to-live and age (p = 0.991), gender (p = 0.272), setting (p = 0.627) and frailty (p = 0.629). Multiple linear regression showed no significant association with Clinical Frailty Scale (p = 0.660), after adjustment for age, gender and setting. Will-to-live was negatively associated with tiredness of life (p = 0.020) and wish-to-die (p < 0.001), but not with depression (p = 0.186). DISCUSSION: Both nursing home residents and older hospitalized patients expressed a strong or very strong will-to-live. Will-to-live was not associated with physical frailty as measured by the Clinical Frailty Scale. Nursing home residents with a weak will-to-live were more likely to have depressive symptoms. Most nursing home residents with a wish-to-die had also a low will-to-live, although some residents had both a high will-to-live and wish-to-die.

Fibromuscular dysplasia - results of a multicentre study in Flanders.

BACKGROUND: Fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory, non-atherosclerotic vascular disease, resulting in focal narrowing of small and medium-sized arteries. Systematic recording of clinical data in central databases as in the US and France provided new insights into FMD. The main objectives of this multicentre study were to explore the epidemiology, pattern of vascular involvement, clinical manifestations, and management of FMD patients in Flanders. PATIENTS AND METHODS: Multicentre, retrospective registry of patients diagnosed with FMD based on medical imaging. RESULTS: Hundred-twenty-three FMD patients (83.7 % female) were included. Mean age at FMD diagnosis was 57.3 years (SD 15.8). More than half of patients (59.5 %) were hypertensive at the time of diagnosis. Neurological complaints such as headache (26.4 %) and dizziness (23.1 %) were also frequently reported. FMD was discovered incidentally in 10 patients (8.3 %). Nearly one quarter (22.8 %) of patients experienced a cerebrovascular event. Aneurysms were found in one-fifth (20.3 %) of patients and 11.4 % had an arterial dissection. FMD affected most frequently the renal (85.3 %), carotid (74.7 %), and vertebral (39.8 %) arteries. Renovascular FMD was more prevalent in men, whereas cerebrovascular FMD was more frequent in women. Multiple affected sites were documented in 25 of 61 (41.0 %) patients, having two or more vascular beds imaged. Digital subtraction angiography was most frequently used for detecting FMD. One third (32.9 %) of patients received an interventional treatment, mainly patients with renovascular FMD (32.8 % underwent percutaneous transluminal angioplasty) and patients with an intracranial carotid aneurysm (36.4 % were treated by means of coiling). CONCLUSIONS: Although differences existed, results of the Flemish registry were broadly in line with the US and French registries. Patient databases help to learn more about the natural history, progression, and management of FMD, based on real life clinical evidence.

Will-to-Live and Self-Rated Health in Older Hospitalized Patients Are Not Predictive for Short-Term Mortality.

Background: Self-assessed will-to-live and self-rated health are associated with long-term survival in community-dwelling older persons but have not been examined in frailer older patients in relation to short-term prognosis. The aim was to explore whether will-to-live and self-rated health are predictive for six-month mortality and can guide ceiling of treatment decisions in hospitalized patients in an acute geriatric ward. We included the Surprise Question as reference, being a well-established clinical tool for short-term prognostication. Methods: This multicentric prospective study included patients of 75 years and older admitted at acute geriatric wards of two Belgian hospitals. Will-to-live and self-rated health were scored on a Likert scale (0-5, 0-4) and assessed by junior geriatricians. The senior geriatricians answered the Surprise Question for clinical judgment of prognosis. Receiver-operator characteristic (ROC) curves were constructed to determine diagnostic accuracy. For time-dependent analysis, Cox regression was performed with adjustment for age and gender. Results: Of 93 included patients in the study, 69 were still alive after six months and 24 died, resulting in a six-month mortality of 26%. The mean age was 86 years (range 75-100), 67% of the patients were women. Median will-to-live and self-rated health were 3 (moderate and good). Both will-to-live and self-rated health were not predictive for six-month mortality (area under the ROC curve [AUC] 0.496, p = 0.951 for will-to-live; 0.447, p = 0.442 for self-rated health) as opposed to Surprise Question (AUC 0.793, p < 0.001). After correction for sex and age, the hazard ratio of six-month mortality was 0.92 for will-to-live (p = 0.667), 0.86 for self-rated health (p = 0.548), and 10.28 for Surprise Question (p < 0.001). Conclusion: Will-to-live and self-rated health are not predictive for six-month mortality in patients admitted to the acute geriatric ward, unlike prognostic tools such as Surprise Question. Clinical Trial Registration Number: B670202100792.

Immune Senescence Markers Predict the Cellular Immune Response to BNT162b2 Vaccination in Hemodialysis Patients.

Background: Chronic kidney disease is associated with increased risk of frailty and accelerated immune senescence, potentially affecting the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. Methods: Humoral and cellular responses against the spike protein of SARS-CoV-2 were determined in 189 COVID-naive hemodialysis patients at week 4 and 8 after vaccination with 2 doses of BNT162b2. Frailty indicators and immune senescence markers were determined at baseline to identify predictors of the immune response. Results: Controlling for age, activities of daily living (ADLs), instrumental ADLs, walking pace, and the clinical frailty score correlated negatively and hand grip strength positively with the humoral response. Controlling for age, the proportions of memory CD4+ T cells, memory CD8+ T cells, CD28null T cells, and CD57+CD8+ T cells correlated negatively with the humoral response, whereas the proportions of memory CD4+ T cells and CD28null T cells correlated negatively and the CD4/CD8 ratio positively with the cellular response. In a multivariate model, only the proportions of memory CD4+ T cells and CD28null T cells independently predicted the cellular response. Conclusions: Markers of immune senescence, but not frailty indicators, independently predict the cellular immune response after vaccination in hemodialysis patients, overruling the effect of chronological age.