Differential utility of various frailty diagnostic tools in non-geriatric hospital departments of several countries: A longitudinal study.

BACKGROUND: There is limited knowledge on the performance of different frailty scales in clinical settings. We sought to evaluate in non-geriatric hospital departments the feasibility, agreement and predictive ability for adverse events after 1 year follow-up of several frailty assessment tools. METHODS: Longitudinal study with 667 older adults recruited from five hospitals in three different countries (Spain, Italy and United Kingdom). Participants were older than 75 years attending the emergency room, cardiology and surgery departments. Frailty scales used were Frailty Phenotype (FP), FRAIL scale, Tilburg and Groningen Frailty Indicators, and Clinical Frailty Scale (CFS). Analyses included the prevalence of frailty, degree of agreement between tools, feasibility and prognostic value for hospital readmission, worsening of disability and mortality, by tool and setting. RESULTS: Emergency Room and cardiology were the settings with the highest frailty prevalence, varying by tool between 40.4% and 67.2%; elective surgery was the one with the lowest prevalence (between 13.2% and 38.2%). The tools showed a fair to moderate agreement. FP showed the lowest feasibility, especially in urgent surgery (35.6%). FRAIL, CFS and FP predicted mortality and readmissions in several settings, but disability worsening only in cardiology. CONCLUSIONS: Frailty is a highly frequent condition in older people attending non-geriatric hospital departments. We recommend that based upon their current feasibility and predictive ability, the FRAIL scale, CFS and FP should be preferentially used in these settings. The low concordance among the tools and differences in prevalence reported and predictive ability suggest the existence of different subtypes of frailty.

Frequent participation in high volume exercise throughout life is associated with a more differentiated adaptive immune response.

Exercise induces changes in the immune system depending on its intensity and duration. For example, transient states of immunodepression can be induced after acute intense physical activity whereas beneficial anti-inflammatory effects of moderate chronic exercise on many diseases and longevity have been described. To study the impact of high volume exercise over a lifetime on aspects of immunity we compared immunological features of 27 young and 12 elderly athletes with 30 young and 26 elderly non-athletes stratified by their CMV serostatus. We characterized blood leukocyte and lymphocyte subpopulations by flow cytometry, quantified TREC content, and measured activation and proliferation ability of T-lymphocytes in the presence of anti-CD3. NK-cells functionality was determined in response to K-562, 721.221 and 721.221-AEH cell-lines. High volume physical activity reduced the total number of circulating leukocytes, neutrophils, and lymphocytes. In the lymphocyte compartment, athletes had higher frequencies of NK-cells and CD8+ T-lymphocytes, whereas CD4+ T-lymphocytes were present at significantly lower levels in CMV-seropositive athletes. We found, in the high volume physical activity individuals, a higher degree of differentiation in CD4+ T-lymphocytes. CD8+ T-lymphocytes from young athletes had reduced TREC content and lower frequencies of recent thymic emigrants. Furthermore, the functional ability of CD4+ and CD8+ T-lymphocytes was significantly impaired in young but not in elderly athletes, and may be compensated for significantly higher activation and degranulation of NK-cells. In conclusion, high volume exercise throughout life appears to be associated with increased levels of biomarkers that are associated with an aging immune system, which are partially reduced with physiological aging.

Effectiveness of a randomized intervention by a geriatric team in frail hospital inpatients in non-geriatric settings: FRAILCLINIC project.

BACKGROUND: Little research has been undertaken on the benefits of frailty management within different hospital settings. The objective of this study is to provide evidence on the viability and effectiveness of frailty management in non-geriatric hospital settings on mortality and functional decline after discharge. METHODS: Data from the FRAILCLINIC (NCT02643069) study were used. FRAILCLINIC is a randomized controlled trial developed in non-geriatric hospital inpatient settings (emergency room, cardiology and surgery) from Spain (2), Italy (2) and the United Kingdom (1). Inpatients must met frailty criteria (according to the Frailty Phenotype and/or FRAIL scale), ≥75 years old. The control group (CG) received usual care. The intervention group (IG) received comprehensive geriatric assessment (CGA) and a coordinated intervention consisting in recommendations to the treating physician about polypharmacy, delirium, falls, nutrition and physical exercise plus a discharge plan. The main outcomes included functional decline (worsening ≥5 points in Barthel Index) and mortality at 3 months. We used multivariate logistic regression models adjusted by age, gender and the Charlson index. Intention-to-treat (ITT) and per-protocol (PP) analyses were used. RESULTS: Eight hundred twenty one participants (IG: 416; mean age 83.00 ± 4.91; 51.44% women; CG: 405; mean age 82.46 ± 6.03; 52.35% women) were included. In the IG, 77.16% of the participants followed the geriatric team's recommendations as implemented by the treating physicians. The intervention showed a benefit on functional decline and mortality [OR: 0.67(0.47-0.96), P-value 0.027 and 0.29(0.14-0.57), P-value < 0.001, respectively) when fully followed by the treating physician. A trend to benefit (close to statistical significance) in functional decline and mortality were also observed when any of the recommendations were not followed [OR (95% CI): 0.72 (0.51-1.01), P-value: 0.055; and 0.64 (0.37-1.10), P-value: 0.105, respectively]. CONCLUSIONS: An individualized intervention in frail in-patients reduces the risk of functional deterioration and mortality at 3 months of follow-up when a care management plan is designed and followed.

[Metabolic syndrome and aging]. / Síndrome metabólico y envejecimiento.

In recent years, the current "obesity epidemic" and its correlate, metabolic syndrome, have been related not only to cardiovascular disease but also to the presence of multiple chronic diseases and even to the development of disability. Therefore, it has been hypothesized that this situation of risk and that of frailty, which has aroused such interest in geriatrics, could share common physiopathologic mechanisms. These mechanisms are reviewed in the present article.

[Strongyloides stercoralis infestation in an immunocompetent 82-year-old woman]. / Infestación por Strongyloides stercoralis en una paciente de 82 años inmunocompetente.

A laboratory finding of eosinophilia in patients with gastrointestinal symptoms should prompt the differential diagnosis of a parasitosis. The diagnosis is based on identification of larvae in three different stool samples. We report the case of an 82-year-old woman who was independent for instrumental and advanced activities of daily living and showed no risk factors for strongyloidiasis who was admitted to our service with diarrhoea and abdominal pain. Blood examination showed peripheral eosinophilia of 38%. Stool sample revealed Strongyloides stercoralis. In the patient's case history, we found similar clinical features with fluctuating eosinophilia over the previous 8 years. The patient was treated with albendazole, resulting in clinical improvement and elimination of eosinophilia.

[Risk factors associated with functional impairment at discharge and at three months after discharge in elderly individuals hospitalized for heart failure]. / Variables asociadas a deterioro funcional al alta y a los 3 meses en ancianos hospitalizados por insuficiencia cardíaca.

OBJECTIVE: To determine the characteristics of elderly persons hospitalized for congestive heart failure and identify the factors associated with functional impairment or death at discharge and 3 months later. MATERIAL AND METHODS: We performed a prospective observational study that included 162 patients admitted to an Acute Geriatric Care Unit with a diagnosis of heart failure from February to July 2007. Socio-demographic, clinical, functional and cognitive factors were recorded during admission. Functional and vital measurements were reported at discharge and 3 months later. RESULTS: The incidence of mortality or functional decline was 48.8% at discharge and was 37.3% 3 months later. In the final model, predictors of functional impairment or mortality at discharge were days of hospital stay and a worse Pfeiffer test score (odds ratio [OR]: 1.74; 95% confidence interval [CI]: 1.33-2.29). Three months after discharge, independent prognostic factors were age (OR: 1.09; 95% CI: 1.02-1.17), hyponatremia (OR: 0.85; 95% CI: 0.77-0.94), length of QRS in milliseconds (OR: 0.98; 95% CI: 0.97-0.99), absence of ventricular hypertrophy (OR: 0.42; 95% CI: 0.19-0.94), and a poor result in the Pfeiffer Test (OR: 1.40; 95% CI: 1.13-1.73). CONCLUSIONS: Cognitive evaluation during hospital admission for heart failure in the elderly helps to select individuals at risk of functional impairment or death at discharge and 3 months later.

[Impact of the elderly patient in the emergency department]. / Impacto del paciente anciano en los servicios de urgencias hospitalarios.

INTRODUCTION: The aging of the population, chronic diseases, and non-urgent visits to the Emergency departments (ED) are considered the reasons for the increase of the demand of care. The aim of this study is to analyse the impact of the older population in the ED, when compared to a younger population. MATERIAL AND METHODS: An observational, descriptive and retrospective study including an analysis of the 92,627 patients that attended the ED in Hospitals from Health Area IV belonging to the Principality of Asturias Health Services during 2009. The analysis included the number of visits, degree of urgency when arriving at the ED, length of stay (LOS), destination after ED assessment, demand of care per time of day, laboratory tests, and radiology, complaints, and social services consultation. A comparison was made between the data of patients over and below 70 years of age. RESULTS: At total of 28,965 (31.27%) patients were over 70 years of age, with a frequency rate in the ED of 52.29% (25.70% in those less than 70 years). Patients over 70 years had a higher priority attention through the Manchester triage scale, receiving more laboratory tests, with a higher LOS. They also had a higher probability of being seen by social services, of being admitted, and death. CONCLUSIONS: Older patients consult the ED with more justifiable reasons than the younger adult population.

Immunosenescence and inflammation characterize chronic heart failure patients with more advanced disease.

BACKGROUND: Chronic heart failure (CHF) is characterized by an inflammatory status with high levels of cytokines such as IL-6. We hypothesized that patients with CHF may develop immunosenescence due to inflammation and that this may be associated with a worse stage of the disease. METHODS AND RESULTS: We compared the immunological features of 58 elderly CHF patients (ECHF), 40 young CHF patients (YCHF), 60 healthy elderly controls (HEC) and 40 healthy young controls (HYC). We characterized leukocyte and lymphocyte subpopulations by flow cytometry, and IL-6 concentration by ELISA. The extent of CHF was classified according to functional and/or morphological criteria: New York Heart Association functional class, AHA/ACC heart failure stages, left ventricular ejection fraction, and left ventricular hypertrophy. CHF patients showed an increased number of leukocytes, neutrophils and monocytes, but a decreased number of lymphocytes. CHF patients had significantly lower levels of B-cells and CD4+ T-cells, increased NK-cells in YCHF, and increased CD8+ T-cells only in ECHF. CHF was associated with high differentiation in CD4+ and CD8+ T-lymphocyte subsets. Aging of T-lymphocyte subpopulations and high IL-6 levels were associated with a worse clinical status. IL-6 also correlated positively with the number of highly differentiated T-lymphocytes and with their accelerated aging. CONCLUSIONS: We conclude that CHF patients show a higher degree of immunosenescence than age-matched healthy controls. T-lymphocyte differentiation and IL-6 levels are increased in patients with an advanced clinical status and may contribute to disease impairment through a compromised adaptive immune response due to accelerated aging of their immune system.

[Delirium in nursing homes. Prevalence and risk factors]. / Delirium en centros residenciales para personas mayores. Estudio de la prevalencia y los factores asociados.

OBJECTIVES: To study the prevalence of delirium in the residential environment and to analyse the associated clinical, functional and mental factors. MATERIAL AND METHODS: A cross-sectional epidemic study was conducted on a population of elderly persons institutionalised in 2011 in 6 nursing homes in Asturias. Socio-demographic, clinical, functional (Barthel Index [BI]) and mental (Mini-Mental State Examination [MMSE]) variables were collected. Delirium was defined by the Confusion Assessment Method. RESULTS: A total of 505 elderly were included in the study (age 83.30 ± 7.33 years, with 67.70% women), and scores on the MMSE of 17.19 ± 10.35 and a BI score of 55.11 ± 35.82. The prevalence of delirium was 11.70%. On examining the risk of delirium among the studied variables, there was statistical significance when considering: BI, MMSE, dementia, pressure ulcers, or urinary catheter, and the prescribing of clomethiazole, ACTH-I or trazodone. In the analysis of the variables in the logistic regression with BI, diagnosis of dementia, the prescribing of clomethiazole or trazodone, in the equation, there was a statistical significance associated with delirium. CONCLUSIONS: The prevalence of delirium in a residential environment in our study population was 11.7%. The results show that BI, diagnosis of dementia, and prescribing of clomethiazole or trazodone were associated with risk of delirium in institutionalised patients.

Relationship between functional ability in older people, immune system status, and intensity of response to CMV.

Shorter survival in the elderly has been associated with deterioration of the immune system and also with functional disability. To analyze the relationship between functional and immune impairment in older individuals, we studied 100 elderly who lived in a nursing home, were age matched, and grouped according to their functional status. We characterized cell subpopulations by flow cytometry, quantified TREC by RT-PCR, and measured the T-cell proliferation and activation response (IFN-γ by ELISPOT, CD69) against anti-CD3 and CMV. Specific antibody titers against influenza virus and CMV were determined by ELISA. Individuals with worse functional status had significantly higher levels of NK cells and fewer B cells. These poorly functioning elders also had a significantly lower proportion of CD4+ T cells, increased CD8+ T cells, and a decreased CD4/CD8 ratio. TREC levels in CD4+ T cells were significantly lower in individuals with a high disability. Lower TREC levels correlated with a lower frequency of naïve T-cell subpopulations (CD45RA+CCR7+) and higher percentages of effector cells (CD45RA-CCR7-). The functionally impaired group had lower anti-CD3 responses, but gradually increased responses against CMV. Similarly, the higher CMV titers were found in elderly with worse functional status. On the contrary, the functional response in vivo, and the titer of antibodies generated after vaccination against influenza virus, was higher in individuals with better performance status. In summary, we concluded that the functional decline of elderly individuals was clearly associated with the aging of their immune system, and the intensity of the response to CMV.

Mortality and functional evolution at one year after hospital admission due to heart failure (HF) in elderly patients.

The aim of this observational study was to describe the characteristics (including functional measures) of the elderly patients hospitalized in the acute geriatric unit (AGU) and diagnosed with HF as well as to determine the variables associated with mortality at one year after discharge. A prospective study including patients aged 70 and over hospitalized for acute decompensated HF was performed. The baseline measures were demographics, comorbidity, clinical, functional and cognitive status. The outcome for this study was death within one year from the index hospital admission date. During the length of the study, 32.7% patients died (20.7% within the first three months). The clinical features associated with HF-related mortality in the univariate analysis were institutionalization, a higher dependence in performing basic activities or instrumental activities of daily living (IADL). Older age did not correlate with mortality, nor did left ventricular hypertrophy (LVH), the ejection fraction or the pharmacological treatment at discharge. After performing the logistic regression analysis, the only variable independently related to a higher mortality risk at one year was the preadmission dependence in performing basic activities of daily living (BADL). The results of this study highlight that preadmission functional and sociodemographic variables are the best predictors of mortality at one year, surpassing the classic prognostic factors. Performing an adequate assessment at the time of admission, which should include a functional evaluation, may help us to better classify patients and to offer them a customized therapeutic plan with better prognostic capabilities.