BackgroundThis study is part of the Trondheim Hip Fracture Trial, where we compared free-living physical behavior in daily life 4 and 12 months following hip surgery for patients managed with comprehensive geriatric care (CGC) in a geriatric ward with those managed with orthopedic care (OC) in an orthopedic ward.MethodsThis is a single centre, prospective, randomized controlled trial. 397 hip fracture patients were randomized to CGC (n = 199) or OC (n = 198) in the Emergency Department with follow-up assessments performed four and 12 months post-surgery. Outcomes were mean upright time, number and length of upright events recorded continuously for four days at four and 12 months post-surgery by an accelerometer-based activity monitor. Missing data were handled by multiple imputation and group differences assessed by linear regression with adjustments for gender, age and fracture type.ResultsThere were no group differences in participants’ pre-fracture characteristics. Estimated group difference in favor of CGC in upright time at 4 months was 34.6 min (17.4 %, CI 9.6 to 59.6, p = .007) and at 12 months, 27.7 min (13.9 %, CI 3.5 to 51.8, p = .025). Average and maximum length of upright events was longer in the CGC (p’s < .042). No group difference was found for number of upright events (p’s > .452).ConclusionParticipants treated with CGC during the hospital stay improved free-living physical behavior more than those treated with OC both 4 and 12 months after surgery, with more time and longer periods spent in upright. Results support findings from the same study for functional outcomes, and demonstrate that CGC impacts daily life as long as one year after surgery.Trials registrationClinicalTrials.gov, NCT00667914, April 18, 2008

BackgroundPain, neuropsychiatric symptoms (NPS) and functional impairment are prevalent in patients with dementia and pain is hypothesized to be causal in both neuropsychiatric symptoms (NPS) and functional impairment. As the exact nature of the associations is unknown, this review examines the strength of associations between pain and NPS, and pain and physical function in patients with dementia. Special attention is paid to the description of measurement instruments and the methods used to detect pain, NPS and physical function.MethodsA systematic search was made in the databases of PubMed (Medline), Embase, Cochrane, Cinahl, PsychINFO, and Web of Science. Studies were included that described associations between pain and NPS and/or physical function in patients with moderate to severe dementia.ResultsThe search yielded 22 articles describing 18 studies, including two longitudinal studies. Most evidence was found for the association between pain and depression, followed by the association between pain and agitation/aggression. The longitudinal studies reported no direct effects between pain and NPS but some indirect effects, e.g. pain through depression. Although some association was established between pain and NPS, and pain and physical function, the strength of associations was relatively weak. Interestingly, only three studies used an observer rating scale for pain-related behaviour.ConclusionsAvailable evidence does not support strong associations between pain, NPS and physical function. This might be due to inadequate use or lack of rating scales to detect pain-related behaviour. These results show that the relationship between pain and NPS, as well as with physical function, is complicated and warrants additional longitudinal evaluation.

BackgroundA better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care.Methods1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis.ResultsVariables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data.Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0–1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0.In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70 – 2.48]).ConclusionsQuantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs.The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.

BackgroundSpirometry-based parameters of pulmonary function such as forced expiratory volume in 1 second (FEV1) have prognostic value beyond respiratory morbidity and mortality. FEV1 divided by height cubed (FEV1/Ht3) has been found to be better at predicting all-cause mortality than the usual standardization as percentage of predicted "normal values" (FEV1%) and its use is independent of reference equations. Yet, limited data are available on the very old adults (80 years and older) and in association to other adverse health outcomes relevant for this age group. This study aims to investigate the short-term prognostic value of FEV1/Ht3 for all-cause mortality, hospitalization, physical and mental decline in a cohort of very old adults.MethodsIn a population-based prospective cohort study of 501 very old adults in Belgium, comprehensive geriatric assessment and spirometry were performed at baseline and after 1.7 ± 0.21 years. Kaplan-Meier curves for 3-year all-cause mortality and hospitalization rates and multivariable analysis adjusted for age, sex, smoking status, co-morbidities, anemia, high C reactive protein and creatinine levels examined the association of FEV1/Ht3 with all-cause mortality, unplanned hospitalization and decline in mental and physical functioning. Physical functioning was assessed by activities of daily living, a battery of physical performance tests and grip strength. Mental functioning was assessed with mini mental state examination and 15 items geriatric depression scale.ResultsIndividuals in the lowest quartile of FEV1/Ht3 had a statistically significant increased adjusted risk for all-cause mortality (hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.10-2.60) and unplanned hospitalization (HR 1.65, 95% CI 1.21-2.25), as well as decline in physical (odds ratio [OR] 1.89, 95% CI 1.05-3.39) and mental functioning (OR 2.39, 95% CI 1.30-4.40) compared to the rest of the study population.ConclusionsIn a cohort of very old adults, low FEV1 expressed as FEV1/Ht3 was found to be a short-term predictor of all-cause mortality, hospitalization and decline in physical and mental functioning independently of age, smoking status, chronic lung disease and other co-morbidities. Further research is needed on FEV1/Ht3 as a potential risk marker for frailty and adverse health outcomes in this age group.

BackgroundThe low physical activity domain of the frailty phenotype has been assessed with various self-reported questionnaires, which are prone to possible recall bias and a lack of diagnostic accuracy. The primary purpose of this study was to define the low physical activity domain of the frailty phenotype using accelerometer-based measurement and to evaluate the internal construct validity among older community-dwellers. Secondly, we examined potential correlates of frailty in this population.MethodsWe conducted a cross-sectional study of 1,527 community-dwelling older men and women aged 65 and over. Data were drawn from the baseline survey of the Sasaguri Genkimon Study, a cohort study carried out in a west Japanese suburban community. Frailty phenotypes were defined by the following five components: unintentional weight loss, low grip strength, exhaustion, slow gait speed, and low physical activity. Of these criteria, physical activity was objectively measured with a tri-axial accelerometer. To confirm our measure’s internal validity, we performed a latent class analysis (LCA) to assess whether the five components could aggregate statistically into a syndrome. We examined the correlates of frailty using multiple stepwise logistic regression models.ResultsThe estimated prevalence of frailty was 9.3% (95% confidence intervals, CI, 8.4-11.2); 43.9% were pre-frail (95% CI, 41.5-46.4). The percentage of low physical activity was 19.5%. Objectively-assessed physical activity and other components aggregated statistically into a syndrome. Overall, increased age, poorer self-perceived health, depressive and anxiety symptoms, not consuming alcohol, no engagement in social activities, and cognitive impairment were associated with increased odds of frailty status, independent of co-morbidities.ConclusionsThis study confirmed the internal construct validity of the frailty phenotype that defined the low energy expenditure domain with the objective measurement of physical activity. Accelerometry may potentially standardize the measurement of low physical activity and improve the diagnostic accuracy of the frailty phenotype criteria in primary care setting. The potential role of factors associated with frailty merits further studies to explore their clinical application.

BackgroundUse of antipsychotic (AP) medications is high and often inappropriate among institutionalized populations. Little is known about the correlates of new AP drug use following admission to long-term care (LTC) settings. This study investigated the frequency and correlates of new AP drug use among newly admitted LTC residents.MethodsThis longitudinal, retrospective study used data from the interRAI - Nursing Home Minimum Data Set version 2.0 (MDS 2.0) instrument. Data about demographic, clinical and social characteristics, and medication use, were collected in Ontario, Canada, from 2003–2011 by trained nurses. Residents with complete admission and 3–6 month follow-up data were included (N = 47,768). Multivariate logistic regression analyses, stratified by gender, explored correlates of new AP drug use upon admission to LTC.ResultsNew AP drug users comprised 7 % of the final cohort. Severe cognitive impairment, dementia, and motor agitation were significantly associated with new AP drug use among both sexes. Additionally, behavioural problems, conflicts with staff and reduced social engagement were strong correlates of new AP drug use.ConclusionsSocial factors were as strongly associated with new AP drug use after LTC admission as clinical factors. Strategies to prevent the potential misuse of AP drugs upon LTC admission should consider the social determinants of such prescribing.