SP - Epidemiology

Background: Multimorbidity patterns is associated with future mortality among older adutls. However, the addictive effect of disability for distinct multimorbidity patters is unclear. Our aim was to identify the multimorbidity patterns of Taiwanese people aged over 50 years and to explore their association between multimorbidity patterns with/without disability and future mortality.

Methods: This longitudinal cohort study used data from the Taiwan Longitudinal Study on Aging. The data were obtained from wave 3, and the multimorbidity patterns in 1996, 1999, 2003, 2007, and 2011 were analyzed separately by latent class analysis (LCA). The association between each disease group with/without disability and mortality was examined using logistic regression.

Results: 5124 older adults with average age of 66.7 years old were included. Four disease patterns were identified in 1996, namely, the cardiometabolic (21.6%), arthritis-cataract (11.6%), relatively healthy (61.2%), and multimorbidity (5.6%) groups. After adjusting all the confounders, the cardiometabolic group with disability showed the highest risk for mortality (odds ratio: 2.83, 95% CI: 1.70-4.70), followed by Multimorbidity group with disability (odds ratio: 2.33, 95% CI: 1.17-4.64) and relatively health group with disability (odds ratio: 1.79, 95% CI: 1.22-2.62) and cardiometabolic group without disability (odds ratio: 1.21, 95% CI: 1.01-1.45).

Conclusion: This longitudinal study reveals disability plays an important role on mortality among older adults with distinct multimorbidity patterns. Older adults with a cardiometabolic multimorbidity pattern with disability had a dismal outcome. Thus, healthcare professionals should put more emphasis on the prevention and identification of cardiometabolic multimorbidity, with routine checkup of their functional limitation.

The coexistence of two or more morbidities, including at least one mental morbidity, is defined as mental-physical multimorbidity (MP-MM). It is linked to significant poor outcomes, such as a high burden of healthcare utilisation, particularly in the elderly. To evaluate the complex connections between the 16 physical and mental morbidities among Brazilian older people from the Brazilian Longitudinal Study of Ageing, we performed a network analysis (NA), a sophisticated multivariate statistical technique to estimate all relationships between morbidities represented by an undirected grafus. The objective was to estimate patterns in a complex set of multiple aleatory variables and display them in a network map within nodes and edges representing the variables and the interrelationships among them. In this study, we applied the NA to model interrelationships among chronic physical morbidities and depression. We utilised data from 6.104 participants of the second wave (2019-2020) of the Brazilian Longitudinal Study of Ageing (ELSI-Brazil). The data were adjusted according to the Ising model with the IsingFit function by R Software. Centrality and stability measures were assessed by the bootstrap method through the bootnet library. In this network, depression, low back pain, and hypertension were the morbidities that had the most effects on the network's overall structure, according to an examination of the centrality metrics of the nodes (strength, proximity, and betweenness). Depression was the morbidity with the higher betweenness. The model's interpretation indicates that depression is the illness that has the highest influence on the model and would likely be the most beneficial area for intervention.

Introduction Monitored dosage systems (MDS) encompass a wide range of devices to help management of medication. This research uses poison centre data to explore risks associated with their use.

Method A search of accidental overdose enquiries to the UK National Poisons Information Service (NPIS) between 1/01/2017-31/12/22, classified as “therapeutic error/medical error” involving patients aged 65 or over was performed. Enquiries involving an MDS were identified. Data were analysed using descriptive statistics and chi-square test.

Results There were 394 enquiries concerning 393 patients and mean patient age was 81 years. There were significantly more females(n=266) than males(n=127), p = <0.0001. Exposures occurred at home (n=372), in care homes(n=18), in prisons(n=2) and in hospital(n=1). Cognitive impairment was reported in 32.5% patients(n=127). The 10 most common medications involved were bisoprolol (n=74), lansoprazole(n=59), atorvastatin(n=58), aspirin(n=47), omeprazole(n=43), amlodipine (n=44), paracetamol(n=42), clopidogrel(n=42), ramipril(n=42) and metformin(n=35). Most patients were asymptomatic(n=312). Common symptoms recorded were somnolence(n=16), dizziness (n=13), confusion(n=11), fatigue(n=7) and hypotension(n=5). Common reasons for incidents were a mistake by patient or family member(n=189), medications taken unwitnessed(n=88), MDS incongruent with current prescription(n=22), patient took another person’s medications(n=19), patient took medication in MDS in addition to that in normal packaging (n=15) and extra doses administered by different people(n=15). Almost 51% of patients were recommended to attend Emergency Department (ED) by the NPIS(n=200) and 18% were advised to contact their GP(n=71).

Conclusion MDS are perceived to improve adherence, these results reveal their potential harm. For example, the majority of patients in these enquiries were advised to seek medical help. MDS harm is likely underreported as this was a retrospective study and some information was not routinely collected. Further work including a prospective study is needed alongside support of safer medicine use through improved communication, education, and alternative tailored support.

Introduction

Motor Neurone Disease (MND) is a neurodegenerative condition affecting the spinal cord and brainstem, commonly associated with a reduced life expectancy. This study describes demographic trends in MND-associated mortality in the United States over 20 years.

Methods

Data were extracted from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research Underlying Cause of Death database. Death certificates from 1999-2020 with MND (International Classification of Diseases-10th Revision code G12.2) recorded as the cause of mortality were extracted and annual MND-associated crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) per 100,000 persons with 95% confidence intervals (CI) were calculated. Joinpont regression was used to calculate the annual trends in MND-associated mortality by calculating the annual percentage change.

Results

Between 1999 to 2020, there were a total of 140,945 MND-associated deaths. Overall AAMR was 1.9 per 100,000 persons (95% CI 1.9-1.9). Male sex had a consistently higher AAMR (2.3 per 100,000 95% CI 2.3-2.3) than female sex (1.6 per 100,000 95% CI 1.5-1.6). White patients had higher AAMR (2.1 per 100,000 95% CI 2.0-2.1) than Black/African Americans (1.1 per 100,000 95% CI 1.0-1.1), American Indians/Alaska Natives (0.8 per 100,000 95% CI 0.7-0.9), Asians/Pacific Islanders (0.8 per 100,000 95% CI 0.7-0.9). The 3 US States with the highest AAMR were Vermont, followed by Minnesota and Maine.

Conclusions

This national study demonstrates that there were a significant number of MND-associated deaths in the United States, with higher rates associated with certain patient demographics. The knowledge of these trends facilitates the design of appropriate services in areas of higher need, allowing for the introduction of pathways that support more suitable care and enhanced quality of life.

Introduction

In the European Union, life expectancy has increased from 74 to 81 years between 1990 and 2018. Time spans living in ill health are also increasing. Vaccine recommendations focus primarily on vaccines that prevent death thereby extending length of life. The focus should also include vaccines that promote healthy ageing (HA), improving the quality of longer lifespans. The aims of this review are to describe the impact of herpes zoster (HZ) in adults ≥50 Years of Age (YOA), and to summarise the available evidence on how the recombinant zoster vaccine (RZV) contributes to HA.

Methods

We conducted a narrative review of published literature on the impact of developing HZ on HA and the ability of vaccination to prevent the subsequent burden of disease. Specifically, we describe HZ impact on functioning ability and quality of life, and impact of RZV on reducing the burden of HZ in adults ≥50 YOA.

Results

One in three people develop HZ in their lifetime. Approximately, 15 million cases of HZ occur annually worldwide in adults ≥50 YOA. Post-herpetic neuralgia (PHN, pain persisting for ≥ 90 days) occurs in up to 30% of patients, with HZ ophthalmicus affecting up to 25% of patients. HZ presents as a unilateral, vesicular rash with pain scored as “worst pain imaginable” in ≥15% of patients. Treatment options for HZ and its complications are limited and suboptimal with only 14% of patients with PHN satisfied with their treatment. Pain significantly impacts sleep, mood, physical, social and mental functioning. RZV elicits a strong and long-lasting immune response, targeting the decline in cellular immunity. RZV reduced the burden of HZ pain and interference on activities on daily living by >90% in adults aged ≥50 YOA.

Conclusion

RZV, by preventing HZ episodes, supports maintenance of functional ability contributing to wellbeing in older age.

Background: Non-communicable disease, multimorbidity and frailty are posing considerable challenges as global populations age. Healthcare systems in Low- and Middle-Income Countries are having to rapidly adapt services to meet the needs of older people.

Objective: This study, the first of its kind in sub-Saharan Africa, aimed to establish whether screening older people for frailty on admission to hospital could be used to identify those at greatest risk of adverse outcomes.

Methods: At baseline assessment, 308 participants aged ≥60 years, admitted to medical wards at four hospitals in the Kilimanjaro Region of Tanzania, were screened for frailty using the Clinical Frailty Scale (CFS). After 10-12 months, participants, and their informants, were contacted by telephone to establish clinical outcomes. The primary outcome was all-cause mortality. Cox regression was used to estimate hazard ratios (+ / - 95% confidence interval) for mortality, with dichotomised CFS frailty status (frail if ≥5) as the independent variable.

Results: Primary outcome data were obtained for 194 (63.0%) of the original participants after a mean follow-up period of 10.8 (+/- 0.9) months. Mean age was 75.1 years and 99 (51%) of the respondents were female. A total of 100 (51.5%) respondents were deceased and hazard ratios for all-cause mortality demonstrate that those with frailty were at significantly greater risk of mortality (HR 2.27 [CI 1.39 – 3.69], p<0.01), an effect that persisted even after adjustment for age, baseline Barthel Index, education and number of chronic conditions.

Conclusion: For older people living in Tanzania, unplanned admission to hospital is associated with high mortality and frailty is a strong independent predicator. In accurately identifying which older people are at the greatest risk, frailty screening using the CFS could provide a starting point for the development of targeted care pathways and interventions. 

Introduction:

The use of pneumonia scores to stratify the prognosis is very useful in general terms, since it allows objectively evaluating the risks in these patients. The main objective was to determine the usefulness of pulse oximetry as a substitute for urea of the CURB 65 score in the evaluation of the severity of comunity acquired pneumonia (CAP) in patients.

Methods:

open-label, mixed-type study, first cross-sectional phase Test vs. Test, second phase follow-up at 8 and 30 days. Carried out between November 2017 and April 2018.

Results:

5 patients, gender distribution was comparable, the main age group was made up of over 65 years. The frequency of comorbidities was greater than 90%, among which hypertension, diabetes and smoking stand out. The mean hospitalization time was 10 days. The variable that most defined the need for hospital admission was hypoxemia with a percentage of 72%, regardless of the score on the CURB 65 scale, it was shown that oxygen saturation <92% is associated with a high 30-day mortality rate ( 43.07%) n=28, (p 0), with a relative risk of at least 4 times more to die. When correlating the CURB 65 and CORB 65 scales with Spearman's Rho test, a correlation coefficient (0.898) was obtained.

Conclusions:

pulse oximetry proved to be a good substitute for urea in the CURB 65 score, useful for defining hospitalization, severity, and mortality in patients with CAP.

Delirium in hip fracture patients admitted from home is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation and readmission to acute services: The IMPACT Delirium study

RS Penfold1,2, AJ Hall2,3,4, A Anand5, ND Clement2,4, AD Duckworth4,6, AMJ MacLullich1,2

1. Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK 

2. Scottish Hip Fracture Audit, Edinburgh, UK 

3. Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK 

4. Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK 

5. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK 

6. Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK 

Aim 

Delirium is associated with adverse outcomes following hip fracture, but specific associations in patients admitted directly from home are less well studied. Here we analysed relationships between delirium in patients admitted from home with: (i) mortality; (ii) total length of hospital stay; (iii) need for post-acute inpatient rehabilitation, and (iv) hospital readmission within 180 days. 

Methods 

This study utilised routine clinical data in a consecutive sample of hip fracture patients aged ≥50 years admitted to a single large trauma centre between 01/03/20-30/11/21. Delirium was prospectively assessed as part of routine care by the 4’A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, level of social deprivation, and American Society of Anesthesiologists grade.  

Results 

A total of 1821 patients (mean age 80.7 years; 71.7% female) were admitted, with 1383 (mean age 79.5; 72.1% female) directly from home. 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1734): 14.1% (189/1340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20 day longer total length of stay (p<0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (Odds Ratio (OR) 1.69, 95% Confidence Interval (CI) 1.13-2.54; p=0.013), requirement for post-acute inpatient rehabilitation (OR 2.82, CI 1.99-4.00; p<0.001), and readmission to hospital within 180 days (OR 1.77, CI 1.01-3.11; p=0.046). 

Conclusions 

Delirium affects 1 in 7 patients with a hip fracture admitted directly from home and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. 

Introduction

The Scottish Care of Older People (SCoOP) collaborative regularly reports outcomes of acute geriatric medicine admissions across Scottish hospitals. The covid pandemic caused major and highly variable restructuring of acute services across the country. Their impact on activity and outcomes is unknown.

Methods

We collated all SMR01/SMR01E hospital episodes from Public Health Scotland from 1^st April 2017 to 31^st March 2022 where over 50% of the total episode was spent under acute geriatric medicine (code AB) and the diagnosis was not stroke. Activity and outcomes in 19 major hospitals were compared across financial years 2017-19 (before-), 2020/21 (during-) and 2021/22 (after lockdowns). 

Results

Admissions fell 15% to 36954 in 2020/21 from an average 42566 before recovering to 41971 in 2021/22. Age, sex and social deprivation profiles differed between hospitals (p<0.001) but remained similar within each hospital at all timepoints. Few hospitals were busier than ever in 2020/21 but some saw large reductions in activity. Mortality at 30 days post-admission was 10% higher in 2020/21 (17.9% v 16.5% in other years, p<0.001), with 2-fold differences across hospitals. Mean median length of stay (LOS) across hospitals was 11.7 days, compared to 12.8 days in 2017-20, p<0.001. There were up to 17-fold differences in median LOS between hospitals (2-34 days) in 2020/21, p<0.001. The impact of the pandemic on LOS within each hospital was also highly variable. Readmission rates at 7 days post-discharge were broadly similar across all years but two-fold differences between hospitals were also seen (4.8%-9.8%, mean 6.8%, p<0.001).

Conclusion

The year 2020/21 saw a 15% fall in acute geriatric medicine admissions overall, with 10% increase in mortality and shorter lengths of stay. However, the impact on the activity and outcomes of individual hospitals were widely disparate, probably reflecting variation in how each hospital service responded to the pandemic.   

Background:

As global populations age, healthcare systems are facing challenges posed by multimorbidity, disability and geriatric syndromes. In high-income countries, frailty is a strong predictor of poor hospital outcomes. Comprehensive Geriatric Assessment is effective but resource-intensive and unavailable in sub-Saharan Africa where specialist geriatric training and allied health infrastructure are limited.

Objective:

To establish clinical outcomes of older adults with frailty admitted to hospital in northern Tanzania.=

Methods:

All adults aged ≥60 years admitted to medical wards at four hospitals were invited to participate. Participants were screened for frailty using the Clinical Frailty Scale (CFS). The primary outcome was inpatient death, with secondary outcomes including length of stay, 30-day readmission and delirium (confirmed using the Confusion Assessment Method [CAM]). Outcomes for frail (≥5 on CFS) and non-frail participants (1-4 on CFS) were compared.

Results:

Over 6 months, 308/540 patients admitted participated. Reasons for non-participation included death (n=34) and discharge (n=159) before researcher attendance. Mean age of participants was 74.9 years and 154 (50.1%) were female. Of these, 205 (67%) participants had a CFS ≥5. 21 (14.9%) frail participants died, compared with 5 (6.4%) in the non-frail group (Chi-squared, p=.095). Length of stay and re-admission rates were higher in frail participants, but differences were not statistically significant. Delirium was diagnosed in 35 (17%) frail participants, compared with 4 (4%) in the non-frail group (Fisher’s Exact test, p=<.001).

Conclusion:

Frailty in older adults admitted to hospitals in northern Tanzania is common and associated with significantly higher rates of delirium. Mortality, readmissions, and length of stay were higher in the frail group, but differences did not reach statistical significance. Type II Error (exacerbated by selection bias from non-inclusion of individuals who were discharged, or died, early in their admission) may explain this. Participants will now be followed-up for 12-months to assess outcomes longitudinally.