Ethnic Differences in Disability Prevalence and Their Determinants Studied over a 20-Year Period: A Cohort Study

Background

To compare disability prevalence rates in the major ethnic groups in the UK and understand the risk factors contributing to differences identified. It was hypothesised that Indian Asian and African Caribbean people would experience higher rates of disability compared with Europeans.

Methods

Data was collected from 888 European, 636 Indian Asian and 265 African Caribbean men and women, aged 58–88 years at 20-year follow-up of community-based cohort study, based in West London. Disability was measured using a performance-based locomotor function test and self-reported questionnaires on functional limitation, and instrumental (IADL) and basic activities of daily living (ADL).

Results

The mean (SD) age of participants at follow-up was 69.6 (6.2) years. Compared with Europeans, Indian Asian people were significantly more likely to experience all of the disability outcomes than Europeans; this persisted after adjustment for socioeconomic, behavioural, adiposity and chronic disease risk factors measured at baseline (locomotor dysfunction: adjusted odds ratio (OR) 2.20, 95% CI 1.56–3.11; functional limitation: OR 2.77, 2.01–3.81; IADL impairment: OR 3.12, 2.20–4.41; ADL impairment: OR 1.58, 1.11–2.24). In contrast, a modest excess risk of disability was observed in African Caribbeans, which was abolished after adjustment (e.g. locomotor dysfunction: OR 1.37, 0.90–1.91); indeed a reduced risk of ADL impairment appeared after multivariable adjustment (OR from 0.99, 0.68–1.45 to 0.59, 0.38–0.93), compared with Europeans.

Conclusions

Substantially elevated risk of disability was observed among Indian Asian participants, unexplained by known factors. A greater understanding of determinants of disability and normative functional beliefs of healthy aging is required in this population to inform intervention efforts to prevent disability.     

The Disability Rate of 5-Year Post-Stroke and Its Correlation Factors: A National Survey in China

Few studies on long-term functional outcome have been conducted in post-stroke patients in China. The objective of this study was to conduct a nationwide survey in China to investigate the 5-year prevalence of post-stroke disability and its correlation factors. A total of 893 patients with ischemic stroke were included. Demographic, clinical and neuro-imaging information were collected with standardized instruments that assessed stroke severity, depression, cognitive impairment, stroke recurrence and physical disability. Disability was assessed with the modified Ranking Score (mRS), of which a cutoff score ≥2 indicates disability. Statistical analysis included chi-square tests, two independent samples t-tests, Mann-Whitney U test and multiple logistic regression analysis. The frequency of disability in this study population was 45%. Multivariate analyses revealed that older age, lower education level, previous history of stroke, stroke severity at admission, depression, cognitive impairment at 3 months, and stroke recurrence within 5 years follow up were all significantly associated with post-stroke disability. The disability rate in 5-year post-stroke was high in Chinese patients. Treatment of depression, secondary prevention of stroke and rehabilitation may benefit disabled patients with stroke in China.     

Gender Differences in Health Expectancies across the Disablement Process among Older Thais

Objectives

To estimate health expectancies based on measures that more fully cover the stages in the disablement process for the older Thais and examine gender differences in these health expectancies.

Methods

Health expectancies by genders using Sullivan’s method were computed from the fourth Thai National Health Examination Survey conducted in 2009. A total of 9,210 participants aged 60 years and older were included in the analysis. Health measures included chronic diseases; cognitive impairment; depression; disability in instrumental activities of daily living (IADL); and disability in activities of daily living (ADL).

Results

The average number of years lived with and without morbidity and disability as measured by multiple dimensions of health varied and gender differences were not consistent across measures. At age 60, males could expect to live the most years on average free of depression (18.6 years) and ADL disability (18.6 years) and the least years free of chronic diseases (9.1 years). Females, on the contrary, could expect to live the most years free of ADL disability (21.7 years) and the least years free of IADL disability (8.1 years), and they consistently spent more years with all forms of morbidity and disability. Finally, and for both genders, years lived with cognitive impairment, depression and ADL disability were almost constant with increasing age.

Conclusion

This study adds knowledge of gender differences in healthy life expectancy in the older Thai population using a wider spectrum of health which provides useful information to diverse policy audiences.     

Development of Two Barthel Index-Based Supplementary Scales for Patients with Stroke

Background

The Barthel Index (BI) assesses actual performance of activities of daily living (ADL). However, comprehensive assessment of ADL functions should include two other constructs: self-perceived difficulty and ability.

Objective

The aims of this study were to develop two BI-based Supplementary Scales (BI-SS), namely, the Self-perceived Difficulty Scale and the Ability Scale, and to examine the construct validity of the BI-SS in patients with stroke.

Method

The BI-SS was first developed by consultation with experts and then tested on patients to confirm the clarity and feasibility of administration. A total of 306 participants participated in the construct validity study. Construct validity was investigated using Mokken scale analysis and analyzing associations between scales. The agreement between each pair of the scales’ scores was further examined.

Results

The Self-perceived Difficulty Scale consisted of 10 items, and the Ability Scale included 8 items (excluding both bladder and bowel control items). Items in each individual scale were unidimensional (H≥0.5). The scores of the Self-perceived Difficulty and Ability Scales were highly correlated with those of the BI (rho = 0.78 and 0.90, respectively). The scores of the two BI-SS scales and BI were significantly different from each other (p<.001). These results indicate that both BI-SS scales assessed unique constructs.

Conclusions

The BI-SS had overall good construct validity in patients with stroke. The BI-SS can be used as supplementary scales for the BI to comprehensively assess patients’ ADL functions in order to identify patients’ difficulties in performing ADL tasks, plan intervention strategies, and assess outcomes.     

Ouderen met een verstandelijke beperking verliezen veel zelfredzaamheid gedurende drie jaar: resultaten van de Gezond Ouder studie (GOUD)

The responsibilities for the care of a significant portion of the population with an intellectual disability (ID) were recently transferred from the government to the municipalities. It is therefore important that policymakers and care professionals know how much support this population needs in their daily life. Therefore, this study focuses on the decline in daily functioning of older adults with ID (≥50 years, n = 703) over 3 years, and if daily functioning is a predictor for all-cause mortality. Daily functioning was operationalized as basic and instrumental activities of daily living (ADL and IADL) and mobility. Fifty-five percent of the total group declined in ADL, 42?% in IADL, and 38?% in mobility. Thirty-nine percent of the participants with mild ID declined in ADL, 55?% in IADL, and 27?% in mobility. Poor daily functioning and mobility was a risk factor for all-cause mortality. This epidemiological study shows a clear decline in the daily functioning of older adults with intellectual disabilities over a 3-year follow-up period. Care providers should be aware of this decline and focus on maintaining as much independence as possible.     

Quantification of Errors in Ordinal Outcome Scales Using Shannon Entropy: Effect on Sample Size Calculations

Objective

Clinical trial outcomes often involve an ordinal scale of subjective functional assessments but the optimal way to quantify results is not clear. In stroke, the most commonly used scale, the modified Rankin Score (mRS), a range of scores (“Shift”) is proposed as superior to dichotomization because of greater information transfer. The influence of known uncertainties in mRS assessment has not been quantified. We hypothesized that errors caused by uncertainties could be quantified by applying information theory. Using Shannon’s model, we quantified errors of the “Shift” compared to dichotomized outcomes using published distributions of mRS uncertainties and applied this model to clinical trials.

Methods

We identified 35 randomized stroke trials that met inclusion criteria. Each trial’s mRS distribution was multiplied with the noise distribution from published mRS inter-rater variability to generate an error percentage for “shift” and dichotomized cut-points. For the SAINT I neuroprotectant trial, considered positive by “shift” mRS while the larger follow-up SAINT II trial was negative, we recalculated sample size required if classification uncertainty was taken into account.

Results

Considering the full mRS range, error rate was 26.1%±5.31 (Mean±SD). Error rates were lower for all dichotomizations tested using cut-points (e.g. mRS 1; 6.8%±2.89; overall p<0.001). Taking errors into account, SAINT I would have required 24% more subjects than were randomized.

Conclusion

We show when uncertainty in assessments is considered, the lowest error rates are with dichotomization. While using the full range of mRS is conceptually appealing, a gain of information is counter-balanced by a decrease in reliability. The resultant errors need to be considered since sample size may otherwise be underestimated. In principle, we have outlined an approach to error estimation for any condition in which there are uncertainties in outcome assessment. We provide the user with programs to calculate and incorporate errors into sample size estimation.     

Relationship of Self-Rated Health to Stroke Incidence and Mortality in Older Individuals with and without a History of Stroke: A Longitudinal Study of the MRC Cognitive Function and Ageing (CFAS) Population

Introduction

Poor self-rated health (SRH) has been associated with increased risk of death and poor health outcomes even after adjusting for confounders. However its’ relationship with disease-specific mortality and morbidity has been less studied. SRH may also be particularly predictive of health outcomes in those with pre-existing conditions. We studied whether SRH predicts new stroke in older people who have never had a stroke, or a recurrence in those with a prior history of stroke.

Methods

MRC CFAS I is a multicentre cohort study of a population representative sample of people in their 65th year and older. A comprehensive interview at baseline included questions about presence of stroke, self-rated health and functional disability. Follow-up at 2 years included self-report of stroke and stroke death obtained from death certificates. Multiple logistical regression determined odds of stroke at 2 years adjusting for confounders including disability and health behaviours. Survival analysis was performed until June 2014 with follow-up for up to 13 years.

Results

11,957 participants were included, of whom 11,181 (93.8%) had no history of stroke and 776 (6.2%) one or more previous strokes. Fewer with no history of stroke reported poor SRH than those with stroke (5 versus 21%). In those with no history of stroke, poor self-rated health predicted stroke incidence (OR 1.5 (1.1–1.9)), but not stroke mortality (OR 1.2 (0.8–1.9)) at 2 years nor for up to 13 years (OR 1.2(0.9–1.7)). In those with a history of stroke, self-rated health did not predict stroke incidence (OR 0.9(0.6–1.4)), stroke mortality (OR 1.1(0.5–2.5)), or survival (OR 1.1(0.6–2.1)).

Conclusions

Poor self-rated health predicts risk of stroke at 2 years but not stroke mortality among the older population without a previous history of stroke. SRH may be helpful in predicting who may be at risk of developing a stroke in the near future.     

Mild Cognitive Impairment Predicts Institutionalization among Older Men: A Population-Based Cohort Study

Background

There is a lack of evidence on the contribution of mild cognitive impairment (MCI) to institutionalization in older adults. This study aimed to evaluate a range of risk factors including MCI of institutionalization in older men.

Methods

Men aged ≥70 years (n = 1705), participating in the Concord Health and Ageing in Men Project, Sydney, Australia were studied. Participants completed self-reported questionnaires and underwent comprehensive clinical assessments during 2005–2007. Institutionalization was defined as entry into a nursing home facility or hostel at any time over an average of 5 years of follow-up. Cox regression analysis was conducted to generate hazard ratios (HR) with 95% confidence intervals (CI).

Results

A total of 125 (7.3%) participants were institutionalized. Piecewise Cox proportional models were generated and divided at 3.4 years (1250 days) of follow-up due to violation of the proportional hazards assumption for the association between MCI and institutionalization (χ² = 6.44, p = 0.01). Dementia, disability in Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), poor grip strength, few social interactions, being a Non-English speaking immigrant and age were predictive of institutionalization during both time periods, whereas MCI (HR = 4.39, 95%CI 2.17–8.87) only predicted institutionalization in the period beyond 3.4 years of follow-up. Being married (HR = 0.42, 95%CI: 0.24–0.72) was protective only during the period after 3.4 years of follow-up.

Discussion

In this study, the strongest predictors of institutionalization were dementia, MCI, ADL and IADL disability. MCI was not a predictor of early institutionalization but became a significant predictor beyond 3.4 years of follow-up.     

Sex-specific differences in the prevalence of sarcopenia among pre-frail community-dwelling older adults in Saudi Arabia

ObjectivesTo assess sex differences in the prevalence of sarcopenia among pre-frail community-dwelling older adults in Saudi Arabia.MethodsThis was a cross-sectional study conducted at a tertiary-level hospital in Riyadh, Saudi Arabia, in 2019. The study participants were pre-frail community-dwelling older adults, according to the Edmonton Frail Scale. The SARC-F questionnaire was used to diagnose sarcopenia. The Katz Activities of Daily Living (ADL) was used to rank the adequacy of performance in six functions: bathing, dressing, toileting, transferring, continence, and feeding, while the Lawton Instrumental Activities of Daily Living scale was used to assess the more complex ADL necessary for living in the community.ResultsIn total, 283 community-dwelling older adults were recruited for this study, with a mean (±SD) age of 70.77 (±6.26) years; 72.7% of the total were female participants. The majority (85.5%) of the patients reported that they needed home care assistance. The mean ADL score of the participants was high, indicating high function and independence (KATZ-ADL: M 4.60 SD 1.75; Lawton Brody: 60%). The overall prevalence of sarcopenia among the studied participants was 65.7%, which was significantly higher among females (71.9%) than among males (59.1%), with a P-value of 0.007. Among the demographic characteristics of the participants, there was a significant difference in the need for home care assistance in female sarcopenic and non-sarcopenic participants (74.1% vs. 25.9%, p = 0.017), but without demonstrable difference in males. Additionally, there was a significant difference (P < 0.05) in the prevalence of sarcopenia between male and female participants according to ADL scores. The strongest predictor for sarcopenia prevalence in males was an ADL score <2 according to the Katz index, with an odds ratio of 6.5, while the need for home care was the only significant predictor of sarcopenia among female participants (OR 3.25, CI: 1.14–9.25, p = 0.02).ConclusionOverall, almost two-thirds of the studied pre-frail community-dwelling older adult population were sarcopenic. The prevalence of sarcopenia was significantly higher among females than males. The strongest predictor of sarcopenia was an ADL score <2 based on the Katz index in males and the need for home care assistance in females.     

Prevalence and Predictors of Mild Cognitive Impairment in Xi’an: A Community-Based Study among the Elders

Mild cognitive impairment (MCI) is an intermediate stage between normal cognitive function and dementia among aging individuals. This study was designed to estimate the prevalence of MCI and explore the possible risk factors including gender disparities among community-dwelling older individuals. The study was conducted in Xi’an, China. This is a cross-sectional study. A total of 815 individuals, 60 years and older were selected by stratified random cluster sampling. Cognitive function was measured using the mini-mental status examination (MMSE), the Chinese version of the Dementia Rating Scales (CDRS) was used to apply the diagnostic of non-dementia, and activities of daily living (ADL) and instrumental activities of daily living (IADL) systems were used to functional status. The association between sociodemographic characteristics, lifestyle, history of chronic diseases and MCI were evaluated separately for men and women using the Pearson χ²- test and binary logistic regression. Of the 815 community-dwelling individuals, 145 were found to have MCI. Overall, the prevalence of MCI was 18.5%, with a prevalence of 19.6% in women (105/535), and 15.3% (40/261) in men. The results of the binary logistical regression analysis indicated that age and history of stroke were associated with MCI in men. For women, the risk factors were lower level of educational and lack of religious attendance. Results suggested that the factors capable of influencing MCI differed profoundly between older men and older women. For this reason, different preventative measures should be adopted to delay or reverse cognitive impairment among community-dwelling older men and women.     

Adult Obesity and the Burden of Disability throughout Life

Objective: To analyze the prevalence of disability throughout life and life expectancy free of disability, associated with obesity at ages 30 to 49 years. Research Methods and Procedures: We used 46 and 20 years of mortality follow‐up, respectively, for 3521 Original and 3013 Offspring Framingham Heart Study participants 30 to 49 years and classified as normal weight, overweight, or obese at baseline. Disability measures were available between 36 and 46 years of follow‐up for 1352 Original participants and at 20 years of follow‐up for 2268 Offspring participants. We measured the odds of disability in the Original cohort after 46 years follow‐up, and we estimated life expectancy with and without disability from age 50. Two disability measures were used, one representing limitations with mobility only and the second representing limitations with activities of daily living (ADL). Results: Obesity at ages 30 to 49 years was associated with a 2.01‐fold increase in the odds of ADL limitations 46 years later. Nonsmoking adults who were obese between 30 and 49 years lived 5.70 (95% confidence interval, 4.11 to 7.35) (men) and 5.02 (95% confidence interval, 3.36 to 6.61) (women) fewer years free of ADL limitations from age 50 than their normal‐weight counterparts. There was no significant difference in the total number of years lived with disability throughout life between those obese or normal weight, due to both higher disability prevalence and higher mortality in the obese population. Discussion: Obesity in adulthood is associated with an increased risk of disability throughout life and a reduction in the length of time spent free of disability, but no substantial change in the length of time spent with disability.     

The Association of Four-Limb Blood Pressure with History of Stroke in Chinese Adults: A Cross-Sectional Study

Objective

We investigated the association of ankle-brachial blood pressure index (ABI), interarm blood pressure (BP) difference and interankle BP difference, obtained by simultaneous four-limb BP measurement, with history of stroke in a Chinese adult population.

Methods

This cross-sectional study included 1485 participants aged ≥35 years in the framework of the China Hypertension Survey. We performed simultaneous four-limb BP measurement using oscillometric devices with the participants in the supine position and calculated ABI and interarm/interankle BP differences between the 4 limbs. Logistic regression analysis was used to estimate the association of these BP parameters and other factors with a history of stroke.

Results

In univariate analyses, participants with ABI <0.9, interarm BP difference ≥15 mmHg, and interankle BP difference ≥10 mmHg had a higher prevalence of stroke than those without (p < 0.0001, p = 0.0152, p = 0.002, respectively). Multiple logistic regression analyses suggested, ABI <0.9 was independently associated with a history of stroke after adjustment for interarm BP difference ≥15 mmHg, interankle BP difference ≥10 mmHg, and traditional risk factors for stroke (p = 0.001). An interankle BP difference ≥10 mmHg was associated with prior stroke after the two variables of hypertension and ABI were removed from the logistic regression model (p = 0.0142). Net reclassification improvement analysis showed that inclusion of interankle BP difference ≥10 mmHg to the independent risk factors (age, family history of stroke, hypertension, and ABI) improved net reclassification by 11.92%.

Conclusion

ABI <0.9 is an independent risk factor for stroke prevalence in Chinese adults and it just detected a small propotion of paticipants. The addition of interankle BP difference ≥10 mmHg to the independent risk factors for stroke may improve the prediction of stroke.     

A Self-Reported Screening Tool for Detecting Community-Dwelling Older Persons with Frailty Syndrome in the Absence of Mobility Disability: The FiND Questionnaire

Background

The “frailty syndrome” (a geriatric multidimensional condition characterized by decreased reserve and diminished resistance to stressors) represents a promising target of preventive interventions against disability in elders. Available screening tools for the identification of frailty in the absence of disability present major limitations. In particular, they have to be administered by a trained assessor, require special equipment, and/or do not discriminate between frail and disabled individuals. Aim of this study is to verify the agreement of a novel self-reported questionnaire (the “Frail Non-Disabled” [FiND] instrument) designed for detecting non-mobility disabled frail older persons with results from reference tools.

Methodology/Principal Findings

Data are from 45 community-dwelling individuals aged ≥60 years. Participants were asked to complete the FiND questionnaire separately exploring the frailty and disability domains. Then, a blinded assessor objectively measured the frailty status (using the phenotype proposed by Fried and colleagues) and mobility disability (using the 400-meter walk test). Cohen''s kappa coefficients were calculated to determine the agreement between the FiND questionnaire with the reference instruments. Mean age of participants (women 62.2%) was 72.5 (standard deviation 8.2) years. Seven (15.6%) participants presented mobility disability as being unable to complete the 400-meter walk test. According to the frailty phenotype criteria, 25 (55.6%) participants were pre-frail or frail, and 13 (28.9%) were robust. Overall, a substantial agreement of the instrument with the reference tools (kappa = 0.748, quadratic weighted kappa = 0.836, both p values<0.001) was reported with only 7 (15.6%) participants incorrectly categorized. The agreement between results of the FiND disability domain and the 400-meter walk test was excellent (kappa = 0.920, p<0.001).

Conclusions/Significance

The FiND questionnaire presents a very good capacity to correctly identify frail older persons without mobility disability living in the community. This screening tool may represent an opportunity for diffusing awareness about frailty and disability and supporting specific preventive campaigns.     

Role of Weight History on Functional Limitations and Disability in Late Adulthood: The ARIC Study

Objective: To examine associations of weight history with functional limitations and disability in white and African‐American men and women. Research Methods and Procedures: Data were from the Atherosclerosis Risk in Communities study (n = 11, 177). Associations of recalled weight status at age 25 and weight change from age 25 to ages 45 to 64 with functional limitations, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) at follow‐up (ages 52 to 75) were examined using logistic regression. Results: Obesity (BMI ≥ 30 kg/m²) at age 25 was associated with functional limitations and ADL and IADL impairment at follow‐up in white and African‐American men and women. For example, obese compared with normal weight (BMI, 18.5 to 24.9 kg/m²) white women had higher odds of mild [odds ratio (95% confidence interval), 1.97 (1.18 to 3.29)] and severe [9.81 (5.92 to 16.27)] functional limitations and ADL [3.48 (2.36 to 5.13)] and IADL [2.95 (2.00 to 4.33)] impairment. In African‐American women, obesity was associated with higher odds of mild [2.71 (1.14 to 6.41)] and severe [6.01 (2.53 to 14.26)] functional limitations and ADL [1.82 (1.10 to 3.00)] and IADL [2.39 (1.47 to 3.90)] impairment. Similar associations were found in men. Compared with weight maintenance (±10 lbs), large weight gain (>30 lbs) from age 25 to ages 45 to 64 was also associated with functional limitations and ADL and IADL impairment in white and African‐American men and women. Discussion: Maintenance of a healthy body weight throughout adulthood may play a role in preventing or delaying the onset of functional limitations and disability, resulting in increased quality of life and decreased health care costs.     

Relation of Pulse Pressure to Long-Distance Gait Speed in Community-Dwelling Older Adults: Findings from the LIFE-P Study

Background

Reduced gait speed is associated with falls, late-life disability, hospitalization/institutionalization and cardiovascular morbidity and mortality. Aging is also accompanied by a widening of pulse pressure (PP) that contributes to ventricular-vascular uncoupling. The purpose of this study was to test the hypothesis that PP is associated with long-distance gait speed in community-dwelling older adults in the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) study.

Methods

Brachial blood pressure and 400-meter gait speed (average speed maintained over a 400-meter walk at “usual” pace) were assessed in 424 older adults between the ages of 70–89 yrs at risk for mobility disability (mean age = 77 yrs; 31% male). PP was calculated as systolic blood pressure (BP) – diastolic BP.

Results

Patients with a history of heart failure and stroke (n = 42) were excluded leaving 382 participants for final analysis. When categorized into tertiles of PP, participants within the highest PP tertile had significantly slower gait speed than those within the lowest PP tertile (p<0.05). Following stepwise multiple regression, PP was significantly and inversely associated with 400-meter gait speed (p<0.05). Other significant predictors of gait speed included: handgrip strength, body weight, age and history of diabetes mellitus (p<0.05). Mean arterial pressure, systolic BP and diastolic BP were not predictors of gait speed.

Conclusions

Pulse pressure is associated long-distance gait speed in community-dwelling older adults. Vascular senescence and altered ventricular-vascular coupling may be associated with the deterioration of mobility and physical function in older adults.     

Ideal Cardiovascular Health Metrics Are Associated with Disability Independently of Vascular Conditions

Background

Vascular risk factors may be associated with disability independently of vascular events. We examined whether the American Heart Association’s 7 ideal cardiovascular health (CVH) metrics were independently associated with disability in a nationally representative cohort.

Methods

Adults age ≥20 years from the National Health and Nutrition Examination Survey 2005–2012 were included. Ideal CVH was calculated as a composite of 7 measures, each scored 0–2. Primary predictors were number of ideal CVH metrics and score of CVH metrics. The outcome was a dichotomous score from 20 activities of daily living (ADL) and instrumental ADLs. Unadjusted and adjusted weighted logistic models estimated associations between ideal CVH and disability. The data were analyzed in 2015.

Results

Among 22692 participants, mean age was 46.9 years. Cardiac disease and stroke were present in 6.6% and 2.8%; 90.3% had poor physical activity and 89.9% poor diet. Among 3975 individuals with full CVH data, in fully adjusted models, OR for disability was 0.90 (95% CI 0.83–0.98) per point increase in ideal CVH score, and 0.84 (0.73–0.97) per additional number of ideal CVH metrics.

Conclusions

CVH metrics were strongly and significantly associated with reduced odds of disability independently of vascular and non-vascular conditions. Poorer CVH may cause subclinical vascular disease resulting in disability.     

Interrelationship of Postoperative Delirium and Cognitive Impairment and Their Impact on the Functional Status in Older Patients Undergoing Orthopaedic Surgery: A Prospective Cohort Study

Background

The impact of postoperative delirium on post-discharge functional status of older patients remains unclear, and little is known regarding the interrelationship between cognitive impairment and post-operative delirium. Therefore, the main purpose was to evaluate the post-discharge functional status of patients who experience delirium after undergoing orthopaedic surgery and the interrelationship of postoperative delirium with underlying cognitive impairment.

Method

This prospective cohort study, conducted at a tertiary care medical center from April 2011 to March 2012, enrolled all subjects aged over 60 years who were admitted for orthopaedic surgery. The baseline characteristics (age, gender, BMI, and living arrangement), surgery-related factors (ASA class, admission type, type of surgery, and length of hospital stay), results of geriatric assessment (postoperative delirium, cognition, depressive mood, comorbidity, pain, malnutrition, polypharmacy, ADL, and instrumental [I]ADL) and 1–12-month postoperative ADL and IADL functional status were collected for analysis.

Results

Overall, 9.1% of 232 patients (mean age: 74.7±7.8 years) experienced postoperative delirium, which was significantly associated with IADL decline at only 6 and 12 months postoperatively (RR: 6.22, 95% CI: 1.08–35.70 and RR: 12.54, 95% CI: 1.88–83.71, respectively). Delirium superimposed on cognitive impairment was a significant predictor for poor functional status at 6 and 12 months postoperatively (RR: 12.80, 95% CI: 1.65–99.40 for ADL at the 6^th month, and RR: 7.96, 95% CI: 1.35–46.99 at the 12^th month; RR: 13.68, 95% CI: 1.94–96.55 for IADL at the 6^th month, and RR: 30.61, 95% CI: 2.94–318.54 at the 12^th month, respectively).

Conclusion

Postoperative delirium is predictive of IADL decline in older patients undergoing orthopaedic surgery, and delirium superimposed on cognitive impairment is an independent risk factor for deterioration of ADL and IADL functional status. Early identification of cognitive function and to prevent delirium are needed to improve functional status following orthopaedic surgery.     

Googling Stroke ASPECTS to Determine Disability: Exploratory Analysis from VISTA-Acute Collaboration

The summed Alberta Stroke Program Early CT Score (ASPECTS) is useful for predicting stroke outcome. The anatomical information in the CT template is rarely used for this purpose because traditional regression methods are not adept at handling collinearity (relatedness) among brain regions. While penalized logistic regression (PLR) can handle collinearity, it does not provide an intuitive understanding of the interaction among network structures in a way that eigenvector method such as PageRank can (used in Google search engine). In this exploratory analysis we applied graph theoretical analysis to explore the relationship among ASPECTS regions with respect to disability outcome. The Virtual International Stroke Trials Archive (VISTA) was searched for patients who had infarct in at least one ASPECTS region (ASPECTS ≤9, ASPECTS=10 were excluded), and disability (modified Rankin score/mRS). A directed graph was created from a cross correlation matrix (thresholded at false discovery rate of 0.01) of the ASPECTS regions and demographic variables and disability (mRS>2). We estimated the network-based importance of each ASPECTS region by comparing PageRank and node strength measures. These results were compared with those from PLR. There were 185 subjects, average age 67.5± 12.8 years (55% Males). Model 1: demographic variables having no direct connection with disability, the highest PageRank was M2 (0.225, bootstrap 95% CI 0.215-0.347). Model 2: demographic variables having direct connection with disability, the highest PageRank were M2 (0.205, bootstrap 95% CI 0.194-0.367) and M5 (0.125, bootstrap 95% CI 0.096-0.204). Both models illustrate the importance of M2 region to disability. The PageRank method reveals complex interaction among ASPECTS regions with respects to disability. This approach may help to understand the infarcted brain network involved in stroke disability.     

Sarcopenic Obesity Predicts Instrumental Activities of Daily Living Disability in the Elderly

Objective: To determine the association of sarcopenic obesity with the onset of Instrumental Activities of Daily Living (IADL) disability in a cohort of 451 elderly men and women followed for up to 8 years. Research Methods and Procedures: Sarcopenic obesity was defined at study baseline as appendicular skeletal muscle mass divided by stature squared <7.26 kg/m² in men and 5.45 kg/m² in women and percentage body fat greater than the 60th percentile of the study sample (28% body fat in men and 40% in women). Incident disability was defined as a loss of two or more points from baseline score on the IADL. Subjects with disability at baseline (scores < 8) were excluded. Cox proportional hazards analysis was used to determine the association of baseline sarcopenic obesity with onset of IADL disability, controlling for potential confounders. Results: Subjects with sarcopenic obesity at baseline were two to three times more likely to report onset of IADL disability during follow‐up than lean sarcopenic or nonsarcopenic obese subjects and those with normal body composition. The relative risk for incident disability in sarcopenic obese subjects was 2.63 (95% confidence interval, 1.19 to 5.85), adjusting for age, sex, physical activity level, length of follow‐up, and prevalent morbidity. Discussion: This is the first study, to our knowledge, to indicate that sarcopenic obesity is independently associated with and precedes the onset of IADL disability in the community‐dwelling elderly. The etiology of sarcopenic obesity is unknown but may include a combination of decreases in anabolic signals and obesity‐associated increases in catabolic signals in old age.     

Dependencia evitable para las actividades de la vida diaria: una perspectiva de género

IntroductionThe aim of this study was to describe gender-related differences in dependence in instrumental activities of daily living (IADL) in people older than 75 years, and to assess the variables associated with dependence in these activities in Spanish men and women.Patients and methodWe performed a cross-sectional study of people older than 75 years living at home in the basic health area of Santa Lucía in the city of Zaragoza (Spain) in 1998 (n = 351). Data were obtained through personal interview. The Lawton-Brody scale for IADL, the Short Portable Mental Status Questionnaire for cognitive deficit, the Geriatric Depression Scale for depressive symptomatology, and the Katz index for self-care activities were also used. Dependence in IADL inside and outside the home were compared in men and women. To assess the relationship between sociodemographic variables and health indicators with dependence in IADL, two multivariate multiple logistic regression models were applied separately for men and women.ResultsThe level of dependence in IADL in our population was very high. In men, dependence in IADL inside and outside the home was not associated with sociodemographic characteristics or health indicators. In women, old age, impaired cognitive function, and dependence in self-care activities were associated with a higher prevalence of dependence in IADL inside the home; old age and depressive symptoms were associated with greater dependence in IADL performed outside the home.ConclusionsThe prevalence of dependence is higher in men than in women. Dependence is associated with health status in women but not in men. The development of gender equality policies aiming to promote the distribution of household tasks could reduce dependence in environmental activities, especially in men.