Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era – A Portuguese study

ObjectivesIdentifying frequent users’ (≥3 admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age.MethodsA cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed.ResultsCGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users.ConclusionsThis study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users’ admissions.     

External sensory-motor cues while managing unexpected slippages can violate the planar covariation law

This study was aimed at investigating the intersegmental coordination of six older adults while managing unexpected slippages delivered during steady walking, and wearing an Active Pelvis Orthosis (APO). The APO was setup either to assist volunteers at the hip levels during balance loss or to be transparent. The Planar Covariation Law (PCL) of the lower limb elevation angles was the main tool used to assess the intersegmental coordination of both limbs (i.e., the perturbed and unperturbed ones). Results revealed that, after the onset of the perturbation, elevation angles of both limbs do not covary, a part from the robot-mediated assistance. These new evidences suggest that external sensory-motor cues can alter the temporal synchronization of elevation angles, thus violating the PCL.     

The relation between limb segment coordination during walking and fall history in community-dwelling older adults

Control of the swing foot during walking is important to prevent falls. The trajectories of the swing foot are adjusted by coordination of the lower limbs, which is evaluated with uncontrolled manifold (UCM) analysis. A previous study that applied this analysis to walking revealed that older adults with fall history had compensatorily great segment coordination to stabilize the swing foot during normal walking. However, it is unknown whether the increase in segment coordination helps for preventing incident falls in the future. At baseline measurement, 30 older adults walked for 20 times at a comfortable speed. UCM analysis was performed to evaluate how the segment configuration in the lower limbs contributes to the swing foot stability. One year after the baseline visit, we asked the subjects if there were incident falls through a questionnaire. The univariate and multivariable logistic regression analyses were performed to assess the association between the index of segment coordination and incident falls with and without adjustment for gait velocity. Twenty-eight older adults who responded to the questionnaire were classified into older adults (n = 12) who had the incident fall and those (n = 16) who did not have falls. It was revealed that older adults who increased the segment coordination associated with swing foot stability tended to experience at least one fall within one year of measurement. The index of the UCM analysis can be a sensitive predictor of incident falls.     

Tasa de filtración glomerular estimada y mortalidad posterior al alta en una unidad geriátrica de agudos

ObjectiveTo determine the relationship between estimated glomerular filtration rate (eGFR) and mortality in a retrospective cohort of older adults admitted to an acute care for the elderly (ACE) unit.Materials and methodsThe study included 1,678 patients aged 60 years and over admitted to an AEC, in Cali, Colombia, from 2012 to 2015, and followed- up until 2016. The primary outcome was mortality. Renal function (eGFR) was estimated using Modification of Diet in Renal Disease Study (MDRD-4) equation. The renal function was grouped according to the eGFR (ml/min/1.73 m²) as follows: slightly decreased (≥ 60), moderately decreased (30-59), and severely decreased (< 30). Bivariate survival and multivariate Cox regression analyses were performed.ResultsIn the univariate analysis, patients with severely decreased eGFR had higher mortality than those with a higher eGFR (P = .046). In the group with severely decreased eGFR, survival was lower in the functionally dependent group (Barthel index [IB] < 60) than in the independent group (IB ≥ 60) (log rank test; P = .001). In the multivariate analysis, there was a significant increase in the risk of death in the elderly with severely decreased eGFR (< 30) compared with slightly decreased eGFR (≥ 60) (hazard ratio [HR], 1.44; 95% confidence interval [CI]; 1.02-2.05, P = .039). There was also a significant increase in the risk of death in the dependent elderly compared to the independent ones [HR 1.72; 95% CI; 1.26-2.34, P = .000], those who had the high morbidity (≥ 4) with low albumin (< 3.2 g/dL) compared with those with low morbidity (0-3) and high albumin (≥ 3.2) [HR 1.77; 95% CI; 1.18-2.65, P = .005], and in those with a high (16-102 mg/dL) C-reactive protein (CRP) compared with those with low CRP (0-15) [HR 1.42; 95% CI; 1.01-2.01, P = .043].ConclusionsThe risk of mortality after hospital admission to an AEC unit is greater in patients with eGFR < 30. Poor functional status performance, high comorbidity, low plasma albumin, and increased inflammation markers are additional prognostic factors to be taken into account. The improvement in the functional status could improve the survival after hospitalisation.     

Muscle contributions to recovery from forward loss of balance by stepping

The purpose of this study was to determine the muscular contributions to the stepping phase of recovery from forward loss of balance in 5 young and 5 older adults that were able to recover balance in a single step, and 5 older adults that required multiple steps. Forward loss of balance was achieved by releasing participants from a static forward lean angle. All participants were instructed to attempt to recover balance by taking a rapid single step. A scalable anatomical model consisting of 36 degrees-of-freedom was used to compute kinematics and joint moments from motion capture and force plate data. Forces for 94 muscle actuators were computed using static optimisation and induced acceleration analysis was used to compute individual muscle contributions to net lumbar spine joint, and stepping side hip joint and knee joint accelerations during recovery. Older adults that required multiple recovery steps used a significantly shorter and faster initial recovery step and adopted significantly more trunk flexion throughout recovery compared to the older single steppers. Older multiple steppers also produced significantly more force in the stance side hamstrings, which resulted in significantly higher hamstring induced flexion accelerations at the lumbar spine and extension accelerations at the hip. However since the net joint lumbar spine and hip accelerations remained similar between older multiple steppers and older single steppers, we suggest that the recovery strategy adopted by older multiple steppers was less efficient as well as less effective than for older single steppers.     

Vitamin E ingestion improves several immune functions in elderly men and women

The effects of diet supplementation with the antioxidant vitamin E (200 mg daily) on several blood neutrophil, lymphocyte and natural killer cell functions have been investigated in healthy elderly men and women before supplementation, after 3 months of supplementation and 6 months after the end of supplementation (post-supplementation). In parallel, samples of healthy adult men and women were used as age controls. In elderly men and women, an impairment of immune functions was observed in comparison with the respective adult controls and the intake of vitamin E resulted in a significant enhancement of immune parameters in both elderly men and women, bringing their values close to those in the adults. These effects were not found in post-supplementation samples in several but not in all functions. The present findings suggest that supplementation with vitamin E can produce an improvement of immune functions and therefore of health in aged people.     

'It's really a myriad of different signals, not just the textbook': the complexities of diagnosing depression in gay men in general practice

This paper reports on in-depth interviews with general practitioners (GPs) about their views and experiences of diagnosing depression in gay men - some of whom are living with HIV - and the broader social contexts in which such a diagnosis is located. This analysis is a key outcome of a collaboration between social researchers, primary healthcare researchers, GPs and community partners, to investigate the management of depression in gay men in primary care settings. As the qualitative component of this project, semi-structured in-depth interviews were conducted with 16 GPs with high caseloads of gay men, in three geographical settings in Australia: Sydney, Adelaide and a rural-coastal town. GPs considered the diagnosis and management of depression to be an integral part of primary care, especially in gay male patients. They had a heightened sense of awareness that depression was common in the group of patients they were seeing. Central to diagnosing depression was the ongoing, long-term relationship GPs had with their gay male patients. GPs were vigilant and proactively inquired about depression, taking into account somatic, social and psychological indicators. In their approach to diagnosing depression, GPs considered not only the life circumstances of individual patients but also the broader social context of stigma related to homosexuality, and the effects that the HIV epidemic has had on individuals, especially on gay men who have been living with HIV for a long time.     

10周核心力量练习对男性中老年人平衡能力的影响

目的：探讨核心力量练习对中老年男性平衡能力的影响,为运动锻炼改善老年人平衡能力和降低跌倒风险提供依据。方法：选取16名50~60岁男性中老年人,随机分为试验组（核心力量练习）和对照组,每组8人。利用悬吊绳和瑜伽垫进行动、静态支撑与推拉练习以及徒手下肢力量等间歇性组合核心力量训练,共练习10周,每周4~5次,每次50~60 min。对照组保持原有生活习惯。锻炼前后测定受试者静态平衡和动态平衡等指标。结果：①锻炼后试验组闭眼单脚站立时间和动态平衡得分较锻炼前显著升高分别为（9.00±2.27） s、（10.63±1.69） s,P<0.01;（77.38±10.94）、（89.50±5.53）,P<0.01。②锻炼后试验组星形伸展平衡测试（SEBT）,右腿支撑时左腿在8个方向、左腿支撑时右腿在6个方向的SEBT值均较锻炼前显著增加（P<0.01）。结论：10周核心力量练习显著提高男性中老年人的动、静态平衡能力。     

La infección por VIH como causa de envejecimiento acelerado y fragilidad

The HIV-infected population is aging due to the success of combination antiretroviral therapy, which prolongs survival, as well as the growing number of newly diagnosed cases in adults 50 years old and over. HIV-infected individuals suffer from an accelerated aging due to the persistent and chronic activation of the immune system that leads to immune exhaustion and accelerated immunosenescence, even when on optimal immuno-virological control treatment. The clinical expression of the immunosenescence state is an increased prevalence of aging-related non-HIV associated comorbidities and a rising prevalence of frailty occurring earlier than in the general population. Thus, HIV-infected patients are biologically older than their chronological age, and they suffer from aging-related problems, such as frailty, which should be assessed.     

Health and transitions into nonemployment and early retirement among older workers in Canada

Extending working lives is considered a viable solution to fiscal and macroeconomic challenges related to population ageing. Opportunities for sustained employment, however, are not experienced equally among older population, particularly among those with a health problem. This study aims to examine the longer-term effect of health on employment trajectories in later part of working life using a unique survey-administrative linked dataset for Canada. Specifically, we apply competing-risks models to analyze whether different aspects of health conditions at baseline predict subsequent exit routes, including nonemployment and early retirement. The nonparametric findings of the paper show that only about 33% of workers aged 50–62 with a health problem at baseline remained employed at age 64, compared to 55% of healthy workers. Exiting into nonemployment seemed more common among leavers with activity limitations, while early retirement was more likely among healthy leavers. These results are robust even when individuals’ preferences for work and financial factors were controlled for. Moreover, we identify differential impacts of specific chronic diseases on early work exit. Not all symptoms affect employment transitions to a similar extent. Older workers who reported the comorbidity of mental and musculoskeletal disorders faced an increased risk of nonemployment, while the presence of diabetes and cardiovascular problems at baseline were more predictive of early retirement.