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After intensive care--what then?

The total dependence that, from necessity, must be the lot of an intensive care patient can lead to a state of learned helplessness as they recover. In addition, the physical frailty of these patients further confounds their first attempts at independence. It is at this stage that patients need clear information about the road ahead and in a form that they can refer back to as needed when they are discharged to the general wards and then home. As many intensive care patients have little or no memory of the intensive care unit (ICU) afterwards and only gradually come to understand how ill they have been, the provision of an information booklet on discharge to the general wards seemed likely to be the most sensible approach. The booklet addresses topics such as transfer to the wards and possible problems patient might face during their convalescence. In addition common sense advice is offered to help patients regain their independence and control of their own health. The information is presented in a clear concise way and the booklet is liberally illustrated with cartoons. Relatives are encouraged to read the booklet as well and provisional results have shown it to be well received by both patients and relatives.

Audiovisual Aids↗

Comparison of methods for analyzing recurrent events data: application to the Emergency Department Visits of Pediatric Firearm Victims.

In many medical conditions subjects can experience recurrent incidents. A common feature for the recurrent events data and multi-stage failure time observations is that the events are naturally ordered and occur in a certain sequence over time. To analyze such data, conventional methods based on either the frequency of events or the time to the first event or overall survival time is often inefficient and unsophisticated. If data have repeated events over a period with censored failure time in longitudinal studies, more complex analytic approaches are needed to obtain accurate estimates and efficient inferences, because adjustment is necessary for existing correlation between recurrent failure times within a subject. For analyzing different kinds of recurrent event data we review the existing models-multiple failure time models and frailty models, which allow use of all the available information to accurately estimate the relative risks of recurrences in a given dataset. Using the Pediatric Firearm Victim's Emergency Department Visit Study, the results from the proposed models are compared, and applicability and appropriateness of each model are discussed.

Emergency Service, Hospital↗

Carotenoids as protection against sarcopenia in older adults.

Sarcopenia, or loss of muscle mass and strength, plays a major role in the disablement process in older adults and increases the risk of impaired physical performance, falls, physical disability, frailty, and death. Oxidative stress is a major mechanism implicated in the pathogenesis of sarcopenia; aging muscle shows increased oxidative damage to DNA, protein, and lipids. Carotenoids quench free radicals, reduce damage from reactive oxygen species, and appear to modulate redox-sensitive transcription factors such as NF-kappaB that are involved in the upregulation of IL-6 and other proinflammatory cytokines. Recent epidemiological studies in community-dwelling older adults show that low serum/plasma carotenoids are independently associated with low skeletal muscle strength and the development of walking disability. These observations are consistent with a growing number of studies showing that a diet with high intake of fruits and vegetables is associated with a reduced risk of inflammation, hypertension, diabetes, cardiovascular disease, and mortality.

Adult↗

Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly.

PURPOSE: To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients. METHODS: The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse. RESULTS: For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05). CONCLUSION: Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.

Aged↗

Pulmonary embolism as a cause of death in patients who died with cancer.

Little is known about the frequency of death from pulmonary embolism in patients who die with cancer. We investigated this on the basis of data from death certificates, as listed by the United States Bureau of the Census in the period 1980-1998. Among patients with cancer who died over the 19-year period of study, pulmonary embolism was the listed cause of death in 0.21% (95% confidence interval, [CI] 0.21-0.22%). The frequency of death from pulmonary embolism in patients who died with cancer decreased from 0.39% in 1980 to 0.15% in 1998. Adjustment of the data for the frailty of the diagnosis of fatal pulmonary embolism based on death certificates indicated a likely range of 0.60% to 1.05% for the frequency of death from pulmonary embolism among patients who died with cancer in the period 1980-1998. In conclusion, with modern diagnostic, prophylactic, and therapeutic methods, death from pulmonary embolism in patients who died with cancer was 1% or less.

Autopsy↗

The influence of Tai Chi training on the center of pressure trajectory during gait initiation in older adults.

OBJECTIVE: To determine if a program of intense Tai Chi exercise that has been shown to reduce the risk of falling in older adults improves postural control by altering the center of pressure (COP) trajectory during gait initiation. DESIGN: Before-after trial. SETTING: Biomechanics research laboratory. PARTICIPANTS: Twenty-eight older adults transitioning to frailty who participated in either a 48-week intervention of intense Tai Chi training or a wellness education (WE) program. INTERVENTIONS: Eight Tai Chi forms emphasizing trunk rotation, weight shifting, coordination, and narrowing of lower-extremity stance were taught twice weekly. WE program participants met once a week and received lectures focused on health. Main outcome measures The COP was recorded during gait initiation both before and after the 48-week intervention by using a forceplate sampling at 300 Hz. The COP trajectory was divided into 3 periods (S1, S2, S3) by identifying 2 landmark events. Displacement and average velocity of the COP trace in the anteroposterior (x) and mediolateral (y) directions, as well as smoothness, were calculated. RESULTS: Tai Chi training increased the posterior displacement of the COP during S1 and improved the smoothness of the COP during S2. CONCLUSIONS: Tai Chi improved the mechanism by which forward momentum is generated and improved coordination during gait initiation, suggesting improvements in postural control.

Aged↗

Effects of exercise programs on falls and mobility in frail and pre-frail older adults: A multicenter randomized controlled trial.

OBJECTIVES: To determine the effects of moderate intensity group-exercise programs on falls, functional performance, and disability in older adults; and to investigate the influence of frailty on these effects. DESIGN: A 20-week, multicenter randomized controlled trial, with 52-week follow-up. SETTING: Fifteen homes for the elderly. PARTICIPANTS: Two hundred seventy-eight men and women (mean age +/- standard deviation, 85+/-6y). INTERVENTIONS: Two exercise programs were randomly distributed across 15 homes. The first program, functional walking (FW), consisted of exercises related to daily mobility activities. In the second program, in balance (IB), exercises were inspired by the principles of Tai Chi. Within each home participants were randomly assigned to an intervention or a control group. Participants in the control groups were asked not to change their usual pattern of activities. The intervention groups followed a 20-week exercise program with 1 meeting a week during the first 4 weeks and 2 meetings a week during the remaining weeks. MAIN OUTCOME MEASURES: Falls, Performance Oriented Mobility Assessment (POMA), physical performance score, and the Groningen Activity Restriction Scale (GARS) (measuring self-reported disability). RESULTS: Fall incidence rate was higher in the FW group (3.3 falls/y) compared with the IB (2.4 falls/y) and control (2.5 falls/y) groups, but this difference was not statistically significant. The risk of becoming a faller in the exercise groups increased significantly in the subgroup of participants who were classified as being frail (hazard ratio [HR] = 2.95; 95% confidence interval [CI], 1.64-5.32). For participants who were classified as being pre-frail, the risk of becoming a faller decreased; this effect became significant after 11 weeks of training (HR = .39; 95% CI, .18-.88). Participants in both exercise groups showed a small, but significant improvement in their POMA and physical performance scores. In the FW group, this held true for the GARS score as well. Post hoc analyses revealed that only the pre-frail participants improved their POMA and physical performance scores. CONCLUSIONS: Fall-preventive moderate intensity group-exercise programs have positive effects on falling and physical performance in pre-frail, but not in frail elderly.

Accidental Falls↗

Health professionals, Jewish religion and community structure in the service of the aging holocaust survivor.

Many holocaust survivors are now reaching old age and this is accompanied by the increased likelihood of physical frailty and deterioration of their cognitive capacities. These changes can be accompanied by exacerbation of traumatic memories, which might once have been effectively suppressed. This, in turn, may manifest itself in fresh anxieties. Their attitudes towards health professionals, Jewish religious ritual and the community are some of the issues discussed. Possible strategies for the more effective medical and social management of the aged holocaust survivors are also considered.

Aged↗

The impact of cognitive impairment on the rehabilitation process in geriatrics.

A study has been carried out in our geriatric rehabilitation wards, to know better the role of cognitive dysfunction in treatment outcome and processing, mainly functional recovery and comorbidity. We analyzed 478 frail inpatients, 2/3 of them were females, aged 78.7 + 9.2 years, consecutively admitted to the unit. Assessment of cognitive function was performed by the mini mental state examination (MMSE), of functional status by Barthel index (BI), of co-morbidity by cumulative illness rating scale (CIRS) both at the admission and discharge for each patient, together with the usual clinical parameters and social outcome. More than one people in three lived alone and showed some communication problems; one in seven needed modifications in food preparation or nutritional system;more than one in five had pressure sore >/= 2 (EPUAP = European Pressure Ulcers Advisory Panel classification). The mean (+/- SD) levels of the admitted were: MMSE = 20 +/- 7.2; BI total score = 45.5 +/- 28.9; CIRS class = 4 +/- 2, CIRS severity score = 1.9 +/- 0.4. Of the patients, 74.5% were discharged to home. Mean functional gain was 20 points at BI: 65.6 +/-30.7; MMSE improved to 21.6 +/- 7.1 (p = 0.00005 for both comparisons, by Wilcoxon test).MMSE was positively correlated to BI (r = 0.6, p = 0.0005) and negatively correlated (p =0.0005) to CIRS comorbidity (r = -0.33) and severity (r = -0.26), and to age (r = -0.38, p =0.0005) both at admission and at discharge. MMSE at admission was correlated neither to functional gain, nor to improvement of clinical indicators, nor to measures of functional and clinical efficiency. MMSE at discharge showed similar results. In a stepwise multiple correlation analysis, taking the gain in BI as the dependent variable, while BI, serum albumin level, MMSE, CIRS severity and comorbidity indexes at admission as independent variables, MMSE together with BI admission total score and CIRS severity index retained a strong association with functional gain, whilst admission serum albumin levels and CIRSindex lost it. Consistently with some literary data, we showed the actual possibility of functional and clinical gains for people cared in a geriatric rehabilitation ward, all through a wide range of MMSE score, including subnormal scores. Poor cognitive status bears heavily on frailty, but does not hamper the outcomes of genuine rehabilitative efforts in geriatrics.

Aged↗

Functional recovery after hip fracture in old-old elderly patients.

Hip fracture is epidemic and prevalence increased with advanced age. Impact of comorbid and cognitive status, gender, type of fracture, operative delay and pre-fracture ambulatory levels on functional outcome was shown in previous studies. We studied functional outcome after rehabilitation for hip fracture in old-old elderly (85 years and older) and compared it to young elderly (65-74 years) community-dwelling patients. Before the fracture, old-old elderly patients were more functional dependent, has had more comorbid diseases, and more of them live alone than young elderly. The waiting time to surgery and mean length of stay in orthopedic ward were longer than in young elderly. On admission to rehabilitation treatment, old-old patients presented with more depressed mood, were more cognitive impaired, and more suffer from pain. Old-old patients presented with laboratory data of malnutrition (decreased serum levels of albumin, cholesterol, hemoglobin, hematocrit, lymphocyte count) and inflammation (increased of transferrin and C-reactive protein). Improvement in Functional Independence Measurement (FIM) scale was found in both groups but significantly better in young elderly than in old-old elderly. The change in FIM during the rehabilitation period (DeltaFIM) were in FIM total and in those parts of FIM concerning locomotion. The mean duration of rehabilitation stay was significantly longer in old-old elderly patients. On discharge old-old elderly patients more suffer from pain and difference between the groups according to the laboratory and to the cognitive data increased. Age per se is indicator of frailty and determinate functional recovery after hip fracture.

Activities of Daily Living↗

[Quality of life in HIV-infected children and adolescents under highly active antiretroviral therapy: change over time, effects of age and familial context].

OBJECTIVE: To evaluate Quality of life (QoL) of HIV-infected children under highly active antiretroviral therapies, and its change over 18 months. MATERIALS AND METHODS: QoL was evaluated by self-administred questionnaires (french versions of AUQUEI, OK-ado, and compilation of both) in 23 young living with HIV/AIDS (6-15 yrs), under antiretroviral multitherapies, and re-evaluated 18 months later in 19 of them. RESULTS: At baseline, QoL in HIV-infected children-adolescents was relatively good. The answers given to each items and the mean score from infected children were similar to those obtained in uninfected healthy children. Moreover, infected adolescents distinguished definitly from healthy adolescents, describing higher QoL. The mean satisfaction score from the whole group decreased between M0 and M18 (mainly in the youngests), and mainly concerned 3 fields (self-esteem, health and school) while their somatic health remained stable or improved. An effect of the familial context was also observed for these 3 fields. CONCLUSION: The progressive decline of QoL in HIV-infected children, and the surprising high and steady level of satisfaction over-time provided by the adolescents, underlined the frailty of this population and the need for a psychologic management associated to the medical follow-up. Such a multidisciplinary approach should take into account the preoccupations and difficulties of each age-class, those linked to the diagnosis itself, and to the familial or scolar contexts, in order to preserve QoL of this pediatric population, as far as possible, in a long term.

Adolescent↗

Soy isoflavone phyto-pharmaceuticals in interleukin-6 affections. Multi-purpose nutraceuticals at the crossroad of hormone replacement, anti-cancer and anti-inflammatory therapy.

Interleukin-6 is a pleiotropic cytokine which plays a crucial role in immune physiology and is tightly controlled by hormonal feedback mechanisms. After menopause or andropause, loss of the normally inhibiting sex steroids (estrogen, testosterone) results in elevated IL6 levels that are further progressively increasing with age. Interestingly, excessive IL6 production promotes tumorigenesis (breast, prostate, lung, colon, ovarian), and accounts for several disease-associated pathologies and phenotypical changes of advanced age, such as osteoporosis, rheumatoid arthritis, multiple myeloma, neurodegenerative diseases and frailty. In this respect, pharmacological modulation of IL6 gene expression levels may have therapeutical benefit in preventing cancer progression, ageing discomforts and restoring immune homeostasis. Although "plant extracts" are used in folk medicine within living memory, it is only since the 20th century that numerous scientific investigations have been performed to discover potential health-protective food compounds or "nutraceuticals" which might prevent cancer and ageing diseases. About 2000 years ago, Hippocrates already highlighted "Let food be your medicine and medicine be your food". Various nutrients in the diet play a crucial role in maintaining an "optimal" immune response, such that deficient or excessive intakes can have negative consequences on the organism's immune status and susceptibility to a variety of pathologies. Over the last few decades, various immune-modulating nutrients have been identified, which interfere with IL6 gene expression. Currently, a broad range of phyto-pharmaceuticals with a claimed hormonal activity, called "phyto-estrogens", is recommended for prevention of various diseases related to a disturbed hormonal balance (i.e. menopausal ailments and/or prostate/breast cancer). In this respect, there is a renewed interest in soy isoflavones (genistein, daidzein, biochanin) as potential superior alternatives to the synthetic selective estrogen receptor modulators (SERMs), which are currently applied in hormone replacement therapy (HRT). As phyto-chemicals integrate hormonal ligand activities and interference with signaling cascades, therapeutic use may not be restricted to hormonal ailments only, but may have applications in cancer chemoprevention and/or NF-kappaB-related inflammatory disorders as well.

Animals↗

Anemia and the elderly: clinical considerations.

Anemia is a common problem in the management of elderly patients. Anemia in the elderly is linked to an increase in morbidity and mortality, and serves as an independent variable associated with poor outcomes. In the elderly population, anemia is a risk factor for cardiovascular health and early death, contributes to fatigue, and negatively impacts on cognitive function, physical function, and the quality of life and serves as a marker of increased vulnerability. A greater understanding of pathophysiology of anemia in the setting of chronic disease has provided insights into the rationale for the potential clinical application of erythropoietic agents in the treatment of anemia. The impact of erythropoietic therapy, as it relates to specific afflictions affecting the older age patient, including diminished exercise tolerance, frailty, loss of functional capacity, immobility, depression, increased care needs and cardiovascular fitness, remains to be determined and is worthy of further investigation.

Age Factors↗

Structure activity studies of the serine-AIB dipeptide domain in 2,3-dihydroisothiazole based growth hormone secretagogues.

A series of growth hormone secretagogues (GHSs) based on 2,3-dihydroisothiazole has been synthesized in the search for a potential treatment of growth hormone deficiency or frailty in the elderly. This paper describes the evaluation of the SAR of the benzyl-D-Ser-aminoisobutyric acid dipeptide fragment. Introduction of substituents in the peptide backbone and in the phenyl ring has been investigated, as well as replacements for the benzyl group and for the AIB residue. A number of modifications resulted in enhanced potency over the parent benzyl-D-Ser-AIB derivative.

Aminobutyrates↗

The use of Flammacerium in British Burns Units.

INTRODUCTION: Flammacerium (cerium nitrate-silver sulphadiazine) is marketed throughout Europe, but is only available in UK on a named patient basis. Anecdotally it is widely used in civilian burns units across the country despite the regulatory constraint, although little literature exists regarding its use in UK. We designed a postal survey to assess the use of Flammacerium countrywide and whether its 'named patient only' designation causes problems in treating burns patients. METHODS: Postal questionnaires were sent to the directors of the 18 adult burns units listed by the British Burns Association, requesting information on the use of Flammacerium. The indications and limitations of its use were recorded, as were any problems obtaining supplies. Finally, burns units were asked if they would like to see Flammacerium fully licensed in this country. RESULTS: Replies were received from 14 units (response rate=78%). Six units use Flammacerium frequently, six occasionally and two units never use it. It is used in those patients not undergoing early wound excision and closure because of co-morbidity, general age or frailty, paucity of donor sites or mixed depth pattern burns. It was generally used in the belief that it reduces the inflammatory response to burn injury (8/12), decreases bacterial colonization (10/12) and provides a firm eschar for easier wound management (11/12). Although 8 units had no problems with supplies of the agent, 10 respondents indicated they would like to see Flammacerium fully licensed in UK.

Attitude of Health Personnel↗

Urinary incontinence in the frail elder.

Urinary incontinence (UI) is a complex disorder affecting a large segment of the frail older population. Physical factors such as medication use and disease comorbidity can affect continence control. Cognitive disorders and functional decline pose additional challenges in management of urinary symptoms. Those individuals who have adequate socioeconomic support and caregiver assistance may have a greater advantage in maintaining continence.Physical, cognitive, functional, and psychosocial factors each contribute to the risk profile for both the development of frailty and the likelihood of experiencing UI.

Aged↗

ESPEN Guidelines on Enteral Nutrition: Geriatrics.

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Aged↗

frailtypack: a computer program for the analysis of correlated failure time data using penalized likelihood estimation.

Correlated survival outcomes occur quite frequently in the biomedical research. Available software is limited, particularly if we wish to obtain smoothed estimate of the baseline hazard function in the context of random effects model for correlated data. The main objective of this paper is to describe an R package called frailtypack that can be used for estimating the parameters in a shared gamma frailty model with possibly right-censored, left-truncated stratified survival data using penalized likelihood estimation. Time-dependent structure for the explanatory variables and/or extension of the Cox regression model to recurrent events are also allowed. This program can also be used simply to obtain directly a smooth estimate of the baseline hazard function. To illustrate the program we used two data sets, one with clustered survival times, the other one with recurrent events, i.e., the rehospitalizations of patients diagnosed with colorectal cancer. We show how to fit the model with recurrent events and time-dependent covariates using Andersen-Gill approach.

Cluster Analysis↗