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PubMed1999

The attitudes of patients to integrated medical care.

AIM: To establish the attitude of inpatients to integrated medical care. SETTING: A district general hospital which had recently adopted the model of integrated medical care. METHODS: 205 patients of all ages were interviewed and asked about their general views and their personal experience of integrated medical care and their preference had they been given a choice. Those patients who had previously been admitted before integration were asked if they felt the quality of care had changed. RESULTS: Integrated medical wards were preferred by most patients and this preference was greater in older patients. However, 30% identified patients on their wards who they felt should be segregated on account of confusion, frailty or youthfulness. Of the 69 who had been admitted before integration, 88% commented that the quality of care was either the same or better. CONCLUSION: Integrated medical care was the preferred model of care, especially by elderly patients. The special needs of some patients were, however, recognized. Perhaps the ideal model is a needs-related policy within a fully integrated system.

Adolescent↗

PubMed2004

A national census of care home residents.

BACKGROUND: the medical and dependency characteristics of UK care home residents have not been well described. This undermines care commissioning, development and regulation. Data to inform policy and practice are needed. OBJECTIVE: to survey the dependency and clinical diagnoses of 16,043 people resident in the 244 care homes distributed across the UK managed by the largest provider of care in the UK. RESULTS: (i) Return rate of 97% (15,483 returns suitable for analysis). (ii) 25% were 'residential' and 75% in 'nursing' care. (iii) Medical morbidity and associated disability rather than non-specific frailty and social needs had driven admission in over 90% of residents. (iv) More than 50% of residents had dementia, stroke or other neurodegenerative disease. (v) Overall, 76% of residents required assistance with their mobility or were immobile. 78% had at least one form of mental impairment and 71% were incontinent. 27% of the population were immobile, confused and incontinent. (vi) Considerable overlap in dependency between residential and nursing care observed: only 40% of those in residential care were ambulant without assistance and 46% were incontinent. CONCLUSIONS: the practicality of acquiring information on care home residents has been demonstrated. The care needs of people in care homes are largely determined by progressive chronic diseases. A single assessment and commissioning at the point of entry to care services is unlikely to address changing needs. Alternatives to institutional long-term care should only be considered in the context of current resident profiles, the practicality of providing alternative models and likely projected population needs.

Aged↗

PubMed2006

Is grip strength associated with health-related quality of life? Findings from the Hertfordshire Cohort Study.

OBJECTIVE: to investigate the relationship between grip strength and health-related quality of life (HRQoL). DESIGN: cross-sectional survey within a cohort study design. SETTING: the county of Hertfordshire in the UK. PARTICIPANTS: a total of 2,987 community-dwelling men and women aged 59-73 years of age. MEASUREMENTS: grip strength was used as a marker of sarcopaenia and measured using a Jamar dynamometer. HRQoL was assessed using the eight domain scores of the Short Form-36 (SF-36) questionnaire, and subjects in the lowest sex-specific fifth of the distribution were classified as having 'poor' status for each domain. RESULTS: men and women with lower grip strength were significantly more likely to report a poor as opposed to excellent to fair overall opinion of their general health (GH) [odds ratio (OR) per kilogram decrease in grip strength = 1.13, 95% CI = 1.06-1.19, P < 0.001 in men, 1.13, 95% CI = 1.07-1.20, P < 0.001 in women]. Among men, after adjustment for age, size, physical activity and known co-morbidity, decreased grip strength was associated with increased prevalence of poor SF-36 scores for the physical functioning (PF) (OR per kilogram decrease in grip strength = 1.03, 95% CI = 1.01-1.06, P = 0.007) and GH domains (OR = 1.03, 95% CI = 1.01-1.05, P = 0.01). Similar associations were seen in women. CONCLUSIONS: our findings suggest that lower grip strength is associated with reduced HRQoL in older men and women. This does not appear to be explained by age, size, physical activity or co-morbidity and may reflect the link between sarcopaenia and generalised frailty. Individuals with sarcopaenia may benefit from interventions to improve muscle mass and strength before the onset of chronic disorders usually associated with impaired HRQoL.

Accidental Falls↗

PubMed2005

Aging muscle.

Age causes structural and functional changes in skeletal muscle in a wide range of species, including humans. Muscle changes in humans start in the fourth decade of life and cause frailty and disabilities. Associated changes in body composition form the basis of many metabolic disorders, such as insulin resistance, type 2 diabetes, hypertension, and hyperlipidemia, which result in an increased incidence of cardiovascular death. Decreases in the synthesis rates of many muscle proteins, specifically of myosin heavy chain and mitochondrial proteins, occur with age. The underlying causes of the reduction in mitochondrial biogenesis and ATP production seem to be decreases in mitochondrial DNA and messenger RNA. Reduced ATP production could be the basis of reduced muscle protein turnover, which requires energy. Both aerobic exercise and resistance exercise enhance muscle protein synthesis and mitochondrial biogenesis. Insulin and amino acids have also been shown to enhance muscle mitochondrial biogenesis and mitochondrial protein synthesis. However, the insulin-induced increase in muscle mitochondrial ATP production is defective in type 2 diabetic patients with insulin resistance. Moreover, a dissociation between increases in muscle mitochondrial biogenesis and insulin sensitivity after exercise has been noted in older persons. It remains to be determined whether muscle mitochondrial dysfunction causes or results from insulin resistance. Exercise seems to enhance the efficiency of muscle mitochondrial DNA in rodents. Reduced physical activity as a contributor of age-related mitochondrial dysfunction remains to be determined. It is proposed that a reduction in tissue mitochondrial ATP production signals the hypothalamic centers to reduce spontaneous physical activities. Voluntary physical activity is regulated by cognitive centers and could attenuate the progressive decline in mitochondrial functions that occurs with age.

Adult↗

PubMed2005

Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.

Obesity causes serious medical complications and impairs quality of life. Moreover, in older persons, obesity can exacerbate the age-related decline in physical function and lead to frailty. However, appropriate treatment for obesity in older persons is controversial because of the reduction in relative health risks associated with increasing body mass index and the concern that weight loss could have potential harmful effects in the older population. This joint position statement from the American Society for Nutrition and the NAASO, The Obesity Society reviews the clinical issues related to obesity in older persons and provides health professionals with appropriate weight-management guidelines for obese older patients. The current data show that weight-loss therapy improves physical function, quality of life, and the medical complications associated with obesity in older persons. Therefore, weight-loss therapy that minimizes muscle and bone losses is recommended for older persons who are obese and who have functional impairments or medical complications that can benefit from weight loss.

Aged↗

PubMed2005

Increased falling as a risk factor for fracture among older women: the study of osteoporotic fractures.

More frequent falling is associated with a higher risk of fracture among older women, but it is not known whether an increased rate of falling, independent of the average rate, also increases fracture risk. The authors examined the relation between an increase in the rate of falls during the first 4 years of follow-up and the subsequent fracture rate, reported for a median of 6.3 years (1986-1998), in 9,106 US women aged 65 years or more. Women in the upper quartile of increasing falls (>0.44 falls/year/year) had greater risks of subsequent hip fracture (rate ratio = 1.42, 95% confidence interval: 0.99, 2.04) and fracture of the proximal humerus (rate ratio = 1.79, 95% confidence interval: 1.08, 2.95) than women without an increase in falls, after adjustment for age, average rate of falls over 4 years, and known risk factors for fracture. Risks of distal forearm, ankle, or foot fracture were not elevated. The associations between fracture risk and increasing falls were not accounted for by baseline physical or cognitive function. An increase in the rate of falls, independent of the average rate, may be associated with a higher risk of frailty (hip and proximal humerus) fractures but not fractures at other sites.

Accidental Falls↗

PubMed2005

Transitions between states of disability and independence among older persons.

The objectives of this prospective cohort study, conducted in New Haven, Connecticut, from 1998 to 2004, were to describe disability states experienced by older persons, to evaluate the rate of transitions between states and the duration of disability episodes, and to determine whether these findings differ on the basis of physical frailty--a condition of low physical capacity and vulnerability to adverse functional outcomes. Participants included 754 persons aged 70 years or older who were initially independent in four key activities of daily living: bathing, dressing, walking, or transferring. Disability was assessed during monthly telephone interviews for a median of 60 months, and participants were classified each month according to the following four states: no disability, mild disability (one or two activities), severe disability (three or four activities), and death. Transitions between states of disability and independence were common, with a majority of both frail and nonfrail participants experiencing at least one transition. The rate of transitions varied greatly among individuals. Nonfrail participants had lower rates of transition from less to more disability, higher rates of transition from more to less disability, and slightly shorter durations of disability. To fully understand the disabling process, investigators and clinicians must consider the episodic and recurrent nature of disability.

Activities of Daily Living↗

PubMed2006

Performance-based physical functioning in African-American and Caucasian women at midlife: considering body composition, quadriceps strength, and knee osteoarthritis.

In 2000, body composition, x-ray-defined knee osteoarthritis, and self-reported knee pain information from a cross-sectional, community-based study of 211 African-American and 669 Caucasian women in southeast Michigan (mean age, 47 years) was related to performance-based physical functioning measures to characterize development of functional limitations. Body composition was assessed with bioelectrical impedance. Functioning measures were gait assessment, timed walk, timed stair climb with and without videography, and isometric quadriceps strength. Knee osteoarthritis was determined by Kellgren-Lawrence score from radiography, whereas knee pain was self-reported. Almost 31% of mid-aged women walked at functionally inadequate speeds, and over 12% walked at speeds considered typical of frailty in older women. Ten percent of women had skeletal muscle mass levels less than a proposed cutpoint for increased physical disability risk in older adults. Gait measures correlates included increasing age, increasing fat mass (in kilograms), knee joint pain, and reduced quadriceps strength. Stair climbing correlates included skeletal muscle mass (in kilograms) and its change, painful knee osteoarthritis, and reduced quadriceps strength. Race differences in walking measures and stair climbing time diminished when the authors accounted for other factors. Compromised physical functioning began earlier than expected, with indications that approximately 12-31% of women might benefit from interventions to forestall future decline.

Adult↗

PubMed2006

Developmental origins of midlife physical performance: evidence from a British birth cohort.

The authors hypothesized that 1) physical growth, as a marker of the early development of muscle fibers, and 2) advanced childhood motor and cognitive abilities, as markers of central nervous system development, would be positively related to midlife standing balance and chair rising, independently of later life experiences. They tested these hypotheses in a representative British sample of 1,374 men and 1,410 women aged 53 years in 1999 with prospective childhood measures of heights and weights, age at first standing and walking, cognitive ability, and motor coordination. Weight gain before age 7 years was positively related to adult performance in men but not women, independently of later body size, social class, physical activity, and health status. Attainment of motor milestones at the modal age and higher scores on tests of cognitive ability and motor coordination were associated with better performance, independently of other factors. This study is the first to show that childhood growth and development affect midlife performance; prevention of disability and frailty in later life may need to start early.

Adolescent↗

PubMed2005

Vinorelbine and prednisone in frail elderly patients with intermediate-high grade non-Hodgkin's lymphomas.

BACKGROUND: Frail patients with non-Hodgkin's lymphoma (NHL) are generally excluded from clinical trials and not even treated. The aim of this study was to evaluate the efficacy and tolerability of vinorelbine and prednisone in frail elderly patients with NHL. PATIENTS AND METHODS: Thirty consecutive frail elderly patients were entered in a phase II study with vinorelbine 25 mg/m2 i.v. on days 1 and 8 and oral prednisone 30 mg total dose on days 1-8 for six cycles. Criteria of frailty were age > or =80 years, or age > or =70 years and three or more comorbidities of grade 3 or at least one comorbidity of grade 4 according to the Cumulative Illness Rating Scale (CIRS), or not self-sufficient or the presence of one or more geriatric syndromes. RESULTS: Of 30 evaluable patients, three (10.0%) achieved a complete response (CR), nine (30.0%) showed a partial response (PR), while 10 presented with stable disease and eight with progressive disease. The median duration of CR was 29 months (range 5-36 months), and the median duration of PR was 1 month (range 1-22 months). Three patients had grade 3 neutropenia and one had grade 4. One grade 4 neurotoxicity was observed. Three patients died because of heart failure within 28 days of therapy, and one patient died after 4 days because of rapid progression. The median overall survival was only 10 months. CONCLUSION: Vinorelbine and prednisone is a relatively non-toxic combination with modest activity in frail patients with NHL. If initial aggressive chemotherapy has been excluded, this combination could be tried to obtain a temporary palliation.

Aged↗

PubMed2000

Joint modelling of longitudinal measurements and event time data.

This paper formulates a class of models for the joint behaviour of a sequence of longitudinal measurements and an associated sequence of event times, including single-event survival data. This class includes and extends a number of specific models which have been proposed recently, and, in the absence of association, reduces to separate models for the measurements and events based, respectively, on a normal linear model with correlated errors and a semi-parametric proportional hazards or intensity model with frailty. Special cases of the model class are discussed in detail and an estimation procedure which allows the two components to be linked through a latent stochastic process is described. Methods are illustrated using results from a clinical trial into the treatment of schizophrenia.

Journal Article↗

PubMed2005

Bayesian latent variable models for mixed discrete outcomes.

In studies of complex health conditions, mixtures of discrete outcomes (event time, count, binary, ordered categorical) are commonly collected. For example, studies of skin tumorigenesis record latency time prior to the first tumor, increases in the number of tumors at each week, and the occurrence of internal tumors at the time of death. Motivated by this application, we propose a general underlying Poisson variable framework for mixed discrete outcomes, accommodating dependency through an additive gamma frailty model for the Poisson means. The model has log-linear, complementary log-log, and proportional hazards forms for count, binary and discrete event time outcomes, respectively. Simple closed form expressions can be derived for the marginal expectations, variances, and correlations. Following a Bayesian approach to inference, conditionally-conjugate prior distributions are chosen that facilitate posterior computation via an MCMC algorithm. The methods are illustrated using data from a Tg.AC mouse bioassay study.

Acrylates↗

PubMed2005

Analysis of clustered recurrent event data with application to hospitalization rates among renal failure patients.

End-stage renal disease (commonly referred to as renal failure) is of increasing concern in the United States and many countries worldwide. Incidence rates have increased, while the supply of donor organs has not kept pace with the demand. Although renal transplantation has generally been shown to be superior to dialysis with respect to mortality, very little research has been directed towards comparing transplant and wait-list patients with respect to morbidity. Using national data from the Scientific Registry of Transplant Recipients, we compare transplant and wait-list hospitalization rates. Hospitalizations are subject to two levels of dependence. In addition to the dependence among within-patient events, patients are also clustered by listing center. We propose two marginal methods to analyze such clustered recurrent event data; the first model postulates a common baseline event rate, while the second features cluster-specific baseline rates. Our results indicate that kidney transplantation offers a significant decrease in hospitalization, but that the effect is negated by a waiting time (until transplant) of more than 2 years. Moreover, graft failure (GF) results in a significant increase in the hospitalization rate which is greatest in the first month post-GF, but remains significantly elevated up to 4 years later. We also compare results from the proposed models to those based on a frailty model, with the various methods compared and contrasted.

Biometry↗

PubMed2005

Multivariate survival analysis for case-control family data.

Multivariate survival data arise from case-control family studies in which the ages at disease onset for family members may be correlated. In this paper, we consider a multivariate survival model with the marginal hazard function following the proportional hazards model. We use a frailty-based approach in the spirit of Glidden and Self (1999) to account for the correlation of ages at onset among family members. Specifically, we first estimate the baseline hazard function nonparametrically by the innovation theorem, and then obtain maximum pseudolikelihood estimators for the regression and correlation parameters plugging in the baseline hazard function estimator. We establish a connection with a previously proposed generalized estimating equation-based approach. Simulation studies and an analysis of case-control family data of breast cancer illustrate the methodology's practical utility.

Age of Onset↗

PubMed2026

New Evidence in Heart Failure: 2026 Update.

Heart failure (HF) remains a major cause of morbidity, mortality, impaired quality of life and healthcare expenditure worldwide. The global burden of HF continues to increase due to population aging, improved survival, and the growing prevalence of cardiovascular, renal, and metabolic comorbidities. Simultaneously, the pace of scientific progress in HF has accelerated considerably. Recent advances have refined our understanding of HF epidemiology, prognosis, and disease trajectories, including emerging concepts of HF improvement, remission, and recovery. The Second Universal Definition of HF has also updated the classification framework, moving beyond the traditional ejection fraction-based categories. HF is now broadly classified into two major phenotypes: heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Novel mechanistic insights highlight the role of inflammation, immune activation, metabolic dysfunction, mitochondrial biology, and multisystem interactions in HF progression. There has also been significant progress in the characterization and management of major comorbidities, including chronic kidney disease (CKD), diabetes, obesity, atrial fibrillation (AF), pulmonary hypertension, frailty, malnutrition, and cancer. Diagnostic innovations include novel biomarkers, multi-omics technologies, artificial intelligence-based approaches, advanced imaging techniques, congestion assessment tools, and emerging digital health solutions. Important advances have occurred in specific HF aetiologies, including cardiomyopathies, cardiac amyloidosis (CA), myocarditis, arrhythmia-induced cardiomyopathy (AiCM), and Chagas cardiomyopathy. Therapeutic developments continue to reshape HF management across the spectrum of left ventricular ejection fraction. Recent evidence has focused on optimization of guideline-directed medical therapy in HFrEF, expansion of evidence-based therapies in HFpEF, and growing roles for sodium-glucose cotransporter-2 inhibitors, finerenone, incretin-based therapies, and transcatheter valve interventions. Collectively, these advances support the transition from a predominantly phenotype-based approach towards a more personalized and biologically informed model of HF care, with the potential to further improve outcomes across the entire HF spectrum.

Journal Article↗

PubMed2006

Influence of LDL-receptor mutation type on age at first cardiovascular event in patients with familial hypercholesterolaemia.

AIMS: To investigate the influence of different LDL-receptor (LDLR) gene mutations on age at first cardiovascular event in familial hypercholesterolaemia (FH) patients. METHODS AND RESULTS: Dutch FH patients (n = 862) with known LDLR mutations from a retrospective cohort study were included. A gamma frailty Cox model was used. An event was defined as the first cardiovascular event. Gender, hypertension, smoking, diabetes, HDL cholesterol, LDL cholesterol (LDL-C), or triglycerides were included as covariates. Furthermore, the effect of LDLR mutation type on LDL and HDL cholesterol levels was investigated using mixed effects models, including gender, smoking, body mass index, and age at time of lipid measurement as covariates. A total of 86 different LDLR mutations were present in this cohort. Twenty-two percent of patients experienced an event (median age: 47.1 year; range: 25.6-85.8 years). The effect of LDLR mutation type on event-free survival is only significant in the models without LDL-C levels. Also, LDLR mutation type was significantly associated with LDL-C levels (P = 0.007), but not with HDL cholesterol levels (P = 0.12). CONCLUSION: In the present study, LDL-C levels are a more important risk factor of event-free survival than the type of LDLR mutation.

Adult↗

PubMed2006

Methods for analysing recurrent events in health care data. Examples from admissions in Ebeltoft Health Promotion Project.

BACKGROUND: Evaluation of health care contacts from first events alone often misses large amounts of potentially important data and may produce different results than evaluation of all data including recurrent events. OBJECTIVE: We aim to bring the different methodological approaches for analysing longitudinal health care data to the attention of researchers in primary care. METHODS: We used hospital admission data from the Ebeltoft Health Promotion Project, a randomized trial in primary care examining the effect of preventive health checks. Comparisons included three randomized groups: an intervention group receiving health checks, a group where intervention consisted of a health check followed by a health discussion with the GP and one control group. RESULTS: Both intervention groups had approximately 20% fewer hospital admissions than the control group over a 6 year period. If dependence among recurrent events is excluded, such a reduction amounts to a highly significant effect. Use of the standard Poisson distribution for analysing recurrent events and exclusion of their dependent structure causes data interpretation to be incorrect, because the model does not account for the extra variability between persons; the resulting 95% CIs would therefore be too small. CONCLUSION: Analysis of health care contacts should embrace both first and recurrent events and it should use a model appropriate to these data. An individual rate model that includes a parameter of an unspecified individual event distribution frailty may be a natural choice when analysing longitudinal data of contacts to the health care system in broad terms.

Denmark↗

PubMed1995

Effects of exercise on body composition and functional capacity of the elderly.

The capacity of older men and women to adapt to regularly performed exercise has been demonstrated by many laboratories. Aerobic exercise results in improvements in functional capacity and reduced risk of developing type II diabetes in the elderly. High-intensity resistance training (above 60% of the 1 repetition maximum) has been demonstrated to cause large increases in strength in the elderly. In addition, resistance training results in significant increases in muscle size in elderly men and women. Resistance training has also been shown to significantly increase energy requirements and insulin action of the elderly. We have recently demonstrated that resistance training has a positive effect on multiple risk factors for osteoporotic fractures in previously sedentary post-menopausal women. Since the sedentary lifestyle of a long-term care facility may exacerbate losses of muscle function, we have applied this same training program to frail, institutionalized elderly men and women. In a population of 100 nursing home residents, a randomly assigned high-intensity strength training program resulted in significant gains in strength and functional status. In addition, spontaneous activity, measured by activity monitors, increased significantly in those participating in the exercise program, while there was no change in the sedentary control group. The fact that significant muscle hypertrophy was seen in this population indicates that age does not decrease the capacity to adapt to a progressive resistance training program. Therefore, exercise may minimize or reverse the syndrome of physical frailty which is so prevalent among the oldest old.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗