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Background and Aim The aim of this systematic review was to quantify the association between frailty and COVID-19 in relation to mortality in hospitalised patients. Methods Medline, Embase, Web of Science and the grey literature were searched for papers from inception to 10 September 2020; the search was re-run in Medline up until the 9 December 2020. Screening, data extraction and quality grading were undertaken by two reviewers. Results were summarised using descriptive statistics, including a meta-analysis of overall mortality; the relationships between frailty and COVID-19 mortality were summarised narratively. Results A total of 2,286 papers were screened resulting in 26 being included in the review. Most studies were from Europe, half from the UK, and one from Brazil; the median sample size was 242.5, median age 73.1 and 43.5% were female. In total, 22/26 used the Clinical Frailty Scale; reported mortality ranged from 14 to 65%. Most, but not all studies showed an association between increasing frailty and a greater risk of dying. Two studies indicated a sub-additive relationship between frailty, COVID-19 and death, and two studies showed no association. Conclusions Whilst the majority of studies have shown a positive association between COVID-19-related death and increasing frailty, some studies suggested a more nuanced understanding of frailty and outcomes in COVID-19 is needed. Clinicians should exert caution in placing too much emphasis on the influence of frailty alone when discussing likely prognosis in older people with COVID-19 illness. [ABSTRACT FROM AUTHOR]

Background: the complex management for patients presenting to hospital with vertebral fragility fractures provides justification for the development of specific services for them. A systematic review was undertaken to determine the incidence of hospital admission, patient characteristics and health outcomes of vertebral fragility fracture patients to inform the development of such a service. Methods: non-randomised studies of vertebral fragility fracture in hospital were included. Searches were conducted using electronic databases and citation searching of the included papers. Results: a total of 19 studies were included. The incidence of hospital admission varied from 2.8 to 19.3 per 10,000/year. The average patient age was 81 years, the majority having presented with a fall. A diagnosis of osteoporosis or previous fragility fracture was reported in around one-third of patients. Most patients (75% men and 78% women) had five or more copathologies. Most patients were managed non-operatively with a median hospital length of stay of 10 days. One-third of patients were started on osteoporosis treatment. Inpatient and 1-year mortality was between 0.9 and 3.5%, and 20 and 27%, respectively, between 34 and 50% were discharged from hospital to a care facility. Many patients were more dependent with activities of daily living on discharge compared to their pre-admission level. Older age and increasing comorbidities was associated with longer hospital stay and higher mortality. Conclusion: these findings indicate that specific hospital services for patients with vertebral fragility fractures should take into consideration local hospitalisation rates for the condition, and should be multifaceted-providing access to diagnostic, therapeutic, surgical and rehabilitation interventions. [ABSTRACT FROM AUTHOR]

Background Optimising timely discharge from hospitals is an international priority. In 2020, the Coronavirus disease 2019 (COVID-19) pandemic resulted in the United Kingdom Government implementing the Discharge to Assess (D2A) model across England. This funded temporary care home placement to allow further recovery and assessment of care needs outside of the hospital. Objectives Determine if older adults discharged from hospital to care homes after implementation of D2A differ in their characteristics or outcomes. Design and methods Two cohorts of older adults discharged from hospital to care homes pre- and post-implementation of the D2A model (n  = 244), with 6 months of follow-up. Data were extracted from routinely collected healthcare records. Results The mean duration of the hospital admission was reduced (29 vs. 23 days (P  = 0.02)) but discharges to care homes did not increase with implementation of D2A (n  = 161 in both cohorts prior to exclusions). In July–December 2020 (post-implementation), 28% of people were living in a private residence 6 months post-discharge, compared with 18% in the same period in 2019 (P  = 0.09). When those who died were excluded, this changed to 40 vs. 28% (P  = 0.19). There was no change in 6-month mortality (26 vs. 35% (P  = 0.17)), and no increase in readmission rate (0.48 vs. 0.63 (P  = 0.21) readmissions-per-patient over 6 months). No differences in key characteristics were found. However, patients were placed in care homes further from admission addresses (17.3 vs. 9.8 km (P  = 0.00001)). Conclusions Implementation of D2A did not result in poorer outcomes but was associated with a reduced length of hospital stay. [ABSTRACT FROM AUTHOR]

Background low mobility of hospitalised older adults is associated with adverse outcomes and imposes a significant burden on healthcare and welfare systems. Various interventions have been developed to reduce this problem; at present, however, their methodologies and outcomes vary and information is lacking about their long-term sustainability. This study aimed to evaluate the 2-year sustainability of the WALK-FOR (walking for better outcomes and recovery) intervention implemented by teams in acute care medical units. Methods a quasi-experimental three-group comparative design (N  = 366): pre-implementation, i.e. control group (n  = 150), immediate post-implementation (n  = 144) and 2-year post-implementation (n  = 72). Results mean participant age was 77.6 years (± 6 standard deviation [SD]) and 45.3% were females. We conducted an analysis of variance test to evaluate the differences in primary outcomes: number of daily steps and self-reported mobility. Levels of mobility improved significantly from the pre-implementation (control) group to the immediate and 2-year post-implementation groups. Daily step count: pre-implementation (median: 1,081, mean: 1,530 SD = 1,506), immediate post-implementation (median: 2,225, mean: 2,724. SD = 1,827) and 2-year post-implementation (median: 1,439, mean: 2,582, SD = 2,390) F  = 15.778 P  < 0.01. Self-reported mobility: pre-implementation (mean:10.9, SD = 3.5), immediate post-implementation (mean: 12.4, SD = 2.2), 2-year post-implementation (mean: 12.7, SD = 2.2), F  = 16.250, P  < 0.01. Conclusions the WALK-FOR intervention demonstrates 2-year sustainability. The theory-driven adaptation and reliance on local personnel produce an effective infrastructure for long-lasting intervention. Future studies should evaluate sustainability from a wider perspective to inform further in-hospital intervention development and implementation. [ABSTRACT FROM AUTHOR]

Background the aim of this systematic review and meta-analysis was to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints. Methods MEDLINE, CINAHL, CENTRAL and Embase databases were systematically searched from 2008 to February 2022. Screening, data extraction and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence. The primary outcome was incidence of functional decline between baseline 2-week prehospital admission status and discharge and at follow-up. Results 11 trials recruiting 7,496 participants across three countries were included. AGU care resulted in a reduction in functional decline at 6-month follow-up (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.66–0.93; moderate certainty evidence) and an increased probability of living at home at 3-month follow-up (RR 1.06, 95% CI 0.99–1.13; high certainty evidence). AGU care resulted in little or no difference in functional decline at hospital discharge or at 3-month follow-up, length of hospital stay, costs, the probability of living at home at discharge, mortality, hospital readmission, cognitive function or patient satisfaction. Conclusions AGU care improves clinical and process outcomes for hospitalised older adults with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures. [ABSTRACT FROM AUTHOR]

Objective to evaluate the sensitivity, specificity and test–retest reliability of the Delirium Early Monitoring System-Delirium Observation Screening Scale (DEMS-DOSS). Design prospective diagnostic accuracy study of a convenience sample of admitted older adults with DEMS-DOSS and reference standard assessments. Setting 60-bed aged care precinct at a metropolitan hospital in Sydney, Australia. Participants 156 patients (aged ≥65 years old) were recruited to participate between April 2018 and March 2020. One hundred participants were included in the analysis. Measurements Participants were scored on the DEMS-DOSS. Trained senior aged care nurses conducted a standardised clinical interview based on the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV delirium criteria, within two hours of DEMS-DOSS completion. The senior aged care nurse undertaking the DSM-IV interview was blinded to the results of the DEMS-DOSS. Results Participants' mean age was 84 (SD ±7.3) years and 39% (n  = 39) had a documented diagnosis of dementia. Delirium was detected in 38% (n  = 38) according to the reference standard. The DEMS-DOSS had a sensitivity of 76.3% and a specificity of 75.8% for delirium. The area under the receiver operating characteristics curve for delirium was 0.76. The test–retest reliability of the DEMS-DOSS was found to be high (r  = 0.915). Conclusion DEMS-DOSS is a sensitive and specific tool to assist with monitoring new onset and established delirium in hospitalised older adults. Further studies are required to evaluate the impact of the monitoring tool on health outcomes. [ABSTRACT FROM AUTHOR]

Objective to investigate the effect of potentially inappropriate medications (PIMs) on inpatient falls and to identify whether PIMs as defined by STOPPFall or the designated section K for falls of STOPP v2 have a stronger association with inpatient falls when compared to the general tool STOPP v2. Methods a retrospective observational matching study using an electronic health records dataset of patients (≥70 years) admitted to an academic hospital (2015–19), including free text to identify inpatient falls. PIMs were identified using the STOPP v2, section K of STOPP v2 and STOPPFall. We first matched admissions with PIMs to those without PIMs on confounding factors. We then applied multinomial logistic regression analysis and Cox proportional hazards analysis on the matched datasets to identify effects of PIMs on inpatient falls. Results the dataset included 16,678 hospital admissions, with a mean age of 77.2 years. Inpatient falls occurred during 446 (2.7%) admissions. Adjusted odds ratio (OR) (95% confidence interval (CI)) for the association between PIM exposure and falls were 7.9 (6.1–10.3) for STOPP section K, 2.2 (2.0–2.5) for STOPP and 1.4 (1.3–1.5) for STOPPFall. Adjusted hazard ratio (HR) (95% CI) for the effect on time to first fall were 2.8 (2.3–3.5) for STOPP section K, 1.5 (1.3–1.6) for STOPP and 1.3 (1.2–1.5) for STOPPFall. Conclusions we identified an independent association of PIMs on inpatient falls for all applied (de)prescribing tools. The strongest effect was identified for STOPP section K, which is restricted to high-risk medication for falls. Our results suggest that decreasing PIM exposure during hospital stay might benefit fall prevention, but intervention studies are warranted. [ABSTRACT FROM AUTHOR]

Background identifying drug-related hospital admissions (DRAs) in older people is difficult. A standardised chart review procedure has recently been developed. It includes an adjudication team (physician and pharmacist) screening using 26 triggers and then performing causality assessment to determine whether an adverse drug event (ADE) occurred (secondary to an adverse drug reaction, overuse, misuse or underuse) and whether the ADE contributed to hospital admission (DRA). Objective to assess the performance of those triggers in detecting DRA. Design retrospective study using data from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people) trial. Settings four European medical centres. Subjects multimorbid (≥ 3 chronic medical conditions) older (≥ 70 years) inpatients with polypharmacy (≥ 5 chronic medications) were enrolled in the OPERAM trial (N  = 2,008) and followed for 12 months. We included patients with ≥1 adjudicated hospitalisation during the follow-up. Methods the positive predictive value (PPV; number of DRAs identified by trigger/number of triggers) was calculated for each trigger and for the tool as a whole. Results of 1,235 hospitalisations adjudicated for 832 patients, 716 (58%) had at least one trigger; an ADE was identified in 673 (54%) and 518 (42%) were adjudicated as DRAs. The overall PPV of the trigger tool for detecting DRAs was 0.66 [0.62–0.69]. Conclusions this tool performs well for identifying DRAs in older people. Based on our results, a revised version of the tool was proposed but will require external validation before it can be incorporated into research and clinical practice. [ABSTRACT FROM AUTHOR]

Introduction Hospitalization is associated with acute changes in sarcopenia status in older people, but the influencing factors are not fully understood. Pre-admission care dependency level as a risk factor has not yet been investigated. Objective Evaluate if pre-admission care dependency level is an independent predictor of sarcopenia changes following hospitalization. Setting and subjects Data came from the Sarcopenia 9+ EAMA Project, a European prospective multi-centre study. For this study, 227 hospitalised older people were included from four different hospitals in Belgium, Spain and Poland, between 18 February 2019 and 5 September 2020. Methods Sarcopenia status at admission and discharge were calculated using a combined score (desirability value) based on muscle mass (calf circumference), strength (grip) and function (walking speed). Ratio of admission to discharge status was the outcome (desirability ratio; 1.00 meaning no difference). Predictor variable was the pre-admission care dependency level, classified into three groups: independent older people living at home, dependent older people living at home and older people living in a care home. Linear regression models were applied, considering potential confounders. Results Mean desirability ratio for dependent older people living at home ('middle dependent group') was lower (0.89) compared to independent older people (0.98; regression coefficient −0.09 [95% CI −0.16, −0.02]) and care home patients (1.05; −0.16 [95% CI −0.01, −0.31]). Adjusting for potential confounders or using another statistical approach did not affect the main results. Conclusion Dependent older people living at home were at higher risk of deterioration in sarcopenia status following hospitalization. In-depth studies investigating causes and potential interventions of these findings are needed. [ABSTRACT FROM AUTHOR]

Background Acute hospitalisation and delirium have individually been shown to adversely affect trajectories of cognitive decline but have not previously been considered together. This work aimed to explore the impact on cognition of hospital admission with and without delirium, compared to a control group with no hospital admissions. Methods The Delirium and Cognitive Impact in Dementia (DECIDE) study was nested within the Cognitive Function and Ageing Study II (CFAS II)–Newcastle cohort. CFAS II participants completed two baseline interviews, including the Mini-Mental State Examination (MMSE). During 2016, surviving participants from CFAS II–Newcastle were recruited to DECIDE on admission to hospital. Participants were reviewed daily to determine delirium status. During 2017, all DECIDE participants and age, sex and years of education matched controls without hospital admissions during 2016 were invited to repeat the CFAS II interview. Delirium was excluded in the control group using the Informant Assessment of Geriatric Delirium Scale (i-AGeD). Linear mixed effects modelling determined predictors of cognitive decline. Results During 2016, 82 of 205 (40%) DECIDE participants had at least one episode of delirium. At 1 year, 135 of 205 hospitalised participants completed an interview along with 100 controls. No controls experienced delirium (i-AGeD>4). Delirium was associated with a faster rate of cognitive decline compared to those without delirium (β = −2.2, P  < 0.001), but number of hospital admissions was not (P  = 0.447). Conclusions These results suggest that delirium during hospitalisation rather than hospitalisation per se is a risk factor for future cognitive decline, emphasising the need for dementia prevention studies that focus on delirium intervention. [ABSTRACT FROM AUTHOR]

Background although frailty and delirium are among the most frequent and burdensome geriatric syndromes, little is known about their association and impact on short-term mortality. Objective to examine, in hospitalized older persons, whether frailty is associated with delirium, and whether these two conditions, alone or in combination, affect these patients' 30-day survival. Design observational study nested in the Delirium Day project, with 30-day follow-up. Setting acute medical wards (n  = 118) and rehabilitation wards (n  = 46) in Italy. Subjects a total of 2,065 individuals aged 65+ years hospitalized in acute medical (1,484 patients, 71.9%) or rehabilitation (581 patients, 28.1%) wards. Methods a 25-item Frailty Index (FI) was created. Delirium was assessed using the 4AT test. Vital status was ascertained at 30 days. Results overall, 469 (22.7%) patients experienced delirium on the index day and 82 (4.0%) died during follow-up. After adjustment for potential confounders, each FI score increase of 0.1 significantly increased the odds of delirium (odds ratio, OR: 1.66 [95% CI: 1.45–1.90]), with no difference between the acute (OR: 1.65 [95% CI: 1.41–1.93]) and rehabilitation ward patients (OR: 1.71 [95% CI: 1.27–2.30]). The risk of dying during follow-up also increased significantly for every FI increase of 0.1 in the overall population (OR: 1.65 [95% CI: 1.33–2.05]) and in the acute medical ward patients (OR: 1.61 [95% CI: 1.28–2.04]), but not in the rehabilitation patients. Delirium was not significantly associated with 30-day mortality in either hospital setting. Conclusions in hospitalized older patients, frailty is associated with delirium and with an increased risk of short-term mortality. [ABSTRACT FROM AUTHOR]

Background while the HIV epidemic remains a considerable challenge in sub-Saharan Africa, a dramatic reduction in the associated mortality has led to a fundamental shift in the public health priorities aimed at tackling multimorbidity. Against the unprecedented level of urbanisation taking place in Tanzania, the burden of multimorbidity and its consequences among ageing adults, in the form of costly inpatient hospitalisation, remain unquantified. Methods we used data from one of Africa's largest urban population cohort, the Dar es Salaam Health and the Demographic Surveillance System, to quantity the extent of multimorbidity (occurrence of 2 ≥ health conditions) and discordant multimorbidity (occurrence of conditions in 2 ≥ domains in mental health, non-communicable and communicable health) among 2,299 adults aged ≥40 years in Dar es Salaam, Tanzania. We fitted logistic regression models to investigate the association between multimorbidity and inpatient hospitalisation. Results the prevalence of multimorbidity and discordant multimorbidity were 25.3 and 2.5%, respectively. Although the severe forms of multimorbidity (2.0% with ≥4 health conditions) and discordancy were low, hospitalisation was significantly higher based on the regression analyses. Household food insecurity was the only socio-economic variable that was significantly and consistently associated with a greater hospitalisation. Conclusion we found an alarmingly high degree of multimorbidity among this ageing urban population where hospitalisation was driven by multimorbidity. As public health resources remain scarce, reducing costly inpatient hospitalisation requires multilevel interventions that address clinical- and structural-level challenges (e.g. food insecurity) to mitigate multimorbidity and promote long-term healthy independent living among older adults in Tanzania. [ABSTRACT FROM AUTHOR]

Introduction Hyponatraemia is associated with increased morbidity and mortality; the aetiology and outcomes of hyponatraemia in older patients have not been defined in prospective studies. Methods A single-centre 9-month prospective observational study in which clinical outcomes in hospitalised patients ≥ 65 years (older patients with hyponatraemia (OP-HN)) and those <65 years (young patients with hyponatraemia (YP-HN)) with hyponatraemia were analysed, and compared with eunatraemic controls (older patients with normonatraemia (OP-NN) and young patients with normonatraemia (YP-NN)). Results In total, 1,321 episodes of hyponatraemia in 1,086 patients were included; 437 YP-HN, median age 54 years (IQR 44,60) and 884 OP-HN, median age 77 years (IQR 71,82). A total of 1,120 consecutive eunatraemic control patients were simultaneously recruited; 690 OP-NN, median age 77 years (IQR 71,83) and 430 YP-NN, median age 52 years (IQR 41,58). Euvolaemic hyponatraemia was the commonest cause of hyponatraemia in both age groups (48% in YP-HN and 46% in OP-HN). Sixty-two percent of OP-HN received hyponatraemia-directed treatment within the initial 48 h, compared with 55% of YP-HN, P  = 0.01. Despite the greater treatment rates in OP-HN, younger patients were 24% more likely to be discharged with normal plasma sodium concentration (pNa) compared with older patients, relative risk (RR) 1.24 (95% confidence interval (CI) 1.12–1.37), P  < 0.001. Using OP-NN as the reference group, the RR of in-hospital death in OP-HN was 2.15 (95% CI 1.3–3.56), P  = 0.002. Using YP-NN as the reference group, the RR of in-hospital death in YP-HN was 4.34 (95% CI 1.98–9.56), P  < 0.001. Conclusion Despite greater rates of HN-targeted treatment, the risk of in-hospital death is increased in older hyponatraemic patients compared with older eunatraemic controls. The impact of hyponatraemia on mortality is even greater in younger patients. [ABSTRACT FROM AUTHOR]

Background During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome have been conflicting. Objective The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands. Methods This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality. Results A total of 1,376 patients were included (median age 78 years (interquartile range 74–84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6–9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1–3, patients with CFS 4–5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3–3.0)) and patients with CFS 6–9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8–4.3)). Conclusions The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms. [ABSTRACT FROM AUTHOR]

Background Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce. Objectives To estimate the prevalence of LC among older patients admitted to acute medical wards and to assess the main clinical characteristics of LC along with its association with major clinical outcomes and to explore the possibility that well-distinguished phenotypic profiles of LC have classificatory and prognostic properties. Methods A cohort of 6,193 older subjects hospitalised between 2010 and 2018 and included in the REPOSI registry was analysed. Results LC was diagnosed in 315 patients (5%). LC was associated with rehospitalisation (age–sex adjusted hazard ratio, [aHR] 1.44; 95% CI, 1.10–1.88) and with mortality after discharge, independently of all confounders (multiple aHR, 2.1; 95% CI, 1.37–3.22), but not with in-hospital mortality and incident disability. Three main clinical phenotypes of LC patients were recognised: relatively fit subjects (FIT, N = 150), subjects characterised by poor social support (PSS, N = 89) and, finally, subjects with disability and multimorbidity (D&M, N = 76). PSS subjects had an increased incident disability (35% vs 13%, P  < 0.05) compared to FIT. D&M patients had a higher mortality (in-hospital: 12% vs 3%/1%, P  < 0.01; post-discharge: 41% vs 12%/15%, P  < 0.01) and less rehospitalisation (10% vs 32%/34%, P  < 0.01) compared to PSS and FIT. Conclusions LC has a relatively low prevalence in older hospitalised subjects but, when present, accounts for worse post-discharge outcomes. Phenotypic analysis unravelled the heterogeneity of LC older population and the association of selected phenotypes with different clinical and prognostic features. [ABSTRACT FROM AUTHOR]

Background Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing. Objectives To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards. Research design Retrospective cohort. Participants All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months. Measures The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI. Results 12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84–0.97]): 15% in patients with CI (OR 0.85 [0.74–0.98]) and 7% in patients without (OR 0.93 [0.85–1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI. Conclusions Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration. [ABSTRACT FROM AUTHOR]

Background Frailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, comorbid adults. Awareness of atypical presentations is critical to facilitate early identification. Objective To assess how frailty affects presenting COVID-19 symptoms in older adults. Design Observational cohort study of hospitalised older patients and self-report data for community-based older adults. Setting Admissions to St Thomas' Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application. Subjects Hospital cohort: patients aged 65 and over (n  = 322); unscheduled hospital admission between 1 March 2020 and 5 May 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n  = 535); reported test-positive for COVID-19 from 24 March (application launch) to 8 May 2020. Methods Multivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19. Results Hospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults and fatigue and shortness of breath. Conclusions This is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium. [ABSTRACT FROM AUTHOR]

Background: delirium and dementia are common in the general hospital, being present in nearly 50% of older unselected admissions to hospital. Cognitive impairment is a risk factor for delirium, but the prevalence of previously undiagnosed cognitive impairment (dementia or mild cognitive impairment) in patients with delirium is unknown. Methods: we performed a prospective cohort study of people over 70 years admitted to hospital with delirium to establish the prevalence of previously unrecognised prior cognitive impairment. Delirium was diagnosed at baseline using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Mild cognitive impairment and dementia were diagnosed 3 months following recruitment in survivors using the International Working Group on Mild Cognitive Impairment criteria and DSM- IV criteria, respectively. Results: delirium was identified in 17.9% of older patients, and 82 participants with delirium were assessed at 3 months: 5 (6%) had persistent delirium, 14 (17%) had mild cognitive impairment and 47 (57%) had dementia. In 17 participants with prior dementia and 14 with prior mild cognitive impairment, the diagnosis had been unrecognised, amounting to 31/82 (38%) of all patients with delirium having some form of previously undiagnosed cognitive impairment. Conclusion: given that over 1/3 of older patients with delirium were found to have a previously undiagnosed cognitive impairment, the development and evaluation of services to follow-up and manage patients with delirium are warranted. [ABSTRACT FROM AUTHOR]

Background: delirium and dementia co-exist commonly in hospital. Older people with delirium have high rates of undiag-nosed dementia, but delirium affects the use of cognitive testing in dementia diagnosis. Novel methods to detect dementia in delirium are needed. The purpose of the study was to investigate the diagnostic test accuracy of informant tools to detect dementia in hospitalised older people with delirium. Methods: the presence of dementia on admission was assessed using the short form of the Informant Questionnaire of Cognitive Decline in the Elderly (IQCODE-SF) and Alzheimer's Disease 8 (AD8) in people over 70 years old with delirium. Reference standard diagnosis was made using Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria at 3 months. The main outcome measures were the diagnostic test accuracy of the IQCODE-SF and the AD8 in diagnosing DSM-IV dementia. Results: dementia prevalence at 3 months was 61 %. The area under the receiver operating characteristic curve (AUROC) was 0.93 (P< 0.0005) for admission IQCODE-SF and 0.91 (P< 0.0005) for admission AD8. An IQCODE-SF test result of >3.82 on admission had a sensitivity of 0.91 (0.79-0.97) and specificity of 0.93 (0.76-0.99) for detecting dementia. An AD8 of >6 had a sensitivity of 0.83 (0.69-0.92) and specificity of 0.90 (0.72-0.97) for detecting dementia. Conclusion: the IQCODE-SF and AD8 are sensitive and specific tools to detect prior dementia in older people with delirium. The routine use of either tool in practice could have important clinical impact, by improving the recognition and hence management of those with dementia. [ABSTRACT FROM AUTHOR]

Introduction: global population projections forecast large growth in demand for long-term care (LTC) and acute hospital services for older people. Few studies report changes in hospitalisation rates before and after entry into LTC. This study compares hospitalisation rates 1 year before and after LTC entry. Methods: the Older Persons' Ability Level (OPAL) study was a 2008 census-type survey of LTC facilities in Auckland, New Zealand. OPAL resident hospital admissions and deaths were obtained from routinely collected national databases. Results: all 2,244 residents (66% = female) who entered LTC within 12 months prior to OPAL were included. There were 3,363 hospitalisations, 2,424 in 12 months before and 939 in 12 months after entry, and 364 deaths. In the 6 to 12 months before LTC entry, the hospitalisation rate/100 person-years was 67.3 (95% confidence interval [CI] 62.5-72.1). Weekly rates then rose steeply to over 450/100 person-years in the 6 months immediately before LTC entry. In the 6 months after LTC entry, the rate fell to 49.1 (CI 44.9-53.3; RR 0.73 (CI 0.65-0.82, P < 0.0001)) and decreased further 6 to 12 months after entry to 41.1 (CI 37.1-45.1; rate ratio [RR] 0.61 (CI 0.54-0.69, P< 0.0001)). Conclusions: increased hospitalisations a few months before LTC entry suggest functional and medical instability precipitates LTC entry. New residents utilise hospital beds less frequently than when at home before that unstable period. Further research is needed to determine effective interventions to avoid some hospitalisations and possibly also LTC entry. [ABSTRACT FROM AUTHOR]

Background: screening for frailty might help to prevent adverse outcomes in hospitalised older adults.Objective: to identify the most predictive and efficient screening tool for frailty.Design and setting: two consecutive observational prospective cohorts in four hospitals in the Netherlands.Subjects: patients aged ≥70 years, electively or acutely hospitalised for ≥2 days.Methods: screening instruments included in the Dutch Safety Management Programme [VeiligheidsManagementSysteem (VMS)] on four geriatric domains (ADL, falls, undernutrition and delirium) were used and the Identification of Seniors At Risk, the 6-item Cognitive Impairment Test and the Mini-Mental State Examination were assessed. Three months later, adverse outcomes including functional decline, high-healthcare demand or death were determined. Correlation and regression tree analyses were performed and predictive capacities were assessed.Results: follow-up data were available of 883 patients. All screening instruments were similarly predictive for adverse outcome (predictive power 0.58–0.66), but the percentage of positively screened patients (13–72%), sensitivity (24–89%) and specificity (35–91%) highly differed. The strongest predictive model for frailty was scoring positive on ≥3 VMS domains if aged 70–80 years; or being aged ≥80 years and scoring positive on ≥1 VMS domains. This tool classified 34% of the patients as frail with a sensitivity of 68% and a specificity of 74%. Comparable results were found in the validation cohort.Conclusions: the VMS-tool plus age (VMS+) offers an efficient instrument to identify frail hospitalised older adults at risk for adverse outcome. In clinical practice, it is important to weigh costs and benefits of screening given the rather low-predictive power of screening instruments. [ABSTRACT FROM PUBLISHER]

Background: prognostication for frail older adults is complex, especially when they become seriously ill.Objectives: to test the measurement properties, especially the predictive validity, of a frailty index based on a comprehensive geriatric assessment (FI-CGA) in an acute care setting in relation to the risk of death, length of stay and discharge destination.Design and setting: prospective cohort study. Inpatient medical units in a teaching, acute care hospital.Subjects: individuals on inpatient medical units in a hospital, n = 752, aged 75+ years, were evaluated on their first hospital day; to test reliability, a subsample (n = 231) was seen again on Day 3.Measurements: all frailty data collected routinely as part of a CGA were used to create the FI-CGA. Mortality data were reviewed from hospital records, claims data, Social Security Death Index and interviews with Discharge Managers.Results: thirty-day mortality was 93 (12.4%; 95% confidence interval (CI) = 10–15%) of whom 52 died in hospital. The risk of dying increased with each 0.01 increment in the FI-CGA: hazard ratio (HR) = 1.05, (95% CI = 1.04–1.07). People who were discharged home had the lowest admitting mean FI-CGA = 0.38 (±standard deviation 0.11) compared with those who died, FI-CGA = 0.51 (±0.12) or were discharged to nursing home, FI-CGA = 0.49 (±0.11). Likewise, increasing FI-CGA values on admission were significantly associated with a longer length of hospital stay.Conclusions: frailty, measured by the FI-CGA, was independently associated with a higher risk of death and other adverse outcomes in older people admitted to an acute care hospital. [ABSTRACT FROM PUBLISHER]

Background: hospitalised older people are at risk for poor functioning after hospital discharge. We aimed to validate the predictive ability of the Identification Seniors At Risk-Hospitalized Patients (ISAR-HP) screening questionnaire to identify older patients at risk for functional dependence by comparing groups with different ISAR-HP scores on cognitive and physical functioning, mortality, health-related quality of life (HRQoL) and loneliness.Design: a longitudinal prospective cohort study.Setting: a 450-bed hospital in the Netherlands.Subjects: four hundred and sixty patients 65 years or older admitted between June 2010 and October 2010.Methods: participants were classified into five risk groups at hospital admission using the ISAR-HP. We interviewed patients at hospital admission and at 3 and 12 months after admission using validated questionnaires to score HRQoL, physical functioning, cognitive functioning and loneliness. Differences in survival were quantified by a concordance statistic (c).Results: cognitive functioning, physical functioning, loneliness and HRQoL differed significantly between groups during the 1-year follow-up after hospital admission (all comparisons P < 0.05), with high-risk groups having lower scores than low-risk groups for functioning and loneliness, although not always for HRQoL. The lowest risk group (ISAR-HP = 0) scored consistently higher on functioning and HRQoL than all other groups. Mortality differed significantly between groups (P < 0.001, c = 0.67).Conclusions: the ISAR-HP can readily distinguish well-functioning older patients from patients with low functioning and low HRQoL after hospital admission. The ISAR-HP may hence assist in selecting patients who may benefit from individually tailored reactivation treatment that is provided next to treatment of their medical condition. [ABSTRACT FROM AUTHOR]

Objective: Dementia is common and often undiagnosed. Improving rates of diagnosis has become a key part of current dementia guidelines. Older people admitted to hospital are a potential target population for screening for dementia. The objective was to report whether instruments advocated in screening for dementia had been validated in hospital inpatients and to make recommendations on evidence-based screening for dementia in this population.Design: a systematic review was performed by an initial electronic database search using three key search criteria. Studies were then selected in a systematic fashion using specific predetermined criteria. Pooled meta-analysis was performed. Inclusion criteria were studies where the study group were inpatients in general hospitals, including a clearly defined group of older people (60 or older), they used a recognised screening instrument compared with a reference standard, and included at least 10 cases of dementia. Demographic data as well as sensitivity and specificity were recorded from the selected studies.Results: in total nine studies describing validation of six discreet instruments satisfied all our criteria and we were able to perform meta-analysis with one instrument, the Abbreviated Mental Test Score (AMTS). With a cut-off of <7, pooled analysis of the AMTS showed a sensitivity of 81%, a specificity of 84% and an area under the curve (AUC) of 0.88.Conclusion: a small number of instruments have been validated for screening for dementia in general hospital. Understanding strengths and weaknesses of currently available instruments allows informed decisions about screening in this setting. [ABSTRACT FROM AUTHOR]

Background: inpatient falls are an important safety challenge, with around half causing physical injuries that compromise the recovery of older, frailer patients. Falls risk scores are in widespread use, but validation studies of their predictive values are few.Objectives: to assess the predictive values of the Morse falls score (MFS) in an acute general hospital.Methods: age, admitting speciality, MFS, and any falls in the subsequent 7 days were collected in April 2011 through case note review and incident reporting systems.Results: a total of 467 inpatients were included in the study; 51% were aged 75+ years; 56% had an MFS ≥25; 23% had an MFS ≥55; 28 fell. An MFS ≥25 was not significantly better than chance in the total sample or in any subgroups considered (YI: −0.01 to 0.15). An MFS ≥55 was significantly better than chance for the total sample (YI: 0.39), patients ≥75 years (YI: 0.31) and geriatrician-led wards (YI 0.37), although either sensitivity or specificity fell below 70% in each of these groups. Other subgroups did not demonstrate significantly better accuracy than chance, but may have been affected by type II error.Conclusions: using MFS ≥25 cannot be clinically justified, while using MFS ≥55 would be contingent on an effective intervention that was ethically acceptable to withhold from the patients with an MFS < 55, despite >40% of falls occurring in that group. Given similar limitations of alternative falls risk scores, hospitals should consider directly assessing and acting on individual patients' specific modifiable risk factors for falls. [ABSTRACT FROM PUBLISHER]

Objective: to examine whether the Danish 1905 cohort members had more active hospital treatment than the 1895 cohort members from ages 85 to 99 years and whether it results in higher in-hospital and post-operative mortality.Methods: in the present register-based follow-up study the complete Danish birth cohorts born in 1895 (n = 12,326) and 1905 (n = 15,477) alive and residing in Denmark at the age of 85 were followed from ages 85 to 99 years with regard to hospitalisations and all-cause and cause-specific surgical procedures, as well as in-hospital and post-operative mortality.Results: the 1905 cohort members had more frequent hospital admissions and operations, but they had a shorter length of hospital stay than the 1895 cohort at all ages from 85 to 99 years. The increase in primary prosthetic replacements of hip joint was observed even within the 1895 cohort: no patients were operated at ages 85–89 years versus 2.2–3.6% at ages 95–99 years. Despite increased hospitalisation and operation rates, there was no increase in post-operative and in-hospital mortality rates in the 1905 cohort. These patterns were similar among men and women.Conclusions: the observed patterns are compatible with more active treatment of the recent cohorts of old-aged persons and reduced age inequalities in the Danish healthcare system. No increase in post-operative mortality suggests that the selection of older patients eligible for a surgical treatment is likely to be based on the health status of old-aged persons and the safety of surgical procedures rather than chronological age. [ABSTRACT FROM PUBLISHER]