Search

ObjectivesThe burden often associated with informal caregiving for patients with dementia is associated with negative effects on health, both physiologically and in terms of caregiver cognition. There is wide variation in the level of burden experienced by dementia caregivers. To better understand caregiver burden, it is thus important to understand the factors associated with level of burden.MethodsIn the current study, we collected carer burden and putative associated factors at baseline, 6 and 12 months. Hierarchical regression was used to assess the impact of these factors on caregiver burden. We assessed self-reported carer burden, patient behavioural and safety issues, and level of difficulty associated with providing assistance with activities of daily living (ADL). Patients’ age was also recorded, and trained nurses assessed patient cognitive performance using the quick mild cognitive impairment screen.ResultsAt baseline, patients’ age, cognition and ADLs were associated with burden, and safety and challenging behaviour were both significantly associated with burden independent of the other factors. Change in burden was associated with change in carer-reported safety at 6-month follow-up, and with change in safety and change in carer-reported challenging behaviours at 12-month follow-up.ConclusionsSafety issues and challenging behaviours are associated with carer burden, even after accounting for cognitive and functional impairment in the person with dementia. As dementia progresses, monitoring these factors may help to inform stress-management strategies for caregivers.

Background The Royal College of Physicians of Ireland and the National Clinical Programme for Older People conducted a national survey of Specialist Geriatric Services (SGS) in 2014. The survey was repeated in 2018-2019 period to collect data on the resources available for the care of older people attending hospitals and associated communities in Ireland. Methods Participants were geriatrician leads or proxies in each hospital in Ireland. Questions based on the 2014 survey were updated to include frailty and dementia-delirium specific questions. Data were collected between September 2018 and April 2019 using an electronic survey. Comments from open-ended questions were analysed using qualitative analysis methods. Results In total, 20 fully complete and 18 incomplete responses were received. Most complete responses were from model 3 or 4 hospitals (n= 14/20). Less than half (47%) reported having a dedicated specialist geriatric ward in their institution. Half (50%) reported currently developing an integrated plan for services for frail older people with complex care needs. Barriers to managing frailty that were identified included limited access to funding and staffing. 82% reported that their group/area/unit/department engaged in case-finding for frailty. The most commonly used frailty-specific screening tools were the CFS (n=9), VIP (n=6), FRAIL scale (n=4), and PRISMA-7 (n=3). A National Frailty Education Programme governance structure was operational in 9/20 sites. Half (50%) reported that their hospital has an integrated pathway for people with dementia and/or delirium, although (82%) stated that their hospital does not formally screen all older people for cognitive impairment in the ED/AMAU, and does not formally screen people at risk for delirium on wards on a daily basis (100%). Conclusion Limited staffing and resources were reported for many aspects of SGS in Ireland. Although frailty and dementia-delirium are recognised as priority areas, there is need for standardised assessment and screening approaches.

Background Multiple instruments are available to screen for frailty in the Emergency Department (ED). Despite this, few studies have compared their predictive validity among older adults attending ED. This study aimed to investigate the diagnostic accuracy of a variety of different short frailty and risk-prediction instruments to predict 30-day readmission, length of stay (LOS), one-year mortality and institutionalisation. Methods Consecutive patients aged ≥70 attending a university hospital ED were screened and assessed for frailty. Outcomes were obtained from hospital records. The following instruments were compared: the Clinical Frailty Scale (CFS), PRISMA-7, Identification of Seniors at Risk tool, FRAIL scale, Groningen Frailty Indicator (GFI) and Risk Instrument for Screening in the Community (RISC). Results In all, 193 patients were included, median age 79+/-9; 55% were female. Based upon a CGA, 60% (116/193) were classified as frail. Those identified as frail were significantly older (p=0.03) and reported lower quality of life scores (p Conclusion Short frailty screening instruments applied in ED have poor-modest predictive validity for important healthcare outcomes, particularly hospital re-admission. The RISC score had the highest diagnostic accuracy for institutionalisation and death but this was fair at best, suggesting that instrument selection should be pragmatic with the expectation of identifying frailty.

Background Urinary incontinence (UI) is defined by the International Continence Society as “any involuntary leakage of urine.” UI can negatively impact patients' physical and mental wellbeing and quality of life. Since older adults constitute a growing hospital population, evaluation and improvement of this patient group's quality of care is recognized as a priority in the study hospital. A continence assessment helps to determine what the problem is and what management is required. This audit aims to determine whether appropriate assessments of continence in older adults presenting to the hospital setting were completed and documented. Methods An audit tool was adapted from the Royal College of Physicians National Continence Audit tool and the hospital's own elimination documentation pathway. On a chosen day a general medical ward and a specialist geriatric medicine ward were assessed. Medical charts, nursing notes, emergency department proforma, frailty intervention team proforma and skin integrity proforma were reviewed. Documentation of continence status, symptoms, type, investigations, continence wear, catheterisation and management were assessed. Continence care plans and evidence of communication/discussion with patients were also assessed. Results Thirty-one sets of documentation were reviewed. Twenty-four patients were aged over 65. Of these patients 12 were male and 12 were female. Four patients had no continence status documented. Forty-two percent of those reviewed over 65 had documented incontinence and of these only 40% had the elimination section of their nursing proforma fully completed. Six of the patients with documented incontinence had their symptoms/type of incontinence documented. Two Patients had urinary catheters, the indications for these catheters were documented Conclusion This audit found that overall the assessment and documentation of continence in older adults was sub-optimal. Based on this audit an assessment tool and education program will be introduced to the specialist geriatric medicine ward with the goal of improving assessment of continence and optimal management.

Background Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent condition before frailty becomes established. Despite this, there is no widely accepted definition of pre-frailty to support its early identification and management. This study applied an international consensus approach to define and better understand pre-frailty. Methods A modified electronic two-round Delphi Consensus study was conducted. In all, 23 experts from 12 countries with different backgrounds participated. The questionnaire was developed following a systematic literature review. An online consensus meeting was conducted with eight Delphi participants and two external experts. Qualitative and quantitative methods were employed for data analysis. An agreement level of 70% was applied for accepting statements. Results A total of 71 statements were circulated in Round 1. Of these, 52.8% were accepted. Fifty-one statements were re-circulated in Round 2, of which 92.1% were accepted. The online consensus meeting produced a consensus statement describing the concept, multi-factorial nature, and mechanism of pre-frailty as well as assessment, prevention and management approaches. All experts agreed that physical and non-physical factors such as psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life outcomes. Practitioners should regard pre-frailty as a multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It might be reversed or attenuated by targeted interventions. Brief, feasible and validated tools are recommended for opportunistic screening or case-finding followed by confirmation with multi-dimensional assessment. Conclusion It is difficult to establish consensus on one compact definition of pre-frailty, which is a multi-dimensional concept not only associated with physical impairment, but also with cognitive, nutritional, socioeconomic and other aspects of frailty. However, it may be too early to agree on an operational definition of pre-frailty since none yet exists for frailty.

Background Frailty is a multi-factorial, age-related syndrome, often defined in terms of accumulation of deficits. This approach uses the proportion of a list of age-associated items (signs, symptoms, diseases, impairments, etc.) available to identify frailty. Some frailty indexes (FI) include more functional aspects than others. This study examines whether functional components and diseases or risk factors predict the same phenomena. Methods Data were included from The Survey of Health, Ageing and Retirement in Europe (SHARE) wave seven for participants age ≥50 years. A 52-item FI was constructed from physical health data with 26 functional and 26 non-functional items. Functional items were obtained from activities of daily living questions (ph048 & ph049), and health-related activity limitation (gali question). Non-functional items were obtained from questions on BMI, self-perceived health, disease/risks (ph006), medication use (sleep, anxiety/depression, osteoporosis), and frailty related symptoms (ph048). Participants missing one or more of the 52 items were excluded. Data were analysed at individual and country-level to assess for significant differences. Results In total, 73,510 (97.3%) participants had complete frailty data available and were included. The mean score for the FI-52 was 0.12 (95% CI: 0.11-0.12). Mean FI scores for the functional and non-functional components were 0.12 (95% CI:0.12-0.12) and 0.11 (95% CI:0.11-0.11), respectively, representing a significant difference (p Conclusion Findings suggest that having more functional items in a frailty index results in significantly higher frailty estimates but this only amounted to an approximately 5% difference. Although moderate-strong correlation was observed, further research is needed to investigate if the proportion of functional components influences risk-prediction at population-level.

Background Sleep disturbance is common in hospital, potentially resulting in poor clinical outcomes. Frailty is similarly prevalent and associated with multiple adverse events. Despite this, little is known about the interaction between frailty and sleep among older hospital inpatients. Methods Consecutive, non-critically ill patients aged ≥70, admitted medically through a large university hospital emergency department (ED) during the preceding 24 hours, were evaluated with measures assessing overnight sleep quality (Richards Campbell Sleep Questionnaire/RCSQ), baseline sleep (Pittsburgh Sleep Quality Index/PSQI) and insomnia (Insomnia Severity Index/ISI). Additional variables included medications, frailty (PRISMA-7 scores ≥3 and Clinical Frailty Scale/CFS scores ≥5), functional and cognitive status, and night-time noise levels. Patients were reassessed 48 hours later. Results Over four weeks, 152 patients, mean age 80 (±6.8) years were included; 61% were male (n=92). In all, 43% were frail (mean CFS score 4.23±1.6), median PRISMA-7 score 4±4; a further 24% were pre-frail. The median Charlson Comorbidity Index score was 6±2. The majority, 72% (110/152), reported impaired baseline sleep quality (PSQI ≥5) and 13% (20/152) had clinical insomnia (ISI ≥15). The median time spent in ED was 23±13 hours, median duration asleep was only one hour (range 0-8). After adjusting for possible confounders, frailty status was significantly associated with lower PSQI (p Conclusion The prevalence of sleep disturbance and clinical insomnia among older adults admitted through ED is high and overnight sleep quality low, although these did not impact on LOS or 30-day re-admission rates. Frail patients reported significantly poorer baseline sleep but did not have higher rates of insomnia or experience worse overnight sleep.

Introduction The prevalence of frailty at population level is unclear. We examined this in population-based studies, investigating sources of heterogeneity. Methods PubMed, Embase, CINAHL and Cochrane Library databases were searched for observational population-level studies published between 1 January 1998 and 1 April 2020, including individuals aged ≥50 years, identified using any frailty measure. Prevalence estimates were extracted independently, assessed for bias and analysed using a random-effects model. Results In total, 240 studies reporting 265 prevalence proportions from 62 countries and territories, representing 1,755,497 participants, were included. Pooled prevalence in studies using physical frailty measures was 12% (95% CI = 11–13%; n = 178), compared with 24% (95% CI = 22–26%; n = 71) for the deficit accumulation model (those using a frailty index, FI). For pre-frailty, this was 46% (95% CI = 45–48%; n = 147) and 49% (95% CI = 46–52%; n = 29), respectively. For physical frailty, the prevalence was higher among females, 15% (95% CI = 14–17%; n = 142), than males, 11% (95% CI = 10–12%; n = 144). For studies using a FI, the prevalence was also higher in females, 29% (95% CI = 24–35%; n = 34) versus 20% (95% CI = 16–24%; n = 34), for males. These values were similar for pre-frailty. Prevalence increased according to the minimum age at study inclusion. Analysing only data from nationally representative studies gave a frailty prevalence of 7% (95% CI = 5–9%; n = 46) for physical frailty and 24% (95% CI = 22–26%; n = 44) for FIs. Conclusions Population-level frailty prevalence varied by classification and sex. Data were heterogenous and limited, particularly from nationally representative studies making the interpretation of differences by geographic region challenging. Common methodological approaches to gathering data are required to improve the accuracy of population-level prevalence estimates. Protocol registration PROSPERO-CRD42018105431.

Introduction: differentiating mild cognitive impairment (MCI) from normal cognition (NC) is difficult. The AB Cognitive Screen (ABCS) 135, sensitive in differentiating MCI from dementia, was modified to improve sensitivity and specificity, producing the quick mild cognitive impairment (Qmci) screen. Objective: this study compared the sensitivity and specificity of the Qmci with the Standardised MMSE and ABCS 135, to differentiate NC, MCI and dementia. Methods: weightings and subtests of the ABCS 135 were changed and a new section ‘logical memory’ added, creating the Qmci. From four memory clinics in Ontario, Canada, 335 subjects (154 with MCI, 181 with dementia) were recruited and underwent comprehensive assessment. Caregivers, attending with the subjects, without cognitive symptoms, were recruited as controls (n = 630). Results: the Qmci was more sensitive than the SMMSE and ABCS 135, in differentiating MCI from NC, with an area under the curve (AUC) of 0.86 compared with 0.67 and 0.83, respectively, and in differentiating MCI from mild dementia, AUC of 0.92 versus 0.91 and 0.91. The ability of the Qmci to identify MCI was better for those over 75 years. Conclusion: the Qmci is more sensitive than the SMMSE in differentiating MCI and NC, making it a useful test, for MCI in clinical practice, especially for older adults.

Introduction: the Qmci is a sensitive and specific test to differentiate between normal cognition (NC), mild cognitive impairment (MCI) and dementia. We compared the sensitivity and specificity of the subtests of the Qmci to determine which best discriminated NC, MCI and dementia. Objective: the objective was to determine the contribution each subtest of the Qmci makes, to its sensitivity and specificity in differentiating MCI from NC and dementia, to refine and shorten the instrument. Methods: existing data from our previous study of 965 subjects, testing the Qmci, was analysed to compare the sensitivity and specificity of the Qmci subtests. Results: all the subtests of the Qmci differentiated MCI from NC. Logical memory (LM) performed the best (area under the receiver operating curve of 0.80), registration the worst, (0.56). LM and verbal fluency had the largest median differences (expressed as percentage of total score) between MCI and NC, 20 and 25%, respectively. Other subtests did not have clinically useful differences. LM was best at differentiating MCI from NC, irrespective of age or educational status. Conclusion: the Qmci incorporates several important cognitive domains making it useful across the spectrum of cognitive impairment. LM is the best performing subtest for differentiating MCI from NC.