Frail Elderly Persons Research Articles

The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status.

To estimate the prevalence of malnutrition in frail elders undergoing rehabilitation and the association between their nutritional status and physical function. Observational study of new participants undergoing ambulatory rehabilitation. Two Geriatric Day Hospitals (GDH) in Montreal, Quebec. 121 women and 61 men. Evaluation of nutritional status, body composition and physical function. The nutritional status was assessed with a composite index based on anthropometric measurements and serum albumin, as well as using the Mini Nutritional Assessment (MNA) questionnaire. Patients were classified as well-nourished, having mild/at risk of malnutrition or malnourished. Body composition was estimated by bioimpedance and handgrip strength and gait speed by standard methods. 13% of patients were found to be mildly malnourished, whereas 6% were malnourished. Malnourished patients were older and had worse cognition, lower BMI, and % body fat (all p<0.05). Malnourished patients and those with mild malnutrition had lower weight, triceps skinfold thickness, muscle and fat mass (all, p<0.003). Handgrip strength was different according to the nutritional status (p=0.034) and correlated with muscle mass (r=0.65, p<0.001). MNA classified 53% of patients as being at risk whereas 3% were malnourished and it correlated with gait speed (r=0.26, p=0.001). There is a high prevalence of patients in GDH at risk or with mild malnutrition. Being malnourished was associated with worse physical performance, which suggests that a nutritional intervention may be of benefit in improving their physical function.

Prevention of progression to dementia in the elderly: rationale and proposal for a health-promoting memory consultation (an IANA Task Force).

Alzheimer's disease (AD) is the most frequent form of dementia and according to the most recent estimation it affects nearly 27 million people in the world. The onset of the disease is generally insidious. It is becoming increasingly evident that the underlying pathophysiological mechanisms are active long before the appearance of the clinical symptoms of the disease. In the current context, it is important to develop strategies to delay the onset of cognitive decline. Delaying the onset by 5 years would reduce the prevalence by half at term, and a delay of 10 years would reduce it by three-quarters. The effectiveness of currently suggested preventive approaches remains to be confirmed, but certain strategies could be applied straight away to at-risk subjects. We propose that a health-promoting memory consultation should be set up for elderly persons who have attended a specialized memory consultation and in whom the diagnosis of dementia and of AD in particular, has not been established by standardized tools. Through this consultation, they would be offered full multidimensional investigation of all aspects of their health status, follow-up could be organized, general practitioners in private practice could be made more conscious of this population and the elderly could be made more aware of the risk factors to which they are exposed. The development of an information policy for the elderly would meet a present need. In our reflection, we must take into account the question of how to give this preventive consultation its due place in the healthcare pathway of the elderly person in order to ensure coordinated follow-up with all the other health professionals involved. The principle of the health-promoting memory consultation is undergoing validation in a large French multicentre preventive trial in 1200 frail elderly persons aged 70 years followed for three years, the Multidomain Alzheimer Preventive Trial (MAPT).

Arch support use for improving balance and reducing pain in older adults

Purpose The purpose of this study was to examine the effects of arch supports on balance, functional mobility, and pain in the back and lower extremity joints among older adults. Design A single-factor within-subjects design was used. Method A convenience sample of older adults formed a single group for fitting with arch supports. Balance, functional mobility, and self-reported pain in the back and lower extremities were measured without the arch supports, immediately after the insertion of the supports in the subjects' shoes, and after 6 weeks of arch support use. Findings Sixty-seven older adults completed the study. The measures used indicated statistically significant improvements in scores for the Berg Balance Scale [Berg, K., Williams-Dauphinee, S., & Williams, J. I., (1995). The Balance Scale: Reliability assessment for elderly residents and patients with an acute stroke. Scandinavian Journal of Rehabilitation Medicine, 27, 27–31] and functional mobility [Timed Up and Go test; Podsiadlo, D., & Richardson, S. (1991). The Timed “Up and Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142–148] as well as reduced back, foot, knee, and hip pain ( p < .05). There was no statistically significant change in ankle pain ( p > .05). Implications Knowledge of interventions that enhance health and well-being is essential for nurses. Arch supports may provide improved balance and functional mobility while reducing back and lower extremity joint pains. Further research is needed to support evidence-based practice.

Emotional support from family members and subjective health in caregivers of the frail elderly at home in Japan

This study sought to determine the factors associated with subjective health in caregivers of the frail elderly living at home, using multivariate regression analysis. Data were collected from 130 caregivers of frail elderly persons listed on a roster for utilization of day service or short stay service from two Home Visit Nursing Care Stations, using self-administered questionnaire from January to February of 2005. Family caregivers were defined as co-residents family members who provided a minimum of 1 h of daily care for at least 3 months. Multiple logistic regression analysis was performed to examine the factors associated with subjective health in caregivers of the frail elderly at home. Subjects with good health had less depressive symptom ( p = 0.001), much emotional support ( p = 0.003) and low caregiver burden ( p = 0.03). Multivariate logistic regression analysis showed good health had a significantly positive association with only much emotional support after adjustment for confounders. Of the total effect of emotional support on subjective health, the direct effect (84.7%) was much greater than the indirect effect (15.3%). Results indicate that much emotional support from family member for caregiver is essential for better subjective health in caregivers.

Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older

This cross-sectional analysis of a population-based cohort investigates the postural changes in blood pressure (BP) and heart rate and assesses the prevalence of orthostatic hypotension (OH) and its associations with the medicines used by an elderly population. The study population (n=1000) was a random sample of persons aged 75 years or older in the City of Kuopio, Finland. In 2004, altogether, 781 persons participated in the study. After the exclusion of persons living in institutional care (n=82) and those without orthostatic test (n=46), the final study population comprised 653 home-dwelling elderly persons. OH was defined as a > or =20 mm Hg drop of systolic BP or a > or =10 mm Hg drop of diastolic BP or both 1 or 3 min after standing up from supine position. Systolic BP dropped for more than half of the home-dwelling elderly when they stood up from a supine to a standing position. The total prevalence of OH was 34% (n=220). No significant gender or age differences were seen. The prevalence of OH was related to the total number of medicines in regular use (P<0.05). OH and postural changes in BP are more common among the home-dwelling elderly than reported in previous studies. The prevalence of OH is related to the number of medicines in regular use. There is an obvious need to measure orthostatic BP of elderly persons, as low BP and OH are important risk factors especially among the frail elderly persons.

Adequacy of Nutrient Intake Among Elderly Persons Receiving Home Care

ABSTRACT This study examines the adequacy of the dietary intake based on age, sex, and level of nutritional risk among 98 frail elderly persons receiving home care through Community Care Access Centres. The dietary intakes were measured using 24-hour recalls and were compared with the dietary reference intake. The participants' intakes of both macronutrients and micronutrients were found to be inadequate. On average, elderly persons were consuming more than the recommended amount of protein, but the average intakes of many vitamins and minerals were less than optimal based on the average intakes. Paradoxically, more than half of elderly participants were overweight or obese. The results highlight the need for appropriate nutrition, education, and support for elderly persons receiving home care.

Exercise but not diet-induced weight loss decreases skeletal muscle inflammatory gene expression in frail obese elderly persons

Many obese elderly persons have impaired physical function associated with an increased chronic inflammatory response. We evaluated 12 wk of exercise (aerobic and resistance) or 12 wk of weight loss (approximately 7% reduction) on skeletal muscle mRNAs for toll-like receptor-4 (TLR-4), mechanogrowth factor (MGF), TNF-alpha, and IL-6 in 16 obese (body mass index 38+/-2 kg/m2) older (69+/-1 yr) physically frail individuals. Vastus lateralis muscle biopsies were obtained at 0 and 12 wk and analyzed by real-time RT-PCR. Body composition was assessed by dual-energy x-ray absorptiometry. Body weight decreased (-7.5+/-1.2 kg, P=0.001) in the weight loss group but not in the exercise group (-0.3+/-0.8 kg, P=0.74). Fat-free mass (FFM) decreased (-2.9+/-0.6 kg, P=0.010) in the weight loss group and increased (1.6+/-0.6 kg, P=0.03) in the exercise group. Exercise resulted in a 37% decrease in TLR-4 mRNA (P<0.05) while weight loss had no significant effect. Additionally, exercise led to a significant (50%) decrease in IL-6 and TNF-alpha mRNA (P<0.05) while weight loss had no effect. Exercise increased MGF mRNA (approximately 2 fold, P<0.05), but weight loss had no effect. In conclusion, exercise but not weight loss had a beneficial effect on markers of muscle inflammation and anabolism in frail obese elderly individuals.

Geriatrician Offers Simpler Frailty Assessment

Geriatrician Offers Simpler Frailty Assessment

Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence

Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions. To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease. Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005. 47 hospitals and 79 subacute care facilities. 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months. Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position. The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators. 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs. No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

虚弱高齢者における口唇閉鎖力と日常生活機能ならびに認知機能との関連性

Few studies have reported the influence of declining labial closure force on ADL among frail elderly persons. We therefore investigated to elucidate the relationships among labial closure force, ADL and cognitive function in frail elderly persons. The subjects were 92 frail elderly persons. Labial closure forces were examined using "Lip De Cum". The ADL and cognitive status of the subjects were evaluated using the ADL20 scale and HDS-R respectively. Furthermore, the symptoms related to dysphagia and salivation were evaluated by a patient-reported outcome. The labial closure force was significantly related to total score and each sub-score of the ADL20 scale, and it was also related to HDS-R score. Furthermore, the labial closure force was significantly associated with salivation and 5 symptoms related to dysphagia as follows: weight loss, episodes of pyrexia, difficulties in swallowing, food falling from the mouth, sensation of food being stuck in the esophagus. Labial closure force among frail elderly persons correlated with ADL and cognitive function. These findings suggest that declining labial closure force is closely related with decreasing comprehensive physical and mental activities.

Improving Outcomes of Elderly Patients with Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.

The Characteristic of a Simple Exercise Program under the Instruction of Physiotherapists -For General Elderly People and Frail Elderly People-

[Purpose] The purpose of this study was to validate the characteristic of an exercise program consisting of simple exercise methods under the instruction of physiotherapists for general elderly people living in a community (general elderly group) and a frail elderly group. [Subjects] The general elderly group consisted of 44 persons (74.2 ± 4.38 years old: 6 men, 38 women) and the frail elderly group, 30 persons (80.6 ± 6.12 years old: 10 men, 20 women). [Methods] The measurement items were weight, body fat percentage, grip strength, knee extensor strength, sitting trunk flexion, one leg standing, functional reach test, timed up and go test, 10-m walking time, TMIG Index of Competence, MOS Short-Form 36-Item Health Survey, and the Life-Space Assessment. In each group, group and individual exercises were provided by physiotherapists. All the exercises were easy to perform. [Results] Knee extensor strength of the frail elderly group improved to almost the same level of the general elderly group. There were significant improvements in balance, gait ability, social and psychological attitudes in both groups. [Conclusion] We think that muscle strengthening exercises without exercise tools as resistance under the instruction of physiotherapists would be effective for improving the muscle strength of frail elderly persons.

Network-based rehabilitation increases formal support of frail elderly home-dwelling persons in Finland: randomised controlled trial

The AGE study is a national randomised, long-term, multicentre research project aimed at comparing a new network-based rehabilitation programme with the use of standard health and social services. The use of home help services is associated with increasing age, living alone and having difficulties with activities of daily living. During a rehabilitation intervention the elderly participants' need for care can be assessed. The focus of this paper is to investigate the possible effects of the network-based rehabilitation programme on the use of informal and formal support among home-dwelling elderly at a high risk of long-term institutionalisation. The randomised controlled trial with a 12-month follow-up was implemented in 7 rehabilitation centres and 41 municipalities in Finland. The participants were recruited between January and October 2002. A total of 708 home-dwelling persons aged 65 years or older with progressively decreasing functional capacity and at the risk of being institutionalised within 2 years participated. Persons with acute or progressive diseases or poor cognitive capacity (Mini Mental State Examination<18 points), and those who had participated in any inpatient rehabilitation during the preceding 5 years, were excluded. Participants were randomly allocated to the intervention group (n=343) or to the control group (n=365). The intervention consisted of a network-based rehabilitation programme specifically designed for frail elderly people. Main outcome measures included the help received from relatives and municipal or private services. The use of municipal services increased more in the intervention group (P<0.05) than in the control group. Support from relatives decreased in the control group. The rehabilitees' ability to manage with daily activities decreased and they received additional help; hence, in this respect the rehabilitation model seems successful. A longer follow-up within the still ongoing AGE study is needed to verify whether the programme actually can delay long-term care.

A network‐based rehabilitation model for frail elderly people: development and assessment of a new model

Living independently at home promotes the well-being of people aged 65 and over. In Finland, the municipalities are responsible for providing social and health services, including rehabilitation of the elderly. Rehabilitation is in practice carried out by independent rehabilitation centres. The Social Insurance Institution of Finland is a national agency responsible for financing and developing rehabilitation. Combining the efforts of these three agencies, a new network-based inpatient rehabilitation model was established to support the community living of frail elderly persons at high risk of institutionalization. This article describes the new model and evaluates the cooperation within the rehabilitation network, as well as the contents of the rehabilitation. The new model was evaluated in two phases using diverse methods. First, the networks were assessed as they were being established in 2000, and secondly, when they were operational in 2002. The first phase involved 53 networks operating in 46 municipalities and 12 rehabilitation centres, and the second 44 networks in 41 municipalities and seven rehabilitation centres. The data were collected by questionnaires, interviews and reports. The rehabilitation networks were functional, although constant development and search for better working practices was time consuming. Two different approaches in the networks were found: the 'networks of creators' were able to carry out the new tasks highly successfully, while the 'networks of followers' only managed to do the minimum as instructed. Motivated network members and adequate resources appeared to be essential for a successful rehabilitation process. It is possible to create a functional rehabilitation network involving different agencies. Further development work is necessary to make the network-based rehabilitation model more efficient.

Distance to achieve steady state walking speed in frail elderly persons

This study aims to determine the length of the gait initiation phase before achieving steady state walking in frail older people. Based on body fixed sensors, habitual walking was analysed in 116 community-dwelling older persons (mean age 83.1 years, 84% women). The start of steady state walking was identified using an algorithm taking into account speeds from consecutive strides. On average, participants reached a walking speed of 0.66 m/s after an acceleration phase of 1.43 m (89% after 2.47 m). When spatio-temporal variables were calculated from 4, 6, 8, 10, or 20 consecutive stride cycles after achieving steady state, similar values were observed for mean gait speed and stride length. The variability of these factors differed depending on the number of gait cycles. Assessments of steady state gait in frail elderly people should therefore exclude the first 2.5 m of walking. If gait variability is to be assessed, it is recommended that more than 20 stride cycles be used.

Fear of Falling among Community-dwelling Elderly Women Receiving Visiting Nursing Services in Japan

Although fear of falling is a common and serious problem among elderly people, little is known about the risk factors associated with fear of falling among frail elderly persons in Japan. To assess the fear of falling and investigate related factors, we conducted a study among 167 Japanese women aged 59 or older, who were receiving visiting nursing services. Fear of falling was measured by asking subjects about being afraid of falling (yes/no) and completing the Japanese version of Falls Efficacy Scale (FES). Fear of falling (being afraid of falling) was reported by 135 (80.8%) of the subjects. The overall FES score was significantly (p<0.01) lower in subjects who reported fear of falling (mean +/-Â standard deviation=19.8 +/- 5.5) than in those who did not (26.1 +/- 7.2). The Japanese version of FES effectively identified persons having a fear of falling. Multiple linear regression analysis showed that palsy, incontinence, and falls during the past year were significantly associated with an increase in fear of falling (measured by FES). The present study suggests that fear of falling is common among elderly women receiving visiting nursing services. Preventive strategies to reduce fear of falling and falls are needed, and would contribute to prevention of being bedridden and institutionalized for the frail elderly. Language: en

What influences dental students to serve special care patients?

This study examines factors associated with graduating dental students' motivation to deliver services to special care patients. We investigated community context and student characteristics, which would influence potential behavior. Higher percentages of older adults and low-income residents in the community were positively correlated with interest in serving special care populations. Factors which correlated with individual student characteristics included having a father with at least a college education, a higher number of weeks spent in extramural clinical rotations, preparedness to provide care to disabled patients, and service orientation and socially conscious attitudes. Frail elderly and disabled persons have limited access to dental care, which is compounded by a shortage of skilled dental professionals who are willing to treat these populations. Our findings suggest that interest in special care dentistry is partly conditioned by the dental school's demographic and dental market context. This study is important to dental educators and policymakers because the challenge of providing care to the "special patient" will increase in the future.

錠剤の大きさが虚弱高齢者の服薬に与える影響―服薬模擬調査による検討―

The purpose of the present study was to examine the effect of the size of tablets on the status of swallowing and handling during taking medicine among frail elderly persons. The subjects of the present study were 73 frail elderly persons. After they conducted simulation taking medicine, they determined the desirable size of tablets using subjective evaluation. Their behavior and the time required for the simulation were examined. We also evaluated their activities of daily living using the ADL20, and swallowing ability using the repetitive saliva swallowing test (RSST). There was a significant difference in behavior during taking medicine between the frail elderly with low swallowing ability and other subjects with normal swallowing ability, that is, the elderly persons with low swallowing ability tend to swallow three tablets after several trials (p<0.05). Also, the required time for simulation taking medicine was related significantly to the size of tablets (p<0.01). The most desirable size based upon easiness of swallowing and handling is 7-8mm. These results suggest that medicine taking behavior was influenced greatly by the decline of swallowing ability and ADL, and the prescriptions for the frail elderly are needed to meet their swallowing ability.

ASSOCIATION BETWEEN PSYCHOTROPIC DRUG USE AND HEART FAILURE THERAPY IN ELDERLY LONG‐TERM CARE RESIDENTS

ASSOCIATION BETWEEN PSYCHOTROPIC DRUG USE AND HEART FAILURE THERAPY IN ELDERLY LONG‐TERM CARE RESIDENTS

A network-based geriatric rehabilitation programme: study design and baseline characteristics of the patients

The objective of this paper is to present the design and participants of an ongoing randomized controlled trial on a network-based geriatric rehabilitation programme, targeted at frail elderly persons with progressively declining health and a high risk of institutionalization. Forty-one municipalities, seven rehabilitation centres and a total of 741 frail elderly (65+years) community-living persons participated in the study. Assessments included measurements of physical capacity (balance, handgrip strength, walking speed), Functional Independence Measure, Geriatric Depression Scale, 15 Dimension quality of life questionnaire and Mini Mental State Examination. Questionnaires covered physical, social and psychological factors. The participants were old (mean age 78 years, range 65-96) and mainly female (86%). They were physically frail and most of them (66%) had experienced deterioration of health within 1 year. The majority lived alone (72%) and received regular help from other people (99%). The mean Mini Mental State Examination and Geriatric Depression Scale scores were 25.2 and 4.1 points, respectively. Depressive mood (Geriatric Depression Scale>6 points) was found in 17% and declined cognitive function (Mini Mental State Examination<24 points) in 28% of the participants. Differences between the randomized intervention and control groups were insignificant. Since the number of participants is sufficient statistically, the prospects for evaluating the effectiveness of the programme, and identifying potential benefactors, are good.