Loss Of Functional Independence Research Articles

Intergenic Interactions of ESR1, GSTO1 and AGER and Risk of Dementia in Community-Dwelling Elderly (SADEM Study)

Background: Dementia causes the loss of functional independence, resulting in a decrease in the quality of life of those who suffer from it. Aims: This study aimed to investigate the interactions influencing susceptibility to the development of dementia through multifactor dimensionality reduction (MDR). Methods: the study population was made up of 221 cases and 534 controls. We performed an MDR analysis as well as a bioinformatic analysis to identify interactions between the genes GSTO1_rs4925, AGER_rs2070600, and ESR1_rs3844508 associated with susceptibility to dementia. Results: We observed associations between the polymorphism of GSTO1 and risk of dementia for the site rs4925 with the recessive model (OR = 1.720, 95% CI = 1.166–2.537 p = 0.006). Similarly, the site AGER rs2070600 showed risk of dementia with an additive model of inheritance (OR = 7.278, 95% CI = 3.140–16.868; p < 0.001). Furthermore, we identified the best risk model with a high precision of 79.6% that, when combined with three environmental risk factors, did not give an OR = 26.662 95%CI (16.164–43.979) with p < 0.001. Conclusions: The MDR and bioinformatics results provide new information on the molecular pathogenesis of dementia, allowing identification of possible diagnostic markers and new therapeutic targets.

Loss of Functional Independence after Plastic Surgery in Older Patients: American College of Surgeons National Surgical Quality Improvement Program Database.

Maintenance of functional independence is an important patient-centered outcome. As the evidence on loss of independence (LOI) in older patients undergoing plastic surgery is lacking, this study investigates the extent of LOI, identifying factors associated with LOI. The 2021-2022 American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients (>65 years old) who underwent plastic surgery and provided data on their functional independence. The primary outcome was LOI on discharge. Data on perioperative factors, including patient characteristics and comorbidities, surgical details, and outcome measures such as operation time, length of hospital stay, surgical and medical complications, mortality, and discharge destination were extracted. Of 2112 patients who underwent plastic surgery, most were independent on discharge (n = 1838, 87%). A total of 163 patients lost their independence (LOI rate: 7.7%). Patients discharged as dependent were more likely to have experienced surgical and medical complications, and less likely to be discharged home (all <0.0001). Factors independently associated with LOI included age (1.08, P = 0.0001), a history of a fall within the last 6 months (2.01, P = 0.03), inpatient setting (2.30, P = 0.0002), operation time (1.00, P = 0.01), and length of hospital stay (1.13, P = 0.0001). Approximately 8% of older patients undergoing plastic surgery are found to be at risk of postsurgical LOI. Future prospective and multicenter studies should evaluate the risks for short- and long-term LOI with the goal of developing interventions that optimize the care for this patient population.

Whole-Body Vibration to Improve Physical Function Parameters in Nursing Home Residents Older Than 80Years: A Systematic Review With Meta-Analysis.

Loss of functional independence is more likely in older adults who reside in an institution as a consequence of a decline in muscle mass and a loss of force production capacity. The aim of this review was to assess the effect of whole-body vibration (WBV) interventions on the strength, balance, and mobility of nursing home residents older than 80years. An electronic search in MEDLINE, Scopus, and CINAHL databases was conducted. Randomized controlled trials that involved nursing home residents older than 80years, that investigated WBV interventions compared with nonintervention, usual care, or placebo, and that measured physical function outcomes including strength, balance, gait, and mobility were included. Risk of bias was assessed by 2 reviewers using the Physiotherapy Evidence Database scale. The standardized mean differences (SMD) between the experimental and control groups were calculated with a random-effects model for each outcome, and subgroup analysis was conducted for different outcomes. In total, 2864 articles were identified; of these, 14 randomized controlled trials met the inclusion criteria. The meta-analysis revealed that WBV significantly increased the lower limb muscle strength (SMD = 0.59; 95% CI = 0.16 to 1.03), mobility (SMD = 0.45; 95% CI = 0.10 to 0.81), gait score (SMD = 0.26; 95% CI = 0.01 to 0.51), balance (SMD = 0.41; 95% CI = 0.01 to 0.81), and physical performance (SMD = 1.33; 95% CI = 0.33 to 2.33). WBV may be an effective intervention to improve the strength, balance, mobility, walking ability, and physical performance of older nursing home residents. WBV presents a safe, accessible alternative for improving health in this vulnerable population, warranting further research and integration into health care practices.

Abstract TP87: Trending the Impact of Non-Body Weight Supported Treadmill Training on Physical Functioning and Depressive Symptoms in Chronic Stroke Survivors

Introduction: Stroke is the most common cause of adult-onset disability and is often associated with chronic limitations in activities of daily living (ADLs). Relatedly, the loss of functional independence has been suggested in increasing the likelihood of post-stroke depression, yet limited strategies are available to mitigate these risks. The objective of this secondary analysis study was to determine the immediate and residual impact of non- body weight supported treadmill training (NBWTT) on ADL and PHQ-9 in chronic stroke survivors. We hypothesized that training would result in improvement in ADL and depressive symptoms. Method: Data from 40-community-dwelling stroke survivors with mild-moderate walking impairment were used for this analysis. All participants underwent nine training sessions (3 per week x 3 weeks) of backward (BLTT/n=19) or forward (FLTT/n=21) NBWTT. The Stroke Impact Scale -16 (ADL-measure) and PHQ-9 (depression screen) were collected at baseline, post-training, at 30- and 90-day follow-up. Results: Both BLTT and FLTT resulted in an improvement in SIS-16 (p&lt;0.01) and PHQ9 &lt;0.01); however, there were no significant differences between groups. Post-training improvements in SIS and PHQ-9 were minimally inversely correlated (p&lt;0.01, R2=0.2). While the impact of training on SIS-16 and PHQ-9 were still present at 30 and 90-days post-training, these differences were no longer significant. Conclusion: Our preliminary findings suggest that NBWTT resulted transient improvements in both ADL and symptoms of depression. Future studies should investigate ways to extend the effects of training on these and similar quality of life measures.

THU430 Post Discharge Treatment Practice And Outcomes Following Osteoporotic Hip Fracture - A Tertiary Care Center Experience

Abstract Disclosure: N. Vaghasia: None. Y. Yin: None. F. Hasan: None. Introduction: Osteoporosis remains significantly undertreated. Even after osteoporotic hip fracture most patients remain untreated. Patients who sustain hip fracture have significant morbidity like subsequent fractures, loss of functional independence and high rate of readmission to hospital and also have high rate of mortality in subsequent years compared to controls. The objective of our study is to understand treatment practice and outcomes following hip fracture at a tertiary care hospital. Methods: We did a retrospective study of patients admitted between January 2016 and June 2020 with hip fracture at two tertiary care academic hospital. We included patient above 40 years of age who and previously not treated for osteoporosis. We excluded patients with traumatic fracture, advanced renal disease and active malignancy. We collected demographics like age, sex and race. Other variables like admitting and discharging team, length of hospital stay, readmission and mortality rate, referral to specialty (Endocrinology/Rheumatology) on discharge, specialty follow up after discharge, treatment initiation after discharge, preadmission and postadmission DXA scan and polypharmacy (five or more daily prescription medication) were collected. The primary objective of the study was to see the differences in treatment practice of osteoporosis fracture based on follow up with specialist versus primary care physician. Secondary objective was to see differences in outcomes like readmission and mortality based on treatment initiation and follow up with specialist. Results: Among the 421 patients reviewed, 253 met inclusion criteria. Among them 70.2% (177) were above 70 years age; 70.8% (179) were female; 94.4% (239) were Caucasian; 3.6% (9) were given referral to specialist on discharge; 8% (20) followed with specialist; 69.1% (170) were on polypharmacy; 64.3% (159) had readmission within two years and 23.6% (58) died within two years of hip fracture. Patients followed by specialist had higher chances of being treated with osteoporosis medication (70% vs. 6.9%, p&amp;lt;0.0001) and having post fracture DXA scan (84.2% vs. 13%, p&amp;lt;0.0001). Following specialist had higher chances of being treated within six months of fracture (40% vs. 4.3%, p&amp;lt;0.0001). Among those presented with hip fracture only 22.8% of female ≥ 65 years and 4.2% of male ≥ 70 years had preadmission DXA scan. Patients treated after hip fracture had lower rate of readmission (56.7% vs. 65.4%) and mortality (10% vs. 25.1%) however did not reach statistical significance due to small sample size of overall patients treated. Conclusion: Our study suggest that osteoporotic hip fracture remains significantly untreated. Follow up with specialist increases one’s chance of being treated especially early on after the fracture. Our study also suggest that screening guidelines of getting DXA scan in both female and male is significantly neglected. Presentation: Thursday, June 15, 2023

Recent advances in predicting, preventing, and managing postoperative delirium.

Postoperative delirium (POD) is a major public health problem associated with poor patient outcomes such as increased hospital lengths of stay, loss of functional independence, and higher mortality. Depending on the study, the reported incidence ranges from 5% to 65%, with the highest incidence in hip and cardiac surgery. Anesthesiologists should be familiar with the predisposing and precipitating factors of POD, particularly screening for preoperative cognitive impairment and frailty syndrome. Screening tools, for example, the Mini-Mental State Exam, Mini-Cog, 4 A's test for delirium screening, and Montreal Cognitive Assessment, can be used to assess for cognitive impairment and the Clinical Frailty Scale to assess for frailty syndrome. The Hospital Elder Life Program is the standard prevention protocol that is tried and tested in reducing the incidence of POD. Prehabilitation, lung protective strategies, pharmacologic agents such as ramelteon, a melatonin receptor agonist, glucocorticoids, dexmedetomidine, and non-pharmacologic agents, such as noise reduction strategies and the encouragement of nocturnal sleep, have all led to a decrease in the incidence of POD and are being studied for their efficacy. However, the data are inconclusive to date. Intraoperatively, preventing hypotension and blood pressure swings, ensuring adequate pain control and anesthetic depth, and using age-adjusted minimum alveolar concentration (MAC) titration reduce the incidence of POD. The incidence of POD using regional or general anesthesia is similar. In this narrative review, we will discuss the current understanding of the predictors, pathophysiology, prevention, and management of POD and identify areas of further research.

Clinical Factors Associated with Poor Outcomes in Patients with Central Nervous System Tuberculosis Treated in San Francisco, CA from 2011 to 2021 (S25.006)

<h3>Objective:</h3> To identify risk factors associated with mortality and poor functional outcomes in patients with central nervous system tuberculosis (CNS TB) cared for in San Francisco, CA. <h3>Background:</h3> CNS TB is one of the most severe forms of TB. Studies evaluating risk factors for mortality and disability due to CNS TB are lacking across low- and high-resource settings. <h3>Design/Methods:</h3> Search terms were used to identify medical records from patients with possible CNS TB at two medical centers in San Francisco, CA between January 1st, 2011, and November 1st, 2021. Data was extracted from a sample (n=75) of cases who met criteria for definite or suspected CNS TB warranting treatment with anti-tuberculous medications. Logistic regression models were performed to identify associations of demographic factors, comorbidities, and clinical signs/symptoms with mortality and functional outcomes. <h3>Results:</h3> Of 75 cases of CNS TB, most were men (60%), 18–64 years of age (67%), foreign-born (75%), and publicly insured (60%). Diabetes (28%) and hypertension (45%) were common comorbidities. The prevalence of HIV (9.8%) was 32 times higher than in the general California population. Many patients experienced long-term moderate to severe impairments in mobility (56%) and cognition (47%) and loss of independent function (50%). Increasing age (OR=1.04 per year, 95%CI:1.00–1.07), hypertension (OR=5.40, 95%CI:1.24–23.10), intubation (OR=9.14, 95%CI: 2.14–39.07), and altered mental status (OR=7.09, 95%CI: 1.61–31.30) were significantly associated with increased odds of mortality. Altered mental status at presentation (p&lt;0.001) and hydrocephalus (p=0.040) were associated with a greater likelihood of long-term cognitive impairment. <h3>Conclusions:</h3> Mortality and functional impairment were common in patients with CNS TB cared for over the past decade in San Francisco. Older patients and those with hypertension had worse outcomes, as did patients presenting with altered mental status and hydrocephalus. Earlier CNS TB diagnosis and more effective treatment, including for patients with select risk factors, are needed to improve outcomes. <b>Disclosure:</b> Mr. HERNANDEZ CASTILLO has nothing to disclose. Dr. Chow has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Medicolegal consulting. The institution of Dr. Chow has received research support from NIH. Dr. Louie has nothing to disclose. Ms. Romo has nothing to disclose.

A Review of Frailty Analysis in Older Adults: From Clinical Tools Towards Fully Automated Preventive Systems

Frailty is a geriatric syndrome characterized by sarcopenia and physiological impairment. Although the majority of older adults wish to age at home, being frail threatens this choice since it increases the risk of falls and loss of functional independence. Hence, frailty screening and early detection are needed to stop or at least slow down the physical weakening process. In this paper, we present a review in which we discuss the proposed methods from the literature that targets frailty detection and analysis, starting from traditional clinical tools then introducing data-driven studies before highlighting the importance of fully automated systems. We conducted a review study by searching several databases such as Google Scholar, IEEE Xplore, MDPI, and ScienceDirect to name a few. This work presents clinical tools and classical performance tests to assess the health status and the physical function, as well as statistical and observational studies to analyze the frailty syndrome. Moreover, we discuss briefly the work of our research team in this context, represented by the development of a telemonitoring system which aims at the transition from a curative to a preventive model. Firstly, this review points out the absence of a gold standard to detect frailty in older individuals. Secondly, it discusses the limitations of self-reported measures/questionnaires and other traditional performance tests which are based on subjective data and done under supervised conditions. Thirdly, our study emphasizes the lack of robust approaches that target the early detection of frailty and the prediction of a future risk of physical worsening. We propose new research directions based, on the one hand, on automatic activity identification and tracking and, on the other hand, on the analysis of spontaneous speech of elderly. This paper describes research findings and highlights the existing gaps in the context of frailty, and serves as a state of the art for researchers. Additionally, this work suggests future research directions regarding the early detection and prevention of frailty.

NIH Toolbox Emotion Battery Findings Among People with HIV: Normative Comparisons and Clinical Associations.

Depression and other aspects of emotional health in people with HIV (PWH) can affect functional independence, disease progression, and overall life quality. This study used the NIH Toolbox Emotion Battery (NIHTB-EB), which assesses many features of emotional health, to more comprehensively investigate differences among adults living with and without HIV, and to identify factors associated with emotional health for PWH. Participants (n=1451; age: M=50.19, SD=16.84; 47.90% women) included 433 PWH living in southern California seen from 2003 to 2021 (64.72% AIDS, 92.25% on antiretroviral therapy) and 1018 healthy participants from NIHTB-EB national normative cohort. Participants completed the NIHTB-EB and PWH underwent comprehensive HIV disease and psychiatric evaluations. We investigated differences in emotional health by HIV status via independent samples t-tests (continuous scores) and Chi2 tests ("problematic" emotional health scores). Multivariable linear regression models examined correlates of emotional health among PWH. PWH had significantly worse emotional health than people without HIV across Social Satisfaction (Cohen's d=0.71, p<0.001), Psychological Well-Being (Cohen's d=0.49, p<0.001) and Negative Affect (Cohen's d=0.19, p<0.01) summary T-scores, and most component scales. PWH also had higher rates of "problematic" emotional health, particularly in Social Satisfaction (45% vs 17%, p<0.0001). Poor emotional health among PWH was associated with lifetime Major Depressive and Substance Use Disorders, relationship status (lost relationship versus in relationship), unemployment, and cognitive difficulties and loss of functional independence. The NIHTB-EB identified that difficulties with multiple aspects of emotional health are common among PWH, and appear to be relatively independent of cognitive impairment as well as HIV disease and treatment history, but are strongly associated with everyday functioning. Given the cross-sectional nature of this study, longitudinal studies should be employed to evaluate causality pertaining to predictors of emotional health in PWH. These findings may inform interventions to promote emotional wellbeing in PWH.

Seizure burden and neuropsychological outcomes of new-onset refractory status epilepticus: Systematic review.

Long-term sequelae of the new onset refractory status epilepticus (NORSE) include the development of epilepsy, cognitive deficits, and behavioral disturbances. The prevalence of these complications has been previously highlighted in case reports and case series: however, their full scope has not been comprehensively assessed. We conducted a systematic review of the literature (PROSPERO ID CRD42022361142) regarding neurological and functional outcomes of NORSE at 30 days or longer following discharge from the hospital. A systematic review protocol was developed using guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Of the 1,602 records for unique publications, 33 reports on adults and 52 reports on children met our inclusion criteria. They contained the description of 280 adults and 587 children of whom only 75.7 and 85% of patients, respectively had data on long-term follow-up. The mean age of adult and pediatric patients was 34.3 and 7.9 years, respectively; and the longest duration of follow up were 11 and 20 years, respectively. Seizure outcomes received major attention and were highlighted for 93.4 and 96.6% of the adult and pediatric NORSE patients, respectively. Seizures remained medically refractory in 41.1% of adults and 57.7% of children, while seizure freedom was achieved in only 26 and 23.3% of these patients, respectively. The long-term cognitive outcome data was provided for just 10.4% of the adult patients. In contrast, cognitive health data were supplied for 68.9% of the described children of whom 31.9% were moderately or severely disabled. Long-term functional outcomes assessed with various standardized scales were reported in 62.2 and 25.5% of the adults and children, respectively with majority of patients not being able to return to a pre-morbid level of functioning. New onset psychiatric disorders were reported in 3.3% of adults and 11.2% of children recovering from NORSE. These findings concur with previous observations that the majority of adult and pediatric patients continue to experience recurrent seizures and suffer from refractory epilepsy. Moderate to severe cognitive disability, loss of functional independence, and psychiatric disorders represent a hallmark of chronic NORSE signifying the major public health importance of this disorder.

Neurophysiologic predictors of individual risk for post-operative delirium after elective surgery.

Post-surgical delirium is associated with increased morbidity, lasting cognitive decline, and loss of functional independence. Within a conceptual framework that delirium is triggered by stressors when vulnerabilities exist in cerebral connectivity and plasticity, we previously suggested that neurophysiologic measures might identify individuals at risk for post-surgical delirium. Here we demonstrate the feasibility of the approach and provide preliminary experimental evidence of the predictive value of such neurophysiologic measures for the risk of delirium in older persons undergoing elective surgery. Electroencephalography (EEG) and transcranial magnetic stimulation (TMS) were collected from 23 patients prior to elective surgery. Resting-state EEG spectral power ratio (SPR) served as a measure of integrity of neural circuits. TMS-EEG metrics of plasticity (TMS-plasticity) were used as indicators of brain capacity to respond to stressors. Presence or absence of delirium was assessed using the confusion assessment method (CAM). We included individuals with no baseline clinically relevant cognitive impairment (MoCA scores ≥21) in order to focus on subclinical neurophysiological measures. In patients with no baseline cognitive impairment (N=20, age=72 ± 6), 3 developed post-surgical delirium (MoCA=24 ± 2.6) and 17 did not (controls; MoCA=25 ± 2.4). Patients who developed delirium had pre-surgical resting-state EEG power ratios outside the 95% confidence interval of controls, and 2/3 had TMS-plasticity measures outside the 95% CI of controls. Consistent with our proposed conceptual framework, this pilot study suggests that non-invasive and scalable neurophysiologic measures can identify individuals at risk of post-operative delirium. Specifically, abnormalities in resting-state EEG spectral power or TMS-plasticity may indicate sub-clinical risk for post-surgery delirium. Extension and confirmation of these findings in a larger sample is needed to assess the clinical utility of the proposed neurophysiologic markers, and to identify specific connectivity and plasticity targets for therapeutic interventions that might minimize the risk of delirium.

Impact of adverse events on independence in daily functioning of older adults with advanced cancer treated with systemic therapy.

269 Background: Older adults with advanced cancer are at increased risk of treatment-related toxicities, which can compromise physical performance and independence in daily functioning. However, studies evaluating the relationship of toxicities with functional capacity in this population are scarce. The aim of this analysis is to assess the effect of clinician-reported toxicities (CRTs) and patient-reported symptomatic toxicities (PRSTs) on physical performance and independence in daily functioning. Methods: This is a secondary analysis of GAP 70+ (NCT02054741, n = 718), a cluster randomized trial of older patients (70+ years) with advanced cancer initiating a new systemic therapy regimen. Impairments in physical performance [measured by Short Physical Performance Battery (SPPB)], and functional independence [measured by activities of daily living (ADL), and instrumental ADL (IADL)] were classified by established cut points. CRTs were collected by Common Terminology Criteria for Adverse Events (CTCAE) and PRSTs by Patient-Reported Outcome version of CTCAE (PRO-CTCAE). PRST grade was determined by severity of the items (0 = none, 1 = mild, 2 = moderate, 3 = severe, 4 = very severe). To count as a PRST event, symptom severity had to increase from pre-treatment level (baseline adjusted method). Patients without baseline impairment in SPPB, IADL, and ADL (n = 104, 308, 461, respectively), who provided data after baseline were included in the analysis. To assess the association of experiencing toxicity within 3 months and developing functional impairment within 6 months, generalized estimating equation (GEE) modeling was used. Models were adjusted for practice sites (random effect) and the study arm. Results: Patients were 70-96 years old (mean 77), 56% were male, and majority (87%) were white. Gastrointestinal (34%) and lung (25%) were the most common cancer types. During treatment, impairments in SPPB developed in 57.7% (60/104), in IADL 47.4% (146/308), and in ADL 31.0% (143/461). There was no association of CRT grade with developing impairment in SPPB (p = 0.92). A greater proportion of patients who experienced grade ≥ 3 CRT, compared to those with grade 2 and grade ≤ 1 CRT, developed impairment in IADL (54.4 vs 38.3 vs 25.2%, p = 0.01) and also in ADL (34.8 vs 23.9 vs 22.7%, p = 0.02). Patients who experienced grade ≥ 3 PRST, compared to those with grade 2 and grade ≤ 1 PRST, were more likely to developed impaired SPPB (73.6 vs 50.4 vs 27.8%, p = 0.01), IADL (50.8 vs 45.4 vs 31.5%, p = 0.20), and ADL (38.1 vs 18.5 vs 19.7%, p &lt; 0.01). Conclusions: Assessing both patient- and clinician-reported toxicity provides insight into loss of independent functioning. Information patients provide about symptoms can help with early detection of decline in physical performance in older adults. These findings may help to guide interventions to mitigate functional decline. Clinical trial information: NCT02054741.

Management of Dementia.

This article describes an approach to managing patients following a diagnosis of dementia, including medical management, nonpharmacologic strategies, safety interventions, caregiver support, mobilization of community resources, and advanced care planning. Dementia clinical syndromes are frequently caused by mixed pathologies, leading to varied clinical presentations that include memory loss, behavioral changes, communication challenges, safety concerns, and loss of independent function. Medications for treating dementia currently target cognitive and behavioral symptoms, although disease-modifying therapies for Alzheimer disease may be making their way into widespread clinical practice soon. Identification and treatment of co-occurring medical problems, such as obstructive sleep apnea, adverse medication effects, mood disorders, hearing loss, pain, alcohol misuse, and vascular risk factors, may mitigate the impact of these conditions on cognitive decline. Mobilization of clinical and community-based interprofessional teams will ensure that people with dementia and their care partners have the expertise, support, and access to resources they need. Addressing goals of care early in the disease course will allow people with dementia to contribute to their care plan by expressing their wishes. Developing a structured approach to treating common causes of dementia and related comorbid medical conditions, identifying a local network of interprofessional clinical and community-based referrals, and providing readily available educational resources will help clinicians provide quality dementia care management that extends beyond the clinic visit. Encouraging patients and families to engage in clinical research will advance the identification of effective therapies, preventive strategies, and quality care models for the future.

Predictors of Mortality in 433 Nonagenarians Inside the Mugello Study: A 10 Years Follow-Up Study.

to identify the predictors of mortality in a cohort of nonagenarians inside the "Mugello study" after 10years follow-up. Information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 non-selected participants aged 90-99years, living in the Mugello area (Italy). Participants were followed over 10years and their dates of death were retrieved from the municipal registers. Cox regression analysis was used to determine significant potential prognostic factors. The mortality rate was 96.5%. Cox proportional hazards analysis showed that a lower cognitive status was significantly associated with higher mortality as well as a poorer functional status, a higher comorbidity, and a higher number of drugs consumption. Impaired cognitive function, loss of functional independence, higher comorbidity, and higher drugs intake were the stronger predictors of mortality.

Divergence Between Informant and Self-Ratings of Activities of Daily Living Impairments in Parkinson's Disease.

ObjectiveTo examine the agreement between self- and informant-reported activities of daily living (ADL) deficits in Parkinson’s Disease (PD) patients, and to examine factors influencing ADL ratings.BackgroundIn PD, the loss of functional independence is an important outcome of disease progression. The valid assessment of ADL function in PD is essential, but it is unclear to what extent informants’ and patients’ perceptions of their daily functions concur, and how other factors may influence both ratings.MethodsData of 150 PD patients who underwent cognitive and motor testing, as well as their informants were analyzed. The 10-item Functional Activities Questionnaire (FAQ), completed separately by patients (FAQ-S) and their informants (FAQ-I), assessed ADL function. Weighted κ statistics summarized level of agreement, and a discrepancy score (FAQ-I – FAQ-S) quantified agreement. Correlation analyses between FAQ total scores, patient and informant characteristics, and cognitive scores were conducted, with post hoc regressions to determine the associations between both FAQ scores and cognition, independent of patient characteristics.ResultsThe sample included 87 patients with normal cognition, 50 with mild cognitive impairment, and 13 with dementia. Overall, there was fair to moderate agreement between patients and informants on individual FAQ items (0.27 ≤ κ ≤ 0.61, p < 0.004), with greater discrepancies with increasing cognitive impairment. Patients’ age, motor severity, non-motor burden, and depression also affected both ratings (0.27 ≤ r ≤ 0.50, p < 0.001), with motor severity showing the greatest influence on both ratings. Both the FAQ-I and FAQ-S were correlated with almost all cognitive domains. Post hoc regression analyses controlling for patient characteristics showed that the attention domain was a significant predictor of both the FAQ-S and FAQ-I scores, and memory was also a significant predictor of the FAQ-I score. Only 29.3% of patients agreed perfectly with informants on the FAQ total score, with informants most commonly rating ADL impairments as more severe than patients.ConclusionsPatient and informant ratings of ADL function using FAQ items showed moderate agreement, with only few items reaching substantial agreement. Ratings of both were associated with patient cognitive status, but also other characteristics. In addition to patient and informant reports, objective measures are needed to accurately classify ADL deficits in PD.

Sarcopenia in chronic kidney disease – A brief review

Sarcopenia is a progressive age -related loss of muscle mass associated with a decline in muscle function and physical performance. Patients with chronic kidney disease experience substantial loss of muscle mass, weakness, and poor physical performance. Indeed, with the progression of chronic kidney disease, skeletal muscle dysfunction contributes to mobility limitation, loss of functional independence, and vulnerability to disease complications. There is a lack of robust data on the negative effect of the impact of kidney disease on skeletal muscle dysfunction, as well as on screening and treatment strategies that can be used in clinical practice to prevent functional decline and disability. Therefore, sarcopenia may be an underestimated condition with major implications for people with chronic kidney disease, even before the start of dialysis, which makes research into this topic necessary. The purpose of this review is to expand on some fundamental topics of sarcopenia, with an emphasis on the setting of chronic kidney disease patients.

The demographics and outcomes in patients with bilateral distal radius fractures

Although distal radius fractures are quite common, bilateral distal radius fractures seldomly occur. Due to this, treatment is primarily based on surgeon experience with unilateral fractures, however bi- lateral fractures add a level of complexity : loss of functional independence. The purpose of this study was to examine a cohort of patients with bilateral distal radius fractures to identify differences in demographics, mechanism of injury, and outcomes to further our understanding of these rare injuries. 23 patients were identified retrospectively over a 5-year period that met inclusion criteria. The medical records were reviewed with multiple demographic and clinical parameters recorded and analyzed. Males were more likely to sustain high-energy mechanisms (80% vs. 53%). Patients <50 years old were more likely to sustain high-energy mechanisms (90% vs. 46%) and were more likely to be treated operatively (80% vs. 62%). The most commonly associated injury was a head injury (30%). All patients treated non-operatively reported minimal/no pain upon final follow-up where 57% of patients treated operatively noted regular pain. 75% of patients with medical comorbidities had minimal/no pain upon final follow- up. Conclusions : Patients with bilateral fractures were more likely to be younger males who suffered from higher energy mechanisms. Age was a critical factor in determining treatment strategy. Rates of associated head injuries were elevated, which is an important factor for the clinician to keep in mind when treating this population. As we further our understanding of this unique population, we can improve our treatment approaches and subsequently attain better outcomes.

Spinal toxoplasmosis in a young man with undiagnosed HIV infection

Spinal cord lesions are potentially devastating conditions leading to reduced mobility, loss of functional independence, and even ventilator dependence, dictated by the level of injury. Tissue diagnosis is paramount to differentiate between primary brain tumours such as ependymomas and glioblastomas, infarction, infection and demyelination. We present the case of a 30-year-old gentleman with subacute neck pain, nausea and evolving right upper limb weakness and paraesthesiae. MRI-spine demonstrated an intramedullary cervical spine mass with associated oedema, thought to represent an ependymoma. Open tissue biopsy revealed numerous bradyzoites on haematoxylin & eosin staining, subsequently confirmed by directed polymerase chain reaction testing as Toxoplasma gondii. Detailed immunological work-up led to a diagnosis of HIV infection, with detection of HIV antibodies and HIV-1 p24 antigen, an HIV-1 viraemia (log 6.33 copies/mL) and low CD4 count (16 cells/mL). Toxoplasmosis is the most common central nervous system infection in HIV patients not receiving appropriate prophylaxis.1 It may occur in up to 30% of such patients who are seropositive for Toxoplasma gondii,2 typically manifesting when CD4+ counts fall below 100 cells/mm3.3 This case highlights the importance of close collaboration between histopathology, microbiology and infectious diseases specialists in diagnosis of a spinal cord infection with associated HIV infection. 1.Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327: 1643–8.2.Grant IH, Gold JW, Rosenblum M, et al. Toxoplasma gondii serology in HIV-infected patients: the development of central nervous system toxoplasmosis in AIDS. AIDS 1990; 4: 519–21.3.Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR Recomm Rep 2009; 58: 1–207.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank

Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Strategies to Support Physical Activity Participation in Older Adults With Heart Failure

Physical activity (PA) is recommended for people living with heart failure (HF). Despite evidence of its benefits, participation in PA is low in this population, putting them at risk for loss of functional independence and additional health burdens. The aim of this pilot study was to ask older adults living with stable, chronic HF to identify strategies to support regular PA. Patients in an outpatient HF rehabilitation program were recruited to participate in focus groups about their PA knowledge, attitudes, and preferences as part of a stakeholder engagement project. At the beginning of the focus group, participants completed a questionnaire listing 8 potential strategies to optimize PA, and were asked to identify the top 4 strategies that they thought would be most beneficial to support regular PA participation. This was the focus of the current analysis. Thirteen adults with HF (M age=65; 46% female; 62% African American; M BMI=32.6 kg/m2) were enrolled. Top-rated strategies endorsed by participants to support long-term adherence to PA included provision of an exercise guide to support home-based exercise and supplement health provider-supervised exercise sessions (69%), group education classes (64%), completion of fitness assessments at regular intervals (62%), and provision of a transition pathway from an exercise rehabilitation program to a community-based exercise program (62%). The remaining strategies were endorsed by fewer than 50% of participants, and included remote delivery and support options. These results have important implications for future program development and implementation efforts to support PA among older adults with stable, chronic HF.