Vulnerability In Older Patients Research Articles

1883 The Psychological Impact of Hospital Discharge on the Older Person

Abstract Introduction Older people often require hospitalisation but prolonged length of stay and deconditioning in the acute setting is associated with adverse outcomes. 35% of older people do not recover functionally after discharge. Less is known on the psychological impact and coping mechanisms of vulnerable older people after discharge. Our aim was to explore factors signalling psychological vulnerability in older patients, post-discharge to inform better discharge planning. Methods A systematic search for studies reporting poor discharge outcomes in older people was performed in Medline, CINAHL, PsycInfo between 2010-2022. The search terms were ’older patients >65 year’, ‘post-discharge’, ’psychological distress’, ’loneliness’, ‘anxiety’, ‘depression’, and ‘length of hospital stay’. Exclusion criteria included COVID-19 disease, dementia (+/- severe cognitive impairment), individuals aged <65 and those under palliative care services. Results 1,666 records were identified of which 878 were excluded as they were outside of our date limits or were not in English Language. 681 were excluded after application of exclusion criteria and 699 were excluded because of insufficient details. 31 duplicates were removed leaving 38 articles that were assessed for eligibility. 7 of these reports were found suitable, comprising of 1,131 patients. Three highly relevant themes identified relating to post-discharge outcomes across all studies were social isolation, lack of support, depression, apathy and fear, which led to further psychological distress. Older patients with tendency toward depressive symptoms had an increase likelihood of death. Conclusion It appears discharge processes fail to address psychological factors that permit successful transition from hospital. Pre-discharge screening of psychological symptoms and coping ability may assist in identifying older patients who are at risk of mental as well as subsequent physical deterioration. Better knowledge of positive and negative predictors of a successful transition from hospital to home would enable more holistic, effective, and inclusive discharge planning processes for older people.

Age-related Pancoronary Characteristics in Patients with ST-segment Elevation Myocardial Infarction

Background: Age-related vulnerable characteristics of pancoronary plaques in patients with ST-segment elevation myocardial infarction (STEMI) have not been systemically evaluated by optical coherence tomography (OCT). Therefore, we sought to explore the discrepancies in pancoronary characteristics between younger and older patients with STEMI through OCT. Methods: This retrospective single-center study included 588 patients who had STEMI and underwent three-vessel OCT through emergency percutaneous coronary intervention between October 2016 and September 2018. With a median age of 56 years as a cutoff, the patients were divided into a younger group (≤56 years, n = 298) and an older group (>56 years, n = 290). Results: A total of 795 non-culprit plaques were found in 298 of the younger patients, whereas 858 non-culprit plaques were identified in 290 of the older patients. Fewer high-risk OCT plaques (15.8% vs. 23.1%; P = 0.025), as well as other structures (cholesterol crystals, P = 0.001; microchannels, P = 0.032; calcifications, P < 0.001; spotty calcifications, P < 0.001; large calcifications, P < 0.001; and thrombi, P = 0.001) were identified in younger patients than older patients, at the patient level. In addition, pancoronary vulnerability in younger patients was independently predicted by culprit plaque rupture {CLIMA-defined high-risk plaques (odds ratio [OR]: 3.179; 95% CI: 1.501 to 6.733; P = 0.003), non-culprit rupture (OR: 3.802; 95% CI: 1.604 to 9.014; P = 0.002), non-culprit thin-cap fibroatheroma (OR: 3.536; 95% CI: 2.051 to 6.094; P < 0.001)}, hypertension (OR: 1.920; 95% CI: 1.099 to 3.355; P = 0.022), and total cholesterol (OR: 1.094; 95% CI: 1.002 to 1.195; P = 0.045). In older patients with STEMI, the predictor was male sex (OR: 3.031; 95% CI: 1.352 to 6.795; P = 0.007). Conclusions: Among patients with STEMI, younger patients had limited vulnerable plaque characteristics, and pancoronary vulnerability was associated with culprit plaque rupture, hypertension, and total cholesterol. In contrast, older patients had greater pancoronary vulnerability with the single predictor of male sex, thus suggesting that traditional risk factors have limited applicability in predicting pancoronary vulnerability in older patients.

Geriatric 8 and Vulnerable Elders Survey-13 predict length of hospital stay and postoperative complications in Japanese patients undergoing urological surgery

IntroductionThe Geriatric 8 (G8) and Vulnerable Elders Survey-13 (VES-13) are established screening tools for assessing vulnerability in older patients. Here we investigated their usefulness as predictors of length of hospital stay and postoperative complications in Japanese patients undergoing urological surgery. Materials and MethodsThis study included 643 patients who underwent urological surgery (74% were for malignancy) at our institute from 2017 to 2020. G8 and VES-13 scores were routinely recorded upon admission. These indices and other clinical data were obtained through chart review. The correlation between G8 group (high, >14; intermediate, 11–14; low, <11) or VES-13 group (normal, <3; high, ≥3) and length of total hospital stay (LOS), postoperative hospital stay (pLOS), and postoperative complications including delirium were analyzed. ResultsThe median patient age was 69 years. A total of 44%, 45%, and 11% of patients were classified into high, intermediate, and low G8 groups, respectively, while 77% and 23% were classified into normal and high VES-13 groups, respectively. Univariate analyses revealed that low G8 scores were associated with prolonged LOS (vs. intermediate, odds ratio [OR] 2.87, P < 0.001; vs. high, OR 3.87, P < 0.001), prolonged pLOS (vs. intermediate, OR 2.37, P = 0.005; vs. high, OR 3.06, P < 0.001), and delirium (vs. intermediate, OR 3.23, P = 0.007; vs. high, OR 5.38, P < 0.001), and high VES-13 scores were associated with prolonged LOS (OR 2.85, P < 0.001), prolonged pLOS (OR 2.97, P < 0.001), and Clavien-Dindo grade ≥ 2 complications (OR 1.74, P = 0.044), and delirium (OR 3.18, P = 0.001). Furthermore, multivariate analyses revealed that low G8 and high VES-13 scores were independent factors which predicted prolonged LOS (low G8; vs. intermediate, OR 2.96, P < 0.001; vs. high, OR 3.94, P < 0.001; high VES-13; OR 2.98, P < 0.001) and prolonged pLOS (low G8; vs. intermediate, OR 2.41, P = 0.008; vs. high, OR 3.18, P = 0.002; high VES-13; OR 3.47, P < 0.001), respectively. DiscussionThe G8 and VES-13 may be effective tools for predicting prolonged LOS/pLOS and postoperative complications in Japanese patients who undergo urological surgery.

Comparison of two frailty screening tools in older patients with colorectal cancer

IntroductionGeriatric assessment (GA) is widely used to detect vulnerability in older patients. As this process is time-consuming, prescreening tools have been developed to identify patients at risk for frailty. We aimed to assess whether the Geriatric 8 (G8) or the Korean Cancer Study Group Geriatric Score (KG-7) shows better performance in identifying patients who are in need of full GA.Materials and methodsA consecutive series of patients aged ≥ 60 years with colorectal cancer were included. The sensitivity, specificity, predictive value, and 95% confidence intervals (95% CI) were calculated for the G8 and the KG-7 using the results of GA as the reference standard. ROC(Receiver Operating Characteristic) was used to evaluate the accuracy of the G8 and the KG-7.ResultsOne hundred four patients were enrolled. A total of 40.4% of patients were frail according to GA, and 42.3% and 50.0% of patients were frail based on the G8 and the KG-7, respectively. The sensitivity and specificity of the G8 were 90.5% (95% CI: 77.4–97.3%) and 90.3% (95% CI: 80.1–96.4%), respectively. For the KG-7, the sensitivity and specificity were 83.3% (95% CI: 68.6–93.0%) and 72.6% (95% CI: 59.8–83.1%), respectively. Compared to the KG-7, the G8 had a higher predictive accuracy (AUC: (95% CI): 0.90 (0.83–0.95) vs. 0.78 (0.69–0.85); p < 0.01). By applying the G8 and the KG-7, 60 and 52 patients would not need a GA assessment, respectively.ConclusionBoth the G8 and the KG-7 showed a great ability to detect frailty in older patients with colorectal cancer. In this population, compared to the KG-7, the G8 had a better performance in identifying those in need of a full Geriatric Assessment.

Outcomes of vulnerable elderly patients undergoing elective major surgery: a prospective cohort study.

Identifying patients at risk of postoperative complications and trying to prevent these complications are the essence of preoperative evaluation. While not overtly frail or disabled, vulnerable patients with mild frailty may be missed by routine assessments and may still have a worse postoperative course. We performed a prospective cohort study evaluating vulnerability in older patients undergoing elective surgery. Vulnerability was assessed using the Clinical Frailty Scale. Our primary outcome was postoperative hospital length of stay (LOS) and our secondary outcome was non-home hospital discharge. We performed multivariable analyses to assess the association between vulnerability and our primary and secondary outcome. Between 1 January 2017 and 1 January 2018, 271 older patients with a median [interquartile range (IQR)] age of 72 [69-76] yr underwent frailty assessment prior to surgery. Eighty-eight (32.5%) of the cohort were classified as vulnerable. The median [IQR] duration of hospital LOS was 4 [2-7] days for vulnerable patients, 4 [2-6] days for robust patients, and 7 [3-10] days for frail patients. After adjusting for confounders, hospital LOS was not longer for vulnerable patients than for robust patients, but was associated with a higher rate of non-home discharge (odds ratio, 3.7; 95% confidence interval, 1.1 to 12.9; P=0.04). Vulnerability was not associated with a longer hospital LOS but with higher risk of non-home discharge. Vulnerable patients might benefit from early identification and advanced planning with earlier transfer to rehabilitation centres.

Validation of G8 and its acuracy as a predictor of object in oncological patients with age of ≥ 60 YEARS. prospective cohort of 889 brazilian elderly cancer patients.

e23036 Background: The G8, a questionnaire with 8 questions, has been specifically developed as a screening tool for vulnerability in older patients (70+) with cancer, with results suggesting 14 points as a threshold (equivalent to 90% sensitivity and 60% specificity). Its prognostic value for early death was not evaluated in Brazilian population. Methods: Cancer patients (60 years or older) with solid organ malignancies were included in a prospective cohort in a Brazilian Geriatric Oncology Clinic, between 2015 and 2017. Before the start of any oncologic therapy, a Comprehensive Geriatric Assessment (CGA) with 12 questionnaires was performed. For this study, we analyzed the G8 (Figure 1) considering items from Mini Nutritional Assessment (MNA), polypharmacy ( &gt; 3 medications per day), self reported health status and the age of patient. G8 score was considered abnormal if ≤14, and early death (within six months of surveillance) was the gold standard for the study accuracy. Cox proportional hazard risk and Kaplan-Meier survival curves were performed. Results: 889 patients were enrolled and there were 145 (16.3 %) early deaths. Overall, 52% were male, the extremes of age were from 60 to 97 (mean 72.5 ± 0.24), and 38% were &lt; 70 years old. The most common cancers were prostate (31.2%), digestive tract (21.9%) and breast (16.0%); 30.4% were metastatic. 470 (52,9%) from all patients had abnormal (≤ 14) G8 score; 128 (27.2%) who had abnormal G8 score died within the first 6 months, versus 17 (4.1%) with normal score (Table 1). At cut point 14, the G8 sensitivity was 88.3% (CI95% 81.9 - 93.0); specificity 54.0% (CI95% 50.4 - 57.7); positive predictive value 27.2% (CI95% 23.3 - 31.5); negative predictive value 95.9% (CI95% 93.6 - 97.5); area under ROC curve was 0.819 (Figure 2). For those older than 70, the G8 sensitivity was 91% (CI95% 83.4 - 96.1). Abnormal scores showed significant differences in survival probability (Figure 3). Conclusions: G8 score is a strong and consistent predictor of overall 6-month survival, regardless of age, metastatic status or tumor site in Brazilian older (60 or older) oncologic patients. This finding strengthens the clinical utility of this instrument in the Geriatric Oncology and may be an option to extend the practice of Geriatric Assessment in countries with medium-low economic development, even in the younger elderly population.

Assessing Frailty and Vulnerability in Older Adults with Cancer

Aging is associated with decreased physiologic reserve, and older adults are more susceptible to cancer treatment toxicity. In this review, we discuss the implications of frailty and vulnerability in older patients with cancer. We also review a number of instruments that can be used to assess frailty and vulnerability and propose a practical approach to incorporate these tools in a general oncology or geriatric clinic. In older patients with cancer, frailty and vulnerability are associated with all-cause mortality, postoperative complications, and treatment intolerance/toxicities. If feasible, a comprehensive geriatric assessment should be used to assess of frailty and vulnerability. If a full geriatric assessment cannot be performed, screening tools such as the Balducci’s criteria, Vulnerable Elders Survey-13, Triage Risk Screening Tool, Groningen Frailty Index, and Geriatric 8 may be used. Future studies should evaluate geriatric assessment domains that have the greatest predictive value for toxicity for each cancer type and treatment.

The Biology of Aging and Cancer: Frailty, Inflammation, and Immunity.

The majority of patients with common malignancies are older adults. Intrinsic complex biological changes of aging along with inflammation, immunosenescence, age-associated chronic diseases, and extrinsic environmental and psychosocial factors have significant impact on not only development and behavior of individual malignancies, but also physiologic reserve and vulnerability of older patients who suffer from them. As a result, clinical practice of geriatric oncology demands integration of careful geriatric assessment and management. This article provides an overview of basic biology of aging and its relationship with cancer. After a brief introduction about the definition and mechanisms of aging, as well as age-related biological and physiological changes, the discussion mainly focuses on recent development and insights into the relationship of frailty, inflammation, and immunity with cancer, highlighting how the new knowledge can help further improve assessment and treatment of older patients with malignancies and promote cancer research.

The Biology of Aging and Cancer: Frailty, Inflammation, and Immunity

The majority of patients with common malignancies are older adults. Intrinsic complex biological changes of aging along with inflammation, immunosenescence, age-associated chronic diseases, and extrinsic environmental and psychosocial factors have significant impact on not only development and behavior of individual malignancies, but also physiologic reserve and vulnerability of older patients who suffer from them. As a result, clinical practice of geriatric oncology demands integration of careful geriatric assessment and management. This article provides an overview of basic biology of aging and its relationship with cancer. After a brief introduction about the definition and mechanisms of aging, as well as age-related biological and physiological changes, the discussion mainly focuses on recent development and insights into the relationship of frailty, inflammation, and immunity with cancer, highlighting how the new knowledge can help further improve assessment and treatment of older patients with malignancies and promote cancer research.

Combined age- and trauma-related proteomic changes in rat neocortex: a basis for brain vulnerability

This proteomic study investigates the widely observed clinical phenomenon, that after comparable brain injuries, geriatric patients fare worse and recover less cognitive and neurologic function than younger victims. Utilizing a rat traumatic brain injury model, sham surgery or a neocortical contusion was induced in 3 age groups. Geriatric (21 months) rats performed worse on behavioral measures than young adults (12–16 weeks) and juveniles (5–6 weeks). Motor coordination and certain cognitive deficits showed age-dependence both before and after injury. Brain proteins were analyzed using silver-stained two-dimensional electrophoresis gels. Spot volume changes (>2-fold change, p<0.01) were identified between age and injury groups using computer-assisted densitometry. Sequences were determined by mass spectrometry of tryptic peptides. The 19 spots identified represented 13 different genes that fell into 4 general age- and injury-dependent expression patterns. Fifteen isoforms changed differentially with respect to both age and injury (p<0.05). Further investigations into the nature and function of these isoforms may yield insights into the vulnerability of older patients and resilience of younger patients in recovery after brain injuries.

Management and Perioperative Morbidity Among Patients With Surgically Managed Pancreatic Adenocarcinoma: A Population-Based Analysis Using SEER-Medicare Data

Introduction: Older patients with pancreatic cancer are often not offered pancreaticoduodenectomy (PD) due to potentially high perioperative risk and prolonged post-operative recovery. These patients may have undetected vulnerabilitities related to frailty that may adversely affect surgical outcomes. Methods: PD-eligible patient over 50 were enrolled onto this IRB-approved prospective observational study. Extensive perioperative clinical information including Vulnerable Elder Survey (VES-13), short physical performance battery (SPPB), and Fried's Criteria for frailty were collected. Complications were prospectively recorded and graded according to established guidelines (Clavien scores). Quality of life (QoL) measures were taken at baseline and at 1, 3, and 6-months post-PD. Results: Seventyeight patients were enrolled from 10/1/2007-9/1/2010: 53 had a PD (median age 68 years;range 46-85) and 25 were inoperable or declined PD. Significant preoperative vulnerability was identified in resected patients; VES-13 >3 in 24%; SPPB <10 in 49%; Fried's exhaustion in 40%. The perioperative morbidity rate was 70% and three patients died (8.6%). Twenty-three patients (43%) had severe complications (Clavien grade≥ III). Abnormal VES13 showed predictive promise for post-operative admission to the SICU rs(53)=.34, p<.05, longer SICU stays rs(53)=.42, p<.01, and total hospital days rs(53)=.26, p=.09. Self-reported exhaustion predicted complications and post-operative admission to the SICU, χ2(1, N = 53) = 4.1, p<.05. Older age was predictive of not being discharged to home rs(53)= -.35, p<.05 and perioperative death, rs(53)=.31, p<.05. 22 patients have complete QoL data that shows a wide variance at baseline, a significant drop-off at 1 month and return to baseline by 6 months. Conclusion: We identified significant vulnerability in older patients undergoing PD. Early analyses suggest that comprehensive perioperative geriatric measures can predict post-surgical outcomes. If sought for and identified, these issues could be managed expectantly, leading to more accurate preoperative counseling and in-hospital care.

Comprehensive Perioperative Geriatric Assessments May Predict Surgical Outcomes in a Prospective Study of Older Patients Undergoing Pancreaticoduodenectomy

Introduction: Older patients with pancreatic cancer are often not offered pancreaticoduodenectomy (PD) due to potentially high perioperative risk and prolonged post-operative recovery. These patients may have undetected vulnerabilitities related to frailty that may adversely affect surgical outcomes. Methods: PD-eligible patient over 50 were enrolled onto this IRB-approved prospective observational study. Extensive perioperative clinical information including Vulnerable Elder Survey (VES-13), short physical performance battery (SPPB), and Fried's Criteria for frailty were collected. Complications were prospectively recorded and graded according to established guidelines (Clavien scores). Quality of life (QoL) measures were taken at baseline and at 1, 3, and 6-months post-PD. Results: Seventyeight patients were enrolled from 10/1/2007-9/1/2010: 53 had a PD (median age 68 years;range 46-85) and 25 were inoperable or declined PD. Significant preoperative vulnerability was identified in resected patients; VES-13 >3 in 24%; SPPB <10 in 49%; Fried's exhaustion in 40%. The perioperative morbidity rate was 70% and three patients died (8.6%). Twenty-three patients (43%) had severe complications (Clavien grade≥ III). Abnormal VES13 showed predictive promise for post-operative admission to the SICU rs(53)=.34, p<.05, longer SICU stays rs(53)=.42, p<.01, and total hospital days rs(53)=.26, p=.09. Self-reported exhaustion predicted complications and post-operative admission to the SICU, χ2(1, N = 53) = 4.1, p<.05. Older age was predictive of not being discharged to home rs(53)= -.35, p<.05 and perioperative death, rs(53)=.31, p<.05. 22 patients have complete QoL data that shows a wide variance at baseline, a significant drop-off at 1 month and return to baseline by 6 months. Conclusion: We identified significant vulnerability in older patients undergoing PD. Early analyses suggest that comprehensive perioperative geriatric measures can predict post-surgical outcomes. If sought for and identified, these issues could be managed expectantly, leading to more accurate preoperative counseling and in-hospital care.

Trends in the Palliative Surgical Management of Patients With Unresectable Pancreatic Adenocarcinoma: Lessons Learned From a Large, Single Institution Experience

Introduction: Older patients with pancreatic cancer are often not offered pancreaticoduodenectomy (PD) due to potentially high perioperative risk and prolonged post-operative recovery. These patients may have undetected vulnerabilitities related to frailty that may adversely affect surgical outcomes. Methods: PD-eligible patient over 50 were enrolled onto this IRB-approved prospective observational study. Extensive perioperative clinical information including Vulnerable Elder Survey (VES-13), short physical performance battery (SPPB), and Fried's Criteria for frailty were collected. Complications were prospectively recorded and graded according to established guidelines (Clavien scores). Quality of life (QoL) measures were taken at baseline and at 1, 3, and 6-months post-PD. Results: Seventyeight patients were enrolled from 10/1/2007-9/1/2010: 53 had a PD (median age 68 years;range 46-85) and 25 were inoperable or declined PD. Significant preoperative vulnerability was identified in resected patients; VES-13 >3 in 24%; SPPB <10 in 49%; Fried's exhaustion in 40%. The perioperative morbidity rate was 70% and three patients died (8.6%). Twenty-three patients (43%) had severe complications (Clavien grade≥ III). Abnormal VES13 showed predictive promise for post-operative admission to the SICU rs(53)=.34, p<.05, longer SICU stays rs(53)=.42, p<.01, and total hospital days rs(53)=.26, p=.09. Self-reported exhaustion predicted complications and post-operative admission to the SICU, χ2(1, N = 53) = 4.1, p<.05. Older age was predictive of not being discharged to home rs(53)= -.35, p<.05 and perioperative death, rs(53)=.31, p<.05. 22 patients have complete QoL data that shows a wide variance at baseline, a significant drop-off at 1 month and return to baseline by 6 months. Conclusion: We identified significant vulnerability in older patients undergoing PD. Early analyses suggest that comprehensive perioperative geriatric measures can predict post-surgical outcomes. If sought for and identified, these issues could be managed expectantly, leading to more accurate preoperative counseling and in-hospital care.

Chair Rise Ability and Length of Stay in Hospitalized Older Adults

To the Editor: Length of stay is an important indicator of recovery associated with acute hospitalization.1 Typically, combinations of variables such as advanced age, frailty status, fall history, immobility, and malnutrition are used as a general set of risk indicators for prolonged length of stay.2,3 This study sought to determine whether a simple, objective test—ability to rise once from a chair—could identify older patients at risk for longer length of stay. Patients were categorized into those able and unable to perform a chair rise task. Associations between chair rise ability and length of stay were examined, adjusting for demographic, functional, and clinical measures. A convenience sample of 83 patients aged 65 and older admitted to an Acute Care for Elders (ACE) unit was studied. Patients were excluded from participation if they were transferred from a nursing home or unable to get out bed, had a stroke or lower extremity trauma-related diagnosis, were cognitively unable to provide their own informed consent, or reported one or more limitations in activities of daily living 2 weeks before admission. Patients were asked to stand up once from a straight-backed, regular-height (17 cm) chair with their hands folded across their chest. A licensed physical therapist performed the assessment within 24 hours of admission. If the patient was able to stand up once without the use of his or her hands, the test was recorded as successful and otherwise as unsuccessful. Interviewers trained in clinical research also collected patient information in a face-to-face interview and using medical chart review. To compare the association between length of stay and chair rise ability, three generalized estimating equation models were computed using a poisson distribution. The first model included chair rise ability, the second model added demographic measures, and the third model added functional and clinical measures. Mean age ± standard deviation was 74.2 ± 6.2 (range 65–89); 57.8% were women. Forty-two patients (50.6%) were unable to perform the chair rise task. The unadjusted mean length of stay for patients who could not perform the chair rise task was 1.5 days longer than for those who could perform the task (3.0 ± 1.7 vs 4.5 ± 2.6 days). Table 1 shows associations between length of stay and chair rise ability with and without adjustment for relevant covariates. Odd ratios and 95% confidence intervals are presented for each of the three models. Only chair rise ability was significantly associated with length of stay in all models. Table 1 Generalized Linear Regression Models Assessing the Association Between Length of Hospital Stay and Chair Rise Ability (N = 83) The study showed chair rise ability assessed within the first 24 hours of hospital admission was significantly associated with length of stay. After adjusting for relevant covariates, patients who could not perform the chair rise task had, on average, expected lengths of stay of approximately 45% longer than those who could. Recent research showing linkages between measures of lower-body performance and the overall health and well-being of older adults supports the use of chair rise ability as a clinical risk indicator in an acute care setting.4 Rising from a seated to standing position is known to be a bio-mechanically challenging activity.5 It requires threshold levels of muscular strength and adequate balance control. At the time of chair transfer, hip torques can be much larger than those required for walking or stair climbing,6,7 and the body is in a statically unstable position.6,8,9 The findings of the current study indicate that the inability to rise once from a chair reflects a state of functional and physiological vulnerability in older patients, placing them at risk for adverse outcomes during hospitalization, which could lead to complications related to the longer stay.10 Although the sample was not randomly selected, men and women were equally represented, and all patients included in the analyses reported no activity of daily living limitations 2 weeks before hospitalization. Factors associated with illness severity that may have influenced length of stay were also not identified; however, because the chair rise assessment was performed within 24 hours of admission, the association between chair rise ability and length of stay suggests that patient ability or inability to perform the task acted as a proxy for overall health and vitality. The chair rise task described in this study is an easily interpretable, objective measure that any member of the healthcare team can perform. The inability to rise once from a chair without use of the hands may be one way to characterize older patients who may be at risk for longer length of hospital stay, which has implications for decisions regarding early preventative measures, inpatient therapy services, and potential postdischarge level of care.

Do older people who self‐harm receive the hospital care they need?

Although self‐harm is most common in younger people in Britain, the risk of suicide subsequent to an initial act of self‐harm is considerably greater in older age groups. Four characteristics have been shown to be associated with increased vulnerability in older people who self‐harm: increased suicidal intent, physical illness, mental illness and social isolation. This paper is part of a broader analysis of all self‐harm presentations to a British hospital accident and emergency department over a five‐year period. It examines the prevalence of these vulnerability indicators in patients aged 65 or over, and considers whether greater vulnerability in older patients is reflected in their clinical management within the hospital and in community support planning on discharge.At the first presentation older patients (n=91) exhibited greater vulnerability than did younger patients (n=2,326). Despite this, we found no evidence that older self‐harm patients were any more likely than younger patients to routinely receive either a psychosocial assessment from a member of staff with specialist mental health training, or community aftercare planning on discharge from the hospital. This study lends weight to recently published national guidelines recommending that all acts of self‐harm in older people be regarded as evidence of serious suicidal intent at the outset.