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FRAMEWORK IMPLEMENTATION OF THE INSPIRE ICOPE-CARE PROGRAM IN COLLABORATION WITH THE WORLD HEALTH ORGANIZATION (WHO) IN THE OCCITANIA REGION

 

N. Tavassoli1, A. Piau1,2, C. Berbon1, J. De Kerimel1, C. Lafont1, P. De Souto Barreto1,2, S. Guyonnet1,2, C. Takeda1, I. Carrie1, D. Angioni1, F. Paris1, C. Mathieu1, P.J. Ousset1, L. Balardy1, T. Voisin1, S. Sourdet1, J. Delrieu1, V. Bezombes1, V. Pons-Pretre1, S. Andrieu1,2, F. Nourhashemi1,2, Y. Rolland1,2, M.E. Soto1,2, J. Beard3, Y. Sumi4, I. Araujo Carvalho4, B. Vellas1,2

 

1. Gerontopole, W.H.O Collaborative Center for Frailty, Clinical Research and Geriatric Training, Toulouse University Hospital, 31059 Toulouse, France; 2. UPS/INSERM, UMR1027, F-31073 Toulouse, France; 3. ARC Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, Australia; 4. Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland.

Corresponding author: Neda Tavassoli, Équipe Régionale Vieillissement et Prévention de la Dépendance (ERVPD), La Cité de la Santé, Bâtiment Ex-Biochimie, Hôpital La Grave, Place Lange, TSA 60033, 31059 Toulouse Cedex 9, France, Phone number: +335 61 77 70 13, Fax number: +335 61 77 64 75, E-mail address: tavassoli.n@chu-toulouse.fr

J Frailty Aging 2020;in press
Published online May 19, 2020, http://dx.doi.org/10.14283/jfa.2020.26

 


Abstract

Introduction: Limiting the number of dependent older people in coming years will be a major economic and human challenge. In response, the World Health Organization (WHO) has developed the «Integrated Care for Older People (ICOPE)» approach. The aim of the ICOPE program is to enable as many people as possible to age in good health. To reach this objective, the WHO proposes to follow the trajectory of an individual’s intrinsic capacity, which is the composite of all their physical and mental capacities and comprised of multiple domains including mobility, cognition, vitality / nutrition, psychological state, vision, hearing. Objective: The main objective of the INSPIRE ICOPE-CARE program is to implement, in clinical practice at a large scale, the WHO ICOPE program in the Occitania region, in France, to promote healthy aging and maintain the autonomy of seniors using digital medicine. Method: The target population is independent seniors aged 60 years and over. To follow this population, the 6 domains of intrinsic capacity are systematically monitored with pre-established tools proposed by WHO especially STEP 1 which has been adapted in digital form to make remote and large-scale monitoring possible. Two tools were developed: the ICOPE MONITOR, an application, and the BOTFRAIL, a conversational robot. Both are connected to the Gerontopole frailty database. STEP 1 is performed every 4-6 months by professionals or seniors themselves. If a deterioration in one or more domains of intrinsic capacity is identified, an alert is generated by an algorithm which allows health professionals to quickly intervene. The operational implementation of the INSPIRE ICOPE-CARE program in Occitania is done by the network of Territorial Teams of Aging and Prevention of Dependency (ETVPD) which have more than 2,200 members composed of professionals in the medical, medico-social and social sectors. Targeted actions have started to deploy the use of STEP 1 by healthcare professionals (physicians, nurses, pharmacists,…) or different institutions like French National old age insurance fund (CNAV), complementary pension funds (CEDIP), Departmental Council of Haute Garonne, etc. Perspective: The INSPIRE ICOPE-CARE program draws significantly on numeric tools, e-health and digital medicine to facilitate communication and coordination between professionals and seniors. It seeks to screen and monitor 200,000 older people in Occitania region within 3 to 5 years and promote preventive actions. The French Presidential Plan Grand Age aims to largely implement the WHO ICOPE program in France following the experience of the INSPIRE ICOPE-CARE program in Occitania.

Key words: ICOPE program, older people, dependency, remote monitoring, STEP, intrinsic capacity, INSPIRE, Occitania, care implementation, clinical practice.


 

Introduction

The INSPIRE program was recently funded in Toulouse, France, which aims to identify the hallmarks of biological aging and allows us to propose, in the future, innovative therapeutics to prevent or restore impaired function (1). To achieve this objective, a Human Translational Cohort as well as an Animal cohort will be created to discover biomarkers of aging. The INSPIRE ICOPE-CARE program is a part of the INSPIRE program. Its main objective is to implement, at a large scale in the Occitania region, South-Western France, the WHO ICOPE program in the daily clinical routine. The ambition of INSPIRE ICOPE-CARE is to evaluate and follow about 200,000 older adults by 2025.
WHO defines the notion of healthy aging (2), not as having no pathology since diseases happen throughout life, but as being able to keep doing what we have reason to value for as long as possible. Healthy aging partly depends on the maintenance of optimal levels of intrinsic capacity during aging, intrinsic capacity being a combination of all mental and physical capacities. WHO has developed the Integrated Care for Older People (ICOPE) program, a function- and person-centered care pathway during aging (3); as WHO Collaborative center for frailty, clinical research and geriatric training, the Gerontopole of Toulouse University Hospital played an important role in its elaboration. This program was created based on the analysis of more than 500 major original publications and the recommendations of a committee on aging including experts from WHO and almost 50 international experts from research, care and the academic world.
The ICOPE program is a care pathway, which consists of a participative and integrated healthcare approach that takes into account the individuals’ capacities, their associated pathologies, the environment, their lifestyle, but also their wishes and aspirations. Emphasis is placed on the fact that the patient must be involved in his/her care and monitoring (4). In the ICOPE program, there are 5 steps in the care of the subject: STEP 1: Screen for declines in intrinsic capacity; STEP 2: Undertake a person-centered assessment in primary care; STEP 3: Define the goal of care and develop a personalized care plan; STEP 4: Ensure a referral pathway and monitoring of the care plan with links to specialized geriatric care; STEP 5: Engage community and support caregivers (Figure 1). The focus of the ICOPE program is on three important points: 1- the patient is centrally involved in his/her care and monitoring, 2- the care plan considers the importance of caregivers and the use of local resources offered by the community; 3- a large place is given to new technologies or “digital medicine” (3,4). Indeed, information and communication technologies are crucial in the current context of medical demographic constraints, as well as the need to continuously monitor large populations.

The objective of ICOPE program is to prevent or delay the onset, and decrease the severity of care dependency. The goal is to enable as many people as possible to age in good health. To reach this objective, WHO proposes to follow the trajectory of intrinsic capacity covering six operational domains: mobility, cognition, vitality / nutrition, psychological state, vision, hearing (5, 6).
The large INSPIRE Program has two principal objectives (1). The first main objective is to build a resource and research platform for Geroscience extending from animals to humans, from cells to individuals, from research to clinical care. Although chronological age (civil age, date of birth) has always been used as the operational definition of aging, it does not necessarily reflect the biological process of aging. The second main objective of INSPIRE program is to implement in clinical care the WHO ICOPE Program. In the current paper, we describe the methods of implementation of the ICOPE program in the context of the INSPIRE initiative, the « INSPIRE ICOPE-CARE program”.

Figure 1
5 Steps of WHO ICOPE program

 

Method

Objectives of the “INSPIRE ICOPE-CARE program”

The main objective of the INSPIRE ICOPE-CARE program is to implement, at a large scale in the Occitania region, South-Western France, the WHO ICOPE program in a daily clinical routine. Secondary objectives are to explore the acceptability of the INSPIRE ICOPE-CARE program by both older adults and health care professionals, as well as to examine the use of new digital tools in the evaluation and monitoring of intrinsic capacity.

Population

The target population in the INSPIRE ICOPE-CARE program is independent seniors aged 60 years and over in Occitania region, in France. The actors are healthcare professionals, trained professionals, but also caregivers and seniors themselves. Indeed, the STEP 1 tool may be used by any person who has undergone a training course on ICOPE. To follow this population, the six domains of intrinsic capacity are systematically monitored with pre-established tools (STEP 1, and then if appropriate STEP 2, STEP 3, STEP 4, STEP 5). This allows the health professionals to intervene quickly if a decline occurs in any domain.

STEP 1 – Screen for declines in intrinsic capacity

The first tool proposed by WHO to evaluate intrinsic capacity is a screening tool referred to as ICOPE STEP 1. It is very simple, and usable by actors who are not necessarily health professionals after a brief training course (Figure 2). It allows a rapid assessment of the six operational domains of intrinsic capacity by very simple tests. In the INSPIRE ICOPE-CARE program, this tool has been adapted by the Toulouse Gerontopole to become a tool capable of monitoring intrinsic capacity over time. Then, the adapted ICOPE STEP 1 was elaborated in digital format to make it possible to undertake remote monitoring in a large-scale.

Figure 2
WHO STEP 1 screening tool (from WHO with permission)

 

The mobile phone is the technology that has spread best among the older population and is therefore an ideal support to remotely screen or monitor health indicators (7). Thus, two tools were developed by the Toulouse Gerontopole: a) the ICOPE MONITOR, an application, which is an adapted version of the ICOPE WHO application, accessible via smartphone or tablet; and b) the BOTFRAIL, an internet conversational robot, accessible via computer, smartphone or tablet. These two complementary tools can be used in two modes: professional mode and self-assessment mode for the senior or his/her caregiver. Both are connected to the pre-existing Gerontopole frailty database created in 2016 to collect medical and socio-demographic data from frail older people who received a face to face standardized gerontological assessment in the Occitania region. Data from more than 6,000 patients in 180 different health centers have already been collected since 2017. The database complies with all French and European regulations in terms of health data security. The authorization of the French “National Commission for Data Protection” was granted on April 13, 2017 (Ref. Nb. MMS/OSS/NDT171027, authorization request Nb. 19141154).
These tools may be used by everyone. However, in the context of the INSPIRE ICOPE-CARE program, during the first (face to face) STEP 1 screening, the professional collects the senior’s oral consent to keep his/her data in the frailty database as well as to monitor his/her intrinsic capacity regularly. If the assessment is normal, lifestyle advice is provided by the professional who also trains the senior or his family/caregiver to use the tools in «self-assessment» mode.

Remote screening of STEP 1 – ongoing monitoring
The ongoing screening of intrinsic capacity deficits is based on a remote monitoring system. After having been taught by health professionals how to use the ICOPE MONITOR app and/or BOTFRAIL tool, seniors are invited to continuously use the STEP 1 every 4-6 months. If the senior cannot carry out the self-assessment, a professional will intervene every 6 months to perform the STEP 1 follow-up. STEP 1 data collected using the ICOPE MONITOR application or BOTFRAIL every 4 to 6 months are transmitted to the Gerontopole frailty database. If a deterioration in one or more domains of intrinsic capacity is identified during monitoring, an alert is generated by an algorithm. During the first deployment phase of the project, the management and processing of these alerts is carried out by the experienced nurses of the Gerontopole in collaboration with the primary care providers [General Practitioners (GP) and nurses]. When an alert is detected, the senior or family (as appropriate) will be contacted to verify the clinical relevance of the intrinsic capacity deficit. If the deficit is confirmed, the GP will be contacted to initiate STEP 2. This first phase makes it possible to evaluate the relevance of the alerts, adjust the algorithm and develop decision trees (Figure 3 & Table 1).

Figure 3
Diagram of the INSPIRE ICOPE-CARE program

 

Table 1
Tele-health supports and INSPIRE ICOPE-CARE program

Note. The follow-up is always digital (self-assessment / caregiver or nurse support). Depending on the geographical context and health resources, STEP 2 can be performed face-to-face or through telemedicine tools. The actors involved are also context-dependent; Note: Tele -consultation is a tele-health consultation between a doctor/nurse and the senior. Tele expertise is between two health professionals; General Practitioner, GP, geriatricians, G.

 

STEP 2 and STEP 3 – Undertake a person-centered assessment in primary care, define the goal of care and develop a personalized care plan

If the screening of intrinsic capacity is abnormal, STEP 2 (person-centered assessment) and STEP 3 (personalized care plan) are carried out by the GP or, if possible, by a nurse trained in geriatrics using the delegation of task as part of the “French protocol of cooperation” or the «Hospital outside the walls» care unit, as described below:
– The cooperation protocol was developed by the Gerontopole of Toulouse and the Occitania Regional Health Agency (ARS) and obtained the approval from the High Authority for Health (HAS) on December 4, 2013 (8, 9). It aims to delegate to a self-employed trained nurse (40 hours of training), the geriatric assessment of older people identified as frail. At the end of this assessment, the nurse, can immediately refer the person to the GP (in the case of warning signs or unexplained or multiple anomalies), to social services, appropriate health professionals (specialist physicians, physiotherapists,…) or themselves initiate preventive measures. The delegated nurse intervenes at the request of the GP after obtaining the consent of the patient. The nurse’s evaluations and proposed interventions are re-analyzed and discussed during a multi-professional concertation meeting with patient’s GP, organized no later than 30 days following the geriatric assessment. This model of care is funded by local health authorities. To date, more than 160 nurses have been trained in the Occitania region.
– The «Hospital outside the walls» care unit of Gerontopole is an innovative unit of care created in 2015 at the Toulouse University Hospital to take care of frail older people outside the hospital. The geriatric evaluation of the older people is carried out by experienced trained nurses of the Gerontopole at their homes or in public spaces close to their homes. These nurses, with the support of a hospital geriatrician, propose a personalized care plan to the older people evaluated. This plan is then sent to the person’s GP who ensures its implementation and follow-up. This model has been rolled out in other hospital centers in the Occitania region. To date seven hospitals in the region have their own «Hospital outside the walls» care unit.

STEP 4 – Ensure a referral pathway and monitoring of the care plan with links to specialized geriatric care

As mentioned above, monitoring consists of the repetition every 4-6 months of STEP 1, either by self-assessment or with the help of a family member or professional caregiver. Digital medicine used in the INSPIRE ICOPE-CARE program makes it possible to simultaneously monitor large populations regardless of where they live and the extent of local medical resources and can also ensure the implementation and follow up of the personalized care plan proposed in STEP 3. Thus, digital medicine allows to focus the action of the health professionals on those who need and when they need (efficient use of resources and personalized medicine) using a dashboard and by the generation of automatized and graduated alerts (the algorithm will evolve over time). When a coordination meeting is necessary between the GP and other health professionals especially nurses who realized STEP2 and STEP3, tele-health consultations may be used (called tele-expertise). To make it possible, we are deploying the use of a tele-health platform to facilitate access to this expertise throughout the region regardless of location. In the context of “complexes cases”, the GP may request a tele-consultation or tele-expertise with geriatricians and other physicians (e.g. psychiatrists) in the reference center. In these situations all the Gerontopole’s paramedical resources: physiotherapists, nutritionists, neuropsychologists and social workers may be involved, as well.
Lastly, digital remote monitoring tools are an excellent support for assessing adherence to the care plan, coordinate care, but also for providing information or educational content (nutrition, physical activity) to seniors.

STEP 5 – Engage community and support caregivers

This stage allows the establishment of an ecosystem favorable to «healthy aging». At this step, town halls, departments, and regions as well as several organizations (Departmental Councils, pension funds, insurances,…) can set up efficient organizations to encourage and promote «healthy aging». The INSPIRE ICOPE-CARE program is part of this step and plays an important role in bringing together different actors and organizations around the same objective which is the adaptation of our society to aging well.

Implementation of concrete actions in the Occitania region

The operational implementation of the INSPIRE ICOPE-CARE program in Occitania will be promoted by the network of Territorial Teams of Aging and Prevention of Dependency (ETVPD) which have more than 2,200 members composed of professionals in the medical, medico-social and social sectors. This Network was created in 2012 by the Gerontopole of Toulouse with the support of the Occitania Regional Health Agency (ARS). The objective of this network is to prevent dependency among seniors in Occitania by promoting care, training, research and innovation in gerontology. Several meetings take place every year in different territories in Occitania allowing to exchange with the actors of the field and to advance on innovative projects. The INSPIRE ICOPE-CARE program is currently the main project on which the territorial teams are working.
A number of targeted actions have started to facilitate the use of STEP 1 by healthcare professionals or different institutions:
Physicians: The GP has the principal role for the implementation of the intervention plan proposed to the senior in the INSPIRE ICOPE-CARE program. His/her adherence to the program is essential. We are currently working with the regional union of physicians and the University Department of General Medicine (DUMG) to establish a follow-up strategy adapted to the GP’s work.
Nurses: In the INSPIRE ICOPE-CARE program, the nurse, in connection with the GP, will coordinate the implementation of intervention plans. First, we started the implementation of the INSPIRE ICOPE-CARE program with our experienced nurses of the Gerontopole who work at the «Hospital outside the walls» care unit of Toulouse University Hospital. Since January 2019, these nurses have used the STEP 1 tool for all their patients; to date (March 2020), around 950 seniors have been assessed. Some preliminary data on step 1 in 755 subjects showed that mean age was 80.9 ± 7.3 years, 67.3% were female (n=298) and 699 (92.6%) had at least one domain of intrinsic capacity affected. Table 2 shows the results of the STEP 1 evaluations.
The nurses especially those trained on frailty assessment in the framework of cooperation protocol (more than 160 nurses) are also involved. Since January 2020, the Gerontopole has organized several training courses on the use of STEP 1 and ICOPE. To date, 94 nurses have been trained and 240 are registered for the next sessions. An agreement was signed between the Toulouse University Hospital and the Occitania Regional Health Agency to pay nurses 15 euros for this evaluation.

Table 2
STEP 1 analysis performed on the first 755 subjects evaluated

 

Pharmacists: In collaboration with the regional union of pharmacists and the pharmacy unit of Toulouse University Hospital, volunteer pharmacists and 6th year pharmacy students are also trained on the ICOPE program. To date (March 2020), 65 pharmacists have been trained and approximately 80 are registered for the next training sessions. The STEP 1 will be performed in the pharmacies by the pharmacists and in the event of an abnormal STEP 1, the pharmacist will direct the patient to his/her GP.
Institutions: A partnership is set up with CEDIP (CEntre D’Information et de Prévention – Agirc-Arrco), which is a complementary pension fund in France, to carry out STEP 1 for their beneficiaries. To date (March 2020), more than 300 seniors have been assessed. An analysis made on 207 subjects with usable data showed that mean age was 70.1 years, 61.8% were female (n=128) and 86.5% (n=179) had at least one domain of intrinsic capacity affected. The domain most affected was vision (64.7%) followed by hearing (60.9%) and cognition (41.5%).
A collaboration is developed with French National old age insurance fund (CNAV) to implement STEP 1 within the usual professional practices of home caregivers and create an innovative and specific prevention offer for young precarious retirees (62-70 years old).
Departmental Council of Haute Garonne is a partner of the Gerontopole of Toulouse. Their assessors are planned to be trained in June 2020 to carry out STEP 1 for all independent seniors who request them for a personalized autonomy allowance.
Several other actions are planned. A project is being developed with the French Mutual Insurance, which brings together the majority of existing mutual health insurance companies in France, to disseminate information about this program to primary healthcare providers. The Federation of Health Homes of Occitania (FORMS) was contacted to set up the INSPIRE ICOPE-CARE program in Health Homes. We are also collaborating with the Post Office, to set up an experiment in three cities in the Toulouse agglomeration in order to carry out STEP 1 by trained postmen from the Post Office. The experiment is due to start in September 2020. We are also working with spas, which receive a large number of seniors each year.

INSPIRE ICOPE-CARE program: perspectives and future challenges for the care of individuals during aging

It is always difficult to change habits and implement new care pathways in clinical practice. The INSPIRE ICOPE-CARE program plans to screen and monitor the intrinsic capacity of 200,000 older people in Occitania region within five years and promote preventive actions, instead of only punctual, curative ones. WHO with ICOPE program is determined to reduce the number of older people worldwide who are care dependent by 15 million by 2025, which would mean 150,000 in France and 15,000 in Occitania (10).
The INSPIRE ICOPE-CARE program is in full agreement with the national project of “Ma santé 2022” (My Health 2022) (11), in which the French Ministry of Health highlights the following aspects: to organize healthcare around the older people and give them a qualified and relevant care, be more active in prevention in order to promote home maintenance and develop a better organization of care between healthcare providers with the support of digital medicine. In order to achieve these objectives, the nurses’ role has to be redefined, giving them a stronger place in the assessment and the coordination of the patient’s healthcare pathway. Another change has to take place in communication and organization between hospital and primary healthcare providers, especially GPs. To establish this new organization, the INSPIRE ICOPE-CARE program supports “Ma Santé 2022” by joining the projects of several Professional regional health communities (CPTS) in the Occitania region. The CPTS are a new mode of organization that allows health professionals to come together in the same territory around a common medical and medico-social project. Moreover, The French Presidential Plan Grand Age aims to largely implement the WHO ICOPE program in France following the experience of the INSPIRE ICOPE-CARE program in Occitania.
This initiative draws significantly on numeric tools, e-health and digital medicine to facilitate communication and coordination between professionals and seniors (12, 13), it plays an important role in the future of geriatrics (14-17). The INSPIRE ICOPE-CARE program will also allow us to implement in clinical practice the discoveries of INSPIRE platform concerning clinical and biological biomarkers (18-22).

 

Funding: The Inspire Program was supported by grants from the Region Occitanie/Pyrénées-Méditerranée (Reference number: 1901175), the European Regional Development Fund (ERDF) (Project number: MP0022856), ARS «Agence Régional de Santé d’Occitanie» and the Inspire Chairs of Excellence funded by: Alzheimer Prevention in Occitania and Catalonia (APOC), EDENIS, KORIAN, Pfizer, Pierre-Fabre, Fondation Avenir Cogfrail Grant.
Potential Conflicts of Interest: The authors declare that they have no conflict of interest for the present paper.
Acknowledgements: The authors thank all the health professionals participating in the INSPIRE ICOPE CARE Program especially Cendrine Blazy and Dr Marie Dominique Medou from Occitania Regional Health Agency and all the members of the Gerontopole “Hospital of the walls” care unit (Augusto S, Bouchon L, Cazes MC, Da Costa F, Poly M, Vaysset S) and all the members of the Occitania Territorial Teams of Aging and Prevention of Dependency.
Ethical standards: The INSPIRE protocol has been approved by the French Ethical Committee located in Rennes (CPP Ouest V) in October 2019. This research has been registered on the site http://clinicaltrials.gov (ID NCT04224038). In the INSPIRE ICOPE-CARE program, all the senior’s data are collected in the Gerontopole Frailty database. This database complies with all French and European regulations in terms of health data security. The authorization of the French “National Commission for Data Protection” was granted on April 13, 2017 (Ref. Nb. MMS/OSS/NDT171027, authorization request Nb. 19141154). During the first (face to face) STEP 1 screening, the professional collects the senior’s oral consent to keep his/her data in the frailty database as well as to monitor his/her intrinsic capacity regularly.
Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

 

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22. Rodriguez-Mañas L, Araujo de Carvalho I, Bhasin S, Bischoff-Ferrari HA, Cesari M, Evans W, Hare JM, Pahor M, Parini A, Rolland Y, Fielding RA, Walston J, Vellas B. ICFSR Task Force Perspective on Biomarkers for Sarcopenia and Frailty. J Frailty Aging. 2020;9(1):4-8. doi: 10.14283/jfa.2019.32. PubMed PMID: 32150207.

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THE SUSTAINED IMPACT OF A MEDICAL SCHOOL-BASED PHYSICAL ACTIVITY MODULE ON INTERNS’ PERCEIVED COMPETENCE IN ADVISING OLDER ADULTS ABOUT EXERCISE

 

A.D. Jadczak1,2, R. Visvanathan1,2,3

1. Adelaide Geriatrics Training and Research with Aged Care (G-TRAC) Centre, Adelaide Medical School, University of Adelaide, South Australia, Australia; 2. National Health and Medical Research Council Centre of Research Excellence Frailty and Healthy Ageing, University of Adelaide, South Australia, Australia; 3. Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia.
Corresponding author: Agathe Daria Jadczak PhD, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital DX 465701, 28 Woodville Road, Woodville South, SA 5011, Australia, Phone: +61 8 8133 4012 Email: agathedaria.jadczak@adelaide.edu.au

J Frailty Aging 2020;9(3)155-157
Published online November 26, 2019, http://dx.doi.org/10.14283/jfa.2019.39

 


Abstract

The study aimed to examine the sustained impact of a 1.5-hour medical school-based physical activity (PA) module on interns’ perceived competence and importance in advising older adults about exercise. The modified Exercise and Physical Activity Competence Questionnaire (EPACQ) was administered in 2017 (CG: control group) and 2018 (IG: intervention group) two years post-course. The perceived competence of both, CG (n=23) and IG (n=18), decreased significantly over two years (p≤0.05) with no difference between the groups (p>0.05). However, 72.2% (n=13) of the interns who attended the PA module still felt competent in advising older adults about exercise (4.21±0.66) compared to 47.8% (n=11) of the CG (3.89±0.67). The perceived importance decreased significantly in both groups (p≤0.05) with no difference between the groups (p>0.05). However, both groups still perceived exercise for older people as important (CG:4.55±0.61; IG:4.83±0.47). Subsequently, continued professional development is likely to be a key requirement for ensuring sustainability over time.

Key words: Perceived competence, exercise prescription, interns, medical education, older people.


 

Introduction

Given the growing body of evidence about the health and wellbeing benefits of exercise to older people, the importance of exercise promotion and physical activity (PA) advice in clinical practice is increasing (1, 2). However, doctors often cite a lack of education during medical school as one of the reasons why they may be reluctant to counsel their patients on exercise (3).
In our previous research, we demonstrated that 5th-year medical students’ (enrolled in a 6-year program) perceived exercise for older people as important but felt only moderately competent in advising older people about exercise (4). Based on these research findings, we introduced a 1.5-hour PA module, including a one-hour exercise tutorial combined with a 30-minute practical exercise counselling session, to a university geriatric medicine undergraduate teaching program. We demonstrated that the PA module impacted positively on senior medical students’ perceived competence when compared to baseline (5). However, it remained to be determined if following exposure to this PA module, the improvements in perceived competence were sustained over time.
The aim of this study, therefore, was to investigate the sustained impact of the PA module provided during 5th-year of medical school on interns’ perceived competence and importance in advising older adults about exercise at the commencement of their internship two years later.

 

Methods

Initial study and PA module

In 2015 (control) and 2016 (PA module), all University of Adelaide 5th-year medical students taking part in a 4.5-week Geriatric Medicine Course at the Queen Elizabeth Hospital (TQEH) campus were invited to participate in the study.
In 2015 (control), the Geriatric Medicine Course had no specific tutorials focused on exercise prescription but students did have access to therapy programs, a community based exercise class, and reading material on exercise recommendations and the effects of multi-component exercise on frailty (5).
In 2016 (intervention), a 1.5-hour PA module was introduced to the existing Geriatric Medicine Course consisting of a one-hour exercise tutorial combined with a 30-minute practical exercise counselling session (5). The tutorial provided information on how to assess older peoples’ physical activity levels, how to determine their levels of risk, how to customise the advice, and how to prescribe and refer a patient to an exercise program (5).
The modified Exercise and Physical Activity Competence Questionnaire (EPACQ) (6) was administered before and after the 4.5-week Geriatric Medicine Course in 2015 (control) and 2016 (PA module) (4, 5), and again in 2017 and 2018 when 5th-year medical students commenced their internship and became qualified doctors.

Participants

In 2017 and 2018, all commencing interns taking part in an orientation lecture held in the Central Adelaide Local Health Network (CALHN) in South Australia were invited to participate in this study. All interns were advised that participation was voluntary and provided informed consent by completing and returning the questionnaire to the researcher.
By collecting information about interns’ date of birth, gender, nationality, university and campus where they completed their 5th-year geriatric medicine undergraduate teaching program, we were able to identify those who attended the 5th-year Geriatric Medicine Course in 2015 (control) and 2016 (PA module) at TQEH. However, only those who completed the initial questionnaire in 2015 and 2016 were included in this study. The study received ethics approval from the University of Adelaide Human Research Ethics Committee (H-2015-001).

Study questionnaire

The EPACQ is a self-evaluation questionnaire and includes six skills related to exercise prescription with responses being graded on a Likert scale ranging from 1 (not competent or important) to 6 (very competent or important) (6). A mean score of ≥4 indicated overall perceived competence or importance (6). The EPACQ was modified to address older people and included four additional skills in relation to the risks and benefits of exercise, the referral to exercise and the identification of age-related limitations.

Statistical analysis

IBM SPSS Statistics Version 24 was used to perform the statistical analyses. A linear mixed-effects model was performed to investigate the interaction between time and group. A compound symmetry covariance structure was used to adjust for repeated measurements over time. Assumptions of a linear model were found to be upheld by inspection of histograms and scatter plots. Post-hoc comparisons were performed as the interaction structure was considered to be important in interpreting the results. Descriptive data is presented as mean and standard deviation (SD). The significance level was set at α ≤0.05.

 

Results

Participants

Out of 167 interns who responded to the questionnaire in 2017 (n=84) and 2018 (n=83), a total of 55 interns (n=27 in 2017; n=28 in 2018) indicated to have completed their 5th-year geriatric medicine undergraduate teaching program at the University of Adelaide TQEH campus.
However, only 41 interns (n=23 in 2017; n=18 in 2018) could be identified as being one of the 161 medical students who attended the Geriatric Medicine Course in 2015 (n=81) and 2016 (n=80) and completed the initial questionnaire. Subsequently, 23 students (28.4% out of n=81) from 2015 (control) and 18 students (22.5% out of n=80) from 2016 (PA module) were included in this study. The groups did not differ in their baseline characteristics (Table 1).

Table 1 Participants’ baseline characteristics

Table 1
Participants’ baseline characteristics

SD = standard deviation; *significant

 

Sustained impact of the PA module

No significant interaction was found between time and group for mean competence (p=0.239) or mean importance (p=0.427).
However, post-hoc analysis revealed a significant increase in perceived competence in both groups immediately after the course (p≤0.001) with the intervention group (4.92±0.31) feeling more competent (p=0.003) than the control group (4.30±0.66) post-course.
Two years later, the perceived competence in both groups decreased significantly (p≤0.05) with no differences between the groups (p=0.114). However, the intervention group still met the mean competence threshold of ≥4 (4.21±0.66) compared to the control group (3.89±0.67), and 72.2% (n=13) of the interns who attended the PA module still felt competent in advising older adults about exercise compared to 47.8% (n=11) of the control group.
The perceived importance increased in both groups immediately after the course (p≤0.05) with no differences between the groups (p=0.174), and decreased significantly two years later (p≤0.05). No differences were found between the groups (p=0.102), and both groups still met the mean importance threshold of ≥4 with all of the interns (100%, n=18) who attended the PA module perceiving exercise for older people as important (score ≥4) compared to 78.3% (n=18) of the control group (Table 2).

Table 2 Sustained impact of the PA module

Table 2
Sustained impact of the PA module

PA: physical activity; CG: control group; SD = standard deviation; ≥ 4 = competent/important;  ∆=change; *=significant

 

Discussion

No significant differences between control and intervention group were found for perceived competence or importance two years post-course. However, immediately after the course, interns who attended the PA module felt significant more competent than the control group.
Research related to medical school based interventions is sparse and inconclusive. One study investigated the effects of a 3-hour geriatrics didactic lecture compared to an interactive session using a quiz on 1st-year medical students’ knowledge and attitudes towards older people, and confirmed that a more interactive approach led to better knowledge immediate after the course, however, no differences were found at one-year follow (7). Other studies using more objective measurements found sustained effects, however, they only focused on one-year post-intervention (8, 9). One study investigated 4th-year medical students’ musculoskeletal examination skills using Objective Structured Clinical Examination (OSCE) and confirmed that an additional 6-hour medical school-based interactive clinical course improved essential examination skills not only immediately after the course but also one-year later (8). Another study examined the effects of a 1.5-hour simulator training using an objective test on laparoscopy skills in 1st and 2nd-year medical students and found that one-year later, students have retained a great part of their skills (9).
Interactive and more comprehensive medical education programs seem to be more effective than didactic lecture or reading material. In addition, more objective measurements might be needed when assessing the sustained effects of medial school education programs.
The effects of such educational interventions tend to decay over time (10) and the significant drop in perceived competence and importance as seen in this study suggests that continued professional development is a key requirement for ensuring sustainability of competence over time.
One limitation of this study was that data was only available from a few students who attended the PA module and that the study was conducted in only one local health network. Another limitation was the lack of objective assessment of skills, and the benefit of the intervention to older people was not considered. Because of the small sample size, the impact of confounding factors such as gender, student interest in PA, and student’s exam performance on findings could not be investigated.

 

Acknowledgments: The authors would like to thank Prof David Wilson for reviewing the manuscript and all the students and interns who participated in this study.
Conflict of interest: The authors declare no conflicts of interest.
Author contributions: Both authors contributed to the study design, implementation of the study, analysing and interpretation of the results and preparing the final manuscript.

 

References

1.    Andersen RE, Blair SN, Cheskin LJ, Bartlett SJ. Encouraging patients to become more physically active: the physician’s role. Ann Intern Med 1997;127(5):395-400.
2.    Taylor D. Physical activity is medicine for older adults. Postgrad Med J 2014;90(1059):26-32.
3.    Glasgow RE, Eakin EG, Fisher EB, Bacak SJ, Brownson RC. Physician advice and support for physical activity: results from a national survey. Am J Prev Med 2001;21(3):189-196.
4.    Jadczak AD, Tam KL, Yu S, Visvanathan R. Medical students’ perceptions of the importance of exercise and their perceived competence in prescribing exercise to older people. Australas J Ageing 2017;36(3):E7-E13.
5.    Jadczak AD, Tam KL, Visvanathan R. Educating Medical Students in Counselling Older Adults About Exercise: The Impact of a Physical Activity Module. J Frailty Aging 2018;7(2):113-119.
6.    Connaughton AV, Weiler RM, Connaughton DP. Graduating medical students’ exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep 2001;116(3):226-234.
7.     Diachun LL, Dumbrell AC, Byrne K, Esbaugh J. . . . But does it stick? Evaluating the durability of improved knowledge following an undergraduate experiential geriatrics learning session. J Am Geriatr Soc 2006:54(4):696-701.
8.    Perrig M, Berendonk C, Rogausch A, Beyeler C. Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills-a controlled study. BMC Med Educ 2016;16(1):35.
9.    Sant’Ana GM, Cavalini W, Negrello B, et al. Retention of laparoscopic skills in naive medical students who underwent short training. Surg Endosc 2017:31(2):937-944.
10.    Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev 2013;2013(3):CD002213.

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NEW SIMPLIFIED SCREENING METHOD FOR POSTPRANDIAL HYPOTENSION IN OLDER PEOPLE

 

R. ABBAS1,2,3, A. TANGUY1, D. BONNET-ZAMPONI1,2,4,5, R. DJEDID5, A. LOUNIS6, M.-L. GAUBERT-DAHAN6

 

1. Département d’épidémiologie et recherche clinique, Hôpital Bichat, AP-HP, Paris, France; 2. ECEVE, UMR 1123, INSERM, Université Paris Diderot,  Sorbonne Paris Cité, Paris, France; 3. CIC-EC 1425, INSERM, Hôpital Bichat, AP-HP, Paris, France; 4. OMEDIT Ile de France, Paris, France; 5. Rehabilitation unit, Geriatrics, Hôpital Bretonneau, AP-HP, Paris, France; 6. Rehabilitation unit, GHI Le Raincy-Montfermeil, France
Corresponding author: Rachid Abbas, Département d’épidémiologie et recherche clinique, CIC-EC 1425, AP-HP, Hôpital Bichat, Paris France, rachid.abbas@aphp.fr

J Frailty Aging 2018;7(1):28-33
Published online January 22, 2018, http://dx.doi.org/10.14283/jfa.2018.2

 


Abstract

Background: Postprandial hypotension (PPH) is an important disorder in the older people that remain underdiagnosed. The reference PPH diagnostic method is too demanding, because blood pressure (BP) needs to be measured 8 times in 2 hours. Objectives: Our primary objective was to define a new simplified PPH diagnostic method and to evaluate its performances. Design: We conducted a cross-sectional study. Setting: Two geriatric rehabilitation units in France. Participants: 104 patients (70 women, 34 men) with high risk of PPH were included. Measurements: BP was measured twice before the midday meal in seated position at the table, and every 15 minutes for 90 minutes after the end of the meal. Receiver Operating Characteristic curves were plotted for each postprandial BP measure to determine the best postprandial measure in terms of sensitivity and specificity. The optimal diagnostic threshold was calculated with Youden’s index according to BP difference before and after the meal. Results: A new simplified diagnostic method is proposed: a decrease of at least 10 mmHg systolic BP between BP measures before the meal and 75 minutes after the end of the meal. This new method had a sensitivity of 82% (95%CI 66 – 92) and a specificity of 91% (95%CI 81 – 97). Conclusion: This new diagnostic method is fast, efficient and suitable for everyday use. It could improve PPH diagnosis in older people. Larger studies are needed to validate it.

Key words: Postprandial, hypotension, diagnostic techniques and procedures, older people, cardiovascular.


 

Introduction

Postprandial hypotension (PPH) is a prevalent but not well diagnosed disorder in older people, although it is associated with increased risk of syncope (1), falls (2, 3)(4), coronary event and stroke (5). PPH is an independent predictor of mortality among older people (6). PPH is distinct from and probably more common than orthostatic hypotension. Prevalence is estimated to be between 24%-36% in institutionalized older people (7, 8) and 67% in hospitalized older people (9).
The epidemiology and pathophysiology of PPH are not fully defined. Possible contributors include inadequate sympathetic nervous system compensation for meal-induced splanchnic blood pooling; impairments in baroreflex function; inadequate postprandial increase in cardiac output; and impaired peripheral vasoconstriction, insulin-induced vasodilation, and release of vasodilatory gastrointestinal peptides (10).
Several symptoms are related to PPH: syncope, falls, dizziness, weakness, light-headedness, scotoma, nausea, and elocution disorders. The precise relationship between such symptoms and postprandial reductions in blood pressure (BP) is unclear. BP maintenance after a meal may depend on the interaction of some or all of the mechanisms outlined previously to compensate for the increase in bowel blood volume. The impairment of one or more of these mechanisms could result in inadequate compensation, leading to hypotension. If so, the occurrence of symptoms depends on adequate compensatory cerebral autoregulation in the individual patient.
PPH could be avoidable with lifestyle and dietary rules: being careful in the 2 hours after a meal, walking or lying down, and eating the right foods.
Despite the harmful consequences of PPH and the relative simplicity of corrective measures, PPH remains under-diagnosed. PPH is defined as a decrease in systolic blood pressure of 20 mmHg or more within 2 hours from the start of a meal (10). The standard PPH diagnostic method consists of 9 measures: 1 measure before the meal and every 15 minutes for 120 minutes after the start of the meal (10, 11). This standard method is time-consuming and difficult to implement in clinical practice. This could explain the under-diagnosis of PPH. Alternative diagnostic methods have been proposed. Jansen recommends measuring BP at intervals of 10 minutes for 2 hours after the start of the meal (12). Kearney et al repeated measurements every 20 minutes for 2 hours after meal intake (13), and Kawaguchi et al. every 30 minutes (14). Others authors use ambulatory measurement of BP over 24 hours and study three consecutive meals (15). The most commonly accepted threshold for BP decrease is 20 mmHg (10); others have proposed recently a threshold of 30 mmHg (16)(17). These alternative methods remain very demanding and do not address the problem of feasibility of PPH diagnosis in clinical practice.
The aim of this study was to find a new simplified PPH diagnostic method and to evaluate its diagnostic performances.

 

Methods

Patient selection

This cross-sectional evaluation study was performed on patients hospitalized consecutively in 2 geriatric rehabilitation centers in the Paris area: one in Bretonneau hospital (APHP), a university hospital located in Paris and one in general hospital located in Montfermeil near Paris. Between July and August 2014, every inpatient was screened for eligibility. The inclusion criterion was to be able to sit in an armchair. Patients with an acute condition, receiving palliative care, unable to cooperate and/or to give a consent and/or dependent for eating were excluded from the study.
Non-opposition to collection of data was obtained for each patient included. All procedures were approved by the Institutional Review Board -IRB 00006477- of HUPNVS, Paris 7 University, AP-HP (approval n°15-077). Data collection procedures for this research were reported to the French authority for data and privacy protection (Commission nationale de l’informatique et des libertés).

Study design

The PPH reference diagnostic method was performed during the midday meal on each patient included. Before the first measure, patients sat at the meal table for at least 20 minutes. A trained nurse measured BP with an adapted armband seven times: once before the meal and six times afterwards, every 15 minutes from the end of the meal. The patient left the table 90 minutes after the end of the meal.
The PPH diagnosis with the reference method is defined as a decrease of 20 mmHg systolic BP or more between the measurement before the meal and the lowest of the six measurements afterwards. The new simplified PPH diagnostic method was defined as a decrease in systolic BP between one measurement before the meal and one measurement afterwards. Each of the six postprandial BP measures was considered to determine the simplified PPH diagnostic method providing the best diagnostic performances in comparison with the reference method.

Data collection

Data were collected for each patient included during their hospital stay by the geriatrician in charge from medical records: age, gender, level of disability with activities of daily living score (ADL) (18) and instrumental activities of daily living score (IADL) (19), the Cumulative Illness Rating Scale in Geriatrics score (CIRS-G) (20), comorbidities thought to be linked to PPH (hypertension (21), diabetes mellitus (22), diastolic heart failure, Parkinson’s disease (23), treatments to be linked to PPH (diuretics, nitrates, beta-blockers, calcium antagonists, angiotensin converting enzyme inhibitors, angiotensin II antagonists, anti-diabetics, insulin, levodopa). Events suggesting PPH (syncope, falls, coronary event, and stroke) (5) in the previous year were systematically collected by questioning patient and his/her carer(s). Clinical manifestations suggesting PPH (syncope, falls, dizziness, weakness, light-headedness, scotoma, nausea, elocution disorder, coronary event, and stroke) (24) and occurring at the time of any BP measure were collected by a nurse.

Data analysis

Analyses were performed on all patients included. Quantitative variables were examined for normality prior to analyses. Demographic and clinical characteristics for the individuals with PPH diagnosis and those without were reported as means and standard deviations (or median and interquartile intervals) for quantitative data, and frequencies and proportions for categorical data. They were compared using independent sample t-tests or Wilcoxon tests for continuous data and chi-square or Fisher tests for categorical data. For each of the six candidate simplified diagnostic methods, diagnostic performance was assessed. Receiver Operating Characteristic (ROC) curves were plotted and their Areas Under the ROC Curves (AUC) were estimated to determine the best postprandial measure in term of sensitivity and specificity. Once the best time point for BP measurement for simplified PPH diagnosis was determined, the optimal diagnostic threshold was determined as that which maximized the Youden index, which corresponds to the value providing the best tradeoff between sensitivity and specificity. For the simplified PPH diagnosis method and for each of the time points measures Cohen’s kappa coefficient of agreement was computed. All the 95% confidence intervals (95% CI) were calculated by binomial method. The number of patients required was 100 to estimate PPH prevalence expected to be 30% with a precision of 7.8% for a 95% confidence interval. Analyses were performed using SAS, version 9.2 (SAS Institute, Inc., Cary, NC).

 

Results

Study population

Between July and August 2014, 202 consecutive older people were admitted to the two rehabilitation centers and were screened for eligibility; 104 were eligible, did not oppose data collection and were included. Of the 104 participants, 39 patients (37.5%) were diagnosed with PPH.
The study population was elderly (mean age 86 years, range 63 – 102), mostly women (67%) with a high level of dependence (ADL 6-items mean score 3.22 ± 1.82, IADL 4-items mean score 1.35 ± 1.05) and a high level of comorbidity (CIRS-G average 15.02 ± 5.43). The most frequently observed comorbidities were hypertension (n=90, 87%) and diabetes (n=32, 31%). The treatments potentially related to PPH or treatments that could aggravate PPH most frequently reported were angiotensin converting enzyme inhibitors (n=46, 25%), beta-blockers (n=41, 22%), calcium antagonists (n=30, 16%), and diuretic drugs (n=29, 15%), far ahead of antidiabetics (n=16, 9%), insulin (n=16, 9%), and levodopa (n=4, 2%).  Many patients (n=79, 76%) reported events suggesting PPH in the preceding year, the most frequent being falls (n=63, 62%).
Demographic and clinical characteristics of the patients included with and without PPH are summarized in table 1. Diuretic prescriptions were more frequent among patients without PPH (p=0.03). No other significant difference was observed between patients with PPH and the others.

Table 1 Patients’ clinical characteristics according to the presence of postprandial hypotension (n=104)

Table 1
Patients’ clinical characteristics according to the presence of postprandial hypotension (n=104)

ADL, activities of daily living; IADL, instrumental activities of daily living; CIRS-G, cumulative illness rating scale for geriatrics; PPH postprandial hypotension; sd, standard deviation.
* Chi-squared test or Fisher’s exact test (as required); †Student’s t-test ; ‡Clinical events includes (falls, syncope, stroke and coronary events) ; §Clinical manifestations includes (weakness, dizziness, light-headedness and nausea).

 

PPH diagnosis method

All 6 postprandial measures yielded a simplified PPH diagnosis method with a specificity of 100%. The sensitivities ranged from 30.8% to 56.4%. The best-performing BP measurement times were 30 minutes (Sensitivity= 56.4% CI 95% 39.6 – 72.2) and 75 minutes after the meal (Sensitivity = 46.2% CI 95% 30.1 – 62.8). Figure 1 presents Receiver Operating Characteristic curves (ROC curves) for the diagnostic performance of each post-prandial BP measure. The largest area under the curve (0.93; 95%CI 0.87 – 0.98) was observed for BP measurement 75 minutes after the meal.

Postprandial hypotension diagnosis receiver operating characteristics curves for each BP measurement time (n=104)

Postprandial hypotension diagnosis receiver operating characteristics curves for each BP measurement time (n=104)

AUC, area under the receiver operating characteristics curve; 95%CI, 95% confidence interval;  BP, blood pressure.

 

Optimal PPH test

Figure 2 presents the Youden index for simplified PPH diagnosis according to systolic BP difference at 75 minutes. The optimal threshold maximizing the Youden index was 10 mmHg. The best simplified PPH diagnostic measure was the one with a threshold of 10 mmHg decrease in systolic BP measured 75 minutes after the meal, and it had a sensitivity of 82% (95% CI 66 – 92) and a specificity of 91% (95% CI 81 – 97). Cohen’s kappa agreement coefficient was 0.73 (95%CI 0.60-0.87) between the optimal simplified PPH test and the reference method. The simplified method showed better agreement than other single time points measures (table 2).

Figure 2 Youden index for simplified postprandial hypotension diagnosis according to systolic BP difference at 75 minutes (n=104)

Figure 2
Youden index for simplified postprandial hypotension diagnosis according to systolic BP difference at 75 minutes (n=104)

Table 2 Agreement with the reference postprandial hypotension diagnosis method for the simplified method and each time points measures. (n=104)

Table 2
Agreement with the reference postprandial hypotension diagnosis method for the simplified method and each time points measures. (n=104)

95% CI, 95% confidence interval

 

Discussion

A new simplified PPH diagnostic method is thus proposed: a decrease of at least 10 mmHg systolic BP between BP measure before the meal and 75 minutes after the end of the meal. This new method had a sensitivity of 82% (95% CI 66 – 92) and a specificity of 91% (95% CI 81 – 97).

PPH prevalence in our population of patients admitted consecutively to geriatric rehabilitation units was 37.5%, not far from that described in the literature for nursing homes (36%) (8) and low-level care residents (38%) (6). To our knowledge no study has previously reported the prevalence of PPH in rehabilitation center. In rehabilitation center, patients have numerous characteristics similar to those in nursing home: multiple chronic conditions, polypharmacy, impairment in functional abilities and mostly a stable clinical condition. It is not therefore surprising that PPH prevalence in rehabilitation center is close to that found in nursing homes.
The postprandial BP nadir occurs between 30 and 60 minutes after eating according to Aronow et al. (7), 90 minutes after the start of the meal (sitting position) according to Jung Tae Son et al. (25), and between 60 and 120 minutes from the meal according to Ong et al. (26). Taking into account that a meal lasts about 30 minutes, and the difficulties in practice of measuring precisely the beginning and end of the meal, the best measurement time reported in our study (BP measure at 75 minutes) seems to fit well with the data reported in the literature.
Our study has several strengths: no eligible non-included patient, a multicentric design, and the collection of clinical data at the time of the BP measures by the geriatrician in charge. In addition, BP measures were standardized and we took the precaution of waiting 20 minutes at rest in sitting position before the first BP measurement, to avoid measures of BP reduction resulting from orthostatism, noted by other authors in previous studies (3, 6, 9, 17). Puisieux and al. showed the good intraindividual reproducibility of standardized postprandial BP measurements (27).
This pragmatic study designed to match “real life” practice may have been limited by potential bias. First, the composition of the meal was not recorded, nor was the meal standardized, in contrast to some interventional studies (26). Carbohydrate-rich meals (13, 28) and warms meals (29) increase the risk of PPH. However, a standardization of meals does not reflect daily practice and did not seem suited to the objective of this pragmatic study (17) aiming to develop an easy, accessible diagnostic method for PPH. Second, drugs with effect on BP were not discontinued in our study, whereas some authors discontinued drugs 24 hours before PPH screening (17). However, care was taken to postpone taking these drugs in the morning or the evening.  We observed that patients using diuretics were less likely to have PPH. This unexpected result needs to be confirmed in other studies. Third, our screening of PPH was restricted to the midday meal, although PPH is known to be most prevalent in the morning and least prevalent in the evening (30). The midday meal was chosen because it is the meal where the patients are the most likely to be seated at table. This could have led to underestimate PPH prevalence but our observed prevalence appears consistently with the prevalence found in the literature (6, 8) so we believe this had a minor impact on the validity of our study. Fourth, our study showed no link between clinical events in the preceding year, clinical manifestations of PPH and PPH diagnosed according to the gold standard. These data were collected by questioning the patients because these are usually not collected in medical records which may have introduced a bias. Our study was not designed to assess the link between PPH and clinical events such as falls which may have multiple risk factors. This result shows that it is questionable to assess the risk of PPH solely on questioning patients and enhances the usefulness of our simplified diagnostic method.
Despite these limitations, our simplified PPH diagnostic method could improve PPH screening as compared to the reference method because it reduces the number of BP measurements (2 measurements versus 9) at meal times. Despite the complications of PPH, the diagnosis is not implemented in clinical practice because patients are not necessarily cooperative and the staff is not always available at mealtimes. The development of this simplified PPH diagnostic method in a pragmatic study ensures its feasibility in clinical practice, and its sensitivity and its specificity are satisfactory. Larger studies are required to validate this new simplified diagnostic method, which could improve PPH diagnosis in older people.

 

Conflict of interest: none.
Funding: No funding was raised for this study.
Ehical standards: All study procedures were approved by the local Institutional Review Board -IRB 00006477 (approval n°15-077).

 

References

1.     Lipsitz LA, Pluchino FC, Wei JY, et al. Cardiovascular and norepinephrine responses after meal consumption in elderly (older than 75 years) persons with postprandial hypotension and syncope. Am J Cardiol 1986;58:810–5.
2.     Bueno-Cavanillas A, Padilla-Ruiz F, Jiménez-Moleón JJ, et al. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol 2000;16:849–59.
3.     Puisieux F, Bulckaen H, Fauchais AL, et al. Ambulatory blood pressure monitoring and postprandial hypotension in elderly persons with falls or syncopes. J Gerontol A Biol Sci Med Sci 2000;55:M535–540.
4.     Le Couteur DG, Fisher AA, Davis MW, et al. Postprandial systolic blood pressure responses of older people in residential care: association with risk of falling. Gerontology 2003;49:260–4.
5.     Aronow WS, Ahn C. Association of postprandial hypotension with incidence of falls, syncope, coronary events, stroke, and total mortality at 29-month follow-up in 499 older nursing home residents. J Am Geriatr Soc 1997;45:1051–3.
6.     Fisher AA, Davis MW, Srikusalanukul W, et al. Postprandial hypotension predicts all-cause mortality in older, low-level care residents. J Am Geriatr Soc 2005;53:1313–20.
7.     Aronow WS, Ahn C. Postprandial hypotension in 499 elderly persons in a long-term health care facility. J Am Geriatr Soc 1994;42:930–2.
8.     Vaitkevicius PV, Esserwein DM, Maynard AK, et al. Frequency and importance of postprandial blood pressure reduction in elderly nursing-home patients. Ann Intern Med 1991;115:865–70.
9.     Vloet LCM, Pel-Little RE, Jansen PAF, et al. High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals. J Gerontol A Biol Sci Med Sci 2005;60:1271–7.
10.     Jansen RW, Lipsitz LA. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med 1995;122:286–95.
11.     Puisieux F. Postprandial hypotension in the elderly. Presse Médicale 2003;32:1226–30, 1237.
12.     Jansen RWMM. Postprandial hypotension: simple treatment but difficulties with the diagnosis. J Gerontol A Biol Sci Med Sci 2005;60:1268–70.
13.     Kearney MT, Cowley AJ, Stubbs TA, et al. Depressor action of insulin on skeletal muscle vasculature: a novel mechanism for postprandial hypotension in the elderly. J Am Coll Cardiol 1998;31:209–16.
14.     Kawaguchi R, Nomura M, Miyajima H, et al. Postprandial hypotension in elderly subjects: spectral analysis of heart rate variability and electrogastrograms. J Gastroenterol 2002;37:87–93.
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16.     Wieling W, Schatz IJ. The consensus statement on the definition of orthostatic hypotension: a revisit after 13 years. J Hypertens 2009;27:935–8.
17.     Van Orshoven NP, Jansen PA, Oudejans I, et al. Postprandial hypotension in clinical geriatric patients and healthy elderly: prevalence related to patient selection and diagnostic criteria. J Aging Res 2010;2010:243752.
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22.     Sasaki E, Kitaoka H, Ohsawa N. Postprandial hypotension in patients with non-insulin-dependent diabetes mellitus. Diabetes Res Clin Pract 1992;18:113–21.
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AN INTERNATIONAL POSITION STATEMENT ON THE MANAGEMENT OF FRAILTY IN DIABETES MELLITUS: SUMMARY OF RECOMMENDATIONS 2017

 

A.J. SINCLAIR1,*, A. ABDELHAFIZ2, T. DUNNING3, M. IZQUIERDO4, L. RODRIGUEZ MANAS5, I. BOURDEL-MARCHASSON6, J.E. MORLEY7, M. MUNSHI8, J. WOO9, B. VELLAS10,*

 

1. Foundation for Diabetes Research in Older People, Diabetes Frail Ltd and University of Aston, United Kingdom; 2. Rotherham General Hospital, United Kingdom; 3. Deakin University, Geelong, Australia; 4. Public University of Navarre, Spain; 5. Universitario Hospital de Getafe, Madrid, Spain; 6. CHU Bordeaux, Bordeaux, France; UMR 5536 Univ Bordeaux/CNRS, France; 7. St Louis University, USA; 8. Harvard University, USA; 9. Hong Kong Geriatrics Society. 10; Gerontopole and Hopitaux de Toulouse, France. *Co-Chairs. Endorsed by the European Diabetes Working Party for Older People (EDWPOP), the 2017 International Conference of Frailty & Sarcopenia Research (ICFSR), the Hong Kong Geriatrics Society, and an International Group of Experts.
Corresponding author: Professor Alan Sinclair, Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Medici Medical Practice, 3 Windsor Street, Luton, Bedfordshire, UK. Email: Sinclair.5@btinternet.com, Phone: 00 44 (0)1628 738464

J Frailty Aging 2018;7(1):10-20
Published online October 4, 2017, http://dx.doi.org/10.14283/jfa.2017.39

 


Abstract

Aim: the the International Position Statement provides the opportunity to summarise all existing clinical trial and best practice evidence for older people with frailty and diabetes. It is the first document of its kind and is intended to support clinical decisions that will enhance safety in management and promote high quality care. Methods: the Review Group sought evidence from a wide range of studies that provide sufficient confidence (in the absence of grading) for the basis of each recommendation. This was supported by a given rationale and key references for our recommendations in each section, all of which have been reviewed by leading international experts. Searches for any relevant clinical evidence were generally limited to English language citations over the previous 15 years. The following databases were examined: Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Hand searching of 16 key major peer-reviewed journals was undertaken by two reviewers (AJS and AA) and these included Lancet, Diabetes, Diabetologia, Diabetes Care, British Medical Journal, New England Journal of Medicine, Journal of the American Medical Association, Journal of Frailty & Aging, Journal of the American Medical Directors Association, and Journals of Gerontology – Series A Biological Sciences and Medical Sciences. Results: two scientific supporting statements have been provided that relate to the area of frailty and diabetes; this is accompanied by evidence-based decisions in 9 clinical domains. The Summary has been supported by diagrammatic figures and a table relating to the inter-relations between frailty and diabetes, a frailty assessment pathway, an exercise-based programme of intervention, a glucose-lowering algorithm with a description of available therapies. Conclusions: we have provided an up to date evidence-based approach to practical decision-making for older adults with frailty and diabetes. This Summary document includes a user-friendly set of recommendations that should be considered for implementation in primary, community-based and secondary care settings.

Key words: Diabetes mellitus, frailty, older people, sarcopenia, position statement, management.


 

Introduction

Diabetes mellitus, predominantly type 2 diabetes, occurs more frequently in aging populations, and as this condition can be associated with increased healthcare expenditure in managing diabetes-related hospital admissions and the associated vascular complications, the challenge of providing focused and effective diabetes care to an aging population is daunting (1).
Diabetes mellitus has a considerable impact on our aging society and this is acknowledged by the following findings: the seventh highest cause of years lost and eight highest cause of disability adjusted life years in Western countries in those aged 60–79 years, HR of death is 1.91 (men) and 2.53 (women); the highest rates of major lower-extremity amputation, myocardial infarction (MI), visual loss, and end-stage renal disease of any age group; those aged ≥75 years also have double the rate of emergency department visits for hypoglycemia than the general population with diabetes; and an ADL restriction increases healthcare costs of care 3-fold and admission to a care home increases costs 9-fold (2-4).
The Working Group for this Position Statement acknowledge that frailty is now increasingly seen as a new emerging complication of diabetes (5) and may be present in 32-48% of adults aged 65 years and over with diabetes (6) and is associated with adverse outcomes and reduced survival (7). Frailty has previously been identified as a key priority area for action (8), and other organisations have recognised the impact of multi-morbidity and frailty in the overall management of older people with diabetes (2, 9).
As a consequence, it is now increasingly recognised that modern day recommendations for managing diabetes in older people should be more closely-aligned with additional individual characteristics such as functional status, presence of frailty and dependency, comorbidity profiles, maintaining quality of life, and life expectancy (10). This is because the presence of these features are likely to influence treatment goals, the care model adopted, and how the clinician plans on-going care – in this Position Statement we have placed a strong emphasis on this approach.

 

Main Purpose of the Position Statement

(1) Arrive at a consensus on how we approach the management of key issues of managing frailty in older people with diabetes.
(2) Identify a series of key recommendations in key areas that will support clinicians in everyday clinical practice to manage more effectively the complex issues seen in aging individuals with frailty
(3) Provide a platform for commissioners of healthcare and policy makers to plan and coordinate care pathways in their local regions for those older people with diabetes who are developing frailty (pre-frail), have developed frailty, and those progressing to disability
Although a helpful commissioning guide for diabetes services in older people has previously been published in the United Kingdom (11), we still observe that the syndrome of frailty has received little or no attention in the management plans of older people with diabetes. As diabetes is now also recognised as an independent risk factor for frailty, and that frailty is a major determinant of disability in diabetes populations, the review group has developed this Position Statement in a timely fashion to be the first comprehensive attempt to produce relevant and practical recommendations for managing frailty in older people with diabetes. Its clear intention is to form a significant support platform for clinicians in several clinical settings including primary and secondary healthcare, as well as in care homes.

Definition of Frailty

For the purposes of this Position Statement the review group characterises frailty as a summary concept based on:
•     as a vulnerability state that leads to a range of measurable adverse outcomes such as falls or a decline in physical performance
•     decline in physiological reserve and the inability to resist to physical or psychological stressors
•     a pre-disability condition

The phenotypic manifestations of frailty were objectively defined by Linda Fried and colleagues in the United States in 2001 (12) which were centred around five components of exhaustion, physical activity, walk speed, hand grip strength, and weight loss. A further competing model of describing frailty based on the Canadian Health Study was introduced by Kenneth Rockwood and colleagues where a score (Frailty Index) is developed that is based on the number of deficits (or comorbidities) that are present which in turn determines the risk an individual has of an adverse outcome (13). Both measures have been validated and have prognostic significance in terms of predicting outcomes.  The Frail test developed by John Morley and colleagues, and validated in multiple populations, is increasing seen as an effective screening tool for frailty and combines components of both former approaches (14). The Working Group recognise that cognitive and psychosocial elements of frailty exist but this Position Statement has focused on the physical performance aspects in diabetic subjects only.
We have also recognised that the age-related progressive loss of muscle and function called sarcopenia may be an underlying pathophysiological process in frailty with many of the clinical recommendations logically being applicable to older patients with diabetes who are sarcopenic (6). The development/onset of diabetes leads to an acceleration of the muscle loss (15) and various factors appear to be operating including insulin resistance, AGE toxicity, changes in capillary circulation, neuropathic effects, inflammatory processes including genetic factors (16).
This Position Statement places a major emphasis on the importance of focused assessment of both physical and cognitive domains in assisting the clinician in making decisions about the functional status and comorbidity level of individuals as a guide to treatment strategies adopted. Physicians predominately working with older people often combine this series of assessments into a management tool called a comprehensive geriatric assessment (CGA) (17). This is coupled with advice on safe glucose lowering therapies, key aspects of patient safety, avoiding hospitalization and aged care home residency, and avoiding hypoglycemia.
The review group has also concluded that relevant outcome measures will also prove to have an important influence in deciding if a specific management strategy is worthwhile in routine clinical care of older people with diabetes and frailty.  These should include glycaemia targets, quality of life, measures of physical performance (grip strength, walk speed) in addition to those measures more routinely measured such as rates of admission to hospital, falls rate, and changes in cognition and balance (5).
The review group has placed emphasis on how to enhance the quality of overall public health by providing recommendations for the prevention of frailty, and specific guidance in the area of primary care and in the education of health and social care professionals. This Position Statement has included sufficient information to guide providers of diabetes or geriatric medicine services on where to direct resources to manage older people with diabetes and frailty optimally and creates the opportunity for clinical care standards to be adopted
The review group has taken the decision to develop this Position Statement to address management decisions in older people aged 70 years and over with frailty and diabetes. However, these definitions can be quite arbitrary and are compounded by the lack of correlation between chronological and biological age in different continents. We feel that a threshold of 70+ years ensures that people with diabetes will more likely to exhibit those characteristics of functional loss associated with frailty and that these better determine the recommendations we have given. Age thresholds for management, however, can be an ad hoc viewpoint and that the clinician has the important responsibility to decide what clinical guideline is most appropriate for their older patients by determining their functional status, level of medical 0comorbidities, and degree of frailty. As it has been recognised elsewhere an age threshold of 70+ years also usually signifies a change in social role and the emergence of changes in dependency.

 

Methodology

An important limiting factor for producing specific evidence-based clinical recommendations for older people with diabetes and frailty is the relative lack of clinical evidence from randomised controlled trials involving older subjects with both index conditions. As frailty is also a specific entity and is only now emerging as a diagnosable condition, it is also not possible to extrapolate evidence from clinical studies in younger adults as the condition would have been absent in the latter in most cases.  The review group has considered this implication and has sought evidence from a wide range of studies that provide sufficient confidence for the basis of each recommendation. This limitation influenced our decision not to grade our recommendations at a particular level of evidence but we have provided a rationale and key references for our recommendations in each chapter, all of which have been reviewed by leading international experts.
Searches were generally limited to English language citations over the previous 15 years. The primary strategy attempted to locate any relevant systematic reviews or meta-analyses, but randomised controlled and controlled trials were our main focus. All members provided disclosure statements to minimise bias. The following databases were examined: Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Hand searching of 16 key major peer-reviewed journals was undertaken by two reviewers (AJS and AH) and these included Lancet, Diabetes, Diabetologia, Diabetes Care, British Medical Journal, New England Journal of Medicine, Journal of the American Medical Association, Journal of Frailty & Aging, Journal of the American Medical Directors Association, and Journals of Gerontology – Series A Biological Sciences and Medical Sciences.

 

Key Principles of Position Statement

These principles incorporate the important elements of managing older adults with frailty and diabetes which include:
•    individualising goals of care with functional status, complexity of illness including comorbidity profiles, and life expectancy
•    Where possible, all therapeutic decisions should be based on comprehensive geriatric assessment and risk stratification
•    Identifying and subsequent assessment of key risks in frail older adults with diabetes: hypoglycemia, worsening ADL and IADL with mobility disorder, falls, and adverse events from treatment
•    A clear focus on patient safety, avoiding hospital/emergency department admissions and institutionalization by recognizing the deterioration early and maintaining independence and quality of life to a dignified death
•    A management plan that incorporates educational support for families and carers, and health and social care professionals
•    An emphasis to promote locally relevant interdisciplinary diabetes care teams to develop specific pathways for frail older people with diabetes
•    An encouragement to promote high quality clinical research and audit in the area of frailty management in diabetes

We hope that this Position Statement will form a platform for all clinicians as part of renewed emphasis on specific management approaches to those who are frail and have diabetes.

 

Scientific Supporting Statements

Inter-relationships between Frailty, Sarcopenia and Diabetes Mellitus

Sarcopenia, frailty and diabetes seem to be reciprocally related and may share a similar pathogenetic pathway (see Figure 1).  As diabetes leads to sarcopenia, it is also plausible that sarcopenia leads to lower muscle glucose uptake, hyperglycemia and hyperinsulinaemia and eventually insulin resistance which are the precursor to diabetes development (18). Muscle weakness has been shown to be associated with increased risk of diabetes (OR 1.69, 95% CI 1.37 to 2.10). (19, 20)  Muscle fat infiltration or myosteatosis may also alter glucose metabolism setting off insulin resistance and promoting the development of sarcopenia and diabetes (21).  Chronic low grade inflammation is another link or contributing factor to the occurrence of chronic diseases associated with aging such as diabetes, sarcopenia and frailty (22). Diabetes and frailty have also been shown to share a common cardiovascular risk factors pathway suggesting a reciprocal relationship (23). Obesity is another factor associated with inflammation, oxidative stress and insulin resistance and may have a pathophysiological burden potentiating sarcopenia, frailty and diabetes.  The term sarcopenic obesity has been used to describe sarcopenia plus increased visceral fat and has been shown to be associated with increased risk of atherosclerosis more than obesity alone.  This suggests that sarcopenia combined with visceral obesity may have a synergistic effect increasing the risk of vascular complications and metabolic syndrome that lead to diabetes and frailty (24).

Figure 1 Frailty – Sarcopenia – Diabetes Inter-Relations

Figure 1
Frailty – Sarcopenia – Diabetes Inter-Relations

Sinclair AJ, Abdelhafiz AH, Rodriguez-Manas L. Frailty and sarcopenia – newly emerging and high impact complications of diabetes. J Diabetes Complications 2017: online: doi.org/10.1016/j.jdiacomp. 2017.05.003

 

Muscle Changes in Frailty and Diabetes Mellitus

Aging is associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning (25-27). Major contributing factors during the aging process include partial functional muscle denervation following by re-innervation of abandoned fibres, decreased maximal voluntary activation of the agonist muscles or changes in degree of agonist-antagonist co-activation (28), and the loss of spinal motor neurones leads to a decline in in the size and/or number of individual muscle fibres, especially of fast-twitch fibres. The consequences are related with an impaired mechanical muscle performance (i.e reduced maximal muscle strength, power) that can adversely affect the ability of an older person to remain functionally independent to perform daily activity tasks  (29) (i.e. walking, stair walking, rising from a chair). Along with a decrease in muscle size, aging is also associated with a decrease in muscle quality as a consequence of increased amount of intramyocellular adipose tissue (i.e., muscle fat infiltration) and connective tissue (30,31).
Sarcopenia is a hallmark sign of frailty syndrome, which results in loss of muscle strength, poor mobility and balance and, consequently, an increased risk of falls, adverse health outcomes, dependency, institutionalisation and death  (32). Sarcopenia not only has been related with substantial reorganization in the neuromuscular system and the central nervous system, but also is associated with numerous factors, many of which are biological mechanisms contributory of aging, such as low-grade chronic inflammation (33), decline in mitocondrial function and biogenesis (34), reduced satellite cell numbers that impaired regenerative capacity, apoptosis activation and decline in hormones that are important in muscle mass maintainance (i.e. IGF-1, DHEA, testosterone and estrogens) (27, 29, 35).

Sections with Recommendations

Please note that the key references per domain of recommendations are provided online and the full set of recommendations that relate to the rationale, evidence base and implementation in routine clinical care of the International Position Statement are available at EDWPOP website (http://edwpop.org).

Assessment Processes for Frailty

Narrative: Screening for geriatric syndromes including frailty should be part of stepped care approach in older people with diabetes particularly in primary and community care settings. Where there is evidence of physical or cognitive impairment, or functional loss, referral to geriatricians or other skilled clinicians for a comprehensive assessment is needed.(see Figure 2);

Figure 2 Frailty Assessment Pathway

Figure 2
Frailty Assessment Pathway

 

Recommendations

•    Requirements for screening tools are as follows: quick, no need for special equipment and time consuming measurements involving use of cut-off values, no need for administration by professional staff, validated against consensus definitions and/or clinical assessments.
•    Examples of screening tools* that fulfil the above criteria include the FRAIL score for frailty screening; the SARC-F for sarcopenia; the Rapid Cognitive screen (RCS) for cognitive impairment; and the simplified nutrition questionnaire (SNAQ).
•    Health and social professionals engaged in direct patient care should acquire the basic skills to assess for functional status and frailty
•    Those with abnormal screening results should undergo further examination by a clinician to detect underlying reversible conditions if any, such as hypothyroidism, vitamin D deficiency, anaemia, etc.
•    Optimal Group nutrition plus resistance exercise classes should be prescribed as a continuing regular activity
•    Management of diabetes should be individualized based on the presence/absence of these syndromes, using re-ablement and goal setting as targets in addition to blood parameters.

Glucose Regulation

Narrative: The overarching principle of management of glucose levels in frail older adults with diabetes is to aim for the best glycemic control that can be achieved without increasing the risk of hypoglycemia and without lowering their quality of life through additional treatment-burden effects (see Table 1, Figure 3).

Table 1 Glucose-lowering therapies in Frail Older Adults with Diabetes

Table 1
Glucose-lowering therapies in Frail Older Adults with Diabetes

Narrative: Each class of agent can be used in frail people with diabetes but cautions are present: numerous factors must be taken into account in prescribing a safe but effective glucose-lowering agent; Abbreviations: HbA1c: glycosylated haemoglobin; eGFR: estimated glomerular filtration rate; GI: gastrointestinal; TZDs: thiazolidinediones; DPP-4: dipeptidyl peptidase 4 :  SGLT-2: sodium-glucose cotransporter 2 ; GLP-1:  glucagon-like peptide – 1  

 

Recommendations

•    Prescribed glucose-lowering medications should have a low risk of hypoglycemia, minor side effects profile and be cost-effective .
•    “Start low and go slow” when dosing and titrating medications in frail older adults.
•    The glycemic goal should be individualized based on comorbid medical conditions in addition to cognitive and functional status.  In mild to moderate frail older adults, an A1C target range of 7 – 8.0% (53 – 64 mmol/mol) is appropriate depending on self-care management abilities and presence of additional risk factors for hypoglycemia; in severe frailty, a HbA1c range of 7.5 – 8.5% (59 – 69 mmol/mol) is more protective.
•    Many frail older adults have medical conditions that interfere with HbA1c measurements. In such cases, focus on random blood glucose targets at 120-200 mg/dl (6.7 – 11.1 mmol/l) throughout the day, instead of HbA1c targets.
•    Metformin should be used as the first line of therapy due to its low risk of hypoglycemia, low cost, and good tolerability. In frail patients, weight loss and gastrointestinal side effects should be watched for carefully.
•    DPP-4 inhibitors should be considered for those older adults requiring smaller post-prandial glucose lowering, or used in combination with basal insulin.
•    GLP-1 agonists should be used for post-prandial glucose lowering. They have a low risk of hypoglycemia but are only available in injectable form. They should be considered when carer-support is needed for injections, due to their availability in once-a-week formulations, as well as availability in combination with basal insulin. Caution should be present where further weight loss might be an issue.
•    Sulfonylurea and non-sulfonylurea secretagogues have a high risk of hypoglycemia and should be avoided in frail older adults due to poor consequences such as traumatic falls. However, they are useful when the cost of medications is an issue or other costlier agents are not available.
•    Before initiating insulin therapy, the physical and cognitive capabilities of a frail older adult should be evaluated. Once-a-day basal insulin should be used with other non-insulin agents if further glucose lowering is required.
•    Intensive therapy with a complex insulin regimen is not recommended in older adults. Simplified therapies should be the goal in frail older adults with diabetes.
•    Carers should receive basic education and training on hypoglycemia and its treatment

 

Exercise Intervention

Narrative:  Along with pharmacological and dietary interventions, physical training including resistance and endurance training is required for effective benefits to be realised in the management of frailty in older adults with diabetes (Figure 4).

Figure 4

Figure 4

Recommendations

•    In addition to the beneficial effects of exercise interventions on glycemic control, and on the cardiovascular risk factors associated with diabetes, physical exercise should be employed as an effective intervention to improve neuromuscular and cardiorespiratory function, as well as functional capacity and quality of life in older diabetic patients
•    The combination of resistance and endurance training should be considered to be the most effective exercise intervention to promote overall physical fitness in older diabetic patients
•    On the basis of recent evidence, exercise strategies to improve neuromuscular and cardiovascular parameters and functional performance in frail older individuals with diabetes should include the following :
–    Resistance-training programs should be performed two to three times per week, with two to three sets of 8–12 repetitions at an intensity that starts at 30%–40% and progresses to 80% of 1RM.
–    To optimise the functional capacity of individuals, resistance training programs should include exercises in which daily activities are simulated, such as the sit-to stand exercise. Part of resistance training exercises (especially lower limbs) should be performed as fast as possible (muscle power training) in order to optimize skeletal power output and, consequently, functional capacity.
–    Endurance training should include walking with changes in pace and direction, treadmill walking, step-ups, stair climbing, and stationary cycling. Endurance exercise may start at 5–10 min during the first weeks of training and progress to 15–30 min for the remainder of the program.  The intensity should start between 40 and 50 % of HRmax and progress to 70–80 % of HRmax.
–    The Rate of Perceived Exertion (Borg) scale is an alternative method for prescribing the exercise intensity, and an intensity of 12–14 on the Borg scale appears to be well tolerated. This method can be applied to:  multi-directional weight lifts, heel–toe walking, line walking, stepping practice, standing on one leg, weight transfers (from one leg to the other), and modified Tai Chi exercises.
–    Multi-component training programs should include gradual increases in the volume, intensity, and complexity of the exercises, along with the simultaneous performance of resistance, endurance, and balance exercises.

 

Management of Multimorbidities

Narrative:  All frail older people with diabetes require a comprehensive assessment to include identifying all relevant co-morbidities including diabetes-related vascular complications.

Recommendations

•    Screening for dementia and cognitive problems is recommended to implement safe and quality care and to provide support for carers.
•    Targets for care for comorbidities should be established in each case and adapted according to the patient’s health status: this should form part of an individualised care plan.
•    The glycaemic goal should be individualised based on the presence or not of frailty and other comorbid medical conditions in addition to cognitive and functional status.
•    In mild to moderate frail older adults, an A1C target range of 7 – 8.0% (53 – 64 mmol/mol) is appropriate depending on self-care management abilities and presence of additional risk factors for hypoglycemia; in severe frailty, a HbA1c range of 7.5 – 8.5%  (59 – 69 mmol/mol) is more protective.
•    Many frail older adults have medical conditions that interfere with HbA1c measurements. In such cases, focus on random blood glucose targets at 120-200 mg/dl (6.7 – 11.1 mmol/l) throughout the day, instead of HbA1c targets.
•       Hypertension is commonly associated with type 2 diabetes and adds to the increased risk for cardiovascular disease.  Therefore, screening and treating hypertension in older people with diabetes is essential.
•    A target of 140/90 mmHg is reasonable but systolic blood pressure <140mmHg may be associated with adverse events.  All major antihypertensive drug classes can be used to achieve the target.
•    Dyslipidaemia often co-exists with diabetes and statin therapy is recommended in order to reduce cardiovascular risk unless specifically contraindicated.
•    The addition of fibrate or niacin to statin therapy has no benefit and should not be considered for older people with diabetes.
•    In those with a frequent history of urinary or chest infections, reduce infection risk by adjusting the HbA1c to be ≤ 8.5% (≤ 69 mmol/mol).
•    Bladder control may be improved by aiming for a HbA1c of  ≤ 8.5%  (≤ 69 mmol/mol) owing to the resulting decrease of polyuria linked to hyperglycemia
•    Nutritional status and oral health should be assessed with the purpose to optimise nutrition and physical function
•    The patient with both cancer and diabetes requires integrative care to lower the potential toxicities during cancer treatment and to continue to favor active treatment and outcomes.

 

Hypoglycemia Management

Narrative: Risk factors for hypoglycemia (defined as a state when blood glucose levels fall below 4 mmol/L (72mg/dL) are highly prevalent among older people with diabetes and carry both short term and longer term risks.

Recommendations

•    Frail older people with diabetes should have their hypoglycemia risk regularly assessed.
•    Educational programmes should be available to patients and their carers that suit their cognitive abilities.
•    A care plan that includes an individualised optimum blood glucose range should be in place.
•    Cognitive function and instrumental daily activities ability should be regularly checked especially in patients on insulin therapy.
•    Blood glucose monitoring is useful in certain patients at risk of hypoglycemia such as those on insulin.
•    A relaxed HbA1c target of 59-69 mmol/mol (7.5-8.5%) is appropriate in moderate to severe frailty.
•    Hypoglycaemic medications with lower hypoglycaemic potential should be used if there are no contraindications.
•    Simplification of insulin regimens from multiple to once daily basal insulin injection is recommended when feasible.
•    Regular review and de-intensification of hypoglycaemic medications in patients with tight glycaemic control is recommended.
•    Complete withdrawal of hypoglycaemic medications may be considered in patients with significant weight loss and recurrent hypoglycemia.
•    Patients on end of life or palliative care will require an approach that focuses on comfort and symptom control.

 

Primary and Community Care

Narrative: Multidisciplinary care is required for optimal management of frail older people with diabetes in the community: this requires all those with direct care responsibilities learn the key assessment procedures for the early identification and diagnosis of frailty (see Figure 2).

 

Figure 3 Treatment Strategies for Frail Older Adults with type 2 Diabetes

Figure 3
Treatment Strategies for Frail Older Adults with type 2 Diabetes

Abbreviations: SPPB, Short Physical Performance Battery; 4 MGS – 4 metre gait speed Based on Sinclair AJ, Abdelhafiz A, Rodriguez Manans L (2017) (5)

 

Recommendations

•    Care must be individualized in terms of setting appropriate glycemic, blood pressure, and lipid targets and choice of medication.
•    Older patients with both diabetes and frailty may have significant co-morbidities or reduced life expectancy that alters the risk–benefit balance of aggressive management of cardiovascular risk: optimal management of these co-morbidities and risks requires a broad range of health practitioner expertise and is ideally suited to a primary and community health environment
•    Additional issues such as polypharmacy, mental illness, risk of falls, urinary incontinence, social isolation, persistent pain, and medication adherence all need to be considered as part of the management plan.
•    Primary health practitioners are also best placed to advise and assist their patients in relation to those lifestyle behaviours most likely to prevent or delay the development of type 2 diabetes and/or frailty:  this requires a public health perspective that includes attention to the social determinants of health and strong collaboration with public health and social services.
•    Older people with diabetes in care homes are often frail and thus are highly vulnerable and require complex nursing and medical care in addition to assistance with personal hygiene.
•    Risk factors for hypoglycemia are highly prevalent in residents of care homes.
•    Maintaining health status and functional capacity, and eventually a dignified end of life using individualized care plans are key care goals for all residents with diabetes and frailty
•    Where possible, primary and community care teams need to work with local care homes to ensure that each care home with diabetes residents should have an agreed Diabetes Care Policy or Protocol

 

Inpatient Care

Narrative: at any one time point, a large number of hospital beds are occupied by older people with diabetes and the presence of frailty increases the length of stay, and delays recovery. The majority of hospital admissions due diabetes are associated with emergencies such as hypoglycemia and the presence of frailty increases these risks.

Recommendations

•    Random blood glucose level should be checked in all older patients acutely admitted to hospital to screen for undiagnosed cases.
•    Diabetes status for older people with diabetes including diabetes-related complications and hypoglycaemic medications should be clearly documented in medical records on admission.
•    Routine blood testing should include renal and liver functions along with blood glucose and HbA1c check.
•    Blood glucose should be regularly monitored during hospital admission to help adjust hypoglycaemic therapy.
•    Random blood glucose levels should be maintained above 6mmol (108 mg/dl) (to minimise hypoglycemia) but below 15 mmol/L (270 mg/dl) to avoid osmotic symptoms.
•    Patients should have access to diabetes specialist multidisciplinary team assessment when needed.
•    Hospitals should have clearly written medical guidelines for the treatment of diabetes-related emergencies such as diabetic ketoacidosis and hypoglycemia.
•    A Hypoglycemia Treatment Kit should be available in each ward and staff should be familiar with its use.
•    Patients who can self-administer their insulin should be encouraged with minimal supervision from the staff.
•    The routine use of sliding scale insulin is not encouraged due to its complications and inconsistent messages.
•    Patients should be well hydrated and their renal function checked before having any radiologic investigation that includes contrast injection.
•    At discharge, patients should have clear documentations of any change of medications and future care plans smoothly communicated to primary care teams.

 

Educational Aspects for Health Professionals in Clinical Settings

Narrative: The theoretical framework and associated clinical practice should be incorporated in frailty education programs in diabetes. A sound educational platform should form the basis of an integrated care system that provides continuity of care and interdisciplinary team care.

Recommendations for education providers

•    Education programs should encompass reflection in and on practice, and use individual experiences to enhance learning.
•    Health professionals involved in diabetes care should adopt positive proactive approaches to older age to help dispel ageist attitudes and stereotypes.
•    Frail older people with diabetes should be engaged in education programmes for clinicians when possible and relevant. People’s stories are powerful teaching/learning tools.
•    Traditional teaching and modern technology such as simulation, short podcasts, and online learning resources should be used to deliver frailty education e.g. Geriatric E-learning Modules (MiniGEMS,) Camden Education Module-frailty, and De Villiers Continuing Medical

 

Education Program

Recommendations for clinicians

•    Clinicians should provide coordinated interdisciplinary team care.
•    Clinicians should not use ageist language and stereotypes of older people. Older people are not a homogenous group. Obese and thin older people can be frail.
•    Clinicians should provide frailty care within an holistic person-centred model of care and decide the care plan with the individual.
•    Clinicians should commence screening older people with diabetes for pre-frailty and frailty before age 70.
•    Clinicians should undertake frailty assessments during diabetes complication screening programs, when health status changes and before hospital admissions.
•    Clinicians should undertake medicine reviews before prescribing new medicines and at regular intervals to determine whether any medicines or medicine combinations might contribute to frailty.
•    Clinicians should include light to moderate resilience training to improve function and reduce falls risk soon after admission to hospital or aged care home.
•    Clinicians should use self-administered questionnaires to complement physical assessments e.g. The Flourishing Scale.
•    Clinicians should include frailty education in the individual’s diabetes education and care plan.
•    Clinicians should tailor frailty education to suit older people with diabetes health literacy/education level and their pre- and frailty risk, social situation and life expectancy.
•    Clinicians should consult family carers; they can provide very useful information about the individual’s social situation, functional changes and health status.

Recommendations for service providers

•    Service providers should ensure clinicians have access to relevant technology to support optimal frailty care and education.
•    Service providers should ensure guidelines, algorithms, policies and referral pathways are based on the best available evidence and are accessible.
•    Service providers must ensure resources are available to support clinicians to deliver quality care and frailty education.
•    Service providers should promote frailty education resources for older people with diabetes and their family carers that meet readability standards.

 

Research Directions

Narrative:  Knowledge of many topics pertaining to the fields of frailty and diabetes show many gaps of knowledge – the role of insulin resistance, mechanisms of target organ damage, relationship between sarcopenia glucose metabolism and frailty, clinical targets in subpopulations, screening and diagnosis of frailty in older people with diabetes, usefulness of technology in the management of older frail people with diabetes, selection of drug regimes, usefulness of new drugs taking into account the therapeutic objectives in these patients, cost-effectiveness analysis, models of care: all raising many targets and opportunities for research.

Recommendations

•    A multidisciplinary approach is required to produce effective worthwhile research: participants from basic science, pharmacologists, geriatricians, endocrinologists, nurses, health economists, physiotherapists, epidemiologists, and engineers.
•    Basic science approaches need to examine the key underlying interrelationships: insulin resistance, endothelial dysfunction, low-grade pro-inflammatory activity, low testosterone levels, impairments in the bioenergetics response to exercise, the role of different signalling routes such as PGC1-alpha between both entities (diabetes and frailty.
•    The development of aging models should be of help to study in depth some of these underlying mechanisms, and be used to raise hypotheses that fit clinical observations
•    Clinical and epidemiological science should provide new knowledge on the components of frailty and diabetes that have prognostic value in terms of clinical outcomes, modulation of health trajectories, and survival
•    The design and implementation of information and communication platforms to screen, early diagnose and manage patients with frailty and diabetes is needed; this will enable patients (and their families) to be empowered; validation of such platforms in real clinical settings is an important requirement
•    The development of Randomised Clinical Trials, going beyond traditional outcome assessments is needed with a focus on changes in function (physical and cognitive), quality of life, use of resources, costs, and survival

 

All authors listed as part of the Expert Working Group have met full authorship criteria in this manuscript.
Full version, including rationale, evidence base and implementation in routine clinical care and associated citations for each set of recommendations of this International Position Statement is available at: http://edwpop.org
Conflict of Interest Statement: Members of the Position Statement Expert Review Group have declared no conflicts of interest in respect of commercial enterprises, governments, and non-governmental organizations. No fees were paid to Review Group members in connexion with the current activity.
Permissions: Modification, alteration, enhancement or distribution of this document is not permitted without the express permission of the Secretariat at the European Diabetes Working Party for Older People (EDWPOP). Please contact EDWPOP on: 00 (44) 1628 314879 or email ajsinclair@diabetesfrail.org.

ANNEXE

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ASSESSMENT OF HEALTH INEQUALITIES AMONG OLDER PEOPLE USING THE EPICES SCORE: A COMPOSITE INDEX OF SOCIAL DEPRIVATION

 

B. BONGUE1,3, A. COLVEZ1,4, E. AMSALLEM1, L. GERBAUD1,2, C. SASS1

 

1. Centre technique d’appui et de formation des centres d’examens de santé (Cetaf), France; 2. CHU de Clermont-Ferrand ; Laboratoire EA 4681 PEPRADE, Université d’Auvergne, Clermont-Ferrand, France; 3. Laboratoire EA 4607 SNA-EPIS, Université Jean Monnet Saint-Étienne, France; 4. Géronto-CLEF, Montpellier, France

Corresponding author: Bienvenu Bongue, PhD, 67-69 Avenue de Rochetaillée, 42100 Saint-Étienne, France, Tel: + 33 -4-77 81 63 73, Fax: +33 -4-77 81 17 18, E-mail: bienvenu.bongue@cetaf.fr

 


Abstract

Abstract: Background: Most of the indicators commonly used to assess social deprivation are poorly suited to study health inequalities in older people. The EPICES (Evaluation of Deprivation and Inequalities in Health Examination Centres) score is a new composite index commonly used to measure individual deprivation. Objective: To assess the relationships between health indicators and the EPICES score in older people. Design, Setting, and participants: We performed a cross-sectional study using the data from the 2008 ESPS Survey (Health, HealthCare and Insurance Survey). Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. Main outcomes and measures: Deprivation was measured using the EPICES score. Health indicators were: Disability, physical performance, cognitive decline, self-perceived health status, and health-care use and participation in prevention programs (missing teeth not replaced, healthcare renunciation, no hemoccult test [60-75 years] and no mammography [60-75 years]). Results: Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. The mean age was 70.5± 8.2 years. 52.8% were women. 25.8% were living in poor households. According to the EPICES score, 35.1% were deprived. The EPICES score is linked to all the health indicators assessed in this study: Physical disability, cognitive decline; lifestyle and health care accessibility. These relationships increase steadily with the level of social deprivation. For example, the risk of having difficulties in walking 500m without help or an assistive device is multiplied by 13 (RR=13.5 [7.9-20.8]) in the elderly of quintile 5 (maximum precariousness). Limitations: The observational nature limits inferences about causality. Conclusion: The EPICES score is linked to health indicators. It could be a useful instrument to assess health inequalities in older people living in the community.

Key words: Health inequalities, deprivation, older people.


 

Introduction

With the ageing of the population, analysis of health inequalities among older people has become a priority in public health (1). Although research on this topic is increasing, it does remain sparse. Two major explanations could support this paucity of research of health inequalities in older people: past assumptions of homogeneity of older people and difficulties in measuring social deprivation or socio-economic position (SEP) in this population (2). Therefore the relationship between health inequalities and social deprivation remains confused in older people. Some studies have suggested that there is only a weak relationship between social deprivation and ill health in older adults (3) or that there is a lower mortality differential between older people living in affluent and deprived areas(4).
Over the past 2 decades there has been a stereotypical view of older people as a homogeneous social group – an acceptance of the view that old age is a time of universal and inevitable biological decline resulting in universal ill health and therefore SEP not being an important variable of differentiation amongst older people (5). However, as in the working age population, recent studies suggest health inequalities in older people even in later life (6-8)
The second explanation concerns the measurement of SEP in older people. Measuring SEP or social deprivation in older adults is an important challenge. O’Reilly highlights the difficulties in using established SEP measures in older people and concludes that many of the commonly used indicators to measure social deprivation are inherently biased against older people (9). Hyde and Jones showed the importance of using a composite indicator (10).
In the French preventive Health Examination Centres (HEC) in addition to the administrative legal definition of social deprivation (11), social and material deprivation is measured using the EPICES score (EPICES; Evaluation of Deprivation and Inequalities in Health Examination Centres). The EPICES score was developed in 2002 and was based on an initial questionnaire of 42 items selected by a panel of French experts from the National Health Insurance relative to dimensions of deprivation as defined by Wrezinski and Townsend (12, 13). A factorial correspondence analysis identified 11 salient items of which calculation of the EPICES score. The score is computed by adding each question coefficient to intercept whenever the answer is «yes». This tool takes into account multiple dimensions of socioeconomic conditions, including psychological aspects and social support (14, 15). In a previous study, our team has shown the relevance of categorization of the EPICES score (15).
The EPICES score was validated in people aged 18 to 59 years old (15). Although the usefulness of this tool was previously shown in various populations (16-20), it has been scarcely used in older people.
The aim of this study was to assess the relationships between health indicators and the EPICES score in older people using data from the French ESPS survey (Enquête Santé Protection Sociale) conducted in 2008.

 

Materials and Methods

Population

Our study was performed using data from the 2008 ESPS Survey (Health, HealthCare and Insurance Survey (ESPS)(21). In France, the ESPS survey collects detailed self-reported information on morbidity every two years. This survey is a representative sample of National Health Insurance Beneficiaries. Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. The completion ratio was 65%.
The study was conducted in accordance with the ethical standards set forth in the Helsinki Declaration (1983). A written informed consent for participation was obtained for participants.

Outcomes

– Deprivation was assessed using the EPICES score. This score is calculated according to an algorithm based on the response to 11 questions (Appendix 1), and varies from 0 (the least deprived) to 100 (the most deprived) (22). Although the EPICES score has a continuous distribution (as an increase in the score shows an increase in social deprivation and its consequences), a deprivation state is usually defined as a score of ≥30.17. However the EPICES score can also be used as a continuous variable divided into 5 equally sized groups.
– The occupation was subdivided into 7 classes: farmers, artisans/traders, executives, middle management, employees, workers and others grouping/including people with no professional activity. Retirees are classified according to their former category.
– The poverty line is the minimum level of income deemed adequate in a particular country. In France, the poverty line was 949 euros in 2008. Households with income per consumption unit below the poverty line were defined as «poor households».

Health indicators

Health indicators were assessed using a self-report questionnaire. Participants with chronic disease were those reporting at least one chronic disease during the interview. The BMI (body mass index) was used to assess obesity (BMI ≥30 kg/m2). Disability was assessed by limitation of usual activities for at least six months due to a health problem. Difficulties in walking 500m without help or an assistive device, difficulties in going up or down stairs without help or an assistive device, and difficulties in washing themselves were used to assess physical performance. The inability to remember what time of the day it was, was used to assess cognitive decline. Health-care use and participation in prevention programs were assessed using data from:  number of missing teeth not replaced, healthcare renunciation, participation in colorectal cancer screening (hemoccult test [60-75 years]), and participation in breast cancer screening (mammography [60-75 years]). The other predictors examined were age, sex, current tobacco use, self-perceived health status, missing teeth not replaced, and healthcare renunciation (23).

Statistical analyses

All analyses were performed using the SPSS v18 software for Windows (SPSS Inc., Chicago, IL). Descriptive analyses were used to describe the sample studied. The population was divided into quintiles according to the EPICES score. Quintile 1 involved subjects with the lowest scores (equivalent to no precariousness or social deprivation) and quintile 5, subjects with the highest score (maximum precariousness). Quintile 1 was the reference category. Bivariate and multivariate analyses were performed. Multiple logistic regression adjusted to sex and age was used to analyse the relationship between the quintiles of the EPICES score, health status and sociodemographic variables. Adjusted relative risks (RRs) and their 95% confidence intervals (CIs) were calculated.

 

Results

The study population included 2,754 subjects aged 60 and over who filled in all 11 questions of the EPICES score in the 2008 ESPS Survey. The mean EPICES score was 22.0 ±17.8 [0 – 90.5]. The mean age of the study sample was 70.5± 8.2 years [min: 60; max 100]. 52.8% of participants were women. 25.8% lived in poor households. According to the EPICES score, 35.1% of participants were deprived. 25.8% lived in poor households. 46.5% of participants reported at least one chronic disease. The characteristics of the study sample are presented in table 1. The risk of belonging to the blue-collar social category or a poor household category increases with the «EPICES score» quintiles. Thus, an elderly person with an EPICES score greater than 48.52 (Quintile 5) is 3.4 times more likely to belong to the blue collar category and 6.4 times more likely to belong to a poor household (Table 2).

Table 1 Characteristics of the study sample

Table 1
Characteristics of the study sample

* Poverty line was 949 euros in 2008 in France; † Poor health status: a value of ≤ 7 represented a poor health status in a visual analogue scale [0-10]; # An indicator of equality in health care access; § Cognitive decline: Not remembering what time of the day it is

 

Table 2 Prevalence and RR [95%CI] between socioeconomic status, health indicators and the «EPICES score»

Table 2
Prevalence and RR [95%CI] between socioeconomic status, health indicators and the «EPICES score»

RR [95%CI], adjusted to age and sex; Q1: first quintile, minimal precariousness, Q5: fifth quintile, maximal precariousness; * Poverty line was 949 euros in 2008 in France; ǂ Reference class: Executives; ‡ Poor health status (a value of ≤ 7 represented a poor health status in a visual analogue scale [0-10]); # For the mammography screening analyses, two EPICES score classes (Q1 and Q2) were merged (sample size)

 

The increase of the EPICES score is linked to a worsening of all the health indicators assessed in our study: physical disability, cognitive decline, lifestyle and health care accessibility (Table 2). These relationships increase steadily with the level of social deprivation. The most significant relationships are observed for physical disability indicators in particular. For example, the risk of having difficulties in walking 500m without the help of someone or an assistive device is multiplied by 13 (RR=13.5 [95%CI 7.9-20.8]) in the older people of quintile 5 (maximum precariousness). After adjustments of the poverty status or the socio-professional category, trends did not change and all relationships remained statistically significant (data not shown).

 

Discussion

The present study demonstrated that the deprivation state assessed by the EPICES score is significantly related to health indicators and standard indicators of social deprivation such as occupation and poverty. The EPICES score includes 11 items assessing various dimensions of deprivation in one multi-composite scale. This is especially true for the items focusing on social support, which is very important for the assessment of needs in frail older people. Price (24) suggests the need for a multi-component tool to measure social inequality or deprivation in older people. Our results suggest that the EPICES score would be a suitable screening tool for this population.
This study also demonstrated for the first time strong links between deprivation and physical disability in older people (difficulties in walking 500 meters without an assistive device, difficulties in going up or down stairs without help or assistance, and difficulties in washing themselves). These relationships are proportional (“score-dependent”), showing the suitability of using the quantitative version of the EPICES score in older people. Our results also showed that the EPICES score was related to several economic indicators (occupation, poverty), lifestyle (tobacco consumption, health-care use), dental status and obesity. These results are in accordance with our previous study (15) and suggest the usefulness of this tool in older people living in the community.
The ESPS is the sole representative sample of French National Health Insurance beneficiaries which covers 85% of the French population. However, these findings should be interpreted with caution. We performed a cross-sectional study. Thus the relationships observed in this study cannot lead to the conclusion that there is a casual link between various variables. Another limitation could be a non-response bias. The completion ratio was 65%. There was no difference between respondents and non-respondents in terms of sex and age. However there was a difference in income (poverty) between the groups. The non-respondents mostly came from poor households (33.9% vs. 25.8%; p<0.001).
Few deprivation screening tools were described in the literature (the NZiDep)(25), the FWID (26) and the DIPCare-Q (27). These screening tools were scarcely used in older people and some of them were poorly adapted to the French setting. When performing an assessment of needs in retired people, income as well as social support (by a social worker or/and family support) should be taken into account. The best advantage of the «EPICES score» is that, while this index includes various items to assess social support, the tool is easy to use and not time-consuming (22). Furthermore, we have previously shown that the associations between the EPICES score and the health variables were stronger than those observed with the French administrative definition of precariousness (28).

 

Conclusion

The EPICES score is linked to health indicators and can identify social deprivation in older people. This screening tool can be a useful instrument to measure deprivation in older people living in the community. Due to the fact that the relationships observed in this study are score-dependent, the quantitative form may be more useful in older people. Thus, gradients in health inequalities can be investigated.

 

Competing interests: The authors declare that they have no competing interests.
Acknowledgements: The authors thank all the study participants, the investigators of IRDES (Institut de recherche et documentation en économie de la santé) and specially Mr Yann BOURGUEIL and Mr Thierry ROCHEREAU. We also thank Mr Norbert DEVILLE the director of the technical support and training centre for the French health examination centres (CETAF: Centre technique d’appui et de formation des centres d’examens de santé) for the administrative support. This work was supported by the CETAF.

 

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Appendix 1 EPICES score (Evaluation de la Précarité et des Inégalités de santé dans les Centres d’Examens de Santé - Evaluation of Deprivation and Inequalities in Health Examination Centres)

Appendix 1
EPICES score (Evaluation de la Précarité et des Inégalités de santé dans les Centres d’Examens de Santé – Evaluation of Deprivation and Inequalities in Health Examination Centres)

SYSTEMATIC LITERATURE REVIEW ON THE RELATIONSHIP BETWEEN BIOMARKERS OF SARCOPENIA AND QUALITY OF LIFE IN OLDER PEOPLE

 

T. WOO1,2,3, S. YU1,2,3, R. VISVANATHAN1,2,3

 

1. Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, South Australia, Australia; 2. Adelaide Geriatrics Training and Research with Aged Care (G-TRAC) Centre, School of Medicine, University of Adelaide, South Australia, Australia; 3. National Health and Medical Research Council Centre of Research Excellence: Frailty Trans-disciplinary Research To Achieve Healthy Ageing, University of Adelaide, South Australia, Australia.

Corresponding author: Dr Tsung Woo (Tsung.Woo@sa.gov.au, Phone +61-8-8222 6000, Fax +61-8-8222 8593)

 


Abstract

Sarcopenia is a multi-faceted geriatric syndrome that is prevalent in the older population. It is an independent risk factor for a variety of devastating health outcomes that threaten the independence of older people. Quality of life is also very important to older people. The objective of this systematic review therefore was to determine the relationship between the biomarkers of sarcopenia (or sarcopenia) and health related quality of life in older people. Systematic searches were done using the electronic databases from MEDLINE and EMBASE. Search terms included sarcopenia, biomarkers of sarcopenia (e.g. muscle mass, grip strength, muscle performance), and health related quality of life. A total of 20 studies were finally included in this review. Only four studies were deemed of good quality. Sarcopenia was associated with poor health related quality of life in both genders from the one cross sectional study defining sarcopenia as per consensus definition. One high quality longitudinal study demonstrated that better physical performance and muscle strength was associated with a slower rate of decline in health related quality of life over six years. Muscle performance and strength were associated with health related quality of life but muscle mass was not in cross-sectional studies. Good quality and longitudinal studies where sarcopenia is defined as per consensus guidelines are required if the  impact of the disease on quality of life is to be clarified. 

 

Key words: Sarcopenia, quality of life, older people, muscle mass, muscle function.


 

Introduction

Sarcopenia is said to be a multi-factorial geriatric syndrome, with its key characteristic being an age-associated loss of skeletal muscle mass and function (1). There are multiple interacting intrinsic (e.g. age related biological changes, chronic inflammatory states) and extrinsic (e.g. decreased physical activity and poor nutrition) factors that contribute to a cascade of events resulting in the undesirable manifestation of sarcopenia (1). Sarcopenia is an independent risk factor for numerous adverse health outcomes including physical disability and functional decline (2, 3), increased mortality (4, 5), increased risk of falls, fractures, and hospitalization (6).

Our research group has recently reported that in older people aged 80 years and older, one in five experience sarcopenia (7). Similar to many other western countries, the proportion of older people aged 85 years and over is projected to experience the fastest growth rate of all age groups. This age group is projected to more than quadruple within 30 years by 2045 (8). This revolutionary shift in the demographic profile of Australia towards an older population coupled with a high prevalence of sarcopenia and its associated disability will inevitably place a tremendous strain on the health care system. Doing nothing is unaffordable and cost-effective interventions are necessary.

There is currently no unifying clinical definition of sarcopenia. According to the European Working Group On Sarcopenia in Older People (EWGSOP) (9), there are three key essential elements for the diagnosis of sarcopenia. The core diagnostic feature of sarcopenia is the presence of a low skeletal muscle mass, which must be in combination with either low muscle strength or poor muscle performance. Muscle performance is commonly assessed by the usual gait speed (on a 4-m course), timed up-and-go (TUG) test, and the short physical performance battery (SPPB). The TUG test serves as an assessment of dynamic balance, and it assesses the total time required for a person to stand up from a chair unaided, walk a short distance (3 m), turn around, return, and sit down again (10).  The SPPB is a composite measure of physical performance consisting of three different sets of routine: standing balance, gait speed, and chair stand. The total SPPB score is 12, and a SPPB score of eight or less is defined as sarcopenia (3).

At an older age, when mortality is an ever looming reality, compounded by an increasing chronic disease burden, loss of independence, and social isolation, the focus and emphasis of care should no longer be purely about the duration of life but instead consider also the quality of life.  Health related quality of life (HRQoL) is a multidimensional concept involving the subjective assessment of various dimensions of an individual’s health status. These dimensions consist of physical function, mental or psychological status, bodily pain, emotional wellbeing, functional capacity, occupational function, and social integration (11). Therefore, quality of life in an older person is perceived as an ability to continue leading a contented, meaningful, and fulfilling life (12).  The Short Form 36-item Health Survey (SF-36) (13)and the European Quality of Life Questionnaire (EQ-5D) (14)are common generic HRQoL tools that are used in community dwelling older people, and they demonstrate adequate reliability, validity, and responsiveness (15). 

To date, the understanding of the relationship between sarcopenia and HRQoL is limited. The aim of this systematic literature review is to evaluate the available evidence regarding the relationship between biomarkers of sarcopenia (or sarcopenia) and HRQoL in older people. 

Methods

Criteria for considering studies for this systematic review

The titles and abstracts of all articles identified by the literature searches were reviewed to determine if the studies met the following inclusion and exclusion criteria.

 Articles were included in this review if the following criteria were fulfilled:

• The average age of participants were 65 years and older. 

• Biomarkers of sarcopenia (or sarcopenia) were specifically and clearly defined as a study variable in the study.

• HRQoL was one of the outcome measured in the study.

• The study utilised a validated and well-defined instrument specifically designed to measure HRQoL. 

• The study was published in a journal and in English.

 

Articles were excluded from this review if:

• The study examined specific disease populations e.g. patients with end stage kidney disease, stroke, end stage heart failure or chronic obstructive lung disease, advanced cancer, and those undergoing an elective surgical intervention.

• The study’s primary aim was to assess the effects of an exercise intervention on quality of life. 

• Research proposals or commentaries were excluded.

Search methods for identification of studies

Systematic searches for the identification of studies were done using the electronic databases from MEDLINE (from 1946 to  December 2015) and EMBASE (from 1974 to December 2015). The search terms initially included “sarcopenia”, and “quality of life”. To further expand the search, various terms relating to the biomarkers of sarcopenia, including “muscle mass”, “muscle strength”, “grip strength”, “hand strength”, “muscle performance”, “physical performance”, “short physical performance battery”, “walk speed”, “gait speed”, and “muscle function”, were used. An age limit of 65 years or more was set for this search, and only studies in English were included. The titles of articles listed in the reference lists of relevant studies were also reviewed for additional studies. 

Study selection, data collection, and analysis

One review author screened the title and abstracts of all the records identified through the electronic databases as well as through the reference lists of relevant studies. Two authors independently assessed the full text articles for eligibility. The studies included in the systematic review were independently  assessed by two authors for quality and risk of bias within and across studies. Data pertaining to the study population (sample size, average age), study design and follow up period, study setting, sarcopenia definition, variables used as biomarkers of sarcopenia, the quality of life instrument  used, and outcomes were extracted to populate the tables presented in this review. The principal summary measure was to determine an association or correlation between biomarkers of sarcopenia (or sarcopenia) with quality of life. 

The quality of each article was assessed using the Modified Appraisal Joanna Briggs Institute (JBI) Qari Critical Checklist and QUADAS Checklist (16). The overall quality of each study was assessed as good, moderate, and poor. Where there was a huge discrepancy in the quality rating of a study, a third reviewer would independently assess the study in order to give a final quality verdict. 

Results

A total of 970 records were screened, and 29 full text articles were assessed for eligibility. Nine  studies were excluded for the following reasons: in four of the studies, the average age of subjects were less than 65 years old, two studies did not utilise a validated quality of life instrument, one study primarily assessed the effects of aerobic fitness on quality of life, one study only investigated the association of subjects with lower back pain and quality of life, and finally one other study evaluated the association of psychosocial factors with quality of life (QEOL). Finally, 20 studies were included in this systematic literature review (17-36).

Except for Bindawas’ (17) and Trombetti’s (18) longitudinal studies, the rest of the 18 studies were cross sectional in design. All the studies were community based with the sample sizes varying from less than 50 to approximately 7000. The SF-36 tool was the most commonly utilised HRQoL instrument, used in 13 studies. The other HRQoL tools included the EQ-5D (in five studies), 12-Item Short Form Health Survey (SF-12) (in one study) , and the Quality of Well-Being Scale-Self Administered (QWB-SA) (in one study) (37). Four studies were of good quality (17, 19, 24, 35), and the other 16 studies were of moderate quality (18, 20-23, 25-34, 36). 

Longitudinal studies

None of the longitudinal studies defined sarcopenia based on a current consensus definition. The two studies (17, 18) instead evaluated the association between biomarkers of sarcopenia and quality of life. The Bindawas’ (17) study investigated 621 subjects who were followed-up over a period of six years, whilst the smaller Trombetti’s (18) study, had a total of 48 subjects with a follow up period of 3 years (Table 1). The Trombetti’s (18) study was found to be of moderate quality whilst the Bindawas’ (17)study was of good quality. Both studies used SPPB as a measure of physical performance and the SF-36 as the quality of life tool. Different measures for muscle strength however were used. The Bindawas’ (17) study assessed the total body muscle strength, which is the sum of the muscle strengths in both lower and upper limbs, whilst the Trombetti’s (18) study measured only the leg extensor muscle strength. After adjustment for confounding factors, only the larger Bindawas’ (17) study showed that subjects with higher SPPB scores had significantly slower rates of decline in the SF-36 physical component summary (PCS) scores over time, and that a low SPPB score was significantly associated with a poorer PCS score. In contrast, Trombetti’s (18) study was underpowered to find a significant correlation between SPPB and PCS score over time after adjustment for potential confounding variables. The study by Bindawas (17) showed that higher muscle strength was significantly associated with a slower rate of decline in the PCS score in the SF-36 over time. In contrast, Trombetti’s (18) study did not find a significant association between muscle strength or muscle mass and the PCS score in the SF-36 following adjustment for confounders.  

 

Table 1 Longitudinal studies

* Data presented as n (%), mean ± standard deviation, range

 

Cross-sectional studies

Studies assessing sarcopenia and HRQoL

Only the study by Patel (19) assessed the relationship between sarcopenia using the EWGSOP definition (9), which was defined as a low muscle mass in combination with either low gait speed or low grip strength, and HRQoL (Table 2). The overall quality of Patel’s study (19) was good. The study by Patel (19), comprised of two main groups of participants where the definition used to define sarcopenia was similar for both groups. The first group consisted of 103 community dwelling men from the Hertfordshire Sarcopenia Study (HSS) whose muscle mass was assessed using dual X-ray absorptiometry (DXA) lean mass and the skin-fold-based fat-free mass (FFM). The second group consisted of 1787 participants from the Hertfordshire Cohort Study (HCS) whereby muscle mass was measured using the skin-fold-based FFM approach only. Low muscle mass was defined as the lowest third of the sex specific DXA lean mass or skin-fold-based FFM. Patel and team (19)used the HSS cohort to prove a high correlation between DXA lean mass and skin-fold-based FFM, thereby justifying the use of skin-fold-based FFM as a marker of muscle mass in the larger cohort. Patel’s study (19) demonstrated that HCS males and females with sarcopenia had significantly poorer self-reported general health and physical functioning scores in the SF-36 but there was no adjustment for confounding variables (e.g. cognition, co-morbidities etc). The use of the skin fold test however to assess fat free mass is prone to error due to age-related changes in fat deposits and loss of skin elasticity in older individuals (9).   

Studies assessing low muscle mass and HRQoL

Four studies (20-23) defined sarcopenia as low skeletal muscle mass only (Table 2). All four studies were of moderate quality. Except for the Pedrero-Chamizo’s study which used bio-electrical impedance anaylsis to assess muscle mass (20), the other three studies (21-23)measured skeletal muscle mass using DXA. 

 

Table 2 Studies assessing sarcopenia/muscle mass and health related quality of life

HSS: Hertfordshire Sarcopenia Study , HCS: Hertfordshire Cohort Study , EWGSOP: European Working Group on Sarcopenia in Older People , DXA: Dual-energy X-ray absorptiometry, FFM: Fat-free mass, BMD: Bone mineral density, SD: Standard deviation, BMI: Body mass index. * Data presented as n (%), mean ± standard deviation, range.

 

Studies by Kim (21), Silva-Neto (22), and Iannuzzi-Sucich (23) defined low muscle mass as more than two standard deviations below the mean of the sex-specific young reference group. Kim’s study (21) also used the cut-off value of the lowest 20% in the gender specific older study subjects as the definition of low muscle mass. The  studies by Pedrero-Chamizo (20) and Kim (21) used the EQ-5D quality of life tool, and the SF-36 tool was utilised in Silva-Neto (22) and Iannuzzi-Sucich (23) studies. Out of the four studies, Silva-Neto’s study (22) had the smallest sample size of 56 subjects, all of whom were female participants. The other three studies included both genders, and had sample sizes ranging from approximately 300 to 4400.

Only Pedrero-Chamizo’s (20) and Kim’s (21) studies adjusted for confounding factors. The other two studies by Silva-Neto (22) and  Iannuzzi-Sucich (23) did not adjust for potential confounders. All four studies did not assess for mood or cognition. The study by Iannuzzi-Sucich (23) only included Caucasian participants and the studies by Pedrero-Chamizo (20) and Silva-Neto (22) had inherent gender biasness. 

All four studies (20-23) did not find a significant association between low muscle mass and HRQoL in females and only the studies by Kim (21) and Iannuzzi-Sucich (23) noted an association between lower muscle mass and poorer HRQOL. 

Studies assessing grip strength and HRQoL 

There were a total of nine cross sectional studies assessing the relationship between grip strength and quality of life, with sample sizes ranging from approximately 56 to 7000 (Table 3). Apart from Silva-neto’s study (22), the three studies by Samuel (25), Wanderley (27), and Sartor-Glittenberg (28)had small sample sizes of approximately 85 subjects. Gender biasness was also inherent in Wanderley’s study (27).  Only Sayer’s study (24) was of good quality, and it specifically evaluated the relationship of grip strength and quality of life. The other eight studies were of moderate quality, and they included grip strength as part of the biomarkers of sarcopenia (22, 25-31). Four studies by Sartor-Glittenberg (28), Horder (29), Olivares (30), and Takata (31) overlapped with physical performance measures. All the studies used the SF-36 quality of life tool, except for Olivares’ study (30), which used the EQ-5D instrument. Out of the nine studies, eight studies (22, 24-27, 29-31) showed that grip strength was significantly associated with health related quality of life in both genders, especially in the physical domains, except the study by Silva-Neto (22) included only female participants. The study by Sartor-Glittenberg (28) was underpowered to find a significant association between grip strength and quality of life. 

 

Table 3 Studies assessing grip strength and health related quality of life

PF: Physical function, GH: General health, RP: Role physical, VT: Vitality, BP: Bodily pain, SF: Social function, RE: Role emotional, MH: Mental health, QoL: Quality of life. * Data presented as n (%), mean ± standard deviation, range.

 

Only the studies by Sayer (24) and Wanderley (27) adjusted for confounders. Studies by Samuel (25), Imagama (26), and Horder (29) did not adjust for confounding factors. All nine studies did not evaluate mood and cognition. Samuel’s study (25) did not adequately describe how grip strength was measured. 

Studies assessing physical performance and HRQoL 

There were a total of nine studies assessing physical performance with quality of life (28-36), with sample sizes ranging from approximately 70 to 7100 (Table 4). The two largest studies were by Olivares (30) and Garber (35), which had samples sizes of about 7100 and 900 participants respectively. There was significant gender biasness in Olivares’ (30), Ekstrom’s (34), and Garber’s (35) studies as there were disproportionately more females (more than 70% females) than males. Only Garber’s study (35) was of good quality, the remainder eight studies were of moderate quality. Out of the nine studies, Horder (29) was the only study that did not adjust for potential confounders for the association between physical performance (gait speed) and quality of life. 

 

Table 4 Studies assessing physical performance and health related quality of life

PCS: Physical component summary, ADL: Activities of daily living, IADL: Instrumental activities of daily living, TUG: Timed up-and-go, GH: General health, PF: Physical function, RP: Role physical, BP: Bodily pain, VT: Vitality, SF: Social function, MH: Mental health, MCS: Mental component summary.
* Data presented as n (%), mean ± standard deviation, range

 

The assessment of physical performance consisted of several performance measures including gait speed, TUG, and SPPB.  The SF-36 was the most commonly used quality of life tool (28, 29, 31, 35),  followed by the EQ-5D (30, 32, 33). The Ekstrom’s study (34) used the SF-12 tool, whilst the Groessl’s study (36) utilised the Quality of Well-Being Scale-Self Adminsitered (QWB-SA) (37). 

Six studies (28, 29, 31-34) evaluated gait speed and quality of life. Five studies (28, 29, 31, 32, 34) showed that gait speed was significantly associated with quality of life. Fusco’s study (33), with the smallest sample size of 73, was underpowered to show any significant association between gait speed and quality of life in both males and females after adjustment for confounders. Four studies assessed TUG and quality of life (28, 30, 34, 35) and all showed significant association of TUG and quality of life after confounders were adjusted for. However, the study by Sartor-Glittenberg (28) only showed significant association with the mental component summary score of the SF-36 and not the physical component. SPPB and quality of life was evaluated in three studies (32, 33, 36) and only two studies (32, 36) showed significant association with quality of life in both genders after adjustment for potential confounders. Fusco’s study (33) only showed significant association of SPPB and the EQ-5D visual analogic scale in females, and was underpowered to find a significant association between SPPB and quality of life in the male subjects. 

The studies by Fusco (33), Ekstrom (34), and Garber (35) assessed participant’s cogntion as well as mood. Additionally, Garber’s study (35) also assessed for the number of medications taken per day and the number of falls over the past six months, and showed that polypharmacy was an independent predictor of TUG. 

 

Discussion

The one cross-sectional study which adhered to the EWGSOP guidelines demonstrated that sarcopenia was associated with poor HRQoL in both genders (19). From the two longitudinal studies investigating the relationship between biomarkers of sarcopenia and HRQoL (17, 18), only Bindawas’ study (17) demonstrated that  better physical performance and muscle strength was significantly associated with a slower rate of decline in HRQoL over six years . The majority of cross-sectional studies that used grip strength as a marker for muscle strength (22, 24-31) found that lower grip strength was significantly associated with poorer HRQoL (22, 24-27, 29-31). Slower gait speed was also associated with poorer HRQoL in seven out of eight cross-sectional studies (20, 26, 28, 29, 31, 33, 34, 36). Higher muscle performance was significantly associated with better quality of life (28-32, 34-36). Of significant concern, only four studies were deemed of good quality (17, 19, 24, 35).  

As people age, it is the quality rather than quantity of life that is important (38). Both the EWGSOP (9) and the Asian Working Group on Sarcopenia (AWGS) (39) have explicitly recommended that quality of life should be one of the primary outcomes for future sarcopenia intervention trials. It is therefore surprising that there has only been one study to date that has considered both the consensus definition for sarcopenia and quality of life. When it comes to investigating the relationship between biomarkers of sarcopenia and quality of life, there has only been one study with a large enough sample size and therefore good quality. Therefore, a research gap exists and more studies investigating both sarcopenia (using consensus definitions) and quality of life are necessary. 

When looking at associations from cross- sectional research, it appears that there is a relationship between various measures of performance and strength (e.g. gait speed, grip strength etc.) and HRQOL. However, the relationship between muscle mass per se and HRQoL is not as convincing. Interventions for sarcopenia should include a focus on improving strength and performance. Currently, it is proposed that an improvement in gait speed by 0.1m/s is clinically meaningful (40).

All the studies included in this literature review utilized generic HRQoL tools. Generic HRQoL instruments have been designed for the general population, irrespective of age and disease. As such, one of the limitations that is apparent in the generic tool is that with increasing age, declining health status, and deteriorating cognition, the completion of such HRQoL instruments becomes increasingly difficult (41). Another drawback in most of the generic HRQoL instruments is the heavy emphasis on the domain of physical function. Therefore, there is a risk that the HRQoL in older people will be underestimated using generic HRQoL tools as other facets of HRQoL in older people are not given enough attention (12). Another limitation of generic HRQoL assessment tools is that it may not be relevant to a specific disease state such as sarcopenia and therefore lack necessary sensitivity to small but significant changes in a person’s health perception or values (12, 42). 

A specific quality of life questionnaire for sarcopenic subjects, the SarQoL (Sarcopenia Quality of Life) questionnaire has been recently developed (43). However, there is yet to be a study investigating the association between sarcopenia (or biomarkers of sarcopenia) and quality of life using the SarQoL instrument.

This literature review has several strengths. This is the first systematic literature review to evaluate the relationship between sarcopenia and its various biomarkers with HRQoL in older people. We have also investigated the quality of studies through this review. There are however some limitations. Some research articles may have been missed, especially in relation to single biomarkers of sarcopenia, and this would be due to the search terms utilized. As articles not published in English were excluded, there is the risk that relevant research papers in other languages may have been missed.

 

Conclusion

To summarize, we conclude that there is a need for high quality studies including longitudinal studies and studies adhering to consensus definitions for sarcopenia. There appears to be a strong association between muscle performance and strength and biomarkers of sarcopenia. From one longitudinal study, better physical performance and muscle strength was associated with a slower rate of decline in HRQoL over a period of 6 years. Cost-effective interventions for sarcopenia are necessary, especially interventions that improve HRQoL. Therefore, confirmation of the HRQoL burden arising from sarcopenia will assist in confirming the seriousness of this public health issue and provide researchers with the necessary backing to progress in the quest for cost-effective interventions.

 

Conflict of interest statement: Dr. Woo has nothing to disclose. Dr. Yu has nothing to disclose. Professor Visvanathan is on the «Malnutrition in the elderly» board of Nestle Australia and has participated in international initiatives (i.e. PROTAGE and MNA Initiative) made possible by educational grants by Nestle Inc. In the past, Professor Visvanathan has received educational and research grant funding from Organon Pty Ltd, Servier, Novartis and Pfizer.

 

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SOCIAL DETERMINANTS OF DISCHARGE OUTCOMES IN OLDER PEOPLE ADMITTED TO A GERIATRIC MEDICINE WARD

 

M. HAWKER1, R. ROMERO-ORTUNO2

 

1. University of Cambridge, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom; 2. Department of Medicine for the Elderly, Addenbrooke’s Hospital, Hills Road, Cambridge, United Kingdom

Corresponding author: Martha Hawker, University of Cambridge, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom, Mh666@cam.ac.uk

 


Abstract

 The factors determining hospital discharge outcomes in older people are complex. This retrospective study was carried out in an in-patient geriatric ward over a month in 2015 and aimed to explore if self-reported feeling of loneliness and clinical frailty contribute to longer hospital stays or higher rates of readmission to hospital after discharge in the older population. Twenty-two men and twenty-five women (mean age 85.1 years) were assessed. There was a significant multivariate association between both self-reported loneliness (p=0.021) and the Clinical Frailty Scale (p=0.010) with length of stay, after adjusting for age, dementia and living alone. In multivariate analysis, patients who lived alone were more likely to be readmitted to hospital within 30 days (p=0.036). Loneliness, living alone and clinical frailty were associated with adverse discharge outcomes. Lower thresholds for referral to voluntary organisations and for psychosocial interventions in patients who report loneliness or live alone may be beneficial. 

 

Key words: Loneliness, frailty, discharge outcomes, older people.


 

Introduction

Little is known about how the complex interplays between social and medical factors affect outcomes of hospital admission in older people. Various clinical tools to predict outcomes have been devised, for example the LACE index for hospital readmissions, but none have had discriminative ability that has been above fair (c-statistic range 0.56-0.77) for the older population (1). The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) score has been used with some success to predict mortality within one year of hospital discharge in older patients which takes into account ability to travel independently, ability to walk, educational level and independence in housekeeping (2). However, there are many variables that this tool does not take into account. Levels of loneliness have been shown to be higher in the over 65s (3) and show a U-shaped distribution of loneliness with higher levels of loneliness in the under 25s and over 65s. Loneliness has previously been found to be a predictor of hospital emergency department use (4). Frailty (as measured by the Clinical Frailty Scale) has previously been shown to be an independent predictor of prolonged length of stay and mortality in hospital (5). 

This study aimed to examine the link between loneliness and clinical frailty with discharge outcomes (length of stay, 30-day readmission) in the older population. 

 

Methods

A retrospective study was carried out in an in-patient geriatric ward over a month in 2015. Patients were asked about feeling of loneliness (yes or no). Patients with very severe cognitive difficulties who could not self-report on loneliness were excluded from the study. The hospital computer system was then used to find data on the patient’s medical characteristics, including comorbidities, their cognitive function (MMSE score), and their frailty (9-point Clinical Frailty Scale (CFS)). Information on the length of stay and whether the patient was readmitted to hospital within 30 days of discharge was also collected. Statistical analyses were run using SPSS. 

Descriptives were given as mean with standard deviation (SD) or percentage as appropriate. In order to establish multivariate predictors of length of stay we used multiple linear regression, and in order to establish multivariate predictors of 30-day readmission we used binary logistic regression. As the sample size was 47 we included a maximum of 5 predictors in each model. 

Service evaluation approval was obtained from the clinical audit department of Addenbrooke’s Hospital, Cambridge (reference number 4339).

 

Results

In n=47 (22 men and 25 women), the mean age was 85.1 years (SD 5.8). Eleven patients (23.4%) had a history of dementia, and the mean MMSE in the sample was 21.2 (SD 5.8). The mean CFS was 5.3 (SD 1.4). The patients in the sample had a wide range of presenting complaints; the most common were fall (13 patients), chest infection/pneumonia (11 patients) and anemia (6 patients). Twenty-six patients lived alone and 16 reported that they felt lonely. The mean length of stay was 19.3 days (SD 16.4) and 9 patients (21.4%) were readmitted within 30 days of discharge.

Patients who were lonely had a longer mean length of stay (24 days compared to 17 in the non-lonely group). In the total sample, multivariate regression analysis showed significant links between loneliness and length of stay (p=0.021) and between the CFS and length of stay (p=0.010) when controlling for age, dementia status and living alone (Table 1). 

 

Table 1 Factors affecting length of stay (days). Bivariate analyses show each single variable separately tested versus length of stay. The multivariate analysis is then reported on the second part of the table

 

Patients who lived alone were more likely to be readmitted to hospital within 30 days (p=0.036). On multivariate analysis, advancing age appeared to reduce the likelihood of being readmitted to hospital within 30 days (Table 2).

 

Table 2 Factors affecting 30-day readmission. CI: confidence interval

 

Discussion

This study showed a significant link between clinical frailty and length of stay, which is in accordance with published literature (5). Self-reported loneliness also appeared to have a significant impact on length of stay, independently of clinical frailty. Our findings complement previous evidence on the importance of psychosocial factors in hospital outcomes in older people (6, 7). Living alone seemed to increase the risk of being readmitted to hospital within 30 days. Living alone has previously been shown to correlate with subsequent presentation to the emergency department (7). Our results support the need of bridging between social sciences, healthcare community services, and hospital setting, where frailty is particularly
prevalent.

The main limitation of this study is that it had a small sample size and therefore low statistical power, meaning that the number of predictors we could use in a model was limited. There may also have been some degree of selection bias as patients needed to be cognitively able to answer questions about their social circumstances satisfactorily. Furthermore, a larger sample size may have yielded more significant results, for example, the frequency of contact with friends, family or neighbours may have been a significant predictor of length of stay or rate of readmission. It would be interesting to repeat this study in future with a larger sample size. 

The interventions that could be put in place to improve the patient’s level of frailty are nutrition and exercise (8). In addition, loneliness could potentially be improved by psychosocial interventions (9) and utilising voluntary services supporting older people (e.g. Age UK in the UK). Having a lower threshold for involving voluntary organisations may mean that patients are able to participate in social activities that could reduce their loneliness. This in turn could reduce their length of stay in hospital, perhaps via psychosocial mechanisms enhancing recovery. Further research is needed in this area. 

 

Funding: No funding was required for this study.

Conflicting Interest: None

 

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