The incidence and mortality of refeeding syndrome in older hospitalized patients, based on three different diagnostic criteria: A longitudinal study.

BACKGROUND & AIMS: Refeeding syndrome (RFS) lacks both a global definition and diagnostic criteria. Different diagnostic criteria are used; serum phosphate (traditional criterion (TC)), the Friedli consensus recommendations, and the ASPEN. We investigated the incidence of RFS in older hospitalized patients and the mortality rates in patients with or without RFS using these three different diagnostic criteria. METHODS: This is a longitudinal study with data originating from a randomized controlled trial conducted between March 2017 and August 2019. A total of 85 malnourished hospitalized patients at risk of RFS according to the National Institute for Health and Clinical Excellence tool for detecting patients at risk of RFS, were included. All patients were provided with enteral tube feeding, and electrolytes were measured daily during the intervention period. Friedli and ASPEN included phosphate, magnesium, and potassium in their definitions, but used different cut-off values. Incidences were recorded, and Kaplan-Meier estimates were used to determine whether mortality was more prevalent in patients with RFS. Regression analysis was used to test for confounders regarding the association between RFS and death, and Kappa was used to test for agreement between the three diagnostic criteria. RESULTS: The mean (SD) age of the patients was 79.8 (7.4) years, and the mean (SD) BMI was 18.5 (3.4) kg/m2. The mean (SD) kcal/kg/day was 19 (11) on day one and 26 (15) on day seven. The incidences of RFS differed with the criteria used; 12.9% (TC), 31.8% (Friedli), and 65.9% (ASPEN). Mortality was high, with 36.5% (n = 31) and 56.5% (n = 48) of patients dead at three-month and one-year follow-up, respectively. In the TC, 8/11 (72.7%) with RFS vs. 40/74 (54.1%) without RFS died within one-year, in Friedli 15/27 (55.5%) with RFS vs. 33/58 (56.9%) without RFS died, and in ASPEN 32/56 (65.9%) with RFS, vs. 16/29 (55.2%) without RFS died within one-year. There was no statistically significant difference in mortality between patients with or without RFS regardless of which criteria were used. Age was the only variable associated with death at one-year. The Kappa analysis showed very low agreement between the categories. CONCLUSION: Our results show that using different diagnostic criteria significantly impacts incidence rates. However, regardless of criteria used, the mortality was not significantly higher in the group of patients with RFS compared to the patients without RFS. Furthermore, none of the criteria showed a significant association with death at one-year. This supports the need for a global unified diagnostic criterion for RFS. This study was registered in ClinicalTrials.gov (identifier NCT03141489).

Rehabilitation after total or hemi elbow arthroplasty: a systematic review.

Introduction: Total and hemi elbow arthroplasty (TEA/HEA) are relatively uncommon orthopedic procedures, but physiotherapists are involved in both pre- and postoperative treatment of people who undergo TEA/HEA. The purpose of this article is to summarize existing knowledge about the effects of rehabilitation versus standard care after total and hemi elbow arthroplasty (TEA/HEA). Methods: A systematic literature review was conducted searching Ovid MEDLINE ®, SweMED+, Cochrane, Embase, AMED and PEDro. "The Preferred Reporting Items for Systematic Review and Meta-Analysis" was followed. Results: No one has studied the effects of rehabilitation after TEA/HEA. The aim of the only study included was to assess the safety and length of hospital stay (LOS) after omission of casting, start of early mobilization and implementation of functional discharge criteria. Results show that the non-casting cohort had a shorter mean LOS (5.4 days) than the index cohort (6.2 days). The cohort with functional discharge criteria had a shorter mean LOS (3.8 days) than the cohort without functional discharge (5.4 days). Conclusion: Effects of rehabilitation components or programs after TEA/HEA are still unknown. It is important to focus on the lack of evidence in this field, and plan for more studies to come.

Physical Function and Health-Related Quality of Life in Older Adults With or at Risk of Mobility Disability Post-discharge: 8-Month Follow-Up of a Randomized Controlled Trial.

The objective of this study was to evaluate physical function and health-related quality of life 4 months after the cessation of a 4-month exercise intervention in 89 older adults after discharge from hospital. Linear mixed regression models were used to evaluate between-group differences. Data were analyzed according to the intention-to-treat principle. There was no statistically significant between-group difference in the Short Physical Performance Battery (mean difference 0.5 points, 95% confidence interval [-0.6, 1.5], p = .378). There was a statistically significant difference in favor of the intervention group in functional capacity (the 6-min walk test; mean difference 32.9 m, 95% confidence interval [1.5, 64.3], p = .040) and physical health-related quality of life (physical component summary of medical outcome Study 36-Item Short-Form Health Survey; mean difference 5.9 points, 95% confidence interval [2.0, 9.7], p = .003). Interventions aiming to maintain or increase physical function and health-related quality of life should be encouraged in this population.

Refeeding syndrome occurs among older adults regardless of refeeding rates: A systematic review.

Refeeding syndrome is a life-threatening clinical disorder that can occur when treating malnutrition. The aim was to examine the current knowledge of refeeding syndrome in patients ≥ 65 + years with special focus on the incidence of hypophosphatemia (HP) in relation to refeeding rate (kcal/kg/day), number of days until the lowest level of phosphate occurs (day of nadir), refeeding rates and adverse events, and death. Specifically, we hypothesized that higher energy provision would cause a higher incidence of HP. A search was conducted in the available databases. Two cohort studies, 1 case control, and a total of 12 case series/case reports, which accounted for 19 individual patient cases, were eligible. The incidence of HP (<0.5 mmol/L) was 15% and 25% in the 2 cohort studies and 4% in the case control study. The mean day of nadir was between days 2 and 3 in the cohort studies, day 11 in the case control study, and day 3 in the cases series/case reports. Importantly, a rapid drop in phosphate occurred receiving both 30 kcal/kg/day and 8 to 10 kcal/kg/day. The cohort studies reported high death rates-26% and 23%-using both 10 and 20 kcal/kg/day, respectively. Adverse events were noted in most all case series/case reports. Clinicians should be aware that HP may occur in up to 25% of older hospitalized adults, and importantly, it occurs even when refeeding cautiously. Hence, electrolytes should be closely monitored, especially between days 2 and 4, which is when the day of nadir occurs most frequently.

A comparison of two different refeeding protocols and its effect on hand grip strength and refeeding syndrome: a randomized controlled clinical trial.

PURPOSE: Optimal refeeding protocols in older malnourished hospital patients remain unclear. We aimed to compare the effect of two different refeeding protocols; an assertive and a cautious protocol, on HGS, mortality and refeeding syndrome (RFS), in patients ≥ 65 years METHODS: Patients admitted under medical or surgical category and at risk of RFS, were randomized to either an enteral nutrition (EN) refeeding protocol of 20 kcal/kg/day, reaching energy goals within 3 days (intervention group), or a protocol of 10 kcal/kg/day, reaching goals within 7 days (control group). Primary outcome was the difference in hand grip strength (HGS) at 3 months follow-up, in an intention to treat analysis. RFS (phosphate < 0.65 mmol/L) during the hospital stay and mortality rates at 3 months were secondary outcomes. RESULTS: A total of 85 patients were enrolled, with mean (SD) age of 79.8(7.4) and 54.1% female, 41 in the intervention group and 44 in the control group. HGS was similar at 3 months with mean change of 0.42 kg (95% CI - 2.52 to 3.36, p = 0.78). Serum phosphate < 0.65 mmol/L was seen in 17.1% in the intervention group and 9.3% in the control group, p = 0.29. There was no difference in mortality rates (39% vs 34.1%, p = 0.64). An indication of more respiratory distress was found in the intervention group, 53.6% vs 30.2%, p = 0.029. CONCLUSION: A more assertive refeeding protocol providing 20 kcal/kg/day did not result in improved HGS measured 3 months after discharge compared with a cautious refeeding (10 kcal/kg/day) protocol. No difference in incidence of mortality or RFS was found. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Record 2017/FO148295, Registered: 21st of February, 2017.

Associations between health-related quality of life and physical function in older adults with or at risk of mobility disability after discharge from the hospital.

PURPOSE: To optimise the treatment for older adults after hospitalisation, thorough health status information is needed. Therefore, we aimed to investigate the associations between health-related quality of life (HRQOL) and physical function in older adults with or at risk of mobility disability after hospital discharge. METHODS: This cross-sectional study recruited 89 home-dwelling older people while inpatients within medical wards at a general hospital in Oslo, Norway. HRQOL [the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36)] and physical function [the Short Physical Performance Battery (SPPB)] were measured a median of 49 [interquartile range (IQR) 26-116] days after discharge. Simple linear regression analyses were conducted, and multivariable regression models were fitted. RESULTS: The mean age of the patients was 78.3 years; 43 (48.9 %) were females. Multivariable regressions showed positive associations between SPPB and the physical subscales {physical functioning [B (95% CI) 4.51 (2.35-6.68)], role physical [B (95% CI) 5.21 (2.75-7.67)], bodily pain [B (95% CI) 3.40 (0.73-6.10)] and general health [B (95% CI) 3.12 (1.13-5.12)]}. Univariable regressions showed no significant associations between SPPB and the mental subscales {vitality [B (95% CI) 1.54 (- 0.10-3.18)], social functioning [B (95% CI) 2.34 (- 0.28-4.96)], role emotional [B (95% CI) 1.28 (- 0.96-3.52)] and mental health [B (95% CI) 1.00 (- 0.37-2.36)]}. CONCLUSION: The results reinforce that physical function and physical HRQOL are strongly linked, and interventions improving physical function might improve physical HRQOL. However, this hypothesis would have to be tested in a randomised controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov. Registered 19 September 2016 (NCT02905383).

Effects of a multicomponent high intensity exercise program on physical function and health-related quality of life in older adults with or at risk of mobility disability after discharge from hospital: a randomised controlled trial.

BACKGROUND: Many older people suffer from mobility limitations and reduced health-related quality of life (HRQOL) after discharge from hospital. A consensus regarding the most effective exercise-program to optimize physical function and HRQOL after discharge is lacking. This study investigates the effects of a group-based multicomponent high intensity exercise program on physical function and HRQOL in older adults with or at risk of mobility disability after discharge from hospital. METHODS: This single blinded parallel group randomised controlled trial recruited eighty-nine home dwelling older people (65-89 years) while inpatient at medical wards at a general hospital in Oslo, Norway. Baseline testing was conducted median 49 (25 percentile, 75 percentile) (26, 116) days after discharge, before randomisation to an intervention group or a control group. The intervention group performed a group-based exercise program led by a physiotherapist twice a week for 4 months. Both groups were instructed in a home-based exercise program and were encouraged to exercise according to World Health Organisation's recommendations for physical activity in older people. The primary outcome, physical performance, was measured by the Short Physical Performance Battery (SPPB). Secondary outcomes were 6-min walk test (6MWT), Berg Balance Scale (BBS), grip strength, Body Mass Index (BMI), and HRQOL (the Short-Form 36 Health Survey (SF-36)). Data were analysed according to the intention-to-treat principle. Between-group differences were assessed using independent samples t-test. RESULTS: The groups were comparable at baseline. Intention-to-treat analysis showed that the intervention group improved their functional capacity (6MWT) and the physical component summary of SF-36 significantly compared to the control group. No further between group differences in change from baseline to 4 months follow-up were found. CONCLUSIONS: A high intensity multicomponent exercise program significantly improved functional capacity and physical HRQOL in older adults with or at risk of mobility disability after discharge from hospital. The study suggests that this population can benefit from systematic group exercise after hospital-initial rehabilitation has ended. TRIAL REGISTRATION: ClinicalTrials.gov . NCT02905383 . September 19, 2016.

Reliability and validity of the Norwegian-language version of the elderly mobility scale in older hospitalised patients.

BACKGROUND AND PURPOSE: Reliable and valid assessment tools are needed to evaluate and predict physical function in older hospitalised patients. The purpose of this study was to determine the reliability and validity of the Norwegian-language version of the Elderly Mobility Scale (EMS-N) for use with geriatric patients. METHODS: Fifty patients admitted to a medical ward in a hospital in Norway were included. The inclusion criteria were acute hospital admission because of medical issues, age ≥65 years and referred to a physiotherapist for a physical function review. The original version of the Elderly Mobility Scale (EMS) was translated from English to Norwegian before initiating this study. EMS-N was tested for internal consistency, test-retest reliability and criterion validity by using the short physical performance battery (SPPB) as the gold standard. Internal consistency was measured by Cronbach's alpha. Test-retest reliability was estimated by linear weighted kappa and the intra-class correlation coefficient (ICC). RESULTS: The mean age of participants was 82 (range 65-95). The main admission diagnoses were acute functional decline (64%, n = 32) or acute infection (26%, n = 13). Internal consistency was estimated at 0.88. Test-retest reliability: six of the seven EMS-N items showed very good consistency, and the last item showed good consistency, ICC was estimated at 0.99. The standard error of measurement (SEM) reflected the absolute reliability, calculated at 0.52. The minimal detectable change (MDC) was calculated with 95 and 90% confidence intervals at 1.44 and 1.21, respectively. Criterion validity was calculated by a correlation analysis of the EMS-N and the SPPB. The rho value was estimated as 0.75, which corresponds to a high correlation and indicated good criterion validity. DISCUSSION: EMS-N exhibited good internal consistency and good to very good test-retest reliability and criterion validity. EMS can safely be used as an assessment tool for hospitalised geriatric patients.

Associations between Cognition and Hand Function in Older People Diagnosed with Mild Cognitive Impairment or Dementia.

BACKGROUND/AIMS: The aim of this study was to examine the associations between different cognitive domains and hand function in older people diagnosed with mild cognitive impairment (MCI) or dementia. METHODS: This study is cross-sectional, including 98 community-living older people aged ≥65 years with MCI or dementia. Assessments of hand function included grip strength, the Finger Tapping Test, and the Grooved Pegboard. Cognitive assessments were the Mini-Mental State Examination, the Clock Drawing Test, and Trail Making Tests A and B, as well as a 10-word List Learning Test. Statistical analyses were based on descriptive statistics and univariable and multivariable analyses. RESULTS: Sixty participants were diagnosed with MCI and 38 were diagnosed with dementia. The mean age was 78.8 years (SD 7.4). Analyses of hand function, cognitive tests, and demographic factors showed an association between cognitive tests, in particular executive function (EF), and hand function. CONCLUSIONS: The findings indicated an association between physical and cognitive function. Among the cognitive domains, declines in EF were most related to a reduced physical function.

Physical Fitness in Older People Recently Diagnosed with Cognitive Impairment Compared to Older People Recently Discharged from Hospital.

BACKGROUND/AIMS: There is evidence of an association between cognitive function and physical fitness. The aim of this study was to compare physical fitness in patients with cognitive impairment with a group of older people recently discharged from hospital. METHODS: A cross-sectional study with 98 patients recently diagnosed with cognitive impairment and 115 patients recently discharged from hospital. Associations between the study group variable and different components in the Senior fitness test were examined, controlling for demographic factors and comorbidity. RESULTS: The group recently diagnosed with cognitive impairment indicated poorer results on three of six physical fitness components (p < 0.05). CONCLUSION: Older adults with cognitive impairment are in need of individually tailored physical activity programs to increase the level of physical fitness.

Physical Fitness in Older People with Mild Cognitive Impairment and Dementia.

Maintenance of physical activity and good physical fitness is important for functional independence. This study had two aims: examine the physical fitness level in older persons with mild cognitive impairment (MCI) or dementia, and examine the relationship between the components of physical fitness and cognitive domains in this group. The cross-sectional study included community-living older people ≥ 65 years of age with MCI or dementia. Physical fitness and cognition were assessed using the Senior Fitness Test and five cognitive tests. Most of the participants scored below the criteria for maintaining physical independence in later years. There were significant associations between the components of physical fitness and cognition, except flexibility. Declines in executive function were most related to declines in physical fitness. These factors should receive more attention in people with MCI and dementia because they risk losing independence.

Reliability of the senior fitness test in community-dwelling older people with cognitive impairment.

BACKGROUND AND PURPOSE: In older people with cognitive impairment, we require reliable and valid measures to assess physical fitness and to measure change, for example, as a result of an exercise intervention. The purpose of our study was to determine the relative and absolute test-retest reliability of the Senior Fitness Test (SFT) in older people with cognitive impairment. METHODS: A test-retest reliability study was conducted for the Senior Fitness Test in older people with cognitive impairment. Participants were tested at two time points with a time interval of 24 hours to 1 week between tests. The Intraclass Correlation Coefficient model 3.1 (ICC, 3.1) with 95% confidence intervals (CIs) was used as a measure of relative reliability. The standard error of measurement and minimal detectable change (MDC) were used to measure absolute reliability. RESULTS: The ICC reflected very high reliability (0.93-0.98) in all SFT items, indicating that there was no systematic error in the measurements. MDC values at the 90% CIs were calculated: chair stand test = 2.0 repetitions, armcurl test = 2.3 repetitions, chair sit and reach test = 6.0 cm, back scratch test = 4.6 cm, 2.45-m up-and-go test = 1.4 seconds and 6-minute walk test = 37.1 metres. DISCUSSION: The SFT battery showed high to very high test-retest reliability and thus may be suitable for detecting changes in physical fitness and evaluating physical fitness in older people with cognitive impairment, both in research and for clinical purposes.

Disability in instrumental activities of daily living in elderly patients with mild cognitive impairment and Alzheimer's disease.

BACKGROUND/AIMS: The aim is to examine disability in instrumental activities of daily living (IADL) in elderly persons with mild cognitive impairment (MCI) and Alzheimer's disease (AD), further to identify items of IADL which separate the two conditions and to explore potential gender differences. METHODS: A cross-sectional study of 729 patients aged ≥65 years recruited from outpatient memory clinics. Multiple logistic regression analysis was used in the main analysis to explore the association between IADL and diagnosis. RESULTS AND CONCLUSIONS: We found an association between IADL and diagnosis, and a difference in the proportion of disability in IADL in patients with MCI and AD, i.e. 66 and 88%, respectively. Six of the 8 items revealed differences in the proportions of patients with IADL disability among MCI and AD. No substantial gender differences were found, except for laundry.

Altered vision destabilizes gait in older persons.

This study assessed the effects of dim light and four experimentally induced changes in vision on gait speed and footfall and trunk parameters in older persons walking on level ground. Using a quasi-experimental design, gait characteristics were assessed in full light, dim light, and in dim light combined with manipulations resulting in reduced depth vision, double vision, blurred vision, and tunnel vision, respectively. A convenience sample of 24 home-dwelling older women and men (mean age 78.5 years, SD 3.4) with normal vision for their age and able to walk at least 10 m without assistance participated. Outcome measures were gait speed and spatial and temporal parameters of footfall and trunk acceleration, derived from an electronic gait mat and accelerometers. Dim light alone had no effect. Vision manipulations combined with dim light had effect on most footfall parameters but few trunk parameters. The largest effects were found regarding double and tunnel vision. Men increased and women decreased gait speed following manipulations (p=0.017), with gender differences also in stride velocity variability (p=0.017) and inter-stride medio-lateral trunk acceleration variability (p=0.014). Gender effects were related to differences in body height and physical functioning. Results indicate that visual problems lead to a more cautious and unstable gait pattern even under relatively simple conditions. This points to the importance of assessing vision in older persons and correcting visual impairments where possible.