Mortality among older patients admitted to the medical wards of Groote Schuur Hospital, Cape Town, South Africa, 2010 - 2013.

BACKGROUND: Geriatric medicine is an evolving specialty in Africa, and little is known about mortality among older patients admitted to medical wards. OBJECTIVES: To determine mortality rates and associated factors among older medical inpatients. METHODS: Electronic data on patients aged ≥60 years admitted to the medical wards of Groote Schuur Hospital, Cape Town, South Africa, between January 2010 and December 2013 were analysed. Data extracted included sex, age, causes of death, and length of stay from date of admission to discharge or death. Results of laboratory tests carried out during the admission were also obtained. RESULTS: In all, 11 254 older patients were admitted (mean (standard deviation) age 70.7 (7.9) years). There were 1 701 deaths (15.1%). The unadjusted mortality rate was 29.6 deaths per 1 000 patient-days (PD). The majority (87.5%) were admitted as emergency cases. Mortality in the first 24 hours was 32.4 deaths per 1 000 PD. There was a significant increase in mortality with increasing age (p<0.001). Stroke was the commonest cause of mortality (14.5%). The predictors of mortality were short length of stay on admission (odds ratio (OR) 1.047, 95% confidence interval (CI) 1.033 - 1.061), high white blood cell count (OR 1.064, 95% CI 1.054 - 1.074), low platelet count (OR 0.999, 95% CI 0.996 - 1.000), low haemoglobin (OR 0.940, 95% CI 0.917 - 0.964) and high blood urea (OR 1.042, 95% CI 1.033 - 1.051). CONCLUSIONS: Mortality among older medical inpatients was high. Modifiable predictors of mortality, especially related to laboratory derangements, should be identified and addressed promptly.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa.

BACKGROUND: The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries. METHODS: Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa. RESULTS: This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa. CONCLUSIONS: Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Prevalence of Falls in an Urban Community-Dwelling Older Population of Cape Town, South Africa.

OBJECTIVE: Falls are a major cause of disability and mortality in older adults. Studies on falls in this population have mainly been conducted in high income countries, and scant attention has been given to the problem in low and middle income countries, including South Africa. The aim of the study was to establish a rate for falls in older adults in South Africa. DESIGN: A cross-sectional survey with a 12-month follow-up survey. SETTING: Three purposively selected suburbs of Cape Town: Plumstead, Wynberg Central and Gugulethu. PARTICIPANTS: Eight hundred and thirty seven randomly sampled ambulant community-dwelling subjects aged ≥ 65 years grouped according to ethnicity in three sub-samples: black Africans, coloureds (people of mixed ancestry) and whites. MEASUREMENTS: Data were collected on socio-demographic and health characteristics, and history of falls using a structured questionnaire and a protocol for physical assessments and measurements. RESULTS: Of the total baseline (n=837) and follow-up (n=632) survey participants, 76.5% and 77.2 % were females with a mean (S.D) age of 74 years (6.4) and 75 years (6.2), respectively. Rates of 26.4% and 21.9% for falls and of 11% and 6.3% for recurrent falls, respectively, were calculated at baseline and follow-up. Fall rates differed by ethnic sub-sample at baseline: whites 42 %, coloureds 34.4% and black Africans 6.4 % (p=0.0005). Rates of 236, 406 and 354 falls per 1000 person years were calculated for men, women and both genders, respectively. Recurrent falls were more common in women than in men. CONCLUSION: Falls are a significant problem in older adults in South Africa. Effective management of falls and falls prevention strategies for older people in South Africa, need to be developed and implemented.

Does chair type influence outcome in the timed "Up and Go" test in older persons?

OBJECTIVE: To test the effects of the use of a collapsible, portable chair (chair B), as opposed to a 'standard' chair (chair A), on the outcome of the timed "Up and Go" (TUG) test. DESIGN: Cross-sectional. SETTING: Multipurpose senior centres. PARTICIPANTS: Mobile older persons (N=118, mean age 77 years (range 62-99 years)). OUTCOME MEASURES: Time to complete the timed "Up and Go" test using chair A and chair B, and inter-rater agreement in the time scores. RESULTS: Time taken to complete the TUG test did not differ by chair type [median (interquartile range, IQR) = 12.3 (9.53-15.9) and 12.6 (9.7-16.6)] seconds for Chair A and B respectively, p-value=0.87. In multiple regression analyses, factors that impacted on time difference in test performance for the two chairs were use of a walking aid during the test [Odds ratio (OR) = 3.7 95%CI 1.1-11.9, p=0.031], observed difficulty with mobility (OR= 27.7 95%CI 2.6-290, p=0.006), and a history of arthritis in the knees (OR= 2.9 95%CI 1.0-8.7, P=0.05). In an inter-rater agreement analysis, no significant difference was found between time scores recorded by the two raters; median (IQR) = 12.4 (10.9-15.9) and 12.3 (7.2-59.1) seconds for the occupation therapist and for the research assistant, respectively (Wilcoxon matched pairs test, p=0.124, Spearman correlation coefficient = 0.99, p < 0.001). CONCLUSION: The use of a portable canvas chair with standardised specifications offers an acceptable alternative to the use of a 'standard' chair in assessments of fall risk using the TUG test in field settings where field workers are reliant on public transport.

Clinical predictors of outcome in acute upper gastrointestinal bleeding.

OBJECTIVE: Endoscopy has traditionally been used to risk-stratify patients with upper gastrointestinal bleeding (UGIB). This is problematic in resource-poor environments. The study aimed to identify patients who would not require urgent endoscopy by identifying clinical variables before endoscopy that predict uneventful recovery. DESIGN: Prospective, descriptive cross-sectional study. SETTING: Groote Schuur Hospital, Cape Town. SUBJECTS: Two hundred consecutive patients aged over 12 years, presenting with haematemesis and/or melaena. OUTCOME MEASURES: Good outcome, i.e. no blood transfusion, endotherapy or surgery, and alive at 1 month following presentation. RESULTS: Eighty patients (40%) had a good outcome. Haemoglobin > 10 g/dl (odds ratio (OR) 25.5, 95% confidence interval (CI): 8.9-74.8; p < 0.001), absence of melaena (OR 4.8, 95% CI: 1.79-12.94, p = 0.002) and absence of syncope (OR 4.0, 95% CI: 1.67-9.48; p = 0.002) were independent predictors of good outcome. The three variables combined as a positive test had the best association with good outcome when compared with a single variable or a combination of two variables. The three-variable model had sensitivity for good outcome of 34%, specificity of 98%, and likelihood ratio for a positive test of 13.5 and for a negative test of 0.68. Thirty patients (15%) had the combination for the prediction rule, i.e. haemoglobin > 10 g/dl, no melaena and no syncope; 3 (10%) had a poor outcome (required endotherapy). CONCLUSION: The prediction rule accurately excluded poor outcome, a priority in the clinical context, but did not predict good outcome. Clinical implications are a 15% reduction in unnecessary urgent endoscopies, with less than 5% of patients with poor outcome not undergoing urgent endoscopy. These findings may have particular clinical relevance in under-resourced health care environments.