Association Between Chronic Diseases and Frailty in a Sample of Older Greek Inpatients.

INTRODUCTION: Previous reports have associated frailty with the existence of various chronic diseases. Especially for cardiovascular diseases, this relationship seems to be bidirectional as common pathophysiological mechanisms lead to the progression of both diseases and frailty. The study aimed to examine the relationship between chronic diseases and frailty in a sample of older Greek inpatients Methodology: In 457 consecutively admitted older patients (226, 49.5% females), the median age was 82 years (interquartile range [IQR] 75-89), and demographic factors, medical history, cause of admission, and the degree of frailty assessed with the Clinical Frailty Scale were recorded. The level of frailty was calculated for the pre-hospital status of the patients. Parametric tests and logistic regression analysis were applied to identify diseases independently associated with frailty. RESULTS: Using the scale, 277 patients (60.6%) were classified as frail and 180 as non-frail (39.4%). In univariate analysis, frail patients were more likely to have respiratory disease, dementia, Parkinson's disease, chronic kidney disease (CKD), atrial fibrillation (AFIB), neoplastic disease, depression, stroke, heart failure (HF), and coronary artery disease. In binomial regression analysis, the diseases that were statistically significantly associated with frailty were respiratory diseases (P = 0.009, odds ratio [OR] = 2.081, 95% confidence interval [CI] 1.198-3.615), dementia (P ≤ 0.001, OR = 20.326, 95% CI 8.354-49.459), Parkinson's disease (P = 0.049, OR = 3.920, 95% CI 1.005-15.295), CKD (P = 0.018, OR = 2.542, 95% CI 1.172-5.512), AFIB (P = 0.017, OR = 1.863, 95% CI 1.118-3.103), HF (P = 0.002, OR = 2.411, 95% CI 1.389-4.185), and coronary artery disease (P = 0.004, OR = 2.434, 95% CI 1.324-4.475). CONCLUSIONS: Among diseases independently associated with frailty, chronic diseases such as respiratory diseases, dementia, Parkinson's disease, CKD, and cardiovascular diseases (AFIB, HF, and coronary heart disease) have an important role. Recognizing the diseases that are highly related to frailty may contribute, by their optimal management, to delaying the progression or even reversing frailty in a large proportion of the elderly.

Does Old Age Comprise Distinct Subphases? Evidence from an Analysis of the Relationship between Age and Activities of Daily Living, Comorbidities, and Geriatric Syndromes.

BACKGROUND: Older individuals are usually treated as a homogenous group despite evidence that old age consists of distinct subphases. This observational study including 493 older patients aimed to identify differences among age subgroups of older persons. Receiver operating characteristic (ROC) curve analysis was then applied to identify the optimal age cutoff points to distinguish those age groups. METHODS: Data were collected on the demographics of older patients, their medical and medication histories, dependence on activities of daily living (ADLs), and instrumental activities of daily living (IADLs). Non-parametric tests (Kruskal-Wallis and Mann-Whitney U tests) and ROC curves were used for statistical analysis. RESULTS: The 65-79 and ≥80 years of age groups showed distinct frailty status, comorbidity, and dependency in ADLs. The median age to remain completely independent in IADLs was 76-79 years, while the median age for being free from geriatric syndromes was slightly higher (77-80 years) and reached 82 years for the absence of delirium, falls, and swallowing problems. In the ROC analysis, the optimal cutoff ages for the presence of frailty, cognitive impairment, and dependency in ADLs were 80-82 years. CONCLUSION: The 65-79 and ≥80 years of age groups differed significantly in numerous parameters, underscoring the need to address these distinct age groups differently, both for applying medical therapies and interventions, as well as for conducting health research.

The role of frailty among the predictors of depression on informal caregivers of older adults: a mediation analysis.

BACKGROUND: Providing care for older adults has been associated with the presence of depressive symptoms among their informal caregivers. Numerous caregivers and older adults' characteristics have been mentioned as predictors of caregivers' depression. However, studies dealing with the impact of older adults' frailty status on caregivers' depression are scarce. This study was conducted to clarify the precise relationship between caregivers' depression, caregivers' burden, caregivers' characteristics and patients' characteristics, including frailty, among the variables that may have an impact on caregivers' depression. METHODS: In this cross-sectional study, patients and caregivers' characteristics were recorded for 311 patient-caregiver dyads, when the patient was admitted to the hospital. For the purpose of the study, a mediation analysis was used with patients and caregiver characteristics considered to be predictors, subjective caregivers' burden as the mediator, and caregivers' depression as the outcome variable. RESULTS: Only patients' frailty and caregivers' subjective burden had a direct effect on caregivers' depression. Moreover, caregivers' gender, patients' frailty status and comorbidity, duration of caregiving, and the relationship with the patient, had an indirect effect through caregivers' burden that acted as mediator. Regarding total effects, caregivers burden followed by patients' frailty status had the greater impact on caregivers' depression. CONCLUSIONS: By organising interventions to reduce caregivers' depression, patients' frailty status could be among the targets of those interventions considering that frailty might be delayed or reversed.

A Case Report on a Giant Hepatic Inflammatory Adenoma in a Young Female That Presented as Spontaneous Intrahepatic Hematoma.

Among the extensive variety of disorders that can cause acute abdominal pain are hepatocellular adenomas (HCAs), pathological entities that otherwise are asymptomatic. Here, we describe a 33-year-old female who presented in the emergency department with acute abdominal pain and a history of liver focal nodular hyperplasia (FNH) diagnosed 10 years ago. An abdominal magnetic resonance imaging (MRI) revealed that the cause of the pain was an intrahepatic hematoma. The mass was surgically removed, and the biopsy revealed inflammatory adenomas, a subtype of HCA. Hepatic adenoma diagnosis remains challenging by clinical and imaging techniques, and usually, a biopsy is the main diagnostic tool. HCA should be differentiated from hepatocellular carcinoma (HCC), FNH, hepatic angioleiomyoma, and hepatic hemangioma. In our case, HCA was misdiagnosed in the past as FNH. HCA rarely may present as acute right abdomen pain, and a potential catastrophic hemorrhage or rupture must be excluded.

Neck Abscess Due to Pocket Shot: Is It Just the Tip of the Iceberg?

A 45-year-old Caucasian male presented to the emergency department for pain and swelling on the left side of his neck for the past 10 days. His medical history revealed that he was an intravenous (IV) drug abuser. Physical examination demonstrated a 5×5 cm red, swollen bump with a positive fluctuation on the left supraclavicular area concerning for an abscess. Fluid aspiration from the abscess was performed, and three sets of blood cultures were obtained, which later all came back positive for methicillin-resistant Staphylococcus aureus (MRSA). His initial blood tests revealed elevated levels of platelets, leukocytes, and C-reactive protein (CRP) and anemia. The computed tomography (CT) scan showed an enlarged pectoralis major with the presence of air. The retrosternal, infraclavicular, and supraclavicular regions also contained air. The clinical diagnosis was therefore supported by the laboratory results and imaging. Additionally, transthoracic echocardiography showed no vegetations, and transesophageal echocardiography was scheduled. Antibacterial treatment was initiated empirically from the emergency room with meropenem and vancomycin, planned for four weeks. Repeat cultures were obtained for the following three days, which were all negative. However, the patient left the hospital against medical advice and did not complete his antibiotic treatment. The risk of a peripherally inserted central catheter (PICC) line being misused for illegal narcotics was considered too high; hence, it was not recommended for continued IV antibiotic therapy at home. Those with a history of intravenous drug use, after using the most accessible injection sites, oftentimes resort to finding alternative and potentially more dangerous injection sites. The major veins of the neck, such as the jugular, subclavian, or brachiocephalic veins, are commonly used. This technique is referred to as a "pocket shot" by intravenous drug abusers (IVDAs). Apart from the apparent abscess, clinicians should oversee for other complications including underlying pus collections, pneumothorax, mediastinitis, osteomyelitis, and hemothorax.

Translation of the Pictorial Fit-Frail Scale Into the Greek Language and Examination of Its Validity and Reliability.

BACKGROUND: For the evaluation of frailty, a great variety of research tools are used internationally; however, only two have been translated and validated in Greek. The aim of the study was to translate the Pictorial Fit-Frail Scale (PFFS) into the Greek language and examine its validity and reliability. METHODS: Initially, the PFFS scale was translated into the Greek language through a six-step process. Subsequently, in a sample of 157 elderly patients (47.1% women), construct validity was examined with the known-groups method using the one-way ANOVA test and criterion concurrent validity by comparison with the Clinical Frailty Scale (CFS) using Pearson's correlation coefficient. Finally, inter-rater reliability and test-retest reliability were checked using the intraclass correlation coefficient. RESULTS: A comparison of known groups showed that older patients with greater dependence on activities of daily living, greater impairment of cognitive function, reduced mobility, balance, and swallowing disorders, as well as those who were socially withdrawn, scored higher on the PFFS scale, supporting the construct validity. The positive correlation between PFFS and CFS (r = 0.625, p ≤ 0.001) demonstrated the concurrent criterion validity of the PFFS scale. Intraclass correlation was excellent for both inter-rater reliability (0.951 (95% CI: 0.934-0.964)) and test-retest reliability (0.948 (95% CI: 0.930-0.962)). CONCLUSION: The translated PFFS scale in Greek is a valid and reliable tool.

Factors associated with health-related quality of life of informal caregivers of older patients and the mediating role of subjective caregivers' burden.

BACKGROUND: Caregiving has been associated with increased subjective burden and decreased health-related quality of life (HRQOL) for caregivers. The aim of the study was to clarify the precise relationship between caregivers' burden, caregivers' HRQOL, and other risk factors, considering that subjective burden was a risk factor for poor HRQOL, which may also mediate the effects of some known risk factors. METHODS: In this cross-sectional study, patients' and their informal caregivers' characteristics were recorded for 311 patient-caregiver dyads. Subjective caregiver burden and caregivers' HRQOL were assessed using the Zarit Burden Interview and the 12-item Short-Form Health Survey (SF-12), respectively. Mediation analysis was used to examine the relationships between variables. Caregivers' mental component summary (MCS) and physical component summary (PCS) scores were regarded as outcome variables, caregivers' subjective burden was considered the mediator, and patients' and caregivers' characteristics were treated as predictors. RESULTS: Caregivers' subjective burden was negatively related to both PCS and MCS of caregivers' HRQOL, after controlling for the effects of demographic and clinical variables. Moreover, significant associations, mostly indirect via caregivers' subjective burden, existed between caregivers' socio-demographic characteristics, duration of caregiving, patients' frailty status, patients' co-morbidity, and caregivers' HRQOL. CONCLUSION: Caregivers' subjective burden plays a major and mediating role on influencing caregivers' HRQOL. Our findings may direct future research and promote the implementation of interventions to reduce caregivers' burden and improve caregivers' HRQOL.

Factors Affecting Caregivers' Burden in a Sample of Greek Family Caregivers Caring for Older Adults.

Caregivers' burden may vary across different countries. The aim of this study was to evaluate factors associated with caregivers' burden in a sample of Greek patient-caregiver dyads, including patients' frailty status among the evaluated variables. In 204 patient-caregiver dyads, patients' and caregivers' characteristics were recorded. Caregiver burden was evaluated by using the Zarit Burden Interview, and patients' frailty status by using Clinical Frailty Scale (CFS). Parametric and non-parametric tests and logistic regression analysis were applied to identify the factors that had a significant association with caregivers' burden. Increasing CFS score (p = .001, OR = 1.467, 95%CI 1.178-1.826) and longer duration of caregiving (p = .003, OR = 1.017, 95%CI 1.006-1.028) were associated with an increased likelihood of caregivers' burden. Patients' frailty status is probably a modifiable factor among them that has an impact on caregivers' burden. Strategies and interventions in order to prevent, delay or reverse frailty may have a positive impact on reducing this burden.

The Indirect Effect of the Frailty of Dependent Elderly People Needing Hospitalization on Their Informal Caregivers' Anxiety.

Background A high prevalence of anxiety symptoms has been identified among the caregivers of disabled older people. The aim of the study was to explore the relationships between objective burden (intensity of care and burdensome characteristics of the care recipient, like frailty status), caregiver characteristics, subjective burden, and anxiety in a sample of informal caregivers caring for hospitalized elderly patients.  Methods In this cross-sectional study, patients' and their informal caregivers' characteristics were recorded for 311 patient-caregiver dyads. Subjective caregiver burden and caregivers' anxiety were assessed by using the Zarit Burden Interview and the Hospital Anxiety and Depression Scale (HADS), respectively. Correlation coefficients and path analysis were used to examine the relationship between variables. Caregivers' anxiety was considered as the outcome variable. Caregivers' subjective burden was entered as a mediator between caregiver characteristics-objective burden and anxiety. An objective burden was measured based on the care needs of the dependent elderly (frailty status, cognitive impairment, comorbidity, independence in activities of daily living, behavioral problems, hours spent on caregiving, and duration of caregiving). Results Abnormal anxiety symptoms (HADS score 11-21) were reported by 92 caregivers (29.6%). Borderline cases (HADS score 8-10) were 66 caregivers (21.2%). A mild, moderate, or severe subjective burden was recorded for 113 (36.3%), 100 (32.2%), and 26 (8.4%) caregivers, respectively. The female gender of the caregiver, the spousal relationship with the patient, and the subjective burden were directly related to higher levels of caregivers' anxiety. A subjective burden was found to be a significant mediator in the relationship between duration of caregiving, patients' frailty status, caregiver gender, patients' comorbidity, and caregivers' anxiety. Conclusion Among the risk factors for caregivers' anxiety, the frailty status of the patient is probably the only modifiable factor via interventions targeting frailty reversion or reduction.

A Case of an Inflamed Pericardial Cyst As the Cause of Acute Onset Chest Pain in a Young Patient and Review of the Literature.

Among the extensive variety of disorders that can cause chest pain are the complicated pericardial cysts, pathological entities that otherwise are asymptomatic. Here, we describe a 34-year-old male patient with a symptomatic pericardial cyst presenting at the emergency department with acute chest pain that woke him up about six hours prior to presentation. The work up for his acute chest pain revealed a well-defined, fluid-filled, rounded mass next to the pericardium on the right cardiophrenic angle and increased acute phase reactants. The cyst was surgically removed and the biopsy showed signs of intense inflammatory infiltration with negative culture of the fluid. The patient received intravenous antibiotics for two weeks with complete resolution of the symptoms and remained asymptomatic for about two months after surgical excision. Among other symptoms that may be induced from the presence of a pericardial cyst, the acute onset of chest pain, in this otherwise benign condition, probably indicates the existence of a complication such as rupture, inflammation, or hemorrhage. Careful exclusion of other etiologies of chest pain is mandatory as the surgical excision of a complicated pericardial cyst remains the only therapeutic option.

The Case Report of a 97-Year-Old Patient With Chronic Anemia and Hemoglobin Value of 1.7 g/dl and Review of the Literature.

Although hemoglobin levels beneath 6.5 g/dl are considered to be life-threatening and the patients theoretically suffer from a cluster of symptoms, few cases of patients who seek medical assistance when their hemoglobin levels had fallen beneath 3 g/dl have been reported in the literature. Here, we describe the case of a 97-year-old patient who was transferred to the emergency department with dyspnea and the initial screening tests showed a hemoglobin level of 1.7 g/dl, due to iron deficiency. The patient was hemodynamically stable, and no ischemic lesions were seen on the electrocardiogram. His dyspnea was due to a lower respiratory tract infection and bilateral pleural effusion. He was bedridden for two years. His absence of physical activity in combination with the slow onset of anemia and the absence of severe underlying pulmonary and cardiovascular diseases could hide the symptoms until additional stressful events, such as the respiratory tract infection and the deterioration of heart function, occurred. So, we must keep in mind that in elderly patients with reduced physical activity and without severe pulmonary and cardiovascular comorbidities, the symptoms of severe anemia may go unnoticed until hemoglobin reaches life-threatening levels.

Factors Associated With Mortality in Elderly Hospitalized Patients at Admission.

Background Several factors have been associated with mortality prediction among older inpatients. The objective of this study was to assess the factors associated with mortality in hospitalized elderly patients. Methods A total of 353 consecutively admitted elderly patients (47.9% women), with a median age of 83 years (interquartile range 75.00-88.00), were enrolled in the study and patient characteristics were recorded. Comorbidities were assessed using Charlson Comorbidity Index (CCI), activities of daily living by Barthel Index (BI), frailty was assessed using the Clinical Frailty Scale (CFS), cognition by Global Deterioration Scale (GDS) and symptom severity at admission by quick Sequential Organ Function Assessment (qSOFA) score. CFS, GDS and BI were estimated for the premorbid patients' status. Parametric and non-parametric tests and binary logistic regression analysis were applied to identify the factors associated with mortality. A receiver operating characteristic (ROC) curve was used to analyse the prognostic value of CFS and qSOFA. Results In total, 55 patients (15.6%) died during hospitalization. In regression analysis, the factors associated with mortality were the qSOFA score at admission (p=0.001, odds ratio [OR]=1.895, 95% confidence interval [CI] 1.282-2.802) and the premorbid CFS score (p=0.001, OR=1.549, 95% CI 1.1204-1.994). The classifiers both have almost similar area under the curve (AUC) scores, with CFS performing slightly better. More specifically, both CFS (AUC 0.79, 95% CI 0.73-0.85, p=0.001) and qSOFA (AUC 0.75, 95% CI 0.67-0.83, p<0.001) showed almost the same accuracy for predicting inpatients' mortality. Conclusion This study strengthens the perception of premorbid frailty and disease severity at admission as factors closely related to mortality in hospitalized elderly patients. Simple measures such as CFS and qSOFA score may help identify, in the emergency department, elderly patients at risk, in order to provide timely interventions.

Posterior Mitral Valve Annulus Vegetation in the Presence of Mitral Annulus Calcification: A Case Report.

The evaluation of patients who present at the emergency department with fever and a history of cardiac valve replacement should be thorough, and the possibility of endocarditis must be high in the differential diagnosis. The modified Duke's criteria are recommended for the diagnosis of endocarditis, and the role of positron emission tomography-computed tomography (PET-CT) scan is highlighted in the presence of bioprosthetic valves among the recent guidelines. Here, we describe a challenging case of endocarditis in a patient with severe mitral annulus calcification and bioprosthetic aortic valve replacement. Transesophageal echocardiography revealed an echogenic mass on the posterior mitral annulus, which was confirmed to be a vegetation on the PET-CT scan. Despite adequate antibiotic therapy and no indication for emergency cardiac surgery, in the fourth week of treatment, an embolic event in the ophthalmic artery occurred, and the patient was admitted for surgery. Intraoperatively, the presence of vegetation was confirmed. Because severe mitral annulus calcification may act as a nidus for infective endocarditis, special attention must be paid to these patients. Additional studies are required in patients with residual vegetation at the end of antibiotic treatment, especially if they have increased dimensions, to accurately formulate the optimal management plan.

Validation of the revised 9-scale clinical frailty scale (CFS) in Greek language.

BACKGROUND: Among many screening tools that have been developed to detect frailty in older adults, Clinical Frailty Scale (CFS) is a valid, reliable and easy-to-use tool that has been translated in several languages. The aim of this study was to develop a valid and reliable version of the CFS to the Greek language. METHODS: A Greek version was obtained by translation (English to Greek) and back translation (Greek to English). The "known-group" construct validity of the CFS was determined by using test for trends. Criterion concurrent validity was assessed by evaluating the extent that CFS relates to Barthel Index, using Pearson's correlation coefficient. Both inter-rater and test-retest reliability were assessed using intraclass correlation coefficient. RESULTS: Known groups comparison supports the construct validity of the CFS. The strong negative correlation between CFS and Barthel Index (rs = - 0,725, p ≤ 0.001), supports the criterion concurrent validity of the instrument. The intraclass correlation was good for both inter-rater (0.87, 95%CI: 0.82-0.90) and test-retest reliability (0.89: 95%CI: 0.85-0.92). CONCLUSION: The Greek version of the CFS is a valid and reliable instrument for the identification of frailty in the Greek population.