Identification of Mortality Risks in the Advancement of Old Age: Application of Proportional Hazard Models Based on the Stepwise Variable Selection and the Bayesian Model Averaging Approach.

Identifying factors that affect mortality requires a robust statistical approach. This study's objective is to assess an optimal set of variables that are independently associated with the mortality risk of 433 older comorbid adults that have been discharged from the geriatric ward. We used both the stepwise backward variable selection and the iterative Bayesian model averaging (BMA) approaches to the Cox proportional hazards models. Potential predictors of the mortality rate were based on a broad range of clinical data; functional and laboratory tests, including geriatric nutritional risk index (GNRI); lymphocyte count; vitamin D, and the age-weighted Charlson comorbidity index. The results of the multivariable analysis identified seven explanatory variables that are independently associated with the length of survival. The mortality rate was higher in males than in females; it increased with the comorbidity level and C-reactive proteins plasma level but was negatively affected by a person's mobility, GNRI and lymphocyte count, as well as the vitamin D plasma level.

Prevalent medication-related harm identified in patients admitted to a geriatric ward: cross-sectional and survival based contributors.

INTRODUCTION: Medication­related harm (MRH) has been recognized as a global public health issue. OBJECTIVES: This study aimed to assess the prevalence and causes of MRH in geriatric patients. Another objective of the study was to recognize how MRH and drugs prescribed after geriatric interventions affect survival. PATIENTS AND METHODS: It was a cross­sectional study of 301 geriatric patients admitted to the hospital for any cause, combined with a 2­year survival analysis. Altogether, 71 drug items were included. Medication­related harm was defined based on clinical reasoning. Logistic regression models were applied to identify the explanatory variables for each type of MRH. The Cox proportional hazards model was used to determine the association of MRH and postdischarge medications with patient survival. RESULTS: Medication­related harms were identified in 35.2% of the study patients. Those included, among others, hypotension (19.3%), hypoglycemia (13.3%), parkinsonism (4.3%), and benzodiazepine addiction (5.7%). Logistic regression, applied to estimate the impact of drugs before admission on MRH of any type, demonstrated an independent negative effect of typical neuroleptics, antidiabetic medication, benzodiazepines, and supplements, except vitamin D. After geriatric interventions, 4 drug classes showed a positive association with survival: thiazides (hazard ratio [HR], 0.45; 95% CI, 0.22-0.93), selective serotonin reuptake inhibitors (SSRIs; HR, 0.51; 95% CI, 0.34-0.75), paracetamol (HR, 0.54; 95% CI, 0.33-0.88), and angiotensin­converting enzyme inhibitors (ACEIs; HR, 0.59; 95% CI, 0.4-0.89). CONCLUSIONS: Geriatric-based deprescribing and drug optimization mitigate the negative impacts of MRH on patient survival and may decrease the rehospitalization rate and healthcare costs. Thiazides, ACEIs, SSRIs, and paracetamol, if indicated, were associated with better survival in geriatric patients.

Cognitive Functioning of Geriatric Patients: Is Hypovitaminosis D the Next Marker of Cognitive Dysfunction and Dementia?

The study objective is to investigate whether vitamin D is associated with the cognitive function of geriatric patients. This cross-sectional study involved 357 patients hospitalized in the geriatric ward who complained of memory problems (mean age: 82.3 years). The level of cognitive function was measured with the Mini-Mental State Examination (MMSE) and the clinical diagnosis of dementia was established according to the International Classification of Diseases (ICD-10) criteria. The serum 25-hydroxy vitamin D was measured with liquid chromatography-tandem mass spectrometry. The iterative Bayesian model averaging (BMA) procedure was applied to linear and logistic regression models in order to identify the best set of factors describing cognitive dysfunction and dementia, respectively. According to BMA, there is strong evidence that higher vitamin D levels, higher body mass index (BMI), and higher mobility function measured with the Timed Up and Go (TUG) test are independently associated with better cognitive performance and lower risk of dementia. Additionally, there is strong evidence that fewer years of education and lower vitamin B12 plasma levels independently describe worse cognitive performance. However, vitamin B12 levels higher than 800 pg/mL is negatively associated with the MMSE performance. Hypovitaminosis D in geriatric patients is an underrated marker of cognitive dysfunction and dementia.

For better or worse: Factors predicting outcomes of family care of older people over a one-year period. A six-country European study.

OBJECTIVES: Demographic change has led to an increase of older people in need of long-term care in nearly all European countries. Informal carers primarily provide the care and support needed by dependent people. The supply and willingness of individuals to act as carers are critical to sustain informal care resources as part of the home health care provision. This paper describes a longitudinal study of informal care in six European countries and reports analyses that determine those factors predicting the outcomes of family care over a one-year period. METHODS: Analyses are based on data from the EUROFAMCARE project, a longitudinal survey study of family carers of older people with baseline data collection in 2004 and follow-up data collection a year later in six European countries (Germany, Greece, Italy, Poland, Sweden, and the United Kingdom), N = 3,348. Descriptive statistics of the sample characteristics are reported. Binary logistic random-intercept regressions were computed, predicting the outcome of change of the care dyad's status at follow-up. RESULTS: Where care is provided by a more distant family member or by a friend or neighbour, the care-recipient is significantly more likely to be cared for by someone else (OR 1.62) or to be in residential care (OR 3.37) after one year. The same holds true if the care-recipient has memory problems with a dementia diagnosis (OR 1.79/OR 1.84). Higher dependency (OR 1.22) and behavioural problems (OR 1.76) in the care-recipient also lead to a change of care dyad status. Country of residence explained a relatively small amount of variance (8%) in whether a care-recipient was cared for by someone else after one year, but explained a substantial amount of variance (52%) in whether a care-recipient was in residential care. Particularly in Sweden, care-recipients are much more likely to be cared for by another family or professional carer or to be in residential care, whereas in Greece the status of the care dyad is much less likely to change. DISCUSSION: The majority of family carers continued to provide care to their respective older relatives over a one-year period, despite often high levels of functional, cognitive and behavioural problems in the care-recipient. Those family carers could benefit most from appropriate support. The carer/care-recipient relationship plays an important role in whether or not a family care dyad remains intact over a one-year period. The support of health and social care services should be particularly targeted toward those care dyads where there is no partner or spouse acting as carer, or no extended family network that might absorb the caring role when required. Distant relatives, friends or acquaintances who are acting as carers might need substantial intervention if their caregiving role is to be maintained.

Prescribing or deprescribing in older persons: what are the real­life concerns in geriatric practice?

INTRODUCTION    Multimorbidity in older adults leads to polypharmacy with all its hazardous outcomes and drug­related problems. OBJECTIVES    We aimed to assess the difference in the number of drugs between admission to and discharge from a geriatric ward and identified the patient­related factors associated with changes in the drug regimen. PATIENTS AND METHODS    This retrospective cross­sectional study included 301 geriatric patients who underwent drug optimization in line with the Beers and STOPP/START criteria. The numbers of drugs per individual at hospital admission and discharge were compared using the Wilcoxon signed­rank test. A multiple linear regression model was used to identify patient characteristics that influenced the observed difference in the number of drugs following geriatric hospitalization. RESULTS    A significant reduction of 1.29 in the number of drugs per patient, on average, was observed. The Spearman's correlation coefficient between the number of prescribed medications and the number of coexisting conditions per individual changed from 0.28 to 0.51. The patient­related characteristics that jointly and independently explained (P <0.001) the difference in the number of drugs in the multiple regression model (R2 = 0.73) were the number of drugs on admission, number of coexisting conditions, age, fact of living alone, and the incidence of adverse drug reactions. CONCLUSIONS    Geriatric hospitalization results in deprescribing rather than prescribing medications, especially in individuals who were overtreated, older, undernourished, at risk of an adverse drug reaction, and living alone. Appropriate deprescribing may potentially lead to fewer drug­related problems in the senior population as well as reduce health care costs.

Silent strain of caregiving: exploring the best predictors of distress in family carers of geriatric patients.

OBJECTIVES: The aim of this article was to identify the best predictors of distress suffered by family carers (FCs) of geriatric patients. METHODS: A cross-sectional study of 100 FC-geriatric patient dyads was conducted. The negative impact of care (NIoC) subscale of the COPE index was dichotomized to identify lower stress (score of ≤15 on the scale) and higher stress (score of ≥16 on the scale) exerted on FCs by the process of providing care. The set of explanatory variables comprised a wide range of sociodemographic and care-related attributes, including patient-related results from comprehensive geriatric assessments and disease profiles. The best combination of explanatory variables that provided the highest predictive power for distress among FCs in the multiple logistic regression (LR) model was determined according to statistical information criteria. The statistical robustness of the observed relationships and the discriminative power of the model were verified with the cross-validation method. RESULTS: The mean age of FCs was 57.2 (±10.6) years, whereas that of geriatric patients was 81.7 (±6.4) years. Despite the broad initial set of potential explanatory variables, only five predictors were jointly selected for the best statistical model. A higher level of distress was independently predicted by lower self-evaluation of health; worse self-appraisal of coping well as a caregiver; lower sense of general support; more hours of care per week; and the motor retardation of the cared-for person measured with the speed of the Timed Up and Go (TUG) test. CONCLUSION: Worse performance on the TUG test was only the patient-related predictor of distress among the variables examined as contributors to the higher NIoC. Enhancing the mobility of geriatric patients through suitably tailored kinesitherapeutic methods during their hospital stay may mitigate the burden endured by FCs.

Objective drivers of subjective well-being in geriatric inpatients: mobility function and level of education are general predictors of self-evaluated health, feeling of loneliness, and severity of depression symptoms.

PURPOSE: Identification of optimal predictors for different indicators of subjective well-being (SWB) in geriatric inpatients: (1) self-evaluated health status (SEH), (2) feeling of loneliness (FoL), and (3) severity of depression symptoms (SoDS). Investigation of the relationship between response categories of the SWB indicators and their predictors. METHODS: The data were collected retrospectively from hospital records. All 555 geriatric inpatients underwent a comprehensive geriatric assessment, including the Timed Up and Go (TUG) test. The Bayesian information criterion was applied in ordinal logistic regression models to identify optimal predictors of SEH, FoL, and SoDS among different objective factors. RESULTS: After controlling for high-stress situations in the recent past, motor slowness measured with the TUG test, and a level of education were jointly selected as the best predictors of all three SWB indicators. The speed of performing the TUG test improved SEH (OR = 2.08) and decreased both FoL (OR = 0.41) and SoDS (OR = 0.41). A higher level of education improved SEH (OR = 1.05) and alleviated both FoL (OR = 0.96) and SoDS (OR = 0.92). Additionally, a higher level of SEH was positively correlated with a lower BMI, improved instrumental activities of daily living (I-ADL), and higher hemoglobin level. FoL was reinforced by the level of comorbidity, and SoDS was increased by impaired basic ADL. CONCLUSION: Although SWB in geriatric inpatients can be explained by objective comorbidities and disabilities, the good motor function (i.e., a TUG test outcome of less than about 20 s) and a higher level of education were the general predictors that exert an independent beneficial impact on all three SWB indicators.

[Expert's opinion on recommendations for water and other beverages consumption in elderly?]. / Stanowisko Grupy Ekspertów w sprawie zalecen dotyczacych spozycia wody i innych napojów przez osoby w wieku podeszlym.

The article encloses definition of water role and its body requirement, review of water balance and management in older persons regarding characteristic of this age group and concomitant disorders. Based on current literature and expert's opinion the recommendations for water consumption were expressed with estimation of insufficient apply and oversupply, evaluation of hydration state, domestic water sources in diet with accent on influence of proper hydration on comfort and good health.

Disabled older people's use of health and social care services and their unmet care needs in six European countries.

BACKGROUND: The national health and social care systems in Europe remain poorly integrated with regard to the care needs of older persons. The present study examined the range of health and social care services used by older people and their unmet care needs, across six European countries. METHODS: Family carers of older people were recruited in six countries via a standard protocol. Those providing care for disabled older people (n = 2629) provided data on the older person's service use over a 6-month period, and their current unmet care needs. An inventory of 21 services common to all six countries was developed. Analyses considered the relationship between older people's service use and unmet care needs across countries. RESULTS: Older people in Greece, Italy and Poland used mostly health-oriented services, used fewer services overall and also demonstrated a higher level of unmet care needs when compared with the other countries. Older people in the United Kingdom, Germany and Sweden used a more balanced profile of socio-medical services. A negative relationship was found between the number of different services used and the number of different areas of unmet care needs across countries. CONCLUSIONS: Unmet care needs in older people are particularly high in European countries where social service use is low, and where there is a lack of balance in the use of health and social care services. An expansion of social care services in these countries might be the most effective strategy for reducing unmet needs in disabled older people.

Components of the difficulties, satisfactions and management strategies of carers of older people: a principal component analysis of CADI-CASI-CAMI.

OBJECTIVES: To perform a psychometric evaluation of the Carers Assessment of Difficulties Index, Carers Assessment of Satisfactions Index and the Carers Assessment of Managing Index (CADI-CASI-CAMI). METHOD: Data was collected in three European countries from informal carers of older people (n = 295) via a common protocol. Carers completed: (a) a questionnaire containing items on demographics and caregiving characteristics and (b) the CADI-CASI-CAMI indices. Principal component analysis of the CADI-CASI-CAMI indices was followed by internal consistency analysis of emergent components. Scales derived by summing items loading on the components were analysed for their association with the demographic and caregiving characteristic variables. RESULTS: CADI produced six internally consistent and interpretable components, CASI five and CAMI seven. Subscales derived from the components were significantly associated with the demographic and caregiving characteristic variables, providing initial support for construct validity. CONCLUSION: The CADI-CASI-CAMI indices are recommended as an assessment tool for in-depth work with family carers of older people and as a research tool for large-scale studies of family care.

Negative impact and positive value in caregiving: validation of the COPE index in a six-country sample of carers.

PURPOSE: The present study attempts to further validate the COPE Index on a large sample of carers drawn from six European countries. DESIGN AND METHODS: We used a cross-sectional survey, with approximately 1,000 carers recruited in each of six countries by means of a common standard evaluation protocol. Our saturation recruitment of a designated quota of carers occurred by means of several channels, in identified geographical zones within countries. Interviews were carried out with primary informal carers by use of a common assessment tool. We subjected items of the COPE Index to principal component analysis and we assessed emergent components through the use of Cronbach's alpha reliability procedures. We examined factor components as summative scales for confirmatory correlations with caregiving and psychological variables. RESULTS: Three components emerged, which we identified as the negative impact of caregiving, the positive value of caregiving, and the quality of support for caregiving. Internal consistency was good for negative impact and satisfactory for positive value and quality of support. Negative value was most consistently and strongly correlated with caregiving and psychological variables, although we did find diverse associations between these variables and the COPE Index subscales. IMPLICATIONS: The COPE Index is a brief, first-stage assessment of some sophistication that can enable health and social care professionals to develop appropriately targeted interventions to enhance the positive aspects of the caregiving experience and quality of support, as well as reduce the negative impacts of caregiving.

Rural and urban caregivers for older adults in Poland: perceptions of positive and negative impact of caregiving.

This study examines rural-urban differences in informal caregivers' perceptions of caregiving. The study's theoretical framework is based on the two-factor model of caregiving, which views caregiving as having both positive and negative impact. Data were collected in personal interviews with 126 rural and 127 urban caregivers in the Bialystok region. The COPE-Index was used to assess caregivers. Rural caregivers reported a greater negative impact of caregiving than their urban counterparts, controlling for caregiver socio-demographic characteristics and care-recipient disability level. There was no difference in caregivers' perceptions of positive aspects of caregiving. These findings are consistent with previous research, which suggests that rural caregivers experience greater caregiver burden. Better understanding of rural-urban differences in caregiving outcomes can be useful in designing supportive services for informal caregivers in Poland.

[Health-related quality of life in the elderly after coronary artery bypass grafting]. / Zdrowotne wykladniki jakosci zycia osób starszych po zabiegach pomostowania tetnic wiencowych.

Despite of higher operative risk in the elderly, coronary artery bypass grafting (CABG) is more often performed in this age group to achieve the remission of the disease and to improve the quality of life. The aim of the study was to assess some subjective and objective health indices in the elderly two years after CABG (I group) in comparison to analogous group of older patients just waiting for CABG (II group). 109 patients aged 65 years and older, consecutively discharged from the Cardiac Surgery Department 2 years ago, were analyzed as well as 60 patients currently waiting for such surgery. Both groups of patients did not differ with demographic features. The health related quality of life was measured with the EASYCare questionnaire and similar one of own construction supplemented with some items of the WHOQol-BREF scale. Two years after CABG, 100 patients were available for the study (six persons died and three persons refused). Response rate was 92%. Significant reduction of symptoms of the coronary artery disease were shown. The chest pain was declared in 18% in I group vs 70% in II group; palpitation in 23% in I group vs 38% in II group and effort angina in 38% in I group vs 65% in II group. The positive evaluation of the health status was declared significantly more often in the patients of I group in comparison to patients in II group. CABG caused positive change concerning health-related quality of life in the elderly two years after surgery.

[Health care services for the elderly living in the rural area of Poland]. / Opieka zdrowotna nad ludzmi starymi na wsi.

UNLABELLED: The aim of the paper was the indepth comparison of the health services use by the elderly living in rural and urban area of Poland. The representative survey of the 65-year old and older people was carried out in the year 2000, as a comparative study to the Piotrowski's survey from 1967. The sample (total N = 1821; consisted of 743 people living in rural and 1078 in urban area), was corresponding to the demographic structure of the general older population in Poland. RESULTS: As far as concerning socio-demographic features there were found slightly higher percentage of 'old old' people in rural community, their much worse living conditions and material situation in comparison to counterparts in urban community. The elderly living in the countryside have shown the worse subjective and objective health and functional indices. The positive selfrated health was found only in 12% of respondents living in rural and in 22% living in urban area. 71% people living in villages declared three or more complaints simultaneously while in the cities much less (57%). Moreover, the impairment of vision, hearing, chewing were found significantly more frequently among rural inhabitants, as well as almost twice higher percentages of dependence on P-ADL. The use of health services by the elderly during the last 12 months, in term of doctor's outpatient consultations, dentist visits rehabilitation, except of nurse visits, was significantly lower in countryside than in the cities. Use of an emergency (17%) and hospital stays (22%) was the same in the both sites. CONCLUSIONS: (1) Health status and functional ability of the older people living in rural area are dramatically worse than in cities. (2) Health care system for elderly people in Poland does not fulfill the geriatric standards in term of the commonness, availability and complexity. (3) The chance to improve health care on the elderly is an enhancement of knowledge and competence of practitioners in gerontology. The development of the geriatric base in the Medical Universities is a crucial for that.

[The spreading of big geriatric centers in the community dwelling elderly: the challenge for the primary health care]. / Rozpowszechnienie wielkich zespolów geriatrycznych w populacji osób w póznej starosci--wyzwanie dla podstawowej opieki zdrowotnej.

As the giants of geriatrics are considered: immobility, instability, incontinence, intellectual impairment, depression, visual and auditory impairment. They have multiple causation, chronic course, no simple cure and make the elderly person dependent on others for care. The paper presents the results of the study on the prevalence of the giants of geriatrics in community dwelling elderly people 75 yers old +. The study design: cross-sectional questionnaire study, survey. Population studied lived in two chosen areas (the urban and the rural one) with the high percentages of the demographic senility. The interviewers were doctors and nurses serving the studied areas. 463 randomly selected elderly people (233 from the rural and 230 from the urban area) took part in the study. The serious locomotive disability (III/IV group according to J. Piotrowski) was observed in 17.1% of the probands (20.4% in the urban and 13.7% in the rural area; the worse locomotive ability was observed in women and in the older age groups.). Falls were reported by 45.1% of the group (more frequently by women and in the rural area--58.3% vs. 31.9% in the city). Visual impairment reported 21.1% of probands in the urban area and above 50% in rural one and auditory impairment respectively 30.8% and 53.9% of them (in both cases positive correlation with the age was noticed). Incontinence of urine was found in 31.7% of cases in the city and in 46% of them in the rural area (more frequently in women) and incontinence of faeces in 6% (without urban/rural differences). The pathologic result of the Geriatric Depression Scale was observed in 49.2% of the elderly (more frequently in women) and of the Cognitive Impairment Test by Katzman in 20.5% (more frequently in women and in the older age groups). Only 18.4% of the studied group of the elderly maintained the community nurse visited their home during the last 12 months (27.8% in the city and 9% in the rural area) and more frequently--34.3%--general practitioner (respectively 48.7% and 20.2%). The marginal percentage of the elderly (and only in the city) received any kind of physical rehabilitation or contacted the social worker. In the presence of high rate of disability in the elderly population the most important need is the development of community care for the elderly with the great emphasis on the role of community/home nurses and rehabilitation institutions for the elderly on the primary care level.

[Coronary artery bypass grafting in the elderly: early results]. / Pomostowanie tetnic wiencowych u chorych w wieku starszym--wczesne wyniki leczenia operacyjnego.

Indications for CABG (coronary artery bypass grafting) procedures are on the rise with ageing population. Because in the world literature there is not consensus on the elderly patients operative risk estimation we have conducted a retrospective analysis of 300 consecutive patients treated at Cardiac Surgery Department of Bialystok University Centre. The postoperative mortality and morbidity rates were assessed in an each case. 103 patients over 65 and 197 younger patients were included to the study. An operative risk was assessed according to EuroSCORE protocol and was higher in the elderly group. Strangely enough, this was not accompanied by higher mortality and morbidity rates, which were rather similar in the two groups. A female gender and an inclination to gastrointestinal bleeding were the independent risk factors in the elderly group. Probably diabetes mellitus is to be held for the higher mortality rate amongst them. In conclusion, the results of the presented investigation suggest that a biological and not a chronological age is essential in the qualification for CABG procedures.

[Hypertension in the advanced old aged: prevalence and treatment in comparative urban and rural survey]. / Nadcisnienie tetnicze w póznej starosci: czestosc wystepowania, problemy terapii--porównawcze badania srodowiska miejskiego i wiejskiego.

UNLABELLED: Hypertension is a serious medical, social and economical problem. It is accepted that high blood pressure is one of the major risk factors of all kinds of cardiovascular diseases. The aim of the study was to estimate the prevalence of hypertension and evaluate the difficulties with antihypertensive treatment in the rural and urban community dwelling elderly in advanced old age. The survey was carried out, as a screening, in systematically sampled 463 people 75 years old and over, coming from area served by primary health units (230 in urban area--Bialystok and 233 in rural area--Sokólka). Estimation of blood pressure (single measure) and medical anamnesis concerning earlier diagnoses and pharmacological treatment was made in proband's home by general practitioner or community nurse. The diagnosis of hypertension was established according to the WHO-ISN criteria. RESULTS: In general 49.1% of the elderly in urban and 70.4% in rural area had elevated systolic or/and diastolic blood pressure independently on antihypertensive medication; significantly more frequent in female than in male. 32% of the elderly in urban and 22% in rural area had normal blood pressure without antihypertensive treatment ("healthy"), whereas respectively 19% and 7% had normal blood pressure with antihypertensive treatment. 21% of persons in Bialystok city and 38% in Sokólka had elevated high arterial pressure and hadn't any antihypertensive treatment. The results of the study confirm the high prevalence of hypertension in elderly population, higher in rural than urban area. Therapy of hypertension in studied group was ineffective in most of the hypertensive patients, mainly in neglected rural area. The differences between urban and rural samples can be partly explained by socio-demografic characteristic of the two studied population.

[Determinants of dementia in the advanced old age elderly]. / Uwarunkowania otepienia w populacji osób w póznej starosci.

The development of civilization and progress in medicine made the prolongation of the life span and increased share of the advanced old age people in the population. The consequence of this process is growth in frequency of diseases related to age including dementia. However diagnosis of cognitive impairment is still difficult and it makes some problems in an everyday medical practice. The aim of this report is to define main and significant determinants of dementia basing on the MMSE scale. This could make it easier to suspect the cognitive disorders to make indepth diagnosis and to start earlier therapy. The sample consisted of 124 community dwelling persons 75-year old and over. 64 of them were mildly, moderately or severely demented according to Katzman scale administered previously and 60 were intellectually intact. The both groups of persons were tested with MMSE. Geriatric Depression Scale, ADL scale (EASY-Care questionnaire) and short internal and neurological examination. The multiple regression model were used, where dependent variable was the MMSE score and independent variables social-demographic data, ADL and GSD scales and data from interview and medical examination. 72 variables were included to the model and 39 of them were significantly connected with cognitive impairment. The valid factors explained dementia in 78.7% (adjusted R2 = 0.787). The strongest connection was found with (1) an ignorance of own date of birth, (2) low education level, (3) behaviour disorders and (4) an advanced old age. These determinants, including difficulties with handling own money, have explained dementia in 57%. The presence such symptoms could make easier to suspect the cognitive disorders, to make in-depth diagnosis, and to start earlier therapy.