Proof-of-concept for an automatable mortality prediction scoring in hospitalised older adults.

Introduction: It is challenging to prognosticate hospitalised older adults. Delayed recognition of end-of-life leads to failure in delivering appropriate palliative care and increases healthcare utilisation. Most mortality prediction tools specific for older adults require additional manual input, resulting in poor uptake. By leveraging on electronic health records, we aim to create an automatable mortality prediction tool for hospitalised older adults. Methods: We retrospectively reviewed electronic records of general medicine patients ≥75 years at a tertiary hospital between April-September 2021. Demographics, comorbidities, ICD-codes, age-adjusted Charlson Comorbidity Index (CCI), Hospital Frailty Risk Score, mortality and resource utilization were collected. We defined early deaths, late deaths and survivors as patients who died within 30 days, 1 year, and lived beyond 1 year of admission, respectively. Multivariate logistic regression analyses were adjusted for age, gender, race, frailty, and CCI. The final prediction model was created using a stepwise logistic regression. Results: Of 1,224 patients, 168 (13.7%) died early and 370 (30.2%) died late. From adjusted multivariate regression, risk of early death was significantly associated with ≥85 years, intermediate or high frail risk, CCI > 6, cardiovascular risk factors, AMI and pneumonia. For late death, risk factors included ≥85 years, intermediate frail risk, CCI >6, delirium, diabetes, AMI and pneumonia. Our mortality prediction tool which scores 1 point each for age, pneumonia and AMI had an AUC of 0.752 for early death and 0.691 for late death. Conclusion: Our mortality prediction model is a proof-of-concept demonstrating the potential for automated medical alerts to guide physicians towards personalised care for hospitalised older adults.

Reproductive factors and risk of physical frailty among Chinese women living in Singapore.

SETTING: Although age at menopause has been linked to higher risk of physical frailty in later life, little is known about other reproductive factors. OBJECTIVES: Our study aimed to investigate the associations between 1) age at menarche, 2) age at natural menopause, 3) duration of reproductive period, 4) number of children, 5) use of oral contraceptives (OCP), and 6) use of hormone replacement therapy (HRT) with the risk of physical frailty in late life. DESIGN: We used data from 5934 women of the Singapore Chinese Health Study who experienced natural menopause, and participated in the third follow-up interviews when physical frailty was assessed. Logistic regression was used to evaluate association of reproductive factors evaluated during baseline and prior follow-up interviews with physical frailty at follow-up 3. PARTICIPANTS: Community-dwelling Chinese women living in Singapore. Participants had a mean age of 52.6 years at baseline (1993-1998), and a mean age of 72.8 years during the third follow-up (2014-2017). MEASUREMENTS: Sociodemographic characteristics, level of education, smoking history, physical activity, and history of physician-diagnosed comorbidities were collected. Participants' weight and height were self-reported. We used a modified Cardiovascular Health Study phenotype to assess physical frailty. RESULTS: Age at menarche was inversely associated with the likelihood of physical frailty (Ptrend = 0.001); each one-year decrease in age at menarche was associated with a 9% increase (95% CI: 4%-14%) in odds of physical frailty. Age at menopause was also inversely associated with the likelihood of physical frailty (Ptrend = 0.009); every one-year decrease in age at menopause was associated with 2% (0%-4%) increased odds. In the assessment of frailty, younger ages at menarche and menopause were associated with greater likelihood of being in the slowest quintile for timed up-and-go and weakest quintile for handgrip strength. Conversely, duration of reproductive period, parity, and use of oral contraceptives or hormone replacement therapy were not significantly associated with the likelihood of physical frailty. CONCLUSIONS: In our population-based cohort of Chinese women, younger ages at menarche and menopause were associated with higher likelihood of physical frailty in later life.

Relative deficiency in interferon-γ-secreting CD4+ T cells is strongly associated with poorer COVID-19 vaccination responses in older adults.

Although the two-dose mRNA vaccination regime provides protection against SARS-CoV-2, older adults have been shown to exhibit poorer vaccination responses. In addition, the role of vaccine-induced T-cell responses is not well characterised. We aim to assess the impact of age on immune responses after two doses of the BNT162b2 mRNA vaccine, focussing on antigen-specific T-cells. A prospective 3-month study was conducted on 15 young (median age 31 years, interquartile range (IQR) 25-35 years) and 14 older adults (median age 72 years, IQR 70-73 years). We assessed functional, neutralising antibody responses against SARS-CoV-2 variants using ACE-2 inhibition assays, and changes in B and T-cell subsets by high-dimensional flow cytometry. Antigen-specific T-cell responses were also quantified by intracellular cytokine staining and flow cytometry. Older adults had attenuated T-helper (Th) response to vaccination, which was associated with weaker antibody responses and decreased SARS-CoV-2 neutralisation. Antigen-specific interferon-γ (IFNγ)-secreting CD4+ T-cells to wild-type and Omicron antigens increased in young adults, which was strongly positively correlated with their neutralising antibody responses. Conversely, this relationship was negative in older adults. Hence, older adults' relative IFNγ-secreting CD4+ T cell deficiency might explain their poorer COVID-19 vaccination responses. Further exploration into the aetiology is needed and would be integral in developing novel vaccination strategies and improving infection outcomes in older adults.

Group Model Building on causes and interventions for falls in Singapore: insights from a systems thinking approach.

BACKGROUND: Falls in older adults are the result of a complex web of interacting causes, that further results in other physical, emotional, and psychological sequelae. A conceptual framework that represents the reciprocal dynamics of these causal factors can enable clinicians, researchers, and policymakers to clarify goals in falls intervention in older adults. METHODS: A Group Model Building (GMB) exercise was conducted with researchers and clinicians from academic units and public healthcare institutes in Singapore. The aim of the exercise was to produce a shared visual representation of the causal structure for falls and engage in discussions on how current and future falls intervention programmes can address falls in the older adults, especially in the Asian context. It was conducted in four steps: 1) Outlining and prioritising desirable patient outcomes, 2) Conceptual model building, 3) Identifying key intervention elements of effective falls intervention programmes, 4) Mapping of interventions to outcomes. This causal loop diagram (CLD) was then used to generate insights into the current understanding of falls causal relationships, current efforts in falls intervention in Singapore, and used to identify gaps in falls research that could be further advanced in future intervention studies. RESULTS: Four patient outcomes were identified by the group as key in falls intervention: 1) Falls, 2) Injurious falls, 3) Fear of falling, and 4) Restricted mobility and life space. A CLD of the reciprocal relationships between risk factors and these outcomes are represented in four sub-models: 1) Fear of falling, 2) Injuries associated with falls, 3) Caregiver overprotectiveness, 4) Post-traumatic stress disorder and psychological resilience. Through this GMB exercise, the group gained the following insights: (1) Psychological sequelae of falls is an important falls intervention outcome. (2) The effects of family overprotectiveness, psychological resilience, and PTSD in exacerbating the consequences of falls are not well understood. (3) There is a need to develop multi-component falls interventions to address the multitude of falls and falls related sequelae. CONCLUSION: This work illustrates the potential of GMB to promote shared understanding of complex healthcare problems and to provide a roadmap for the development of more effective preventive actions.

Reducing Falls Among Community-Dwelling Older Adults From Clinicians' Perspectives: A Systems Modeling Approach.

Background and Objectives: Falls among older adults are a significant health problem globally. Studies of multicomponent fall prevention programs in randomized controlled trials demonstrate effectiveness in reducing falls; however, the translation of research into the community remains challenging. Although there is an increasing interest to understand the factors contributing to implementation barriers, the dynamic relationships between factors are less well examined. Furthermore, evidence on implementation barriers from Asia is lacking as most of these studies originate from the West. As such, this study aims to engage stakeholders in uncovering the factors that facilitate or inhibit implementing community-based fall prevention programs in Singapore, with a focus on the interrelationship between those factors. Research Design and Methods: Health care professionals familiar with fall prevention programs were invited to discuss the enablers and challenges to the implementation. This effort was facilitated using a systems modeling methodology of Group Model Building (GMB) to share ideas and create a common conceptual model of the challenges. The GMB employs various engagement techniques to draw on the experiences and perceptions of all stakeholders involved. Results: This process led to the development of a Causal Loop Diagram (CLD), a qualitative conceptual model of the dynamic relationships between the barriers and facilitators of implementing fall prevention programs. Results from the CLD show that implementation is influenced by two main drivers: health care provider factors that influenced referrals, and patient factors that influenced referral acceptance and long-term adherence. Key leverage points for potential interventions were identified as well. Discussion and Implications: The overall recommendation emphasized closer coordination and collaboration across providers to ensure sustainable and effective community-based fall prevention programs. This has to be supported by a national effort, involving a multidisciplinary stakeholder advisory group. These findings generated would be promising to guide future approaches to fall prevention.

Impact of exercise and leucine-enriched protein supplementation on physical function, body composition, and inflammation in pre-frail older adults: a quasi-experimental study.

Background: Exercise and a protein-enriched diet are essential for muscle protein synthesis, cellular growth, mitochondrial function, and immune function. The U.S. Food and Nutrition Board's current guideline on recommended dietary allowance for protein in older adults is 0.8 g/kg per day, which may not be sufficient in vulnerable pre-frail older adults. Aims: This study aimed to evaluate the impact of leucine-enriched protein supplementation with or without exercise over 3 months in pre-frail older adults who consumed ≤1 g/kg/day of protein on improving (i) physical function, (ii) body composition measures, and (iii) inflammatory biomarkers such as interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α). Methods: A non-randomized cluster quasi-experimental study guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist of 178 pre-frail older adults [112 control, 44 nutrition (Nu), and 22 in the nutrition with exercise (Nu+Ex) group] comparing the effect of Nu+Ex and Nu on physical function, body composition, and inflammation. At 0, 3, and 6 months, questionnaires on demographics, depression, perceived health, and cognition were administered. Physical function assessment (short physical performance battery [SPPB] test, gait speed, handgrip strength, 5× sit-to-stand [STS]) was conducted, and body composition analysis was performed using a bioelectrical impedance analysis machine. IL-6 and TNF-α were measured at 0 and 3 months. Results: At 3 months, there were significant improvements in gait speed, 5× STS, SPPB scores, depression, perceived health, fat-free mass, and appendicular skeletal muscle mass indices in the Nu+Ex group. Both Nu+Ex and Nu groups had improvements in body cell mass and reductions in IL-6 and TNF-α. The improvements were not sustained after 6 months. Conclusion: Our study results need to be validated in future longitudinal randomized studies with a larger sample size focusing on populations at risk.

Illness severity assessment of older adults in critical illness using machine learning (ELDER-ICU): an international multicentre study with subgroup bias evaluation.

BACKGROUND: Comorbidity, frailty, and decreased cognitive function lead to a higher risk of death in elderly patients (more than 65 years of age) during acute medical events. Early and accurate illness severity assessment can support appropriate decision making for clinicians caring for these patients. We aimed to develop ELDER-ICU, a machine learning model to assess the illness severity of older adults admitted to the intensive care unit (ICU) with cohort-specific calibration and evaluation for potential model bias. METHODS: In this retrospective, international multicentre study, the ELDER-ICU model was developed using data from 14 US hospitals, and validated in 171 hospitals from the USA and Netherlands. Data were extracted from the Medical Information Mart for Intensive Care database, electronic ICU Collaborative Research Database, and Amsterdam University Medical Centers Database. We used six categories of data as predictors, including demographics and comorbidities, physical frailty, laboratory tests, vital signs, treatments, and urine output. Patient data from the first day of ICU stay were used to predict in-hospital mortality. We used the eXtreme Gradient Boosting algorithm (XGBoost) to develop models and the SHapley Additive exPlanations method to explain model prediction. The trained model was calibrated before internal, external, and temporal validation. The final XGBoost model was compared against three other machine learning algorithms and five clinical scores. We performed subgroup analysis based on age, sex, and race. We assessed the discrimination and calibration of models using the area under receiver operating characteristic (AUROC) and standardised mortality ratio (SMR) with 95% CIs. FINDINGS: Using the development dataset (n=50 366) and predictive model building process, the XGBoost algorithm performed the best in all types of validations compared with other machine learning algorithms and clinical scores (internal validation with 5037 patients from 14 US hospitals, AUROC=0·866 [95% CI 0·851-0·880]; external validation in the US population with 20 541 patients from 169 hospitals, AUROC=0·838 [0·829-0·847]; external validation in European population with 2411 patients from one hospital, AUROC=0·833 [0·812-0·853]; temporal validation with 4311 patients from one hospital, AUROC=0·884 [0·869-0·897]). In the external validation set (US population), the median AUROCs of bias evaluations covering eight subgroups were above 0·81, and the overall SMR was 0·99 (0·96-1·03). The top ten risk predictors were the minimum Glasgow Coma Scale score, total urine output, average respiratory rate, mechanical ventilation use, best state of activity, Charlson Comorbidity Index score, geriatric nutritional risk index, code status, age, and maximum blood urea nitrogen. A simplified model containing only the top 20 features (ELDER-ICU-20) had similar predictive performance to the full model. INTERPRETATION: The ELDER-ICU model reliably predicts the risk of in-hospital mortality using routinely collected clinical features. The predictions could inform clinicians about patients who are at elevated risk of deterioration. Prospective validation of this model in clinical practice and a process for continuous performance monitoring and model recalibration are needed. FUNDING: National Institutes of Health, National Natural Science Foundation of China, National Special Health Science Program, Health Science and Technology Plan of Zhejiang Province, Fundamental Research Funds for the Central Universities, Drug Clinical Evaluate Research of Chinese Pharmaceutical Association, and National Key R&D Program of China.

Delirium is significantly associated with hospital frailty risk score derived from administrative data.

OBJECTIVES: Delirium is highly prevalent in hospitalised older adults, under-diagnosed and associated with poor outcomes. We aim to determine (i) association of frailty measured using Hospital Frailty Risk Score (HFRS) with delirium, (ii) impact of delirium on mortality, 30-days readmission, extended length of stay (eLOS) and cost (eCOST). METHODS: Retrospective cohort study was conducted on 902 older adults ≥75 years discharged from an academic tertiary hospital between March and September 2021. Data was obtained from hospital administrative database. RESULTS: Delirium was prevalent in 39.1%, 58.1% were female with mean age 85.3 ± 6.2 years. Patients with delirium were significantly older, had higher HFRS, pneumonia, urinary tract infection (UTI), E.coli and Klebsiella infection, constipation, dehydration, stroke and intracranial bleed, with comorbidities including dementia, diabetes, hypertension, hyperlipidaemia and chronic kidney disease. In-hospital mortality, 30-days mortality, 30-days readmission, median LOS and cost was significantly higher. Delirium was significantly associated with at least intermediate frailty (OR = 3.52; CI = 2.48-4.98), dementia (OR = 2.39; CI = 1.61-3.54), UTI (OR = 1.95; CI = 1.29-2.95), constipation (OR = 2.49; CI = 1.43-4.33), Klebsiella infection (OR = 3.06; CI = 1.28-7.30), dehydration (OR = 2.01; CI = 1.40 - 2.88), 30-day mortality (OR = 2.52; CI = 1.42-4.47), 30-day readmission (OR = 2.18; CI = 1.36-3.48), eLOS (OR = 1.80; CI = 1.30-2.49) and eCOST (OR = 1.67; CI = 1.20-2.35). CONCLUSIONS: Delirium was highly prevalent in older inpatients, and associated with dementia, frailty, increased cost, LOS, 30-day readmissions and mortality. Hospital Frailty Risk Score had robust association with delirium and can be auto-populated from electronic medical records. Prospective studies are needed on multicomponent delirium preventive measures in high-risk groups identified by HFRS in acute care settings.

Clinically Interpretable Machine Learning Models for Early Prediction of Mortality in Older Patients with Multiple Organ Dysfunction Syndrome: An International Multicenter Retrospective Study.

BACKGROUND: Multiple organ dysfunction syndrome (MODS) is associated with a high risk of mortality among older patients. Current severity scores are limited in their ability to assist clinicians with triage and management decisions. We aim to develop mortality prediction models for older patients with MODS admitted to the ICU. METHODS: The study analyzed older patients from 197 hospitals in the United States and 1 hospital in the Netherlands. The cohort was divided into the young-old (65-80 years) and old-old (≥80 years), which were separately used to develop and evaluate models including internal, external, and temporal validation. Demographic characteristics, comorbidities, vital signs, laboratory measurements, and treatments were used as predictors. We used the XGBoost algorithm to train models, and the SHapley Additive exPlanations (SHAP) method to interpret predictions. RESULTS: Thirty-four thousand four hundred and ninety-seven young-old (11.3% mortality) and 21 330 old-old (15.7% mortality) patients were analyzed. Discrimination AUROC of internal validation models in 9 046 U.S. patients was as follows: 0.87 and 0.82, respectively; discrimination of external validation models in 1 905 EUR patients was as follows: 0.86 and 0.85, respectively; and discrimination of temporal validation models in 8 690 U.S. patients: 0.85 and 0.78, respectively. These models outperformed standard clinical scores like Sequential Organ Failure Assessment and Acute Physiology Score III. The Glasgow Coma Scale, Charlson Comorbidity Index, and Code Status emerged as top predictors of mortality. CONCLUSIONS: Our models integrate data spanning physiologic and geriatric-relevant variables that outperform existing scores used in older adults with MODS, which represents a proof of concept of how machine learning can streamline data analysis for busy ICU clinicians to potentially optimize prognostication and decision making.

Percutaneous coronary intervention in patients aged 80 years old and above: a systematic review and meta-analysis.

Background: Ischaemic heart disease remains the main cause of death in the world. With increasing age, frailty and comorbidities, senior patients aged 80 years old and above who undergo percutaneous coronary intervention (PCI) are at higher risk of mortality and other complications. Aims: We aimed to examine the overall outcomes for this group of patients. Methods: Four databases (PUBMED, EMBASE, SCOPUS and CENTRAL) were searched. Studies with patients aged 80 years old and above who underwent PCI for all indications were included. Pooled outcomes of all-cause death, cardiac death, in-hospital death, subsequent stroke/transient ischaemic attack (TIA), subsequent myocardial infarction (MI), subsequent congestive cardiac failure (CCF), and overall major adverse cardiac events (MACE) were obtained for meta-analysis. Results: From 2,566,004 patients, the pooled cumulative incidence of death was 19.22%, cardiac death was 7.78%, in-hospital death was 7.16%, subsequent stroke/TIA was 1.54%, subsequent MI was 3.58%, subsequent CCF was 4.74%, and MACE was 17.51%. The mortality rate of all patients was high when followed up for 3 years (33.27%). ST-elevation myocardial infarction patients had more outcomes of in-hospital death (14.24% vs 4.89%), stroke/TIA (1.93% vs 0.12%), MI (3.68 vs 1.55%) and 1-year mortality (26.16% vs 13.62%), when compared to non-ST-elevation myocardial infarction patients. Conclusions: There was a high mortality rate at 1 year and 3 years post-PCI in the overall population of senior patients aged 80 years old and above, regardless of indication. This necessitates further studies to explore the implications of these observations.

The "Iron Tale"- iron indices and handgrip strength in community-dwelling adults.

Sarcopenia is a precursor for physical frailty and is associated with adverse outcomes. Low handgrip strength (HGS) is one of the diagnostic criteria for sarcopenia. Multiple factors can influence muscle quality, including muscle composition, architecture, fat infiltration, fibrosis, excessive iron deposition, and neural activation. There is limited evidence on the association of iron and HGS in community-dwelling older adults. We aim to examine the association of HGS with iron indices and inflammation. The Healthy Older People Everyday study is a subset of the Singapore Population Health Studies cohort. Complete cross-sectional data and iron indices were available for 477 participants. Sociodemographics, comorbidities, and final scores of the FRAIL scale, Barthel Index, Lawton Scale, HGS, and timed-up-and-go were collected and analyzed. Laboratory parameters including hemoglobin, hsCRP and iron indices were measured. The mean age of the participants was 70.9 ± 5.0 years, 258(54.1%) were females, and most were of Chinese(85.3%) ethnicity. Amongst the participants, 6.9% were frail, 39.4% were pre-frailt, and 53.7% were robust. Mean HGS was 22.2 ± 7.0 kg. Low HGS was prevalent in 47.8%, the highest amongst Indians. Prevalence of diabetes, chronic kidney disease, and ischaemic heart disease were significantly higher in those with low HGS. In multivariate regression adjusting for age, sex, comorbidities and Hb, ferritin (ß = 0.004 95%CI 0.0002-0.007, p = 0.04), transferrin saturation (ß = 0.06 95%CI 0.01-0.10, p = 0.02) and hsCRP (ß = - 0.15 95%CI - 0.26 to - 0.04, p < 0.01) were significantly associated with HGS. CRP was negatively associated with HGS, whereas ferritin and transferrin saturation were positively associated with HGS. Older people with iron deficiency should be assessed for sarcopenia, and vice versa, as both can occur in multisystemic disorder, and need to be managed concurrently. Prospective longitudinal studies and clinical trials may be required to establish the causal effect of iron deficiency on muscle strength and sarcopenia and the benefits of iron therapy to improve function and quality of life.

Outcomes of Care by Geriatricians and Non-geriatricians in an Academic Hospital.

Introduction: While hospitalist and internist inpatient care models dominate the landscape in many countries, geriatricians and internists are at the frontlines managing hospitalized older adults in countries such as Singapore and the United Kingdom. The primary aim of this study was to determine outcomes for older patients cared for by geriatricians compared with non-geriatrician-led care teams. Materials and Methods: A retrospective cohort study of 1,486 Internal Medicine patients aged ≥75 years admitted between April and September 2021 was conducted. They were either under geriatrician or non-geriatrician (internists or specialty physicians) care. Data on demographics, primary diagnosis, comorbidities, mortality, readmission rate, Hospital Frailty Risk Score (HFRS), Age-adjusted Charlson Comorbidity Index, Length of Stay (LOS), and cost of hospital stay were obtained from the hospital database and analyzed. Results: The mean age of patients was 84.0 ± 6.3 years, 860 (57.9%) females, 1,183 (79.6%) of Chinese ethnicity, and 902 (60.7%) under the care of geriatricians. Patients under geriatrician were significantly older and had a higher prevalence of frailty, dementia, and stroke, whereas patients under non-geriatrician had a higher prevalence of diabetes and hypertension. Delirium as the primary diagnosis was significantly higher among patients under geriatrician care. Geriatrician-led care model was associated with shorter LOS, lower cost, similar inpatient mortality, and 30-day readmission rates. LOS and cost were lower for patients under geriatrician care regardless of frailty status but significant only for low and intermediate frailty groups. Geriatrician-led care was associated with significantly lower extended hospital stay (OR 0.73; 95% CI 0.56-0.95) and extended cost (OR 0.69; 95% CI 0.54-0.95). Conclusion: Geriatrician-led care model showed shorter LOS, lower cost, and was associated with lower odds of extended LOS and cost.

The Acceptability of Digital Technology and Tele-Exercise in the Age of COVID-19: Cross-sectional Study.

BACKGROUND: With the COVID-19 pandemic, telehealth has been increasingly used to offset the negative outcomes of social isolation and functional decline in older adults. Crucial to the success of telehealth is end user adoption. OBJECTIVE: This study aims to investigate perception and acceptability of digital technology among Asian older adults. METHODS: The Healthy Ageing Promotion Program for You (HAPPY) dual-task exercise was conducted virtually to participants aged ≥60 years. Questionnaires were administered digitally and collected data on demographics, perceptions of digital technology and evaluation of HAPPY, the 6-item Lubben Social Network Scale, intrinsic capacity using the Integrated Care for Older People tool, and a functional screening with the FRAIL scale and five chair rises. Descriptive analysis was used. RESULTS: A total of 42 participants were digitally interviewed. The mean age was 69.1 (4.7) years. Hearing, vision, and 3-item recall difficulty were present in 14% (n=6), 12% (n=5), and 24% (n=10) of participants, respectively. Of the participants, 29% (n=12) had possible sarcopenia and 14% (n=6) were prefrail. Around 24% (n=10) were at risk of social isolation. Most of the participants (n=38, 91%) agreed that technology is good, and 79% (n=33) agreed that technology would allow them to be independent for longer. Over three-quarters of participants (n=33, 79%) agreed that they have the necessary knowledge, and 91% (n=38) had technological assistance available. However, 57% (n=24) were still apprehensive about using technology. Despite 71% (n=30) of older adults owning their devices, 36% (n=15) felt finances were limiting. Through digital HAPPY, 45% (n=19) of participants reported feeling stronger, 48% (n=20) had improved spirits, and 40% (n=17) and 38% (n=16) had improved mood and memory, respectively. CONCLUSIONS: The majority of older adults in this study believed in digital technology and had the necessary knowledge and help, but almost half still felt apprehensive and had financial barriers to adopting technology. A digitally administered exercise program especially in a group setting is a feasible option to enhance intrinsic capacity in older adults. However, more work is needed in elucidating sources of apprehension and financial barriers to adopting technology.

Patterns of improvement in functional ability and predictors of responders to dual-task exercise: A latent class analysis.

Background: Exercise is the pillar for healthy aging. "Non-responders" may be due to a mismatch in exercise prescription. A latent cluster analysis (LCA) profile can be useful to uncover subpopulations sharing similar profiles or outcomes. We aim to use the LCA to develop a response prediction model for older adults who would benefit from The Healthy Aging Promotion Program for You, a community-embedded dual-task exercise program. Methods: A total of 197 participants completed the 3-month follow-up, and the complete data were available for 136 community-dwelling older adults. Inclusion criteria were age ≥60 years, pre-frail or frail and ambulant, mild cognitive impairment, and ability to provide consent. Data collected include demographics, education, falls, physical function (Katz ADL scale and Lawton's IADL scale), physical activity (rapid assessment of physical activity), cognition (Montreal Cognitive Assessment; MoCA), frailty (FRAIL scale), and perceived health, pain, anxiety/depression, fear of falling, and social isolation (Lubben Social Network Scale). The body mass index (BMI), handgrip strength, and short physical performance battery (SPPB) were measured. Those who improved in frailty, anxiety/depression, pain, Lubben, MoCA, SPPB, fear-of-falling, physical activity, falls, and HGS were classified as responders. Results: The mean age was 74.7 years, BMI 23.5 kg/m2, 23.5% were male, 96.3% were of Chinese ethnicity, 61% were pre-frail, education level of 4.3 years, and the MoCA score of 23.3 ± 4.8. Two clusters were identified: non-responders (61.8%) and responders (38.2%). Responders had significant improvement in cognition (44.2% vs. 0, p < 0.001) and SPPB (gait:28.8% vs. 0, p < 0.001; balance:42.3% vs. 15.5%, p = 0.001; chair-stand:65.4% vs. 4.8%, p < 0.001). Responders were significantly older (76.9 vs. 73.3 years, p = 0.005), had higher BMI (24.8 vs. 22.8 kg/m2, p = 0.007), lower education (3.4 vs. 4.9 years, p = 0.021), lower MoCA scores (21.8 vs. 24.3, p = 0.002), and lower SPPB scores (8.7 vs. 10.6, p < 0.001). The predictive variables for the responder cluster were age ≥75 years, BMI ≥23 kg/m2, robust, no anxiety, pain, fear of falling, MoCA ≤22, Lubben ≤12, SPPB score: chair-stand ≤2, balance ≤2, gait >2, handgrip strength <20 kg, no falls and RAPA >3. With an optimal cut-off of ≥12, this prediction model had sensitivity of 76.9%, specificity of 70.2%, positive predictive value 61.5%, and negative predictive value of 83.1%. Conclusion: Response to dual-task exercise was influenced by age, SPPB, BMI, and cognition. Prospective longitudinal studies are needed to validate this LCA model and guide the development of public health strategies.

Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking.

Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.

The Case for Intermittent Carbapenem Dosing in Stable Haemodialysis Patients.

PURPOSE: Antimicrobial resistant infections are common in patients on haemodialysis, often needing long courses of carbapenems. This results in a longer hospital stay and risk of iatrogenic complications. However, carbapenems can be given intermittently to allow for earlier discharge. We aim to describe the clinical outcomes of intermittent versus daily meropenem in stable, intermittently haemodialysed patients. METHODS: In total, 103 records were examined retrospectively. Data collected include demographics, clinical interventions and outcomes such as hospital length of stay (LOS), 30-day readmission rates and adverse events. FINDINGS: Mean age 61.6 ± 14.2 years, 57.3% male. Most common bacteria cultured were Klebsiella pneumoniae (16.5%). The most common indication was pneumonia (27.2%). Mean duration of therapy on meropenem was 12.4 ± 14.4 days; eight patients needed more than 30 days of meropenem. In total, 55.3% did not have intervention for source control; 86.4% received daily dosing of meropenem; 7.8% patients received intermittent dosing of meropenem only, and 5.8 patients received both types of dosing regimens. LOS of the index admission was shorter for the intermittent arm (15.5 ± 7.6 days versus daily: 30.2 ± 24.5 days), though 30-day readmission was higher (50% versus daily: 38.2%). IMPLICATIONS: We recommend further rigorous randomised controlled trials to investigate the clinical utility of intermittent meropenem dosing in patients on stable haemodialysis.

Healthcare utilisation in the last year of life in internal medicine, young-old versus old-old.

BACKGROUND: With increasing cost of healthcare in our aging society, a consistent pain point is that of end-of-life care. It is particularly difficult to prognosticate in non-cancer patients, leading to more healthcare utilisation without improving quality of life. Additionally, older adults do not age homogenously. Hence, we seek to characterise healthcare utilisation in young-old and old-old at the end-of-life. METHODS: We conducted a single-site retrospective review of decedents under department of Advanced Internal Medicine (AIM) over a year. Young-old is defined as 65-79 years; old-old as 80 years and above. Data collected was demographic characteristics; clinical data including Charlson Comorbidity Index (CCI), FRAIL-NH and advance care planning (ACP); healthcare utilisation including days spent in hospital, hospital admissions, length of stay of terminal admission and clinic visits; and quality of end-of-life care including investigations and symptomatic control. Documentation was individually reviewed for quality of communication. RESULTS: One hundred eighty-nine older adult decedents. Old-old decedents were mostly females (63% vs. 42%, p = 0.004), higher CCI scores (7.7 vs 6.6, p = 0.007), similarly frail with lower polypharmacy (62.9% vs 71.9%, p = 0.01). ACP uptake was low in both, old-old 15.9% vs. young-old 17.5%. Poor prognosis was conveyed to family, though conversation did not result in moderating extent of care. Old-old had less healthcare utilisation. Adjusting for sex, multimorbidity and frailty, old-old decedents had 7.3 ± 3.5 less hospital days in their final year. Further adjusting for cognition and residence, old-old had 0.5 ± 0.3 less hospital admissions. When accounted for home care services, old-old spent 2.7 ± 0.8 less hospital days in their last admission. CONCLUSION: There was high healthcare utilisation in older adults, but especially young-old. Enhanced education and goal-setting are needed in the acute care setting. ACP needs to be reinforced in acute care with further research to evaluate if it reduces unnecessary utilisation at end-of-life.

Cumulative Effect of Visual Impairment, Multimorbidity, and Frailty on Intrinsic Capacity in Community-Dwelling Older Adults.

Objectives: We aim to determine the prevalence of vision impairment (VI) and its cumulative impact on multimorbidity, frailty, physical and cognitive function, and quality of life. Method: In all, 780 community-dwelling older adults were interviewed for demographic data and a one-off physical activity screening. Covariate measurements include vision via Snellen chart, multimorbidity, five-item FRAIL (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight) scale and Mini-Mental State Examination (MMSE). Outcome variables taken were Barthel Index, Lawton Instrumental Activities of Daily Living (IADL) scale, grip strength, Timed Up and Go (TUG), and EuroQol 5D (EQ-5D). Results: In all, 426 (54.6%) were female, mean age was 71.3 ± 0.2 years; 240 (30.8%) had VI. The interaction between VI, multimorbidity, and frailty significantly impacts grip strength, TUG, quality of life, and IADL. Discussion: Our study is the first to look at the interaction of VI, multimorbidity, frailty, and its combined impact on key domains of intrinsic capacity. Our results further support vision screening to enable aging in place and highlight importance of screening for frailty and cognition in those with VI.