Medicine (RMH) - Research Publications
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ItemPatterns of Objectively Measured Sedentary Behavior and Physical Activity and Their Association with Changes in Physical and Functional Performance in Geriatric Rehabilitation Inpatients(ELSEVIER SCIENCE INC, 2023-05)OBJECTIVES: To examine whether The Ending PyJama (PJ) Paralysis campaign, focused on increasing in-hospital physical activity, affects objectively measured sedentary behavior and physical activity patterns and if these are associated with changes in physical and functional performance in geriatric rehabilitation inpatients. DESIGN: Quasi-experimental study. SETTING AND PARTICIPANTS: Within the REStORing health of acutely unwell adulTs (RESORT) observational, longitudinal cohort of geriatric rehabilitation inpatients, the Ending PJ Paralysis campaign was implemented on 2 out of 4 wards. METHODS: Objectively measured sedentary behavior and physical activity were measured by an inertial sensor (ActivPAL4) for 1 week, comparing control (non-PJ) and intervention (PJ) groups using linear mixed models. Mean sedentary behavior and physical activity measures and their association with physical and functional performance changes were investigated by linear regression analyses, stratified by low vs high performance at admission using the median as a cut-off. RESULTS: A total of 145 (n = 68 non-PJ and n = 77 PJ) inpatients with a mean age of 83.0 (7.7) years (55.9% female inpatients) were included. The median nonupright time was 23.1 [22.1-23.6] and 23.0 [21.8-23.6] hours/day for non-PJ and PJ groups, respectively. Objectively measured sedentary behavior and physical activity measures did not significantly change over measurement days and were independent of the Ending PJ Paralysis campaign. For inpatients with low performance at admission, lower sedentary behavior [B(SE) -0.013 (0.005) to -0.157 (0.045), P < .01] and higher physical activity [B(SE) 0.033 (0.007) to 0.814 (0.200), P < .01] measures were associated with improved physical performance. In addition, lower sedentary behaviour [B(SE) = -0.058 (0.024), P < .05 and higher physical activity [B (SE) 0.060 (0.024) to 0.683 (0.182), P < .05] were associated with improved instrumental functional performance. CONCLUSIONS AND IMPLICATIONS: In geriatric rehabilitation inpatients, the Ending PJ Paralysis campaign did not affect objectively measured sedentary behavior and physical activity patterns. Lower mean sedentary behaviour and higher physical activity measures were associated with improved physical and functional performance in inpatients with low performance.
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ItemPathophysiological Mechanisms Explaining the Association Between Low Skeletal Muscle Mass and Cognitive Function(OXFORD UNIV PRESS INC, 2022-10-06)Low skeletal muscle mass is associated with cognitive impairment and dementia in older adults. This review describes the possible underlying pathophysiological mechanisms: systemic inflammation, insulin metabolism, protein metabolism, and mitochondrial function. We hypothesize that the central tenet in this pathophysiology is the dysfunctional myokine secretion consequent to minimal physical activity. Myokines, such as fibronectin type III domain containing 5/irisin and cathepsin B, are released by physically active muscle and cross the blood-brain barrier. These myokines upregulate local neurotrophin expression such as brain-derived neurotrophic factor (BDNF) in the brain microenvironment. BDNF exerts anti-inflammatory effects that may be responsible for neuroprotection. Altered myokine secretion due to physical inactivity exacerbates inflammation and impairs muscle glucose metabolism, potentially affecting the transport of insulin across the blood-brain barrier. Our working model also suggests other underlying mechanisms. A negative systemic protein balance, commonly observed in older adults, contributes to low skeletal muscle mass and may also reflect deficient protein metabolism in brain tissues. As a result of age-related loss in skeletal muscle mass, decrease in the abundance of mitochondria and detriments in their function lead to a decrease in tissue oxidative capacity. Dysfunctional mitochondria in skeletal muscle and brain result in the excessive production of reactive oxygen species, which drives tissue oxidative stress and further perpetuates the dysfunction in mitochondria. Both oxidative stress and accumulation of mitochondrial DNA mutations due to aging drive cellular senescence. A targeted approach in the pathophysiology of low muscle mass and cognition could be to restore myokine balance by physical activity.
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ItemConsensus guidelines for sarcopenia prevention, diagnosis and management in Australia and New Zealand(WILEY, 2023-02)BACKGROUND: Sarcopenia is an age-associated skeletal muscle condition characterized by low muscle mass, strength, and physical performance. There is no international consensus on a sarcopenia definition and no contemporaneous clinical and research guidelines specific to Australia and New Zealand. The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force aimed to develop consensus guidelines for sarcopenia prevention, assessment, management and research, informed by evidence, consumer opinion, and expert consensus, for use by health professionals and researchers in Australia and New Zealand. METHODS: A four-phase modified Delphi process involving topic experts and informed by consumers, was undertaken between July 2020 and August 2021. Phase 1 involved a structured meeting of 29 Task Force members and a systematic literature search from which the Phase 2 online survey was developed (Qualtrics). Topic experts responded to 18 statements, using 11-point Likert scales with agreement threshold set a priori at >80%, and five multiple-choice questions. Statements with moderate agreement (70%-80%) were revised and re-introduced in Phase 3, and statements with low agreement (<70%) were rejected. In Phase 3, topic experts responded to six revised statements and three additional questions, incorporating results from a parallel Consumer Expert Delphi study. Phase 4 involved finalization of consensus statements. RESULTS: Topic experts from Australia (n = 62, 92.5%) and New Zealand (n = 5, 7.5%) with a mean ± SD age of 45.7 ± 11.8 years participated in Phase 2; 38 (56.7%) were women, 38 (56.7%) were health professionals and 27 (40.3%) were researchers/academics. In Phase 2, 15 of 18 (83.3%) statements on sarcopenia prevention, screening, assessment, management and future research were accepted with strong agreement. The strongest agreement related to encouraging a healthy lifestyle (100%) and offering tailored resistance training to people with sarcopenia (92.5%). Forty-seven experts participated in Phase 3; 5/6 (83.3%) revised statements on prevention, assessment and management were accepted with strong agreement. A majority of experts (87.9%) preferred the revised European Working Group for Sarcopenia in Older Persons (EWGSOP2) definition. Seventeen statements with strong agreement (>80%) were confirmed by the Task Force in Phase 4. CONCLUSIONS: The ANZSSFR Task Force present 17 sarcopenia management and research recommendations for use by health professionals and researchers which includes the recommendation to adopt the EWGSOP2 sarcopenia definition in Australia and New Zealand. This rigorous Delphi process that combined evidence, consumer expert opinion and topic expert consensus can inform similar initiatives in countries/regions lacking consensus on sarcopenia.
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ItemThe Association of Changes in Physical Performance During Geriatric Inpatient Rehabilitation With Short-Term Hospital Readmission, Institutionalization, and Mortality: RESORT(ELSEVIER SCIENCE INC, 2022-11)OBJECTIVES: Geriatric inpatient rehabilitation aims to restore function, marked by physical performance, to enable patients to return and remain home after hospitalization. However, after discharge some patients are soon readmitted, institutionalized, or may die. Whether changes in physical performance during geriatric rehabilitation are associated with these short-term adverse outcomes is unknown. This study aimed to determine the association of changes in physical performance during geriatric inpatient rehabilitation with short-term adverse outcomes. DESIGN: Observational longitudinal study. SETTING AND PARTICIPANTS: Geriatric rehabilitation inpatients of the REStORing health of acutely unwell adulTs (RESORT) cohort study of the Royal Melbourne Hospital (Melbourne, Australia) were included. METHODS: The change from admission to discharge in the Short Physical Performance Battery (SPPB) score, balance, gait speed (GS), chair stand test (CST), and hand grip strength (HGS) were calculated and analyzed using logistic regression analysis with readmission, incidence of institutionalization, and mortality, and ≥1 adverse outcome within 3 months postdischarge. RESULTS: Of 693 inpatients, 11 died during hospitalization and 572 patients (mean age 82.6 ± 7.6 years, 57.9% female) had available physical performance data. Within 3 months postdischarge, 47.3% of patients had ≥1 adverse outcome: readmission was 20.8%, institutionalization was 26.6%, and mortality was 7.9%. Improved SPPB score, balance, GS, CST, and HGS were associated with lower odds of institutionalization and mortality. Improved GS was additionally associated with lower odds of readmission [odds ratio (OR) 0.35, 95% CI 0.16-0.79]. CST score had the largest effect, with a 1-point increase associating with 40% lower odds of being institutionalized (OR 0.60, 95% CI 0.42-0.86), 52% lower odds of mortality (OR 0.48, 95% CI 0.29-0.81), and a 24% lower odds of ≥1 adverse outcome (OR 0.76, 95% CI 0.59-0.97). CONCLUSIONS AND IMPLICATIONS: Improvement in physical performance was associated with lower odds of short-term institutionalization and mortality indicating the prognostic value of physical performance improvement during geriatric inpatient rehabilitation.
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ItemNo Preview AvailableAssociation of a modified laboratory frailty index with adverse outcomes in geriatric rehabilitation inpatients: RESORT(ELSEVIER IRELAND LTD, 2022-04)A higher number of laboratory measurements is associated with mortality in patients admitted to hospital, but is not part of the frailty index based on laboratory tests (FILab). This study aimed to modify the FI-Lab (mFI-Lab) by accounting for the number of laboratory measurements and compare its validity to predict institutionalization and mortality at three-month post-discharge with the clinical frailty scale (CFS) in geriatric rehabilitation inpatients. In 1819 patients (median age 83.3 [77.6-88.3], 56.6% female), a higher FI-Lab was not associated with institutionalization but a higher risk of mortality. A higher mFI-Lab was associated with lower odds of institutionalization but a higher risk of mortality. A higher CFS was associated with institutionalization and higher mortality. The Akaike information criterion value was lowest for the CFS, followed by the mFI-Lab and the FI-Lab. The CFS is better than the mFI-Lab predicting short-term adverse outcomes in geriatric rehabilitation inpatients. When using laboratory data to estimate frailty, the mFI-Lab rather than the FI-Lab should be used.
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ItemNo Preview AvailableComparison of the modified Frailty-Index based on laboratory tests and the Clinical Frailty Scale in predicting mortality among geriatric rehabilitation inpatients: RESORT(ELSEVIER IRELAND LTD, 2022)OBJECTIVE: To compare the associations of the FI-lab, modified (m)FI-lab and Clinical Frailty Scale (CFS) with one-year mortality. STUDY DESIGN: An observational longitudinal inception cohort of inpatients admitted to the geriatric rehabilitation wards in the Royal Melbourne Hospital, Victoria, Australia. MAIN OUTCOME MEASURES: The measured ratio was defined as the proportion of measured laboratory tests to the total number of tests (n = 77). The FI-lab is the proportion of abnormal results to the total measured laboratory tests. The mFI-lab was calculated by dividing the FI-lab by the measured ratio. The measured ratio of laboratory tests, FI-lab, mFI-lab and CFS were assessed at admission to geriatric rehabilitation. Patients' mortality data were obtained from the Registry of Births, Deaths and Marriages Victoria and medical records. RESULTS: The total of 1819 inpatients had a median age of 83.3 [77.5-88.3] years and 56.5% were female. The median measured ratio, FI-lab, mFI-lab and CFS scores were 0.58 [0.47-0.70], 0.31 [0.23-0.38], 0.51 [0.38-0.69] and 6 (Abbasi et al., 2018Gill, Gahbauer, Allore & Han, 2006; Howlett et al., 2014;) respectively. The one-year mortality rate was 17.1%. The measured ratio was not associated with one-year mortality. Higher FI-lab (hazard ratio (HR)=1.180, 95%CI: 1.037-1.343), mFI-lab (HR=1.074, 95%CI: 1.030-1.119) and CFS scores (HR=1.350, 95%CI: 1.191-1.530) were associated with higher risk of one-year mortality. The area under the curve (AUC) of FI-lab, mFI-lab and CFS with one-year mortality were 0.581, 0.587 and 0.612 respectively. CONCLUSION: The FI-lab, mFI-lab and CFS poorly predict mortality in geriatric rehabilitation inpatients despite the statistically significant associations shown.
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ItemNo Preview AvailableUnresolved inflammation during hospitalization is associated with post-discharge institutionalization and mortality in geriatric rehabilitation inpatients: The RESORT cohort(PERGAMON-ELSEVIER SCIENCE LTD, 2021-12)BACKGROUND: Inflammation contributes to adverse health outcomes in community-dwelling populations. Little is known about inflammation in hospitalized older adults and its association with adverse outcomes. This study aimed to evaluate the association of the inflammatory markers C-reactive protein (CRP) and albumin measured during acute and geriatric rehabilitation hospitalization with institutionalization and mortality in geriatric rehabilitation inpatients. METHODS: Within the REStORing health of acutely unwell adulTs (RESORT) cohort, CRP and albumin were measured as part of usual care during acute and geriatric rehabilitation hospitalization. Inflammatory markers are presented as median, peak (CRP: maximum; albumin: minimum), variation (interquartile range) and direction of change (increased CRP or decreased albumin: positive or negative difference between last measurement and median of preceding measurements). Logistic regression was used to determine the associations between inflammatory markers and institutionalization at three-month and all-cause mortality at three- and twelve-month post-discharge. RESULTS: Geriatric rehabilitation inpatients (n = 1846) with a median age of 83.3 years (interquartile range 77.6-88.3) and 56.6% of female were included. Increased CRP during geriatric rehabilitation was associated with institutionalization. Higher median, peak and increased levels of CRP during geriatric rehabilitation but not during acute hospitalization were associated with higher mortality. Lower CRP variation during acute hospitalization but higher CRP variation during geriatric rehabilitation was associated with higher mortality. Lower median level of albumin during both hospitalizations were associated with higher mortality. CONCLUSIONS: Inflammation characterized by lower albumin during acute hospitalization and, higher CRP and lower albumin during geriatric rehabilitation was associated with mortality in geriatric rehabilitation inpatients. Increased CRP during geriatric rehabilitation was associated with institutionalization. Unresolved inflammation in geriatric rehabilitation might indicate ongoing disease activity leading to adverse outcomes.
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ItemNo Preview AvailableAssociations of objectively measured physical activity and sedentary behaviour with fall-related outcomes in older adults: A systematic review(ELSEVIER FRANCE-EDITIONS SCIENTIFIQUES MEDICALES ELSEVIER, 2022-03)BACKGROUND: Higher physical activity (PA) and lower sedentary behaviour (SB) are associated with better muscle strength, balance, and functional ability, which are imperative for avoiding falls. This systematic review aimed to describe the association between objectively measured PA and SB with falls, fear of falling, and fractures. METHODS: Six databases were searched from inception to July 21, 2020 for articles reporting the association of objectively measured PA/SB with falls, fear of falling, and/or fractures in community-dwelling older adults ≥60 years old. Results were synthesized in effect-direction heat maps and albatross plots expressed as Pearson's correlation coefficients (R). RESULTS: A total of 43 articles were included, representing 27,629 (range 26-5545) community-dwelling older adults (mean [SD] age 76.6 [8.4] years, 47% female). Longitudinal associations were reported in 13 articles and cross-sectional associations in 30. Falls were reported in 11 articles, fear of falling in 18 and fractures in 2. Higher PA and lower SB were associated with less fear of falling (median [interquartile range] Rs = steps: -0.214 [0.249; -0.148], total PA: -0.240 [0.267; -0.144], and moderate-to-vigorous PA: -0.180 [0.382; -0.121]), but these associations did not extend to falls or fractures, which showed inconsistent effect directions. CONCLUSION: Fear of falling is associated with less engagement in PA and more SB, thus indicating that it is a psychological barrier to an active lifestyle. Varying effect directions for associations between PA and SB with falls and fractures may provide evidence for non-linear associations and require further research considering details of the fall or fracture incident. PROSPERO REGISTRATION NUMBER: CRD42018103910.
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ItemLongitudinal Changes in Muscle Mass, Muscle Strength, and Physical Performance in Acutely Hospitalized Older Adults(ELSEVIER SCIENCE INC, 2021-04)OBJECTIVES: Acute hospitalization may lead to a decrease in muscle measures, but limited studies are reporting on the changes after discharge. The aim of this study was to determine longitudinal changes in muscle mass, muscle strength, and physical performance in acutely hospitalized older adults from admission up to 3 months post-discharge. DESIGN: A prospective observational cohort study was conducted. SETTING AND PARTICIPANTS: This study included 401 participants aged ≥70 years who were acutely hospitalized in 6 hospitals. All variables were assessed at hospital admission, discharge, and 1 and 3 months post-discharge. METHODS: Muscle mass in kilograms was assessed by multifrequency Bio-electrical Impedance Analysis (MF-BIA) (Bodystat; Quadscan 4000) and muscle strength by handgrip strength (JAMAR). Chair stand and gait speed test were assessed as part of the Short Physical Performance Battery (SPPB). Norm values were based on the consensus statement of the European Working Group on Sarcopenia in Older People. RESULTS: A total of 343 acute hospitalized older adults were included in the analyses with a mean (SD) age of 79.3 (6.6) years, 49.3% were women. From admission up to 3 months post-discharge, muscle mass (-0.1 kg/m2; P = .03) decreased significantly and muscle strength (-0.5 kg; P = .08) decreased nonsignificantly. The chair stand (+0.7 points; P < .001) and gait speed test (+0.9 points; P < .001) improved significantly up to 3 months post-discharge. At 3 months post-discharge, 80%, 18%, and 43% of the older adults scored below the cutoff points for muscle mass, muscle strength, and physical performance, respectively. CONCLUSIONS AND IMPLICATIONS: Physical performance improved during and after acute hospitalization, although muscle mass decreased, and muscle strength did not change. At 3 months post-discharge, muscle mass, muscle strength, and physical performance did not reach normative levels on a population level. Further research is needed to examine the role of exercise interventions for improving muscle measures and physical performance after hospitalization.
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ItemGeriatric home-based rehabilitation in Australia: Preliminary data from an inpatient bed-substitution model(WILEY, 2022-06)BACKGROUND: The REStORing health of acutely unwell adulTs (RESORT) is an observational longitudinal cohort, including geriatric rehabilitation inpatients aged ≥65 years admitted to a geriatrician-led rehabilitation service at a tertiary hospital. The aim of this study is to describe a home-based bed-substitution rehabilitation model for geriatric inpatients, including patient phenotype, and health outcomes at preadmission, admission, discharge, and three-month follow-up. METHODS: A standardized Comprehensive Geriatric Assessment was performed on admission and discharge, including demographics (home situation, cognitive impairment, medical diagnoses, etc.), frailty (Clinical Frailty Scale (CFS)), mobility (patient-reported and Functional Ambulation Classification), physical performance (Short Physical Performance Battery (SPPB), handgrip strength), and functional independence (Activities of Daily Living (ADL), Instrumental ADL (IADL)). Service provision data (health care staff visits, length of stay (LOS), and negative events (e.g., falls)) were extracted from medical records. Three-month outcomes included mobility, ADL and IADL scores, institutionalization, and mortality. RESULTS: Ninety-two patients were included with a mean age of 81.1 ± 7.8 years, 56.5% female. Twenty-nine (31.5%) patients lived alone, 39 (42.4%) had cognitive impairment and the commonest geriatric rehabilitation admission reason was falls (n = 30, 32.6%). Patients received care from nurses, physicians, and a median of four (interquartile range (IQR) 3-6) allied health disciplines for a median LOS of 13.0 days (IQR 10.0-15.0). On a population level, patient mobility and functional independence worsened from preadmission to admission. CFS, SPPB, ADL, and IADL scores improved from admission to discharge, and seven (7.6%) patients fell. At three-month follow-up, patient-reported mobility was comparable to preadmission baseline, but functional independence (ADL, IADL) scores worsened for 27/69 (39.1%) and 28/63 (44.4%), respectively. CONCLUSIONS: Hospitalization-associated decline in mobility and functional independence improved at discharge and three-months, but was not fully reversed in the multidisciplinary home-based geriatric rehabilitation bed-substitution service. Future research should compare outcomes to equivalent hospital-based geriatric rehabilitation and evaluate patient perspectives.