Editor’s view—clustering of multiple problems in individual patients

Clustering of multiple problems

One of the defining features of the common presentations in geriatric medicine (or geriatric giants, as they are frequently termed) is how they tend to cluster together in the same individuals. The development of one tends to rapidly lead to another and then another. In this issue, a systematic review and meta-analysis of the relationship between falls and delirium finds evidence that the relationship is bi-directional and potentially complex [1]. The authors found plenty of room for improvement in the evidence base. For now, the message to clinicians is to ensure to look carefully for the presence of falls and delirium in those presenting with either one.

Another area where there is evidence of bi-directional relationships is that between cognitive and sensory decline. Although hearing and visual loss have potential be important reversible risk factors for the development of dementia, long term studies that control for other risk factors for dementia are lacking. In a 25-year follow-up of over 1800 participants in the Maastricht Ageing Study, baseline hearing loss was an independent risk factor for faster decline in all cognitive domains [2]. The relationship with visual loss was less clear cut and no evidence was found between sensory and risk of incident dementia. The authors correctly point out that the evidence that improving hearing or vision results in lower risk of dementia is very limited to say the least. However, there are other benefits of improving sensory impairment including better functional independence and quality of life, so this should remain a public health priority irrespective of its ability to prevent dementia.

Our latest issue also investigates the increased risk of dementia in those with auto-immune conditions [3]. Inflammation may be important in the pathogenesis of dementia. In a UK Biobank study of over 50,000 individuals, those with autoimmune conditions has a 25% increased risk of being diagnosed with dementia over those without. Importantly, the authors also found that the increased risk was associated with brain structural changes including lower total brain surfaces in both hemispheres, higher volume of leukoariosis and less healthy white matter microstructures. The authors suggest this is an important clue to the pathogenesis of dementia.

Predicting outcomes

One of the things patients and their families and carers value the most is knowing the prognosis of their condition. In the December issue we have a number of articles with significant advances in the area of outcome prediction across a range of settings. In a multicentre cohort study of 21 976 patients undergoing surgery, patients with high Hospital Frailty Risk Scores (a validated measure of frailty) had a 3.5-fold increase in length of stay in hospital, 13-fold higher odds of in-hospital death and 2.5 higher odds of readmission than those with low scores [4]. This is important because frailty is potentially reversible, raising the intriguing possibility of greatly improving outcomes after surgery with good pre-operative and post-operative care. They also found a significant association with malnutrition and adverse outcomes, which again ought to be a reversible risk. They also found that the association between social deprivation and adverse outcomes after surgery was completely attenuated when corrected for frailty and malnutrition.

Although many people’s health declines rapidly when they need to move into a care home, this is not always the case. In an impressive study of over 200 000 Canadian care home residents, Egbuji et al [5] found their cohort could be usefully grouped into four distinct health trajectories, with almost 50% of residents in the group showing no or minimal decline in health over 36 months. The remainder were grouped into ‘catastrophic decline’ (22.7%), rapid decline with some recovery (18.7%) or ‘[slow] progressive decline’ (14.4%). They found the strongest predictor of which trajectory a new resident would follow was their baseline activities of daily living hierarchy score. They also found those with Parkinson’s disease were especially likely to experience catastrophic decline while those with dementia were most likely to have no or minimal decline in their health. They highlight the importance of personalised care for all long term care residents and suggest their model could be used to assist immediate and advance care planning.

At the other end of the life spectrum, another large UK biobank study reinforces the remarkable influence of early life influences on ageing [6]. Maternal smoking, non-breast feeding and low birth weight were all independently associated with higher biological age and shorter telomere length. I am a little sceptical of the utility of such markers of senescence, at least for clinical practice. However, the authors suggest their finding that modifiable social environment risk factors mediated the rate of biological ageing shows that it could be important to identify and act upon high-risk individuals. Bai et al. [7] also suggest targeted interventions focusing on hypertension, mental wellness, lifestyle factors, and integrated treatments for functional decline will help prevent cardio-metabolic multi-morbidity in old age. As a further example of a modifiable risk factor, encouraging the population to reduce the intake of ultra-processed foods may also slow down biological ageing [8].

Treatments for sarcopenic obesity

Sarcopenic obesity is a feature of ageing but is associated with adverse outcomes. A comprehensive systematic review and meta-analysis of randomised controlled trials for sarcopenic obesity found nutritional and exercise interventions in isolation were of limited effectiveness, especially in reversing muscle loss, but the combination of both strategies may be especially worthwhile [9]. The challenge is that such interventions are challenging to implement and maintain.

How frailty affects the brain in hyperacute stroke

In a small but important study, Dohle et al. [10] found that frailty has a significant and independent effect on the penumbral fraction in hyperacute stroke. This affects the amount of brain that is potentially salvageable with stroke reperfusion strategies. C-reactive protein was associated with both the frailty index and penumbral fraction, suggesting inflammation may play a role in explaining why those with frailty respond less well to reperfusion therapies after stroke.

Declaration of Conflicts of Interest:

None declared.

Declaration of Sources of Funding:

None declared.

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