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Objectives: During the coronavirus disease (COVID‐19) pandemic, patients with altered mental status (AMS: dementia, delirium and delirium superimposed on dementia) were profoundly affected by an abrupt transformation in healthcare systems. Here, we evaluated quality‐care outcomes, including length of stay (LOS), in‐hospital mortality, early readmission and mortality after hospital discharge, in older adults admitted for AMS during the pandemic and compared them to patients admitted prior to the pandemic. Methods: Chi‐squared and Fisher's exact tests were used to examine changes to admissions for AMS before and during the pandemic, and their outcomes. Logistic regression analyses, with reference to pre‐pandemic data, were conducted to examine the impact of the pandemic on outcomes. Design: Prospective data of 21,192 non‐COVID admissions to an acute general medical department in a Surrey (UK) hospital were collected from patients admitted before (1st April 2019 to 29th February 2020) and during the pandemic (1st March 2020 to 31st March 2021). Results: There were 10,173 (47.7% men) from the pre‐pandemic and 11,019 (47.5% men) from the pandemic periods; overall mean age = 68.3yr. During the pandemic AMS patients had significantly higher admission rates (1.1% vs 0.6%, P < 0.001). However, median LOS in hospital was shorter (9.0 days [IQR = 5.3–16.2] vs 15.5 days [IQR = 6.2–25.7], P < 0.001) and thus were less likely to stay in hospital >3 weeks: adjusted OR = 0.26 (95%CI = 0.12–0.57). In‐hospital mortality and readmission within 28 days of discharge did not change during the pandemic, but were less likely to die within 30 days of discharge: adjusted OR = 0.32 (95%CI = 0.11–0.96). Conclusions: This combination of higher admission rate, shorter LOS, and an unchanging early readmission suggests a higher admission‐discharge turnover of different patients with AMS and provides important insights into the potential impact of the COVID‐19 pandemic on healthcare delivery to individuals with AMS. Key points: During the coronavirus disease (COVID‐19) pandemic, patients with altered mental status (AMS: dementia, delirium and delirium superimposed on delirium) were profoundly affected by an abrupt transformation in healthcare systems.Patients admitted with AMS during the pandemic had higher admission rates but shorter length of stay (LOS) in hospital, whilst mortality in hospital and readmission within 28 days of discharge did not change during the pandemicThese observations suggest a higher admission‐discharge turnover of different patients with AMS and provide important insights into the potentially impact of the COVID‐19 pandemic on healthcare delivery to individuals with AMS. [ABSTRACT FROM AUTHOR]

We measured rates of hospital admissions for mental health disorders and self‐poisoning during the pandemic in patients without COVID‐19, compared to those admitted before the pandemic. Data were collected from 01/04/2019 to 31/03/2021, including the pandemic period from 01/03/2020. There were 10 173 (47.7% men) from the pre‐pandemic and 11 019 (47.5% men) from the pandemic periods; mean age = 68.3 year. During the pandemic, admission rates for mental health disorders and self‐poisoning were higher for any given age and sex. Self‐poisoning was increased with toxic substances, sedatives and psychotropic drugs, but reduced with nonopioid analgesics. Patients admitted with mental health disorders had lower readmission rates within 28 days during the pandemic, but did not differ in other outcomes. Outcomes from self‐poisoning did not change between the two study periods. [ABSTRACT FROM AUTHOR]

Hip fracture in older adults is associated with poor prognosis. We tested the hypothesis that a single standardized measure, pre-fracture mobility, can be used as an early indicator of patients at high health risk after a hip fracture. Analysis of prospectively collected data of older adults admitted with a hip fracture between April-2009 and June-2019 in a single NHS hospital, UK. Pre-fracture mobility status (freely mobile, mobilising outdoors with one aid or with two aids, and limited to indoors), was used to predict length of stay (LOS) and mortality in hospital, and discharge destination. Among 3073 (2231 women, 842 men) admitted from their own home (mean ± SD age = 82.7 ± 9.3 yr), 159 died and 2914 survived to discharge: 1834 back to their home, 772 to rehabilitation, 66 to residential care, 141 to nursing care and 101 to unknown destinations. Compared with LOS of 15.9 ± 15.6 days in patients who mobilised freely before fracture (reference), those who were able to mobilise outdoors with one aid stayed 3.5 days, and those with two aids or confined to indoor mobility stayed one week longer in hospital. In-patient mortality was increased among patients who mobilised outdoors with two aids: OR = 2.1 (95%CI = 1.3–3.3), and those limited to indoors: OR = 2.1 (1.3–1.5). Finally, a change in residence on discharge was more likely in those who mobilised outdoors with two aids (OR = 1.8, 95%CI = 1.2–2.6), and those limited to indoors (OR = 1.9, 95%CI = 1.2–2.9). In conclusion, pre-fracture mobility may be a useful early indicator for identifying patients at increased risk of adverse outcomes after an acute hip fracture. [ABSTRACT FROM AUTHOR]

Background: The LACE index scoring tool (Length of stay, Acuity of admission, Co-morbidities and Emergency department visits) has been designed to predict hospital readmissions. We evaluated the ability of the LACE index to predict age-specific frequent admissions and mortality. Methods: Analysis of prospectively collected data of alive-discharge episodes between 01/04/2017 and 31/03/2019 in an NHS hospital. Data on 14,878 men and 17,392 women of mean age 64.0 years, SD = 20.5, range 18.0–106.7 years were analysed. The association of the LACE index with frequency of all-cause readmissions within 28 days of discharge and over a 2-year period, and with all-cause mortality within 30 days or within 6 months after discharge from hospital were evaluated. Results: Within LACE index scores of 0–4, 5–9 or ≥ 10, the proportions of readmission ≥ 2 times within 28 days of discharge were 0.1, 1.3 and 9.2% (χ2 = 3070, p < 0.001) and over a 2-year period were 1.7, 4.8 and 19.1% (χ2 = 3364, p < 0.001). Compared with a LACE index score of 0–4, a score ≥ 10 increased the risk (adjusted for age, sex and frequency of admissions) of death within 6 months of discharge by 6.8-fold (5.1–9.0, p < 0.001) among all ages, and most strongly in youngest individuals (18.0–49.9 years): adjusted odds ratio = 16.1 (5.7–45.8, p < 0.001). For those aged 50–59.9, 60–69.9, 70–79.9 and ≥ 80 years, odds ratios reduced progressively to 9.6, 7.7, 5.1 and 2.3, respectively. Similar patterns were observed for the association of LACE index with mortality within 30 days of hospital discharge. Conclusions: The LACE index predicts short-term and long-term frequent admissions and short-term and medium-term mortality, most pronounced among younger individuals, after hospital discharge. [ABSTRACT FROM AUTHOR]

Background the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. Methods the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1–3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. Results from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3–4.3). Prolonged LOS was increased with 4AT scores of 1–3 (OR = 2.4, 95%CI = 1.4–4.1) or ≥4 (OR = 3.1, 95%CI = 1.9–6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2–8.2) but not with a 4AT score of 1–3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4–6.8). These associations persisted after excluding patients with dementia. 4AT score = 1–3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. Conclusions for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge. [ABSTRACT FROM AUTHOR]

Background: Most National Health Service (NHS) hospital bed occupants are older patients because of their frequent admissions and prolonged length of stay (LOS). We evaluated demographic and clinical factors as predictors of LOS in a single NHS Trust and derived an equation to estimate LOS. Methods: Stepwise logistic and linear regressions were used to predict prolonged LOS (upper-quintile LOS > 17 days) and LOS respectively, from demographic factors and acute and pre-existing conditions. Results: Of 374 (men:women = 127:247) admitted patients (20% to orthogeriatric, 69% to general medical and 11% to surgical wards), median age of 85 years (IQR = 78–90), 77 had acute first hip fracture; 297 had previous hip fracture (median time since previous fracture = 2.4 years) and 21 (7.1%) had recurrent hip fracture, with median time since first fracture = 2.4 years. Median LOS was 6.5 days (IQR = 1.8–14.8), and 38 (10.2%) died after 4.8 days (IQR = 1.6–14.3). Prolonged LOS was associated with discharge to places other than usual residence: OR = 3.1 (95% CI 1.7–5.7), acute stroke: OR = 10.1 (3.7–26.7), acute first hip fractures: OR = 6.8 (3.1–14.8), recurrent hip fractures: OR = 9.5 (3.2–28.7), urinary tract infection/pneumonia: OR = 4.0 (2.1–8.0), other acute fractures: OR = 9.8 (3.0–32.3) and malignancy: OR = 15.0 (3.1–71.8). Predictive equation showed estimated LOS was 11.6 days for discharge to places other than usual residence, 15 days for pre-existing or acute stroke, 9–14 days for acute and recurrent hip fractures, infections, other acute fractures and malignancy; these factors together explained 32% of variability in LOS. Conclusions: A useful estimate of outcome and LOS can be made by constructing a predictive equation from information on hospital admission, to provide evidence-based guidance for resource requirements and discharge planning. [ABSTRACT FROM AUTHOR]

Background: low bone mineral density measured by dual-energy x-ray absorptiometry is associated with increased mortality. The relationship between other skeletal phenotypes and mortality is unclear. The aim of this study was to determine the relationship between quantitative heel ultrasound parameters and mortality in a cohort of European men. Methods: men aged 40-79 years were recruited for participation in a prospective study of male ageing: the European Male Ageing Study (EMAS). At baseline, subjects attended for quantitative ultrasound (QUS) of the heel (Hologic—SAHARA) and completed questionnaires on lifestyle factors and co-morbidities. Height and weight were measured. After a median of 4.3 years, subjects were invited to attend a follow-up assessment, and reasons for non-participation, including death, were recorded. The relationship between QUS parameters (broadband ultrasound attenuation [BUA] and speed of sound [SOS]) and mortality was assessed using Cox proportional hazards model. Results: from a total of 3,244 men (mean age 59.8, standard deviation [SD] 10.8 years), 185 (5.7%) died during the follow-up period. After adjusting for age, centre, body mass index, physical activity, current smoking, number of co-morbidities and general health, each SD decrease in BUAwas associated with a 20% higher risk of mortality (hazard ratio [HR] per SD = 1.2; 95% confidence interval [CI] = 1.0-1.4). Compared with those in higher quintiles (2nd-5th), those in the lowest quintile of BUA and SOS had a greater mortality risk (BUA: HR = 1.6; 95% CI = 1.1-2.3 and SOS: HR = 1.6; 95% CI = 1.2-2.2). Conclusion: lower heel ultrasound parameters are associated with increased mortality in European men. [ABSTRACT FROM AUTHOR]

Background: vitamin D deficiency has been associated with an increased risk of mortality, but whether this relationship is causal or linked to co-existent comorbidity and adverse life factors remains uncertain. Our objective was to determine whether endogenous 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)2D) and parathyroid hormone (PTH) levels predicted all-cause, cardiovascular and cancer mortality independently of health and lifestyle factors.Setting: prospective cohort analysis within the European Male Ageing Study.Participants: 2,816 community-dwelling men aged 40–79 years at baseline.Methods: Cox regression was used to examine the association of all-cause mortality with 25(OH)D, 1,25(OH)2D and PTH; cardiovascular and cancer mortality were modelled using competing-risks regression. Results were expressed as hazard ratios (HR) and 95% confidence intervals (CIs) for Cox models; sub-hazard ratios (SHR) and 95% CIs for competing-risks models.Results: a total of 187 men died during a median of 4.3 years of follow-up. Serum levels of 25(OH)D (per 1 SD decrease: HR = 1.45; 95% CI = 1.16, 1.81) and 1,25(OH)2D (per 1 SD decrease: HR = 1.20; 95% CI = 1.00, 1.44) were associated with an increased risk of all-cause mortality after adjusting for age, centre, smoking, self-reported morbidities, physical activity and functional performance. Only levels of 25(OH)D <25 nmol/l predicted cancer mortality (SHR = 3.33; 95% CI = 1.38, 8.04).Conclusion: lower 25(OH)D and 1,25(OH)2D levels independently predicted all-cause mortality in middle-aged and older European men. Associations with cancer mortality were only observed among men with very low levels of 25(OH)D. These associations were only partially explained by the range of adverse health and lifestyle factors measured here. [ABSTRACT FROM AUTHOR]

Background: the link between the vitamin D endocrine axis and frailty remains undefined, with few studies examining the joint effect of vitamin D and parathyroid hormone (PTH) levels. Our objective was to determine the association of frailty with serum 25-hydroxyvitamin D (25(OH)D) and PTH.Setting: cross-sectional analysis within the European Male Ageing Study (EMAS).Participants: a total of 1,504 community-dwelling men aged 60–79 years.Methods: frailty was classified using a frailty phenotype (FP) and frailty index (FI). The association of frailty with 25(OH)D and PTH was examined using multinomial logistic regression; individual FP criteria with 25(OH)D and PTH using binary logistic regression. Results were expressed as relative odds ratios (ROR) and 95% confidence intervals (CIs) for multinomial; odds ratios (OR) and 95% CIs for binary models.Results: using the FP, 5.0% of subjects were classified as frail and 36.6% as prefrail. Lower levels of 25(OH)D were associated with being prefrail (per 1 SD decrease: ROR = 1.45; 95% CI: 1.26–1.67) and frail (ROR = 1.89; 95% CI: 1.30–2.76), after adjusting for age, centre and health and lifestyle confounders (robust group = base category). Higher levels of PTH were associated with being frail after adjustment for confounders (per 1 SD increase: ROR = 1.24; 95% CI: 1.01–1.52). Comparable results were found using the FI. Among the five FP criteria only sarcopenia was not associated with 25(OH)D levels, while only weakness was associated with PTH.Conclusion: lower 25(OH)D and higher PTH levels were positively associated with frailty in older men. Prospective data would enable the temporal nature of this relationship to be explored further. [ABSTRACT FROM PUBLISHER]

We evaluated factors and outcomes associated with elapsed time to surgery (ETTS) in 1,081 men and 2,891 women (mean age 83.5 years ±9.1) undergoing hip fracture surgery (from 2009-2019). Mortality rates were 4.8%, 6.3%, 6.2% and 10.3% (chi-squared 19.0; p<0.001), and hospital length of stay (LOS) >19 days were 31.9%, 32.8%, 33.8% and 43.2% (chi-squared 18.5; p<0.001) for ETTS <24 hours, 24-35 hours, 36-47 hours and ≥48 hours, respectively. There were no differences between ETTS categories for failure to mobilise within 1 day of surgery, pressure ulcers or discharge to nursing care. After adjustment for age, sex, American Society of Anesthesiologists' score and years of data collection, compared with Sunday, the risk of ETTS ≥36 hours was highest on Friday (odds ratio (OR) 3.50; 95% confidence interval (CI) 2.43-5.03) and Saturday (OR 4.70; 95% CI 3.26-6.76). Compared with ETTS <24 hours, there were increases in the risk of death when ETTS ≥48 hours (OR 2.31; 95% CI 1.47-3.65) and LOS >19 days (OR 1.34; 95% CI 1.02-1.75). The median (interquartile range (IQR)) LOS for ETTS <24 hours was 12.7 days (IQR 8.0-23.0), 24-35 hours was 13.5 days (IQR 8.4-22.9), 36-47 hours was 14.1 days (IQR 8.9-23.3) and ≥48 hours was 16.9 (IQR 10.8-27.0; p<0.001). The 10-year period of collection did not change the conclusion. Admissions towards the end of the week are associated with delayed ETTS for hip fractures, while delay in surgery, particularly beyond 48 hours, is associated with increased risk of mortality and prolonged LOS. [ABSTRACT FROM AUTHOR]