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INTRODUCTION: Multimorbidity is common among older people and may contribute to adverse health effects, such as functional limitations. It may help stratify rehabilitation of older medical patients, if we can identify differences in function under and after an acute medical admission, among patient with different patterns of multimorbidity. AIM: To investigate differences in function and recovery profiles among older medical patients with different patterns of multimorbidity the first year after an acute admission. METHODS: Longitudinal prospective cohort study of 369 medical patients (77.9 years, 62% women) acutely admitted to the Emergency Department. During the first 24 h after admission, one month and one year after discharge we assessed mobility level using the de Morton Mobility Index. At baseline and one-year we assessed handgrip strength, gait speed, Barthel20, and the New Mobility Score. Information about chronic conditions was collected by national registers. We used Latent Class Analysis to determine differences among patterns of multimorbidity based on 22 chronic conditions. RESULTS: Four distinct patterns of multimorbidity were identified (Minimal chronic disease; Degenerative, lifestyle, and mental disorders; Neurological, functional and sensory disorders; and Metabolic, pulmonary and cardiovascular disorders). The "Neurological, functional and sensory disorders"-pattern showed significant lower function than the "Minimal chronic disease"-pattern in all outcome measures. There were no differences in recovery profile between patients in the four patterns. CONCLUSION: The results support that patients with different patterns of multimorbidity among acutely hospitalized older medical patients differ in function, which suggests a differentiated approach towards treatment and rehabilitation warrants further studies.

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BACKGROUND: Medication errors due to inaccurate measures of kidney function are common among elderly patients. We investigated differences between estimated glomerular filtration rate (eGFR) based on creatinine and cystatin C and how these differences would affect prescribing recommendations among acutely hospitalized elderly patients. We also identified factors associated with discrepancies between estimates. METHODS: Estimated glomerular filtration rate and chronic kidney disease (CKD) classifications were determined for 338 acutely hospitalized elderly patients using equations from Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Berlin Initiative Study (BIS) and Cockcroft-Gault (CG). Prescribed renal risk medications were compared with dosing guidelines in Renbase® . Linear regression models were used to identify explanatory variables for eGFR discrepancies between equations. Muscle weakness was assessed by handgrip strength; inflammation was assessed by smoking status, serum C-reactive protein (CRP), soluble urokinase plasminogen activator receptor (suPAR) and neutrophil gelatinase-associated lipocalin (NGAL); and organ dysfunction was assessed by thyroid-stimulating hormone (TSH) and FI-OutRef. RESULTS: Median eGFR values were 65.5, 60.7, 54.1, 57.1, 55.1 and 57.6 mL/min/1.73m2 according to CKD-EPICr , CKD-EPIComb , CKD-EPICys , BISCr , BISComb and CGCr , respectively. Depending on choice of equation, renal risk medications were prescribed at higher than recommended dose in 13.6% to 22.5% of patients using normalized GFR units and 9.9% to 19.1% of patients using absolute units. Age, handgrip strength, CRP, suPAR, NGAL and smoking status had significant association with eGFR discrepancies between creatinine- and cystatin C-based equations. CONCLUSIONS: Significant discrepancies in eGFR and CKD classification were observed when switching between eGFR equations in acutely hospitalized elderly patients. Switching from a creatinine-based equation to its corresponding cystatin C-based equation resulted in lower GFR estimates, and these differences were larger than in community-dwelling older populations. Switching between CKD-EPICr , CGCr and the alternative equations would result in clinically relevant changes to medication prescribing. Discrepancies between equations were associated with high age, muscle weakness and inflammation.

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OBJECTIVES: To investigate whether systemic inflammation in acutely admitted older medical patients (age >65 years) is associated with physical performance and organ dysfunction. Organ dysfunction´s association with physical performance, and whether these associations are mediated by systemic inflammation, was also investigated. METHODS: A cross-sectional study in an Emergency Department. Physical performance was assessed by handgrip strength and de Morton Mobility Index (DEMMI), and organ dysfunction by FI-OutRef, the number of standard blood tests outside the reference range. Systemic inflammation was assessed by suPAR, TNFα, and IL-6. Associations were investigated by regression analyses adjusted for age, sex, cognitive impairment, CRP, and VitalPAC Modified Early Warning Score. RESULTS: A total of 369 patients were evaluated. In adjusted analyses, suPAR and TNFα was associated with both physical performance measures (p<0.001- p=0.004), and IL-6 with handgrip strength (p=0.007). All inflammation biomarkers were associated with FI-OutRef (p<0.001). FI-OutRef was also associated with physical performance (all p<0.001); suPAR being the inflammatory biomarker with the highest impact when adjusting for inflammation. CONCLUSION: Inflammatory biomarkers are potentially feasible for systematic assessment of vulnerability. Moreover, suPAR may be an important mediator between organ dysfunction and physical performance.

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BACKGROUND: Older people have the highest incidence of acute medical admissions. Old age and acute hospital admissions are associated with a high risk of adverse health outcomes after discharge, such as reduced physical performance, readmissions and mortality. Hospitalisations in this population are often by acute admission and through the emergency department. This, along with the rapidly increasing proportion of older people, warrants the need for clinically feasible tools that can systematically assess vulnerability in older medical patients upon acute hospital admission. These are essential for prioritising treatment during hospitalisation and after discharge. Here we explore whether an abbreviated form of the FI-Lab frailty index, calculated as the number of admission laboratory test results outside of the reference interval (FI-OutRef) was associated with long term mortality among acutely admitted older medical patients. Secondly, we investigate other markers of aging (age, total number of chronic diagnoses, new chronic diagnoses, and new acute admissions) and their associations with long-term mortality. METHODS: A cohort study of acutely admitted medical patients aged 65 or older. Survival time within a 3 years post-discharge follow up period was used as the outcome. The associations between the markers and survival time were investigated by Cox regression analyses. For analyses, all markers were grouped by quartiles. RESULTS: A total of 4,005 patients were included. Among the 3,172 patients without a cancer diagnosis, mortality within 3 years was 39.9%. Univariate and multiple regression analyses for each marker showed that all were significantly associated with post-discharge survival. The changes between the estimates for the FI-OutRef quartiles in the univariate- and the multiple analyses were negligible. Among all the markers investigated, FI-OutRef had the highest hazard ratio of the fourth quartile versus the first quartile: 3.45 (95% CI: 2.83-s4.22, P < 0.001). CONCLUSION: Among acutely admitted older medical patients, FI-OutRef was strongly associated with long-term mortality. This association was independent of age, sex, and number of chronic diagnoses, new chronic diagnoses, and new acute admissions. Hence FI-OutRef could be a biomarker of advancement of aging within the acute care setting.

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OBJECTIVE: Mobility limitations relate to dependency in older adults. Identification of older patients with mobility limitations after hospital discharge may help stratify treatment and could potentially counteract dependency seen in older adults after hospitalization. We investigated the ability of four physical performance measures administered at hospital admission to identify older medical patients who manifest mobility limitations 30 days after discharge. DESIGN: Prospective cohort study of patients (≥65 years) admitted to the emergency department for acute medical illness. During the first 24 hours, we assessed: handgrip strength, 4-meter gait speed, the ability to rise from a chair (chair-stand), and the Cumulated Ambulation Score. The mobility level 30 days after discharge was evaluated using the de Morton Mobility Index. RESULTS: A total of 369 patients (77.9 years, 62% women) were included. Of those, 128 (40%) patients had mobility limitations at follow-up. Univariate analyzes showed that each of the physical performance measures was strongly associated with mobility limitations at follow-up (handgrip strength(women), OR 0.86 (0.81-0.91), handgrip strength(men), OR 0.90 (0.86-0.95), gait speed, OR 0.35 (0.26-0.46), chair-stand, OR 0.04 (0.02-0.08) and Cumulated Ambulation Score OR 0.49 (0.38-0.64). Adjustment for potential confounders did not change the results and the associations were not modified by any of the covariates: age, gender, cognitive status, the severity of the acute medical illness, and the Charlson Comorbidity Index. Based on prespecified cut-offs the prognostic accuracy of the four measures for mobility limitation at follow-up was calculated. The sensitivity and specificity were: handgrip strength(women), 56.8 (45.8-67.3), 75.7 (66.8-83.2), handgrip strength(men), 50.0 (33.8-66.2), 80.8 (69.9-89.1), gait speed, 68.4 (58.2-77.4), 81.4 (75.0-86.8), chair-stand 67.8 (58.6-76.1), 91.8 (86.8-95.3), and Cumulated Ambulation Score, 40.2 (31.6-49.2), 92.0 (87.1-95.4), respectively. CONCLUSION: Physical performance measures, particularly chair-stand and gait speed assessed at admission to an emergency department, were able to identify mobility limitation in acutely admitted older medical patients 30 days after hospital discharge.

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INTRODUCTION: Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients, and the most important cause of death in the developed world. Optimised treatment and care will benefit patients as well as the health economy. This study investigated in-hospital compliance with guidelines for treatment and care of patients with CAP. MATERIAL AND METHODS: A retrospective nationwide study examining 100 patient records from 20 Danish hospitals regarding patients 65 years and older admitted for CAP. RESULTS: A total of 74 patients with a mean age 81.6 years were included. The mean length of stay was 9.2 days, 30- and 90-day mortality rates were 12.2 and 17.6% and readmission rates 4% (seven days) and 9.5% (30 days). Severity assessment was made in two cases. Observations of vital parameters were unsystematic and the respiratory rate was measured only in six cases. Diagnostic tests and treatment initiation were mostly in accordance with guidelines. The mean number of days on intravenous antibiotics was 5.5. Nutrition and mobilisation were neglected or only sporadically addressed. No systematic plan for treatment and care was found. CONCLUSION: While medical treatment mainly concurred with guidelines, a potential for reduced costs by early discharge planning and use of systematic assessment tools for site-of-care and treatment decisions was indicated. The lack of systematic interventions in the prevention and treatment of malnutrition and functional decline constitutes a threat to a successful final patient outcome. FUNDING: The Danish Ministry of Health funded the study. TRIAL REGISTRATION: The Danish Data Register approved the project (J. No. 2010-41-5358).

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OBJECTIVES: To examine mechanisms underlying the increased inflammatory state of HIV-infected patients, by investigating the association of HIV-related factors, demography, lifestyle, and body composition with the inflammatory marker soluble urokinase plasminogen activator receptor (suPAR). METHODS: suPAR was measured in EDTA-plasma and associated with HIV-related factors (HIV-duration, combination antiretroviral treatment (cART), nadir CD4+ cell count, CD4+ cell count, and HIV RNA); demography; lifestyle; and body composition determined by Dual energy X-ray Absorptiometry (DXA) scan, in multiple linear regression analyses adjusted for biological relevant covariates, in a cross-sectional study of 1142 HIV-infected patients. RESULTS: Increased suPAR levels were significantly associated with age, female sex, daily smoking, metabolic syndrome and waist circumference. cART was associated with 17% lower suPAR levels. In cART-treated patients 10-fold higher HIV RNA was associated with 15% higher suPAR, whereas there was no association in untreated patients. Patients with CD4+ cell count <350 cells/µL had higher suPAR levels than patients with CD4+ cell count ≥350 cells/µL , though not significantly. We found no association with nadir CD4+ cell count or with duration of HIV-infection [corrected]. Finally, suPAR was not associated with adipose tissue distribution, but strongly associated with low leg muscle mass [corrected].In patients infected through intravenous drug use (IDU), CD4+ cell counts ≥350 cells/µL were associated with 27% lower suPAR (p = 0.03), andsuPAR was 4% lower pr. year during treatment (p = 0.05); however, there was no association with HIV RNA, duration of HIV-infection, nor cART [corrected]. CONCLUSION: We found elevated suPAR levels in untreated patients compared to patients on cART. Moreover, we observed a significant positive association between suPAR and HIV RNA levels in cART-treated patients. Age, HIV-transmission through IDU, metabolic syndrome, smoking, and low leg muscle mass were also significantly associated with suPAR levels. Our study therefore indicates, that also other aspects of living with HIV than virologic and immunologic markers add to the increased inflammation in HIV-infected patients.

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INTRODUCTION: Soluble urokinase plasminogen activator receptor (suPAR) is the soluble form of the membrane-bound receptor (uPAR) expressed predominantly on various immune cells. Elevated plasma suPAR concentration is associated with increased mortality in various patient groups, and it is speculated that suPAR is a low-grade inflammation marker reflecting on disease severity. The aim of this prospective observational study was to determine if the plasma concentration of suPAR is associated with admission time, re-admission, disease severity/Charlson Comorbidity Index Score, and mortality. METHODS: We included 543 patients with various diseases from a Danish Acute Medical Unit during a two month period. A triage unit ensured that only medical patients were admitted to the Acute Medical Unit. SuPAR was measured on plasma samples drawn upon admission. Patients were followed-up for three months after inclusion by their unique civil registry number and using Danish registries to determine admission times, readmissions, International Classification of Diseases, 10th Edition (ICD-10) diagnoses, and mortality. Statistical analysis was used to determine suPAR's association with these endpoints. RESULTS: Increased suPAR was significantly associated with 90-day mortality (4.87 ng/ml in survivors versus 7.29 ng/ml in non-survivors, P < 0.0001), higher Charlson Score (P < 0.0001), and longer admission time (P < 0.0001), but not with readmissions. The association with mortality remained when adjusting for age, sex, C-reactive protein (CRP), and Charlson Score. Furthermore, among the various Charlson Score disease groups, suPAR was significantly higher in those with diabetes, cancer, cardiovascular disease, and liver disease compared to those without comorbidities. CONCLUSIONS: SuPAR is a marker of disease severity, admission time, and risk of mortality in a heterogeneous cohort of patients with a variety of diseases. The independent value of suPAR suggests it could be of value in prognostic algorithms.

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