JAMDA 16 (2015) 258e261
JAMDA journal homepage: www.jamda.com
Letters to the Editor
Borrowing From Geriatrics to Treat Ebola in Africa
Edwin J. Hassid, MD California Pacific Medical Center San Francisco, California http://dx.doi.org/10.1016/j.jamda.2014.11.008
To the Editor: The current Ebola epidemic has severely strained the medical infrastructure in the 3 West African countries in which it is centered. It is reported that Sierra Leone has been so overwhelmed by the number of Ebola cases that it has been forced to treat patients at home instead of hospitalizing them. Even when patients are hospitalized, shortages of medical personnel often preclude the use of parenteral rehydration. A method borrowed from geriatrics may help solve this problem. Instead of rehydrating patients intravenously, one could instead use clysis, in which fluids are given through needles inserted under the skin. This time-tested technique has been effectively used in nursing homes where nurses may lack the skills to insert intravenous lines. The benefits of this technique include the ease and rapidity of insertion, as well as the fact that nonmedical personnel can be easily trained to provide it. Although clysis is not as effective as intravenous hydration at delivering large volumes of fluids and electrolytes, it can nonetheless be useful in rehydrating dehydrated patients, such as those with Ebola, especially when the alternative is no parenteral hydration at all.1 Another idea relates to the fact that, although mortality is high in cases of Ebola virus, some people survive and are presumably immune to the strain of Ebola that caused their illness. Able-bodied survivors of Ebola could be hired to care for new cases, and, if the care could be simplified, such as by using clysis instead of intravenous hydration, they could be rapidly trained to provide this care. Being immune to Ebola, they would not need to use the onerous isolation precautions needed by nonimmune health care workers and could instead use standard isolation techniques. This cadre of Ebola-immune workers could provide the bulk of direct contact with patients with Ebola. Nonimmune doctors and nurses could then minimize their direct contact with patients with Ebola and instead spend more of their time directing the immune workers. As a result, a small number of medical providers could then effectively care for a larger number of patients. I believe that instituting these simple measures would provide a way for the very limited number of medical personnel in the affected countries to safely care for a much larger number of patients and hopefully begin to slow the spread of this virulent illness.
References 1. Thomas DR, Cote TR, Lawhorne L, et al, and the Dehydration Council. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc 2008;9: 292e301.
Psychosocial Resources: Moderators or Mediators of Frailty Outcomes? To the Editor: Characterized by a diminished reserve and a reduced ability to cope with stressors, frailty is a multidimensional syndrome that remains one of the most fundamental challenges to health and aged care systems worldwide.1 Frailty is a dynamic entity,2 and as such, may be amenable to change with physical activity, protein supplementation, and/or a reduction in polypharmacy.3 In addition to these biomedical factors, an older adult’s psychosocial resources also can be considered as a potential target for frailty intervention, particularly in the early stages of frailty.4 Psychosocial resources include social support, well-being, coping style, and a sense of personal control.5 In recent years, the relationship between frailty and psychosocial resources has gained much research interest4,6e8: the general consensus is that an older person with higher psychosocial resources will have a greater ability to cope with frailty.4 Nonetheless, despite these established links between frailty and psychosocial resources, there is a paucity of research looking at how psychosocial resources can alter the outcomes of frailty. Being able to reliably predict adverse outcomes in frail older adults, including the likely response to potential therapies, is a key requirement for a good frailty measurement tool.9 Accordingly, it is reasonable to propose that a better understanding of the protective effect of psychosocial factors on frailty outcomes will inform the application of frailty measurement tools. When examining frailty and psychosocial resources together to investigate their impact on adverse health outcomes, there are 2 approaches to consider. First, psychosocial resources may be seen as moderators of the association between frailty and adverse outcomes. A moderator variable may change the strength and/or direction of the effect of a predictor (that is, frailty) on adverse outcomes, and is not necessarily causally related to the predictor and/or outcome.10 Moderation is usually tested statistically with interaction effects between the predictor and moderator variables on the outcome variable. Two recent studies have investigated the moderation effect of psychosocial resources on frailty outcomes in older people: psychosocial resources were found to be beneficial for frail older people in the hospital setting, shielding them from adverse clinical outcomes,11 but on the other hand, were not found to be beneficial in community-dwelling older people.12
Letters to the Editor / JAMDA 16 (2015) 258e261
Second, psychosocial resources may serve as mediators of the relationship between frailty and adverse outcomes. Mediation analyses tell us why or how psychosocial resources affect clinical outcomes in frail older people, because mediator variables are usually in the causal pathway between predictors and outcomes.10 It is possible that frailty alters the psychosocial resources of individuals and makes them even more vulnerable to adverse outcomes. Mediation analyses test the extent to which a mediator accounts for the effects of the predictor (frailty) on the outcomes.10 A recent article investigating the mediation effects of several factors on frailty found that although social participation increased the likelihood of frailty worsening, the worsening of frailty was not able to be explained by social participation, or lack thereof.13 However, no studies have yet looked at psychosocial resources as mediators of the association of frailty with adverse outcomes. All in all, it is likely that psychosocial resources are both moderators and mediators of frailty. However, with so little research in existence, no conclusive results can be drawn. Moreover, the 2 studies known to date have used only relatively short follow-up periods (3 years). Given the long life-course progression of psychosocial resources14 and frailty,15 it is likely that both moderation and mediation effects will become more evident with longer-term follow-up. Subsequently, a need exists to investigate the long-term protective effect of psychosocial resources on frailty, particularly using mediation effect studies. Gaining a more comprehensive understanding of how an older person handles frailty, whether by the use of coping mechanisms, having a strong sense of self-control, or an involvement in social support networks, can be used to tailor patient-centered care and potentially reduce the burden associated with frailty.
References 1. Rodriguez-Manas L, Feart C, Mann G, et al. Searching for an operational definition of frailty: A Delphi method based consensus statement: The frailty operative definition-consensus conference project. J Gerontol A Biol Sci Med Sci 2013;68:62e67. 2. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 3. Morley JE, Malmstrom TK. Frailty, sarcopenia, and hormones. Endocrinol Metab Clin North Am 2013;42:391e405. 4. Cooper R, Huisman M, Kuh D, Deeg DJ. Do positive psychological characteristics modify the associations of physical performance with functional decline and institutionalization? Findings from the longitudinal aging study Amsterdam. J Gerontol B Psychol Sci Soc Sci 2011;66:468e477. 5. Taylor SE, Seeman TE. Psychosocial resources and the SES-health relationship. Ann N Y Acad Sci 1999;896:210e225. 6. Sanchez-Garcia S, Sanchez-Arenas R, Garcia-Pena C, et al. Frailty among community-dwelling elderly Mexican people: Prevalence and association with sociodemographic characteristics, health state and the use of health services. Geriatr Gerontol Int 2014;14:395e402. 7. Andrew MK, Fisk JD, Rockwood K. Psychological well-being in relation to frailty: A frailty identity crisis? Int Psychogeriatr 2012;24:1347e1353. 8. Gobbens RJ, van Assen MA, Luijkx KG, et al. Determinants of frailty. J Am Med Dir Assoc 2010;11:356e364. 9. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013;381: 752e762. 10. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173e1182. 11. Dent E, Hoogendijk EO. Psychosocial factors modify the association of frailty with adverse outcomes: A prospective study of hospitalised older people. BMC Geriatr 2014;14:108. 12. Hoogendijk EO, van Hout HPJ, van der Horst HE, et al. Do psychosocial resources modify the effects of frailty on functional decline and mortality? J Psychosom Res 2014;77:547e551, http://dx.doi.org/10.1016/j.jpsychores. 2014.09.017. 13. Etman A, Kamphuis CB, van der Cammen TJ, et al. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Eur J Public Health; 2014 [Epub ahead of print]. 14. Pearlin LI, Nguyen KB, Schieman S, Milkie MA. The life-course origins of mastery among older people. J Health Soc Behav 2007;48:164e179.
259
15. Alvarado BE, Zunzunegui MV, Beland F, Bamvita JM. Life course social and health conditions linked to frailty in Latin American older men and women. J Gerontol A Biol Sci Med Sci 2008;63:1399e1406.
Elsa Dent, PhD, BAppSc (Hons) Discipline of Public Health The School of Population Health The University of Adelaide, Adelaide, Australia Emiel O. Hoogendijk, MSc Gérôntopole, Toulouse University Hospital Toulouse, France http://dx.doi.org/10.1016/j.jamda.2014.11.014
Searching for a Polypharmacy Threshold Associated With Frailty To the Editor: Polypharmacy is a major health issue, particularly in older people in nursing homes.1e5 It has been identified as an area in nursing homes in which there is a major need for research.6 Further, frailty has been identified as a major precursor to disability and mortality.7 Five cross-sectional studies (4 Australian and 1 Chinese) have assessed the link between polypharmacy and frailty status in various populations.8e12 Of them, 4 demonstrated a significant association.8e10,12 All of these studies used Fried et al’s criteria13 to define frailty, but polypharmacy definition varied between 4 and 6.5 drugs. These thresholds were arbitrarily chosen except in the study by Gnjidic et al.8 In this work, the authors defined the threshold of 6.5 drugs by using a receiver operating characteristics (ROC) curve and the Youden index. The study was performed in Australian community-dwelling men of 70 years and older; this threshold deserves to be confirmed in other countries and in cohorts including both men and women. Our study was aimed at assessing the threshold of polypharmacy associated with frailty in an elderly population in France. We carried out a cross-sectional study that included all the patients consulting for the first time at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability in Toulouse, France, from January 2013 to October 2013. This clinic is aimed at detecting frail or prefrail status, performing a comprehensive geriatric assessment, and organizing a plan of care in patients older than 65 years referred by their general practitioner.14 A standardized assessment of medical history, comorbidities, drug exposures, and cognitive status is completed and prospectively computerized. Frailty was defined by 3 or more of Fried et al’s criteria.13 We counted the number of drugs (including topical forms) at the time of visit for each patient. A regression logistic model assessing the link between the number of drugs and frailty was used to build a ROC curve. The threshold for polypharmacy was defined by the number of drugs with the maximal value of the Youden index. The Youden index is (sensitivity þ specificity 1) and corresponds to the maximal effectiveness of the marker.15 The association of polypharmacy thresholds (ranging from 4 to 12) with frailty in a multivariate logistic regression model adjusted for age, gender, cognitive impairment (Mini-Mental State Examination [MMSE]
JAMDA journal homepage: www.jamda.com
Letters to the Editor
Borrowing From Geriatrics to Treat Ebola in Africa
Edwin J. Hassid, MD California Pacific Medical Center San Francisco, California http://dx.doi.org/10.1016/j.jamda.2014.11.008
To the Editor: The current Ebola epidemic has severely strained the medical infrastructure in the 3 West African countries in which it is centered. It is reported that Sierra Leone has been so overwhelmed by the number of Ebola cases that it has been forced to treat patients at home instead of hospitalizing them. Even when patients are hospitalized, shortages of medical personnel often preclude the use of parenteral rehydration. A method borrowed from geriatrics may help solve this problem. Instead of rehydrating patients intravenously, one could instead use clysis, in which fluids are given through needles inserted under the skin. This time-tested technique has been effectively used in nursing homes where nurses may lack the skills to insert intravenous lines. The benefits of this technique include the ease and rapidity of insertion, as well as the fact that nonmedical personnel can be easily trained to provide it. Although clysis is not as effective as intravenous hydration at delivering large volumes of fluids and electrolytes, it can nonetheless be useful in rehydrating dehydrated patients, such as those with Ebola, especially when the alternative is no parenteral hydration at all.1 Another idea relates to the fact that, although mortality is high in cases of Ebola virus, some people survive and are presumably immune to the strain of Ebola that caused their illness. Able-bodied survivors of Ebola could be hired to care for new cases, and, if the care could be simplified, such as by using clysis instead of intravenous hydration, they could be rapidly trained to provide this care. Being immune to Ebola, they would not need to use the onerous isolation precautions needed by nonimmune health care workers and could instead use standard isolation techniques. This cadre of Ebola-immune workers could provide the bulk of direct contact with patients with Ebola. Nonimmune doctors and nurses could then minimize their direct contact with patients with Ebola and instead spend more of their time directing the immune workers. As a result, a small number of medical providers could then effectively care for a larger number of patients. I believe that instituting these simple measures would provide a way for the very limited number of medical personnel in the affected countries to safely care for a much larger number of patients and hopefully begin to slow the spread of this virulent illness.
References 1. Thomas DR, Cote TR, Lawhorne L, et al, and the Dehydration Council. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc 2008;9: 292e301.
Psychosocial Resources: Moderators or Mediators of Frailty Outcomes? To the Editor: Characterized by a diminished reserve and a reduced ability to cope with stressors, frailty is a multidimensional syndrome that remains one of the most fundamental challenges to health and aged care systems worldwide.1 Frailty is a dynamic entity,2 and as such, may be amenable to change with physical activity, protein supplementation, and/or a reduction in polypharmacy.3 In addition to these biomedical factors, an older adult’s psychosocial resources also can be considered as a potential target for frailty intervention, particularly in the early stages of frailty.4 Psychosocial resources include social support, well-being, coping style, and a sense of personal control.5 In recent years, the relationship between frailty and psychosocial resources has gained much research interest4,6e8: the general consensus is that an older person with higher psychosocial resources will have a greater ability to cope with frailty.4 Nonetheless, despite these established links between frailty and psychosocial resources, there is a paucity of research looking at how psychosocial resources can alter the outcomes of frailty. Being able to reliably predict adverse outcomes in frail older adults, including the likely response to potential therapies, is a key requirement for a good frailty measurement tool.9 Accordingly, it is reasonable to propose that a better understanding of the protective effect of psychosocial factors on frailty outcomes will inform the application of frailty measurement tools. When examining frailty and psychosocial resources together to investigate their impact on adverse health outcomes, there are 2 approaches to consider. First, psychosocial resources may be seen as moderators of the association between frailty and adverse outcomes. A moderator variable may change the strength and/or direction of the effect of a predictor (that is, frailty) on adverse outcomes, and is not necessarily causally related to the predictor and/or outcome.10 Moderation is usually tested statistically with interaction effects between the predictor and moderator variables on the outcome variable. Two recent studies have investigated the moderation effect of psychosocial resources on frailty outcomes in older people: psychosocial resources were found to be beneficial for frail older people in the hospital setting, shielding them from adverse clinical outcomes,11 but on the other hand, were not found to be beneficial in community-dwelling older people.12
Letters to the Editor / JAMDA 16 (2015) 258e261
Second, psychosocial resources may serve as mediators of the relationship between frailty and adverse outcomes. Mediation analyses tell us why or how psychosocial resources affect clinical outcomes in frail older people, because mediator variables are usually in the causal pathway between predictors and outcomes.10 It is possible that frailty alters the psychosocial resources of individuals and makes them even more vulnerable to adverse outcomes. Mediation analyses test the extent to which a mediator accounts for the effects of the predictor (frailty) on the outcomes.10 A recent article investigating the mediation effects of several factors on frailty found that although social participation increased the likelihood of frailty worsening, the worsening of frailty was not able to be explained by social participation, or lack thereof.13 However, no studies have yet looked at psychosocial resources as mediators of the association of frailty with adverse outcomes. All in all, it is likely that psychosocial resources are both moderators and mediators of frailty. However, with so little research in existence, no conclusive results can be drawn. Moreover, the 2 studies known to date have used only relatively short follow-up periods (3 years). Given the long life-course progression of psychosocial resources14 and frailty,15 it is likely that both moderation and mediation effects will become more evident with longer-term follow-up. Subsequently, a need exists to investigate the long-term protective effect of psychosocial resources on frailty, particularly using mediation effect studies. Gaining a more comprehensive understanding of how an older person handles frailty, whether by the use of coping mechanisms, having a strong sense of self-control, or an involvement in social support networks, can be used to tailor patient-centered care and potentially reduce the burden associated with frailty.
References 1. Rodriguez-Manas L, Feart C, Mann G, et al. Searching for an operational definition of frailty: A Delphi method based consensus statement: The frailty operative definition-consensus conference project. J Gerontol A Biol Sci Med Sci 2013;68:62e67. 2. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 3. Morley JE, Malmstrom TK. Frailty, sarcopenia, and hormones. Endocrinol Metab Clin North Am 2013;42:391e405. 4. Cooper R, Huisman M, Kuh D, Deeg DJ. Do positive psychological characteristics modify the associations of physical performance with functional decline and institutionalization? Findings from the longitudinal aging study Amsterdam. J Gerontol B Psychol Sci Soc Sci 2011;66:468e477. 5. Taylor SE, Seeman TE. Psychosocial resources and the SES-health relationship. Ann N Y Acad Sci 1999;896:210e225. 6. Sanchez-Garcia S, Sanchez-Arenas R, Garcia-Pena C, et al. Frailty among community-dwelling elderly Mexican people: Prevalence and association with sociodemographic characteristics, health state and the use of health services. Geriatr Gerontol Int 2014;14:395e402. 7. Andrew MK, Fisk JD, Rockwood K. Psychological well-being in relation to frailty: A frailty identity crisis? Int Psychogeriatr 2012;24:1347e1353. 8. Gobbens RJ, van Assen MA, Luijkx KG, et al. Determinants of frailty. J Am Med Dir Assoc 2010;11:356e364. 9. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013;381: 752e762. 10. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173e1182. 11. Dent E, Hoogendijk EO. Psychosocial factors modify the association of frailty with adverse outcomes: A prospective study of hospitalised older people. BMC Geriatr 2014;14:108. 12. Hoogendijk EO, van Hout HPJ, van der Horst HE, et al. Do psychosocial resources modify the effects of frailty on functional decline and mortality? J Psychosom Res 2014;77:547e551, http://dx.doi.org/10.1016/j.jpsychores. 2014.09.017. 13. Etman A, Kamphuis CB, van der Cammen TJ, et al. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Eur J Public Health; 2014 [Epub ahead of print]. 14. Pearlin LI, Nguyen KB, Schieman S, Milkie MA. The life-course origins of mastery among older people. J Health Soc Behav 2007;48:164e179.
259
15. Alvarado BE, Zunzunegui MV, Beland F, Bamvita JM. Life course social and health conditions linked to frailty in Latin American older men and women. J Gerontol A Biol Sci Med Sci 2008;63:1399e1406.
Elsa Dent, PhD, BAppSc (Hons) Discipline of Public Health The School of Population Health The University of Adelaide, Adelaide, Australia Emiel O. Hoogendijk, MSc Gérôntopole, Toulouse University Hospital Toulouse, France http://dx.doi.org/10.1016/j.jamda.2014.11.014
Searching for a Polypharmacy Threshold Associated With Frailty To the Editor: Polypharmacy is a major health issue, particularly in older people in nursing homes.1e5 It has been identified as an area in nursing homes in which there is a major need for research.6 Further, frailty has been identified as a major precursor to disability and mortality.7 Five cross-sectional studies (4 Australian and 1 Chinese) have assessed the link between polypharmacy and frailty status in various populations.8e12 Of them, 4 demonstrated a significant association.8e10,12 All of these studies used Fried et al’s criteria13 to define frailty, but polypharmacy definition varied between 4 and 6.5 drugs. These thresholds were arbitrarily chosen except in the study by Gnjidic et al.8 In this work, the authors defined the threshold of 6.5 drugs by using a receiver operating characteristics (ROC) curve and the Youden index. The study was performed in Australian community-dwelling men of 70 years and older; this threshold deserves to be confirmed in other countries and in cohorts including both men and women. Our study was aimed at assessing the threshold of polypharmacy associated with frailty in an elderly population in France. We carried out a cross-sectional study that included all the patients consulting for the first time at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability in Toulouse, France, from January 2013 to October 2013. This clinic is aimed at detecting frail or prefrail status, performing a comprehensive geriatric assessment, and organizing a plan of care in patients older than 65 years referred by their general practitioner.14 A standardized assessment of medical history, comorbidities, drug exposures, and cognitive status is completed and prospectively computerized. Frailty was defined by 3 or more of Fried et al’s criteria.13 We counted the number of drugs (including topical forms) at the time of visit for each patient. A regression logistic model assessing the link between the number of drugs and frailty was used to build a ROC curve. The threshold for polypharmacy was defined by the number of drugs with the maximal value of the Youden index. The Youden index is (sensitivity þ specificity 1) and corresponds to the maximal effectiveness of the marker.15 The association of polypharmacy thresholds (ranging from 4 to 12) with frailty in a multivariate logistic regression model adjusted for age, gender, cognitive impairment (Mini-Mental State Examination [MMSE]
