Journal of the Indian Academy of Geriatrics

: 2021  |  Volume : 17  |  Issue : 4  |  Page : 111--119



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 Comparision of Clinical Outcomes Across Select Age Groups, Elderly Compared with Young with Novel SARS COVID 19 Infection. A Retrospective Hospital Based Cohort Study from A Tertiary Care Hospital in Kerala

Arun David, Alex Baby Paul, Priya Vijayakumar, George Paul

Department of Geriatrics, Amrita Institute of Medical Science and Research, Kochi, Kerala, India

Background: Severe acute respiratory syndrome corona virus 2 (SARS-COV-2) pandemic affected the entire world since 2019. India being one among the worst affected nation with the pandemic. This study was done to identify the difference in clinical outcome in elderly comapred with other age groups.

Objective: To study about differences in co morbidity profile and clinical outcome between elderly patients and other age groups affected with COVID-19 infection.

Methods: Retrospective study was conducted. Data of 330 patients diagnosed and treated with COVID-19 infection were analyzed for a period of two months in the defined time period. Patients were grouped into two categories. Patients above the age of 65 diagnosed and treated for COVID 19 was included as Elderly group and the rest of the patients were in control group. The co morbidities and clinical outcome among both groups were analyzed.

Results: 330 patients were analysed among which 263 patients were less than 65 and 67 were elderly. There was a higher prevalence of Coronary artery disease (64.5%), Chronic kidney disease (63.6%), Cerebrovascular accident (62.5%) and Chronic obstructive lung disease (75%) among the elderly group. Non invasive ventillation (51.2%) and Mechanical ventilation (64.7%) was required more among the elderly. Sepsis (58.8%), Respiratory failure (52%), ARDS (64.3%), Heart failure (85.7%), Acute kidney injury (64.3%), Hypoproteinemia (55.6%), Metabolic acidosis (61.5%) and Coagulopathy (71.4%) was more among the elderly group with statistically significant p value <0.001. Comparing the clinical outcome mortality rate (59.1%) was more among the elderly compared to patients less than 65 years.

Conclusion: From the current study it was very evident that elderly patients admitted due to COVID-19 infection had more co morbidities, complications and worse outcome compared to the younger patients. Clinicians and Geriatricians should emphasize on meticulous care in elderly age group with SARS COVID 19 infection.

 Correlation between Severity of the Chronic Kidney Disease and Cognitive Decline

K. S. Kesavaraj, G. Jayalakshmi, G. S. Shanthi

Department of Geriatric Medicine, Madras Medical College, Chennai, Tamil Nadu, India

Background: Prevalence of Chronic kidney disease (CKD) is on the rise in the Indian population due to long standing comorbidities like diabetes, hypertension and partly by improved longevity following advanced remedies. They have high risk of developing cognitive impairment compared to general population, because of increased cerebrovascular events, impaired clearance of uremic metabolites and polypharmacy in CKD patients. Cognitive decline in patients with kidney disease may affect the level of compliance with dialysis treatment, medication adherence and fluid & dietary restrictions. Therefore, early identification of possible precursors of dementia and treatment of modifiable risk factors is of paramount importance.

Objectives of the Study: To determine the correlation between severity of the Chronic kidney disease and cognitive decline using Addenbrooke's cognitive score.

Methodology: This study included 150 CKD patients aged 60 and above from either sexes selected randomly excluding subjects with parkinsonism, stroke and dementia. We used eGFR values based on the MDRD formula to categorize the participants into Stage 2, Stage 3a, Stage 3b, Stage 4 and Stage 5 (ESRD) as defined by KDIGO. Prevalence of Cognitive decline was evaluated using Addenbrooke's cognitive examination (ACE-III) score in these patients. Results were analysed by using IBM SPSS software version 2.0.

Results: In this cross sectional study , the stage-wise prevalence of CKD were respectively 2%, 12%, 46%, 33% and 7% for G2, G3a, G3b, G4 and G5. Among the study population 139 had Cognitive decline based on Addenbrooke's score (ACE) and 11 of them had No Cognitive decline. In CKD stage G4 & G5 the prevalence of cognitive decline is 100% compared to G3 & G2 which is 87% and the difference between these two were statistically significant (p < 0.05). Among the study variables literacy of the individual had significant correlation with cognitive decline. Other variables like Hypertension, Dyslipidemia, Diabetes and Smoking were found to be insignificant.

Conclusion: In our study population with CKD 92.66 % had cognitive decline with significant overall reduction in attention (62%), language function (68%) and visuo-spatial function (47%). In CKD severe categories (G4 & G5) had more prevalence of cognitive decline compared to mild (G2 & G3) and their difference in prevalence was statistically significant. Based on the above finding, cognitive decline was positively associated with severity of the disease.

 Intrinsic Capacity of Community Dwelling Older Adults: An Observational Study from South India

Abhijith Rajaram Rao, Prabha Adhikari

Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India

Objectives: WHO has conceptualized the use of Intrinsic capacity (IC) as a measure of an individual's functional capacity. The objective of this study was to investigate the proportion of older adults, aged 60 years and above, living in the community with impaired intrinsic capacity and its different domains.

Materials and Methods: The study was a cross-sectional study, conducted in the community. Community dwelling older adults who were not moribund, and able to provide informed consent were included. A trained healthcare staff conducted documented socio-demographic factors and conducted comprehensive geriatric assessment (CGA). Vitality was assessed using unintentional 3 kg weightloss and body-mass index (BMI). Vitality was scored as 2 if both were normal, score was 1 if anyone was true, and 0 if BMI was <18.5 with loss of weight. Cognition was assessed using 3-word recall and mini-mental status examination. The score was 0 if both were impaired, 1 if either of them were impaired, and 2 if both were normal. Sensory domain included hearing assessment using whisper test and vision using a screening question. The score was 0 if both were impaired, if either were impaired the score was 1 and 2 if both were intact. The psychological domain was assessed with a screening question and GDS-15. And similar to the cognition domain, participants were score between 0 to 2. Locomotor domain was assessed using the timed-up and go test and 30-second chair rise test and the participants were scored 2, 1 and 0 according to their ability to perform both the test, either one of them or neither of them, respectively. All statistical analyses were performed using Stata V14.

Results: A total of 1,000 older adults aged 60 years and above were included, and 629 (63%) of them were women. The mean (±SD) age of the population was 68.5 ± 7.48 years, 778 (79%) were below the age of 75 years. 821 (82%) had intact activities of daily living (ADL). Only 45 (4.5%) of the participants had a completely intact IC, whereas 180 (17.98%) had impairment in one domain. Vitality, cognition, mood, sensory and locomotor domains were impaired in 156 (16%), 243 (24%), 102 (10%), 750 (75%) and 732 (73%) respectively. Taking ADL as gold standard, total score of intrinsic capacity was corelated with ADL to find out suitable cut-off value for good intrinsic capacity in older adults. A score of ≥7, with optimum sensitivity (68.86%) and specificity (50.28%) was selected. Increasing age, presence of hypertension, diabetes, cardiovascular disease, chronic respiratory illness and multimorbidity were associated with poor intrinsic capacity.

Conclusion: The proportion of older adults with decline in IC is high. Sensory and locomotor domains were the most affected. Advancing age and comorbidities are associated with decline in IC. These domains have a scope for intervention through screening and correction of hearing and vision and physical therapy. Further longitudinal studies are needed to establish the prognostic role of IC.

 Prevalence of Sarcopenia among Ambulatory Elderly (>65 Years) with Type 2 Diabetes Mellitus

Amtoj Singh Lamba, Monica Gupta, Sarabmeet Singh Lehl, Ravinder Kaur1, Anita S. Malhotra2

Departments of General Medicine, 1Radiodiagnosis and 2Physiology, Government Medical College and Hospital, Chandigarh, India

Background: Sarcopenia is defined as progressive and generalized loss of muscle mass, strength and physical performance and is responsible for reduced mobility and increased incidence of falls, fractures, functional disability, and dependence. There is a dearth of comprehensive data addressing the prevalence of sarcopenia in India among elderly with type 2 diabetes mellitus (T2DM).

Objective: To define prevalence of sarcopenia in ambulatory geriatric patients (>65 years) with type 2 diabetes mellitus.

Materials and Methods: A cross- sectional study was carried out comprising of 50 ambulatory patients with the diagnosis of type 2 diabetes mellitus. Participants with inflammatory or degenerative arthritis, chronic kidney or liver disease, BMI < 18.5 and advanced Alzheimer's / cognitive impairment were excluded from the study. Participants were assessed for sarcopenia using muscle mass, muscle strength and functional status. Muscle mass measurement was done using bioelectrical impedance analysis to calculate skeletal muscle index. Muscle strength and functional status was assessed using hand grip strength and short physical performance battery respectively. Using them, the prevalence of sarcopenia was estimated as per AWGS (Asian Working Group for Sarcopenia) recommendations.

Results: A total of 50 individuals participated in the study. Males outnumbered females (54% vs 46%) and 56% of the study population belonged to the urban area. The mean skeletal muscle index among males was 7.92 (± 1.92) kg/m2 and among females was 6.93 ((± 2.26) kg/m2. The mean hand grip strength among males was 20.71(± 7.87) kg and among females was 14.28 (±3.35) kg. The mean SPPB score in the study population was 6.46 (±2.10) [Males 7.07(± 1.89) Females 5.74 (±2.13)]. Among males, 9 participants had SMI <7 kg/m2, 25 had HGS< 28.0 kg and 19 had SPPB score <9 (p value <0.001). Likewise, among females, 2 participants had SMI<5.4 kg/m2, 20 had HGS< 18 kgs and 21 had SBBP score<9 (p value <0.001). Using AWGS criteria to assess sarcopenia, only 1 female and 2 males were found to have sarcopenia and 1 female and 7 males were found to have severe sarcopenia.

Conclusion: Using AWGS criteria, the overall prevalence of sarcopenia in the study population was 22% with a prevalence of 33.33% and 8.69% among males and females respectively. Therefore, early identification of sarcopenia should prompt establishment of effective interventions to improve the patient's functional status and quality of life.

 Risk Factors for Ischemic Stroke in Young Adults and Elderly in A Tertiary Care Hospital in Rural India

Challa Indrani, Hema Kumar, Betsy Mathew, Reddy Bhargav

PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Introduction: Stroke is leading cause of death and disability and can affect individuals of any age, although its incidence and prevalence increases sharply with age. Most patients with ischemic stroke have multiple risk factors, recognition and control of which are important in primary and secondary preventive strategies.

Objectives: To compare risk factor profile of ischemic stroke in young adults and elderly patients.

Materials and Methods: This is an observational cross-sectional hospital-based study conducted in PES Institute of Medical Sciences & Research, Kuppam from December 2018 to June 2020. Adults admitted with clinical and radiological evidence of acute ischemic cerebrovascular events were included. Traditional risk factors for stroke were compared in the young adults (less than 60 years old) and the elderly (60 years old and above). Data was analyzed using SPSS version 21.

Results: A total of 120 patients were studied of which 42 were young adults (<60 years; mean age50.6±6.5) and 78 were elderly (≥60 years; mean age 70.5±8.1). Of all the traditional risk factors which were compared in the two groups, hypertension alone was significantly more common in the elderly as compared to young adults (p=0.012).

Conclusion: Among the traditional risk factors systemic hypertension alone was found to be significantly more common in elderly with acute ischemic stroke. Hence it is important to abolish the myth that high blood pressure is “normal” for elderly and does not require as aggressive control as in younger persons. Health education of public about good control of hypertension including isolated systolic hypertension which is common in elderly goes a long way in stroke prevention.

 Correlation between Polypharmacy and Gait Speed in Older Adults

Thotup Bhutia, P. Dinesh, G. Usha, Priya Malini

Department of Geriatric Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

Background: Polypharmacy is an important geriatric syndrome in elderly. It is defined as use of > 5 medication. It is an independent risk factor for disability, falls and mortality in elderly. Gait speed is marker of adverse outcomes like falls, mortality and disability in elderly. This study is done to see correlation between polypharmacy and gait speed in elderly.

Objective: To analyse the relationship between polypharmacy and gait speed in older adults.

Methodology: A cross sectional analytical study was conducted among outpatients in department of geriatric medicine, Madras medical college, Chennai. Sample size includes 144 patients above 60 years from both sexes selected by simple random sampling after application of inclusion and exclusion criteria. Patients with known neurological disorder like dementia, stroke, Parkinson's disease, using assistive devices, hearing and vision impairment, any condition which impair mobility are excluded from the study. A detailed medication history and medical history were obtained by available medical records and review of medications. Over the counter medication use, herbal agents and non-prescription drugs were taken into account. Gait speed was assessed among the groups by instructing the individuals to walk at their usual pace along an eight meter track. The first two and last two meters were disregarded, since these corresponds to the periods of acceleration and deceleration of gait. Time taken to complete four meters was noted. Normal gait speed is 80cm/sec (0.8m/s) to 120cm/sec (1.2m/s). Data are tabulated and statistically analysed.

Results: Mean age of study population was 70.21±7.28 in no polypharmacy group and 70.95±5.82 in polypharmacy group. Mean gait speed of study population was 67.45±14.77 in no polypharmacy group and 57.59±10.57 in polypharmacy group. Association between polypharmacy and gait speed persisted even after adjusting for age, sex, education and body mass index.

Conclusion: In this study, elderly people taking multiple medications exhibited slowness in gait speed which clearly indicates polypharmacy adversely affects gait speed. So restricting the number of medications to the minimum will help to avoid the complications with regard to drug therapy in elderly.

 Study on Fall Risk Assessment in Older Fallers Attending Fall Clinic

C. Kavinilavu, K. Uma Kalyani, S. Deepa

Department of Geriatric Medicine, Madras Medical College & RGGGH, Chennai, Tamil Nadu, India

Introduction: The risk for falling increases in the elderly population, resulting in an increase in serious outcomes and associated health care costs. Fall risk assessment in routine clinical evaluation is important for early identification of fall risk in elderly and provide information that can guide interventions at the earliest.

Objectives: To determine the risk of fall among older fallers by Timed up and go test (TUG) and performance-oriented mobility assessment (POMA).

1. To assess the risk factors for falls in older fallers.

Methodology: A cross sectional study was conducted among 113 elderly patients aged 60 and above with history of fall attending the fall clinic of Geriatric department of Madras Medical College, Chennai from Jan 2019 and Jan 2021. Detailed history on comorbidity status, medications, hearing and vision impairment, history of urinary incontinence,use of assistive devices were collected. Hearing and vision were assessed clinically using whisper test and Snellen's chart respectively. Blood pressure was measured in sitting/lying and in the standing position and sensations were tested in both feet. Patients medications were reviewed. Risk of fall was assessed using the Timed up and go test and POMA scale and results were recorded and analysed.

Results: Out of 113 elderly, 37% (n= 42) were found to have high risk of fall. Among the risk factors analysed 45% (n=51) were on polypharmacy and 40.7% (n=46) had multimorbidity as contributing factors. 15% (n=18) were found to have vision impairment. out of which, 8 patients had cataract. Hearing impairment was noticed among 13% (n=15) of the fallers and only 2 patients were using hearing aids. Urinary incontinence was diagnosed among 11% (n=12). Use of assistive devices for walking was found among 5% (n=6) of fallers. Other risk factors like peripheral neuropathy and orthostatic hypotension were found among 6% (n=7) and 5% (n=6) respectively.

Conclusion: In this study, nearly one third of the older fallers have high risk of fall. Polypharmacy and multimorbidity were the most common contributing factors. Untreated hearing and visual impairment and urinary incontinence were other major risk factors, treatment of which will decrease the incidence of fall. Proper and appropriate use of assistive devices in patients with impaired mobility is essential. Review of medications and prescription of appropriate drugs would reduce risk of fall among elderly patients.

Keywords: Elderly, fall risk assessment, risk factors

 Poisoning in Elderly - A Retrospective Study

V. Vishnupriya Reddy, Betsy Mathew, K. Ganesh

PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Introduction: Poisonings are common in India. In the elderly, unintentional, accidental poisoning is said to be common due to factors like impaired cognition, poor vision and hearing. In most studies, elderly account for a small fraction of the total poisoning exposures. But they have a high risk for mortality due to multiple comorbidities, frailty and age-related changes in renal and hepatic function.

Objectives: To compare the profile of acute self-poisoning cases among young adults (below 60 years of age) and elderly (60 years and older) admitted to our ICU.

Materials and Methods: This was a retrospective study conducted in PES Institute of Medical Sciences & Research, Kuppam from March 2020 to March 2021. All acute self-poisoning cases admitted to ICU were included. Descriptive analysis was done by calculating mean +/- standard deviation. For inferential analysis Chi square test was used.

Results: A total of 200 patients were studied of which 183 (91.5%) were young adults (mean age 28.8±11.1 years) and only 17 (8.5%) were elderly (mean age 65.2±6.1 years). Mortality was 2.7 % in young and 5.95% in old but the difference was not statistically significant. Overall Mean length of hospital stay was 5.7 days where as it is 5.1 days in young adults and 14.2 days in elderly. Longer length of hospital stay (above 7 days) was more in elderly (64.3%) than in the young (25.6%) p value 0.002. The type of poison consumed was not significantly different in the two groups and organophosphorus compound was most preferred in both groups.

Conclusion: Although literature states that majority of acute self-poisoning in elderly is accidental, in our series all were intentional self-harm. Depression is common in elderly but often missed by medical practitioners due to its atypical presentation and suicide attempts are more likely to be successful in them. General management of poisoning in elderly parallels that in young but comorbidities and concurrent medications have to be considered when treating them. Once patient has recovered special attempt must be made to enquire into the circumstance of the overdose-social isolation, bereavement, physical illness which can be tackled by a multi-disciplinary team.

 A Descriptive Study on Urinary Incontinence in Older People Attending Geriatric OPD

S. Nivedita, D. Priyamalini, S. Deepa

Department of Geriatric Medicine, Regional Geriatric Centre, Madras Medical College and RGGGH, Chennai, Tamil Nadu, India

Introduction: Urinary incontinence is one of the geriatric giants which is commonly overlooked by both patients and physicians. It has significant health implications and requires detailed assessment and holistic management.

Objectives: To determine the prevalence of various types of incontinence among older people To assess the various risk factors associated withurinary incontinence.

Methodology: A cross sectional study was conducted among older patients aged 60 and above with history of urinary incontinence attending the Geriatric outpatient department, Madras Medical College, Chennai from January 2019 to November 2021. The 3 Item questionnaire was administered to all the patients. Detailed history regarding urinary symptoms, comorbidities, medications, parity, hysterectomy were collected. Clinical examination including general examination, systemic examination, cognition by MMSE, functional status by Barthel index and examination of the genitourinary system was done. Data were obtained and analysed.

Results: Of the 121 older participants, 59.5% (n = 72) were females and 40.4% (n = 49) were males. 33.88 % (n = 41) had urge incontinence, 34.7% (n= 42) had stress incontinence, 17.35% (n = 21) had mixed incontinence, 8.33% (n = 6) had overflow incontinence and 9.09% (n = 11) had functional incontinence. It is found to increase with age (>70) in both sexes 33 (67.34%) male, 43(%) female patients. The comorbidities associated were diabetes (69%), hypertension (57%), coronary artery disease (26.22%), stroke (24.7%), hypothyroidism (15.7%), chronic obstructive pulmonary disease (24.79%), osteoarthritis (31.43%), UTI (15.7%) and constipation (14.8%). Multi morbidity was seen in 62.53% of patients with incontinence. Mild cognitive impairment was seen in 3.31% .10.74% of patients with incontinence were partially dependent for their ADL. Polypharmacy was seen in 33% of patients with incontinence. In males, prostate enlargement was seen in 16.33%. In females, 34.27% are multiparous, 22.2% had atrophic vaginitis, 16.6% had cystocele.

Conclusion: In this study, Stress incontinence was found to be commonest type of incontinence followed by urge incontinence. Around 70% of the patients with incontinence had diabetes. One third of patients with incontinence were on 5 or more drugs.

 Improvement in Quality of Life in COPD Patients with Minimal Interventions

Prashant Ahlawat, Prateek Upadhyay1

Departments of General Medicine and 1Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India

Objective: Describing interventions which improves quality of life in COPD patients.

Materials and Methods: COPD is chronic, debilitating disease for which main focus is done on treatment of symptoms such as cough and bronchoconstriction. With time our knowledge has improved and have gained a lot of insight in pathophysiology of COPD. Surgical interventions such as lung transplantation have not reached to common man however minimal interventions can be done at peripheral centers. much of the technology can be made available at multiple centers and is affordable to common man. Some of the interventions which can be done are: 1) Lung flute is a handheld device that is approved by FDA to supplement patients' mucus clearing ability. Patients blow vigorously through the mouthpiece of flute and breathe passes through mylar reed which causes vibration deep within the lungs leading to loosening of mucus within the airway. 2) Bronchial rheoplasty: is done under monitored anesthesia care and deep sedation. This system delivers pulsed electrical fields (high frequency short duration, non-thermal electrical fields) to airway epithelium. This causes cell death via disrupting homeostasis leading to cellular swelling and apoptosis. 3) Targeted lung denervation(TLD) therapy is delivered via a dual cooled radiofrequency catheter designed to target tissue heating at depth, thereby producing a narrow band of ablation around main bronchus while minimizing effects to mucosal surface. 4) Bronchoscopic lung volume reduction or valve surgery is simple procedure of about 30 min duration The valve is one way and put in diseased portion of lung which cuts off supply of disease portion of lung thus leads to collapse of the diseased lung and inflation of normal lung and leading to improvement in symptoms. 5) Biologic therapies: Inflammatory markers which are targeted in asthma and COPD are immunoglobulin E, interleukins such as IL-5, IL-4, IL-13,IL-17 IL-33 ; thymic stromal lymphopoietin, CXCR2 AND CCR3.CXCR2 antagonists, Navarixin; IL-5 therapies – mepolizumab, reslizumab; benralizumab – monoclonal antibody targeting IL-5Rα; monoclonal antibodies that targets IL -13 are lebrikizumab and tralokinumab. These are helpful by decreasing airway eosinophilia and asthma exacerbations. 6) Stem cells can be unipotent, totipotent or pluripotent. Cytokines released by MSCs can help in repairing the structure of tissue, improvement in function of tissue by decreasing inflammation and regeneration of new cells. MSCs can effectively inhibit the progression of COPD by regulating the balance between protease and anti- protease. Additionally, stem cell transplant can reduce oxidative stress.

Results: Above interventions results in significant improvement in quality of life in COPD patients.

 Analysis of Factors Influencing Frailty in Elderly Patients

K. Soundharya, D. Thangam, G. S. Shanthi

Department of Geriatric Medicine, MMC and RGGGH, Chennai, Tamil Nadu, India

Introduction: Frailty is a clinical syndrome that involves multiple physiological systems characterized by decreased reserve and impaired response to stress and influenced by multimorbidity, sarcopenia and various other risk factors. If intervened early it can be reversible. Hence screening for frailty is useful to identify individuals at high risk of developing adverse health outcomes. Sarcopenia the syndrome of loss of muscle mass, quality and strength, is more common in older adults and has been considered a precursor syndrome or the physical manifestation of frailty. This Study aims in finding the relationship between frailty and various other risk factors including sarcopenia.

Objectives: To assess the degree of frailty and sarcopenia across age, sex, multimorbid status and to assess the relationship of frailty with regard to multimorbidity, polypharmacy, functional status and functional performance in elderly patients screened at frailty clinic at Geriatric op department at RGGGH.

Methodology: Cross sectional observational study. 115 patients who were screened at frailty clinic in Geriatric op department were included in this study. Fried's criteria was used to determine the frailty and Ishii's formula was used to identify sarcopenia. The comorbid conditions and medication history of all patients were recorded. Functional status was assessed using Katz Index and Functional performance was examined using Gait speed and Timed Up and Go test (TUG) test .The relationship between frailty and sarcopenia, relationship between frailty and other risk factors were statistically analysed using SPSS version 21.

Results: Among 115 study population 58.3% (n-67) were male and 41.7% (n -48) were female. Among them 30.4 % (n-35) were frail, 54.8% (n-63) were prefrail and 14.8% (17) were non frail. In the age group of (60 -69 ,n- 48) 27% were frail and 53 % were prefrail, in the age group (70-79, n-47) 31.9 % were frail and 55.3% were prefrail and above 80 years of age (n-20) 35% were frail and 65 % were prefrail. Frailty was high in very old elderly .Among participants 57% (n-20) of female individuals were frail and 42.8% (n-15) of male were found to be frail. 60 % of frail individuals had multimorbidity but there was no significant statistical association and 51% of frail individuals had history of polypharmacy both of which had no significant statistical association in our study. Functional dependence was more in frail group which was statistically significant with p value (0.023) Functional performance was poor in frail group which was also statistically significant with p value (0.001).80%of frail individuals had sarcopenia in our study ,Frailty and sarcopenia had significant statistical association with p value (0.000).

Conclusion: In our study frailty was more prevalent in female than male similar to the previous studies conducted in southern India ,Italy and it's prevalence increases with increasing age .Several risk factors association with frailty were assessed,among them sarcopenia had highest influence followed by poor functional performance and impaired functional status. Although many individuals with multimorbidity and history of polypharmacy had frailty, the correlation was not statistically significant.

 An Association between Thyroid Function and EGFR in Patients with Chronic Kidney Disease – A Hospital Based Cross Sectional Study

P. Kavin, V. Subramanian

Government Villupuram Medical College and Hospital, Villupuram, Tamil Nadu, India

Introduction: In chronic kidney disease (CKD), as the glomerular filtration rate (GFR) falls, possibility of developing clinical and subclinical hypothyroidism is higher making more challenging for the clinician to timely diagnose and treat it.

Objectives: To study the prevalence of hypothyroidism among CKD patients and its association between eGFR.

Methodology: A cross sectional study was performed in Government Villupuram Medical College Hospital on 300 non-dialysis dependent CKD inpatients (>18 years of age) from November 2019 to October 2020 to determine the prevalence of hypothyroidism and its association with eGFR.

Inclusion Criteria: All Non-Dialysis dependent CKD patients age more than 18 years.

Exclusion Criteria: All subjects on drugs causing hypothyroidism, on antithyroid drugs presumably for hyperthyroidism, end stage renal disease on renal replacement therapy, polycystic kidney disease, glomerulonephritis, rheumatologic or autoimmune diseases or prior renal transplant.

Results: Among 300 patients, 49 (16.33%) had overt hypothyroidism, 86(28.67%) had subclinical hypothyroidism . There was no observed variability in distribution in respect to age and gender. Odds of developing hypothyroidism rose significantly with fall in eGFR with cross production ratio from 0.65(stage-2) to 2.5(stage-5) CKD- (p < 0.001). There was also Increased prevalence of diabetes mellitus with coexisting hypothyroidism. Dyslipidaemia, Hypercholesterolemia, Increased BMI, Increased Systolic BP are seen in overt and subclinical hypothyroidism cases with significantly lower serum albumin, serum calcium and lower Mean Hb.

Conclusion: There is an inverse association between eGFR & hypothyroidism. Clinicians must consider the dangers of thyroid disease and provide appropriate treatment in conjunction to treating CKD. In future more definitive studies are needed to examine whether correction of confirmed hypothyroidism with thyroid hormone replacement could ultimately improve kidney outcomes.

 Impact of Multimorbidity on Functional Status in Older Adults Attending Geriatric Outpatient Department

M. Divyavani, S. Mohanavel, D. Priyamalini, S. Deepa

Department of Geriatric Medicine, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Multimorbidity is common in older people, it's association with functional status of elderly determines the quality of life of older adults. Multi morbidity leads to increased health service utilization as well as reduced life expectancy associated with high economic burden. This study was done to assess the association of multimorbidity and it's impact on functional status of older people attending geriatric out patient department, Madras Medical College.

Objectives: To determine the relationship between: 1. Multimorbidity (≥2 diseases) and functional status, 2. Multimorbidity and gait speed.

Methodology: Cross sectional and observational study 150 patients with multimorbidity attending Geriatric OPD were selected by simple random sampling. The functional status of the patients was assessed by using Modified Barthel Activities of Daily Living (ADL) index, Lawton Instrumental Activities of Daily Living (IADL) Scale and performance status was assessed using Gait Speed. And the results were statistically analyzed.

Results: Fifty seven percent of study participants were male. Patients having 3 diseases were more in this study constituting about 43%, followed by 2 diseases with 35% and 4 diseases with 22%. In this study males have greater number of multimorbid disease. 60% of the patients were functionally dependent partially in at least one ADL activity. This study had found that as the multimorbidity increase from 2 and above more patients became partially dependent in function and is statistically significant (P value 0.022). Mean modified Barthel ADL score decreased significantly as the multimorbid diseases increased(P value 0.009) and gait speed decreased significantly as number of multimorbid diseases increased from 2 to 4(P value 0.003).

Conclusion: In this study, there was a significant decrease in mean modified Barthel ADL score and gait speed as the number of multimorbid diseases increased.

Keywords: Functional status, gait speed, modified barthel ADL, multimorbidity, older adults

 Is Handgrip Strength A Useful Tool to Detect Slow Walking Speed in Older Adults: A Cross Sectional Study on Community Dwelling Geriatric Outpatients

Reuben Jerrald Felix, Gopinath Kango Gopal

Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu, India

Background: Frailty has become a global issue among older adults because of its increasing prevalence and impact on incidence of hospitalisation and mortality. Its evaluation in older adults is of great concern for public health. Hand grip strength and walking speed are the two most important factors that reflect the severity of sarcopenia associated with frailty. However, measuring walking speed in older adults is not an easy task as the living environment, cognitive and functional decline in older adults may have a significant impact on the feasibility of performing the test. Hence there is a compelling need to identify a proxy for assessing the walking speed. Hand grip strength is well known to be associated with malnutrition, osteoporosis, cognitive impairment and multimorbidity. Because of its easy availability, accessibility, and clinical relevance it was instinctive to consider measuring hand grip strength as a proxy for walking speed.

Objectives: The main objective of this study was to determine whether handgrip strength can be used as a proxy for identifying slow walking speed and to determine the optimal cut-off values according to the AWGS updated criteria in 2019.

Materials and Methods: A cross sectional study was conducted among older adults aged 60 years and above who visiting the Geriatric outpatient clinic in Christian medical college and hospital, Vellore. Participants were recruited if they were able to perform both the 6-meter walking test and handgrip strength test. According to the 2019 Asian working group for sarcopenia diagnostic criteria, slow walking speed was defined as a 6-meter walking speed < 1.0 m/s. Handgrip strength was measured using a digital handheld dynamometer. Multiple Linear regression analysis was used to determine the relationship between handgrip strength and walking speed. Receiver operating characteristic analysis was used to determine the optimal cut off values for hand grip strength in detecting slow walking speed.

Results: A total of 100 participants were included in the study. The mean age was 67.75 ±6.2 years and there were 63 males. Most of the study participants belonged to low socioeconomic status and had a sedentary lifestyle. Average BMI of the participants was 23.6 ± 4. On multiple linear regression analysis, handgrip strength was found to have a significant association with walking speed in both men and women (P<0.001). The optimal cut off value for handgrip strength to detect slow walking speed was 28 kg for all participants (sensitivity: 59.6%, specificity: 98.1%, area under the curve: 0.87, accuracy: 80%), 28 kg for men (sensitivity: 84.9%, specificity: 96.7%, area under the curve: 0.92, accuracy: 90%) and 20 kg for women (sensitivity: 100%, specificity: 91%, area under the curve: 0.95, accuracy: 94%).

Conclusion: Our study shows that handgrip strength assessment can be used as a surrogate indicator for detecting slow walking speed. Hence large population studies are warranted to examine the validity of using hand grip strength as a proxy for gait speed assessments to assess frailty especially in older adults with functional and cognitive limitations.

 An Interesting Case of Reversible Quadriparesis in Elderly

K. Manimozhi, D. Thangam, G. S. Shanthi

Department of Geriatric Medicine, MMC and RGGGH, Chennai, Tamil Nadu, India

Introduction: Genetic disorders presenting for the first time in Geriatric age group is not very common. However in certain circumstances, this has to be considered as a differential diagnosis in uncommon presentation like multiple electrolyte abnormalities in a patient, presenting for the first time beyond the age of 60 years.

Case Report: History and Clinical Findings: We are reporting a case of 64 years old man who presented to our OP department in a wheel chair with history of Acute onset of non progressive weakness of all 4 limbs of 4 days duration. This is the first episode with no preceeding history of gastrointestinal disturbance or any other illness. No known comorbids, no history of chronic drug intake. Patient is chronic alcoholic and non smoker. No history of similar episodes among family members. On examination vitals stable with no clinical signs of respiratory distress. Examination of Central nervous system showed hypotonia of all 4 limbs with power of 2/5 with absent deep tendon reflexes and bilateral plantar flexor. His Higher mental functions and cranial nerves examination was normal. There is no involvement of sensory or autonomic or Cerebellar system. All other systems were clinically normal.

Investigations: Initial investigations showed serum Potassium of 1.6 meq (severe hypokalemia), serum magnesium 1.5 mg (hypomagnesemia), serum phosphate 1.9 mg (hypophospatemia) with normal serum calcium (8.6 mg) and renal clearance. Blood sugar and Thyroid function was normal. Serum Sodium -142. ABG showed metabolic alkalosis (PH-7.48) with urinary calcium Creatinine ratio of 0.06 (hypocalciuria). Urinary spot Sodium -20 and spot Potassium -8. MRI Brain and spine screening didnot show any significant structural abnormality. Nerve conductionstudy normal. ECG revealed findings of U waves. On day 4, the patient developed carpopedalspasm while checking BP hence serum calcium repeated which showed hypocalcemia (6.3 mg/dl) with normal paratharmone and elevated serum CPK (6704 IU/ml).

Treatment: Initially patient was treated with oral and IV Potassium supplement. Muscle weakness and clinical symptoms improved and patient became ambulant. But for optimum correction of Potassium patient needed IV magnesium & oral spirinolactone. Hypocalcemia was treated with IV and oral calcium. Patient clinically improved and he was discharged with advicd for follow-up.

Discussion: This is a case of multiple electrolytes abnormalitie severe enough to cause quadriparesis. Since the other common cause for multiple electrolyte abnormality like gastrointestinal loss, renal failure, endocrine abnormality not present. In this case renal functional abnormality like channelopathy considered. Patient had hypokalemia, hypomagnesemia with metabolic alkalosis, hypocalciuria (urine calcium Creatinine ratio <0.2) and hypocalcemia we came to a conclusion of Gitelmans Phenotype with hypocalcemia. Another differential diagnosis was Bartter's syndrome type 3. But it is present in neonatal or infantile period with hypercalciuria,nephrocalcinosis. So the diagnosis was made in favor of Gitelman's Phenotype with hypocalcemia.

Conclusion: Hence when patients present with hypokalemic paralysis with normal renal clearance with no obvious cause channelopathy has to be considered. Only few cases are reported in literature regarding hypokalemic paralysis with renal channelopathies in elderly. This case reported for it's rarity Gitelman's Phenotype with hypocalcemia.

 Correlation between Cognitive Decline and Frailty Syndrome

P. Santhosh Manikandan, P. Dinesh, G. S. Shanthi

Department of Geriatric Medicine, Madras Medical College, Chennai, Tamil Nadu, India

Background: Frailty is defined as a reduced physiological reserve in multiple organ systems with decreased capacity to withstand environmental stress and it is preceded by a prefrail stage characterized by increased risk of geriatric syndromes. Cognitive decline is commonly seen with aging. It is unclear if it is related to frailty syndrome as the classical Fried's Phenotypic model doesn't include cognitive impairment, disability, and functional decline in its characteristics which is more prevalent in elderly. In-spite of these limitations, phenotypic model has been validated for identifying frailty for research purpose. This study is done to assess if the relationship between cognitive decline and frailty.

Objective of the Study: To find the correlation between cognitive decline and frailty.

Materials and Methods: This cross sectional study was conducted among patients attending geriatric medicine department in Rajiv Gandhi Government General Hospital, Chennai. This study included 200 patients aged 60 and above from either sexes selected based on simple random sampling after applying inclusion and exclusion criteria. Individuals with severe cardiac, pulmonary, musculoskeletal disorders , stroke , parkinsonism , dementia are excluded. Patients are classified according to Fried's phenotypic criteria which includes weight loss, exhaustion, low physical activity, slowness and weakness into three categories as Frail, Pre frail, Non Frail based on the scores obtained from Fried's criteria. Presence of cognitive decline is screened in all these 3 categories using Mini-Cog which includes clock drawing and 3 word recall. Results were analysed by using IBM SPSS software version 2.0.

Results: In this study the prevalence of Frailty is 25 % (n=50), pre frailty is 54.5% (n=109), no frailty is 20.5% (n=41). Among the study participants, cognitive decline is present in 10% (n=20) and no cognitive decline present in 90% (n=180). Applying inferential statistics, cognitive decline is seen in 22% of frail individuals, 7% of pre frail individuals, 2 % of non frail individuals. Association between frailty and cognitive decline is found to be statistically significant whereas association between pre frailty and cognitive decline is not statistically significant.

Conclusion: From the results obtained it can be concluded that frailty is associated with cognitive decline whereas pre frailty is not associated with cognitive decline. Further longitudinal studies and community based studies are needed to understand these associations in a better manner.

 Correlation between Neutrophil to Lymphocyte Ratio and Severity of Sepsis in Elderly Patients

Ebenezer Lalhruaitluanga, K. Sushmitha, G. Usha

Department of Geriatric Medicine, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Sepsis is a major cause of morbidity and mortality worldwide especially in developing countries. In elderly due to immunosenescence, there is decreased function of both innate and acquired immunity which makes them more vulnerable to develop infections. So sepsis is more common in them. NLR has been used to assess prognosis in various diseases including cancers, inflammatory conditions, surgical conditions etc. The validity of NLR in sepsis assessment can be done by comparing NLR with validated sepsis severity scores like SOFA, APACHE, SAPS 2 score.

Objectives: 1) To determine the efficacy of NLR as prognostic marker for sepsis in comparison to already established scores like SOFA,APACHE II,SAPS II in elderly sepsis patients.

2) To correlate the association between NLR and outcomes in elderly sepsis patients.

Methodology: This prospective observational study included 200 patients, aged 60 above, who met qSOFA criteria (score ≥ 2) on admission and excluded patients with chronic inflammatory conditions, hematological disorders, history of steroid usage, history of chemotherapy and radiotherapy, and who developed sepsis after initial hospitalization. Blood was drawn for hematological workup ,and relevant cultures from suspected source of infection along with radiological investigations were done.For each patient, SOFA score, APACHE II score and SAPS II scores on admission were calculated, then NLR was correlated with all three scores, and those patients in whom sepsis was proven by investigations were followed up until discharge or death (upto 1 month).

Results: The patients were arbitrarily categorized into 5 groups based on NLR values, Of the 200 patients studied 9% had NLR value 1-3, 30% had 3-6, 23.5% had 6-9, 36.5% had 9-18 and 1% had >18. In our study it has been found that 46.8% patients were having SOFA score of 7 – 8, 34.8% patients were having a score of 3 – 6, 18.4% in the range of 11 – 15. Regarding APACHE II score, 15.9% had a score of 7 – 10, 56.7% had a score of 11 – 20,27.4% had a score of 21 – 33. Regarding SAPS II score, 52.7% had a score of 21 – 40,22.9% had a score of 41 – 50,24.4% had a score of 51 – 80. Higher NLR was associated with higher values of all scores. It was found that among patients with NLR > 9, 37.5% of them died during the study, so there was statistical significant association of NLR with mortality (p<0.05). Higher NLR was associated with poorer outcomes.

Conclusion: In our study it was found that NLR correlated well with SOFA (p value <0.01), APACHE II(p value <0.01) and SAPS II score(p value <0.01).This indicates that NLR can be used as prognostic marker of sepsis in elderly patients as it correlates with all established sepsis severity scores. In our study NLR also correlated well with outcome in sepsis patients as higher NLR was present in non-survivors than survivors (p value <0.05). Therefore NLR can also be used to predict mortality in elderly sepsis patients.