Avraham Weiss

Functional gain of hip fracture patients in different cognitive and functional groups.

Objective: To follow up six months post hip fracture and to compare functional gain of patients in different cognitive and functional groups. Design: Prospective longitudinal study of hip fracture patients with functional evaluation pre-fracture, prior to discharge from orthopaedic department and one, three and six months post fracture. Setting: Department of Orthopaedics, Rabin Medical Center, Golda Campus with follow-up at Beit-Rivka Geriatric Rehabilitation Hospital, both in Petach Tikvah, Israel, with a minority of patients followed at home or nursing home. Measurement: Cognition evaluated by Mini-Mental State Examination, prefracture functioning by Functional Independence Measure and Katz Index of ADL. Functional outcome assessed by Functional Independence Measure gain defined as the difference between Functional Independence Measure scores at six months and just prior to discharge from the Department of Orthopaedics. Results: Moderately cognitively impaired and normal patients had the same Functional Independence Measure – A (self-care) and Functional Independence Measure – B (motor) gains. Pre-fracture independent patients had significantly higher Functional Independence Measure – A and Functional Independence Measure – B gains. A multiple regression analysis examining age, sex, Mini-Mental State Examination score, Katz score, type of fracture, surgery versus conservative treatment and the pre-fracture Functional Independence Measure score showed that only the pre-fracture Functional Independence Measure – B scores and Katz scores are the independent variables for motor and self-care gains, respectively. Conclusions: Pre-fracture motor and not cognitive level has been the most important predictive factor for motor gain after hip fracture. Cognitively impaired hip fracture patients can achieve and maintain the same motor functional gain as normal patients, if they were mobile pre-fracture.

Relationship of In-Hospital Medication Modifications of Elderly Patients to Postdischarge Medications, Adherence, and Mortality

Background: Medication regimens are constantly modified and updated during a patients hospitalization. These modifications and those made after discharge might increase the risk for nonadherence, polypharmacy, and poor outcomes among elderly patients. Objectives: To investigate the extent of in-hospital modification of medication regimens of elderly patients and its relationship to medication adherence as well as one-month postdischarge drug regimen modifications and to examine the relationship of the modifications, adherence, and polypharmacy to mortality and readmissions 3 months postdischarge. Methods: Clinical and demographic data, postdischarge medication modifications, and adherence were prospectively obtained in 212 elderly patients. Inhospital drug regimen modifications were retrospectively recorded. Results: The average ± SD in-hospital medication regimen modification rate was 49.8% ± 28.4. No modifications were found in 9.7% of the patients. Using demographic and clinical parameters, we performed regression analysis and found that patients who were admitted with polypharmacy, discharged home, and cognitively normal experienced fewer medication modifications (p conclusions: Hospitalization of elderly patients is characterized by extensive medication regimen modifications, which are directly correlated with postdischarge modifications and may indicate an increased risk of mortality.

Different C-Reactive Protein Kinetics in Post-Operative Hip-Fractured Geriatric Patients with and without Complications

Background: Hip fracture is a frequent injury in the elderly, and is associated with a high incidence of functional impairment, complications and mortality. Objective: To determine kinetics of C-reactive protein (CRP), fibrinogen and erythrocyte sedimentation rate (ESR) in hip-fractured patients over a 1-month post-operative period; to examine the relationship of these parameters to cognition, operation type, post-operational complications, functional level 1 month post-operatively and 6-month mortality. Methods and Subjects: 32 aged patients operated on for hip fracture were prospectively followed-up for 6 months. Fracture, type of operation and anesthetic risk were recorded. Cognition was evaluated by the Mini-Mental State Examination and pre-fracture functional level evaluated by the Katz Index of ADL. Follow-up included complications, mortality and functional outcome. CRP, fibrinogen and ESR were assessed during the first 10 h post-fracture; 48–60 h, and 7 and 30 days post-operatively, respectively. Results: Only CRP kinetics were found to differ in patients with complications vs. those without, as a group (p = 0.006), and in patients suffering infections, delirium and cardiovascular complication vs. patients with no complications (p = 0.06, 0.03, 0.02, respectively). Mean (±SEM) CRP 48–60 h post-operatively was 20.9 ± 2.1 and 13.1 ± 1.6 mg/dl in complicated and uncomplicated patients, respectively (p = 0.002). The mean CRP 48–60 h post-operatively was highly correlated with the CRP area under the curve, R = 0.88 (p < 0.001). A cut-off level of 15 mg/dl for CRP, 48– 60 h post-operatively, was calculated for patients with complications (sensitivity 93%, specificity 65%, p = 0.003). CRP, fibrinogen and ESR were not related to fracture or type of operation, cognition, anesthetic risk, 1-month post-operative functioning and 6-month mortality. Conclusions: CRP measurement in elderly patients operated for hip fracture may be valuable in assessing and monitoring complications.

Continuity and adherence to long-term drug treatment by geriatric patients after hospital discharge: a prospective cohort study.

AbstractBackground: Increased life expectancy is associated with an increased prevalence of chronic diseases and drug consumption. Changes often occur in the medication regimen after hospitalization. The extent and nature of these changes and the adherence of elderly patients have not yet been fully investigated. Objective: To investigate the extent and reasons for modifications to the medication regimens of elderly patients and their adherence to treatment during the first month following hospital discharge. Methods: This was a prospective cohort study of 198 patients aged ≥65 years in the Acute Geriatric Ward, Beilinson Hospital, Rabin Medical Center, Israel. Clinical, demographic and medication regimen data were recorded for all patients at an interview conducted prior to discharge. After 1 month, the patient, caregiver or general practitioner (GP) were interviewed regarding the extent and reasons for modifications to the medication regimen and adherence to treatment. Results: At 1-month post-discharge, on average, 36.7% of patient medications had been modified compared with the discharge prescription. No modification was found in 16% of patients. During the observation month, 62% of prescribed long-term medications were taken without modification as recommended at discharge and during follow-up, 50% of all changes were characterized by the addition of a drug or an increase in dosage, and 26%, 16% and 8% consisted of cancelling, omission or switching within the same medication type, respectively. Seventy percent of medication regimen changes were based on specialists’ recommendations or secondary to a change in the patients’ medical state, and 13%, 8%, 3% and 6% were as a result of poor adherence, adverse effects, administrative restrictions and other reasons, respectively. There was no correlation between medication regimen change and age, gender, physical function, cognitive function and length of hospital stay. Patients discharged home experienced less regimen modification than those discharged elsewhere (p = 0.02). Patients who visited their GP only once experienced less regimen modification (p = 0.03). Regression analysis showed that the only factors affecting medication regimen changes were GP visits and chronic diseases (p < 0.01, R2 = 0.09). The overall mean adherence among 145 home-dwelling patients was 96.7%. Twenty-seven percent and 6% were under- and over-adherent, respectively, to at least one drug; under-adherence was more widespread than over-adherence. No correlation was found between the overall mean adherence and other clinical parameters or regimen change. However, non-adherence to at least one drug was associated with more medication regimen changes (p = 0.001), was more common in patients discharged with prescriptions for seven or more drug types per day (p = 0.01) and was associated with failing to visit the patient’s GP 1 month after discharge (p = 0.02). Conclusion: The majority of elderly patients experienced modifications in their medication regimen during the first month following hospital discharge. Thirty percent of patients were non-adherent to at least one drug. To improve adherence to a hospital medication regimen, patients should be encouraged to visit their GP and the number of long-term drugs should be reduced.

Looking beyond polypharmacy: quantification of medication regimen complexity in the elderly.

BACKGROUND Polypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied. OBJECTIVE Our aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels. METHODS We retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity. RESULTS The mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r=0.94, P<0.001) and the number of daily doses (r=0.87, P<0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P<0.001). Positive correlations were observed between the Cumulative Illness Rating Scale-Geriatrics score and both the number of medications and the MRCI score (r=0.40, r=0.46, P<0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P<0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r=-0.188, P= 0.028); however, no such correlation was found regarding the number of medications at discharge. CONCLUSIONS The MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity.

Tight Calorie Control in geriatric patients following hip fracture decreases complications: A randomized, controlled study

BACKGROUND & AIMS Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known. METHODS A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure. RESULTS 50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049). CONCLUSION We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.

Influence of orthostatic hypotension on mortality among patients discharged from an acute geriatric ward

BACKGROUND: Orthostatic hypotension (OH) is a common finding among older patients. The impact of OH on mortality is unknown.OBJECTIVE: To study the long-term effect of OH on total and cardiovascular mortality.PATIENTS AND METHODS: A total of 471 inpatients (227 males and 244 females), with a mean age of 81.5 years who were hospitalized in an acute geriatric ward between the years 1999 and 2000 were included in the study. Orthostatic tests were performed 3 times during the day on all patients near the time of discharge. Orthostatic hypotension was defined as a fall of at least 20 mmHg in systolic blood pressure (BP) and/or 10mmHg in diastolic BP upon assuming an upright posture at least twice during the day. Patients were followed until August 31, 2004. Mortality data were taken from death certificates.RESULTS: One hundred and sixty-one patients (34.2%) experienced OH at least twice. Orthostatic hypotension had no effect on all cause and cause specific mortality. Over a follow-up of 3.47±1.87 years 249 patients (52.8%) had died 83 of whom (33.3%) had OH. Age-adjusted mortality rates in those with and without OH were 13.4 and 15.7 per 100 person-years, respectively. Cox proportional hazards model analysis demonstrated that male gender, age, diabetes mellitus, and congestive heart failure increased and high body mass index decreased total mortality.CONCLUSIONS: Orthostatic hypotension is relatively common in elderly patients discharged from acute geriatric wards, but has no impact on vascular and nonvascular mortality.

Validity of the Medication-Based Disease Burden Index Compared with the Charlson Comorbidity Index and the Cumulative Illness Rating Scale for Geriatrics

AbstractBackground: Co-morbidity is common in older people. A co-morbidity index reduces coexisting illnesses and their severity to a single numerical score, allowing comparison with scores from other patients. Recently, the Medication-Based Disease Burden Index (MDBI) was developed. Objective: The aim of the study was to assess the MDBI’s validity in hospitalized elderly patients. Methods: Clinical and demographic data and data on patients’ medications on admission were obtained prospectively. Retrospectively, we applied the MDBI to the patients’ medication regimens, determining their co-morbidity using the Charlson Comorbidity Index and Cumulative Illness Rating Scale for Geriatrics (CIRS-G). The MDBI’s criterion validity was assessed against the Charlson and CIRS-G indices. Convergent and discriminant validities were also assessed. The MDBI’s predictive validity was assessed by its ability to predict 3-month post-discharge readmissions or mortality compared with the Charlson and CIRS-G indices. Results: MDBI scores were correlated with the Charlson and CIRS-G indices’ scores (r = 0.44 and r = 0.37, respectively [p<0.001]). MDBI, Charlson Co-morbidity Index and CIRS-G scores were correlated with the number of drugs (r = 0.52, r = 0.34 and r = 0.40, respectively [p<0.001]) and were the same in both sexes. No significant differences in MDBI scores were found between cognitively normal and impaired mental status (IMS) patients or between the functionally independent and partially/fully dependent patients. Charlson Comorbidity Index and CIRS-G scores were significantly lower in IMS patients and in dependent patients. The MDBI had no predictive ability for 3-month mortality but had good predictive power for a composite of 3-month mortality or readmissions (odds ratio [OR] 2.99 [95% CI 0.99, 9.03; p = 0.051]). However, CIRS-G and Charlson indices had good predictive ability for mortality (OR 1.50 [95% CI 1.22,1.84; p<0.001] and OR 2.06 [95% CI 1.40, 3.02; p<0.001], respectively) and for a composite of 3-month mortality or readmissions (OR 1.24 [95% CI 1.11, 1.34; p<0.001] and OR 1.39 [95% CI 1.12, 1.72; p = 0.003], respectively). Conclusions: The MDBI showed satisfactory criterion, convergent and discriminant validities and good predictive validity for mortality or readmission, but failed to differentiate between cognitive and functional patient groups. The MDBI should be investigated in larger studies to determine its validity in settings where medication data rather than diagnostic data are more readily available. In clinical practice with elderly patients, we recommend employing co-morbidity indices that are based on medical records, such as the Charlson Comorbidity Index and CIRS-G.

Effects of external pressure on arteries distal to the cuff during sphygmomanometry

The aim of this study was to examine the effect on distal arteries of external pressure, applied by upper arm sphygmomanometer cuff. Photoplethysmographic (PPG) signals were measured on the index fingers of 44 healthy male subjects, during the slow decrease of cuff air pressure. For each pulse the ratio of PPG amplitude to its baseline (AM/BL) and its time delay (/spl Delta/TD) relative to the contralateral hand were determined as a function of cuff pressure. At cuff pressures equal to systolic blood pressure, pulses reappeared with the pulse time delay in the cuffed arm significantly greater than in the noncuffed arm, with (/spl Delta/TD)(mean/spl plusmn/SD)150/spl plusmn/31 ms (p<0.001). At cuff pressures equal to diastolic blood pressure (81/spl plusmn/12 mmHg),/spl Delta/TD was 42/spl plusmn/19 ms (p<0.001), and at 50 mmHg, which is below diastolic blood pressure, (/spl Delta/TD) was still significantly positive at 6/spl plusmn/9 ms (p<0.001). AM/BL relative to its initial value rose at cuff pressures between systolic and diastolic blood pressure, then deceased to 0.6/spl plusmn/0.41 (p<0.001) at diastolic blood pressure and 0.54/spl plusmn/0.24 (p<0.001) at 50 mmHg. The changes in (/spl Delta/TD) and AM/BL can be interpreted as originating from changes in the compliance of conduit arteries and small arteries with cuff inflation and deflation.

Body mass index and risk of all-cause and cardiovascular mortality in hospitalized elderly patients with diabetes mellitus

Aims  Obesity is linked to increased morbidity and mortality risk in both the general population and in patients with diabetes mellitus; however, recent reports suggest that, in hospitalized elderly individuals, the association between body mass index (BMI) and mortality may be inverse. The present study sought to investigate the association between BMI and survival in hospitalized elderly individuals with diabetes mellitus.