Céline Lazarovici

Caractéristiques, consommation de ressources des usagers des services d’urgences de plus de 75 ans en France: Résultats d’une enquête nationale

BACKGROUND Because the elderly tend to have complex and multiple diseases, they are likely to use emergency department (ED) resources at higher rates than other age groups. This study sought to determine the characteristics and resource use of the elderly patients (>or=75 years old) visiting EDs in France and assessed the effect of age on resource use. METHODS The sample was selected from the DREES prospective study of 150 French EDs for one week in 2002. A case report form was completed for each patient, stating the reasons for consultation, method of arrival, treatment, and outcome. Data were weighted to produce a representative national description. RESULTS Of the 9801 patients seen that week, the elderly (n=1153) accounted for 11.8% of all ED visits, that is, 26 676 ED visits weekly nationwide. In this group, the mean age was 83 years and 60.9% were women. Most patients arrived by medical transportation: 55.6% by nonemergency ambulances and 24.6% by emergency medical transport. More than 75% were referred by their general practitioner (GP). Medical problems (69.5%) were much more frequent than trauma (24.8%). Clinical status was stable in 62% of cases. Use of ED resources was high: radiographs for 74.0%, laboratory testing for 71.0% and electrocardiography for 64.0%. The percentage of unnecessary or avoidable visits was small: 8.7% were not admitted, were clinically stable, and came for diagnostic tests that could have been performed on an outpatient basis. Age was an independent factor of pre-ED and ED resource use. CONCLUSION Unplanned health care of the elderly uses substantial ED resources. Elderly patients appear to use available resources appropriately. Demographic trends show that their ED use will increase. Accordingly, analysis of the organization and funding of ED services for this population is indispensable.Resume Position du probleme La predominance des maladies multiples et complexes chez les personnes âgees fait qu’elles sont a risque d’utiliser de facon plus importante les ressources des services d’urgences (SU). Cette etude avait pour but de decrire les caracteristiques des patients âges (≥ 75 ans) frequentant les SU et d’evaluer l’effet de l’âge sur la consommation de ressources. Methodes L’echantillon etait issu d’une enquete prospective appelee DREES 2002, menee en janvier 2002 aupres de 150 SU en France pendant une semaine. Une fiche medicale anonyme a ete etablie, pour chaque patient, mentionnant les modes et motifs de recours, les soins recus, et le devenir. Les donnees ont ete ponderees pour une description representative. Resultats Parmi les 9 801 personnes incluses, il y avait 1 153 patients âges (11,8 %), ce qui representait 26 676 passages au SU en France par semaine. La moyenne d’âge etait de 83 ans et 60,9 % etaient des femmes. Les transports medicalises etaient les plus utilises (55,6 % arrivaient par ambulance). Un medecin etait a l’origine de l’admission dans 76,6 % des cas. Les problemes somatiques etaient plus frequents (69,5 %) que les traumatismes (24,8 %). L’etat clinique des patients a ete juge stable dans 62% des cas. Une radiographie a ete realisee dans 74 % des cas, un prelevement biologique dans 71% des cas et un electrocardiogramme dans 64 % des cas. Une proportion de recours evitable (8,7%) correspondait aux patients âges non hospitalises, stables cliniquement, ayant la possibilite d’effectuer certains actes diagnostiques en ville et dont le motif de recours etait l’acces au plateau technique. L’âge etait un facteur independant de consommation de ressources pre- et intra-SU. Conclusion La prise en charge non programmee des personnes âgees de plus de 75 ans implique une consommation importante de ressources au sein des SU. Les malades âges semblent utiliser les ressources disponibles de facon adaptee. L’evolution demographique amplifiera le nombre de personnes âgees se presentant aux SU, imposant une reflexion sur leur organisation et leurs moyens.

Clinical usefulness in geriatric patients of combining CHADS2 and HEMORR2HAGES scores to guide antithrombotic prophylaxis in atrial fibrillation.

Background and aims: Two scores exist to assess the benefits and risks of antithrombotic therapy in patients with atrial fibrillation: CHADS2 [for Congestive heart failure, Hypertension, Age over 75, Diabetes mellitus; and 2 points for a history of Stroke] and HEMORR2HAGES [for Hepatic or renal failure, Ethanol abuse, Malignancy, Older (age over 75), Reduced platelet count or function, 2 points for Rebleeding risk Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk (including neurodegenerative and psychiatric disorders) and history of Stroke]. The potential value of using both scores routinely was studied in order to guide the choice of antithrombotic therapy for geriatric patients. Methods: Retrospective calculation of CHADS2 and HEMORR2HAGES scores and discharge treatment were collected for all patients with atrial fibrillation during a six-month period. All files were analysed when there were differences between therapeutic choices and the results of analysis of combining the two scores. Results: 83 patients were identified. Their mean age was 89.2±4.9 years and 30% of them were on oral anticoagulants on discharge. Usual prescription habits of oral anticoagulants correlated strongly with each of the scores and with the difference between the two scores. The clinical usefulness of using the two scores seemed poor since they indicated that two-thirds of the patients had a similar risk of hemorrhagic and ischemic events. Conclusions: Based on this preliminary study, the CHADS2 and HEMORR2HAGES scores are associated with the prescription of oral anticoagulants, but their routine use may not significantly change the choice of antithrombotic therapy for patients with atrial fibrillation.

Hémopathies et sujets âgés : expérience d’un service de court séjour gériatrique

BACKGROUND Ageing of population due to improvement in life expectancy has increased blood diseases (BD) incidence in the elderly population. In addition, treatments get more and more complex with increasingly late diagnosis as well as concomitant comorbidities. METHODS We describe a series of 54 patients with BD, followed-up in an acute care geriatric department. Autonomy, way of life, nutritional status, comorbidities, treatment, mortality and evolution were analyzed. RESULTS Mean age at BD was 86+/-6 years (range 75-99) for 29 women and 25 men. Median follow up was 20 months (0-60). Lymphoma was the most frequent BD (44%). Thirty-one patients (57%) received chemotherapy. Mortality rate was 41% (22 patients). Forty patients (74%) were discharged and 25 patients (46%) required enhanced professional assistance. Survival was significantly decreased in patients with albuminemia less than or equal to 30 g/l. IADL score less than or equal to 3, ADL score less than or equal to 5, performance status more than or equal to 2, MMS less than 25 and weight loss more than or equal to 3 kg. After multivariate analysis, only albuminemia less than or equal to 30 g/l tended to predict death (hazard ratio 3.57, 95% confidence interval 0.96-13.3, p=0.06). CONCLUSION Our study confirms the importance of nutritional status on survival. A global geriatric evaluation is required for appropriate treatment, as currently available therapeutic protocols are not really adapted for old population. Additional studies should be conducted in this direction.

Article originalCaractéristiques, consommation de ressources des usagers des services d’urgences de plus de 75 ans en France: Résultats d’une enquête nationaleCharacteristics and resource use of emergency department users older than 75 years: Results from a French national study

BACKGROUND Because the elderly tend to have complex and multiple diseases, they are likely to use emergency department (ED) resources at higher rates than other age groups. This study sought to determine the characteristics and resource use of the elderly patients (>or=75 years old) visiting EDs in France and assessed the effect of age on resource use. METHODS The sample was selected from the DREES prospective study of 150 French EDs for one week in 2002. A case report form was completed for each patient, stating the reasons for consultation, method of arrival, treatment, and outcome. Data were weighted to produce a representative national description. RESULTS Of the 9801 patients seen that week, the elderly (n=1153) accounted for 11.8% of all ED visits, that is, 26 676 ED visits weekly nationwide. In this group, the mean age was 83 years and 60.9% were women. Most patients arrived by medical transportation: 55.6% by nonemergency ambulances and 24.6% by emergency medical transport. More than 75% were referred by their general practitioner (GP). Medical problems (69.5%) were much more frequent than trauma (24.8%). Clinical status was stable in 62% of cases. Use of ED resources was high: radiographs for 74.0%, laboratory testing for 71.0% and electrocardiography for 64.0%. The percentage of unnecessary or avoidable visits was small: 8.7% were not admitted, were clinically stable, and came for diagnostic tests that could have been performed on an outpatient basis. Age was an independent factor of pre-ED and ED resource use. CONCLUSION Unplanned health care of the elderly uses substantial ED resources. Elderly patients appear to use available resources appropriately. Demographic trends show that their ED use will increase. Accordingly, analysis of the organization and funding of ED services for this population is indispensable.Resume Position du probleme La predominance des maladies multiples et complexes chez les personnes âgees fait qu’elles sont a risque d’utiliser de facon plus importante les ressources des services d’urgences (SU). Cette etude avait pour but de decrire les caracteristiques des patients âges (≥ 75 ans) frequentant les SU et d’evaluer l’effet de l’âge sur la consommation de ressources. Methodes L’echantillon etait issu d’une enquete prospective appelee DREES 2002, menee en janvier 2002 aupres de 150 SU en France pendant une semaine. Une fiche medicale anonyme a ete etablie, pour chaque patient, mentionnant les modes et motifs de recours, les soins recus, et le devenir. Les donnees ont ete ponderees pour une description representative. Resultats Parmi les 9 801 personnes incluses, il y avait 1 153 patients âges (11,8 %), ce qui representait 26 676 passages au SU en France par semaine. La moyenne d’âge etait de 83 ans et 60,9 % etaient des femmes. Les transports medicalises etaient les plus utilises (55,6 % arrivaient par ambulance). Un medecin etait a l’origine de l’admission dans 76,6 % des cas. Les problemes somatiques etaient plus frequents (69,5 %) que les traumatismes (24,8 %). L’etat clinique des patients a ete juge stable dans 62% des cas. Une radiographie a ete realisee dans 74 % des cas, un prelevement biologique dans 71% des cas et un electrocardiogramme dans 64 % des cas. Une proportion de recours evitable (8,7%) correspondait aux patients âges non hospitalises, stables cliniquement, ayant la possibilite d’effectuer certains actes diagnostiques en ville et dont le motif de recours etait l’acces au plateau technique. L’âge etait un facteur independant de consommation de ressources pre- et intra-SU. Conclusion La prise en charge non programmee des personnes âgees de plus de 75 ans implique une consommation importante de ressources au sein des SU. Les malades âges semblent utiliser les ressources disponibles de facon adaptee. L’evolution demographique amplifiera le nombre de personnes âgees se presentant aux SU, imposant une reflexion sur leur organisation et leurs moyens.