Christian Swine

Risk factors predicting later functional decline in older hospitalized patients.

Abstract With the demographic and epidemiological changes, an increasing number of older subjects are admitted to hospital. These patients are at increased risk of adverse health outcomes, including functional decline, increased length of stay, institutionalization, geriatric syndromes (e.g. delirium), hospital readmissions and death. Age, basic demographic data, diagnosis and comorbidities are not sufficient to estimate the risk of a further negative evolution of the frail older patient during and after hospitalization. As functional decline begins soon after admission, it is important to screen vulnerable patients early in order to plan appropriate orientation to geriatric programmes and to target interventions. This narrative review analyses which appropriate parameters, available soon after admission, may help to identify the older patients at risk of functional decline and to stratify their risk. Functional decline was defined here as loss of independence in basic care or admission in nursing home. The main risk factors identified by this analysis are functional status before or at admission, cognitive performance and social characteristics. These data may be easily and quickly collected by the nursing staff on admission, and further assessed by the geriatric liaison team, in order to optimize care management in frail older patients.

Evolving definitions of frailty

This article presents the current status of the definitions of frailty. The theoretical definitions are summarized, and the main elements of these definitions are developed. Frailty as a geriatric syndrome is briefly put into debate, and a model showing the relationships between the factors involved and the outcomes of frailty is proposed. The dynamics of functional decline and geriatric syndromes are put into the perspective of different stages of frailty. For the practical use of the concept, the operational definitions and the principal tools, indices and scales from the literature are briefly described, along with their main characteristics.

Early diagnosis of dehydration in hospitalized geriatric patients using clinical and laboratory criteria

ContextDehydration is a common yet underdiagnosed condition, which is associated with poor prognosis in older patients. The clinical and laboratory criteria for assessing dehydration are of variable or poor diagnostic value in this population and require further validation.ObjectivesTo test different clinical and laboratory criteria for the early diagnosis of dehydration in hospitalized older patients as compared to the standard diagnosis based on a body weight gain ≥u20093% during the first week of admission.DesignProspective study using clinical and laboratory criteria for dehydration selected by an expert panel.SettingAcute geriatric unit.ParticipantsGeriatric patients (nu2009=u2009112; aged 83u2009±u20096xa0years) admitted to the unit.MeasurementsUsing selected criteria (skin fold, dry mouth, calf muscle consistency, systolic blood pressureu2009<u200990xa0mmHg, orthostatic blood pressure drop, postural dizziness, thirst, apathy or delirium, urea, creatinine, uric acid, proteins, hemoglobin), expert clinicians prospectively assessed the patients to make a clinical diagnosis of dehydration upon admission. Clinicians were asked to provide a yes/no answer for each criterion and a global yes/no answer for dehydration, along with its estimated probability. Body weight was measured at admission and at Day 7. Laboratory parameters were assessed at baseline and at Day 7. The clinical diagnosis made at admission was retrospectively compared to the standard diagnosis made at Day 7 (>u20093% weight gain) to test the values of each criterion separately, the global diagnosis, and its estimated probability.ResultsIn total, 100 patients with complete data (mean age 83u2009±u20096xa0years) were considered for analysis. Dehydration was the principal reason for admission in three patients only but was clinically diagnosed as part of the study in 39 patients, whereas the standard diagnosis of dehydration was ascertained in 20. Inter-rater agreement (kappa) was fair for the clinical criteria and clinical diagnosis, moderate to near perfect for the laboratory criteria, and substantial for the estimated probability of dehydration. When matched with the standard diagnosis, the final clinical diagnosis of dehydration had 70% sensitivity and 69% specificity, with a 90% negative predictive value. Individually, both clinical and laboratory criteria had good specificity (65–90%), but poor sensitivity (<u200955%).ConclusionsCompared with the standard diagnosis, dehydration was overdiagnosed by systematic clinical assessment upon admission in this frail population. However, clinicians performed better at excluding dehydration. Clinical acumen seems better than any individual clinical symptom or sign.