Cristina Cornali

End-stage nursing home residents with dementia: recognizing the need for palliative care.

1. Glew CM, Rentler RJ. Use of proton pump inhibitors and other acid suppressive medications in newly admitted nursing facility patients. J Am Med Dir Assoc 2007;8:607–609. 2. Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006;296:2947–2953. 3. Centanni M, Gargano L, Canettieri G, et al. Thyroxine in goiter, Helicobacter pylori infection, and chronic gastritis. N Engl J Med 2006;354: 1787–1795. 4. Laheij RJ, Sturkenboom MC, Hassing R, et al. Risk of communityacquired pneumonia and use of gastric acid-suppressive drugs. JAMA 2004;292:1955–1960.

Implementation of guidelines for type 2 diabetes mellitus in a post-acute geriatric setting

Background and aims: Several health organizations have developed guidelines for type 2 diabetes mellitus, but it is known that population aging poses challenges to their application. We evaluated the reasons for not implementing guidelines for type 2 diabetes mellitus (DM) in patients admitted to a post-acute geriatric ward. Methods: 209 patients (78.8±6.9 years old, female 72.7%) affected by DM, consecutively admitted in a Geriatric Evaluation and Rehabilitation Unit (GERU) between 2003 and 2005 for 32.2±11.5 days. The GERU geriatricians generated an algorithm for DM management following the guidelines proposed by the American Diabetes Association (2001) and the California Healthcare Foundation/American Geriatric Society (2003). The fit between medical choices and the guideline or the reasons for non-implementation were recorded on clinical charts. Results: Guidelines were implemented in 82.3% of cases. The main reason for non-application was the physician’s judgment of the patient’s clinical condition. Subjects in the non-implementation group had worse functional status, their somatic comorbidity was more severe, and their clinical condition more unstable. They were also affected by more serious psychological and behavioral symptoms associated with dementia. In a multivariate logistic regression analysis, adjusting for age, gender, cognitive, functional status, and number of drugs, the burden of comorbidity was the only independent determinant for not implementing the guidelines (OR 2.27, 95% CI 1.36–3.81, p=0.002). Conclusions: although the guidelines for DM have previously been adapted to a geriatric setting, they are not applied in a significant percentage of old frail patients. Severe comorbidity is the main limitation for applying guidelines, but also polypharmacy, disability, cognitive impairment, and behavioral disturbances are factors taken into consideration before starting treatment of a very old patient affected by diabetes.

P2-325 Predictors of institutionalization in demented patients discharged from a rehabilitation unit

BACKGROUND The decision to place a patient with dementia in long-term care is complex and based on the patients and the caregivers characteristics, and on the sociocultural context. Most studies assessing predictors of nursing home placement focused primarily on the characteristics of either the patient, such as dementia severity and difficult behaviors, or the caregiver, such as subjective burden and health status. However, only a few studies comprehensively investigated how both a caregivers and a patients characteristics influence nursing home placement. OBJECTIVE To identify the patients and the caregivers characteristics that influence discharge to a nursing home in demented patients consecutively admitted to an intermediate care setting. METHODS Observational study of 214 patients with dementia consecutively admitted to a Rehabilitation Unit for Dementia in Northern Italy (length of stay 35.1 +/- 14.9 days). The main evaluated outcome was the final destination (home vs nursing home). RESULTS In a multivariate logistic regression analysis, adjusted for age, gender, cognitive status, and behavioral disturbances, 4 predictors were associated with nursing home placement: living alone (OR 8.79, 95% CI 2.33-33.16; P = .001), degree of dementia severity (CDR, OR 1.69, 95% CI 1.02-2.83; P = .04), compromised functional status (Barthel index admission, OR 3.15, 95% CI 1.05-9.48; P = .04), and caregivers burden (CBI, OR 2.89, 95% CI 1.15-7.29; P = .02). CONCLUSIONS Data suggest that living alone, patients functional impairment, severity of dementia, and caregivers burden were independent predictors of institutionalization. The interaction between a patients and a caregivers characteristics has an important effect on the rate of nursing home placement in demented patients.