Jean-Luc Novella

Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units

BACKGROUND among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors. OBJECTIVE to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments. DESIGN prospective multi-centre study. SETTING nine French hospitals. SUBJECTS one thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort). METHODS using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment. RESULTS data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0-3.9), poor overall condition (OR = 2.01, 95% CI = 1.3-3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2-2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1-2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3--0.8). CONCLUSIONS markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.

Early Markers of Prolonged Hospital Stays in Older People: A Prospective, Multicenter Study of 908 Inpatients in French Acute Hospitals

OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals.

Derivation and validation of a mortality-risk index from a cohort of frail elderly patients hospitalised in medical wards via emergencies: the SAFES study

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

FACTORS RELATING TO CARER BURDEN FOR FAMILIES OF PERSONS WITH MUSCULAR DYSTROPHY

OBJECTIVE To assess the burden on family carers of persons with muscular dystrophy living in their homes and to determine factors contributing to carer burden. METHODS The study included 56 dyads of people with muscular dystrophy and their family carers. The variables for carer burden were compared by logistic regression in 2 carer groups (burden + /burden-). RESULTS The mean age of the patients with muscular dystrophy was 32.7 years (median 26.7, range 15-65 years) and that of the carers 51 years (median 48, range 30-80 years). The carers reported the care burden using the Zarit Burden Inventory (median score 23, range 0-57/88). Multivariate analysis produced 3 adjusted explicative factors: carer characteristics related to risk of perceived burden are self-report of poor social functioning on the SF-36 (OR = 26.6 (2.6-278); p=0.006), self report of anxiety on the Hospital Anxiety Scale (OR = 7.1 (1.4-36); p=0.02) and being a carer under 48 years of age (OR = 7.8 (1.7-34.5); p=0.007). However, it was difficult to dissociate the different health variables of the carers from each other. CONCLUSION This approach should lead to better decision-making by medical teams, patients and their carers.

Predicting early mortality among elderly patients hospitalised in medical wards via emergency department: the SAFES cohort study.

Objectives: The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.Design: Prospective multicentre cohort.Setting: Nine French teaching hospitals.Participants: One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.Results: Crude mortality rate after a six-week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1–3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5–16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2–33.1; p< .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 – 0.75; p< .001). The six-week mortality rate increased significantly (p< .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5–1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4–12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1–24.7) in the highest risk group.Conclusions: A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

Potentially inappropriate use of psychotropic medications in hospitalized elderly patients in France: cross-sectional analysis of the prospective, multicentre SAFEs cohort.

AbstractBackground: In France, there is evidence to suggest that 50% of elderly individuals are prescribed psychotropic medications. However, it is known that use of these agents increases the risk of falls, fractures and delirium in older people. Objective: To study the consumption of ‘potentially inappropriate medication’ (PIM) among patients aged ≥75 years, paying particular attention to psychotropic drugs and the factors influencing the use of ‘potentially inappropriate psychotropics’ (PIPs). Method: This was a cross-sectional analysis of a prospective multicentre cohort of 1306 hospitalized French patients aged ≥75 years (the SAFEs [Sujet Âgé Fragile: Évaluation et suivi (Frail Elderly Subjects: Evaluation and follow-up)] cohort). The present analysis involved the 1176 patients for whom there was information on the usual treatments being taken in the 2 weeks before hospitalization. The drugs were coded according to the Anatomical Therapeutic Chemical classification; the Beers list as updated in 2003 defined which medications were considered PIPs. Standardized geriatric assessment variables were recorded on inclusion in the study. Logistic regression analysis was performed to identify factors linked to use of psychotropics and PIPs. Results: The mean number of drugs taken was 5.7 ± 2.9 per patient. Twenty-eight percent of patients took at least one PIM. The number of patients who had taken at least one psychotropic drug in the 2 weeks before hospitalization (mean 1.6 ± 0.9 psychotropics per patient) was 589 (50.1%). More than half of both the 510 patients with a depressive syndrome and the 543 patients affected by dementia were treated with psychotropics. Multivariate analysis showed that prescription of psychotropics was linked to the presence of a dementia syndrome (odds ratio [OR] = 1.4; 95% CI 1.1, 1.9; p = 0.03), the presence of a depressive syndrome (OR = 1.7; 95% CI 1.3, 2.1; p < 0.001), living in an institution (OR = 2.2; 95% CI 1.5, 3.4; p < 0.001), use of more than five drugs (OR = 3.2; 95% CI 2.5, 4.2; p < 0.001) and Charlson’s co-morbidity score >1 (OR = 0.6; 95% CI 0.5, 0.8; p = 0.001). Nineteen percent of all psychotropics prescribed were PIPs. Of these PIPs, 66.5% were anxiolytics, 28.4% were antidepressants and 5.1% were antipsychotics. Use of PIPs in the multivariate analysis was associated only with consumption of more than five drugs (OR = 1.7; 95% CI 1.1, 2.5; p = 0.01). Conclusion: PIM use is common among hospitalized older adults in France. The most important determinant of risk of receiving a psychotropic medication or a PIP was the number of drugs being taken. The elderly, who have multiple comorbidities, complex chronic conditions and are usually receiving polypharmacy, are at increased risk for adverse drug events. These adverse events are often linked to problems that could be preventable such as delirium, depression and falls. Regular review of prescriptions would help optimize prescription of psychotropics in the elderly. The Beers list is a good tool for evaluating PIMs but is too restrictive with respect to psychotropics; in the latter respect, the list could usefully be widened.

Evaluation of the Quality of Life in Dementia with a Generic Quality of Life Questionnaire: The Duke Health Profile

Objective: The study was designed to determine the acceptability, feasibility and validity of measuring quality of life in a representative sample of dementia patients with a generic instrument, the Duke Health Profile. Method: The French version of the Duke Health Profile was administered to 148 subjects with a mental disorder according to the DSM-III-R diagnostic criteria. The feasibility and acceptability of employing the instrument were determined by the refusal rate, the type of administration, and the percentage and distribution of missing data. Reliability was determined with Cronbach’s α coefficient. Instrument reproducibility was assessed with the intraclass correlation coefficient for test-retest values. Internal construct validity was determined by factor analysis. Discriminant capacity was determined by comparing the average scores on each measure among patients with and without an additional chronic pathology. The measurements obtained were compared by source of information (patient, family proxy and care provider proxy). Results: The feasibility and acceptability of the instrument was good. Only 2% of the patients refused to complete the questionnaire. Help from the interviewer was necessary in 79% of the cases. The average completion time was 10.6 min. Missing data exist in only 3.5% of the cases on average, except among patients with severe dementia (Mini Mental State Examination <10). For reliability, internal consistency was acceptable (Cronbach’s coefficient α = 0.5–0.7) when the self-esteem (0.23) and social health (0.26) concepts were eliminated. Reproducibility as measured by test-retest scores was moderate to good (intraclass correlation coefficient r = 0.53–0.80), except for anxiety (0.48) and perceived health (0.45). Severity of dementia mainly affected the feasibility, acceptability and reproducibility of the instrument. The family proxy seemed to agree more with the patient than did the care provider proxy. Conclusion: Quality of life can be measured in patients with dementia, but special tools need to be developed for severe dementia.

Transcultural adaptation and psychometric validation of a French-language version of the QoL-AD

Objectives: The aim of this study was to assess the psychometric properties and the transcultural adaptation into French of the quality-of-life in Alzheimers disease (QoL-AD). Methods: A total of 120 patient-proxy pairs were recruited in six French hospitals and one French-speaking Swiss hospital to take part in the study. The patients presented mild to moderate AD (MMSE ≥ 10). The QoL-AD was administered by an interviewer for patients and was self-administered for caregiver proxies. Thus, the psychometric validation enabled the study of feasibility, acceptability, reliability and convergent and discriminant validity of the instrument. Results: The French version of the QoL-AD showed good internal consistency (Cronbachs α coefficient ≥ 0.70) and good reliability (Intra-class correlation > 0.80) at a 2-week interval, for patient and caregiver questionnaires. Convergent validity, as indicated by correlation between the QoL-AD (disease-specific instrument) and the dimensions of the Duke Health Profile (generic instrument), was also good for eight dimensions in the Duke profile (p < 0.05). Discriminant validity showed a significant difference for depression (p = 0.0025) and did not show significant difference for two groups of dementia (p = 0.11). Conclusion: There is now a validated French version of the QoL-AD available, following transcultural adaptation according to international recommendations, which possesses good psychometric qualities.

Feasibility, acceptability and internal consistency reliability of the nottingham health profile in dementia patients.

Background: Few studies have evaluated subjective health status in dementia patients. Objectives: The aim of the study was to determinate the feasibility, acceptability and internal consistency reliability of measuring subjective health status in dementia patients with the Nottingham Health Profile (NHP). Design: The French version of the NHP was administered to 145 dementia patients and their proxies (family caregivers and formal caregivers). Measures: The refusal rate, type of administration and time for completion were used as indicators of feasibility. Internal consistency reliability was determined with Cronbach’s α coefficient and test-retest reliability assessed with the intraclass correlation coefficient for test-retest values. The measurements obtained were compared by source of information (patient and proxies). Results: The 145 subjects had an average age of 82 and 78% were women. 73% had a Mini-Mental State <16. Ninety-four percent of the items were correctly filled in, but an interviewer had to be present because of problems in attention or comprehension. The test-retest reliability for subjects was good (ρ < 0.7), but response agreement between patients and their proxies was just acceptable for physical domains (ρ < 0.6) and poor for psychological and social domains (ρ < 0.4). Conclusions: Self-rating of perceived health status by dementia patients seems feasible with the questionnaire with adaptations in the administration, but other methods are needed to approach the more subjective domains of the quality of life.

Factors Associated with Caregivers’ Underestimation of Quality of Life in Patients with Alzheimer’s Disease

Objective: The aim of this study was to identify the factors associated with differences between how Alzheimer’s disease (AD) patients and their caregivers rate the patient’s health-related quality of life (QoL). Methods: Cross-sectional, multicentre study. Patients were 65 years or more, suffering from mild to moderate AD, native French speakers, with a main caregiver. Interrater agreement of the QoL-AD was assessed using the intraclass coefficient. A generalised linear model was used to identify factors related to the difference in health-related QoL scores between patients and their caregivers. Results: The 122 patients of the study were 82 ± 6 years old and mainly women (69%). Independent factors related to the difference between patients and caregivers were: Mini Mental State Exam score (β = 0.32; 95% CI = 0.05–0.59); instrumental activities of daily living score (β = –0.61; 95% CI = –1.14 to –0.07); total Neuropsychiatric Inventory score (β = 0.10; 95% CI = 0.05–0.59), and Zarit’s burden score (β = 0.09; 95% CI = 0.01–0.17). Conclusion: Practitioners must take into account the trend towards underestimation when health-related QoL is rated by caregivers or proxies.