Moustapha Dramé

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.

Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities

OBJECTIVE the study aimed to determine the prevalence of and risk factors for inappropriate prescribing (IP) and prescribing omission (PO) in elderly with mental co-morbidities. PARTICIPANTS One hundred fifty consecutive inpatients with mental co-morbidities hospitalised for acute medical illness (mean age 80 +/- 9, 70% of women) were considered for the study. MEASUREMENTS IP and PO were prospectively identified according to STOPP/START criteria at hospital admission. RESULTS over 95% were taking >or=1 medication (median = 7) which amounted to 1,137 prescriptions. The prevalence of IP was 77% and PO was 65%. The most frequent encountered IP concerned drugs adversely affecting fallers (25%) and antiaggregants therapy without atherosclerosis (14%). PO concerned antidepressants with moderate/severe depression (20%) and calcium-vitamin D supplementation (18%). Independent predictors for IP were increased number of concomitant drugs (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.13-1.89), being cognitively impaired (OR 1.83, 95% CI 1.55-2.24), and having fallen in the preceding 3 months (OR 2.03, 95% CI 1.52-2.61) or hospitalised in the preceding year (OR 1.09, 95% CI 1.02-1.23). Concerning PO, psychiatric disorder (OR 1.64, 95% CI 1.42-2.01) and increase level of co-morbidities (OR 1.79, 95% CI 1.48-1.99) were identified. Living in an institutional setting was a predictive maker for both IP (OR 1.45, 95% CI 1.27-1.74) and PO (OR 1.67, 95% CI 1.32-1.91). CONCLUSION IP and PO were highly prevalent raising the need of a greater health literacy concerning geriatric conditions in non-geriatrician practitioners who care elderly as well as in the community, in hospital and institutional settings for improving quality and safety in prescribing medication.

Analysis of case management programs for patients with dementia: A systematic review

People suffering from dementia are particularly vulnerable to the gaps between the health and social service systems. Case management is a professional field that seeks to fill in these gaps and remedy this fragmentation.

Prediction of the fetal status in noninvasive management of alloimmune thrombocytopenia

Fetal/neonatal alloimmune thrombocytopenia is the most common cause of severe thrombocytopenia in the fetus and in an otherwise healthy newborn. To counter the consequences of severe fetal thrombocytopenia, antenatal therapies have been implemented. Predictive parameters for fetal severe thrombocytopenia are important for the development of noninvasive strategy and tailored intervention. We report here data concerning 239 pregnancies in 75 HPA-1bb women. Analysis of the index cases (diagnosis of fetal/neonatal alloimmune thrombocytopenia) did not show any significant correlation between the severity of the disease and the maternal genetic background (ABO blood group and HLA-DRB3 allele). Subsequent pregnancies were managed, and therapy effectiveness was evaluated. The highest mean newborn platelet count was observed for a combination of intravenous immunoglobulin and steroids (135 × 10⁹/L; 54 newborns) compared with intravenous immunoglobulin alone (89 × 10⁹/L; 27 newborns). The maternal anti-HPA-1a antibody concentration measured before any treatment and before 28 weeks of gestation was predictive of the fetal status. The weighted areas under curves of the maternal alloantibody concentrations were predictive of therapy response. To conclude, this large retrospective survey gives new insights on maternal predictive parameters for fetal status and therapy effectiveness allowing noninvasive strategies.

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.

Interdisciplinary Geriatric and Psychiatric Care Reduces Potentially Inappropriate Prescribing in the Hospital: Interventional Study in 150 Acutely Ill Elderly Patients with Mental and Somatic Comorbid Conditions

BACKGROUND Potentially inappropriate medications and prescription omissions (PO) are highly prevalent in older patients with mental comorbidities. OBJECTIVE To evaluate the effect of interdisciplinary geriatric and psychiatric care on the appropriateness of prescribing. DESIGN Prospective and interventional study. SETTING Medical-psychiatric unit in an academic geriatric department. PARTICIPANTS Participants were 150 consecutive acutely ill patients aged on average 80.0 ± 8.1 years suffering from mental comorbidities and hospitalized for any acute somatic condition. INTERVENTION From admission to discharge, daily collaboration provided by senior geriatrician and psychiatrist working in a usual geriatric interdisciplinary care team. MEASUREMENTS Potentially inappropriate medications and PO were detected and recorded by a trained independent investigator using STOPP/START criteria at admission and discharge. RESULTS Compared with admission, the intervention reduced the total number of medications prescribed at discharge from 1347 to 790 (P < .0001) and incidence rates for potentially inappropriate medications and PO reduced from 77% to 19% (P < .0001) and from 65% to 11% (P < .0001), respectively. Independent predictive factors for PIP at discharge were being a faller (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.43-2.09) and for PO, the increased number of medications (OR 1.54; 95% CI 1.13-1.89) and a Charlson comorbidity index greater than 2 (OR 1.85; 95% CI 1.38 - 2.13). Dementia and/or presence of psychiatric comorbidities were predictive factors for both potentially inappropriate medications and PO at discharge. CONCLUSION These findings hold substantial promise for the prevention of IP and OP in such a comorbid and polymedicated population. Further evaluations are, however, still needed to determine if such an intervention reduces potentially inappropriate prescribing medication-related outcomes, such as incidence of adverse drug events, rehospitalization, or mortality.