Pascale Cornette

Predicting functional adverse outcomes in hospitalized older patients: a systematic review of screening tools.

BACKGROUND Functional decline frequently occurs following hospitalisation in older people and may be prevented or minimized by specific management. Such care processes needs appropriate early screening of older hospitalized patients. OBJECTIVE To identify instruments able to detect on admission older hospitalized patients at risk of functional decline at and after discharge. METHODS Functional decline is defined as loss of independence in activities of daily living (functional decline) or admission in nursing home. The systematic search used Medline 1970-2007, Web of Science 1981-2007 and references list of relevant papers. An independent epidemiologist assessed methodological quality of the retained articles. RESULTS We found 12 studies developing predictive tools, including 7145 patients. Functional outcomes were assessed at or after discharge. Preadmission functional status, cognition, and social support were major components for prediction of functional evolution. Few instruments are fully validated and data concerning reliability are often lacking. Operational characteristics are moderate (sensitivity 29-87%, negative likelihood ratio 0.2-0.8). CONCLUSIONS Instruments predicting functional adverse outcomes are difficult to compare due to heterogeneity of functional outcomes and hospital settings. The reason why so many tools have been developed is probably because none gives full satisfaction: their general predictive validity and performances are insufficient. Further research is needed to improve the screening of frail older patients admitted to hospital with standardized and validated tools.

Differential risk factors for early and later hospital readmission of older patients.

Background and aims: This study aimed at analyzing rates and factors associated with early and later readmission (0–1 month and 2–3 months after discharge, respectively) of older people after index hospitalization. Methods: This prospective observational study was conducted in two teaching hospitals. People 70 years and over were interviewed within 48 h of emergency admission. Socio-demographic and medical factors were collected, together with functional factors including Activities of Daily Living (basis and instrumental), cognitive state, and geriatric syndromes. Medical diagnosis, length of stay, and destination were collected at discharge, and patients were followed up by phone 1 and 3 months after discharge. During these interviews, outcomes on readmission, institutionalization, need for help, and death were evaluated. Results: The population of 625 patients had a mean age of 80.0 years. The rate of early readmission (0–1 month) was 10.7% and the overall rate within 3 months was 23.1%. Logistic regression analysis showed that variables predicting early readmission were previous hospitalization within 3 months, a longer length of stay, and a discharge diagnosis in chapter 8 (respiratory system) and chapter 10 (genito-urinary system) of the ICD-9-CM. Variables predicting later readmission were previous hospitalization within 3 months, a discharge diagnosis in chapter 7 (circulatory system) of the ICD-9-CM, and a poor pre-admission IADL score. Conclusions: In a medicalized population of older people, several risk factors may be identified for 0–1 month and 2–3 month readmission. Besides severe morbidities at discharge, diagnoses and previous hospitalization, pre-admission IADL was an independent risk factor for 2–3 month readmission.

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.

COMPARISON OF THREE TOOLS PREDICTING FUNCTIONAL DECLINE AFTER HOSPITALIZATION OF OLDER PATIENTS

patotoxicity in older adults than reported in previous studies of younger adults, which found that clinical hepatitis developed in 1.1% (14/1,264) of patients receiving a rifampicin-containing regimen and hyperbilirubinemia in 0.6% of patients. The difference may be attributable to the effects of aging on hepatic function. In addition, the findings of the current study indicate the importance of close monitoring of liver function while using rifampicin for MRSA bacteremia in older adults. In conclusion, treatment with a rifampicin-containing regimen for MRSA bacteremia is likely to rapidly induce rifampicin resistance, especially in very old patients. The higher mortality rate of patients with emergence of rifampicin-resistant MRSA during rifampicin-containing treatment and the higher frequency of hepatotoxicity in patients with current rifampicin usage in MRSA bacteremia warrant clinical attention and further study.

Prediction of risk of in-hospital geriatric complications in older patients with hip fracture

Background and aims: Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams. Methods: A retrospective cohort of consecutive community-living elderly patients (age≥75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR). Results: Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53–58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off). Conclusions: None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention.

Changes in the clinical features of older patients admitted from the emergency department.

Demographic changes and healthcare reforms may impact the profile of hospitalized older persons. In this study, we sought to compare the characteristics of two prospective cohorts recruited at a ten-year interval (1999, n=253-2009, n=355). They included older patients (≥75 years) admitted through the emergency department for at least 48 h in acute non-geriatric wards in the same university hospital. The exclusion criteria were patients who were admitted directly to the intensive care unit, who were dependent for all 6 Activities of Daily Living (ADL), who had recently suffered from a major stroke, or whose with a life expectancy of less than 3 months. Median age was higher in 2009 than in 1999 (83 vs. 81; p=0.020), with a higher proportion of those aged 85 years and over (p=0.026). Patients in the 2009 cohort were less likely to live in a nursing home (p=0.018), more dependent for the basic ADL (p<0.001), more independent for the instrumental ADL (p<0.001). They were more likely to have fallen in the previous year (p<0.001). They took more medications (p<0.001). Their length-of-stay was shorter (p<0.001), but they were more likely to be discharged to a rehabilitation center (p<0.001). They underwent more early re-admissions (p=0.020) and similar 3-month functional decline (p=0.614). In conclusion, within a decade, the social, functional and medical characteristics of older patients admitted to hospital have changed significantly. In view of the high consumption of in-patient services by this population, hospitals must adapt to these rapid changes.

A Belgian survey on geriatric assessment in oncology focusing on large-scale implementation and related barriers and facilitators

OBJECTIVES The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate. RESULTS Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration. CONCLUSION Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.

Peripheral parenteral nutrition in geriatric wards.

Abstract Poor nutritional status significantly contributes to morbidity and mortality in elderly. Malnutrition and denutrition are amenable to interventions aimed to improve outcomes in acute conditions so that nutritional support is frequently initiated during hospitalisation. If the enteral route remains the first evidence-based choice when the gut is functional, this approach may be difficult to perform in some “geriatric” situations like delirium, agitation, coma or pulmonary congestion. In the first days of the acute condition, when the patient is still stable, an alternative to the enteral route may also be considered. Although there is no evidence that parenteral nutrition is better than enteral nutrition, the peripheral intravenous route may be of interest especially when the enteral route is contraindicated. Moreover, the technique of peripheral parenteral nutition reduces central cannulation-related complications like pneumothorax. We emphasize here the place of this alternative method for a short duration nutritional support when supplement of caloric intake is needed. We discuss indications, a practical approach, our experience and analyze the evidences for this complementary nutritional support.