Simone Franzoni

International Association of Gerontology and Geriatrics: A Global Agenda for Clinical Research and Quality of Care in Nursing Homes

A workshop charged with identifying the main clinical concerns and quality of care issues within nursing homes was convened by the International Association of Gerontology and Geriatrics, with input from the World Health Organization. The workshop met in Toulouse, France, during June 2010. Drawing on the latest evidence and mindful of the international development agenda and specific regional challenges, consensus was sought on priority actions and future research. The impetus for this work was the known variation in the quality of nursing home care experiences of older people around the world. The resulting Task Force recommendations include instigation of sustainable strategies designed to enhance confidence among older people and their relatives that the care provided within nursing homes is safe, mindful of their preferences, clinically appropriate, and delivered with respect and compassion by appropriately prepared expert doctors, registered nurses, administrators, and other staff. The proposals extend across 4 domains (Reputational Enhancement and Leadership, Clinical Essentials and Care Quality Indicators, Practitioner Education, and Research) that, in concert, will enhance the reputation and status of nursing home careers among practitioners, promote effective evidence-informed quality improvements, and develop practice leadership and research capabilities.

Good Nutritional Oral Intake Is Associated with Equal Survival in Demented and Nondemented Very Old Patients

OBJECTIVE: To evaluate the association of oral food intake with survival in very old demented nursing home patients.

Factors related to length of stay in a Geriatric Evaluation and Rehabilitation Unit

Factors related to length of stay were examined in 295 elderly patients (mean age=79.0±7.3, range 65–94; males=75, females=220), consecutively admitted to a Geriatric Evaluation and Rehabilitation Unit (GERU, P. Richiedei Hospital, Gussago, Brescia, Italy) over a twelve-month period (November 1, 1993–October 31, 1994). Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS), Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living (IADL), Tinetti Scale, Prognostic Nutritional Index (PNI), number of diseases and number of administered drugs were evaluated. An Index of Disease Severity (IDS) was utilized to estimate the level of comorbidity severity. Three comorbidity classes were thus defined: I) patients with no disease of relevant severity; II) patients with only one disease of relevant severity accompanied by clinically significant comorbidity; and III) patients with two or more relevant diseases. The variables associated with the length of stay proved to be classes of comorbidity, MMSE, dependence in BADL and IADL, Tinetti scale, and PNI. The association of longer length of stay with greater comorbidity was enhanced by impairment in gait and balance (Tinetti <18) and malnutrition (PNI >45). These data suggest that the length of stay in hospital is related to comorbidity in patients with conditions of physical and biomedical frailty.

A nutritional index predicting mortality in the nursing home

OBJECTIVE: To define a sensitive and specific index, based on nutritional indicators, predicting mortality in nursing home patients.

Prevalence and predictors of depressive symptoms in a nursing home

The aim of the study was to identify the prevalence of depressive symptoms (GDS score) and predictors of mood changes over a 12‐month period in 56 nursing home residents (13 males and 43 females; mean age 81.1 ± 8.6). At baseline, 48.2% of the residents who scores above 11 on the MMSE had a GDS score > 15. GDS score was associated with pain, disabling diseases and self‐evaluation of health, and independently with dissatisfaction with the nursing home environment, low level of nursing home social activities and younger age. Five depressed residents became non‐depressed, eight non‐depressed became depressed and 14 residents remained persistently depressed 12 months after baseline. After controlling for potential confounders, increasing GDS score was independently associated with decreasing basic activities of daily living, increasing number of clinical problems and younger age. Our data support the hypothesis that specific emotional adjustments can be found even in the apparently static environment of the nursing home.

Social, functional and health status influences on mortality: Consideration of a multidimensional inquiry in a large elderly population

Health status, functional status, and social influences were analyzed as risk factors associated with mortality in 1201 elderly subjects (70–75 years old), living in the center of Brescia, Northern Italy, followed up for three years.Mortality was positively associated with degree of impairment in health status, functional status, and mental status as measured by cognitive function and mood depression. Among social conditions no relation was found between mortality and living alone, education, or income, while a significant inverse relationship has been found between mortality and activities. In defining risk factors of mortality in aged people not only health status and cognitive function have to be taken into account but also social activities; these latter may act as protective factors buffering the organism from the effects of noxious stimuli.

Venlafaxine-Induced Reset Osmostat Syndrome: Case of a 79-Year-Old Depressed Woman:

The presence of hyponatremia, especially in a frail and very old patient, is associated with a greater morbidity and mortality rate. We report the case of a depressed 79-year-old woman who was treated with venlafaxine, in whom a drug-induced hyponatremia occurred in the absence of other possible causes. The case is discussed in the context of the multipotential factors that induce hyponatremia, with particular attention to the geriatric patient.

Mood improvement in elderly women after in-hospital physical rehabilitation

OBJECTIVE To evaluate the relationship between change in depressive symptoms and in-hospital physical rehabilitation in elderly women. DESIGN Longitudinal study. SETTING Hospital facility (geriatric evaluation and rehabilitation unit). PATIENTS One hundred twenty-three elderly inpatient women (mean age: 78.4+/-6.9 years, range 60 to 93) with good cognitive status (Mini Mental State Examination: 23.1+/-5.1) consecutively admitted over a 7-month period. INTERVENTION Physical therapy tailored to individual needs (five sessions a week of 30 to 45 minutes each). MAIN OUTCOMES MEASURES On admission: cognition (MMSE), depressive symptoms (Geriatric Depression Scale [GDS]), functional status (basic and instrumental activities of daily living [BADL, IADL], Tinetti scale), and somatic health. On discharge: depressive symptoms and gait and balance performances (Tinetti scale). RESULTS Seventy-five patients (61%) did not show changes on Tinetti scale over the hospitalization period and 48(39%) had a change of 3 or more points. Nonresponders had no change of GDS over the hospitalization period for all levels of physical disability on admission, whereas responders had relevant improvement of depressive symptoms when markedly disabled on admission, and progressively smaller improvements of depressive symptoms with increasing function on admission. CONCLUSIONS The study provides evidence that mood status changes synchronically with disability.

CHANGE IN FUNCTIONAL STATUS DURING HOSPITALIZATION IN OLDER ADULTS: A GERIATRIC CONCEPT OF FRAILTY

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COMBINED HYPOALBUMLNEMIA AND HYPOCHOLESTEROLEMIA AS A PREDICTOR OF MORTALITY IN OLDER PATIENTS IN A SHORT-TERM PERIOD

inhibitor because of lack of access to objective assessments of left ventricular function in the first instance. However, in this US study, treatment with ACE inhibitors is still disappointingly low at only 35% of patients despite confirmed objective evidence of impaired left ventricular function. Possible additional reasons for low levels of ACE inhibitors use include concerns about the small numbers of frail older patients included in the SOLVD study.’ The mortality benefits demonstrated may not apply to frail older patients with impaired renal function, and the higher likelihood of associated postural hypotension may also be deterring clinicians from initiating treatment. In a nursing home setting where access to objective assessment of left ventricular function by radionuclide ventriculography is likely to be limited, objective assessments of left ventricular function may be possible using portable echocardiography.4 If wider use of ACE inhibitors in frail older patients is to be advocated, then more trial evidence is required that demonstrates benefit in terms of quality of life and activities of daily living measurements? These end-points are more meaningful in a frail older population than mortality data alone. We are currently evaluating the impact of the ACE inhibitor perindopril on quality of life measures, cognition, and 6-minute walking distance. Useful effect on these end points would augment the case for a more widespread use of ACE inhibitors in nursing home residents with systolic dysfunction.