Stefania Cossi

Predictors of successful rehabilitation in geriatric patients: subgroup analysis of patients with cognitive impairment.

Background and aims: Understanding which patients benefit from rehabilitation programs may be useful in balancing resources and needs. The aim of this study was to evaluate whether cognitive and nutritional status are associated with functional improvement after rehabilitation in old persons. Methods: 2650 patients (aged ≥60 years) consecutively admitted to a geriatric rehabilitation unit in Italy between August 2001 and December 2005, were included. Functional status was evalutated with the Tinetti scale, cognitive status with the Mini-Mental State Examination (MMSE), and nutritional status with the Mini-Nutritional Assessment Short Form (MNA-SF). To identify predictors of functional recovery, multiple logistic regression models were run, with improvement on the Tinetti scale score as dependent variable. Results: Eighty per cent of old persons functionally improved after rehabilitation, ranges being 84% of those with MMSE≥24 to 58% of those with MMSE<10. Persons with both good cognition and good nutritional status were most likely to improve [odds ratio (OR)=2.5; 95% confidence interval (95% CI)=1.9–3.2]. Stratifying the sample according to cognitive status, we found that in patients with MMSE≥18 better nutritional status emerged as a factor associated with functional improvement, whereas in patients with severe cognitive impairment (MMSE<18), the only associated factor was a higher MMSE score. Conclusions: The resultsof the present study suggest that both good cognition and good nutritional status are associated with functional improvement in older persons. However, patients with poor cognition can also improve, depending on their degree of cognitive impairment, and they should not be routinely excluded from rehabilitation.

Adverse outcomes in older hospitalized patients: The role of multidimensional geriatric assessment

Background and aims: This study was carried out to detect the incidence of adverse outcomes in hospitalized older patients and the role of multidimensional assessment in identifying predictors of adverse outcomes, which include in-hospital mortality and the need for admission to rehabilitation units or nursing homes after hospital discharge. Methods: 923 patients at least 65 years old (mean age 78.7± 7.2, 49% women) admitted to the acute care geriatric ward of an internal medicine department were included in the study. On admission, each patient underwent a comprehensive medical, functional, neuropsychological, sociodemographic and nutritional assessment. Results: Incidence of mortality and other adverse outcomes was 6 and 16%, respectively. In- hospital mortality was independently predicted by older age (OR per year: 1.07, 95% CI: 1.02–1.12), male gender (OR: 3.97, 1.99–7.95), higher comorbidity (OR: 2.09, 1.01–4.33), higher heart rate (OR: 2.87, 1.30–6.35), lower systolic blood pressure (OR: 2.22, 1.03–4.81), lower serum albumin values (OR: 3.20, 1.63–6.29) and a lower MMSE score at hospital admission (OR: 5.51, 2.34–12.9). Adverse outcomes were independently predicted by older age (OR per year: 1.03, 1.01–1.06), higher comorbidity (OR: 2.00, 1.35–2.94), lower serum albumin values (OR: 2.57, 1.69–3.90) and a lower admission MMSE score (OR: 2.49, 1.68–3.71). Conclusions: A multidimensional geriatric assessment should be comprised of simple parameters available early, like serum albumin and MMSE score, that are predictive of adverse outcomes in older hospitalized patients, along with other health indicators (comorbidity, heart rate and blood pressure).

Vitamin D and health status in elderly

Recently, vitamin D has aroused considerable interest for several reasons. Many epidemiological studies have shown a widespread deficiency of vitamin D at all ages, and the recent finding that many organs and tissues have vitamin D receptors has fostered the clinical and biological relevance of vitamin D. Elderly people are at high risk for vitamin D deficiency if their life style entails few outdoor activities, their skin is thick and they exhibit impairment of renal function. In the elderly, vitamin D deficiency is very important because it can affect the function of many organs such as the muscle–skeletal, cardio-vascular systems and kidney, and may be involved in various diseases and pathological conditions including type II diabetes, cancer and cognitive decline. In the present review, the most relevant features of vitamin D are described as well as the clinical consequences of hypovitaminosis D in the elderly. Finally, the role of an adequate oral supplementation in the geriatric population is stressed.

Rehabilitation and Nursing Home Admission after Hospitalization in Acute Geriatric Patients

OBJECTIVES This study explored the effect of multimorbidity, cognitive and physical impairment, and sociodemographic factors on the choice of allocation of geriatric patients at hospital discharge. DESIGN Cross-sectional study SETTING AND PARTICIPANTS Eight hundred thirty patients 65 years or older admitted into an acute geriatric ward in Italy were evaluated (1998-2000). MEASUREMENTS Social characteristics before hospitalization, multimorbidity, physical functioning, and cognitive status were related to allocation of living place after hospitalization (home, rehabilitation unit, or nursing home). RESULTS Most patients were discharged to their homes (85%); 7% of the younger patients (65-74 years) and 11% of the very old (75+ years) were referred to a rehabilitation unit, while only among the very old 4% were discharged to a nursing home. Worse functional status, longer hospitalization, and being affected by dementia and cerebrovascular diseases (CVD) were associated with the admission to both rehabilitation and nursing home. Cognitive impairment and multimorbidity played a role in discharge destination, but only in functionally impaired patients. Living alone before hospitalization was correlated only with being discharged to a rehabilitation unit. CONCLUSION In geriatric patients, both medical and sociodemographic characteristics are key factors for referral to rehabilitation or nursing home at discharge.

Total lymphocyte count and in-hospital mortality in older persons with multimorbidity

Background and aims: Low total lymphocyte count (TLC) has been found to be a poor prognostic factor in adults affected by heart diseases, malignancy, and renal failure. The aims of this study were to verify if a low TLC was associated with in-hospital mortality in older persons and to evaluate whether this association was independent of the presence of multiple co-existing diseases (multimorbidity). Methods: The authors carried out a cross-section analysis of data of 65+ years old patients (n=596) admitted to a Geriatric Unit in Northern Italy. TLC, total white blood cell count (WBC) and serum albumin were assayed the day after admission. The presence and severity of diseases were evaluated with the Geriatric Index of Comorbidity (GIC). Other covariates included age, gender, cigarette smoking, cognition (Mini-Mental State Examination) and function (Activities of Daily Living). Logistic regression models were created to study factors affecting in-hospital death. Results: TLC was inversely correlated with both age and multimorbidity. Patients in the lowest tertile of TLC had the highest association with death during hospitalization (OR 6.1, 95% CI 1.1–33.6) independently of multimorbidity and all the other covariates. Stratifying the sample by degree of multimorbidity, this association was clearest in patients with the least severe multimorbidity (GIC ≤3). Conclusions: Although TLC and multimorbidity were correlated, they emerged as independent predictors of in-hospital death. Further investigations into possible biological mechanisms underlying the association of lymphocytes and adverse outcomes in old persons are needed.

EMERGING CHANGES IN THE CARE OF OLDER PEOPLE

that even slight indentations could cause dysphagia. Osteophyte-induced dysphagia can be treated conservatively or surgically. Nonsteroidal antiinflammatory drugs can be used to reduce local inflammation. Patients should also be started on a diet of soft food. If these conservative measures are not adequate, surgical resection may be necessary. In conclusion, cervical osteophytes can cause difficulty swallowing and should always be included in the differential diagnosis for dysphagia of unknown etiology, especially in the geriatric population. A high index of suspicion is required to establish the diagnosis of osteophyte-induced dysphagia. This pathology is serious but curable, so it is important to avoid missed diagnoses. Radiological investigation, and barium swallow studies in particular, is important for all patients with dysphagia.