Acute Geriatric Patients Research Articles

SUN-P036: Nutritional Status and Health-Related Quality of Life in Acute Geriatric Patients

SUN-P036: Nutritional Status and Health-Related Quality of Life in Acute Geriatric Patients

P-036: Hospital at Home for acute geriatric patients

P-036: Hospital at Home for acute geriatric patients

SUN-PP081: Nutritional Status and Independence in Activities of Daily Living (ADL) in Acute Geriatric (AG) Patients

SUN-PP081: Nutritional Status and Independence in Activities of Daily Living (ADL) in Acute Geriatric (AG) Patients

Short- and longer-term predictive capacity of the Multidimensional Prognostic Index: The timing of the assessment is of no consequence

BackgroundSeveral studies have tested the ability of the Multidimensional Prognostic Index (MPI) to predict mortality for acute elderly patients admitted to hospital. We compared the reliability of MPI scores obtained both on admission to, and at discharge from hospital. We tested MPI performance in predicting short- and longer-term mortality grouped into three risk groups and according to single MPI scores. MethodsA longitudinal prospective study was conducted on 699 elderly patients admitted to the Geriatric Unit at Padua General Hospital. MPI scores were obtained on admission and at discharge. In-hospital and one-year mortality was recorded. Adjusted Cox's regression models were used to assess the prognostic value of the MPI scores. Results691 were included in the study: 459 (66.4%) women and 232 (33.6%) men, mean age=85.2±7.0 years. Patients were grouped as: low risk MPI 12.5%; moderate risk MPI 28.6%; severe risk MPI 58.9%.The cumulative in-hospital mortality rate was 7.4%. In the adjusted model, only MPI score (not MPI risk group) was significantly associated with in-hospital death ([HR]=1.22, 95%CI 1.07–1.39).1-Year crude mortality rate: 39.2%. The patients’ MPI scores at admission and at discharge were equally predictive of death (adjusted HR of MPI on admission 1.20 [1.15–1.27], p<0.0001; at discharge 1.24 [1.18–1.30], p<0.0001). The performance (AUC) of the MPI score on admission and at discharge proved much the same. ConclusionsThis study confirmed the value of the MPI in predicting mortality for acute elderly patients. Grouping MPI scores into risk levels may not be appropriate when applied to hospitalized acute geriatric patients. The prognostic value of MPI scores was confirmed only for MPI value ≥0.68. Judging from our study, the timing of the assessment during a patient's hospital stay (on admission or at discharge) may be irrelevant for longer-term prognostic purposes.

P140: Functional decline during hospitalization is a modifiable factor associated with mortality and institutionalization in acute geriatric patients

P140: Functional decline during hospitalization is a modifiable factor associated with mortality and institutionalization in acute geriatric patients

Nutritional status according to Mini Nutritional Assessment is related to functional status in geriatric patients--independent of health status.

The aim of this study was to investigate the relationship between nutritional and functional status in acute geriatric patients including mobility and considering health status. Cross-sectional study. Hospital. 205 geriatric patients (median age 82.0 (IQR: 80-86) years, 69.3% women). Nutritional status was determined by Mini Nutritional Assessment (MNA) and patients were categorized as well-nourished (≥ 24 points), at risk of malnutrition (17-23.5 points) or as malnourished (< 17 points). Functional status was determined by Barthel Index (BI) and Timed 'Up and Go' Test (TUG) and related to MNA categories. Using binary multiple logistic regression the impact of nutritional status on functional status was examined, adjusted for health status. 60.3% of the patients were at risk of malnutrition and 29.8% were malnourished. Ability to perform basic activities of daily living (ADL) decreased with declining nutritional status. The proportion of patients unable to perform the TUG increased with worsening of nutritional status (45.0% vs. 50.4% vs. 77.0%, p<0.01). After adjusting for age, gender, number of diagnoses, disease severity and cognitive function, a higher MNA score significantly lowered the risk of being dependent in ADL (OR 0.85, 95 % CI 0.77-0.94) and inability to perform the TUG (OR 0.90, 95 % CI 0.82-0.99). Nutritional status according to MNA was related to ADL as well as to mobility in acute geriatric patients. This association remained after adjusting for health status.

From words to action

The following case study aims to explore management's, health professionals' and patients' experiences on the extent to which there is visibility of management support in achieving effective interdisciplinary team working, which is explicitly declared in the mission statement of a 60-bed acute rehabilitative geriatric hospital in Malta. A total of 21 semi-structured interviews were conducted with the above-mentioned key stakeholders. Three main distinct yet interdependent themes emerged as a result of thematic analysis: "managing a team-friendly hospital", "interdisciplinary team components", and "interdisciplinary team processes". The findings show that visibility of management support and its alignment with the process and content levels of interdisciplinary teamwork are key to integrated care for acute rehabilitative geriatric patients. The emerging phenomena may not be reproducible in a different context; although many of the emerging themes could be comfortably matched with the existing literature. The implications are geared towards raising the consciousness and conscientiousness of good practice in interdisciplinary teamwork in hospitals, as well as in emphasizing organizational and management support as crucial factors for team-based organizations. Interdisciplinary teamwork in acute rehabilitative geriatrics provides optimal quality and integrated health care delivery with the aim that the older persons are successfully discharged back to the community. The authors draw on solid theoretical frameworks--the complexity theory, team effectiveness model and the social identity theory--to support their major finding, namely the alignment of organizational and management support with intra-team factors at the process and content level.

Severity and Management of Drug–Drug Interactions in Acute Geriatric Patients

Previous studies have investigated the prevalence of drug-drug interactions (DDIs) among the elderly in different care settings, but data describing the frequency and management of DDIs among acute geriatric patients appear to be absent. The aim of this study was to investigate the severity and interdisciplinary management of DDIs in patients admitted to an acute geriatric ward. The study was conducted at Oslo University Hospital, Norway, over a period of 19 weeks in 2010/11. On admission and daily during the hospital stay, prescribed medications were reviewed by pharmacists to identify DDIs with the aid of web-based databases. DDIs defined to be of potential clinical relevance, i.e., those classified as "major" (generally avoid) or "moderate" (precautions recommended), were following assessments by pharmacists presented at interdisciplinary meetings with geriatricians and nurses, and discussed in relation to the possible implementation of monitoring actions or changes in prescribing. The odds for prescribing changes were compared in relation to DDI type ("pharmacokinetic" vs. "pharmacodynamic") and severity ("major" vs. "moderate"). The project group retrospectively assessed the possible causal relationships between hospitalizations and DDIs. The pharmacists identified 245 DDIs of major (n = 13) or moderate (n = 232) severity in 80 (63.5 %) of the 126 patients included on admission and/or during hospitalization. In 94 of 162 cases where the pharmacists alerted the geriatricians (58.0 %), prescribing changes or monitoring actions were implemented. Prescribing changes (n = 38) were performed significantly more often for major than for moderate DDIs [odds ratio (OR) 3.8; 95 % confidence interval (CI) 1.2-12.2, p = 0.03], and significantly more often for pharmacokinetic than for pharmacodynamic DDIs (OR 4.9; 95 % CI 2.2-10.9, p < 0.01). For 28 of 126 patients (22.2 %), a causal relationship between hospitalizations and DDIs was assessed as "possible". The present study shows that acute geriatric patients are frequently exposed to DDIs for which active management is recommended in order to avoid unfavorable clinical outcomes. The integration of pharmacists into interdisciplinary teams could prevent potentially severe DDIs in the elderly.

A high prevalence of malnutrition in acute geriatric patients predicts adverse clinical outcomes and mortality within 12 months

Background & aimsOlder malnourished patients experience increased length of hospital stay and greater morbidity compared to their well nourished counterparts. This study aimed to assess whether nutritional status at hospital admission predicted clinical outcomes at 12 months follow-up. MethodsSecondary data analysis of 2602 consecutive patient admissions to an acute tertiary hospital in New South Wales, Australia on or before 1st June 2009. Twelve-month data was analysed in a sub-sample of 774 patients. Nutritional status was determined within 72 h of admission using the Mini Nutritional Assessment (MNA). Outcomes, obtained from electronic patient records included hospital readmission rate, total length of stay (LOS), change in level of care at discharge, and in-hospital mortality. ResultsA third (34%) of patients were malnourished and 55% at risk of malnutrition. Using a Cox proportional hazards regression model, controlling for underlying illness and age, patients at risk of malnutrition were 2.46 (95% CI: 1.36, 4.45; p = 0.003) times more likely to have a poor clinical outcome (mortality/discharge to higher level of care), while malnourished patients had a 3.57 (95% CI: 1.94, 6.59; p = 0.000) times higher risk. ConclusionsA poor nutritional status carries a substantially greater risk of death and/or loss of dependency in older adults. Interventions to improve the nutritional status of patients during their hospital stay, and following discharge back to the community, are needed to lower the risk of adverse outcomes.

Dehydration diagnosis is not helped by bun/creatinine ratio in acute geriatric patients

Dehydration diagnosis is not helped by bun/creatinine ratio in acute geriatric patients

Impact of computerized physician order entry on medication errors

BackgroundInformation is scarce on the impact of the clinical electronic record on the frequency and severity of medication errors in acute geriatric patients. Material and methodsAn analytical and descriptive pre–post study was conducted on the implementation of computerized provider order entry systems (CPOE), over a 6 year period. A voluntary reporting system was used to detect the medication errors using the IR2 report form of the UK National Health Service, the Global Trigger Tool and the walk rounds with the Pharmacy Service. The severity categories were taken from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index Categorizing Errors. ResultsA total of 1887 medication errors (1553 patients) were detected in the period of study, and represented the first adverse event reported (29.3%). 8.5 adverse events per 100 admissions were found (0.24 in the categories E through I) and the prescription errors represented a 27.6%. By drugs dispensed, adverse events were 2.07 times more frequent in the 3 year period (2007–2009) with electronic clinical record than in the 3 year period with the hand-written system (2004–2006), being more frequent with antibiotics (1.92 times), antipyretic (2.21 times) and opiates (2.72 times). For serious errors and by doses dispensed, there were 5.18 times less frequent serious errors in the period related to the electronic record, drug omission (46.8 times less frequent), wrong dose (10.53 times) and antibiotics (10.84 times). ConclusionFrequent medication errors were found in acute geriatric patients. An increase in medication errors and a decline in the severity of the detected errors were found in relationship to the electronic clinical record. For these reasons, the implementation of the electronic clinical record should be monitored.

Validation of a German Version of the Confusion Assessment Method for Delirium Detection in a Sample of Acute Geriatric Patients with a High Prevalence of Dementia

Objectives: To assess validity and interrater reliability of an operationalized German version of the Confusion Assessment Method (CAM) in geriatric patients with comorbid dementia and high delirium risk. Design: Prospective cross-sectional cohort study with double CAM assessment by a medical and nonmedical rater. Setting: Random sample of frail, cognitively impaired elderly with acute disease requiring hospital care. Participants: A total of 39 frail elderly, mean age 83 ± 7 years, 72% (n = 28) female, with cognitive impairments, a high prevalence of dementia (86%, n = 33) and a significant risk of delirium. Of these, 13 revealed delirium, which was superimposed on dementia in 11. Measurements: A translated and operationalized version of the CAM was validated against a neuropsychiatric and geriatric consensus reference standard based on DSM-IV. Additional measures included the Short Portable Mental Status Questionnaire, the Mini-Mental State Examination and the Delirium Index for cognitive impairment severity, the Informant Questionnaire on Cognitive Decline for dementia diagnosis and the Barthel Index, illness severity (Cumulative Illness Rating Scale) and medication. Results: Delirium was correctly detected by CAM algorithm in 10 out of 13 delirious patients resulting in a high sensitivity of 0.77 and a specificity of 0.96–1.00 for both raters. Likelihood ratio revealed an almost 20-fold risk of delirium with positive CAM testing. Interrater reliability was excellent with a Cohen’s ĸ of 0.95 (CI 0.74–1.0) for the algorithm, single items’ ĸ values varied between 0.5 and 1. Conclusions: The German CAM is a reliable and valid measure of delirium, even in frail, acutely diseased elderly with concomitant dementia.

Rehabilitation and Nursing Home Admission after Hospitalization in Acute Geriatric Patients

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. Cross-sectional study Eight hundred thirty patients 65 years or older admitted into an acute geriatric ward in Italy were evaluated (1998-2000). 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). 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. In geriatric patients, both medical and sociodemographic characteristics are key factors for referral to rehabilitation or nursing home at discharge.

The Role of Colonization Pressure in Nosocomial Transmission of Methicillin Resistant Staphylococcus aureus

BACKGROUND/OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is a serious nosocomial pathogen and colonized or infected patients are a major reservoir for patient-to-patient transmission. Despite strict adherence to infection prevention and control (IP&C) procedures, a general medicine unit serving nephrology, infectious disease and acute geriatric patients in our tertiary care teaching hospital continued to experience ongoing transmission and outbreaks of MRSA. The objective of the study was to determine the role that colonization pressure (CP) plays in nosocomial transmission of MRSA on a general medicine unit. Also, to propose a threshold CP above which additional IP&C practices should be implemented in order to prevent MRSA transmission and avoid an outbreak.

The effect of electric stimulation treatment on the functional rehabilitation of acute geriatric patients with stroke—a preliminary study

The most common neurological damage in acute stroke/cerebrovascular accident (CVA) is a decline in the senso-motor capacities of both the upper and the lower extremities with a more severe injury in the upper ones. Motor improvement of the affected limb can be attained through frequent intensive exercise by electrical stimulation (ES). The objective of this study was to examine the effect of the ES treatment using Handmaster ES device on the functional rehabilitation of elderly patients after acute CVA. Twenty-two elderly with different levels of damage and partial movements in their upper limb joints underwent a 3-week treatment. Nine of them were treated for additional 3-weeks after a 3-week break. After the first 3-week treatment, significant improvements were observed, in all the subjects, in the active range of motion (ROM) of the shoulder and the wrist joints, on manual dexterity tests and on functional independence measure (FIM). After the two periods of treatment the nine subjects exhibited significant improvements in ROM and in manual dexterity. FIM score increased by the same rate after each of the three stages. This preliminary study has proven that the Handmaster treatment can improve the geriatric rehabilitation outcome of elderly patients with senso-motor deficit caused by acute CVA.

Operant therapy with pain patients: evidence for its effectiveness

This investigation provides a behavioral conceptualization for clinical pain, a summary of the research supporting such a model, and a more detailed review of the evidence supporting the clinical efficacy of operant learning/conditioning strategies. Within the behavioral model, clinical pain is defined as an interacting cluster of individualized overt, covert, and neurophysiological responses capable of being produced by relevant tissue damage-irritation, and produced and maintained by other antecedent and consequent stimulus conditions. Based on an extensive review of existing research, it is concluded that the behavioral conceptual model as a whole and that portion based on operant conditioning techniques have strong research evidence when applied to patients with chronic low back pain. In contrast, there is insufficient evidence to date supporting the efficacy of operant methods with other chronic painful conditions, acute pain states, pediatric and geriatric pain patients, cancer pain states, or across cultures. Continued research in these and others areas is recommended. Future possibilities and issues surrounding the use of operant conditioning techniques with pain patients, highlighting research needs, are discussed.

Nutritional status using mini nutritional assessment and subjective global assessment predict mortality in geriatric patients.

To evaluate the clinical assessment of nutritional status and mortality in geriatric patients. Prospective follow-up study. Acute geriatric inpatient ward. Eighty-three consecutive acute geriatric patients (mean age +/- standard deviation = 83 +/- 7; 68% women). Patients were classified as (1) having protein-energy malnutrition (PEM), (2) having moderate PEM or being at risk for PEM, or (3) being well nourished according to Subjective Global Assessment (SGA) and Mini Nutritional Assessment (MNA). Body mass index ((BMI) kg/m2), arm anthropometry, and handgrip strength were determined. In a subgroup of patients (n = 39), body composition was analyzed using dual energy x-ray absorption and bioelectrical impedance. Three-year mortality data were obtained from the Swedish population records. Twenty percent and 26% of the patients were classified as having PEM based on SGA and MNA, respectively, whereas 43% and 56%, respectively, were classified as having moderate PEM or being at risk for PEM. Objective measures, such as BMI, arm anthropometry, handgrip, and body fat were 20% to 50% lower in the malnourished group than in the well-nourished subjects (P <.05). Moreover, mortality was higher in those classified as being malnourished, ranging from 40% after 1 year to 80% after 3 years, compared with 20% after 1 year (P =.03-0.17) and 50% after 3 years (P <.01) in patients classified as being well nourished. Fewer than one-third of newly admitted geriatric patients had a normal nutritional status according to SGA and MNA. BMI, arm anthropometry, body fat mass, and handgrip strength were reduced, and 1-, 2-, and 3-year mortality was higher in patients classified as malnourished. The present data justify the use of SGA and MNA for the assessment of nutritional status in geriatric patients.

Recognition of cognitive impairment by day and night nursing staff among acute geriatric patients.

The recognition of cognitive impairment by day and night nursing staff was studied in an acute geriatric unit. Seventy-six patients were randomly selected from a prospective sample of admissions. DSM-III-R diagnoses were established on all patients. Day and night staff were interviewed about each patient's clinical condition and asked to state whether or not they thought they were cognitively impaired or confused. Day staff were reasonably good at differentiating cognitively unimpaired from those with dementia and or delirium [kappa = 0.62, 95% confidence interval (CI) = 0.46-0.78]. All patients thought by day staff to be cognitively impaired were found to be so, although day staff did fail to identify some patients with cognitive impairment. Night staff performed less well (kappa = 0.37, 95% CI 0.18-0.57) and identified cognitively normal patients as being cognitively impaired, as well as failing to identify patients who were cognitively impaired. Night nursing interviews were not thought to have contributed to the management of any patient. The usefulness of night-time nursing interviews for research and general inpatient management purposes is questioned and the importance of daytime nursing interviews emphasized.

A study of serum zinc, albumin, alpha-2-macroglobulin and transferrin levels in acute and long stay elderly hospital patients

Serum zinc levels measured by atomic absorption spectrophotometry were found to be low (less than 10.5 mumols/l) in 38% of acute geriatric admissions, 69% of long stay geriatric patients and 19% of a control group of elderly hospital patients with a normal serum albumin. There was a significant positive correlation between serum zinc and serum albumin in all groups. In acutely ill geriatric patients only, there was a weak but statistically significant positive correlation between serum zinc and alpha-2-macroglobulin (A2M) (r = 0.20), P less than 0.05). Serum transferrin was low in 46% of acute geriatric patients and 22% of long stay geriatric patients but there was no correlation between serum zinc and serum transferrin levels in any patient group. There were significant differences in serum zinc, A2M and transferrin levels between the acute and long stay geriatric patients. The differences in serum zinc levels between these patients groups could not be explained by changes in serum A2M, transferrin or albumin. Changes mediated by an acute phase response may have influenced results in the acute geriatric group of patients.

Upper gastrointestinal haemorrhage in the elderly: a record of 92 patients in a joint geriatric/surgical unit.

Ninety-two consecutive elderly patients suffering from acute gastrointestinal bleeding were studied over a 3-year period. All were admitted to a specially designated Geriatric/Surgical Ward under the care of consultant physicians in geriatric medicine. The nurses were trained to look after acute surgical and geriatric patients. Patients were aged between 65 and 93 years. All were managed jointly by the surgeons and physicians. Only 13 needed emergency surgery which was preceded by urgent endoscopy. The rest were managed conservatively with intravenous cimetidine and blood transfusions as required. The overall mortality was low at 5.4%. It is concluded that in a series of elderly patients with acute gastrointestinal bleeding the mortality was not high in a unit where the management was conservative and there was joint care between geriatricians and surgeons.