Admission Of Older Patients Research Articles

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s.

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays. The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance. During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions. Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

Effect of age and residential status on the predictive performance of CURB-65 score.

The CURB-65 score was designed to predict 30-day mortality and decide the site of care of pneumonia. It is uncertain how age and residential status affect the accuracy of CURB-65 score in older patients. This study aimed to evaluate the effect of age and residential status on the performance of CURB-65 score in predicting 30-day all-cause mortality of pneumonia in older patients. We used combined data from two prospective observational cohorts of adult patients with pneumonia. Older patients aged ≥ 65 years were analysed. Of 1644 patients, 1200 were living in the community and 464 residing in nursing homes. The 30-day mortality rates of community-acquired pneumonia (CAP) and nursing home-acquired pneumonia (NHAP) were 10.7% and 14.2% respectively. In each age group of CAP and NHAP, mortality increased with pneumonia severity. Mortality decreased with advancing age in NHAP, and the reverse was true for CAP. In NHAP but not CAP, the proportion of highly severe pneumonia (CURB-65 score ≥ 3) was lower in older patients. The overall predictive performance of CURB-65 score was comparable in CAP and NHAP. The accuracy deteriorated with advancing age in NHAP but not CAP. Using the cut-off score of ≥3 (highly severe pneumonia), the CURB-65 score achieved high negative predictive values (>90%) in CAP and NHAP. Advancing age adversely affected the predictive performance of CURB-65 score in NHAP but not CAP. The score was not helpful in guiding the site of care at admission in older patients with pneumonia.

P212: Can acute admissions of older patients be avoided? The role of primary health care

P212: Can acute admissions of older patients be avoided? The role of primary health care

Understanding Clinical Importance of Frailty and Designing a Frailty Assessment Tool in Acute Hospitals

Introduction: Managing the acute admission of older patients is a challenge in hospitals. Frail older people represent a larger proportion of acute admissions. Length of inpatient stay, inpatient mortality and the 90-day readmission rate are significant in this group of patients. In order to reduce the risks of adverse outcomes, frailty should be screened using an appropriate assessment tool and these patients must receive a Comprehensive GeriatricAssessment (CGA). Methods: Based on current evidences a frailty screening tool was designed and developed. The tool was validated by means of testing the inter-observer and intra-observer reproducibility. The process of validation was conducted by independent observers who did not provide any contribution in developing this tool. Results: A total of twenty patients were included. Ten patients were involved in testing the inter-observer reproducibility and eight out of total ten patients (80%) were received the same frailty scores. The intra-observer reproducibility was evaluated in ten patients and ten out of total ten patients (100%) obtained the same scores. Conclusion: The results shown on testing the inter-observer and intra-observer reproducibility of the tool were satisfactory. Thus this tool can be considered as an applicable frailty screening tool in acute hospitals.

Digoxin and 30-day All-cause Hospital Admission in Older Patients with Chronic Diastolic Heart Failure

BackgroundIn the main Digitalis Investigation Group (DIG) trial, digoxin reduced the risk of 30-day all-cause hospitalization in older systolic heart failure patients. However, this effect has not been studied in older diastolic heart failure patients. MethodsIn the ancillary DIG trial, of the 988 patients with chronic heart failure and preserved (> 45%) ejection fraction, 631 were age ≥ 65 years (mean age 73 years, 45% women, 12% non-whites), of whom 311 received digoxin. ResultsAll-cause hospitalization 30-day post randomization occurred in 4% of patients in the placebo group and 9% each among those in the digoxin group receiving 0.125 mg and ≥ 0.25 mg a day dosage (P = .026). Hazard ratios (HR) and 95% confidence intervals (CI) for digoxin use overall for 30-day, 3-month, and 12-month all-cause hospitalizations were 2.46 (1.25-4.83), 1.45 (0.96-2.20) and 1.14 (0.89-1.46), respectively. There was one 30-day death in the placebo group. Digoxin-associated HRs (95% CIs) for 30-day hospitalizations due to cardiovascular, heart failure, and unstable angina causes were 2.82 (1.18-6.69), 0.51 (0.09-2.79), and 6.21 (0.75-51.62), respectively. Digoxin had no significant association with 30-day all-cause hospitalization among younger patients (6% vs 7% for placebo; HR 0.80; 95% CI, 0.36-1.79). ConclusionsIn older patients with chronic diastolic heart failure, digoxin increased the risk of 30-day all-cause hospital admission, but not during longer follow-up. Although chance finding due to small sample size is possible, these data suggest that unlike in systolic heart failure, digoxin may not reduce 30-day all-cause hospitalization in older diastolic heart failure patients.

Digoxin Reduces 30-day All-cause Hospital Admission in Older Patients with Chronic Systolic Heart Failure

BackgroundHeart failure is a leading cause of hospital admission and readmission in older adults. The new United States healthcare reform law has created provisions for financial penalties for hospitals with higher than expected 30-day all-cause readmission rates for hospitalized Medicare beneficiaries aged ≥65 years with heart failure. We examined the effect of digoxin on 30-day all-cause hospital admission in older patients with heart failure and reduced ejection fraction. MethodsIn the main Digitalis Investigation Group trial, 6800 ambulatory patients with chronic heart failure (ejection fraction ≤45%) were randomly assigned to digoxin or placebo. Of these, 3405 were aged ≥65 years (mean age, 72 years; 25% were women; 11% were nonwhite). The main outcome in the current analysis was 30-day all-cause hospital admission. ResultsIn the first 30 days after randomization, all-cause hospitalization occurred in 5.4% (92/1693) and 8.1% (139/1712) of patients in the digoxin and placebo groups, respectively, (hazard ratio {HR} when digoxin was compared with placebo, 0.66; 95% confidence interval {CI}, 0.51-0.86; P=.002). Digoxin also reduced both 30-day cardiovascular (3.5% vs 6.5%; HR, 0.53; 95% CI, 0.38-0.72; P<.001) and heart failure (1.7 vs 4.2%; HR, 0.40; 95% CI, 0.26-0.62; P<.001) hospitalizations, with similar trends for 30-day all-cause mortality (0.7% vs 1.3%; HR, 0.55; 95% CI, 0.27-1.11; P=.096). Younger patients were at lower risk of events but obtained similar benefits from digoxin. ConclusionsDigoxin reduces 30-day all-cause hospital admission in ambulatory older patients with chronic systolic heart failure. Future studies need to examine its effect on 30-day all-cause hospital readmission in hospitalized patients with acute heart failure.

The role of social isolation in frequent and/or avoidable hospitalisation: rural community-based service providers’ perspectives

Research on frequent or avoidable hospital admission has not focussed on the perspectives of service providers or rural settings. The link between social isolation and admission is not well explored, although social isolation is known to have negative health effects. This paper reports further analysis from a study investigating service providers' perspectives on factors influencing frequent hospital admission in older patients with chronic disease, and explores the perceived role of social isolation. Semi-structured interviews with 15 purposively sampled community-based service providers in rural New South Wales, Australia were thematically analysed. Social isolation was repeatedly identified as an important contributory factor in frequent and/or avoidable admission. Patients were described as socially isolated in three broad and interrelating ways: living alone, not socialising and being isolated from family. Social isolation was perceived to contribute to admission by limiting opportunities offered by social interaction, including opportunities for: improving mental health, pain tolerance and nutritional status; facilitating access to services; reinforcing healthful behaviours; and providing a monitoring role. Social isolation is perceived to contribute to admission in ways that may be amenable to intervention. Further research is needed to understand patients' perspectives on the role of social isolation in admission, in order to inform policy and programs aimed at reducing hospitalisation among older people with chronic disease. WHAT IS KNOWN ABOUT THE TOPIC? Social isolation has been shown to adversely affect physical health and mental health and wellbeing across a range of populations. However, less is known about the influence of social isolation on hospital admission among older people with chronic disease, and in particular in instances where admission might have been avoided. WHAT DOES THIS PAPER ADD? This paper adds to our understanding of the ways in which social isolation might link to hospital admission among older people with chronic conditions. It does this by reporting the perspectives of community-based service providers with many years' experience of working with this patient group. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Practitioners need to consider the wider determinants of hospital admission among older patients with chronic disease, including social structures and support. For policy makers the implications are to review support for such patients and explore the possible impact of reducing social isolation on hospital admission.

The European Medicines Agency Discovers the Geriatric Patient

Polypharmacy in older persons is not new. A century ago, James Ensor painted his mother on her deathbed, with 20 bottles of medicines on her bedside table. However, polypharmacy is a growing problem because the life expectancy from birth is increasing (by 3 months on average every year in the more developed world), with people enjoying better health and living longer. It is, however, the group of older people that consume the most medications. In 1989, Turner published a review that is still relevant today, and in which he indicated that there was a need for clinical trials in elderly subjects. Indeed, most trials have excluded older patients by age or by co-morbidities, a problem that still exists today; for example, the newly introduced oral anticoagulants have not been tested in the oldest patients. The recent FEVER (Felodipine Event Reduction) trial in patients with systolic blood pressure concluded that ‘‘the goal systolic blood pressure has to be £140mmHg in elderly hypertensives’’. However, patients aged‡80 yearswere excluded from this trial. In fact, all clinicians are prescribing off-label treatments for many of their older, co-morbid and frail patients. This is not acceptable and not ethical. The reality is that one-third of the hospital admissions of older patients are related to their long-term medicine intake.

Outcomes of emergency admission of older patients: impact of cognitive impairment

Many older patients admitted to hospital as an emergency present with cognitive impairment. This review examines whether this is detected reliably by health-care professionals, and considers how it has an impact on outcome for the patient.

Postoperative complications and mortality in older patients having non‐cardiac surgery at three Melbourne teaching hospitals

To determine the incidence of postoperative complications, including 30-day mortality rate, and need for intensive care unit (ICU) admission in older patients after non-cardiac surgery. Prospective observational study of all patients aged 70 years or older having elective and non-elective, non-cardiac surgery, and staying at least 1 night after surgery in one of three Melbourne teaching hospitals, June to September 2004. Postoperative complications and 30-day mortality rate. 1102 consecutive patients were audited in mid 2004; 70% had pre-existing comorbidities. The 30-day mortality rate was 6%; 19% had postoperative complications; and 20% of patients spent at least 1 night in ICU. On multivariate analysis, preoperative factors associated with 30-day mortality included age (odds ratio [OR], 1.09 per year over 70 years; 95% CI, 1.04-1.13; P < 0.001); increasing severity of systemic disease (American Society of Anesthesiologists physical status classification) (OR, 2.53; 95% CI, 1.65-3.86; P < 0.001); and albumin level < 30 g/L (OR, 2.23; 95% CI, 1.09-4.57; P = 0.03). Postoperative factors associated with 30-day mortality were unplanned ICU admission (OR, 3.95; 95% CI, 1.63-9.55; P = 0.003); sepsis (OR, 2.75; 95% CI, 1.17-6.47; P = 0.02); and acute renal impairment (OR, 2.40; 95% CI, 1.06-5.41; P = 0.04). Thoracic surgery was the only surgical specialty significantly associated with mortality (OR, 3.96; 95% CI, 1.44-9.10; P = 0.008) in the multivariate analysis. Older patients having surgery had high rates of comorbidities and postoperative complications, placing considerable demands on critical care services. Patient factors were often stronger predictors of mortality than the type of surgery.

Does Functional Decline Prompt Emergency Department Visits and Admission in Older Patients?

Background: Older patients may visit the emergency department (ED) when their illness affects their function. Objectives: To quantify the function of older ED patients, to assess whether functional decline (FD) had occurred, and to determine whether function contributes to the ED visit and hospital admission. Methods: The authors performed an institutional review board–approved, prospective, cross-sectional study in a community teaching hospital ED. Eligible patients were older than 74 years of age, with an illness at least 48 hours old. Patients from a nursing facility and those without a proxy who were unable or unwilling to complete the questions were excluded. The Older Americans Resources and Services Questionnaire, which tests seven instrumental activities of daily living (IADL) and seven physical ADLs (PADL), was used. Data are presented as means or proportions with 95% confidence intervals (95% CI), and comparisons as 95% CI for the difference between proportions. Results: The authors enrolled 90 patients (mean age, 81.6 yr [SD ± 4.9], 40% male). Dependence in at least one IADL was reported by 68% (95% CI = 57% to 77%), and in at least one PADL by 61% (95% CI = 50% to 71%). Functional decline was reported by 74% (95% CI = 64% to 83%). Two thirds of those with IADL decline and three quarters of those with PADL decline said that this contributed to their ED visit. Seventy-seven percent with, and 63% without, IADL decline were admitted (14% difference, 95% CI =−6.1% to 33%). Seventy-nine percent with and 61% without PADL decline were admitted (18% difference, 95% CI =−1.4% to 38%). Conclusions: Functional decline is common in older ED patients and contributes to ED visits in older patients; its role in admission is unclear.

Does Functional Decline Prompt Emergency Department Visits and Admission in Older Patients?

Older patients may visit the emergency department (ED) when their illness affects their function. To quantify the function of older ED patients, to assess whether functional decline (FD) had occurred, and to determine whether function contributes to the ED visit and hospital admission. The authors performed an institutional review board-approved, prospective, cross-sectional study in a community teaching hospital ED. Eligible patients were older than 74 years of age, with an illness at least 48 hours old. Patients from a nursing facility and those without a proxy who were unable or unwilling to complete the questions were excluded. The Older Americans Resources and Services Questionnaire, which tests seven instrumental activities of daily living (IADL) and seven physical ADLs (PADL), was used. Data are presented as means or proportions with 95% confidence intervals (95% CI), and comparisons as 95% CI for the difference between proportions. The authors enrolled 90 patients (mean age, 81.6 yr [SD +/- 4.9], 40% male). Dependence in at least one IADL was reported by 68% (95% CI = 57% to 77%), and in at least one PADL by 61% (95% CI = 50% to 71%). Functional decline was reported by 74% (95% CI = 64% to 83%). Two thirds of those with IADL decline and three quarters of those with PADL decline said that this contributed to their ED visit. Seventy-seven percent with, and 63% without, IADL decline were admitted (14% difference, 95% CI = -6.1% to 33%). Seventy-nine percent with and 61% without PADL decline were admitted (18% difference, 95% CI = -1.4% to 38%). Functional decline is common in older ED patients and contributes to ED visits in older patients; its role in admission is unclear.

Does Functional Decline Prompt Emergency Department Visits and Admission in Older Patients?

Does Functional Decline Prompt Emergency Department Visits and Admission in Older Patients?