Cumulative Illness Rating Scale For Geriatrics Research Articles

Usefulness of Oximetry for Sleep Apnea Screening in Frail Hospitalized Elderly

BackgroundSleep Apnea Syndrome (SAS) prevalence increases with age. In the elderly, symptoms are less specific (falls, cognitive or functional decline, polymedication). Polysomnography, the gold standard technique to diagnose SAS, is challenged by sleep laboratories' waiting lists and high associated costs. Nocturnal oximetry is an easy-to-use tool widely available outside the sleep medicine field identifying intermittent hypoxia, the landmark of SAS. It might be an interesting and easy way to screen for SAS in the functionally and cognitively impaired elderly living in long-term care settings. ObjectivesThe primary goal of this study was to assess the accuracy of the variability index of nocturnal pulse oximetry to detect moderate to severe SAS in patients older than 75 hospitalized in stable condition. The secondary goals were to assess the accuracy of the other indices of pulse oximetry (oxygen desaturation index [ODI]), and to determine the prevalence of moderate to severe SAS in our population. MethodsIn-hospital sleep studies with simultaneous respiratory polygraphy and nocturnal pulse oximetry were performed. Comorbidities were assessed by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) in association with a comprehensive geriatric assessment. ResultsEighty patients (mean age 85.3 ± 5.3 years) were included. Seventy-two percent of the patients exhibited moderate to severe SAS (95% CI 58.9–82.9), including 59.5% of severe SAS (apnea + hypopnea index >30/hour). SaO2 variability index using a threshold of 0.51, the sensitivity and negative predictive value (NPV) were 100%. With a value above 0.88, positive predictive value and specificity were high (respectively 96.6% and 93.8%). ODI of 3% or higher and 4% or higher were highly specific but less sensitive. ConclusionPrevalence of moderate to severe SAS in multimorbid hospitalized elderly patients is high. Automatic analysis of the variability of nocturnal SaO2 is a reliable tool for geriatricians to screen and rule out moderate to severe SAS. Our study suggests an important role of pulse oximetry as the first step in the diagnostic strategy for moderate to severe SAS in this population.

Poster #M207 USE OF RELIABLE CHANGE INDEX TO EVALUATE CLINICAL SIGNIFICANCE IN THE POSITIVE AND NEGATIVE SYNDROME SCALE (PANSS): A CATIE ANALYSIS

Cognition predicts functional competence among individuals with schizophrenia across the lifespan. However, as these individuals age, increasing levels of medical burden may also contribute to functional deficits both directly and indirectly through cognition. Thus, we assessed the relationship among, cognition, medical burden, and functional competence in older individuals with schizophrenia.We analyzed data obtained from 60 community-dwelling participants with schizophrenia and 30 control participants aged 50 or above. Cognition was assessed using the MATRICS Consensus Cognitive Battery (MCCB), functional competence was assessed using the USCD Performance-Based Skills Assessment (UPSA), and medical burden was assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Group differences were assessed using independent samples t-tests or chi-square tests. Mediation analyses using bootstrapping techniques were used to assess whether cognition mediated the effects of medical burden on functional competence.Participants with schizophrenia had higher levels of medical burden, cognitive deficits, and functional impairments. In participants with schizophrenia, cognition, but not medical burden, predicted functional competence after adjusting for age, education, gender, clinical symptoms, and anticholinergic burden of medications. In control participants, cognition and medical burden both predicted functional competence after adjusting for age, education, and gender. Further, cognition was found to fully mediate the association between medical burden and functional competence in control participants.Cognition is a robust predictor of functional competence among older individuals with schizophrenia, regardless of medical burden. Cognitive deficits associated with schizophrenia may mask any further cognitive impairment associated with medical burden and its impact on function.

Health care costs in the elderly in Germany: an analysis applying Andersen’s behavioral model of health care utilization

BackgroundTo analyze the association of health care costs with predisposing, enabling, and need factors, as defined by Andersen’s behavioral model of health care utilization, in the German elderly population.MethodsUsing a cross-sectional design, cost data of 3,124 participants aged 57–84 years in the 8-year-follow-up of the ESTHER cohort study were analyzed. Health care utilization in a 3-month period was assessed retrospectively through an interview conducted by trained study physicians at respondents’ homes. Unit costs were applied to calculate health care costs from the societal perspective. Socio-demographic and health-related variables were categorized as predisposing, enabling, or need factors as defined by the Andersen model. Multimorbidity was measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Mental health status was measured by the SF-12 mental component summary (MCS) score. Sector-specific costs were analyzed by means of multiple Tobit regression models.ResultsMean total costs per respondent were 889 € for the 3-month period. The CIRS-G score and the SF-12 MCS score representing the need factor in the Andersen model were consistently associated with total, inpatient, outpatient and nursing costs. Among the predisposing factors, age was positively associated with outpatient costs, nursing costs, and total costs, and the BMI was associated with outpatient costs.ConclusionsMultimorbidity and mental health status, both reflecting the need factor in the Andersen model, were the dominant predictors of health care costs. Predisposing and enabling factors had comparatively little impact on health care costs, possibly due to the characteristics of the German social health insurance system. Overall, the variables used in the Andersen model explained only little of the total variance in health care costs.

Elderly Patients with Painful Bone Metastases. The Impact of Comorbidity on the Choice of Radiation Therapy Regimen

Background: The aim of this study was to demonstrate comparable pain relief with two schedules of radiotherapy(RT) for painful bone metastases in elderly patients assessed at baseline with the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Materials and methods: 132 elderly were analyzed. 77 received a single 8-Gy fraction and 55 received 20 Gy in 5 fractions. The choice of the treatment schedule was related to comorbidity, disability, target size and compliance. Pain intensity was measured with Numeral Rating Scale (NRS: 0=no pain; 10=high pain). Complete response was defined a pain reduction >3 of three points, partial response as a pain reduction ≥2 (2 ≤ pain reduction ≤ 3), no response was defined by pain score<2. Pain evaluation was recorded at baseline and at 1-4-8 weeks after completing RT. Results: overall response: 90.3% in 8 Gy arm (49.8% complete and 40.5% partial), 94.6% in 20 Gy arm (44.6% complete and 50%partial). No high grade toxicity were reported. The relief of pain was attained faster with single fraction (p-value ~ 0.2). We observed maximum response of pain control after 8 weeks and no significant differences were noted between two groups. The re-treatment rate was 17.6% vs. 11.1% respectively. Conclusions: no significant differences between the two arms in terms of pain response, pain control and toxicity. Our experience showed that not influenced by age, but in the elderly, life expectancy, comorbidities evaluated with the CIRS-G, and compliance, are crucial in selecting of shorter treatment.

Comparison of the clinical profile of Parkinson's disease between Spanish and Cameroonian Cohorts

BackgroundThere are limited data in terms of the clinical profile of Parkinson's disease in sub-Saharan African patients. ObjectiveTo compare the clinical profile and access to standard antiparkinsonian therapies of a Cameroonian cohort of patients with an age, sex, and disease duration-matched Spanish cohort (Longitudinal Study of Parkinson's disease, ELEP). MethodsObservational, cross-sectional design. Demographic data were collected and the following ELEP assessments were applied: Scales for Outcomes in Parkinson's disease (SCOPA) Motor, Autonomic, Cognition, Sleep and Psychosocial; Hoehn and Yahr staging; modified Parkinson Psychosis Rating Scale; Cumulative Illness Rating Scale-Geriatrics; Hospital Anxiety and Depression Scale; pain and fatigue visual analog scales; Zarit, and EuroQoL. Results74 patients with idiopathic Parkinson's disease were included (37 from each country) with a mean age of 64.4±10.5years old, 70.3% males, and mean disease duration of 5.6±5.9years. Compared to the Spanish cohort, Cameroonians were intermittently treated, less frequently received dopaminergic agonists (p<0.001), had a trend for taking lower doses of levodopa (p=0.06), and were more frequently on anticholinergics (p<0.0005). Cameroonians were more severely impaired in terms of motor (Hoehn Yahr stage, p=0.03; SCOPA-Motor, p<0.001), cognitive status (p<0.001), anxiety and depression (p<0.001), psychosis (p=0.008), somnolence, fatigue and pain (p<0.001, respectively), caregiver burden (p<0.0001), and quality of life (p=0.002). Instead, autonomic, comorbidity, and nocturnal sleep problems were similarly found. ConclusionsLimited and intermittent access to dopaminergic drugs has a negative impact on motor symptoms, nonmotor symptoms and quality of life in patients with Parkinson's disease and their caregivers.

Functional Decline in Older Patients With Cancer Receiving First-Line Chemotherapy

To determine factors associated with early functional decline during first-line chemotherapy in older patients. Patients age ≥ 70 years receiving first-line chemotherapy for cancer were prospectively considered for inclusion across 12 centers in France. Functional decline was defined as a decrease of ≥ 0.5 points on the Activities of Daily Living (ADL) scale between the beginning of chemotherapy and the second cycle. Factors associated with functional decline were sought from pretreatment abbreviated comprehensive geriatric assessment, including ADL, Instrumental ADL (IADL), Mini-Nutritional Assessment (MNA), Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS15), and Timed Get Up and Go (GUG) test, and from comorbidities (Cumulative Illness Rating Scale-Geriatrics), MAX2 index, and baseline biologic and clinical information. Of 364 included patients, 50 experienced functional decline (16.7%; median, 0.5 points). Abnormal preadmission performance status, IADL, GDS15, MMSE, GUG, and MNA were associated with increased likelihood of functional decline (univariate analysis). In the multivariate model adjusted for baseline ADL and MAX2 index, high baseline GDS (odds ratio [OR], 2.16; 95% CI, 1.09 to 4.30; P = .03) and low IADL scores (OR, 2.87; 95% CI, 1.06 to 7.79; P = .04) were independently associated with increased risk of functional decline. Our results outline associations between baseline depression, instrumental dependencies, and early functional decline during chemotherapy for older patients. ADL should be sequentially evaluated early during treatment. Baseline evaluation of GDS15 and IADL may be proposed to anticipate this event.

Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: The ELCAPA-02 study

G-8 screening tool showed good screening properties for identifying vulnerable elderly patients with cancer who would benefit from a comprehensive geriatric assessment (CGA). We investigated whether tumour site and metastatic status affected its accuracy. Cross-sectional analysis of a prospective cohort study. Geriatric-oncology clinics of two teaching hospitals in the urban area of Paris. Patients aged 70 or over (n = 518) with breast ( n= 113), colorectal (n = 108), urinary-tract (n = 89), upper gastrointestinal/liver (n = 85), prostate (n = 69), or other cancers (n = 54). Reference standard for diagnosing vulnerability was the presence of at least one abnormal test among the Activities of Daily Living (ADLs), Instrumental ADL, Mini-Mental State Examination, Mini Nutritional Assessment, Cumulative Illness Rating Scale-Geriatrics, Timed Get-Up-and-Go, and Mini-Geriatric Depression Scale. Sensitivity, specificity and likelihood ratios of G-8 scores ≤ 14 were compared according to tumour site and patient characteristics. Median age was 80; 48.2% had metastases. Prevalence of vulnerability and abnormal G-8 score was 84.2% (95% confidence interval [95% CI], 81-87.3) and 79.5% (95% CI, 76-83). The G-8 was 86.9% sensitive (95% CI, 83.4-89.9) and 59.8% specific (95% CI, 48.3-70.4). G-8 performance varied significantly (all p values < 0.001) across tumour sites (sensitivity, 65.2% in prostate cancer to 95.1% in upper gastrointestinal/liver cancer; and specificity, 23.1% in colorectal cancer to 95.7% in prostate cancer) and metastatic status (sensitivity and specificity, 93.8% and 53.3% in patients with metastases vs. 79.5% and 63.3% in those without, respectively). Differences remained significant after adjustment on age and performance status. These G-8 accuracy variations across tumour sites should be considered when using G-8 to identify elderly patients with cancer who could benefit from CGA.

Geriatric syndromes as predictors of one-year mortality in an outpatient practice

Introduction.– Polypharmacy is a term that describes patients who receive many medications. Unfortunately, using multiple medicationsmay cause problems such as the increased risk of inappropriate use of medications, nonadherence and adverse effects. Method.– We prospectively studied patients hospitalised at Geriatric Department during September to October 2012. Diagnoses, reason for admission, prescription before hospitalisation and after discharge were recorded. Polypharmacy was defined as the concomitant use of five or more medications and high-level polypharmacywas defined as concomitant use of ten ormoremedications. Results.–Hundred and twelve patientswere included,meanpatient age was 86.34±6.27years; 63.3% were female. Cumulative Illness Rating Scale for Geriatrics (CIRS-G): total score 9.84±7.07. Mean Charlson’s index: 2.16. The number of drugs prescribed amounted to 7.25 before hospitalisation and 8.12 at discharge. Hospitalisation led to a significant increase in numbermedications (P=0.001). Polypharmacy on admission and at discharge was observed in 83.03%and91.07% respectively, existing statistically significant difference (P=0.035). High-level polypharmacy on admission and at discharge was observed in 45.53% and 49.10% respectively. We observed a significant reduction in proton pump inhibitors and benzodiazepines. On the other hand, the laxative medication was increased at discharge (34.8 vs 53.5%, P=0.001). Conclusions.– Our study shows a high prevalence of polypharmacy in older spanish. Hospitalisation led to a significant increase in the number of medications and in the prevalence of polypharmacy. It is necessary to implement strategies to identify, and use properly drugs in elderly population.

Outcomes in complex patients with delirium and subsyndromal delirium one year after hospital discharge

There has been an increasing interest in delirium as a clinical syndrome in elderly patients in the last years (de Rooij et al., 2005). Until now the diagnosis has been dichotomous, but recent studies appear to show that a further categorization of this syndrome may lead to a higher diagnostic and prognostic value. The subsyndromal delirium (SSD) displays some of the symptoms without developing the full syndrome and it is intermediate in severity between non-delirious controls and full syndromal delirium, although it has no officially recognized diagnostic criteria (Levkoff et al., 1996). There is growing evidence about the prognostic significance of SSD among elderly individuals, but to date there are very few published studies on SSD in elderly patients. The goal of our study was to corroborate one-year outcomes after discharge. With this aim we performed a prospective multicenter study in March 2011 that recruited patients aged 75 years and older admitted to the acute geriatric wards of three tertiary hospitals in Spain – Complejo Hospitalario de Navarra, Hospital Universitario de Getafe, and Hospital Marqués de Valdecilla – at the same time during a 48-hour period, and were then followed up for one year. Four geriatricians were responsible for the patients’ screening and enrollment. A thorough geriatric assessment included clinical and demographic information (age, sex, education level, living arrangements before admission, presence of visual and hearing impairment) and comorbidity with the Cumulative Illness Rating Scale-Geriatric (CIRS-G). The CIRS-G rates 13 body systems on a five-point severity scale and is reliable because it allows all comorbid diseases from clinical examinations and medical files to be taken into account in a comprehensive manner.

The external validity of MRI‐defined vascular depression

Multiple diagnostic criteria have been used to define vascular depression (VD). As a result, there are discrepancies in the clinical characteristics that have been established for the illness. The aim of this study was twofold. First, we used empirically established diagnostic criteria to determine the clinical characteristics of magnetic resonance imaging (MRI)-defined VD. Second, we assessed the agreement between a quantitative and qualitative method for identifying the illness. We examined the baseline clinical and neuropsychological profile of 38 patients from a larger, double-blind, randomized, 12-week clinical trial comparing nortriptyline with sertraline in depressed older adults. Ten patients met quantitative criteria for MRI-defined VD based on the highest quartile of deep white matter hyperintensity (DWMH) volume. Fourteen patients met qualitative criteria for MRI-defined VD based on a DWMH score of 2 or higher on the Fazekas' modified Coffey rating scale. Age, gender, cumulative illness rating scale-geriatric (CIRS-G) score, two measures of psychomotor retardation [the psychomotor retardation item of the Hamilton Rating Scale for Depression (HRSD) as well as performance on the Purdue Pegboard], and performance on the Stroop Color/Word test (a measure of the response inhibition component of executive functioning) were significantly different between those with VD and non-VD. Patients with VD have a distinct clinical and neuropsychological profile that is mostly consistent across different methods for identifying the illness. These findings support the notion that MRI-defined VD represents a unique and valid subtype of late-life depression.

The External Validity of MRI-defined Vascular Depression

Objective Multiple diagnostic criteria have been used to define vascular depression (VD). As a result, there are discrepancies in the clinical characteristics that have been established for the illness. The aim of this study was twofold. First, we used empirically established diagnostic criteria to determine the clinical characteristics of magnetic resonance imaging (MRI)-defined VD. Second, we assessed the agreement between a quantitative and qualitative method for identifying the illness. Method We examined the baseline clinical and neuropsychological profile of 38 patients from a larger, double-blind, randomized, 12-week clinical trial comparing nortriptyline with sertraline in depressed older adults. Ten patients met quantitative criteria for MRI-defined VD based on the highest quartile of deep white matter hyperintensity (DWMH) volume. Fourteen patients met qualitative criteria for MRI-defined VD based on a DWMH score of 2 or higher on the Fazekas' modified Coffey rating scale. Results Age, gender, cumulative illness rating scale-geriatric (CIRS-G) score, two measures of psychomotor retardation [the psychomotor retardation item of the Hamilton Rating Scale for Depression (HRSD) as well as performance on the Purdue Pegboard], and performance on the Stroop Color/Word test (a measure of the response inhibition component of executive functioning) were significantly different between those with VD and non-VD. Conclusions Patients with VD have a distinct clinical and neuropsychological profile that is mostly consistent across different methods for identifying the illness. These findings support the notion that MRI-defined VD represents a unique and valid subtype of late-life depression. Copyright © 2013 John Wiley & Sons, Ltd.

Stroke Subtypes and Comorbidity among Ischemic Stroke Patients in Brasilia and Cuenca: A Brazilian–Spanish Cross-cultural Study

With the increase in life expectancy worldwide, changes in stroke subtypes and burden of stroke population are expected in both developing and developed countries. Prevalence of stroke subtypes and comorbidity in ischemic stroke patients was assessed in Brasilia, Brazil, and Cuenca, Spain. This was an international (Brazilian-Spanish) cross-sectional study. Stroke subtypes were assessed by means of Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. Modified Rankin scale was used to measure functional recovery and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) was used to assess comorbidity. A total of 500 patients (mean age 66.2±16.4 years; 48% female; 48.2% Spanish) were included in the study. Spanish patients were significantly older than Brazilian ones (76.4±11.2 versus 56.7±14.6 years; P<.0001). Prevalence of ischemic cardiopathy (20.3% versus 6.2%) and atrial fibrillation (25.7% versus 6.6%) was significantly higher in Spanish stroke patients, whereas they less frequently used tobacco (28.3% versus 52.9%); P less than .0001. Prevalence of stroke subtypes in Spanish and Brazilian stroke patients was: stroke of undetermined etiology (58.1% versus 32.4%), cardioembolism (24.5% versus 11.6%), lacunar infarct (11.6% versus 25.5%), atherothrombotic (3.7% versus 19.7%), and other causes (2.1% versus 10.8%); P less than .0001. The Spanish sample had a significantly higher frequency of comorbidities. The CIRS-G total score and CIRS-G mean number of affected organs significantly increased with age, and correlated with the level of functional dependence as measured by Rankin scale (rS=0.50; P=.0005). Spanish stroke people had a higher frequency of comorbid conditions, atrial fibrillation, and cardioembolism and these facts were associated with age. Atherothrombotic and lacunar strokes were more common in the younger Brazilian stroke population.

Evaluative Frailty Index for Physical Activity (EFIP): A Reliable and Valid Instrument to Measure Changes in Level of Frailty

Physical activity is assumed to be important in the prevention and treatment of frailty. It is unclear, however, to what extent frailty can be influenced because instruments designed to assess frailty have not been validated as evaluative outcome instruments in clinical practice. The aims of this study were: (1) to develop a frailty index (i.e., the evaluative frailty index for physical activity [EFIP]) based on the method of deficit accumulation and (2) to test the clinimetric properties of the EFIP. The content of the EFIP was determined using a written Delphi procedure. Intrarater reliability, interrater reliability, and construct validity were determined in an observational study (n=24). Intrarater reliability and interrater reliability were calculated using Cohen kappa and intraclass correlation coefficients (ICCs). Construct validity was determined by correlating the score on the EFIP with those on the timed "up & go" test (TUG), the performance-oriented mobility assessment (POMA), and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Fifty items were included in the EFIP. Interrater reliability (Cohen kappa=0.72, ICC=.96) and intrarater reliability (Cohen kappa=0.77 and 0.80, ICC=.93 and .98) were good. As expected, a fair to moderate correlation with the TUG, POMA, and CIRS-G was found (.61, -.70, and .66, respectively). Reliability and validity of the EFIP have been tested in a small sample. These and other clinimetric properties, such as responsiveness, will be assessed or reassessed in a larger study population. The EFIP is a reliable and valid instrument to evaluate the effect of physical activity on frailty in research and in clinical practice.

Pilot Study of Comprehensive Geriatric Assessment (CGA) in Allogeneic Transplant: CGA Captures a High Prevalence of Vulnerabilities in Older Transplant Recipients

Comprehensive geriatric assessment (CGA) is frequently used in oncology to measure the health status of older adults with cancer, but it has not been studied in allogeneic hematopoietic cell transplantation (HCT). We conducted a prospective pilot study of CGA in allogeneic HCT recipients aged ≥50 years to examine the prevalence of vulnerabilities in this population. Patients aged ≥50 years eligible for HCT were enrolled. CGA consisted mainly of self-reported, performance-based, and chart-extracted measures evaluating domains of comorbidity, physical and mental function, frailty, disability, and nutrition. Of 238 eligible patients, 166 completed CGA and underwent HCT. Only 1% had a Zubrod Performance Status score >1; 44% had high comorbidity defined by the Hematopoietic Cell Transplantation Comorbidity Index, and 66% had high comorbidity defined by the Cumulative Illness Rating Scale–Geriatrics. The presence of additional vulnerability was frequent. Disability was present in 40% by Instrumental Activities of Daily Living. Self-reported physical and mental function were significantly lower than population age group norms, 58% were pre-frail, and 25% were frail. Among those with Zubrod Performance Status score of 0, 28% demonstrated disability, 58% were pre-frail, 15% were frail, 35% reported low physical function, and 55% reported low mental function. CGA uncovers a substantial prevalence of undocumented impairments in functional status, frailty, disability, and mental health in older allogeneic HCT recipients.

Influence of selective comorbidity predictors on functional recovery after hip fracture in an older population

The purpose of the study was to evaluate the influence of four comorbidities from the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and their severity on functional status outcome after a rehabilitation program measured by the Berg Balance Scale (BBS) in patients with hip fracture. The study included 203 patients whose functional status was evaluated by the BBS at admission (Group 1), at discharge (Group 2) and 3 months after discharge (Group 3). Further comorbidity parameters from the CIRS-G were assessed: musculoskeletal impairment, neurological, vascular and cognitive impairment. For the evaluation of CIRS-G severity degree we used the range 0-4. At admission there were non-significant differences in mean values of BBS between parameters for the same CIRS-G severity degree. Significant differences between BBS values were noticed in the period after discharge (Group 2((musculoskeletal)); P<0.05, Group 2((neurological and cognitive)); P<0.01) and after 3 months of follow-up (Group 3((musculoskeletal, neurological and cognitive)); P<0.01). Higher effects of CIRS-G severity degree on BBS values in Group 2 and Group 3 for neurological impairment (η(2)(Group2)=29.76 and η(2)(Group3)=28.35) and even higher for cognitive impairment (η(2)(Group2)=34.35 and η(2)(Group3)=40.63) were noticed. Increase in CIRS-G severity degree of cognitive and neurological impairment in patients after hip fracture that were included in the rehabilitation program correlates closely with functional status after discharge and after 3 months of follow-up. Rehabilitation of patients after hip fracture should be mandatory for functional recovery regardless of the comorbidity and functional status.

Malnutrition: a highly predictive risk factor of short-term mortality in elderly presenting to the emergency department.

To identify independent risk factors of mortality among elderly patients in the 3 months after their visit (T3) to an emergency department (ED). Prospective cohort study. University hospital ED in an urban setting in France. One hundred seventy-three patients aged 75 and older were admitted to the ED over two weeks (18.7% of the 924 ED visits). Of these, 164 patients (94.8%) were included in our study, and 157 (95.7%) of them were followed three months after their ED visit. During the inclusion period (T0), a standardized questionnaire was used to collect data on socio-demographic and environmental characteristics, ED visit circumstances, medical conditions and geriatric assessment including functional and nutritional status. Three months after the ED visits (T3), patients or their caregivers were interviewed to collect data on vital status, and ED return or hospitalization. Among the 157 patients followed at T3, 14.6% had died, 19.9% had repeated ED visits, and 63.1% had been hospitalized. The two independent predictive factors for mortality within the 3 months after ED visit were: malnutrition screened by the Mini Nutritional Assessment short-form (MNA-SF) (OR=20.2; 95% CI: 5.74-71.35; p<.001) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score (OR=1.1; 95% CI: 1.01-1.22; p=.024). Malnutrition is the strongest independent risk factor predicting short-term mortality in elderly patients visiting the ED, and it was easily detected by MNA-SF and supported from the ED visit.

Involvement of the frontal lobe and executive function in deception: A NIRS study

Cognition predicts functional competence among individuals with schizophrenia across the lifespan. However, as these individuals age, increasing levels of medical burden may also contribute to functional deficits both directly and indirectly through cognition. Thus, we assessed the relationship among, cognition, medical burden, and functional competence in older individuals with schizophrenia.We analyzed data obtained from 60 community-dwelling participants with schizophrenia and 30 control participants aged 50 or above. Cognition was assessed using the MATRICS Consensus Cognitive Battery (MCCB), functional competence was assessed using the USCD Performance-Based Skills Assessment (UPSA), and medical burden was assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Group differences were assessed using independent samples t-tests or chi-square tests. Mediation analyses using bootstrapping techniques were used to assess whether cognition mediated the effects of medical burden on functional competence.Participants with schizophrenia had higher levels of medical burden, cognitive deficits, and functional impairments. In participants with schizophrenia, cognition, but not medical burden, predicted functional competence after adjusting for age, education, gender, clinical symptoms, and anticholinergic burden of medications. In control participants, cognition and medical burden both predicted functional competence after adjusting for age, education, and gender. Further, cognition was found to fully mediate the association between medical burden and functional competence in control participants.Cognition is a robust predictor of functional competence among older individuals with schizophrenia, regardless of medical burden. Cognitive deficits associated with schizophrenia may mask any further cognitive impairment associated with medical burden and its impact on function.

Impact of Comorbidities on Hospital-Acquired Infections in a Geriatric Rehabilitation Unit: Prospective Study of 252 Patients

Hospital-acquired infections (HAIs) remain a major source of morbidity and mortality in long-term care units, despite advances in antimicrobial therapy and preventive measures. Our aim was to investigate risk factors for HAIs, especially in the elderly, and to describe the relationship between comorbidities (number, severity, and specific diseases) and HAIs using a comprehensive inventory of comorbidities. Prospective cohort study Geriatric rehabilitation unit in a university hospital in the Paris metropolitan area. Participants were 252 consecutive patients aged 75 years or older (mean age, 85 ± 6.2 years) and admitted between 2006 and 2008. Surveillance of HAI was conducted. A complete inventory of comorbidities was done using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Potential risk factors were evaluated in 2 risk models, one with HAI acquisition, CIRS-G, activities of daily living score less than 10, and at least 1 invasive procedure (yes/no) and the other with HAI acquisition and specific invasive procedures and diseases. Of the 252 patients, 97 experienced HAIs, for an incidence of 5.6 infections per 1000 bed-days. The most common HAI sites were the respiratory tract (48%; 65/136) and urinary tract (37%; 51/136). The CIRS-G global score and comorbidity index were higher in patients with than without HAIs. Among HAI categories, respiratory and urogenital diseases were more prevalent in the group with HAIs. In the model combining CIRS-G, activities of daily living score less than 10, and at least 1 invasive procedure, independent risk factors for HAI were CIRS-G index (odds ratio [OR], 1.55; 95% confidence interval [95% CI], 1.13-2.11; P = .005) and invasive procedures (OR, 5.18; 95% CI, 2.77-9.71; P < .001). In the model including specific procedures and diseases, independent risk factors for HAI were intravenous catheter (OR, 7.39; 95% CI, 2.94-18.56; P < .001), urinary catheter (OR, 3.33; 95% CI, 1.40-7.88; P = .006), gastrointestinal endoscopy (OR, 3.69; 95% CI, 1.12-12.16; P = .03), pressure sores (OR, 2.52; 95% CI, 1.04-6.10; P = .03), and swallowing impairment (OR, 3.37; 95% CI, 1.16-9.74; P = .02). This study identified several important risk factors for HAIs. There is a need for HAI prevention via the implementation of infection-control programs, including surveillance, in rehabilitation units.

Screening older cancer patients: first evaluation of the G-8 geriatric screening tool

Development of a geriatric screening tool is necessary to identify elderly cancer patients who would benefit from comprehensive geriatric assessment (CGA). We develop and evaluate the G-8 screening tool against various reference tests. Analyses were based on 364 cancer patients aged>70 years scheduled to receive first-line chemotherapy included in a multicenter prospective study. The G-8 consists of seven items from the Mini Nutritional Assessment (MNA) questionnaire and age. Our primary reference test is based on a set of seven CGA scales: Activities Daily Living (ADL), Instrumental ADL, MNA, Mini-Mental State Exam, Geriatric Depression Scale, Cumulative Illness Rating Scale-Geriatrics, and Timed Get Up and Go. We considered the presence of at least one questionnaire with an impaired score as an abnormal reference exam. Additional reference exams are also discussed. The prevalence of being at risk varied from 60% to 94% according to the various definitions of the reference test. When considering the primary reference test, a cut-off value of 14 for the G-8 tool provided a good sensitivity estimate (85%) without deteriorating the specificity excessively (65%). The G-8 shows good screening properties for identifying elderly cancer patients who could benefit from CGA.

Looking Beyond Polypharmacy: Quantification of Medication Regimen Complexity in the Elderly

BackgroundPolypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied. ObjectiveOur aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels. MethodsWe retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity. ResultsThe mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r=0.94, P<0.001) and the number of daily doses (r=0.87, P<0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P<0.001). Positive correlations were observed between the Cumulative Illness Rating Scale–Geriatrics score and both the number of medications and the MRCI score (r=0.40, r=0.46, P<0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P<0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r=−0.188, P= 0.028); however, no such correlation was found regarding the number of medications at discharge. ConclusionsThe MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity.