Department Of Geriatric Medicine Research Articles

Accidental falling in community-dwelling elderly with chronic kidney disease

PurposeThe aim of the current study was to evaluate the association between a decreased estimated glomerular filtration rate (eGFR) and accidental falling in elderly patients who visited the day clinic of the department of geriatric medicine of the University of Medical Center Utrecht (UMCU).Study designA cross-sectional analysis with people aged ≥ 65 years of the Utrecht Cardiovascular Cohort was performed. Patients were stratified into different stages of kidney disease (< 45, 45–59, and ≥ 60 ml/min per 1.73 m2). Logistic regression models were used to evaluate the association between chronic kidney disease and falling.ResultsOur analysis included 1000 participants with a mean age 79.4 (± 6.6) years, of whom 38% had an eGFR of < 60 ml/min per 1.73 m2 and 17% < 45 ml/min per 1.73 m2. Univariate analysis showed a significant higher prevalence [odds ratio 1.75 (95% confidence interval 1.21–2.53; p ≤ 0.01)] of falling in the population with an eGFR < 45 ml/min per 1.73 m2 compared to patients with an eGFR ≥ 60 ml/min per 1.73 m2. After correcting for multiple potential confounders in the multivariate analysis, this association was no longer present.ConclusionsIn geriatric patients ≥ 65 years, patients with a decreased eGFR fall more often than patients with a preserved kidney function. This seems to be related with the risk profile of patients with CKD and not with a decreased eGFR itself, as after correcting for potential confounders no association remained. Nevertheless, accidental falling is a highly prevalent problem in the elderly CKD population. Therefore, nephrologists should actively ask about accidental falling, and thereby screen for high-risk patients.

Transitions in Assisted Living

Transitions in Assisted Living

Raised serum cystatin C can be a potential biomarker of frailty detected by cumulative deficit model.

ObjectiveIdentification of frailty by clinical criteria is often delayed to the advanced stage. A reliable biomarker to identify frailty or its risk does not currently exist. We aimed to determine the association between serum cystatin C and frailty in subjects without renal dysfunction.MethodsWe carried out a cross‐sectional observational study in the Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India. The study involved 125 participants, aged 65 years or older. Frailty status was assessed with Frailty Index criteria (cumulative deficit model). Serum cystatin C was estimated with the nephelometry method and its association with frailty was analyzed.ResultsMean age of the study sample was 76.32 years with 72 (57.6%) male and 53 (42.4%) female participants. Seventy‐three subjects were frail; the mean cystatin C levels in the frail and non‐frail groups were 1.28 mg/L (±0.39) and 1.12 mg/L (±0.27), respectively, and the difference was significant (P < 0.05). A cutoff of 1.12 mg/L was found to be 60.27% sensitive and 57.69% specific in identification of frailty. Multivariate analysis showed that higher cystatin C level was associated with 2.52 (1.05‐6.02) times the risk of being frail.ConclusionHigher levels of cystatin C were found in frail subjects. Cystatin C seems to be a promising marker for identifying frailty in older adults without renal abnormalities.

A nutritional intervention program improves the nutritional status of geriatric patients at nutritional risk—a randomized controlled trial

Objectives: To investigate the effect of a nutrition intervention program for geriatric nutritional at-risk patients. Design: A randomized controlled trial. Setting: Department of geriatric medicine in a university hospital and in the primary healthcare sector, Copenhagen. Subjects: Geriatric patients (N = 144) at nutritional risk. Intervention: The intervention consisted of an individual dietary plan for home, including pre-discharge advice on nutritional intake, combined with three follow-up visits after discharge (one, four, and eight weeks). Main measures: Change in body weight, Barthel Index, hand-grip strength and self-rated health from baseline (discharge) to three months after discharge, readmission, and mortality (90 and 120 days). Results: The mean (SD) age in total sample was 87.2 (6.2) years. Sample size in the intervention group (IG) was N = 72, and in the control group (CG), N = 72. IG had a mean (SD) weight gain of 0.9 (4.2) kg compared to a weight loss of 0.8 (3.6) kg in the CG (P = 0.032). In addition, an improvement in self-rated health was seen in the IG compared to CG (IG: 23 (47%) vs. CG: 12 (24%); P = 0.021). No significant difference between groups was found in functional status, mortality, or readmission rates. Conclusion: An individual dietary plan based on everyday food, combined with three follow-up visits (one, four, and eight weeks) after discharge, led to an improvement in nutritional status and self-rated health in geriatric patients.

The impact of sarcopenia on the results of lumbar spinal surgery

ObjectivesAs the population ages, the number of lumbar spinal surgeries performed on sarcopenic patients will increase. The purpose of this study was to investigate the prevalence of sarcopenia and evaluated its impact on the results of lumbar spinal surgery. MethodsThis study included 2 groups: One group consisted of patients who underwent whole-body dual-energy X-ray absorptiometry (DXA) scanning before the option of undergoing surgery for lumbar spinal disease (LSD group) and a second group consisted of patients underwent DXA scanning for osteoporosis screening under hospital watch at the geriatric medicine department (control group). In order to evaluate the impact of sarcopenia on the clinical outcome of lumbar spinal surgery, the Japanese Orthopedic Association (JOA) score, the recovery rate based on the JOA score, and visual analogue scale (VAS) scores for lower back pain, lower extremity pain, and lower extremity numbness were compared within the LSD group. ResultsThe prevalence of sarcopenia showed no statistical difference between groups (control group, 50.7%; LSD group, 46.5%). In the LSD group, while the changes in VAS scores showed no statistical difference between the nonsarcopenia subgroup and sarcopenia subgroup, the sarcopenia subgroup demonstrated inferior JOA scores and recovery rates at the final follow-up when compared with the nonsarcopenia subgroup (P < 0.05). ConclusionsThis study demonstrated a high prevalence of sarcopenia among the elderly populations in Japan and a negative impact of sarcopenia on clinical outcomes after lumbar spinal surgery.

Editorial introductions

Editorial introductions

Global Leadership Initiative on Malnutrition: Progress Report From ASPEN Clinical Nutrition Week 2017.

Journal of Parenteral and Enteral NutritionVolume 42, Issue 2 p. 266-267 Commentary Global Leadership Initiative on Malnutrition: Progress Report From ASPEN Clinical Nutrition Week 2017 Gordon L. Jensen MD, PhD, Corresponding Author Gordon L. Jensen MD, PhD gordon.jensen@med.uvm.edu Larner College of Medicine, University of Vermont, Burlington, Vermont, USA Corresponding Author: Gordon L. Jensen, MD, PhD, Larner College of Medicine, University of Vermont, Office of the Dean, E-126 Given Building, 89 Beaumont Ave, Burlington, VT 05405, USA. Email: gordon.jensen@med.uvm.eduSearch for more papers by this authorTommy Cederholm MD, PhD, Tommy Cederholm MD, PhD Department of Geriatric Medicine, Uppsala University Hospital, and Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, SwedenSearch for more papers by this author Gordon L. Jensen MD, PhD, Corresponding Author Gordon L. Jensen MD, PhD gordon.jensen@med.uvm.edu Larner College of Medicine, University of Vermont, Burlington, Vermont, USA Corresponding Author: Gordon L. Jensen, MD, PhD, Larner College of Medicine, University of Vermont, Office of the Dean, E-126 Given Building, 89 Beaumont Ave, Burlington, VT 05405, USA. Email: gordon.jensen@med.uvm.eduSearch for more papers by this authorTommy Cederholm MD, PhD, Tommy Cederholm MD, PhD Department of Geriatric Medicine, Uppsala University Hospital, and Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, SwedenSearch for more papers by this author First published: 12 December 2017 https://doi.org/10.1177/0148607117707761Citations: 10 Financial disclosure: None declared. Conflicts of interest: None declared. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume42, Issue2February 2018Pages 266-267 RelatedInformation

Effects of near-infrared visualization puncture technology in senile patients with difficulties in venipuncture

Objective To improve the success rate of puncture among senile patients with difficulties in venipuncture by applying the near-infrared visualization puncture technology. Methods This study selected 160 elderly patients with difficulties in peripheral venipuncture of department of General Surgery and Geriatric Medicine Department by random sampling to carry out peripheral venipuncture at Xuanwu Hospital of Capital Medical University from June 2015 to December 2016. Those patients were divided into control group and observation group with the random number table, 80 patients in each group. Patients in control group received peripheral venipuncture by nurses' personal experience along with assessing vessel by routine visual method and touch method without any accessory equipment. Patients in observation group received peripheral venipuncture by the location of infrared vessel imager. The infrared vessel imager was used to evaluate the vessel shape and depth to understand vascular branches so as to locate target vessel. And then, this study compared the success rate, time and site of punctures between two groups. Results The success rate of first puncture of observation group was 91.25% significantly higher than that of control group (χ2=43.495, P<0.01) . The puncture time [ (3.7±1.8) min]of observation group was less than that of control group with a significant difference (t=4.629, P<0.01) . In the aspect of site of punctures, there was 72.5% of patients with punctures in observation group in forearm vein higher than that in control group (χ2=46.920, P<0.01) . Conclusions The near-infrared visualization puncture technology can improve the success rate of puncture in elderly patients with difficulties in peripheral venipuncture, short the puncture time and help to achieve forearm venipuncture with the first choice. This technology can also relieve the pain of elderly patients, save consumptive material cost and reduce nurses' pressure on puncture. It is worth to be used widely in clinical application. Key words: Aged; Venipuncture; Visualization technique

Frailty in Hospitalized Older Adults: Comparing Different Frailty Measures in Predicting Short- and Long-term Patient Outcomes

ObjectivesData for the assessment of frailty in acutely ill hospitalized older adults remains limited. Using the Frailty Index (FI) as “gold standard,” we compared (1) the diagnostic performance of 3 frailty measures (FRAIL, Clinical Frailty Scale [CFS], and Tilburg Frailty Indicator [TFI]) in identifying frailty, and (2) their ability to predict negative outcomes at 12 months after enrollment. DesignProspective cohort study. ParticipantsWe recruited 210 patients (mean age 89.4 ± 4.6 years, 69.5% female), admitted to the Department of Geriatric Medicine in a 1300-bed tertiary hospital. MeasurementsPremorbid frailty status was determined. Data on comorbidities, severity of illness, functional status, and cognitive status were gathered. We compared area under receiver operator characteristic curves (AUC) for each frailty measure against the reference FI. Multiple logistic regression was used to examine the independent association between frailty and the outcomes of interest. ResultsFrailty prevalence estimates were 87.1% (FI), 81.0% (CFS), 80.0% (TFI), and 50.0% (FRAIL). AUC against FI ranged from 0.81 (95% confidence interval [CI] 0.72–0.90: FRAIL) to 0.91 (95% CI 0.87–0.95: CFS). Only FRAIL was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031). FRAIL and CFS were significantly associated with increased length of hospitalization (10 [6.0–17.5] vs 8 [5.0–14.0] days, P = .043 and 9 [5.0–17.0] vs 7 [4.25–11.75] days, P = .036, respectively). CFS and FI were highly associated with mortality at 12-month (CFS, frail vs nonfrail: 32.9% vs 2.5%, P < .001, and FI, frail vs nonfrail: 30.6% vs 3.7%, P < .001). CFS also conferred the greatest risk of 12-month mortality (odds ratio [OR] 5.78, 95% CI 3.19–10.48, P < .001) and composite outcomes of institutionalization and/or mortality (OR 3.69, 95% CI 2.31–5.88, P < .001), adjusted for age, sex, and severity of illness. ConclusionOur study affirms the utility of frailty assessment tools among older persons in acute care. FRAIL conferred highest risk of in-hospital mortality. However, CFS had greatest risk of mortality and institutionalization within 12 months.

David Gwyn Seymour

David Gwyn Seymour (“Gwyn”) was born in Ynysybwl near Pontypridd in south Wales and qualified from Birmingham University in 1973. After rapid acquisition of his MRCP (UK) in 1975, he...

Integrating Care and Improving Flow for Frail Older Adults through the Development of an Acute Inpatient Frailty Service

Introduction: The National Clinical Programme for Older People in Ireland recommends the implementation of methods to identify frailty in the Emergency Department (ED) and to integrate the care of frail older adults between primary, secondary and social care. Although several models of frailty assessment teams have been piloted nationally, research into their effects on healthcare outcomes is limited. Description of practice change implemented: An integrated care pathway, consisting of dedicated medical, nursing and health and social care professional (HSCP) staff, was developed through the department of geriatric medicine, to assess frail older adults at the earliest possible point following admission through the ED. All patients >75 years admitted over the preceeding 24 hours are screened for frailty using the PRISMA-7. Those screening positive are discussed by the Frailty Service Multi-Disciplinary Team (MDT) and those deemed frail are assessed by Comprehensive Geriatric Assessment (CGA) in the ED and managed as inpatients, if appropriate. The same MDT meet daily to review progress to provide consistent and integrated care linking in with community services and an intergrated care manager. Aim and theory of change: To evaluate the experience of developing and integrating a Frailty Medicine strand within an University Hospital with existing medical, nursing and HSCP models of caring for frail older adults and to investigate whether this new model has a positive impact on healthcare outcomes including hospital length of stay (LOS) and 30-day readmission rates. Targeted population: Consecutive older adults (aged ≥75 years) that were medically stable (not requiring immediate resuscitation, intensive care or specialist medical care) and admitted through a University Hospital ED, on service operational days, were targeted. Frailty was screened using the PRISMA-7 (cut-off ≥3) and confirmed by a Consultant Geriatrician using CGA. Those admitted overnight and remaining on ED trolleys were prioritized. Timeline: We examined differences in outcomes for frail older adults after the introduction of the new service during 14 days in October 2016. Highlights: In total, 102 older patients were screened for frailty; their median age was 81 years (interquartile +/-8) and their median PRISMA-7 score was 5 (+/-4). Of these, 22 frail inpatients admitted overnight and remaining on ED trolleys were assessed and managed on the new integrated frailty pathway. Of the remainder, 54/80 (67.5%) patients were confirmed as frail but were not managed due to limited service capacity or exclusionary criteria. There was no statistically significant difference in median age (82.5+/-6 versus 83+/-8, respectively, z=-0.46, p=0.65) or PRISMA-7 scores (5+/-2 versus 5+/-2, respectively, z=-0.49, p=0.63) between those managed on the frailty pathway and frail patients receiving usual care. The median LOS of those taken over and managed throughout their admission on the frailty pathway (n=21) was 7 days (9-5=+/-4) compared to 8.5 days (12-6=+/-6), for those receiving usual care, z=-1.2, p=0.23. Likewise, no significant differences in 30-day readmission rates were found. Comments on Sustainability: Sustainability of this Frailty Service is dependent on targeted goal setting, enhanced resources and the incorporation of patient important outcomes particularly the quality of care (access, effectiveness and patient-centeredness). Wider integration with community services is planned. Comments on Transferability: Different models of frailty assessment have been created as a response to the increasing numbers of older adults attending and admitted through Irish ED’s. This new model incorporating dedicated medical with nursing and HSCP resources shows potential but requires comparison and validation against existing models nationally and internationally. Conclusions: While no statistically significant differences in outcomes were shown, a trend towards reduced LOS and readmission rates over those receiving usual care was found. Discussions: These results suggest that targeting frail older adults (≥75), screening positive for frailty with CGA and management, directly after admission into an ED, may improve healthcare outcomes. Further research with larger samples (as the sample is likely underpowered), measured over longer periods, is now required to overcome potential sources of bias. Lessons learned: This project shows the potential to identify and manage frail older adults with interdisciplinary integrated care from ED admission throughout their inpatient stay until discharge. While the Frailty Service is yet limited, there is scope to further integrate with existing hospital and community-based services for older adults to improve patient flow and transitions of care.

BLOOD TAU LEVEL AS A MARKER FOR ALZHEIMER’S DISEASE AND ITS CORRELATION WITH TOTAL TAU DEPOSITION IN THE BRAIN

Tau deposition in cortex has been shown to be closely related to cognition, predominantly memory decline, in post-mortem studies of both aging and AD. Blood levels of Tau as a marker of AD and its correlation with deposition in cortex is studied. Patients attending Memory Clinic of the Department of Geriatric Medicine were evaluated for their cognitive symptoms with MMSE scoring systems. Dementia related to Vascular, Metabolic, Depression, other degenerative causes (eg. Parkinsonism) were excluded. A total of 85 selected subjects underwent further cognitive evaluation in the form of CDR, imaging evaluation that included MRI scan and PET scan [18 FDG and 18F T807 (TAU)]. Blood samples were analysed for tau and phosphorylated-tau proteins. Study subjects were divided into 3 categories: Normal Controls, Mild Cognitive Impairment and Probable AD (Based on NINDS-ADRDA criteria). Mean 18F T807 (TAU) binding as measeured by SUVmax of different neocortical regions among the groups showed an increase binding with decrease in cognition but with notable overlap among the groups. Binding, particularly in posterior cingulate area, of the Tau showed increase binding which was statistically significant (p<0.05). Blood markers in the form of serum tau and phosphorylated tau was evaluated among the groups which showed an increasing trend with decline in the cognition and the values were statistically significant. Blood levels of tau and phosphorylated tau proteins can be used as a surrogate marker for memory decline.

Abstracts from The 35th Annual National Neurotrauma Symposium July 7-12, 2017 Snowbird, Utah.

Abstracts from The 35th Annual National Neurotrauma Symposium July 7-12, 2017 Snowbird, Utah.

Frailty and Risk of Adverse Outcomes in Hospitalized Older Adults: A Comparison of Different Frailty Measures

ObjectivesThere is a paucity of data for the assessment of frailty in acutely ill hospitalized older adults. We aim to (1) compare the performance of frailty measures [5-item scale of fatigue, resistance, ambulation, illnesses, and loss of weight) (FRAIL), Tilburg Frailty Indicator (TFI), and Clinical Frailty Scale (CFS)] in identifying frailty, using the widely adopted Frailty Index (FI) as “gold standard,” and (2) compare their ability to predict negative outcomes among hospitalized older adults. DesignProspective cohort study. SettingAcute inpatient care. ParticipantsA total of 210 patients (mean age 89.4 ± 4.6 years, 69.5% female) admitted to the Department of Geriatric Medicine. MeasurementsPremorbid frailty status was assessed by FI, FRAIL, TFI, and CFS. We collected data on comorbidities, severity of illness, functional status, and cognitive status. We compared area under receiver operator characteristic curves for FRAIL, TFI, and CFS against the reference FI. Multiple logistic regression was performed to examine the association between frailty and the primary outcome of in-hospital mortality. ResultsFrailty prevalence estimates were 87.1% (FI), 50% (FRAIL), 80% (TFI), and 81% (CFS). Area under receiver operator characteristics against FI ranged from 0.81 [95% confidence interval (CI) 0.72–0.90: FRAIL] to 0.91 (95% CI 0.87–0.95: CFS), with no significant difference on receiver operating characteristic curve contrast. Frailty, as defined by FRAIL score ≥3, was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031) and length of hospitalization [10 days (6.0–17.5) vs 8 days (5.0–14.0), P = .043]. FI [odds ratio (OR) = 1.15, 95% CI 1.00–1.33, P = .05], FRAIL (OR = 3.31, 95% CI 1.43–7.67, P = .005), and CFS (OR = 2.57, 95% CI 1.14–5.83, P = .023) independently predicted in-hospital mortality adjusted for age, sex, and severity of illness. ConclusionsFRAIL and CFS are simple frailty measures that may identify older adults at highest risk of adverse outcomes of hospitalization. FRAIL performed better in predicting in-hospital mortality.

Editorial introductions

Editorial introductions

Polypharmacy and Adherence: Key Components of Integrated Care Findings from the SIMPATHY Project

Context, aims and objectives : As many as half of all patients with chronic conditions are using their medicines in a way that is not fully effective, resulting in sub-optimal treatment and subsequent increases in hospitalisations and emergency department visits. High levels of inappropriate prescribing further compound this problem. These issues are especially germane to older patients. Safe and effective pharmacotherapy remains one of the greatest challenges in this population, where models of healthcare delivery lag behind the enormous growth in single disease focused pharmacotherapy. The implications for safe, efficient, effective and sustainable deployment of healthcare resources are significant from both a healthcare systems and societal perspective. Integrated care models have the potential to mitigate inappropriate polypharmacy, while simultaneously diminishing problems related to poor adherence. Project SIMPATHY addresses both of these issues by aiming to stimulate and support innovation throughout the European Union regarding the management of polypharmacy and adherence in the older patient. The SIMPATHY Consortium has completed case studies in eight EU countries, providing useful insights into how different health care systems address this challenge. This workshop will present these findings, using them as a basis for discussion on the practicalities of integrating new practices into existing workflow, highlighting the opportunities that an integrated care model can provide. Target participants : Policymakers, health system administrators, managers, clinicians Proposed structure and timing : What do we mean when we say polypharmacy? How does it apply to me? Alpana Mair; Deputy Chief Pharmaceutical Officer for Scotland, Healthcare Quality and Strategy Directorate, Scottish Government Health Department Medicines management should be a key component of integrated care, affecting nearly all providers in all settings, and is paramount in the older population. However, health care providers are often faced with problems related to inappropriate management of polypharmacy and poor adherence by patients. This presentation will introduce the audience to the concept of polypharmacy and adherence, its importance, and what tools and evidence already exist to create solutions. Looking at Europe: A diverse and emerging picture of polypharmacy Jennifer McIntosh; Research Scientist at Hospital Clinic Barcelona / FCRB Building on original research undertaken by the SIMPATHY Consortium, a picture of current policies around polypharmacy in Europe has emerged. The picture is complex, with multiple economic, social, and cultural factors explaining the development of these programmes. The details of this picture provide a strong foundation for the development of future policies for appropriate management of polypharmacy. This presentation will detail the findings of 8 European case studies, showcasing current approaches polypharmacy management. _(Important: The details of each case study will be presented in a set of 8 posters that will be submitted to the conference by each institution carying out the work)_ Scaling up polypharmacy management: The Scottish success story Alpana Mair; Deputy Chief Pharmaceutical Officer for Scotland, Healthcare Quality and Strategy Directorate, Scottish Government Health Department Implementing a new programme into existing practice is one of the most challenging aspects of creating integrated health care systems. The Scottish National Health Service has achieved this by successfully developing and implementing a comprehensive polypharmacy management policy throughout their healthcare system. This programme has become a model on an international level, and is currently a reference point for the development of European wide policies to address polypharmacy in the elderly. This presentation will describe the rationale that prompted the development of the Scottish programme, unique features of the programme including leveraging national level patient data to identify patients at risk for inappropriate polypharmacy, and management strategies that facilitated the integration of the programme into daily practice on a wide scale. Polypharmacy and teamwork: The Catalan multidisciplinary experience Carles Codina; Head of Pharmacy Department at Hospital Clinic Barcelona - Consorci Hospitalari de Vic Nuria Molist; physician at the Acute Geriatrician Unit Consorci Hospitalari de Vic - Hospital Santa Creu de Vic Introducing new practices requires champions, especially in complex institutions. Although multidisciplinary teams are becoming the functional decision making unit, their implementation requires support from multiple stakeholders. Pharmacists in particular have a central role to play on these teams in developing a new understanding about the importance of appropriate polypharmacy management. This presentation will describe the development and implementation of a patient centred multidisciplinary care team, highlighting the role both the pharmacy and geriatric medicine departments played in creating a successful and sustainable programme. Facilitated discussion Albert Alonso (moderator); Innovation Directorate at Hospital Clinic Barcelona This work has been supported by the SIMPATHY project, grant agreement number 663082, co-funded by the European Commission CHAFEA Health Program

Reasons doctors provide futile treatment at the end of life: a qualitative study

ObjectiveFutile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the...

Dedicated orthogeriatric service reduces hip fracture mortality.

Hip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture. We piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency. A dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (N=206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (N=248). Patients in the orthogeriatric service group experienced significant reductions in 1-year mortality (χ2=13.34, P<0.001), length of acute hospital stay (U=-3.77, P<0.001) and requirements for further rehabilitation (χ 2=26.59, P<0.001). Patients in the pre-service establishment group were significantly more dependent following their fracture than the patients in the orthogeriatric service group (χ 2=5.34, P=0.021). A multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes.

A hybrid genetic algorithm-queuing multi-compartment model for optimizing inpatient bed occupancy and associated costs.

Explore how efficient intelligent decision support systems, both easily understandable and straightforwardly implemented, can help modern hospital managers to optimize both bed occupancy and utilization costs. This paper proposes a hybrid genetic algorithm-queuing multi-compartment model for the patient flow in hospitals. A finite capacity queuing model with phase-type service distribution is combined with a compartmental model, and an associated cost model is set up. An evolutionary-based approach is used for enhancing the ability to optimize both bed management and associated costs. In addition, a "What-if analysis" shows how changing the model parameters could improve performance while controlling costs. The study uses bed-occupancy data collected at the Department of Geriatric Medicine - St. George's Hospital, London, period 1969-1984, and January 2000. The hybrid model revealed that a bed-occupancy exceeding 91%, implying a patient rejection rate around 1.1%, can be carried out with 159 beds plus 8 unstaffed beds. The same holding and penalty costs, but significantly different bed allocations (156 vs. 184 staffed beds, and 8 vs. 9 unstaffed beds, respectively) will result in significantly different costs (£755 vs. £1172). Moreover, once the arrival rate exceeds 7 patient/day, the costs associated to the finite capacity system become significantly smaller than those associated to an Erlang B queuing model (£134 vs. £947). Encoding the whole information provided by both the queuing system and the cost model through chromosomes, the genetic algorithm represents an efficient tool in optimizing the bed allocation and associated costs. The methodology can be extended to different medical departments with minor modifications in structure and parameterization.

Exhaustion of family caregivers: a masked domestic crisis? A psychodynamic and systemic approach

We try, from our clinical practice in a geriatric medicine department, to identify the processes involved in family crisis, especially in the relationship carer/cared. Psychodynamic and systemic determinants are highlighted to understand how family caregivers may suffer burn out, and suggest preventive measures.