Geriatric Index Of Comorbidity Research Articles

The geriatric index of comorbidity as an outcome predictor of patients with acute mesenteric ischemia due to superior mesentery artery thromboembolism.

To describe the impact of comorbidities on in-hospital mortality and overall survival in patients with acute mesenteric ischemia (AMI) due to superior mesentery artery (SMA) thromboembolism. A retrospective study was conducted for 40 patients with AMI due to SMA thromboembolism who were treated in our hospital between February 2013 and December 2019. The presence of comorbidities was described and their severities were classified into 1-4 levels by Geriatric Index of Comorbidity (GIC), the comorbidities were defined as any distinct additional clinical entity that has existed. Univariate and cox proportional-hazards analyses were performed to determine the effect of comorbidities on in-hospital mortality and overall survival. During a mean follow-up of 15.05 ± 18.02months (range from 0.3 to 58months) for the 40 patients with AMI due to SMA thromboembolism, In-hospital mortality rate was 52.5% (21/40). One-year, 2-year, and 3-year overall estimated survival rates by the Kaplan-Meier method were 45%, 34%, and 26.5%, respectively, the average overall survival time was 20.84 ± 3.95 (95% CI: 13.10-28.58) months. In-hospital mortality was significantly related to the GIC classification (χ2 = 7.86, p = 0.049). The average overall survival was significantly related to the malignant tumor in pre-existing comorbidities and GIC classification (log-rank, p = 0.001). Cox proportional-hazards regressions analysis showed that the class 4 of comorbidities was an independent prognostic factor of mortality (p = 0.031, HR = 10.45 [95% CI: 1.24-87.70]). Comorbidity is common and an important factor associated with all-cause mortality in AMI patients due to SMA thromboembolism. In managing AMI patients, we recommend a timely diagnosis of both AMI condition and its associated comorbidities.

Predictivity of the comorbidity indices for geriatric syndromes

BackgroundThe aging population and increasing chronic diseases make a tremendous burden on the health care system. The study evaluated the relationship between comorbidity indices and common geriatric syndromes.MethodsA total of 366 patients who were hospitalized in a university geriatric inpatient service were included in the study. Sociodemographic characteristics, laboratory findings, and comprehensive geriatric assessment(CGA) parameters were recorded. Malnutrition, urinary incontinence, frailty, polypharmacy, falls, orthostatic hypotension, depression, and cognitive performance were evaluated. Comorbidities were ranked using the Charlson Comorbidity Index(CCI), Elixhauser Comorbidity Index(ECM), Geriatric Index of Comorbidity(GIC), and Medicine Comorbidity Index(MCI). Because, the CCI is a valid and reliable tool used in different clinical settings and diseases, patients with CCI score higher than four was accepted as multimorbid. Additionally, the relationship between geriatric syndromes and comorbidity indices was assessed with regression analysis.ResultsPatients’ mean age was 76.2 ± 7.25 years(67.8% female). The age and sex of multimorbid patients according to the CCI were not different compared to others. The multimorbid group had a higher rate of dementia and polypharmacy among geriatric syndromes. All four indices were associated with frailty and polypharmacy(p < 0.05). CCI and ECM scores were related to dementia, polypharmacy, and frailty. Moreover, CCI was also associated with separately slow walking speed and low muscle strength. On the other hand, unlike CCI, ECM was associated with malnutrition.ConclusionsIn the study comparing the four comorbidity indices, it is revealed that none of the indices is sufficient to use alone in geriatric practice. New indices should be developed considering the complexity of the geriatric cases and the limitations of the existing indices.

Spread of COVID-19 Infection in Long-Term Care Facilities of Trieste (Italy) during the Pre-Vaccination Era, Integrating Findings of 41 Forensic Autopsies with Geriatric Comorbidity Index as a Valid Option for the Assessment of Strength of Causation.

Background: in 2020, a new form of coronavirus spread around the world starting from China. The older people were the population most affected by the virus worldwide, in particular in Italy where more than 90% of deaths were people over 65 years. In these people, the definition of the cause of death is tricky due to the presence of numerous comorbidities. Objective: to determine whether COVID-19 was the cause of death in a series of older adults residents of nursing care homes. Methods: 41 autopsies were performed from May to June 2020. External examination, swabs, and macroscopic and microscopic examination were performed. Results: the case series consisted of nursing home guests; 15 men and 26 women, with a mean age of 87 years. The average number of comorbidities was 4. Based only on the autopsy results, the defined cause of death was acute respiratory failure due to diffuse alveolar damage (8%) or (31%) bronchopneumonia with one or more positive swabs for SARS-CoV-2. Acute cardiac failure with one or more positive swabs for SARS-CoV-2 was indicated as the cause of death in in symptomatic (37%) and asymptomatic (10%) patients. Few patients died for septic shock (three cases), malignant neoplastic diseases (two cases), and massive digestive bleeding (one case). Conclusions: Data from post-mortem investigation were integrated with previously generated Geriatric Index of Comorbidity (GIC), resulting in four different degrees of probabilities: high (12%), intermediate (10%), low (59%), and none (19%), which define the level of strength of causation and the role of COVID-19 disease in determining death.

Craniocervical trauma above the age of 90: are current prognostic scores sufficient?

Clinical data following head or spine trauma in patients over 90years is rare. The aim of this study was to analyze this patient cohort, assessing clinical characteristics, outcomes, and survival rates and to identify variables that may predict early mortality. A retrospective analysis of all patients over the age of 90 that were treated between January 2006 and December 2016 at our department was performed. Patient characteristics, type of injury, and comorbidities were analyzed with regard to the 30-day mortality rate as the primary outcome. One hundred seventy-nine patients were identified. Mean age was 93 (range 90-102); 105 (59%) patients were female. One hundred thirty-two (74%) and 34 (19%) of patients presented with head and spinal trauma, respectively. Fourteen patients (8%) had a combined head and spine injury. One hundred (56%) patients were treated operatively. Mean Charlson comorbidity index was 4.1 (range 0-18), mean diagnosis count was 6.2 (range 0-12), mean geriatric index of comorbidity (GIC) was 3.3 (range 1-4), and mean Barthel index was 28 (range 0-100). The 30-day mortality rate was 31%. Multivariate cox regression analysis showed that head trauma had a 1.66 hazard ratio (p = 0.036) of dying within 30days of admission, whereas a higher Glasgow coma score and surgical treatment had a hazard ratio of 0.88 (p = 0.0001) and 0.72 (p = 0.05) to reach the primary outcome. None of the standard geriatric scores reached any significant correlation with the primary outcome. Standard geriatric prognostic scores seem less reliable to predict mortality for patients above the age of 90. Higher Glasgow coma score and surgical treatment were associated with a higher survival probability.

Inaccuracy of standard geriatric scores in nonagenarians following hospitalization for various spinal pathologies.

Demographic trends make it incumbent on spine surgeons to recognize the special challenges involved in caring for older patients. The aim of this study was to identify variables that may predict early mortality in geriatric patients over the age of 90 following elective hospitalization for various spinal pathologies. Retrospective analyses of all patients over the age of 90years, which were electively treated between 2006 and 2016 at out department for various spinal conditions, were performed. Patient characteristics, type of treatment, and comorbidities were analyzed with regard to the 30-day mortality rate. Twenty-six patients were identified. Mean age was 93years (range 91-97), 19 (73%) were female. Eighteen (69%) patients were treated operatively. Mean hospital stay was 13days (range 2-51). Seventeen (65%) patients were on anticoagulation therapy. Mean Charlson Comorbidity Index (CCI) was 5.3 (range 1-11); mean diagnosis count (DC) was 8.3 (range 2-17); mean Geriatric Index of Comorbidity (GIC) was 2.8 (range 1-4); and mean comorbidity-polypharmacy score (GPS) was 13.3 (range 5-23). The 30-day mortality rate was 16.7% in the surgically treated group compared with 12.5% in the conservatively treated group (p = 0.9), anticoagulation therapy (p = 0.91), gender (p = 0.49), length of hospital stay (p = 0.33), GIC (p = 0.54), CCI (p = 0.74), GPS (p = 0.82), and DC (p = 0.65) did not correlate with the 30-day mortality rate. Cause of death was pulmonary embolism in two cases and unknown in one case. Thirty-day mortality rate in patients over 90years old with degenerative spinal diseases is relatively high regardless of the treatment modality. Standard geriatric prognostic scores seem less reliable for these patients.

Modern approaches to the assessment of comorbidity in patients

Aim. To provide modern data on advantages and disadvantages of available international comorbidity scales and indices. Materials and methods. Data of 29 scientific sources published in Russian and foreign literature press within 1973-2018 are considered. Results. The presence of comorbidity in a patient is an issue of modern medicine. In most cases some comorbid diseases if timely diagnosed and managed in accordance with algorithms for medical care can be corrected and treated. In order to control risks of development of complications and to prescribe an effective therapy for comorbidity the international and national clinical guidelines have been created. They include algorithms for clinical and instrumental assessment of complications and provide scales and indices, such as Cumulative lllness Rating Scale (CIRS), Charlson comorbidity index, Kaplan-Feinstein index, Index of Co-Existent Disease (ICED), Geriatric Index of Comorbidity (GIC), Functional Comorbidity Index (FCI) et al. Data of Canadian comparative study of 5 international scales of comorbidity in patients with head and neck cancers showed a significant impact of comorbidity on survival of patients with different stages of neoplasms. It was emphasized that the index of comorbidity is necessary to control an impact of comorbid diseases on the patients' status in the long-term period. The Kaplan-Feinstein scale was the best index for assessing a survival of patients with head and neck cancer. According to V.de Groot, the most widely studied comorbidity index for predicting mortality is the Charlson index. Each index has its advantages and disadvantages and is used in different clinical situations. Conclusion. General comorbidity index is a comprehensive summary score of a disease combination or severity, which combines all conditions, problems and illnesses of patients, weights them by severity, and it significantly affects treatment tactics and outcome in a future.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Oldest Adults: Predictors of In-Hospital Mortality and Need for Post-acute Care

ObjectivesOlder age is associated with higher risk of death during acute exacerbations of chronic obstructive pulmonary disease (AE-COPD). Older patients hospitalized for AE-COPD often require post-acute care after acute phase. The aim of this study was to evaluate components of a comprehensive geriatric assessment and clinical/laboratory parameters, in order to find predictors of in-hospital mortality and need for post-acute care in patients aged 80 and older hospitalized for AE-COPD. DesignProspective observational study. SettingHospital assessment. Participants121 patients consecutively admitted to an internal medicine and geriatrics department for AE-COPD. MeasuresActivities of Daily Living (ADL) Hierarchy scale, Geriatric Index of Comorbidity, cognitive impairment, and clinical and laboratory parameters were collected. ResultsMean age: 87.0 ± 4.9 years; male: 54.5%. In-hospital mortality (18.2% of patients) was significantly associated with functional disability, high comorbidity, cognitive impairment, anemia, older age, lower albumin, higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) and white blood cell levels, oral corticosteroids taken before admission, and no angiotensin-converting enzyme inhibitors or angiotensin receptor blockers taken before admission. In a stepwise logistic regression, functional dependence (P = .006), cognitive impairment (P = .038), and oral corticosteroids therapy before hospitalization (P = .035) were independently associated with a higher risk of in-hospital mortality. Among laboratory parameters, only NT-proBNP remained significantly associated with in-hospital mortality (P = .026). The need for post-acute care (18.2% of survivors) was associated with older age, higher admission Pco2, greater comorbidity, and cognitive impairment. In a stepwise logistic regression, only cognitive impairment (P = .016) and ln_Pco2 (P = .056) confirmed their association with the need for post-acute care. Conclusions/implicationsPreadmission functional dependence, cognitive impairment, and corticosteroid use, plus elevated NT-proBNP at admission are risk factors for mortality during an AE-COPD in the oldest old. Therefore, medical providers should consider these, as well as the patient's advance directives, in planning hospital care. Furthermore, providers should arrange especially careful posthospitalization monitoring and frequent follow-up of individuals with cognitive impairment and baseline hypercapnia.

Identifying elderly cancer patients in need of palliative care assessment in the critical care setting: a prospective single-center observational study

Introduction: Identifying factors that can help move palliative care assessments upstream appears to be potentially beneficial for older cancer patients in the critical care setting. Aim: This study aimed to determine the profile of older cancer patients admitted to the intensive care unit (ICU) and examine possible associations with criteria for a palliative care assessment. Materials and Methods: Data were collected on demographics and ICU outcome (death vs discharge) from patients aged ≥ 65 years with advanced cancer admitted to a general ICU from August 2013 to July 2014 in a single institution. Chronic conditions were scored using Charlson comorbidity index (CCI) and geriatric index of comorbidity (GIC). Severity of illness (prognosis) was assessed with simplified acute physiology score (SAPS3) and sequential organ failure assessment (SOFA), and performance status with Karnofsky performance scale (KPS) and palliative performance scale (PPS) on admission and day 7. Patients were screened for unmet palliative care needs on admission (PC1) and day 7 (PC2) using the Center to Advance Palliative Care primary/secondary criteria. Results: Of 71 patients included, 52.1% were women; mean (SD) age was 76.9 (7.1) years. GIC scores were correlated with PC1 (rs=0.326, P=0.005) and PC2 (rs=0.262, P=0.027). PC1 was correlated with prognostic scores (SAPS3: rs=0.236, P=0.047; SOFA: rs=0.263; P=0.027), while PC2 was correlated with both prognostic scores (SAPS3: rs=0.321, P=0.006; SOFA: rs=0.343, P=0.003) and performance status (KPS: rs=−0.413, P=0.0003; PPS: rs=−0.505, P=0.0001). Patients who died in the ICU (N=39, 54.9%) or were discharged (N=32, 45.1%) differed significantly in performance status (KPS, P=0.012; PPS, P=0.005), but not in prognostic scores (SAPS3, P=0.31; SOFA, P=0.41) or comorbidity indices (CCI, P=0.85; GIC, P=0.94). Conclusion: Our findings suggest that early palliative care should be integrated into intensive care to avoid potentially inappropriate interventions or procedures in older cancer patients admitted to the ICU with poor performance status and prognostic scores.

The Severity of Acute Illness and Functional Trajectories in Hospitalized Older Medical Patients.

Acute diseases and hospitalization are associated with functional deterioration in older persons. Although most of the functional decline occurs before hospitalization in response to the acute diseases, the role played by comorbidity in the functional trajectories around hospitalization is unclear. Observational prospective study of 696 elderly individuals hospitalized in two Italian general medicine wards. Functional status of the elderly patients at 2 weeks before hospitalization (baseline), at hospital admission, and at discharge was measured by the Barthel Index. Comorbidity was measured at admission by the Geriatric Index of Comorbidity (GIC), a tool mostly based on illness severity. The association of GIC with changes in functional status before hospitalization (between baseline and admission), during hospitalization (between admission and discharge), and in the overall period between baseline and discharge was assessed by logistic regression analyses. Hospitalization-associated disability (HAD) was defined as a functional decline between baseline and discharge. Illness severity (GIC 3-4 vs 1-2: odds ratio [OR] 2.2, 95% CI [confidence interval] 1.5-3.3, p < .0001) and older age significantly predicted prehospital functional decline (between baseline and admission). Illness severity (OR 1.9, 95% CI 1.2-3, p = .004) and older age were also predictive of HAD, even after adjustment for each coded primary discharge diagnosis. After adjustment for the occurrence of prehospital functional decline, however, illness severity and older age were not predictive of HAD anymore. The severity of illnesses was strongly associated with adverse functional outcomes around hospitalization, but frailty, intended as functional vulnerability to the acute disease before hospitalization, was a stronger predictor of HAD than illness severity and age.

Comorbidity and prognostic indices do not improve the 5-year mortality prediction of components of comprehensive geriatric assessment in hospitalized older patients.

BackgroundAdvancing age is associated with increased vulnerability to chronic health problems. Identifying factors that predict oldest-old status is vital for developing effective clinical interventions and public health strategies.MethodsObservational prospective study of patients aged 75 years and older consecutively admitted to an Acute Geriatric Ward of a tertiary hospital. After a comprehensive geriatric assessment all patients were assessed for five comorbidity indices and two prognostic models. Univariate and multivariate logistic regression models were fitted to assess the association between each score and 5-year mortality. The ability of each score to predict mortality was assessed using the area under the receiver operating characteristic curve.Results122 patients were enrolled. All patients were followed up for five years. 90 (74%) of them died during the study period. In the logistic regression analyses, apart from age, cognitive impairment and Barthel Index, three indices were identified as statistically associated with 5-year mortality: the Geriatric Index of Comorbidity and the two prognostic indices. The multivariate model that combined age, sex, cognitive impairment and Barthel showed a good discriminate ability (AUC = 0.79), and it did not improve substantially after adding individually any of the indices.ConclusionsSome prognostic models and the Geriatric Index of Comorbidity are better than other widely used indices such as the Charlson Index in predicting 5-year mortality in hospitalized older patients, however, none of these indices is superior to some components of comprehensive geriatric assessment.

The origin, development and current concepts of «comorbidity» and «polymorbidity»

The article aims to study the current concepts of polymorbidity and comorbidity by a literature review. This article presents the terms used to denote a combination of several diseases for one person, named as «combined», «concomitant», «associated» diseases or conditions, «comorbidity», «polymorbidity», «multimorbidity», «multifactorial disease», «polypathia», «co-disease», «dual diagnosis», «plural diseases». Definitions for currently commonly used terms «comorbidity», «polymorbidity» and «multimorbidity» are given, the historical aspects of their occurrence are discussed. The differences between the concepts of «comorbidity» and «polymorbidity», despite their frequent use as synonyms, are listed. The existing classifications of comorbidity, including definitions of trans-systemic, trans-nosologic and chronological comorbidity, are reviewed. The classification developed by H.C. Kraemer and M. van den Akker (1998), which presents a causal, complicated, iatrogenic, unclear and random comorbidity, is described. The assessment scales for the evaluation of this phenomenon, such as Cumulative Illness Rating Scale, Kaplan-Feinstein index, Cumulative Illness Rating Scale for Geriatrics, Index of Co-Existent Disease, Geriatric Index of Comorbidity, Functional Comorbidity Index, and Total Illness Burden Index, are presented. Detailed description of the comorbidity assessment by Charlson index as the most used and having the least disadvantages, is given. Description of the quantitative evaluation of polymorbidity is given, variation of the number of diseases depending on patient’s age is shown. The list for the most common pathologies that can be combined in a single patient is outlined. Diseases typical for the patients of elderly and senile age are described. The problem of comorbidity becomes more and more important in the areas where social conditions promote the increase of the life expectancy of elderly and senile patients, which requires a common approach to the problems of comorbidity.

Telomere length, comorbidity, functional, nutritional and cognitive status as predictors of 5 years post hospital discharge survival in the oldest old.

Telomere length has been considered in many cross-sectional studies as a biomarker of aging. However the association between shorter telomeres with lower survival at advanced ages remains a controversial issue. This association could reflect the impact of other health conditions than a direct biological effect. To test whether leukocyte telomere length is associated with 5-year survival beyond the impact of other risk factors of mortality like comorbidity, functional, nutritional and cognitive status. Prospective study. A population representative sample of 444 patients (mean age 85 years; 74% female) discharged from the acute geriatric hospital of Geneva University Hospitals (January-December 2004), since then 263 (59.2%) had died (December 2009). Telomere length in leukocytes by flow cytometry. In univariate model, telomere length at baseline and cognitive status were not significantly associated with mortality even when adjusting for age (R²=9.5%) and gender (R²=1.9%). The best prognostic predictor was the geriatric index of comorbidity (GIC) (R²=8.8%; HR=3.85) followed by more dependence in instrumental (R²=5.9%; HR=3.85) and based (R²=2.3%; HR=0.84) activities of daily living and lower albumin levels (R²=1.5%; HR=0.97). Obesity (BMI>30: R²=1.6%; HR=0.55) was significantly associated with a two-fold decrease in the risk of mortality compared to BMI between 20-25. When all independent variables were entered in a full multiple Cox regression model (R²=21.4%), the GIC was the strongest risk predictor followed by the nutritional and functional variables. Neither telomeres length nor the presence of dementia are predictors of survival whereas the weight of multiple comorbidity conditions, nutritional and functional impairment are significantly associated with 5-year mortality in the oldest old.

Telomere length, comorbidity, functional, nutritional and cognitive status as predictors of 5 years post hospital discharge survival in the oldest old

Telomere length has been considered in many cross-sectional studies as a biomarker of aging. However the association between shorter telomeres with lower survival at advanced ages remains a controversial issue. This association could reflect the impact of other health conditions than a direct biological effect. To test whether leukocyte telomere length is associated with 5-year survival beyond the impact of other risk factors of mortality like comorbidity, functional, nutritional and cognitive status. Prospective study. A population representative sample of 444 patients (mean age 85 years; 74% female) discharged from the acute geriatric hospital of Geneva University Hospitals (January–December 2004), since then 263 (59.2%) had died (December 2009). Telomere length in leukocytes by flow cytometry. In univariate model, telomere length at baseline and cognitive status were not significantly associated with mortality even when adjusting for age (R2=9.5%) and gender (R2=1.9%). The best prognostic predictor was the geriatric index of comorbidity (GIC) (R2=8.8%; HR=3.85) followed by more dependence in instrumental (R2=5.9%; HR=3.85) and based (R2=2.3%; HR=0.84) activities of daily living and lower albumin levels (R2=1.5%; HR=0.97). Obesity (BMI>30: R2=1.6%; HR=0.55) was significantly associated with a two-fold decrease in the risk of mortality compared to BMI between 20–25. When all independent variables were entered in a full multiple Cox regression model (R2=21.4%), the GIC was the strongest risk predictor followed by the nutritional and functional variables. Neither telomeres length nor the presence of dementia are predictors of survival whereas the weight of multiple comorbidity conditions, nutritional and functional impairment are significantly associated with 5-year mortality in the oldest old.

Prospective Comparison of 6 Comorbidity Indices as Predictors of 1-Year Post-Hospital Discharge Institutionalization, Readmission, and Mortality in Elderly Individuals

Older patients often suffer from multiple comorbid conditions. Few comorbidity indices are valid and reliable in the elderly and were rarely compared. To compare the performance, relevance, and ability of 6 widely used and validated comorbidity indices--Charlson Comorbidity Index, Cumulative Illness Rating Scale-Geriatrics, Index of Coexistent Diseases, Kaplan, Geriatric Index of Comorbidity (GIC), and Chronic Disease Score--to predict adverse outcomes after discharge (1-year risk of rehospitalization, institutionalization, and death). Prospective study with 1-year follow-up, between January 2004 and December 2005 in 444 elderly patients (mean age, 85; 74% female) discharged from acute geriatric hospital, Geneva University Hospitals. In univariate analyses, Cumulative Illness Rating Scale?Geriatrics and GIC were the predictors with the largest coefficient of determination for mortality with (R(2) of 9.3%, respectively 8.8%). GIC was also the only significant predictor of institutionalization (R(2) = 6.0%). Higher risk of readmission was significantly associated with GIC (R(2) = 14.0%), Cumulative Illness Rating Scale-Geriatrics (R(2) = 5.6%), Charlson Comorbidity Index (R(2) = 3.1%), and Chronic Disease Score (R(2) = 1.7). Understanding how to efficiently predict these adverse outcomes in hospitalized elders is important for a variety of clinical and policy reasons. GIC and Cumulative Illness Rating Scale-Geriatrics may improve hospital discharge planning in a geriatric hospital treating very old patients with acute disease.

Characteristics of patients in a ward of Academic Internal Medicine: implications for medical care, training programmes and research

To describe the characteristics of "delayed discharge patients" and the factors associated with "delayed discharges", we performed a 12-month observational study on patients classified as "delayed discharge patients" admitted to an Academic Internal Medicine ward. We assessed the demographic variables, the number and severity of diseases using the Geriatric Index of Comorbidity (GIC), the cognitive, affective and functional status using, respectively, the Mini Mental Stare Examination, the Geriatric Depression Scale and the Barthel Index. We assessed the total length of stay (T-LHS), the total inappropriate length of stay (T-ILHS), the median length of stays (M-LHS), the median inappropriate length of stay (M-ILHS) and evaluated the factors associated with delayed discharge. "Delayed discharge patients" were 11.9% of all patients. The mean age was 81.9 years, 74.0% were in the IV class of GIC and 33.5% were at the some time totally dependent and affected by severe or non-assessable cognitive impairments. The patients had 2584 T-LHS, of which 1058 (40.9%) were T-ILHS. Their M-LHS was 15 days, and the M-ILHS was 5 days. In general, the greater the LHS, the greater is the ILHS (Spearman's rho + 0.68, P < 0.001). Using a multivariate analysis, only the absence of formal aids before hospitalisation is independently associated with delayed discharge (F = 4.39, P = 0.038). The majority of the delays (69%) resulted from the difficulty in finding beds in long-term hospital wards, but the longest M-ILHS (9 days) was found in patients waiting for the Geriatric Evaluation Unit. The profile of patients and the pattern of hospital utilisation suggest a need to reorient the health care system, and to develop appropriate resources for the academic functions of education, research and patient care.

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

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

Predictive Validity of Measures of Comorbidity in Older Community Dwellers: The Insufficienza Cardiaca negli Anziani Residenti a Dicomano Study

To compare the ability of five measures of comorbidity to predict mortality and incident disability in basic activities of daily living (BADLs) in unselected older persons. An assessment of the data obtained from the Insufficienza Cardiaca negli Anziani Residenti a Dicomano (ICARe Dicomano) Study, a longitudinal epidemiological survey on heart failure in older people. Dicomano, a small, rural town near Florence, Italy. The entire population aged 65 and older living in Dicomano, Italy, was enrolled in the ICARe Dicomano Study. At baseline (1995), comorbidity was quantified in 688 participants, based on clinical diagnoses, using disease count (DC), Charlson Comorbidity Index (CCI), Index of Co-Existent Diseases (ICED), and Geriatric Index of Comorbidity (GIC), or on drug use, using Chronic Disease Score (CDS). Incident ADL disability was assessed in 1999 and vital status in 2004. Mortality increased with the severity of comorbidity, with hazard ratios around 2 when comparing the highest and the lowest quartiles of DC, CCI, and ICED in Cox regressions adjusted for age, sex, and physical and cognitive performance. Prediction of mortality with GIC and CDS was only borderline significant. All measures predicted incident ADL disability; the strongest risk gradient (hazard ratio = 8.2 between the highest and lowest quartiles) was observed with ICED. Physical and, to a minor extent, cognitive performance added significantly to predicting mortality and incident BADL disability. All the measures of comorbidity predicted death and BADL disability in older community dwellers. DC, CCI, and ICED performed better than GIC and CDS. Physical performance measures are strong, independent contributors to the prediction of these outcomes.

Poor mental and physical health differentially contributes to disability in hospitalized geriatric patients of different ages.

To evaluate the relationship between depressive symptoms, cognition and somatic diseases on functional status of geriatric patients at hospital discharge. Patients 65+ years consecutively admitted to the acute care geriatric ward of the Internal Medicine Department I, Civil Hospital of Brescia, Italy, from February 1998 to December 2000 (n = 830) were examined. Functional disability was defined as need of physical assistance in at least one of the basic Activities of Daily Living (ADL). The Greenfield Index of Disease Severity (IDS) and the Geriatric Index of Comorbidity (GIC) were used to measure number and severity of diseases. The Mini-Mental State Examination (MMSE) assessed cognitive status and the Geriatric Depression Scale (GDS) measured depressive symptoms. Prevalence of functional disability at discharge was 29.3% in the younger age group (65-74 years) and 55.2% in the older age group (75+ years). Using logistic regression models, older age, poorer cognitive status, and depressive symptoms were independently associated with functional disability in the younger and older age group, respectively. Additionally cognitive impairment and depressive symptoms showed an additive association with disability, especially in younger patients, while comorbidity was correlated with functional status only in the oldest old, in particular among those who were cognitively impaired. Functional disability after acute hospitalization is highly prevalent in geriatric patients. Depressive symptoms, comorbidity, and cognitive impairment often coexist, interact and are differentially associated with function depending on age. Considering that depressive symptoms are a modifiable problem, their detection in hospital settings may help clinicians in targeting subjects at high risk of functional disability.