Severe Functional Dependence Research Articles

Functional dependence as a contributing factor for patient hand contamination by multi-drug resistant organisms (MDROs) in acute care.

Patient hands' contribution to disease transmission in healthcare settings is an important, understudied topic. We assessed correlation between patient functional dependence and hand contamination with multi-drug resistant organisms (MDROs) in acute-care settings. Secondary, cross-sectional analyses of 399 general medicine patients enrolled in two tertiary-care hospitals over a six-month period. Our predictor was patient functional status evaluated using Katz Activities of Daily Living scale, scored as follows: functionally independent (scored 0), moderately dependent (score 1-3), and severely dependent (score of 4 or more). Our outcome was patient hand contamination with MDROs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, and resistant gram-negative bacteria. Of 399 patients, 298 were functionally independent, 45 were moderately dependent, and 56 were severely dependent. Odds of MDRO hand contamination were 2.63 (95% CI, 1.21-5.72) times higher in the severely dependent category compared to the independent category. Patients with feeding dependence had the highest odds of hand contamination with MDROs (OR 4.76, 95% CI, 1.54-14.71), followed by continence, dressing, and toileting. In addition to patient colonization, environmental contamination with MRSA was associated with patient function, with odds 2.60 (95% CI, 1.16-5.82) times higher in severely dependent patients. Patients with severe functional dependence are more likely to harbor MDROs on their hands and less likely to be able to cleanse them independently. Functionally dependent patients have high room contamination with MDROs. Patient hand hygiene interventions in the hospital should target this high-risk group.

Prevalence of functional dependence and chronic diseases in the community-dwelling Brazilian older adults: an analysis by dependence severity and multimorbidity pattern

BackgroundDespite the advancements in knowledge about health care for older adults, essential gaps persist regarding the effects of chronic diseases as epidemiological markers of the state of functional dependence. This study aimed to identify the prevalence of moderate and severe functional dependence in Brazilian older adults and its association with chronic diseases and verify the multimorbidity patterns by dependence status.MethodsThis cross-sectional analytical study used data from 11,177 community-dwelling Brazilian older adults from the 2013 National Health Survey conducted in Brazil. The dependent variables were moderate and severe functional dependence in basic activities of daily living (BADLs) and instrumental ADLs (IADLs). The independent variables were defined based on the questions applied to measure each morbidity in a self-reported manner and asked, "Has a doctor ever diagnosed you as having (each disease)? Multimorbidity was simultaneously considered present for older adults with ≥ 2 chronic morbidities. The association between functional dependence on BADLs and IADLs separately by severity and the independent variables was verified from crude and adjusted estimates of the point prevalence ratios and their 95% confidence intervals using the regression model Poisson with robust variance. To group diseases into patterns, exploratory factor analysis was used.ResultsThe prevalences of moderate and severe BADL dependence were 10.2% (95% CI, 9.6–10.7) and 4.8% (95% CI, 4.4–5.2), respectively. Moderate and severe IADL dependence prevalences were 13.8% (95% CI, 13.1–14.4) and 15.6% (95% CI, 14.9%–16.2), respectively. When changing the condition from moderate to severe dependence in BADLs, in the presence of other mental illnesses and stroke, the probability of dependence increased more than four times in the case of other mental illnesses and more than five times for stroke. There was a linear trend for dependence severity, both moderate and severe, whereas, for severe dependence on IADLs, this same factor maintained a linear trend toward an increase in probability as the number of diseases simultaneously increased.ConclusionsChronic diseases are associated with functional dependence, with greater emphasis on mental illnesses and stroke in severe disability, considering their acute adverse effects.

Fortalezas sistémicas y necesidades en atención paliativa domiciliaria: explorando la complejidad

ObjectiveWe aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients. MethodsQuantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson's chi-square test to analyze the comparison of proportions. ResultsForty-six hundred patients (74.4% oncologic) with a mean age of 76.2years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92-8.63]), microsystem (both patient 0.51 [0.28-0.94]) and caregiver (OR: 3.90 [1.48-10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37-3.60]). ConclusionsTo improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice.

Association between chronic conditions, multimorbidity, and dependence levels in Chinese community-dwelling older adults with functional dependence: a cross-sectional study in south-central China.

The rising prevalence of multimorbidity and functional dependence in community-dwelling older adults contribute to the demand for home care services. Evidence on how chronic conditions, especially multimorbidity, affect dependence levels among older adults with functional dependence in a socio-cultural context is much needed to inform policy, workforce, aged care service development to meet the care needs of this population. This study aimed to determine the association between chronic conditions, multimorbidity and dependence levels among Chinese community-dwelling older adults with functional dependence. A cross-sectional study was conducted with 1,235 community-dwelling older adults with functional dependence in Hunan province, China, from June to October 2018. Data on socio-demographic factors, cognitive function, vision and hearing conditions, activities of daily living (ADLs), and health conditions were collected, and binary logistic regression analyses were used to determine the association between chronic conditions, multimorbidity and dependence levels, with adjustments for relevant covariates. Among the participants, 62.9% had multimorbidity. Parkinson's disease, stroke, COPD, hypertension, mood and psychotic disorders (Anx/Sch/Dep) were significantly associated with high levels of functional dependence. After adjusting for demographic variables, cognitive function, vision, and hearing conditions, we observed a significant relationship between multimorbidity and higher functional dependence, but this association became insignificant when including certain chronic diseases closely associated with high-level dependence. Study revealed that Parkinson's disease and stroke notably increase dependency risk across seven ADL domains, demonstrating their extensive impact on daily functioning. The prevalence of multimorbidity among Chinese community-dwelling older adults with functional dependence is very high. The association of multimorbidity with functional dependence is mediated by specific chronic conditions. These findings highlight the necessity of adopting an integrated care model that combines medical and social care, with a particular emphasis on managing multimorbidity and critical chronic conditions that lead to severe functional dependence to preventing and diminish the onset of disabilities.

Systemic strengths and needs in palliative home care: exploring complexity

ObjectiveWe aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients. MethodsQuantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson’s chi-square test to analyze the comparison of proportions. ResultsForty-six hundred patients (74.4% oncologic) with a mean age of 76.2 years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92–8.63]), microsystem (both patient 0.51 [0.28−0.94]) and caregiver (OR: 3.90 [1.48–10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37–3.60]). ConclusionsTo improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice.

Prevalence of long-term decision regret and associated risk factors in a large cohort of ICU surrogate decision makers

BackgroundWhether surrogate decision makers regret decisions about the use of life support for incapacitated, critically ill patients remain uncertain. We sought to determine the prevalence of decision regret among surrogates of adult ICU patients and identify factors that influence regret.MethodsWe conducted a secondary analysis of data from the PARTNER 2 trial, which tested a family support intervention for surrogates of critically ill adults. At 6-month follow-up, surrogates rated their regret about life support decisions using the Decision Regret Scale (DRS), scored from 0 to 100, with higher scores indicating more regret. We used multiple linear regression to identify covariates associated with decision regret based on a psychological construct of regret. We constructed two models using the full cohort; model 1 included patient outcomes; model 2 focused on covariates known at the time of ICU decision-making. Subgroup analyses were also conducted based on patient survival status at hospital discharge and 6-month follow-up.Results748 of 848 surrogates had complete DRS data. The median (IQR) DRS score was 15 (0, 25). Overall, 54% reported mild regret (DRS 5–25), 19% moderate-strong regret (DRS 30–100), and 27% no regret (DRS 0). Poor patient outcome at 6 months (death or severe functional dependence) was associated with more regret in model 1 (β 10.1; 95% C.I. 3.2, 17.0). In model 2, palliative care consultation (3.0; 0.1, 5.9), limitations in life support (LS) prior to death (6.3; 3.1, 9.4) and surrogate black race (6.3; 0.3, 12.3) were associated with more regret. Other modulators of regret in subgroup analyses included surrogate age and education level, surrogate-patient relationship, death in hospital (compared to the post-discharge period), and code status at time of ICU admission.ConclusionsOne in five ICU surrogate decision makers experience moderate to strong regret about life support decisions in ICU. Poor patient outcomes are linked to more regret. Decisions to limit life support prior to patient death may also increase regret. Future studies are needed to understand how regret relates to decision quality and how to lessen lasting regret.

Factors associated with elder abuse and neglect in rural Uganda: A cross-sectional study of community older adults attending an outpatient clinic.

Elderlies are vulnerable to abuse, and evidence suggests that one in three elderlies experience abuse. Abuse can impact the well-being of older persons, decreasing their quality of life, leading to mental health challenges, and increasing morbidity and mortality rates. Evidence on older person/elder abuse and neglect is vital to facilitate initiatives, but there are fewer studies on elder abuse and neglect in Africa, particularly in Uganda. Thus, this study aimed to determine the prevalence of different types of abuse and neglect, and their associated factors among older persons (aged 60 years and above) attending an outpatient clinic. In this cross-sectional study, information on sociodemographic characteristics, functional impairment using the Barthel Index, and elder abuse severity using the Hwalek-Sengstock Elder Abuse Screening Test were collected. In addition, types of abuse were assessed using questions adapted from the US National Research Council on elder mistreatment monograph. Linear and logistic regression analyses were used to determine the factors associated with elder abuse severity and the different types of abuse, respectively. Overall, the prevalence of elder abuse was 89.0%. Neglect was the most common type of elder abuse (86%), followed by emotional abuse (49%), financial abuse (46.8%), physical mistreatment (25%), and sexual abuse (6.8%). About 30.4% of the abused elders experienced at least two forms of abuse. Factors associated with elder abuse severity were having a secondary level of education and physical impairment. Moderate to severe functional dependence was associated with almost all forms of abuse. Individuals who reported the presence of a perpetrator were likely to experience neglect, emotional, and physical mistreatment. However, those who reported their perpetrators to the police had a higher likelihood of experiencing emotional abuse but were less likely to experience financial abuse. Emotional abuse was also associated with age above 80 years and attaining education (primary and secondary). Physical impairment and chronic medical conditions reduced the likelihood of experiencing neglect and financial abuse, and physical abuse, respectively. Uganda has a high prevalence of elder abuse and neglect. There is a need to design interventions for older adults at risk to prevent elder abuse from escalating further, where the present findings can be worthy of help.

Predicting 30-Day Perioperative Outcomes in Adult Spinal Deformity Patients With Baseline Paralysis or Functional Dependence.

Patients undergoing surgical treatment of adult spinal deformity (ASD) are often preoperatively risk stratified using standardized instruments to assess for perioperative complications. Many ASD instruments account for medical comorbidity and radiographic parameters, but few consider a patient's ability to independently accomplish necessary activities of daily living (ADLs). Patients ≥18 years undergoing ASD corrective surgery were identified in National Surgical Quality Improvement Program. Patients were grouped by (1) plegic status and (2) dependence in completing ADLs ("totally dependent" = requires total assistance in ADLs, "partially dependent" = uses prosthetics/devices but still requires help, "independent" = requires no help). Quadriplegics and totally dependent patients comprised "severe functional dependence," paraplegics/hemiplegics who are "partially dependent" comprised "moderate functional dependence," and "independent" nonplegics comprised "independent." Analysis of variance with post hoc testing and Kruskal-Wallis tests compared demographics and perioperative outcomes across groups. Logistic regression found predictors of inferior outcomes, controlling for age, sex, body mass index (BMI), and invasiveness. Subanalysis correlated functional dependence with other established metrics such as the modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI). A total of 40,990 ASD patients (mean age 57.1 years, 53% women, mean BMI 29.8 kg/m2) were included. Mean invasiveness score was 6.9 ± 4.0; 95.2% were independent (Indep), 4.3% moderate (Mod), and 0.5% severe (Sev). Sev had higher baseline invasiveness than Mod or Indep groups (9.0, 8.3, and 6.8, respectively, P < 0.001). Compared with the Indep patients, Sev and Mod had significantly longer inpatient length of stay (LOS; 10.9, 8.4, 3.8 days, P < 0.001), higher rates of surgical site infection (2.2%, 2.9%, 1.5%, P < 0.001), and more never events (17.7%, 9.9%, 4.0%, P < 0.001). Mod had higher readmission rates than either the Sev or Indep groups (30.2%, 2.7%, 10.3%, P < 0.001). No differences in implant failure were observed (P > 0.05). Controlling for age, sex, BMI, CCI, invasiveness, and frailty, regression equations showed increasing functional dependence significantly increased odds of never events (OR, 1.82 [95% CI 1.57-2.10], P < 0.001), specifically urinary tract infection (OR, 2.03 [95% CI 1.66-2.50], P < 0.001) and deep venous thrombosis (OR, 2.04 [95% CI 1.61-2.57], P < 0.001). Increasing functional dependence also predicted longer LOS (OR, 3.16 [95% CI 2.85-3.46], P < 0.001) and readmission (OR, 2.73 [95% CI 2.47-3.02], P < 0.001). Subanalysis showed functional dependence correlated more strongly with mFI (r = 0.270, P < 0.001) than modified CCI (mCCI; r = 0.108, P < 0.001), while mFI and mCCI correlated most with one another (r = 0.346, P < 0.001). Severe functional dependence had significantly longer LOS and more never-event complications than moderate or independent groups. Overall, functional dependence may show superiority to traditional metrics in predicting poor perioperative outcomes, such as increased LOS, readmission rate, and risk of surgical site infection and never events.

Clinical Features and Risk Factors for Mortality Among Long-term Care Facility Residents Hospitalized Due to COVID-19 in Spain.

COVID-19 severely impacted older adults and long-term care facility (LTCF) residents. Our primary aim was to describe differences in clinical and epidemiological variables, in-hospital management, and outcomes between LTCF residents and community-dwelling older adults hospitalized with COVID-19. The secondary aim was to identify risk factors for mortality due to COVID-19 in hospitalized LTCF residents. This is a cross-sectional analysis within a retrospective cohort of hospitalized patients ≥75 years with confirmed COVID-19 admitted to 160 Spanish hospitals. Differences between groups and factors associated with mortality among LTCF residents were assessed through comparisons and logistic regression analysis. Of 6 189 patients ≥75 years, 1 185 (19.1%) were LTCF residents and 4 548 (73.5%) were community-dwelling. LTCF residents were older (median: 87.4 vs 82.1 years), mostly female (61.6% vs 43.2%), had more severe functional dependence (47.0% vs 7.8%), more comorbidities (Charlson Comorbidity Index: 6 vs 5), had dementia more often (59.1% vs 14.4%), and had shorter duration of symptoms (median: 3 vs 6 days) than community-dwelling patients (all, p < .001). Mortality risk factors in LTCF residents were severe functional dependence (adjusted odds ratios [aOR]: 1.79; 95% confidence interval [CI]: 1.13-2.83; p = .012), dyspnea (1.66; 1.16-2.39; p = .004), SatO2 < 94% (1.73; 1.27-2.37; p = .001), temperature ≥ 37.8°C (1.62; 1.11-2.38; p = .013); qSOFA index ≥ 2 (1.62; 1.11-2.38; p = .013), bilateral infiltrates (1.98; 1.24-2.98; p < .001), and high C-reactive protein (1.005; 1.003-1.007; p < .001). In-hospital mortality was initially higher among LTCF residents (43.3% vs 39.7%), but lower after adjusting for sex, age, functional dependence, and comorbidities (aOR: 0.74, 95%CI: 0.62-0.87; p < .001). Basal functional status and COVID-19 severity are risk factors of mortality in LTCF residents. The lower adjusted mortality rate in LTCF residents may be explained by earlier identification, treatment, and hospitalization for COVID-19.

Dependencia funcional y diabetes mellitus tipo 2 en adultos mayores afiliados al Seguro Social de Salud del Perú: análisis de la ENSSA-2015

Objetivo: estimar la prevalencia de dependencia funcional y evaluar su asociación con la diabetes mellitus tipo 2 (DM) en adultos mayores afiliados al Seguro Social de Salud (EsSalud) del Perú en 2015. Materiales y métodos: análisis secundario de los datos de la Encuesta Nacional Socioeconómica de Acceso a la Salud de los Asegurados de EsSalud 2015 (ENSSA-2015), una encuesta de hogares con muestreo probabilístico bietápico, representativa a nivel nacional de la población de afiliados a EsSalud. Se incluyeron adultos mayores (60 años a más) afiliados EsSalud. La dependencia funcional fue evaluada mediante el índice de Katz (≥ 1 punto). La DM fue evaluada mediante autorreporte del participante. Se estimaron razones de prevalencia ajustadas (RPa) por potenciales factores de confusión mediante regresión log-Poisson múltiplejunto con sus intervalos de confianza al 95% (IC 95%) y valores p. Todos los análisis tuvieron en cuenta el muestreo complejo de la ENSSA-2015. Resultados: se incluyeron 10 985 participantes de 12 805 elegibles en el análisis. Las prevalencias de dependencia funcional parcial y severa fueron de 12,9% (IC 95%: 11,9-13,8) y 6,0% (IC 95%: 5,3-6,7), respectivamente. La prevalencia de dependencia funcional (parcial o severa) en diabéticos fue 23% mayor que la de no diabéticos, luego de controlar por potenciales factores de confusión (RPa-1,23; IC 95%: 1,04-1,44; p=0,013). Conclusiones: cerca de uno de cada cinco adultos mayores afiliados a EsSalud tuvieron algún grado de dependencia funcional (parcial o severa). Asimismo, la DM estuvo asociada con una mayor probabilidad de tener dependencia funcional en esta población.

Variables asociadas con mortalidad en una población de pacientes mayores de 80 años y con algún grado de dependencia funcional, hospitalizados por COVID-19 en un Servicio de Geriatría

ObjectiveThe SARS-CoV-2 pandemic conditions high mortality rates in hospitalized elderly. Currently, a few studies include octogenarian patients and none of them analyze the impact of functional status on this health outcome. Our objective is to describe the characteristics of patients older than 80 years hospitalized for coronavirus disease 2019 (COVID-19), to determine the mortality rate and to identify associated factors. Material and methodsProspective observational study carried out on patients over 80 years admitted for COVID-19 in a Geriatrics Service. Sociodemographic, clinical, functional, mental, analytical, radiological, therapeutic and healthcare variables were collected. The factors associated with in-hospital lethality were analyzed by bivariate analysis. Results58 cases with laboratory-confirmed COVID-19 were included, mean age 88.3 ± 5.4 years, 69% women, 65.5% moderate-severe cognitive impairment and previous Barthel index 40.66 ± 36. The main symptoms were fever (60,3%), dyspnea (53.4%) and deterioration of functional condition (50%). The most frequent comorbidities were cardiovascular disease (75.9%), hypertension (HT) (74.1%) and chronic kidney disease (CKD) (50%). A mortality rate of 41,4% was detected and the associated factors were: severe functional dependence (OR = 3.8 [1.2-12.2]), moderate-severe cognitive impairment (OR = 4.9 [1-25.4]) and CKD (OR = 3.2 [1.1-9.7]). ConclusionHigh mortality rates are observed in older patients hospitalized for COVID-19, with a higher risk of dying in those with severe functional dependence or cognitive impairment. These findings reinforce the value of Geriatric Assessment to develop strategies to adapt diagnostic and therapeutic decision-making and to optimize care for elderly patients in the event of a new epidemic outbreak.

Development and Validation of an Exercise Programme for Recovery Balance Impairments in Poststroke Patients

Background: Deterioration of balance is one of the most common and disabling physical-motor deficits in patients after a stroke that have a negative impact on quality of life and increase the risk of falls. Previous studies have evaluated the effectiveness of the exercises on specific aspects of balance. However, there is no structured exercise program divided by levels for balance impairment in poststroke patients. Methods: Delphi method was used to design the exercise programme, and then a pilot study was performed. For the pilot study, we included 14 poststroke adults patients (n = 7 in each group), with balance impairment, without previous severe functional dependence, sensorial deficit or dementia. Our 4 weeks intervention (5 times/week) is based on 9 exercise of progressive difficulty, offering a multidimensional approach training (biomechanical constraints, stability limits, anticipatory, postural responses, and sensory orientation). Patients in the intervention arm received 45 minutes of usual rehabilitation plus 15 minutes of the intervention proposed. The usual-care arm received 60 minutes of usual rehabilitation. Balance impairment (Mini BESTest) was assessed at the baseline and at 4 weeks. Differences between groups were analysed using Mann-Whitney U test. Results: The agreement for the intervention designed was reached after 2 rounds. Participants in pilot study were 69 (SD = 9.7) years, 21.4% females. Post-treatment, median improvements in Mini BESTest were 20 (SD = 8) and 11 (SD = 10) points, P < .01 for intervention and control group respectively. Conclusion: A multidimensional approach of balance impairments in poststroke patients through the validated exercise programme proposed, may improve balance deficits.

Adverse Drug Events in Patients with Dementia and Neuropsychiatric/Behavioral, and Psychological Symptoms, a One-Year Prospective Study.

Older people usually present with adverse drug events (ADEs) with nonspecific symptoms such as cognitive decline, recurrent falls, reduced mobility, and/or major deterioration. The aims of this study were to assess the ADEs of patients with dementia and presenting neuropsychiatric/behavioral, and psychological symptoms in dementia (BPSD) and to categorize and identify the principal factors that allow to prevent ADEs, and separately ADEs that result in falls. To that end, a one-year prospective study in a psychogeriatric ward (July 2015 to July 2016) was performed. All patients admitted to this ward were eligible for enrolment. Patients who met any of the following criteria were excluded from the study: Patients without cognitive impairment, a length of stay under 7 days, and palliative or previous psychiatric pathology. We included 65 patients (60% women, 84.9 years ± 6.7) with mild to moderate cognitive impairment, moderate to severe functional dependence, and a high prevalence of geriatric syndromes and comorbidity. A total of 87.7% were taking five or more drugs (mean 9.0 ± 3.1). ADEs were identified during the interdisciplinary meeting and the follow up by clinical record. Sixty-eight ADEs (81.5% patients) were identified, of which 73.5% were not related to falls. From these, 80% were related to drugs of the nervous system. The Naranjo algorithm determined that 90% of ADEs were probable. The severity of the ADEs was Category E in 34 patients (68%). The number of preventable ADE according to the Schumork–Thornton test was 58%. The main ADE was drowsiness/somnolence (27.7%). ADEs related to falls represented a 26.5%. The balance between effective treatment and safety is complex in these patients. A medication review in interdisciplinary teams is an essential component to optimize safety prevention.

Long-term prognostic value of functional status and delirium in emergency patients with decompensated heart failure.

Heart failure (HF) is prevalent in older adults and is associated with impaired physical and cognitive function. However, these factors are rarely included in studies about long-term prognosis of HF. The aim of the study was to determine whether functional status and delirium at admission (prevalent delirium) would predict 1-year mortality in patients with decompensated HF (DHF). We performed a prospective observational study in adult patients with DHF attended at two Spanish Emergency Departments (ED) in the context of the Epidemiology Acute HF Emergency project. Functional status was assessed by Barthel Index (BI) and prevalent delirium by the Brief Confusion Assessment Method within the first 24h of admission. We used Kaplan-Meier survival curves for delirium and multivariable Cox regression models to estimated hazard ratio (HR) and survival probability for death while adjusting for six potential confounders. We enrolled 239 patients (age 81.7 ± 9.4years, women 61.1%). BI < 60 was 23.4 and 14.6% of patients had delirium. Age (HR 1.046 CI 95% 1.014-1.080, p < 0.004) and BI (HR 0.979 CI 95% 0.972-0.979, p < 0.001) were independently associated with 1-year mortality. In patients without severe functional dependence at admission, delirium (HR 3.579 CI 95% 1.730-7.403, p < 0.001) and age (HR 1.051 CI 95% 1.014-1.090, p = 0.007) independently predicted long-term mortality. Age and functional dependence are strong predictors of long-term mortality in patients with DHF. In patients without severe functional dependence, delirium-a potentially modifiable risk factor-identified a subgroup of patients with higher mortality. Evaluating functional status and delirium in ED could improve decision-making and future care of patients with DHF.

In-hospital mortality risk score for very old patients hospitalized with decompensated chronic heart failure.

To derive a risk score to predict in-hospital mortality for very old patients with decompensated chronic heart failure (DCHF). Retrospective cohort study that included patients≥80years admitted to a Geriatric Acute Care Unit with DCHF between January 2012 and December 2014. We analyzed 70 candidate risk factors and in-hospital mortality. We derived a risk model using multivariate logistic regression model and constructed a scale for scoring risk. We used bootstrapping techniques for the internal validation. We included 629 patients with mean age of 90 (SD5) years, 470 (73.1%) being women. Eighty-six (13.7%) patients died during the hospitalization. Factors included in the final risk model were NYHA class III-IV, severe functional dependence (Katz activities of daily living index<2), infection as cause of exacerbation of heart failure, number of medications≥8, albumin<3mg/dL, glomerular filtration rate<60mL/min, level of potassium in blood>5.5mEq/L and red blood cell distribution width (RDW)>17%. In-hospital mortality in risk groups was 3.0, 4.6, 9.5, 15.1 and 36.3%, respectively. The area under ROC curve risk for score after bootstrapping was 0.77 (95%: CI 0.70-0.83). This risk score could be useful for stratifying risk for in-hospital mortality among very old patients admitted to hospital for DCHF.

INFLUENCE OF ARTERIAL HYPERTENSION WITH DIFFERENT DURATION ON NEUROLOGICAL AND FUNCTIONAL OUTCOME OF ISCHEMIC STROKE

Relevance. The outcome of acute ischemic stroke depends on the complex interaction of many factors, such as those that are not controllable, and those that can be affected. An important prognostic value of blood pressure level during the first day after a stroke has been proven. At the same time, the relationship between the primary ischemic stroke outcome and various characteristics of arterial hypertension (duration, severity of pre-existing arterial hypertension, its course) continues to be studied.&#x0D; Objective: to study the relationship between the degree of neurological recovery and functional dependence in patients after ischemic stroke within 1 year, depending on the duration of arterial hypertension in the pre-stroke period.&#x0D; Materials and methods. The study included 156 patients, 6 patients were excluded because of the loss of communication with them and refusal to participate in the study. 150 patients, 74 (49,3 %) women and 76 (50,7 %) men aged 43 to 80 years (mean age 67.4±0,71 years) with a history of ischemic stroke and the presence of arterial hypertension were examined during the year, on 1, 21 days, after 6 and 12 months. The stroke severity was evaluated by NIHSS, functional dependence – by the Barthel Index. The diagnosis of arterial hypertension, its severity, duration was based on data from clinical, instrumental examination and medical documentation.&#x0D; Results. The severity of ischemic stroke by NIHSS at the time of admission was 9,5±0,35 points; the average degree of neurological disorders severity was determined in 57,4 % of patients. The arterial hypertension duration in the history of examined patients varied from 2 to 45 years, the average 12,3±0,64 years. The most commonly reported was the arterial hypertension with its duration 6-10 years (46 %). In the case of arterial hypertension duration up to 5 years, the ischemic stroke has developed in 18,7 % of patients. The duration of arterial hypertension in anamnesis significantly correlated with the severity of the neurological deficiency at the time of admission and at the end of the acute period (r=0,65; r=0,66, respectively). The degree of functional dependence in patients with arterial hypertension duration over 10 years was worse comparatively with patients that had arterial hypertension duration up to 5 years and even with patients with a duration from 6 to 10 years after 6 and 12 months period (61,7±2,1; 90,9±1.1; 82,8±1,4 and 64,9±2,7; 93,2±0,9; 85,7±1,3, correspondingly, all p &lt;0,05).&#x0D; Conclusions. The reliable direct relationship between the arterial hypertension duration and the degree of neurological disorders in the acute period of ischemic stroke and the reverse relationship between the duration of arterial hypertension and the degree of functional recovery in all periods of the study were found. The most patients with moderate and severe functional dependence in a year have arterial hypertension duration more than 10 years.

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

BackgroundPatients with severe stroke often do not have the capacity to participate in discussions on treatment restrictions because of a reduced level of consciousness, aphasia, or another cognitive disorder. We assessed the role of advance directives and proxy opinions in the decision-making process of incapacitated patients.MethodsSixty patients with severe functional dependence (Barthel Index ≤6) at day four after ischemic stroke or intracerebral hemorrhage were included in a prospective two-center cohort study. The decision-making process with respect to treatment restrictions was assessed by means of a semi-structured questionnaire administered to the treating physician at the day of inclusion.ResultsForty-nine patients (82%) did not have the capacity to participate in the decision-making process. In eight patients, there was no discussion on treatment restrictions and full care was installed. In 41 patients, the decision whether to install treatment restrictions was discussed with proxies. One patient had a written advance directive. In the remaining 40 patients, proxies based their opinion on previously expressed wishes of the patient (18 patients) or advised in the best interest of the patient (22 patients). In 36 of 41 patients, treatment restrictions were installed after agreement between physician and proxy. At six months, 23 of 49 patients had survived. In only three of them the decision on treatment restrictions was based on previously expressed wishes. Remarkably, two of these survivors could not recall any of their alleged previously expressed wishes.ConclusionsTreatment restrictions were installed in the majority of incapacitated patients after stroke. Proxy opinions frequently served as the best way to respect the patients’ autonomy, but their accuracy remains unclear.

Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department

The aim of this study was to determine the accuracy of systemic inflammatory response syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) score and GYM score to predict 30-day mortality in older non-severely dependent patients attended for an episode of infection in the emergency department (ED). We performed an analytical, observational, prospective cohort study including patients 75years of age or older, without severe functional dependence, attended for an infectious process in 69 Spanish EDs for 2-day three-seasonal periods. Demographic, clinical and analytical data were collected. The primary outcome was 30-day mortality after the index event. We included 1071 patients, with a mean age of 83.6 [standard deviation (SD) 5.6] years; 544 (50.8%) were men. Seventy-two patients (6.5%) died within 30days. SIRS criteria ≥ 2 had a sensitivity of 65% [95% confidence interval (CI) 53.1-75.9] and a specificity of 49% (95% CI 46.0-52.3), a qSOFA score≥2 had a sensitivity of 28% (95% CI 18.2-39.8) and a specificity of 94% (95% CI 91.9-95.1), and a GYM score≥1 had a sensitivity of 81% (95% CI 69.2-88.6) and a specificity of 45% (95% CI 41.6-47.9). A GYM score≥1 and a qSOFA score≥2 were the cut-offs with the highest sensitivity (p<0.001) and specificity (p<0.001), respectively. The area under the curve (AUC) was 0.73 (95% CI 0.66-0.79; p<0.001) for the GYM score, 0.69 (95% CI 0.61-0.76; p<0.001) for the qSOFA score and 0.65 (95% CI 0.59-0.72; p<0.001) for SIRS. A GYM score≥1 may be the most sensitive score and a qSOFA score≥2 the most specific score to predict 30-day mortality in non-severely dependent older patients attended for acute infection in EDs.

Treatment restrictions in patients with severe stroke are associated with an increased risk of death.

IntroductionTreatment restrictions in the first 2 days after intracerebral haemorrhage have been independently associated with an increased risk of early death. It is unknown whether these restrictions also affect mortality if these are installed several days after stroke onset.Patients and methodsSixty patients with severe functional dependence at day 4 after ischaemic stroke or intracerebral haemorrhage were included in this prospective two-centre cohort study. The presence of treatment restrictions was assessed at the day of inclusion. Information about mortality, functional outcome (modified Rankin scale) score and quality of life (visual analogue scale) was recorded 6 months after stroke onset. Poor outcome was defined as modified Rankin scale >3. Satisfactory quality of life was defined as visual analogue scale ≥ 60.ResultsAt 6 months, 30 patients had died, 19 survivors had a poor functional outcome and 9 patients had a poor quality of life. Treatment restrictions were independently associated with mortality at 6 months (adjusted relative risk, 1.30; 95% confidence interval, 1.06–1.59; p = 0.01), but not with functional outcome.DiscussionOur findings were observed in 60 selected patients with severe stroke.ConclusionThe instalment of treatment restrictions by itself may increase the risk of death after stroke, even if the first 4 days have passed. In future stroke studies, this potential confounder should be taken into account. Quality of life was satisfactory in the majority of the survivors, despite considerable disability.

Short-term prognostic factors in the elderly patients seen in emergency departments due to infections

ObjectivesTo analyse factors associated with short-term mortality in elderly patients seen in emergency departments (ED) for an episode of infectious disease. Materials and methodsA prospective, observational, multicentre, analytical study was carried out on patients aged 75years and older who were treated in the ED of one of the eight participating hospitals. An assessment was made of 26 independent variables that could influence mortality at 30days. They covered epidemiological, comorbidity, functional, clinical and analytical factors. Multivariate logistic regression analysis was performed. ResultsThe study included 488 consecutive patients, 92 (18.9%) of whom died within 30days of visiting the ED. Three variables were significantly associated with higher mortality: severe functional dependence, with Barthel index≤60 [odds ratio (OR) 8.92; 95% confidence interval (CI): 4.98–15.98, p=0.003], systolic blood pressure <90mmHg [OR 7.34; 95% CI: 4.39–12.26, p=0.005] and serum lactate >4mmol/l [OR 21.14; 95% CI: 8.94–49.97, p=0.001]. The area under the curve for the model was 0.971 (95% CI: 0.951–0.991; p<0.001). ConclusionsSeveral factors evaluated in an initial assessment in the ED, including the level of functional dependence, systolic blood pressure and, especially, serum lactate, were found to determine a poor short-term prognosis in the elderly patients who presented with an episode of an infectious disease.