A meta-analysis is published in this issue of International Psychogeriatrics titled “Decisional capacity to consent to treatment and research in patients affected by Mild Cognitive Impairment–A ...systematic review and meta-analysis” (Parmigiani et al., 2020). Its objective is to compare the ability to decide to take treatment or participate in clinical research of Mild Cognitive Impairment (MCI) patients versus Alzheimer’s patients and patients without neurocognitive disorders. Patients affected by MCI are at higher risk of impaired capacity to consent to treatment and research compared to healthy patients, despite being at lower risk compared to patients affected by Alzheimer disease. So clinicians and researchers need to carefully evaluate decisional capacity in MCI patients providing informed consent. A small number of studies was included in the analyze so it was not possible to determine many factors associated with decisional capacity in patients with MCI. It was not possible to conclude completely. Indeed, this study suffers of the current heterogeneity of existing tests of decisional capacity. It exists at several levels: on the type of capacity tested, the type of test, the methodology of the studies and the populations studied (Gilbert et al., 2017) (Pennington et al., 2018). There is no Gold standard for assessing decision-making capacity but there are a few validated tests such as the MacCAT-T (Grisso et al., 1997) or the UBACC (Jeste et al., 2007). They all include four dimensions of decision-making capacity, which are understanding, reasoning, appreciation and choice (Appelbaum, 2007). Despite their multiplicity, these tests are essential for assessing decision-making ability because clinicians’ judgement is not sufficient. Indeed, it is known that there is inter-observer variability (Janofsky et al., 1992) (Fazel et al., 1999) which can lead to two different assessments for the same patient.Moreover, there is an over-confidence bias in any clinical evaluation (Miller et al., 2015) which causes the clinician to be too certain of his judgment. This is the case for clinicians who overestimate MCI patients (Oshima et al., 2020). This bias can be controlled by the use of decision-ability tests that decrease inter-rater variability through the use of standardized tools.
Background
Dementia patients represent a significant volume of hospital admissions and impose a high cost on the health system. There is a significantly higher length of hospital stay (LOHS) for ...elderly demented patients.
Methods
This study was carried out in an acute psychogeriatric unit specialising in behavioural and psychological symptoms in dementia. Socio‐demographic, cognitive and nutritional variables were taken into account. We first compared the patients returning home (group 1) after hospital discharge with those transferred to the rehabilitation psychogeriatric unit (group 2). We secondarily explored the correlation of LOHS with the variables described above for the two groups.
Results
We retained 92 patients (of 375 admitted) for our study, mean age 83.9 ± 6.6, Mini‐Mental State Examination 12.8 ± 9.6, initial weight 61.7 ± 13.2 kg and body mass index 24.8 ± 4.7. We noticed significant differences in cognitive status but not in nutritional variables or in socio‐demographic characteristics between the two groups. Only weight in nutritional variables was significantly associated with LOHS in the acute psychogeriatric unit.
Conclusions
Our main finding underlined the key role of cognitive factors in patient discharge home. And only initial weigh seems have an influence in LOHS instead of cognitive status or socio‐demographic characteristics.
Current French and international policy (Programme des Nations Unies concernant les personnes handicapées, n.d.) advocates user participation, and new French laws require medical staff and hospitals ...to respect patients’ choices about home or nursing home discharge. The Mini-Mental State Examination (MMSE) is not sufficient to determine a patient’s decision-making ability because it is not directly correlated with cognitive abilities. Practitioners can easily get into difficulty when dealing with age-related issues, such as the risk associated with a discharge decision, and adopt “paternalist” behavior (Sheehan, 2014). ...few patients were under legal protection and one could argue that medical teams exceed the limits of legality by deciding for the patient without a formal legal framework.
Abstract
Background
There is limited information describing the characteristics and outcomes of hospitalized older patients with confirmed coronavirus disease 2019 (COVID-19).
Method
We conducted a ...multicentric retrospective cohort study in 13 acute COVID-19 geriatric wards, from March 13 to April 15, 2020, in Paris area. All consecutive patients aged 70 years and older, with confirmed COVID-19, were enrolled.
Results
Of the 821 patients included in the study, the mean (SD) age was 86 (7) years; 58% were female; 85% had ≥2 comorbidities; 29% lived in an institution; and the median interquartile range Activities of Daily Living scale (ADL) score was 4 2–6. The most common symptoms at COVID-19 onset were asthenia (63%), fever (55%), dyspnea (45%), dry cough (45%), and delirium (25%). The in-hospital mortality was 31% (95% confidence interval CI 27–33). On multivariate analysis, at COVID-19 onset, the probability of in-hospital mortality was increased with male gender (odds ratio OR 1.85; 95% CI 1.30–2.63), ADL score <4 (OR 1.84; 95% CI 1.25–2.70), asthenia (OR 1.59; 95% CI 1.08–2.32), quick Sequential Organ Failure Assessment score ≥2 (OR 2.63; 95% CI 1.64–4.22), and specific COVID-19 anomalies on chest computerized tomography (OR 2.60; 95% CI 1.07–6.46).
Conclusions
This study provides new information about older patients with COVID-19 who are hospitalized. A quick bedside evaluation at admission of sex, functional status, systolic arterial pressure, consciousness, respiratory rate, and asthenia can identify older patients at risk of unfavorable outcomes.
Background There is limited information describing the characteristics and outcomes of hospitalized older patients with confirmed coronavirus disease 2019 (COVID-19). Method We conducted a ...multicentric retrospective cohort study in 13 acute COVID-19 geriatric wards, from March 13 to April 15, 2020, in Paris area. All consecutive patients aged 70 years and older, with confirmed COVID-19, were enrolled. Results Of the 821 patients included in the study, the mean (SD) age was 86 (7) years; 58% were female; 85% had ≥2 comorbidities; 29% lived in an institution; and the median interquartile range Activities of Daily Living scale (ADL) score was 4 2–6. The most common symptoms at COVID-19 onset were asthenia (63%), fever (55%), dyspnea (45%), dry cough (45%), and delirium (25%). The in-hospital mortality was 31% (95% confidence interval CI 27–33). On multivariate analysis, at COVID-19 onset, the probability of in-hospital mortality was increased with male gender (odds ratio OR 1.85; 95% CI 1.30–2.63), ADL score <4 (OR 1.84; 95% CI 1.25–2.70), asthenia (OR 1.59; 95% CI 1.08–2.32), quick Sequential Organ Failure Assessment score ≥2 (OR 2.63; 95% CI 1.64–4.22), and specific COVID-19 anomalies on chest computerized tomography (OR 2.60; 95% CI 1.07–6.46). Conclusions This study provides new information about older patients with COVID-19 who are hospitalized. A quick bedside evaluation at admission of sex, functional status, systolic arterial pressure, consciousness, respiratory rate, and asthenia can identify older patients at risk of unfavorable outcomes.
The Alzheimer's plans have led to significant progress in the care management of elderly people suffering from Alzheimer's disease or other forms of dementia, but the medical and social network ...remains fragmented in geriatrics. We have proposed to caregivers a monthly videoconference combining expert presentations and discussion of clinical cases. Several health professions were represented. The main positive point was the time saved. The videoconferencing improved multidisciplinary exchanges, especially for patients with complex problems and their families.
The behavioral and psychological symptoms of dementia (BPSD) are well known in patients with major cognitive impairment (Bessey and Walaszek,2019). The COVID-19 pandemic calls into ques- tion the ...organization of Cognitive and Behavioral Units (CBUs) specialized in the management of BPSD (Bellelli and Trabucchi, 2011; Koskas et al., 2011) to limit the risk of contamination for hospitalized patients and staff. Moderate-to-severe cognitivedisorders and BPSDs such as wandering and agitation explain patients’ lack of understanding of the basic protective measures against COVID-19 and their difficulty in implementing them (BMJ Best Practice, 2020). It is also difficult to find the right balance between protective but coercive measures and respect for patients’ dignity. Another difficulty is how to streamline hospital procedures to reduce workload and limit the risk of mental and physical exhaustion.
L’hospitalisation des personnes âgées s’accompagnent d’un risque de déclin fonctionnel, et d’une grande fréquence de réadmission. Nous avons cherché à comprendre les processus de prise de décisions ...cliniques qui influencent l’orientation des patients âgés après leur sortie de l’hôpital. Les procédures déterminant l’orientation d’un patient âgé après une hospitalisation en service aigu ne sont pas claires. Nous avons comparé les décisions d’orientation (retour à domicile ou maison de retraite) réalisées par l’équipe avec celles d’un groupe d’experts; les décisions étaient prises de manière indépendante et aveugle. Cent deux (102) patients ont été inclus (âge moyen : 83,13 ± 6,74). Il existe une différence statistiquement significative entre les décisions des experts et de l’équipe (p <.001 ; coefficient kappa : 0,468). Les décisions du panel étaient plus étroitement associées à l’isolement (p = 0,018), aux aidants fiables (p = 0,004), aux problèmes sociaux (p = 0,001), et à la présence de comportements perçus comme agressifs (p = 0,001). Les deux processus de décision ont pris en compte le refus de soins (p = 0,025 et 0,016 respectivement) et les problèmes sociaux (p = 0,001 et < 0,001 respectivement). Les modalités de sortie des hôpitaux diffèrent selon les pays, les équipes et le type de patients, mais notre étude suggère la nécessité d’une évaluation plus précise des besoins du patient. We aimed to understand clinical decision-making processes that influence the orientation of older patients after hospital discharge. We compared discharge decisions (i.e., discharge home, or nursing home stay) of the hospital team with those of an expert panel. Both panel and hospital team made their decisions independently. The blind study included 102 patients (mean age: 83.13 ± 6.74). There is a statistically significant difference between expert and hospital team decisions (p < .001; kappa coefficient: 0.468). Panel decisions were more closely associated with isolation (p = .018), reliable caregivers (p = .004), social problems (p = .001), and behavioural symptoms perceived as aggressive (p = .001). Both decision processes considered refusal of care (p = 0,025 and 0.016 respectively) and social problems (p = .001 and < 0.001 respectively). Discharge planning models differ depending on the country, team and patient’s condition. Our study suggests more precise evaluation of patients’ needs.
ABSTRACTWe aimed to understand clinical decision-making processes that influence the orientation of older patients after hospital discharge. We compared discharge decisions (i.e., discharge home, or ...nursing home stay) of the hospital team with those of an expert panel. Both panel and hospital team made their decisions independently. The blind study included 102 patients (mean age: 83.13 ± 6.74). There is a statistically significant difference between expert and hospital team decisions (p < .001; kappa coefficient: 0.468). Panel decisions were more closely associated with isolation (p = .018), reliable caregivers (p = .004), social problems (p = .001), and behavioural symptoms perceived as aggressive (p = .001). Both decision processes considered refusal of care (p = 0,025 and 0.016 respectively) and social problems (p = .001 and < 0.001 respectively). Discharge planning models differ depending on the country, team and patient's condition. Our study suggests more precise evaluation of patients' needs.
Elderly hospitalized patients have uncertain or questionable capacity to make decisions about their care. Determining whether an elderly patient possesses decision-making capacity to return at home ...is a major concern for geriatricians in everyday practice. To construct and internally validate a new tool, the dream of home test (DROM-test), as support for decision making hospitalization discharge destination for the elderly in the acute or sub-acute care setting. The DROM-test consists of 10 questions and 4 vignettes based upon the 4 relevant criteria for decision-making: capacity to understand information, to appreciate and reason about medical risks and to communicate a choice. A prospective observational study was conducted during 6 months in 2 geriatric care units in Bretonneau Hospital (Assistance publique, Hôpitaux de Paris). We compared the patient decision of DROM-test regarding discharge recommendations with those of an Expert committee and of the team in charge of the patient. 102 were included: mean age 83.1 + 6.7 70; 97, 66.67% females. Principal components analysis revealed four dimensions: choice, understanding, reasoning and understanding. The area under the ROC curve was 0.64 for the choice dimension, 0.59 for the understanding, 0.53 for the reasoning and 0.52 for the apprehension. Only the choice dimension was statistically associated with the decision of the committee of experts (p=0.017). Even though Drom-test has limitations, it provides an objective way to ascertain decision-making capacity for hospitalised elderly patients.
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