Frail elderly patients during their hospitalization can benefit of a comprehensive geriatric assessment (CGA) by an inpatient geriatric consultation team (IGCT). This assessment yields ...recommendations aiming to improve medical and social management during the patient's hospital stay and after discharge.
This study examines the socio-demographic profile of patients assessed by the IGCT and describes the type of recommendations, their adherence rate at 3 months and their impact in terms of mortality, rehospitalization, and institutionalization.
Retrospective, single center study including all patients assessed by the IGCT during the 4 first months of 2009. These 151 patients fulfilled criteria of either medical and/or social frailty or had been submitted to an inappropriate in-hospital trajectory. Hospital records and telephone follow-up (with informal and/or professional caregivers as well as primary care physicians) were used to monitor the implementation of recommendations up to three months after hospital discharge.
Mean age of the 151 patients was 85.6 years, 63% were women. 94% of patients lived at home, 70% had a non-supportive environment, 85% were frail and 11% had dementia. On admission, 64% of them had an acute functional loss. 93% of patients were admitted via the emergency room where 67% benefited from CGA. The median hospital duration stay was 14 days. At discharge, 76% of patients went back home, 12% were institutionalized and 12% had died. Three months after discharge, 18% of the 134 patients surviving hospitalization had been readmitted, 26% institutionalized and 12% had died. The CGA yielded an average of 7 recommendations (median value). The mean adherence rate was 78%. The majority of medical recommendations concerned ancillary care and standard medical management, showing high adherence rates (95%). Recommendations concerning the management of cognitive problems were less frequent and overall poorly adhered to (62%).
Mean adherence rate was maximal (97%) when the number of recommendations was limited to 4 and it dropped under 80% with more than 5 recommendations. The recommendations concerning management at home were generally followed (60-77%). Regarding to social outcomes, the main recommendation was to mobilize home assistance and its financial support. There was no significant difference between adherence rate in the hospital and in the community. The extent of adherence rate did not correlate with mortality or readmission at 3 months.
OBJECTIVES: To compare the epidemiological and microbiological characteristics of bloodstream infection (BSI) between the young old (65–75), old (76–85), and old old (>85).
DESIGN: Retrospective ...study.
SETTING: Forty‐six hospitals in southeast France.
PARTICIPANTS: One thousand seven hundred forty patients aged 65 and older with BSI, seen between January 1 and December 31, 1998.
MEASUREMENTS: Epidemiological and microbiological data and outcome.
RESULTS: Community‐acquired BSIs (CABSIs) were significantly more frequent in the old old, but microbiological data were similar to those in the young‐old group. Conversely, microbiological data were significantly different for nosocomial BSIs (NSBIs). Escherichia coli was the main pathogen in the old old and Staphylococcus aureus in the young old. Mortality was independently associated with the presence of methicillin‐resistant S. aureus in NSBI and CABSI.
CONCLUSIONS: The differences in NBSI are important in serious infectious diseases and often require empirical antibiotic therapy. Age is also a risk factor but only for CABSI and suggests that the old‐old patients represent a frail population in the community. Further prospective studies are needed to confirm these findings and analyze predisposing factors.
Improving care and health course for hospitalized elderly patients is one of the tasks set out in the "Rapport du parcours de santé des PAERPA" (elderly people with or at risk of functional decline). ...Identification of the needs of a mobile geriatric team (MGT) intervention for the patients remain difficult in emergency department and in medical surgical units. A screening tool is needed and should be simple and fast to use. Its implementation implies that it is efficient and previously validated. The aim of our study was to evaluate the validity and predictive performances of the Triage risk stratification tool (TRST) for identify patients aged over 75 years, requiring the intervention of the MGT. This is a prospective, national, multicenter study including consecutive patients aged 75 years and older, hospitalized in emergency services and medical-surgical units in September and October 2013. The TRST was considered positive when the score was greater than 2 of 5 points. A supplementary question with binary answer (yes/no) was asked to MGT, in order to define if MGT intervention was useful. This issue has served as a "gold standard" for assessing the validity and predictive test performance. In emergency departments, the TRST was performed in 427 patients, 347 were positive. Results showed high sensitivity (79%), and poor specificity (19%) of the test in emergency units, showing that TRST did not permit to identify patients requiring MGT intervention. In contrast, the TRST seems more performant in medical-surgical (n=63 patients) units with good predictive performances (positive predictive value 90% and negative predictive value 87%). The specificity of TRST in emergency services is insufficient to generalize its use. However, performances of the TRST in other units are encouraging to propose a validation as part of a national research project.
Background The preservation of autonomy and the ability of elderly to carry out the basic activities of daily living, beyond the therapeutic care of any pathologies, appears as one of the main ...objectives of care during hospitalization. Objectives To identify early clinical markers associated with the loss of independence in elderly people in short stay hospitals. Methods Among the 1,306 subjects making up the prospective and multicenter SAFEs cohort study (Sujet Agé Fragile: Évolution et suivi—Frail elderly subjects, evaluation and follow-up), 619 medical inpatients, not disabled at baseline and hospitalized through an emergency department were considered. Data used in a multinomial logistic regression were obtained through a comprehensive geriatric assessment (CGA) conducted in the first week of hospitalization. Dependency levels were assessed at baseline, at inclusion and at 30 days using Katz's ADL index. Baseline was defined as the dependence level before occurrence of the event motivating hospitalization. To limit the influence of rehabilitation on the level of dependence, only stays shorter than 30 days were considered. Results About 514 patients were eligible, 15 died and 90 were still hospitalized at end point (n = 619). Two-thirds of subjects were women, with a mean age of 83. At day 30 162 patients (31%) were not disabled; 61 (12%) were moderately disabled and 291 severely disabled (57%). No socio-demographic variables seemed to influence the day 30 dependence level. Lack of autonomy (odds ratio (OR) = 1.9, 95% confidence interval (CI) = 1.2–3.6), walking difficulties (OR = 2.7, 95% CI = 1.3–5.6), fall risk (OR = 2.1, 95% CI = 1.3–6.8) and malnutrition risk (OR = 2.2, 95% CI = 1.5–7.6) were found in multifactorial analysis to be clinical markers for loss of independence. Conclusions Beyond considerations on the designing of preventive policies targeting the populations at risk that have been identified here, the identification of functional factors (lack of autonomy, walking difficulties, risk of falling) suggests above all that consideration needs to be given to the organization per se of the French geriatric hospital care system, and in particular to the relevance of maintaining sector-type segregation between wards for care of acute care and those involved in rehabilitation
Identifier les facteurs prédictifs du déclin fonctionnel de la personne âgée après une hospitalisation en court séjour gériatrique (CSG).
Étude descriptive rétrospective portant sur tous les patients ...hospitalisés consécutivement en CSG au CHU de Grenoble entre janvier et avril 2007. N’ont pas été considérés les patients décédés pendant l’hospitalisation et déjà hospitalisés ou totalement dépendants à l’état de base (considéré 2 semaines avant l’hospitalisation J-15). Critère de jugement principal : diminution du score des Activités de la vie Quotidienne (AVQ) entre l’état de base et la sortie d’hospitalisation. Analyse portant sur les données sociodémographiques, l’évaluation gériatrique et le mode d’admission.
Cent quatre-vingt-quatre patients ont été inclus dans l’étude (âge moyen 86,4±6,2 ans, 64,1 % de femmes). L’admission par les urgences était majoritaire (77,2 %). La durée moyenne de séjour était de 16,0±9,5 jours. Pour 95 % des patients ayant un déclin fonctionnel à la sortie, ce déclin avait eu lieu les 15 jours précédant l’admission en CSG. Un déclin fonctionnel récent, les AVQ à J0, une escarre, une hypoalbuminémie et une admission par les urgences étaient significativement associés au déclin fonctionnel à la sortie (p<0,05). En analyse multivariée, le déclin fonctionnel récent était très fortement associé au déclin fonctionnel à la sortie (OR=58,8, IC 95 % : 16,0–216,9, p<0,01). Après son exclusion, les AVQ à J0 (OR=3,2, IC 95 % : 1,6–6,6, p<0,01), l’hypo-albuminémie (OR=2,6, IC 95 % : 1,2–5,6, p=0,01) et l’admission par les urgences (OR=2,6, IC 95 % : 1,0–6,6, p=0,05) restaient indépendamment associés au déclin fonctionnel à la sortie de l’hospitalisation.
L’amélioration de la prise en charge des personnes âgées grâce au modèle des CSG permet de limiter les conséquences fonctionnelles délétères de l’hospitalisation. Cette étude a montré que le déclin fonctionnel récent à l’admission était le facteur prédictif principal du déclin fonctionnel du sujet âgé après une hospitalisation. Son identification précoce ainsi qu’une amélioration du réseau ville-hôpital devraient permettre une orientation directe des patients vers une prise en charge multidisciplinaire en CSG et par là, d’améliorer leur pronostic fonctionnel.
To identify the predictors of functional decline of older persons after hospitalization in an Acute Care for Elder unit (ACE).
Retrospective observational study based on a population hospitalised in ACE unit in Grenoble University Hospital. Dead patients within hospitalisation and patient fully disable or already hospitalized 15 days before hospitalisation were excluded. The primary outcome was the functional decline defined by a loss in activity daily life (ADL) between discharge and 15 days before hospitalisation. The predictive factors included socio-demographic data, geriatric assessment and the admission pathway.
184 patients were included (mean 86.4±6.2 years, 64.1% women). The admission by emergency department was predominant (77.2%). The mean length of stay was 16.0±9.5 days. A functional decline as present for 31,0% des patients; for 95% of these patients, the functional decline occured before admission to ACE. Factors associated with functional decline at discharge were: recent functional decline, ADL level at admission, pressure sore, denutrition and admission via the emergency room (ER) (p<0.05). In the multivariate analysis, recent functional decline was strongly associated with functional decline at discharge (OR=58.8, p<0.01). Outside this factor, ADL level at admission (OR=3.2, p<0.01), hypoalbuminemaia (OR=2.6, p=0.01) and an admission via the ER (OR=2.6, p=0.05) were independantly associated with functional decline at discharge.
Better management of hospitalised older persons, according to the ACE model, has diminished the negative functional effects of hospitalization. Identification of recent functional decline rather than other usually identified predictors would be useful for detection of older patients who might benefit from a geriatric program. Detecting and correcting early malnutrition and developing direct admissions mechanisms may improve functional prognosis of hospitalised older patients.
recurrent falls are a major public health problem associated with high morbidity and mortality as well as increased dependence. Multifactorial intervention has been shown to reduce recurrence by 20% ...(Profet study). The French Health Authority (Haute autorité de santé or HAS) recommends since 2009 a systematic screening for and assessment of risk factors as well as the implementation of preventive measures.
to examine whether the management of falls in older patients discharged home from the emergency department is consistent with the HAS guidelines.
descriptive retrospective analysis of 1238 medical records of patients over 75 years, who consulted for falls from April to October 2010 in the emergency department of in 13 centers in the North-Alps region. The study is part of a program to improve the quality of care led by the French Network of North-Alps Emergency Departments (Réseau nord alpin des urgences, RENAU).
Screening of risk factors for falls was documented in varying rates: electrocardiogram 29%, cognitive impairment 25%, functional assessment 16%, walking difficulties 11%, postural hypotension 5%. A comprehensive geriatric assessment was undertaken for 3.8% of the patients.
risk factors for falls are insufficiently documented in elderly patients discharged home from the emergency room after a fall-related visit. Completeness rates are similar to those found in previous studies. A standardized protocol for older fallers, specifically adapted to the work routine in the emergency department could be useful. The RENAU has proposed an algorithm to streamline the orientation of older fallers and promote the use of geriatric network.
To identify the predictors of functional decline of older persons after hospitalization in an Acute Care for Elder unit (ACE).
Retrospective observational study based on a population hospitalised in ...ACE unit in Grenoble University Hospital. Dead patients within hospitalisation and patient fully disable or already hospitalized 15 days before hospitalisation were excluded. The primary outcome was the functional decline defined by a loss in activity daily life (ADL) between discharge and 15 days before hospitalisation. The predictive factors included socio-demographic data, geriatric assessment and the admission pathway.
184 patients were included (mean 86.4±6.2 years, 64.1% women). The admission by emergency department was predominant (77.2%). The mean length of stay was 16.0±9.5 days. A functional decline as present for 31.0% des patients; for 95% of these patients, the functional decline occurred before admission to ACE. Factors associated with functional decline at discharge were: recent functional decline, ADL level at admission, pressure sore, denutrition and admission via the emergency room (ER) (p<0.05). In the multivariate analysis, recent functional decline was strongly associated with functional decline at discharge (OR=58.8, p<0.01). Outside this factor, ADL level at admission (OR=3.2, p<0.01), hypoalbuminemaia (OR=2.6, p=0.01) and an admission via the ER (OR=2.6, p=0.05) were independently associated with functional decline at discharge.
Better management of hospitalised older persons, according to the ACE model, has diminished the negative functional effects of hospitalization. Identification of recent functional decline rather than other usually identified predictors would be useful for detection of older patients who might benefit from a geriatric program. Detecting and correcting early malnutrition and developing direct admissions mechanisms may improve functional prognosis of hospitalised older patients.
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