Purpose
Frailty is a recent concept used for evaluating elderly individuals. Our study determined the prevalence of frailty in intensive care unit (ICU) patients and its impact on the rate of ...mortality.
Methods
A multicenter, prospective, observational study performed in four ICUs in France included 196 patients aged ≥65 years hospitalized for >24 h during a 6-month study period. Frailty was determined using the frailty phenotype (FP) and the clinical frailty score (CFS). The patients were separated as follows: FP score <3 or ≥3 and CFS <5 or ≥5.
Results
Frailty was observed in 41 and 23 % of patients on the basis of an FP score ≥3 and a CFS ≥5, respectively. At admission to the ICU, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores did not differ between the frail and nonfrail patients. In the multivariate analysis, the risk factors for ICU mortality were FP score ≥3 hazard ratio (HR), 3.3; 95 % confidence interval (CI), 1.6–6.6;
p
< 0.001, male gender (HR, 2.4; 95 % CI, 1.1–5.3;
p
= 0.026), cardiac arrest before admission (HR, 2.8; 95 % CI, 1.1–7.4;
p
= 0.036), SAPS II score ≥46 (HR, 2.6; 95 % CI, 1.2–5.3;
p
= 0.011), and brain injury before admission (HR, 3.5; 95 % CI, 1.6–7.7;
p
= 0.002). The risk factors for 6-month mortality were a CFS ≥5 (HR, 2.4; 95 % CI, 1.49–3.87;
p
< 0.001) and a SOFA score ≥7 (HR, 2.2; 95 % CI, 1.35–3.64;
p
= 0.002). An increased CFS was associated with significant incremental hospital and 6-month mortalities.
Conclusions
Frailty is a frequent occurrence and is independently associated with increased ICU and 6-month mortalities. Notably, the CFS predicts outcomes more effectively than the commonly used ICU illness scores.
The use of telemonitoring solutions via wearable sensors is believed to play a major role in the prevention and therapy of physical weakening in older adults. Despite the various studies found in the ...literature, some elements are still not well addressed, such as the study cohort, the experimental protocol, the type of research design, as well as the relevant features in this context. To this end, the objective of this pilot study was to investigate the efficacy of data-driven systems to characterize older individuals over 80 years of age with impaired physical function, during their daily routine and under unsupervised conditions. We propose a fully automated process which extracts a set of heterogeneous time-domain features from 24-hour files of acceleration and barometric data. After being statistically tested, the most discriminant features fed a group of machine learning classifiers to distinguish frail from non-frail subjects, achieving an accuracy up to 93.51%. Our analysis, conducted over 570 days of recordings, shows that a longitudinal study is important while using the proposed features, in order to ensure a highly specific diagnosis. This work may serve as a basis for the paradigm of future monitoring systems.
Rhabdomyolysis is a common condition in older adults, often associated with falls. However, prognostic factors for rhabdomyolysis have mainly been studied in middle-aged populations.
To test the ...hypothesis that age influences rhabdomyolysis prognostic factors.
This retrospective single-center observational study included all patients with a creatine kinase (CK) level greater than five times normal, admitted to Rennes University Hospital between 2013 and 2019. The primary endpoint was 30-day in-hospital mortality rate.
343 patients were included (median age: 75 years). The mean peak CK was 21,825 IU/L. Acute renal failure occurred in 57.7% of the cases. For patients aged 70 years and over, the main etiology was prolonged immobilization after a fall. The 30-day in-hospital mortality rate was 10.5% (23 deaths). The Charlson score, number of medications and CK and creatinine levels varied according to age. Multivariate analysis showed age to be a factor that was associated, although not proportionally, with 30-day in-hospital mortality.
Factors influencing rhabdomyolysis severity were not randomly distributed according to age. The term rhabdomyolysis encompasses various clinical realities and is associated with different mechanisms. More research is needed to better understand the physio-pathological and prognostic factors of rhabdomyolysis, especially in older adults.
We analyze here major changes over the last decade in the French healthcare system for older people, in terms of the integrated care concept.
During this period, the major theme of public policies ...was "care coordination." Despite some improvements, the multiplication of experimental programs and the multiplicity of stakeholders distanced the French healthcare system from an integrated care model. Professionals and organizations generally welcomed these numerous programs. However, most often, the programs were insufficiently implemented or articulated, notably at a clinical level, because of the persistence of a high level of fragmentation of governance, despite the creation of regional health agencies 10 years ago. The COVID-19 crisis has highlighted this fragmentation. Moreover, we still lack data on the impact of these programs on people's health trajectories and personal experiences.
The French healthcare system seems more fragmented in 2020 than in 2010, despite improvements in the culture of professional collaboration. The future health reform is an opportunity to capitalize upon this progress and to implement "integrated care." This implies a strong and continuous national leadership in governance and change management.
Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians ...from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear.
ClinicalTrials.gov NCT00912600.
Malnutrition is related to poor outcomes. Food intake semi-quantitative assessment is helpful for malnutrition screening. Aims: to assess maintenance over one month of one-day semi-quantitative ...assessment of food intake (primary aim) and its performance in diagnosing malnutrition (secondary aim) in older people living in a nursing home. Food portions consumed at lunch and dinner were measured during 20 days by the Simple Evaluation of Food Intake (SEFI)
assisted by photography (SEFI
-AP) in 70 residents. Nutritional status was assessed in each patient during the first week of food intake monitoring according to Global Leadership Initiative on Malnutrition criteria. Food intake was decreased, i.e., SEFI
-AP < 7, in 39% (n = 27/73) of patients. According to the methods, 36 to 48% (n = 25 to 33/73) of patients had malnutrition, and 6 to 37% (n = 4 to 25/73) sarcopenia. According to a generalized linear model on ranks with repeated measures, the SEFI
-AP medians of lunch (
= 0.11) and means of lunch and dinner (
= 0.15) did not vary over time. Day 3 SEFI
-AP anticipated decreased food intake from days 4 to 20, with a sensitivity of 78% (95% confidence interval (CI), 62-94), a specificity of 30% 95%CI, 17-44 and positive and negative predictive values of 41% 95%CI, 28-55 and 68% 95%CI, 48-89. The performance of SEFI
-AP for diagnosis of malnutrition using calf circumference <31 cm as a phenotypic criterion was correct: area under the curve = 0.71 95%CI, 0.59-0.83. SEFI
-AP sensitivity was better if ≤9.5 than <7, and inversely for specificity. The food intake of older people living in nursing homes is stable over one month. One-day SEFI
-AP correctly anticipates food intake during the following month and predicts diagnosis of malnutrition. Any decrease in food intake should lead to suspect malnutrition.
There is a consensus that the use of comprehensive geriatric assessment (CGA) is good clinical practice for older patients with solid tumors or hematological malignancies. To be complete, a CGA must ...include a geriatric assessment and an intervention plan. According to the SIOG consensus, a CGA should assess several domains: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and the presence of geriatric syndromes. Progress has been made in the definition of the best way to detect problems, but the benefits are mostly based on prognosis stratification and on the adaptation of cancer treatment. The present review aims to evaluate the level of evidence regarding geriatric interventions proposed following the detection of a problem in cancer patients in each domain mentioned in the SIOG consensus. An online search of the PubMed database was performed using predefined search algorithms specific for each domain of the CGA. Eligible articles had to have well-defined interventions targeting specific domains of the CGA. We screened 1864 articles, but only a few trials on single-domain interventions were found, and often, these studies involved small groups of patients. This review highlights the scarcity of published studies on this topic. The specific impacts of CGA-based interventions have not yet been demonstrated. Multi-domain interventions seem promising, especially when they are based on global assessments. However, standardization seems difficult considering the lack of evidence for each domain. New studies are necessary in multiple care contexts, and innovative designs must be used to balance internal and external validity. An accurate description of the intervention and what "usual care" means will improve the external validity of such studies.
Nursing home (NH) residents accounted for half of the deaths during the 2020 spring wave of the coronavirus disease 2019 (COVID-19) epidemic in France. Our objective was to identify structural and ...managerial factors associated with COVID-19 outbreaks in NHs.
We conducted in July 2020 a retrospective study by questionnaire addressed to NH directors in the Brittany region of France. The questions related to structural characteristics of the establishment, human resources, and crisis management decisions. The primary endpoint was the occurrence of at least one confirmed case of COVID-19 among residents between March 1, 2020 and May 31, 2020. The secondary endpoint was total mortality during this period. We used multivariate regressions to identify factors associated with these outcomes.
Responses were collected from 231 NHs hosting 20,881 residents, representing a participation rate of 47%. In 24 (10%) NHs, at least one resident presented confirmed COVID-19. NHs often implemented stringent protective measures, with 65% of them choosing to confine residents to their rooms. In multivariate analysis, factors associated with a reduced risk of case occurrence were in-room meal service, early ban of family visits, and daily access to an outdoor space. No association was found between mortality and the factors studied. Our results show an early and strict implementation of lockdown measures, with good epidemiological results in a context of shortage of personal protective equipment (PPE) and non-vaccination. Nevertheless, it raises ethical questions concerning respect of residents' wellbeing and rights.
Cessation of communal dining seems to be the main measure likely to be effective in preventive terms. It does not seem that room lockdown and cessation of group activities should be recommended, particularly if mask wearing is possible.
In 2009, case management interventions were a new social service in France implemented within the framework of the PRISMA-France program (2006-2010). People who had benefitted from case management ...intervention were individuals, over 60 years old living at home in situations deemed complex by professionals. Their informal caregivers were also considered as users of the service. This research accompanied the interventions during the implementation of PRISMA-France attempting to explore the users' (old people and their informal caregivers) and case managers' first experiences of case management. Its aim is to provide a thorough knowledge of the dispositive in order to reveal any initial failings and to ensure optimum conditions for the onset of full implementation.
The study had a qualitative explorative design. Cross-linked representations of case-management were obtained through opened-ended and guided interviews with three types of informants: old people (19), their informal caregivers (11) and the case managers (5) who participated in the program during the first 6 months. Thematic analysis of the data was carried out.
The analysis revealed that each group of people generated its own representations of the case manager's role, even though the three groups of informants shared the idea that the case manager is first and foremost a helper. The case managers insisted on their proximity to the old people and their role as coordinators. The informal caregivers saw the professional as a partner and potential provider of assistance in accompanying old people. The old people focused on the personal connections established with the case manager.
The innovative and experimental dimension of case management in France and the flexible nature of the role generated a broad spectrum of representations by those involved. These different representations are, in part, the fruit of each individual's projected expectations of this social service. Analyzing the first representations of the case manager's role during the implementation phase of the CM service appears as a necessary step before considering the effects of the services. The implementation and the success of a case management model have to be evaluated regarding the previous healthcare context and the expectations of the people involved.
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