Objectives
Delirium is a serious condition, which poses treatment challenges during hospitalisation for COVID‐19. Improvements in testing, vaccination and treatment might have changed patient ...characteristics and outcomes through the pandemic. We evaluated whether the prevalence and risk factors for delirium, and the association of delirium with in‐hospital mortality changed through the pandemic.
Methods
This study was part of the COVID‐OLD study in 19 Dutch hospitals including patients ≥70 years in the first (spring 2020), second (autumn 2020) and third wave (autumn 2021). Multivariable logistic regression models were used to study risk factors for delirium, and in‐hospital mortality. Differences in effect sizes between waves were studied by including interaction terms between wave and risk factor in logistic regression models.
Results
1540, 884 and 370 patients were included in the first, second and third wave, respectively. Prevalence of delirium in the third wave (12.7%) was significantly lower compared to the first (22.5%) and second wave (23.5%). In multivariable‐adjusted analyses, pre‐existing memory problems was a consistent risk factor for delirium across waves. Previous delirium was a risk factor for delirium in the first wave (OR 4.02), but not in the second (OR 1.61) and third wave (OR 2.59, p‐value interaction‐term 0.028). In multivariable‐adjusted analyses, delirium was not associated with in‐hospital mortality in all waves.
Conclusion
Delirium prevalence declined in the third wave, which might be the result of vaccination and improved treatment strategies. Risk factors for delirium remained consistent across waves, although some attenuation was seen in the second wave.
Key points
Prevalence of delirium in the third COVID‐19 wave was significantly lower compared to the first and second wave
Risk factors for delirium remained consistent across waves
Delirium was not independently associated with in‐hospital mortality
Falling is a common and serious problem in the elderly. Previous studies suggest that the use of psychotropic drugs increases the risk of falling. However, the contribution of these drugs on fall ...risk has not been quantified on a daily basis among the general population of nursing homes until now.
To assess the association between fall incidence and the prescription of psychotropic drugs and different categories of psychotropic drugs (antipsychotics, antidepressants, and benzodiazepines) among a general nursing home population.
Retrospective observational study, data collection per person-day.
9 nursing homes in Eindhoven, the Netherlands.
2368 nursing home residents, resulting in 538,575 person-days.
Association between the prescription of psychotropic drugs and falls.
A total of 2368 nursing home residents were included, which resulted in a data set of 538,575 person-days. Prescription of at least 1 psychotropic drug per day occurred during a total of 318,128 person-days (59.1%). Scheduled prescriptions with or without an as-needed prescription were involved in a total of 270,781 person-days (50.3%). The prescription of psychotropic drugs on a scheduled basis was found to be associated with almost a 3-fold increase in fall incidence (OR 2.88; 95% CI 1.52-5.44). An increase in fall incidence was found following the prescription of antipsychotics (OR 1.97; 95% CI 1.51-2.59) and antidepressants (OR 2.26; 95% CI 1.73-2.95). This increased fall risk was found for prescriptions on a scheduled basis as well as for prescriptions on an as-needed basis.
The prescription of psychotropic drugs is associated with a strongly increased risk of falling among nursing home residents. To our knowledge, this is the first study among the general nursing home population in which the association between daily falls and daily prescriptions of psychotropic drugs and groups of psychotropic drugs was specified.
During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome ...have been conflicting.
The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands.
This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality.
A total of 1,376 patients were included (median age 78 years (interquartile range 74-84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6-9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1-3, patients with CFS 4-5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3-3.0)) and patients with CFS 6-9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8-4.3)).
The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.
Background
In the Netherlands, it is customary to discuss directives regarding resuscitation, intubation, and ICU-admission with patients and/or their relatives upon hospital-admission. The outcome ...of this discussion is documented in a code status. Ideally, these advance care planning (ACP)-related decisions are made by a patient (and/or their relatives) and a professional together in a shared decision-making (SDM) process, to improve patient satisfaction and prevent undesired care. Given the bad outcomes in older COVID-19 patients, it is particularly important to discuss the code status upon admission. This study aims to describe the practice of SDM regarding code status during the COVID-pandemic. Specific aims were to find out to what extend patients took part in this decision-making process and whether all key elements of SDM for a shared decision were documented in medical reports.
Methods
In this retrospective cohort study, we included COVID-19 patients aged 70 years and older, admitted to two large teaching hospitals in the Netherlands, during the first months of the COVID-19 pandemic in 2020. Data about code status and the decision-making process were extracted from electronic healthcare records.
Results
Code status was documented for 274 of 275 included patients. Patient participation in the decision-making process was described in 48%. In 19% all key elements of shared decision-making have been described. Key elements of SDM were defined as the presence of a completed code status form, the presence of clinical notes showing that both patient’s wishes and values and the opinion of the healthcare professional about the predicted outcome was taken into consideration and clinical notes of a patient–healthcare professional interaction during the admission.
Conclusion
Our results show that a proper SDM process regarding code status is possible, even in hectic times like the COVID-19-pandemic. However, shared decision-making was not common practice in older patients with COVID-19 regarding code status (an ACP-related decision) in the early phase of the COVID-19 pandemic. Only in 19% of the patients, all key elements of SDM regarding code status were described.
Abstract
Background
as the coronavirus disease of 2019 (COVID-19) pandemic progressed diagnostics and treatment changed.
Objective
to investigate differences in characteristics, disease presentation ...and outcomes of older hospitalised COVID-19 patients between the first and second pandemic wave in The Netherlands.
Methods
this was a multicentre retrospective cohort study in 16 hospitals in The Netherlands including patients aged ≥ 70 years, hospitalised for COVID-19 in Spring 2020 (first wave) and Autumn 2020 (second wave). Data included Charlson comorbidity index (CCI), disease severity and Clinical Frailty Scale (CFS). Main outcome was in-hospital mortality.
Results
a total of 1,376 patients in the first wave (median age 78 years, 60% male) and 946 patients in the second wave (median age 79 years, 61% male) were included. There was no relevant difference in presence of comorbidity (median CCI 2) or frailty (median CFS 4). Patients in the second wave were admitted earlier in the disease course (median 6 versus 7 symptomatic days; P < 0.001). In-hospital mortality was lower in the second wave (38.1% first wave versus 27.0% second wave; P < 0.001). Mortality risk was 40% lower in the second wave compared with the first wave (95% confidence interval: 28–51%) after adjustment for differences in patient characteristics, comorbidity, symptomatic days until admission, disease severity and frailty.
Conclusions
compared with older patients hospitalised in the first COVID-19 wave, patients in the second wave had lower in-hospital mortality, independent of risk factors for mortality.
The better prognosis likely reflects earlier diagnosis, the effect of improvement in treatment and is relevant for future guidelines and treatment decisions.
Objectives
A high incidence of delirium has been reported in older patients with Coronavirus disease 2019 (COVID‐19). We aimed to identify determinants of delirium, including the Clinical Frailty ...Scale, in hospitalized older patients with COVID‐19. Furthermore, we aimed to study the association of delirium independent of frailty with in‐hospital outcomes in older COVID‐19 patients.
Methods
This study was performed within the framework of the multi‐center COVID‐OLD cohort study and included patients aged ≥60 years who were admitted to the general ward because of COVID‐19 in the Netherlands between February and May 2020. Data were collected on demographics, co‐morbidity, disease severity, and geriatric parameters. Prevalence of delirium during hospital admission was recorded based on delirium screening using the Delirium Observation Screening Scale (DOSS) which was scored three times daily. A DOSS score ≥3 was followed by a delirium assessment by the ward physician In‐hospital outcomes included length of stay, discharge destination, and mortality.
Results
A total of 412 patients were included (median age 76, 58% male). Delirium was present in 82 patients. In multivariable analysis, previous episode of delirium (Odds ratio OR 8.9 95% CI 2.3–33.6 p = 0.001), and pre‐existent memory problems (OR 7.6 95% CI 3.1–22.5 p < 0.001) were associated with increased delirium risk. Clinical Frailty Scale was associated with increased delirium risk (OR 1.63 95%CI 1.40–1.90 p < 0.001) in univariable analysis, but not in multivariable analysis. Patients who developed delirium had a shorter symptom duration and lower levels of C‐reactive protein upon presentation, whereas vital parameters did not differ. Patients who developed a delirium had a longer hospital stay and were more often discharged to a nursing home. Delirium was associated with mortality (OR 2.84 95% CI1.71–4.72 p < 0.001), but not in multivariable analyses.
Conclusions
A previous delirium and pre‐existent memory problems were associated with delirium risk in COVID‐19. Delirium was not an independent predictor of mortality after adjustment for frailty.
Key points
A previous episode of delirium and pre‐existent memory problems were independent predictors of delirium risk in older adults hospitalized with COVID‐19.
Reports on the association of delirium with poor outcomes, independent of frailty, in older hospitalized COVID‐19 patients have been conflicting.
In this study, delirium was not a predictor of in‐hospital mortality independent of frailty.
Adverse drug reactions (ADRs) are a common, and often preventable, cause of hospital admission, especially in the elderly, and can occur during hospitalization. In this current opinion article, we ...present three cases of recurrence of a serious ADR due to re-prescription of a withdrawn medication that highlight the need for a system to prevent the undesirable re-prescription of medications withdrawn because of an ADR. In addition, we describe an electronic system that could help prevent undesirable re-prescription following an ADR. Such a system should document ADRs systematically at the patient level, make this information available to relevant healthcare providers and the patient, and flag re-prescription of the offending drug. The effectiveness and cost effectiveness of such a system would need to be determined.
Optimizing polypharmacy is often difficult, and critical appraisal of medication use often leads to one or more changes. We developed the Prescribing Optimization Method (POM) to assist physicians, ...especially general practitioners (GPs), in their attempts to optimize polypharmacy in elderly patients. The POM is based on six questions: (i) is undertreatment present and addition of medication indicated; (ii) does the patient adhere to his/her medication schedule; (iii) which drug(s) can be withdrawn or which drugs(s) is/are inappropriate for the patient; (iv) which adverse effects are present; (v) which clinically relevant interactions are to be expected; and (vi) should the dose, dose frequency and/or form of the drug be adjusted?
The aim of this study was to evaluate the usefulness of the POM as a tool for improving appropriate prescribing of complex polypharmacy in the elderly.
Forty-five GPs were asked to optimize the medication of two case histories, randomly chosen from ten histories of geriatric patients admitted to a hospital geriatric outpatient clinic with a mean +/- SD of 7.9 +/- 1.2 problems treated with 8.7 +/- 3.1 drugs. The first case was optimized without knowledge of the POM. After a 2-hour lecture on the POM, the GPs used the POM to optimize the medication of the second case history. The GPs were allowed 20 minutes for case optimization. Medication recommendations were compared with those made by an expert panel of four geriatricians specialized in clinical pharmacology. Data were analysed using a linear mixed effects model.
Optimization was significantly better when GPs used the POM. The proportion of correct decisions increased from 34.7% without the POM to 48.1% with the POM (p = 0.0037), and the number of potentially harmful decisions decreased from a mean +/- SD of 3.3 +/- 1.8 without the POM to 2.4 +/- 1.4 with the POM (p = 0.0046).
The POM improves appropriate prescribing of complex polypharmacy in case histories.
Abstract
Background
During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty ...with poor outcome have been conflicting.
Objective
The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands.
Methods
This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality.
Results
A total of 1,376 patients were included (median age 78 years (interquartile range 74–84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6–9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1–3, patients with CFS 4–5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3–3.0)) and patients with CFS 6–9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8–4.3)).
Conclusions
The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.
The Netherlands Pharmacovigilance Centre Lareb received four cases of severe symptomatic hyponatraemia or syndrome of inappropriate antidiuretic hormone secretion (SIADH) in association with valproic ...acid use, in which a causal relationship was suspected. This study describes these cases and gives support for this association from Vigibase, the adverse drug reaction (ADR) database of the WHO Collaborating Centre for International Drug Monitoring, the Uppsala Monitoring Centre. Cases of hyponatraemia in valproic acid users are described. In a case/non-case analysis, the strength of the association between reported cases of hyponatraemia and the use of valproic acid in Vigibase was established by calculating a reporting odds ratio, adjusted for possible confounding by concomitant medication. Four females aged 57, 67, 71 and 88 years developed symptomatic hyponatraemia or SIADH after starting valproic acid. Despite concomitant medication or co-morbidity, a causal relationship was plausible. In Vigibase, valproic acid is disproportionally associated with hyponatraemia and SIADH (corrected reporting odds ratio 1.83 95% CI 1.61, 2.08). Based on the described cases and the reports from Vigibase, a causal relationship between valproic acid use and hyponatraemia or SIADH can be suspected. The mechanism by which valproic acid could cause hyponatraemia or SIADH has not been fully elucidated. Valproic acid use could lead to reduced sensitivity of hypothalamic osmoreceptors. It also might directly affect tubular cell function, thereby leading to SIADH. It might be expected that a combination of effects on the osmoreceptors and a lack of compensation of the salt-water unbalance by the nephrons causes SIADH in some patients using valproic acid. It could be a dose- or concentration-related adverse effect. In this report, severe symptomatic hyponatraemia and SIADH have been associated with the use of valproic acid. With this study, not only is the number of published cases doubled, but also the data from Vigibase strongly support the association. Since hyponatraemia and SIADH have a high morbidity, health professionals should be aware of this potential ADR.
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