We developed prediction models for hospital admission and prolonged length of stay in older adults admitted from the emergency department (ED).
This was a retrospective cohort study of patients aged ...70 years or older who visited a geriatric ED in Brazil (N=5,025 visits). We randomly allocated participants to derivation and validation samples in a 2:1 ratio. We then selected 21 variables based on their clinical relevance and generated models to predict the following outcomes: hospital admission and prolonged length of stay, defined as the upper tertile of hospital stay. We used backward stepwise logistic regressions to select our final predictors and developed risk scoring systems based on the relative values of their β coefficients.
Overall, 57% of the participants were women, 31% were hospitalized, and 1% died in the hospital. The upper tertile of hospital stay was greater than 7 days. Hospital admission was best predicted by a model including male sex, aged 90 years or older, hospitalization in the previous 6 months, weight loss greater than or equal to 5% in the previous year, acute mental alteration, and acute functional decline. The prediction of prolonged length of stay retained the same variables, except male sex, which was substituted for fatigue. The final scoring system reached areas under the receiver operating characteristic curve of 0.74 for hospital admission and 0.79 for prolonged length of stay, and their accuracies were confirmed in the validation models.
The PRO-AGE scoring system predicted hospital admission and prolonged length of stay in older adults with good accuracy, using a simple approach and only 7 easily obtained clinical variables.
Abstract Previous magnetic resonance imaging (MRI) studies described consistent age-related gray matter (GM) reductions in the fronto-parietal neocortex, insula and cerebellum in elderly subjects, ...but not as frequently in limbic/paralimbic structures. However, it is unclear whether such features are already present during earlier stages of adulthood, and if age-related GM changes may follow non-linear patterns at such age range. This voxel-based morphometry study investigated the relationship between GM volumes and age specifically during non-elderly life (18–50 years) in 89 healthy individuals (48 males and 41 females). Voxelwise analyses showed significant ( p < 0.05, corrected) negative correlations in the right prefrontal cortex and left cerebellum, and positive correlations (indicating lack of GM loss) in the medial temporal region, cingulate gyrus, insula and temporal neocortex. Analyses using ROI masks showed that age-related dorsolateral prefrontal volume decrements followed non-linear patterns, and were less prominent in females compared to males at this age range. These findings further support for the notion of a heterogeneous and asynchronous pattern of age-related brain morphometric changes, with region-specific non-linear features.
This study sought to explore and externally validate the Carpenter instrument's efficacy in predicting postdischarge fall risk among older adults admitted to the emergency department (ED) for reasons ...other than falls or related injuries.
A prospective cohort study was conducted on 779 patients aged ≥ 65 years from a tertiary hospital in São Paulo, Brazil, who were monitored for up to 6 months post-ED hospitalization. The Carpenter instrument, which evaluates the four risk factors nonhealing foot sores, self-reported depression, inability to self-clip toenails, and prior falls, was utilized to assess fall risk. Follow-up by telephone occurred at 30, 90, and 180 days to identify falls and mortality. Fine-Gray models estimated the predictive power of Carpenter instrument for future falls, considering death as a competing event and sociodemographic factors, frail status, and clinical measures as confounders.
Among 779 patients, 68 (9%) experienced a fall within 180 days post-ED admission, and 88 (11%) died. The majority were male (54%), with a mean age of 79 years. Upon utilizing the Carpenter score, those with a higher fall risk (≥2 points) displayed more comorbidities, greater frailty, and increased clinical severity at baseline. Regression analyses showed that every additional point on the Carpenter score increased the hazard of falls by 73%. Two primary contributors to its predictive potential were identified: a history of falls in the preceding year and an inability to self-clip toenails. However, the instrument's discriminative accuracy was suboptimal, with an area under the curve of 0.62.
While the Carpenter instrument associated with a higher 6-month postadmission fall risk among older adults post-ED visit, its accuracy for individual patient decision making was limited. Given the significant impact of falls on health outcomes and health care costs, refining risk assessment tools remains essential. Future research should focus on enhancing these assessments and devising targeted proactive strategies.
...investigators did not assess transferences between different levels of acute care and it is plausible that older patients admitted to ICU for unforeseen clinical deterioration may have influenced ...their findings 4. ...we sought to compare the characteristics and outcomes of acutely ill older patients admitted from the emergency department (ED) based on whether their admissions to ICU were planned at the ED or occurred later due to unexpected clinical deteriorations.2 Material and methods We conducted a prospective cohort of patients aged ≥65 years admitted from the ED to a tertiary hospital in Brazil between November 2021 and April 2022 5. Demographic (age) and clinical characteristics (baseline functional and frailty status, delirium rates, and acute clinical severity) of patients experiencing unplanned ICU admissions differed from those directly admitted to the ICU and those not using ICU (Table 1). ...unplanned ICU admissions were associated with prolonged LoS and hospital-acquired infections (Table 1). ...although in-hospital mortality was higher in patients admitted to the ICU directly from the ED, those who had unplanned ICU admission while in the hospital presented higher mortality within the following months after discharge.4 Discussion Our findings indicate that older patients with unplanned ICU admissions generally present with worse baseline physical frailty and disability, and elevated levels of delirium and illness acuity in the ED compared to those not requiring ICU during hospitalization.
Falls are the main cause of morbidity among older adults. In this context, assistive gait devices are used to improve function and safety. However, inadequate selection and use can result in poor ...gait and risk of injury. All patients admitted to our emergency department (ED) undergo a medical evaluation in which, based on their clinical condition, the protocol for indication and training in the use of walking aids can be triggered. Patients need to be clinically stable and have enough physical and cognitive function to benefit from it. Once the patient is deemed able, the next step is an assessment of needs and potential benefits. After the patient and his proxy agree to undergo specific evaluation and training, the physician or the ED nurse calls the physical therapy team to carry out a broader assessment that includes the Timed Up and Go (TUG) test. Following the functional evaluation, the physical therapist identifies the mobility needs of the patient and indicates the most appropriate walking device. The TUG test is performed again with the use of the mobility aid device and the results are compared to confirm the improvement in the patient’s performance regarding balance and mobility. Finally, the physical therapist refers the patient to the rehab center of our hospital for further rehabilitation, if applicable, and provides a written document with the type of the suggested device and possible purchase locations. Hospital Sírio-Libanês is a leading philanthropic tertiary hospital in São Paulo, Brazil. It has 474 beds, 33 specialized centers, and is certified by the Joint Commission International. Its Emergency Department (ED) receives more than 90,000 visits every year, and, since 2017, it has housed a geriatric ED program (Pronto Atendimento Geriátrico Especializado ProAGE). ProAGE is an initiative designed to provide high-quality, specialized care to older adults in the ED. In 2019, ProAGE received the Level III geriatric ED accreditation (GEDA) of the American College of Emergency Physicians (ACEP) and became the first of its kind in the southern hemisphere. In 2022, ProAGE joined the Geriatric Emergency Department Collaborative (GEDC) and to this day remains its only center in South America. This manuscript will discuss the institutional protocol for the indication of mobility aids and training older patients to use them safely which was devised to adhere to international guidelines and comply with GEDA.
Background/Aims: The purpose of our study was to evaluate vascular risk factors and other clinical variables as predictors of cognitive and functional decline in elderly patients with mild to ...moderate dementia. Methods: The clinical characteristics of 82 elderly patients (mean age 79.0 ± 5.9 years; 67.1% females) with mild to moderate dementia were obtained at baseline, including years of education, Framingham Coronary Heart Disease Risk score, Hachinski Ischemic Score (HIS), Clinical Dementia Rating (CDR), Mini-Mental State Examination (MMSE) score, Functional Activities Questionnaire (FAQ) score, Burden Interview Scale score, and Neuropsychiatric Inventory (NPI) score. Changes in MMSE and FAQ scores over time were assessed annually. The association between baseline clinical variables and cognitive and functional decline was investigated during 3 years of follow-up through the use of generalized linear mixed effects models. Results: A trend was found towards steeper cognitive decline in patients with less vascular burden according to the HIS (β = 0.056, p = 0.09), better cognitive performance according to the CDR score (β = 0.313, p = 0.06) and worse caregiver burden according to the Burden Interview Scale score (β = -0.012, p = 0.07) at baseline. Conclusion: Further studies with larger samples are necessary to confirm and expand our findings.
Abstract
Background
Although coronavirus disease 2019 (COVID-19) disproportionally affects older adults, the use of conventional triage tools in acute care settings ignores the key aspects of ...vulnerability.
Objective
This study aimed to determine the usefulness of adding a rapid vulnerability screening to an illness acuity tool to predict mortality in hospitalised COVID-19 patients.
Design
Cohort study.
Setting
Large university hospital dedicated to providing COVID-19 care.
Participants
Participants included are 1,428 consecutive inpatients aged ≥50 years.
Methods
Vulnerability was assessed using the modified version of PRO-AGE score (0–7; higher = worse), a validated and easy-to-administer tool that rates physical impairment, recent hospitalisation, acute mental change, weight loss and fatigue. The baseline covariates included age, sex, Charlson comorbidity score and the National Early Warning Score (NEWS), a well-known illness acuity tool. Our outcome was time-to-death within 60 days of admission.
Results
The patients had a median age of 66 years, and 58% were male. The incidence of 60-day mortality ranged from 22% to 69% across the quartiles of modified PRO-AGE. In adjusted analysis, compared with modified PRO-AGE scores 0–1 (‘lowest quartile’), the hazard ratios (95% confidence interval) for 60-day mortality for modified PRO-AGE scores 2–3, 4 and 5–7 were 1.4 (1.1–1.9), 2.0 (1.5–2.7) and 2.8 (2.1–3.8), respectively. The modified PRO-AGE predicted different mortality risk levels within each stratum of NEWS and improved the discrimination of mortality prediction models.
Conclusions
Adding vulnerability to illness acuity improved accuracy of predicting mortality in hospitalised COVID-19 patients. Combining tools such as PRO-AGE and NEWS may help stratify the risk of mortality from COVID-19.
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