[Factors predictive of long-term mortality in patients aged 75 years or older hospitalized from the emergency department: the SAFES cohort]

The Association of Body Mass Index on Falls Risk and Mortality in Hospitalized Patients of Different Old-Age Categories Requiring Nutritional Support

Malnutrition affect clinical outcomes in hospitalized old age patients, but the data on the related outcomes on the basis of different age categories are still limited. We aimed to investigate the interplay of associations among body mass index (BMI), falls risk, and mortality rate in different older adult patient age categories. This retrospective study included hospitalized patients aged ≥ 65 years who received artificial nutrition. Demographic, biochemical, and survival data were collected. BMI was evaluated using the World Health Organization BMI cutoffs for Asians, and patients were classified into high (≥ 23.0 kg/m2), normal (18.5-22.9 kg/m2), and low (< 18.5 kg/m2) BMI groups. The Morse Fall Scale was used to assess falls risk. By age categories, all patients (n = 4,642) were divided into the 65-74 (n = 2,649) and ≥ 75 (n = 1,993) years age groups. We found that the proportion of low-BMI and high risk of falls increased with age. Further, low-BMI was associated with increased falls risk in both age groups. Overall survival rate tended to be lower in the low-BMI and ≥ 75 years group than that in other patient groups, but did not differ significantly compared with the low-BMI and 65-74 years group. Low-BMI was associated with increased falls risk and mortality; however, the association depended on specific patient age groups.

Evaluation of Nutritional Status in an Acute Geriatric Unit: Retrospective Study and Analysis of Frailty Syndrome

INTRODUCTION

The aim of our study is to evaluate the nutritional status of patients in an acute geriatric unit.

METHODS

Patients included in the study were hospitalized in an acute geriatric unit over a period of 6 months. The nutritional status of each patient was evaluated with anthropometric measurements (the BMI and MNA scales), and biological measurements (albumin). Frailty was evaluated using three scales: the Fried scale, the CFS and the modified SEGA scale.

RESULTS

A total of 359 patients were included, comprising 251 women (70%) with an average age of 85.28 years. The study showed that 102 elderly subjects were considered undernourished according to the BMI scale, 52 subjects were undernourished according to the MNA scale, and 50 subjects were undernourished according to their albumin levels. The relationships between undernutrition and frailty syndrome studied in our work show that elderly subjects who are undernourished according to the BMI and MNA scales are significantly frail according to Fried and Rockwood, whereas those who are undernourished according to their albumin levels are significantly frail according to Fried and the modified SEGA scale.

CONCLUSION

The relationship between undernutrition and the frailty syndrome is close, and their joint screening is necessary, whether on an outpatient or in-hospital basis, in order to prevent negative events related to comorbidities and geriatric syndromes.

Facteurs prédictifs du risque de réhospitalisation et de perte d’autonomie chez des personnes âgées admises aux urgences : une étude pilote

Introduction&#160;: the number of elderly patients admitted to emergency departments (EDs) continues to rise each year. However, due to time and structural constraints, these facilities do not allow for optimal identification of patients at risk of rehospitalization and loss of independence.Objective&#160;: to identify the characteristics of patients over the age of 75 discharged from the ED without indications for hospitalization, and to illustrate the importance of advanced practice nurses (APN) in identifying predictive factors of loss of independence.Method&#160;: a prospective, single-center, observational pilot study of a cohort of 67 patients in an emergency department.Results&#160;: the study allowed the researchers to characterize a female, aging, and vulnerable patient population. Re-evaluation at the six-month mark revealed a functional decline in 23% of patients. Relevant predictive autonomy loss factors including recent cognitive decline, hearing impairment, and weight loss are put forward for future research.Discussion&#160;: these results, in line with the findings of previous studies, highlight the potential added value of APNs in indentifying the functional decline within this patient population.Conclusion&#160;: given the diverse, complex, and fragile health condition of elderly patients when discharged from the emergency department, APNs play a key role in improving care and preventing loss of independence within this patient population.

Low performance of prognostic tools for predicting death before dialysis in older patients with advanced CKD

INTRODUCTION

Chronic kidney disease (CKD) is a disease which is spreading worldwide, especially among older patients. Several prognostic scores have been developed to predict death in older CKD patients, but they have not been validated. We aimed to evaluate the existing risk scores for predicting death before dialysis start, identified via an in-depth review, in a cohort of elderly patients with advanced CKD.

METHODS

We performed a review to identify scores predicting death, developed in and applicable to CKD patients. Each score was evaluated with an absolute risk calculation from the patients' baseline characteristics. We used a French prospective multicentre cohort of elderly patients (> 75 years) with advanced CKD [estimated glomerular filtration rate (eGFR) < 20 mL/min/1.73 m²], recruited from nephrological centres, with a 5-year follow-up. The outcome considered was death before initiating dialysis. Discrimination [area under curve (AUC)], calibration and Brier score were calculated for each score at its time frame.

RESULTS

Our review found 6 equations predicting death before dialysis in CKD patients. Four of these (GOLDFARB, BANSAL, GRAMS 2 and 4 years) were evaluated. The validation cohort (Parcours de Soins des Personnes Âgées Parcours de Soins des Personnes Âgées, PSPA) included 573 patients, with a median age of 82 years and a median eGFR of 13 mL/min/1.73 m². At the end of follow-up, 287 (50%) patients had started dialysis and 238 (41%) patients had died before dialysis. The four equations evaluated showed average discrimination (AUC 0.61-0.70) and, concerning calibration, a global overestimation of the risk of death.

DISCUSSION

The available scores predicting death before dialysis showed low performance among older patients with advanced CKD in a French multicentre cohort, indicating the need to upgrade them or develop new scores for this population.

Concordance in mSEGA Tool to Frailty Diagnosis between Medical Doctors and Nurses

Introduction: It is currently considered that screening for frailty in elderly subjects is a major public health issue. Methods: a cross-sectional pilot study involving elderly subjects (over 75 years of age) admitted at the emergency department of the hospital of Troyes, France in the period from 24 August to 30 August 2017 was conducted. The patients were screened for frailty using the modified SEGA (Short Emergency Geriatric Assessment) (part A) grid (mSEGA), correlated with the subjective opinion of the triage nurse and the senior physician. Results: 100 patients were included during the pilot study period, the mean age was 84.34 years (range: 75–97), 56 patients (56%) were female, and the average CHARLSON score was 4.28 (range: 0–11). The patients’ previous medical histories were remarkable for cardiovascular diseases. The main reason for hospital admission was fall (26 subjects, 26%). Hospitalization was required for 52 subjects (52%). The average mSEGA score was 6.3 +/− 3.59. The completion time for the SEGAm (part A) score was about 5 minutes. According to Cohen’s kappa, the concordance between the subjective opinion of the triage nurse and the mSEGA grid was average, while the concordance between the subjective opinions of the senior physicians was good. Conclusion: The mSEGA score appears to be well-suited and useful in the emergency department. It is easy to use, allows an overall evaluation of the patient, and is not time-consuming.

Is Chikungunya Virus Infection an Independent Risk Factor for 2-Year Mortality in Older Afro-Caribbean Subjects?

Purpose

The aim of this study was to investigate whether Chikungunya virus infection (CVI) was an independent risk factor for 2-year mortality in Afro-Caribbean subjects aged 65 years or older.

Patients and methods

A retrospective cohort study was performed from January 2014 to December 2016 in the University Hospital of Martinique. Subjects aged ≥65 years admitted to the hospital were included. Baseline characteristics and concurrent manifestations at admission were collected. Subjects were followed up by phone for 2 years.

Results

A total of 687 old Afro-Caribbean subjects (80.4±8.0 years) were included: 467 positive for CVI (Chik+) and 220 negative for CVI (Chik-). During the follow-up, 180 (26.2%) died. The proportion of deaths was higher among Chik- (40.9%) than among Chik+ subjects (21.6%) (p<0.0001). By multivariable analysis, when adjusted for age polyarthralgia, neurological troubles, cardiovascular disorders, absence of neutrophilia, thrombocytopenia, hypernatremia, and hospital stay, Chik+ subjects had significantly higher survival rates (HR: 0.58; 95% CI: 0.40-0.85) than Chik- ones.

Conclusion

Within the two years following hospital admission of subjects aged ≥65 years or older, Chik+ subjects had significantly higher survival rates than Chik- ones.

Long-term survival and clinical forms in the acute phase of Chikungunya virus infection in older Caribbeans

OBJECTIVE

To investigate whether the long-term survival in elderly patients with prior Chikungunya virus infection (CVI) is associated with the clinical form presented in the acute phase, as defined by the WHO classification.

METHODS

Retrospective cohort study performed in Martinique University Hospitals. Patients who attended the emergency department for suspected CVI, and who had a positive biological diagnosis of CVI by reverse transcription-polymerase chain reaction on a plasma sample between 10 January and 31 December 2014 were eligible for inclusion. Time-to-death was the primary outcome. The independent relationship between clinical forms and time-to-death was analysed using a Cox model.

RESULTS

In total, 268 patients were included. Mean age was 80 ± 8 years, 53% were women. Median length of follow-up was 28 months (range: 0-39). During follow-up, 53 (19.8%) patients died. Median survival time was 13.2 months (range: 0-33.6). At the end of follow-up, death rates were 4.6% for acute clinical cases, 19.0% for atypical cases, 19.2% for severe acute cases and 23.5% for unclassifiable cases. By multivariable analysis, the clinical form of CVI at admission was found to be independently associated with long-term survival (atypical form: HR = 2.38; 95% CI = 2.15-2.62; severe acute form: HR = 2.40; 95% CI = 2.17-2.64; unclassifiable form: HR = 2.28; 95% CI = 2.06-2.51).

CONCLUSION

The clinical form at presentation with CVI has a significant impact on long-term survival. Management of CVI patients should be tailored according to their clinical form at admission.

Treatment goals for distal radius fractures in 2018: recommendations and practical advice

The goals of distal radius fracture treatment in patients above 65 years of age would not change over time if the fracture were the only factor to consider. However, people change, and fixation methods also change. Since this fracture heals in nearly every case and volar plates have eliminated the worry of malunion, we are left with two main goals. In active patients with weakened bones, the aim is to help them regain their quality of life as quickly as possible while avoiding iatrogenic conditions. This compromise is possible because of new tools-but at what price?

[Treatment of extra-articular distal radius fractures in active elderly patients]

Extra-articular distal radius fractures in active elderly patients are common and predominantly affect females. The high number of patients lost to follow-up compromises the evaluation of outcomes. Treatment aims to control the comminution and allow fast recovery of pre-injury activity levels. Fixation with volar locking plates is the gold standard. The role of bone substitutes in this type of injury is unclear.

Predictors of Long-Term Mortality in Oldest Old Patients (90+) Hospitalized to Medical Wards via the Emergency Department: The SAFES Cohort

OBJECTIVES

To identify risk factors for long-term mortality in patients aged 90 years and over who are admitted to hospital through the emergency department.

DESIGN

Prospective cohort study (SAFES cohort; Sujet Agé Fragile - Évaluation Suivi).

SETTING

8 university teaching hospitals and one regional, non-academic hospital in France.

PARTICIPANTS

Among 1306 patients in the SAFES cohort, 291 patients aged 90 or over were included.

MEASUREMENTS

At inclusion, we recorded socio-demographic data (age, sex, level of education, living alone or in an institution, number of children, presence of helper/caregiver), and data from geriatric evaluation (dependence status, risk of depression, dementia, delirium, nutritional status, walking disorders, risk of falls, comorbidities, risk of pressure sores). Vital status at 36 months was obtained from the treating physician, the general practitioner, administrative registers, or during follow-up consultations.

RESULTS

Among 291 patients included, 190 (65.3%) had died at 36 months. Risk factors for mortality at 36 months identified by multivariate analysis were risk of malnutrition (HR 1.6, 95%CI 1.1-2.3, p=0.004) and delirium (HR 1.6, 95%CI 1.1-2.3, p=0.01).

CONCLUSION

Risk of malnutrition and presence of delirium are risk factors for mortality at 36 months in subjects aged 90 years and over hospitalized through the emergency department.

Relationship between anticholinergic drug use and one-year outcome among elderly people hospitalised in medical wards via emergency department: the SAFES cohort study

AIM

To investigate the relationship between anticholinergic drug use and one-year outcome of elderly patients hospitalised via the emergency department.

METHODS

Prospective, multicentre, cohort study of patients aged 75 years and older. Comprehensive geriatric evaluation was performed. We included in this analysis all patients for whom data on drug use was available. Anticholinergic drugs were coded using the online database "Thesorimed". One-year mortality and nursing home admission were analysed using a Cox model, with matching on the propensity to use anticholinergic drugs.

RESULTS

In total, 1176 subjects were included in this analysis, average age 85±6 years, 65% women. Overall, 144 (12%) were taking at least one anticholinergic drug. Mortality and nursing home admission at one year were respectively 29% and 30% in the anticholinergic group, and 34% and 33% respectively in subjects not taking anticholinergic drugs. No significant relationship was observed between anticholinergic drug use and the main endpoints.

CONCLUSION

Although we did not observed any statistically significant relationship between use of anticholinergic drugs and one-year outcome in elderly patients, the long-term use of anticholinergic drugs can have deleterious effects on memory and functional capacity, and therefore requires prescriptions to be reviewed regularly.

Rapid cognitive decline, one-year institutional admission and one-year mortality: analysis of the ability to predict and inter-tool agreement of four validated clinical frailty indexes in the SAFEs cohort

OBJECTIVES

To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD - defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes.

DESIGN

One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study.

SETTING

Nine university hospitals in France.

PARTICIPANTS

1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department.

MEASUREMENTS

Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: G1 - not frail; G2 - moderately frail; and G3 - severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient.

RESULTS

All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died. With the Rockwood index, all subjects who experienced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used. No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from -0.02 to 0.15.

CONCLUSION

These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology.

Efficiency and applicability of comprehensive geriatric assessment in the emergency department: a systematic review

BACKGROUND AND AIMS

Comprehensive geriatric assessment (CGA) may benefit frail or chronically ill patients in the emergency department (ED), but take too much time to be performed routinely in ED. An alternative approach is to use first a screening tool to detect high-risk patients and then perform CGA in these patients only. This systematic review focuses on the use and value of CGA in ED for evaluation of older patients and its influence on adverse outcomes. This approach is compared with an alternative one using existing screening tools, validated in ED, to detect high-risk patients needing subsequent CGA. This review ends by suggesting a short assessment of CGA to be used in ED and ways to improve home discharge management from ED.

METHODS

A systematic English Medline literature search was conducted in December 2009, with no date limit with the following Medical Subject Heading (MeSH) terms: "Frail Elderly", "Health Services for Aged", "Community Health Nursing", "Emergency Service, Hospital", "Geriatric Assessment", "Patient Discharge", "Risk Assessment" and "Triage".

RESULTS

We selected 8 studies on CGA efficiency and 14 on screening tools. CGA in ED is efficient for decreasing functional decline, ED readmission and possibly nursing home admission in high-risk patients. As CGA takes too much time to be performed routinely in ED, validated screening tools can be applied to detect high-risk patients who will benefit most from CGA.

CONCLUSIONS

The selected studies demonstrated that screening of high-risk patients is more efficient than age-based screening, and that CGA performed in ED, followed by appropriate interventions, improves outcomes.