[Functional decline during hospitalization in elderly patients. Benefits of admission to the geriatrics service]

[Effectiveness and efficiency of acute geriatric units: A classic topic revisited]

Previous meta-analyses have shown that the hospital admission of older patients in acute geriatric units (AGU) compared to admission to other conventional units, significantly reduced the risk of functional deterioration during hospitalization, increasing the possibility of returning home, with an added reduction in cost of hospitalization. A new meta-analysis on the subject has recently been published in Age and Aging, which adds six new studies to the five clinical trials analyzed in previous meta-analyses. This article analyzes the results of this new meta-analysis, delving into the characteristics of the new studies included and making some considerations on the implications for care in the future development of AGU.

Hospital-associated deconditioning: Not only physical, but also cognitive

INTRODUCTION

Hospital-associated deconditioning (HAD) or post-hospital syndrome is well recognized as reduced functional performance after an acute hospitalization. Recommendations for the management of HAD are still lacking, partly due to a poor understanding of the underlying processes. We aimed to review existing data on risk factors, pathophysiology, measurement tools, and potential interventions.

MATERIALS AND METHODS

We conducted a systematic review from bibliographical databases in English, Spanish and French with keywords such as 'post-hospitalization syndrome' or 'deconditioning'. We selected studies that included people aged 60 years or older. Three researchers independently selected articles and assessed their quality.

RESULTS

From 4421 articles initially retrieved, we included 94 studies. Most were related to risk factors, trajectories and measures, and focused on the physical aspects of deconditioning. Risk factors for HAD included age, nutritional status, mobility, and pre-admission functional status, but also cognitive impairment and depression. Regarding interventions, almost all studies were devoted to physical rehabilitation and environmental modifications. Only one study focused on cognitive stimulation.

DISCUSSION

In the last decade, studies on HAD have mostly focused on the physical domain. However, neurological changes may also play a role in the pathophysiology of HAD. Beyond physical interventions, cognitive rehabilitation and neurological interventions should also be evaluated to improve deconditioning prevention and treatment in the hospital setting.

In-hospital complications in an acute care geriatric unit

Introduction: In-hospital complications frequently occur in hospitalized people over 65 worsening their clinical outcomes. There are, however, few studies on the factors associated with in-hospital complications in elderly patient care. Objective: To evaluate factors associated with in-hospital complications in a geriatric acute care unit in Bogotá, Colombia. Materials and methods: We conducted an analytical, observational, retrospective study in a cohort of 1,657 patients over 65 years of age who received care in the geriatric unit of a high complexity hospital in Bogotá, Colombia. The dependent variable was in-hospital complications and the independent variables, the degree of functional dependence on admission, dementia, nutritional status, social support, comorbidity, and polypharmacy. We used Poisson’s linear regression model to identify associated variables. Results: The bivariate analysis showed that functional dependence (PR=2.092, p≤0.001) and malnutrition (PR=2.850, p≤0.001) were associated with a higher rate of hospital-acquired infection. In the multivariate analysis, functional dependence (PR=1.931, p=0.003) and malnutrition (PR=2.502, p=0.002) remained independent factors for in-hospital complications. Conclusion: In acute care centers, integral assessment at admission to identify functional dependence and malnutrition predicts in-hospital complications.

[Predictive factors of functional decline at hospital discharge in elderly patients hospitalised due to acute illness]

OBJECTIVE

To compare baseline characteristics and those found during hospitalisation as predictors of functional decline at discharge (FDd) in elderly patients hospitalised due to acute illness.

MATERIAL AND METHOD

A review was made of the computerized records of patients admitted to a Geriatric Acute Unit of a tertiary hospital over a 10 year period. A record was made of demographic, clinical, functional and health-care variables. Functional decline at discharge (FDd) was defined by the difference between the previous Barthel Index (pBI) and the discharge Barthel Index (dBI). The percentage of FDd (%FDd=(pBI-dBI/pBI)×100) was calculated. The variables associated with greater %FDd in the bivariate analysis were included in multivariate logistic regression models. The predictive capacity of each model was assessed using the area under the ROC curve.

RESULTS

The factors associated with greater %FDd were advanced age, female gender, to live in a nursing home, cognitive impairment, better baseline functional status and worse functional status at admission, number of diagnoses, and prolonged stay. The area under the ROC curve for the predictive models of %FDd was 0.638 (95% CI: 0.615-0.662) based on the previous situation, 0.756 (95% CI: 0.736-0.776) based on the situation during admission, and 0.952 (95% CI: 0.944-0.959) based on a combination of these factors.

CONCLUSIONS

The overall assessment of patient characteristics, both during admission and baseline, may have greater value in prediction of FDd than analysis of factors separately in elderly patients hospitalised due to acute illness.

[Hospitalisation as a risk for functional decline in older adults]

FUNCTIONAL DECLINE: (FD) is a risk associated with hospital admission in older people, due to its high prevalence (35-70%) and its serious consequences.

AIM

To determine the incidence of FD in the elderly after hospital admission at the Geriatric and Internal Medicine wards of a tertiary teaching hospital (Albacete, Spain).

METHOD

A cohort study has been designed, whose primary focus was FD, defined as the loss of independence to perform the activities of daily living between preadmission status and discharge. Demographic characteristics, comorbidity, length of hospital stay and cognitive status have been analysed. Data collection was performed by interviews with patients and caregivers during hospitalization and after discharge (by phone), as well as by revision of clinical records.

RESULTS

104 patients were evaluated, of which 51.9% were female; the average age was 79.97 years (dt=7.89) IC 95% [78.43, 81.5] and the average length of stay was 10.11 days (dt=7.65) IC 95% [8.62,11.6]. The proportion of patients who showed a normal cognitive status on the first in-hospital day was 41.4% (43 patients). FD was present in 60 (57.7%) patients in the first day of hospitalisation; when discharged, 32.6% of 92 patients who could be evaluated showed FD. 19% of patients who were previously independent in activities of daily living developed a serious dependence after discharge. FD was associated statistically with age and a history of previous falls.

CONCLUSIONS

FD takes place in a high percentage of the elderly patients. Among the previously independent patients, 19% remains in a situation of dependence after discharge.

Herpes zoster-associated mortality in Europe: a systematic review

Background

Reactivation of latent varicella zoster virus, partly due to age-related immunosenescence and immunosuppressive conditions, results in herpes zoster (HZ) and its associated complications. The management of the most important complication, post-herpetic neuralgia (PHN), is challenging, particularly in the elderly, and is generally unsatisfactory. No previous reviews have reported the incidence of HZ-associated mortality.

Methods

We carried out a systematic literature review to identify studies and databases providing data for HZ-associated mortality in adults aged ≥50 years in Europe.

Results

We identified 12 studies: Belgium (1); France (1); Germany (1); the Netherlands (2); Portugal (1); Spain (4) and England/Wales (2) and 4 databases from Europe: France; Germany and England/Wales. The incidence was available from eight studies; it was highest in those aged ≥95 in France (19.48/100,000). In the European (WHO) database, the overall mortality ranged from 0 to >0.07/100,000. The age- and gender-specific HZ mortality rates from the other databases showed that while in younger age groups the HZ mortality rate was higher in males, in older patients the rate was much higher in women. The case fatality rate was 2 and 61/100 000 in those 45–65 and ≥65 years, respectively. A similar increase with age was seen for the hospital fatality rate; 0.6% in those 45–65 years in the UK and 7.1% in those ≥80 in Spain.

Conclusions

Although the data were sparse and heterogeneous, HZ-associated mortality clearly increases with age. In addition, the elderly who develop HZ often have underlying diseases and are at increased risk of functional decline and loss of independence. Mortality should be taken into account in health-economics models.

[Review of functional impairment associated with acute illness in the elderly]

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

[Development of a risk-mortality index for elderly patients discharged from a geriatric acute care unit]

OBJECTIVES

To identify predictive factors for 6 and 12-months mortality after discharge from a geriatric acute care unit, and from these, derive a mortality-risk index.

METHODS AND ANALYSIS

Prospective cohort study will be conducted on patients over 70 years-old admitted to a geriatric acute care unit and survived to hospital discharge. The main outcome measure will be mortality at 6 months and 12 months after discharge. Independent variables include sociodemographics, functional status, comorbidities, and clinical and laboratory characteristics. Risk factors associated with mortality will be constructed using multivariate logistic regression models. To build the mortality index, points will be assigned to each risk factor by dividing each beta coefficient in the logistic model by the lowest beta coefficient. A score will be assigned to each subject by adding up the points for each risk factor present in the model. The predictive accuracy of the model will be determined by comparing the predicted versus observed mortality in the study population and calculating the area under the ROC curves in both populations.

CONCLUSIONS

The risk-mortality index developed would allow an easy estimate to be made of individual risk of death at 6 months and 12 months after discharge from a geriatric acute care unit, with the purpose of establishing care plans and individualising treatment, according to real objectives.

[Efficiency of acute geriatric units in Spain hospitals]

OBJECTIVES

To review published data from Spanish hospitals in which comparisons had been made between the mean length of stay in patients admitted to acute geriatric units (AGU) and those admitted to other departments using the diagnosis-related groups (DRG) classification system and to describe our own experience.

MATERIAL AND METHODS

The Spanish reports collected in a previous systematic review were reviewed. The case mix of our hospital was added by analyzing episodes in patients older than 74 years old discharged during a 24-month period and included in the most frequent DRGs. The length of stay in patients admitted to the AGU was compared with that in the remaining medical departments in the hospital and with the standard average stay in the corresponding autonomous region.

RESULTS

Data were obtained from five Spanish general hospitals. The comparison revealed that the mean length of stay in the AGU was 8-19% shorter than that of similar patients in the other medical departments of the same hospitals. In one hospital, the reduction in the mean length of stay was 21% in patients older than 80 years. In three of the four hospitals where comparisons with the standard were performed, the mean length of stay in the AGU was lower for most of the DRGs, showing reductions of 7-9%.

CONCLUSIONS

These results allow us to conclude that, based on the commonly used patient classification and coding system, Spanish AGUs are more efficient than the remaining medical services in the acute hospitalization of elderly patients in our setting.