Use of inpatient hospital services by people aged 90-99 years

The treatment of nursing home-acquired pneumonia using a medically intensive Hospital in the Home service

OBJECTIVES

To compare the outcomes for patients with nursing home-acquired pneumonia (NHAP) treated completely in a Hospital in the Home (HITH) setting with those of patients treated in a traditional hospital ward.

DESIGN

Case-control study.

SETTING AND PARTICIPANTS

All patients admitted by the Royal Melbourne Hospital for treatment of NHAP from 1 July 2013 to 31 January 2014.

INTERVENTION

Admission to the Royal Melbourne Hospital HITH Unit within 48 hours of presentation.

MAIN OUTCOME MEASURES

Length of stay, in-hospital and 30-day mortality, hospital readmissions (30-day), complications and unplanned returns to hospital.

RESULTS

Sixty HITH patients and 54 hospital (control) patients were identified. Thirty-two patients (53%) were admitted directly to HITH without any hospital or emergency stay, 25 (42%) were referred directly from the emergency department. HITH patients were more likely to be male, older and dehydrated, and less likely to have an advanced care directive or to have had non-invasive ventilation. There were no significant differences in CURB-65 or CORB scores between the two patient groups; similar proportions were given intravenous fluids or supplemental oxygen. There were no adjusted differences in median length of stay between HITH and control patients (-1.00 days; 95% CI, -2.72 to 0.72; P = 0.252) or in overall mortality at 30 days (HITH v control patients: adjusted odds ratio [aOR], 1.97; 95% CI, 0.67-5.73). Inpatient mortality was lower for HITH patients (aOR, 0.19; 95% CI, 0.05-0.75) but unadjusted postdischarge 30-day mortality was higher (OR, 13.25; 95% CI 1.67-105.75). There were no differences between the two groups with regard to complications (falls and pressure wounds) and 30-day readmission rates (aOR, 1.59; 95% CI, 0.30-8.53).

CONCLUSIONS

This study suggests that HITH may be an effective and safe alternative to hospital treatment for residents of aged care facilities presenting with NHAP.

Validation of the Cumulative Illness Rating Scale (CIRS) in hospitalized nonagenarians

This is a retrospective analysis of patients aged 90-99 years, admitted over a 6-month period to a district hospital. One hundred three patients were included in the study with an average age of 92 years and a male to female ratio of 1:3. Fifty-five percent of the patients hospitalized came from nursing care facilities. Comparisons were made of patient characteristics from nursing homes and the community. The physical burden of illness was measured by the CIRS, Illness Severity Index (SI), and Co-morbidity Index (CI). The average length of stay was 6.3 days for those from nursing care facilities and 10.2 days from the community as compared with 3.3 days for total hospital in-patients. Excluding deceased patients there was a significant (p < 0.05) correlation between patient's CIRS to length of stay in hospital but was equivocal for SI and CI. There were no association between patient's CIRS, SI, and CI to mode of referral and residence. The mortality rate for this group was 13% as compared with the hospital rate of 10.2%. CIRS, SI, and CI were useful in distinguishing the mortally ill from the morbidly ill; otherwise there were no differences, between patients who hail from nursing care facilities or from the community and whether they were referred by carers, nursing staff, medical practitioners/specialists or themselves. There were significant differences in the CIRS scores between deceased and survivors indicating CIRS is potentially useful tool in predicting outcome. The SI and CI composites performed equally well in predicting outcome.

Nonagenarians on a rehabilitation unit: characteristics, progress, and outcomes

OBJECTIVE

To determine the diagnostic, functional, and demographic characteristics and to review the progress of nonagenarians admitted to a general rehabilitation unit. In addition, to compare their outcomes with a selected group of younger patients.

DESIGN

A 4-yr retrospective chart review of the 40 admitted nonagenarians. Functional status was assessed by means of the FIM instrument.

RESULTS

The most common diagnostic category was hip or femur fracture. Only two of the 40 patients required a transfer back to an acute medical unit. Mean FIM gain was 14.42 points. Nineteen of the 40 patients were discharged directly to their homes. Discharge home was related to younger age, living situation before hospitalization, and whether the patient lived alone or with others prehospitalization. No admission FIM score was related to discharge disposition. Compared with younger hip or femur fracture patients, nonagenarians were more likely to be women, be unmarried, not lived at home before admission, and less likely to be discharged home.

CONCLUSION

The majority of this select group of nonagenarians was able to complete a structured program on a rehabilitation unit. Their demographic and functional characteristics and long-term outcomes merit further study.

Functional status and self-rated health in 2,262 nonagenarians: the Danish 1905 Cohort Survey

OBJECTIVES

To describe the functional capacity and self-rated health of a large cohort of nonagenarians.

DESIGN

A cross-sectional survey of all Danes born in 1905 (92-93 years of age), carried out August to October 1998.

SETTING

Participants' homes.

PARTICIPANTS

Two thousand two hundred and sixty-two nonagenarians, corresponding to a participation rate of 63% (of these, 20% participated by proxy).

MEASUREMENTS

Activities of daily living (ADLs) and self-rated health were assessed by interview. Five items from Katz's ADLs (bathing, dressing, transfer, toileting, and eating) were used to construct a three-level five-item ADL scale (not disabled (no disabilities), moderately disabled (1-2 disabilities), severely disabled (3-5 disabilities)). From responses to a more extensive list of questions on ADLs (26 items), we identified scales of strength and agility by means of factor analysis. Furthermore, a 26-item ADL scale was made. Physical performance tests (chair stand, timed walk, lifting a 2.7 kg box, maximum grip-strength, and flexibility tests) were performed among nonproxy responders.

RESULTS

According to the five-item ADL scale, 50% of the men and 41% of the women were categorized as not disabled, while 19% and 22%, respectively, were categorized as severely disabled. The five-item ADL scale correlated highly with the 26-item ADL scale (r = 0.83). The ADL scales showed moderate-to-good correlation with each other (r = 0.74-0.83), and with the physical performance tests (r = 0.31-0.58). Only 3.7% of the women and 6.3% of the men walked (normal pace) with a speed of at least 1 meter per second, which is the minimum walking speed required to cross signaled intersections in Denmark. A total of 56% considered their health to be excellent or good. Of the participants, 74% were always or almost always satisfied with their lives, even though only 45% reported that they "felt well enough to do what they wanted." The analyses showed that no single ADL item seemed to be of particular importance for how the participants rated their health.

CONCLUSION

The Danish 1905 cohort survey is the largest and the only nationwide survey of a whole birth-cohort of nonagenarians. A total of 2,262 fairly nonselected nonagenarians participated. The level of both self-reported disability and functional limitations measured by physical performance tests among nonagenarians was high. Despite their lower mortality, women were more disabled than men and did not perform as well as men in the physical performance tests. Nevertheless, the majority of the participants considered their health to be good and were satisfied with their lives.

The Danish 1905 cohort: a genetic-epidemiological nationwide survey

OBJECTIVES

The authors studied nonagenarians, a rapidly growing age group whose cognitive and physical abilities have yet to be investigated systematically.

METHODS

All Danes born in 1905 were invited to participate in a home-based 2-hour multidimensional interview, including cognitive and physical performance tests and collection of DNA, carried out by lay interviewers. Population-based registers were used to evaluate representativeness.

RESULTS

There were 2,262 participants. A total of 1,632 (72%) gave a DNA sample. Participants and nonparticipants were highly comparable with regard to marital status, institutionalization, and hospitalization patterns, but men and rural area residents were more likely to participate. Six months after the survey began, 7.2% of the participants and 11.8% of the nonparticipants had died.

DISCUSSION

Despite the known difficulties of conducting surveys among the extremely old, it was possible to conduct a nationwide survey, including collection of DNA, among more than 2,000 fairly nonselected nonagenarians using lay interviewers.

[Impact of aging on hospital caseload]

PURPOSE

The progressive ageing of the population has led to a rise in the number of hospital admissions among people older than 64 years. The present study analyses the impact of this phenomenon comparing the case-mix of patients older and younger than 65 years.

METHODS

An analysis of the case-mix of all patients admitted to two acute hospitals of Barcelona Spain has been performed using the minimum basic data set of hospital discharges during 1997. The patients were grouped according to diagnosis-related groups (DRG). The characteristics of disease severity and complexity (admissions through emergencies department, DRG average weight, Charlson comorbidity index, average length of stay adjusted by case-mix, percentage of patients with an abnormal length of stay, readmissions and mortality rates were compared between the group of patients of 0-64 years and the group of 65 years and over. A further analysis was carried out for three subgroups of the aged patient population: 65-74, 75-84 and > 84 years.

RESULTS

The patients group of 65 years and over presented, in comparison with the younger than 65 qulaction, a higher average weight (1.16 vs 0.96), a higher percentage of admissions through emergency department (49.2% vs 44.4%), more comorbidity (Charlson's Index of 0.98 vs 0.66), a higher average length of stay adjusted DRG (9.4 vs 8.1), a higher percentage of patients with an abnormal length of stay (4.7% vs 3.2%), a higher readmissions percentage (8.6% vs 7.5%) and a higher mortality (6.3% vs 1.6%). All observed differences between the two groups were statistically significant. The analysis of the three subgroups of patients of 65 years and over showed that the variables admissions through the emergency department, length of stay and rate of mortality were significantly related to ageing, while the factor of complexity of comorbidity remained stable for all the subgroup of patients.

CONCLUSIONS

The case-mix of patients older than 65 years presents some characteristics associated with a higher complexity, severity and comorbidity, which imply more hospitalization days in relation to younger patients. Hospitals and the health care system at large should design specific strategies to face the fast and progressive ageing of patients admitted to hospitals, since this means a relevant change of the case-mix and the profile of health care requirements.