Delirium in elderly home-treated patients: a prospective study with 6-month follow-up.

Delirium usually occurs during hospitalisation. The aims of this study were to evaluate the incidence of delirium in "hospital-at-home" compared to a traditional hospital ward and to assess mortality, hospital readmissions and institutionalisation rates at 6-month follow-up in elderly patients with intermediate/high risk for delirium at baseline according to the criteria of Inouye. We performed a prospective, non-randomised, observational study with 6-month follow-up on 144 subjects aged 75 years and older consecutively admitted to the hospital for an acute illness and followed in a geriatric hospital ward (GHW) or in a geriatric home hospitalisation service (GHHS). Baseline socio-demographic information, clinical data, functional, cognitive, nutritional status, mood, quality of life, and caregiver's stress scores were collected. Of the 144 participants, 14 (9.7%) had delirium during their initial hospitalisation: 4 were treated by GHHS and 10 in a GHW. The incidence of delirium was 16.6% in GHW and 4.7% in GHHS. All delirious patients were very old, with a high risk for delirium at baseline of 60%, according to the criteria of Inouye. In GHW, the onset of delirium occurred significantly earlier and the mean duration of the episode was significantly longer. The severity of delirium tended to be higher in GHW compared to GHHS. At 6-month follow-up, mortality was significantly higher among patients who suffered from an episode of delirium. Moreover, they showed a trend towards a greater institutionalisation rate. GHHS may represent a protective environment for delirium onset in acutely ill elderly patients.

Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.

We aimed to evaluate the efficacy and safety of oxycodone/acetaminophen (O/A) and codeine/acetaminophen (C/A) vs. conventional therapy (CT) without opioids in older women suffering from osteoarthritis (OA)-related pain, sub-optimally responsive to prior conventional treatments. We performed a 6 week, randomized, single blind, controlled study in three nursing homes. We enrolled 154 women with painful OA. They were assigned to treatment with O/A (n=52) and C/A (n=52) vs. CT (n=50). We evaluated at baseline and at week 6: average pain in the last week (mean pain, MeP), pain at rest (RP), pain in movement (MP) (numeric rating scale, NRS); depressive symptoms (Beck Depression Inventory-II, BDI-II); functional status (activities of daily living, ADL) and cognitive status (mini mental state evaluation, MMSE). We considered the adverse events (AEs) in the study period. At week 6, MeP, RP and MP were significantly reduced in all three groups (p<0.001); compared to CT, O/A and C/A were associated with greater reductions in MeP (p<0.001 and p=0.004, respectively), in RP (p=0.028 and p=0.032, respectively) in MP (p<0.001 and p=0.002, respectively) and with significant improvement in BDI-II score (p=0.05 and p=0.04, respectively) and ADL value (p=0.04 and p=0.05, respectively). AE rates did not differ between groups.

Predictors of treatment failures during chemotherapy: A prospective study on 110 older cancer patients.

Several instruments have been proposed to improve treatment decisions in elderly cancer patients, but evidence of their impact in clinical practice is limited. The aim of this study was to analyze the role of clinical and functional factors in predicting serious adverse events, including death, severe toxicity or treatment interruption, during chemotherapy in elderly cancer patients. The survey evaluated elderly with lung or colon or breast cancer treated with chemotherapy, followed by S. Giovanni Battista Hospital. We enrolled 110 consecutive patients older than 70 years of age with lung (n=45), colon (n=50) and breast (n=15) cancer between October 2004 and October 2005. Overall, 73/110 patients (66.4%) experienced adverse events as death (n=14), grades III and IV toxicity (n=40), or treatment interruption for other reasons (n=19). The variables with stronger predictivity were advanced stage, toxicity of treatment, level of comorbidity and Karnofsky performance status (KPS). instrumental activities of daily living (IADL) index and age itself were not independent predictors. In conclusion our results confirm the need of a careful selection of elderly patients suitable for chemotherapy, giving more weight to comorbidity and KPS scores than to age itself. The potential role of other functional evaluations need to be further assessed in randomized controlled trials.

Predictors of falls and hospitalization outcomes in elderly patients admitted to an acute geriatric unit.

We aimed to identify fall incidence, predictors and characteristics and to investigate hospitalization outcomes for elderly inpatients. In 340 men and 280 women consecutively admitted to a Acute Geriatric Ward of a University Hospital the following variables were evaluated: demographics, clinical history, main disease responsible for hospitalization, comorbidity (cumulative illness rating scale: CIRS 1 and 2) gait and balance deficit (Tinetti's scales), cognition/function (short portable mental status questionnaire: SPMSQ); activities of daily living: ADL; instrumental activities of daily living: IADL; delirium (confusion assessment method: CAM), drugs administered during hospitalization. Overall 80 falls occurred in 70 patients. The incidence rate of falls was of 6.0 per 1000 patient-days with 2.0 falls per bed/year. Age (relative risk=RR=1.050; 95% confidence interval=CI=1.013-1.087), delirium (RR=3.577; 95% CI 1.096-11.672), diabetes (RR=5.913; 95% CI 1.693-20.644), balance deficit (RR=0.914; 95% CI 0.861-0.970) and polypharmacy (RR=1.226; 95% CI 1.122-1.340) were independently predictive of falling. Fallers had a prolonged length of stay (LOS) (35.5+/-47.8 days vs. 23.2+/-27.2; p=0.01) and more frequent nursing home placements (12.9% vs.5.6%; p<0.005). The knowledge of falling predictors might help in planning specific preventive strategies to improve the patients' global health status and to reduce the costs of medical care.

Substitutive "hospital at home" versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial.

OBJECTIVES: To evaluate hospital readmission rates and mortality at 6-month follow-up in selected elderly patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: Prospective randomized, controlled, single-blind trial with 6-month follow-up. SETTING: San Giovanni Battista Hospital of Torino. PARTICIPANTS: One hundred four elderly patients admitted to the hospital for acute exacerbation of COPD were randomly assigned to a general medical ward (GMW, n=52) or to a geriatric home hospitalization service (GHHS, n=52). MEASUREMENTS: Measurements of baseline sociodemographic information; clinical data; functional, cognitive, and nutritional status; depression; and quality of life were obtained. RESULTS: There was a lower incidence of hospital readmissions for GHHS patients than for GMW patients at 6-month follow-up (42% vs 87%, P<.001). Cumulative mortality at 6 months was 20.2% in the total sample, without significant differences between the two study groups. Patients managed in the GHHS had a longer mean length of stay than those cared for in the GMW (15.5+/-9.5 vs 11.0+/-7.9 days, P=.010). Only GHHS patients experienced improvements in depression and quality-of-life scores. On a cost per patient per day basis, GHHS costs were lower than costs in GMW ($101.4+/-61.3 vs $151.7+/-96.4, P=.002). CONCLUSION: Physician-led substitutive hospital-at-home care as an alternative to inpatient care for elderly patients with acute exacerbations of COPD is associated with a substantial reduction in the risk of hospital readmission at 6 months, lower healthcare costs, and better quality of life.

Chronic pain in a sample of nursing home residents: prevalence, characteristics, influence on quality of life (QoL).

Chronic pain is common in the elderly, but it is often under-estimated and under-treated. The aim of this study was to evaluate the prevalence and characteristics of chronic pain in nursing home residents and to analyze its influence on patient's QoL and functional status. We studied 105 patients (mean age 82.2+/-9 years), living in two nursing homes in Torino, Italy. The McGill Pain Questionnaire (MGPQ), the Visual Analogical Scale (VAS) and the Face Pain Scale (FPS) were used to test pain. Depression, functional and cognitive status were also evaluated by using specific instruments, such as the Geriatric Depression Scale (GDS), Instrumental Activities of Daily Living (IADL), Activities of Daily Living (ADL) and the Mini-Mental State Examination (MMSE). Pharmacological and non-pharmacological treatments were documented. It was found that chronic pain was present in 82.9% of the sample; it lasted over 24 months and it was persistent in half of them (49.4%). We observed that chronic pain in the elderly has a strong affective component and its intensity influences older patients' mood, nutrition, sleep and QoL. Our study showed that chronic pain was under-treated. We conclude that chronic pain in institutionalized elderly is common and worsens patients' QoL. It is important to assess and manage pain as a relevant problem in particular for the population at increased risk for under-recognition and under-treatment.

Dehydroepiandrosterone sulfate (DHEA-S) and Alzheimer's dementia in older subjects.

OBJECTIVES AND METHODS: We investigated the association of serum dehydroepiandrosterone sulfate (DHEA-S) levels with dementia of Alzheimer's type (DAT) and impairment in selected cognitive domains (memory, language, attention and working memory) in 158 patients (75.5+/-6.7 years, 46 men) with first-diagnosed probable DAT and in 158 age- and sex-matched controls. As secondary goal, we evaluated whether DHEA-S baseline levels were associated with cumulative 6-year mortality. RESULTS: A negative correlation between DHEA-S levels and age was observed (R=-0.25, p<0.001). Age-stratified analysis did not show significant differences of DHEA-S levels between DAT patients and controls. No significant association was found between DHEA-S levels and impairment in selected cognitive domains. Cox regression analysis showed that baseline DHEA-S levels were not associated with cumulative 6-year mortality. CONCLUSIONS: In a sample of newly-diagnosed DAT patients, we did not find significant association between presence of DAT or impairment in cognitive domains and DHEA-S levels; baseline DHEA-S levels are not associated with cumulative mortality in patients and controls.

[Adverse drug reactions as cause of visit to the emergency department: incidence, features and outcomes]. / Le reazioni avverse ai farmaci come causa di ricorso al Pronto Soccorso: incidenza, caratteristiche e risultati.

The aim of the study was to determine incidence, features and outcomes of the adverse drug reactions (ADR) among emergency department (ED) visits of S. Giovanni Battista Hospital in Turin. We evaluated 16.055 patients among ED visits in a period of five months; the mean age was 59.6 +/- 20.2 year (range 17-93 y; 8.054 women and 8.001 men); 426 (2.6%) had ADRs, and 91 (21.4%) were admitted to the hospital. In multivariate analysis only the number of medicines was positive correlated with ADR. The drugs most frequently ADR-related were: anticoagulants (21.8%), antibiotics (17.6%), NSAIDs (9.9%), hypoglycaemic agents (9.6%), ACE-inhibitors (4.7%), antipyretics (4%) and alfa-litics (3.3%); the most common clinic events were: gastrointestinal bleeding (21.1%), rash (19.7%), confusion (23.9%), hypoglycaemia (8.4%), dyspnoea (7.0%), syncope and wheezing (5.6%), gastrointestinal bleeding (2.8%), anaemia (2.8%), haematomas (4.2%), vomiting (4.2%). Factor associated with increased ADR-hospital admission were increasing age (over 65 years old), gastrointestinal diseases, dementia and ADL-dependence. ADR-patients' Emergency Department mortality was higher than noADR-patients' one. The mean duration of hospitalization was higher in ADR-patients. It is necessary to reduce the number of drugs and improve studies and prevention strategies targeted to reduce the impact of ADR, specially in the elderly population.

Early re-hospitalization of elderly people discharged from a geriatric ward.

BACKGROUND AND AIMS: Hospitalized elderly patients generally have a high level of disability and comorbidity. In many cases, at hospital discharge, the achieved health status balance is poor, and consequently the risk of further disability and hospital readmission is great. Identifying factors leading to hospital readmission could be helpful in reducing such events. The aim of the study was to evaluate the incidence and predictive factors of hospital readmission. METHODS: We conducted an observational cohort study of a group of patients discharged from the Geriatric Ward of the San Giovanni Battista Hospital, Torino (Italy). The study sample contained 839 patients aged 80.6 +/- 6.3 years. The average hospital stay was 17.5 +/- 18.9 days (range 1-274 days). RESULTS: Follow-up lasted three months, at the end of which 107 patients (12.8%) had been readmitted, 83 (9.9%) had only one readmission and 24 (2.9%) one or more readmissions. The first readmission took place within 15 days of discharge for 24 patients (2.9%) and within 30 days of discharge for 27 (3.2%). A new hospital admission within 15 days of discharge increased the risk of mortality (RR=3) and also the probability of a second re-hospitalization. 10.1% patients died; 88.2% of the patients who died had at least one readmission, whereas only 4.2% of live patients had a new hospital admission. CONCLUSIONS: Tumors, dementia, comorbidity, high education level, day hospital course and period of convalescence were all significantly and independently related to readmission.

Positive effects of aerobic physical activity in institutionalized older subjects complaining of dyspnea.

Dyspnea is a common complaint in older subjects, but in some patients a disease responsible for this symptom is not found. We aimed to evaluate the effects of a short program of regular aerobic physical activity on dyspnea and ability to walk in a sample of older nursing home residents without evidence of cardiac and pulmonary disease. Limitation from dyspnea in daily activities was reported by 82% of residents; 34% of these individuals did not show any evidence of cardiac or pulmonary disease. In these subjects a 4-week period of daily exercise training compared with no intervention resulted in a significant improvement of dyspnea and endurance to walking. Dyspnea is an extremely common complaint in elderly residents in long-term facilities. About one-third of these subjects do not show evidence of cardiac or pulmonary disease. In these individuals a short period of exercise training has favorable effects on dyspnea and ability to walk.

The ankle-brachial index is not related to mortality in elderly subjects living in nursing homes.

Low ankle-brachial index (ABI) levels are associated with increased risk of all-cause and cardiovascular mortality in middle-aged and older adults. We evaluated the association between low ABI and all-cause and cardiovascular mortality in elderly patients living in nursing homes. In 632 subjects (mean age 82.1 +/-7.4 years, 137 men) living in 3 municipal nursing homes, ABI, prevalent cardiovascular diseases, and conventional risk factors were evaluated at baseline in 1998. After a 3-year follow-up the relation between a low ABI and mortality outcomes was evaluated by using multivariable Cox proportional hazards analysis. A low ABI (<0.90) was observed in 177 participants (28%). After 3 years, 304 subjects (48.1%) died; death occurred in 53.6% of those with low ABI and in 45.9% of those with normal ABI. No significant relation between low ABI and all-cause (hazard ratio [HR] 1.1, 95% confidence interval [CI] 0.7-2.0) or cardiovascular mortality (HR 1.3, 95% CI 0.8-2.1) was observed. Among elderly patients living in nursing homes, there is a high prevalence of low ABI, which is not related to all-cause and cardiovascular mortality.

[Comorbidity in the elderly: a sample of 2373 hospitalized elderly patients]. / La comorbilità nell'anziano: studio in 2373 pazienti ricoverati in una Divisione per acuti.

The aim of this study was to discuss about prevalence and clinical rilevance of comorbidity in the elderly patients. Our sample included 2373 (mean age 77.8 +/- 8.5; 1302 men and 1071 woman) consecutively admitted to the University Department of Geriatric Medicine of Torino. We examined some demographic variables, cognitive and functional status, main pathologies. Severity of illness was assessed using the C.I.R.S. The coexistence of two or more diseases was 83%: cardiovascular and chronic pulmonary diseases were the most frequently recorded (respectively 68% and 27%). The comorbidity and severity indexes of C.I.R.S. were associated respectively with mortality (O.R. 1.78; C.I. 1.36 - 2.33) and length of hospital staying (O.R. 2.35; C.I. 1.19 - 4.65). Comorbidity is an important specific prognostic indicator for reliable risk stratification of older patients.

Cognitive function after carotid endarterectomy: greater risk of decline in symptomatic patients with left internal carotid artery disease.

BACKGROUND: The risk of cognitive decline in patients undergoing carotid endarterectomy (CE) for left internal carotid artery (ICA) (LICA) disease before or after the occurrence of ischemic symptoms has not been fully elucidated. We evaluated whether patients undergoing CE for symptomatic LICA stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right ICA disease. METHODS: In a series of patients aged 65 years and older, consecutively undergoing CE and free from cognitive impairment, cognitive function was evaluated through the age- and education-adjusted Mini Mental State Examination and the Clock Drawing Task at baseline and at the end of the study period (average follow-up: 44.4 +/- 14.3 months). RESULTS: The analysis included 103 patients (mean age 72.6 +/- 7.0 years; 73 men), of whom 50 had LICA disease (29 symptomatic). At the end of the study period, Mini Mental State Examination score was reduced in patients with symptomatic LICA disease (P < .001) but not in other patients, whereas the Clock Drawing Task score was reduced in both patients with LICA and right ICA. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals, either measured by the Mini Mental State Examination score (F = 5.18, P = .002) or by the Clock Drawing Task score (F = 9.42, P = .001). CONCLUSIONS: Patients undergoing CE for symptomatic LICA disease appear to be at increased risk of cognitive decline than other individuals. Further studies are needed to confirm these findings and to evaluate whether LICA endarterectomy before occurrence of cerebrovascular ischemic symptoms may provide additive benefit in the prevention of cognitive decline.

Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial.

OBJECTIVES: To evaluate whether home treatment of elderly patients with acute uncomplicated first ischemic stroke is associated with different mortality rates and clinical outcomes from those of patients treated on a general medical ward (GMW). DESIGN: Randomized, controlled, single-blind trial. SETTING: S. Giovanni Battista Hospital of Turin. PARTICIPANTS: One hundred twenty elderly patients admitted to the emergency department of the hospital with first acute ischemic stroke were randomized to home treatment from a geriatric home hospitalization service (GHHS) or to GMW treatment. MEASUREMENT: Main outcome was cumulative survival at 6 months in the two groups. Residual functional impairment, neurological deficit, depression, morbidity, and admission to rehabilitation and long-term care facilities were considered as secondary outcomes in survivors. RESULTS: One hundred twenty patients (mean age 82; 54 men and 66 women) were enrolled (60 in each study arm). The cumulative proportion of cases surviving at 6 months was 0.65 in the GHHS group and 0.60 in GMW group (log-rank test P=.53). Functional and neurological parameters were significantly improved in both GHHS and GMW patients, without significant differences between the two groups. Depression score was significantly better in home-treated patients (P<.001), who were more likely to remain at home at 6 months than hospital-treated patients and had a lower rate of select medical complications. CONCLUSION: Home-treated elderly patients with ischemic stroke have better depressive scores and lower rates of admission to nursing homes. These results should prompt further studies to evaluate home hospitalization for elderly stroke patients.

[Falls in hospitalized elderly patients: incidence and risk factors]. / Le cadute nell'anziano ospedalizzato: incidenza e fattori di rischio.

Aim of the study was to determine the incidence and risk factors for falls in hospitalized elderly patients. In a prospective observational study we investigated the characteristics of 620 elderly patients. We examined demographic variables, cognitive and functional status, main pathologies and drugs. Balance and gait were evaluated by Tinetti's scale. Seventy patients (11.3%) fell during hospitalization. The incidence rate of first falls was 5.2 per 1000 patient-days. Five independent variables were significantly and independently associated to falls: age, balance impairment, acute cognitive impairment, diabetes, and use of tricyclic antidepressants. Falls are common in hospitalized elderly patients and risk factors identification can be useful for a targeted multiple intervention falls prevention programme.

[Malnutrition and dementia: importance of care during food intake]. / Malnutrizione e demenza: importanza di una corretta assistenza durante il pasto.

Aim of this work is to assess the effects on nutritional status of appropriate care in food intake in demented patients. In a long term care in Turin, we enrolled 96 patients aged 75-103 years free from metabolic, hematologic and neoplastic diseases and not showing signs of acute illness. Seventy seven of these patients were affected by dementia. No statistically significant differences were found between demented patients and controls in nutritional status and daily nutrient intake and only need for care in food intake was independently associated with dementia. Our data demonstrate that similar caloric intakes can be obtained in demented and non demented patients with an appropriate level of care in food intake.

Predictive factors of in-hospital mortality in older patients admitted to a medical intensive care unit.

OBJECTIVES: To identify prognostic factors that are independently predictive of in-hospital mortality in older patients hospitalized in a medical intensive care unit (MICU). DESIGN: Prospective cohort study. SETTING: A MICU in an Italian university hospital. PARTICIPANTS: Patients aged 65 and older consecutively admitted to the MICU directly from the first-aid unit. MEASUREMENTS: Upon admission, the following variables were examined: demographics, clinical history (diabetes mellitus, active neoplasm, cognitive impairment, immobilization, pressure ulcers, use of nutritional support, home oxygen therapy), physiopathology (Acute Physiology and Chronic Health Evaluation (APACHE) II), and cognition/function (activity of daily living (ADL), instrumental activity of daily living (IADL), Short Portable Mental Status Questionnaire (SPMSQ)). The vital status of the patient at the end of hospitalization was recorded. RESULTS: Over a period of 10 months, 659 patients were recruited (mean age +/- standard deviation = 76.6 +/- 7.5; 352 men and 307 women). There were 97 deaths (14.71%). The following factors proved to be significantly associated with in-hospital mortality: old age, low body mass index (BMI) values, low values of albumin, high scores on APACHE II, functional impairment (ADL, IADL), cognitive impairment (SPMSQ), history of cognitive deterioration, history of confinement to bed, and presence of pressure ulcers. Using multivariate analysis, the following variables were independently predictive of in-hospital mortality: lack of independence in ADLs (P <.001), moderate-to-severe cognitive impairment on SPMSQ (P <.001), score on APACHE II (P =.002), and low BMI values (P =.031). CONCLUSION: The prognosis of older patients hospitalized in medical intensive care units depends not only on the acute physiological impairments, but also on a series of preexisting conditions, such as loss of functional independence, severe and moderate cognitive impairment, and low BMI.