Prevalence, Clinical Correlates, and Use of Glucose-Lowering Drugs among Older Patients with Type 2 Diabetes Living in Long-Term Care Facilities.

Prevalence, clinical correlates, and use of glucose-lowering drugs were comprehensively evaluated among 863 nursing home older patients with diabetes (mean age 82.9 ± 2.1 years): functional dependence and cognitive impairment were present in 84.1% and 68% of patients, respectively, and 66.3% of patients had 2-4 comorbidities. HbA1c values < 7.0% were documented in 54.9% of diabetic; significantly lower HbA1c levels were observed in demented patients than in nondemented subjects. Documented hypoglycemic episodes were reported for 57 patients (6.6%), without significant association with age, functional dependence, cognitive impairment, or HbA1c levels. About one-fifth of older long-term facilities residents have diabetes, with concomitant poor health conditions and high prevalence of cognitive impairment and functional dependence. Roughly three-fourths of these older and frail diabetic patients have HbA1c values lower than optimal, suggesting a potential for hypoglycemic harm especially among patients with severe cognitive impairment.

Predictive effects of muscle strength after hospitalization in old patients.

BACKGROUND AND AIMS: Frailty is a common situation that often influences clinical outcomes, disability or institutionalization. The present study aims to evaluate the weight of hand grip strength (HGS) reduction in terms of death or re-hospitalizations, at 3-month and 1-year follow-up. METHODS: Observational study performed on hospitalized patients aged 65 years or more. The HGS was measured twice: at hospital admission and discharge. The statistical analysis was performed using SPSS, version 18 for Windows. The χ (2) test was used to evaluate the relationship between HGS and different variables. Three-month and 1-year survival and hospital re-admissions have been analyzed using Kaplan-Meier's curves. The analyses have been adjusted for age and gender. RESULTS: A total of 201 hospitalized patients have been recruited. Of them, 76 were males. The mean age was 81.79 ± 7.409 years. Of all the patients enrolled, 66.2 and 45.3 % did not show any impairment performing activities of daily living and instrumental activities of daily living, respectively. Moreover, patients were not cognitively impaired [SPMSQ (short portable mental status questionnaire ) m ± SD = 1.47 ± 0.794]. At 3-month follow-up patients with strength reduction had a relative risk of death more than seven times higher than the others (p = 0.047). Same results were observed at 1-year follow-up (95 % CI = 1.85-9.84; p = 0.000). There was no significant relationship between HGS and hospital re-admissions. CONCLUSIONS: Effects of strength reduction occurring during a period of hospitalization could produce effects even after hospitalization itself. This increases the relevance of maintaining usual physical performance of patients even during hospitalization.

Insomnia among hospitalized elderly patients: prevalence, clinical characteristics and risk factors.

Insomnia can determine an increase in falls and accidents, hospitalization and nursing home placement. The aims of our study are to evaluate prevalence, clinical characteristics and predictors of sleep disorders in elderly inpatients admitted to a Geriatric Acute Care Ward. This longitudinal observational study consecutively recruited patients aged 65 and older admitted to a Geriatric Acute Care Unit between January the 1st 2007 and June 31st 2007. During the 3rd day of length of stay (LOS), patients were asked if they suffered with sleep disorders. Patients reporting sleep disturbances during the first 3 days of LOS were included in the study. Patients were evaluated for insomnia, comorbidity, self-rated health, functional status, cognitive impairment and pain. Of the 280 subjects investigated, 80 referred sleep disorders during LOS with a prevalence of 36.7%. Patients with sleep problems scored significantly worse on the cumulative index rating scale (CIRS) severity index (p=0.007), on the numeric rating scale (NRS) (p=0.01) and on the activities of daily living (ADL) scale (p<0.001). The CIRS severity index resulted the best predictor for insomnia related to hospitalization (OR 7.9, SE 0.85, p=0.01). The knowledge of insomnia predictors might help in planning preventive strategies to improve patients' global health status and quality of life.

Functional decline two weeks before hospitalization in an elderly population.

INTRODUCTION: The use of hospital care increases significantly with age. Older people coming to the emergency department have three to seven times higher rates of hospitalization than younger people. Hospitalization can lead to loss of independence and also need for long-term care at discharge. METHODS: A prospective observational non-randomized study of elderly patients admitted to the Department of Geriatric Medicine, University of Torino, Italy, between October 2006 and May 2007. RESULTS: The mean age of 123 subjects was 82.2±7.3 years. Among patients with dependence two weeks before admission, as reported by their caregivers, bathing, toileting and dressing were the most compromised ADL functions. In the same patients, shopping and transportation were reported as the most frequent IADL functions lost. Functional decline before hospitalization was significantly associated with a worsening in functional decline during the length of stay (RR 2.2, CI 1.05-4.66) and with discharge to a long-term facility (RR 2.1, CI 1.04-4.44). CONCLUSIONS: As functional decline two weeks before hospitalization influences hospital discharge and functional outcomes, it is certainly interesting to evaluate the impact of a dedicated early rehabilitation program for elderly patients. A well-structured program involving geriatricians, physiatricians and physiotherapists could be helpful for better short-term prognoses.

Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial.

BACKGROUND: Although the hospital is the standard venue for short-term medical care, it may be hazardous for older persons. This study was performed to evaluate the feasibility and effectiveness of a physician-led hospital-at-home service for selected elderly patients with acute decompensation of chronic heart failure (CHF). METHODS: Prospective, single-blind, randomized controlled trial with 6-month follow-up for patients 75 years or older admitted to the hospital from April 1, 2004, through April 31, 2005, for acute decompensation of CHF. Patients were randomly assigned to the general medical ward (n = 53) or to the Geriatric Home Hospitalization Service (GHHS; n = 48). The GHHS provides diagnostic and therapeutic treatments by hospital health care professionals in the home of the patient. RESULTS: Patient mortality at 6 months was 15% in the total sample, without significant differences between the 2 settings of care. The number of subsequent hospital admissions was not statistically different in the 2 groups, but the mean (SD) time to first additional admission was longer for the GHHS patients (84.3 [22.2] days vs 69.8 [36.2] days, P = .02). Only the GHHS patients experienced improvements in depression, nutritional status, and quality-of-life scores. CONCLUSIONS: Substitutive hospital-at-home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF. This type of care demonstrated clinical feasibility and efficacy in comparison with its alternative. Trial Registration clinicaltrials.gov Identifier: NCT00623571.

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.

Implications of routinely measuring Ankle-Brachial Index (ABI) among patients attending at a Lipid Clinic.

BACKGROUND: Low (< or = 90) Ankle Brachial Index (ABI) values identify patients at high risk for cardiovascular (CV) disease and mortality. Implications for CV risk classification from routinely measuring ABI in the context of a Lipid Clinic have not been fully investigated. We aimed to evaluate whether and to what extent routine ABI determination on top of conventional risk prediction models may modify CV risk classification. METHODS: Consecutive asymptomatic non-diabetic individuals free from previous CV events attending for a first visit at a Lipid Clinic underwent routine ABI determination and conventional CV risk classification according either to national CUORE model (including age, gender, smoking, total and high density lipoprotein cholesterol, systolic blood pressure and current use of blood pressure lowering drugs) and SCORE model for low risk countries. RESULTS: In the overall sample (320 subjects, mean age 64.8 years) 77 subjects (24.1%) were found to have low ABI value. Forty-two of 250 subjects (16.8%) and 47 of 215 individuals (21.3%) at low or moderate risk according to the CUORE and SCORE models, respectively, were found to have low ABI values, and should be reclassified at high risk. CONCLUSION: In a series of consecutive asymptomatic individuals in a Lipid Clinic, we observed a high prevalence of low ABI values among subjects deemed at low or moderate risk on conventional prediction models, leading to CV high-risk reclassification of roughly one fifth of patients. These findings reinforce recommendations for routine determination of ABI at least within referral primary prevention settings.

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 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.

Risk factors of functional decline during hospitalization in the oldest old.

BACKGROUND AND AIMS: The number of hospital admissions of the elderly is increasing and hospitalization often leads to functional decline. The aim of this study was to identify major risk factors for functional decline in the hospitalized oldest old. METHODS: Prospective, observational, non-randomized study of patients aged >/=80 years, admitted for at least two days to the University Department of Geriatric Medicine of Torino, Italy, between November 2003 and November 2004. For detection of functional decline, the ADL scale was used, referring to the number of dependent ADL. RESULTS: At discharge, ADL mean scores were significantly higher than on admission (2.5+/-2 vs 2.3+/-1.9, p<0.001). 23.9% of the sample lost at least one ADL function during hospitalization, and 19.2% were transferred to long-term care, compared with 5.4% of those with no functional decline. Length of hospitalization, neoplasm, low level of albumin and high number of drugs prescribed were associated with functional decline. At multivariate analysis, only in-hospital stay was an independent risk factor for functional decline (RR 1.1 per day of hospitalization, CI 1.03-1.14). CONCLUSIONS: Hospitalization of the oldest old increases the risk of functional decline, especially if prolonged. It is important to identify patients at high risk for functional decline after hospital admission.

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.

[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.

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.

[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.