Evaluation of the tolerance of ceftriaxone by subcutaneous route in patients ≥75 years old in geriatric departments: a prospective observational study.

OBJECTIVES: The subcutaneous (SC) route provides an alternative to the IV or oral route for drug administration in the elderly. The benefits of SC administration have been proven for hydration but are still debated for antibiotics because tolerance remains uncertain, especially in the frail geriatric population. Here, we aimed to improve current knowledge concerning the tolerance profile of ceftriaxone SC administration at both the systemic and cutaneous level, as well as in terms of pain. PATIENTS AND METHODS: This was a prospective descriptive study of SC ceftriaxone tolerance in a geriatric department. We included all patients over 75 years of age who received a prescription for SC ceftriaxone in our hospital over a 5 month period. METHODS: We evaluated the systemic and local tolerance of SC ceftriaxone. Nurses were asked about their perceptions concerning its use. RESULTS: Among 117 patients, 57% presented with pain and 60% with a mild local adverse effect, such as the formation of oedema in one-third of patients, induration or transient erythema. Finally, there were no serious local adverse effects and two systemic adverse effects were observed (one diarrhoea and one Clostridioides difficile colitis). Pain was mainly related to the skin breach and oedema formation. CONCLUSIONS: We did not find any worrying signs concerning the use of SC ceftriaxone but this study shows that its wide use must consider pain management, which is often overlooked.

Impact of a Very Short-Stay Post-Emergency Geriatric Unit on Early Readmissions.

BACKGROUND AND OBJECTIVES: In 2017, our French 1671-bed university hospital opened a 12-bed unit for very short stays, post-emergency (unit of transitory admission in geriatric [UTAG] area), dedicated to frail patients older than 75 years requiring short-term care. We sought to investigate whether this new organization's shortened length of stay (LOS) was associated or not with a higher rate of readmission. METHODS: We conducted a retrospective descriptive study based on the daily activity of the UTAG over 6 months including all patients consecutively hospitalized in the unit via the computerized medical file of the hospital. The data collected included the Rockwood score, the primary diagnoses, the LOS and any 1-month readmission. RESULTS: From August 2019 to January 2020, 646 older adult patients were hospitalized in the UTAG. Two-thirds of the hospitalized patients were women; the mean age of this population was 86.7 ± 6.2 years. The main causes of hospitalization were infectious pathologies (19.8%), falls and their consequences (17.3%), and cardiac pathologies (17.2%). The mean LOS was of 2.7 ± 2.0. Seventy readmissions were observed in the month after discharge. One-month readmissions were more frequent when patients had presented with acute heart failure and among nursing home residents. CONCLUSION: The creation of the UTAG reduced LOS and so contributed to decreased iatrogenic disabilities without putting patients at increased risk of readmission. The development of cardiac and geriatric dedicated outpatient pathways and a community-based geriatric mobile team intervening in nursing homes could optimize the care of frail older adult patients and avoid readmissions.

Factors Associated with Transfer from an Acute Geriatric Unit to a Post-Acute Care Facility among Community-Dwelling Patients: Results from the DAMAGE Cohort.

Background: Acute geriatric units (AGUs) require efficient discharge planning tools. Risk factors for discharge from an AGU to post-acute care (PAC) have not previously been investigated in detail. Methods: The objective is to identify risk factors for PAC transfer. The DAMAGE (prospective multicenter cohort) consecutively included more than 3500 subjects aged 75 or older and admitted to an AGU. The patients underwent a comprehensive geriatric assessment (CGA) during their stay in the AGU. Only community-dwelling patients admitted to the AGU from the emergency department were included in the analysis. We recorded the characteristics of the care pathway and identified risk factors for discharge to home or to a PAC facility. Results: 1928 patients were included. Loss of functional independence (a decrease in the Katz activities of daily living (ADL) score between 1 month prior to admission and AGU admission), living alone, social isolation, a high Katz ADL score at home, a low Katz ADL on admission, and delirium on admission were risk factors for transfer to PAC. Obesity, an elevated serum albumin level, and community-acquired infection were associated with discharge to home. Neither sex nor age was a risk factor for home discharge or transfer to PAC. Conclusion: The present results might help clinicians and discharge planning teams to identify patients at risk of transfer to PAC more reliably and promptly in AGUs.

Transition to Comfort Care Only and End-of-Life Trajectories in an Acute Geriatric Unit: A Secondary Analysis of the DAMAGE Cohort.

OBJECTIVES: Comfort care for a dying patient increases the quality of the end of life. End-of-life situations are frequently managed in acute geriatric units (AGUs), and transition to comfort care only is often necessary. However, the frequency of transition to comfort care and the latter's putative link with the end-of-life trajectory (sudden death, cancer, organ failure, and frailty with or without dementia) have not previously been studied in acute geriatric units. We sought to (1) describe end-of-life trajectories and the transition to comfort care only, and (2) analyse the relationship between the two, prior to death in an AGU. DESIGN: A secondary analysis of a subgroup of the DAMAGE cohort (a prospective multicentre cohort of 3509 patients aged 75 years and over and admitted consecutively to an AGU). SETTING/PARTICIPANTS: DAMAGE patients who died in an AGU after a stay of at least 48 hours. METHODS: Data on the end-of-life trajectory and the transition to comfort care only were extracted from medical records. RESULTS: Of the 177 included patients, 123 (69.5%) transitioned to comfort care only in the AGU. A frailty trajectory (in patients living with dementia or not) accounted for nearly 70% of deaths. Paradoxically, only frailty among people living without dementia was not significantly associated with a more frequent transition to comfort care [odds ratio (95% confidence interval): 1.44 (0.44-4.76), relative to a patient dying suddenly]. CONCLUSIONS AND IMPLICATIONS: Transition to comfort care only is frequent in AGUs and is linked to the end-of-life trajectory (except for frail patients living without dementia). The frailty trajectory is one of the most frequent, and, therefore, physicians must be aware of the need to improve practice in this context.

Mortality risk and antibiotic use for COVID-19 in hospitalized patients over 80.

INTRODUCTION: Patients over 80 years of age are more prone to develop severe symptoms and die from COVID-19. Antibiotics were massively prescribed in the first days of the pandemic without evidence of super infection. Antibiotics may increase the risk of mortality in cases of viral pneumonia. With age and antibiotic use, the microbiota becomes altered and less protective effect against lethal viral pneumonia. Thus we assessed whether it is safe to prescribe antibiotics for COVID-19 pneumonia to patients over 80 years of age. METHOD: We conducted a retrospective monocentric study in a 1240-bed university hospital. Our inclusion criteria were patients aged ≥ 80 years, hospitalized in a COVID-19 unit, with either a positive SARS-CoV-2 RT-PCR from a nasopharyngeal swab or a CT scan within 72 h after or prior to hospitalization in the unit suggestive of infection. RESULTS: We included 101 patients who received antibiotics and 48 who did not. The demographics in the two groups were similar. Overall mortality was higher for the group that received antibiotics than for the other group (36.6% vs 14.6%,). According to univariate COX analysis, the risk of mortality was higher (HR = 1.98 [0.926; 4.23]) but non-significantly for the antibiotic group. In multivariate analysis, independent risk factors of mortality were an increased leukocyte count and decreased oxygen saturation (HR = 1.097 [1.022; 1.178] and HR = 0.927 [0.891; 0.964], respectively). CONCLUSION: This study raises questions about the interest of antibiotic therapy, its efficacy, and its effect on COVID-19 and encourages further research.

Potentially Inappropriate Prescribing for Prostatic Hyperplasia in Older Persons.

OBJECTIVES: In the context of improved medication management of older patients, we wished to evaluate the overprescription of potentially inappropriate drugs [α1-blockers and 5α-reductase inhibitors (5-ARI)] for benign prostate hyperplasia (BPH). These drugs are considered by geriatricians to increase the risk of falls and pharmacodynamic interactions, but these properties have not yet been proven. DESIGN: This was a descriptive study of drug prescriptions in a geriatric academic center. SETTING AND PARTICIPANTS: We included all patients older than 75 years who received a prescription for α1-blockers or 5-ARIs for 2 weeks in our hospital. METHODS: We evaluated the prevalence of the potentially inappropriate prescription of α1-blockers and 5-ARI in older people during hospitalization using a new tool consisting of an 8-item list of explicit indicators developed using the most recent summary of product characteristics (SmPC) and latest European Association of Urology (EAU) guidelines. RESULTS: A population of 117 patients (≥75 years) was included in the study. The median age was 84.5 (±6.3) years. The average time since urological medication prescription was 1.2 ± 1.6 years. According to explicit criteria, 84 patients (71.8%) received at least 1 potentially inappropriate urologic medication, 77 (91.7%) related to α1-blockers. Patients with a potentially inappropriate prescription for α1-blockers and/or 5-ARIs more frequently had urological assessments (P = .026), more frequently showed pharmacological interactions, with the risk of orthostatic hypotension (P = .005) or arrhythmia (P = .028), and experienced more falls in their history (P = .043). The misuse group was associated with an increased risk of falls, with an odds ratio of 3.22 (P = .039, 95% confidence interval 1.08-10.2). CONCLUSIONS AND IMPLICATIONS: In our study, potentially inappropriate prescriptions for older individuals for BPH was close to 72% and mainly involved α1-blockers. Potentially inappropriate prescriptions for BPH were associated with a threefold higher frequency of falls.

Development of a Predictive Score for Mortality at 3 and 12 Months After Discharge From an Acute Geriatric Unit as a Trigger for Advanced Care Planning.

BACKGROUND: There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). OBJECTIVE: We developed a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. METHODS: Devenir Après la Médecine Aigue Gériatrique (DAMAGE) is a French multicenter, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical checkup, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. RESULTS: A total of 3 509 patients were assessed and 3 112 were included. The patient population was very old and frail or dependant, with a high proportion of deaths at 3 months (n = 455, 14.8%) and at 12 months (n = 1 014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. CONCLUSIONS: Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients. Clinical Trials Registration Number: NCT02949635.

Humoral anti-SARS-CoV-2 immune response after two doses of Comirnaty vaccine in nursing home residents by previous infection status.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with increased morbidity and mortality in older adults. Although the advent of the first vaccines has significantly reduced these rates, data on older adults in clinical trials are scarce. OBJECTIVES: We quantified and compared the humoral response in individuals with vs. without pre-existing seropositivity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in a cohort of 69 patients living in a nursing home and who had received the recommended two doses of the Comirnaty (Pfizer-BioNTech®) vaccine. RESULTS: All 69 patients (100%) tested positive for antibodies against SARS-CoV-2 at 2 months post-vaccination. Residents with a pre-vaccination infection had significantly higher titers of anti-spike 1 IgG than those with no prior infection (median [interquartile range]: 55,726 [14463-78852] vs. 1314 [272-1249] arbitrary units, respectively; p < 0.001). The same result was observed for neutralizing antibodies titers (704 [320-1280] vs. 47 [20-40] respectively; p < 0.001). Between the pre-vaccination and post-vaccination periods, for IgG and neutralizing antibodies, we observed a 49 and 8-fold increase respectively. In comparison to the wild-type Receptor Binding Domain (RBD), the binding capacity of these vaccine sera was significantly decreased on the B.1.351 and P.1 variants RBD but not decreased with respect to the B.1.1.7 RBD. Although all nursing home residents developed a humoral response following Comirnaty vaccine, its intensity appeared to depend on the pre-vaccination serological status. CONCLUSION: Our results raise the question of how many doses of vaccine should be administered in older and how long the protection will be effective.

COVID-19 serology in nursing homes and long-term care facilities: prevalence of seroconversion in the Amiens-Picardie University Hospital.

INTRODUCTION: Since December 2019, an emerging infectious viral disease triggered by SARS-CoV-2 has caused a global pandemic. Elderly people, being more fragile, are the most affected by the severity and lethality of this disease. The residential care facility for dependent elderly people (Ehpad) and the long-term care facilities at the Amiens University Hospital registered their first COVID-19 cases in February 2020, which lead to the opening of a dedicated COVID-19 unit and aspecific protocol for isolation. METHODS: This descriptive study analysed the prevalence of COVID-19 seroconversion within the Ehpad and the long-term care facilities at the Amiens University Hospital. Both this screening test and the nasopharyngeal swab PCRs were used to assess the impact of the COVID-19 epidemic on the residents of the Ehpad and the long-term care facilities. RESULTS: On 15 and 16 June 2020, the serological tests for COVID-19 were positive for 146 (66.1%) of the residents tested. The seroconversion rate was significantly different (p < 0.001) between the Ehpad (88.7%) and the long-term care facility (45.6%). DISCUSSION: During the epidemic, there was no excess mortality index within the Ehpad and the long-term care facility services of the Amiens University Hospital. Among frail patients, the role of immunosenescence can be evoked to account for the absence of this inflammatory reaction. This study showed that isolating the infected patient in a dedicated unit significantly reduces the risk of seroconversion and contamination compared to isolating them within their own unit.

Risk Factors for Hospital Readmission and Death After Discharge of Older Adults from Acute Geriatric Units: Taking the Rank of Admission into Account.

OBJECTIVE: To analyze the impact of the number of hospital readmissions on the risks of further hospital readmission and death after adjustment for a range of risk factors. METHODS: We performed a multicentre prospective study of the DAMAGE cohort in the Hauts-de-France region of France. Patients aged 75 and over hospitalized initially in an acute geriatric unit (AGU) were included and followed up for 12 months. The risk of hospital readmission was analyzed using a Cox model, and its extension for recurrent events and the risk of death were analyzed using a Cox model for time-dependent variables. RESULTS: A total of 3081 patients were included (mean (SD) age: 86.4 (5.5)). In the multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital readmission rose progressively to 2.66 (1.44; 5.14), and the risk of death rose to 2.01 (1.23; 3.32) after five hospital admissions, relative to a patient with no hospital readmissions. The number of hospital readmissions during the follow-up period was the primary risk factor and the best predictor of the risk of hospital readmission and the risk of death. CONCLUSION: Hospital readmission is the primary risk factor for further hospital readmissions and for death in older subjects discharged from an AGU.

Impact of a training session for prescribers on the relative prescription of cefotaxime over ceftriaxone in elderly patients.

BACKGROUND: The prescription of ceftriaxone should be limited to patients with biliary tract infections and those lacking intravenous access. A specific training session for prescribers about the clinical relevance and economic value of prescribing cefotaxime instead of ceftriaxone might decrease the use of the latter in geriatric medicine. OBJECTIVES: To determine the clinical and economic impact of a training session for prescribers on the subsequent prescription of third-generation cephalosporin, that is, the percentage of appropriate prescriptions and the cost of third-generation cephalosporin administration before and after the training session. METHODS: In a preliminary observational quasi-experimental, open-label study, appropriateness of cefotaxime and ceftriaxone prescription over a 4-week period immediately before the training session were compared with those during a 4-week period immediately afterwards. KEY FINDINGS: For 46 patients (29 before the training session and 17 afterwards), the proportion of cefotaxime prescriptions increased (from 3% to 35%; P = 0.007), and the proportion of appropriate prescriptions increased at the start of treatment (from 45% to 76%; P = 0.064) and at the end (from 76% to 88%; P = 0.450). The daily per-patient cost of treatment was €8 for cefotaxime and from €1.63 to €3.42 for ceftriaxone, depending on the administration route. CONCLUSIONS: A training session for prescribers was associated with a decrease in ceftriaxone prescriptions encouraging further studies to improve the training session and then evaluate medico-economic impact through randomized clinical trials.

Evaluation of a rail-travel simulator for elderly adults with cognitive disorders. The Grand-Via Project, a travel therapy pilot study.

BACKGROUND AND PURPOSE: Travel therapy can reduce anxiety symptoms in elderly adults with cognitive disorders. The objective of this pilot study was to evaluate the use of a rail-travel simulator in this purpose. MATERIALS AND METHODS: The study was a prospective, single centre cohort survey. Our study population consisted of persons either from the nursing home, the cognitive and behavioural unit or the day-care centre of our university hospital. Participants were accompanied on a virtual trip using a film projection in a replica of train compartment. Participants were interviewed before and after each session using a short questionnaire developed by a multi-disciplinary team. RESULTS: Forty-two participants performed sessions. While only 58.3% of the participants reported being relaxed before the session, this rate increased significantly to 87.5% by the end of the trip. A majority of participants gave their personal impressions and half of the group reported memories evoked by the experience. CONCLUSION: The majority of elderly persons who completed the virtual trip replied positively about the experience. We need now to confirm the efficacy of our simulator using a randomised controlled trial.

[Covid-19 serology in nursing home and long-term care: prevalence of seroconversion in the Amiens-Picardie University Hospital]. / Sérologie Covid-19 en Ehpad et soins de longue durée : prévalence de la séroconversion au CHU Amiens-Picardie.

Since December 2019, an emerging infectious viral disease implicating a coronavirus SARS-CoV-2 has caused a global pandemic. Elderly people, being more fragile, are the most affected by the severity and lethality of this disease. The NH and LTCU of the Amiens University Hospital registered their first Covid-19 cases in February 2020, which lead to the opening of a Covid-19 dedicated unit and of specific protocol for confinement. This descriptive study was analyzing the prevalence of Covid-19 seroconversion within the NH and the LTCU of the Amiens University Hospital. Both this screening test and the nasopharyngeal swab PCRs were in order to assess the impact of the Covid-19 epidemic in NH and LTCU. On June 15th and 16th, the serological tests for Covid-19 were positive for 146 (66.1%) of the residents tested. The seroconversion rate was significantly different (p < 0.001) between the NH (88.7%) and the LTCU (45.6%). During the epidemic, there was no excess mortality index within the NH and LTCU services of the Amiens University Hospital. Among frail patients, the role of immunosenescence can be discussed to account for the absence of this inflammatory reaction. This study showed that isolating the infected patient in a dedicated unit significantly reduces the risk of seroconversion and contamination compared to isolating them within their own unit.

[Geriatric units at the beginning of the 2020 COVID-19 epidemic in France]. / Les unités de gériatrie au début de l'épidémie du Covid-19 de 2020 en France.

The COVID-19 epidemic that started in November in China became a national epidemic from March 16, 2020 with the declaration of population containment in order to reduce the spread of the virus in France. From March 17 to March 27, 2020, the monitoring unit of the French society of geriatrics and gerontology decided to conduct a survey to analyze the implementation of the mobilization of geriatric units, given that this epidemic had shown that it resulted in excess mortality mainly among the elderly. The survey was able to bring together the response of 34 services, nine of which were located in a high epidemic cluster zone. Dedicated acute geriatric units for patients infected with COVID-19 were present in eight facilities, only outside the cluster zones. Nine geriatric follow-up and rehabilitation services were dedicated, an additional telemedicine activity concerned 35% of the facilities, and family listening and tablet communication facilities concerned 36% of the facilities. This survey is a snapshot of an initial moment in the epidemic. It provides an opportunity to describe the context in which this epidemic occurred in terms of geriatric policy, and to assess the responsiveness and inventiveness of these services in meeting the needs of the elderly.

Tolerability of Midazolam to treat acute agitation in elderly demented patients: A systematic review.

WHAT IS KNOWN AND OBJECTIVE: Behavioural disorders are difficult to manage in elderly demented patients because of the lack of appropriate drugs or difficulties surrounding the route of administration. The tolerability of Midazolam is well described in the emergency management of agitation for young patients, when administered intramuscularly or intravenously. However, very little data are available on the use of oral Midazolam for this indication and in the elderly population. METHODS: A literature review was conducted, and studies were included if involving adults, receiving Midazolam, alone or in combination, whatever the route, dosage or indication and if they reported adverse events related to the use of Midazolam. RESULTS AND DISCUSSION: Forty-one articles were included. Eleven different adverse events were identified from the studies. Hypotension and desaturation were the two most frequent adverse events reported. Adverse reactions appear to be more common in older patients but also when Midazolam was used in combination with other drugs. The frequency of these adverse effects was lower than those reported for neuroleptic drugs. WHAT IS NEW AND CONCLUSION: The oral route appears to be appropriate to provide a rapid and well-tolerated response. Further studies will be needed to confirm the good tolerance of oral Midazolam in the management of acute agitation in elderly demented patients.

Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice.

BACKGROUND: While there is a general consensus of the impact of an orthogeriatric organisation in terms of elderly patient mortality post hip fracture, it is unclear which, among these various care models, is the most optimal. METHODS: A systematic review of the literature was undertaken using the keywords "Femoral fractures or total hip replacements or Accidental, falls" and "Aged, 80 and over" and "Mortality". The review is presented following PRISMA guidance. RESULTS: Eighteen studies were identified, published between 1988 and 2015. The number of elderly subjects participating in these studies was between 37 and 951; their mean age was 82.6 ± 7.4 years, and average mortality in these studies was 17.7%. The odds ratio (OR) and 95% CI for association between implementation of the orthogeriatric model and mortality in all patients studied were 0.85 (0.74-0.97). In the analysis by subgroup on the type of orthogeriatric model, the group "Orthogeriatric ward" gave homogenous results, with ORs and 95% CIs of 0.62 (0.48-0.80) unlike other models: "Shared care by orthopaedists and geriatricians "and "Geriatric advice in orthopaedic ward". CONCLUSIONS: Elderly patients with hip fracture admitted early into any sort of orthogeriatric models or more specifically to a dedicated orthogeriatric ward had reduced long-term mortality. This study has to be completed by RCT showing the efficacy of orthogeriatric ward compared to other models using outcomes such as quality of life or functional recovery.