[Staff hebdomadaire qualité et gestion des risques en gériatrie: un outil d'appropriation de la démarche qualité pour le management des unités]. / Staff hebdomadaire qualité et gestion des risques en gériatrie : un outil d'appropriation de la démarche qualité pour le management des unités.

The quality approach has become essential in geriatric hospital services, but also in the medico-social sector. This process is continuous and shared by all those in charge of the care units, to facilitate unit management and support caregivers in this approach. The weekly structured quality staff meeting is a relevant tool to facilitate the understanding and appropriation of this approach by the medical and nursing managers of the care units.

[Recognizing acute confusional syndrome and neurocognitive disorders in the emergency department]. / Reconnaître un syndrome confusionnel aigu et des troubles neurocognitifs aux urgences.

In the heart of the emergency room, when the nurse takes charge of the patient, he/she must be able to distinguish between an acute confusional syndrome and psychobehavioral symptoms related to neurocognitive disorders. Indeed, early identification of the confusional syndrome is essential to accelerate the implementation of non-drug measures by the nurse in order to reduce its duration and the induced complications.

Direct phone communication to primary care physician to plan discharge from hospital: feasibility and benefits.

BACKGROUND: The discharge summary is the main vector of communication at the time of hospital discharge, but it is known to be insufficient. Direct phone contact between hospitalist and primary care physician (PCP) at discharge could ensure rapid transmission of information, improve patient safety and promote interprofessional collaboration. The objective of this study was to evaluate the feasibility and benefit of a phone call from hospitalist to PCP to plan discharge. METHODS: This study was a prospective, single-center, cross-sectional observational study. It took place in an acute medicine unit of a French university hospital. The hospitalist had to contact the PCP by telephone within 72 h prior discharge, making a maximum of 3 call attempts. The primary endpoint was the proportion of patients whose primary care physician could be reached by telephone at the time of discharge. The other criteria were the physicians' opinions on the benefits of this contact and its effect on readmission rates. RESULTS: 275 patients were eligible. 8 hospitalists and 130 PCPs gave their opinion. Calls attempts were made for 71% of eligible patients. Call attempts resulted in successful contact with the PCP 157 times, representing 80% of call attempts and 57% of eligible patients. The average call completion rate was 47%. The telephone contact was perceived by hospitalist as useful and providing security. The PCPs were satisfied and wanted this intervention to become systematic. Telephone contact did not reduce the readmission rate. CONCLUSIONS: Despite the implementation of a standardized process, the feasibility of the intervention was modest. The main obstacle was hospitalists lacking time and facing difficulties in reaching the PCPs. However, physicians showed desire to communicate directly by telephone at the time of discharge. TRIAL REGISTRATION: French C.N.I.L. registration number 2108852. Registration date October 12, 2017.

[A TPE programme for patients with neurodegenerative diseases and their carers]. / Un programme d'ETP pour les patients porteurs d'une maladie neurodégénérative et leurs aidants.

The team of the geriatric department of the Grenoble-Alpes (38) University Hospital Center has created the Accompagner therapeutic education program to meet the needs of patients suffering from neurocognitive disorders in the context of a neurodegenerative disease and their families. Presentation and current organization of the workshops.

Perception of domestic risks among carers for dependent older persons.

BACKGROUND: Despite growing interest for home care, little evidence exists on the perception of domestic risk among carers for dependent older persons. This study aims to characterize the risks to which carers of aging dependent individuals are exposed, and to determine whether these risk dimensions are predictive for effective support, for burden, and for psychological distress. METHODS: Seventy care partners were questioned about the risk situations identified at the homes of the old people they care for, about the burden they felt in their role, and about their feelings of psychological distress. Securing was evaluated by means of sensibility measures, and overprotection was evaluated by means of specificity measures. RESULTS: Risk rates were high for loneliness of the old people, wandering, burns, and unsatisfactory health monitoring. There was very little overlap between identification of the risks and implementation of solutions by the caregiver, except for the risks that involved heat. The distinction between accurate securing and overprotection is especially important, because the burden of care partners was linked to uncontrolled domestic risks. CONCLUSION: Typologies of reactions to risk, characterized by a signal detection approach, could contribute to a better understanding of the situations experienced by care partners, especially situations of neglect and of overprotection.

Evaluation of a therapeutic education program for French family caregivers of elderly people suffering from major neurocognitive disorders: Preliminary study.

The pertinence of a therapeutic program of education has been studied with regard to carers of patients suffering from major neurocognitive disorders. The program, adapted to the needs expressed by the carers, consisted of three workshops with a view to supplying general information about the pathologies, specific information on behavioral disorders, and specific aids to identify and manage their emotional reactions. The results of this preliminary study show a moderate significant benefit to the level of anxiety in the participants, taking into account the specific expectations of the carers and bringing to light further needs.

[General practitioners and neurodegenerative diseases]. / Généraliste et pathologie neurodégénérative.

Cognitive disorders with memory loss are common among the patients of general practitioners. In collaboration with an outpatient diagnosis service and referral memory consultations, they are involved in the diagnosis, the implementation and the follow-up of suitable care for the patient and their family.

Factors affecting dementia screening by general practitioners in community-dwelling elderly populations: a large cross-sectional study in 2 areas of France.

In patients aged 75 years and above, dementia is associated with increased expenditure and high morbimortality. Although the incidence of dementia is well known, it is often underrecognized in primary care. We conducted a cross-sectional study in 2 areas in the southeast of France to identify the factors affecting dementia-screening implementation by the French general practitioners (GPs). In May 2008, an anonymized survey was sent by e-mail and/or post to all GPs with a large clinic practice. Two months later, reminder letters were sent. Overall, 493 GPs answered (26.8%) to self-reported behavior. Of these, 73.2% felt that annual screening was useful, although only 24.5% implemented it each year and 17.5% implemented it every 2 to 5 years. Factors that favorably influenced screening practices were: the older age of the GPs; belief in the usefulness of annual dementia screening; increased frequency of follow-up visits by elderly patients; and the proportion of dementia in the GP's practice. The main barrier to annual screening was the social problems encountered in the medical care of 75-year-old patients. Regardless of the differences in European national health policies or health care systems, all GPs encounter the same difficulties when dealing with elderly dementia patients.

[Study of cardiovascular drugs usage, among elderly subjects admitted to the emergency department for syncopal falls in Rhône-Alpes region]. / Étude de l'exposition médicamenteuse aux cardiotropes des sujets âgés consultant aux urgences pour chute avec malaise en Rhône-Alpes.

Study of cardiovascular drugs usage, among elderly subjects admitted to the emergency department for syncopal falls in Rhône-Alpes region. Polypharmacy and cardiovascular medication usage are risk factors for falls in the elderly. This study included subjects aged 75 and over, admitted in the emergency department for falls, based on evaluation data of professional practices carried out in the Nord Alpine region by the French Network of North-Alps Emergency Departments (Réseau Nord Alpin des Urgences, RENAU). The patients included were divided into 4 groups: "syncope", "accidental falls", "repeated falls" and "other types of fall". From the emergency room admission prescriptions, we studied the consumption of cardiovascular drugs in number and quality in the "syncope" group compared to other types of falls. The main objective in this study was to highlight higher cardiovascular drug usage among the elderly patients admitted to the emergency department for syncopal falls, in comparison with other types of falls. We included 1,476 patients among whom 262 patients came for "syncopal falls". We found superior usage of cardiovascular medication among syncopal falls compared to other type of falls (p < 0,01). However, there is no statistically significant association between inappropriate cardiovascular drug prescriptions, and the type of falls. The "standardized" fall assessment whose orthostatic hypotension investigation, is not always exhaustive in the emergency room. Orthostatic hypotension diagnostic is insufficiently sought in the emergency room. This study highlights a significantly higher usage of diuretic medication within the syncope group, in comparison to the other groups, and especially loop diuretic. Antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, calcium inhibitor) are also recurrent within the syncope group compared to the others. A careful supervising of these prescriptions among elderly patients seems required. These data prompt to revise prescriptions during fall related hospitalizations, and then with the primary-care physician, or with the cardiologist.

Évaluation d'une formule d'estimation de l'état nutritionnel biologique chez des personnes âgées hospitalisées de manière non programmée.

Résumé Introduction. Une interprétation fiable de l'albuminémie est essentielle pour l'évaluation nutritionnelle biologique (ENB) de la personne âgée. L'objectif principal était d'évaluer si une formule de correction proposée en cas d'inflammation prolongée pouvait être extrapolée aux situations d'inflammation biologique aiguës : albuminémie corrigée = albuminémie dosée + protéine C réactive (CRP)/25. Méthode. Cette étude observationnelle prospective monocentrique incluait des patients âgés hospitalisés de manière non programmée au CHU Grenoble-Alpes. Un recueil clinique et biologique était réalisé à J1 et J8. Le critère de jugement principal était la comparaison de l'albuminémie corrigée par la formule à J1 avec l'albuminémie dosée à J8. Résultat. Parmi 175 patients analysés, la moyenne de la CRP était de 64 mg/L (3 ; 324) à J1 et 24 mg/L (3 ; 99) à J8. Entre l'albuminémie corrigée à J1 et l'albuminémie dosée à J8, la corrélation était de p = 0,58, [IC 95 % : 0,47 ; 0,67], p < 0,001, et la différence moyenne de 2,9 mg/L (-13,5 ; 18), IC 95 %[-3,68 ; -2,20], p < 0,001. Entre l'albuminémie dosée à J1 et l'albuminémie dosée à J8, la corrélation était de p = 0,74, IC 95 % [0,66 ; 0,80], p < 0,001, et la différence moyenne de 0,4 mg/L (-14 ; 11), IC 95 % [-0,24 ; 1,02], p = 0,23. DISCUSSION: La formule proposée ne peut pas être extrapolée aux situations d'inflammation biologique aiguës au cours desquelles l'albuminémie dosée semble être stable. L'albuminémie dosée pourrait servir telle quelle de référence à l'ENB, en s'intégrant dans une histoire clinique. Abstract Introduction. A reliable interpretation of albumin is essential for the elderly's biological nutritional assessment (BNA), but is complex because many parameters change it. The main objective was to evaluate the extrapolation of a correction formula proposed for prolonged inflammation to acute biological inflammation situations: corrected albuminemia = measured albuminemia + CRP/25. METHOD: This prospective, single-center observation study included patients over 65 years of age who were unexpectedly hospitalized in geriatrics and internal medicine at Grenoble University Hospital, excluding carriers of active neoplasia, hepatic insufficiency, nephrotic syndrome, and those for whom a ABI persisted on the eighth day. A clinical and biological collection was made on the first and eighth days. The primary endpoint was the comparison of albuminemia corrected by the formula on day 1 with measured albuminemia on day 8. RESULTS: One hundred and seventy-five patients were analyzed. The average CRP was 64 (3; 324) mg/L on day 1 and 24 (3; 99) mg/L on day 8. Between corrected albumin at day 1 and albumin at day 8, the correlation was ρ = 0.58, 95%CI [0.47; 0.67], P < 0.001, and the mean difference of 2.9 (-13,5; 18) mg/L, 95%CI [-3.68;-2.20], P < 0.001. Between D1 albumin and D8 albumin, the correlation was ρ = 0.74, 95%CI [0.66; 0.80], P < 0.001, and the mean difference of 0.4 (-14; 11) mg/L, 95%CI [-0.24; 1.02], P = 0.23. DISCUSSION: The proposed formula cannot be extrapolated to acute inflammatory situations. Measured albuminemia appears to be stable during acute biological inflammation situations. Measured albuminemia could be used as a reference for BNA, integrated into a clinical history.

Evaluating biological nutritional status in elderly people with unscheduled hospitalisation.

A reliable interpretation of albumin levels is essential when assessing nutrition in elderly people, but this is complex as it is affected by a number of parameters. The main objective of this study was to evaluate whether a correction formula proposed for prolonged inflammation could be extrapolated to acute biological inflammation situations: corrected albuminemia = measured albuminemia + CRP/25. This prospective, single-centre observation study included patients over 65 years of age who were the subject of an unscheduled hospitalisation in the geriatrics and internal medicine departments of Grenoble University Hospital, excluding carriers of active neoplasia, hepatic insufficiency, nephrotic syndrome and those who continued to present with an acute biological inflammation on the eighth day. Clinical and biological samples were taken on the first and eighth days. The primary objective was the comparison of albumin levels, corrected using the formula on day (d) 1, with albumin levels measured on d8. One hundred and seventy-five patients were analysed. Average CRP was 64 (3; 324) mg/L on d1 and 24 (3; 99) mg/L on d8. Between the corrected albumin levels on d1 and albumin levels measured on d8, the correlation was ρ = 0.58, 95% CI [0.47; 0.67], P < 0.001, with a mean difference of 2.9 (-13.5; 18) mg/L, 95% CI [-3.68-2.20], P < 0.001. Between the albumin levels measured on d1 and d8, the correlation was ρ = 0.74, 95%CI [0.66; 0.80], P < 0.001, with a mean difference of 0.4 (-14; 11) mg/L, 95%CI [-0.24; 1.02], P = 0.23. The proposed formula cannot be extrapolated to acute inflammatory situations. Albumin levels appear to be stable during acute biological inflammation. Albumin levels could be used as a reference for biological nutritional assessments and be integrated into the patient's clinical history.

Satisfaction survey of general practitioners calling upon an external mobile geriatric team.

The external mobile geriatric team (équipe mobile de gériatrie extrahospitalière [EMGEH]) at the University Hospital of Grenoble-Alps intervenes with elderly subjects in complex medical and social situations at home at the request of general practitioners (GPs). To evaluate the satisfaction of GPs after EMGEH intervention. The secondary outcomes were the follow-up of recommendations and training requests from community care partners. Retrospective monocentric satisfaction survey of the 124 GPs who used the EMGEH between January 2015 and December 2018. Participation rate of 44%, representative of independent GPs in urban or semi-rural practices. Participants were "satisfied" or "very satisfied" (84.2%) with the responsiveness of the EMGEH, and 85.5% responded favourably to the content of the evaluation. The EMGEH was described as playing an expert and supportive role for GPs. The recommendations were followed by more than 89% of respondents. As many as 83.6% of participants wanted the EMGEH to conduct training sessions, mainly for the management of "behavioural disorders". Following this survey, five recommendations were formulated: decrease the response time by recruiting trained staff, systematically send an e-mail following the report to the requesting doctor, use a platform to exchange information, develop partnerships with the psychiatry team, and create an online resource space. This study contributed towards improving the relationship between the community and the hospital by strengthening links between the GPs within the CHUGA health region and the EMGEH.

[Satisfaction survey about general practitioners who used an External Mobile Geriatric Team]. / Enquête de satisfaction auprès des médecins généralistes ayant eu recours à une équipe mobile de gériatrie extrahospitalière.

CONTEXT: The External Mobile Geriatric Team (EMGT) of the University Hospital of Grenoble-Alps (UHGA) intervenes with elderly subjects in a complex medicosocial situation at home at the request of the general practitioner (GPs). OBJECTIVE: To evaluate the satisfaction of GPs after EMGT intervention. The secondary outcomes were the follow-up of recommendations and the training request of community partners. METHOD: Retrospective monocentric satisfaction survey of the 124 GPs who used EMGT from January 2015 to December 2018. RESULTS: Participation rate of 44 %, representative of GPs liberal urban or semi-rural. Participants were "satisfied" or "very satisfied" with the responsiveness of EMGT to 84,2 % and 85,5 % respond favorably to the content of the evaluation. EMGT was described as having an expert and supportive role for GPs. The recommendations were followed more than 89 %. The participants wanted to 83,6 % that the EMGT conducts training sessions, mainly for "behavioral disorders management". Following this survey, five improvement proposals were formulated: decrease the response time by recruiting trained staff, systematically send an e-mail post-analysis of the report to the doctor-applicant, use a platform of exchange, develop the partnership with the psychiatry team, and create a dematerialized resource space. CONCLUSION: This study contributed to the improvement of the city-hospital relationship by strengthening the links between the GPs of the CHUGA sanitary territory and the EMGT.

Outbreak of Human Metapneumovirus in a Nursing Home: A Clinical Perspective.

OBJECTIVES: To describe a human metapneumovirus (hMPV) outbreak occurring in a nursing home for older adults and to identify the risk factors associated with the clinical infection. DESIGN: A retrospective, case-controlled study. SETTING AND PARTICIPANTS: A French nursing home for older adults between December 27, 2014 and January 20, 2015. Probable cases were residents presenting at least 1 respiratory symptom or 1 constitutional symptom. Confirmed cases identified in the same way as probable cases but with a positive RT-PCR test for hMPV. Controls were residents with no symptoms of respiratory infection. MEASURES: Identification of hMPV was realized on nasal swab samples by RT-PCR. RESULTS: Seventy-eight older people were resident at the time of the outbreak. Three of the 4 tested were positive for hMPV by RT-PCR and negative for 13 other viruses or bacteria. All probable infected residents presented cough; other symptoms were scarcer. An inflammatory response was present, with median C-reactive protein at 50 mg/L. The median duration of the illness was 7 days. The rate of infection among residents was high (51%), with 5 hospitalizations (12.5%) and 1 death (2.5%). In multivariate analysis, vaccination against influenza virus appeared to emerge as associated with a probable hMPV infection, but this might be an artifact, as the proportion of unvaccinated residents was low (15%). A clear infected population profile was hard to define, although limited autonomy and low ADL score may play a role. Basic hygiene precautions were reinforced, but droplet precautions seemed difficult to apply rigorously to this population. CONCLUSIONS/IMPLICATIONS: Clinical and biological presentations were nonspecific. The rate of infection was high, highlighting the need for the rapid introduction of strict precautions to contain the infection.

[Safety at home for people with dementia: Preliminary evaluation of situations-at-risk in a French geriatric memory clinic]. / Sécurité à domicile des personnes démentes : étude préliminaire sur les situations à risque en consultation mémoire de gériatrie en France.

Community-dwelling people with Alzheimer's disease are exposed to situations-at-risk at home, but this phenomenon has rarely been studied empirically. The purpose of this pilot study was to describe the safety problems experienced at home in a sample of patients with dementia seen in a memory clinic, and also to identify the factors associated with these situations-at-risk. Study participants were 38 demented persons who were living at home, and assessed in a memory clinic with a caregiver-relative. Caregiver-relatives took part in a semi-structured interview in which they completed a French version of the Safety Assessment Scale (Poulin de Courval et al., 2006). The results show that all people with dementia were exposed to risks at home. Patients living alone were perceived to be more at risk at home than those living with someone. The most commonly reported risks concerned fire, nutrition and polymedication. The assessment gathers interesting information, addressing a wide range of risks at home. The Safety Assessment Scale is a useful tool to detect the risks at home and to focus the interview with the caregivers towards their prevention, since improvements are likely to enhance safety.

[One-year mortality after a hip fracture: prospective study of a cohort of patients aged over 75 years old]. / Mortalité des 75 ans et plus après une fracture de l'extrémité supérieure du fémur : suivi d'une cohorte prospective.

Hip fracture (HF) is a serious complication of the elderly who have suffered a fall. Studies focused on patients over 75 years old without excluding the most vulnerable are not frequent. Before we can think about the creation of an orthogeriatric unit, we evaluated the mortality rate one year after a HF only of patients over 75 years old and we identified associated factors with mortality, functional status and living. METHODS: Prospective observational study of 75 years and older hospitalized for a HF in a conventional orthopaedic unit. Surgical and geriatric data collected was: instrumental activities of daily life ADL (IADL), comorbidity (cumulative illness rating scale-geriatric (CIRS-G)), mini nutritional assessment (MNA), severity, preoperative delay. A phone assessment one year after HF was about: vital and functional status, living place. RESULTS: The mean age of 113 patients included was 87 years (76-100). The mortality rate was 35%. It was associated with low IADL day -15 (p< 0.01), elevated CIRS-G (p< 0.01), severity (p=0.05) and malnutrition (p=0.05). Preoperative delay average was 70.7 h (+/- 59) and 48.6% had surgery within 48 hours. Among survivors and from the data available, 45% had a functional decline one year after the HF and 11% were admitted in a nursing home. CONCLUSION: Without any exclusion of frailty patients, the one-year mortality rate of HF of people aged 75 years and older was 35%. HF is a public health challenge due to its high prevalence, poor prognosis with considerable expense. The associated factors help to explain why geriatricians are required and support the project of creating an orthogeriatric unit. Nevertheless, geriatric care will not likely change prognosis of the most vulnerable patients but could improve the level of care.

Nitrous oxide-oxygen mixture during care of bedsores and painful ulcers in the elderly: a randomized, crossover, open-label pilot study.

Bedsore and ulcer care can often be painful and no standardized analgesic method exists today for pain relief during treatment in adults and the elderly. To evaluate the analgesic efficacy of a nitrous oxide-oxygen mixture vs. morphine during painful bedsore and ulcer care in adult and elderly patients, we conducted a randomized, crossover, multicenter, prospective, open-label, pilot study. Thirty-four inpatients, aged 53-96 years (median 84 years), were recruited in Grenoble University Hospital, Annecy Hospital and Chambéry Hospital, France, from January to June 2001. Each of the 34 patients received morphine (M), nitrous oxide-oxygen mixture (E), or morphine+nitrous oxide-oxygen mixture (ME) during painful care in a crossover protocol. Treatments were changed every two days and the study duration was six days. Analgesia was evaluated before and after each care session using a behavioral scale to evaluate pain in noncommunicating adults (ECPA), a visual analog scale (VAS), a global hetero-evaluation scale (GHES), and the DOLOPLUS-2 scale. There was a significant overall difference (P<0.01) among the three treatments. On the ECPA, the average difference after and before care was +5.2+/-8.6 (M), -0.3+/-8 (E), and -0.6+/-7.4 (ME), respectively. There was a significant difference between M and E, and M and ME (each P<0.01). No difference was found between E and ME (P=0.97). There were similar significant differences in the GHES and DOLOPLUS-2 scales (all tests P<0.01). Post hoc comparisons showed a significant difference (P<0.01) between M and E, and between M and ME without any additional effect for M+E. No differences were found with regard to safety or tolerability. This pilot study demonstrates the superiority of nitrous oxide-oxygen mixture over morphine for analgesia. This experience suggests that this mixture has ease of use, rapid effect, and limited contraindications when used during painful bedsore and ulcer care in elderly patients. Furthermore, it is well accepted by these patients and by nursing staff.

Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units.

BACKGROUND: among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors. OBJECTIVE: to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments. DESIGN: prospective multi-centre study. SETTING: nine French hospitals. SUBJECTS: one thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort). METHODS: using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment. RESULTS: data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0-3.9), poor overall condition (OR = 2.01, 95% CI = 1.3-3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2-2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1-2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3--0.8). CONCLUSIONS: markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.

[Early indicators of prolonged hospitalization of the elderly: pilot study at Strasbourg University Hospital]. / Indicateurs précoces de durée de séjour prolongée chez les sujets âgés: étude pilote réalisée au CHRU de Strasbourg.

OBJECTIVES: The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. METHODS: This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Agé Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG). RESULTS: The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A "risk of malnutrition" (OR=14.07) and "mood disorders" (OR=2,5) were both early markers for prolonged hospitalization. Although not statistically significant, "walking difficulties" (OR=2.72) and "cognitive impairment" (OR=5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization. CONCLUSION: Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

Early markers of prolonged hospital stays in older people: a prospective, multicenter study of 908 inpatients in French acute hospitals.

OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals. DESIGN: A prospective, multicenter study. SETTING: Nine hospitals in France. PARTICIPANTS: One thousand three hundred six patients aged 75 and older were hospitalized through an emergency department (Sujet Agé Fragile: Evaluation et suivi (SAFEs)--Frail Elderly Subjects: Evaluation and follow-up). MEASUREMENTS: Data used in a logistic regression were obtained through a gerontological evaluation of inpatients, conducted in the first week of hospitalization. The center effect was considered in two models as a random and fixed effect. Two limits were used to define a prolonged hospital stay. The first was fixed at 30 days. The second was adjusted for Diagnosis Related Groups according to the French classification (f-DRG). RESULTS: Nine hundred eight of the 1,306 hospital stays that made up the cohort were analyzed. Two centers (n=298) were excluded because of a large volume of missing f-DRGs. Two-thirds of subjects in the cohort analyzed were women (64%), with a mean age of 84. One hundred thirty-eight stays (15%) lasted more than 30 days; 46 (5%) were prolonged beyond the f-DRG-adjusted limit. No sociodemographic variables seemed to influence the length of stay, regardless of the limit used. For the 30-day limit, only cognitive impairment (odds ratio (OR)=2.2, 95% confidence interval (CI)=1.2-4.0) was identified as a marker for prolongation. f-DRG adjustment revealed other clinical markers. Walking difficulties (OR=2.6, 95% CI=1.2-16.7), fall risk (OR=2.5, 95% CI=1.7-5.3), cognitive impairment (OR=7.1, 95% CI=2.3-49.9), and malnutrition risk (OR=2.5, 95% CI=1.7-19.6) were found to be early markers for prolonged stays, although dependence level and its evolution, estimated using the Katz activity of daily living (ADL) index, were not identified as risk factors. CONCLUSION: When the generally recognized parameters of frailty are taken into account, a set of simple items (walking difficulties, risk of fall, risk of malnutrition, and cognitive impairment) enables a predictive approach to the length of stay of elderly patients hospitalized under emergency circumstances. Katz ADLs were not among the early markers identified.