Telemedicine-assisted care of an older patient with COVID-19 and dementia: bridging the gap between hospital and home.

Hospital at Home (HaH) has been proposed as a solution to relieve pressure on hospital beds during the COVID-19 pandemic; however, caregivers' feelings of inadequacy and concerns on the need for tighter clinical monitoring might lead to unnecessary and potentially harmful hospital admissions in frail older patients with mild or atypical COVID-19. Here we report the case of a 91-year old woman with severe dementia and atypical COVID-19 that could be successfully managed by our HaH thanks to her highly motivated caregivers and the support of a telemedicine solution (TMS) to provide caregiver training and support as well as supplementary telemonitoring. Despite some well-known issues on TMS use, the hybrid in-person and tele-visit approach of TMS-assisted HaH could help to create a "secure" environment, empowering caregivers to manage frail older adults with COVID-19 at home, avoiding unnecessary admissions to closed wards and their negative physical, functional and psychological outcomes.

Acute Kidney Injury and Chronic Kidney Disease in the Elderly and Polypharmacy.

BACKGROUND: Acute kidney injury (AKI) incidence is reported to be 10 times higher in aged people. Related to their higher prevalence of chronic kidney disease (CKD), older patients are at high risk of toxic effects driven by drugs. METHODS: The demographics, hospitalizations, visits to the Emergency Department, pharmacological therapy, and lab tests were analyzed in 71,588 individuals. RESULTS: Data showed a higher prevalence of AKI as well as CKD in the elderly as compared to the younger group, with an associated very high mortality. A broad number of drugs was prescribed, ranging from 1 to 35, the majority being between 5 and 9 drugs. CONCLUSION: Elderly patients who developed AKI had a higher number of hospitalizations (underlying frailty), were more likely to progress to more severe stages of CKD and to be affected by other non-renal pathologies (associated comorbidities) and to be given heavier pharmacological prescriptions (polypharmacy).

[Technological advances and hospital-at-home care]. / L'innovazione tecnologica e l'ospedalizzazione a domicilio.

Advances in the miniaturization and portability of diagnostic technologies, information technologies, remote monitoring, and long-distance care have increased the viability of home-based care, even for patients with serious conditions. Telemedicine and teleradiology projects are active at the Hospital at Home Service of Torino.

[Acute decompensation of heart failure in the elderly frail patient: an innovative model of care]. / Lo scompenso cardiaco acuto nel paziente anziano fragile: un innovativo modello di cura.

Heart failure is a major and growing public health problem that affects close to 10 million European and 5 million North Americans. Substitutive hospital-at-home care, defined as"a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care", may be a safe and efficacious alternative to traditional hospital care for elderly patients with an acutely decompensated heart failure. Data discussed in this paper suggest that hospital-at-home management of selected elderly patients with acute decompensation of chronic heart failure may be associated with delayed additional admissions, improvements in quality of life and alleviation of depressive symptoms without adverse effects in regard to mortality.

Home management of hematological patients requiring hospital admission.

The hospital-at-home service (HHS) could be considered as an alternative to the traditional ward for elderly patients. We aimed at evaluating the home management of elderly people requiring transfusions. The ever-increasing demand on acute hospital services requires alternative methods of delivering all aspects of health care. HHS demonstrated to be as efficacious as a traditional ward for elderly and functionally compromised patients. The method was a retrospective descriptive study enrolling patients needing an hospital admission from 1st January 2007 to 31st December 2007 and reporting an hematological discharge's diagnosis as primary or secondary diagnosis. A total of 54 patients were evaluated in this study. Of them, 34 (62.9%) needed a hemocomponent transfusion for a total volume of 112 blood units and 49 platelet pools. Patients requiring at least one blood or platelet transfusion were more functionally compromised and presented a higher level of acute physiology and chronic health evaluation, compared to the non-transfused ones. The conclusion was that hematological subjects mainly the frail ones and functionally highly compromised with acute illnesses could be treated at home as an alternative of the traditional medical ward. This could be the starting point for future studies that will be able to increase the power of hospital-at-home service for this type of patients.

The experience of a geriatric hospital at home service for acutely ill elderly patients with pressure ulcers: an observational study .

UNLABELLED:  Background. Pressure ulcers are an often underestimated problem affecting elderly patients. METHODS: An observational study was undertaken to evaluate patients admitted from January 2000 to December 2001 to a geriatric hospital affiliated at home service. RESULTS: Four hundred sixty-six patients (44.4% men and 55.6% women) were enrolled. Seventy-nine (16.9%) patients presented with a pressure ulcer upon admission. These patients were more functionally and cognitively impaired and had the poorest nutritional status. Anorexia and asthenia were significantly higher in patients with pressure ulcers (P < 0.001), and prevalence of constipation and dysphagia was significantly different between the two groups (P <0.05). Relative risk of new onset of pressure ulcers was significantly linked to age (1.09, CI 95% 1.02-1.15), to the number of functions lost (1.79, CI 95% 1.15-2.78), and to comorbidity (2.79, CI 95% 1.26-6.18). The relative risk of death during hospital admission was significantly linked to age (1.02, CI 95% 1.00-1.05), number of activities of daily living (ADL) functions lost (1.2, CI 95% 1.08-1.33), underweight (1.31, CI 95% 1.06-1.62), and the presence of pressure ulcers (1.59, CI 95% 1.23-2.05). CONCLUSION: Home treatment of acutely ill elderly patients with pressure ulcers is feasible and efficacious. .

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.

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data.

BACKGROUND: Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care. METHODS: We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured. RESULTS: We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54-1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45-0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96-2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded. INTERPRETATION: For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.

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.

[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.

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.