Dementia among older in-hospital patients with obstructive airway disease: frequency and consequences.

BACKGROUND: Dementia may influence as a co-morbid condition the management of chronic obstructive airway disease. However, the frequency and the consequences of dementia in older people with chronic obstructive airway disease are largely unknown. PATIENTS AND METHODS: The frequency and the severity of dementia in geriatric in-hospital patients and its impact on feasibility of lung function testing and drug treatment provided were determined. RESULTS: Out of a total of 1,424 patients with obstructive airway disease, 433 (30%) suffered from mild and 307 (22%) suffered from moderate to severe dementia. The frequency of any treatment for obstructive airway disease on admission decreased from 58% in subjects without dementia to 51% of those with mild and to 36% of those with moderate to severe dementia (p<0.01). The feasibility of performing lung function testing also decreased with increasing prevalence of dementia from 86% to 66% and 43%, respectively (p<0.001). CONCLUSION: Dementia is a frequent finding in older in-hospital patients with obstructive airway disease. The majority of subjects with dementia were not able to perform lung function testing. Furthermore, the risk of undertreatment for chronic obstructive airway disease increased. Future guidelines for management of obstructive airway disease must also take into account the special needs and skills of older subjects with dementia.

The terminal phase of life as a team-based clinical global judgment: prevalence and associations in an acute geriatric unit.

BACKGROUND: In most elderly people, the final-terminal-phase of life is characterized by permanent dependency and a complete inability to perform activities of daily living. Treatment targets usually switch from rehabilitation to palliation. However, the prevalence of the clinical judgment "last phase of life" and its association with in-hospital death is unknown in geriatric patients. PATIENTS AND METHODS: We retrospectively analyzed GEMIDAS data from two geriatric units. Patients without cancer and an in-hospital stay of at least 1 week were included in our study. Prevalence of the terminal phase of life was clinically assessed according to the proposals made by M. Gillick. This clinical judgment was pronounced by the geriatric team after a stay in the hospital of at least 1 week. The clinical judgment took into account all available assessment parameters, as well as the impact of a geriatric treatment trial. In addition, the association between the clinical judgment and the risk of in-hospital mortality was analyzed. RESULTS: Records from 2,433 (56%) patients in hospital A and from 1,912 (44%) patients in hospital B were analyzed. The frequency of a terminal phase of life was 30% and 9% (p<0.01), respectively. The frequency depended on the manner of admission to the hospital. In both hospitals, mortality was significantly higher in terminal patients (27% and 37%) than in other patients (0-8% and 0-6%). In both hospitals, the risk of in-hospital mortality was significantly associated with the clinical judgment (OR 3.1 and 2.7), heart failure (OR 2.2 and 2.1), and dementia (OR 2.0 and 1.8). Age, residency in a nursing home, and the Barthel Index on admission were all without relevant impact. CONCLUSION: The frequency of the clinical construct "terminal phase of life" varies in geriatric units between 9% and 30%. This clinical construct is significantly associated with increased in-hospital mortality. Therefore, this construct possesses external validity. Further studies are needed in order to assess the significance of such a clinical judgment, the associations with clinical burdens of symptoms, and the supply structure required to cover the needs of patients and their families.

Cyclical nocturnal oxygen desaturation and impact on activities of daily living in elderly patients.

It is well known, that sleep disordered breathing (SDB) is associated with functional impairment in stroke patients. In elderly non-stroke subjects this relation is unclear. We evaluated 539 elderly patients (median age was 81 years, range 41 to 100 years). We measured activities of daily living (ADL) with the Barthel-Index (BI, 0-100) on admission and discharge, excessive daytime sleepiness (EDS), and the nocturnal oxygen desaturation index (ODI). BI on admission was 54+/-33 in men and 55+/-31 in women (n.s.). More than 50% of the subjects had an ODI above 10/h. The mean BI on discharge was 65+/-31 in men and 67+/-29 in women (n.s.). With increasing SDB severity (quartiles of ODI), BI on admission decreased from 58+/-33 to 46+/-31 (P<0.001) and BI on discharge decreased from 70+/-31 to 59+/-29 (P<0.001). The frequency of EDS increased with increasing severity of SDB from 14.150% (first quartile of ODI) to 40.3% (forth quartile of ODI) (P<0.001). In 330 subjects without EDS, BI on admission did not differ regarding ODI. BI on discharge decreased from 78+/-22 (first quartile of ODI) to 66+/-25 (forth quartile of ODI) (P<0.04). SDB and EDS have a negative and independent impact on activities of daily living in elderly non-stroke subjects. Regarding the high frequency of SDB in the elderly and the effect size on ADL further interventional studies are warranted.

Feasibility of the Epworth Sleepiness Scale in a sample of geriatric in-hospital patients.

Excessive daytime sleepiness (EDS) is a major health concern in geriatric patients. EDS affects quality of life, daytime function, and mortality. The Epworth Sleepiness Scale (ESS) is a standard tool for the assessment daytime sleepiness, but the feasibility of the ESS has never been investigated in elderly subjects. We applied the ESS to a random sample of geriatric in-hospital patients. The aim of the study was to reveal the frequency and the risk factors for processing failure of the ESS in geriatric patients. 458 patients with a mean age of 82+/-8 years were included. One hundred sixty six (36%) completed the ESS, 118 (28%) patients had omissions of items, and 174 (38%) patients were unable to respond to any item. Completion of the ESS correlated significantly with age, disability, dementia, impairment of vision, and hearing. Omitted items were related to mobility and activities outside the house. Logistic regression analysis with completed ESS as a dependent variable revealed that dementia, disability, heart failure, and COPD were independent and significant risk factors for processing failure. The majority of patients of a geriatric unit are unable to complete the ESS. Since EDS is a frequent finding with a negative impact on health, the development of a reliable and valid tool for the assessment of EDS in elderly subjects is needed.

Influence of type of treatment for sleep apnea on activities of daily living in a sample of elderly patients with severe sleep apnea.

Sleep disordered breathing (SDB) is a frequent finding in the elderly. SDB is related to morbidity, mortality, quality of life, disability, and cognitive impairment. Treatment of choice for SDB is nasal positive airway pressure breathing (nCPAP). The impact of treatment for SDB on activities of daily living (ADLs) is unclear. We therefore investigated the relationship between SDB and ADLs in a sample of elderly in-hospital patients with severe SDB defined as a oxygen desaturation index of 30 events per hour. All patients eligible were assigned to nCPAP therapy. Patients with refusal of nCPAP were offered nocturnal oxygen supply via nasal prongs. The Barthel-index (BI) at admission and discharge was used to measure ADLs. Two hundred patients with a mean age of 81+/-7 years were included. 22 (11%) patients accepted nCPAP therapy, 42 (21%) patients accepted oxygen therapy and 136 (68%) patients refused both treatment options. The subgroups did not differ significantly in BI at admission and length of stay in hospital. BI increased from 42+/-28 to 49+/-30 in patients with refusal of any treatment, from 39+/-23 to 61+/-20 in patients with oxygen therapy and from 48+/-35 to 72+/-28 in patients with nCPAP therapy. The BI at discharge differed significantly between all three patients groups (p< 0.03). Logistic regression analysis revealed that Barthel Index at admission and treatment with nCPAP or treatment with oxygen were independently associated with a gain in BI of at least 30 points. Age, dementia or length of in-hospital stay showed no association with gain in BI. This is the first study that shows an impact of treatment for severe SDB on ADLs in elderly patients. Furthermore, treatment with nCPAP and oxygen supply nearly had the same impact on ADLs. Since the higher rate of acceptance of oxygen therapy and the important impact of oxygen supply on BI, administration of oxygen seems to be a rational alternative in elderly subjects with severe sleep apnea and refusal of nCPAP.