Observed daytime sleepiness in in-hospital geriatric patients and risk of falls.

BACKGROUND: Daytime sleepiness and falls are frequent in geriatric in-hospital patients; however, the relationship between both events is not clear. To test the hypothesis that observed daytime sleepiness is associated with falls in geriatric in-hospital patients data collected from medical records of patients who were admitted to an acute geriatric department were retrospectively analyzed. METHODS: The data from the medical records of patients who were admitted to the geriatric department of the Alfried-Krupp-Hospital in Essen, Germany in the period from January 2018 to March 2020 were retrospectively analyzed. Personal data, data concerning the geriatric assessment, observed daytime sleepiness, and falls were recorded. RESULTS: From a total of 1485 patients who were consecutively admitted to hospital, the data of 1317 (87%) patients could be included for further analysis. During the hospital stay 146 (11%) patients fell at least once, 35 (3%) patients had more than 1 fall and 64 falls (44%) occurred while patients were standing (bipedal fall). Daytime sleepiness was observed in 73% of the patients with bipedal falls and in 65% patients with nonbipedal falls (p < 0.01). Falls correlated significantly with the history of a recent fall, the length of hospital stay, the Barthel index (BI) on admission, the mini mental state examination (MMSE), dementia and observed daytime sleepiness. No correlation was found between falls and age, multimorbidity, and the number of drugs used. Drugs related to falls were medications to treat Parkinson's disease, antidepressants and neuroleptics. In a multiple logistic regression analysis in-hospital falls were significantly and independently associated with a history of falls, length of in-hospital stay, dementia, and observed daytime sleepiness. CONCLUSION: Observed daytime sleepiness is associated with in-hospital falls in geriatric patients. Prospective interventional studies are needed to confirm this relationship, and to quantify the impact of sleepiness on the risk of falling. Additionally, the impact of treatment for observed daytime sleepiness on the risk of falling should be assessed. The assessment of sleepiness should become a routine task in geriatrics.

[Lung function test in advanced age]. / Lungenfunktionsprüfung im höheren Lebensalter.

Advanced age is not an obstacle to carring out a lung function test. In most cases a lung function test is necessary due to the fact that about 20% of older persons are affected by an obstructive respiratory disorder. Standard values for the lung function test are available up to advanced ages. The experience of the examiner and a calm environment for the lung function test have an impact on the quality of the measurement results. Severe cognitive impairments and severe immobility make the performance of a lung function test impossible. Simple geriatric assessments can help to reliably identify these patients. Alternative lung function test procedures have to be validated in order to adequately diagnose this vulnerable subgroup of patients at risk.

Clinical and functional patient characteristics predict medical needs in older patients at risk of functional decline.

BACKGROUND: The rising number of older multimorbid in-patients has implications for medical care. There is a growing need for the identification of factors predicting the needs of older patients in hospital environments. Our aim was to evaluate the use of clinical and functional patient characteristics for the prediction of medical needs in older hospitalized patients. METHODS: Two hundred forty-two in-patients (57.4% male) aged 78.4 ± 6.4 years, who were consecutively admitted to internal medicine departments of the University Hospital Essen between July 2015 and February 2017, were prospectively enrolled. Patients were assessed upon admission using the Identification of Seniors at Risk (ISAR) screening followed by comprehensive geriatric assessment (CGA). The CGA included standardized instruments for the assessment of activities of daily living (ADL), cognition, mobility, and signs of depression upon admission. In multivariable regressions we evaluated the association of clinical patient characteristics, the ISAR score and CGA results with length of hospital stay, number of nursing hours and receiving physiotherapy as indicators for medical needs. We identified clinical characteristics and risk factors associated with higher medical needs. RESULTS: The 242 patients spent [median(Q1;Q3)]:9.0(4.0;16.0) days in the hospital, needed 2.0(1.5;2.7) hours of nursing each day, and 34.3% received physiotherapy. In multivariable regression analyses including clinical patient characteristics, ISAR and CGA domains, the factors age (ß = - 0.19, 95% confidence interval (CI) = - 0.66;-0.13), number of admission diagnoses (ß = 0.28, 95% CI = 0.16;0.41), ADL impairment (B = 6.66, 95% CI = 3.312;10.01), and signs of depression (B = 6.69, 95% CI = 1.43;11.94) independently predicted length of hospital stay. ADL impairment (B = 1.14, 95%CI = 0.67;1.61), cognition impairment (B = 0.57, 95% CI = 0.07;1.07) and ISAR score (ß =0.26, 95% CI = 0.01;0.28) independently predicted nursing hours. The number of admission diagnoses (risk ratio (RR) = 1.06, 95% CI = 1.04;1.08), ADL impairment (RR = 3.54, 95% CI = 2.29;5.47), cognition impairment (RR = 1.77, 95% CI = 1.20;2.62) and signs of depression (RR = 1.99, 95% CI = 1.39;2.85) predicted receiving physiotherapy. CONCLUSION: Among older in-patients at risk for functional decline, the number of comorbidities, reduced ADL, cognition impairment and signs of depression are important predictors of length of hospital stay, nursing hours, and receiving physiotherapy during hospital stay.

Health outcome of older hospitalized patients in internal medicine environments evaluated by Identification of Seniors at Risk (ISAR) screening and geriatric assessment.

BACKGROUND: Hospitals are in need of valid and economic screening and assessment tools that help identifying older patients at risk for complications which require intensified support during their hospital stay. METHODS: Five hundred forty-seven internal medicine in-patients (mean age 78.14 ± 5.96 years; 54.7% males) prospectively received Identification of Seniors at Risk (ISAR) screening. If screening results were positive (ISAR score ≥ 2), a comprehensive geriatric assessment (CGA) was performed. We explored sensitivity and specificity of different ISAR and CGA cutoffs. Further, we analyzed the risk of falls and how patients got discharged from hospital. RESULTS: ISAR+/CGA abnormal patients spent more days in hospital (16.1 ± 14.5), received more nursing hours per day (3.0 ± 2.3), more hours of physiotherapy during their hospital stay (2.2 ± 3.2), and had more falls (10.1%) compared to ISAR+/CGA normal (10.9 ± 12.3, 2.0 ± 1.2, 1.2 ± 4.3, and 2.8%, respectively, all p ≤ 0.016) and ISAR- (9.6 ± 11.5, 2.3 ± 4.5, 0.7 ± 2.0, and 2.2%, respectively, all p ≤ 0.002) patients. ISAR+/CGA abnormal patients terminated their treatment regularly with being discharged back home less often (59.6%) compared to ISAR+/CGA normal (78.5%, p = 0.002) and ISAR- (78.2%, p = 0.056) patients. ISAR cutoff≥2 and CGA defined as abnormal in case of impairment of ADL plus another CGA domain achieved best sensitivity/specificity. CONCLUSIONS: Abnormal geriatric risk screening and assessment are associated with longer hospital stay and higher amount of nursing and physiotherapy during hospital stay, greater risk of falling, and a lower percentage of successfully terminated treatment in older in-patients.

Sleep in older adults and in subjects with dementia.

The neuronal structures for the regulation of sleep and wakefulness are located in the brain. This complex network is vulnerable to numerous factors, most importantly neurodegenerative diseases and drugs. The macrostructure and microstructure of sleep change with age. These changes are more pronounced in subjects with dementia. Sleep disorders in subjects with dementia may be independent of dementia or caused by dementia. Furthermore, epidemiological studies reveal that sleep disorders per se may induce dementia by reduction of cerebral clearance of beta-amyloids. The population attributable risk (PAR) of sleep disturbances to the incidence of dementia is estimated to be about 15%; therefore, management of sleep disturbances in older adults and subjects with dementia gives the opportunity of an impact on incidence and course of dementia. Sleep history should be taken from each individual and obvious sleep disturbances, especially sleep apnea, should be managed according to current guidelines. Future studies that concern the incidence and the management of dementia must take into account sleep and sleep disturbances.

Effects of "Fit fOR The Aged" (FORTA) on pharmacotherapy and clinical endpoints--a pilot randomized controlled study.

PURPOSE: The feasibility of applying the Fit fOR The Aged (FORTA) list, a drug classification combining positive and negative labeling of drugs, should be studied in geriatric patients and medication quality and clinical endpoints measured. FORTA labels range from A (indispensable), B (beneficial), C (questionable) to D (avoid). METHODS: A prospective randomized controlled pilot trial was performed in hospitalized geriatric patients in whom the FORTA instrument or standard care was applied. Patients were randomly admitted to an intervention and a control ward. Changes of FORTA label distributions between admission and discharge, over- and under-prescription rates, clinical endpoints including the number of falls during the hospitalization, and Barthel Index (BI) at admission and discharge were measured. RESULTS: Polypharmacy persisted in both groups. At discharge, a higher rate of A drugs was prescribed in the intervention group (58 patients, median age 84 years) vs. standard care (56 patients, median age 83 years, p < 0.02), and both over- and under-prescriptions were significantly lower in the FORTA than in the control group (p < 0.03). Two (3.4%) intervention, but 12 (21.4%) control, patients fell at least once (p < 0.001). The fall rate per 1,000 patient years was 1.5 ± 8.3 in the intervention and 10.6 ± 25.4 in the control group (p < 0.004). CONCLUSIONS: This pilot study shows that the application of the FORTA list is feasible in geriatric patients. In this small study, the medication quality improved in the intervention group, but polypharmacy persisted in both groups. The fall rate was significantly lower in the intervention group. These encouraging results must be interpreted carefully.