Physicians' impression on the elders' functionality influences decision making for emergency care.

BACKGROUND AND AIMS: This study analyzes the elements that compose the emergency physicians' criterion for selecting elderly patients for intensive care treatment. This issue has not been studied in-depth. METHODS: A cross-sectional study was conducted at 4 university teaching hospitals, covering 101 randomly selected elderly patients admitted to emergency department and their respective physicians. Physicians were asked to forecast their plans for treatment or therapeutic abstention, in the event that patients might require aggressive measures (cardiopulmonary resuscitation or admission to critical care units). Data were collected on physicians' reasons for taking such decisions and their patients' functional capacity and cognitive status (Katz index and Informant Questionnaire on Cognitive Decline in the Elderly). A logistic regression model was constructed taking physicians' decisions as the dependent variables and adjusting for patient factors and physician impressions. RESULTS: The functional status reported by reliable informants and the mental status measured by validated instruments were not coincident with the physicians' perception (functional status κ, 0.47; mental status κ, 0.26). A multivariate analysis showed that the age and the functional and mental status of patients, as perceived by the physicians, were the variables that better explained the physicians' decisions. CONCLUSIONS: Physicians' impressions on the functional and mental status of their patients significantly influenced their selection of patients for high-intensity treatments despite the fact that some of these impressions were not correct.

[Cognitive assessment of elderly patients in the emergency department: a comparison between standard tools, medical records and physicians' perception]. / Evaluación cognitiva de los pacientes ancianos en el servicio de urgencias: comparación entre instrumentos estándar, historia clínica y la percepción de los médicos.

INTRODUCTION: We evaluated the accuracy of physician recognition of cognitive impairment in elderly patients in emergency departments (ED). In particular, we evaluated the accuracy of the subjective impression of the physician on patients' cognition (a comparison of the information obtained from the responsible physician with the S-IQCODE, a cognitive impairment screening test), and the accuracy of the medical records (a comparison of the information in the medical record with the S-IQCODE). MATERIAL AND METHODS: Cross-sectional study on 101 elderly patients selected at random from those attending ED, their ED physicians, and family member-carer. The study was conducted in the ED of four tertiary university teaching hospitals in a city, from July through November 2003. Cognitive data shown in the patient's medical records were compared against the S-IQCODE obtained from the family member-carer, using the kappa (kappa) concordance index. The physicians' impressions on the patients' cognitive status were also compared against the S-IQCODE results, using the kappa (kappa) concordance index. Each patient and their family member-carer were paired with a single physician. A logistic regression model was constructed to identify factors associated with the physicians' impressions of the patients' cognitive capacity. RESULTS: The concordance between information on cognitive decline from medical records and the results of the S-IQCODE, was 0.47 (IC95%: 0.05-0.88). Concordance between the physicians' impression on the presence of cognitive impairment, and the S-IQCODE obtained from family member-carer was 0.26 (IC95% 0.06-0.45). The multivariate analysis demonstrated that the functional status of patients, as perceived by the physicians, were the variable that better explained the physicians' impressions of patient cognitive function. CONCLUSIONS: The cognitive status of elderly patients is not properly assessed by emergency department physicians.

Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians' perceptions.

BACKGROUND: We evaluated the accuracy of physician recognition of functional status impairment in older emergency departments (ED) patients. In particular, we evaluated the accuracy of medical records (a comparison of the information in the medical record with the functional status based on proxy interviews), and the accuracy of physician knowledge (a comparison of the information obtained from the responsible physician with the functional status based on proxy interviews). METHODS: Cross-sectional study on 101 frail older patients selected at random from among those attending ED, their ED physicians, and respondents. The study was conducted at ED in four general university teaching hospitals in a city, from July through November 2003. Functional data shown on patients' medical records were compared against functional data obtained from respondents (family members), using Kendall's Tau-b statistic. In addition patients' Katz Indices (which assesses six basic activities of daily living--basic ADL) based on interviews with ED physicians were compared against those obtained from respondents, using the coefficient of concordance weighted kappa (kappa). Each patient and his respondent were paired with a single physician. RESULTS: The correlation between information on dependence for basic ADL obtained from medical records and that furnished by respondents, was 0.41 (95% CI 0.27-0.55). Concordance between the respective Katz Indices obtained from physicians and respondents was 0.47 (95% CI 0.38-0.57). CONCLUSION: Older subjects' functional status is not properly assessed by emergency department physicians.

[Prevalence of depression and associated medical and psychosocial factors in elderly hospitalized patients with heart failure in Spain]. / Prevalencia de depresión, y factores biomédicos y psicosociales asociados, en ancianos hospitalizados con insuficiencia cardiaca en España.

INTRODUCTION AND OBJECTIVES: This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain. METHODS: The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale. RESULTS: In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23-3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98-4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41-4.51), being dependent for > or =3 BADLs (aOR=2.47; 95% CI, 1.20-5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28-3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93-5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93-5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14-3.17). CONCLUSIONS: Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients.

Evaluación cognitiva de los pacientes ancianos en el servicio de urgencias: Comparación entre instrumentos estándar, historia clínica y la percepción de los médicos / Cognitive assessment of elderly patients in the emergency department: A comparison between standard tools, medical records and physicians' perception

Introducción. Hemos evaluado la exactitud con la que los médicos juzgan la capacidad cognitiva de los pacientes ancianos en el servicio de urgencias. En particular hemos evaluado la validez de la impresión subjetiva que el médico tiene sobre la cognición de sus pacientes (comparando su juicio clínico con el resultado del S-IQCODE, un test de cribado de deterioro cognitivo) y la validez de los datos de la historia clínica (comparando la información cognitiva contenida en la historia con el resultado del S-IQCODE). Material y métodos. Estudio transversal sobre 101 pacientes ancianos seleccionados al azar de entre aquellos que acudieron al servicio de urgencias, sus médicos y sus familiares-informadores. El estudio se llevó a cabo en 4 grandes hospitales universitarios entre julio y noviembre de 2003. El antecedente de deterioro cognitivo recogido en la historia fue comparado con el resultado del S-IQCODE, mediante el índice de concordancia Kappa (k). Además la impresión que los médicos pudieran tener sobre la presencia de deterioro cognitivo en sus pacientes, también fue comparada con el S-IQCODE usando el coeficiente de concordancia k. Cada paciente y su informador fueron emparejados con un solo médico. Se realizó un análisis multivariado para detectar factores asociados a la impresión del médico sobre la cognición de su paciente. Resultados. La concordancia entre la información sobre deterioro cognitivo contenida en la historia y los resultados del S-IQCODE fue de 0,47 (IC95%: 0,05–0,88). La concordancia entre la opinión del médico y el S-IQCODE fue de 0,26 (IC95%: 0,06–0,45). El análisis multivariado mostró que la impresión que el médico tenía de la situación cognitiva del paciente, estaba ligada a la impresión del médico sobre la situación funcional de su paciente, más que a ningún otro factor relacionado con la salud del paciente. Conclusiones. La situación cognitiva de los pacientes ancianos no es bien evaluada por los médicos del servicio de urgencias(AU)

Introduction. We evaluated the accuracy of physician recognition of cognitive impairment in elderly patients in emergency departments (ED). In particular, we evaluated the accuracy of the subjective impression of the physician on patients' cognition (a comparison of the information obtained from the responsible physician with the S-IQCODE, a cognitive impairment screening test), and the accuracy of the medical records (a comparison of the information in the medical record with the S-IQCODE). Material and methods. Cross-sectional study on 101 elderly patients selected at random from those attending ED, their ED physicians, and family member-carer. The study was conducted in the ED of four tertiary university teaching hospitals in a city, from July through November 2003. Cognitive data shown in the patient's medical records were compared against the S-IQCODE obtained from the family member-carer, using the kappa (k) concordance index. The physicians’ impressions on the patients’ cognitive status were also compared against the S-IQCODE results, using the kappa (k) concordance index. Each patient and their family member-carer were paired with a single physician. A logistic regression model was constructed to identify factors associated with the physicians’ impressions of the patients’ cognitive capacity. Results. The concordance between information on cognitive decline from medical records and the results of the S-IQCODE, was 0.47 (IC95%: 0.05–0.88). Concordance between the physicians’ impression on the presence of cognitive impairment, and the S-IQCODE obtained from family member-carer was 0.26 (IC95% 0.06–0.45). The multivariate analysis demonstrated that the functional status of patients, as perceived by the physicians, were the variable that better explained the physicians’ impressions of patient cognitive function. Conclusions. The cognitive status of elderly patients is not properly assessed by emergency department physicians(AU)

Prevalencia de depresión, y factores biomédicos y psicosociales asociados, en ancianos hospitalizados con insuficiencia cardiaca en España / Prevalence of Depression and Associated Medical and Psychosocial Factors in Elderly Hospitalized Patients With Heart Failure in Spain

Introducción y objetivos. En este trabajo se estima la prevalencia de depresión y se identifican los factores biomédicos y psicosociales asociados en ancianos hospitalizados con insuficiencia cardiaca en España. Métodos. Se estudió a 433 pacientes ≥ 65 años ingresados de urgencia en 4 hospitales españoles desde enero de 2000 hasta junio de 2001, con diagnóstico principal o secundario de insuficiencia cardiaca. Se consideró que había depresión ante la presencia de 3 síntomas en la Escala de Depresión Geriátrica de 10 ítems. Resultados. Del total de pacientes estudiados, 210 (48,5%) presentaron depresión. Las cifras correspondientes fueron 71 (37,6%) en varones y 139 (57,0%) en mujeres. La depresión fue más frecuente en los pacientes con las siguientes características: grado funcional III-IV de la NYHA (odds ratio ajustada [ORa] = 2,00; intervalo de confianza [IC] del 95%, 1,23-3,24); peor puntuación en los aspectos físicos de la calidad vida (ORa = 3,14; IC del 95%,1,98-4,99); dependencia en 1 o 2 actividades básicas de la vida diaria (ABVD) (ORa = 2,52; IC del 95%, 1,41-4,51); dependencia en 3 o más ABVD (ORa = 2,47; IC del 95%, 1,20-5,07); limitación en alguna actividad instrumental de la vida diaria (ORa = 2,20; IC del 95%, 1,28- 3,79); hospitalización previa por insuficiencia cardiaca (ORa = 1,71; IC del 95%, 1,93-5,45); estaban solos en casa más de 2 h al día (ORa = 3,24; IC del 95%, 1,93- 5,45); menor satisfacción con el médico de atención primaria (ORa = 1,90; IC del 95%, 1,14-3,17). Conclusiones. La depresión es muy frecuente en los ancianos hospitalizados con insuficiencia cardiaca, y se asocia con varios factores biomédicos y psicosociales. Esta elevada frecuencia, el peor pronóstico de la insuficiencia cardiaca en presencia de síntomas depresivos y la existencia de instrumentos diagnósticos sencillos y un tratamiento eficaz apoyan el cribado sistemático de la depresión en estos pacientes (AU)

Introduction and objectives. This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain. Methods. The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale. Results. In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23-3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98-4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41-4.51), being dependent for ≥3 BADLs (aOR=2.47; 95% CI, 1.20-5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28-3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93-5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93-5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14-3.17). Conclusions. Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients (AU)