The relationship between total anticholinergic burden (ACB) and early in-patient hospital mortality and length of stay in the oldest old aged 90 years and over admitted with an acute illness.

The use of prescription drugs in older people is high and many commonly prescribed drugs have anticholinergic effects. We examined the relationship between ACB on mortality and in-patient length of stay in the oldest old hospitalised population. This was a retrospective analysis of prospective audit using hospital audit data from acute medical admissions in three hospitals in England and Scotland. Baseline use of possible or definite anticholinergics was determined according to the Anticholinergic Cognitive Burden Scale. The main outcome measures were decline in-hospital mortality, early in-hospital mortality at 3- and 7-days and in-patient length of stay. A total of 419 patients (including 65 patients with known dementia) were included [median age=92.9, inter-quartile range (IQR) 91.4-95.1 years]. 256 (61.1%) were taking anticholinergic medications. Younger age, greater number of pre-morbid conditions, ischemic heart disease, number of medications, higher urea and creatinine levels were significantly associated with higher total ACB burden on univariate regression analysis. There were no significant differences observed in terms of in-patient mortality, in-patient hospital mortality within 3- and 7-days and likelihood of prolonged length of hospital stay between ACB categories. Compared to those without cardiovascular disease, patients with cardiovascular disease showed similar outcome regardless of ACB load (either =0 or >0 ACB). We found no association between ACB and early (within 3- and 7-days) and in-patient mortality and hospital length of stay outcomes in this cohort of oldest old in the acute medical admission setting.

A simple 5-point scoring system, NaURSE (Na+, urea, respiratory rate and shock index in the elderly), predicts in-hospital mortality in oldest old.

BACKGROUND: the mortality is high in acutely ill oldest old patients. Understanding the prognostic factors which influence mortality will help clinicians make appropriate management decisions. METHODS: we analysed prospective mortality audit data (November 2008 to January 2009) to identify variables associated with in-patient mortality in oldest old. We selected those with P < 0.10 from univariate analysis and determined at which cut-point they served as the strongest predictor of mortality. Using these cut-off points, we constructed multivariate logistic regression models. A 5-point score was derived from cut-off points which were significantly associated with mortality tested in a smaller independent re-audit sample conducted in October 2011. RESULTS: a total of 405 patients (mean 93.5 ± 2.7 years) were included in the study. The mean length of stay was 18.5 ± 42.4 days and 13.8% died as in-patients. Variables (cut-off values) found to be significantly associated with in-patient mortality were admission sodium (>145 mmol/l), urea (≥14 mmol/l), respiratory rate (>20/min) and shock index (>1.0): creating a 5-point score (NaURSE: NaURS in the Elderly). The crude mortality rates were 9.5, 19.9, 34.4, 66.7, and 100% for scores 0, 1, 2, 3 and 4, respectively. Using the cut-off point of ≥2, the NaURSE score has a specificity of 87% (83.1-90.3) and sensitivity of 39% (28.5-50.0), with an AUC value of 0.69 (0.63-0.76). An external independent validation study (n = 121) showed similar results. CONCLUSIONS: the NaURSE score may be particularly useful in identifying oldest old who are likely to die in that admission to guide appropriate care.

Identification of possible determinants of inpatient mortality using Classification and Regression Tree (CART) analysis in hospitalized oldest old patients.

Current demographic trends suggest that there will be increasing numbers of older people in the future. Relatively little information is available regarding factors which influence mortality in the acutely unwell oldest old. This study uses the CART technique on data relating to the oldest old, to identify potential predictors of inpatient mortality in patients over 90 years old admitted acutely to the hospital due to various medical emergencies in two UK centers. The sample included 393 patients aged 90 years and older, with 67.5% females and 32.5% males and a mean age of 91.1 years. We aimed to generate hypotheses in order to identify potential acute illness prognostic indicators of inpatient mortality in this age group. The factors identified in this analysis which were associated with inpatient mortality in this patient population were raised serum urea concentration (>13.95 mmol/L), low oxygen saturation levels (<94%), hyponatremia (<128 mmol/L), and raised white cell count (>17 × 10(9)/L). The predictability of using these cut off points in inpatient as well as early in-hospital death should be validated in future studies.