The role of an Acute Care for the Elderly unit in achieving hospital quality indicators while caring for frail hospitalized elders.

Acute Care for the Elderly (ACE) units have successfully decreased length of stay, hospital costs, and readmission rates. Furthermore, patients return home with increased functional capacity and improved satisfaction with their hospital stay. The ACE unit concept was geared toward patients returning to independent living, but the average hospitalized geriatric patient is increasingly more frail, vulnerable, and dependent. The purpose of this study is 2-fold: (1) to determine if the ACE unit continues to offer the same benefit to the frail, often bedbound elderly, and (2) to determine if such a unit is able to maintain standard hospital quality indicators. A total of 1096 cases discharged from the Memorial-Hermann ACE unit between July 2008 and June 2010 were compared to a sample of 383 patients with similar illness severity who were discharged between July 2007 and June 2008. Metrics measured include: average length of stay (ALOS), case mix index (CMI), case mix adjusted average length of stay (CMI adj ALOS), average direct costs per case, and readmission rate. Patient satisfaction was measured using Hospital Consumer Assessment of Healthcare Providers and Systems and Press-Ganey surveys; quality and safety data were provided by Memorial-Hermann's Quality and Safety Department. The ACE unit resulted in a statistically significant decrease in ALOS and CMI adj LOS with a simultaneous increase in Health Care Financing Administration CMI, indicating that the unit was serving a sicker, more frail population. The readmission rate was 11.95%. The decrease in length of stay, readmission rate, and direct cost translates into a decrease in cost per case. Furthermore, the ACE unit successfully met hospital quality indicators.

Fracture risk and bone mineral density reduction associated with proton pump inhibitors.

Many patients receive prolonged proton pump inhibitor (PPI) therapy for upper gastrointestinal disorders, but the long-term safety of PPIs, particularly increased risk of hip and nonhip fractures, has been questioned. To summarize the current literature on the risk of bone mineral density (BMD) reduction and fracture associated with PPI therapy, we conducted a literature search to identify all pertinent studies from 1980-February 2011. A total of 14 observational studies were included in this review. Most studies evaluated the risk of fracture associated with prolonged PPI exposure. Eight studies found an increased fracture risk at the hip, and five studies found an increased fracture risk at the spine associated with PPIs. Three studies showed reduction in fracture risk associated with PPIs after discontinuation for 1 month-1 year. Three studies evaluated the risk of BMD reduction associated with PPIs but did not find consistent changes in baseline or subsequent BMD. The current data suggest a modest increase in the risk of hip fracture and vertebral fracture associated with PPIs, although some studies showed conflicting results. Further studies will be needed to determine whether the increased risk of fracture is due to PPI exposure or residual confounding.

The effect of geriatric and palliative medicine education on the knowledge and attitudes of internal medicine residents.

A recent Institute of Medicine report on geriatric work force issues recommends training residents in settings with geriatric patients and increasing certification requirements to include competence in the care of older adults. Although the number of internal medicine programs with a geriatric curriculum has increased, the scope and effectiveness of these programs vary. The purpose of this study was to evaluate the effect of a new academic geriatric and palliative medicine curriculum on the knowledge and attitudes of third-year internal medicine and fourth-year medicine and pediatrics residents. The study was conducted at The University of Texas Medical School at Houston. A new Division of Geriatric and Palliative medicine was created that offered inpatient, consultation, ambulatory, and home visit experiences in addition to didactic lectures. The University of Michigan Geriatrics Clinical Decision Making Assessment and the University of California at Los Angeles Geriatric Attitude Test was used to evaluate pre- and post-rotation knowledge and attitudes. Residents' knowledge improved after completing the rotation, as shown by a 6.9-point increase in posttest scores (P<.001). There was also a 10-point improvement in pretest scores over the course of the year (P=.03). Fifty-seven percent of residents had an improvement in attitude. This study shows that an increase in geriatric and palliative teaching opportunities provided by the establishment of a geriatric and palliative medicine division improves residents' knowledge significantly.

Acute care for the elderly: a literature review.

Traditionally, acute medical care has been insufficient to meet the complex care needs of frail older adults. The purpose of this study was to evaluate the effectiveness of Acute Care for the Elderly (ACE) units at improving hospitalization outcomes for adults older than 65 years of age. A review of the literature was performed, focusing on randomized controlled trials, clinical trials, reviews, and meta-analyses from 1990 to 2008. This review revealed ACE to be associated with positive global outcomes (eg, cost, length of stay, readmission rates, utilization, rehabilitation, cognition, function, patient/staff satisfaction). Furthermore, some studies may point to a decreased incidence of delirium and polypharmacy. Though larger studies with consistent operational definitions and replicative studies are needed, the literature presents compelling evidence that warrants further investigation of ACE as a valuable alternative paradigm of acute geriatric care.

Frailty in Parkinson's disease and its clinical implications.

The purpose of our study was to determine the prevalence of frailty in Parkinson's disease (PD) patients and the relationship between individual frailty criteria and the severity of PD. We measured the five components of frailty (Fried et al.) and the severity of PD (unified Parkinson's disease rating scale (UPDRS)) in 50 optimally treated PD patients. Frailty was more prevalent in PD patients. While UPDRS scores differed between frail and non-frail participants (44.8+/-15.8 vs. 31.4+/-12.7, P<0.002), higher scores were not indicative of frailty. Weekly caloric expenditure best predicted frailty status (OR=22.0 [4.5,107.8]). Frailty and PD bear distinct therapeutic and prognostic significance; however, their clinical picture may overlap and screening PD patients for frailty may be warranted.

Frailty: an emerging geriatric syndrome.

Frailty is a new and emerging syndrome in the field of geriatrics. The study of frailty may provide an explanation for the downward spiral of many elderly patients after an acute illness and hospitalization. The fact that frailty is not present in all elderly persons suggests that it is associated with aging but not an inevitable process of aging and may be prevented or treated. The purpose of this article is to review what is known about frailty, including the definition, epidemiology, and pathophysiology, and to examine potential areas of future research.