Ferric Gluconate Complex in Elderly Hospital Inpatients without Terminal Kidney Failure.

BACKGROUND: Anemia is a common health issue for elderly patients. For patients with iron deficiency who cannot tolerate iron supplementation by the oral route, the parenteral route may be used. Options for parenteral iron supplementation include ferric gluconate complex (FGC). OBJECTIVES: To evaluate the safety of FGC in elderly patients without terminal kidney failure and to assess its efficacy in treating iron-deficiency anemia. METHODS: An observational chart review was conducted at a tertiary care university health centre. Patients included in the study were 65 years of age or older, had received at least 1 dose of FGC between January 1, 2014, and December 31, 2015, and had a hemoglobin count of less than 130 g/L (men) or less than 120 g/L (women) at baseline. For each patient, the observation period began when the first dose of FGC was administered and ended 60 days after the last dose. The main safety outcome (occurrence of any adverse reaction) was evaluated for every patient, with the efficacy analysis being limited to patients with a diagnosis of iron-deficiency anemia. RESULTS: A total of 144 patients were included in the study, of whom 76 had iron-deficiency anemia. No serious, life-threatening adverse reactions were reported. The most commonly reported adverse reactions were nausea and vomiting. The mean increase in hemoglobin count was 13.5 g/L, a statistically significant change from baseline. CONCLUSIONS: These results show that FGC is safe for use in elderly patients, with very few mild adverse reactions. Use of FGC led to increased hemoglobin count within 60 days. Of the 3 options for parenteral iron supplementation available in Canada, iron sucrose has not been studied in elderly patients, and iron dextran has a higher incidence of anaphylaxis, whereas FGC appears to be a safe alternative for patients with intolerance to oral iron.

CONTEXTE: L'anémie est un problème de santé courant chez les patients âgés. Les patients qui présentent une carence en fer et une intolérance à la prise de suppléments de fer par la voie orale peuvent être traités par voie parentérale. Le complexe de gluconate ferrique de sodium (CGFS) représente l'une des options d'apport complémentaire en fer par voie parentérale. OBJECTIFS: Évaluer l'innocuité du CGFS chez le patient âgé qui n'est pas atteint d'insuffisance rénale terminale et évaluer son efficacité dans le traitement de l'anémie ferriprive. MÉTHODES: Une analyse observationnelle a été menée au moyen des dossiers médicaux dans un établissement de santé universitaire de soins tertiaires. Les patients dont le dossier médical a été retenu pour l'analyse étaient âgés de 65 ans ou plus, avaient reçu au moins une dose de CGFS entre le 1er janvier 2014 et le 31 décembre 2015 et présentaient initialement un taux d'hémoglobine de moins de 130 g/L (hommes) ou de moins de 120 g/L (femmes). Pour chaque patient, la période d'observation s'étendait du moment où la première dose de CGFS avait été administrée au soixantième jour suivant la dernière dose. Le principal paramètre d'évaluation de l'innocuité (survenue de toute réaction indésirable) faisait l'objet d'une évaluation pour chaque patient. L'analyse de l'efficacité se limitait aux patients ayant reçu un diagnostic d'anémie ferriprive. RÉSULTATS: Au total, 144 patients ont été admis à l'étude et, parmi eux, 76 présentaient une anémie ferriprive. Aucune réaction indésirable grave menaçant la vie du patient n'a été notée. Les réactions indésirables les plus souvent signalées étaient des nausées et des vomissements. L'augmentation moyenne des taux d'hémoglobine était de 13,5 g/L, un changement statistiquement significatif comparé à la valeur de départ. CONCLUSIONS: Les résultats montrent que le CGFS est sécuritaire pour le patient âgé et qu'il ne provoque que très peu de réactions indésirables légères. L'emploi du CGFS a produit une augmentation des taux d'hémoglobine en moins de 60 jours. Parmi les 3 options d'apport complémentaire en fer pris par voie parentérale disponibles au Canada, le fer-saccharose n'a pas été étudié auprès de patients âgés et le fer-dextran est associé à une plus grande incidence de cas d'anaphylaxie; or, le CGFS semble être une solution sécuritaire pour les patients qui présentent une intolérance au fer administré par voie orale.

Median and Dorsal Raphe Serotonergic Neurons Control Moderate Versus Compulsive Cocaine Intake.

BACKGROUND: Reduced expression of the serotonin transporter (SERT) promotes anxiety and cocaine intake in both humans and rats. We tested the hypothesis that median raphe nucleus (MRN) and dorsal raphe nucleus (DRN) serotonergic projections differentially mediate these phenotypes. METHODS: We used virally mediated RNA interference to locally downregulate SERT expression and compared the results with those of constitutive SERT knockout. Rats were allowed either short access (ShA) (1 hour) or long access (LgA) (6 hours) to cocaine self-administration to model moderate versus compulsive-like cocaine taking. RESULTS: SERT knockdown in the MRN increased cocaine intake selectively under ShA conditions and, like ShA cocaine self-administration, reduced corticotropin-releasing factor (CRF) immunodensity in the paraventricular nucleus of the hypothalamus. In contrast, SERT knockdown in the DRN increased cocaine intake selectively under LgA conditions and, like LgA cocaine self-administration, reduced CRF immunodensity in the central nucleus of the amygdala. SERT knockdown in the MRN or DRN produced anxiety-like behavior, as did withdrawal from ShA or LgA cocaine self-administration. The phenotype of SERT knockout rats was a summation of the phenotypes generated by MRN- and DRN-specific SERT knockdown. CONCLUSIONS: Our results highlight a differential role of serotonergic projections arising from the MRN and DRN in the regulation of cocaine intake. We propose that a cocaine-induced shift from MRN-driven serotonergic control of CRF levels in the hypothalamus to DRN-driven serotonergic control of CRF levels in the amygdala may contribute to the transition from moderate to compulsive intake of cocaine.

The Delirium Drug Scale is associated to delirium incidence in the emergency department.

ABSTRACTBackground:The Delirium Drug Scale (DDS) is an evaluation scale developed to assess a patient's drug burden for delirium. The primary goal is to validate the association between the DDS score and the incidence of delirium. METHODS: This study was an observational retrospective cross-sectional chart review study in patients aged 75 years and older. It was carried out in three emergency departments of a tertiary care university health center. Patients were included if a medication list was available. Delirium present upon admission was assessed during the first five days of admission. RESULTS: A total of 1,205 subjects were included in the analysis. The mean age was of 83.4 years, and 62.4% were female. The prevalence of delirium was 19.1%. A total of 745 patients (62%) were exposed to DDS medication. The relative risk for the low (1-2) and high (>2) exposure group according to the DDS score was of 1.26 (CI: 0.95; 1.66) and 2.18 (CI: 1.61; 2.96) compared to a score of 0. In the multivariate analysis, dementia, anxiety, insomnia, history of delirium, infection, and acute kidney failure were significantly associated to delirium. When adjusted for confounding variables, the DDS score was associated with the incidence of delirium with an odd ratio (OR) of 1.29 (CI: 1.16; 1.44). CONCLUSIONS: This study found that DDS score was associated with delirium incidence. The association persisted in the multivariate analysis adjusted for 26 known risks and precipitating factors for delirium.

Noradrenaline-induced release of newly-synthesized accumbal dopamine: differential role of alpha- and beta-adrenoceptors.

Previous studies have shown that intra-accumbens infusion of isoproterenol (ISO), a beta-adrenoceptor-agonist, and phenylephrine (PE), an alpha-adrenoceptor-agonist, increase the release of accumbal dopamine (DA). In the present study we analyzed whether the ISO-induced release of DA is sensitive to pretreatment with the DA synthesis inhibitor alpha-methyl-para-tyrosine (AMPT). Earlier studies have shown that the PE-induced release of DA is derived from DA pools that are resistant to AMPT. In addition to PE, the alpha-adrenoceptor-antagonist phentolamine (PA) was also found to increase accumbal DA release. Therefore, we investigated whether similar to the DA-increasing effect of PE, the DA increase induced by PA is resistant to AMPT. Pretreatment with AMPT prevented the ISO-induced increase of accumbal DA. The accumbal DA increase after PA was not reduced by the DA synthesis inhibitor, independently of the amount of DA released. These results show that mesolimbic beta-, but not alpha-adrenoceptors, control the release of accumbal newly-synthesized DA pools. The DA-increasing effects of PE have previously been ascribed to stimulation of presynaptic receptors located on noradrenergic terminals, whereas the DA-increasing effects of PA and ISO have been ascribed to an action of these drugs at postsynaptic receptors on dopaminergic terminals. The fact that AMPT did not affect the accumbal DA response to PE and PA, whereas it did prevent the accumbal DA increase to ISO, supports our previously reported hypothesis that the noradrenergic neurons of the nucleus accumbens containing presynaptic alpha-adrenoceptors impinge upon the dopaminergic terminals in the nucleus accumbens containing postsynaptic adrenoceptors of the alpha but not of the beta type. The putative therapeutic effects of noradrenergic agents in the treatment of DA-related disorders are shortly discussed.

Prevalence of glaucoma in hospitalized older adults with Alzheimer's disease.

OBJECTIVE: To determine the prevalence of glaucoma in older adults with dementia of the alzheimer's type (DAT). METHODS: retrospective chart review: the prevalence of glaucoma was determined in older adults with a diagnosis of DAT or mixed dementia (DAT with vascular contribution) admitted to the geriatric and neurology units of the Centre hospitalier de l'université de Montréal and the hôpital Maisonneuve-rosemont between april 2008 and april 2009 (n=220; DAT group). they were matched for age and date of hospitalisation to the first 220 individuals without dementia (control group) recruited from other medical units in the same hospitals: gastroenterology, internal medicine or cardiology. a diagnosis of glaucoma was deemed positive if recorded in the chart or if there was a medication compatible with this diagnosis. Chi-square tests were used for between-group comparisons. RESULTS: Subjects' age ranged from 66 to 101 years. the prevalence of glaucoma was 6.8% in our study population (n=30/440). glaucoma was significantly more prevalent in the DAT group (n= 21; 9.5%) than in the control group (n= 9; 4.1%) [χ1² = 5.15; p = 0.023]. CONCLUSIONS: the prevalence of glaucoma was higher in a group of older adults with DAT than in a comparable control group. these results underscore the importance of providing regular eyecare for persons affected by DAT.

Predictors of quality-of-care processes in geriatric assessment units: toward a better organizational framework.

OBJECTIVES: To identify the structural and patient characteristics associated with better care processes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-four Geriatric Assessment Units (GAU). PARTICIPANTS: Patients aged 65 and older who were admitted to a GAU for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, completion of advance health care directives) assessed through chart audit; 14 patient- and 23 GAU-related characteristics obtained from hospitalization records, national databases, and GAU managers. RESULTS: A total of 877 hospitalization records were included. Final models were based on multilevel modeling using stepwise variable selection. Strongest predictors of better comprehensiveness were longer hospital length of stay (LOS), higher clinical complexity (eg, higher mortality risk), and having a geriatrician as attending physician. Comprehensiveness score increased sharply up to 3 weeks LOS and then tended to plateau. Better informational continuity was associated with more comprehensive care, higher risk of mortality, acute rather than rehabilitation care, communication with community health care professionals within 48 hours after admission, and a target LOS of 3 weeks or longer. The completion of advance directives was more likely in the presence of advanced age, higher risk of mortality, cognitive impairment, discharge to another care facility, longer LOS, university-affiliated institution, and nonurban location. CONCLUSION: In GAUs, quality-of-care processes are related to both structural and patient characteristics. Our results pointed toward an organizational framework that may help to streamline the geriatric units and better use resources, notably by narrowing the admission criteria, targeting a proper LOS, improving communication with community organizations, and making systematic completion of advance directives.

Quality-of-care processes in geriatric assessment units: principles, practice, and outcomes.

OBJECTIVES: To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-nine Geriatric Assessment Units. PARTICIPANTS: Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases. RESULTS: A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55-0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82-1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74-0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59-0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes. CONCLUSION: A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.

Vision in the global evaluation of older individuals hospitalized following a fall.

INTRODUCTION: The objective of this study was to verify if vision is appropriately evaluated in older individuals admitted to a Geriatric Assessment Unit following a fall. METHODS: A retrospective clinical chart review of 158 patients from 3 university-based Geriatric Assessment Units is presented. The clinical charts of patients admitted following a fall in the Geriatric Assessment Units of 3 Montreal hospitals, between April 2006 and 2008, were reviewed. Clinical charts from age- and sex-matched controls hospitalized in the Geriatric Assessment Units during the same period but without a history of fall or fracture, were also reviewed. Pertinent sociodemographic, medical, and visual characteristics were extracted from the charts and entered into a database for analysis. RESULTS: The mean age ± standard deviation for the cases (n = 79) and controls (n = 79) were 82.3 ± 6.2 years and 81.7 ± 6.4 years, respectively. Most falls were not a result of accidents, but rather were more often related to underlying medical problems that were multifactorial in origin. More cases than controls were taking antiarrhythmic and antidepressant medications, whereas more controls were taking calcium channel blockers. Cases were more likely to have cataracts, age-related macular degeneration, and decreased visual acuity. Although cases were referred more often than controls for an eye examination, they were not referred in a systematic fashion. DISCUSSION: Our results indicate that more visual problems are identified in persons who fall and, even if they are referred more often than controls for an eye examination, their vision is not evaluated systematically by an eye care specialist despite current clinical recommendations. CONCLUSION: These data indicate that eye care professionals should work more closely with the medical team to improve the overall clinical care of older individuals with a history of falls.

A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model.

BACKGROUND: Elderly patients admitted to Geriatric Assessment Units (GAU) typically have complex health problems that require multi-professional care. Considering the scope of human and technological resources solicited during hospitalization, as well as the many risks and discomforts incurred by the patient, it is important to ensure the communication of pertinent information for quality follow-up care in the community setting. Conventional discharge summaries do not adequately incorporate the elements specific to an aging clientele. OBJECTIVE: To develop a discharge summary adapted to the frail elderly patient (D-SAFE) in order to communicate relevant information from hospital to community services. METHODS: The items to be included in the D-SAFE have been determined by means of a modified Delphi method through consultation with clinical experts from GAUs (11 physicians and 5 pharmacists) and the community (10 physicians and 5 pharmacists). The consensus analysis and the level of agreement among the experts were reached using a modified version of the RAND®/University of California at Los Angeles appropriateness method. RESULTS: A consensus was reached after two rounds of consultation for all the items evaluated, where none was judged "inappropriate". Among the items proposed, four were judged to be "uncertain" and were eliminated from the final D-SAFE, which was divided into two sections: the medical discharge summary (22 main items) and the discharge prescription (14 main items). CONCLUSIONS: The D-SAFE was developed as a more comprehensive tool specifically designed for GAU inpatients. Additional research to validate its acceptability and practical impact on the continuity of care is needed before it can be recommended for use on a broader scale.

Short-term geriatric assessment units: 30 years later.

BACKGROUND: The increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them. METHODS: In 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their unit's operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile. RESULTS: Overall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAU's operation. CONCLUSIONS: The GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAU's primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

[Management of osteoporosis in short-term geriatric units]. / Prise en charge de l'ostéoporose dans les unitéés de courte durée gériatriques.

OBJECTIVE: To identify the recommendations in Canadian and American clinical practice guidelines for the management of osteoporosis that are applicable to vulnerable, older patients in short-term geriatric units (STGU). DESIGN: Modified Delphi approach according to the RAND/UCLA method. SETTING: A panel of experts from various regions of Quebec. PARTICIPANTS: The panel consisted of 6 physicians, 5 pharmacists, and 3 nutritionists recognized by their peers for their expertise in STGU. METHODS: Eleven recommendations from the North American guidelines were submitted to a panel of experts who were asked to identify those most appropriate for the management of osteoporosis in STGU. Each expert's level of agreement with the recommendations and the experts' general level of agreement were used to determine the relevance of the recommendations. FINDINGS: The experts reached a consensus on each of the 11 recommendations. Seven recommendations were deemed appropriate for the management of osteoporosis in vulnerable, older patients in STGU. Bone mineral density measurement as a parameter for follow-up was the only recommendation deemed inappropriate in this context. The experts remained uncertain about 3 recommendations: systematic screening for osteoporosis by bone mineral density measurement; systematic screening or evaluation of the risk factors for fractures; and pharmacologic prevention in vulnerable, older patients with an increased risk of fracture. CONCLUSION: Some of the recommendations issued in the North American recommendations appear to be less appropriate for managing osteoporosis in vulnerable, older patients in STGU. The recommendations retained in this study could be used to standardize interventions for these patients and to determine the extent to which current practice follows the recommendations.

Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition.

BACKGROUND: The number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This study's objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs). METHODS: The methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002-2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis. RESULTS: Three quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability. CONCLUSION: Content validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.

[Validation of indicators of the management of cognitive impairment in geriatric assessment units]. / Validation d'indicateurs de la prise en charge des atteintes des fonctions cognitives dans les unités d'évaluation gériatrique.

OBJECTIVE: To analyze and adapt a set of quality indicators for assessment and management of patients with cognitive disorders, which are seen very frequently in geriatric assessment units in Quebec. DESIGN: Modified Delphi technique. SETTING: Province of Quebec. PARTICIPANTS: Seven clinicians from 3 different medical faculties in Quebec were selected for their expertise in dementia and geriatric care. METHOD: From among the indicators developed in 2001 using the RAND method, 22 items selected for their relevance to evaluation and management of cognitive disorders were adapted to clinical practice in the Quebec hospital system. These indicators, along with evidence from the literature, were submitted by mail to a panel of experts. The experts were asked to rate, on a scale of 1 to 9, their level of agreement with the indicators in terms of their validity and quality and the need for them to be recorded in patients' medical charts. For an indicator to be retained, it had to be accepted according to its median value, to be rated in the upper third of the scale, and to be approved by the panelists. Indicators not accepted at first were modified according to experts' comments and then re-submitted to the same panel for a second round. RESULTS: Of 22 indicators submitted in the first round, 21 were validated. They covered assessment, investigation, evaluation, treatment, and follow-up. The indicator found questionable was modified and then accepted during the second round. CONCLUSION: This study identified 22 indicators relevant to assessment and management of patients with cognitive disorders in geriatric assessment units. These indicators will serve as a basis for evaluation of dementia in a larger study of the quality of care in all short-term geriatric assessment units in Quebec.

Admission criteria in short-term geriatric assessment units: a Delphi study.

BACKGROUND: In recent years, short-term geriatric care units that operate using an interdisciplinary approach have been established in Quebec and elsewhere, in order to provide frail elderly persons with better health care. The purpose of this study is to determine criteria that target the greatest number of individuals most likely to benefit from hospitalization in this type of care unit. METHODS: A Delphi survey was conducted. The panel of experts consisted of 54 physicians and nurses working in short-term geriatric care units in Quebec. Three questionnaires were mailed and 4-level Likert scales were used. Median values, and 25th and 75th percentiles to a maximum of 2, were chosen a priori as the definition of consensus. RESULTS: The survey used 14 inclusion criteria and 17 exclusion criteria. Inclusion criteria were divided into two categories and exclusion criteria were divided into four. INTERPRETATION: A typical clinical profile of a patient who should be admitted to a STGCU emerges: an elderly person presenting multiple pathologies, acute or sub-acute functional disability, and often related psychosocial problems. The instrument developed by this project is a practical guide for professionals in STGAUs as well as those responsible for allocating resources in the health care system.