Prevalence of Geriatric Syndromes and the Need for Hospice Care in Older Patients of the Emergency Department: A Study in an Asian Medical Center.

BACKGROUND: The prevalence of geriatric syndromes and the need for hospice care in the emergency department (ED) in Asian populations remain unclear. This study was conducted to fill the data gap. METHODS: Using a newly developed emergency geriatric assessment (EGA), we investigated the prevalence of geriatric syndromes and the need for hospice care in older ED patients of a tertiary medical center between September 1, 2016, and January 31, 2017. RESULTS: We recruited a total of 693 patients with a mean age of 78.0 years (standard deviation 8.2 years), comprising 46.6% of females. According to age subgroups, 37.4% of patients were aged 65-74 years, 37.4% were aged 75-84 years, and 25.2% were aged ≥85 years. The prevalence rates of geriatric syndromes were as follows: delirium (11.4%), depression (23.4%), dementia (43.1%), deterioration of activities of daily living (ADL) for <1 year (29.4%), vision impairment (22.2%), hearing impairment (23.8%), sleep disturbance (13.1%), any fall in <1 year (21.8%), polypharmacy (28.7%), pain (35.1%), pressure ulcer (5.6%), incontinence or retention (29.6%), indwelling device or physical restrain (21.6%), nutrition problem (35.7%), frequent use of medical resources (50.1%), lack of advance care planning (84.0%), caregiver problem (4.6%), socioeconomic problem (5.5%), and need for family meeting (6.2%). The need for hospice care was 11.9%. Most geriatric syndromes increased with advancing age except depression, sleep disturbance, polypharmacy, pain, nutrition problem, lack of advance care planning, caregiver problem, and socioeconomic problem. CONCLUSION: Geriatric syndromes and the need for hospice care were common in the older ED patients. Further studies about subsequent intervention for improving geriatric care are needed.

Hypotension, bedridden, leukocytosis, thrombocytopenia and elevated serum creatinine predict mortality in geriatric patients with fever.

AIM: The geriatric population (aged ≥65 years) accounts for 12-24% of all emergency department (ED) visits. Of them, 10% have a fever, 70-90% will be admitted and 7-10% of will die within a month. Therefore, mortality prediction and appropriate disposition after ED treatment are of great concern for geriatric patients with fever. We tried to identify independent mortality predictors of geriatric patients with fever, and combine these predictors to predict their mortality. METHODS: We enrolled consecutive geriatric patients visiting the ED between 1 June and 21 July 2010 with the following criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. We used 30-day mortality as the primary end-point. RESULTS: A total of 330 patients were enrolled. Hypotension, bedridden, leukocytosis, thrombocytopenia and serum creatinine >2 mg/dL, but not age, were independently associated with 30-day mortality. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) ranged from 18.2% to 90.9%, 34.7% to 100%, 9.0% to 100% and 94.5% to 98.2%, respectively, depending on how many predictors there were. CONCLUSIONS: The 30-day mortality increased with the number of independent mortality predictors. With at least four predictors, 100% of the patients died within 30 days. With none of the predictors, just 1.8% died. These findings might help physicians make decisions about geriatric patients with fever.

The impact of rotating night shifts on the breast milk collection volume among employed breastfeeding mothers.

OBJECTIVES: The health benefits of breastfeeding are widely recognized. The World Health Organization recommends exclusive breastfeeding for six months after birth and for two years or longer together with nutritionally adequate complementary foods. To respond to the needs of industry, employed breastfeeding mothers must adapt to the rotating night shift (RNS). However, the RNS is associated with a higher risk of health problems in career women. We investigated the relationship between the RNS and breast milk volume. METHODS: Mothers who used a breastfeeding room while working at a technology company in Taiwan voluntarily participated in this study from March 1 through April 30, 2013. We compared two groups: breastfeeding mothers on (RNS(+)) and not on a RNS (RNS(-)) to determine independent predictors for breast milk volume. We analyzed data from 109 participants: RNS(+) group n=56; RNS(-) group n=53. RESULTS: There was no significant difference in daily milk collection volume between the groups. Daily milk collection frequency and exclusive breastfeeding were independent predictors for a daily breast milk collection volume >350 ml. CONCLUSIONS: The RNS may not affect the breast milk volume. This result may help the government and employers make policies more appropriate for supporting employed breastfeeding mothers.

Clinical characteristics of hyperglycemic crises in patients without a history of diabetes.

AIMS/INTRODUCTION: Hyperglycemic crises without a history of diabetes have not been well studied. We compared the clinical characteristics of patients with and without a history of diabetes, and evaluated the glycated hemoglobin levels. MATERIALS AND METHODS: Consecutive adult patients (aged >18 years) visiting the emergency department (ED) between January 2004 and December 2010 were enrolled if they met the criteria for a hyperglycemic crisis. Patients were separated into those without and those with a history of diabetes. The 30-day mortality was the primary end-point. RESULTS: We enrolled 295 patients who made 330 visits to the ED. Patients without a history of diabetes made up 24.5% (81/330) of the hyperglycemic crises. Patients without a history of diabetes were more prone than patients with a history of diabetes to be younger and male, and to have better consciousness and renal function, more significant diabetic signs and symptoms (e.g., thirst, polydipsia, polyuria and bodyweight loss), higher blood sugar, and less opportunity of infection and mortality. Most of the patients (93.8%, 76/81) had glycated hemoglobin of ≥6.5%. CONCLUSIONS: The present study delineates the clinical characteristics of patients with hyperglycemic crises, but without a history of diabetes. Most patients had glycated hemoglobin ≥6.5%, which raises the argument of using this biomarker for routine screening of diabetes.

Geriatric Fever Score: a new decision rule for geriatric care.

BACKGROUND: Evaluating geriatric patients with fever is time-consuming and challenging. We investigated independent mortality predictors of geriatric patients with fever and developed a prediction rule for emergency care, critical care, and geriatric care physicians to classify patients into mortality risk and disposition groups. MATERIALS AND METHODS: Consecutive geriatric patients (≥65 years old) visiting the emergency department (ED) of a university-affiliated medical center between June 1 and July 21, 2010, were enrolled when they met the criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. Thirty-day mortality was the primary endpoint. Internal validation with bootstrap re-sampling was done. RESULTS: Three hundred thirty geriatric patients were enrolled. We found three independent mortality predictors: Leukocytosis (WBC >12,000 cells/mm3), Severe coma (GCS ≤ 8), and Thrombocytopenia (platelets <150 10(3)/mm3) (LST). After assigning weights to each predictor, we developed a Geriatric Fever Score that stratifies patients into two mortality-risk and disposition groups: low (4.0%) (95% CI: 2.3-6.9%): a general ward or treatment in the ED then discharge and high (30.3%) (95% CI: 17.4-47.3%): consider the intensive care unit. The area under the curve for the rule was 0.73. CONCLUSIONS: We found that the Geriatric Fever Score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in geriatric patients with fever, although external validation should be performed to confirm its usefulness in other clinical settings. It might help preserve medical resources for patients in greater need.

Long-term prognosis of patients with carbon monoxide poisoning: a nationwide cohort study.

BACKGROUND: Carbon monoxide poisoning (COP) often produces severe complications and can be fatal. Because this topic has not been well delineated, we investigated long-term prognoses of patients with COP (COP[+]). METHODS: In this retrospective nationwide cohort study, 441 COP[+] patients and 8820 COP[-] controls (120) from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database. RESULTS: Thirty-seven (8.39%) COP[+] patients and 142 (1.61%) controls died (P<0.0001) during follow-up. Incidence rate ratios (IRR) of death were 5.24 times higher in COP[+] patients than in controls (P<0.0001). The risk of death was particularly high in the first month after COP (IRR: 308.78; 95% confidence interval [CI]: 40.79-2337.56), 1 to 6 months after (IRR: 18.92; 95% CI: 7.69-46.56), and 6-12 months after (IRR: 4.73; 95% CI: 1.02-21.90). After adjusting for age, gender, and selected comorbidities, the hazard ratio of death for COP[+] patients was still 4.097 times higher than for controls. Moreover, older age (≥30 years old), male gender, diabetes mellitus, hypertension, and low income were also independent mortality predictors. CONCLUSIONS: COP significantly increases the risk for long-term mortality. Early follow-up and secondary prevention of death are needed for patients with COP.

A positive Babinski reflex predicts delayed neuropsychiatric sequelae in Chinese patients with carbon monoxide poisoning.

As the human population increased in China, the carbon monoxide is a serious environmental toxin in public health. However, predicting the delayed neuropsychiatric sequelae (DNS) of carbon monoxide poisoning (COP) has not been well studied. We investigated the independent predictors of DNS in patients with COP. This study was conducted at four hospitals in China. Data were retrospectively collected from 258 patients with COP between November 1990 and October 2011. DNS was the primary endpoint. A positive Babinski reflex was the independent predictor for DNS: sensitivity = 53.8% (95% confidence interval [CI]: 26.1-79.6), specificity = 88.6% (95% CI: 83.7-92.1), positive predictive value (PPV) = 20.0% (95% CI: 9.1-37.5), and negative predictive value (NPV) = 97.3% (95% CI: 94.0-98.9). The area under the receiver operating characteristic curve = 0.712 (95% CI: 0.544-0.880). A positive Babinski reflex was very memorable, immediately available, and applicable in clinical practice. Even when the sensitivity and PPV of a positive Babinski reflex were unsatisfactory, it had a good specificity and NPV for excluding the risk of DNS. In patients without a positive Babinski reflex, the risk for DNS was only 2.7%. This finding may help physicians make decisions about dispositions for patients with COP.