[Inappropriate admissions of Ehpad residents to emergency departments]. / Admissions inappropriées des résidents d'Ehpad aux urgences.

After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.

Potentially inappropriate use of furosemide in a very elderly population: An observational study.

OBJECTIVE: Little is known about furosemide prescription modalities in elderly people. We describe furosemide prescription in ambulatory elderly patients. METHODS: All patients aged over 80 years, affiliated to Mutualité Sociale Agricole de Bourgogne, a French regional health insurance plan, with a medical prescription delivered in March 2015, were retrospectively included. RESULTS: Among 15 141 patients with a median age of 86 years, comprising 61.3% of women, 3937 patients (26%) had a prescription for furosemide. Severe heart failure was the most common chronic comorbidity (27.7%). Furosemide was considered a long-term therapy for almost all patients (98.7% with prescriptions for 3 months or more). Recommended indications for long-term furosemide therapy included severe heart failure (50.9%), chronic nephropathy (3%) and cirrhosis (0.1%). The furosemide prescription rate increased with age (81-85: 20.4%, 86-90: 28.5%, 91-95: 35.6%, >95: 42.7%, P<.001), and the increase was associated with a decrease in recommended heart failure therapeutics (beta-blockers, angiotensin-conversion-enzyme-inhibitors or angiotensin-receptor-blockers). Prescribers were mostly general practitioners (81.3%). Plasma electrolytes were controlled in less than a half of the patients with furosemide. CONCLUSIONS: In this large study, long-course furosemide was prescribed in a quarter of ambulatory patients. Half of those taking furosemide suffered from severe heart failure. Age was associated with a linear increase in furosemide use and a decrease in recommended heart failure therapeutic prescriptions. A large part of these prescriptions do not seem to be in accordance with recommendations.

A New Prognosis Score to Predict Mortality After Acute Pneumonia in Very Elderly Patients.

OBJECTIVES: Acute pneumonia (AP) induces an excess of mortality among the elderly. We evaluated the value of a new predictive biomarker index compared to usual prognosis scores for predicting in-hospital and 1-year mortalities in elderly inpatients with AP. DESIGN: Retrospective study in 6 clinical departments of a university hospital. SETTING: Burgundy university hospital (France). PARTICIPANTS: All patients aged 75 and over with AP and hospitalized between January 1 and June 30, 2013, in the departments of medicine (5) and intensive care (1) of our university hospital. MEASUREMENTS: A new index, which we named UBMo, was created by multiplying the uremia (U in the formula) by the N-terminal-pro-brain natriuretic peptide (NT-proBNP) plasmatic rate (B), divided by the monocyte count (Mo). RESULTS: Among the 217 patients included, there were 138 community-acquired pneumonia, 56 nursing home-acquired pneumonia, and 23 hospital-acquired pneumonia. In-hospital and 1-year mortality rates were respectively 19.8% and 43.8%. In multivariate analysis, Pneumonia Severity Index (PSI), unlike CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30 breaths/min, blood pressure <90 mmHg systolic or ≤60 mmHg diastolic, age ≥65) score, was associated with in-hospital and 1-year mortalities. UBMo index performed better than PSI and CURB-65 scores in predicting both in-hospital and 1-year mortalities. For in-hospital mortality, the areas under the receiver operating characteristic curves (AUCs) were 0.89 (95% CI = 0.84-0.94), 0.72 (95% CI = 0.65-0.80), and 0.63 (95% CI = 0.54-0.72), respectively, for the 3 scores. For 1-year mortality, the AUCs were 0.93 (95% CI = 0.89-0.98), 0.66 (95% CI = 0.59-0.74), and 0.58 (95% CI = 0.50-0.66), respectively, for the 3 scores. The cut point for the UBMo index of 20,000 × 10-9 ng·mmol/L had a sensitivity of 93.1% and 80.9% and a specificity of 76.3% and 95.8%, respectively, for in-hospital and 1-year mortalities. CONCLUSION: If confirmed by prospective studies, the UBMo index appears very efficient in identifying patients at high risk of in-hospital and 1-year mortalities after an AP.

Prolonged stays in hospital acute geriatric care units: identification and analysis of causes.

In France, the population of very old frail patients, who require appropriate high-quality care, is increasing. Given the current economic climate, the mean duration of hospitalization (MDH) needs to be optimized. This prospective study analyzed the causes of prolonged hospitalization in an acute geriatric care unit. Over 6 months, all patients admitted to the target acute geriatric care unit were included and distributed into two groups according to a threshold stay of 14 days: long MDH group (LMDHG) and short MDH group (SMDHG). These two groups were compared. 757 patients were included. The LMDHG comprised 442 with a mean age of 86.7 years, of whom 67.65% were women and the SMDHG comprised 315 with a mean age of 86.6 years, of whom 63.2% were women. The two groups were statistically similar for age, sex, living conditions at home (alone or not, help), medical history and number of drugs. Patients in the LMDHG were more dependent (p=0.005), and were more likely to be hospitalized for social reasons (p=0.024) and to have come from their homes (p=0.011) than those in the SMDHG. The reasons for the prolonged stay, more frequent in the LMDHG than the SMDHG (p<0.05), were principally: waiting for imaging examinations, medical complications, and waiting for discharge solutions, assistance from social workers and/or specialist consultations. In order to reduce the MDH in acute geriatric care unit, it is necessary to consider the particularities of the patients who are admitted, their medico-socio-psychological management, access to technical facilities/consultations and post-discharge accommodation.