Home telemonitoring in smart rurality: results from the HIS2R interreg feasibility pilot study.

AIMS: The Health in Smart Rurality Interreg project aims to assess the feasibility of telemonitoring in rural areas across the Franco-Belgian border among patients affected by heart failure or chronic obstructive pulmonary disease. The objectives were to better understand strengths or barriers to implementing telemonitoring for early detection of potential adverse events, for improving quality of life, communication, and care coordination. METHODS: Using a prospective 6-month observational design, interconnected pads were provided to community-dwelling adults aged over 60 years. The device monitored daily body weight, temperature, cardiac rate, blood pressure, and oxygen saturation. Using predefined warning thresholds, data were analyzed by a nurse case-manager who also provided therapeutic education during their contacts. RESULTS: Out of 87 eligible and screened patients, 21 (24%) were included in the study. At the end of the follow-up, 19 patients (90%) were re-assessed. The rate of hospitalization and mortality was high (32% and 10%, respectively). A total of 644 alerts were recorded (median of 29 alerts/patients) with a high rate of technically-related alerts (TRA) (26%). Out of the 475 non-TRA, 79% and 1% have led to an intervention by the case-manager or the physician, respectively. Therapeutic adjustment was proposed for 12 patients during that period. CONCLUSION: Telemonitoring appears to be a promising solution for the follow-up of patients living far from medical resources. The contribution of a case-manager is of added-value in managing alerts, therapeutic education, and coaching. Many questions remain open such as the improvement of technical aspects and long-term compliance in a real-world setting.

A comparison of clinical characteristics between old and oldest-old patients hospitalised for SARS-COV2.

OBJECTIVES: Oldest-old patients may have an unusual SARS-COV2 presentation that can jeopardise diagnosis and management. The aim of this study was to compare the clinical characteristics and outcomes of oldest-old (≥85 years) and old patients (75-85 years) admitted with COVID-19 to Belgian hospitals during the first wave of the pandemic. METHODS: We conducted a multicentre, retrospective, observational study in ten Belgian hospitals. We reviewed the electronic clinical records of patients ≥75 years hospitalised with COVID-19 from March to June 2020. RESULTS: A total of 986 patients were placed on the register (old group: n = 507; oldest-old group: n = 479). Before hospitalisation, the oldest-old (OO) group presented with more geriatric syndromes including comorbidities, frailty, falls, cognitive impairment, and incontinence. At admission, the OO group presented with less cough, less headache, and less fever but significantly more delirium than old (O) group. Members of the OO group were admitted less frequently to intensive care units (ICUs). A geriatrician was consulted to help in the decision-making process more often for the OO group. The global mortality of the cohort was 47%, with no difference between the two groups. Patients in the OO group were more often institutionalised after hospitalisation and less often referred for rehabilitation. CONCLUSIONS: The OO patients presented with more geriatric syndromes that make them vulnerable to dependence and institutionalisation after a hospital stay, without having a higher mortality rate than O patients. Geriatrician expertise is necessary in the management of frail older patients.

Investigating the relationship between specific executive functions and functional decline among community-dwelling older adults: results from a prospective pilot study.

BACKGROUND: As cognitive functions and, more specifically, executive functions (EF) seem to influence autonomy among the elderly, we investigated the role of each of the five EF sub-components (inhibition, spontaneous flexibility, reactive flexibility, planning, and updating in working memory) for the risk of functional decline. METHOD: A total of 137 community-dwelling participants over 75 years of age were included in a prospective cohort study and assigned to three groups: individuals with neuro-degenerative cognitive disorders, those having cognitive disorders with non-degenerative aetiology, and a control group without any cognitive problems. We measured each EF sub-component and assessed functional decline by evaluating basic (b-ADL) and instrumental activities of daily living (i-ADL) at baseline and 6 months later. We conducted three separate multiple logistic regression models to examine the extent to which the five EF facets predicted overall functional decline at the end of the follow-up period. RESULTS: We found that people who exhibited a decline in b-ADLs or/and i-ADLs over 6 months had worse performance on inhibition and two flexibility tasks than those who did not experience a decline. The results suggest that decliners have more difficulties in managing unforeseen events. Inhibition and updating in working memory predicted a decline in b-ADL while spontaneous and reactive flexibilities predicted a decline in i-ADL. CONCLUSION: In our sample, specific executive dysfunctions were associated with a decline in functional status. With respect to the risk of decline in b-ADL, deficits in inhibition may represent a risk factor, as it regulates over-learned activities. Bothtypes of flexibility, which allow the shifting and generating of adaptive responses, predicted decline in i-ADL. In sum, paying more attention to particular EF profiles would help clinicians to anticipate some aspects of functional decline.

Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study.

BACKGROUND: Benzodiazepine receptor agonist (BZRA) use is highly prevalent in hospitalised older people although these drugs are associated with numerous and serious adverse events. Deprescribing can reduce risks associated with chronic BZRA use. The aim of this study was to measure the prevalence of, and factors associated with, BZRA deprescribing in acute geriatric units. METHODS: During a one-year period, this multicentre retrospective study included patients aged ≥70 years, hospitalised in acute geriatric units, and using ≥1 BZRA on admission. BZRA deprescribing at discharge was defined as: ≥25% decrease in lorazepam-equivalent admission dose; discontinuation of all BZRAs; or cessation of a rescue prescription at discharge. BZRA cessation was defined as discontinuation of all BZRAs at discharge. We identified social, medical, geriatric and medication factors associated with BZRA deprescribing using logistic regression. RESULTS: In total, 561 patients were included (mean age: 85.3±5.9 years, 70% of women). BZRA deprescribing occurred in 240 (42.8%), including 85 with BZRA cessation (15.2%). Deprescribing occurred more frequently in patients with a BZRA-related adverse event on admission or during hospital stay (odds ratio (OR) 4.5; 95% confidence interval [2.6; 7.9]), with an antidepressant (1.6 [1.1; 2.4]) and a higher lorazepam-equivalent dosage on admission (OR 1.2 [1; 1.4]), and less frequently in patients with antipsychotic drug (OR 0.5 [0.3; 0.8]). BZRA cessation was more likely in patients with a BZRA-related adverse event (OR 2.2 [1.2; 4.3]) and a lower lorazepam-equivalent dosage on admission (OR 0.5 [0.3; 0.6]). CONCLUSIONS: During hospitalisation in the acute geriatric units of our hospital, BZRA deprescribing occurred in 42.8% of the patients. Identification of an BZRA-related adverse event by the treating physician appears to be a major factor: this reactive deprescribing accounted for 74% of cases in our study. Further prospective studies are needed to measure long-term persistence of in-hospital deprescribing and encourage proactive management.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

Prevalence of multidrug-resistant organisms in nursing homes in Belgium in 2015.

OBJECTIVES: Following two studies conducted in 2005 and 2011, a third prevalence survey of multidrug-resistant microorganisms (MDRO) was organised in Belgian nursing homes (NHs) using a similar methodology. The aim was to measure the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum ß-lactamase producing Enterobacteriaceae (ESBLE) and carbapenemase-producing Enterobacteriaceae (CPE) in NH residents. Risk factors for MDRO carriage were also explored. METHODS: Up to 51 randomly selected residents per NH were screened for MDRO carriage by trained local nurses between June and October 2015. Rectal swabs were cultured for ESBLE, CPE and VRE, while pooled samples of nose, throat and perineum and chronic wound swabs were obtained for culture of MRSA. Antimicrobial susceptibility testing, molecular detection of resistance genes and strain genotyping were performed. Significant risk factors for MDRO colonization MDRO was determined by univariate and multivariable analysis. RESULTS: Overall, 1447 residents from 29 NHs were enrolled. The mean weighted prevalence of ESBLE and MRSA colonization was 11.3% and 9.0%, respectively. Co-colonization occurred in 1.8% of the residents. VRE and CPE carriage were identified in only one resident each. Impaired mobility and recent treatment with fluoroquinolones or with combinations of sulphonamides and trimethoprim were identified as risk factors for ESBLE carriage, while for MRSA these were previous MRSA carriage/infection, a stay in several different hospital wards during the past year, and a recent treatment with nitrofuran derivatives. Current antacid use was a predictor for both ESBL and MRSA carriage. CONCLUSIONS: In line with the evolution of MRSA and ESBL colonization/infection in hospitals, a decline in MRSA carriage and an increase in ESBLE prevalence was seen in Belgian NHs between 2005 and 2015. These results show that a systemic approach, including surveillance and enhancement of infection control and antimicrobial stewardship programs is needed in both acute and chronic care facilities.

Implementing a screening tool to improve prescribing in hospitalized older patients: a pilot study.

Background The use of STOPP-START criteria during hospitalization reduced inappropriate medications in randomized controlled trials. Objective To evaluate whether the implementation of a screening tool (short version of STOPP-START criteria) in routine geriatric practice reduces potentially inappropriate medications (PIM) and potential prescribing omissions (PPO) at discharge. Methods We conducted a retrospective interrupted time series analysis. Four periods were selected between February and September 2013: (1) baseline situation; (2) screening tool made available to physicians; (3) 3 months later; (4) weekly meetings with junior doctors and a clinical pharmacist to review treatments according to the tool. The primary outcome was the proportion of patients with prescribing improvement from admission to discharge. Results We included 120 patients (median age 85 years). The prevalence of PIMs and PPOs on admission was 56% (67/120) and 51% (61/120) respectively. Hospitalization improved prescribing appropriateness in 49% of patients with PIMs (33/67) and 39% of patients with PPOs (24/61). The use of the screening tool by way of multidisciplinary meetings was a predictor of PIMs reduction at discharge. Conclusions The sole distribution of a screening tool in a geriatric unit did not reduce PIMs and PPOs. Multidisciplinary meetings to review treatments should be encouraged.

Executive dysfunctions as a good predictor of misuse of respiratory inhalers among hospitalized patients: a prospective survey.

The objectives of the study are to determine the prevalence and potential risk factors of misuse of respiratory inhalers among hospitalized patients admitted at the CHU UcL Namur, site Godinne. Using a cross-sectional design, patients using respiratory inhalers since more than 7 days were recruited from a database established by the hospital pharmacy. Inhaler technique was assessed using a standardised check-list and graded misuse as major or minor errors using previously published criteria. Demographic and clinical data were prospectively collected using standardised tools. Among the 100 consecutive patients selected for the study (median of age: 68 years), the prevalence of misuse was 40%. According to univariate analysis, main risk factors of misuse were age, executive dysfunction, a low grip strength, a low level of manual dexterity and the type of inhaler used. The best predictor of misuse according to multivariate analysis was executive dysfunction as assessed by the BREF scale (batterie rapide d'efficience frontale) (adjusted odds ratio: 1.35 [CI95%: 1.11-1.64]; p: 0.002). A BREF score ≤ 12/18 was associated with a six-fold increase of respiratory inhaler misuse risk. We conclude that executive dysfunction is associated with a higher risk of respiratory inhalers misuse. A short screening of executive function, using the BREF scale, before starting respiratory inhaler may improve the selection of inhaler devices and therefore the compliance to treatment.

Epidemiology of multidrug-resistant microorganisms among nursing home residents in Belgium.

OBJECTIVES: A national survey was conducted to determine the prevalence and risk factors of methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum ß-lactamases-producing Enterobacteriaceae (ESBLE) and vancomycin-resistant enterococci (VRE) among nursing home residents in Belgium. METHODS: A random stratified, national prevalence survey was conducted in nursing home residents who were screened for carriage of ESBLE, MRSA and VRE by multisite enriched culture. Characteristics of nursing homes and residents were collected by a questionnaire survey and were analysed by multilevel logistic regression analysis. RESULTS: Of 2791 screened residents in 60 participating nursing home, the weighted prevalence of ESBLE and MRSA carriage were 6.2% (range: 0 to 20%) and 12.2% (range: 0 to 36%), respectively. No cases of VRE were found. No relationship was found between ESBLE and MRSA prevalence rates within nursing homes and the rate of co-colonization was very low (0.8%). Geographical variations in prevalence of MRSA and ESBLE and in distribution of ESBL types in nursing home residents paralleled that of acute hospitals. Risk factors of ESBLE carriage included previously known ESBLE carriage, male gender, a low level of mobility and previous antibiotic exposure. Risk factors for MRSA colonization were: previously known MRSA carriage, skin lesions, a low functional status and antacid use. CONCLUSIONS: A low prevalence of ESBLE carriage was found in nursing home residents in Belgium. The prevalence of MRSA carriage decreased substantially in comparison to a similar survey conducted in 2005. A low functional status appeared as a common factor for ESBLE and MRSA carriage. Previous exposure to antibiotics was a strong predictor of ESBLE colonization while increased clustering of MRSA carriage suggested the importance of cross-transmission within nursing homes for this organism. These results emphasize the need for global coordination of the surveillance of MDRO within and between nursing homes and hospitals.

Feasibility of implementing a practice guideline for fall prevention on geriatric wards: a multicentre study.

BACKGROUND: About 40% of all adverse events in hospital are falls, but only about one in three Belgian hospitals have a fall prevention policy in place. The implementation of a national practice guideline is urgently needed. OBJECTIVE AND DESIGN: This multicentre study aimed to determine the feasibility of a previously developed guideline. SETTING, PARTICIPANTS AND METHOD: Seventeen geriatric wards, selected at random out of 40 Belgian hospitals who agreed to take part in the study, evaluated the fall prevention guideline. After the one-month test period, 49 healthcare workers completed a questionnaire on the feasibility of the guideline. RESULTS: At the end of the study, 512 geriatric patients had been assessed using the practice guideline. The average time spent per patient on case finding, multifactorial assessment and initiating a treatment plan was 5.1, 76.1 and 30.6 min, respectively. For most risk assessments and risk modifications, several disciplines considered themselves as being responsible and capable. The majority (more than 69%) of the respondents judged the practice guideline as useful, but only a small majority (62.3%) believed that the guideline could be successfully integrated into their daily practice over a longer period of time. Barriers for implementation included a large time investment (81.1%), lack of communication between the different disciplines (35.8%), lack of motivation of the patient (34.0%), lack of multidisciplinary teamwork (28.3%), and lack of interest from the hospital management (15.4%). CONCLUSION: Overall, the guideline was found useful, and for each risk factor (except for visual impairment), at least one discipline felt responsible and capable. Towards future implementation of the guideline, following steps should be considered: division of the risk-factor assessment duties and interventions among different healthcare workers; patient education; appointment of a fall prevention coordinator; development of a fall prevention policy with support from the management of the hospital.

Health outcomes of older patients colonized by multi-drug resistant bacteria (MDRB): a one-year follow-up study.

The objective of this study was to examine whether asymptomatic colonization with MDRB would affect outcomes in older patients one year after hospitalization in a geriatric ward. Patient samples were analyzed to identify specific MDRBs, including methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobaceriaceae (ESBLE), and vancomycin-resistant enterococci (VRE). Among 337 patients screened at hospital admission, 62 (18%) carried one or more MDRB isolates (MRSA: n=23; ESBLE: n=39; VRE: n=2). At 12 months after admission, 320 patients were interviewed by telephone (17 patients lost to follow up) to assess all-cause mortality, nursing home admissions, functional decline, and hospital readmissions. All-cause mortality rates were similar in MDRB carriers (34%; n=61) and non-carriers (30%; n=259) (P=0.512). Nursing home admission, functional decline, and hospital readmission did not differ between the two groups. In this population, predictors of mortality were: male gender (P=0.002), cognitive disorders at admission (P=0.028), low pre-albumin level at admission (P=0.048), a high level of co-morbidities (P=0.002), and a history of an acute condition in the three months prior to initial hospital admission (P=0.024). In conclusion, in this cohort of older patients, asymptomatic MDRB colonization was not significantly associated with adverse health outcomes at a one-year follow-up after hospitalization. The potential limitations of the study were the small sample size, relatively high mortality rate, and lack of MDRB reassessment during the follow-up.

[The Get-up early test, elaboration process of a new screening tool for psychomotor disadaptation syndrome]. / Élaboration d'un test de dépistage du syndrome de désadaptation psychomotrice : le Get-up early test.

Major features of the psychomotor disadaptation syndrome (SDPM) include motor skill dysfunctions with alteration of postural capabilities, walking abilities and psychomotric automatisms. Mini motor test (TMM) is the gold standard used by skilled physiotherapists in order to assess the syndrome. The aim of this article is to present the elaboration process of a new SDPM screening tool, called the Get-up early test. The test was firstly elaborated through consensus of nine experts in the geriatric field. This first 5-items version had poor inter-rater reproducibility and was therefore modified in a new 4-item version. This new version had substantial inter-rater concordance. Compared to the TMM as gold standard, in two different settings (acute ward and nursing home), with a cut-off value≥1/4, diagnostic performance was good (sensibility: 0.73 and specificity 0.88; area under curve: 0.823). The last step was to implement the screening tool in three Mobile geriatric units and we report here their experience. The Get-up early test may be suggested as a new screening tool in order to detect SDPM before more in-depth comprehensive geriatric assessment, and to early adapt the care plan.

Multidrug-resistant bacteria colonization amongst patients newly admitted to a geriatric unit: a prospective cohort study.

OBJECTIVES: To determine prevalence, incidence and risk factors of colonization by extended-spectrum ß-lactamase-producing Enterobacteriacae (ESBLE), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in aged subjects admitted to an acute geriatric unit at a teaching hospital. METHODS: During 12 months, 337 patients were screened by nasal, oropharyngeal, groin, axillary and rectal swabs upon admission and at discharge. RESULTS: The prevalence of ESBLE, MRSA and VRE carriage upon admission was 11.6%, 7.5% and 0.6%, respectively. The incidence density of ESBLE and MRSA carriage was respectively of 1.77 and 2.40 new cases for 1000 patient-days. No cases of VRE acquisition were found. Risk factors for ESBLE colonization on admission were: multiple contacts with the hospital within the previous year, chronic catheter use and a high level of dependency. For MRSA, risk factors were: chronic wounds, anti-acid use and a high level of dependency. CONCLUSION: This study shows a high prevalence of asymptomatic colonization of ESBL-producing Escherichia coli in patients admitted to an acute geriatric ward, as high as MRSA carriage. A low functional status is a common risk factor both for ESBLE and for MRSA colonization and it highlights the need to reinforce infection control measures.

Clinical profiles of patients colonized or infected with extended-spectrum beta-lactamase producing Enterobacteriaceae isolates: a 20 month retrospective study at a Belgian University Hospital.

BACKGROUND: Description of the clinical pictures of patients colonized or infected by ESBL-producing Enterobacteriaceae isolates and admitted to hospital are rather scarce in Europe. However, a better delineation of the clinical patterns associated with the carriage of ESBL-producing isolates may allow healthcare providers to identify more rapidly at risk patients. This matter is of particular concern because of the growing proportion of ESBL-producing Enterobacteriaceae species isolates worldwide. METHODS: We undertook a descriptive analysis of 114 consecutive patients in whom ESBL-producing Enterobacteriaceae isolates were collected from clinical specimens over a 20-month period. Clinical data were obtained through retrospective analysis of medical record charts. Microbiological cultures were carried out by standard laboratory methods. RESULTS: The proportion of ESBL-producing Enterobacteriaceae strains after exclusion of duplicate isolates was 4.5% and the incidence rate was 4.3 cases/1000 patients admitted. Healthcare-associated acquisition was important (n = 104) while community-acquisition was less frequently found (n = 10). Among the former group, two-thirds of the patients were aged over 65 years and 24% of these were living in nursing homes. Sixty-eight (65%) of the patients with healthcare-associated ESBL, were considered clinically infected. In this group, the number and severity of co-morbidities was high, particularly including diabetes mellitus and chronic renal insufficiency. Other known risk factors for ESBL colonization or infection such as prior antibiotic exposure, urinary catheter or previous hospitalisation were also often found. The four main diagnostic categories were: urinary tract infections, lower respiratory tract infections, septicaemia and intra-abdominal infections. For hospitalized patients, the median hospital length of stay was 23 days and the average mortality rate during hospitalization was 13% (Confidence Interval 95%: 7-19). Escherichia coli, by far, accounted as the most common ESBL-producing Enterobacteriaceae species (77/114; [68%]) while CTX-M-1 group was by far the most prevalent ESBL enzyme (n = 56). CONCLUSION: In this retrospective study, the clinical profiles of patients carrying healthcare-associated ESBL-producing Enterobacteriacae is characterized by a high prevalence rate of several major co-morbidities and potential known risk factors. Both, the length of hospital stay and overall hospital mortality rates were particularly high. A prospective case-control matched study should be designed and performed in order to control for possible inclusion bias.

Translating fall incidence data into fall-preventive measures in geriatric wards--a survey in Belgian hospitals.

BACKGROUND: Fall incidents and their negative outcomes represent a considerable problem in hospitals, especially in geriatric wards, and require implementation of strategies to prevent these undesirable events. For this reason, the College of Geriatrics, a body funded by the Belgian Government to set up quality improvement initiatives in geriatric wards, selected 'Fall prevention in Belgian hospitals' as a quality project for the year 2006. OBJECTIVES: Before developing and implementing a practice guideline specifically adapted to the clinical context in Belgian geriatric wards, this study was set up to gain insight into fall prevention measures currently implemented in geriatric wards of Belgian hospitals. METHODS: In this study, we used a cross-sectional survey design. The study involved 113 hospitals with a geriatric department. Participants were geriatricians, head nurses, medical directors, care coordinators and occupational therapists. Measurements were carried out using a survey questionnaire (response rate: 56.6%). RESULTS: Less than one third (32.8%) of Belgian geriatric wards had a formal fall prevention policy. However, more than 90.0% systematically registered falls, but less than a quarter used these data to improve preventive measures. Although the majority used screening (78.1%), comprehensive assessment (92.2%), and preventive strategies (98.4%) when patients are admitted, only about 10% used a standard plan to direct these efforts. Furthermore, 93.8% acknowledged using physical restraints as a fall prevention strategy. CONCLUSION: Given the high rates and complexity of falls in geriatric wards, hospitals need to further implement evidence-based assessment and standard intervention care plans to maintain uniformity and quality of care.