Urinary incontinence as a marker of higher mortality in patients receiving home care services.

OBJECTIVE: To evaluate urinary incontinence (UI) as a predictor of nursing home admission, hospitalization or death in patients receiving home care services. SUBJECTS AND METHODS: A total of 699 community-dwelling participants receiving home care services in Geneva were evaluated in Autumn 2004 using the Minimal Data Set-Home Care, a validated instrument that includes grading of UI. Data on death, hospitalization and nursing home admission were collected up until June 2007. The impact of UI on time-dependent outcomes was analysed using survival analysis and multivariate regression Cox models to adjust for age, gender, body mass index, cardiac failure, cognitive impairment, delirium, depression, disability, alcohol and tobacco use, self-rated health, faecal incontinence and number of medications. RESULTS: We found that UI was present in 193 participants (27.8%). After adjustment for confounding factors, UI was associated with a longer length of hospital stay: +36.7 days, (95% confidence interval [CI]: 1.2-72.3) and a higher mortality rate (hazard ratio [HR] 1.6; 95% CI: 1.1-2.6). The HR for death was 1.5 (95% CI: 0.9-2.5) for participants complaining of one episode of urinary leakage per week at most, 2.0 (95% CI: 1.2-3.5) for those presenting with two or more episodes per week and 4.2 (95% CI: 2.3-7.7; P for trend: <0.001) for daily UI compared with participants without UI. Institutionalization (HR 1.1; 95% CI: 0.6-2.2) and hospitalization rates (HR 1.0; 95% CI: 0.7-1.3) were not different between patients with or without UI. CONCLUSION: In a cohort of patients receiving home care services, UI was a strong predictor of length of hospital stay and mortality, increasing with UI severity.

Pitfalls in the emergency department triage of frail elderly patients without specific complaints.

QUESTION UNDER STUDY: Elderly patients represent an increasing proportion of emergency department (ED) admissions. When no specific complaint is identified, the reason for referral is commonly called "home care impossible". The aim of this study was to describe a population of elderly patients who present to the ED of a 1200-bed university hospital without specific complaint, and to assess how they were evaluated in the ED. METHODS: Data on triage, mode of admission and discharge were collected. After the initial evaluation in the ED, patients were classified in two categories: (1) patients identified with a medical problem requiring rapid care or investigation, (2) patients without a medical problem considered as true "home care impossible". These latter patients underwent a complete assessment using the Minimal Data Set-Home Care (MDS-HC). RESULTS: During the 10-week study period 253 patients (mean age 81 years) were referred because of "home care impossible". An acute medical problem was identified in 129 of those patients (51%). All these patients were triaged in lower acuity categories. 33 (26%) were undertriaged due to (1) absence of vital signs measurement, (2) poor recognition of neurological symptoms, (3) atypical clinical presentation. The remaining patients were considered as true "home care impossible". The MDS-HC evaluation revealed a high level of biopsychosocial comorbidities. CONCLUSIONS: Frail elderly patients admitted without specific complaints are at risk of inappropriate or delayed evaluation due to undertriage at the door of the ED. A more specific geriatric assessment should be integrated early in the triage process of these patients.