Preferences about information and decision-making among older patients with and without cancer.

Background: information of older patients with cancer is crucial to ensure optimal care. Objectives: to compare older patients with and without cancer regarding their preferences about medical information, decision-making and surrogate designation. Design: an intention-to-act questionnaire was completed by patients ≥70 y enroled in the ELderly CAncer PAtients cohort between January and June 2013 and by patients in the same age group enroled in a cross-sectional survey conducted in 2005 in acute geriatric wards. Setting: Henri-Mondor Teaching Hospital in the Paris conurbation, France. Results: the group with cancer had 133 patients [mean age, 79.6 ± 6.5 y; 54.9% women]. The main tumour sites were colorectal [24.1%], breast [23.3%] and prostate [15.8%]; 34.8% had metastases. All these patients wanted full information, 74.2% wanted to participate in decisions about their care, 87.2% would designate a family member to serve as a surrogate in life-threatening situations and 15% had already designated a surrogate. Compared to patients without cancer, those with cancer more often wanted to receive information in a life-threatening situation [93.6% versus 79.2%; P < 0.001]. Factors independently associated with patients wanting their informed consent to be obtained for all interventions were having children [adjusted odds ratio (aOR), 2.13; 95% confidence interval, 1.24; 3.66; P = 0.006], higher Mini Mental State Examination score [aORper point, 1.09; 1.02; 1.17], younger age in the group without cancer [aOR>82 y vs. ≤82 y, 0.50; 0.29-0.88] and being cancer-free [≤82 y, aOR, 0.30; 0.14-0.63; >82 y, aOR, 0.41; 0.17-0.97]. Conclusion: older patients with cancer expressed a strong preference for receiving information and participating in decisions about their care.

Association between borderline dysnatremia and mortality insight into a new data mining approach.

BACKGROUND: Even small variations of serum sodium concentration may be associated with mortality. Our objective was to confirm the impact of borderline dysnatremia for patients admitted to hospital on in-hospital mortality using real life care data from our electronic health record (EHR) and a phenome-wide association analysis (PheWAS). METHODS: Retrospective observational study based on patient data admitted to Hôpital Européen George Pompidou, between 01/01/2008 and 31/06/2014; including 45,834 patients with serum sodium determinations on admission. We analyzed the association between dysnatremia and in-hospital mortality, using a multivariate logistic regression model to adjust for classical potential confounders. We performed a PheWAS to identify new potential confounders. RESULTS: Hyponatremia and hypernatremia were recorded for 12.0% and 1.0% of hospital stays, respectively. Adjusted odds ratios (ORa) for severe, moderate and borderline hyponatremia were 3.44 (95% CI, 2.41-4.86), 2.48 (95% CI, 1.96-3.13) and 1.98 (95% CI, 1.73-2.28), respectively. ORa for severe, moderate and borderline hypernatremia were 4.07 (95% CI, 2.92-5.62), 4.42 (95% CI, 2.04-9.20) and 3.72 (95% CI, 1.53-8.45), respectively. Borderline hyponatremia (ORa = 1.57 95% CI, 1.35-1.81) and borderline hypernatremia (ORa = 3.47 95% CI, 2.43-4.90) were still associated with in-hospital mortality after adjustment for classical and new confounding factors identified through the PheWAS analysis. CONCLUSION: Borderline dysnatremia on admission are independently associated with a higher risk of in-hospital mortality. By using medical data automatically collected in EHR and a new data mining approach, we identified new potential confounding factors that were highly associated with both mortality and dysnatremia.

Are elderly patients' opinions sought before admission to an intensive care unit? Results of the ICE-CUB study.

BACKGROUND: demand for intensive care of the very elderly is growing, but few studies report inclusion of their opinions in the admission decision-making process. Whether or not to refer a very elderly patient to intensive care unit is a difficult decision that should take into account individual wishes, out of respect for the patient's decision-making autonomy. METHODS: in 15 emergency departments, patients over 80 years old who had a potential indication for admission to intensive care, and that were capable of expressing their opinion were included. Frequency of opinions sought before referral decision and individual and organisational factors associated were recorded and analysed. RESULTS: a total of 2,115 patients were included. Only 270 (12.7%) of them were asked for their opinion, and there were marked variations between study centres (minimum: 1.1% and maximum: 53.6%). A history of dementia reduced the probability of a patient being asked for his or her opinion (OR 0.47, 95% CI: 0.25-0.83). Patients' opinion was most often sought when their functional autonomy was conserved (OR 2.10, 95% CI: 1.39-3.21) and when a relative had been questioned (OR 5.46, 95% CI: 3.8-7.88). Older attending physicians were less likely to ask for the patient's opinion (older physician versus younger physician, OR 0.48, 95% CI: 0.35-0.66). CONCLUSIONS: elderly patients are therefore rarely asked for their opinion prior to intensive care admission. Our results indicate that respect of the decision-making autonomy of elderly subjects in the admission process to an intensive care unit should be reinforced.

Case management for the elderly with complex needs: cross-linking the views of their role held by elderly people, their informal caregivers and the case managers.

BACKGROUND: In 2009, case management interventions were a new social service in France implemented within the framework of the PRISMA-France program (2006-2010). People who had benefitted from case management intervention were individuals, over 60 years old living at home in situations deemed complex by professionals. Their informal caregivers were also considered as users of the service. This research accompanied the interventions during the implementation of PRISMA-France attempting to explore the users' (old people and their informal caregivers) and case managers' first experiences of case management. Its aim is to provide a thorough knowledge of the dispositive in order to reveal any initial failings and to ensure optimum conditions for the onset of full implementation. METHODS: The study had a qualitative explorative design. Cross-linked representations of case-management were obtained through opened-ended and guided interviews with three types of informants: old people (19), their informal caregivers (11) and the case managers (5) who participated in the program during the first 6 months. Thematic analysis of the data was carried out. RESULTS: The analysis revealed that each group of people generated its own representations of the case manager's role, even though the three groups of informants shared the idea that the case manager is first and foremost a helper. The case managers insisted on their proximity to the old people and their role as coordinators. The informal caregivers saw the professional as a partner and potential provider of assistance in accompanying old people. The old people focused on the personal connections established with the case manager. CONCLUSION: The innovative and experimental dimension of case management in France and the flexible nature of the role generated a broad spectrum of representations by those involved. These different representations are, in part, the fruit of each individual's projected expectations of this social service. Analyzing the first representations of the case manager's role during the implementation phase of the CM service appears as a necessary step before considering the effects of the services. The implementation and the success of a case management model have to be evaluated regarding the previous healthcare context and the expectations of the people involved.

[The role of external mobile geriatric teams in nursing homes]. / Apport des équipes mobiles gériatriques externes en Ehpad.

Since 2000, the mobile team of Bretonneau Hospital in Paris has helped to improve the assessment and care management of the elderly at home by strengthening the link between community health professionals and hospital geriatric services. In January 2008, an external mobile geriatric team working with nursing homes was created for the whole of the Paris area in order to strengthen the link between care homes accommodating often highly dependent elderly people and the hospital.

Multidisciplinary teams of case managers in the implementation of an innovative integrated services delivery for the elderly in France.

BACKGROUND: The case management process is now well defined, and teams of case managers have been implemented in integrated services delivery. However, little is known about the role played by the team of case managers and the value in having multidisciplinary case management teams. The objectives were to develop a fuller understanding of the role played by the case manager team and identify the value of inter-professional collaboration in multidisciplinary teams during the implementation of an innovative integrated service in France. METHODS: We conducted a qualitative study with focus groups comprising 14 multidisciplinary teams for a total of 59 case managers, six months after their recruitment to the MAIA program (Maison Autonomie Integration Alzheimer). RESULTS: Most of the case managers saw themselves as being part of a team of case managers (91.5%). Case management teams help case managers develop a comprehensive understanding of the integration concept, meet the complex needs of elderly people and change their professional practices. Multidisciplinary case management teams add value by helping case managers move from theory to practice, by encouraging them develop a comprehensive clinical vision, and by initiating the interdisciplinary approach. CONCLUSIONS: The multidisciplinary team of case managers is central to the implementation of case management and helps case managers develop their new role and a core inter-professional competency.

Long-term safety and efficacy of imatinib mesylate (Gleevec®) in elderly patients with chronic phase chronic myelogenous leukemia: results of the AFR04 study.

Data from registries suggest that the median age of chronic myelogenous leukemia (CML) patients is 10-15 years older than that of clinical trials. We conducted a prospective phase II study to evaluate imatinib mesylate (IM, 400 mg daily) in newly diagnosed chronic phase CML (CP-CML) patients. Patients aged 70 years and over diagnosed with CP-CML within 12 months were eligible. Thirty patients were enrolled from April 2002 to October 2004. Median age was 74.8 years (range, 70-90). Male/female ratio was 1.72. At inclusion, comorbidities were reported in all but one patient, Cumulative Illness Rating Scale for Geriatrics comorbidity mean index was 1.47, and 66% of patients had cardiovascular disease. The median daily IM dose was 392 mg (range, 256-445). IM was interrupted in patients with severe comorbidities. Treatment discontinuation was observed in 36.6% of patients. Cumulative incidence of complete cytogenetic response was 71.4 and 78.5% at 12 and 24 months, respectively. A high level of sustained responses was observed in patients with mild or moderate comorbidities. Seven-year estimated overall survival was 80.8% (95% CI: 59.0-91.7). Two-thirds of the patients were still on long-term therapy at cut-off, and no patients had died from progression. This trial was registered at http://www.clinicaltrials.gov as # NCT00219765.

Ethical issues in the introduction of case management for elderly people.

As case management is under development in France for elderly people, this study sets out to identify and analyse key situations responsible for ethical dilemmas for French case managers. We based our study on the analyses of individual interviews made with case managers and focus-group discussions, bringing together all case managers working in local organisations running for at least a year. We identified three situations giving rise to ethical dilemmas: in the order of importance, the refusals of care, the practicalities of collecting and sharing personal data and the allocation of resources. These three situations can lead to conflict between the principle of beneficence and those of respect for autonomy, non-maleficence and justice. We describe here how French case managers practically deal with these situations.

Exploring representations and experiences of case-management users: towards difficulties and solutions to leading qualitative interviews with older people with complex living conditions.

BACKGROUND: By matching needs to resource services, case management could be a useful tool for improving the care of older people with complex living conditions. Collecting and analysing the users' experiences represents a good way to evaluate the effectiveness and efficiency of a case-management service. However, in the literature, fieldwork is very rarely considered and the users included in qualitative research seem to be the most accessible. AIM: This study was undertaken to describe the challenges of conducting qualitative research with older people with complex living conditions in order to understand their experiences with case-management services. METHODS: Reflective analysis was applied to describe the process of recruiting and interviewing older people with complex living conditions in private homes, describing the protocol with respect to fieldwork chronology. The practical difficulties inherent in this type of study are addressed, particularly in terms of defining a sample, the procedure for contacting the users and conducting the interview. The users are people who suffer from a loss of autonomy because of cognitive impairment, severe disease and/or psychiatric or social problems. Notably, most of them refuse care and assistance. RESULTS: Reflective analysis of our protocol showed that the methodology and difficulties encountered constituted the first phase of data analysis. CONCLUSION: Understanding the experience of users of case management to analyse the outcomes of case-management services requires a clear methodology for the fieldwork.

Attitudes toward Alzheimer's disease: a qualitative study of the role played by social representation on a convenient sample of French general practitioners.

BACKGROUND AND AIMS: It is commonly thought that Alzheimer's disease (AD) is under-diagnosed and that insufficient numbers of patients are receiving pharmacological treatment. These observations are often attributed to poor management of the disease by general practitioners (GPs) related to their lack of training in identifying cognitive decline. Our hypothesis is that there may be a relation between GPs' perceptions and their attitudes toward AD. METHODS: We conducted a qualitative study, through semi-directive interviews focusing on their representations, of 25 GPs, masters in training courses, in Paris. RESULTS: Analysis of interviews revealed five general trends. AD is seen by GPs as a "disease of autonomy", without specific medical treatment. Cognitive symptoms are less meaningful in GPs' view than the loss of autonomy. The main thing is to keep the patient at home. For GPs, the family is described as an essential partner in coping with the insufficiencies of available social programs. The use of specialists is less to confirm the diagnosis than to announce the "bad news". GPs declare scepticism as to the efficacy of AD medications, only granting them a certain "care" effect or a social role. The image of AD remains highly negative. The stigma of AD is seen as a barrier to its diagnosis. CONCLUSIONS: This study is somewhat preliminary because of sample size. Nevertheless, the social representations of the disease influence GPs' attitudes toward making diagnoses in France. Priority seems to focus more on assisting GPs and families at the social level, rather than diagnosis or access to treatment.

Analysis of case management programs for patients with dementia: a systematic review.

BACKGROUND: People suffering from dementia are particularly vulnerable to the gaps between the health and social service systems. Case management is a professional field that seeks to fill in these gaps and remedy this fragmentation. METHODS: We report the results of a systematic literature review of the impact of case management programs on clinical outcomes and the utilization of resources by persons with dementia. We focused on randomized controlled trials (RCTs) and attempted to identify the factors that might contribute to greater program efficacy. Because the evaluation methods in these studies varied, we used the effect size method to estimate the magnitude of the statistically significant effects reported. RESULTS: Our search strategy identified 17 references relating to six RCTs. Four of these six RCTs reported moderately statistically significant effects (effect size, 0.2-0.8) on their primary end point: the clinical outcome in three and resource utilization in one. Two of the RCTs reported weak or no effects (effect size, <0.2) on their primary end point. Because of the wide variety of the end points used, an overall effect size could not be calculated. Parameters that appear to be related to greater case management efficacy are the integration level between the health and social service organizations and the intensity of the case management. CONCLUSIONS: Integration and case management intensity seem to determine the magnitude of the clinical effects in this new professional field. Further studies are needed to clarify the economic impact.

[Level of evidence for case management in Alzheimer's disease: a literature review]. / Niveau de preuve de la gestion de cas dans la maladie d'Alzheimer : revue de littérature.

Alzheimer's disease or related diseases patients are particularly vulnerable to fragmentation of the French system of care and support. The government has decided to implement a national plan from which two key steps are the implementation of integration and case management. We report results of a review of the literature on both the definition of these concepts and their impacts as reported in randomized controlled studies. Important differences are noticeable between studies concerning the spectrum of integration (acute and long-term care, social and health sectors, institutional and liberal sectors and financing mode notably). Case-management has multiple sense, and it must be paid attention to intensity and context of the intervention. According to available evidence, case management is likely to improve, for the person with Alzheimer's, quality of care, quality of life and quality of life of caregivers at least. Conditions for a program to be successful are adequate targeting of the target population, sufficient level of integration and adequate intensity of case management. The programs most successful and most intensive relate an effect on prevention of loss of autonomy, even death, and no extra cost. The effects on hospitalization or entry into the institution are currently hypothetical and should be further studied.

Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units.

BACKGROUND: among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors. OBJECTIVE: to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments. DESIGN: prospective multi-centre study. SETTING: nine French hospitals. SUBJECTS: one thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort). METHODS: using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment. RESULTS: data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0-3.9), poor overall condition (OR = 2.01, 95% CI = 1.3-3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2-2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1-2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3--0.8). CONCLUSIONS: markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.

Residents' involvement in the admission process in long-term care settings in France: results of the "EHPA 2000" survey.

In order to identify the factors influencing residents' involvement in the decision-making process prior to admission to a long-term care setting, we analyzed results of a national survey of residents of long-term care settings in France. We interviewed 3538 residents in 584 long-term care settings. Only 38.1% of residents said they had taken part in the admission process. Risk factors for non-involvement were the care level of the long-term care settings (odds ratio=OR=8.11 [5.63-11.68] and 2.73 [2.26-3.30], respectively, for long-term care units and retirements homes as compared to residential homes), lack of autonomy (dressing/washing) (OR=1.95 [1.66-2.30] versus autonomous), inability to answer questions on income (OR=2.16 [1.83-2.56]), age under 80 (OR=1.29 [1.04-1.61]) versus >90 years old patients, and being married (OR=1.60 [1.13-2.26]). Resident involvement in the decision-making process influenced subsequent feelings about institutional life. Older adults said that they were frequently not involved in the decision-making process prior to admission to a long-term care setting. This was particularly true for the high-care level long-term care settings, where organizational factors might intervene and for vulnerable elders for whom loss of autonomy could be lived as a loss of citizenship.

Tolerability of an equimolar mix of nitrous oxide and oxygen during painful procedures in very elderly patients.

BACKGROUND AND OBJECTIVE: Although an equimolar mix of nitrous oxide-oxygen (N(2)O/O(2)) [Kalinox] is widely used as an analgesic, there have been few specific studies of this product in the elderly. In this article, we investigate the tolerability of this equimolar mix in very elderly patients undergoing painful procedures. METHODS: This was a prospective, observational study of patients hospitalised in the geriatric short-stay unit of a teaching hospital between July 2001 and September 2003. All patients aged >/=80 years who were scheduled for invasive care procedures were eligible for inclusion. Sixty-two patients were recruited and underwent a total of 68 procedures. The procedures were divided into four classes based on the degree of pain they were expected to cause and their duration. Patients received the equimolar N(2)O/O(2) mix (Kalinox) for 5 minutes before the beginning of the procedure and throughout its duration. The inhaled treatment was administered via a high-concentration mask. Assessments were carried out during the inhalation and over the 15 minute period following inhalation. The primary endpoint of the study was tolerability of the equimolar N(2)O/O(2) mix, and all adverse events were recorded. Secondary endpoints were the efficacy of the product (assessed on a verbal rating scale and/or the Doloplus scale), its ease of use and its acceptability to patients and staff. RESULTS: Fourteen patients (22.6%) each reported at least one adverse event: impaired hearing (n = 1), altered perception of the environment (n = 8), anxiety (n = 1), headache (n = 3) and drowsiness at the end of the procedure (n = 2). All these disorders subsided rapidly after treatment was completed. CONCLUSION: This study shows the favourable tolerability of the equimolar N(2)O/O(2) mix in very elderly subjects, which makes this product a valuable tool for the management of acute pain in this age group.

[Early indicators of prolonged hospitalization of the elderly: pilot study at Strasbourg University Hospital]. / Indicateurs précoces de durée de séjour prolongée chez les sujets âgés: étude pilote réalisée au CHRU de Strasbourg.

OBJECTIVES: The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. METHODS: This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Agé Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG). RESULTS: The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A "risk of malnutrition" (OR=14.07) and "mood disorders" (OR=2,5) were both early markers for prolonged hospitalization. Although not statistically significant, "walking difficulties" (OR=2.72) and "cognitive impairment" (OR=5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization. CONCLUSION: Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

Changes in One-Year Mortality in Elderly Patients Admitted with Acute Myocardial Infarction in Relation with Early Management.

BACKGROUND: Elderly patients are underrepresented in acute myocardial infarction trials. Our aim was to determine whether, in elderly patients, changes in management in the past 15 years are associated with improved 1-year mortality after hospital admission for myocardial infarction. METHODS: We used data from 4 1-month French registries, conducted 5 years apart from 1995 to 2010, including 3389 elderly patients (≥75 years of age). RESULTS: From 1995 to 2010, mean age remained stable (82.1 years), similar in ST- and non-ST-elevation myocardial infarction patients. Obesity, diabetes, hypertension, and hypercholesterolemia increased. History of prior myocardial infarction, stroke, and peripheral artery disease remained stable, while history of heart failure decreased. Major changes in management were noted: early percutaneous coronary intervention, early treatment with antiplatelet agents, low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and statins all increased. Early mortality after hospital admission decreased from 25.0% to 8.4%. One-year mortality decreased from 36.2% to 20.0% (adjusted hazard ratio 2010 vs 1995: 0.47, 0.39-0.57), both for ST-elevation myocardial infarction (36.8% to 21.1%) and non-ST-elevation myocardial infarction (34.8% to 19.1%). Mortality reduction was observed in all age groups, including those ≥85 years of age (from 46.2% to 31.4%). The study period, however, was no longer associated with decreased mortality when variables reflecting management changes were taken into account. CONCLUSIONS: Early and 1-year mortality after hospital admission of elderly patients with acute myocardial infarction has substantially decreased over the past 15 years. This improvement is likely mediated by increasing use of recommended management strategies. These data support the application of guidelines derived from trials mostly including younger patients to elderly populations as well.

Early markers of prolonged hospital stays in older people: a prospective, multicenter study of 908 inpatients in French acute hospitals.

OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals. DESIGN: A prospective, multicenter study. SETTING: Nine hospitals in France. PARTICIPANTS: One thousand three hundred six patients aged 75 and older were hospitalized through an emergency department (Sujet Agé Fragile: Evaluation et suivi (SAFEs)--Frail Elderly Subjects: Evaluation and follow-up). MEASUREMENTS: Data used in a logistic regression were obtained through a gerontological evaluation of inpatients, conducted in the first week of hospitalization. The center effect was considered in two models as a random and fixed effect. Two limits were used to define a prolonged hospital stay. The first was fixed at 30 days. The second was adjusted for Diagnosis Related Groups according to the French classification (f-DRG). RESULTS: Nine hundred eight of the 1,306 hospital stays that made up the cohort were analyzed. Two centers (n=298) were excluded because of a large volume of missing f-DRGs. Two-thirds of subjects in the cohort analyzed were women (64%), with a mean age of 84. One hundred thirty-eight stays (15%) lasted more than 30 days; 46 (5%) were prolonged beyond the f-DRG-adjusted limit. No sociodemographic variables seemed to influence the length of stay, regardless of the limit used. For the 30-day limit, only cognitive impairment (odds ratio (OR)=2.2, 95% confidence interval (CI)=1.2-4.0) was identified as a marker for prolongation. f-DRG adjustment revealed other clinical markers. Walking difficulties (OR=2.6, 95% CI=1.2-16.7), fall risk (OR=2.5, 95% CI=1.7-5.3), cognitive impairment (OR=7.1, 95% CI=2.3-49.9), and malnutrition risk (OR=2.5, 95% CI=1.7-19.6) were found to be early markers for prolonged stays, although dependence level and its evolution, estimated using the Katz activity of daily living (ADL) index, were not identified as risk factors. CONCLUSION: When the generally recognized parameters of frailty are taken into account, a set of simple items (walking difficulties, risk of fall, risk of malnutrition, and cognitive impairment) enables a predictive approach to the length of stay of elderly patients hospitalized under emergency circumstances. Katz ADLs were not among the early markers identified.

[Characteristics and resource use of emergency department users older than 75 years. Results from a French national study]. / Caractéristiques, consommation de ressources des usagers des services d'urgences de plus de 75 ans en France. Résultats d'une enquête nationale.

BACKGROUND: Because the elderly tend to have complex and multiple diseases, they are likely to use emergency department (ED) resources at higher rates than other age groups. This study sought to determine the characteristics and resource use of the elderly patients (>or=75 years old) visiting EDs in France and assessed the effect of age on resource use. METHODS: The sample was selected from the DREES prospective study of 150 French EDs for one week in 2002. A case report form was completed for each patient, stating the reasons for consultation, method of arrival, treatment, and outcome. Data were weighted to produce a representative national description. RESULTS: Of the 9801 patients seen that week, the elderly (n=1153) accounted for 11.8% of all ED visits, that is, 26 676 ED visits weekly nationwide. In this group, the mean age was 83 years and 60.9% were women. Most patients arrived by medical transportation: 55.6% by nonemergency ambulances and 24.6% by emergency medical transport. More than 75% were referred by their general practitioner (GP). Medical problems (69.5%) were much more frequent than trauma (24.8%). Clinical status was stable in 62% of cases. Use of ED resources was high: radiographs for 74.0%, laboratory testing for 71.0% and electrocardiography for 64.0%. The percentage of unnecessary or avoidable visits was small: 8.7% were not admitted, were clinically stable, and came for diagnostic tests that could have been performed on an outpatient basis. Age was an independent factor of pre-ED and ED resource use. CONCLUSION: Unplanned health care of the elderly uses substantial ED resources. Elderly patients appear to use available resources appropriately. Demographic trends show that their ED use will increase. Accordingly, analysis of the organization and funding of ED services for this population is indispensable.

Treatment intensity, age and outcome in medical ICU patients: results of a French administrative database.

BACKGROUND: Intensive care unit (ICU) patients are aging, and older age has been associated with higher mortality in ICU. As previous studies have reported that older age was also associated with less intensive treatment, we investigated the relationship between age, treatment intensity and mortality in medical ICU patients. METHODS: Data were extracted from the administrative database of 18 medical ICUs. Patients with a unique medical ICU stay and a Simplified Acute Physiology Score II (without age-related points) >15 were included. Treatment intensity was described with a novel indicator, which is a four-group classification based upon the most frequent ICU procedures. The relationship between age, treatment intensity and hospital mortality was analyzed with the estimation of standardized mortality ratio in the four groups of treatment intensity. RESULTS: A total of 23,578 patients, including 3203 patients aged ≥80 years, were analyzed. Hospital mortality increased from 13 % for the younger patients (age < 40 years) to 38 % for the older patients (age ≥ 80 years), while Simplified Acute Physiology Score II (without age-related points) increased only from 36 (age < 40 years) to 43 (age ≥ 80). Hospital mortality increased with age in the four groups of treatment intensity. Standardized mortality ratio increased with age among the patients with less intensive treatment but was not associated with age among the patients with the highest treatment intensity. CONCLUSION: Our results support the fact that the increase in mortality with age among ICU patients is not related to an increase in severity. Using a new tool to estimate ICU treatment intensity, our study suggests that mortality of ICU patients increases with age whatever the treatment intensity is. Further investigations are required to determinate whether this increase in mortality among older ICU patients is related to undertreatment or to a lower efficiency of organ support treatment.