Five-year survival and prognostic factors in a cohort of hospitalized nonagenarians

The influence of nationwide COVID-19 lockdown on the functional impairment and long-term survival of dependent people for carrying out basic activities of daily living in a neighborhood of the city of Madrid, Spain: Orcasitas Cohort Longitudinal Study

Background

Prolonged confinement can lead to personal deterioration at various levels. We studied this phenomenon during the nationwide COVID-19 lockdown in a functionally dependent population of the Orcasitas neighborhood of Madrid, Spain, by measuring their ability to perform basic activities of daily living and their mortality rate.

Methods

A total of 127 patients were included in the Orcasitas cohort. Of this cohort, 78.7% were female, 21.3% were male, and their mean age was 86 years. All participants had a Barthel index of ≤ 60. Changes from pre- to post-confinement and 3 years afterward were analyzed, and the effect of these changes on survival was assessed (2020-2023).

Results

The post-confinement functional assessment showed significant improvement in independence over pre-confinement for both the Barthel score (t = -5.823; p < 0.001) and the classification level (z = -2.988; p < 0.003). This improvement progressively disappeared in the following 3 years, and 40.9% of the patients in this cohort died during this period. These outcomes were associated with the Barthel index (z = -3.646; p < 0.001) and the level of dependence (hazard ratio 2.227; CI 1.514-3.276). Higher mortality was observed among men (HR 1.745; CI 1.045-2.915) and those with severe dependence (HR 2.169; CI 1.469-3.201). Setting the cutoff point of the Barthel index at 40 provided the best detection of the risk of death associated with dependence.

Conclusions

Home confinement and the risk of death due to the COVID-19 pandemic awakened a form of resilience in the face of adversity among the population of functionally dependent adults. The Barthel index is a good predictor of medium- and long-term mortality and is a useful method for detecting populations at risk in health planning. A cutoff score of 40 is useful for this purpose. To a certain extent, the non-institutionalized dependent population is an invisible population. Future studies should analyze the causes of the high mortality observed.

Outcomes in very elderly ICU patients surgically treated for proximal femur fractures

Proximal femur fractures (PFF) are a common injury in elderly patients that significantly impact mobility and daily living activities. Mortality rates in this population are also high, making effective treatment essential. Recent advances in intensive and geriatric care have enabled complex surgical interventions that were previously not feasible. However, there is a lack of studies focusing on outcome parameters in very elderly patients (≥ 90 years) who receive intensive care treatment following PFFs. In this retrospective study, we analyzed multi-layered data of 148 patients who were 90 years or older and received intensive care after trauma and orthopedic surgical treatment for PFFs or periprosthetic fractures between 2009 and 2019. All patients received a 365-day follow-up. To identify potential predictors of mortality, all deceased and surviving patients were subjected to multiple logistic regression analyses. We found that 22% of patients deceased during in-hospital care, and one-year survival was 44%. Independent predictors of one-year all-cause mortality included higher CCI and SOFA scores at ICU admission. Overall, 53% of patients who resided in private dwellings prior to admission were able to return home. Our study highlights the utility of using CCI and SOFA scores at ICU admission as prognostic indicators in critically ill very elderly patients who undergo surgical treatment for PFFs. These scores can provide valuable insight into the severity of illness and potential outcomes, which can inform resource allocation, prioritize endangered patients, and aid in end-of-life discussions and planning with patients and their families. Our findings can help improve the management of PFFs in very elderly patients and contribute to optimized patient care.

Characteristics and treatment of nonagenarian patients with vascular disease admitted to internal medicine services. NONAVASC-2 registry

INTRODUCTION

Vascular disease (VD) is the most frequent cause of morbidity and mortality and its prevalence increases with age. Old patients are not included in studies on VD, their characteristics and treatments being unknown.

OBJECTIVE

Know the clinical characteristics of nonagenarian patients hospitalized in Internal Medicine services with a diagnosis of established VD and the adequacy of their pharmacological management.

MATERIAL AND METHODS

The NONAVASC-2 registry is an observational, prospective, multicentre study. Hospitalized patients for any cause were included. Data collection was carried out through an anonymous online database with sociodemographic, clinical, analytical, therapeutic and evolutionary parameters.

RESULTS

One thousand forty-nine patients with a mean age of 93.14 years (57.8% women) were included. The prevalence of risk factors and VD was high: hypertension (84.9%), dyslipidemia (50.9%) and diabetes mellitus (29.4%). 33.4% presented severe-total dependency. 82.9% received antithrombotic treatment (53.7% antiplatelets, 25.4% anticoagulation and 3.8% double therapy). Only 38.2% received statins. The percentage of severe dependence (39.2% vs 24.1%; p = 0.00) and severe cognitive impairment (30.8% vs 13.8%; p = 0.00) was significantly higher among patients who did not receive them. 19% died during admission.

CONCLUSIONS

Nonagenarian patients with VD present high comorbidity, dependence and mortality. Despite being in secondary prevention, 17% did not receive antithrombotics and only 38% received statins. The underprescription is conditioned, among other factors, by the functional status. More studies are necessary to determine the impact of this issue on their prognosis.

Mortality in the Oldest-Old Adults After Discharge From Acute Geriatric Ward

Aim: To examine risk factors for post-discharge mortality in the oldest-old patients. Methods: We have assessed the risk factors for mortality after discharge from acute geriatric ward in 448 patients aged ≥90. Results: Low albumin, high urea, and full dependence were risk factors for mortality within 1 month and within 1 year after discharge from hospital. Age-adjusted Charlson Comorbidity Index score, neuroleptic drug treatments and frailty were specific risk factors for post-discharge mortality within 1 year. By Cox regression analysis, the risk factors associated with higher hazard ratios for post-discharge mortality within 14 years follow-up were age-adjusted Charlson Comorbidity Index score, poor functional status, anemia and dementia as comorbidities, neuroleptic drug treatments, low albumin, high urea, and high vitamin B12. Conclusion: Optimal treatment of the condition due to which the patient has been hospitalized and of the medical complications that occurred during hospitalization, while preventing functional decline, might secure longer post-discharge survival.

Epidemiological and Clinical Features in Very Old Men and Women (≥80 Years) Hospitalized with Aortic Stenosis in Spain, 2016-2019: Results from the Spanish Hospital Discharge Database

(1) Background: The aging population poses challenges for hospital systems. Aortic stenosis is among the most frequent diseases in very old patients. The aim of this study was to describe gender and age differences in the clinical characteristics of very old patients hospitalized with aortic stenosis (AoS) in Spain from 2016 to 2019. (2): Methods: A retrospective observational study analyzing data from the national surveillance system for hospital data. Variables analyzed were age group, sex, length of stay, deaths, and comorbidity. (3) Results: The analysis included 46,967 discharges. Altogether, 7.6% of the admissions ended in death. The main reason for admission was heart failure (34.3%), and this increased with age (80−84 years: 26% versus 95−99 years: 56.6%; p < 0.001). The main treatment procedure was the transcatheter aortic valve replacement (12.7%), performed in 14.3% of patients aged 80−84 versus 0.5% in patients aged 95−99 (p < 0.001). In the multivariable analysis, women were admitted with more comorbidities (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.06−1.20). Mortality was similar, albeit women were admitted less for syncope (OR 0.83, 95% CI 0.74−0.93). Women also underwent fewer coronary catheterizations (OR 0.81, 95% CI 0.77−0.87) and echocardiograms (OR 0.96, 95% CI 0.94−0.98). (4) Conclusions: Aortic stenosis leads to a high number of hospital admissions. Women with AoS presented more heart failure and less cardiovascular pathology than men. Also, women are admitted with fewer episodes of syncope and have fewer ultrasounds and catheterizations.

12-month survival in nonagenarians inside the Mugello study: on the way to live a century

Background

Life expectancy has increased over the last century and a growing number of people is reaching age 90 years and over. However, data on nonagenarians’ health trends are scarce due to difficulties in investigating this specific population. This study aims to identify risk factors for one-year mortality in nonagenarians using data collected within the “Mugello Study”.

Methods

Complete information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 nonagenarians, as well as information about survival after 1 year from the interview.

Results

The sample included 314 women (72.5%) and 119 men (27.5%) with a median age of 92 years (range 90-99 years). The mortality rate was 20.3% (88 deaths). After adjustment for age and sex, a significantly higher risk of dying within 12 months was observed in individuals with more severe cognitive impairment (HR = 5.011, p < 0.001), more severe disability in basic activities of daily living (HR = 4.193, p < 0.001), sedentary lifestyle (HR = 3.367, p < 0.001), higher number of drugs assumed (HR = 1.118, p = 0.031), and kidney dysfunction (HR = 2.609, p = 0.004). When all the variables were included in the analysis, only older age (HR = 1.079, p = 0.048), lower cognitive function (HR = 2.859, p = 0.015), sedentary lifestyle (HR = 2.030, p = 0.026), and kidney dysfunction (HR = 2.322, p = 0.018) remained significantly associated with reduced survival.

Conclusions

Data from the Mugello study support the hypothesis that survival at 12 months in nonagenarians is not a stochastic process and that older age, reduced cognitive function, sedentary lifestyle, and the presence of kidney dysfunction are associated with mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02908-9.

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

[Baseline characteristics of nonagenarians hospitalised due to acute kidney injury compared to other age groups]

BACKGROUND

The increase in life expectancy leads to higher hospitalisation rates in elderly patients. The aim of this work is to study the characteristics of the population over 90 years of age that are admitted due to acute kidney injury (AKI).

MATERIAL AND METHODS

A cross-sectional study was conducted that included all patients admitted to hospital with AKI in the years 2013 and 2014. Epidemiological characteristics, comorbidity, medication and baseline analytical data were collected, and a comparison was made between patients with age over 90 years-old and the others.

RESULTS

A total of 1733 patients were included, of whom 264 (15%) were over 90 years-old. A significantly higher proportion of these patients were women. The most frequent cause of AKI in patients older than 90 years was functional (81%) (p < 0.001 compared to other age groups). The main cause of hospital admission was infection. In the group of over 90 years of age, a higher prevalence was found for arterial hypertension (p = 0.005), chronic kidney disease (p = 0.014), congestive heart failure (p = 0.006), and cognitive impairment (p < 0.0001). The baseline glomerular filtration rate by CKD-EPI was lower in the group of patients older than 90 years (p < 0.0001). Patients under 90 years admitted to hospital due to AKI, had a higher prevalence of diabetes mellitus (p < 0.001), dyslipidaemia (p < 0.001), history of neoplasia (p < 0.001), and a higher Barthel index (p < 0.0001).

CONCLUSIONS

Nonagenarians admitted due to AKI have functional aetiology as the most common factor. These patients have a higher prevalence of hypertension, heart failure, chronic kidney disease, low functional status, and more cognitive impairment.

Safety of Outpatient Parenteral Antimicrobial Therapy in Nonagenarians

Background

Although widely accepted for adults, the safety of outpatient parenteral antimicrobial therapy (OPAT) in very old patients has not been examined.

Methods

Nonagenarians (age ≥90 years) discharged from the hospital on OPAT over a 5-year period were identified from the Cleveland Clinic OPAT Registry. Three matched controls (<90 years) were selected for each nonagenarian. Times to OPAT-related emergency department (ED) visit and OPAT-related readmission were compared across the 2 groups in multivariable subdistribution proportional hazards competing risks regression models. Incidence of adverse drug events and vascular access complications were compared using negative binomial regression.

Results

Of 126 nonagenarians and 378 controls, 7 were excluded for various reasons. Among the remaining 497 subjects, 306 (62%) were male, 311 (63%) were treated for cardiovascular or osteoarticular infections, and 363 (73%) were discharged to a residential health care facility. The mean (SD) ages of nonagenarians and controls were 92 (2) and 62 (16) years, respectively. Compared with matched controls, being a nonagenarian was not associated with increased risk of OPAT-related ED visit (hazard ratio [HR], 0.77; 95% CI, 0.33-1.80; P = .55), OPAT-related readmission (HR, 0.78; 95% CI, 0.28-2.16; P = .63), adverse drug event from OPAT medications (incidence rate ratio [IRR], 1.00; 95% CI, 0.43-2.17; P = .99), or vascular access complications (IRR, 0.66; 95% CI, 0.27-1.51; P = .32). Nonagenarians had a higher risk of death overall (HR, 2.64; 95% CI, 1.52-4.58; P < .001), but deaths were not from OPAT complications.

Conclusions

Compared with younger patients, OPAT in nonagenarians is not associated with higher risk of OPAT-related complications. OPAT can be provided as safely to nonagenarians as to younger patients.

Morbidity Measures Predicting Mortality in Inpatients: A Systematic Review

OBJECTIVES

Morbidity is an important risk factor for mortality and a variety of morbidity measures have been developed to predict patients' health outcomes. The objective of this systematic review was to compare the capacity of morbidity measures in predicting mortality among inpatients admitted to internal medicine, geriatric, or all hospital wards.

DESIGN

A systematic literature search was conducted from inception to March 6, 2019 using 4 databases: Medline, Embase, Cochrane, and CINAHL. Articles were included if morbidity measures were used to predict mortality (registration CRD42019126674).

SETTING AND PARTICIPANTS

Inpatients with a mean or median age ≥65 years.

MEASUREMENTS

Morbidity measures predicting mortality.

RESULTS

Of the 12,800 articles retrieved from the databases, a total of 34 articles were included reporting on inpatients admitted to internal medicine, geriatric, or all hospital wards. The Charlson Comorbidity Index (CCI) was reported most frequently and a higher CCI score was associated with greater mortality risk, primarily at longer follow-up periods. Articles comparing morbidity measures revealed that the Geriatric Index of Comorbidity was better predicting mortality risk than the CCI, Cumulative Illness Rating Scale, Index of Coexistent Disease, and disease count.

CONCLUSIONS AND IMPLICATIONS

Higher morbidity measure scores are better in predicting mortality at longer follow-up period. The Geriatric Index of Comorbidity was best in predicting mortality and should be used more often in clinical practice to assist clinical decision making.

Functional impairment and serum albumin predict in-hospital mortality in nonagenarians with acute infection: a retrospective cohort study

Background

Acute infection leads to substantial mortality in the nonagenarian population. However, the predictive efficacies of functional status and biochemical indexes for in-hospital mortality in these patients remain to be determined.

Methods

A single-center, retrospective cohort study was performed. Consecutive nonagenarian patients who were admitted to our department from January 1, 2014 to December 31, 2016 for acute infectious diseases were included. Baseline data for medical history, functional status, and biochemical indexes were obtained on admission. The outcomes of these patients during hospitalization were recorded. Predictors of in-hospital mortality were identified via logistic regression analyses.

Results

A total of 162 patients were included, and 46 patients died (17.2%) during hospitalization. Univariate analysis showed that the prevalence rates of atrial fibrillation (32.1%) and malignant disease (26.5%) were higher in nonagenarian patients who died during hospitalization than in those who discharged. Multivariate logistic regression analyses identified malignant disease (odds ratio [OR] 2.73, 95% confidence interval [CI]: 1.10–6.78), ADL category (OR 0.82, 95% CI: 0.75–0.89) and serum albumin (OR 0.86, 95%CI 0.78–0.95) as independent predictors of in-hospital mortality in nonagenarian patients hospitalized for acute infection.

Conclusions

Functional impairment as well as serum albumin may be independent predictors of in-hospital mortality in nonagenarian patients hospitalized for acute infectious diseases. Stratification of patients according to Barthel Index score and serum albumin is very necessary.

Performance status and in-hospital mortality of elderly patients with community acquired pneumonia

To evaluate the role of performance status evaluated by the Eastern Cooperative Oncology Group (ECOG) score in predicting 30-day mortality in subjects hospitalized for community acquired pneumonia (CAP), this was a prospective study of patients consecutively hospitalized for CAP at a large University Hospital in Italy. Performance status was evaluated using the ECOG score that in a 0-5 point scale indicates progressive functional deterioration. The end-point of the study is the 30-day mortality. Two-hundred-sixteen patients were enrolled, 75.9% were aged > 70 years, 31.5% had severe pneumonia at CURB-65 score (3-4), and 27.5% of patients had severe disability (ECOG 3-4). Thirty-day mortality is 15.3%. Progression in ECOG score independently increases the probability of 30-day mortality at multivariable logistic regression analysis (HR 2.19, 95% CI 1.60-3.01, p < 0.0001). ECOG 3 or 4 determines a four-fold increase in 30-day mortality (HR 4.07, 95% CI 1.84-9.02, p < 0.001). ECOG score 3 or 4 is highly predictive of death in patients classified at low risk of mortality by CURB-65 (0-2 points) score. Functional status is directly related to outcome in elderly patients hospitalized for CAP. The use of a very simple and fast tool, such as the ECOG score, might help to better stratify the risk of short-term mortality, especially in patients otherwise classified at low risk of death by CURB-65 score.

[Functional status as an independent risk factor in elderly patients admitted to an Intensive Care Unit]

OBJECTIVE

To assess the association of previous functional status in elderly patients admitted to the ICU, estimated by the Barthel and Short Form-Late Life Function and Disability instrument scales, and the relationship with prognosis and functional capacity at hospital discharge.

MATERIAL AND METHODS

Observational prospective study of ICU-admitted patients older than 74 years, with a length of stay greater than 48hours. Demographic data, social background, comorbidities, disability questionnaire (Barthel, Short Form-Late Life Function and Disability instrument), main diagnosis and severity (SAPS 3) on ICU admission were recorded. Factors associated with mortality or poor functional status at hospital discharge (Barthel Index less than 35) were established by multivariate analysis.

RESULTS

During the study period, 219 elderly patients were admitted in ICU, of whom 129 (15%) had an ICU length of stay greater than 48hours. The median age was 80 years (77-83), with 52% women. Main diagnoses on admission included ischaemic heart disease (19%), another medical diagnosis (38%), and surgical procedure (43%). A Barthel score <36 (median 95, 85-100) was observed in 3% of the patients on admission. The median ICU length of stay was 5 days (4-8). ICU mortality was 6% (hospital mortality: 10%). On hospital discharge, 7% had severe dependence (Barthel <36). In this population, factors independently associated with mortality or poor functional status at hospital discharge were the pre-admission functional status, based on Short Form-Late Life Function and Disability instrument (OR 0.95, 95% CI, 0.91 to 0.98), and the severity on admission assessed by SAPS 3 (OR 1.10, 95% CI, 1.02 to 1.18), p=.0007.

CONCLUSIONS

In elderly patients requiring ICU admission, a higher SAPS 3 score and functional impairment on admission were associated with mortality or severe dependence upon discharge.

Mortality hospital of nonagenarian patients in Internal Medicine

OBJECTIVES

To describe the predictors of hospital mortality in nonagenarian patients.

PATIENTS AND METHOD

We retrospectively studied 421 patients aged 90 years or older hospitalised in a department of internal medicine. Using logistic regression, we analysed the association between demographic, clinical and functional parameters and hospital mortality.

RESULTS

The mean age was 92.5 years (SD±2.5), and 265 (62.9%) of the patients were women. The main diagnoses were infectious diseases (257 patients, 61%) and heart failure (183, 43.5%), and the mean stay was 11.9 days (SD±8.6). During the hospitalisation, 96 patients died (22.8%). The predictors of mortality were age (P=.002), functional state (P=.006), comorbidity (P=.018) and diagnoses of pneumonia (P=.001), sepsis (P=.012) and respiratory failure (P<.001).

CONCLUSION

The hospital mortality of nonagenarian patients treated in internal medicine exceeds 20% and is associated with pneumonia, comorbidity burden and functional impairment.

Five-year survival after surgery in nonagenarian patients

AIM

In countries with longer life expectancies, the nonagenarian population is increasing. Therefore, there is greater demand for healthcare, including surgical procedures. The aim of the present study was to determine the outcomes of surgery carried out on nonagenarians in terms of long-term survival after the procedure.

METHODS

We carried out a cross-longitudinal study on a cohort of 159 nonagenarian patients, who underwent a non-cardiac, non-traumatic surgical procedure in our institution between January 1999 and December 2011. The following variables were recorded: sociodemographic characteristics, American Society of Anesthesiologists score, Charlson Comorbidity Index, surgical site, postoperative complications, operative mortality and long-term survival. The output variable was long-term survival.

RESULTS

Of the 159 patients,99 women (62%) and 60 men (38%), with a mean age of 91.8 years (SD ± 2.0 years), 44 cases were operations for malignant disorders (28%), 117 cases (74%) under emergency conditions and 42 cases (26%) were elective treatments. The operative mortality was 29%, 4.8% for elective surgery and 37.6% for emergency surgery (P < 0.001). The postoperative complication rate, including death, was 60%. The probability of survival at 1, 3, and 5 years was 59.6%, 35.8% and 24.1%, respectively. In multivariate analysis, American Society of Anesthesiologists score (HR 2.07, 95% CI 1.58-2.72), emergency surgery (HR 1.64, 95% CI 1.05-2.57) and postoperative medical complications (HR 2.58, 95% CI 1.73-3.85) were independently related to 5-year survival.

CONCLUSIONS

These findings support the perioperative safety of elective general surgery in nonagenarian patients. In selected nonagenarian patients with no cognitive impairment, surgery must not be denied. These data might be useful for surgical decision-making or informed consent for nonagerians. Geriatr Gerontol Int 2017; 17: 2389-2395.

Effect of Permanent Atrial Fibrillation on Cognitive Function in Patients With Chronic Heart Failure

In patients with chronic heart failure (HF), cognitive impairment (CI) is associated with poorer treatment adherence and higher readmission and mortality rates. Previous studies suggest that atrial fibrillation (AF) could impair cognitive function. This study sought to assess the association between permanent AF (permAF) and CI in patients with HF. We evaluated cognitive function in 881 patients with stable HF (73 ± 11 years, 44% women, 48% with preserved ejection fraction) using the Mini-Mental State Examination test (n = 876) and the Pfeiffer's Short Portable Mental Status Questionnaire (n = 848). CI was defined as a Mini-Mental State Examination score <24 or Short Portable Mental Status Questionnaire (errors) >2. The independent association between permAF and CI was assessed by binary logistic regression analysis. A total of 295 patients (33.5%) had CI, in 5.1% of cases moderate/severe. Patients with permAF had more frequently any degree of CI (43% vs 31%), and moderate/severe CI (8% vs 5%). In the multivariate analysis, CI was associated with permAF (odds ratio 1.54, 95% C.I. 1.05 to 2.28), an older age, female gender, diabetes mellitus, chronic kidney disease, previous stroke, New York Heart Association class III/IV, and lower systolic blood pressure. No interaction was found for AF and CI between patients with reduced and preserved ejection fraction. In conclusion, the presence of permAF is independently associated with CI in patients with HF, both with reduced and preserved ejection fraction. Given the clinical impact of CI in the HF population, active assessment of cognitive function is particularly warranted in patients with HF with permAF.

Mortality and functional status at one-year of follow-up in elderly patients with prolonged ICU stay

OBJECTIVE

To evaluate mortality and functional status at one year of follow-up in patients>75 years of age who survive Intensive Care Unit (ICU) admission of over 14 days.

DESIGN

A prospective observational study was carried out.

SETTING

A Spanish medical-surgical ICU.

PATIENTS

Patients over 75 years of age admitted to the ICU.

PRIMARY VARIABLES OF INTEREST

ICU admission: demographic data, baseline functional status (Barthel index), baseline mental status (Red Cross scale of mental incapacity), severity of illness (APACHE II and SOFA), stay and mortality. One-year follow-up: hospital stay and mortality, functional and mental status, and one-year follow-up mortality.

RESULTS

A total of 176 patients were included, of which 22 had a stay of over 14 days. Patients with prolonged stay did not show more ICU mortality than those with a shorter stay in the ICU (40.9% vs 25.3% respectively, P=.12), although their hospital (63.6% vs 33.8%, P<.01) and one-year follow-up mortality were higher (68.2% vs 41.2%, P=.02). Among the survivors, one-year mortality proved similar (87.5% vs 90.6%, P=.57). These patients presented significantly greater impairment of functional status at hospital discharge than the patients with a shorter ICU stay, and this difference persisted after three months. The levels of independence at one-year follow-up were never similar to baseline. No such findings were observed in relation to mental status.

CONCLUSIONS

Patients over 75 years of age with a ICU stay of more than 14 days have high hospital and one-year follow-up mortality. Patients who survive to hospital admission did not show greater mortality, though their functional dependency was greater.

A comorbidity prognostic effect on post-hospitalization outcome in a geriatric rehabilitation setting: the pivotal role of functionality, assessed by mediation model, and association with the Brass index

BACKGROUND

Discharge planning is a critical feature of hospital's care in geriatric rehabilitation centers. The aim of this study was to evaluate the effects of comorbidity and functionality in identifying patients who are at risk of discharge problems. We also evaluate the association between Blaylock Risk Assessment Screening Score, BRASS index (BI), and post-hospitalization outcome (PHO).

METHODS

Eighty patients (58 women and 22 men, with mean age equal to 83.28 ± 6.77 years) at geriatric rehabilitation division admission were screened with Geriatric Multidimensional Assessment (GMA). Then, BI and PHO were evaluated (mean follow-up time was 205.1 ± 95.8 days). By Structural Equation Model, we evaluated the existing causal relationships between comorbidity, functionality and PHO, elements of GMA, and the association between PHO and BI.

RESULTS

Comorbidity acted on PHO through functionality with indirect effect only (+0.703, P = 0.019). So, the functionality assumes a pivotal role of the causal relationship comorbidity to PHO. BI is positively associated with PHO: correlation returned was equal to +0.313 (P = 0.019).

CONCLUSIONS

The comorbidity has a role in getting worse PHO, but its effect is possible only through the mediation of functional status. The study also demonstrated the positive association between BI and PHO.

Functional status and mortality at month and year in nonagenarians hospitalized due to acute medical illness

OBJECTIVES

To analyze risk factors associated with short and long-term mortality in nonagenarians hospitalized due to acute medical conditions.

DESIGN, SETTING, AND PARTICIPANTS

Prospective study of all patients aged 90 years or older admitted in a geriatric unit during 2009 due to medical acute illness. Baseline variables were collected at admission (sex, cause of admission, Charlson index, serum albumin, functional, and mental status), functional loss at admission (as the difference between Barthel index(BI) 2 weeks before admission and BI at admission), and functional loss at discharge(as the difference between BI 2 weeks before admission and BI at discharge). The association of these variables with mortality at 1 month and 1 year after admission was analyzed by multivariate Cox regression analysis.

RESULTS

Out of all patients admitted, 434 (33%) were 90 years old or older and 76.3% were female. Mortality at 1 month and 1 year after admission was 19% and 57%, respectively. In the month mortality multivariate analysis, being older (HR, 1.11; 95% CI=1.02 to 1.20), a previous Barthel index less than 40 points (HR, 5.87; 95% CI=1.16 to 29.67), and functional loss at admission (HR; 1.13; 95% CI=1.03 to 1.25) were independent risk factors. When patients that died 1 month after admission were excluded, the presence of hypoalbuminemia <3g/dl (HR, 2.70; 95% CI=1.69 to 4.32) and functional loss at discharge (HR-1.08, 95% CI=1.03 to 1.14) were the factors associated with 1 year mortality.

CONCLUSIONS

In nonagenarians, functional impairment is the most important risk factor associated with short and long-term mortality after hospitalization due to acute medical illness.

Impact on clinical events and healthcare costs of adding telemedicine to multidisciplinary disease management programmes for heart failure: Results of a randomized controlled trial

BACKGROUND

The role of telemedicine in the management of patients with chronic heart failure (HF) has not been fully elucidated. We hypothesized that multidisciplinary comprehensive HF care could achieve better results when it is delivered using telemedicine.

METHODS AND RESULTS

In this study, 178 eligible patients with HF were randomized to either structured follow-up on the basis of face-to-face encounters (control group, 97 patients) or delivering health care using telemedicine (81 patients). Telemedicine included daily signs and symptoms based on telemonitoring and structured follow-up by means of video or audio-conference. The primary end-point was non-fatal HF events after six months of follow-up. The median age of the patients was 77 years, 41% were female, and 25% were frail patients. The hazard ratio for the primary end-point was 0.35 (95% confidence interval (CI), 0.20-0.59; p-value < 0.001) in favour of telemedicine. HF readmission (hazard ratio 0.39 (0.19-0.77); p-value=0.007) and cardiovascular readmission (hazard ratio 0.43 (0.23-0.80); p-value=0.008) were also reduced in the telemedicine group. Mortality was similar in both groups (telemedicine: 6.2% vs control: 12.4%, p-value > 0.05). The telemedicine group experienced a significant mean net reduction in direct hospital costs of €3546 per patient per six months of follow-up.

CONCLUSIONS

Among patients managed in the setting of a comprehensive HF programme, the addition of telemedicine may result in better outcomes and reduction of costs.

Prognostic factors of long-term survival in geriatric inpatients. Should we change the recommendations for the oldest people?

OBJECTIVES

Identification of optimal predictors of the 5.5-year survival in former geriatric inpatients.Investigation of the direction and shape of the relationship between mortality risk and its predictors.

DESIGN

Retrospective survival analysis with the application of the Cox proportional hazards model.

SETTING

Teaching geriatric unit.

PARTICIPANTS

478 inpatients (mean age 77.9; +6.8) discharged from geriatric ward during year 2008, without any exclusion criteria.

MEASUREMENTS

Comprehensive geriatric assessment of numerous health variables, body mass index (BMI), clinical and biochemical findings, and outcomes of the final diagnosis. Records on the dates of deaths were obtained from the Provincial Office of Population Register.

RESULTS

During the 5.5-year follow-up 209 (43.7%) patients died. In the multivariate setup, six risk factors with an independent impact on mortality were identified: age (p=0.036), cognitive functioning on the Blessed test (p=0.005), score on instrumental ADL (p<0.0001), score on Charlson comorbidity index (p<0.0001), cholesterol level (p<0.0001), BMI (p<0.0001), and hemoglobin level (p=0.02). The latter two predictors exhibited a significant inverted J-shaped association with mortality, i.e., considerably higher risk of death corresponds to the lower values of these variables in comparison to their higher levels.

CONCLUSION

Older age, worse IADL and cognitive functioning, and higher comorbidity were recognized as endangering one's long-term survival. On the other hand, moderate obesity (BMI 36), higher cholesterol and the absence of anemia (hemoglobin 13.6 g/dL) are associated with longer survival. Therefore, irrespective of the individualized treatment and physical exercise, nutrient-dense food seems to be a key recommendation to prevent frailty or malnutrition in the oldest and comorbid population.

Characteristics and outcome in nonagenarians admitted in general internal medicine and other specialties

To describe the characteristics of nonagenarians admitted to the surgical and medical divisions at a tertiary hospital and compare them with nonagenarians admitted to other hospital care services.

METHODS

A retrospective study of all hospital discharge episodes via the registry of the Basic Minimum Data Set at the Hospital General Universitario de Alicante from January 2007 until December 2011.

RESULTS

Of the 165,870 hospitalizations, 2461 (1.5%) were nonagenarians. The highest number of admitted nonagenarians was in the Division of General Internal Medicine (DGIM) (n=751), followed by the short stay unit (SSU) (n=633). The rate of nonagenarians per 100 admissions to the DGIM was 10.2, significantly higher than that of those admitted to the SSU (6.2) (p<0.001), the service of orthopedic and trauma surgery (2.2) (p<0.001), and other specialties. Females comprised 64.8% of the nonagenarians. Mortality was 17% for the nonagenarians admitted, while for those admitted to the DGIM it was 27.7%. Those hospitalized in the SSU had a lower risk of death during hospitalization (8.1%) (odds ratio [OR] 0.23, 95% confidence interval [CI] 0.16-0.32) and a greater risk of being admitted for diseases and disorders of the circulatory system (OR: 1.58, 95% CI: 1.22-2.05), particularly for heart failure and shock (OR: 1.82, 95% CI: 1.30-2.53), and being discharged with home hospitalization (OR: 8.05, 95% CI: 5.5-11.8).

CONCLUSIONS

Nonagenarian patients represent a tenth of those admitted to the DGIM. The profile of nonagenarians admitted to the DGIM is different from other hospital services. Hospital mortality for nonagenarians admitted to the DGIM is high and superior to other hospital services.

In nonagenarians, acute kidney injury predicts in-hospital mortality, while heart failure predicts hospital length of stay

BACKGROUND/AIMS

The elderly constitute an increasing proportion of admitted patients worldwide. We investigate the determinants of hospital length of stay and outcomes in patients aged 90 years and older.

METHODS

We retrospectively analyzed all admitted patients aged >90 years from the general medical wards in a tertiary referral medical center between August 31, 2009 and August 31, 2012. Patients' clinical characteristics, admission diagnosis, concomitant illnesses at admission, and discharge diagnosis were collected. Each patient was followed until discharge or death. Multivariate logistic regression analysis was utilized to study factors associated with longer hospital length of stay (>7 days) and in-hospital mortality.

RESULTS

A total of 283 nonagenarian in-patients were recruited, with 118 (41.7%) hospitalized longer than one week. Nonagenarians admitted with pneumonia (p = 0.04) and those with lower Barthel Index (p = 0.012) were more likely to be hospitalized longer than one week. Multivariate logistic regression analysis revealed that patients with lower Barthel Index (odds ratio [OR] 0.98; p = 0.021) and those with heart failure (OR 3.05; p = 0.046) had hospital stays >7 days, while patients with lower Barthel Index (OR 0.93; p = 0.005), main admission nephrologic diagnosis (OR 4.83; p = 0.016) or acute kidney injury (OR 30.7; p = 0.007) had higher in-hospital mortality.

CONCLUSION

In nonagenarians, presence of heart failure at admission was associated with longer hospital length of stay, while acute kidney injury at admission predicted higher hospitalization mortality. Poorer functional status was associated with both prolonged admission and higher in-hospital mortality.