Risk factors predicting later functional decline in older hospitalized patients

Delirium: Prevalence and outcome in the very old in 27 medical departments during a one-year prospective study

OBJECTIVE

The prevalence and effects of delirium in very old individuals aged ≥80 years have not yet been systematically evaluated. Therefore, this large single-center study of the one-year prevalence of delirium in 3,076 patients in 27 medical departments of the University Hospital of Zurich was conducted.

METHODS

Patient scores on the Delirium Observation Screening scale, Intensive Care Delirium Screening Checklist, Diagnostic and Statistical Manual, 5th edition, and electronic Patient Assessment-Acute Care (nursing tool) resulted in the inclusion of 3,076 individuals in 27 departments. The prevalence rates were determined by simple logistic regressions, odds ratios (ORs), and confidence intervals.

RESULTS

Of the 3,076 patients, 1,285 (41.8%) developed delirium. The prevalence rates in the 27 departments ranged from 15% in rheumatology (OR = 0.30) to 73% in intensive care (OR = 5.25). Delirious patients were more likely to have been admitted from long-term care facilities (OR = 2.26) or because of emergencies (OR = 2.24). The length of their hospital stay was twice as long as that for other patients. Some died before discharge (OR = 24.88), and others were discharged to nursing homes (OR = 2.96) or assisted living facilities (OR = 2.2).

CONCLUSION

This is the largest study to date regarding the prevalence of delirium in patients aged ≥80 years and the medical characteristics of these patients. Almost two out of five patients developed delirium, with a high risk of loss of independence and mortality.

Many Paths to Recovery: Comparing Basic Function and Participation in High-Functioning Older Adults After Acute Hospitalization

Function after acute hospitalization is mostly operationalized by Basic Activities of Daily Living (BADL), a limited concept that overshadows a wide range of instrumental, social, and recreational activities, otherwise referred to as participation. Participation is important for patients' health and quality of life after hospitalization. This study focuses on high-functioning older adults, examining functional recovery after hospitalization by comparing BADL assessment with assessment of participation at one and three months following discharge relative to pre-hospitalization. Quantitative data were collected from 72 participants divided into two age groups of hospitalized older adults (age 65-74, n = 38; age ≥75, n = 34), followed by home visits after 1 month and telephone interviews 3 months after discharge. Both groups experienced a significantly greater decline in participation, compared with BADL, which were mostly preserved. A comprehensive assessment of participation better captures functional changes in high-functioning older adults. Early identification of participation withdrawal is crucial for preventing disability.

The impact of partial-oral endocarditis treatment on anxiety and depression in the POET trial

BACKGROUND

The Partial-Oral versus Intravenous Antibiotic Treatment of Endocarditis Trial (POET) found that partial-oral outpatient treatment was non-inferior to conventional in-hospital intravenous treatment in patients with left-sided infective endocarditis. We examined the impact of treatment strategy on levels of anxiety and depression.

METHODS

Patients completed the Hospital Anxiety and Depression Scale (HADS) at randomization, at antibiotic completion, and after month 3 and month 6. Changes in anxiety and depression (each subdimension 0-21, high scores indicating worse) were calculated using a repeated measure analysis of covariance model with primary assessment after 6 months. Change in score of 1.7 represented a minimal clinical important difference (MCID).

RESULTS

Among the 400 patients enrolled in the POET trial, 263 (66%) completed HADS at randomization with reassessment rates of 86-87% at the three subsequent timepoints. Patients in the partial-oral group and the intravenous group had similar improvements after 6 months in levels of anxiety (-1.8 versus -1.6, P = 0.62) and depression (-2.1 versus -1.9, P = 0.63), although patients in the partial-oral group had numerically lower levels of anxiety and depression throughout. An improvement in MCID scores after 6 months was reported by 47% versus 45% (p = 0.80) patients for anxiety and by 51% versus 54% (p = 0.70) for depression.

CONCLUSION

Patients with endocarditis receiving partial-oral outpatient treatment reported similar significant improvements in anxiety and depression at 6 months, as compared to conventionally treated, but numerically lower levels throughout. These findings support the usefulness of partial-oral treatment.

Patient-related risk factors for in-hospital functional decline in older adults: A systematic review and meta-analysis

BACKGROUND

Functional decline (FD) is a common and serious problem among hospitalised older adults.

OBJECTIVE

This systematic review and meta-analysis aims to identify patient-related risk factors for in-hospital FD in older adults.

METHODS

Previous reviews on this topic (1970-2007) and the databases PubMed, Embase, and CINAHL (January 2007-December 2020) were searched. Reference lists of included articles were screened. Studies investigating patient-related risk factors for FD from (pre)admission to discharge in older adults admitted to an acute geriatric or internal medical unit were included. Study quality was assessed using the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using random-effects models. The quality of evidence was assessed using GRADE.

RESULTS

Twenty-nine studies met the inclusion criteria. Statistically significant risk factors were living in a nursing home (OR, 2.42; 95% CI, 1.29-4.52), impairment in instrumental activities of daily living (OR, 2.08; 95% CI, 1.51-2.86), history of falls (OR, 1.71; 95% CI, 1.00-2.92), cognitive impairment (OR, 1.83; 95% CI, 1.56-2.14), dementia (OR, 1.71; 95% CI, 1.23-2.38), delirium (OR, 2.34; 95% CI, 1.88-2.93), (risk of) malnutrition (OR, 1.76; 95% CI, 1.03-3.03), hypoalbuminemia (OR, 1.79; 95% CI, 1.36-2.36), comorbidity (OR, 1.09; 95% CI, 1.03-1.16), and the presence of pressure ulcers (OR, 3.33; 95% CI, 1.82-6.09). The narrative synthesis suggested prehospital FD, needing assistance with walking, and low body mass index as additional risk factors.

CONCLUSIONS

Several patient-related risk factors for in-hospital FD were identified that can be used at hospital admission to identify older patients at risk of FD.

Physical Resilience in Daily Functioning Among Acutely Ill Hospitalized Older Adults: The Hospital-ADL Study

OBJECTIVES

Insight into older adults' physical resilience is needed to predict functional recovery after hospitalization. We assessed functional trajectories in response to acute illness and subsequent hospitalization and investigated baseline variables and dynamic variables associated with these trajectories.

DESIGN

Prospective observational cohort study (Hospitalization-Associated Disability and impact on daily Life Study).

SETTING AND PARTICIPANTS

This study included 207 older adults (aged 79.8 ± 6.9 years, 49% female, 57% frail) acutely hospitalized in 6 Dutch hospitals.

METHODS

Functional disability was assessed using the 15-item modified activities of daily living index retrospectively 2 weeks before admission, and prospectively from admission up to 3 months after discharge. Baseline variables including frailty, somatic, physical, and psychosocial factors were assessed at admission. Dynamic variables (step count, pain, fatigue, and fear of falling) were continuously or repeatedly assessed during hospitalization. We performed individual spline modeling using random effects. Baseline variables and within-person mean levels and variability in the dynamic variables were assessed as predictors of functional trajectories.

RESULTS

Functional disability significantly increased before admission and decreased from admission to 3 months post discharge. Frail participants had a significantly higher increase in functional disability before admission compared with nonfrail participants. Lower step count, higher pain scores, and higher within-person variability in fear of falling were significantly associated with higher increase in functional disability before admission. Higher within-person variability in fear of falling was associated with more recovery.

CONCLUSIONS AND IMPLICATIONS

Older adults increase in functional disability before hospitalization and start to recover from admission onward. Frailty and dynamic variables are associated with a higher increase in functional disability after acute illness. Our findings give more insight into older adults' physical resilience, which may improve the prediction of functional recovery and may improve therapeutic decision-making and rehabilitation strategies to improve functional recovery after acute hospitalization.

Developing a predictive model for hospital-associated disability among older patients hospitalized for an acute illness: the HAD-FREE Score

PURPOSE

To develop a predictive model to identify hospitalized older patients at risk of functional decline.

METHODS

This retrospective cohort study recruited participants aged 65 years and over admitted to internal medicine wards of a tertiary medical center in Taiwan during May to October 2017 for developing predictive model (n = 1698) and those admitted during November to December 2017 for validation study (n = 530) of the model. Demographic data, geriatric assessments and hospital conditions (admission route and length of hospital stay) were collected for analysis.

RESULTS

Overall, of the 1698 participants (mean age 75.8 ± 7.9 years, 60.9% male) enrolled in the development study, 20.1% had functional decline. Results of multivariate logistic regression showed that older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥ 5 days were independent predictive factors for decline. A scoring system, HAD-FREE Score, constructed from the above predictive factors ranged from 0 to 18 points and ≥ 6 points was chosen as the cut-off point. The area under the receiver operating characteristic analysis was 0.748 (95% confidence interval: 0.720-0.776), the sensitivity was 65.3% and the specificity was 71.3%. Validation of the HAD-FREE Score showed moderate discriminative ability in the validation study.

CONCLUSION

A HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. This scoring system can be the basis of an automatic dynamic tracking within the electronic medical record to identify those older patients at risk of functional decline during hospitalization.

Retrospective analysis of endocarditis patients to investigate the eligibility for oral antibiotic treatment in routine daily practice

Background

According to the current guidelines of the European Society of Cardiology, patients with left-sided infective endocarditis are treated with intravenous antibiotics for 4–6 weeks, leading to extensive hospital stay and high costs. Recently, the Partial Oral Treatment of Endocarditis (POET) trial suggested that partial oral treatment is effective and safe in selected patients. Here, we investigated if such patients are seen in our daily clinical practice.

Methods

We enrolled 119 adult patients diagnosed with left-sided infective endocarditis in a retrospective, observational study. We identified those that would be eligible for switching to partial oral antibiotic treatment as defined in the POET trial (e.g. stable clinical condition without signs of infection). Secondary objectives were to provide insight into the time until each patient was eligible for partial oral treatment, and to determine parameters of longer hospital stay and/or need for extended intravenous antibiotic treatment.

Results

Applying the POET selection criteria, the condition of 38 patients (32%) was stable enough to switch them to partial oral treatment, of which 18 (47.3%), 8 (21.1%), 9 (23.7%) and 3 patients (7.9%) were eligible for switching after 10, 14, 21 days or 28 days of intravenous treatment, respectively.

Conclusion

One-third of patients who presented with left-sided endocarditis in routine clinical practice were possible candidates for switching to partial oral treatment. This could have major implications for both the patient’s quality of life and healthcare costs. These results offer an interesting perspective for implementation of such a strategy, which should be accompanied by a prospective cost-effectiveness analysis.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01490-2) contains supplementary material, which is available to authorized users.

The Effect of Caregiver-Mediated Mobility Interventions in Hospitalized Patients on Patient, Caregiver, and Health System Outcomes: A Systematic Review

OBJECTIVE

To synthesize the evidence examining caregiver-mediated mobility interventions in a hospital setting and whether they improve patient, caregiver, or health system outcomes.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus databases from inception to September 7, 2018.

STUDY SELECTION

Two reviewers independently selected original research in inpatient settings that reported on an intervention delivered by a caregiver (eg, family, friend, paid worker) and directed to the patient's mobility. Mobility interventions were categorized based on the level of caregiver engagement using a 3-category framework: inform (provision of education on patient's condition and management), activate (prompting caregivers to take action in patient care), and collaborate (encouraging interaction with providers or other caregivers).

DATA EXTRACTION

One reviewer extracted data, and another checked the data. Quality was assessed using the Cochrane Collaboration's risk of bias tool and Grading of Recommendations, Assessment, Development and Evaluation approach.

DATA SYNTHESIS

Forty studies met the inclusion criteria; most were randomized controlled trials (n=16/40, 40.0%) and investigated older adults (n=18/40, 45.0%) with stroke (n=20/40, 50.0%). Inform (n=2) and activate (n=4) interventions and combined inform-activate (n=5/6, 83.3%) and inform-activate-collaborate (n=6/10, 60.0%) interventions were reported to improve patient mobility. Inform-activate and inform-collaborate interventions were reported to improve caregiver outcomes (eg, burden) (n=13/19, 68.4%). Studies that engaged caregivers in all 3 strategies (inform-activate-collaborate) were reported to improve health system outcomes (eg, hospital readmission) (n=4/6, 66.7%). Most studies were of unclear (n=22/40, 55.0%) or low risk of bias (n=11/40, 27.5%) for most domains.

CONCLUSIONS

Engaging caregivers in mobility of hospitalized patients may improve patient mobility as well as caregiver and health system outcomes.

Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey

BACKGROUND

Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany.

METHODS

A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested.

RESULTS

486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement.

CONCLUSIONS

Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.

Frailty as a predictor of adverse outcomes in hospitalized older adults: A systematic review and meta-analysis

Frailty syndrome is prevalent among hospitalized older adults as are the occurrence of adverse outcomes. This systematic review and meta-analysis investigated whether frailty in older adults at hospital admission predicts adverse outcomes. Manual (ProQuest, conferences annals and references) and electronic searches (PUBMED, EMBASE, Web of Science, Lilacs, CINAHL, PsycINFO and Google Scholar) were performed. We included prospective studies of hospitalized older adults. Primary outcomes were functional decline at hospital discharge and mortality after discharge. Other data were considered secondary outcomes. Methodological quality was evaluated by the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Twenty-eight papers were included, corresponding to 19 cohorts (5 cohorts for functional decline and 16 for mortality), with moderate to good methodological quality. Being frail [RR: 1.32 (95%CI: 1.04; 1.67)] and pre-frail [RR: 1.51 (95%CI: 1.05; 2.17)] are risk factors for functional decline compared with being nonfrail. Frail individuals had a relative risk for in-hospital mortality and mortality in medium- and long-term compared to nonfrail (in-hospital RR: 8.20, medium RR: 9.49 and long RR: 7.94) and pre-frail (in-hospital RR: 3.19, medium RR: 3.31 and long RR: 3.72). The overall mortality risk in frail individuals is 3.49 and 2.14 times compared to nonfrail and pre-frail, respectively. Length of hospital stay was higher for frail older adults (13.5 days) compared with pre-frail (10.5 days) and nonfrail (8.3 days). Therefore, being frail at hospital admission is a risk factor for in-hospital mortality, long hospital stay, functional decline at hospital discharge, and mortality in the medium- and long-term.

The novel use of oral antibiotic monotherapy in prosthetic valve endocarditis caused by Finegoldia magna: a case study

Background

Finegoldia magna, a Gram-positive anaerobic coccus, is part of the human normal microbiota as a commensal of mucocutaneous surfaces. However, it remains an uncommon pathogen in infective endocarditis, with only eight clinical cases previously reported in the literature.

Currently, infective endocarditis is routinely treated with prolonged intravenous antibiotic therapy. However, recent research has found that switching patients to oral antibiotics is non-inferior to prolonged parenteral antibiotic treatment, challenging the current guidelines for the treatment of infective endocarditis.

Case presentation

This case report focuses on a 52-year-old gentleman, who presented with initially culture-negative infective endocarditis following bioprosthetic aortic valve replacement. Blood cultures later grew Finegoldia magna. Following initial intravenous antibiotic therapy and re-do surgical replacement of the prosthetic aortic valve, the patient was successfully switched to oral antibiotic monotherapy, an unusual strategy in the treatment of infective endocarditis inspired by the recent publication of the POET trial. He made excellent progress on an eight-week course of oral antibiotics and was successfully discharged from surgical follow-up.

Conclusions

This case is the 9th reported case of Finegoldia magna infective endocarditis in the literature. Our case also raises the possibility of a more patient-friendly and cost-effective means of providing long-term antibiotic therapy in suitable patients with prosthetic valve endocarditis and suggests that the principles highlighted in the POET trial can also be applicable to post-operative patients after cardiac surgery.

Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis

BACKGROUND

Patients with infective endocarditis on the left side of the heart are typically treated with intravenous antibiotic agents for up to 6 weeks. Whether a shift from intravenous to oral antibiotics once the patient is in stable condition would result in efficacy and safety similar to those with continued intravenous treatment is unknown.

METHODS

In a randomized, noninferiority, multicenter trial, we assigned 400 adults in stable condition who had endocarditis on the left side of the heart caused by streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci and who were being treated with intravenous antibiotics to continue intravenous treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. The primary outcome was a composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed.

RESULTS

After randomization, antibiotic treatment was completed after a median of 19 days (interquartile range, 14 to 25) in the intravenously treated group and 17 days (interquartile range, 14 to 25) in the orally treated group (P=0.48). The primary composite outcome occurred in 24 patients (12.1%) in the intravenously treated group and in 18 (9.0%) in the orally treated group (between-group difference, 3.1 percentage points; 95% confidence interval, -3.4 to 9.6; P=0.40), which met noninferiority criteria.

CONCLUSIONS

In patients with endocarditis on the left side of the heart who were in stable condition, changing to oral antibiotic treatment was noninferior to continued intravenous antibiotic treatment. (Funded by the Danish Heart Foundation and others; POET ClinicalTrials.gov number, NCT01375257 .).

Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care

OBJECTIVES

To propose a new multicomponent measure of hospital-associated complications of older people (HAC-OP) and evaluate its validity in a large hospital sample.

DESIGN

Observational study using baseline (pre-intervention) data from the Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital cluster randomized controlled trial.

SETTING

Acute medical and surgical wards in 4 hospitals in Queensland, Australia.

PARTICIPANTS

Individuals aged 65 and older (mean age 76, 48% female) with a hospital stay of 72 hours or longer (N=434).

MEASUREMENTS

We developed a multicomponent measure including 5 well-recognized hospital-associated complications of older people: hospital-associated delirium, functional decline, incontinence, falls, and pressure injuries. To evaluate construct validity, we examined associations with common risk factors (aged ≥75, functional impairment, cognitive impairment, history of falls). To evaluate predictive validity, we examined the association between length of stay, facility discharge, and 6-month mortality and any HAC-OP and total number of HAC-OP.

RESULTS

Overall, 192 (44%) participants had 1 or more HAC-OP during their admission. Any HAC-OP was strongly associated with the proposed shared risk factors, and there was a strong and graded association between HAC-OP and length of stay (9.1±7.4 days for any HAC-OP vs 6.8 ±4.1 days with none, p < .001), facility discharge (59/192 (31%) vs 27/242 (11%), p < .001) and 6-month mortality (26/192 (14%) vs 17/242 (7%), p = .02).

CONCLUSION

This study provides evidence of construct and predictive validity of the proposed measure of HAC-OP as a potential outcome measure for research investigating and improving hospital care of older people. J Am Geriatr Soc 67:352-356, 2019.

Effects of a nursing care program on functional outcomes in older acute medical in-patients: protocol for a randomized controlled trial

Background:

Hospitalization often leads to long periods of bed rest and inactivity which is associated with an increase in length of hospital stay, loss of capacity for basic self-care and discharge into a nursing home.

Objective:

This trial aims to verify if a nursing care program centered on basic self-care and predefined physical activity, improves functional outcomes in older hospitalized patients.

Methods:

This is a 2-group randomized controlled trial with repeated measures: 182 older acute medical patients will be blindly randomly allocated to the control group (n = 91) or intervention group (n = 91). The intervention will consist of nursing care intervention centered on basic self-care that includes a twice daily walking training, plus privileging pre-established trips to the toilet by walking and all daytime meals seated, off the bed. The main outcome was changes in the number of independent activities of daily living from 2 weeks before admission (baseline) to discharge. Trial registration: ClinicalTrials.gov (Identifier NCT03106064).

Results:

This intervention has the potential to change the outcomes of the older patient in the acute setting.

Conclusion:

The loss of independence in self-care is determinant in future health care needs. If our hypothesis is correct and demonstrate that this nursing care program centered on basic self-care for older acute medical patients improves functional outcomes, a change in the paradigmatic organization of hospital care may be justifiable.

Functional trajectories of older patients admitted to an Acute Care Unit for Elders

AIMS AND OBJECTIVES

To describe the functional trajectories of older medical inpatients and to identify factors associated with overall and in-hospital functional decline.

BACKGROUND

Functional decline during a hospital stay is an important clinical outcome because independence remains a major determinant of older persons' quality of life and health care demands.

DESIGN AND METHODS

Participants (n = 189) were admitted to the Acute Care Unit for Elders of a Swiss academic hospital and were aged 65 years and older. Performance in basic activities of daily living at home (self-reported), at hospital admission (observed) and at discharge (observed) was collected. Differences in scores for basic activities daily living between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline. Predictors of in-hospital and overall decline were identified using bivariate and multivariate logistic regression analyses.

RESULTS

Pre-admission, in-hospital and overall functional decline occurred in 56.1%, 17.5% and 43.4% of the participants, respectively. In contrast, in-hospital functional improvement occurred in 40.2% of the participants. No predictors of pre-admission decline were identified, whereas pre-admission performance in instrumental activities of daily living was associated with in-hospital decline. Male gender and in-hospital delirium were associated with overall functional decline.

CONCLUSIONS

Most older inpatients experienced functional decline before their hospital admission, but only a minority experienced decline during their stay. Importantly, delirium was a strong predictor of overall functional decline.

IMPLICATIONS FOR PRACTICE

Low performance in instrumental activities of daily living prior to admission and delirium occurrence identified older patients at higher risk for in-hospital and overall functional decline. Gerontological nurses should play a key role in identifying these patients to provide preventative interventions and recovery care to preserve or restore their functional independence.

Herpes zoster-associated mortality in Europe: a systematic review

Background

Reactivation of latent varicella zoster virus, partly due to age-related immunosenescence and immunosuppressive conditions, results in herpes zoster (HZ) and its associated complications. The management of the most important complication, post-herpetic neuralgia (PHN), is challenging, particularly in the elderly, and is generally unsatisfactory. No previous reviews have reported the incidence of HZ-associated mortality.

Methods

We carried out a systematic literature review to identify studies and databases providing data for HZ-associated mortality in adults aged ≥50 years in Europe.

Results

We identified 12 studies: Belgium (1); France (1); Germany (1); the Netherlands (2); Portugal (1); Spain (4) and England/Wales (2) and 4 databases from Europe: France; Germany and England/Wales. The incidence was available from eight studies; it was highest in those aged ≥95 in France (19.48/100,000). In the European (WHO) database, the overall mortality ranged from 0 to >0.07/100,000. The age- and gender-specific HZ mortality rates from the other databases showed that while in younger age groups the HZ mortality rate was higher in males, in older patients the rate was much higher in women. The case fatality rate was 2 and 61/100 000 in those 45–65 and ≥65 years, respectively. A similar increase with age was seen for the hospital fatality rate; 0.6% in those 45–65 years in the UK and 7.1% in those ≥80 in Spain.

Conclusions

Although the data were sparse and heterogeneous, HZ-associated mortality clearly increases with age. In addition, the elderly who develop HZ often have underlying diseases and are at increased risk of functional decline and loss of independence. Mortality should be taken into account in health-economics models.

[Review of functional impairment associated with acute illness in the elderly]

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

Relationship of patient volume and service concentration with outcome in geriatric rehabilitation

OBJECTIVE

Although geriatric rehabilitation (GR) is beneficial for restoration of activities and participation after hospitalization of vulnerable older persons, little is known about the optimal organization of care of these postacute facilities. This study examines the relationship of patient volume and service concentration with successful GR (short length of stay and discharge home) in skilled nursing facilities (SNFs).

DESIGN

A national multicenter retrospective cohort study.

SETTING AND PARTICIPANTS

All patients indicated for GR in a Dutch SNF.

MEASUREMENTS

Nurses filled out digital registration forms from patient records. Patients were studied in 3 predefined diagnostic groups: total joint replacement, traumatic injuries, and stroke. Facility characteristics were obtained by structured telephone interviews with facility managers. Volume was based on the number of discharges in a 3-month period and categorized in low-, medium-, and high-volume facilities. Concentration was defined at the organizational level in which the population consists of 80% or more of 1 or 2 diagnostic groups, with the prerequisite of having a minimum of 10 rehabilitation beds.

RESULTS

From 88 facilities, 2269 GR patients (mean age 78.2 years [SD 9.7]; 68.2% female) were included. The median length of stay in the SNF was 45 days (interquartile range 23-81), 57% of the patients were discharged home, and 9.8% died during GR. Of patients with total joint replacement (n = 501), concentration was related to successful rehabilitation (odds ratio 5.7; 95% confidence interval 1.3-24.3; P = .020, adjusted for age and gender); this relationship was not found for patients with traumatic injuries or stroke. Volume showed no relation with successful rehabilitation in any of the 3 diagnostic groups.

CONCLUSION

This study may indicate that concentration in an SNF, as a proxy for specialization, favors successful GR in total joint replacement. This relationship was not found for the traumatic injuries or stroke groups, or for volume. The relation on functional outcome in GR needs further investigation.

Partial oral treatment of endocarditis

BACKGROUND

Guidelines for the treatment of left-sided infective endocarditis (IE) recommend 4 to 6 weeks of intravenous antibiotics. Conversion from intravenous to oral antibiotics in clinically stabilized patients could reduce the side effects associated with intravenous treatment and shorten the length of hospital stay. Evidence supporting partial oral therapy as an alternative to the routinely recommended continued parenteral therapy is scarce, although observational data suggest that this strategy may be safe and effective.

STUDY DESIGN

This is a noninferiority, multicenter, prospective, randomized, open-label study of partial oral treatment with antibiotics compared with full parenteral treatment in left-sided IE. Stable patients (n = 400) with streptococci, staphylococci, or enterococci infecting the mitral valve or the aortic valve will be included. After a minimum of 10 days of parenteral treatment, stable patients are randomized to oral therapy or unchanged parenteral therapy. Recommendations for oral treatment have been developed based on minimum inhibitory concentrations and pharmacokinetic calculations. Patients will be followed up for 6 months after completion of antibiotic therapy. The primary end point is a composition of all-cause mortality, unplanned cardiac surgery, embolic events, and relapse of positive blood cultures with the primary pathogen.

CONCLUSION

The Partial Oral Treatment of Endocarditis study tests the hypothesis that partial oral antibiotic treatment is as efficient and safe as parenteral therapy in left-sided IE. The trial is justified by a review of the literature, by pharmacokinetic calculations, and by our own experience.

Reducing "iatrogenic disability" in the hospitalized frail elderly

BACKGROUND

Hospitalization is the first cause of functional decline in the elderly: 30 to 60% of elderly patients lose some independence in basic activities of daily living (ADL) during a stay in hospital. This loss of independence results from the acute condition that led to admission, but is also related to the mode of management.

OBJECTIVE

This paper is a review of the literature on functional decline in elderly hospitalized patients. It is the first stage in a project aiming to prevent dependence that is induced during the course of care.

METHODS

During a 2-day workshop in Monaco, a task force of 20 international experts discussed and defined the concept of "iatrogenic disability".

RESULTS

1- "Iatrogenic disability" was defined by the task force as the avoidable dependence which often occurs during the course of care. It involves three components that interact and have a cumulative effect: a) the patient's pre-existing frailty, b) the severity of the disorder that led to the patient's admission, and lastly c) the hospital structure and the process of care. 2- The prevention of "iatrogenic disability" involves successive stages. - becoming aware that hospitalization may induce dependence. Epidemiological studies have identified at-risk populations by the use of composite scores (HARP, ISAR, SHERPA, COMPRI, etc). - considering that functional decline is not a fatality. Quality references have already been defined. Interventions to prevent dependence in targeted populations have been set up: simple geriatric consultation teams, single-factor interventions (aimed for example at mobility, delirium, iatrogenic disorders) or multidomain interventions (such as GEM and ACE units, HELP, Fast Track, NICHE). These interventions are essentially centered on the patient's frailty and have limited results, as they take little account of the way the institution functions, which is not aimed at prevention of functional decline. The process of care reveals shortcomings: lack of geriatric knowledge, inadequate evaluation and management of functional status. The group suggests that interventions must not only identify at-risk patients so that they may benefit from specialized management, but they must also target the hospital structure and the process of care. This requires a graded "quality approach" and rethinking of the organization of the hospital around the elderly person.