Determinants of short and long term functional recovery after hospitalization for community-acquired pneumonia in the elderly: role of inflammatory markers

Malnutrition, Functional Decline, and Institutionalization in Older Adults after Hospital Discharge Following Community-Acquired Pneumonia

BACKGROUND AND AIMS

Community-acquired pneumonia (CAP) is a major threat to older adults, but mid-term implications are poorly described. The aim was to analyze functional decline, institutionalization, malnutrition, and risk factors after hospital admission for CAP.

METHODS

This prospective observational study included patients over 65 years discharged after CAP between May 2019 and July 2021. We performed a comprehensive geriatric assessment and a general nutritional assessment 30-60 days after CAP. This included the MNA and blood test with trace elements and vitamins. The main outcomes were functional decline, institutionalization, and malnutrition. Multivariate logistic regression was used for the analyses.

RESULTS

In total, 144 patients of 77.15 ± 7.91 years, 55.6% male, and 9% previously institutionalized were analyzed. At hospital admission, the Charlson Comorbidity Index (CCI) was 1.5 ± 1.6, the Pneumonia Severity Index was 98.1 ± 25.9, and the previous Barthel Index (BI) was 93.06 ± 17.13. Hospital stay was 9.72 ± 7.88 days. After 44.6 ± 14.4 days, 48.6% patients showed functional decline and 19.4% were institutionalized. Age (OR 1.17; CI 95% 1.09-1.26), previous institutionalization (29.1; 3.7-224.7), BI (1.09; 1.05-1.14), CCI (1.5; 1.1-2.1), and length of stay (1.1, 1.02-1.18) were independently associated with functional decline. The only predictors of new institutionalization were previous BI (0.96; 0.93-0.99) and length of stay (1.06; 1.00-1.13). The MNA indicated malnutrition in 28% of the community-dwelling patients and 67.9% of those institutionalized, with risk of malnutrition being 45.7% and 9.5%, respectively, after an average of 44.6 days of CAP diagnosis. The predictors of malnutrition were previous institutionalization (10.62; 2.20-51.21), BI (0.95; 0.92-0.98), and length of stay (1.12; 1.04-1.20). Micronutrient deficiencies were mainly zinc (61.8%), vitamin D (54.5%), and vitamin C (45.1%). An MNA score < 17 points or hypoalbuminemia showed good specificity to identify these deficiencies.

CONCLUSIONS

After CAP admission, functional decline, institutionalization, and malnutrition rates were high. Longer hospital stay was a common risk factor for all outcomes. The presence of hypoalbuminemia or an MNA < 17 in older patients should prompt suspicion of deficiencies in micronutrients, such as vitamin D, C, and zinc.

Functional decline, long term symptoms and course of frailty at 3-months follow-up in COVID-19 older survivors, a prospective observational cohort study

BACKGROUND

Aging is one of the most important prognostic factors increasing the risk of clinical severity and mortality of COVID-19 infection. However, among patients over 75 years, little is known about post-acute functional decline.

OBJECTIVE

The aim of this study was to identify factors associated with functional decline 3 months after COVID-19 onset, to identify long term COVID-19 symptoms and transitions between frailty statesafter COVID-19 onset in older hospitalized patients.

METHODS

This prospective observational study included COVID-19 patients consecutively hospitalized from March to December 2020 in Acute Geriatric Ward in Nantes University Hospital. Functional decline, frailty status and long term symptoms were assessed at 3 month follow up. Functional status was assessed using the Activities of Daily Living simplified scale (ADL). Frailty status was evaluated using Clinical Frailty Scale (CFS). We performed multivariable analyses to identify factors associated with functional decline.

RESULTS

Among the 318 patients hospitalized for COVID-19 infection, 198 were alive 3 months after discharge. At 3 months, functional decline occurred in 69 (36%) patients. In multivariable analysis, a significant association was found between functional decline and stroke (OR = 4,57, p = 0,003), history of depressive disorder (OR = 3,05, p = 0,016), complications (OR = 2,24, p = 0,039), length of stay (OR = 1,05, p = 0,025) and age (OR = 1,08, p = 0,028). At 3 months, 75 patients described long-term symptoms (49.0%). Of those with frailty (CFS scores ≥5) at 3-months follow-up, 30% were not frail at baseline. Increasing frailty defined by a worse CFS state between baseline and 3 months occurred in 41 patients (26.8%).

CONCLUSIONS

This study provides evidence that both the severity of the COVID-19 infection and preexisting medical conditions correlates with a functional decline at distance of the infection. This encourages practitioners to establish discharge personalized care plan based on a multidimensional geriatric assessment and in parallel on clinical severity evaluation.

Distinctive features of severe SARS-CoV-2 pneumonia

The coronavirus disease 2019 (COVID-19) pandemic is among the most important public health crises of our generation. Despite the promise of prevention offered by effective vaccines, patients with severe COVID-19 will continue to populate hospitals and intensive care units for the foreseeable future. The most common clinical presentation of severe COVID-19 is hypoxemia and respiratory failure, typical of the acute respiratory distress syndrome (ARDS). Whether the clinical features and pathobiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia differ from those of pneumonia secondary to other pathogens is unclear. This uncertainty has created variability in the application of historically proven therapies for ARDS to patients with COVID-19. We review the available literature and find many similarities between patients with ARDS from pneumonia attributable to SARS-CoV-2 versus other respiratory pathogens. A notable exception is the long duration of illness among patients with COVID-19, which could result from its unique pathobiology. Available data support the use of care pathways and therapies proven effective for patients with ARDS, while pointing to unique features that might be therapeutically targeted for patients with severe SARS-CoV-2 pneumonia.

Persistent Functional Decline Following Hospitalization with Influenza or Acute Respiratory Illness

Background/objectives

Influenza is associated with significant morbidity and mortality, particularly for older adults. Persistent functional decline following hospitalization has important impacts on older adults' wellbeing and independence, but has been under‐studied in relation to influenza. We aimed to investigate persistent functional change in older adults admitted to hospital with influenza and other acute respiratory illness (ARI).

Design

Protective observational cohort study.

Setting

Canadian Immunization Research Network Serious Outcomes Surveillance Network 2011 to 2012 influenza season.

Participants

A total of 925 patients aged 65 and older admitted to hospital with influenza and other ARI.

Measurements

Influenza was laboratory‐confirmed. Frailty was measured using a Frailty index (FI). Functional status was measured using the Barthel index (BI); moderate persistent functional decline was defined as a clinically meaningful loss of ≥10 to <20 points on the 100‐point BI. Catastrophic disability (CD) was defined as a loss of ≥20 points, equivalent to full loss of independence in two basic activities of daily living.

Results

Five hundred and nineteen (56.1%) were women; mean age was 79.4 (standard deviation=8.4) years. Three hundred and forty‐six (37.4%) had laboratory‐confirmed influenza. Influenza cases had lower baseline function (BI = 77.0 vs 86.9, P < .001) and higher frailty (FI = 0.23 vs 0.20, P < .001) than those with other ARI. A total of 8.4% died, 8.2% experienced persistent moderate functional decline, and 9.9% experienced CD. Higher baseline frailty was associated with increased odds of experiencing functional decline, CD, and death. The experience of functional decline and CD, and its association with frailty, was the same for influenza and other ARI.

Conclusion

Functional loss in hospital is common among older adults; for some this functional loss is persistent and catastrophic. This highlights the importance of prevention and optimal management of acute declines in health, including influenza, to avoid hospitalization. In the case of influenza, for which vaccines exist, this raises the potential of vaccine preventable disability.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BACKGROUND

In some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.

METHODS

We used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.

RESULTS

Among the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80-88] had available ADL scores at baseline (median score 7 [IQR 4-10]) and at discharge (median 9 [6-12]). Median CIRS-G score was 11 [8-13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27-7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17-8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4-37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83-6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.

CONCLUSION

Baseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.

Spontaneous resolution of idiopathic intestinal obstruction after pneumonia: A case report

BACKGROUND

Duodenal obstruction is a common clinical scenario that can either be mechanical or a pseudo-obstruction. Clinical management of intestinal obstruction starts from localization and proceeds to histological examination of the stenotic intestine. Systemic factors and dysfunction of distant organs might contribute to the development of intestinal obstruction. Here, we report a unique case of idiopathic mechanical duodenal obstruction, which resolved spontaneously after 3 mo of conservative treatment, but was followed by intestinal pseudo-obstruction.

CASE SUMMARY

An 84-year-old woman presented with worsened postprandial vomiting accompanied by prolonged pneumonia. Thorough noninvasive investigations revealed complete circumferential stenosis in the descending duodenum without known cause. Exploratory surgery was postponed due to septic shock and possible pulmonary fungal infection. Conservative treatment for 3 mo for ileus and control of pulmonary infection resolved the intestinal obstruction completely. Unfortunately, 2 wk later, she had regurgitation and postprandial vomiting again, complicated by deteriorating wheezing and dyspnea. Computed tomography revealed a dilated stomach and proximal duodenum without new intestinal stricture or pulmonary infiltration. The patient fully recovered after combined treatment with antireflux agents, enema, prokinetics, and bronchodilators.

CONCLUSION

This complicated case highlights the inter-relationship of local and systemic contributions to ileus and gut dysfunction, which requires multidisciplinary treatment.

Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients With Pneumonia

IMPORTANCE

Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Physical and occupational therapists help improve functional mobility and may be of help in this population.

OBJECTIVE

To evaluate whether use of physical and occupational therapy in the acute care hospital is associated with 30-day hospital readmission risk or death.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included the electronic health records and administrative claims data of 30 746 adults discharged alive with a primary or secondary diagnosis of pneumonia or influenza-related conditions from January 1, 2016, to March 30, 2018. Patients were treated at 12 acute care hospitals in a large health care system in western Pennsylvania. Data for this study were analyzed from September 2019 through March 2020.

EXPOSURES

Number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6).

MAIN OUTCOMES AND MEASURES

Outcomes were 30-day hospital readmission or death. Generalized linear mixed models were estimated to examine the association of therapy use and outcomes, controlling for patient demographic and clinical characteristics. Subgroup analyses were conducted for patients older than 65 years, for patients with low functional mobility scores, for patients discharged to the community, and for patients discharged to a post-acute care facility (ie, skilled nursing or inpatient rehabilitation facility).

RESULTS

Of 30 746 patients, 15 507 (50.4%) were men, 26 198 (85.2%) were White individuals, and the mean (SD) age was 67.1 (17.4) years. The 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95% CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95% CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95% CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting.

CONCLUSIONS AND RELEVANCE

In this study, the number of therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.

Ultrasensitive digital quantification of cytokines and bacteria predicts septic shock outcomes

Quantification of pathogen and host biomarkers is essential for the diagnosis, monitoring, and treatment of infectious diseases. Here, we demonstrate sensitive and rapid quantification of bacterial load and cytokines from human biological samples to generate actionable hypotheses. Our digital assay measures IL-6 and TNF-α proteins, gram-negative (GN) and gram-positive (GP) bacterial DNA, and the antibiotic-resistance gene bla_TEM with femtomolar sensitivity. We use our method to characterize bronchoalveolar lavage fluid from patients with asthma, and find elevated GN bacteria and IL-6 levels compared to healthy subjects. We then analyze plasma from patients with septic shock and find that increasing levels of IL-6 and bla_TEM are associated with mortality, while decreasing IL-6 levels are associated with recovery. Surprisingly, lower GN bacteria levels are associated with higher probability of death. Applying decision-tree analysis to our measurements, we are able to predict mortality and rate of recovery from septic shock with over 90% accuracy.

Ultrasensitive methods for detection of biomarkers for infectious disease are needed for diagnosing, monitoring and targeting treatment. Here the authors develop a digital assay for inflammatory markers, bacterial DNA and antibotic-resistance genes and apply it to characterise asthma patients and predict mortality from septic shock.

Gender differences in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is the most common type of lower respiratory tract infection and a major cause of morbidity and mortality in adults worldwide. Sex and gender play an active role in the incidence and outcomes of major infectious diseases, including CAP.

EVIDENCE ACQUISITION

We searched the following electronic databases from January 2001 to December 2018: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), Cochrane Database of Systematic Reviews and ACP Journal Club database.

EVIDENCE SYNTHESIS

Several studies have reported higher male susceptibility to pulmonary infections and higher risk of death due to sepsis. Biological differences (e.g. hormonal cycles and cellular immune-mediated responses) together with cultural, behavioral and socio-economic differences are important determinants of the course and outcome of CAP. However, gender-related bias in the provision of care and use of hospital resources has been reported among women, resulting in delayed hospital admission and consequently necessary care.

CONCLUSIONS

CAP is more severe in males than in females, leading to higher mortality in males, especially in older age. To identify gender differences in CAP can guide patient's prognostication and management.

ADL recovery trajectory after discharge and its predictors among baseline-independent older inpatients

Background

Among the previous studies about the ADL recovery and its predictors, the researches and resources used to study and protect the baseline-independent older patients from being permanently ADL-dependent was few. We aimed to describe the level of activities of daily living (ADL) at discharge and ADL change within 6 months after discharge in older patients who were ADL-independent before admission but became dependent because of acute illness, and to identify the predictors of early rehabilitation,so as to provide the basis to early intervention.

Methods

Stratified cluster sampling was used to recruit 520 hospitalised older patients who were ADL-independent from departments of internal medicine at two tertiary hospitals from August 2017 to May 2018. Demographics, clinical data, and ADL status at 1, 3, and 6 months after discharge were collected. Data were analysed using descriptive statistics, Student’s t-test, Pearson’s chi-square test,Spearman’s correlation analysis, binary logistic regression analysis, and receiver operating characteristic (ROC) curve analysis.

Results

There were 403 out of 520 patients completing the 6-month follow-up, and 229 (56.8%) regained independence at 6 months after discharge. There was an overall increasing trend in ADL with time. The recovery rate was the highest within the first month after discharge, gradually declined after 1 month, and changed less obviously from 3 to 6 months after discharge (p < 0.001). ADL score at discharge (OR = 1.034, p < 0.001), age (OR = 0.269, p = 0.001), post-discharge residence (OR = 0.390, p < 0.05), and cognition status at discharge (OR = 1.685, p < 0.05) were predictors of ADL recovery. The area under the curve of the four predictors combined was 0.763 (p < 0.001).

Conclusion

Studying ADL recovery rate and its predicting indicators of the baseline independent inpatients at different time points provide a theoretical reference for the formulation of nursing plans and allocation of care resources.

General Adaptation in Critical Illness: Glucocorticoid Receptor-alpha Master Regulator of Homeostatic Corrections

In critical illness, homeostatic corrections representing the culmination of hundreds of millions of years of evolution, are modulated by the activated glucocorticoid receptor alpha (GRα) and are associated with an enormous bioenergetic and metabolic cost. Appreciation of how homeostatic corrections work and how they evolved provides a conceptual framework to understand the complex pathobiology of critical illness. Emerging literature place the activated GRα at the center of all phases of disease development and resolution, including activation and re-enforcement of innate immunity, downregulation of pro-inflammatory transcription factors, and restoration of anatomy and function. By the time critically ill patients necessitate vital organ support for survival, they have reached near exhaustion or exhaustion of neuroendocrine homeostatic compensation, cell bio-energetic and adaptation functions, and reserves of vital micronutrients. We review how critical illness-related corticosteroid insufficiency, mitochondrial dysfunction/damage, and hypovitaminosis collectively interact to accelerate an anti-homeostatic active process of natural selection. Importantly, the allostatic overload imposed by these homeostatic corrections impacts negatively on both acute and long-term morbidity and mortality. Since the bioenergetic and metabolic reserves to support homeostatic corrections are time-limited, early interventions should be directed at increasing GRα and mitochondria number and function. Present understanding of the activated GC-GRα's role in immunomodulation and disease resolution should be taken into account when re-evaluating how to administer glucocorticoid treatment and co-interventions to improve cellular responsiveness. The activated GRα interdependence with functional mitochondria and three vitamin reserves (B1, C, and D) provides a rationale for co-interventions that include prolonged glucocorticoid treatment in association with rapid correction of hypovitaminosis.

Patient-reported outcome measurement in community-acquired pneumonia: feasibility of routine application in an elderly hospitalized population

Background

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide, but few studies have evaluated the feasibility of routine patient-reported outcome measures (PROMs) in this illness. This study investigates the feasibility and limitations of three credible PROM instruments in a representative hospitalized cohort to identify potential barriers to routine application.

Methods

A sample of multimorbid hospitalized subjects meeting a standardized CAP definition was recruited. Demographic and clinical data of those able and unable to participate in PROM assessment were compared. The EQ-5D-5L, CAP-Sym 18 Questionnaire, and Late-Life Function and Disability Instrument (LLFDI) were administered (via face-to-face interview) at admission and discharge and (via phone interview or mail) at 30 and 90 days post-discharge. Feasibility measures included the proportion of individuals able to participate in assessment, attrition rates, data completeness, and instrument completion times. Scores at admission and 30 days post-discharge were examined for association with age.

Results

Of 82 subjects screened, 44 (54%) participated. Cognitive impairment (n = 12, 15%) commonly precluded participation. Seventeen (39%) participants were lost to follow-up by 90 days. Missing data at item level was negligible for all instruments, regardless of the mode of completion. Completion of the three instruments collectively in a face-to-face interview took a median of 17 min (IQ range 13-21) per participant. The burden of reported symptoms at admission was higher for younger participants aged 18-74 years (mean (standard deviation)) CAP-Sym 18 score at admission 34.2 (18.6) vs. 19.0 (11.3) for those aged ≥ 75 years.

Conclusions

Routine application of PROMs can provide valuable information relating to multiple aspects of clinical recovery for individuals hospitalized with CAP. However, heterogeneous demographic characteristics and complex underlying health status introduce challenges to feasibility and interpretability of these instruments in this population.

Trial registration

ClinicalTrials.gov, NCT02835040.

Effects of the bass brushing method on dental plaque and pneumonia in older adults hospitalized with pneumonia after discharge: A randomized controlled trial

AIM

The purpose of this pilot study was to evaluate the effects of the Bass brushing method on dental plaque and pneumonia in older adults hospitalized with pneumonia after discharge.

BACKGROUND

Poor oral hygiene may lead to pneumonia. Complications of pneumonia in older adults can be life-threatening during hospitalization and after discharge.

METHODS

Older adults hospitalized with pneumonia (n = 30) were randomly assigned to intervention (with the Bass brushing method; n = 15) or control (with usual care; n = 15) groups. Dental plaque index and pneumonia as detected on chest x-rays were evaluated prior to the intervention (baseline) and every month for six months after discharge.

RESULTS

Participants in the intervention group experienced a sustained reduction in dental plaque from the fourth to the sixth months (p = .024; p = .025; p = .000, respectively) that was not found in the control group. There were no group differences in detected pneumonia throughout the follow-up period. Pneumonia as detected on the chest x-rays at baseline (p = .001) and dental plaque index (p = .021) were significant predictors of the risk of pneumonia across groups.

CONCLUSIONS

The Bass brushing method is a simple and effective oral hygiene practice that reduces dental plaque in older adults hospitalized with pneumonia after discharge.

Pneumonia in the Noninstitutionalized Older Population

BACKGROUND

Pneumonia is a common and potentially serious disease, with an incidence of ca. 300 per 100 000 persons per year. Until now, there have been only a few population-based studies of risk factors for pneumonia.

METHODS

From 2000 to 2002, nearly 10 000 persons aged 50 to 75 were recruited into the prospective ESTHER cohort study while visiting their family physician for a check-up. The mean duration of follow-up was 10.6 years. Data on newly diagnosed pneumonia were acquired from the participants and their physicians by means of standardized questionnaires. Potential associations with various predictors were studied in survival-time regression models.

RESULTS

435 participants had pneumonia at least once during follow-up. The cumulative 10-year-incidence was 4.5% (95% confidence interval [4.0; 4.9]). Multiple regression revealed that age (relative risk [RR]: 1.43 [1.22; 1.67] per 10 years), current cigarette smoking (RR: 1.56 [1.19; 2.05], compared with never having smoked), and known congestive heart failure (RR: 1.65 [1.24; 2.20]) were independently associated with an elevated risk of pneumonia. The risk was insignificantly elevated in persons with diabetes mellitus (RR: 1.29 [0.98; 1.68]). Alcohol consumption, obesity, stroke, and cancer were not associated with an elevated risk of pneumonia in age- and sex-adjusted analyses.

CONCLUSION

Pneumonia plays an important role in the medical care of non-institutionalized older people. With the aid of the predictors identified in this study, primary care physicians can identify patients at risk, smokers can gain additional motivation to quit, treatment compliance can be increased, and patients may become more willing to be vaccinated as recommended in the current guidelines.

Can we predict functional decline in hospitalized older people admitted through the emergency department? Reanalysis of a predictive tool ten years after its conception

Background

In the Emergency Department (ED), early and rapid identification of older people at risk of adverse outcomes, who could best benefit from complex geriatric intervention, would avoid wasting time, especially in terms of prevention of adverse outcomes, and ensure optimal orientation of vulnerable patients. We wanted to test the predictive ability of a screening tool assessing risk of functional decline (FD), named SHERPA, 10 years after its conception, and to assess the added value of other clinical or biological factors associated with FD.

Methods

A prospective cohort study of older patients (n = 305, ≥ 75 years) admitted through the emergency department, for at least 48 h in non-geriatric wards (mean age 82.5 ± 4.9, 55% women). SHERPA variables (i.e. age, pre-admission instrumental Activity of Daily Living (ADL) status, falls within a year, self-rated health and 21-point MMSE) were collected within 48 h of admission, along with socio-demographic, medical and biological data. Functional status was followed at 3 months by phone. FD was defined as a decrease at 3 months of at least one point in the pre-admission basic ADL score. Predictive ability of SHERPA was assessed using c-statistic, predictive values and likelihood ratios. Measures of discrimination improvement were Net Reclassification Improvement and Integrated Discrimination Improvement.

Results

One hundred and five patients (34%) developed 3-month FD. Predictive ability of SHERPA decreased dramatically over 10 years (c = 0.73 vs. 0.64). Only two of its constitutive variables, i.e. falls and instrumental ADL, were significant in logistic regression analysis for functional decline, while 21-point MMSE was kept in the model for clinical relevance. Demographic, comorbidity or laboratory data available upon admission did not improve the SHERPA predictive yield.

Conclusions

Prediction of FD with SHERPA is difficult, but predictive factors, i.e. falls, pre-existing functional limitation and cognitive impairment, stay consistent across time and with literature. As accuracy of SHERPA and others existing screening tools for FD is moderate, using these predictors as flags instead of using composite scales can be a way to screen for high-risk patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0498-0) contains supplementary material, which is available to authorized users.

Step Tests Are Safe for Assessing Functional Capacity in Patients Hospitalized With Acute Lung Diseases

PURPOSE

To investigate the safety of the Chester step test (CST) and the modified incremental step test (MIST) to assess functional capacity in patients hospitalized with acute lung diseases.

METHODS

Seventy-seven hospitalized patients (46 men) performed the CST and the MIST on the same day in random order and the 6-minute walk test (6MWT) the following day. A control group of 20 healthy volunteers performed the same procedures.

RESULTS

No adverse events were observed during the step tests. Mean exercise-induced desaturation was similar between the CST (-2%; 95% CI, -6 to 0), the MIST (-2%; 95% CI, -6 to -1), and the 6MWT (-2%; 95% CI, -5 to 0). Significant correlations were found between the number of steps on the CST and the MIST and lung function (forced vital capacity: r = 0.52 and r = 0.57, respectively), dyspnea (r =-0.54 and r =-0.41, respectively), and the distance walked on the 6MWT (r = 0.59 and r = 0.64, respectively). In addition, a significant correlation was observed between the number of steps and the length of hospitalization. Patients performed poorer on the step tests compared with healthy subjects (P < .05).

CONCLUSIONS

The CST and the MIST are safe and can be used as an alternative test to assess functional capacity in patients hospitalized for acute lung diseases. The worse the performance on the step tests, the lower the pulmonary function and the distance walked on the 6MWT, the greater the dyspnea, and the longer the hospitalization.

Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial

QUESTION

Among people who are hospitalised for community-acquired pneumonia, does an inpatient exercise-based rehabilitation program improve functional outcomes, symptoms, quality of life and length of hospital stay more than a respiratory physiotherapy regimen?

DESIGN

Randomised trial with concealed allocation, intention-to-treat analysis and blinding of some outcomes.

PARTICIPANTS

Forty-nine adults hospitalised for community-acquired pneumonia.

INTERVENTION

The experimental group (n=32) underwent a physical training program that included warm-up, stretching, peripheral muscle strength training and walking at a controlled speed for 15 minutes. The control group (n=17) underwent a respiratory physiotherapy regimen that included percussion, vibrocompression, respiratory exercises and free walking. The intervention regimens lasted 8 days.

OUTCOME MEASURES

The primary outcome was the Glittre Activities of Daily Living test, which assesses the time taken to complete a series of functional tasks (eg, rising from a chair, walking, stairs, lifting and bending). Secondary outcomes were distance walked in the incremental shuttle walk test, peripheral muscle strength, quality of life, dyspnoea, lung function, C-reactive protein and length of hospital stay. Measures were taken 1 day before and 1 day after the intervention period.

RESULTS

There was greater improvement in the experimental group than in the control group on the Glittre Activities of Daily Living test (mean between-group difference 39 seconds, 95% CI 20 to 59) and the incremental shuttle walk test (mean between-group difference 130 m, 95% CI 77 to 182). There were also significantly greater improvements in quality of life, dyspnoea and peripheral muscle strength in the experimental group than in the control group. There were no between-group differences in lung function, C-reactive protein or length of hospital stay.

CONCLUSION

The improvement in functional outcomes after an inpatient rehabilitation program was greater than the improvement after standard respiratory physiotherapy. The exercise training program led to greater benefits in functional capacity, peripheral muscle strength, dyspnoea and quality of life.

REGISTRATION

ClinicalTrials.gov, NCT02103400.

[Impact of a multidimensional intervention in elderly patients with community-acquired pneumonia: IMIEPCAP clinical trial]

INTRODUCTION

The main objective of this study is to determine whether a multidimensional intervention applied to elderly patients admitted to hospital due to pneumonia reduces re-admissions and emergency department visits in the year after the intervention.

METHODOLOGY

This is a single-centre non-pharmacological randomised clinical trial with a parallel design. Three hundred and fourteen patients will be included (157 in each arm). Eligible patients will be ≥65 years old and with a Barthel index ≥60 that are admitted to hospital due to pneumonia. Participants will be randomised to multidimensional intervention or to control group. Two months after hospital discharge the intervention group will receive a geriatric intervention, carried out by a nurse and a physician. It will include assessment of co-morbidities, nutritional, functional and cognitive status, and immunisation. The control group will receive conventional follow-up. The number of re-admissions, visits to the emergency department, functional status, survival, and institutionalisation will be evaluated one year after intervention. If the intervention shows an improvement in the studied outcomes, it would allow us to improve individual outcomes, and indirectly reduce healthcare costs using a relatively simple, standardised tool.

Clinical risk scores and blood biomarkers as predictors of long-term outcome in patients with community-acquired pneumonia: a 6-year prospective follow-up study

OBJECTIVE

Prediction of long-term outcomes in patients with community-acquired pneumonia (CAP) is incompletely understood. We investigated the value of clinical risk scores [pneumonia severity index (PSI) and CURB-65] (Confusion, Urea, Respiratory rate, Blood Pressure, Age >65 years) and blood biomarkers of different physiopathological pathways in predicting long-term survival in a well-characterized cohort of patients with CAP enrolled in an antibiotic stewardship trial.

DESIGN, SETTING AND SUBJECTS

Patients admitted with CAP to six medical centres in Switzerland were prospectively followed for 6 years. Cox regression models and area under the receiver operating characteristics curve (AUC) were used to investigate associations between initial risk assessment and all-cause mortality.

MAIN OUTCOME MEASURE

All-cause mortality during a 6-year follow-up period.

RESULTS

Six-year mortality in the present cohort (median age 73 years) was 45.1% [95% confidence interval (CI) 41.8-48.3%]. Initial PSI and CURB-65 scores both had excellent long-term prognostic accuracy, with a stepwise increase in mortality per risk class. The hazard ratios (95% CI) of the highest PSI and CURB-65 classes (reference: lowest class) were 38.0 (14.0-103.0) and 7.8 (2.2-14.5), respectively, after 6 years. The addition of inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers measured upon hospital admission further improved the prognostic capabilities of the PSI (AUC increase from 0.79 to 0.83; P < 0.0001) and the CURB-65 score (AUC increase from 0.73 to 0.80; P < 0.001).

CONCLUSION

Risk assessment using clinical scores allowed accurate long-term prognostication, which was further improved by the addition of two inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers. These data provide a rationale for a more risk-adapted, 'personalized' strategy for long-term management of patients with CAP.

Observational longitudinal study of symptom burden and time for recovery from community-acquired pneumonia reported by older adults surveyed nationwide using the CAP Burden of Illness Questionnaire

BACKGROUND

Millions of older adults who develop community-acquired pneumonia (CAP) each year survive, but there is a large knowledge gap on the burden of CAP and the recovery process in survivors from the patient perspective.

METHODS

The newly developed CAP Burden of Illness Questionnaire was administered through a Web survey to a nationwide sample of US adults aged ≥50 years who were recently diagnosed with CAP. Survey respondents with unresolved symptoms or other CAP-related health problems completed a second survey 30 days later; a third survey was completed another 30 days later by respondents with unresolved symptoms or problems. Nationally representative results describing the average time to recovery of symptoms and other CAP-related problems were achieved using post-stratification weights.

RESULTS

Five hundred participants completed the initial survey. The time to resolution for the CAP symptoms of weakness, shortness of breath, and tiredness exceeded 3 weeks on average. There was an average of 13 days of absenteeism, and 3 weeks (mean =21 days) before achieving full work/activity productivity after CAP. For participants with health conditions that worsened from pneumonia, chronic emphysema and chronic obstructive pulmonary disease took the longest to return to baseline (mean =60 and 52.4 days, respectively).

CONCLUSION

The results from this study demonstrate that older adults surviving a CAP episode experience a significant multi-symptom illness with long recovery periods to achieve pre-CAP health and productivity. These findings highlight the need for further research on effective clinician-patient communication, the need for patient-centered outcomes in clinical trials for CAP therapeutics, adequate home care during the recovery process, and the pursuit of CAP prevention strategies.

Pneumonia severity, comorbidity and 1-year mortality in predominantly older adults with community-acquired pneumonia: a cohort study

Background

In patients with community-acquired pneumonia (CAP), short-term mortality is largely dependent on pneumonia severity, whereas long-term mortality is considered to depend on comorbidity. However, evidence indicates that severity scores used to assist management decisions at disease onset may also be associated with long-term mortality. Therefore, the objective of the study was to investigate the performance of the pneumonia severity scores CURB-65 and CRB-65 compared to the Charlson Comorbidity Index (CCI) for predicting 1-year mortality in adults discharged from hospital after inpatient treatment for CAP.

Methods

From a single centre, all cases of patients with CAP treated consecutively as inpatients between 2005 and 2009 and surviving at least 30 days after admission were analysed. The patients’ vital status was obtained from the relevant local register office. CURB-65, CRB-65 and CCI were compared using receiver operating characteristics (ROC) analysis.

Results

Of 498 cases analysed, 106 (21.3%) patients died within 1 year. In univariate analysis, age ≥65 years, nursing home residency, hemiplegia, dementia and congestive heart failure were significantly associated with mortality. CURB-65, CRB-65 and CCI were also all associated with mortality at 1 year. ROC analysis yielded a weak, yet comparable test performance for CURB-65 (AUC and corresponding 95% confidence interval [CI] for risk categories: 0.652 [0.598-0.706]) and CCI (AUC [CI]: 0.631 [0.575-0.688]; for CRB-65 0.621 [0.565-0.677] and 0.590 [0.533-0.646]).

Conclusions

Neither CURB-65 or CRB-65 nor CCI allow excellent discrimination in terms of predicting longer term mortality. However, CURB-65 is significantly associated with long-term mortality and performed equally to the CCI in this respect. This fact may help to identify CAP survivors at higher risk after discharge from hospital.

The incidence of cardiovascular events after hospitalization due to CAP and their association with different inflammatory markers

Background

Late prognosis of Community-Acquired Pneumonia (CAP) patients is related to cardiovascular events. Persistence of inflammation-related markers, defined by high circulatory levels of interleukin 6 and 10 (IL-6/IL-10), is associated with a higher post-event mortality rate for CAP patients. However, association between these markers and other components of the immune response, and the risk of cardiovascular events, has not been adequately explored. The main objectives of this study are: 1) to quantify the incidence of cardiovascular disease, in the year post-dating their hospital admittance due to CAP and, 2) to describe the distribution patterns of a wide spectrum of inflammatory markers upon admittance to and release from hospital, and to determine their relationship with the incidence of cardiovascular disease.

Methods/design

A cohort prospective study. All patients diagnosed and hospitalized with CAP will be candidates for inclusion. The study will take place in the Universitary Hospital La Princesa, Spain, during two years. Two samples of blood will be taken from each patient: the first upon admittance and the second one prior to release, in order to analyse various immune agents. The main determinants are: pro-adrenomedullin, copeptin, IL-1, IL-6, TNF-α, IL-17, IFN-γ, IL-10 and TGF-β, E-Selectin, ICAM-1, VCAM-1 and subpopulations of peripheral T lymphocytes (T regulator, Th1 and Th17), together with other clinical and analytical variables. Follow up will start at admittance and finish a year after discharge, registering incidence of death and cardiovascular events. The main objective is to establish the predictive power of different inflammatory markers in the prognosis of CAP, in the short and long term, and their relationship with cardiovascular disease.

Discussion

The level of some inflammatory markers (IL-6/IL-10) has been proposed as a means to differentiate the degree of severity of CAP, but their association with cardiovascular risk is not well established. In this study we aim to define new inflammatory markers associated with cardiovascular disease that could be helpful for the prognosis of CAP patients, by describing the distribution of a wide spectrum of inflammatory mediators and analyzing their association with the incidence of cardiovascular disease and mortality one year after release from hospital.

Management of community-acquired pneumonia in older adults

Community-acquired pneumonia (CAP) is an increasing problem among the elderly. Multiple factors related to ageing, such as comorbidities, nutritional status and swallowing dysfunction have been implicated in the increased incidence of CAP in the older population. Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcus pneumoniae is still the most common pathogen among the elderly, although CAP may also be caused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in the elderly CAP has a different clinical presentation, often lacking the typical acute symptoms observed in younger adults, due to the lower local and systemic inflammatory response. Several independent prognostic factors for mortality in the elderly have been identified, including factors related to pneumonia severity, inadequate response to infection, and low functional status. CAP scores and biomarkers have lower prognostic value in the elderly, and so there is a need to find new scales or to set new cut-off points for current scores in this population. Adherence to the current guidelines for CAP has a significant beneficial impact on clinical outcomes in elderly patients. Particular attention should also be paid to nutritional status, fluid administration, functional status, and comorbidity stabilizing therapy in this group of frail patients. This article presents an up-to-date review of the main aspects of CAP in elderly patients, including epidemiology, causative organisms, clinical features, and prognosis, and assesses key points for best practices for the management of the disease.

The management of community-acquired pneumonia in the elderly

Pneumonia is one of the main causes of morbidity and mortality in the elderly. The elderly population has exponentially increased in the last decades and the current epidemiological trends indicate that it is expected to further increase. Therefore, recognizing the special needs of older people is of paramount importance. In this review we address the main differences between elderly and adult patients with pneumonia. We focus on several aspects, including the atypical clinical presentation of pneumonia in the elderly, the methods to assess severity of illness, the appropriate setting of care, and the management of comorbidities. We also discuss how to approach the common complications of severe pneumonia, including acute respiratory failure and severe sepsis. Moreover, we debate whether or not elderly patients are at higher risk of infection due to multi-drug resistant pathogens and which risk factors should be considered when choosing the antibiotic therapy. We highlight the differences in the definition of clinical stability and treatment failure between adults and elderly patients. Finally, we review the main outcomes, preventive and supportive measures to be considered in elderly patients with pneumonia.

[Social inequalities in spatial distribution of hospital admissions due to respiratory diseases]

To verify social inequalities in hospital admissions due to respiratory diseases in Salvador, Bahia State, Brazil, 2001-2007, an ecological study was conducted with information zones as the units of analysis. Information zones were stratified according to living conditions and analyzed by Poisson regression. Spatial distribution of hospitalization rates due to respiratory diseases ranged from 3.3 to 80.5/10,000. Asthma, pneumonia, and chronic obstructive pulmonary disease (COPD) showed heterogeneous spatial patterns, in which strata with the worst living conditions showed higher hospitalizations rates. The hospitalization rate for respiratory diseases was 2.4 times higher in zones with very low living conditions as compared to the wealthiest zone. There was a reduction in inequalities in hospital admissions for pneumonia and an increase for asthma and COPD. The sharp social gradient supports the hypothesis that socioeconomic factors are determinants of hospitalizations for respiratory diseases.

Community-acquired pneumonia: symptoms and burden of illness at diagnosis among US adults aged 50 years and older

PURPOSE

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality in older adults, yet few studies have comprehensively measured the burden of CAP symptoms and their impact from the patient perspective. Our Web-survey used the newly developed CAP burden of illness questionnaire (CAP-BIQ) designed to assess the presence of key symptoms, comorbid conditions affected by CAP, psychosocial impacts, productivity, and CAP-associated physician visits in US adults aged 50 years and older.

METHODS

The CAP-BIQ was developed from semi-structured one-on-one interviews and finalized after cognitive debriefings with recently diagnosed CAP patients. The CAP-BIQ was then administered to 500 survey participants with a CAP diagnosis within the past 120 days confirmed by chest imaging recruited from a Web-based panel. Analyses of survey results were weighted for national representativeness, and were compared between relevant age, hospitalization status, and pneumonia-risk subgroups.

RESULTS

The survey participants' mean age was 62.4 years; 45 % were men; and 39.6 % were hospitalized due to CAP. On average, the surveys were completed 56.9 days after pneumonia diagnosis. Nearly all participants reported tiredness, cough, body aches, weakness, shortness of breath, wheezing, and a weak appetite at the time of diagnosis (99.0, 96.8, 96.9, 94.1, 89.1, 85.8, and 78.5 %, respectively). There was generally greater symptom prevalence at diagnosis in younger, nonhospitalized, or high-risk subgroups when compared to their respective older, hospitalized, or low-risk counterparts. Most participants reported at least one cough-related and weakness-related impact on their daily life and activities from CAP. Over three quarters of the respondents (77.4 %) needed assistance from a friend or family member during their bout with pneumonia and a majority of respondents (83.6 %) were satisfied with the care they received from their doctors across the course of their illness.

CONCLUSIONS

This study systematically assessed CAP symptoms and their impacts using the CAP-BIQ, a questionnaire with established content validity. At CAP diagnosis, the range of patient-reported symptoms was broader than previous studies have reported. Additionally, the overwhelming need for caregiver assistance demonstrates the burden this illness places on older adults.

Is prolonged low-dose glucocorticoid treatment beneficial in community-acquired pneumonia?

Community-acquired pneumonia (CAP) has a significant impact on public health in terms of short-term and long-term morbidity and mortality. Irrespective of microbiological etiology, the host's inability to fully downregulate systemic inflammation is the dominant pathogenetic process contributing to acute and long-term morbidity and mortality in CAP. Glucocorticoids are the natural regulators of inflammation, and their production increases during infection. There is consistent evidence that downregulation of systemic inflammation with prolonged low-dose glucocorticoid treatment in patients with severe sepsis and acute respiratory distress syndrome improves cardiovascular and pulmonary organ physiology. A recent meta-analysis of pooled controlled small trials (n = 970) of patients admitted with CAP found improved short-term mortality in the subgroup with severe CAP and/or receiving >5 days of glucocorticoid treatment. We have expanded on this meta-analysis by including patients with CAP recruited in trials investigating prolonged low-dose glucocorticoid treatment in septic shock and/or early acute respiratory distress syndrome (n = 1,206). Our findings confirm a survival advantage for severe CAP (RR 0.66, 95% confidence interval 0.51-0.84; p = .001). A large randomized trial is in progress to confirm the aggregate findings of these small trials and to evaluate the long-term effect of this low-cost treatment.

Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review

BACKGROUND

Readmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF-variables outside a hospital's control.

METHODS

We searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations.

RESULTS

Seventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital.

CONCLUSIONS

A broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.

A rapid flow cytometric method for distinguishing between febrile bacterial and viral infections

Antibiotic resistance due to the inappropriate use of antimicrobials is one of the most critical public health problems worldwide. A major factor underlying the unnecessary use of antibiotics is the lack of rapid and accurate diagnostic tests. Therefore, we aimed to develop a novel rapid flow cytometric method for distinguishing between febrile bacterial and viral infections. In this prospective comparative study, quantitative flow cytometric analysis of FcγRII/CD32, CR1/CD35, MHC Class I receptor (MHCI), and C5aR/CD88 on human phagocytes was performed in 286 hospitalized febrile patients with suspected infection. After using microbiological and serological detection methods, or clinical diagnosis, 205 patients were identified with either bacterial (n=136) or viral (n=69) infection. Receptor data from patients were compared to those of 50 healthy controls. We developed a flow cytometric marker of local and systemic bacterial infections designated "bacterial infection score (BIS)" incorporating the quantitative analysis of FcγRII/CD32, CR1/CD35, C5aR/CD88 and MHCI on neutrophils and/or monocytes, which displays 91% sensitivity and 92% specificity in distinguishing between microbiologically confirmed bacterial (n=77) and serologically confirmed viral infections (n=61) within 1h. The BIS method was effectively applied to distinguish between bacterial and viral (pandemic H1N1 influenza) pneumonia cases with 96% sensitivity and 92% specificity. We propose that the rapid BIS test can assist physicians in deciding whether antibiotic treatment is necessary, thus reducing unnecessary antimicrobial use.

Immunomodulatory effect of NSAID in geriatric patients with acute infection: effects of piroxicam on chemokine/cytokine secretion patterns and levels of heat shock proteins. A double-blind randomized controlled trial. (ISRCTN58517443)

Inflammation in older persons is associated with frailty, cachexia, and disability. We hypothesized that NSAID treatment in addition to antibiotics in older patients with acute infection might rapidly reduce inflammatory cytokines and might be of therapeutic potential to improve outcomes. A double-blind controlled trial was conducted in geriatric patients admitted for acute infection. Patients were randomized to receive either 10 mg piroxicam or placebo. Patients ≥70 years with CRP levels >10 mg/L of acute infectious origin were eligible. Twenty-five cyto-/chemokines as well as heat shock proteins Hsp27 (HSPB1) and Hsp70 (HSPA1A) were measured the first 4 days and then weekly until discharge, with a maximum of 3 weeks. Thirty Caucasian patients were included (median age 84.5 years, 67% female, median CRP 87.5 mg/L). In the piroxicam group, IL-6 and IP-10/CXCL10 decreased significantly during the study period. Relationships between cytokines were disrupted in the piroxicam group: for 12 out of 20 cytokines the number of correlations between changes in serum levels was significantly lower compared to placebo. Serum Hsp70 levels decreased significantly in the piroxicam group, but not in the placebo group. Without heat challenge, intracellular levels of Hsp70 in monocytes decreased in both groups, whereas HsP27 in monocytes increased with piroxicam with a significant difference compared to placebo at 3 weeks. Piroxicam in this setting cannot be considered merely as an anti-inflammatory drug, but rather as an immunomodulator. Further studies are needed to establish whether these effects can change functional outcomes in geriatric patients.

Factors predicting a successful post-discharge outcome for individuals aged 80 years and over

Introduction and background

Methods

Results

Conclusions

Factors predicting a successful post-discharge outcome for individuals aged 80 years and over

Introduction and background

The early post-discharge period is a vulnerable time for older patients with complex care requirements. This paper identifies factors predicting a self-reported successful post-discharge outcome for patients aged 80 years and over by exploring factors related to the discharge process, the provision of formal home-care services, informal care and characteristics of the patients.

Methods

The study reports results from survey interviews with patients admitted from home to 14 hospitals in Norway and later discharged home. Logistic regression analysis was performed to assess the impact of a number of factors on the likelihood that the patients would report that they managed well after discharge.

Results

The odds of managing well after discharge were more than four times higher (OR=4.75, p=0.022) for patients reporting that someone was present at homecoming than for those who came home to an empty house. Patients who reported receiving adequate help from the municipality had an odds four times (OR=4.18, p=0.006) higher of reporting that everything went well after discharge than those who stated the help was inadequate.

Conclusions

Having someone at home upon return from hospital and having adequate formal home-care services are significantly associated with patient-reported success in managing well.

How important is age in defining the prognosis of patients with community-acquired pneumonia?

PURPOSE OF REVIEW

Given that the population is increasing in age, a better understanding of the relationship between chronological age and health-related outcomes (especially mortality) is needed, for both chronic diseases (e.g. diabetes) and acute illnesses (e.g. pneumonia). Our purpose was to review the impact of age on the prognosis of patients with community-acquired pneumonia (CAP).

RECENT FINDINGS

Many studies in patients with CAP have suggested that chronological age is not necessarily independently associated with mortality. Poorer outcomes in the elderly with CAP have been related to severity of disease, comorbid disease burden, functional status, and frailty, but not to age alone. However, many of these studies suffer from 'over-adjustment' due to the use of unmodified severity scores such as the Pneumonia Severity Index or Acute Physiology and Chronic Health Evaluation II (that already include age) in multivariable analyses. Studies accounting for this over-adjustment suggest that age is, in fact, independently associated with mortality in hospitalized patients with CAP. Other outcomes including hospitalization and readmission rates, hospital length of stay, and cost of care are similarly associated with increasing age. Residual confounding is still a problem in many of the observational studies reviewed.

SUMMARY

Contrary to conventional wisdom, chronological age is independently associated with adverse outcomes in patients with CAP. Until better methods (or more clinically-rich datasets) for observational studies are developed that can avoid over-adjustment and better deal with residual confounding, physicians should take into account both a patient's overall health status and his or her chronological age.

Only severely limited, premorbid functional status is associated with short- and long-term mortality in patients with pneumonia who are critically ill: a prospective observational study

BACKGROUND

Severe pneumonia requiring ICU admission has not been well characterized with respect to long-term outcomes or predictors thereof. We examined the association between premorbid functional status and mortality in patients with severe pneumonia.

METHODS

From 2000 to 2002, a population-based cohort of adults with pneumonia who were critically ill was enrolled and prospectively followed. Short-term (30-day) and long-term (1-year) mortality were examined using multivariable Cox regression models.

RESULTS

The final cohort included 271 patients, mean age 61 years, 59% men, and 16% from nursing homes. The mean Pneumonia Severity Index was 113 (71% class IV or V), and the mean Acute Physiology and Chronic Health Evaluation II score was 17. Overall, 121 (45%) patients were functionally independent, 115 (42%) had limited mobility, and 35 (13%) were completely dependent. Mortality was 11% at 30 days and 27% at 1 year; by functional status mortality was 6% at 30 days and 17% at 1 year for patients who were independent, 10% and 31% for patients with limited mobility, and 39% and 48% for patients who were dependent. Mortality was greater for patients who were completely dependent when compared with patients who were independent (adjusted hazard ratio [aHR], 5.3; 95% CI, 2.0-14.1; P < .001 at 30 days; and aHR, 3.0; 95% CI, 1.5-6.1; P = .002 at 1 year) or with patients who had limited mobility (aHR, 4.8; 95% CI, 2.0-11.2, P < .001 at 30 days; and aHR, 2.3; 95% CI, 1.3-4,4, P = .007 at 1 year). There were no mortality differences between patients with limited mobility and patients who were independent.

CONCLUSIONS

One-quarter of patients with pneumonia who are critically ill are dead within 1 year. Severely limited premorbid functional status was associated with mortality; this should be considered at presentation for prognosis and at discharge for targeted follow-up.

Systemic and bronchoalveolar cytokines as predictors of in-hospital mortality in severe community-acquired pneumonia

OBJECTIVES

The aim of this study was to determine whether cytokine expression (interleukin [IL]-1beta, IL-6, IL-8, IL-10, and tumor necrosis factor [TNF]-alpha), C-reactive protein, and endotoxins on the first day of intensive care unit (ICU) admission are associated with hospital mortality in severe community-acquired pneumonia (CAP).

DESIGN

This was a prospective study with bronchoalveolar lavage (BAL) and blood sampling.

SETTING

This study was carried out in a 44-bed medical ICU of a 1700-bed university hospital.

PATIENTS

Participants included 112 mechanically ventilated patients with severe CAP.

INTERVENTIONS

Serum and BAL fluid IL-1beta, IL-6, IL-8, IL-10, TNF-alpha, C-reactive protein, and endotoxins on the first day of ICU admission were obtained.

MEASUREMENTS AND MAIN RESULTS

The concentrations of TNF-alpha in BALF and IL-6, IL-8, IL-10, and TNF-alpha in serum were higher in nonsurvivors than in survivor patients with CAP. Of these 112 patients with severe CAP (39%), 44 developed acute respiratory distress syndrome (ARDS); these patients seemed to have higher serum IL-6, IL-8, and IL-10 levels than did the non-ARDS group. Furthermore, in the ARDS population, we found that the endotoxin levels in the BAL fluid were higher in the survival than in the nonsurvival group and BAL fluid concentrations of IL-6, IL-8, and IL-1beta and sera levels of IL-6 and IL-10 were lower in the survival than in the nonsurvival group, and they were associated with a high negative predictive value.

CONCLUSIONS

Serum and BAL fluid levels of the studied cytokines on admission may provide valuable prognostic information for patients with severe CAP.

Risk factors predicting later functional decline in older hospitalized patients

With the demographic and epidemiological changes, an increasing number of older subjects are admitted to hospital. These patients are at increased risk of adverse health outcomes, including functional decline, increased length of stay, institutionalization, geriatric syndromes (e.g. delirium), hospital readmissions and death. Age, basic demographic data, diagnosis and comorbidities are not sufficient to estimate the risk of a further negative evolution of the frail older patient during and after hospitalization. As functional decline begins soon after admission, it is important to screen vulnerable patients early in order to plan appropriate orientation to geriatric programmes and to target interventions.This narrative review analyses which appropriate parameters, available soon after admission, may help to identify the older patients at risk of functional decline and to stratify their risk. Functional decline was defined here as loss of independence in basic care or admission in nursing home. The main risk factors identified by this analysis are functional status before or at admission, cognitive performance and social characteristics.These data may be easily and quickly collected by the nursing staff on admission, and further assessed by the geriatric liaison team, in order to optimize care management in frail older patients.

Is the concentration of C-reactive protein in bacteraemia associated with age?

BACKGROUND

C-reactive protein (CRP) is an indicator of inflammation, and is often used in the diagnosis of bacterial infections. It is poorly known whether CRP in bacterial infection is age-dependent.

METHODS

Adult patients with a positive blood culture with E. coli or S. pneumoniae during 1994-2004 were included. CRP measured on the same date as the blood cultures were drawn (CRP1), 2-3 days (CRP2) and 4-7 days later (CRP3), were retrieved. The patients were divided into three age groups, < 65, 65-84, and > or = 85, respectively. We studied three cut-off values for CRP and produced age-specific receiver operating characteristics (ROC) curves, using patients with acute coronary or cerebral infarction as controls.

RESULTS

890 patients and 421 controls were available. There was a statistically significant negative correlation between age and CRP1 - 0.072 (p = 0.032). The median CRP1 and CRP2 were significantly higher in the youngest age group. The area under the ROC-curve for the youngest age group was significantly greater than that of the two other age groups, but we found no statistically significant differences in sensitivity related to age. The diagnostic sensitivity of CRP was better for S. pneumoniae than for E. coli, 92.6% vs. 88.0% (p = 0.046) for a cut-off value of 40 mg/L, and 82.4% vs. 61.5% (p =< 0.01) for a cut-off value of 120 mg/L.

CONCLUSION

CRP is better in identifying infection with S. pneumoniae than with E. coli. We found a weakening of the CRP-response with age, but this is hardly of clinical significance.

Effect of social factors on winter hospital admission for respiratory disease: a case-control study of older people in the UK

BACKGROUND

Every winter, hospitals in the UK and other developed countries experience a surge in respiratory admissions. Ecological studies suggest that social circumstances may be an important determinant.

AIM

To establish the most important factors associated with winter hospital admissions among older people presenting with acute respiratory disease, especially the relative effect of social factors.

DESIGN OF STUDY

case-control study.

SETTING

Seventy-nine general practices in central England.

METHOD

Of a cohort of patients consulting medical services with lower respiratory tract infection or exacerbation of chronic respiratory disease, 157 hospitalised cases were compared to 639 controls. Social, medical, and other factors were examined by interview and GP records.

RESULTS

Measures of material deprivation were not significant risk factors for admission at either individual or area level, although social isolation (odds ratio [OR] 4.5; 95% confidence interval [CI] = 1.3 to 15.8) resulted in an increased risk of admission. The most important independent risk factor was the presence of chronic obstructive pulmonary disease (COPD; OR 4.0; 95% CI = 1.4 to 11.4), other chronic disease (OR 2.9; 95% CI = 1.2 to 7.0), or both (OR 6.7; 95% CI = 2.4 to 18.4). Being housebound was also an independent risk factor (OR 2.2; 95% CI = 1.0 to 4.8).

CONCLUSION

Socioeconomic factors had little relative effect compared with medical and functional factors. The most important was the presence of long-term medical conditions (especially COPD), being housebound, and having received two or more courses of oral steroid treatment in the previous year. This combination of factors could be used by primary medical services to identify older patients most vulnerable to winter admissions. Clinicians should ensure that patients with COPD are better supported to manage their condition.

Serum markers in community-acquired pneumonia and ventilator-associated pneumonia

PURPOSE OF REVIEW

This article reviews recent data on the usefulness of serum markers in community-acquired pneumonia and ventilator-associated pneumonia. The focus is on clinical studies, with an emphasis on adult critically ill patients.

RECENT FINDINGS

Serum markers have demonstrated potential value in early prediction and diagnosis of pneumonia, in monitoring the clinical course and in guiding antibiotic therapy. C-reactive protein appears to perform better in diagnosing infection, because several studies have shown that procalcitonin may remain undetectable in some patients, specifically those with pneumonia. Procalcitonin exhibited a better correlation with clinical severity, however. Furthermore, one report demonstrated the efficacy and safety of procalcitonin-guided antibiotic therapy in community-acquired pneumonia.

SUMMARY

Serum markers should only be used as a complementary tool to support the current clinical approach. Use of serum markers, in particular procalcitonin and C-reactive protein, represents a promising strategy in the clinical decision-making process in patients in whom pneumonia is suspected. Specifically, these markers can be used to guide culture sampling and empirical antibiotic prescription, and to monitor the clinical course, adjust the duration of antibiotic therapy and identify nonresponders, in whom an aggressive diagnostic and therapeutic approach may prevent further clinical deterioration.