Implementation of Ward-Based Clinical Pharmacy Services in Belgium—Description of the Impact on a Geriatric Unit

Background:

Patient-centered clinical pharmacy services are still poorly developed in Europe, despite their demonstrated advantages in North America and the UK. Reporting European pilot experiences is, therefore, important to assess the usefulness of clinical pharmacy services in this specific context.

Objective:

To report the results of the first implementation of Belgian clinical pharmacy services targeting patients at high risk of drug-related problems.

Methods:

An intervention study was conducted by a trained clinical pharmacist providing pharmaceutical care to 101 patients (mean age 82.2 y; mean ± SD number of prescribed drugs 7.8 ± 3.5) admitted to an acute geriatric unit, over a 7 month period. All interventions to optimize prescribing, and their acceptance, were recorded. An external panel (2 geriatricians, 1 clinical pharmacist) assessed the interventions' clinical significance. Persistence of interventions after discharge was assessed through telephone calls.

Results:

A total of 1066 interventions were made over the 7 month period. The most frequent drug-related problems underlying interventions were: underuse (15.9%), wrong dose (11.9%), inappropriate duration of therapy (9.7%), and inappropriate choice of medicine (9.6%). The most prevalent consequences were to discontinue a drug (24.5%), add a drug (18.6%), and change dosage (13.7%). Acceptance rate by physicians was 87.8%. Among interventions with clinical impact, 68.3% and 28.6% had moderate and major clinical significance, respectively. Persistence of chronic treatment changes 3 months after discharge was 84%.

Conclusions:

Involving a trained clinical pharmacist in a geriatric team led to clinically relevant and well-accepted optimization of medicine use. This initiative may be a springboard for further development of clinical pharmacy services.

Somatotrope GHRH/GH/IGF-1 axis at the crossroads between immunosenescence and frailty

Immunosenescence, characterized by complex modifications of immunity with age, could be related to frailty syndrome in elderly individuals, leading to an inadequate response to minimal aggression. Functional decline (i.e., the loss of ability to perform activities of daily living) is related to frailty and decreased physiological reserves and is a frequent outcome of hospitalization in older patients. Links between immunosenescence and frailty have been explored and 20 immunological parameters, including insulin-like growth factor-1 (IGF-1), thymopoeisis, and telomere length, were shown to be affected in elderly patients with functional decline. A strong relationship between IGF-1 and thymic ouput was evidenced. IGF-1, a mediator of growth hormone (GH), was subsequently shown to induce interleukin-7 secretion in cultured primary human thymic epithelial cells. We are exploring the stress hypothesis in which an acute stressor is used as the discriminator of frailty susceptibility. GH can counteract the deleterious immunosuppressive effects of stress-induced steroids. Under nonstress conditions, the immunosenescent system preserves physiological responses, while under stress conditions, the combination of immunosenescence and a defect in the somatotrope axis might lead to functional decline.

Functional status and medium-term prognosis of very elderly patients after an ICU stay: a prospective observational study

BACKGROUND

Because the proportion of elderly patients admitted to the intensive care unit (ICU) is increasing, the objective of this study was to test the hypothesis that very elderly patients with better preadmission functional status would have better medium-term survival and functional status after an ICU stay.

METHODS

In this observational study, 96 patients (68% surgical and 32% medical) aged ≥80 years and admitted to the ICU between May 2008 and June 2009 were recruited. Functional status was assessed using a modified Katz Scale and the Lawton Scale. Primary outcomes were: one-year mortality and its independent predictive factors, one-year functional status and perceived quality of life.

RESULTS

Multivariate analysis showed that type of admission (surgical vs. medical), existence of cancer, Sequential Organ Failure Assessment (SOFA) Score at ICU admission and occurrence of septic complications during the ICU stay were independent predictive factors for one-year mortality, but preadmission functional status was not. At one year, despite functional decline in 50% of survivors, 68% perceived their health status to be equivalent to or better than before and 82.6% would agree to a further ICU stay.

CONCLUSION

One-year mortality of very elderly patients after an ICU stay is not related to preadmission functional status but to the type of admission, existence of cancer, SOFA Score at ICU admission and occurrence of septic complications during the ICU stay. Despite functional decline in half of these patients, one year after admission 82.6% would agree to another ICU stay.

[Do the structure and functioning of the elderly's social network influence functional health: a preliminary study]

We examined structural and functional characteristics of social networks related to health and well-being among community-dwelling older adults. A survey was performed in Brussels, using an original name-generating network inventory, to explore the structure and types of social ties (e.g. children, friends, neighbors) which forms the elderly's network. Different kinds of support (instrumental, emotional, social) were assessed due to the multiple contents of social exchanges between the elderly and their network's members. Our results highlighted some important social network resources. Especially, social participation, contacts with friends of the same age and reciprocity of social relationships are likely to promote functional health and well-being in later life. We discuss our findings in relation to major social network's typologies referring to older adults.

The prevalence of sarcopenia in very old individuals according to the European consensus definition: insights from the BELFRAIL study

BACKGROUND

the prevalence of sarcopenia varies widely between studies. The objective of this study was to assess the prevalence of sarcopenia in a representative sample of persons aged 80 years and older according to the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm and the proposed cut-off values. A secondary aim was to investigate the relationship between different individual criteria and low physical performance capacity.

METHODS

baseline data of the prospective BELFRAIL study (BFC80+) were analysed. Sarcopenia status was determined according to the EWGSOP guidelines. The skeletal muscle mass index (SMI) was assessed according to bioelectrical impedance. Muscle strength and muscle performance were evaluated according to grip strength and the modified short physical performance battery (SPPBm). A logistic regression analysis was performed.

RESULTS

according to the EWGSOP algorithm, 12.5% of the participants were classified in the sarcopenia group. Sixty percent of the female participants had muscle strength values below the cut-off and 70% had low SPPBm values. In males, these prevalence values were 49.5% for grip strength and 39.7% for SPPB. The logistic regression analysis showed that low SPPBm was associated with grip strength (OR: 0.88, 95% CI: 0.84-0.92) independent of SMI.

CONCLUSION

in a population-based sample of the very old the prevalence of sarcopenia according to the EWGSOP algorithm is similar to the prevalence of sarcopenia with SMI as a single criterion. A large number of participants with a sufficient SMI value showed low muscle strength and/or a poor SPPBm score. A low SPPBm was associated with grip strength but not with SMI.

Health outcomes of older patients colonized by multi-drug resistant bacteria (MDRB): a one-year follow-up study

The objective of this study was to examine whether asymptomatic colonization with MDRB would affect outcomes in older patients one year after hospitalization in a geriatric ward. Patient samples were analyzed to identify specific MDRBs, including methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobaceriaceae (ESBLE), and vancomycin-resistant enterococci (VRE). Among 337 patients screened at hospital admission, 62 (18%) carried one or more MDRB isolates (MRSA: n=23; ESBLE: n=39; VRE: n=2). At 12 months after admission, 320 patients were interviewed by telephone (17 patients lost to follow up) to assess all-cause mortality, nursing home admissions, functional decline, and hospital readmissions. All-cause mortality rates were similar in MDRB carriers (34%; n=61) and non-carriers (30%; n=259) (P=0.512). Nursing home admission, functional decline, and hospital readmission did not differ between the two groups. In this population, predictors of mortality were: male gender (P=0.002), cognitive disorders at admission (P=0.028), low pre-albumin level at admission (P=0.048), a high level of co-morbidities (P=0.002), and a history of an acute condition in the three months prior to initial hospital admission (P=0.024). In conclusion, in this cohort of older patients, asymptomatic MDRB colonization was not significantly associated with adverse health outcomes at a one-year follow-up after hospitalization. The potential limitations of the study were the small sample size, relatively high mortality rate, and lack of MDRB reassessment during the follow-up.

Clinical profiles of patients colonized or infected with extended-spectrum beta-lactamase producing Enterobacteriaceae isolates: a 20 month retrospective study at a Belgian University Hospital

Background

Description of the clinical pictures of patients colonized or infected by ESBL-producing Enterobacteriaceae isolates and admitted to hospital are rather scarce in Europe. However, a better delineation of the clinical patterns associated with the carriage of ESBL-producing isolates may allow healthcare providers to identify more rapidly at risk patients. This matter is of particular concern because of the growing proportion of ESBL-producing Enterobacteriaceae species isolates worldwide.

Methods

We undertook a descriptive analysis of 114 consecutive patients in whom ESBL-producing Enterobacteriaceae isolates were collected from clinical specimens over a 20-month period. Clinical data were obtained through retrospective analysis of medical record charts. Microbiological cultures were carried out by standard laboratory methods.

Results

The proportion of ESBL-producing Enterobacteriaceae strains after exclusion of duplicate isolates was 4.5% and the incidence rate was 4.3 cases/1000 patients admitted. Healthcare-associated acquisition was important (n = 104) while community-acquisition was less frequently found (n = 10). Among the former group, two-thirds of the patients were aged over 65 years and 24% of these were living in nursing homes. Sixty-eight (65%) of the patients with healthcare-associated ESBL, were considered clinically infected. In this group, the number and severity of co-morbidities was high, particularly including diabetes mellitus and chronic renal insufficiency. Other known risk factors for ESBL colonization or infection such as prior antibiotic exposure, urinary catheter or previous hospitalisation were also often found. The four main diagnostic categories were: urinary tract infections, lower respiratory tract infections, septicaemia and intra-abdominal infections. For hospitalized patients, the median hospital length of stay was 23 days and the average mortality rate during hospitalization was 13% (Confidence Interval 95%: 7-19). Escherichia coli, by far, accounted as the most common ESBL-producing Enterobacteriaceae species (77/114; [68%]) while CTX-M-1 group was by far the most prevalent ESBL enzyme (n = 56).

Conclusion

In this retrospective study, the clinical profiles of patients carrying healthcare-associated ESBL-producing Enterobacteriacae is characterized by a high prevalence rate of several major co-morbidities and potential known risk factors. Both, the length of hospital stay and overall hospital mortality rates were particularly high. A prospective case-control matched study should be designed and performed in order to control for possible inclusion bias.

Differentially abundant transcripts in PBMC of hospitalized geriatric patients with hip fracture compared to healthy aged controls

The abundance of a selection of transcript species involved in inflammation, immunosenescence and stress response was compared between PBMC of 35 geriatric patients with hip fracture in acute phase (days 2-4 after hospitalization) or convalescence phase (days 7-10) and 28 healthy aged controls. Twenty-nine differentially abundant transcripts were identified in acute phase versus healthy ageing. Twelve of these transcripts remained differentially abundant in convalescence phase, and 22 were similarly differentially abundant in acute phase of geriatric infectious diseases. Seven of these 22 transcripts were previously identified as differentially abundant in PBMC of healthy aged versus healthy young controls, with further alteration for CD28, CD69, LCK, CTSD, HMOX1, and TNFRSF1A in acute phase after geriatric hip fracture and infectious diseases. The next question is whether these alterations are common to other geriatric diseases and/or preexist before the clinical onset of the diseases.

Transcriptomic biomarkers of the response of hospitalized geriatric patients with infectious diseases

Background

Infectious diseases are significant causes of morbidity and mortality among elderly populations. However, the relationship between oxidative stress, immune function and inflammatory response in acute phase of the infectious disease is poorly understood.

Results

Herein the abundance of a selection of 148 transcripts involved in immunosenescence and stress response was compared in total RNA of PBMC of 28 healthy aged probands and 39 aged patients in acute phase of infectious disease (day 2-4 after hospitalization) or in convalescence phase (day 7-10). This study provides a list of 24 differentially abundant transcript species in the acute phase versus healthy aged. For instance, transcripts associated with inflammatory and anti-inflammatory reactions (TNFRSF1A, IL1R1, IL1R2, IL10RB) and with oxidative stress (HMOX1, GPX1, SOD2, PRDX6) were more abundant while those associated with T-cell functions (CD28, CD69, LCK) were less abundant in acute phase. The abundance of seven of these transcripts (CD28, CD69, LCK, CTSD, HMOX1, TNFRSF1A and PRDX6) was already known to be altered in healthy aged probands compared to healthy young ones and was further affected in aged patients in acute phase, compromising an efficient response.

Conclusion

This work provides insights of the state of acute phase response to infections in elderly patients and could explain further the lack of appropriate response in the elderly compared to younger persons.

Serum IL-6 and IGF-1 improve clinical prediction of functional decline after hospitalization in older patients

BACKGROUND AND AIMS

Although inflammatory and hormonal markers have been associated with further functional adverse outcomes in community- dwelling seniors, these markers have not been studied from this perspective in acutely ill older patients. This prospective study was designed to determine whether biological markers can improve the predictive value of a clinical screening tool to assess the risk of functional decline in hospitalized older patients.

METHODS

Patients aged 75 years and over admitted for hip fracture, acute heart failure or infection (n=118) were recruited. The clinical screening tool SHERPA was filled in on admission, with concomitant measurement of interleukin-6 (IL-6), insulin-like growth factor 1 (IGF-1), C-reactive protein (CRP), white blood cells, urea, albumin, pre-albumin and total cholesterol. Functional decline was defined as a decrease of one point in the activities of daily living scale between pre-admission and 3-month post-discharge status. We compared the discrimination calibration of SHERPA vs SHERPA+, a logistic regression model including SHERPA and selected biomarkers.

RESULTS

Three months after discharge, functional decline had occurred in 46 patients. IL-6 and IGF-1 were selected, since their levels were significantly different between decliners and non-decliners, and were included in the new logistic regression model SHERPA+. Areas under the ROC curve [95% CI] for functional decline prediction were 0.73 [0.63-0.81] for SHERPA vs 0.79 [0.69-0.86] for SHERPA+ (p=0.14). However, SHERPA+ was better calibrated, as the average predicted risk of functional decline within subgroups matched the proportion which actually underwent functional decline (Brier score=0.185). Since functional decline was higher in patients with hip fracture, the SHERPA+ model was challenged by including the diagnosis. Only SHERPA, IGF-1 and diagnosis were significantly associated with functional decline.

CONCLUSIONS

Selected biological markers may marginally improve the clinical prediction of post-discharge functional decline in hospitalized patients, and may allow to stratify them appropriately. The predictive value of these biomarkers is not fully independent of disease status. Further studies are needed to confirm these results in a cohort representative of older patients admitted through the emergency department.

Predicting functional adverse outcomes in hospitalized older patients: a systematic review of screening tools

BACKGROUND

Functional decline frequently occurs following hospitalisation in older people and may be prevented or minimized by specific management. Such care processes needs appropriate early screening of older hospitalized patients.

OBJECTIVE

To identify instruments able to detect on admission older hospitalized patients at risk of functional decline at and after discharge.

METHODS

Functional decline is defined as loss of independence in activities of daily living (functional decline) or admission in nursing home. The systematic search used Medline 1970-2007, Web of Science 1981-2007 and references list of relevant papers. An independent epidemiologist assessed methodological quality of the retained articles.

RESULTS

We found 12 studies developing predictive tools, including 7145 patients. Functional outcomes were assessed at or after discharge. Preadmission functional status, cognition, and social support were major components for prediction of functional evolution. Few instruments are fully validated and data concerning reliability are often lacking. Operational characteristics are moderate (sensitivity 29-87%, negative likelihood ratio 0.2-0.8).

CONCLUSIONS

Instruments predicting functional adverse outcomes are difficult to compare due to heterogeneity of functional outcomes and hospital settings. The reason why so many tools have been developed is probably because none gives full satisfaction: their general predictive validity and performances are insufficient. Further research is needed to improve the screening of frail older patients admitted to hospital with standardized and validated tools.

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.

Combined effects of functionally-oriented exercise regimens and nutritional supplementation on both the institutionalised and free-living frail elderly (double-blind, randomised clinical trial)

Background

Consistently swelling proportion of the frail elderly within a modern society challenges the overstrained public health sector to provide both adequate medical care and comprehensive assistance in their multiple functional deficits of daily living. Easy-to-apply and task-specific ways of addressing this issue are being sought out, with a view to proposing systemic solutions for nationwide application.

Methods

The present randomised, double-blind, placebo-controlled, 7-week clinical trial aimed to determine whether specifically structured, intensive exercise regimens, combined with nutritional supplementation, might improve and help sustain individual muscle strength and mobility, and possibly enhance individual functional capabilities in an on-going quest for active prevention of care-dependency. Ninety-one frail elderly (F 71 M 20; mean age 79 years) were recruited from both nursing home residents and community dwellers and randomly split into four groups: Group I – progressive resistance exercises (PRE) + functionally-oriented exercises (FOE) + nutritional supplementation (NS), Group II – PRE + FOE + placebo, Group III – standard exercises (SE) + FOE + NS, Group IV – SE + FOE + placebo. Each group pursued a 45 min. exercise session 5 times weekly. The subjects' strength with regard to four muscle groups, i.e. hip and knee extensors and flexons, was assessed at 80% (1 RM) weekly, whereas their balance and mobility at baseline and at the end of the study.

Results

The study was completed by 80 subjects. Despite its relatively short duration significant differences in muscle strength were noted both in Group I and Group II (p = 0.01; p = 0.04; respectively), although this did not translate directly into perceptible improvement in individual mobility. Notable improvements in individual mobility were reported in Group III and Group IV (p = 0.002), although without positive impact on individual muscle strength.

Conclusion

Comprehensively structured, high-intensity regimen made up of diverse exercise types, i.e. functionally-oriented, progressive resistance and standard ones, preferably if combined with nutritional supplementation in adequate volume, demonstrates clear potential for appreciably improving overall functional status in the frail elderly in terms of individual walking capacity and muscle strength.

Trial registration

Central Register of Clinical Trials, Poland – CEBK180/2000.

Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature

Ecthyma gangrenosum is a cutaneous infection most commonly associated with Pseudomonas aeruginosa bacteraemia, but it may also be encountered after breakdown of mechanical defence barriers and local infection. The characteristic lesions of ecthyma gangrenosum are haemorrhagic blisters with surrounding erythema that rapidly evolve to necrotic ulcers. A high mortality rate is reported, especially when diagnosis is delayed and in the absence of appropriate therapy. Ecthyma gangrenosum usually occurs in critically ill and immunocompromised patients. Haematological malignancies and neutropaenia are the major risk factors, but other comorbidities (e.g. diabetes mellitus and malnutrition) have also been involved. Here, we report a case of ecthyma gangrenosum in a non-neutropaenic elderly patient with multiple comorbidities and review the literature on ecthyma gangrenosum.

Evolving definitions of frailty

This article presents the current status of the definitions of frailty. The theoretical definitions are summarized, and the main elements of these definitions are developed. Frailty as a geriatric syndrome is briefly put into debate, and a model showing the relationships between the factors involved and the outcomes of frailty is proposed. The dynamics of functional decline and geriatric syndromes are put into the perspective of different stages of frailty. For the practical use of the concept, the operational definitions and the principal tools, indices and scales from the literature are briefly described, along with their main characteristics.

Appropriate prescribing in elderly people: how well can it be measured and optimised?

Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial

OBJECTIVES

To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing.

DESIGN

Randomized, controlled trial, with the patient as unit of randomization.

SETTING

Acute GEM unit.

PARTICIPANTS

Two hundred three patients aged 70 and older.

INTERVENTION

Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients.

MEASUREMENTS

Appropriateness of prescribing on admission, at discharge, and 3 months after discharge, using the Medication Appropriateness Index (MAI), Beers criteria, and Assessing Care of Vulnerable Elders (ACOVE) underuse criteria and mortality, readmission, and emergency visits up to 12 months after discharge.

RESULTS

Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge (odds ratio (OR)=9.1, 95% confidence interval (CI)=4.2-21.6 and OR=6.1, 95% CI=2.2-17.0, respectively). The control and intervention groups had comparable improvements in the Beers criteria.

CONCLUSION

Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge. This is an important finding, because only limited data exist on the effect of various strategies to improve medication use in elderly inpatients. The present approach has the potential to minimize risk and improve patient outcomes.

Involvement of immunosenescence in the frailty syndrome (85.13)

A determinant factor of immunosenescence is the involution of the T-cell compartment, due to a decline in thymic generation of a diverse T-cell repertoire, as well as in peripheral T-cell homeostasis.

Human immunosenescence was investigated through measurement of telomere length by Q-PCR, evaluation of thymic output by Sj and VβTREC methodology, analysis of T-cell phenotype profile, and multiplex cytokine production after polyclonal stimulation. The diseases scrutinized in the elders were pneumonia, heart failure and hip fracture.

TREC value was negatively correlated with age, but no significant relationship could be evidenced with pathological states. A significant rise in pro-inflammatory cytokines IL-6, IFNγ and TNFα was observed in elderly vs. young controls, while IL-10 was significantly decreased. The cytokine profiles as analyzed by protein array showed at least three different patterns: either increased in elderly vs. young and decreased in pathologic states, either increasing or showing no modifications in all cases.

A significant shortening of telomere length in the elderly was observed when compared to young controls. There was a significant decrease between healthy and sick elders.

Significant correlations were evidenced between morbidity and some immune parameters, supporting that immunosenescence contributes to the frailty syndrome.

Supported by the Walloon Region - Senegene project

Peripheral parenteral nutrition in geriatric wards

Poor nutritional status significantly contributes to morbidity and mortality in elderly. Malnutrition and denutrition are amenable to interventions aimed to improve outcomes in acute conditions so that nutritional support is frequently initiated during hospitalisation. If the enteral route remains the first evidence-based choice when the gut is functional, this approach may be difficult to perform in some "geriatric" situations like delirium, agitation, coma or pulmonary congestion. In the first days of the acute condition, when the patient is still stable, an alternative to the enteral route may also be considered. Although there is no evidence that parenteral nutrition is better than enteral nutrition, the peripheral intravenous route may be of interest especially when the enteral route is contraindicated. Moreover, the technique of peripheral parenteral nutition reduces central cannulation-related complications like pneumothorax. We emphasize here the place of this alternative method for a short duration nutritional support when supplement of caloric intake is needed. We discuss indications, a practical approach, our experience and analyze the evidences for this complementary nutritional support.

Appropriateness of use of medicines in elderly inpatients: qualitative study

OBJECTIVES

To explore the processes leading to inappropriate use of medicines for elderly patients admitted for acute care.

DESIGN

Qualitative study with semistructured interviews with doctors, nurses, and pharmacists; focus groups with inpatients; and observation on the ward by clinical pharmacists for one month.

SETTING

Five acute wards for care of the elderly in Belgium.

PARTICIPANTS

5 doctors, 4 nurses, and 3 pharmacists from five acute wards for the interviews; all professionals and patients on two acute wards for the observation and 17 patients (from the same two wards) for the focus groups.

RESULTS

Several factors contributed to inappropriate prescribing, counselling, and transfer of information on medicines to primary care. Firstly, review of treatment was driven by acute considerations, the transfer of information on medicines from primary to secondary care was limited, and prescribing was often not tailored to elderly patients. Secondly, some doctors had a passive attitude towards learning: they thought it would take too long to find the information they needed about medicines and lacked self directed learning. Finally, a paternalistic doctor-patient relationship and difficulties in sharing decisions about treatment between prescribers led to inappropriate use of medicines. Several factors, such as the input of geriatricians and good communication between members of the multidisciplinary geriatric team, led to better use of medicines.

CONCLUSIONS

In this setting, improvements targeted at the abilities of individuals, better doctor-patient and doctor-doctor relationships, and systems for transferring information between care settings will increase the appropriate use of medicines in elderly people.

Early evaluation of the risk of functional decline following hospitalization of older patients: development of a predictive tool

OBJECTIVE

To develop a predictive tool that could be used on admission to identify older hospitalized people at risk of functional decline 3 months after discharge.

METHODS

This was a prospective cohort study that included 625 patients aged 70 years and older (mean age 80.0 +/- 5.6 years) hospitalized by the way of the emergency room, for at least 48 h, in two academic hospitals. Three months after discharge, 550 patients remained for analysis. On admission, people were assessed for premorbid functional status with the activities of daily living (ADL) scale and instrumental ADL scale. Demographic and medical data, including cognitive function, falls, polypharmacy, comorbidity, continence, mobility and self-rated health, were collected. ADL functioning was re-assessed at discharge and 1 and 3 months later. Functional decline was defined as the loss of at least one point on the ADL scale between the premorbid and 3-month evaluation. Univariate analyses were used to select variables associated with functional decline. A logistic regression model was then constructed to predict functional status 3 months after discharge.

RESULTS

Three months after discharge, 165 (31.5%) patients had declined. The predictive tool SHERPA includes five factors: age, impairment in premorbid instrumental ADLs, falls in the year before hospitalization, cognitive impairment (Abbreviated Mini Mental State below 15/21) and poor self-rated health. Sensitivity and specificity were 67.9% and 70.8%, respectively.

CONCLUSIONS

Older people are at high risk of functional decline following hospitalization. On admission, a simple instrument can easily identify these patients, even though the performance of this instrument is moderate.

Differential risk factors for early and later hospital readmission of older patients

BACKGROUND AND AIMS

This study aimed at analyzing rates and factors associated with early and later readmission (0-1 month and 2-3 months after discharge, respectively) of older people after index hospitalization.

METHODS

This prospective observational study was conducted in two teaching hospitals. People 70 years and over were interviewed within 48 h of emergency admission. Socio-demographic and medical factors were collected, together with functional factors including Activities of Daily Living (basis and instrumental), cognitive state, and geriatric syndromes. Medical diagnosis, length of stay, and destination were collected at discharge, and patients were followed up by phone 1 and 3 months after discharge. During these interviews, outcomes on readmission, institutionalization, need for help, and death were evaluated.

RESULTS

The population of 625 patients had a mean age of 80.0 years. The rate of early readmission (01 month) was 10. 7% and the overall rate within 3 months was 23.1%. Logistic regression analysis showed that variables predicting early readmission were previous hospitalization within 3 months, a longer length of stay, and a discharge diagnosis in chapter 8 (respiratory system) and chapter 10 (genito-urinary system) of the ICD-9-CM. Variables predicting later readmission were previous hospitalization within 3 months, a discharge diagnosis in chapter 7 (circulatory system) of the ICD-9-CM, and a poor pre-admission IADL score.

CONCLUSIONS

In a medicalized population of older people, several risk factors may be identified for 0-1 month and 2-3 month readmission. Besides severe morbidities at discharge, diagnoses and previous hospitalization, pre-admission IADL was an independent risk factor for 2-3 month readmission.

Does negative expiratory pressure (NEP) during spontaneous breathing predict respiratory impairment in elderly?

OBJECTIVE

The purpose of this study is to assess whether expiratory flow limitation (FL), as measured by applying a negative pressure at the mouth during tidal expiration, can evaluate the respiratory impairment in elderly patients.

METHODS

The study was carried out in 67 consecutive elderly inpatients (24 men and 43 women). Negative expiratory pressure (NEP) of -5 (NEP 5) and -10 (NEP 10) cm H2O were applied during spontaneous tidal expiration. According to the results of the NEP technique, the patients were stratified in two categories: not flow limited and flow limited. We realized then classic forced expiratory manoeuvres (FEV1, FVC) and clinical evaluation of dyspnea (NYHA). According to the values of the lung function data, elderly patients were then divided in 3 groups (normal, obstructive, restrictive).

RESULTS

The sensitivity, the specificity, the positive and negative predictive values for the diagnosis of obstructive syndrome by the presence of flow limitation during NEP 5 were 53, 74, 45, 79% respectively and 58, 83, 58, 83% respectively during NEP 10. These findings show that the correlation between FL obtained by the NEP technique during spontaneous breathing and spirometry is not very good despite the fact that both were well correlated with dyspnea score.

CONCLUSIONS

In clinical practice, faced with an elderly dyspneic patient unable to perform maximal expiratory manoeuvres, the evaluation of flow limitation by NEP technique seems nor to be reliable to predict an obstructive functional impairment nor to be able to explain the origin of his dyspnea.

Falls in hemodialysis patients: Prospective study of incidence, risk factors, and complications

BACKGROUND

Falls are common in elderly nonuremic patients and are associated with poor outcomes. Recent international guidelines recommend proper assessment of fallers and those at risk for falling to implement multidimensional preventative strategies. Surprisingly, the incidence, risk factors, and complications of falls in hemodialysis (HD) patients are unknown despite the growing number of elderly patients on HD therapy worldwide.

METHODS

We contacted all patients from 7 Belgian in-center HD units. Consenting patients were evaluated in March 2001 for the presence of risk factors for falling (demographics, selected comorbid conditions, gait/balance tests, main biochemical markers, and drug and HD regimens). Falls (including circumstances and derived complications) subsequently were recorded by staff members of all 7 units for 8 weeks from April 1, 2001, through questioning of patients, relatives, and caregivers. Fractures consecutive to falls were recorded for 12 months.

RESULTS

Three-hundred eight patients agreed to participate (acceptance rate, 94%). They had a median age of 70.9 years (56% men, 27% patients with diabetes). Thirty-nine patients (12.7%) with a median age of 74.7 years fell at least once during the 8 weeks (total, 56 falls), an average incidence of 1.18 fall/patient-year. One third of the falls caused lesions requiring health care or even hospitalization (n = 6). During 12 months, 12 patients (3.9%) experienced a fall-related fracture. Logistic regression identified older age (odds ratio, 1.057/y; P = 0.01), diabetes (odds ratio, 2.747; P = 0.02), high number of prescribed oral drugs (odds ratio, 1.19/drug; P = 0.011), antidepressant use (odds ratio, 5.263; P < 0.001), and failing to walk 10 m without help (odds ratio, 2.057; P = 0.001) as independent risk factors for falling.

CONCLUSION

Falls are common in in-center HD patients. The high-risk population delineated by our logistic model appears as a priority target for intervention studies (including exercise programs and more selective prescription of some drugs in particular) to reduce the incidence and complications of falls.

The opinion of general practitioners on the treatment of prostate and breast cancer in elderly people: results of a survey based on clinical models

AIMS

Several publications have reported age-related differences in the management of people with cancer. Most data have been derived retrospectively from hospital or cancer-centre databases. The aim of the present study was to identify major decisional factors observed in general practitioner (GP) practices, outside the hospital setting, regarding the clinical management of patients with prostate and breast cancer.

MATERIALS AND METHODS

During three national GP meetings in Belgium, questionnaires presenting two simulated patient cases were presented to GPs who were asked two questions: one regarding further staging and referral of the case and the second regarding the treatment of the case. A total of 678 questionnaires were distributed. GPs received two randomly selected cases each: a breast cancer history and a prostate cancer history. Three variables were assessed simultaneously: age, performance status and medical history (comorbidity).

RESULTS

The analysis indicated that elderly patients were more likely to be referred for non-curative treatment (OR 13.71; 95% CI 5.67-33.12; P < 0.0001 for prostate cancer and OR 17.67; 95% CI 4.04-77.31; P < 0.0001 for breast cancer). The other variables (performance status and medical history) did not affect treatment orientation. However, GPs were prepared to seek assistance from oncologists in both cases, irrespective of the patient's age.

CONCLUSION

Age seems to be more important among GPs in deciding how to manage cancer patients than performance status and comorbidity. This is a very common prejudice. They are, nevertheless, inclined to refer people with cancer to oncologists independently of the patient's age.

Diagnosis of suspected Alzheimer's disease is improved by automated analysis of regional cerebral blood flow

PURPOSE

Accurate diagnosis of Alzheimer's disease (AD), the most common form of dementia, remains difficult. In order to assess whether fully automated stereotactic surface projection (3D-SSP) presentation contributes to the diagnosis of AD by single-photon emission computed tomography (SPECT), we investigated the diagnostic accuracy of transaxial display with and without 3D-SSP analysis as well as the correlation between cerebral perfusion in different cortical areas and the mini mental score (MMS).

METHODS

Seventy-two patients referred because of cognitive impairment were included in the study. According to the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) and the Alzheimer's disease and Related Disorders Association (ADRDA) criteria, 27 patients were diagnosed as having probable AD while 45 were classified as non-AD patients. 3D-SSP was used to quantify the regional cerebral blood flow (rCBF) acquired from SPECT imaging.

RESULTS

Compared with the transaxial section presentation alone, 3D-SSP presentation improved the area under the receiver operating curve (p<0.05) as well as intra-observer (k=0.73 vs 0.88) and inter-observer (k=0.50 vs 0.84) reproducibility. Upon normalisation of regional to thalamic activity, multiple regression analysis revealed a strong correlation between the MMS and rCBF in the right parietal cortex (p=0.002).

CONCLUSION

Addition of 3D-SSP to the transaxial section display of ECD-SPECT studies improves the reproducibility and the diagnostic performance in respect of AD in patients with cognitive impairment and provides a valid tool for assessment of the severity of cortical perfusion abnormalities in such patients.

Evaluation of the European Academy for Medicine of Ageing "Teaching the Teachers" program (EAMA course II 1997- 1998)

The European Academy for Medicine of Ageing, founded by professors in geriatric medicine, provides a geriatric education program for European postgraduate physicians in geriatric medicine who are future academics in geriatric medicine in their countries. The course is organized for 30 participants involved in four one week residential sessions over two years. The program of each session involves 20 teachers, and includes state of the art lectures, student's lectures and working-group discussions. A first course took place in 1995-96, a second in 1997-98, a third has been accomplished in 1999-00, a fourth for 2001-02 and a fifth is ongoing for 2003--2004. The sessions are subjected to an evaluation program regarding the skills of the students, the value of the presentations and the satisfaction about the educational activities. The evaluations of the four sessions of EAMA course II (1997-1998) are presented here, with emphasis on the changes across the sessions for the whole group and for the individual students. The results are good to excellent for the main goals of the course, both by self-evaluation and by peer-evaluation. The dynamic process of this European academic-oriented geriatric education program attracts an increasing number of participants seeking the necessary skills and expertise to obtain academic position in geriatrics, and to meet international colleagues for further collaborative opportunities. Changes and adaptations of the following programs are fostered by the evaluation program to enhance weaker points. Accordingly, improvements in the programs and in the evaluation methods have been introduced during the third course, and are tested during the fourth and the fifth course.

The medical management of primary open-angle glaucoma in the elderly patient

Glaucoma is a frequent cause of blindness in the elderly. It is defined as a neuropathy of the optic nerve for which the main risk factor is an elevated intraocular pressure. The management of glaucoma is described with an emphasis on diagnostic procedure and on the topical drug treatment. The potential side effects of these drugs are discussed from the geriatric point of view.

Evaluation of flow limitation in elderly patients unable to perform a forced expiratory maneuver

BACKGROUND AND AIMS

The assessment of pulmonary function in elderly persons is not often easy in the clinical practice because of poor patient collaboration. A new technique, negative expiratory pressure (NEP), should provide a simple, rapid and non-invasive method for detecting flow limitation without collaboration of the patients. Our aim was to investigate whether it is possible to detect an expiratory flow limitation during resting breathing with NEP in elderly patients unable to perform a forced expiratory maneuver.

METHODS

In 15 elderly inpatients (4 males and 11 females, mean age 83+/-4.7 SD years) unable to realize the classical forced expiratory maneuver because of poor coordination or cognitive disturbance, we applied the NEP technique during spontaneous breathing.

RESULTS

NEP application during resting breathing was easily and rapidly performed in all cases without side effects. During NEP (-5cmH2O and NEP -10cmH2O), 6 and 5/15 patients were flow limited; mean flow limitation was 60+/-9% and 70+/-15% respectively. These results were reproducible with repeated NEP tests.

CONCLUSIONS

Application of negative pressure at the mouth during tidal expiration provides a simple method for detecting expiratory flow limitation during spontaneous breathing in elderly patients with poor collaboration.

Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area

The number of geriatric patients admitted to the accident and emergency department is growing. These patients also present increasing functional dependence and a large panel of associated diseases and associated problems. For the purpose of describing this phenomenon, we prospectively studied the epidemiology of patients 75 years and older entering the emergency department of a university hospital localized in a rural area. From January 1996 up to January 1997, 1298 patients aged 75 years or older were admitted to the emergency department. This age group represented 12.3% of all the patients admitted during the period. The gender distribution was almost equal: 56% were female and 44% male. Most of them (75%) were referred by their general practitioner although 15% came spontaneously. The most common complaints were, in decreasing order: general condition impairment (21.5%), dyspnoea (15%), falls and traumas (15%), abdominal problems (13%), thoracic pain (9%), syncope, dizziness (7%) and stroke (5.5%). Hospitalization was necessary in 69% of cases. Among the patients coming spontaneously a larger proportion (55%) were sent back home compared with only 25% of those referred by their general practitioner.