Early diagnosis of dehydration in hospitalized geriatric patients using clinical and laboratory criteria.

CONTEXT: Dehydration is a common yet underdiagnosed condition, which is associated with poor prognosis in older patients. The clinical and laboratory criteria for assessing dehydration are of variable or poor diagnostic value in this population and require further validation. OBJECTIVES: To test different clinical and laboratory criteria for the early diagnosis of dehydration in hospitalized older patients as compared to the standard diagnosis based on a body weight gain ≥ 3% during the first week of admission. DESIGN: Prospective study using clinical and laboratory criteria for dehydration selected by an expert panel. SETTING: Acute geriatric unit. PARTICIPANTS: Geriatric patients (n = 112; aged 83 ± 6 years) admitted to the unit. MEASUREMENTS: Using selected criteria (skin fold, dry mouth, calf muscle consistency, systolic blood pressure < 90 mmHg, orthostatic blood pressure drop, postural dizziness, thirst, apathy or delirium, urea, creatinine, uric acid, proteins, hemoglobin), expert clinicians prospectively assessed the patients to make a clinical diagnosis of dehydration upon admission. Clinicians were asked to provide a yes/no answer for each criterion and a global yes/no answer for dehydration, along with its estimated probability. Body weight was measured at admission and at Day 7. Laboratory parameters were assessed at baseline and at Day 7. The clinical diagnosis made at admission was retrospectively compared to the standard diagnosis made at Day 7 (> 3% weight gain) to test the values of each criterion separately, the global diagnosis, and its estimated probability. RESULTS: In total, 100 patients with complete data (mean age 83 ± 6 years) were considered for analysis. Dehydration was the principal reason for admission in three patients only but was clinically diagnosed as part of the study in 39 patients, whereas the standard diagnosis of dehydration was ascertained in 20. Inter-rater agreement (kappa) was fair for the clinical criteria and clinical diagnosis, moderate to near perfect for the laboratory criteria, and substantial for the estimated probability of dehydration. When matched with the standard diagnosis, the final clinical diagnosis of dehydration had 70% sensitivity and 69% specificity, with a 90% negative predictive value. Individually, both clinical and laboratory criteria had good specificity (65-90%), but poor sensitivity (< 55%). CONCLUSIONS: Compared with the standard diagnosis, dehydration was overdiagnosed by systematic clinical assessment upon admission in this frail population. However, clinicians performed better at excluding dehydration. Clinical acumen seems better than any individual clinical symptom or sign.

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.

Evaluation of the Xpert MRSA assay for rapid detection of methicillin-resistant Staphylococcus aureus from nares swabs of geriatric hospitalized patients and failure to detect a specific SCCmec type IV variant.

Rapid and reliable detection of methicillin-resistant Staphylococcus aureus (MRSA) carriers is crucial for control of MRSA nosocomial transmission. We aimed to evaluate the performance of the GeneXpert real-time PCR system using the Xpert MRSA assay on a collection of 40 representative Belgian MRSA strains and for MRSA screening of geriatric inpatients. Double nasal swabs were used: the first swab for the Xpert MRSA assay and the second for culture onto chromogenic selective medium and enrichment broth. All but 1 of the 40 collection strains were recognized as MRSA by the Xpert MRSA assay. Nares swabs were prospectively collected from 246 inpatients including 25 nasal MRSA carriers. Compared with enriched cultures, the sensitivity, the specificity, and the positive and negative predictive values of the Xpert MRSA assay were 69.2%, 97.7%, 78.3%, and 96.3% respectively. The 7 evaluable false-negative results according to the assay were due to its possible lack of sensitivity (n = 3) and to the occurrence of a Belgian MRSA clone carrying a particular staphylococcal chromosomal cassette mec (SCCmec) type IV variant (n = 4) not targeted by the current Xpert MRSA assay. Because of the evolution of SCCmec in MRSA, new primers should be designed and further studies are warranted to ensure continuous monitoring of this assay.

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.

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.

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.

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.

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.

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.

Delayed diagnosis of meningitis caused by beta-haemolytic group G. Streptococcus in an older woman.

A case of meningitis caused by group G beta-hemolytic Streptococcus (dysgalactiae, subspecies equisimilis) is reported in an 83-year-old woman. Streptococci species other than Streptococcus pneumoniae are seldom found in patients with acute bacterial meningitis, therefore, our discussion is focused on this rare organism. The question of the diagnosis of meningitis in the elderly is also addressed.

Non-invasive ventilation for frail elderly patients with acute respiratory failure.

We describe 3 elderly patients with acute respiratory failure who received respiratory assistance with nasal bi-level positive airway pressure (BiPAP) on the ward. In these patients with poor prognostic factors, non-invasive positive pressure ventilation was preferred as a reasonable alternative to invasive ventilation; indeed, their admission to the intensive care unit for mechanical support was considered inappropriate. Despite the small number of patients and limited experience with the technique, BiPAP is discussed here as a possible treatment for severe respiratory failure when endotracheal ventilation is controversial, especially in frail patients 80 years of age or older, because invasive ventilation is associated with high mortality and morbidity in these patients. Two questions nevertheless need further evaluation in this setting, and are also addressed. The first is technical: can transient non-invasive breathing assistance be delivered on the ward? The second is ethical: is BiPAP a possible alternative when invasive ventilation is considered inappropriate?

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.

Elderly heart failure patients with drug-induced serious hyperkalemia.

We report four cases of hyperkalemia induced by the association of spironolactone with ACE inhibitor in geriatric patients. Over a period of one year, four elderly patients treated for congestive heart failure with this association were admitted to the Geriatric Ward with serious hyperkalemia. These occurrences represented one third of all-cause severe hyperkalemia cases admitted during this one-year period. A common observation in our cases was that the dose of spironolactone employed far exceeded the recommended dosages. These cases illustrate that spironolactone dosage must be kept low in the setting of chronic congestive heart failure treatment, as well as the need for close monitoring of frail elderly patients who are given this combination.

[Innovative teaching, a successful invention: the European Academy for Medicine of Ageing (EAMA). The viewpoint of teachers and students]. / Un enseignement innovant, une création réussie: l'European Academy for Medicine of Ageing (EAMA). Le point de vue des enseignants et des étudiants.

INTRODUCTION: The origins of the EAMA (European Academy for Medicine of Aging) course are described in this paper by the Scientific Committee of this new post-graduate teaching activity. CURRENT KNOWLEDGE AND KEY POINTS: Innovations are constantly introduced to improve training methodology so as to enable the students to update their knowledge, help them improve their skills in data gathering and in the critical interpretation of information, and exchange geriatric experience and know-how. To reach such goals, an interactive teaching method is implemented by the professors, with world experts being called in to ensure scientific soundness and quality. Evaluations by students and teachers are regularly carried out with the aim of perfectly adjusting their training methodologies and increasing the scientific level of exchanges. FUTURE PROSPECTS AND PROJECTS: If the students progress, so do the teachers....