Characteristics and determinants of survival in oldest old nursing home residents admitted to hospital with an acute illness compared to their younger counterparts.

BACKGROUND AND OBJECTIVES: The clinical problems and needs of our oldest old (≥85 years) are often substantially different from those of younger patients, and are arguably different from younger elderly patients (age 65-84). With the increasing number of frail oldest olds residing in Nursing Homes (NH), we aim to identify differences in prognostic indicators and outcomes in this age group compared to younger NH residents. METHODS: We retrospectively identified all consecutive admissions from NHs to an Acute Medical Assessment Unit between January 2005 and December 2007. Admission prognostic indicators and outcomes at follow-up were compared between younger (<85) and older (≥85) age groups. Using multiple regression methods controlling for potential confounders, we compared in-hospital mortality and long-term survival after discharge between the groups. RESULTS: Three hundred and sixteen patients (mean age 84.3, SD 8.34 years) were included (68 % females). Admission characteristics were mostly similar between age groups. In-hospital mortality rates were not significantly different between groups, even after adjusting for possible confounders. Oldest old patients had a significantly greater hazard of dying after discharge (HR 1.37; 1.03-1.83) compared to the younger group after removing explanatory variables with more than 5 % missing data. CONCLUSION: Whilst the admission characteristics are similar between younger and older patients from NHs, there is evidence to suggest worse long-term survival prospects for oldest old patients.

Community-based fall assessment compared with hospital-based assessment in community-dwelling older people over 65 at high risk of falling: a randomized study.

BACKGROUND AND AIMS: The effectiveness of community-based fall assessment programs in older people is unclear. In this study, we examined the effectiveness of community-based fall assessment compared with hospital-based assessment. METHODS: A randomized un-blind study was conducted in 369 older adults aged 65 years and over at high risk of falling. Participants were drawn from a larger cohort of community-dwelling older people. Eligible participants were identified by means of a simple five-item screening tool. A randomly chosen subset population of people at high risk of falling was then randomized into two arms, community-based and hospital-based fall assessments. The total number of falls in both groups was recorded by following up subjects' diaries and telephone interviews at 3, 6 and 12 months. Incidence Rate Ratios (IRR) for the rate of falls at 12 months between community- and hospital-based assessments were analysed as primary outcome, by intention-to-treat analysis. RESULTS: A total of 349 participants completed the study. Attendance to community-based assessment was significantly higher compared with hospital-based assessment in this older population (p=0.012). There were no statistically significant differences between the two groups in total number of falls at the 12 month follow-up. According to Negative Binomial regression, the adjusted IRR of falls in the community based arm was not significantly different from the hospital-based one (IRR 0.95; 95% CI 0.58-1.45, p=0.83). CONCLUSION: This study showed the increased risk of falling according to community-based fall assessment program with respect to a traditional hospital-based one in community-dwelling older adults at high risk of falling.

Vital signs as determinants of immediate and longer term mortality outcome of patients admitted from nursing homes.

BACKGROUND AND AIMS: Hospital admissions from Nursing Homes (NHs) are associated with high mortality. Identifying people with a poor prognosis admitted from NHs is essential to inform appropriate clinical decision making. METHODS: We identified all consecutive admissions from NHs (all ages) to an Acute Medical Assessment Unit (AMU) of a large District General Hospital in UK with a catchment population of ~360,000 between January 2005-December 2007 and reviewed their outcome to end of March 2009 (median follow-up=133 days). The relation between admission vital signs (systolic blood pressure, pulse rate, respiratory rate, body temperature and Glasgow Coma Scale-GCS) and outcomes including in-patient mortality, hospital length of stay and mortality at followup were examined using logistic and Cox regression models. RESULTS: The cohort consisted of 316 patients (32% male), mean age at admission was 83.8 years (SD 8.36 yrs; range=49-99 yrs). Sixty-seven (21%) had at least two admissions during the study period; the maximum number of readmissions was five. We found strong evidence that lower systolic blood pressure and higher respiratory rate at the time of admission were associated with increased probability of in-patient death and reduced survival time but not with length of stay. Older age and lower admission GCS were additionally associated with overall poor prognosis. CONCLUSION: Simple and readily available hospital admission parameters predict not only the in-patient mortality but also longer term outcome for NH residents who require acute hospital admission. Further studies are required to examine whether opportunities exist to intervene and improve outcome in this patient population.

What is the effect of a consultant presence in an acute medical unit?

A cornerstone of the development of acute medicine has been the principle of consultant presence within the acute medical unit (AMU). There is the hypothesis that consultant supervision improves patient care. This view is not currently supported by firm scientific evidence. When Ipswich AMU opened in 2004, there was a consultant presence on some weekdays only. Admission data were collected and assessed with respect to the presence or absence of the consultant. Overall length of stay was significantly lower, by a mean of 1.3 days, when there was a consultant present, and 9% more patients were discharged on the same day of their assessment (95% confidence interval 5.7% to 12.6%, p < 0.001) without affecting readmission or mortality. These results suggest the absence of a consultant leads to fewer same-day discharges and causes the inappropriate admission of patients not needing inpatient management. Further study is required to determine whether these findings are shared by other AMUs.