Routinely assessed biochemical markers tested on admission as predictors of adverse outcomes in hospitalized elderly patients.

AIM: To explore whether routinely assessed biochemical markers tested on admission will predict 3 predefined adverse outcomes for hospitalized elderly patients: discharge to a long-term care facility, in-hospital mortality, and prolonged hospital length of stay (> 14 days). METHODS: A prospective observational study of elderly patients (aged ≥ 75 years) admitted to an acute-care geriatric ward over a 6-month period. Patients were assessed on admission and baseline characteristics were collected. Activities of daily living were assessed by the Barthel Index and cognitive function by the abbreviated mental test. Results from biochemical markers tested on admission were downloaded from the pathology laboratory database using patient details. Patients were followed-up with until discharge or in-hospital mortality. RESULTS: A total of 392 patients formed the study population. Mean (standard deviation) age was 83.2 (± 5.5) years and 283 (72%) patients were men. Thirty-eight (10%) patients were discharged to a long-term care facility, 134 (34%) had a prolonged hospital length of stay, and 33 (8%) died in the hospital. Results from testing 5 biochemical markers independently predicted in-hospital mortality: hypoalbuminemia (adjusted odds ratio [OR], 2.5; 95% CI, 0.9-6.7; P = 0.04), low total cholesterol level (adjusted OR, 2.9; 95% CI, 1.3-6.3; P = 0.01), hyperglycemia (adjusted OR, 2.9; 95% CI, 1.2-7.4; P = 0.02), high C-reactive protein level (adjusted OR, 4.2; 95% CI, 1.3-13.4; P = 0.01), and renal impairment (adjusted OR, 3.8; 95% CI, 1.7-8.7; P = 0.002). High C-reactive protein level independently predicted prolonged hospital length of stay (OR, 1.7; 95% CI, 1.1-2.9; P = 0.03). Hypoalbuminemia predicted discharge to a long-term care facility independent of confounding factors except for physical dysfunction (OR, 2.4; 95% CI, 1.1-5.1; P = 0.03). Significance was reduced after adjustment for Barthel Index score (OR, 1.9; 95% CI, 0.9-4.1; P = 0.08). CONCLUSION: Testing of routinely assessed biochemical markers on admission predicted adverse hospital outcomes for elderly patients. Their inclusion in a standardized prediction tool may help to create interventions to improve such outcomes.

Chronic kidney disease in older people; disease or dilemma?

The majority of patients diagnosed with chronic kidney disease (CKD) are elderly and CKD is linked with poor cardiovascular, cognitive, and disability outcomes in these people. Only a minority of these patients will progress to end stage renal disease (ESRD) while the majority will die due to cardiovascular disease. Thus, only a small number of these patients with CKD will benefit from specialist nephrologist assessment. The priority for the remainder should be cardiovascular disease prevention. We have reviewed specific issues relevant to older people to determine high-risk groups with CKD that are likely to benefit from a more intensive risk reduction intervention and to allow identification of clinically relevant renal disease.

Use of multicompartment compliance aids for elderly patients: patient viewpoints and hospital length of stay.

AIM: To explore elderly (aged > or = 75 years) patients' views regarding the use of multicompartment compliance aids (MCAs) and determine whether MCAs would prolong their length of hospital stay. METHODS: A cross-sectional, prospective study in 3 acute geriatric wards in a district general hospital in the United Kingdom. Patients admitted to the hospital who were found to be users of MCAs were interviewed about their perception of MCAs, and their length of hospital stay was monitored. RESULTS: A total of 1080 older patients were admitted over a 3-month period. Only 51 (4.7%) patients were users of MCAs and constituted the study group. The majority (51%) of MCAs were requested by general practitioners. Eight (16%) patients were asked whether they wished to use the MCAs and 3 (6%) had formal assessment prior to MCA start. On the patients' survey, 18 (35%) patients did not prefer the MCA if they were given the choice. This group of patients had better cognitive function assessed by the Mini-Mental State Examination (24.4 [3.6] vs 21.8 [3.6]; P = 0.02) and were less dependent on social services (39% vs 67%; P = 0.04) in comparison with patients who did prefer the MCA. They expressed a greater lack of autonomy (94% vs 52%; P = 0.002) and decision making (78% vs 49%; P = 0.04). They tended to be more informed about their medications' names (44% vs 6%; P = 0.01), indications (28% vs 9%; P = 0.02), and self-administration of medications (89% vs 39%; P = 0.01). Multicompartment compliance aids resulted in delayed discharges of 40 (78%) patients, with a mean of 1.3 days (standard deviation, 0.9 days; range, 0-3 days per patient) and a total of 65 days. CONCLUSION: The use of MCAs resulted in a lack of autonomy and decision making in older patients and a significant delay of discharges, thereby increasing hospital costs.

Chronic kidney disease in older people: physiology, pathology or both?

The global population is aging due to a reduction in youthful deaths and an extension of the later stages of life. With aging comes a decline in the physiologic functions of various organs and systems. Vascular aging is associated with structural and functional changes of the arterial wall leading to loss of elasticity and compliance. Renal vasculature is not spared as aging is associated with arterial, arteriolar and capillary, glomerular changes (glomerulosclerosis). It is likely that age-related vascular changes are linked to the decline in renal function observed with aging. These changes occur at varying stages of aging depending on predisposing genetic factors and associated life course exposure to cardiovascular risk factors including hypertension and diabetes. The decline in renal function with 'normal' aging in the absence of associated progressive cardiovascular disease is slow and does not seem to be of major clinical significance. The current definition of chronic kidney disease (CKD), including microalbuminuria, and the method of estimation of glomerular filtration rate have inadvertently resulted in an exaggerated prevalence of CKD in the elderly. This is combined with the fact that most of the studies showing decline in renal function with aging are limited by the absence of a correction for associated comorbid confounding factors, resulting in difficulty separating the effect of physiological aging on kidney function from pathological aging due to comorbidities. Such a correction is difficult, if not impossible, to objectively construct. We suggest that only those fractions of older patients with underlying progressive vascular pathology likely to involve the kidneys will, in the future, warrant attention to reduce vascular risk and the associated kidney damage.

Trials review: cardiovascular outcome with intensive glycemic control and implications for patients with type 2 diabetes.

Hyperglycemia is associated with microvascular and macrovascular complications. Intensive glucose control has been shown to reduce microvascular complications. Nevertheless, cardiovascular disease remains the leading cause of death in patients with type 2 diabetes. A positive association exists between hemoglobin A1c level and cardiovascular events, but whether reducing blood glucose will reduce cardiovascular events is still not quite clear. The benefits of intensive glucose control also remain uncertain for the heterogenous group of older patients with type 2 diabetes. This article reviews results of earlier and recently published intervention trials of intensive glucose control and their outcomes and discusses relevant recommendations for adults with type 2 diabetes.