SPICT as a predictive tool for risk of 1-year health degradation and death in older patients admitted to the emergency department: a bicentric cohort study in Belgium.

BACKGROUND: Older patients are increasingly showing multi-comorbidities, including advanced chronic diseases. When admitted to the emergency department (ED), the decision to pursue life-prolonging treatments or to initiate a palliative care approach is a challenge for clinicians. We test for the first time the diagnostic accuracy of the Supportive and Palliative Care Indicators Tool (SPICT) in the ED to identify older patients at risk of deteriorating and dying, and timely address palliative care needs. METHODS: We conducted a prospective bicentric cohort study on 352 older patients (≥ 75 years) admitted to two EDs in Belgium between December 2019 and March 2020 and between August and November 2020. SPICT (French version, 2019) variables were collected during the patients' admission to the ED, along with socio-demographic, medical and functional data. The palliative profile was defined as a positive SPICT assessment. Survival, symptoms and health degradation (≥ 1 point in ADL Katz score or institutionalisation and death) were followed at 12 months by phone. Main accuracy measures were sensitivity, specificity and likelihood ratios (LR) as well as cox regression, survival analysis using the Kaplan Meier method, and ordinal regression. RESULTS: Out of 352 patients included in the study (mean age 83 ± 5.5 years, 43% male), 167 patients (47%) had a positive SPICT profile. At one year follow up, SPICT positive patients presented significantly more health degradation (72%) compared with SPICT negative patients (35%, p < 0.001). SPICT positivity was correlated with 1-year health degradation (OR 4.9; p < 0.001). The sensitivity and specificity of SPICT to predict health degradation were 0.65 (95%CI, 0.57-0.73) and 0.72 (95%CI, 0.64-0.80) respectively, with a negative LR of 0.48 (95%CI, 0.38-0.60) and a positive LR of 2.37 (1.78-3.16). The survival time was shorter in SPICT positive patients than in SPICT negative ones (p < 0.001), the former having a higher 1-year mortality rate (HR = 4.21; p < 0.001). CONCLUSIONS: SPICT successfully identifies older patients at high risk of health degradation and death. It can support emergency clinicians to identify older patients with a palliative profile and subsequently initiate a palliative care approach with a discussion on goals of care.

Palliative profile, one-year mortality and quality of life in older inpatients according to Be-PICT: a multicenter prospective cohort study.

BACKGROUND: A palliative care approach (PCA), including advanced care planning (ACP), should be considered for patients with limited life expectancy. The Belgian Palliative Care Indicators Tool (Be-PICT) has been released to help identify patients who may benefit from such approach. This study aimed at measuring 1-year mortality and describe the quality of life in older inpatients, according to baseline Be-PICT results. METHODS: Prospective multicentre cohort study in older patients (≥ 75 years) admitted at geriatrics and cardiology wards of four Belgian hospitals. The palliative profile was defined as a positive Be-PICT.1, defined by the presence of its three criteria, i.e. a negative physician's answer to the surprise question 'would you be surprised if this patient dies in the 6-12 next months?', ≥ 1 poor health indicator and ≥ 1 life-limiting condition. RESULTS: Of the 379 patients (50% aged ≥85 years; 51% female), 52 (14%) presented a palliative profile and 83 (23%) died within 1 year. Be-PICT.1 showed the following characteristics to predict 1-year mortality: sensitivity 0.54, specificity 0.83, positive and negative predictive values 0.48 and 0.86, positive and negative likelihood ratios 3.22 and 0.55. The patients with a palliative profile were at higher mortality risk (hazard ratio 4.79 p < 0.001) and 1-year mortality rate (45%). Not using the SQ allowed to improve sensitivity to include a larger number of patients who may benefit from ACP and PCA. CONCLUSIONS: Be-PICT.1 is a simple case-finding tool to identify older inpatients being at high mortality risk and candidates for ACP and PCA.

Prognostic value of the Surprise Question for one-year mortality in older patients: a prospective multicenter study in acute geriatric and cardiology units.

OBJECTIVES: To determine the prognostic value of the Surprise Question (SQ) in older persons. METHODS: A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model. RESULTS: The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332-8.834), p < 0.001) independently from the ward. CONCLUSION: The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.

Factors to improve quality for older patients in the emergency department: a qualitative study of patient trajectory.

BACKGROUND: Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED. METHODS: This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes. RESULTS: Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs. CONCLUSIONS: The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.

Supportive and Palliative Care Indicators Tool prognostic value in older hospitalised patients: a prospective multicentre study.

BACKGROUND: An increasing number of older patients are hospitalised. Prognostic uncertainty causes hospital doctors to be reluctant to make the switch from cure to care. The Supportive and Palliative Care Indicators Tool (SPICT) has not been validated for prognostication in an older hospitalised population. AIM: To validate SPICT as a prognostic tool for risk of dying within one year in older hospitalised patients. DESIGN: Prospective multicentre study. Premorbid SPICT and 1-year survival and survival time were assessed. SETTING/PARTICIPANTS: Patients 75 years and older admitted at acute geriatric (n=209) and cardiology units (CUs) (n=249) of four hospitals. RESULTS: In total, 59.3% (124/209) was SPICT identified on acute geriatric vs 40.6% (101/249) on CUs (p<0.001). SPICT-identified patients in CUs reported more functional needs and more symptoms compared to SPICT non-identified patients. On acute geriatric units, SPICT-identified patients reported more functional needs only.The HR of dying was 2.9 (95% CI 1.1 to 8.7) in SPICT-identified versus non-identified after adjustment for hospital strata, age, gender and did not differ between units. One-year mortality was 24% and 22%, respectively, on acute geriatric versus CUs (p=0.488). Pooled average sensitivity, specificity and partial area under the curve differed significantly between acute geriatric and CUs (p<0.001), respectively, 0.82 (95%CI 0.66 to 0.91), 0.49 (95%CI 0.40 to 0.58) and 0.82 in geriatric vs 0.69 (95% CI 0.42 to 0.87), 0.66 (95% CI 0.55 to 0.77) and 0.65 in CUs. CONCLUSIONS: SPICT may be used as a tool to identify older hospitalised patients at risk of dying within 1 year and who may benefit from a palliative care approach including advance care planning. The prognostic accuracy of SPICT is better in older patients admitted at the acute geriatric versus the CU.

An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People.

OBJECTIVES: We aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years. DESIGN: A preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided. SETTING AND PARTICIPANTS: Twenty nine experts, including geriatricians and clinical pharmacists from 8 European countries. MEASURES: For each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round. RESULTS: Consensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs. CONCLUSION AND IMPLICATIONS: We validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies.

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.

Geriatric support in the emergency department: a national survey in Belgium.

BACKGROUND: Older people in the emergency department (ED) represent a growing population and increasing proportion of the workload in the ED. This study investigated the support for frail older people in the ED, by exploring the collaboration between the geriatric services (GS) and the EDs in Belgian hospitals. METHODS: An electronic cross-sectional survey in all Belgian hospitals with an ED (n = 100) about care aspects, collaboration, education and infrastructure for older patients in the ED was collected. Descriptive analyses were performed at national level. RESULTS: Forty-nine of 100 surveys were completed by the GS. The heads of the ED returned only 12 incomplete questionnaires and these results are therefore not reported. Twenty-six of the 49 heads of GSs (53%) indicated that there was an agreement, mainly informal, between the geriatric and the emergency department concerning the management of older people on the ED. A geriatrician was available for specific problems, by phone or in person, in 96% of the EDs during daytime on weekdays. Almost all responding hospitals (96%) had an inpatient geriatric consultation team, of which 85% was available for specific problems at the ED, by phone or bedside during the daytime on weekdays. Twenty-nine heads of the GSs (59%) reported that older patients were screened at ED admission during the day to identify 'at risk' patients. The results of the screening were used in the context of further treatment (76%), to decide on hospital admission (27%), or to justify admission on a geriatric ward (55%). In the year preceding the survey, 25% of the responding hospitals had organised geriatric training for ED healthcare workers. Thirty-four heads of the GS (69%) felt that the infrastructure of the ED was insufficient to give high-quality care for older persons. CONCLUSION: Collaborations between EDs and GS are emerging in Belgium, but are currently rather limited and not yet sufficiently embedded in the ED care. Exploratory studies are necessary to identify how these collaborations can be improved.

Changes in the clinical features of older patients admitted from the emergency department.

Demographic changes and healthcare reforms may impact the profile of hospitalized older persons. In this study, we sought to compare the characteristics of two prospective cohorts recruited at a ten-year interval (1999, n=253-2009, n=355). They included older patients (≥75 years) admitted through the emergency department for at least 48 h in acute non-geriatric wards in the same university hospital. The exclusion criteria were patients who were admitted directly to the intensive care unit, who were dependent for all 6 Activities of Daily Living (ADL), who had recently suffered from a major stroke, or whose with a life expectancy of less than 3 months. Median age was higher in 2009 than in 1999 (83 vs. 81; p=0.020), with a higher proportion of those aged 85 years and over (p=0.026). Patients in the 2009 cohort were less likely to live in a nursing home (p=0.018), more dependent for the basic ADL (p<0.001), more independent for the instrumental ADL (p<0.001). They were more likely to have fallen in the previous year (p<0.001). They took more medications (p<0.001). Their length-of-stay was shorter (p<0.001), but they were more likely to be discharged to a rehabilitation center (p<0.001). They underwent more early re-admissions (p=0.020) and similar 3-month functional decline (p=0.614). In conclusion, within a decade, the social, functional and medical characteristics of older patients admitted to hospital have changed significantly. In view of the high consumption of in-patient services by this population, hospitals must adapt to these rapid changes.

Prediction of risk of in-hospital geriatric complications in older patients with hip fracture.

BACKGROUND AND AIMS: Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams. METHODS: A retrospective cohort of consecutive community- living elderly patients (age ≥ 75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR). RESULTS: Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53- 58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off). CONCLUSIONS: None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention.