[Four types of old patients in the emergency department : A geriatric medicine qualitative and economic viewpoint]. / Vier Typen von alten Patienten in der Notaufnahme : Eine altersmedizinische, qualitative und ökonomische Betrachtung.

BACKGROUND: Lack of clinical management of old patients in the emergency department. QUESTION: How can we manage old patients in the emergency department more effectively, medically and economically? METHODS: Evaluation of current selection and screening methods and recommendations for old patients in the emergency department. Acute inpatient treatment needs, presence of dysfunction in at least two core areas and assessment of advance care needs are examined. RESULT: The identification of old patients in the emergency department as geriatric patients alone shows no control potential. Combining the three test criteria of acute inpatient need for treatment, the presence of dysfunction in at least two core areas and the assessment of advance care needs generates four old patient types that have interesting control potential: the medical traumatology patient, the acute geriatric patient, the rehabilitative geriatric patient, and the ambulatory patient. DISCUSSION: in addition to identifying geriatric patients, screening should map acute inpatient treatment needs, assessment of dysfunction, and analysis of advance care needs to define clinically steerable old patients.

Do independent geriatric outpatients with nocturnal polyuria profit from desmopressin?

OBJECTIVE: To compare the efficacy of desmopressin and placebo in independent geriatric outpatients with nocturnal polyuria (NP). METHODS: A prospective, randomized, single-center, national, double blind, placebo-controlled, fixed-dose, parallel group comparative trial was carried out. The study included 110 geriatric outpatients, 55 patients per treatment group using desmopressin acetate nasal spray (strength: 0.1 mg/ml) once daily of 10 µg/spray blast or placebo. MEASUREMENT: The NP positive geriatric outpatients with >33% nocturnal urine output volume, antidiuretic hormone (ADH) positive or negative were treated over 10 days with intranasal spray in the evening time (7 p.m.), drug or placebo. On day 1 voiding frequency, voiding volumes day and night, serum osmolarity and arginine-vasopressin (AVP) were measured at 7 p.m. On days 2, 5 and 10 creatinine, blood urea nitrogen (bun), blood count and C­reactive protein (CrP), vena cava diameter and bioimpedance were measured and a structured interview was implemented (voiding frequency, sleeping behavior and subjective and cognitive behavior). RESULTS: The NP patients showed a mean night voiding volume of 50.60%, 39.21% (n = 102) showed a low AVP level at baseline with no correlation to sodium concentration or voiding frequencies. The primary efficacy criterion, a decrease of the nocturnal voiding frequency during the course of the clinical trial as change from baseline at day 10 (visit 4) was 50% versus 41.40% in the verum versus placebo group, respectively but the differences were not significant. The U­test showed superiority of AVP-positive NP patients to a positive reaction on desmopressin. Sleeping time hours increased in both groups without significant differences. CONCLUSION: In this 10-day clinical trial desmopressin was not proven to be therapeutically superior to placebo with respect to micturition frequency or sleeping hours. Independent geriatric outpatients with decreased ADH levels seemed to respond and benefit from active treatment with desmopressin. The unexpected results in the placebo group may be due to the effect of intensive outpatient care and information on NP outpatients with normal AVP levels.

What does delirium cost? An economic evaluation of hyperactive delirium.

BACKGROUND: Demographic changes have resulted in an increase in the number of older (> 75 years) multimorbid patients in clinics. In addition to the primary acute diagnoses that lead to hospitalization, this group of patients often has cognitive dysfunctions, such as delirium. According to clinical experience, delirium patients are more time-consuming for clinicians and their function is often poor. The costs caused by delirium patients are currently unknown. In the present study, a retrospective examination of a database was carried out to calculate the costs that arise during the clinical treatment of documented delirium patients. SETTING AND METHODS: The purpose of this retrospective analysis was to collect information recorded by nursing personnel trained in the treatment of delirium and information from a manual documentation matrix for additional time expenditure. In the database analysis anonymous data of previously discharged patients for a time window of 3 months were analyzed. Documented additional expenditure for patients with hyperactive delirium at hospitalization were analyzed by personnel. Material costs, the duration of hospitalization by main diagnosis and age clusters during hospitalization until discharge were also examined. The analysis was performed in a hospital with internal wards. RESULTS: Data for 82 hyperactive delirium patients were examined and an average of approximately 240 min of additional personnel expenditure for these patients was found. These patients were approximately 10 years older (p < 0.01) and were hospitalized for an average of 4.2 days longer (p < 0.01) than non-delirium patients. Hyperactive delirium usually developed within the first 5 days of hospitalization and lasted 1.6 days on average. Patients for whom hyperactive delirium was detected early were hospitalized for significantly less time than those for whom it was detected late (6.85 versus 13.61 days, p = 0.002). Additionally, calculated personnel and material costs, including costs affecting the hospitalization period, amounted to approximately 1200 € per hyperactive delirium patient. This corresponds to approximately 0.3 CMP (casemix points) per patient. CONCLUSION: The calculations of personnel and material costs and duration of hospitalization in patients with hyperactive delirium demonstrated significant additional costs. Early routine detection of delirium can be achieved through training and this approach leads to a shortening of the hospitalization period and lower costs.