Risk factors of functional decline during hospitalization in the oldest old.

BACKGROUND AND AIMS: The number of hospital admissions of the elderly is increasing and hospitalization often leads to functional decline. The aim of this study was to identify major risk factors for functional decline in the hospitalized oldest old. METHODS: Prospective, observational, non-randomized study of patients aged >/=80 years, admitted for at least two days to the University Department of Geriatric Medicine of Torino, Italy, between November 2003 and November 2004. For detection of functional decline, the ADL scale was used, referring to the number of dependent ADL. RESULTS: At discharge, ADL mean scores were significantly higher than on admission (2.5+/-2 vs 2.3+/-1.9, p<0.001). 23.9% of the sample lost at least one ADL function during hospitalization, and 19.2% were transferred to long-term care, compared with 5.4% of those with no functional decline. Length of hospitalization, neoplasm, low level of albumin and high number of drugs prescribed were associated with functional decline. At multivariate analysis, only in-hospital stay was an independent risk factor for functional decline (RR 1.1 per day of hospitalization, CI 1.03-1.14). CONCLUSIONS: Hospitalization of the oldest old increases the risk of functional decline, especially if prolonged. It is important to identify patients at high risk for functional decline after hospital admission.

Chronic pain in a sample of nursing home residents: prevalence, characteristics, influence on quality of life (QoL).

Chronic pain is common in the elderly, but it is often under-estimated and under-treated. The aim of this study was to evaluate the prevalence and characteristics of chronic pain in nursing home residents and to analyze its influence on patient's QoL and functional status. We studied 105 patients (mean age 82.2+/-9 years), living in two nursing homes in Torino, Italy. The McGill Pain Questionnaire (MGPQ), the Visual Analogical Scale (VAS) and the Face Pain Scale (FPS) were used to test pain. Depression, functional and cognitive status were also evaluated by using specific instruments, such as the Geriatric Depression Scale (GDS), Instrumental Activities of Daily Living (IADL), Activities of Daily Living (ADL) and the Mini-Mental State Examination (MMSE). Pharmacological and non-pharmacological treatments were documented. It was found that chronic pain was present in 82.9% of the sample; it lasted over 24 months and it was persistent in half of them (49.4%). We observed that chronic pain in the elderly has a strong affective component and its intensity influences older patients' mood, nutrition, sleep and QoL. Our study showed that chronic pain was under-treated. We conclude that chronic pain in institutionalized elderly is common and worsens patients' QoL. It is important to assess and manage pain as a relevant problem in particular for the population at increased risk for under-recognition and under-treatment.

Early re-hospitalization of elderly people discharged from a geriatric ward.

BACKGROUND AND AIMS: Hospitalized elderly patients generally have a high level of disability and comorbidity. In many cases, at hospital discharge, the achieved health status balance is poor, and consequently the risk of further disability and hospital readmission is great. Identifying factors leading to hospital readmission could be helpful in reducing such events. The aim of the study was to evaluate the incidence and predictive factors of hospital readmission. METHODS: We conducted an observational cohort study of a group of patients discharged from the Geriatric Ward of the San Giovanni Battista Hospital, Torino (Italy). The study sample contained 839 patients aged 80.6 +/- 6.3 years. The average hospital stay was 17.5 +/- 18.9 days (range 1-274 days). RESULTS: Follow-up lasted three months, at the end of which 107 patients (12.8%) had been readmitted, 83 (9.9%) had only one readmission and 24 (2.9%) one or more readmissions. The first readmission took place within 15 days of discharge for 24 patients (2.9%) and within 30 days of discharge for 27 (3.2%). A new hospital admission within 15 days of discharge increased the risk of mortality (RR=3) and also the probability of a second re-hospitalization. 10.1% patients died; 88.2% of the patients who died had at least one readmission, whereas only 4.2% of live patients had a new hospital admission. CONCLUSIONS: Tumors, dementia, comorbidity, high education level, day hospital course and period of convalescence were all significantly and independently related to readmission.

Multidimensional assessment and risk factors for prolonged hospitalization in the elderly.

BACKGROUND AND AIMS: Frailty, multiple pathologies, functional impairment and socioeconomic conditions can prolong the length of hospitalization in the elderly. The aim of our study was to analyze risk factors for prolonged hospitalization. METHODS: Our sample included 1054 patients consecutively admitted to the University Department of Geriatric Medicine of Torino, Italy. We examined some demographic variables (age, sex, socioeconomic conditions), affective, cognitive and functional status, main pathologies, and blood pressure and some hematological parameters (hemoglobin, creatinine, albumin, sodium). RESULTS: The number of functions lost to IADL and ADL, DMI (Dependent Medical Index) dependence, high levels of creatinine and low blood levels of albumin and sodium were associated with longer hospitalization, as also were the following clinical diagnoses: tumor, chronic obstructive pulmonary disease (COPD), hip fractures, peripheral arterial disease (PAD), and pressure sores. Independent predictors of prolonged hospitalization were: the number of functions lost to the ADL index, pressure sores, hip fracture, peripheral arterial disease with critical ischemia, and low levels of sodium. CONCLUSIONS: Multidimensional assessment is essential to identify medical, functional and socioeconomic problems, and can highlight risk factors for prolonged hospitalization.

Risk factors for early and late mortality in hospitalized older patients: the continuing importance of functional status.

BACKGROUND: Prognostic information collected at hospital admission may be useful in defining care objectives and in deciding on therapy for older people. The aim of our study was to identify admission risk factors for in-hospital and postdischarge mortality. METHODS: The study included 987 patients aged 70 years and older admitted to the geriatric ward of San Giovanni Battista Hospital in Torino during 1995 and 1996. Demographic, clinical, and functional variables were collected on admission to hospital and examined as potential risk factors for mortality during hospitalization and at 5 years of follow-up. RESULTS: During their hospital stay, 147 patients (14.9%) died. Risk factors independently associated with in-hospital mortality included functional impairment (Activities of Daily Living [ADL]) (OR [odds ratio] 1.73, CI [confidence interval] 95% 1.02-2.95), dependence related to medical conditions (OR 2.18, CI 95% 1.39-3.42), cerebrovascular disease (OR 3.23, CI 95% 1.64-6.37), cancer (OR 4.52, CI 95% 1.99-10.24), albumin 3.0-3.4 g/dl (OR 4.51, CI 95% 2.76-7.35), albumin <3.0 g/dl (OR 6.83, CI 95% 3.59-13.0), creatinine 1.5-3 mg/dl (OR 2.23, CI 95% 1.36-3.65), creatinine >3 mg/dl (OR 2.55, CI 95% 1.10-5.93), and fibrinogen >/=452 mg/dl (OR 1.91, CI 95% 1.26-2.89). During the 5-year follow-up, 553 patients (67.7%) died. Variables independently associated with mortality in multivariate analysis were age 75-84 years (HR [hazard ratio] 1.40, CI 95% 1.10-1.78), >/=85 years (HR 2.08, CI 95% 1.59-2.72), male sex (HR 1.50, CI 95% 1.24-1.81), ADL dependency (HR 1.24, CI 95% 1.01-1.52), >/=5 errors on Short Portable Mental Status Questionnaire (HR 1.34, CI 95% 1.10-1.63), dependence on Dependence Medical Index (HR 1.36, CI 95% 1.10-1.67), presence of cancer (HR 2.58, CI 95% 1.80-3.71), hemoglobin /=2 (HR 1.49, CI 95% 1.14-1.95). CONCLUSIONS: A complete functional and clinical evaluation at hospital admission permits identification of patients at higher risk of early and long-term mortality.

Post-hospitalization mortality in the elderly.

The level of disability and polypathology in hospitalized elderly is usually high. Multidimensional and functional assessment allows to identify risk factors for clinical and functional failure of patients. Many studies point out that identifying predictors of high-risk patients is a necessary step in accurate targeting. We evaluated 395 subjects (175 women, 202 men, mean age 77.9 year) during their hospitalization in our Geriatric ward. Baseline data included: demographics variables, medical diagnosis, functional evaluation, and laboratory values. After a 6-month follow up 80 (20.2%) subjects died. In our study, male gender, dependence at the Dependence Medical Index (DMI), low serum albumin (< 2.8 g/dl), impaired score at the Instrumental Activities of Daily Living scale (IADL), score lower than 13.7 at the acute physiology and chronic health evaluation (APACHE II) and neoplasm were independent predictors of 6-month post-hospitalization mortality. The high mortality rate of our sample could be a marker of considerable frailty among elderly patients. Our study shows that a poor functional status is a more reliable prognostic factor than type and number of admitting diagnosis. Clinical evaluation, improved with information about functional status, is a feasible and practical way of detecting risk of short term post-hospitalization mortality of elderly subjects.

[An index for evaluation of cognitive-behavioral disorders in elderly people living in nursing homes]. / Un indice di valutazione dei disturbi cognitive-comportamentali nell'anziano istituzionalizzato.

Aim of the study was to create an instrument (DISCO Index) to evaluate cognitive-behavioural disturbances in elderly people. We considered n. 192 elderly people living in Torino's nursing homes, n. 76 people screened by the Geriatric Evaluation Unit (GEU) of S. Giovanni Battista Hospital in Torino and n. 136 subjects evaluated by a Torino's District GEU. Mean age was 81.8 +/- 8.3 years. By evaluating cognitive status and behavioural disturbances we obtained a list of conditions referring to three different degrees of severity depending on care needs. The three categories have been defined as: group A: absent or light cognitive and behavioural disturbances; group B: significant impairment of space-timing orientation, hallucinations and delirium, frequent verbal abuse (outrage, menace), feeding alteration; group C: total disturbance of sleep--awakeness rhythm, frequent real or threatened physical assault, wandering or escape attempts, suicidal ideas or suicidal trials, sever feeding alterations. Functional status was also considered by ADL. 41.1% of the study population belongs to group A, 50.5% to group B and 8.4% to group C. Functional status in the sample was seriously impaired in 64.4% (autonomy loss in more then three functions) while only 9.4% of the subjects was autonomous. The totally of people belonging to the group C was found to be dependent in ADLs.

[Chronic pain in the elderly]. / Il dolore cronico nell'anziano.

Chronic pain is a common problem for the aged. Aim of the study was to evaluate prevalence, characteristics and influence on functional parameters of chronic pain in the elderly. Our study included 105 patients (mean age 82.2 +/- 9 yr). Chronic pain, tested by using the McGill Pain Questionnaire, was present in 87 patients (82.9%); it lasted more than 2 years and it was continuous in half of them (49.4%). Our study shows that chronic pain in the elderly has a strong affective component. Its intensity, evaluated by specific tests such as analogical visual and verbal scales, influences old patient's quality of life.