Criteria for taking an advance decision to limit the transfer to intensive care of patients aged 75 and over, hospitalised in an acute geriatric unit.

OBJECTIVE: Due to the diversity of the elderly population and medical practices, the decision to transfer elderly patients to an intensive care unit is complex. This study aimed to identify the criteria used to take an advance decision to limit transfer to an intensive care unit of patients hospitalised in an acute geriatric unit. METHODS: This retrospective study included, over a ten-month period, patients >75 years and hospitalised in an acute geriatric unit. They were divided into two groups according to whether or not an advanced decision to limit transfer to an intensive care unit had been taken. RESULTS: In total, 906 elderly patients were included in the study. Of them, 446 had no advance decision to limit transfer to an ICU. Univariate analysis showed a correlation between an advance decision to limit transfer to an ICU and a Mini Mental State Examination (MMSE) score of less than 20/30. Malnutrition had no impact on the advance decision. In multivariate analysis, the factors associated with an advance decision to limit transfer to an ICU were an age > 85 years, a hospitalisation in the last six months (Odds Ratio (OR) = 1.72, Confidence Interval (CI) 95% [1.23-2.39]), residence in a nursing home (OR = 1.93, 95% CI [1.18-0.16]) and the presence of bedsores (OR = 2.44, 95% CI [1.20-0.98]). A zero Charlson score was associated with the absence of an advance decision to limit transfer to an ICU (OR = 0.42, 95% CI [0.26-0.67]). CONCLUSION: Some criteria are common to geriatricians, intensive care doctors and emergency physicians, while others are discordant, illustrating differences in physicians' practices.

[Criteria of early limitation of transfer in intensive care unit of patients aged 75 and over hospitalized in an acute geriatric unit]. / Critères de limitation anticipée du transfert en réanimation des patients âgés de 75 ans et plus hospitalisés dans un service de gériatrie aiguë.

Because of heterogeneity of the elderly population and medical practices, the decision of admission of elderly patients (EP) in intensive care unit is more complex. This study aimed to determine the decision criteria for an early limitation of transfer in intensive care unit (ELTICU) of patients hospitalized in an acute geriatric unit. This retrospective study included, over a 10-month period, patients ≥75 years and hospitalized in an acute geriatric unit. They were divided into 2 groups according to whether or not an ELTICU decision was taken. In total, 906 EP were included among them 446 with no ELTICU decision. Univariate analysis showed a correlation between ELTICU and a Mini Mental Status score of less than 20/30. Malnutrition had no impact on ELTICU decision. In multivariate analysis, the factors associated with an ELTICU decision were an age ≥ 85 years, an hospitalization in the last 6 months (Odds Ratio (OR) = 1.72, Confidence Interval (CI) 95% [1.23-2.39]), life in a nursing home (OR = 1.93, 95% CI [1.18-3.16]) and the presence of bedsore(s) (OR = 2.44, 95% CI [1.20-4.98]). A null Charlson score was associated with the absence of an ELTICU decision (OR = 0.42, 95% CI [0.26-0.67]). Some criteria are shared between geriatricians, resuscitators and emergency physicians, while others are discordant, illustrating differences in physicians' practices.

Analysis of COVID-19 in Professionals Working in Geriatric Environment: Multicenter Prospective Study.

Healthcare workers (HCWs) are exposed to a higher risk of coronavirus disease (COVID-19) contamination. This prospective multicenter study describes the characteristics of HCWs tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while working in a geriatric environment. We also compared HCWs with a positive reverse transcription polymerase chain reaction (RTPCR) assay (RTPCR+ group) and those with a negative test result (RTPCR- group). Between 15/5/2020 and 15/9/2020, 258 HCWs, employed in the acute geriatric unit (AGU), geriatric rehabilitation unit (GRU) or nursing home of three hospitals in Burgundy (France) were invited to complete an online survey. Among the 171 respondents, 83 participants, with mean age 42 years and 87.9% female, were tested for SARS-CoV-2 infection. Among these 83 participants, COVID-19 was confirmed in 38 cases (RTPCR+ group) of which 36 were symptomatic, and the RTPCR assay was negative in 45 cases (RTPCR- group) of which 20 participants were symptomatic. A total of 22.9% (of 83) had comorbidities, 21.7% were active smokers, and 65.1% had received the flu vaccine. A total of 37.3% worked in AGU, 19.3% in GRU and 16.9% in nursing homes. The most common symptom described was headache (23.2%), followed by fatigue or cough (12.5% each), and fever or myalgia (10.7% each). There were more participants with normal body mass index (p = 0.03) in the RTPCR+ group. In contrast, there were more users of non-steroidal anti-inflammatory drugs (p = 0.01), active smokers (p = 0.03) and flu vaccinated (p = 0.01) in the RTPCR- group. No difference was found between the two groups for the type of work (p = 0.20 for physicians and p = 0.18 for nurses). However, acquiring COVID-19 was significantly associated with working in AGU (p < 0.001) and nursing homes (p = 0.001). There were significantly more users of surgical masks (p = 0.035) in the RTPCR+ group and more filtering facepiece-2 mask users (p = 0.016) in the RTPCR- group. Our results reflect the first six months of the COVID-19 pandemic in France. Further studies are needed to evaluate and track the risks and consequences of COVID-19 in HCWs.

Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality.

OBJECTIVES: Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: All consecutive patients from a French 62-bed acute geriatric unit over 1 year. METHODS: Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses. RESULTS: In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden. CONCLUSIONS AND IMPLICATIONS: Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.

Direct Oral Anticoagulants versus Vitamin K Antagonists in Patients Aged 80 Years and Older.

The effectiveness of direct oral anticoagulants (DOAC) is non-inferior to vitamin K antagonists (VKA) to treat atrial fibrillation and venous thromboembolism (VTE). In this cross-sectional study, we compared older persons taking DOACs to those taking VKAs. We included ambulatory individuals ≥80 years, affiliated to Mutualité Sociale Agricole of Burgundy, who were refunded for a medical prescription in September 2017. The demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs were compared in the DOAC group and VKA group. Of the 3190 included individuals, 1279 (40%) were prescribed DOACs and 1911 (60%) VKAs. Individuals taking VKAs were older than those taking DOACs (87.11 vs. 86.35 years). In the DOAC group, there were more women (51.92% vs. 48.25%) (p = 0.043), less RCD (89.60% vs. 92.73%) (p = 0.002), less VTE (1.80% vs. 6.59%), less severe heart failure (58.09% vs. 67.87%), less severe hypertension (18.22% vs. 23.60%), less severe kidney diseases (1.49% vs. 3.82%), and fewer drugs per prescription (6.15 vs. 6.66) (p < 0.01 for all). The DOAC group were also less likely to be taking angiotensin receptor blockers (10.79% vs. 13.97%), furosemide (40.81% vs. 49.66%) or digoxin (10.32% vs. 13.66%) than the VKA group (p = 0.009, p < 0.001, and p = 0.005). DOACs were less prescribed than VKAs. Individuals taking VKAs were older and had more severe comorbidities and more drugs per prescription than those taking DOACs.

Factors Determining the Choice of a Career in Geriatrics among Students in Geriatric in-Hospital Training: A Prospective Study of 74 Medical Students.

To understand why students in the 2nd cycle of medical studies choose to complete a Diploma of Specialized Studies (DSS) in geriatrics, we conducted a study to identify the factors influencing the choice of a future specialty. In addition, we assessed the impact of clinical in-hospital training (CIHT) in a geriatric hospital on the students' selection of their future specialty. We included all students who completed CIHT in the geriatric facility of our University Hospital between 1 May and 31 October 2018. Data were collected using a two-part questionnaire: one part was given before CIHT and the other after. The students were classified into two groups: those considering a career in geriatrics (CIG) before CIHT, forming the group DSS geriatrics+ (GDSSG+), and those not considering it, constituting the group DSS geriatrics- (GDSSG-). Seventy-four students aged 22 years old were included. Of these students, 26% were considering a CIG before CIHT. This rate increased significantly to 42% after CIHT (p = 0.04). However, none of the students who indicated that they were potentially interested in pursuing geriatrics before CIHT preselected geriatrics as their first option. For more than 92% of the students, the comprehensive care of geriatric patients was an asset. The main drawbacks were diagnostic and therapeutic limitations (60% of students), then managing aging, disability, and neurocognitive disorders (55% of students). After CIHT, the view of geriatrics improved by 74%. In conclusion, geriatric CIHT improves students' opinions of geriatrics and increases the number of students considering a CIG. However, geriatrics still suffers from a lack of prestige.

Iron in the General Population and Specificities in Older Adults: Metabolism, Causes and Consequences of Decrease or Overload, and Biological Assessment.

Iron is involved in many types of metabolism, including oxygen transport in hemoglobin. Iron deficiency (ID), ie a decrease in circulating iron, can have severe consequences. We provide an update on iron metabolism and ID, highlighting the particularities in older adults (OAs). There are three iron compartments in the human body: 1) the functional compartment, which consists of heme proteins including hemoglobin, myoglobin and respiratory enzymes; 2) iron reserves (IR), which consist mainly of liver stocks and are stored as ferritin; and 3) transferrin. There are two types of ID. Absolute ID is characterized by a decrease in IR. Its main pathophysiological mechanism is bleeding, which is often digestive and can be due to neoplasia, frequent in OAs. Biological assessment shows low serum ferritin and transferrin saturation (TS) levels. Furthermore, hypochromic microcytic anemia is frequent, and the serum-soluble transferrin receptor (sTfR) level is high. Functional ID, in which IR are high or normal, is due to inflammation, which is also frequent in OAs, particularly in its chronic form. Biological assessments show high serum ferritin, normal or low TS, and normal sTfR levels. Moreover, C-reactive protein is elevated, and there is moderate non-regenerative non-macrocytic anemia. The main characteristics of iron metabolism anomalies in the elderly are the high frequency of ID (20% of ID with anemia in adults ≥85 years) and the severity of its consequences, which include cognitive impairment in case of ID or iron overload and decrease of physical activity in case of ID. In conclusion, causes of ID are frequently intertwined in OAs as a result of the polymorbidity that characterizes them. ID can have dramatic consequences, especially in frail OAs. Thus, measuring the appropriate biological markers prevents errors in the positive diagnosis of ID type, clarifies etiology, and informs treatment-related decision-making.

The Prescription of Vitamin K Antagonists in a Very Old Population: A Cross-Sectional Study of 8696 Ambulatory Subjects Aged Over 85 Years.

We compared very elderly people taking vitamin K antagonists (VKA) and those not taking VKA (noVKA). Individuals were included in the noVKA group if there was no VKA on their reimbursed prescriptions during the study period. We also compared three subgroups, constituted by VKA type (fluindione, warfarin, or acenocoumarol). We included individuals aged over 85 years, affiliated to Mutualité Sociale Agricole of Burgundy, who were refunded for prescribed VKA in September 2017. The VKA and noVKA groups were compared in terms of demographic conditions, registered chronic diseases (RCD), number of drugs per prescription and cardiovascular medications. The three VKA subgroups were compared for the same items plus laboratory monitoring, novel and refill VKA prescriptions, and prescriber specialty. Of the 8696 included individuals, 1157 (13.30%) were prescribed VKA. Mean age was 90 years. The noVKA group had fewer women (53.67 vs 66.08%), more RCD (93.43 vs. 71.96%) and more drugs per prescription (6.65 vs. 5.18) than the VKA group (all p < 0.01). Except for direct oral anticoagulants and platelet aggregation inhibitors, the VKA group took significantly more cardiovascular medications. The most commonly prescribed VKA was fluindione (59.46%). Mean age was higher in the warfarin (90.42) than in the acenocoumarol (89.83) or fluindione (89.71) subgroups (p < 0.01). No differences were observed for sex (women were predominant) or RCD. 13% of subjects in this population had a VKA prescription. Fluindione was the most commonly prescribed VKA.

Changes in Treatment of Very Elderly Patients Six Weeks after Discharge from Geriatrics Department.

We assessed the prescriptions of patients hospitalized in a geriatric unit and subsequently discharged. This prospective and observational study was conducted over a two-month period in the geriatrics department (acute and rehabilitation units) of a university hospital. Patients discharged from this department were included over a two-month period. Prescriptions were analyzed at admission and discharge from the geriatrics department (DGD), and six weeks after DGD. We included 209 patients, 63% female, aged 86.8 years. The mean number of medications prescribed was significantly higher at DGD than at admission (7.8 vs. 7.1, p = 0.003). During hospitalization, 1217 prescriptions were changed (average 5.8 medications/patient): 52.8% were initiations, 39.3% were discontinuations, and 7.9% were dose adjustments. A total of 156 of the 209 patients initially enrolled completed the study. Among these patients, 81 (51.9%) had the same prescriptions six weeks after DGD. In univariate analysis, medications were changed more frequently in patients with cognitive impairment (p = 0.04) and in patients for whom the hospital report did not indicate in-hospital modifications (p = 0.007). Multivariate analysis found that six weeks after DGD, there were significantly more drug changes for patients for whom there were changes in prescription during hospitalization (p < 0.001). A total of 169 medications were changed (mean number of medications changed per patient: 1.1): 52.7% discontinuations, 34.3% initiations, and 13% dosage modifications. The drug regimens were often changed during hospitalization in the geriatrics department, and a majority of these changes were maintained six weeks after DGD. Improvements in patient adherence and hospital-general practitioner communication are necessary to promote continuity of care and to optimize patient supervision after hospital discharge.

Impact of Age, Multimorbidity and Frailty on the Prescription of Preventive Antiplatelet Therapy in Older Population.

Platelet aggregation inhibitors (PAI) have widely proven their efficiency for the prevention of ischemic cardiovascular events. We aimed to describe PAI prescription in an elderly multimorbid population and to determine the factors that influence their prescription, including the impact of age, comorbidities and frailty, evaluated through a comprehensive geriatric assessment. This cross-sectional study included all patients admitted to the acute geriatric department of a university hospital from November 2016 to January 2017. We included 304 consecutive hospitalized patients aged 88.7 ± 5.5 years. One third of the population was treated with PAI. A total of 133 (43.8%) patients had a history of cardiovascular disease, 77 of whom were on PAI. For 16 patients, no indication was identified. The prescription or the absence of PAI were consistent with medical history in 61.8% of patients. In the multivariate analysis, among the 187 patients with an indication for PAI, neither age (odds ratio (OR) = 1.00; 95% confidence interval (CI): [0.91-1.08], per year of age), nor comorbidities (OR = 0.97; 95% CI: [0.75-1.26], per point of Charlson comorbidity index), nor cognitive disorders (OR = 0.98; 95% CI [0.91-1.06] per point of Mini Mental State Examination), nor malnutrition (OR = 1.07; 95% CI [0.96-1.18], per g/L of albumin) were significantly associated with the therapeutic decision. PAI were less prescribed in primary prevention situations, in patients taking anticoagulants and in patients with a history of bleeding. In conclusion, a third of our older comorbid population of inpatients was taking PAI. PAI prescription was consistent with medical history for 61.8% of patients. Age, multimorbidity and frailty do not appear to have a significant influence on therapeutic decision-making. Further research is needed to confirm such a persistence of cardiovascular preventive strategies in frail older patients from other settings and to assess whether these strategies are associated with a clinical benefit in this specific population.

Impact of a Diagnosis-Centered Antibiotic Stewardship on Incident Clostridioides difficile Infections in Older Inpatients: An Observational Study.

In 2015, a major increase in incident hospital-onset Clostridioides difficile infections (HO-CDI) in a geriatric university hospital led to the implementation of a diagnosis-centered antibiotic stewardship program (ASP). We aimed to evaluate the impact of the ASP on antibiotic consumption and on HO-CDI incidence. The intervention was the arrival of a full-time infectiologist in the acute geriatric unit in May 2015, followed by the implementation of new diagnostic procedures for infections associated with an antibiotic withdrawal policy. Between 2015 and 2018, the ASP was associated with a major reduction in diagnoses for inpatients (23% to 13% for pneumonia, 24% to 13% for urinary tract infection), while median hospital stays and mortality rates remained stable. The reduction in diagnosed bacterial infections was associated with a 45% decrease in antibiotic consumption in the acute geriatric unit. HO-CDI incidence also decreased dramatically from 1.4‱ bed-days to 0.8‱ bed-days in the geriatric rehabilitation unit. The ASP focused on reducing the overdiagnosis of bacterial infections in the acute geriatric unit was successfully associated with both a reduction in antibiotic use and a clear reduction in the incidence of HO-CDI in the geriatric rehabilitation unit.

The prescription of direct oral anticoagulants in the elderly: An observational study of 19 798 Ambulatory subjects.

OBJECTIVE: Direct oral anticoagulants (DOACs) are increasingly prescribed to elderly people, but the epidemiologic data for this population remains scarce. We compared the elderly population taking DOACs and those not taking DOACs (noDOAC). METHOD: We included individuals over 75 years old, affiliated to Mutualité Sociale Agricole of Burgundy (a French regional health insurance agency), who had been refunded for a prescribed DOAC between 1st and 30th September 2017. The DAOC group (DAOCG) and noDOAC group (noDOACG) were compared in terms of demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs. In the DOACG, we compared the type of prescribing physician and laboratory monitoring for novel prescriptions (initial) and prescription refills (≥ 3 months). RESULTS: Of the 19 798 included patients, 1518 (7.7%) were prescribed DAOCs and 18 280 (92.3%) were not. Mean and median age was 85 years in the 2 groups (DOACG and noDOACG). In the DOACG, there were more men (50% vs 40.2%), more RCD (88.9% vs 68.7%) and more drugs per prescription (6 ± 2.8 vs 5 ± 2.9) (All P < .01). The DOACG also took more antihypertensive drugs. The most commonly prescribed DOACs were apixaban (42.9%) followed by rivaroxaban (38.4%) and dabigatran (18.6%). Complete blood count, serum creatinine and coagulation function tests were requested for 69.4%, 75% and 22.2%, respectively, of patients prescribed DAOCs. CONCLUSIONS: The DOACG had more RCD and drugs per prescription than the noDOACG; routine laboratory monitoring was insufficient. What's known Platelet aggregation inhibitors (low-dose) are recommended for secondary prevention of cardiovascular events in patients suffering from symptomatic atherosclerosis. The main risk of this treatment is bleeding. What's new A prescription for platelet aggregation inhibitors was found in 34% of geriatric inpatients in this prospective study. Compliance to guidelines was better for symptomatic peripheral artery disease than for primary prevention in accordance with recent publications. Geriatric comorbidities had no impact on the prescription of platelet aggregation inhibitors. Underuse of platelet aggregation inhibitors was observed in 11.3% of cases and overuse in 13.7% of cases.