Net clinical benefit of anticoagulation therapy in the elderly patients with atrial fibrillation.

Old age remains one of the strongest risk factors for stroke in patients with atrial fibrillation (AF). Oral anticoagulation (OAC) is the most effective way to prevent thromboembolic disease in patients with atrial fibrillation (AF). Until few years ago, aspirin and vitamin-K antagonists (VKAs) were the primary agents used to prevent thromboembolic disease in patients with AF. The approval of non-vitamin K oral anticoagulants (NOACs) has now expanded the range of therapeutic agents available to providers. The authors highlight practical considerations regarding the selection and use of OAC in older adults to aid clinical decision making.

The Severity of Acute Illness and Functional Trajectories in Hospitalized Older Medical Patients.

BACKGROUND: Acute diseases and hospitalization are associated with functional deterioration in older persons. Although most of the functional decline occurs before hospitalization in response to the acute diseases, the role played by comorbidity in the functional trajectories around hospitalization is unclear. METHODS: Observational prospective study of 696 elderly individuals hospitalized in two Italian general medicine wards. Functional status of the elderly patients at 2 weeks before hospitalization (baseline), at hospital admission, and at discharge was measured by the Barthel Index. Comorbidity was measured at admission by the Geriatric Index of Comorbidity (GIC), a tool mostly based on illness severity. The association of GIC with changes in functional status before hospitalization (between baseline and admission), during hospitalization (between admission and discharge), and in the overall period between baseline and discharge was assessed by logistic regression analyses. Hospitalization-associated disability (HAD) was defined as a functional decline between baseline and discharge. RESULTS: Illness severity (GIC 3-4 vs 1-2: odds ratio [OR] 2.2, 95% CI [confidence interval] 1.5-3.3, p < .0001) and older age significantly predicted prehospital functional decline (between baseline and admission). Illness severity (OR 1.9, 95% CI 1.2-3, p = .004) and older age were also predictive of HAD, even after adjustment for each coded primary discharge diagnosis. After adjustment for the occurrence of prehospital functional decline, however, illness severity and older age were not predictive of HAD anymore. CONCLUSIONS: The severity of illnesses was strongly associated with adverse functional outcomes around hospitalization, but frailty, intended as functional vulnerability to the acute disease before hospitalization, was a stronger predictor of HAD than illness severity and age.

Acute functional decline before hospitalization in older patients.

AIMS: Acute diseases and related hospitalization are crucial events in the disabling process of elderly individuals. Most of the functional decline occurs in the few days before hospitalization, as a result of acute diseases in vulnerable patients. The aim of the present study was to identify determinants of prehospital components of functional decline. METHODS: This was a prospective observational study carried out in three acute geriatric units and two general medicine units of three Italian hospitals. The participants were 1281 patients aged 65 years or older admitted to hospital for acute illnesses and discharged alive. Functional status 2 weeks before hospitalization (preadmission) and at hospital admission was measured by the Barthel Index to identify patients with prehospital decline. In this group of decliners, the percentage extent of prehospital decline (PEPD) was also calculated. RESULTS: Prehospital decline occurred in 541 (42.2%) patients, who were hospitalized mostly in geriatric wards (55.6%). Older age (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.04-1.08) and dementia (OR 2.8, 95% CI 1.4-5.4) were significant predictors of prehospital decline, whereas a high preadmission function was protective (OR 0.992, 95% CI 0.987-0.997). Pulmonary disease as primary discharge diagnosis was also associated with prehospital decline (OR 1.8, 95% CI 1.3-2.5) after adjustment for age, diagnosis of dementia and preadmission function. Amongst decliners, a low preadmission function and the origin of patients (from emergency rooms or other hospital units) were associated with larger PEPD. CONCLUSIONS: Using a clinically meaningful change to define decline, disease-related prehospital disability is observed mainly in persons with low preadmission function, older age and dementia.

Functional recovery of elderly patients hospitalized in geriatric and general medicine units. The PROgetto DImissioni in GEriatria Study.

OBJECTIVES: To investigate the characteristics of patients who regain function during hospitalization and the differences in terms of functional outcomes between patients admitted to geriatric and general medicine units. DESIGN: Multicenter, prospective cohort study. SETTING: Acute care geriatric and medical wards of five Italian hospitals. PARTICIPANTS: One thousand forty-eight elderly patients hospitalized for acute medical diseases. MEASUREMENTS: Functional status 2 weeks before hospital admission (baseline), at admission, and at discharge, as measured using the Barthel Index (BI). RESULTS: Geriatric patients were older (P<.001) and had lower preadmission functional levels (P<.001) than medical patients. Between baseline and discharge, 43.2% of geriatric and 18.9% of medical patients declined in physical function. In the subpopulation of 464 patients who had declined before hospitalization (between baseline and admission), 59% improved during hospitalization (45% of geriatric and 75% of medical patients), whereas only approximately 1% declined further. High baseline function (odds ratio (OR)=1.03, 95% confidence interval (CI)=1.02-1.04, per point of BI) and greater functional decline before hospitalization (OR 0.95, 95% CI 0.94-0.97, per % point of BI decline) were significant predictors of in-hospital functional improvement; type of hospital ward and age were not. CONCLUSION: Although geriatric patients have overall worse functional outcomes, in-hospital functional recovery may be frequent even in geriatric units, particularly in patients with greater preadmission functional loss and high baseline level of function.