The hospital-based, post-acute geriatric evaluation and management unit: the experience of the acute geriatric unit in Trieste.

In 2005, the Azienda Ospedaliero-Universitaria of Trieste (AOUT) activated the hospital-based post-acute geriatric evaluation and management unit (PAGEMU). The purpose of the study is to illustrate the activities of the PAGEMU, and to evaluate the effects of personalized and multidisciplinary care on geriatric inpatients. The evaluation for admission in PAGEMU included general admitting criteria, co-morbidity, autonomy, and assessment of the patient's pre-morbid functional status. During the stay, inpatients completed their treatment plan, comprehensive geriatric assessment was carried out, and rehabilitation and nutritional interventions were implemented. If necessary, a new diagnostic-therapeutic plan was provided. A number of 826 patients were evaluated for admission in PAGEMU (612 patients from surgical departments and 214 from medical wards). The mean length of stay was 19.55 days. Re-evaluation of patients at discharge showed a statistically significant improvement in co-morbidity and in self-sufficiency, not in cognitive or mood status. PAGEMU is a valid model both for patient-oriented and for management-oriented objectives, shortening the length of stay in acute care settings and increasing hospital turnover.

[Frail elderly in hemodialysis]. / L'anziano fragile in dialisi.

A new category of patients aged >75 yrs, namely the elderly, is now being freely admitted to hemodialysis (HD) and this category is becoming predominant. The absence of systematic studies makes this patient category almost indistinguishable from other categories, even though its peculiarity is now evident. At least 30-40% of individuals in this age bracket are expected to be dependent and/or frail, but the incidence of frailty is likely to be higher in the elderly undergoing HD. Due to severe physical and/or mental impairment and often because of strong social hardships, these patients rarely experience clinical stability and are dependent on third parties for their survival. Their care produces complex problems for welfare services and this has proved responsible for modifying the organization of renal care units. These repeated patient admissions to hospital are filling nephrology facilities, and the dialysis management -- mainly concerning outpatients -- requires a much greater use of facilities and staff than normal if compared to average dialysis patients. In 112 elderly patients consecutively admitted to the dialysis program over a period of 10 yrs, we identified 35 dependent or frail patients (31.2%), even taking into consideration only extreme degrees of infirmity. Dependence proved to be the only clinical parameter associated with survival (mortality at 6 months 23.6 vs. 10.6%, p<0.01; Kaplan-Meier survival curves, p<0.03 log-rank test), while comorbidities -- in particular cardiovascular -- that usually affect dialysis mortality rates, did not seem to be discriminating risk factors in the elderly. More precisely, with the confirmation of these data through wider case studies, the idea will be reinforced that, also in dialysis, the elderly must be constantly monitored for dependence and frailty, as is the case in any exclusively geriatric field. Prevention, as well as a therapeutic approach specifically modeled on these conditions, could help to improve the prognosis of this patient category, which is particularly difficult to deal with and is becoming predominant in dialysis units.