Targeting the hospitalized elderly for geriatric consultation

This empirical study reports the proportion of hospitalized elderly patients who were identified as frail. As a part of a randomized controlled trial, standardized criteria were developed to target the frail hospitalized elderly for geriatric consultation. Twelve-hundred patients aged 65 years and older admitted to the medical and surgical services at the Palo Alto Veterans Administration Medical Center were screened. Because of administrative exclusions of the randomized controlled trial (eg, short stay, lived too far away), 749 (62%) were excluded from the clinical screening process. The remaining 451 patients received clinical screening. Of these patients, almost two thirds (64%) were considered "too independent" to benefit from geriatric consultation (ie, independent in activities of daily living with short term illness), while 12% were judged "too impaired" to benefit (ie, had severe dementia or terminal cancer). Only 24% of those clinically screened (9% of the entire sample) were considered appropriate for geriatric consultation. Strikingly, over 42% of those patients aged 76 or older, were judged "too independent." These data suggest that a large majority of the hospitalized elderly may be too well to benefit from geriatric consultation, thus making targeting by age alone inefficient. A realistic estimate of the percentage of hospitalized patients appropriate for geriatric intervention lies somewhere between 18% (the combined percentage of those found appropriate and those already enrolled in geriatric programs) and 24% (the proportion of the clinically evaluated group found appropriate). Targeting of subjects may be accomplished inexpensively using the authors' explicit criteria. Such targeting may help focus the use of interdisciplinary geriatric expertise on those most in need.(ABSTRACT TRUNCATED AT 250 WORDS)     

Unrecognized psychiatric illness in elderly medical-surgical patients.

Research diagnostic criteria were used in a structured interview to evaluate the presence of unrecognized psychiatric illness in 50 acute medical and surgical patients over the age of 65 at the La Jolla Veterans Administration Hospital; 24% of the subjects had unrecognized major mental disorders -- predominantly depression or alcoholism. The geriatric patients most likely to have unrecognized illness were older, widowed or divorced, had past jail and/or psychiatric hospital experiences, and gave histories of vascular disorders. The results are consistent with past literature on the elderly.     

The prevalence and risk factors of dementia in the elderly population in a low socio-economic region of Izmir, Turkey

The aim of this study is to determine the prevalence of and risk factors of dementia in the elderly with a low socio-economical status. The study is a cross-sectional and analytic study. Two hundred and four persons aged 65 years and above were selected by using the cluster sampling method. The presence of dementia was determined by Standardized Mini Mental State Examination (SMMSE). Twenty-three and 18 cut-off points were accepted as the existence of dementia in educated and uneducated older individuals, respectively. Chi-square test, Student's t-test, and logistic regression analysis were used for data analysis. The mean age of older subjects was 70.8+/-6.45 (S.D.); 71.5+/-5.9 in males and 70.3+/-6.8 in females (p=0.19). Ninety-one percent of older people had never attended school, 54.6% were living below the poverty level, and 97% of the residences were in squatter settlements. Dementia was determined in 46 older subjects (22.9%). Dementia was found significantly higher in females, in elderly subjects aged 80 years and above, in older subjects who were in a bad or very bad self-health status and in those who had a chronic disease, did not have any occupation, had a lower monthly income, and with a depressive score eight and above (p<0.05). In our study, the prevalence of dementia in older people was higher, in agreement with many reported studies. We assumed that this was due to the fact that the ratio of the uneducated, poor, and advanced aged subjects in this study was considerably higher. The different prevalence rates in studies demonstrate that the adoption of SMMSE for the study population, the validity-reliability analyses of tests and the standardization of diagnostic criteria are necessary.     

Electroconvulsive therapy in octogenarians

Medical records of 81 older patients (65 years of age and over) who underwent electroconvulsive therapy (ECT) at a university-affiliated private geriatric hospital were reviewed to evaluate the safety and efficacy of this treatment for depression in the "young-old" (65 to 80 years) compared with the "old-old" age group (over 80 years), a group that has not yet been adequately studied. Information was obtained regarding demographics, medical and psychiatric diagnosis, medications, indications for ECT, number and laterality of treatments, outcome, and complications. Thirty-nine patients 80+ years of age (mean age, 85 +/- 3.2) were compared with 42 patients 65 to 80 years of age (mean age, 74 +/- 5.2). Statistical analysis was performed using confidence intervals of the difference in proportions of patients in each group. There were no significant differences in the demographics, number and laterality of ECT treatments, indications for ECT treatment, medical diagnosis, medications, or prior history of falls, but psychiatric diagnoses differed slightly. Patients over 80 years had significantly more cardiovascular complications and falls (95% confidence interval) and tended to have a worse ASA (American Society of Anesthesiologists) scale rating and a somewhat less successful outcome. This study confirms the role of ECT as a relatively safe and effective treatment, which may be lifesaving in selected depressed older patients. Prospective studies are needed to understand better the long-term outcome and to prevent the morbidity and mortality associated with ECT in this frail, high-risk older group.     

Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly

PURPOSE: To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients. METHODS: The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse. RESULTS: For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05). CONCLUSION: Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.     

Screening for frailty: criteria and predictors of outcomes

OBJECTIVE: To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients. DESIGN: Prospective cohort study of 985 patients screened at the time of hospital admission and followed for 1 year with respect to the outcomes of mortality, hospital readmission, and nursing home utilization. SETTING: Palo Alto Veterans Affairs Medical Center, a tertiary care teaching hospital. SUBJECTS: Male patients 65 years of age and older admitted to the Medical and Surgical services during the period from October 1, 1985 through September 30, 1986. RESULTS: Patients were grouped by specific screening criteria into three groups of increasing frailty: Independent, Frail, and Severely Impaired. Each criterion focused on a geriatric condition and was designed to serve as a marker for frailty. Increasing frailty was significantly correlated with increasing length of hospital stay (P less than 0.0001), nursing home utilization (P less than 0.0001), and mortality (P less than 0.0001). Multivariate analyses revealed that the clinical groups were more predictive of mortality and nursing home utilization than were age or Diagnosis-Related Groups (DRGs). Rehospitalization was unrelated to age, clinical group, or DRG, suggesting that utilization may not be driven by the clinical factors measured in this study. CONCLUSIONS: Rapid clinical screening using specific geriatric criteria is effective in identifying frail older subjects at risk for mortality and nursing home utilization. Our findings suggest that geriatric syndromes are more predictive of adverse outcomes than diagnosis per se. This well operationalized screening process is inexpensive as well as effective and could easily be introduced into other hospital settings.     

Geriatric medicine in future

Geriatrics in future will be most concerned with persons aged 80 years or more (very elderly) in Japan. Clinical and pathological features of very elderly patients were reported with comparison to the 65-79 age group. Many very elderly do not show clear-cut clinical signs and symptoms, but have serious underlying diseases. We propose here a concept of "clinical threshold". On evaluating the laboratory data, we must consider the grades of "activity of daily living (ADL)" of the aged patients, because ADL may significantly modify the test results. Furthermore in clinical practice, we should pay attention to both the psychosocial states and physical findings of the patients. "The old age syndrome" proposed by Parker is useful in geriatric medicine. Extensive studies on dementia, especially of Alzheimer's type are required urgently. Molecular biology approaches to this disease have shown great advances in geriatrics. To prevent geriatric disease, well-controlled exercise and diet are important as well as reasonable psychosocial integrity.     

Predictors of length of stay between the young and aged in hospitalized community‐acquired pneumonia patients

Aim: To determine the factors that may prolong the length of stay (LOS) for older patients hospitalized for community‐acquired pneumonia (CAP) and also to see if they are applicable to the younger patients. Methods: A retrospective case record review was conducted of all adult patients who were discharged from the general medical service or the geriatric medicine service of an acute care hospital over 6 months. Results: During the study period, 393 patients were discharged with the diagnosis of pneumonia. Based on the study criteria, 200 patients were included in the study. Of the elderly patients, 39% had severe pneumonia compared to 9.3% in the younger group (P < 0.001), resulting in a higher mortality rate. All patients with severe pneumonia had serum albumin levels of less than 3.7 g/dL. The median LOS was significantly shorter in the younger patients (4 days) compared to the elderly patients (9 days, P < 0.001). Severe pneumonia, dysphagia, chronic renal disease, hypoalbuminemia and older age group were found to be significantly associated with longer LOS. Conclusion: Compared to younger patients, older subjects aged 65 years and above hospitalized with CAP were more likely to have severe pneumonia and longer LOS. Presence of severe pneumonia, dysphagia, chronic renal disease, hypoalbuminaemia and age of more than 65 years were significantly associated with longer LOS for all patients. However, in the younger group, only hypoalbuminaemia remained a significant factor. In the elderly patients, severe pneumonia, dysphagia and type of residence were important factors predicting longer LOS.     

The elderly diabetic's eyes

This review article attempts to clarify current and future issues concerning diabetic retinopathy in the elderly. This retinopathy is often part of multiple geriatric ophthalmological diseases (cataract, glaucoma, age-related macular degeneration [ARMD]). Current management is insufficient. A variety of factors come together to aggravate the situation: the increase in the number of elderly diabetic patients and the decrease in the number of ophthalmologists. Through a review of the literature, seriously lacking in prospective studies specific to the geriatric population, we discuss the epidemiology, the screening problems, and the various issues concerning the overall ophthalmologic and diabetologic management inherent to these patients' age and condition. We stress the seriousness of the visual disability of the older subject, but also the overall morbidity and mortality. We observe that recommendations can only be based on expert opinion. Each section includes a warning on the high iatrogenic risk in this area. The caregiver should avoid two pitfalls: a lax attitude related to fear or defeatism and excessive interventionism that may be inappropriate to the patient's condition.     

Tuberculosis annual report 2009 --Series 4. Elderly TB

In 2009 the tuberculosis (TB) incidence rates of the elderly population aged 65-74, 75-84 and 85 or older were 26.5, 63.4 and 98.1 per 100,000 in Japan, respectively. The TB incidence rate of those aged 65-79 showed a substantial decrease compared to 2000, with the rate decrease of those aged 85 or older being less pronounced. The proportion of TB cases aged 65 or older among all TB patients increased 1.6 times to 58.0% in 2009 from 36.8% in 1987; in particular, the proportion of those aged 80 or older increased 3.6 times to 28.8% from 7.9% in 1987. The proportion of elderly TB cases showed substantial differences between prefectures. The proportion of extra-pulmonary TB among elderly female TB patients aged 65-74 was 34.3% (22.4% for female TB patients aged 15-64). The proportion of bacillary TB among elderly pulmonary TB (PTB) patients was larger than that of young patients, but the proportion of cavitary PTB among elderly PTB patients was smaller than that of young PTB patients. The proportion of TB patients whose cases did not include respiratory symptoms increased with age. Among this group, the proportions of those aged 65-74, 75-84 and 85 or older were 15.9%, 21.3% and 22.7%, respectively. The elderly TB "patient's delay" was shorter than young TB "patient's delay", although the "doctor's delay" for elderly TB patients was longer than that for young TB patients. Most TB patients including elderly TB patients were detected upon their visit to a medical institution with some symptoms; in the case of elderly TB, more patients were detected as outpatients or inpatients for diseases other than TB. The prognosis of newly notified TB patients in 2008 was followed up until the end of 2009. Among TB patients aged 65 or older, 27.6% died within one year and 15.5% died within 3 months. The proportion of death showed a substantial increase with age; the increase was particularly accelerated among those aged 75 years or older.     

The burden of chronic obstructive pulmonary disease in the elderly population

BackgroundChronic obstructive pulmonary disease (COPD) is a common disease and an important health care problem in older adults. The impact of age and specific geriatric issues on COPD in elderly patients has not been well established.MethodsA cross-sectional study of elderly COPD patients was conducted in Japan by using a regional COPD registry database. We compared indices of disease severity (pulmonary function, exercise tolerance, quality of life, and frequency of exacerbations), presence of comorbidities, geriatric conditions (cognitive function, mental status, and activities of daily living [ADL]), and adherence to prescribed drug regimens between elderly and younger patients with COPD.ResultsIn total, 279 patients with stable COPD (median age, 74 years) were identified; 86% of these patients were elderly (65 years of age or older). Elderly COPD patients, especially those who were 75 years of age or older, had significantly more cases of dyspnea, lower exercise tolerance, and poorer ADL and a higher incidence of severe exacerbations than younger patients (all P<0.05). In addition, the prevalence of comorbidities, including cardiovascular disease and cancer, was significantly higher in elderly COPD patients. Elderly COPD patients had specific geriatric conditions, including cognitive impairment. Adherence to inhaled drug regimens in elderly patients was as favorable as that in younger patients.ConclusionsAge and specific geriatric conditions have a great negative impact on COPD in elderly patients. Geriatric conditions should be addressed in the management of elderly COPD patients.     

Survey of the age structure of "age-relevant" articles in four general medical journals

The authors analyzed clinical research articles (1980 to 1982) in four general medical journals: New England Journal of Medicine, Annals of Internal Medicine, Journal of the American Medical Association, and British Medical Journal. Of the 1943 articles surveyed, 38.2% were judged to be clinically "relevant" to the elderly. "Relevant" articles were further analyzed to determine whether they contained enough older subjects to enable the reader to draw any inferences about the particular disease or diagnostic or treatment modality studied. Criteria for "age sufficiency" included: mean age of study group (means) greater than or equal to 60 years; if means was less than 60 years, two SD or the range included at least one patient aged 70 years; and greater than or equal to 20% of the study group was older than 60 years. Overall, slightly more than 50% of clinically relevant articles had too few older subjects by the authors' quite liberal age criteria. No statistically significant differences were found among the four journals. Of the age-relevant articles, 25.5% had a mean age of sample studied of greater than or equal to 60 years, 10.9% of greater than or equal to 65 years, 5.6% of greater than or equal to 70 years, and 2.3% of greater than or equal to 75 years. The average age of all subjects studied for three conditions commonly found among the elderly was calculated: coronary artery disease (51.7 years); hypertension (49.8 years); and cancer (52.9 years). The authors concluded that many of the original articles of these four journals did not include (for 1980 to 1982) enough older subjects in their study samples to enable readers to draw any valid inferences about the older population itself.     

The effect of different diagnostic criteria on the prevalence of malnutrition in a hospitalized geriatric population

Malnutrition is considered an important clinical problem in geriatric hospitalized patients, but no standard diagnostic criteria are available. The aim of this study was to investigate the effect of 7 different sets of diagnostic criteria (6 in hospitalized elderly and 1 in healthy elderly) from nutritional research studies on the prevalence of malnutrition in 151 elderly patients (49 men, 102 women, mean age 82.8 years) consecutively admitted to an acute geriatric ward. Nutritional status was assessed using anthropometric (body mass index, triceps skinfold thickness, mid arm circumference, arm muscle circumference), and laboratory (serum albumin) parameters, and 1 nutritional questionnaire (Mini Nutritional Assessment). The proportion of patients with malnutrition varied between 6.5 and 85%. It is important to assess the nutritional status in elderly patients because the prevalence of malnutrition in hospitalized elderly patients is substantial whatever criteria are used. However, the criteria for the diagnosis can differ by a factor of more than 10 in the number of patients classified as malnourished. A major goal for further research on malnutrition is to define more standardized and validated criteria in order to make comparisons of prevalence and outcome more meaningful, and ensure that all those who will benefit from a nutritional intervention are identified and treated.     

Pharmacotherapy of depression in old age

This review addresses the pharmacotherapy of antidepressants in the elderly. We performed a search based on Medline and the Cochrane Library. In addition to a meta-analysis of 17 randomised controlled studies, 36 randomised controlled trials of patients over the age of 60 published between 1980 and 2005 in English met the selection criteria and were included. Existing evidence suggests that no one class of antidepressant drugs has been found to be more effective than another in the treatment of depression in the elderly. Although newer antidepressants are not more effective than older ones, they are better tolerated and are safe especially in overdose. The adverse effect data suggest modest superiority of selective serotonin reuptake inhibitors over tricyclic antidepressants. The evidence available indicates that antidepressant treatment of four weeks has a beneficial effect compared to placebo. As to prevention of relapse and recurrence, antidepressants should be continued for at least six months after good initial response. In patients with high risk of relapse, treatment should be continued for at least two years. Long-term efficacy has been shown for dosulepin, nortriptyline and citalopram. In patients with dementia with persistent and significant symptoms antidepressant treatment may be indicated. At present, clomipramine, citalopram and sertraline have been reported as being superior to placebo. There is a paucity of data on the use of antidepressants in very elderly individuals, patients with significant comorbidity and patients with dementia. More data on the effect of antidepressants in the elderly, especially in the over 80-age group are needed.     

Predictors of self-reported adherence to direct oral anticoagulation in a population of elderly men and women with non-valvular atrial fibrillation

There is a general lack of studies evaluating medication adherence with self-report scales for elderly patients in treatment with direct oral anticoagulants (DOACs). The aim of the study was to assess the degree of adherence to DOAC therapy in a population of elderly outpatients aged 65 years or older affected by non-valvular atrial fibrillation (NVAF), using the 4-item Morisky Medication Adherence Scale, and to identify potential factors, including the geriatric multidimensional evaluation, which can affect adherence in the study population. A total of 103 subjects, anticoagulated with DOACs for NVAF in primary or secondary prevention, were eligible; 76 showed adequate adhesion to anticoagulant therapy, while 27 showed inadequate adherence. Participants underwent biochemical assessment and Morisky Scale, Instrumental Activities of Daily Living, CHA2DS2-VASc, HAS-BLED, mental status and nutritional evaluations were performed. 2% of subjects assumed Dabigatran at low dose, while 7.8% at standard dose, 9.7% assumed low-dose of Rivaroxaban and 30.1% at standard dose, 6.8% assumed Apixaban at low dose and 39.7% at standard dose, and finally 1% assumed Edoxaban at low dose and 2.9% at standard dose. Most subjects took the DOACs without help (80.6%), while 16 subjects were helped by a family member (15.5%) and 4 were assisted by a caregiver (3.9%). Binary logistic regression considered inappropriate adherence as a dependent variable, while age, male sex, polypharmacotherapy, cognitive decay, caregiver help for therapy assumption, duration of DOAC therapy and double daily administration were considered as independent variables. The double daily administration was an independent factor, determining inappropriate adherence with an OR of 2.88 (p?=?0.048, CI 1.003–8.286).