Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial

OBJECTIVES: To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution. DESIGN: Randomized, controlled intervention trial. SETTING: Orthopedic ward in a university hospital. PARTICIPANTS: Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery. INTERVENTION: Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture. MEASUREMENTS: Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months. RESULTS: Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7-68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months. CONCLUSION: Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery.     

Postacute care for older people in community hospitals: a multicenter randomized, controlled trial

OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care.
DESIGN: Randomized, controlled trial.
SETTING: Seven community hospitals and five general hospitals in the midlands and north of England.
PARTICIPANTS: Four hundred ninety patients needing rehabilitation after hospital admission with an acute illness.
INTERVENTION: Multidisciplinary team care for older people in community hospitals.
MEASUREMENTS: The primary outcome was the Nottingham extended activities of daily living scale (NEADL); secondary outcomes were the Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, mortality, discharge destination, 6-month residence status, and satisfaction with services.
RESULTS: Loss of independence at 6 months was significantly less likely in the community hospital group (mean adjusted NEADL change score group difference 3.27; 95% confidence interval 0.26–6.28; P =.03). The results for the secondary outcome measures were similar for the two groups.
CONCLUSION: Postacute community hospital rehabilitation care for older people is associated with greater independence.     

Factors associated with polypharmacy in elderly home‐care patients

Aim

Polypharmacy, which is often observed in elderly patients, has been associated with several unfavorable outcomes, including an increased risk of potentially inappropriate medications, medication non‐adherence, drug duplication, drug–drug interactions, higher healthcare costs and adverse drug reactions. A significant association between polypharmacy and adverse outcomes among older people living in the community has also been confirmed. A reduction in the number of medications should thus be pursued for many older individuals. Nevertheless, the factors associated with polypharmacy in elderly home‐care patients have not been reported. Here, we investigated those factors in elderly home‐care patients in Japan.

Methods

We used the data of the participants in the Observational Study of Nagoya Elderly with Home Medical investigation. Polypharmacy was defined as the current use of six or more different medications. We carried out univariate and multivariate logistic regression analyses to assess the associations between polypharmacy and each of several factors.

Results

A total of 153 home‐care patients were registered. The mean number of medications used per patient was 5.9, and 51.5% of the patients belonged to the polypharmacy group. The multivariate model showed that the patients’ scores on the Charlson Comorbidity Index and the Mini‐Nutrition Assessment Short Form were inversely associated with polypharmacy, and potentially inappropriate medication was most strongly associated with polypharmacy (odds ratio 4.992).

Conclusions

The present findings showed that polypharmacy was quite common among the elderly home‐care patients, and they suggest that home‐care physicians should prescribe fewer medications in accord with the deterioration of home‐care patients’ general condition. Geriatr Gerontol Int 2018; 18: 33–41 .     

Prevalence of sarcopenia and associated factors in hospitalised older patients: A cross‐sectional study

Objective

To estimate the prevalence and factors associated with sarcopenia in a sample of older inpatients.

Methods

A cross‐sectional study was conducted in three acute geriatric wards in 2012. Sarcopenia was defined according to the criteria of the Asian Working Group for Sarcopenia.

Results

We included 407 patients aged 81.0 ± 8.0 years. The prevalence of sarcopenia was 31% in the whole study population. Multiple logistic regression showed that being a female (odds ratio (OR) 4.75, 95% confidence interval (CI) 2.45–9.20), smoking (OR 2.94, 95% CI 1.26–6.69), cognitive impairment (OR 2.08, 95% CI 1.10–3.95), polypharmacy (OR 2.36, 95% CI 1.28–4.34) and body mass index (OR 0.75, 95% CI 0.68–0.83) were independently associated with sarcopenia.

Conclusion

Sarcopenia was highly prevalent in older inpatients. In addition to factors previously reported to be associated with sarcopenia, we found that polypharmacy was associated with sarcopenia. As the direction of causality remains uncertain, these relationships deserve further study.     

Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharmacy and treatment dilemmas.

BACKGROUND: Heart failure (HF) is difficult to diagnose and treat in older patients. Symptoms may be non-specific and the presence of co-morbidities and polypharmacy complicate treatment strategies. There are, however, few data to quantify the extent of these problems in the very elderly. METHODS: A retrospective study of 116 patients (median age 86; range 65-98) with an established diagnosis of HF during their hospital admission. MAIN OUTCOME MEASURES: the accuracy of diagnosis of heart failure according to the European Society of Cardiology (ESC) definition. The aetiology and frequency of associated co-morbidities and the nature of drug treatment. RESULTS: The specificities of clinical signs, chest X-rays and abnormal ECGs for heart failure (ESC definition) were 50%, 20% and 9%, respectively. Only 28% of patients were admitted for worsening symptoms which could be attributed to HF. None of the patients had HF as their only medical problem. Co-morbidities included chest disease (30%), incontinence (29%), cerebrovascular disease (26%), musculoskeletal problems (41%). Barthel (activities of daily living) score was < or = 16/20 in 35%. Mental state questionnaire (MSQ) score was < or =7/10 in 38%. Ninety percent were taking four or more different medications. Thirty-nine percent were on psychotropic drugs. On discharge, a total of 88% of patients returned home to live independently and 35% were monitored by regular day hospital attendance. CONCLUSION: Heart failure in frail elderly patients is often compounded by other major illnesses and polypharmacy which have a profound impact on their functional status. This has implications for the most effective targeting of evidence based treatment.     

PHARMacy‐based interdisciplinary program for patients with Chronic Heart Failure (PHARM‐CHF): rationale and design of a randomized controlled trial,and results of the pilot study

We report the rationale and design of a community PHARMacy‐based prospective randomized controlled interdisciplinary study for ambulatory patients with Chronic Heart Failure (PHARM‐CHF) and results of its pilot study. The pilot study randomized 50 patients to a pharmacy‐based intervention or usual care for 12 months. It demonstrated the feasibility of the design and showed reduced systolic blood pressure in the intervention group as indicator for improved medication adherence. The main study will randomize patients ≥60 years on stable pharmacotherapy including at least one diuretic and a history of heart failure hospitalization within 12 months. The intervention group will receive a medication review at baseline followed by regular dose dispensing of the medication, counselling regarding medication use and symptoms of heart failure. The control patients are unknown to the pharmacy and receive usual care. The primary efficacy endpoint is medication adherence, pre‐specified as a significant difference of the proportion of days covered between the intervention and control group within 365 days following randomization using pharmacy claims data for three CHF medications (angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, beta‐blockers, and mineralocorticoid receptor antagonists). The primary composite safety endpoint is days lost due to blindly adjudicated unplanned cardiovascular hospitalizations or death. Overall, 248 patients shall be randomized. The minimum follow‐up is 12 months with an expected mean of 24 months. Based on the feasibility demonstrated in the pilot study, the randomized PHARM‐CHF trial will test whether an interdisciplinary pharmacy‐based intervention can safely improve medication adherence and will estimate the potential impact on clinical endpoints. ClinicalTrials.gov Identifier: NCT01692119.