Hospital Discharge Decisions Concerning Older Patients: Understanding the Underlying Process

RÉSUMÉL’hospitalisation des personnes âgées s’accompagnent d’un risque de déclin fonctionnel, et d’une grande fréquence de réadmission. Nous avons cherché à comprendre les processus de prise de décisions cliniques qui influencent l’orientation des patients âgés après leur sortie de l’hôpital. Les procédures déterminant l’orientation d’un patient âgé après une hospitalisation en service aigu ne sont pas claires. Nous avons comparé les décisions d’orientation (retour à domicile ou maison de retraite) réalisées par l’équipe avec celles d’un groupe d’experts; les décisions étaient prises de manière indépendante et aveugle. Cent deux (102) patients ont été inclus (âge moyen : 83,13 ± 6,74). Il existe une différence statistiquement significative entre les décisions des experts et de l’équipe (p <.001 ; coefficient kappa : 0,468). Les décisions du panel étaient plus étroitement associées à l’isolement (p = 0,018), aux aidants fiables (p = 0,004), aux problèmes sociaux (p = 0,001), et à la présence de comportements perçus comme agressifs (p = 0,001). Les deux processus de décision ont pris en compte le refus de soins (p = 0,025 et 0,016 respectivement) et les problèmes sociaux (p = 0,001 et < 0,001 respectivement). Les modalités de sortie des hôpitaux diffèrent selon les pays, les équipes et le type de patients, mais notre étude suggère la nécessité d’une évaluation plus précise des besoins du patient.

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Clinical Course, Serologic Response, and Long-Term Outcome in Elderly Patients with Early Lyme Borreliosis

Journal of Clinical Medicine ◽

10.3390/jcm7120506 ◽

2018 ◽

Vol 7 (12) ◽

pp. 506 ◽

Cited By ~ 6

Author(s):

Katarina Boršič ◽

Rok Blagus ◽

Tjaša Cerar ◽

Franc Strle ◽

Daša Stupica

Keyword(s):

Lyme Borreliosis ◽

Older Patients ◽

Erythema Migrans ◽

Middle Aged ◽

Patient Age ◽

Term Outcome ◽

Long Term Outcome ◽

Incomplete Response ◽

Patient Âgé

Infected elderly people often present with signs and symptoms that differ from those in younger adults, but data on the association between patient age and presentation of early Lyme borreliosis (LB) are limited. In this study, the association between patient age (18–44 years, young vs. 45–64 years, middle-aged vs. ≥ 65 years, elderly) and disease course, microbiologic characteristics, and the long-term outcome of treatment was investigated prospectively in 1220 adult patients with early LB manifesting as erythema migrans (EM) at a single-center university hospital. Patients were assessed at enrolment and followed-up for 12 months. Age was associated with comorbidities, previous LB, presenting with multiple EM, and seropositivity to borreliae at enrolment. The time to resolution of EM after starting antibiotic treatment was longer in older patients. At 12 months, 59/989 (6.0%) patients showed incomplete response. The odds for incomplete response decreased with time from enrolment (odds ratio (OR) of 0.49, 0.50, and 0.48 for 2-month vs. 14-days, 6-month vs. 2-month, and 12-month vs. 6-month follow-up visits, respectively), but were higher with advancing age (OR 1.57 for middle-aged vs. young, and 1.95 for elderly vs. young), in women (OR 1.41, 95% confidence interval (CI) 1.01–1.96), in patients who reported LB-associated constitutional symptoms at enrolment (OR 7.69, 95% CI 5.39–10.97), and in those who presented with disseminated disease (OR 1.65, 95% CI 1.09–2.51). The long-term outcome of EM was excellent in patients of all age groups. However, older patients had slower resolution of EM and higher odds for an unfavorable outcome of treatment (OR 1.57, 95% CI 1.05–2.34 for middle-aged vs. young; and OR 1.95, 95% CI 1.14–3.32 for elderly vs. young), manifested predominantly as post-LB symptoms. The presence of LB-associated constitutional symptoms at enrolment was the strongest predictor of incomplete response.

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Anti-tumor necrosis factor therapy in patients with inflammatory bowel disease; comorbidity, not patient age, is a predictor of severe adverse events

International Journal of Colorectal Disease ◽

10.1007/s00384-020-03716-6 ◽

2020 ◽

Vol 35 (12) ◽

pp. 2331-2338

Author(s):

Vera E. R. Asscher ◽

◽

Quirine van der Vliet ◽

Karen van der Aalst ◽

Anniek van der Aalst ◽

...

Keyword(s):

Tumor Necrosis Factor ◽

Adverse Events ◽

Older Patients ◽

Tumor Necrosis ◽

Patient Age ◽

Younger Patients ◽

Patient Âgé ◽

Serious Infections ◽

Severe Adverse Events ◽

Necrosis Factor

Abstract Purpose To assess safety and effectiveness of anti-tumor necrosis factor (anti-TNF) therapy in IBD patients ≥ 60 years. Methods Ninety IBD patients ≥ 60 years at initiation of anti-TNF therapy, 145 IBD patients ≥ 60 years without anti-TNF therapy and 257 IBD patients < 60 years at initiation of anti-TNF therapy were retrospectively included in this multicentre study. Primary outcome was the occurrence of severe adverse events (SAEs), serious infections and malignancies. Secondary outcome was effectiveness of therapy. Cox regression analyses were used to assess differences in safety and effectiveness. In safety analyses, first older patients with and without anti-TNF therapy and then older and younger patients with anti-TNF therapy were assessed. Results In older IBD patients, the use of anti-TNF therapy was associated with serious infections (aHR 3.920, 95% CI 1.185–12.973, p = .025). In anti-TNF-exposed patients, cardiovascular disease associated with serious infections (aHR 3.279, 95% CI 1.098–9.790, p = .033) and the presence of multiple comorbidities (aHR 9.138 (1.248–66.935), p = .029) with malignancies, while patient age did not associate with safety outcomes. Effectiveness of therapy was not affected by age or comorbidity. Conclusion Older patients receiving anti-TNF therapy have a higher risk of serious infections compared with older IBD patients without anti-TNF therapy, but not compared with younger patients receiving anti-TNF therapy. However, in anti-TNF-exposed patients, comorbidity was found to be an indicator with regards to SAEs. Effectiveness was comparable between older and younger patients.

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Catastrophic Gastrointestinal Bleeding: Always Consider Meckel’s Diverticulum

European Journal of Case Reports in Internal Medicine ◽

10.12890/2019_001224 ◽

2019 ◽

Author(s):

Filipa Pedro ◽

Joana Romano ◽

Marta Rebelo ◽

Rogério Matias ◽

Eduarda Carmo

Keyword(s):

Gastrointestinal Tract ◽

Gastrointestinal Bleeding ◽

Congenital Malformation ◽

Older Patients ◽

Meckel’S Diverticulum ◽

Meckel's Diverticulum ◽

Patient Age ◽

Patient Âgé

Meckel’s diverticulum, a congenital malformation of the gastrointestinal tract, is asymptomatic in the majority of patients but can be associated with some complications. Gastrointestinal bleeding is one such complication and is more common in children than in adults. Despite the variety of examinations available, diagnosis can be difficult, especially in older patients, because the sensitivity of examinations decreases with patient age. Here we present the case of a young man with gastrointestinal bleeding in whom a diagnosis of Meckel’s diverticulum was made intra-operatively.

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A Comparison of Patient and Surgeon Expectations of Spine Surgical Outcomes

Global Spine Journal ◽

10.1177/2192568220907603 ◽

2020 ◽

pp. 219256822090760

Author(s):

Ahmed Aoude ◽

Madison Litowski ◽

Sultan Aldebeyan ◽

Charles Fisher ◽

Hamilton Hall ◽

...

Keyword(s):

Older Patients ◽

Patient Expectations ◽

Research Network ◽

Pain Patient ◽

Limited Data ◽

Patient Age ◽

Patient Âgé ◽

Clinical Scenarios ◽

Age Appropriate ◽

Expected Outcomes

Study Design: Ambispective cohort study. Objective: Limited data exists comparing surgeon and patient expectations of outcome following spine surgery. The objective of this study was to elicit whether any differences exist between patient and surgeon expectations for common spine surgeries. Methods: Ten common age-appropriate clinical scenarios were generated and sent to Canadian spine surgeons to determine surgeon expectations for standard spine surgeries. Patients in the Canadian Spine Outcomes and Research Network (CSORN) registry matching the clinical scenarios were identified. Aggregated patient expectations were compared with surgeon responses for each scenario. A χ2 analysis was then completed to determine discrepancies between surgeon and patient expectations for each scenario. Results: A total of 51 Canadian spine surgeons completed the survey on surgical expectations. A total of 919 patients from multiple centers were identified within the CSORN database that matched the clinical scenarios. Our results demonstrated that patients tend to be more optimistic about the expected outcomes of surgery compared with the treating surgeon. The majority of patients in all clinical scenarios anticipated improvement in back or neck pain after surgery, which differed from surgeon expectations. Results also highlighted the effect of patient age on both patient and surgeon expectations. Discrepancies between patient and surgeon expectations were higher for older patients. Conclusion: We present data on patient and surgeon expectations for spine surgeries and show that differences exist particularly concerning the improvement of neck or back pain. Patient age plays a role in the agreement between the treating physicians and patients in regard to surgical expectations. The reasons for the discrepancies remain unclear.

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Incidence of Coexisting Talar and Tibial Osteochondral Lesions Correlates With Patient Age and Lesion Location

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118790965 ◽

2018 ◽

Vol 6 (8) ◽

pp. 232596711879096 ◽

Cited By ~ 3

Author(s):

Rebecca M. Irwin ◽

Yoshiharu Shimozono ◽

Youichi Yasui ◽

Robin Megill ◽

Timothy W. Deyer ◽

...

Keyword(s):

Older Patients ◽

Distal Tibia ◽

Case Series ◽

Lesion Size ◽

Magnetic Resonance Images ◽

Osteochondral Lesions ◽

Level Of Evidence ◽

Patient Age ◽

Morphologic Characteristics ◽

Patient Âgé

Background: The incidence of coexisting osteochondral lesions (OCLs) of the tibia and talus has been negatively correlated with successful clinical outcomes, yet these lesions have not been extensively characterized. Purpose: To determine the incidence of coexisting tibial and talar OCLs, assess the morphologic characteristics of these lesions, and evaluate whether these characteristics are predictive of outcome. Study Design: Case series; Level of evidence, 4. Methods: A total of 83 patients who underwent surgery for a talar OCL were evaluated for coexisting OCLs of the distal tibia with preoperative magnetic resonance images. Size, location, containment, International Cartilage Repair Society (ICRS) grade, patient age, and patient sex were analyzed for predictors of coexisting lesions or patient outcome. The talar and tibial surfaces were each divided into 9 zones, with 1 corresponding to the most anteromedial region and proceeding laterally and then posteriorly. The Foot and Ankle Outcome Score (FAOS) was evaluated pre- and postoperatively. Results: Twenty-six patients (31%) had coexisting tibial and talar OCLs, with 9 (35%) identified as kissing lesions. Age correlated with coexisting lesion incidence, as older patients were more likely to have a coexisting tibial OCL ( P = .038). More than half of talar OCLs were found in zone 4 (61%), whereas the majority of tibial OCLs were located in zones 2, 4, and 5 (19% each). Patients with coexisting lesions were more likely to have a lateral talar OCL ( P = .028), while those without a coexisting tibial lesion were more likely to have a talar OCL in zone 4 ( P = .016). There was no difference in FAOS result or lesion size between patients with and without coexisting OCLs, but patients with coexisting lesions were more likely to have an ICRS grade 4 talar OCL ( P = .034). For patients with coexisting lesions, kissing lesions were more likely to be located in zone 6 ( P = .043). There was no difference in OCL size or containment between kissing and nonkissing coexisting OCLs. Conclusion: The incidence of coexisting talar and tibial OCLs may be more prevalent than what previous reports have suggested, with older patients being more likely to present with this pathology. The location of a talar OCL correlates with the incidence of a coexisting tibial OCL.

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The Portrayal of the Elderly in Drug Advertisements: A Factor in Inappropriate Prescribing?

Canadian Journal on Aging / La Revue canadienne du vieillissement ◽

10.1017/s0714980800010722 ◽

1990 ◽

Vol 9 (3) ◽

pp. 296-303 ◽

Cited By ~ 5

Author(s):

Joel Lexchin

Keyword(s):

Inappropriate Prescribing ◽

The Elderly ◽

Personnes Âgées ◽

Patient Age ◽

Patient Âgé ◽

Pour Cent

RÉSUMÉLe problème concernant les ordonnances contre-indiquées continue de prendre de l'ampleur et devient un des facteurs contribuant aux réactions néfastes que subissent les personnes âgées. De toute évidence, le médecin qui s'appuie sur les documents promotionnels pour rédiger une ordonnance sera porté à commettre plus d'erreurs. La présente étude se concentre sur deux revues médicales canadiennes importantes et elle examine les réclames publicitaires qui s'adressent aux personnes semblant avoir dépassé les 65 ans. Les gens âgés étaient représentés dans seulement 7 pour cent des annonces. Celles-ci ne semblaient pas tenir compte des besoins particuliers aux personnes âgées en ce qui a trait aux médicaments. Les textes et les illustrations contenus à l'intérieur de ces annonces pourraient être une des causes à l'origine des ordonnances contre-indiquées. Des études de recherche plus approfondies devraient être mises au point dans le but d'examiner plus attentivementles facteurs qui influencent le médecin lorsqu'il décide de rédiger une ordonnance pour un patient âgé. Entretemps, par égard à ce segment de leur pratique, les médecins devraient analyser prudemment les messages publicitaires et demeurer conscients des risques encourus lorsqu'ils s'en servent à titre d'information thérapeutique.

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Médicament et vieillesse

Anthropologie et Sociétés ◽

10.7202/007449ar ◽

2004 ◽

Vol 27 (2) ◽

pp. 119-138 ◽

Cited By ~ 8

Author(s):

Johanne Collin

Keyword(s):

Personnes Âgées ◽

Patient Age ◽

Patient Âgé ◽

Relation Thérapeutique ◽

Medicaments Psychotropes

Résumé Cet article emprunte une approche socioculturelle de la problématique de la vieillesse par rapport au médicament. Il appréhende avec un regard critique le phénomène « médicament » à travers trois énoncés de relations : le « médicament-obligation » comme qualificatif de la relation des personnes âgées au médicament ; le « médicament-concession » en tant que trame de fond de la relation thérapeutique entre médecin et patient âgé ; le « médicament-compassion », enfin, comme métaphore du rôle des médicaments psychotropes en lien avec le statut de la vieillesse dans nos sociétés occidentales avancées.

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Treating Older Patients: Who Treats and Why?

Canadian Journal on Aging / La Revue canadienne du vieillissement ◽

10.1017/s0714980800005316 ◽

1991 ◽

Vol 10 (3) ◽

pp. 232-253

Author(s):

Judith Globerman

Keyword(s):

Older Patients ◽

Personnes Âgées ◽

Chirurgie Orthopédique ◽

Patients Âgés

RÉSUMÉA la lumière de la proportion croissante de personnes âgées recourant aux services de médecins, cette recherche tente de déterminer dans quelle mesure les médecins qui traitent les personnes âgées sont différents de leurs collègues qui ne le font pas. Des études précédentes ont porté sur certaines facettes de cette problématique, notamment en ce qui concerne les caractéristiques des médecins, leurs comportements dans la pratique, leurs attitudes et leurs convictions générales. Cette étude examine à nouveau et de façon systématique ces différentes catégories, à partir d'un groupe de médecins, en utilisant une procédure de régression multiple. Les résultats laissent entendre que les médecins qui suivent des patients âgés dans les domaines de la chirurgie orthopédique, de la chirurgie générale et de l'ophthalmologie, ne sont pas vraiment différents de leurs collègues qui traitent des patients plusjeunes. On explore également dans cette étude d'autres explications concernant le choix des patients âgés. On se demande aussi quelles seraient les implications pour les patients âgés de choisir un médecin doté d'une expertise dans les soins gériatriques.

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Age-Related Risk of Non-Relapse Mortality Associated with Acute Graft-Versus-Host Disease.

Blood ◽

10.1182/blood.v108.11.40.40 ◽

2006 ◽

Vol 108 (11) ◽

pp. 40-40 ◽

Cited By ~ 2

Author(s):

Takahiro Fukuda ◽

Yukiko Iisaka ◽

Fusako Ohara ◽

Atsushi Fujieda ◽

Satoshi Yamasaki ◽

...

Keyword(s):

Older Patients ◽

Conditioning Regimen ◽

Significant Risk ◽

Older Patient ◽

Patient Age ◽

Hematopoietic Stem ◽

Patient Âgé ◽

Increased Risk ◽

Grade Ii ◽

Reduced Intensity

Abstract Background: Although acute GVHD (aGVHD) is a significant cause of non-relapse mortality (NRM) after allogeneic hematopoietic stem cell transplantation (HSCT), its impact on outcomes has not been fully evaluated in older patients who receive reduced-intensity HSCT (RIST). Patients and Methods: We retrospectively surveyed the data of 334 patients (median age, 46 years: range, 1–68) with hematological malignancies who underwent allogeneic HSCT between January, 2000, and June, 2005. The diagnoses included AML/MDS (n=164), CML (n=31), ALL (n=39), lymphoma (n=95), and other malignancies (n=5). Sixty-nine patients (21%) had low- and 265 (79%) had high-risk disease. Patients were conditioned with a fludarabine-based reduced-intensity (n=169) or conventional myeloablative regimen (n=165). Patients received bone marrow (n=131), G-CSF-mobilized PBSC (n=173) or cord blood (n=30) from either an HLA-matched relative (n=138), a mismatched relative (n=41) or an unrelated volunteer (n=155). The median follow-up of surviving patients was 1,210 days (range, 346–2,317). Results: Grade II-IV aGVHD occurred in 146 patients (44%; grade II, n=82; grade III, n=43; grade IV, n=21), 73 patients each in the myeloablative and RIST groups, and the timing was before disease progression or relapse in 144 patients. The incidence of NRM in these 144 patients with aGVHD was 41% (59/144), while this was 29% in the overall 334 patients. The causes of NRM included GVHD (n=22), infections with (n=19) or without (n=9) GVHD, and others (n=9). Hence, aGVHD was the primary cause of NRM. Among these 144 patients with grade II-IV aGVHD, 121 (84%) received ≥1 mg/kg/day of methylprednisone as a primary treatment for GVHD, and 19 of the 121 patients (16%) required additional treatment including switching to tacrolimus (n=11), MMF (n=9), or ATG (n=4). Subsequently, 93 patients (65%) developed chronic extensive GVHD (46 progressive and 47 quiescent). The 2-year probability of NRM after the development of aGVHD was higher as the patient age increased; i.e. 29% for <40 years, 41% for 40–49 years, 55% for 50–59 years, and 67% for ≥60 years (Figure). The 2-year NRM in patients who developed stage 2–4 gut and liver GVHD was significantly higher than that in those who did not (59% vs 30%, and 73% vs 29%, respectively). In a multivariate analysis, the maximum grade of aGVHD (HR 3.4 [95% CI, 2.3–5.1], p<0.0001), transplant from a donor other than an HLA-matched relative (HR 1.9 [95% CI, 1.1–3.4], p=0.03) and older patient age (HR 1.9 [95% CI, 1.4–2.5], p<0.0001) were associated with an increased risk for NRM after the development of aGVHD. In this analysis, disease risk and the intensity of conditioning regimens, i.e. myeloablative or reduced-intensity, were not significant risk factors for NRM. Conclusions: Our data suggest that older patient age is a significant risk factor for NRM after the development of aGVHD, regardless of the type of conditioning regimen. The development of a careful management of aGVHD, focusing on older patients should be the subject of intense clinical research. Figure Figure

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Increasing Age Is Not Independently Associated with Increased 30-Day Morbidity after Hip Arthroscopy

The Journal of Hip Surgery ◽

10.1055/s-0038-1673374 ◽

2018 ◽

Vol 02 (03) ◽

pp. 148-154

Author(s):

Venkat Boddapati ◽

Jamie Confino ◽

Michael Fu ◽

Kyle Duchman ◽

Robert Westermann ◽

...

Keyword(s):

Multivariate Analysis ◽

Postoperative Complications ◽

Hip Arthroscopy ◽

Older Patients ◽

Patient Characteristics ◽

Adverse Outcomes ◽

Improvement Program ◽

Patient Age ◽

Age Cohorts ◽

Patient Âgé

AbstractThe purpose of this study is to examine the 30-day postoperative complications after hip arthroscopy as a function of patient age. The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2016 was used to identify all patients undergoing hip arthroscopy using Current Procedural Terminology and International Classification of Disease codes. Patient characteristics and postoperative complications were compared in a retrospective cohort study with a level of evidence 3 across patient age cohorts using bivariate and multivariate analysis that corrected for differences in baseline patient characteristics. In total, 2,427 patients undergoing hip arthroscopy were identified. Of all identified patients, 667 (27.5%) were under 30 years of age, 596 (24.5%) were between 31 and 40, 599 (24.6%) were between 41 and 50, and 566 (23.3%) were older than 50. Chondroplasty, abrasion arthroplasty, and/or resection of the labrum were the most commonly performed procedures in all age groups. As age increased, patients were more likely to be female and have a higher body mass index, more medical comorbidities, a shorter operative duration, and a higher American Society of Anesthesiologists class. The rate of any 30-day postoperative complication was 1.35% in patients under 30 years of age, 1.68% in patients between 31 and 40, 2.67% in patients between 41 and 50, and 5.12% in patients older than 50 (p < 0.001). Older patients also had a higher rate of deep surgical site infections and blood transfusions (p ≤ 0.001). However, no differences were identified with multivariate analysis. While older patients had higher short-term complications following hip arthroscopy, age alone was not an independent predictor of adverse outcomes. Further investigation is necessary to determine the risk factors associated with significant postoperative morbidity in older patients undergoing hip arthroscopy.

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