250 Delirium, Common but Forgotten

Abstract Background Delirium is a medical emergency prevalent amongst hospitalised older patients and associated with prolonged hospital stay, functional and cognitive decline, institutionalisation and increased mortality. In Irish hospitals, multiple strategies, e-learning courses, delirium guidelines and prevention programs have aimed to improve delirium care with better diagnosis and prevention. With the increasing awareness campaigns, we aimed to review the prevalence, screening and management of delirium in our cohort of older patients. Methods A review of medical notes of all patients admitted under medical teams to an acute geriatric ward was carried out. Data was collected over a 3 week period in an Irish model 3 hospital. The following information was obtained from medical records: 1) Previous diagnosis of delirium/dementia 2) Documentation of a diagnosis of delirium 3) Features of delirium 4) Development of delirium as an inpatient 5) Formal screening for delirium 6) Cause and management of delirium 7) Length of stay. Results Of 79 consecutive admissions to an acute geriatric ward (mean age 81.4, 57% female, 30% previous history of delirium or dementia), 25% (n=20) had a diagnosis of delirium documented. 22% (n=18) of patients had confusion and features of delirium highlighted but no formal diagnosis of delirium made during their inpatient stay. A further 20% (n=16) developed delirium on admission. Only 2.5% (n=2) of admissions had formal screening for delirium with the 4AT. 27.5% (n=11) of patients with delirium had a cause and management plan recorded. 70% (n=28) of patients with delirium had a length of stay of over 15 days. Conclusion This review showed delirium recognition, screening, prevention and management were overlooked to an alarming extent in our cohort of older patients. The next step is introduction of the 4AT screening tool and regular education sessions to increase the awareness of delirium amongst medical teams looking after older patients and improve care and outcomes.

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Can usual gait speed be used as a prognostic factor for early palliative care identification in hospitalized older patients? A prospective study on two different wards

BMC Geriatrics ◽

10.1186/s12877-020-01898-w ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Celine Van de Vyver ◽

Anja Velghe ◽

Hilde Baeyens ◽

Jean-Pierre Baeyens ◽

Julien Dekoninck ◽

...

Keyword(s):

Palliative Care ◽

Prognostic Factor ◽

Prospective Study ◽

Gait Speed ◽

Older Patients ◽

Geriatric Ward ◽

Patients At Risk ◽

Acute Geriatric Ward ◽

One Year ◽

Usual Gait Speed

Abstract Background Timely palliative care in frail older persons remains challenging. Scales to identify older patients at risk of functional decline already exist. However, factors to predict short term mortality in older hospitalized patients are scarce. Methods In this prospective study, we recruited patients of 75 years and older at the department of cardiology and geriatrics. The usual gait speed measurement closest to discharge was chosen. We used the risk of dying within 1 year as parameter for starting palliative care. ROC curves were used to determine the best cut-off value of usual gait speed to predict one-year mortality. Time to event analyses were assessed by COX regression. Results On the acute geriatric ward (n = 60), patients were older and more frail (assessed by Katz and iADL) in comparison to patients on the cardiology ward (n = 82); one-year mortality was respectively 27 and 15% (p = 0.069). AUC on the acute geriatric ward was 0.748 (p = 0.006). The best cut-off value was 0.42 m/s with a sensitivity and specificity of 0.857 and 0.643. Slow walkers died earlier than faster walkers (HR 7.456, p = 0.011), after correction for age and sex. On the cardiology ward, AUC was 0.560 (p = 0.563); no significant association was found between usual gait speed and survival time. Conclusions Usual gait speed may be a valuable prognostic factor to identify patients at risk for one-year mortality on the acute geriatric ward but not on the cardiology ward.

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Ability to detect potentially inappropriate prescribing in older patients: comparative analysis between PIM-Check and STOPP/STARTv2

European Journal of Clinical Pharmacology ◽

10.1007/s00228-021-03171-4 ◽

2021 ◽

Author(s):

Akram Farhat ◽

Alice Panchaud ◽

Amal Al-Hajje ◽

Pierre-Olivier Lang ◽

Chantal Csajka

Keyword(s):

Comparative Analysis ◽

Older Patients ◽

Adverse Drug Events ◽

Inappropriate Prescribing ◽

University Hospital ◽

Potentially Inappropriate Prescribing ◽

Geriatric Ward ◽

Start Criteria ◽

Acute Geriatric Ward ◽

Geriatric Settings

Abstract Purpose Potentially inappropriate prescribing (PIP) is a source of preventable adverse drug events. The objective of this study was a comparative analysis (quantitative and qualitative) between two tools used to detect PIP, PIM-Check and STOPP/START. Methods First, a qualitative analysis (QAC) was conducted to evaluate the concordance between the criteria, which constitute PIM-Check and the gold standard STOPP/START. Second, a retrospective comparative and observational study was performed on the list of treatment at the admission of 50 older patients hospitalized in an acute geriatric ward of a university hospital in Switzerland in 2016 using both tools. Results The QAC has shown that 50% (57 criteria) of STOPP/START criteria are fully or partially concordant with those of PIM-Check. The retrospective study was performed on 50 patients aged 87 years, suffering from 5 co-morbidities (min–max 1–11) and treated by of 8 drugs (min–max 2–16), as medians. The prevalence of the detected PIP was 80% by PIM-Check and 90% by STOPP/START. Medication review shows that 4.2 PIP per patient were detected by PIM-Check and 3.5 PIP by STOPP/START among which 1.9 PIP was commonly detected by both tools, as means. PIM-Check detected more PIP related to cardiology, angiology, nephrology, and endocrinology in older patients but missed the PIP related to geriatric syndromes (e.g., fall, dementia, Alzheimer) detected by STOPP/START. Conclusions By using PIM-Check in geriatric settings, some PIP will not be detected. It is considered as a limitation for this tool in this frail population but brings a certain complementarity in other areas of therapy not covered by STOPP/START.

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The Timed Up and Go Test does not predict length of stay on an acute geriatric ward

Australian Journal of Physiotherapy ◽

10.1016/s0004-9514(06)70050-2 ◽

2006 ◽

Vol 52 (2) ◽

pp. 141-144 ◽

Cited By ~ 10

Author(s):

Neesha Gan ◽

Julienne Large ◽

David Basic ◽

Natalie Jennings

Keyword(s):

Length Of Stay ◽

Geriatric Ward ◽

Timed Up And Go ◽

Acute Geriatric Ward

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Very Low Levels of Physical Activity in Older Patients During Hospitalization at an Acute Geriatric Ward: A Prospective Cohort Study

Journal of Aging and Physical Activity ◽

10.1123/japa.2014-0115 ◽

2015 ◽

Vol 23 (4) ◽

pp. 542-549 ◽

Cited By ~ 33

Author(s):

Morten Villumsen ◽

Martin Gronbech Jorgensen ◽

Jane Andreasen ◽

Michael Skovdal Rathleff ◽

Carsten Møller Mølgaard

Keyword(s):

Physical Activity ◽

Cohort Study ◽

Older Patients ◽

Geriatric Patients ◽

Functional Decline ◽

Activity Level ◽

Accelerometer Data ◽

Geriatric Ward ◽

Acute Geriatric Ward ◽

Low Levels

Lack of activity during hospitalization may contribute to functional decline. The purpose of this study was to investigate (1) the time spent walking during hospitalization by geriatric patients referred to physical and/or occupational therapy and (2) the development in time spent walking during hospitalization. In this observational study, 24-hr accelerometer data (ActivPal) were collected from inclusion to discharge in 124 patients at an acute geriatric ward. The median time spent walking was 7 min per day. During the first quartile of hospitalization, the patients spent 4 (IQR:1;11) min per day walking, increasing to 10 (IQR:1;29) min during the last quartile. Improvement in time spent walking was primarily observed in the group able to perform the Timed Up & Go task at admission. When walking only 7 min per day, patients could be classified as inactive and at risk for functional decline; nonetheless, the physical activity level increased significantly during hospitalization.

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Predictive factors for prolonged hospitalisation in acute pyelonephritis patients admitted to the emergency medicine ward

Hong Kong Journal of Emergency Medicine ◽

10.1177/10249079211000976 ◽

2021 ◽

pp. 102490792110009

Author(s):

Howard Tat Chun Chan ◽

Ling Yan Leung ◽

Alex Kwok Keung Law ◽

Chi Hung Cheng ◽

Colin A Graham

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Length Of Stay ◽

Acute Pyelonephritis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Prolonged Length ◽

Reactive Protein ◽

Prolonged Hospital ◽

Emergency Medicine Ward

Background: Acute pyelonephritis is a bacterial infection of the upper urinary tract. Patients can be admitted to a variety of wards for treatment. However, at the Prince of Wales Hospital in Hong Kong, they are managed initially in the emergency medicine ward. The aim of the study is to identify the risk factors that are associated with a prolonged hospital length of stay. Methods: This was a retrospective cohort study conducted in Prince of Wales Hospital. The study recruited patients who were admitted to the emergency medicine ward between 1 January 2014 and 31 December 2017. These patients presented with clinical features of pyelonephritis, received antibiotic treatment and had a discharge diagnosis of pyelonephritis. The length of stay was measured and any length of stay over 72 h was considered to be prolonged. Results: There were 271 patients admitted to the emergency medicine ward, and 118 (44%) had a prolonged hospital length of stay. Univariate and multivariate analyses showed that the only statistically significant predictor of prolonged length of stay was a raised C-reactive protein (odds ratio 1.01; 95% confidence 1.01–1.02; p < 0.0001). Out of 271 patients, 261 received antibiotics in the emergency department. All 10 patients (8.5%) who did not receive antibiotics in emergency department had a prolonged length of stay (p = 0.0002). Conclusion: In this series of acute pyelonephritis treated in the emergency medicine ward, raised C-reactive protein levels were predictive for prolonged length of stay. Patients who did not receive antibiotics in the emergency department prior to emergency medicine ward admission had prolonged length of stay.

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Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study

BMC Geriatrics ◽

10.1186/s12877-021-02044-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jenny Liu ◽

Therese Palmgren ◽

Sari Ponzer ◽

Italo Masiello ◽

Nasim Farrokhnia

Keyword(s):

Length Of Stay ◽

Hospital Admission ◽

Older Patients ◽

Outcome Measure ◽

Admission Rate ◽

Intervention Period ◽

Total Hospital ◽

Hospital Admission Rate ◽

Emergency Team ◽

Interprofessional Team

Abstract Background Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. Methods An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. Results We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. Conclusions An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.

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108 A Multidisciplinary Team Initiative to End PJ Paralysis Was Successful in Achieving Cultural Change on An Acute Geriatric Ward

Age and Ageing ◽

10.1093/ageing/afab030.69 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

J Butler ◽

T Welford

Keyword(s):

Cultural Change ◽

The Elderly ◽

Recovery Phase ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Service Development ◽

Steady Increase ◽

Geriatric Ward ◽

Additional Equipment ◽

Acute Geriatric Ward

Abstract Introduction Prolonged bedrest amongst the elderly causes deconditioning leading to; increased hospital length of stay, additional social costs and decreased quality of life. An audit on an acute geriatric ward in November 2018, found that over a third of patients medically fit (PMF) to sit out remained in bed all day. Therefore, a service development initiative was undertaken, addressing the misconception that keeping elderly patients in bed is safe, when in fact, unintentional harm results. Method In a root cause analysis, four main reasons for bedrest were identified: risk aversion, unknown function, widespread “bed is safe” culture and lack of equipment. The project tasked getting PMF out of bed each day and was audited daily from November 2018 to present, involving all members of the multi-disciplinary team (MDT) and using a “plan, do, study, act” approach. Results Initially, the project showed an increase in percentage of PMF sitting out each day, but this subsequently decreased with winter pressures. However, for a whole year (February 2019–February 2020) a sustained and significant improvement was achieved (64.3%–89.7%). The pre-COVID19 period (February–March 2020) saw fluctuations in PMF sitting out. Data collection halted during the COVID19 peak, although observationally most patients remained in bed. Auditing resumed from June 2020 (COVID19 recovery phase) which showed a steady increase in PMF out of bed, with recent figures surpassing pre-COVID19 levels (97.8%). Conclusion Cultural change takes time to embed and needs persistent reviewing by a dedicated and engaged MDT. Improvements were made through more accessible doctor’s advice, better MDT education and communication, daily feedback of data and sourcing additional equipment. Disruption to working patterns over the COVID19 period made this unachievable and the project lost impetus. In the COVID19 recovery phase, the specialized MDT reformed and worked successfully to restore the cultural change as evidenced by audited data.

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General Doctor's Consultation Work Begins before Entering the Patient and does not End when Patient Comes Out

International Journal of General Practice ◽

10.14302/issn.2692-5257.ijgp-20-3335 ◽

2020 ◽

Vol 1 (2) ◽

pp. 6-14

Author(s):

Jose Luis Turabian

Keyword(s):

Health Promotion ◽

General Practitioner ◽

Previous History ◽

General Medicine ◽

Management Plan ◽

Case Finding ◽

Limited Resources ◽

Technology Skills ◽

Good Relationship ◽

Quality Framework

The consultation is the activity of meeting and communication between an individual and the doctor for the knowledge and solution of a health problem. In today's busy world of general medicine, constant demands for the general practitioner (GP) arise: she or he should not only make a diagnosis not only should make a differential diagnosis during consultation, but must also establish a good relationship, explore patient ideas, concerns and expectations and negotiate a management plan, taking into account limited resources, the quality framework and results, having Information technology skills, plus, the need to promote health during any consultation. Normally the GP has only 10 minutes to achieve all that, as well as to manage your own emotions, agendas and uncertainty. In this way, novice doctors may find it difficult to move in this situation of complexity, and they can also observe a gap in the literature that really guides them in practice. Rigorous preparation is the key to success for many endeavours. Some tips to perform an efficient and safe consultation work in general medicine are suggested: 1) Focus on the next patient; 2) Preparing the consultation before entering the patient, memorizing the patient's previous history; 3) Establishing a connection with the patient; 4) Remembering the elements that must be in each consultation (the current reason, update other previous processes, chronic diseases and continued attention, "case finding", health promotion); 5) Striking a balance between empathy and assertiveness; 6) Putting in writing and contextualized the clinical record; and 7) Making reflection-safety questions, learning questions, and preparation questions for the next visit. Rigorous preparation is the key to success for the general practitioner in every consultation. Think about these topics of the consultation before doing it, and after it, prepare the next consultation of that patient. All these things are force multipliers.

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SENSITIVITY AND SPECIFICITY OF THE HANDGRIP STRENGTH IN THE PREDICTION OF LOW MUSCLE MASS IN HOSPITALIZED OLDER PATIENTS

Journal of Frailty & Aging ◽

10.14283/jfa.2012.30 ◽

2012 ◽

pp. 1-4

Author(s):

V. Zanandrea ◽

A.P. Rossi ◽

M. Bertocchi ◽

M. Zamboni

Keyword(s):

Muscle Strength ◽

Length Of Stay ◽

Hospital Stay ◽

Muscle Mass ◽

Acute Care ◽

Sensitivity And Specificity ◽

Older Patients ◽

Handgrip Strength ◽

Hospitalized Patients ◽

Acute Care Unit

To the Editor: In the article entitled “Potential prognosticvalue of handgrip strength in older hospitalized patients”published in the first issue of The Journal of Frailty & Aging(1), Savino and colleagues presented the handgrip strength as apredictor of hospitalization length of stay in older patientsadmitted to an acute care unit. Authors reported an inverseassociation between muscle strength at the admission andsubsequent duration of the hospital stay, even after adjustmentfor potential confounders.

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Abstract WMP12: Benefits of Thrombectomy Among Patients Who Did Not Achieve Functional Independence in DEFUSE 3

Stroke ◽

10.1161/str.51.suppl_1.wmp12 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Amrou Sarraj ◽

Maarten Lansberg ◽

Michael P Marks ◽

Michael Mlynash ◽

Jeremy J Heit ◽

...

Keyword(s):

Length Of Stay ◽

Elderly Patients ◽

Older Patients ◽

Mortality Rates ◽

Functional Independence ◽

Severe Disability ◽

Endovascular Thrombectomy ◽

Strong Trend ◽

Baseline Characteristics ◽

Profound Disability

Background: While endovascular thrombectomy (EVT) patients may not achieve functional independence, they may avoid devastating outcomes as in profound disability/death. Methods: DEFUSE 3 patients who did not achieve mRS 0-2 were assessed for a shift towards reductions in severe (mRS 4-6) and profound (mRS 5-6) disability, mortality, length of stay (LOS) and increased rates of home/rehabilitation discharges. Results: 126 of the 182 randomized in DEFUSE 3 did not achieve mRS 0-2 (EVT 51, MM 75). Baseline characteristics were similar. EVT was associated with a higher mRS 3 rate (28% vs 18%) and lower rates of severe (72% vs 82%) and profound disability (39% vs. 50%), EVT vs MM respectively, with a trend for a shift towards less disability aOR=1.6 (95%CI=0.9-3.2, P=0.138), figure 1. Mortality rates were numerically lower with EVT (25% vs 31, p=0.528). EVT patients had a trend for shorter LOS (8.6 (6.5-13.7) vs 9.3 (7.1-16.3) days, p=0.156) and increased rates of home/rehabilitation discharges 51% vs. 40%, p=0.224. Older age correlated independently with severe disability aOR=1.04 per year/age, (95%CI=1.01-1.07, p=0.023) as did more severe strokes, aOR per NIHSS point=1.07, 95%CI=0.99-1.15, P=0.096). Larger final infarct volumes had a trend towards severe disability in EVT aOR=1.005, 95%CI=0.996-1.013, p=0.257, but not in MM aOR=1.0 (95% CI 0.993-1.007, p=0.966). Lack of reperfusion (>90% Tmax>6 reduction) had a strong trend for severe disability in MM (83% in non-reperfusers vs. 50% for reperfusers), p=0.056, but not in EVT: 77% vs. 63%, p=0.484. Conclusion: In patients who did not achieve functional independence, EVT resulted in reduced rates of severe and profound disability, decreased length of stay and increased home and rehabilitation discharges. Older patients, more severe strokes and those who did not achieve reperfusion were more likely to have severe disability especially if not treated with EVT. EVT may result in avoiding severe disability in elderly patients.

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