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Background: Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED. Methods: This is a qualitative study of some 450h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient’s trajectories, in particular those presenting with typically geriatric syndromes. Results: Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs. Conclusions: The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people’s specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.

La thèse vise à étudier les facteurs et caractéristiques des personnes âgées qui ont un impact sur le coût pour l’hôpital et la durée de séjour à l’hôpital et les mécanismes de financement., Doctorat en Santé Publique, info:eu-repo/semantics/nonPublished

Objectifs. Bien que la majorité des décès intra-hospitaliers liés à la COVID-19 survienne chez des patients de plus de 75 ans, cette population a été peu étudiée. Cette étude vise à décrire la présentation clinique et le taux de mortalité intrahospitalière de ces patients. Méthodes. Étude de cohorte rétrospective des 50 premiers patients atteints de la COVID-19 admis en gériatrie aux Cliniques universitaires Saint-Luc. Résultats. Avant l'admission, les patients (âge médian : 88 ans) étaient vulnérables (16%), légèrement/modérément fragiles (32%), sévèrement/très sévèrement fragiles (52%) selon le score de fragilité clinique, et présentaient des syndromes gériatriques (troubles cognitifs 54%, chutes à répétition 44% et dénutrition 40%). Chez 36% des patients, la présentation initiale de la COVID-19 était atypique (symptômes de delirium ou digestifs). La mortalité intra-hospitalière était élevée (52%) et n’était pas associée au degré de fragilité, mais à un âge plus avancé, une tension artérielle systolique plus basse, une lactate déshydrogénase sérique plus élevée et des infiltrats pulmonaires marqués lors du diagnostic. Conclusions. Chez les premiers patients gériatriques atteints de la COVID-19, le symptôme initial était souvent trompeur, la mortalité intra-hospitalière était élevée (52%), et les facteurs pronostiques restent à déterminer, en particulier l’effet de la fragilité clinique.

AIMS: Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery. PATIENTS AND METHODS: All consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery. RESULTS: We included 829 patients; the mean age was 81 years (sd 11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01). CONCLUSION: Our results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into acc

BACKGROUND: In the Emergency Department (ED), early and rapid identification of older people at risk of adverse outcomes, who could best benefit from complex geriatric intervention, would avoid wasting time, especially in terms of prevention of adverse outcomes, and ensure optimal orientation of vulnerable patients. We wanted to test the predictive ability of a screening tool assessing risk of functional decline (FD), named SHERPA, 10 years after its conception, and to assess the added value of other clinical or biological factors associated with FD. METHODS: A prospective cohort study of older patients (n = 305, ≥ 75 years) admitted through the emergency department, for at least 48 h in non-geriatric wards (mean age 82.5 ± 4.9, 55% women). SHERPA variables (i.e. age, pre-admission instrumental Activity of Daily Living (ADL) status, falls within a year, self-rated health and 21-point MMSE) were collected within 48 h of admission, along with socio-demographic, medical and biological data. Functional status was followed at 3 months by phone. FD was defined as a decrease at 3 months of at least one point in the pre-admission basic ADL score. Predictive ability of SHERPA was assessed using c-statistic, predictive values and likelihood ratios. Measures of discrimination improvement were Net Reclassification Improvement and Integrated Discrimination Improvement. RESULTS: One hundred and five patients (34%) developed 3-month FD. Predictive ability of SHERPA decreased dramatically over 10 years (c = 0.73 vs. 0.64). Only two of its constitutive variables, i.e. falls and instrumental ADL, were significant in logistic regression analysis for functional decline, while 21-point MMSE was kept in the model for clinical relevance. Demographic, comorbidity or laboratory data available upon admission did not improve the SHERPA predictive yield. CONCLUSIONS: Prediction of FD with SHERPA is difficult, but predictive factors, i.e. falls, pre-existing functional limitation and cognitive

Older people (OP) account for 12-24% of emergency department (ED) admissions. Their management is often complex because, for example, of the frequent presence of comorbidities and atypical presentations of diseases. They are also at high risk of complications after ED discharge. Interventions based on screening for frailty followed by a comprehensive geriatric assessment adapted to the ED context have shown promising results. However, they mainly aim to improve care coordination for OP discharged to primary care and evidence is not yet strong. Moreover the predictive value of screening tools currently available is at best moderate. The general aim of the thesis is to optimize the care of OP hospitalized through and as soon as the ED. The main objective is to understand the structure and process of care for OP, in particular factors that influence quality of their care in the real context of the ED. This knowledge is needed in order to design effective interventions for OP in the ED. It also questions the predictive abilities of a screening tool for early and rapid identification of frail older people, i.e. those who could best benefit from geriatric intervention., Les patients âgés (PA) représentent 12 à 24% des admissions en salle d’urgences (SU). Leur prise en charge est souvent complexe du fait, notamment, des présentations atypiques des maladies et des comorbidités. Ils sont aussi à haut risque de complications après la sortie de SU. Des interventions basées sur le dépistage de la fragilité suivi d'une évaluation gériatrique globale adaptée, ont montré des résultats prometteurs. Cependant, elles visent principalement à améliorer la coordination des soins entre SU et domicile et les preuves ne sont pas encore solides. De plus, la valeur prédictive des outils de dépistage existants est au mieux modérée. L'objectif général de la thèse est d'optimiser les soins des PA hospitalisés à partir de la SU. L'objectif principal est de comprendre la structure et le processus de leur prise en charge, en particulier les facteurs influençant la qualité des soins en contexte réel, afin de concevoir des interventions efficaces. Il questionne également les capacités prédictives d'un outil de dépistage pour l'identification précoce et rapide des PA fragiles, càd ceux qui pourraient le mieux bénéficier d'une intervention gériatrique., (MED - Sciences médicales) -- UCL, 2017

Le patient cardiaque est devenu un patient âgé, fragile et souffrant de polypathologies. Cette complexité modifie la prise en charge cardiologique habituelle, l’individualisation de chaque situation est nécessaire mais doit reposer sur une évaluation globale de la santé et de la fragilité du patient et une redéfinition des objectifs thérapeutiques axés sur les priorités du patient.

Objectives: The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate. Results: Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration. Conclusion: Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions. Patients and methods: Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above. Results: One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%). Conclusion: Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment. © The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.

For selected patients with symptomatic aortic stenosis, transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR). In addition to co-morbidities, frailty has to be taken into account in the decision-making process. Criteria for patient selection, according to current guidelines, include EuroSCORE and STS score but frailty is not easy to quantify. ISAR (Identification of Seniors At Risk) detects seniors at risk for adverse health outcome after an emergency visit and SHERPA (Score Hospitalier d'Evaluation du Risque de Perte d'Autonomie) assesses the risk of functional decline after hospitalization.

BACKGROUND AND AIMS: Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams. METHODS: A retrospective cohort of consecutive community- living elderly patients (age ≥ 75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR). RESULTS: Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53- 58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off). CONCLUSIONS: None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention

info:eu-repo/semantics/nonPublished

Background: Functional decline frequently occurs following hospitalisation in older people and may be prevented or minimized by specific management. Such care processes needs appropriate early screening of older hospitalized patients. Objective: To identify instruments able to detect on admission older hospitalized patients at risk of functional decline at and after discharge. Methods: Functional decline is defined as loss of independence in activities of daily living (functional decline) or admission in nursing home. The systematic search used Medline 1970-2007, Web of Science 1981-2007 and references list of relevant papers. An independent epidemiologist assessed methodological quality of the retained articles. Results: We found 12 studies developing predictive tools, including 7145 patients. Functional outcomes were assessed at or after discharge. Preadmission functional status, cognition, and social support were major components for prediction of functional evolution. Few instruments are fully validated and data concerning reliability are often lacking. Operational characteristics are moderate (sensitivity 29-87%, negative likelihood ratio 0.2-0.8). Conclusions: Instruments predicting functional adverse outcomes are difficult to compare due to heterogeneity of functional outcomes and hospital settings. The reason why so many tools have been developed is probably because none gives full satisfaction: their general predictive validity and performances are insufficient. Further research is needed to improve the screening of frail older patients admitted to hospital with standardized and validated tools.

Frailty concerns an increasing number of older people and exposes them to an higher risk of negative health outcomes : functional decline, institutionalisation, (re)hospital admission, geriatric syndromes, death). Functional dependence has both personal and public health consequences, e.g. prolonged hospital stay, decreased quality of life and increased health care needs after discharge. However, comprehensive geriatric assessment and acute geriatric interventions have been showed to provide functional benefits and better discharge planning. Inflammation and neuroendocrine dysregulation have been proposed as impaired physiological mechanisms involved in the process of functional decline. Few studies however investigated the potential interest of these biomarkers in hospitalized older patients. The aim of this study was to determine if selected inflammatory and hormonal markers, measured early after admission, could improve the predictive validity of a clinical tool screening for the risk of functional decline following hospitalization of older patients. Main reserch questions developed in this thesis were : 1. Preliminary outcome : How to identify frail older hospitalized patients? 2. Main outcome : do biomarkers contribute to improve the screening of frail hospitalized elderly? 3. secundary outcome : may the dynamics of biomarkers during hospital stay add more useful information in this identification? Proper identification of frailty is indeed a major public health issue to provide adapted care to vulnerable hospitalized elders. Clinical tools predicting functional decline, mainly based on physical or more comprehensive clinical criteria, have shown a moderate discriminative ability and therefore, inclusion of biological factors may improve these performances, as in the estimation of cardiovascular risk (26). Further studies should include larger cohorts, and combine several biomarkers in composite indexes. Another perspective is that persistent changes in inflamm, (ESP 3) -- UCL, 2010

With the demographic and epidemiological changes, an increasing number of older subjects are admitted to hospital. These patients are at increased risk of adverse health outcomes, including functional decline, increased length of stay, institutionalization, geriatric syndromes (e.g. delirium), hospital readmissions and death. Age, basic demographic data, diagnosis and comorbidities are not sufficient to estimate the risk of a further negative evolution of the frail older patient during and after hospitalization. As functional decline begins soon after admission, it is important to screen vulnerable patients early in order to plan appropriate orientation to geriatric programmes and to target interventions.This narrative review analyses which appropriate parameters, available soon after admission, may help to identify the older patients at risk of functional decline and to stratify their risk. Functional decline was defined here as loss of independence in basic care or admission in nursing home. The main risk factors identified by this analysis are functional status before or at admission, cognitive performance and social characteristics.These data may be easily and quickly collected by the nursing staff on admission, and further assessed by the geriatric liaison team, in order to optimize care management in frail older patients.

A la lumière d’un cas clinique en gériatrie, cet article se propose de revoir le syndrome sérotoninergique. Ce syndrome, lié à la toxicité de la sérotonine, recouvre un ensemble de signes cliniques, de gravité variable. La description de ce syndrome nous semble importante dans un objectif de prévention afin d’éviter les prescriptions dangereuses, mais aussi de reconnaissance clinique afin d’évoquer les diagnostics différentiels et d’adopter les mesures thérapeutiques à prendre en urgence., We report the case of an old patient admitted in a geriatric unit, who developed a serotonin syndrome. Serotonin syndrome is characterized by a constellation of symptoms of various seriousness. Improving awareness of this syndrome is important in order to prevent it by appropriate prescription, to recognize this entity among differential diagnosis and to adopt the appropriate treatment in emergency.

Poor nutritional status significantly contributes to morbidity and mortality in elderly. Malnutrition and denutrition are amenable to interventions aimed to improve outcomes in acute conditions so that nutritional support is frequently initiated during hospitalisation. If the enteral route remains the first evidence-based choice when the gut is functional, this approach may be difficult to perform in some "geriatric" situations like delirium, agitation, coma or pulmonary congestion. In the first days of the acute condition, when the patient is still stable, an alternative to the enteral route may also be considered. Although there is no evidence that parenteral nutrition is better than enteral nutrition, the peripheral intravenous route may be of interest especially when the enteral route is contraindicated. Moreover, the technique of peripheral parenteral nutition reduces central cannulation-related complications like pneumothorax. We emphasize here the place of this alternative method for a short duration nutritional support when supplement of caloric intake is needed. We discuss indications, a practical approach, our experience and analyze the evidences for this complementary nutritional support.

L'évaluation des différents domaines de la santé (maladies, fonctionnement, dimension psycho-sociale) est très utile pour organiser les soins et les traitements des personnes âgées. La démarche d'évaluation gériatrique standardisée décrite dans cet article est précédée de la description d'un exemple de dépistage des personnes nécessitant cette approche. Le système de recueil standardisé de données Résident Assessment Instrument Minimal Data Set (RAI MOS®), qui est basé sur le processus d'évaluation gériatrique multidimentionnelle, est présenté comme outil global permettant de compléter l'évaluation par un suivi et une analyse des données dans le but d'améliorer la qualité des soins., [Evaluation of the elderly and the RAI-MDS® (Resident Assessment Instrument Minimal Data Set) system] An assessment of the different health domains (diseases, functioning, psycho-social, resources) is needed in order to oppropriately organize the care and treatments for frail elderly. The process of comprehensive geriatric assessment described here, is introduced by an example of screening tool to target people needing further assessment. The resident assessessment instrument based on the minimal data set (RAI-MDS®) is presented as a global tool able not only to assess the patient and plan care, but also to follow up for a better quality of care.

BACKGROUND AND AIMS: This study aimed at analyzing rates and factors associated with early and later readmission (0-1 month and 2-3 months after discharge, respectively) of older people after index hospitalization. METHODS: This prospective observational study was conducted in two teaching hospitals. People 70 years and over were interviewed within 48 h of emergency admission. Socio-demographic and medical factors were collected, together with functional factors including Activities of Daily Living (basis and instrumental), cognitive state, and geriatric syndromes. Medical diagnosis, length of stay, and destination were collected at discharge, and patients were followed up by phone 1 and 3 months after discharge. During these interviews, outcomes on readmission, institutionalization, need for help, and death were evaluated. RESULTS: The population of 625 patients had a mean age of 80.0 years. The rate of early readmission (01 month) was 10. 7% and the overall rate within 3 months was 23.1%. Logistic regression analysis showed that variables predicting early readmission were previous hospitalization within 3 months, a longer length of stay, and a discharge diagnosis in chapter 8 (respiratory system) and chapter 10 (genito-urinary system) of the ICD-9-CM. Variables predicting later readmission were previous hospitalization within 3 months, a discharge diagnosis in chapter 7 (circulatory system) of the ICD-9-CM, and a poor pre-admission IADL score. CONCLUSIONS: In a medicalized population of older people, several risk factors may be identified for 0-1 month and 2-3 month readmission. Besides severe morbidities at discharge, diagnoses and previous hospitalization, pre-admission IADL was an independent risk factor for 2-3 month readmission.