Objectives: 1) To describe the pattern of return visits to the emergency department (ED) among el... more Objectives: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. Methods: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. Results: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. Conclusions: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.
OBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagno... more OBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium. DESIGN: Prospective cohort study. SETTING: Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal. PATIENTS: Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital. MEASUREMENTS AND MAIN RESULTS: Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the inhospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality. CONCLUSIONS: Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.
A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration i... more A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.
Major and minor depression is frequent in older medical inpatients, but the prognosis of these tw... more Major and minor depression is frequent in older medical inpatients, but the prognosis of these two disorders is not clear. The current study proposed to determine the prognosis of major and minor depression in this population. This prospective, observational cohort study, conducted in Montreal, Quebec, Canada, involved assessment of 380 elderly medical inpatients with major, minor, or no depression at three, six, and 12 months after enrollment using the Diagnostic Interview Schedule and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Information on suicide attempts, completed suicides, and potential prognostic factors was also collected. Analysis of outcomes and potential prognostic factors involved descriptive statistics and multiple logistic regression. Among patients with major depression at enrollment, 13% were recovered, 14% were partially recovered, and 73% remained depressed with a protracted stable or protracted fluctuating course. Among patients with minor depression, 28% were recovered and 72% had a protracted course. Patients diagnosed with major depression at enrollment often had minor depression at follow up and vice versa. The prognosis of both major and minor depression in older medical inpatients is poor and worse than previously thought.
ABSTRACT OBJECTIVE To determine the proportion of elderly people without dementia who would want ... more ABSTRACT OBJECTIVE To determine the proportion of elderly people without dementia who would want disclosure of a diagnosis of Alzheimer’s disease (AD), for themselves or for their spouses, and to verify whether the availability of medication would infl uence their decision. DESIGN A cross-sectional survey with a semistructuredquestionnaire completed during face-to-face interviews. SETTINGMedical and surgical outpatient clinics in St Mary’s
To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for... more To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes. Controlled trial, randomized by day of ED visit, with follow-up at 1 and 4 months. Four university-affiliated hospitals in Montreal. Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk (ISAR) screening tool and their primary family caregivers. One hundred seventy-eight were randomized to the intervention, 210 to usual care. The intervention consisted of disclosure of results of the ISAR screen, a brief standardized nursing assessment in the ED, notification of the primary care physician and home care providers, and other referrals as needed. The control group received usual care, without disclosure of the screening result. Patient outcomes assessed at 4 months after enrollment included functional decline (increased dependence on the Older American Resources and Services activities of daily living scale or death) and depressive symptoms (as assessed by the short Geriatric Depression Scale). Caregiver outcomes, also assessed at baseline and 4 months, included the physical and mental summary scales of the Medical Outcomes Study Short Form-36. Patient and caregiver satisfaction with care were assessed 1 month after enrollment. The intervention increased the rate of referral to the primary care physician and to home care services. The intervention was associated with a significantly reduced rate of functional decline at 4 months, in both unadjusted (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.36-0.99) and adjusted (OR = 0.53, 95% CI = 0.31-0.91) analyses. There was no intervention effect on patient depressive symptoms, caregiver outcomes, or satisfaction with care. A two-stage ED intervention, consisting of screening with the ISAR tool followed by a brief, standardized nursing assessment and referral to primary and home care services, significantly reduced the rate of subsequent functional decline.
A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration i... more A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.
Objectives: To determine the effects of prevalent and incident delirium on length of hospital sta... more Objectives: To determine the effects of prevalent and incident delirium on length of hospital stay.Design: Prospective cohort study, comparing (1) length of stay after admission in cases of prevalent delirium versus controls without prevalent delirium with (2) length of stay after diagnosis in cases of incident delirium versus controls matched by day of diagnosis.Setting: The medical services of a primary, acute care hospital.Participants: Medical admissions of patients aged 65 and older from the emergency department with delirium diagnosed during the first week in hospital. Patients admitted to intensive care or oncology and those with a primary diagnosis of stroke were excluded. A sample of those without delirium was also enrolled.Measurements: Delirium was diagnosed using the Confusion Assessment Method. Data on length of stay and diagnosis-related groups (DRGs) were abstracted from administrative data. Measures of covariates included the Informant Questionnaire on Cognitive Decline in the Elderly, the Delirium Index, the instrumental activities of daily living questionnaire from the Older American Resources and Services project, the Charlson Comorbidity Index, the Clinical Severity Scale, and the Acute Physiology Score.Results: The study sample comprised 359 patients: 204 with prevalent delirium, 37 with incident delirium, and 118 without delirium. After controlling for covariates, prevalent delirium was not associated with a significantly longer hospital stay, but incident delirium was associated with an excess stay after diagnosis of 7.78 days (95% confidence interval=3.07, 12.48). Similar results were obtained using log-transformed or DRG-adjusted estimates of length of stay.Conclusion: In older medical inpatients, incident but not prevalent delirium is an important predictor of longer hospital stay. Interventions to prevent incident delirium may reduce length of stay.
To determine risk factors for major depression in older medical inpatients. In a prospective coho... more To determine risk factors for major depression in older medical inpatients. In a prospective cohort study, 86 older medical inpatients without depression or antidepressant medication were assessed 3, 6, and 12 months after enrollment. Incident major depression was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Potential predictive variables included sociodemographic variables, physical state, cognition, depressive symptoms, medication use, prior depressive episode, social network, support, and bereavement. Cox proportional hazards analysis (with backward variable elimination) was used to determine the best set of predictors. Twenty-six patients (30.2%) met criteria for incident major depression. Predictors of major depression included the following: prior depressive episode, birth outside Canada, low comorbidity, inadequate emotional support, fewer children seen, depressed mood, and diurnal variation. The risk of depression increased with the number of risk factors present. The seven identified risk factors may guide efforts to prevent major depression in older medical inpatients.
Objectives: 1) To describe the pattern of return visits to the emergency department (ED) among el... more Objectives: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. Methods: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. Results: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. Conclusions: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.
OBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagno... more OBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium. DESIGN: Prospective cohort study. SETTING: Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal. PATIENTS: Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital. MEASUREMENTS AND MAIN RESULTS: Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the inhospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality. CONCLUSIONS: Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.
A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration i... more A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.
Major and minor depression is frequent in older medical inpatients, but the prognosis of these tw... more Major and minor depression is frequent in older medical inpatients, but the prognosis of these two disorders is not clear. The current study proposed to determine the prognosis of major and minor depression in this population. This prospective, observational cohort study, conducted in Montreal, Quebec, Canada, involved assessment of 380 elderly medical inpatients with major, minor, or no depression at three, six, and 12 months after enrollment using the Diagnostic Interview Schedule and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Information on suicide attempts, completed suicides, and potential prognostic factors was also collected. Analysis of outcomes and potential prognostic factors involved descriptive statistics and multiple logistic regression. Among patients with major depression at enrollment, 13% were recovered, 14% were partially recovered, and 73% remained depressed with a protracted stable or protracted fluctuating course. Among patients with minor depression, 28% were recovered and 72% had a protracted course. Patients diagnosed with major depression at enrollment often had minor depression at follow up and vice versa. The prognosis of both major and minor depression in older medical inpatients is poor and worse than previously thought.
ABSTRACT OBJECTIVE To determine the proportion of elderly people without dementia who would want ... more ABSTRACT OBJECTIVE To determine the proportion of elderly people without dementia who would want disclosure of a diagnosis of Alzheimer’s disease (AD), for themselves or for their spouses, and to verify whether the availability of medication would infl uence their decision. DESIGN A cross-sectional survey with a semistructuredquestionnaire completed during face-to-face interviews. SETTINGMedical and surgical outpatient clinics in St Mary’s
To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for... more To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes. Controlled trial, randomized by day of ED visit, with follow-up at 1 and 4 months. Four university-affiliated hospitals in Montreal. Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk (ISAR) screening tool and their primary family caregivers. One hundred seventy-eight were randomized to the intervention, 210 to usual care. The intervention consisted of disclosure of results of the ISAR screen, a brief standardized nursing assessment in the ED, notification of the primary care physician and home care providers, and other referrals as needed. The control group received usual care, without disclosure of the screening result. Patient outcomes assessed at 4 months after enrollment included functional decline (increased dependence on the Older American Resources and Services activities of daily living scale or death) and depressive symptoms (as assessed by the short Geriatric Depression Scale). Caregiver outcomes, also assessed at baseline and 4 months, included the physical and mental summary scales of the Medical Outcomes Study Short Form-36. Patient and caregiver satisfaction with care were assessed 1 month after enrollment. The intervention increased the rate of referral to the primary care physician and to home care services. The intervention was associated with a significantly reduced rate of functional decline at 4 months, in both unadjusted (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.36-0.99) and adjusted (OR = 0.53, 95% CI = 0.31-0.91) analyses. There was no intervention effect on patient depressive symptoms, caregiver outcomes, or satisfaction with care. A two-stage ED intervention, consisting of screening with the ISAR tool followed by a brief, standardized nursing assessment and referral to primary and home care services, significantly reduced the rate of subsequent functional decline.
A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration i... more A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.
Objectives: To determine the effects of prevalent and incident delirium on length of hospital sta... more Objectives: To determine the effects of prevalent and incident delirium on length of hospital stay.Design: Prospective cohort study, comparing (1) length of stay after admission in cases of prevalent delirium versus controls without prevalent delirium with (2) length of stay after diagnosis in cases of incident delirium versus controls matched by day of diagnosis.Setting: The medical services of a primary, acute care hospital.Participants: Medical admissions of patients aged 65 and older from the emergency department with delirium diagnosed during the first week in hospital. Patients admitted to intensive care or oncology and those with a primary diagnosis of stroke were excluded. A sample of those without delirium was also enrolled.Measurements: Delirium was diagnosed using the Confusion Assessment Method. Data on length of stay and diagnosis-related groups (DRGs) were abstracted from administrative data. Measures of covariates included the Informant Questionnaire on Cognitive Decline in the Elderly, the Delirium Index, the instrumental activities of daily living questionnaire from the Older American Resources and Services project, the Charlson Comorbidity Index, the Clinical Severity Scale, and the Acute Physiology Score.Results: The study sample comprised 359 patients: 204 with prevalent delirium, 37 with incident delirium, and 118 without delirium. After controlling for covariates, prevalent delirium was not associated with a significantly longer hospital stay, but incident delirium was associated with an excess stay after diagnosis of 7.78 days (95% confidence interval=3.07, 12.48). Similar results were obtained using log-transformed or DRG-adjusted estimates of length of stay.Conclusion: In older medical inpatients, incident but not prevalent delirium is an important predictor of longer hospital stay. Interventions to prevent incident delirium may reduce length of stay.
To determine risk factors for major depression in older medical inpatients. In a prospective coho... more To determine risk factors for major depression in older medical inpatients. In a prospective cohort study, 86 older medical inpatients without depression or antidepressant medication were assessed 3, 6, and 12 months after enrollment. Incident major depression was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Potential predictive variables included sociodemographic variables, physical state, cognition, depressive symptoms, medication use, prior depressive episode, social network, support, and bereavement. Cox proportional hazards analysis (with backward variable elimination) was used to determine the best set of predictors. Twenty-six patients (30.2%) met criteria for incident major depression. Predictors of major depression included the following: prior depressive episode, birth outside Canada, low comorbidity, inadequate emotional support, fewer children seen, depressed mood, and diurnal variation. The risk of depression increased with the number of risk factors present. The seven identified risk factors may guide efforts to prevent major depression in older medical inpatients.
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