Prédiction des issues défavorables des hospitalisations gériatriques
Creators: name: Zekry Berger, Dina Selma
Publisher: name: Université de Genève
Year: 2012
Subjects: info:eu-repo/classification/ddc/618.97
Adverse outcomes
Elderly
Dementia
Functional status
Nutritional status, comorbidities

description: This research project was undertaken to assess the relative contribution of cognitive, functional and nutritional status, comorbidities and biomarkers predicting adverse outcomes in the hospitalized elderly. In older people, dementia is frequently associated with adverse health outcomes (poor functional and nutritional status; higher rates of institutionalization and of readmission; and lower survival rates). The relative weight of dementia of varying type and severity as predictors of adverse health outcomes after other risk factors taken into account remains unclear. In this context, we performed, since 2004, a prospective clinico-biological study aiming to investigate the relationship among clinical and specific biological markers and adverse health outcomes in a population of very old, acutely ill patients discharged from a geriatric hospital. We assessed the extent to which a clinical or a biological marker was of greater added prognostic value than other markers of risk for the adverse outcomes. The studied adverse outcomes were death in hospital, greater length of stay, institutionalization and increase formal home care need after discharge; 1-year risk of rehospitalization, institutionalization and death; and long-term mortality after 5-years of follow-up. The studied clinical markers were cognitive diagnosis (various etiologies and severity of dementia), functional and nutritional status, comorbidities and the studied biomarker was leukocytes telomere length. As few comorbidity indices are valid and reliable in the elderly and were rarely compared, first we compared the performance, relevance and ability of six widely used comorbidity indices (comorbid Charlson index, cumulative illness rating scale (CIRS), index of coexistent diseases (ICED), Kaplan scale, geriatrics index of comorbidity (GIC) and chronic disease score (CDS) to predict the adverse outcomes. As there is evidence of association between telomere length and aging but data investigating the association between telomere length and dementia remained scarce; first, we determined whether telomere length may contribute to the diagnosis of AD and whether they allow to discriminate AD from other dementias; secondly, we assessed whether telomere length alone is associated to the studied adverse outcomes or when combined to the clinical markers provided an additional predictive value. In our cohort of 449 very old inpatients (mean age = 85yrs), we were able to demonstrate, that: - Demented patients, non-demented patients and patients with mild cognitive impairment (MCI) had similar levels of comorbidity, but demented patients had a poorer functional and nutritional status. Till now, demented patients have been reported to be healthier than other old people and these findings could be a consequence of inaccurate symptoms reporting, delaying diagnosis; or may reflect a failure on the part of screening strategies to investigate thoroughly and to diagnose disease in these patients. - Comorbidity scores performed differently predicting the studied adverse outcomes and, according to our results, the CIRS and the GIC are those that we recommend to use in the elderly for clinical and research purposes. The GIC was the most accurate predictor of death during hospitalization, the risk of death being 30 times higher; followed by the CIRS. The CIRS was the strongest predictor of a prolonged hospital stay and institutionalization. Concerning 1-year risk, the GIC and the CIRS were the best predictors for mortality and for readmission. The GIC was the only significant predictor of institutionalization. The CIRS was the strongest risk predictor of 5 years survival after hospital discharge, followed by the GIC. - Dementia predicted only institutionalisation immediately after discharge; whereas higher comorbidity score predicted death in hospital or longer hospital stay, regardless of cognitive status. Functional status was the best predictor of greater home care needs. Regarding the 5-year risk of mortality, the univariate model showed that being older, male and having vascular and severe dementia, higher comorbidity and functional disability were predictive of shorter survival. However, in the full multivariate model adjusted for age and sex, the effect of dementia type or severity completely disappeared when all the variables were added. In multivariate analysis, the best predictor of long-term mortality was higher comorbidity score, followed by functional status. - Telomere length could not be used to distinguish between demented and non demented patients, regardless of the type of dementia, or to predict dementia or MCI conversion. No significant difference in telomere length was observed between cognitively normal patients, demented patients and patients with MCI. Similarly, no significant differences in telomere length were found between patients with different etiologies or severities of dementia. In addition, the combination of telomere length and ApoE polymorphism did not confer a significantly higher dementia risk than ApoEε4 alone. - Telomere length and change in cognitive status (from normal to MCI or dementia, or from MCI to dementia) were not associated after two years of follow-up. Telomere length is not associated with 5-year survival beyond the impact of other risk factors of mortality like comorbidity, functional, nutritional and cognitive status.