European Journal of Internal Medicine 25 (2014) e53–e54
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Nonagenarians: Questions and answers Keywords: Nonagenarians General internal medicine ward Short stay unit
To the Editor, We have read the interesting article published by Ramos et al. which concluded that nonagenarians were most frequently admitted to general internal medicine wards (GIMW) followed by short stay units (SSU) and that intra-hospital mortality was observed in nearly one out of each five cases and was three times higher in GIMW compared to SSU [1]. We would like to make some comments about these findings and decision making regarding the hospitalization to GIMW or SSU of very elderly patients. Firstly, we would like to highlight the differences in intra-hospital mortality rates between these services taking into account that the most common diagnosis-related groups were respiratory and circulatory systems in both units [2]. In our opinion it would have been better to compare the intra-hospital mortality and, especially, the 30-day mortality in each diagnosis-related group between both units. Along this line, we would like to comment on some important variables not collected that could be associated with decision making regarding admission placement and intra-hospital mortality. These include clinical data or that of the management of the acute episode, the clinical, functional and cognitive baseline profile of the nonagenarians, or complications during hospitalization [3,4]. Previous studies have shown that severe comorbidity was nearly 20% in nonagenarians admitted to medical wards [5]. Comorbidities and adverse events during hospitalization were strongly correlated with a longer hospital stay and higher mortality risk [6]. Other authors have suggested an association between functional, cognitive status and hypoalbuminemia with worse outcomes in cardio-respiratory diseases in elderly patients [7,8]. There is a high probability that great differences in these fields may lead to an important bias in the selection of patients to one department or another. Secondly, another interesting finding was that nonagenarians admitted to SSU had a lower mean hospital stay and were more frequently discharged to home hospitalization compared to the GIMW. In conjunction with the results described above, these results formulate the hypothesis regarding the best care plan in nonagenarians requiring admission for an exacerbation of chronic cardiorespiratory conditions, that is, either short length stay in hospital followed by home hospitalization or conventional hospitalization. Prolonged hospital stay is associated with complications secondary to immobility such as pressure sores or functional decline. These factors have been described as the main predictors for in-hospital death in admitted nonagenarians [9]. Finally, we agree with the authors that nonagenarians are a frail and complex population and hospital admission is associated with
a high risk of death regardless of the medical services provided. This therefore justifies the need for protocols including geriatric assessment which have been demonstrated to identify problems and reduce the length of hospital stay and mortality of elderly patients as well as the interest in developing new models of care such as home hospitalization that could diminish the complications associated with hospitalization [10]. Conflicts of interest None. References [1] Ramos JM, Sánchez-Martínez R, Nieto F, Sastre J, Valero B, Priego M, et al. Characteristics and outcome in nonagenarians admitted in general internal medicine and other specialties. Eur J Intern Med 2013;24:740–4. [2] Martínez Ortiz de Zárate M, González Del Castillo J, Julián Jiménez A, Piñera Salmerón P, Llopis Roca F, Guardiola Tey JM, et al. Estudio INFURG-SEMES: epidemiología de las infecciones atendidas en los servicios de urgencias hospitalarios y evolución durante la última década. Emergencias 2013;25:368–78. [3] Julián Jiménez A, Parejo Miguez R, Cuena Boy R, Palomo De Los Reyes MJ, Laín Terés N, Lozano Ancín A. Intervenciones para mejorar el manejo de la neumonía adquirida en la comunidad desde el servicio de urgencias. Emergencias 2013;25:379–92. [4] Aguirre Tejedo A, Miró O, Jacob Rodríguez A, Herrero Puente P, Martín-Sánchez FJ, Alemany X, et al. Papel del factor precipitante de un episodio de insuficiencia cardiaca aguda en relación al pronóstico a corto plazo del paciente: estudio PAPRICA. Emergencias 2012;24:438–46. [5] Lázaro M, Marco J, Barba R, Ribera JM, Plaza S, Zapatero A. Nonagenarian patients admitted to Spanish internal medicine hospital departments. Rev Esp Geriatr Gerontol 2012;47:193–7. [6] Nobili A, Licata G, Salerno F, Pasina L, Tettamanti M, Franchi C, et al. Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study. Eur J Clin Pharmacol 2011;67:507–19. [7] Zuccalà G, Pedone C, Cesari M, Onder G, Pahor M, Marzetti E, et al. The effects of cognitive impairment on mortality among hospitalized patients with heart failure. Am J Med 2003;115:97–103. [8] Yanagisawa S, Miki K, Yasuda N, Hirai T, Suzuki N, Tanaka T. Clinical outcomes and prognostic factor for acute heart failure in nonagenarians: impact of hypoalbuminemia on mortality. Int J Cardiol 2010;145:574–6. [9] Zafrir B, Laor A, Bitterman H. Nonagenarians in internal medicine: characteristics, outcomes and predictors for in-hospital and post-discharge mortality. Isr Med Assoc J 2010;12:10–5. [10] Martín-Sánchez FJ, Fernández Alonso C, Gil Gregorio P. Key points in healthcare of frail elders in the emergency department. Med Clin (Barc) 2013;140:24–9.
Francisco Javier Martín-Sánchez Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain Instituto de Investigación Sanitaria del Hospital San Carlos, Madrid, Spain Corresponding author at: Servicio de Urgencias, Hospital Clínico San Carlos, Calle Profesor Martín-Lagos s/n, 28040 Madrid, Spain. Tel.: +34 91 330 37 50; fax: +34 91 330 35 69. E-mail address: [email protected]. Montserrat Lázaro Nogal Servicio de Geriatría, Hospital Clínico San Carlos, Madrid, Spain
0953-6205/$ – see front matter © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejim.2013.11.001
e54
Letter to the Editor
Juan González del Castillo Juan Jorge González Armengol Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain Instituto de Investigación Sanitaria del Hospital San Carlos, Madrid, Spain
José Manuel Ribera Casado Profesor Emérito de Geriatría, Universidad Complutense de Madrid, Spain 27 October 2013
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Nonagenarians: Questions and answers Keywords: Nonagenarians General internal medicine ward Short stay unit
To the Editor, We have read the interesting article published by Ramos et al. which concluded that nonagenarians were most frequently admitted to general internal medicine wards (GIMW) followed by short stay units (SSU) and that intra-hospital mortality was observed in nearly one out of each five cases and was three times higher in GIMW compared to SSU [1]. We would like to make some comments about these findings and decision making regarding the hospitalization to GIMW or SSU of very elderly patients. Firstly, we would like to highlight the differences in intra-hospital mortality rates between these services taking into account that the most common diagnosis-related groups were respiratory and circulatory systems in both units [2]. In our opinion it would have been better to compare the intra-hospital mortality and, especially, the 30-day mortality in each diagnosis-related group between both units. Along this line, we would like to comment on some important variables not collected that could be associated with decision making regarding admission placement and intra-hospital mortality. These include clinical data or that of the management of the acute episode, the clinical, functional and cognitive baseline profile of the nonagenarians, or complications during hospitalization [3,4]. Previous studies have shown that severe comorbidity was nearly 20% in nonagenarians admitted to medical wards [5]. Comorbidities and adverse events during hospitalization were strongly correlated with a longer hospital stay and higher mortality risk [6]. Other authors have suggested an association between functional, cognitive status and hypoalbuminemia with worse outcomes in cardio-respiratory diseases in elderly patients [7,8]. There is a high probability that great differences in these fields may lead to an important bias in the selection of patients to one department or another. Secondly, another interesting finding was that nonagenarians admitted to SSU had a lower mean hospital stay and were more frequently discharged to home hospitalization compared to the GIMW. In conjunction with the results described above, these results formulate the hypothesis regarding the best care plan in nonagenarians requiring admission for an exacerbation of chronic cardiorespiratory conditions, that is, either short length stay in hospital followed by home hospitalization or conventional hospitalization. Prolonged hospital stay is associated with complications secondary to immobility such as pressure sores or functional decline. These factors have been described as the main predictors for in-hospital death in admitted nonagenarians [9]. Finally, we agree with the authors that nonagenarians are a frail and complex population and hospital admission is associated with
a high risk of death regardless of the medical services provided. This therefore justifies the need for protocols including geriatric assessment which have been demonstrated to identify problems and reduce the length of hospital stay and mortality of elderly patients as well as the interest in developing new models of care such as home hospitalization that could diminish the complications associated with hospitalization [10]. Conflicts of interest None. References [1] Ramos JM, Sánchez-Martínez R, Nieto F, Sastre J, Valero B, Priego M, et al. Characteristics and outcome in nonagenarians admitted in general internal medicine and other specialties. Eur J Intern Med 2013;24:740–4. [2] Martínez Ortiz de Zárate M, González Del Castillo J, Julián Jiménez A, Piñera Salmerón P, Llopis Roca F, Guardiola Tey JM, et al. Estudio INFURG-SEMES: epidemiología de las infecciones atendidas en los servicios de urgencias hospitalarios y evolución durante la última década. Emergencias 2013;25:368–78. [3] Julián Jiménez A, Parejo Miguez R, Cuena Boy R, Palomo De Los Reyes MJ, Laín Terés N, Lozano Ancín A. Intervenciones para mejorar el manejo de la neumonía adquirida en la comunidad desde el servicio de urgencias. Emergencias 2013;25:379–92. [4] Aguirre Tejedo A, Miró O, Jacob Rodríguez A, Herrero Puente P, Martín-Sánchez FJ, Alemany X, et al. Papel del factor precipitante de un episodio de insuficiencia cardiaca aguda en relación al pronóstico a corto plazo del paciente: estudio PAPRICA. Emergencias 2012;24:438–46. [5] Lázaro M, Marco J, Barba R, Ribera JM, Plaza S, Zapatero A. Nonagenarian patients admitted to Spanish internal medicine hospital departments. Rev Esp Geriatr Gerontol 2012;47:193–7. [6] Nobili A, Licata G, Salerno F, Pasina L, Tettamanti M, Franchi C, et al. Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study. Eur J Clin Pharmacol 2011;67:507–19. [7] Zuccalà G, Pedone C, Cesari M, Onder G, Pahor M, Marzetti E, et al. The effects of cognitive impairment on mortality among hospitalized patients with heart failure. Am J Med 2003;115:97–103. [8] Yanagisawa S, Miki K, Yasuda N, Hirai T, Suzuki N, Tanaka T. Clinical outcomes and prognostic factor for acute heart failure in nonagenarians: impact of hypoalbuminemia on mortality. Int J Cardiol 2010;145:574–6. [9] Zafrir B, Laor A, Bitterman H. Nonagenarians in internal medicine: characteristics, outcomes and predictors for in-hospital and post-discharge mortality. Isr Med Assoc J 2010;12:10–5. [10] Martín-Sánchez FJ, Fernández Alonso C, Gil Gregorio P. Key points in healthcare of frail elders in the emergency department. Med Clin (Barc) 2013;140:24–9.
Francisco Javier Martín-Sánchez Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain Instituto de Investigación Sanitaria del Hospital San Carlos, Madrid, Spain Corresponding author at: Servicio de Urgencias, Hospital Clínico San Carlos, Calle Profesor Martín-Lagos s/n, 28040 Madrid, Spain. Tel.: +34 91 330 37 50; fax: +34 91 330 35 69. E-mail address: [email protected]. Montserrat Lázaro Nogal Servicio de Geriatría, Hospital Clínico San Carlos, Madrid, Spain
0953-6205/$ – see front matter © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejim.2013.11.001
e54
Letter to the Editor
Juan González del Castillo Juan Jorge González Armengol Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain Instituto de Investigación Sanitaria del Hospital San Carlos, Madrid, Spain
José Manuel Ribera Casado Profesor Emérito de Geriatría, Universidad Complutense de Madrid, Spain 27 October 2013
