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THE JOURNAL OF NUTRITION, HEALTH & AGING©
RISK OF IN-HOSPITAL MORTALITY FOLLOWING EMERGENCY DEPARTMENT ADMISSION: RESULTS FROM THE GERIATRIC EDEN COHORT STUDY C.P. LAUNAY1,2, C. ANNWEILER1,4, L. DE DECKER3, A. KABESHOVA1,2, B. FANTINO1, O. BEAUCHET1 1. Department of Neuroscience, Division of Geriatric Medicine, Angers University Hospital, Angers, France; 2. UPRES EA 4336, UNAM, Angers University Hospital; 3. Department of Geriatrics, EA 1156-12, Nantes University Hospital, Nantes, France; 4. Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, the University of Western Ontario, London, Ontario, Canada. Corresponding author: Olivier Beauchet, MD, PhD; Department of Neuroscience, Division of Geriatric Medicine, Angers University Hospital, 49933 Angers cedex 9, France; E-mail: [email protected]
; Phone: ++33 2 41 35 45 27; Fax: ++33 2 41 35 48 94, Alternate corresponding author: [email protected]
Abstract: Objective: To determine whether being admitted to emergency department (ED) for social disorders may predict a higher risk of in-hospital mortality among older inpatients. Design: Prospective cohort study (mean follow-up: 9.1±10.0 days). Setting: Angers University Hospital, France. Participants: Four hundred twenty-two inpatients (mean age 84.9±5.6years, 64.2% women). Methods: At their admission to ED, inpatients aged 75 years and over received an assessment composed of 6 items: age, gender, number of drugs daily taken, history of falls during the past 6 months, usual place of life, and use of formal and/or informal home and social services. The reasons for admission to ED as well the diagnosis at the time of hospital discharge were separated into social and health disorders. The length of hospital stay was calculated in number of days using the hospital registry. Inpatients were separated into 2 groups based on the occurrence or not of death during the hospital stay. Results: Older inpatients who died at hospital were more frequently institutionalized (P=0.034) and admitted to ED for social disorders (P=0.002) than those who did not. Multiple Cox regression model revealed that living in institution and social disorders as a reason for admission to ED were significantly associated with the occurrence of death at hospital (P=0.008 and P=0.036). Kaplan-Meier distributions of in-hospital mortality showed that home-living inpatients admitted to ED for social disorders died more and faster during hospitalization than those admitted for health disorders (P=0.016). Conclusion: Being admitted to ED for social disorders and living in institution predicted a higher risk of in-hospital mortality. Key words: In-hospital mortality, social disorders, hospital stay.
mortality among older inpatients because of related misdiagnosis and/or mistreatment of diseases. The purpose of this study was to determine whether being admitted to ED for social disorders may predict a higher risk of in-hospital mortality among older patients.
Introduction The number of unplanned hospitalizations of patients aged 75 and over after visiting Emergency Departments (EDs) is continuously increasing in Europe and in the United States of America (USA) with an incidence estimated around 7% (1-3). These older inpatients are characterized by a higher risk of inhospital mortality compared to younger inpatients (4). In-hospital mortality of older inpatients has been associated to acute diseases which destabilise a vulnerable state of health characterized by cumulate chronic diseases and limited physiologic reserves leading to multiple organ system impairment (4-6). Recently, it has been reported that social disorders reduced the medium-term survival in older community-dwellers (7). The social and health disorders have a complex inter-play and thus admission to ED for social disorders may lead to mismanage (i.e., misdiagnosis and/or mistreatment) of acute and chronic diseases in older patients (4, 6-11). The acute care need is therefore obscured and the delay of recognition of the underlying acute illness contributes to increase the acute problem and may lead to death. We hypothesized that the admission to ED for social disorders, defined as the absence of symptoms of acute diseases combined with an acute increase of the use of formal and/or informal home and social services leading to an inability to stay in its place for life, could predict the risk of in-hospital Received January 3, 2013 Accepted for publication March 1, 2013
Methods Population Between February 2 and April 1 2011, 422 participants (mean age 84.9±5.6years, 64.2% women) were prospectively included in the geriatric ‘Emergency Department Elderly populatioN’ (EDEN) cohort study. The inclusion criteria were an unplanned admission to ED by primary care physicians followed by discharge in an acute care unit of Angers University Hospital, France; age of 75 years and over; and willingness to participate. The local ethics committee of Angers approved the project. Assessment A brief geriatric assessment (BGA) was performed (9). It was composed by the 6 following items: age coded as a binary variable (i.e., > or < 85years), gender (i.e., male versus female), number of drugs daily taken, history of falls during the past 6 months (i.e., yes or no), usual place of life (i.e., home-living 1
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HOSPITALIZATION AND MORTALITY versus institution-dwelling defined as living in nursing home or in senior housing facilities); and the use of formal and/or informal home and social services coded as a binary variable (i.e., yes or no). We chose these items because each of them has been separately associated with a higher risk of death among older inpatients (4, 12-15). Polypharmacy was defined by the highest tertile of the number of drugs taken per day (i.e., >7). A fall was defined as unintentionally coming to rest on the ground, floor, or other lower level. Information on falls and formal or informal home services were obtained from patient, or from a close person who lived with the patient. The non-use of home-help services was defined as living alone without using any formal or informal home services and social help. The use of formal home and social services was sought in both participants who lived at home or in institution since the French health and social system is so that an older adult who lives in institution may use or not additional formal home and social services. The reasons for admission to ED were separated into 2 categories: social disorders defined as the absence of symptoms of acute diseases combined with an acute increase of the use of formal and/or informal home and social services leading to an inability to stay in its place for life; versus health disorders defined as mobility disorders, neuropsychiatric disorders and organ failures (i.e., congestive heart failure, chronic lung disease, chronic kidney disease or cirrhosis). The same classification was used to characterize the diagnosis at the time of hospital discharge. In-hospital mortality was recorded from the administrative registry of Angers University Hospital. The length of stay was also calculated using the administrative registry of Angers University Hospital and corresponded to the delay in days between the first day of admission to ED and the last day of hospitalization in any acute care unit.
into 2 groups based on the occurrence or not of death during the hospital stay. First, between-group comparisons were performed using the Chi-square test. Second, multiple analysis based on Cox regression model was used to identify the most significant baseline characteristics related to the delay of the inhospital death. Third, the time elapsing to death among homeliving inpatients was studied by survival curves computed according to the Kaplan-Meier method and compared by the log-rank test. Participants were censored when they were discharged from the hospital. P-values less than 0.05 were considered statistically significant. All statistics were performed using SPSS (version 19.0; SPSS, Inc., Chicago, IL). Results
As shown in Table 1, older inpatients who died during their hospitalization were more frequently institutionalized (P=0.034 and P= 0.004 for the global comparison between the 3 strata of place of life [i.e., living at home without home-help services versus living at home withhome-help services versus living in institution]) and admitted to ED for social disorders (P=0.002) than those who did not die. In addition, Cox regression model revealed that living in institution and social disorders as a reason for admission to ED were significantly associated with in-hospital mortality (P=0.008 and P=0.036). Kaplan-Meier estimating of the probability of death during the hospital stay of home-living participants admitted or not to ED for socialrelated reasons is reported in Figure 1. Kaplan-Meier distributions showed that those who were admitted to ED for social disorders died more and faster than those who were admitted for health disorders (P=0.016). These results were true only while using the reason for admission. Conversely the diagnosis at the time of hospital Statistical analysis discharge made after further explorations did not differ between The participants’ baseline characteristics were summarized the patients who died during hospitalization and those who did using frequencies and percentages. Participants were separated not (respectively, 70.6% (n=24) versus 62.9% (n=244) with Table 1 Baseline characteristics of inpatients based on in-hospital mortality after an admission to the emergency department and full adjusted risk estimates over time of in-hospital mortality based on multiple Cox regression models (n=422) Characteristics
Baseline characteristics In-hospital mortality* Yes No (n=34) (n=388)
Age > 85 years, n (%) Male, n (%) History of falls in the past 6 months, n (%) Polypharmacy ‡, n (%) Living, n (%): At home and non-use of home-help services § At home and use of home-help services § In institution || Social disorders as a reason for admission to ED, n (%)
Relative risk over time of in-hospital mortality HR [95%CI] P-value
22 (64.7) 9 (26.5) 15 (44.1) 16 (47.1)
202 (52.1) 142 (36.6) 171 (44.1) 161 (41.5)
0.209 0.268 0.852 0.588
1.21 0.97 1.09 0.91
[0.56;2.65] [0.43;2.18] [0.52;2.25] [0.43;1.92]
0.629 0.931 0.826 0.802
9 (26.5) 8 (23.5) 17 (50.0) 14 (41.2)
153 (38.4) 116 (29.9) 120 (30.9) 64 (16.5)
0.197 0.557 0.034 0.002
2.09 3.58 2.25
1.00 (Ref#) [0.76;5.72] [1.39;9.22] [1.06;4.78]
0.152 0.008 0.036
HR: Hazard ratio; CI: Confidence interval; ED: Emergency Department; P-value and HR significant (i.e., P < 0.05) indicated in bold; *: Death during hospitalization; †: Between-group comparison based on Chi-square test; ‡: Taking more than 7 drugs per day; §: Living alone without or with formal and/or informal home services and social help; ||: Living in nursing home or in senior housing facilities; #: Score=1 used as reference level.
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THE JOURNAL OF NUTRITION, HEALTH & AGING© P=0.459 for organ failures, 11.8% (n=4) versus 11.1% (n=43) with P=0.782 for mobility disorders, 5.9% (n=2) versus 14.7% (n=59) with P=0.201 for neuropsychiatric disorders). In particular, there were no differences regarding the diagnosis of social-related conditions (11.8% (n=4) versus 11.3% (n=44) with P=1.000).
An interrelation between health and social vulnerability may explain in part the higher rate of in-hospital death associated with social disorders in our study. We suggest that being admitted to ED for social disorders was not only related to social vulnerability but also to health vulnerability. Older adults’ state of health is heterogeneous because of various cumulate effects of chronic diseases and physiologic decline, contributing to a vicious cycle of increasing vulnerability that leads to a greater risk of new or worsened disability and mortality (5,11). Any event might decompensate this state of increasing vulnerability whose clinical expression may be an acute inability to stay in its environment (17,18). Identifying factors causing such decompensation is challenging and may lead to misdiagnosis and/or mismanage. For instance, Lakhan et al. (18) have reported that geriatric syndromes may be highly prevalent among older inpatients but sometimes neither recognized nor correctly managed. Our results, showing that only the social reason for admission, but not the social condition diagnosed at the time of the discharge (i.e., after further explorations), differed between the inpatients dying during hospitalisation and the others. This strengthened the idea that in-hospital mortality in patients admitted to ED for social disorders was probably due to a misdiagnosis and/or a mistreatment of an initially unrecognized acute disease leading to an acute functional decline with consequent greater death risk. Our results also highlight that institutionalization predicted in-hospital mortality. This is consistent with previous studies that have identified that nursing-home residents are twice as likely to die in hospital (19). In particular, it has been suggested that the frequent hospital readmissions of nursing-home residents may explain the increased risk of dying in the hospital. Curiously, while the hypothesis of poor health conditions characterizing institutionalized older adults may explain a higher rate of death, Kelley et al. (6) have recently reported an opposite result. One explanation may rely on the different healthcare systems across countries. In addition, we did not find any association of in-hospital mortality with age, gender, history of falls and polypharmacy. The high level of vulnerability of oldest-old adults who composed the studied sample of older inpatients could account for these inconclusive results. Some limitations of this study need to be considered. First, selected older inpatients were not representative of the general population of older adults admitted to EDs because we focused in a single ED on patients admitted by their primary care physicians. Second, given a number of differences in healthcare systems across countries, the generalization of our findings could be limited to the French healthcare system. Third, although we were able to control for many characteristics likely to modify the association between social disorders and inhospital mortality, residual potential confounders might still be present. In conclusion, our findings showed that the admission to ED
Figure 1 Kaplan-Meier estimates of the probability of in-hospital mortality among home-living participants admitted or not to the emergency department for social disorders
Discussion Our results show that being admitted to ED for social disorders and living in institution predicted higher risk of inhospital mortality among the studied sample of older inpatients. The fact that admission to ED for social disorders predicted more frequent occurrence of in-hospital death in our study is consistent with previous studies that have shown associations between social factors and survival. For instance, lower social supports corresponding to limited social ties and network have been associated with higher rates of mortality. Blazer (16) has reported in a community-dwelling sample of older adults that lower social supports predicted increased mortality after 30 months with a crude relative risk of 1.96 for impaired roles and available attachments, of 3.86 for impaired perceived social support, and of 2.72 for impaired frequency of social interaction. More recently, Andrew et al. (7) have also shown that a greater social vulnerability was associated with long-term mortality in older adults. Compared to previous findings, we found that social disorders were associated with shorter-term mortality. Furthermore, our approach to measure social vulnerability was not based on patients' self-reported information but on objective measures of increased social needs. 3
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HOSPITALIZATION AND MORTALITY for social disorders predicted in-hospital mortality, underlining that early and adapted care management (i.e., diagnosis and treatment) should be provided to all older inpatients, even those admitted for social disorders. Further research is needed to corroborate this finding.
Acknowledgments: The authors wish to thank Angers University Hospital for technical support. We are grateful to the participants for their cooperation.
Conflict of interest and disclosures: Launay: has no relevant financial interest in this manuscript. Annweiler: has no relevant financial interest in this manuscript. de Decker: has no relevant financial interest in this manuscript. Kabeshova: has no relevant financial interest in this manuscript. Fantino: has no relevant financial interest in this manuscript Beauchet: has no relevant financial interest in this manuscript.
Author Contributions: − Launay has full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses. − Study concept and design: Beauchet. − Acquisition of data: Launay and de Decker. − Analysis and interpretation of data: Launay, Annweiler, de Decker, Kabeshova and Beauchet. − Drafting of the manuscript: Launay and Beauchet. − Critical revision of the manuscript for important intellectual content: de Decker, Fantino and Annweiler. − Obtained funding: Not applicable. − Statistical expertise: Launay and Kabeshova. − Administrative, technical, or material support: Annweiler. − Study supervision: Beauchet.
Sponsor's Role: The study was supported by the “Gérontopôle Autonomie Longévité des Pays de la Loire”. The sponsor had no role in the design and conduct of the study, in the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript.
Funding sources and related paper presentations: None
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