The association of geriatric syndromes with hospital outcomes
Background
Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.
Objective
To study the association of frailty (≥6 points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).
Design
Retrospective observational study.
Setting
Large university hospital in England.
Patients
We analyzed 8202 first nonelective inpatient episodes of people aged 75 years and older between October 2014 and October 2015.
Measurements
The outcomes studied were prolonged length of stay (LOS ≥10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models.
Results
Independently of controlling variables, prolonged LOS was predicted by CFS ≥6: odds ratio (OR) =1.55; 95% confidence interval [CI], 1.36-1.77; P < 0.001; HoD: OR = 2.16; 95% CI, 1.79-2.61; P < 0.001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P < 0.001. Inpatient mortality was predicted by CFS ≥6: OR = 2.29; 95% CI, 1.79-2.94; P < 0.001. Delayed discharge was predicted by CFS ≥6: OR = 1.46; 95% CI, 1.27-1.67; P < 0.001; HoD: OR = 2.17; 95% CI, 1.80-2.62; P < 0.001; and ACS: OR = 2.29; 95% CI: 1.83-2.85; P < 0.001. Institutionalization was predicted by CFS ≥6: OR = 2.56; 95% CI, 2.09-3.14; P < 0.001; HoD: OR = 2.51; 95% CI, 2.00-3.14; P < 0.001; and ACS: OR 1.93; 95% CI, 1.46-2.56; P < 0.001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = 0.006.
Conclusions
Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults. Journal of Hospital Medicine 2017;12:83-89. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Geriatric syndromes are multifactorial health conditions that affect older people and include dementia, delirium, impaired mobility, falls, frailty, poor nutrition, weight loss, incontinence, and difficulties with activities of daily living.1 These syndromes are highly prevalent among older patients admitted to acute-care hospitals2,3 and often add complexity to the clinical status of hospitalized older adults with multiple comorbid conditions.4 In the English National Health Service (NHS), the proportion of older people admitted to acute-care hospitals with geriatric syndromes has increased dramatically.5
The recognition and management of geriatric syndromes by hospitalists requires specific knowledge and skill sets.6 However, geriatricians are a scarce resource in many settings, including the NHS. A challenge for service evaluation and research is the generally poor capture of information about geriatric syndromes compared to specific comorbidities in discharge summaries and hospital coding.7 Steps are being taken in the NHS to address this issue, and in 2013 our center started the routine collection of data on clinical frailty, history of dementia (HoD) and acute confusional state (ACS) in all patients 75 years or older admitted nonelectively to the hospital.8The presence of geriatric syndromes in older inpatients is an important driver of adverse outcomes, particularly length of stay (LOS) and admission to institutional care.9 However, acute illness severity (AIS) is also an important determinant of poor outcomes in the inpatient population and may drive disproportionate changes in health status in the most vulnerable.10 Research studies with geriatric syndromes in acute settings have not been able to simultaneously consider AIS.11 In addition, comorbidity is not always associated with an increased number of geriatric syndromes.12
We aimed to study the association of geriatric syndromes such as frailty, HoD and ACS that are measured in routine clinical care with hospital outcomes (prolonged LOS, inpatient mortality, delayed discharge, institutionalization, and 30-day readmission), while controlling for demographics (age, gender), AIS, comorbidity, and discharging specialty (general medicine, geriatric medicine, surgery).
PATIENTS AND METHODS
Study Design and Setting
This retrospective observational study was conducted in a large tertiary university hospital in England with 1000 acute beds receiving more than 102,000 visits to the emergency department (ED) and admitting over 73,000 patients per year; among the latter, more than 12,000 are 75 years and older.
