l’anziano affetto da demenza in ospedale€“ fenomenologia del paziente anziano con lrti –...

Renzo ROZZINI (Brescia)

L’Anziano Affetto da Demenza in Ospedale

• La malattia somatica nei diversi stadi della demenz a– Stadio di demenza lieve

• Lo stigma vs il diritto della diagnosi– Stadio di demenza intermedia

• Il delirium– Stadio di demenza grave

• Implicazioni prognostiche e scelte terapeutiche• Le riospedalizzazioni • Le malattie infettive (l’esempio delle polmoniti-LR TI)

– Fenomenologia del paziente anziano con LRTI– Mortalità in&out– LRTI e funzione e outcome

• Terapia antibiotica nei pazienti con demenza grave: troppo o troppo poco?

• Parlare alla congregazione invece che al coro• Conclusioni

Sommario

Underlyingstatus

Robust Frail With dementiaFrail and

with dementiaDying

M Gillick, 2000

Lo stato di salute (il background clinico)

Il paziente robusto• Non disabile (BADL=0/6)• Senza demenza (MMSE> 18)

Il paziente fragile• Con disabilità (BADL=1+/6)

Il paziente con demenza• ▼cognitività (MMSE<18)

Il paziente fragile&con demenza• Con disabilità (BADL=1+/6)• ▼cognitività (MMSE<18)








Sommario

Pazienti con delirium durante il ricovero ospedalie ro risultano alla dimissione funzionalmente più compromessi:

Gruppo con delirium: 26% peggiora55% stazionario19% migliora

Gruppo senza delirium: 12% peggiora60% stazionario28% migliora

Delirium: predittore di peggioramento funzionale le gato all’ospedalizzazione

(J Am Geriatr Soc, 1997)

Declino funzionale








Sommario

Stato di salute e outcome correlati allo stato cognitivo in pazienti anziani ricoverati in reparto medico geriatrico per patologia acuta.

Events/total RR a 95% C.I. RRb 95% C.I.

Age >80 267/1625 1.5 1.2-1.8 -- --Being male 217/1366 1.3 1.1-1.6 -- --Alcoholism 33/160 1.7 1.1-2.5 1.7 1.0-2.8BADL before 366/1619 4.2 3.4-5.2 2.5 1.8-3.5APS>4 303/1254 3.6 2.9-4.4 2.1 1.5-2.9Bun/Creat >60 174/954 1.7 1.4-2.1 1.4 1.1-1.8Serum Alb<3.5mg/dl 263/1285 2.4 2.0-2.9 1.5 1.2-1.9Charlson Index > 3 277/1614 1.7 1.4-2.0 -- --Drugs > 5 243/1197 2.0 1.6-2.6 -- --Stroke 43/264 1.3 0.9-1.8 -- --COPD 149/795 1.6 1.3-2.0 -- --Metastatic cancer 43/246 1.3 0.9-1.9 -- --Pneumonia 90/418 1.9 1.5-2.5 -- --

Integrità cognitiva 135/1809 1.0 Ref. 1.0 Ref.MCI&MVCI 121/861 2.0 1.6-2.6 1.9 1.4-2.7AD 128/529 3.9 3.0-5.2 2.4 1.7-3.5VD 102/336 5.4 4.0-7.2 3.3 2.3-4.8

Fattori associati a delirium (n=486) in 3500 pazien ti anziani spedalizzati per patologia acuta.


Age >80 131/1625 1.6 1.2-2.0 -- --Being male 122/1364 1.3 1.1-1.6 -- --Live alone 37/877 0.5 0.3-0.7 -- --Alcoholism 18/160 1.7 1.1-2.9 -- --BADL before 228/1618 14.2 9.1-22.2 4.2 2.0-9.3APS>4 218/1252 14.8 10.2-21.8 7.3 4.9-10.9Bun/Creat >60 88/954 2.4 1.8-3.2 -- --Serum Alb<3.5mg/dl 153/1284 4.6 3.4-6.2 1.5 1.0-2.4Charlson Index > 3 163/1612 2.4 1.8-3.1 -- --Drugs > 5 156/1197 4.9 3.4-6.9 2.1 1.3-3.3COPD 88/794 2.0 1.5-2.6 -- --Pneumonia 53/418 2.3 1.7-3.2 -- --Liver Cirrhosis 16/155 1.5 0.9-2.6 -- --Metastatic cancer 46/245 3.5 2.5-4.9 3.2 1.9-5.3Delirium 122/491 7.6 5.8-9.9 3.6 2.5-5.2


Fattori associati a mortalità intraospedaliera (n=24 7) in 3500 pazienti anziani ricoverati per patologia acuta


Age>80 220/1494 1.8 1.5-2.3 1.2 0.9-1.5Being male 165/1242 1.3 1.1-1.7 -- --Live alone 60/840 0.5 0.4-07 0.6 0.4-0.9Serum Alb<3.5mg/dl 230/1131 3.7 2.9-46 1.7 1.3-2.3BADL before 277/1390 4.6 3.6-5.9 1.6 1.1-2.2APS>4 228/1034 4.1 3.3-5.1 1.7 1.3-2.2Bun/Creat >60 128/866 1.7 1.3-2.2 -- --Charlson Index > 3 236/1449 2.4 1.9-3.0 1.3 1.0-1.7Drugs >5 198/1041 2.3 1.8-3.0 1.5 1.1-1.9COPD 108/706 1.6 1.2-2.0 -- --Pneumonia 77/365 2.4 1.8-3.2 -- --Liver Cirrhosis 24/139 1.7 1.1-2.6 -- --Metastatic cancer 56/199 3.4 2.5-4.8 2.2 1.6-3.0Delirium 83/369 2.6 2.0-3.5 1.5 1.1-2.0


Factori associati a mortalità a tre mesi (n=370) in 3500 pazienti

anziani ricoverati per patologia acuta

Total Without SevD SevD not Br SevD & BrN=1310 N=1155 N=71 N=84M(±SD) M(±SD) M (±SD) M (±SD)

n (%) n (%) n (%) n (%)

Age (years) 79.4 (±7.8) 77.4 (±7.7) 77.0 (±6.9) 79.5 (± 7.0)Gender (male) 425 (32.4) 378 (32.7) 21 (29.9) 26 (31.0)MMSE score 22.2 (±7.9) 24.5 (±4.6) 8.0 (±4.1) 1.8 (±3.6 )GDS score 5.2 (±3.6) 5.2(±3.6) NA NALiving alone 382 (29.7) 382 (33.1) NA NABarthel Index prior 83.2 (±24.2) 88.0 (±17.8) 67.9 (± 22.6) 30.3 (±31.8)Barthel Index at 74.4 (±30.7) 80.7 (±24.8) 55.8 (±20. 3) 3.3 (±5.5)Barthel Index at discharge 76.6 (±29.6) 83.1 (±22.8) 5 5.3 (±21.3) 5.3 (±9.4)No of IADLs lost prior 3.3 (±3.8) 2.8 (±3.8) 6.2 (±2. 2) 7.3 (±1.3)Charlson Index 2.6 (±2.4) 2.4 (±2.3) 3.9 (±2.5) 4.3 (± 2.6)Drugs (n) 4.3 (±1.8) 4.3 (±1.9) 4.1 (±1.8) 3.9 (±1.8)APACHE II score 8.1 (±4.7) 7.7 (±4.3) 9.3 (±4.2) 13.2 (±7.1)APS-APACHE II score 1.9 (±2.9) 1.7 (±2.5) 2.3 (±2.5) 5. 1 (±5.2)Serum Albumin (g/dl) 4.0 (±0.7) 4.1 (±0.6) 3.9 (±0.6) 3 .3 (±0.6)Serum Cholesterol (mg/dl) 203.5 (±32.0) 206.5 (±51.3) 194.1 (±54.2) 168.9 (±45.9)Hemoglobin (g/dl) 12.2 (±2.1) 12.3 (±2.3) 11.8 (±2.2) 1 1.1 (±2.4)LOS (days) 6.9 (±3.3) 6.9 (±3.2) 6.3 (±2.7) 6.7 (±4.6)

Six month mortality 213 (16.3) 144 (12.5) 15 (21.1) 54 (64.4)

Characteristics of 1310 hospitalized elderly patien ts according to their mental status before admission: not affected by severe dem entia, with severe dementia but not confined to bed, and with severe dementia a nd confined to bed.

Age&Aging, 2007

A BN/events RR (95% C.I.) RR (95% C.I.)

Cancer 196/78 4.8 (3.4-6.7) 3.4 (2.3-5.1)Heart failure (NYHA III-IV) 137/40 2.3 (1.5-3.5) 1.8 ( 1.1-2.9)Gastroenteric disease 104/30 2.2 (1.4-3.5) 2.0 (1.3-3. 2)Charlson Index score (3+) 361/126 5.3 (3.9-7.2) 2.6 (1 .7-3.9)APS-APACHE II (4+) 254/95 4.9 (3.5-6.7) 2.2 (1.5-3.2)Drugs number (5+) 680/119 1.9 (1.2-2.6) 1.6 (1.1-2.5)Negative events (1+) 138/43 2.7 (1.8-4.0) 1.6 (1.0-2. 5)

Demenza assente o non grave 1155/144 1.0 (ref.) 1.0 (r ef.)Con demenza grave ma non allettati 71/15 2.4 (1.3-4. 3) 1.7 (1.0-3.1)Con demenza grave e allettati 84/54 6.3 (4.0-9.9) 4.6 (2.8-7.6)

Age 80+ 630/127 1.7 (1.3-2.3) -Gender (male) 425/89 1.6 (1.2-2.1) -Respiratory (COPD/pneumonia) 456/110 2.2 (1.6-2.1) -Renal failure (Creatinine>2.5 mg/dl)) 197/52 2.1 (1.4 -2.9) -Major Stroke 159/41 1.9 (1.3-2.8) -Anemia (Hb< 8.0g/dl) 145/55 3.8 (2.6-5.6) -Liver cirrhosis (Child C) 65/19 2.2 (1.2-3.8) -Congestive Heart failure (NYHA III-IV) 56/23 3.8 (2.2 -6.6) -Diabetes Mellitus (Glucose> 350mg/dl) 73/19 1.8 (1.1 -3.2) -Serum albumin (<3.5g/dl) 275/92 4.0 (2.9-5.5) -

Factors associated to 6-month mortality of 1310 hospitalized elderly patients.

Age&Aging, 2007








Sommario

CURB-65 (Confusion, BUN, FR, BP-65y)score

Confusione (demenza o delirium) 1Azotemia (>45 mg/dl) 1Freq. respiratoria (> 30/min) 1Pressione arteriosa (PAS< 90 o PAD<60mmHg) 1Età (65+) 1

Totale _____

Criteri di Gravità Clinica e Ospedalizzazione

No/CDR 0.5-3 Demenza (CDR 4-5)N=3133 N=367N (%) N (%)

Respiratorio 731 (24.0) 93 (25.8)Cuore 657 (21.6) 32 (8.9)SNC 359 (11.8) 40 (11.1)GE 322 (10.6) 30 (8.3)Infettivo (sepsi) 169 (5.6) 81 (22.4)Fegato 118 (3.9) 15 (4.2)Rene 97 (3.2) 15 (4.2)

Altro 591 (18.8) 55 (14.9)

Prevalenze MDC in pazienti 3500 ricoverati in Geria tria suddivisi per presenza/assenza di Demenza CDR 4-5

Rozzini, et al. Arch Int Med, 2003

In conclusion, hospitalized CAP is associated with many deaths outside the time frame normally considered in this otherwise acute disease . As clinicians, we need to consider the effects of CAP on mortality far beyond hospital discharge. The observ ed high mortality rates are important for prognosticat ion, patient and family counseling, and medical decision making. Improved understanding of the poor long-term prognosis associated with CAP is needed to modify the dismal outcome of this common disease in elderly patients.

1009080706050403020100

(days from diagnosis)

100

90

80

70

60

50

40

Cum

ulat

ive

Sur

viva

l

Yes LRI-Yes dementia

Yes LRI-No dementia

No LRI-Yes dementia

No LRI-No dementia

Three months survival of elderly patients according to lowerrespiratory tract infection (LRI) and dementia

n=2566

n=265

n=345

n=124

JAMDA, 2008

Characteristics and 3-months mortality rate of 3300 in patients affected by Low Respiratory Tract Infections (LRI) and dementia.

Total NoLRI-NoD YLRI-NoD NoLRI-YD YLRI-YD(N=3300) (N=2566) (N=265) (N=345) (N=124) p

M+SD (%) M+SD (%) M+SD (%) M+SD (%) M+SD (%)

Age (years) 79.2+ 8.0 78.4+7.7 80.0+8.2 83.2+7.7 83.4+8.4 0.001Gender (males)(%)* (38.3) (24.5) (24.5) (24.5) (19.3) 0.001MMSE score 21.8+ 8.5 24.9+4.4 23.4+4.9 4.5+4.7 3.7+4.4 0.001GDS score 4.6+ 3.5 4.6+3.5 4.2+3.1 --- --- 0.155Barthel Index (15 days bef) 78.7+ 27.9 86.5+19.8 76.2+26.6 45.7+34.5 30.2+28.7 0.001Barthel Index (on adm) 60.1+ 38.1 71.8+32.2 48.6+37.1 22.0+29.2 5.5+14.2 0.001IADL (functions lost) 3.3+ 2.9 2.6+2.6 3.4+2.9 6.3+2.4 7.0+1.6 0.001Diseases (n) 5.1+ 2.0 5.1+1.9 5.3+2.0 5.2+2.2 5.4+2.3 0.142Charlson Index 5.3+ 1.8 5.0+1.7 5.5+1.9 5.8+2.1 6.5+2.2 0.001Drugs (n) 5.7+ 2.9 5.4+2.6 6.2+3.3 5.8+3.1 6.9+3.0 0.194APACHE II score 10.6+ 5.9 9.1+4.9 13.7+4.9 13.0+6.8 18.3+6.6 0.001APACHE II-APS subscore 4.4+ 5.2 3.1+3.9 6.1+5.1 6.5+6.4 10.9+6.9 0.001Serum Albumin (g/dl) 3.7+ 0.7 3.8+0.6 3.4+0.6 3.3+0.7 3.1+0.6 0.001Hemoglobin (g/dl) 12.5+ 2.3 12.6+2.3 12.2+2.2 12.0+2.5 11.9+2.5 0.000Serum Cholesterol (mg/dl) 187.3+ 53.3 192.2+51.9 162.8+49.6 175.4+53.5 160.9+52.5 0.001CPR (mg/dl) 4.4+ 7.4 2.9+5.7 9.1+10.4 7.3+9.6 11.1+9.1 0.001Creatinine (mg/dl) 1.1+ 0.7 1.1+0.6 1.3+0.8 1.2+1.0 1.4+1.1 0.000Length of stay (days) 6.5+ 3.7 6.5+3.6 7.8+4.1 5.8+4.0 5.4+3.9 0.001

3 mos mortality (%)* (13.9) (9.0) (14.7) (35.4) (54.0) 0.001

JAMDA, 2008

Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled

L. Ferrucci, J. M. Guralnik, M. Pahor, M. C. Corti and R. J. Havlik

OBJECTIVE: To characterize hospital diagnoses, proc edures and charges, and nursing home admissions in the year when older pers ons become severely disabled, comparing those in whom severe disability develops rapidly with those in whom disability develops gradually. MAIN OUTCOME MEASURES: Characteristics associated w ith development of severe disability after the fourth annual follow-up, in wh ich the disability is classified as catastrophic disability if the individual did not r eport any ADL disability in the 2 interviews prior to severe disability onset or as p rogressive disability if the individual had previous disability in 1 or 2 ADLs. RESULTS: In the year during which severe disability developed, hospitalizations were documented for 72.1% of those developing catas trophic disability and for 48.6% of those developing progressive disability. The 6 m ost frequent principal discharge diagnoses included stroke, hip fracture, congestive heart failure, and pneumonia in both severe disability subsets.These diagnoses occu rred in 49% of those with catastrophic disability and 25% of those with progr essive disability. CONCLUSIONS: In the year when they become severely disabled, a large proportion of older persons are hospitalized for a small group of diseases. Hospital-based interventions aimed at reducing the severity and fu nctional consequences of these diseases could have a large impact on reduction of severe disability.

JAMA 1997;277:728–734.

Rozzini, et al. JAGS, 2007

Rozzini, et al. JAGS, 2005








Sommario

Arch Intern Med. 2008;168:349-350.

If a drug is effective in a disease treatment we mu st prescribe it independently from its costs (money or the risks of negative consequences on other persons). T he benefits for a single patient are more important th an any other evaluation. Moreover we have to consider that subjects affected by dementia in advanced stag es are about 0.5% of the general population, thus thei r possible contribution to the diffusion of antibioti c resistant bacteria is rather scanty, not allowing a decision as a consequence of this motivation.

Un trattamento efficace deve essere prescritto indipendentemente dai suoi costi (monetari o rispet to alle possibili conseguenze negative su altri).

La prevalenza della demenza molto grave è di circa 0.5%

Rozzini&Trabucchi (2008)








Sommario

These important studies highlight the need for clini cal investigation of infectious syndromes to be more geriatric in its fo cus. For decades, studies of infection in the elderly have ce ntered on changes in microbiology and the unique aspects of dru g interactions or toxicity commonly found in older adult s. This is not a geriatric focus. A geriatric focus includes assessments of functional capacity, cognitive impairment, comorbidity, nutrition al status,social support, and frailty as important variables. Wi thin the geriatrics and gerontology community (i.e., members of the choir) it is well recognized that specific, validated methods can rigorously measure these variables, but outside of geriatrics and gerontology (i.e., members of the congregation), age is still con sidered thesurrogate marker for all things ‘‘geriatric.’’

JAGS 52:1768–1770, 2004








Sommario

Care of the Aging Patient: From Evidence to ActionCLINICIAN'S CORNER

JAMA. 2011;305(3):284-293. doi: 10.1001/jama.2010.2015

Finding the Right Level of Posthospital Care“We Didn't Realize There Was Any Other Option for

Him”Robert L. Kane, MD

Figure. Hypothetical Trajectories of Functional Dec line for Mr Z

Reuben, D. B. JAMA 2009;302:2686-2694

Kane, R. L. JAMA 2011;305:284-293

Manage underlying medical conditions, considering p atient goals, life expectancy, and comorbid conditions. Consider the functional implications of the patient 's medical conditions. Communicate with those working in supportive roles (eg, home care and nursing home staff). Communicate with families and patients. Use family conferences to discuss end-of-life decisions. Assess whenever an older person is making a major c are transition. Are there any conditions that can be controlled better, any medications that can be reduced or discontinued? Advocate for patients and families getting an oppor tunity to make thoughtful decisions. Facilitate families getting access to their own adv ocates/case managers. Be alert for signs of neglect and abuse. Appreciate the high-risk nature of caregiving.

The Physician's Role in Managing Care Transitions a nd AddressingPlacement Options

l’anziano affetto da demenza in ospedale€“ fenomenologia del paziente anziano con lrti –...

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