O impacto das doenças neurológicas, comorbidades e da multimorbidade em idosos hospitalizados

O envelhecimento global será o fenômeno socioeconômico mais significativo do século XXI. Destarte, as doenças neurológicas (DN) serão evidenciadas, pois acometem muitos idosos, e neles associam-se à incapacidade, e à morte. O objetivo desta tese de compilação de artigos foi questionar se não somente as DN, mas também suas comorbidades, e a multimorbidade (MM), acarretam um impacto deletério aos idosos hospitalizados. Métodos: Reunimos quatro artigos, elaborados especialmente para esta tese: 1- Frequências, características associadas, e o impacto das doenças neurológicas em idosos hospitalizados no Brasil: um estudo de corte transversal retrospectivo. 2- A mortalidade hospitalar entre idosos admitidos com doenças neurológicas não foi predita por nenhum diagnóstico particular, num centro médico terciário. 3- Preditores de readmissão hospitalar, e de longo tempo de internação em idosos admitidos com doenças neurológicas, em centro terciário: uma investigação no mundo real. 4- Multimorbidade, e desfechos associados entre idosos hospitalizados com doenças neurológicas. Resultados: Recrutamos 798 pacientes com idade média de 75,7 ± 9,1. Identificamos 1154 DN e 2675 comorbidades, e 39% dos pacientes tiveram mais de uma DN. O coeficiente de MM foi 92,6%. Idosos foram a maioria dos pacientes com DN, tiveram maiores percentuais de mortalidade hospitalar (MH) (p<0,0001), e longo tempo de internação (TDI) (p<0,0001), do que jovens com DN. Idosos com DN tiveram menores coeficientes de MH (p=0,01), e readmissões (p=0,001), porém maior incidência de longo TDI (p=0,001), do que idosos sem DN. A incidência de MH foi uniformemente alta entre as DN (18%IC = 15-21%), e entre as comorbidades (15-27%). A idade avançada (p<0,001), e status socioeconômico baixo (p=0,003), mas não as DN, nem suas comorbidades, foram preditores de MH. As readmissões incidiram em 252 (31%) pacientes. Não encontramos preditores para readmissões. Longo TDI aconteceu em 408 (51%IC = 48-55%) pacientes. Os preditores de longo TDI foram: baixo status socioeconômico (p=0,001), distúrbio respiratório (p<0,001), infecção (p<0,001), distúrbio geniturinário (p=0,033), e hipertensão (p=0,002). Idosos com DN tiveram uma média de 3,875 ± 1,666 doenças crônicas. Mais de 50% dos pacientes com demência, epilepsia e transtorno do movimento, tiveram 5 ou mais doenças crônicas. Seguiram-se pacientes com doença cerebrovascular, e neuromuscular, principalmente neuropatia diabética. A MM foi associada a readmissão e longo TDI. Conclusões: Nossos estudos confirmaram que as DN, suas comorbidades, a multimorbidade, e o baixo nível socioeconômico, causam grande impacto em idosos hospitalizados com DN. Nesta tese, sugerimos processos para mitigar os desfechos relacionados a essas variáveis independentes, nessa população.The worldwide population ageing will become the most significant socioeconomic phenomenon of the XXI century. Neurological disorders (NDs) will thus be evident since they are common in elders, and associated with disability and mortality. The aim of this compilation thesis was to identify whether not only NDs, but also comorbidities and patient multimorbidity (MM), burden elderly inpatients. Methods: We selected 4 articles specially designed for this thesis: 1- Frequency, associated features, and burden of neurological disorders in older adult inpatients, in Brazil: a retrospective cross-sectional study. 2- Hospital mortality among elderly patients admitted with neurological disorders was not predicted by any particular diagnosis, in a tertiary medical centre. 3- Predictors of readmission and long length of stay in elders admitted with neurological disorders, in a tertiary centre: a real-world investigation. 4- Multimorbidity, and associated outcomes among elderly inpatients with neurological disorders. Results: We enrolled 798 patients with a mean age of 75.7 ± 9.1 years. We identified 1154 NDs and 2675 comorbidities, and more than one ND affected 39% of inpatients. The proportion of MM was 92.6%. Elders with NDs were the majority and had higher rates of hospital mortality (HM) (p<0.0001) and long length of stay (LOS) (p<0.0001) than their younger counterparts. Elders with NDs had lower rates of HM (p=0.01) and readmission (p=0.001), but a higher rate of long LOS (p=0.001) than elderly inpatients without NDs. The incidence of HM among NDs (18%CI = 15-21%) and comorbidities (15-27%) was uniformly high. We identified advanced age (p<0.001) and lower socioeconomic status (p=0.003), but not particular NDs or comorbidities, as predictors of HM. The incidence of patient readmission was 31% (252), but no predictors of readmission were found. Long LOS occurred in 408 patients (51%CI = 48-55%). Predictors of long LOS included: lower socioeconomic status (p=0.001), respiratory disorder (p<0.001), infection (p<0.001), genitourinary disorder (p=0.033), and hypertension (p=0.002). Elderly inpatients with NDs had a mean of 3.875 ± 1.666 chronic disorders. Over 50% of inpatients with dementia, epilepsy, and movement disorder had 5 or more chronic diseases, followed by cerebrovascular disease and neuromuscular disorder, particularly diabetic neuropathy. Patient MM was associated with readmission and long LOS. Conclusions: Our studies confirmed NDs and their comorbidities, patient MM as well as lower socioeconomic status burden elderly inpatients with NDs. In this thesis we made suggestions to mitigate the outcomes related to these independent variables in this population141 f

Frequency, associated features, and burden of neurological disorders in older adult inpatients in Brazil: a retrospective cross-sectional study

Abstract Background The burden of neurological disorders (NDs) in older adult inpatients is often underestimated. We studied diagnostic frequency and comorbidity of NDs among inpatients aged ≥60 years. We compared rates of hospital mortality, length of stay (LOS), and readmission with younger patient counterparts (aged 18–59 years) and older adult non-neurological patients. Methods This was a retrospective cross-sectional study of inpatients in a tertiary care center in Brazil. We compiled data for all patients admitted between 1 January 2009 and 31 December 2010, and selected those aged ≥18 years for inclusion in the study. We collected data for inpatients under care of a clinical neurologist who were discharged with primary diagnoses of NDs or underlying acute clinical disorders, and data for complications in clinical or surgical inpatients. Patients who remained hospitalized for more than 9 days were categorized as having long LOS. Results Older adult inpatients with NDs (n = 798) represented 56% of all neurological inpatients aged ≥18 years (n = 1430), and 14% of all geriatric inpatients (n = 5587). The mean age of older adult inpatients was 75 ± 9.1 years. Women represented 55% of participants. The most common NDs were cerebrovascular diseases (51%), although multimorbidity was observed. Hospital mortality rate was 18% (95% confidence interval [CI], 15–21) and readmission rate was 31% (95% CI, 28–35), with 40% of patients readmitted 1.8 ± 1.5 times. The long LOS rate was 51% and the median LOS was 9 days (interquartile interval, 1–20 days). In younger inpatients mortality rate was 1.4%, readmission rate was 34%, and long LOS rate was 14%. In older adult non-neurological inpatients, mortality rate was 22%, readmission rate was 49%, and long LOS rate was 30%. Conclusions Older adult neurological inpatients had the highest long LOS rate of all patient groups, and a higher mortality rate than neurological patients aged 18–59 years. Readmissions were high in all groups studied, particularly among older adult non-neurological inpatients. Improved structures and concerted efforts are required in hospitals in Brazil to reduce burden of NDs in older adult patients

Antiepileptic drugs patterns in elderly inpatients in a Brazilian tertiary center, Salvador, Brazil

Epilepsy is very prevalent among elderly inpatients and treatment is far from ideal. Objective To analyze prescribing patterns of antiepileptic drugs (AEDs) for hospitalized elderly with epilepsy, their relations with comorbidities and comedications. Method We assessed prescription regimen of elderly patients that were under AED use for treatment of epileptic seizures, during hospitalization. One hundred and nine patients were enrolled. AED regimen was categorized into two groups: Group 1 defined as appropriate (carbamazepine, oxcarbazepine, valproic acid, gabapentin, clobazan and lamotrigine) and Group 2 as inappropriate (phenytoin and phenobarbital). Results We found 73.4% of patients used inappropriate AEDs (p<0.001). Monotherapy was prescribed for 71.6% of patients. The most common comorbidity was hypertension. Potentially proconvulsant drugs as comedications were used for nearly half of patients. Conclusion Inappropriate AED therapy was commonly prescribed regimen for elderly inpatients. Some recommendations are discussed for a better care of elderly inpatients with epilepsy

Etiological prevalence of epilepsy and epileptic seizures in hospitalized elderly in a Brazilian tertiary center – Salvador - Brazil

Epilepsy in the elderly has high incidence and prevalence and is often underecognized. Objective To describe etiological prevalence of epilepsy and epileptic seizures in elderly inpatients. Methods Retrospective analysis was performed on elderly patients who had epilepsy or epileptic seizures during hospitalization, from January 2009 to December 2010. One hundred and twenty patients were enrolled. They were divided into two age subgroups (median 75 years) with the purpose to compare etiologies. Results The most common etiology was ischemic stroke (36.7%), followed by neoplasias (13.3%), hemorrhagic stroke (11.7%), dementias (11.4%) and metabolic disturbances (5.5%). The analysis of etiological association showed that ischemic stroke was predominant in the younger subgroup (45% vs 30%), and dementias in the older one (18.9% vs 3.8%), but with no statistical significance (p = 0.23). Conclusion This study suggests that epilepsy and epileptic seizures in the elderly inpatients have etiological association with stroke, neoplasias and dementias

Mortality predictors of epilepsy and epileptic seizures among hospitalized elderly

Epilepsy and epileptic seizures are common brain disorders in the elderly and are associated with increased mortality that may be ascribed to the underlying disease or epilepsy-related causes.Objective To describe mortality predictors of epilepsy and epileptic seizures in elderly inpatients.Method Retrospective analysis was performed on hospitalized elderly who had epilepsy or epileptic seizures, from January 2009 to December 2010. One hundred and twenty patients were enrolled.Results The most common etiology was ischemic stroke (37%), followed by neoplasias (13%), hemorrhagic stroke (12%), dementias (11.4%) and metabolic disturbances (5.5%). In a univariate analysis, disease duration (p = 0.04), status epilepticus (p < 0.001) and metabolic etiology (p = 0.005) were associated with mortality. However after adjustment by logistic regression, only status epilepticus remained an independent predictor of death (odds ratio = 13; 95%CI = 2.3 to 72; p = 0.004).Conclusion In this study status epilepticus was an independent risk factor for death during hospitalization

Status epilepticus in the elderly: epidemiology, clinical aspects and treatment

The aim of the study was to review the epidemiology, clinical profile and discuss the etiology, prognosis and treatment options in patients aged 60 years or older presenting with <em>status epilepticus.</em> We performed a systematic review involving studies published from 1996 to 2010, in Medline/PubMed, Scientific Electronic Library on line (Scielo), Latin-American and Caribbean Center of Health Sciences Information (Lilacs) databases and textbooks. Related articles published before 1996, when relevant for discussing epilepsy in older people, were also included. Several population studies had shown an increased incidence of <em>status epilepticus</em> after the age of 60 years. <em>Status epilepticus</em> is a medical and neurological emergency that is associated with high morbidity and mortality, and is a major concern in the elderly compared to the general population. Prompt diagnosis and effective treatment of convulsive <em>status epilepticus</em> are crucial to avoid brain injury and reduce the fatality rate in this age group