Variability of Intensive Care Admission Decisions for the Very Elderly

Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear

Electrocardiographic abnormalities in patients admitted for hip fracture

Background: Several risk factors for falls and hip fractures have been recognised, but controversy still exists regarding the importance of rhythm and conduction abnormalities as potentially modifiable risk factors for recurrent falls. The aim of this study was to determine the prevalence of clinically relevant ECG abnormalities in patients with a hip fracture versus controls. Methods: The study was designed as a case-control study within consecutive hip surgery patients in an academic hospital. Cases: patients with traumatic hip fractures. Controls: patients undergoing planned hip surgery (non-traumatic). Cases and controls were 1: 1 matched for age and gender. Inclusion criteria: age >= 50 years. Exclusion criteria: high-energy trauma, pathological and/or previous hip fracture. ECGs were scored using predefined categories. Multivariate logistic regression was performed to calculate odds ratios (OR) and to correct for confounders. Results: We included 888 patients (444 cases). Mean age was 70.9 years (SD 9.3), 70% were female. After correction for potential confounders we found the following associations between clinically relevant ECG abnormalities and hip fractures: atrial fibrillation OR 2.7 (95% CI 1.2-6.1), abnormal QTc prolongation OR 3.9 (2.2-6.8), sinus tachycardia OR 5.0 (2.1-11.8) and sinus bradycardia OR 0.3 (0.1-0.5). Univariately, several markers for decreased cardiac function were also associated with hip fractures. Conclusions: Hip fracture patients are at higher risk for ECG abnormalities than matched patients undergoing hip surgery for other indications. To potentially reduce the risk of future (injurious) falls, increased awareness of these ECG abnormalities is warranted to assess the need for further cardiovascular fall risk assessment

Genetic Polymorphisms in the DRD2, DRD3, and SLC6A3 Gene in Elderly Patients With Delirium

Dopamine excess appears to be critical in the final common pathway of delirium. The aim of this study was to investigate whether genetic polymorphisms in three dopamine-related genes (the dopamine receptor 2 (DRD2), dopamine receptor 3 (DRD3), and the dopamine transporter (SLC6A3) gene) were associated with delirium. Patients aged 65 years and older acutely admitted to the medical department or to the surgical department following hip fracture were included. Delirium was diagnosed by the Confusion Assessment Method. Sixteen single nucleotide polymorphisms (SNPs) and one variable number of tandem repeats in the SLC6A3 gene, nine SNPs in the DRD2 gene, and six SNPs in the DRD3 gene were genotyped. Fifty percent of the 115 surgical patients and 34% of the 605 medical patients experienced delirium. Delirious patients were older and had more frequently pre-existing functional and cognitive impairment (P < 0.001). After correction for multiple testing, one SNP in the SLC6A3 gene (rs393795) was associated with reduced risk of delirium (P = 0.032). Adjusted for age, cognitive impairment, and functional impairment, three SNPs in the DRD2 gene and seven SNPs in the SLC6A3 gene were associated with delirium; none of these associations was significant after correction for multiple testing. Variations in the SLC6A3 gene and possibly the DRD2 gene were associated with delirium. Although validation of these results is needed our results support a role for the dopamine transporter and dopamine receptor 2 in the pathogenesis of delirium. (C) 2009 Wiley-Liss, Inc

The Association of the Dopamine Transporter Gene and the Dopamine Receptor 2 Gene With Delirium, a Meta-Analysis

Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta-analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non-cardiac surgery patients and 502 population-based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had preexisting cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta-analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2-0.6, P= 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta-analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6-1.1, P=0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4-1.0, P=0.06) and 0.8 (95% C.I. 0.5-1.5, P=0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium. (C) 2009 Wiley-Liss, Inc