RESUMEN
Applying evidence-based medicine prevents medical errors highlighting the need for applying Clinical Guidelines (CGs) to improve patient care by nurses. However, nurses often face challenges in utilizing CGs due to patient-specific needs. Developing a Clinical Decision Support System (CDSS) can provide real-time context-sensitive CG-based recommendations. Therefore, there is a need to acquire and represent CGs in a machine-applicable manner. Also, there is a need to be able to provide recommendations episodically, only when requested, and not continuously, and to assess previous partial performance of evidence-based actions on a continuous scale. This study evaluated the feasibility of acquiring and representing major nursing CGs, in a machine-applicable manner for episodic use. Using data from an Israeli geriatric center, the results suggest that an episodic CDSS effectively supports the application of formalized nursing knowledge.
Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Enfermería Basada en la Evidencia , Guías de Práctica Clínica como Asunto , Israel , Humanos , Medicina Basada en la EvidenciaRESUMEN
Medical errors contribute significantly to morbidity and mortality, emphasizing the critical role of Clinical Guidelines (GLs) in patient care. Automating GL application can enhance GL adherence, improve patient outcomes, and reduce costs. However, several barriers exist to GL implementation and real-time automated support. Challenges include creating a formalized, machine-comprehensible GL representation, and an episodic decision-support system for sporadic treatment advice. This system must accommodate the non-continuous nature of care delivery, including partial actions or partially met treatment goals. We describe the design and implementation of an episodic GL-based clinical decision support system and its retrospective technical evaluation using patient records from a geriatric center. Initial evaluation scores of the e-Picard system were promising, with a mean 94% correctness and 90% completeness based on 50 random pressure ulcer patients. Errors were mainly due to knowledge specification, algorithmic issues, and missing data. Post-corrections, scores improved to 100% correctness and a mean 97% completeness, with missing data still affecting completeness. The results validate the system's capability to assess guideline adherence and provide quality recommendations. Despite initial limitations, we have demonstrated the feasibility of providing, through the e-Picard episodic algorithm, realistic medical decision-making support for noncontinuous, intermittent consultations.
Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas , Adhesión a Directriz , Guías de Práctica Clínica como Asunto , Humanos , Registros Electrónicos de Salud , Algoritmos , Errores Médicos/prevención & controlRESUMEN
BACKGROUND: Despite appropriate enteral nutrition, many elderly patients do not reach a good metabolic outcome. Two nutrition formulas are commonly used in Israel with no evidence-based medicine to indicate preference of one over the other. METHODS: We describe a 2-month observational study of patients fed by 1 of the 2 formulas. The first (Osmolite, Abbott Company, Abbott Park, IL) is without fiber, and the second (Easy Fiber, Easyline Company Givataim, Israel) in addition to containing fiber is also richer in protein, vitamins, and minerals. The formula was selected by the primary care physician before enrollment in the study and was not influenced by the investigators. Routine blood tests as well as body weight were monitored at the start of enteral feeding and during the 2 months following as part of the regular follow-up. RESULTS: Fifty-seven patients were fed with the regular formula and 77 with the enriched one. No statistically significant differences were noted between the groups during the follow-up period, in body weight, cholesterol levels, total lymphocyte count, renal function tests, or electrolyte balance. However, in the enriched formula group there was a significant decrease in glucose (p < .05), and increase in albumin (p < .05) and hemoglobin (p = .01) levels. CONCLUSIONS: Enteral feeding with enriched formula appears to improve albumin and hemoglobin levels as well as diabetic control, thus it may be more appropriate than the nonfiber diet for use in long-term care patients.
Asunto(s)
Diabetes Mellitus Tipo 2/prevención & control , Metabolismo Energético/efectos de los fármacos , Nutrición Enteral , Alimentos Formulados/normas , Anciano , Anciano de 80 o más Años , Glucemia/metabolismo , Fibras de la Dieta/administración & dosificación , Fibras de la Dieta/metabolismo , Proteínas en la Dieta/administración & dosificación , Proteínas en la Dieta/metabolismo , Metabolismo Energético/fisiología , Nutrición Enteral/métodos , Medicina Basada en la Evidencia , Femenino , Alimentos Formulados/análisis , Hemoglobinas/metabolismo , Humanos , Masculino , Minerales/administración & dosificación , Minerales/metabolismo , Albúmina Sérica/metabolismo , Resultado del Tratamiento , Vitaminas/administración & dosificación , Vitaminas/metabolismoRESUMEN
PURPOSE: Elderly patients are vulnerable to the dose-dependent adverse effects of iron replacement therapy. Our study examines whether low-dose iron therapy can efficiently resolve iron-deficiency anemia in patients over the age of 80 years and reduce adverse effects. SUBJECTS AND METHODS: Ninety hospitalized patients with iron-deficiency anemia were randomized to receive elemental iron in daily doses of 15 mg or 50 mg as liquid ferrous gluconate or 150 mg of ferrous calcium citrate tablets for 60 days. Thirty control patients without anemia were given 15 mg of iron for 60 days. A 2-hour iron absorption test was performed after the initial dose. Hemoglobin and ferritin levels were measured on day 1, 30, and 60 after initiating therapy. Each patient completed a weekly questionnaire regarding drug-induced adverse effects. RESULTS: Serum iron rose significantly in the anemic patients beginning 15 minutes after the first dose but not in nonanemic patients. Two months of iron treatment significantly increased hemoglobin and ferritin concentrations similarly in all 3 groups of iron-deficiency anemia patients (for example, hemoglobin levels rose from 10.0 g/dL to 11.3 g/dL with 15 mg/d of iron therapy and from 10.2 g/dL to 11.6 g/dL with 150 mg/d). Abdominal discomfort, nausea, vomiting, changes in bowel movements, and black stools were significantly more common at higher iron doses. CONCLUSIONS: Low-dose iron treatment is effective in elderly patients with iron-deficiency anemia. It can replace the commonly used higher doses and can significantly reduce adverse effects.
Asunto(s)
Anemia Ferropénica/tratamiento farmacológico , Antioxidantes/administración & dosificación , Citrato de Calcio/administración & dosificación , Compuestos Ferrosos/administración & dosificación , Anciano , Anciano de 80 o más Años , Antioxidantes/efectos adversos , Antioxidantes/farmacocinética , Citrato de Calcio/efectos adversos , Citrato de Calcio/farmacocinética , Relación Dosis-Respuesta a Droga , Femenino , Ferritinas/sangre , Compuestos Ferrosos/efectos adversos , Compuestos Ferrosos/farmacocinética , Hemoglobinas/análisis , Humanos , Hierro/sangre , Masculino , Recuento de ReticulocitosRESUMEN
BACKGROUND: As there are no prospective randomised trials about percutaneous endoscopic gastrostomy (PEG) insertion, the medical staff and caregivers encounter great difficulty in deciding when and if to perform this procedure. OBJECTIVE: To explore which variables are associated with increased mortality after PEG insertion. DESIGN: Prospective observational study. SETTING: Gastroenterological unit of a 500-bed community hospital. SUBJECTS: All patients over the age of 50 years referred for PEG insertion between January 1992 and December 2002. METHODS: Patients were studied for their indication for PEG insertion as well as their main medical problems, and demographic details and medical records were reviewed yearly until mortality. RESULTS: 674 patients were enrolled (mean age 80.1 years, 42% men). The median survival was worst in diabetic patients (128 days, P <0.05), patients referred from hospital (161 days, P <0.01) and patients over the age of 80 years with dementia (171 days, P <0.001). The best median survival was found among demented patients under the age of 80 (467 days, P <0.05) and women under the age of 80 referred from nursing homes (780 days, P <0.01). CONCLUSIONS: The outcome after PEG insertion is variable, with survival of over a year in many of the patients. These data are important for the medical staff, the patients and their caregivers when deciding about PEG placement.
Asunto(s)
Trastornos de Deglución/terapia , Demencia/mortalidad , Nutrición Enteral/mortalidad , Gastrostomía/mortalidad , Esperanza de Vida , Anciano , Anciano de 80 o más Años , Trastornos de Deglución/etiología , Trastornos de Deglución/mortalidad , Demencia/complicaciones , Nutrición Enteral/métodos , Femenino , Gastroscopía , Gastrostomía/métodos , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Análisis de SupervivenciaRESUMEN
UNLABELLED: Recent case reports described primary esophageal achalasia (PEA) at an older age, even in the very elderly. However, very few cases over the age of eighty were published and there is no data on the clinical presentation and the appropriate treatment at this age. A retrospective record review at a six-hundred bed university-affiliated hospital revealed the diagnosis of PEA in eleven patients over the age of eighty (age range 81-90 years), during a 5-year period. Seven patients complained of cough and dyspnea, most of them also suffered from dysphagia. One patient complained of chest pain. The diagnosis was made in most patients by using a barium meal or gastroscopy, without manometry. Exceedingly few patients had a prolonged response to nitrates or to calcium channel blockers. However, a prolonged one year response was achieved after botulinum toxin injection or pneumatic dilatation. IN CONCLUSION: In contrast to younger patients, the elderly patient with PEA usually does not complain of chest pain but rather of cough and dyspnea. The therapeutic approach should include surgery only in the very fit elderly due to a possible high complication rate. Botulinum toxin injection or pneumatic dilatation are the preferred treatment options.
Asunto(s)
Acalasia del Esófago/epidemiología , Anciano , Anciano de 80 o más Años , Trastornos de Deglución/etiología , Femenino , Humanos , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD), a common entity in the general population, has been shown to be linked with insulin resistance and metabolic syndrome. Several of the components of the metabolic syndrome are more common in the aged population. The aims of the current study were to determine in the aged, the prevalence and the clinical presentation of NAFLD, as well as the relation to the underlying metabolic abnormalities. METHOD: In this prospective study, we evaluated 91 octogenarians with a mean age of 85.56+/-3.76 years, who were admitted to the rehabilitation departments of a geriatric hospital. Clinical evaluation included: abdominal ultrasound (US), fasting glucose and lipid levels, serum liver enzymes, ferritin, iron and transferrin saturation. Elderly patients with NAFLD were compared with 46 young patients with NAFLD. RESULTS: NAFLD diagnosed by US was a common finding in this aged population, is present in 42/91 patients (46.2%). No significant differences were observed between the patients with or without NAFLD in the following: age, gender, chronic illnesses, anthropometric parameters, lipid profile, fasting glucose levels, metabolic syndrome prevalence, serum levels of transaminases, ferritin and iron. Young patients with NAFLD had significantly higher serum levels of triglycerides and a significantly higher prevalence of glucose intolerance, obesity and the metabolic syndrome compared with the elderly patients with NAFLD. CONCLUSIONS: NAFLD was a common finding in our group of elderly patients and the prevalence was higher than reported in the general population. In contrast to the well-described association between the metabolic syndrome and NAFLD in the general population, we did not find this association in the aged group. In addition, none of the patients had stigmata of advanced liver disease. These data suggest that NAFLD is a common and benign finding in the elderly population, but is not associated with the metabolic syndrome.
Asunto(s)
Hígado Graso/diagnóstico , Hígado Graso/epidemiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Biopsia con Aguja , Estudios de Casos y Controles , Estudios de Cohortes , Femenino , Evaluación Geriátrica , Humanos , Inmunohistoquímica , Israel/epidemiología , Pruebas de Función Hepática , Modelos Logísticos , Masculino , Análisis Multivariante , Prevalencia , Probabilidad , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores SexualesRESUMEN
BACKGROUND: In older populations, oral anticoagulation therapy (OAT) is underused by physicians, mainly because of fear of bleeding complications. The aim of this study was to determine the incidence of bleeding complications and associated risk factors in a large heterogeneous group of older patients. METHODS: Combined retrospective and prospective cohort study conducted in geriatric and internal medicine departments. All patients 80 years or older discharged with the recommendation of OAT were followed up for a mean +/- SD of 28.8 +/- 36.3 months. The rate of bleeding events and the quality of anticoagulation were compared across a wide range of demographic and clinical variables and cognitive and functional status. In addition, we assessed the quality of education given to the patient or caregiver on the use of OAT. RESULTS: Among 15 387 patients 80 years or older, 323 (2.1%) were discharged with the recommendation of OAT. The rate of major bleedings was 2.4 events per 1000 patient-months. Socioeconomic and cognitive variables and functional impairments were not associated with an increased rate of bleeding. In multivariate analysis, insufficient education on OAT as perceived by the patient or caregiver (odds ratio [OR], 8.83), polypharmacy (OR, 6.14), and international normalized ratio values above the therapeutic range (OR, 1.08) were the only significant predictive factors for bleeding complications. CONCLUSIONS: The rate of bleeding complications, especially major bleedings, was low in this large group of older patients, many with comorbidities and cognitive and functional impairments. Insufficient OAT education was the major factor that predicted bleeding. Therefore, improving and fostering better methods of OAT education may further reduce bleeding complications.
Asunto(s)
Anticoagulantes/efectos adversos , Hemorragia/epidemiología , Educación del Paciente como Asunto , Seguridad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Monitoreo de Drogas , Femenino , Hemorragia/etiología , Humanos , Incidencia , Israel , Masculino , Estudios Prospectivos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: The authors sought to determine the incidence of delirium, its predisposing and precipitating factors, and its implications for rehabilitation outcomes and mortality in elderly patients. METHODS: This was a prospective cohort study, conducted in Gedera, Israel, from August 2001 to January 2002, with 137 consecutive patients over age 75, with hip fractures, who were admitted to the orthopedic section of the emergency department. They were evaluated at admission, 1 week after the surgery for hip fracture, and 1 month after surgery. The evaluation included assessments of delirium, cognitive, and functional status, and a wide range of demographic and clinical parameters. RESULTS: The cumulative incidence of delirium was 11.4%. No significant difference was found between delirium and non-delirium patients in terms of all demographic, socioeconomic, and perioperative parameters. Mild or moderate cognitive impairment before the fracture and four or more regular medications prescribed to the patient were the only predictive factors for the development of delirium in a multivariate model. Delirium was not a significant predictor of any rehabilitation outcome. CONCLUSION: Results documented that the incidence of delirium after hip fracture in elderly patients is much lower than was reported in several previous studies. Premorbid cognitive impairment was the most significant predisposing factor for the development of delirium. Thorough evaluation of earlier cognitive status could improve the probability of the diagnosis of delirium and pinpoint a limited group of patients for a delirium-prevention approach.
Asunto(s)
Delirio/epidemiología , Fracturas de Cadera/cirugía , Anciano , Anciano de 80 o más Años , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/epidemiología , Estudios de Cohortes , Demografía , Femenino , Humanos , Incidencia , Masculino , Periodo Posoperatorio , Estudios Prospectivos , Factores Socioeconómicos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Hypoglycemia during hospitalization occurs in patients with and without diabetes. The aims of this study were to determine the incidence, associated risk factors, and short- and long-term outcome of hypoglycemia among hospitalized elderly patients. METHODS: This is a case-control study conducted at geriatric and medicine departments. All patients 70 years or older with documented hypoglycemia hospitalized within 1 year (n = 281) were compared with a nonhypoglycemic group of 281 elderly, randomly selected patients from the same hospitalized population. RESULTS: Among 5404 patients 70 years or older, 281 (5.2%) had documented hypoglycemia. Compared with the nonhypoglycemic group, we found the following characteristics to be true in the hypoglycemic group: there were more women than men (58% vs 44%, P =.001); sepsis was 10 times more common (P<.001); malignancy was 2.8 times more common (P =.04); the mean serum albumin level was lower (2.8 g/dL vs 3.4 g/dL, P<.001); and the mean serum creatinine and alkaline phosphatase levels were higher (P<.001 for both). Diabetes was known in 42% of the hypoglycemic group and in 31% of the nonhypoglycemic group (P =.03); 70 patients in the hypoglycemic group were taking sulfonylureas or insulin. Multivariate logistic analysis showed that sepsis, albumin level, malignancy, sulfonyurea and insulin treatment, alkaline phosphatase level, female sex, and creatinine level were all independent predictors of developing hypoglycemia. In-hospital mortality and 3-month mortality were about twice as high in the hypoglycemic group (P<.001). Multivariate analysis of mortality found that sepsis, low albumin level, and malignancy were independent predictors, while hypoglycmia was not. CONCLUSIONS: Hypoglycemia was common in elderly hospitalized patients and predicted increased in-hospital 3- and 6-month cumulative mortality. However, in a multivariate analysis, hypoglycemia was not an independent predictor for mortality, implying that it is only a marker.
Asunto(s)
Hipoglucemia/mortalidad , Pacientes Internos/estadística & datos numéricos , Anciano , Estudios de Casos y Controles , Femenino , Mortalidad Hospitalaria , Humanos , Hipoglucemia/etiología , Israel/epidemiología , Masculino , Análisis Multivariante , Valor Predictivo de las Pruebas , Factores de RiesgoRESUMEN
BACKGROUND: The diagnosis of iron deficiency anemia (IDA) in the elderly is difficult because of the prevalence of chronic diseases, which can cause anemia with high ferritin levels, even in the presence of iron deficiency. Therefore, we studied the sensitivity and specificity of a serum transferrin receptor assay, which is not affected by chronic diseases, in the diagnosis of IDA in elderly patients. METHODS: We performed a prospective controlled study of 49 consecutive male and female patients older than 80 years who were admitted to an acute geriatric department. Bone marrow aspirate confirmed IDA in all 49 patients. Fourteen additional patients, also older than 80 years, with anemia but without evidence of iron deficiency on results of bone marrow examination, served as a control group. All patients underwent evaluation by means of a detailed medical history and results of complete physical examination, routine blood tests, and specific tests for diagnosis and evaluation of anemia. Examination of bone marrow aspirate was performed for all patients. Levels of transferrin receptor in serum were determined by means of a specific enzyme-linked immunosorbent assay. The transferrin receptor-ferritin index (TR-F index) was defined as the ratio of serum transferrin receptor level to log ferritin level. RESULTS: Only 8 patients could be diagnosed as having IDA by means of routine blood test results (serum iron, ferritin, and transferrin saturation levels). In contrast, the TR-F index disclosed IDA in 43 of the 49 patients, thus increasing the sensitivity from 16% to 88%. CONCLUSIONS: The diagnosis of IDA in the elderly by means of routine blood tests has a very low sensitivity. The TR-F index is much more sensitive, and when results are positive, the TR-F index can eliminate the need for bone marrow examination.