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1 Medical and Surgical Department, Geriatric Section, University of Torino, Italy.
2 Unit of Cancer Epidemiology, University of Torino and CPO Piemonte, Italy.
3 Sepulveda Veterans Affairs Medical Center, California.
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Abstract |
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Methods. The study included 987 patients aged 70 years and older admitted to the geriatric ward of San Giovanni Battista Hospital in Torino during 1995 and 1996. Demographic, clinical, and functional variables were collected on admission to hospital and examined as potential risk factors for mortality during hospitalization and at 5 years of follow-up.
Results. During their hospital stay, 147 patients (14.9%) died. Risk factors independently associated with in-hospital mortality included functional impairment (Activities of Daily Living [ADL]) (OR [odds ratio] 1.73, CI [confidence interval] 95% 1.02–2.95), dependence related to medical conditions (OR 2.18, CI 95% 1.39–3.42), cerebrovascular disease (OR 3.23, CI 95% 1.64–6.37), cancer (OR 4.52, CI 95% 1.99–10.24), albumin 3.0–3.4 g/dl (OR 4.51, CI 95% 2.76–7.35), albumin <3.0 g/dl (OR 6.83, CI 95% 3.59–13.0), creatinine 1.5–3 mg/dl (OR 2.23, CI 95% 1.36–3.65), creatinine >3 mg/dl (OR 2.55, CI 95% 1.10–5.93), and fibrinogen 
452 mg/dl (OR 1.91, CI 95% 1.26–2.89). During the 5-year follow-up, 553 patients (67.7%) died. Variables independently associated with mortality in multivariate analysis were age 75–84 years (HR [hazard ratio] 1.40, CI 95% 1.10–1.78), 85 years (HR 2.08, CI 95% 1.59–2.72), male sex (HR 1.50, CI 95% 1.24–1.81), ADL dependency (HR 1.24, CI 95% 1.01–1.52), 5 errors on Short Portable Mental Status Questionnaire (HR 1.34, CI 95% 1.10–1.63), dependence on Dependence Medical Index (HR 1.36, CI 95% 1.10–1.67), presence of cancer (HR 2.58, CI 95% 1.80–3.71), hemoglobin 
11 g/dl (HR 1.46, CI 95% 1.17–1.81), and Charlson's Index 2 (HR 1.49, CI 95% 1.14–1.95).
Conclusions. A complete functional and clinical evaluation at hospital admission permits identification of patients at higher risk of early and long-term mortality.
There are relatively few studies concerning predictors of posthospital mortality of older patients, but from these few it appears that the following factors are important predictors of mortality: increased aged, altered mental status, impaired functional status, and number and type of diagnoses (such as neurological, neoplastic, cardiac, and pulmonary disease) (5–7).
The aim of our study was to evaluate the risk factors for hospital and postdischarge mortality in a cohort of patients, aged 70 years and older, admitted to a geriatric ward.
Our specific objectives were to identify functional measures that predict 5-year mortality in elderly persons after hospitalization, and to define the prognostic importance of clinical parameters and medical diagnoses.
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METHODS |
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Demographic, clinical, and functional variables collected on admission to hospital were analyzed as potential predictors of mortality. Cut-points for continuous variables were based on clinically meaningful thresholds or previously published studies.
We obtained data from standardized interviews performed within 48 hours of admission, with patients or relatives, and from medical records. We interviewed relatives when the patient scored 5 errors on the 10-point Short Portable Mental Status Questionnaire (SPMSQ) (8,9) or was too ill to communicate at the time of admission. Functional assessment was performed using the index of Activities of Daily Living (ADL) (10). ADL impairment was defined as needing help with at least 1 of the 6 basic care skills (i.e., bathing, dressing, toileting, transferring, continence, and feeding). This cut-point has been used previously (11). The Dependence Medical Index (DMI) was used to define dependence for medical reasons (12). Patients were classified as being dependent or independent for medical reasons using the DMI, which groups 7 major criteria and 8 minor criteria. Major criteria are severe impairment in strength and/or motility in at least 2 limbs, double incontinence, pressure sores, severe disturbances in speech and communication, severe decline in sight and/or hearing not modifiable with a prosthesis, terminal illness (death expected within 6 months), and need for multiple and complex therapies. Minor criteria are mild loss of strength and/or motility in at least 2 limbs, incontinence, episodic disorientation, moderate disturbances in speech and communication, decline in sight and/or hearing only partially modifiable with a prosthesis, dizziness with a tendency to fall, chronic unstable balance, and use of a wheelchair. At least 3 minor criteria were needed as determinants of dependence for medical reasons, while only 1 major criteria was sufficient.
Cognitive status was evaluated using the SPMSQ (8,9). Patients with 5 errors on this questionnaire were considered cognitively impaired.
We also collected laboratory values routinely obtained at the time of admission. They included albumin, hemoglobin, total serum cholesterol, high-density lipoprotein (HDL) cholesterol, fibrinogen, and creatinine. Blood pressure was the average of the first two measures using a standard mercury sphygmomanometer with appropriate cuff size. Principal pathologies considered were cardiovascular disease, cerebrovascular disease, pulmonary problem, gastrointestinal problems, cancer, and dementia. These categories were identified according to the International Classification of Diseases, Ninth Revision, Clinical Modification system (ICD-9-CM). Information on length of hospital stay and of principal and secondary medical diagnoses were obtained from discharge abstracts. Comorbidity was evaluated using the Romano-adapted Charlson Index (13). The Charlson Index was originally designed to predict death in longitudinal studies, and it is commonly coded as 0, 1, 2, or more, representing the increasing burden of illness (14). The outcomes of interest were defined as hospital death or death within 5 years after hospital discharge.
The same set of variables, including demographic, socioeconomic, clinical, laboratory, and functional data, was selected a priori as potential risk factors for in-hospital and late mortality. The analysis of risk factors for in-hospital mortality was performed using logistic regression models to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI). Posthospital mortality was analyzed using Cox models to estimate crude and adjusted hazard ratios (HR) and 95% CI. The assumption of proportional hazard was evaluated with graphic methods using survival curves and obtained by the Kaplan-Meier method. All analyses were performed using SAS programs (15).
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RESULTS |
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5 errors on SPMSQ) and dependence on DMI were 36.3% and 29.3% respectively. Mean length of hospital stay was 17.5 days, 45.2% patients stayed more than 14 days. During the hospital stay 147 subjects (14.9%) died.
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2 (Table 1). The variables independently associated with in-hospital mortality in multivariate analysis were: functional impairment (ADL), dependence related to medical conditions (DMI), cerebrovascular disease, cancer, low albumin, high creatinine, high fibrinogen (Table 1).
During 5 years of follow-up, 553 patients (67.7%) died, with a median survival of 36 months (Figure 1). Risk factors associated with 5-year mortality in the univariate analysis included older age, male sex, ADL dependency, cognitive impairment, medical dependency (DMI), presence of cancer, low levels of albumin, hemoglobin and HDL cholesterol, high level of creatinine and fibrinogen, and Charlson's index 2. Protective variables were total cholesterol >200 mg/dL, systolic blood pressure >160 mmHg, and diastolic blood pressure >90 mmHg (Table 2).
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85 years, male sex, ADL dependency, cognitive impairment on SPMSQ, medical dependency (DMI), presence of cancer, hemoglobin 11 g/dL, and Charlson's Index 2 (Table 2). |
DISCUSSION |
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Some studies show that multidimensional evaluation permits identification of specific risk factors for mortality in elderly patients, such as functional dependence, social isolation, poor physical activities, and low income (4,17,18). Identification at hospital admission of clinical and functional risk factors for early and long-term mortality allows optimal planning of medical and socioeconomic interventions for frail elderly patients.
Our study shows a 5-year survival after hospitalization of 32.3% (Figure 1), which reflects the frailty of hospitalized elderly patients. In our study, male sex was not a predictor of in-hospital mortality, but there was a higher long-term mortality in males, as other study authors have demonstrated (2). As expected, mortality was higher among older patients. However, in accordance with the previous study, advanced age was not a significant predictor of in-hospital mortality probably because other elements, such as severity of acute disease at hospital admission, presence of chronic pathologies, and functional impairment have a stronger predictive value on short-term mortality (18–20). Many studies have shown that measures of functional status add important information about mortality risk beyond that provided by medical diagnoses or clinical and laboratory measures (21,22). ADL dependency is an independent risk factor for both in-hospital and postdischarge mortality. It is probable that functional impairment at hospital admission is a further independent predictor of mortality other than the number and type of pathologies that caused hospitalization. This is probably because functional status reflects the severity and interactions of many different illnesses and their relationship with psychosocial factors (6,11,17). The assessment of ADLs of hospitalized older adults is essential for planning appropriate health care after discharge. Without assessing ADL functions, it is difficult to advise a patient about long-term care, identify home care needs and other support services, or evaluate patient caregiver needs (11,23–25).
The prognostic importance of ADL dependence provides further evidence supporting routine assessment of functional status in hospitalized older adults. Dependence due to medical reasons, evaluated using the DMI, is an independent risk factor for both in-hospital and posthospital mortality. The presence of highly disabling conditions, that are by themselves associated with a higher risk of mortality, are among the items listed in the DMI. The DMI is useful because it summarizes clinical conditions and gives a more comprehensive view of the functional status and health status of patients. It is important to point out the independent predictive value of both the ADL and DMI for in-hospital and posthospital mortality.
Cognitive impairment was a risk factor for posthospital mortality, but not for in-hospital mortality when adjusted for other variables. Mortality risk during hospitalization is most likely better related to functional loss than cognitive decline (26).
Cerebrovascular disease and cancer are important risk factors for in-hospital mortality, but only cancer is a predictor of posthospital mortality. Cerebrovascular disease is not a predictor of long-term mortality most likely because of high hospital mortality (about 20%). On the other hand, the risk for long-term mortality of patients affected with cerebrovascular disease is better evaluated by their functional status and comorbidity. Albumin is a marker of frailty and, in this and other studies, is also a predictor of in-hospital mortality because of its correlation with both malnutrition and disease severity (27). Hemoglobin value 11 g/dL on univariate analysis is a risk factor both for in-hospital and posthospital mortality, but only for posthospital mortality after multivariate analysis. The presence of anemia at hospital admission can be considered a marker of severity of clinical condition, because it is frequently related to cancer or other serious pathologies (28–31).
The association between creatinine and mortality may be explained by the direct negative effects of renal dysfunction on multiple organ systems or may reflect generalized decreased tissue perfusion (32).
In accordance with other studies, comorbidity is an independent risk factor only for posthospital mortality (33). Chronic comorbidity is less important in short-term mortality but it gains importance in long-term outcome because death during a hospital stay is more influenced by mean diagnosis, acute complications, or therapeutic procedures.
A complete functional and clinical evaluation at hospital admission permits the identification of patients at higher risk of early and long-term mortality. Early planning of discharge intervention, such as home hospitalization, home care, and nursing home placement (when return to home is impossible) is important for optimizing treatment outcomes. Accurate prediction of posthospitalization outcomes can be helpful in various ways, including improvement of case management during hospital stay, more accurate discharge planning, reduced numbers of rehospitalizations, and better targeting of patients to different services, including specialized geriatric programs (6).
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Acknowledgments |
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Received December 17, 2002
Accepted January 6, 2003
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