Abstract
To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.
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Lang PO, Heitz D, Hedelin G, Drame M, Jovenin N, Ankri J, et al. Early markers of prolonged hospital stays in older people: a prospective, multicenter study of 908 inpatients in French acute hospitals. J Am Geriatr Soc. 2006;54:1031–9. doi:10.1111/j.1532-5415.2006.00767.x.
Lotus Shyu YI, Chen MC, Lee HC. Caregiver’s needs as predictors of hospital readmission for the elderly in Taiwan. Soc Sci Med. 2004;58:1395–403. doi:10.1016/S0277-9536(03)00334-4.
Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219–23.
Saltvedt I, Mo ES, Fayers P, Kaasa S, Sletvold O. Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit. A prospective randomized trial. J Am Geriatr Soc. 2002;50:792–8. doi:10.1046/j.1532-5415.2002.50202.x.
Winograd CH, Gerety MB, Chung M, Goldstein MK, Dominguez F Jr, Vallone R. Screening for frailty: criteria and predictors of outcomes. J Am Geriatr Soc. 1991;39:778–84.
Palmer RM. Acute care. In: Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG, editors. Principles of geriatric medicine and gerontology. New York: McGraw-Hill; 1999. p. 483–487.
Zuliani G, Romagnoni F, Soattin L, Leoci V, Volpato S, Fellin R. Predictors of two-year mortality in older nursing home residents. The IRA study. Istituto di riposo per anziani. Aging (Milano). 2001;13:3–7.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of adl: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.
Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51:451–8. doi:10.1046/j.1532-5415.2003.51152.x.
Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98. doi:10.1016/0022-3956(75)90026-6.
American Psychiatry Association. DSM IV, diagnostic and statistical manual mental disorders. 4th ed. Washington: American Psychiatric Association; 1994.
Gilleard CJ, Willmott M, Vaddadi KS. Self-report measures of mood and morale in elderly depressives. Br J Psychiatry. 1981;138:230–5. doi:10.1192/bjp.138.3.230.
Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45:735–8.
Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (mna-sf). J Gerontol A Biol Sci Med Sci. 2001;56:M366–72.
Norton D, Mclaren R, Exton-Smith A. An investigation of nursing problems in hospitals. New-York: Churchill Livingstone; 1975.
Sundararajan V, Henderson T, Perry C, Muggivan A, Quan H, Ghali WA. New icd-10 version of the charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol. 2004;57:1288–94. doi:10.1016/j.jclinepi.2004.03.012.
Buntinx F, Niclaes L, Suetens C, Jans B, Mertens R, Van den Akker M. Evaluation of charlson’s comorbidity index in elderly living in nursing homes. J Clin Epidemiol. 2002;55:1144–7. doi:10.1016/S0895-4356(02)00485-7.
Heckman J. Dummy endogenous variables in a simultaneous equation system. Econometrica. 1978;46:931–60. doi:10.2307/1909757.
Green DM, Swets JA. Signal detection theory and psychophysics. New-York: Wiley; 1966.
Swets JA, Pickett RM. Evaluation of diagnostic systems: methods from signal detection theory. New-York: Academic Press; 1982.
Metz CE. Receiver operating characteristics methodology in radiologic imaging. Invest Radiol. 1986;21(9):720–33. doi:10.1097/00004424-198609000-00009.
Walter LC, Brand RJ, Counsell SR, Palmer RM, Landefeld CS, Fortinsky RH, et al. Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization. JAMA. 2001;285:2987–94. doi:10.1001/jama.285.23.2987.
Kohn RR. Cause of death in very old people. JAMA. 1982;247:2793–7. doi:10.1001/jama.247.20.2793.
Ponzetto M, Maero B, Maina P, Rosato R, Ciccone G, Merletti F, et al. Risk factors for early and late mortality in hospitalized older patients: the continuing importance of functional status. J Gerontol A Biol Sci Med Sci. 2003;58:1049–54.
Temkin-Greener H, Bajorska A, Peterson DR, Kunitz SJ, Gross D, Williams TF, et al. Social support and risk-adjusted mortality in a frail older population. Med Care. 2004;42:779–88. doi:10.1097/01.mlr.0000132397.49094.b3.
Van Nes MC, Herrmann FR, Gold G, Michel JP, Rizzoli R. Does the mini nutritional assessment predict hospitalization outcomes in older people? Age Ageing. 2001;30:221–6. doi:10.1093/ageing/30.3.221.
Incalzi RA, Capparella O, Gemma A, Landi F, Bruno E, Di Meo F, et al. The interaction between age and comorbidity contributes to predicting the mortality of geriatric patients in the acute-care hospital. J Intern Med. 1997;242:291–8. doi:10.1046/j.1365-2796.1997.00132.x.
Inouye SK, Bogardus ST Jr, Vitagliano G, Desai MM, Williams CS, Grady JN, et al. Burden of illness score for elderly persons: risk adjustment incorporating the cumulative impact of diseases, physiologic abnormalities, and functional impairments. Med Care. 2003;41:70–83. doi:10.1097/00005650-200301000-00010.
Teno JM, Harrell FE Jr, Knaus W, Phillips RS, Wu AW, Connors A Jr, et al. Prediction of survival for older hospitalized patients: the help survival model. Hospitalized elderly longitudinal project. J Am Geriatr Soc. 2000;48:S16–24.
Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157–65. doi:10.1056/NEJMra052321.
Roche V. Southwestern internal medicine conference. Etiology and management of delirium. Am J Med Sci. 2003;325:20–30. doi:10.1097/00000441-200301000-00005.
Donini LM, Savina C, Rosano A, De Felice MR, Tassi L, De Bernardini L, et al. Mna predictive value in the follow-up of geriatric patients. J Nutr Health Aging. 2003;7:282–93.
Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, et al. Risk factors for 5-year mortality in older adults: the cardiovascular health study. JAMA. 1998;279:585–92. doi:10.1001/jama.279.8.585.
Frisoni GB, Fratiglioni L, Fastbom J, Viitanen M, Winblad B. Mortality in nondemented subjects with cognitive impairment: the influence of health-related factors. Am J Epidemiol. 1999;150:1031–44.
Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA. 1998;279:1187–93. doi:10.1001/jama.279.15.1187.
Cohen HJ, Saltz CC, Samsa G, McVey L, Davis D, Feussner JR. Predictors of two-year post-hospitalization mortality among elderly veterans in a study evaluating a geriatric consultation team. J Am Geriatr Soc. 1992;40:1231–5.
Ho SC. Health and social predictors of mortality in an elderly Chinese cohort. Am J Epidemiol. 1991;133:907–21.
Lee SJ, Lindquist K, Segal MR, Covinsky KE. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA. 2006;295(7):801–8. doi:10.1001/jama.295.7.801.
Olsson T, Terent A, Lind L. Rapid emergency medicine score can predict long-term mortality in nonsurgical emergency department patients. Acad Emerg Med. 2004;11(10):1008–13. doi:10.1111/j.1553-2712.2004.tb00667.x.
Acknowledgments
To sources of funding: The French Ministry of Health, funding the Clinical Research Hospital Projects (PHRC 1998); The National Health Insurance Agency for Wage Earners–CNAMTS, France; The Institute of Longevity and Ageing–INSERM, France. To Angela Swaine Verdier for her help with the English draft.
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The authors each declare no conflict of interest. The financial sponsors played no role in the design, execution, analysis and interpretation of data, or in writing the manuscript.
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Dramé, M., Novella, J.L., Lang, P.O. et al. Derivation and validation of a mortality-risk index from a cohort of frail elderly patients hospitalised in medical wards via emergencies: the SAFES study. Eur J Epidemiol 23, 783–791 (2008). https://doi.org/10.1007/s10654-008-9290-y
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DOI: https://doi.org/10.1007/s10654-008-9290-y