- Email: [email protected]
P0007 STROKE IN THE VERY OLD
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 score (0.456, P<0000) and to a lesser extent between Katz and MRC dyspnoea score (-0.345, p<0.000). Independence as measured by Katz was associated with shorter length of stay (p<0.005) for patients discharged alive. Multiple regression analysis suggested dependence of length of stay on MRC dyspnoea score and Katz but not on age or degree of physiological abnormality on admission (MEWS). None of the parameters measured allowed predicting the need for transfer to a rehabilitation ward. Social circumstances were discussed too seldom on admission by senior medical staff (46%) and by junior medical staff (70%). There were strong variations between teams of doctors based on different wards. Conclusion: A subset of patients with complex discharge needs can be identified on admission using simple assessment tools. The absence of a pattern for admission to the rehabilitation ward could suggest the inappropriate usage of rehabilitation beds as overflow beds. Simple tools such as Katz and MRC dyspnoea score could guide medical staff and might allow for proactive discharge planning and shortened length of hospital stay. Keywords: performance status, mortality, length of stay References: 1. Subbe CP et al. Validation of a modified early warning score in medical admissions. QJM 2001; 94:521-6. 2. Katz S et al. Progress in development of the index of ADL. Gerentologist 1970; 10:20–30. 3. Oken, M.M et al. Toxicity and response criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5:649-655.
S11
vs 7%, OR 2.9, P=0.37), hypertension (68% vs 58%, P=0.6), pre-existing disability (70% vs 29%, OR 5.6, P<0.0001), and more points at NIH stroke scale (56% vs 32%, OR 2.6, P=0.006). During hospitalization, incidence of pneumonia was 26% vs 9% (OR 3.7, P<0.003). Fibrinolysis was performed in only one patient in the ≥85 group. Mortality in elderly was higher during hospitalization 24% vs 8%, OR 3.8, P=0.03), as well as within one year (32% vs 13%, OR 3.2, P=0.006). The length of stay was superior in the elderly: over nine days (median) 58% vs 45% (OR 1.6, P= 0.15); over a month 24% vs 10% (OR 2.9, P= 0.01). Fewer very old had dyslipemia (ATPIII criteria): 16% vs 31% (OR 0.4, P<0.05). Hypercholesterolemia 21% vs 39% (OR 0.4, P=0.07), low LDL 11% vs 33% (OR 0.3, P<0.01), high HDL 11% vs 36% (OR 0.3, P= 0.056). Cardioembolism was the commonest mechanism of ischemic stroke in the study group (51.8% vs 40%, P<0.05). Patients discharged to a nursing home and to a chronic management hospital were respectively 7% vs 1%, and 21% vs 12% (P<0.001). Among patients with atrial fibrillation, which prevalence was higher in the very old,mortality during Hospitalization was 31% vs 5% (OR 7.9, P=0.000), and mortality within one year 40% vs 9% (OR 6.6, P=0.000) Conclusions: As expected, very old patients with an ischemic stroke have a poorer prognosis regarding severity of the stroke, medical complications, lenght of stay, disability and mortality. Surprinsingly, dyslipemia does not appear as an important stroke risk factor in the elderly, as opposed to atrial fibrillation, which is strongly associated to mortality. These findings might have therapeutical implications and require further investigation.
P0007
P0008
STROKE IN THE VERY OLD
DIOGENES SYNDROME: NEGLECT OF PERSONAL HYGIENE AND THE LIVING ENVIRONMENT
Sergio Serrano Villar, Cristina Valencia Sanchez, Sabina Herrera Fernandez, Victor Piedrafita Mateo, Ana Bravo, Miguel Angel Cuesta Espinosa, Oscar Fonsere Paton, Gemma Fresco Navacerrada, Pedro Ruiz Artacho, Jesus Porta Etessam. Hospital Clinico San Carlos Introduction: The proportion of elderly people reaching advanced age in developing countries is increasing substantially in recent years. There is a widely accepted notion that very old patients with a stroke have a poorer prognosis than younger ones simply because of older age, but there are very few studies focusing on clinical characteristics and short-term prognosis of very old patients with a stroke. Objectives: To compare clinical characteristics of patients aged over and under 85 years at stroke onset and to investigate very old age as a predictor of poor prognosis. Material & methods: We recorded clinical data on 175 consecutive patients diagnosed with an acute ischemic stroke between 2007 and 2008 in a tertiary hospital in Madrid, Spain,at the onset of the stroke, during hospitalization and within a year since discharge. Results: 25% of patients were 85 years or older at the time of stroke onset. More of the very old were women (76% vs 43%, P<0.01), had atrial fibrillation (42% vs 26%, OR 2.9, P<0.003), chronic kidney disease (11%
N = 172 Women Hypertension Diabetes Mellitus Chronic kidney disease Hypertension Ischemic Heart Disease Dislipydemia Atrial fibrillation Severe stroke (NIHSS>median) Pre-existing disability Cardioembolism Dislipydemia Hipercholesterolemia High LDL Low HDL Hypertriglyceridemia Pneumonia Acute renal failure Death during hospitalization Death within a year Discharge to a nursing home Discharge to a chronic-management hospital Length of stay > median Length of stay > 1 month
Age ≥85
Age <85
25% 76% 62% 31% 11% 68% 16% 16% 42% 56% 70% 51% 31% 21% 13% 70% 11% 26% 22% 24% 32% 7% 18% 58% 24%
75% 43% 59% 23% 7% 58% 19% 31% 26% 32% 29% 41% 19% 39% 30% 60% 36% 9% 14% 8% 13% 2% 14% 45% 10%
Odds Ratio 95% CI
Significance
1.9-8.7 0.6-2.3 0.7-3.2 0.5-5.3 0.5-2.3 0.7-3.1 0.17-0.98 1.4-6.1 1.3-5.2 2.6-11.9 0.8-2.9 0.25-1.1 0.1-1.1 0.11-1.06 0.7-3.6 0.1-0.7 1.5-9.3 0.8-4.3 1.5-9.9 1.3-7.5
0.000 0.7 0.28 0.37 0.6 0.64 0.047 0.003 0.006 0.000 0.4 0.08 0.075 0.056 0.29 0.004 0.003 0.16 0.03 0.006 0.005 0.005 0.15 0.01
0.8-3.2 1.2-7
Aza Abdulla, Ahmed Khwanda, Udayaraj Umasankar. Princess Royal University Hospital, Farnborough Common, Kent, United Kingdom Introduction: Self-neglect is a common feature seen in older adults and along with pathological hoarding (syllogomania) the condition is termed Diogenes syndrome. Objectives/Methods: We describe Diogenes syndrome through a case presentation, its management and epidemiology as it is likely to increase in prevalence in Asia. Case study: An 87-year old woman was admitted to hospital following concerns from her General Practitioner about her self-neglect. In the last four years, she ceased to self-care and stopped disposing of household litter. A neighbour complained of a stench emanating from her house, which was infested with fleas, maggots and flies. Her bed was unusable and she was sleeping in a chair. She lived alone and had a history of bipolar disorder, on Lithium, but had become non-compliant. Social services were involved, but she refused their help. She only allowed her daughter to come in once a week to tidy up and throw out rubbish (which she would occasionally bring back inside after her daughter had left). Her cognitive function was largely intact. She admitted to being a little untidy, but did not consider this a problem and vehemently refused to accept help. She was admitted to a psychiatric unit under section two of the mental health act. Discussion: Diogenes syndrome is characterized by severe self-neglect, domestic squalor, social withdrawal, syllogomania and refusal of help. The disorder is normally detected only when it has reached crisis levels and the alarm is raised by a relative or neighbour. The term was coined by Clark et al in 1975 following the Greek philosopher Diogenes who lived as a recluse. Most adults live alone, are single and exhibit poor personal hygiene and collect rubbish at their homes. They often exhibit certain personality traits in the primary type. The majority have a higher than average intelligence. The secondary type is often associated with conditions such as dementia, depression and substance abuse. Management is challenging. The needs of the patient are complex requiring input from a wide range of services and the process is complicated by the patient’s rejection of these services. The paucity of appropriate guidelines and quality research further compounds these difficulties. The annual incidence of Diogenes Syndrome is estimated at five per 10,000 in those over the age of 60 years. Not much is known about Diogenes syndrome in Asia and in developing countries, largely due to the still preserved extended family and the obligations felt by family members towards their elders, often co-residing together. Key words: Diogenes syndrome, Self-neglect, Syllogomania
S11
vs 7%, OR 2.9, P=0.37), hypertension (68% vs 58%, P=0.6), pre-existing disability (70% vs 29%, OR 5.6, P<0.0001), and more points at NIH stroke scale (56% vs 32%, OR 2.6, P=0.006). During hospitalization, incidence of pneumonia was 26% vs 9% (OR 3.7, P<0.003). Fibrinolysis was performed in only one patient in the ≥85 group. Mortality in elderly was higher during hospitalization 24% vs 8%, OR 3.8, P=0.03), as well as within one year (32% vs 13%, OR 3.2, P=0.006). The length of stay was superior in the elderly: over nine days (median) 58% vs 45% (OR 1.6, P= 0.15); over a month 24% vs 10% (OR 2.9, P= 0.01). Fewer very old had dyslipemia (ATPIII criteria): 16% vs 31% (OR 0.4, P<0.05). Hypercholesterolemia 21% vs 39% (OR 0.4, P=0.07), low LDL 11% vs 33% (OR 0.3, P<0.01), high HDL 11% vs 36% (OR 0.3, P= 0.056). Cardioembolism was the commonest mechanism of ischemic stroke in the study group (51.8% vs 40%, P<0.05). Patients discharged to a nursing home and to a chronic management hospital were respectively 7% vs 1%, and 21% vs 12% (P<0.001). Among patients with atrial fibrillation, which prevalence was higher in the very old,mortality during Hospitalization was 31% vs 5% (OR 7.9, P=0.000), and mortality within one year 40% vs 9% (OR 6.6, P=0.000) Conclusions: As expected, very old patients with an ischemic stroke have a poorer prognosis regarding severity of the stroke, medical complications, lenght of stay, disability and mortality. Surprinsingly, dyslipemia does not appear as an important stroke risk factor in the elderly, as opposed to atrial fibrillation, which is strongly associated to mortality. These findings might have therapeutical implications and require further investigation.
P0007
P0008
STROKE IN THE VERY OLD
DIOGENES SYNDROME: NEGLECT OF PERSONAL HYGIENE AND THE LIVING ENVIRONMENT
Sergio Serrano Villar, Cristina Valencia Sanchez, Sabina Herrera Fernandez, Victor Piedrafita Mateo, Ana Bravo, Miguel Angel Cuesta Espinosa, Oscar Fonsere Paton, Gemma Fresco Navacerrada, Pedro Ruiz Artacho, Jesus Porta Etessam. Hospital Clinico San Carlos Introduction: The proportion of elderly people reaching advanced age in developing countries is increasing substantially in recent years. There is a widely accepted notion that very old patients with a stroke have a poorer prognosis than younger ones simply because of older age, but there are very few studies focusing on clinical characteristics and short-term prognosis of very old patients with a stroke. Objectives: To compare clinical characteristics of patients aged over and under 85 years at stroke onset and to investigate very old age as a predictor of poor prognosis. Material & methods: We recorded clinical data on 175 consecutive patients diagnosed with an acute ischemic stroke between 2007 and 2008 in a tertiary hospital in Madrid, Spain,at the onset of the stroke, during hospitalization and within a year since discharge. Results: 25% of patients were 85 years or older at the time of stroke onset. More of the very old were women (76% vs 43%, P<0.01), had atrial fibrillation (42% vs 26%, OR 2.9, P<0.003), chronic kidney disease (11%
N = 172 Women Hypertension Diabetes Mellitus Chronic kidney disease Hypertension Ischemic Heart Disease Dislipydemia Atrial fibrillation Severe stroke (NIHSS>median) Pre-existing disability Cardioembolism Dislipydemia Hipercholesterolemia High LDL Low HDL Hypertriglyceridemia Pneumonia Acute renal failure Death during hospitalization Death within a year Discharge to a nursing home Discharge to a chronic-management hospital Length of stay > median Length of stay > 1 month
Age ≥85
Age <85
25% 76% 62% 31% 11% 68% 16% 16% 42% 56% 70% 51% 31% 21% 13% 70% 11% 26% 22% 24% 32% 7% 18% 58% 24%
75% 43% 59% 23% 7% 58% 19% 31% 26% 32% 29% 41% 19% 39% 30% 60% 36% 9% 14% 8% 13% 2% 14% 45% 10%
Odds Ratio 95% CI
Significance
1.9-8.7 0.6-2.3 0.7-3.2 0.5-5.3 0.5-2.3 0.7-3.1 0.17-0.98 1.4-6.1 1.3-5.2 2.6-11.9 0.8-2.9 0.25-1.1 0.1-1.1 0.11-1.06 0.7-3.6 0.1-0.7 1.5-9.3 0.8-4.3 1.5-9.9 1.3-7.5
0.000 0.7 0.28 0.37 0.6 0.64 0.047 0.003 0.006 0.000 0.4 0.08 0.075 0.056 0.29 0.004 0.003 0.16 0.03 0.006 0.005 0.005 0.15 0.01
0.8-3.2 1.2-7
Aza Abdulla, Ahmed Khwanda, Udayaraj Umasankar. Princess Royal University Hospital, Farnborough Common, Kent, United Kingdom Introduction: Self-neglect is a common feature seen in older adults and along with pathological hoarding (syllogomania) the condition is termed Diogenes syndrome. Objectives/Methods: We describe Diogenes syndrome through a case presentation, its management and epidemiology as it is likely to increase in prevalence in Asia. Case study: An 87-year old woman was admitted to hospital following concerns from her General Practitioner about her self-neglect. In the last four years, she ceased to self-care and stopped disposing of household litter. A neighbour complained of a stench emanating from her house, which was infested with fleas, maggots and flies. Her bed was unusable and she was sleeping in a chair. She lived alone and had a history of bipolar disorder, on Lithium, but had become non-compliant. Social services were involved, but she refused their help. She only allowed her daughter to come in once a week to tidy up and throw out rubbish (which she would occasionally bring back inside after her daughter had left). Her cognitive function was largely intact. She admitted to being a little untidy, but did not consider this a problem and vehemently refused to accept help. She was admitted to a psychiatric unit under section two of the mental health act. Discussion: Diogenes syndrome is characterized by severe self-neglect, domestic squalor, social withdrawal, syllogomania and refusal of help. The disorder is normally detected only when it has reached crisis levels and the alarm is raised by a relative or neighbour. The term was coined by Clark et al in 1975 following the Greek philosopher Diogenes who lived as a recluse. Most adults live alone, are single and exhibit poor personal hygiene and collect rubbish at their homes. They often exhibit certain personality traits in the primary type. The majority have a higher than average intelligence. The secondary type is often associated with conditions such as dementia, depression and substance abuse. Management is challenging. The needs of the patient are complex requiring input from a wide range of services and the process is complicated by the patient’s rejection of these services. The paucity of appropriate guidelines and quality research further compounds these difficulties. The annual incidence of Diogenes Syndrome is estimated at five per 10,000 in those over the age of 60 years. Not much is known about Diogenes syndrome in Asia and in developing countries, largely due to the still preserved extended family and the obligations felt by family members towards their elders, often co-residing together. Key words: Diogenes syndrome, Self-neglect, Syllogomania