Jarrett P G, Rockwood K, Carver D, Stolee P, Cosway S
Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia.
Arch Intern Med. 1995 May 22;155(10):1060-4.
Atypical disease presentations, such as delirium, are associated with adverse health outcomes. They are also markers of frailty in elderly people, which is itself associated with adverse hospital outcomes. We investigated the relationship between frailty and atypical disease presentation in predicting adverse hospital outcomes and complications of the hospital course of elderly patients admitted to general medical services.
We conducted a cohort study in a large (800 beds) tertiary care university hospital. The prevalence of atypical disease presentations and the incidence of adverse hospital outcomes (death, nursing home admission, prolonged hospital stay, and failure to regain premorbid functional status) were studied in previously well and previously frail elderly patients.
Patients were classified as being well or frail on the basis of the premorbid Barthel Index (well, score of > or = 95 [n = 76]; frail, score of < 95 [n = 117]). Frail elderly were older (80 vs 76 years), more often female (62% vs 46%), and less likely to be community dwelling (89% vs 99%). Atypical disease presentation was more common in the frail elderly (59% vs 25%; P < .001). Of those who presented atypically, the frail most often presented with delirium (61%) and the well presented with falls (37%) and delirium (32%). Of the frail elderly with atypical symptoms, 60% had adverse hospital outcomes compared with 32% of the well elderly who presented typically (P < .05). Logistic regression analysis showed that premorbid functional dependence (odds ratio, 2.48; 95% confidence interval, 1.17 to 5.22), atypical disease presentation (odds ratio, 2.37; 95% confidence interval, 1.20 to 4.67), and functional decline at admission (odds ratio, 5.64; 95% confidence interval, 2.37 to 13.44) were all independently predictive of poor hospital outcomes. By contrast, severity of disease, age, and sex did not confer an increased risk of adverse events.
Premorbid functional dependency, atypical disease presentation, and functional decline on admission have independent impacts on adverse hospital outcomes. Assessment of each should be incorporated into the routine care of elderly patients.
非典型疾病表现，如谵妄，与不良健康结局相关。它们也是老年人虚弱的标志，而虚弱本身与不良医院结局相关。我们研究了在预测综合医疗服务收治的老年患者的不良医院结局及住院期间并发症方面，虚弱与非典型疾病表现之间的关系。
我们在一家大型（800张床位）三级医疗大学医院进行了一项队列研究。研究了既往健康和既往虚弱的老年患者中非典型疾病表现的患病率以及不良医院结局（死亡、入住养老院、住院时间延长和未能恢复病前功能状态）的发生率。
根据病前巴氏指数将患者分为健康或虚弱（健康，评分≥95分[n = 76]；虚弱，评分<95分[n = 117]）。虚弱的老年人年龄更大（80岁对76岁），女性更常见（62%对46%），居住在社区的可能性更小（89%对99%）。非典型疾病表现在虚弱老年人中更常见（59%对25%；P <.001）。在非典型表现的患者中，虚弱者最常表现为谵妄（61%），而健康者表现为跌倒（37%）和谵妄（32%）。有非典型症状的虚弱老年人中，60%有不良医院结局，而典型表现的健康老年人中这一比例为32%（P <.05）。逻辑回归分析显示，病前功能依赖（比值比，2.48；95%置信区间，1.17至5.22）、非典型疾病表现（比值比，2.37；95%置信区间，1.20至4.67）和入院时功能下降（比值比，5.64；95%置信区间，2.37至13.44）均独立预测不良医院结局。相比之下，疾病严重程度、年龄和性别并未增加不良事件的风险。
病前功能依赖、非典型疾病表现和入院时功能下降对不良医院结局有独立影响。对每一项的评估都应纳入老年患者的常规护理中。
