Background: Acute heart failure (AHF) accounts for a major proportion of emergency department (ED) admissions, contributing to severe hospital crowding. Hospital-at-home (HAH) direct from the ED ("admission avoidance") has emerged as an alternative to conventional hospitalization (CH). We performed a systematic review and meta-analysis to evaluate the safety, clinical efficacy, and cost-efficiency of direct ED-to-HAH management in AHF. Methods: Following PRISMA and MOOSE guidelines, we searched PubMed, Web of Science, Cochrane, and Scopus for longitudinal studies (RCTs and observational cohorts) published up to December 31, 2025. Eligible studies compared direct HAH (admission avoidance (≥ 48h) versus CH in adult AHF patients presenting to the ED. Primary endpoint was long-term all-cause mortality. Secondary endpoints included index episode outcomes (in-hospital mortality, length of stay [LoS], care escalation) and 30-day post-discharge outcomes (rehospitalization, direct costs). Random-effects models were used to pool Odds Ratios (OR) and Standardized Mean Differences (SMD) with 95% confidence intervals (CI). Results: Eight studies (3 RCTs, 5 observational cohorts) comprising 3,107 patients (HAH: 817; CH: 2,290) were included. Regarding safety, no differences were found in in-hospital mortality (OR: 0.66; 95% CI: 0.24–1.80) or long-term mortality (7 studies: OR: 0.94; 95% CI: 0.70–1.26; I^2 = 0%; 3 RCTs: OR: 0.90; 95% CI: 0.38–2.13). Care escalation (HAH transfer to CH) occurred in 10.2% of cases (95% CI: 5.7–15.6%). Post-discharge efficacy favored HAH, showing a 40% reduction in 30-day all-cause rehospitalization (OR: 0.60; 95% CI: 0.44–0.82). Although LoS was longer in HAH (SMD: 0.42; 95% CI: 0.18–0.66), index episode costs were significantly lower (SMD: -2.42; 95% CI: -4.11 to -0.74), yielding an average saving of €2,214 per episode. Conclusions: Direct HAH admission from the ED for selected AHF patients is safe, clinically equivalent in mortality, and highly cost-effective, significantly reducing 30-day readmissions. HAH serves as a crucial ED decompression strategy for acute care networks.

Hospital at Home (HaH) has been proposed as a solution to relieve pressure on hospital beds during the COVID-19 pandemic; however, caregivers' feelings of inadequacy and concerns on the need for tighter clinical monitoring might lead to unnecessary and potentially harmful hospital admissions in frail older patients with mild or atypical COVID-19. Here we report the case of a 91-year old woman with severe dementia and atypical COVID-19 that could be successfully managed by our HaH thanks to her highly motivated caregivers and the support of a telemedicine solution (TMS) to provide caregiver training and support as well as supplementary telemonitoring. Despite some well-known issues on TMS use, the hybrid in-person and tele-visit approach of TMS-assisted HaH could help to create a "secure" environment, empowering caregivers to manage frail older adults with COVID-19 at home, avoiding unnecessary admissions to closed wards and their negative physical, functional and psychological outcomes.

This paper reports the case of a patient with a long-standing history of Alzheimer's Disease with dysphagia and total functional dependence, and a left-arm fracture one month before hospitalization with consequently bedrest.

We would like to report the case of an Alzheimer Disease patient affected by Covid-19 admitted to the Hospital at Home Service (HHS) of the University Teaching Hospital of Turin, Italy. HHS is a multidisciplinary service operating 7 days a week that can be directly activated by hospital wards to allow early and supported discharge from hospital. Four doctors and 14 nurses operate 7 days a week and look after 25 patients a day, on average. The HHS provides substitutive hospital-at-home care in a ''clinical unit'' model. Several examinations and treatments can be carried out at home, including blood tests, electrocardiogram, spirometry, pulse oximetry, ultrasonographic investigations, placement of peripherally inserted central catheters, oxygen, and other respiratory therapies, intravenous fluids and drugs, blood transfusions, surgical treatment of pressure ulcers.1Fabris F Molaschi M Aimonino N et al.Home care for demented subjects: new models of care and home-care allowance.Arch Gerontol Geriatr Suppl. 2004; : 155-162https://doi.org/10.1016/j.archger.2004.04.022Crossref PubMed Scopus (10) Google Scholar, 2Aimonino Ricauda N Tibaldi V et al.Substitutive "hospital at home" versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial.J Am Geriatr Soc. 2008; 56: 493-500Crossref PubMed Scopus (122) Google Scholar, 3Tibaldi V Isaia G Scarafiotti C et al.Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial.Arch Intern Med. 2009; 169: 1569-1575Crossref PubMed Scopus (91) Google Scholar, 4Isaia G Astengo MA Tibaldi V et al.Delirium in elderly home-treated patients: a prospective study with 6-month follow-up.Age. 2009; 31: 109-117Crossref PubMed Scopus (33) Google Scholar, 5Ricauda NA Tibaldi V Bertone P et al.The RAD-HOME project: a pilot study of home delivery of radiology services.Arch Intern Med. 2011; 171 (10): 1678-1680Crossref PubMed Scopus (18) Google Scholar On march 15th, an 83-year-old woman was admitted to the emergency department from her private home with mild fever (100,4°F) and drowsiness. Her medical history included only a long-standing history of Alzheimer disease with dysphagia and total functional dependence, and a left arm fracture one month prior to hospitalization. In terms of her mental status, caregivers reported that she was aware of her surroundings at her home, while at hospital admission and during the hospital length of stay she was minimally conscious. She was not able to swallow food and drink, neither to swallow medications. Blood pressure at admission was 80/50 mmHg; she had low oxygen blood saturation (SpO2 90%) without dyspnea or cough. Other blood values were the following: WBC 15070 cells/mm3, hemoglobin 15.4 g/dL, creatinine 1.81 mg/dL, PCR 89 mg/L. Chest X-Ray was negative for pneumonia. While she did not have any history of exposure to COVID, she underwent nasopharyngeal swab which resulted negative. She was then moved to an Acute Medical Ward, where she was treated with cephalosporin and fluid supplementation with marginal improvement of clinical conditions (oxygen supplementation was stopped) and blood chemistries (creatinine 1.01 mg/dL, PCR 59 mg/L), but persistently high WBC count (14310 cells/mm3). On March 23rd, the patient returned home with the support of HHS program. On March 27th a new episode of blood oxygen saturation (SpO2 82%–88%) occurred, associated with diarrhea but without fever. A second nasopharyngeal swab was done, which was positive for Covid-19 infection. According to recommendations from an infectious disease specialist, the patient was treated only with supportive measures, including oxygen supplementation, parenteral nutrition, low-dose heparin, and corticosteroids (betamethasone 8 mg twice daily). It was not possible to administer hydroxicloroquine due to an inability to swallow, while the nasogastric tube was not considered appropriate. On April 10th, the patient is still alive and hemodynamically stable. Along with other cases we have cared for, this case has several clinical implications. First, older patients with dementia and Covid-19 infection may present with mild and atypical symptoms, i.e., namely diarrhea or drowsiness. Second, a negative nasopharyngeal swab does not exclude COVID-19 infection if there is a high clinical suspicion. Third, although these frail older patients have reduced chances to survive this infection, adequate supportive measures may improve survival even without the use of targeted therapies of uncertain and unproven benefit. Some of these patients may die for final worsening of general health status during Covid-19 infection rather than for the infection itself. Indeed, in frail, bedridden patients with dementia, poor nutrition, dehydration, and other clinical complications occur commonly during even mild infective illnesses, and are well recognized risk factors for accelerated worsening health status and death, without the provision of adequate supportive measures. Hopefully, immediate activation of such supportive measures in infected patients with mild disease and without indications for hospital admission might reduce the high mortality rates for Covid-19 infection which are increasingly reported from most long term facilities. Gianluca Isaia, Vittoria Tibaldi and Cristina Tamone collected the data and provided substantial contributions to the conception of the work. Writing support was provided by Gianluca Isaia assisted by Mario Bo. Gianluca Isaia, Renata Marinello and Mario Bo revised the paper critically for important intellectual content. The authors report no funding to disclose or conflicts with any product mentioned or concept discussed in this article.

OBJECTIVE:This study aimed to evaluate the association between polypharmacy and delirium, the association of specific drug categories with delirium, and the differences in drug-delirium association between medical and surgical units and according to dementia diagnosis.METHODS:Data were collected during 2 waves of Delirium Day, a multicenter delirium prevalence study including patients (aged 65 years or older) admitted to acute and long-term care wards in Italy (2015-2016); in this study, only patients enrolled in acute hospital wards were selected (n = 4,133). Delirium was assessed according to score on the 4 "A's" Test. Prescriptions were classified by main drug categories; polypharmacy was defined as a prescription of drugs from 5 or more classes.RESULTS:Of 4,133 participants, 969 (23.4%) had delirium. The general prevalence of polypharmacy was higher in patients with delirium (67.6% vs 63.0%, P = .009) but varied according to clinical settings. After adjustment for confounders, polypharmacy was associated with delirium only in patients admitted to surgical units (OR = 2.9; 95% CI, 1.4-6.1). Insulin, antibiotics, antiepileptics, antipsychotics, and atypical antidepressants were associated with delirium, whereas statins and angiotensin receptor blockers exhibited an inverse association. A stronger association was seen between typical and atypical antipsychotics and delirium in subjects free from dementia compared to individuals with dementia (typical: OR = 4.31; 95% CI, 2.94-6.31 without dementia vs OR = 1.64; 95% CI, 1.19-2.26 with dementia; atypical: OR = 5.32; 95% CI, 3.44-8.22 without dementia vs OR = 1.74; 95% CI, 1.26-2.40 with dementia). The absence of antipsychotics among the prescribed drugs was inversely associated with delirium in the whole sample and in both of the hospital settings, but only in patients without dementia.CONCLUSIONS:Polypharmacy is significantly associated with delirium only in surgical units, raising the issue of the relevance of medication review in different clinical settings. Specific drug classes are associated with delirium depending on the clinical setting and dementia diagnosis, suggesting the need to further explore this relationship.

Background: Acute kidney injury (AKI) incidence is reported to be 10 times higher in aged people. Related to their higher prevalence of chronic kidney disease (CKD), older patients are at high risk of toxic effects driven by drugs. Methods: The demographics, hospitalizations, visits to the Emergency Department, pharmacological therapy, and lab tests were analyzed in 71,588 individuals. Results: Data showed a higher prevalence of AKI as well as CKD in the elderly as compared to the younger group, with an associated very high mortality. A broad number of drugs was prescribed, ranging from 1 to 35, the majority being between 5 and 9 drugs. Conclusion: Elderly patients who developed AKI had a higher number of hospitalizations (underlying frailty), were more likely to progress to more severe stages of CKD and to be affected by other non-renal pathologies (associated comorbidities) and to be given heavier pharmacological prescriptions (polypharmacy).

Advances in the miniaturization and portability of diagnostic technologies, information technologies, remote monitoring, and long-distance care have increased the viability of home-based care, particularly for patients with serious conditions. The Hospital at Home Service (HHS) of Torino is a multidisciplinary, physician-led unit, established in 1985. About 15% of HHS patients have Acute Heart Failure (AHF), requiring on occasion intravenous diuretics and dopamine. A Randomized Controlled Trial of telemonitoring, was initiated in 2014 for patients with AHF receiving home management as an alternative to hospital care. Through the web-platform “Nuvola IT HomeDoctor”, physicians and nurses remotely monitor vital signs (blood pressure, heart rate, oximetry, weight), treating accordingly. The technology is simple, and well accepted by patients and caregivers. We will present an overview of our model of care, and the impact of telemonitoring upon frequency of home visits by HHS staff, and quality of life of patients and caregivers.

The number of nursing home residents being admitted to hospital has been increasing. Residents in nursing homes (NH) are an increasingly vulnerable group with complex medical and care needs. Access to acute care will always be an important component of quality care for nursing homes residents. Nevertheless, reducing preventable hospitalization is fundamental in terms of better quality of care, improved health and cost savings. Evidence indicates that many hospitalizations of NH residents could be avoided, but it is not so clear what specific interventions or combination of interventions effectively decrease potentially avoidable hospital admissions. The objective of this work is a revision of more recent literature on problems and possibile solutions to manage the difficult reationship between hospital and nursing homes.

I progressi nella riduzione delle dimensioni e nella leggerezza delle tecnologie diagnostiche, l’informatizzazione, il monitoraggio remoto e le cure a distanza hanno migliorato la fattibilità delle cure domiciliari, anche per pazienti in condizioni di salute gravi. Progetti di telemedicina e teleradiologia sono in corso presso l’Ospedalizzazione a Domicilio di Torino.

Introduction. This study was performed to evaluate if an early discharge to a Hospital at Home Service (HHS) produced differences in all cause mortality (combined endpoint) and hospital readmissions in elderly patients affected by severe heart failure.Methods. From September 1st 2008 to May 31st 2010, patients 65 years or older admitted to the Emergency Department of the San Giovanni Battista Hospital of Turin for acute decompensated CHF were selected. Patients were randomly assigned to two groups: 26 hospitalized in general wards where they received routine hospital care (group 1), 26 hospitalized and early discharged to the Hospital at Home Service- HHS (within 120 hours) (group 2).Results. Patients were very old (mean age 81 years), comorbid, 73% had severe symptoms of heart failure (NYHA IV), without differences between the two groups. No differences in mortality and hospital readmission rates were found. Mood level improved in HHS patients only.Discussion. This is a pilot study on early discharge for elderly patients with advanced heart failure. Home care should be considered as an important element toward adjusting the transition in frail hospitalized patients effectively.

Introduction. The aim of the study was to evaluate the main features of patients 65 years of age or older admitted to the Emergency Department (ED) for a fall and analyze consequences of falls, new falling events and related predicting factors, hospital recovery rate and institutionalization at 1 month follow-up.Methods. From February 1st to April 30th 2011, 100 patients 65 years of age or older admitted to the ED of the San Giovanni Battista Hospital of Turin for a fall were selected. In the ED a baseline multidimensional assessment was performed. On discharge, we evaluated: allocation, complications, length of hospital stay and diagnosis. At one-month follow-up new falling events, mortality, hospital readmission rate and institutionalization were evaluated.Results. The enrolled patients were very old (mean age 82.5 years), comorbid and in polipharmacy. Twenty four percent of the falls produced traumas, 51% required hospitalization. At 1-month follow-up, 85 patients lived at home, 13 were institutionalized and 2 died. Recurrent falls occurred in 12% of the subjects.Discussion. Patients who access the ED for a fall are often very old and frail. Falls are frequently responsible for traumas and fractures which can determine longer hospitalization or institutionalization. There is need to introduce prevention strategies in order to reduce the incidence of the events and improve quality of life in the elderly with previous falls.

Advances in the miniaturization and portability of diagnostic technologies, information technologies, remote monitoring, and long-distance care have increased the viability of home-based care, even for patients with serious conditions. Telemedicine and teleradiology projects are active at the Hospital at Home Service of Torino.

Introduction. The objective of the study was to evaluate the epidemiology of pressure ulcers and the characteristics of an elderly population with pressure sores admitted to the Hospital at Home Service (HHS) of the San Giovanni Battista Hospital (Torino, Italy). Methods. A descriptive study was conducted on patients admitted to the HHS from January 1st to June 30th 2010, referred from the Emergency Department or other hospital wards. Results. Data of 36 patients with pressure sores were analyzed: 34 patients presented an ulcer upon admission and 2 patients developed pressure ulcers during hospitalization. Patients were very old (mean age 85 years), comorbid, functionally impaired. 50% of patients had stage I ulcers, 28% stage II, 22% stage III-IV; 50% of patients had more than one pressure sore. Most patients were discharged to their home (61%), with programmed health care services in about 17% of cases; mortality rate was 30.5%. Discussion. In our study prevalence rates (about 13%) agree with international data; incidence (0.6%) was lower than data from hospital wards. A possible explanation could be that patients who are at home continue to be followed not only by a multidisciplinary team, but can also rely on the presence of a costant caregiver, who if appropriately educated by the geriatric team, can provide specific and ongoing care.

Demographic, epidemiological, social, and cultural trends in European countries are changing the traditional patterns of care.The next decades will see increasing rates of caredependent older people and non communicable diseases as the leading cause of chronic illness and disability.The break-up of the traditional large family group and urbanization will also lead to gaps in the care of older or disabled family members.These changes in needs and social structure require a different approach to health and social sector policy and services since a disease-oriented approach, alone, is no longer appropriate.An answer to these issues could be home care, a sustainable approach to prevent the need for unnecessary acute or long-term institutionalization and maintain individuals in their home and community as long as possible providing diagnostic, therapeutic and social support (Tarricone & Tsouros, 2008).Home is a place of emotional and physical associations, memories and comfort.Although many people can be happy in assisted-living facilities, retirement communities or nursing homes -and for many people these are better options -leaving home can be disruptive and depressing for some people.Recent trends in health care favour alternatives to traditional hospital care for patients with acute or chronic diseases.Home care used appropriately decreases hospitalization and nursing home use without compromising medical outcomes.Moreover, patients generally prefer to remain in familiar surroundings.Physician support of home care services honors that preference (Levine et al., 2003).Chronic Obstructive Pulmonary Disease (COPD) has been the focus of several hospital at home studies, however, most models studied have been early-discharge schemes that employed nursing care, without physician care in the home.There have been fewer studies of substitutive physician-led clinical unit model of hospital at home. www.intechopen.comChronic Obstructive Pulmonary Disease -Current Concepts and Practice 376 Ageing population: Demographics trendsPopulation ageing is progressing rapidly in many industrialized countries.For the world as a whole, the elderly will grow from 6.9% of the population in 2000 to a projected 19.3% in 2050 (Gavrilov & Heuveline, 2003).Population ageing is a great challenge for the health care systems.As nations age, the prevalence of disability, frailty, and chronic diseases (Alzheimer's disease, cancer, cardiovascular and cerebrovascular diseases, COPD, etc.) is expected to increase dramatically.Frailty is gaining attention in many fields because it increases the risk of hospitalization, falls, mortality and institutionalization. Geriatricians, gerontologists, and social scientists study frailty to better understand its impacts on health, individuals, and society.Frailty has been considered synonymous of disability or co-morbidity, but it is recognized that it is a biological syndrome identified by decreased reserves in multiple organ systems.The incidence of frailty increases with age, reaching more than 32% in those older than 90 years (Fried et al., 2001).Frailty can be a primary diagnosis, when the state is not associated directly with a specific disease, or a secondary diagnosis when the syndrome occur as a result of an acute event or the end stage of many chronic conditions, including severe congestive heart failure, stroke, chronic inflammatory diseases and dementia.The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal environment for frail elderly patients.A new functional impairment and iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common during hospital stay.Chronic obstructive pulmonary disease is a major cause of chronic morbidity and mortality.Patients with COPD usually have progressive airflow obstruction that is not fully reversible, which leads to a history of progressive, worsening breathlessness that can impact on daily activities and health-related quality of life.Winter outbreaks of COPD exacerbations, mostly occurring in elderly people with concurrent chronic co-morbidities, often generate dramatic increases in hospital emergency room admission.Such admissions have increased substantially over the past decade, comprising a significant proportion of all hospital admissions, and are associated with a high rate of readmission contributing to the high costs of care for COPD. Chronic obstructive pulmonary disease: Epidemiological dataChronic obstructive pulmonary disease is a leading cause of mortality and morbidity worldwide, affecting approximately 210 million people and leading to 3 million deaths annually (WHO, 2011).The prevalence and morbidity data greatly understimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced.Furthermore, population-based estimates of COPD prevalence by region are problematic since the disease is progressive, measurement tools and definitions still vary among studies, and implementation of spirometry is often not feasible in developing regions (Lopez et al., 2006a).A recent systematic review and meta-analysis on global burden of COPD reported a prevalence of physiologically defined COPD of 9-10% in adults (Halbert et al., 2006).These www.intechopen.com

Introduction. The aim of this study was to evaluate the feasibility of the Step Training System (STS, an exergame appropriate for training) in old frail patients undergoing rehabilitation. In particular, we focused our attention on factors, such as physical and cognitive functions, which could interfere with an appropriate use of this technology; moreover, we assessed the degree of enjoyment and satisfaction experienced by patients during the training period.Methods. From 1st October 2009 through 31st January 2010, we enrolled 44 elderly patients admitted to the Geriatric Rehabilitation ward of the Prince of Wales Hospital of Sydney. All patients have practiced the STS daily with different speed levels, based on patient's capabilities. At the end of the study period, patients were divided into two groups: poor performers, which have been unable to improve speed velocity over basal speed at the STS, and good performers, including those patients that improved their performances over time.Results. The mean age of the patients was 82.8 years, the mean number of comorbidities was 6.3 per patient, and all patients showed mild cognitive and functional impairment. Fifty two percent of patients reported at least one fall in the previous year. By comparing the 2 groups, good performer patients were more likely to live alone (p = 0.046) and to have an higher score at the cognitive tests. Patients' satisfaction was very high (97% of the patients reported a good-great experience).Discussion. Taking together the results of the present pilot-study demonstrate the utility of the STS in old patients undergoing rehabilitation.

Objectives. Several challenges are posed to the healthcare sector in terms of using innovative tools and technologies. They include a growing ageing population, an epidemic of citizens in chronic conditions, and further development in medical progress which offers new and better treatments. The main goal of this study is to evaluate how telemedicine could be helpful for the home treatment of acutely decompensated chronic heart failure patients or for patients affected by chronic obstructive pulmonary disease (COPD). Methods. Telemonitoring devices have been tested on an elderly population affected by acute heart failure or chronic obstructive pulmonary disease. Results. Eighteen patients have been involved in the study, with a mean age of 86,07 years. They were functional and cognitively impaired. We have collected 772 tele-relevations with only 3 technical problems. Conclusions. Tele-homecare and telemedicine could be useful in different settings and situations: in rural context and in big cities. Our preliminary results demonstrate that telemonitoring elderly patients is feasible. Randomized controlled trials (RCT) are required to evaluate the impact of these new technologies.