Adult failure to thrive in the older rehabilitation patient

New Problems and Iatrogenic Events Among Older Adults in the First 30 Days of Post-Acute Rehabilitation

The current prospective study of 126 older adults examined the new problems and iatrogenic events developing in post-acute rehabilitation. Data were extracted from the electronic health record and a consensual agreement process was used for coding. Of the 578 new problems, 66% (n = 381) were not related to the primary problem treated at the hospital; 41.7% (n = 241) were iatrogenic adverse events. The median problem-free duration was 3 days and median duration to a moderate to severe problem was 8 days. Medication-related adverse events were common. This study did not show that comorbidity or functional level should be used in determining the likelihood of older adults developing new problems or iatrogenic events during post-acute rehabilitation. Inferential findings suggest older adults with a psychiatric diagnosis, cognitive impairment, or failure to thrive may require extra measures, such as comprehensive assessment and early intervention, to prevent new problems and iatrogenic events. [Research in Gerontological Nursing, 14(6), 293-304.].

Massachusetts Inpatient Medicaid Cost Response to Increased Supplemental Nutrition Assistance Program Benefits

OBJECTIVES

To investigate the impact of an increase in Supplemental Nutrition Assistance Program (SNAP) benefits on Medicaid costs and use in Massachusetts.

METHODS

Using single and multigroup interrupted time series models, I examined the effect of an April 2009 increase in SNAP benefits on inpatient Medicaid cost and use patterns. I analyzed monthly Medicaid discharge data from 2006 to 2012 collected by the Massachusetts Center for Health Information and Analysis.

RESULTS

Inpatient costs for the overall Massachusetts Medicaid population grew by 0.55 percentage points per month (P < .001) before the SNAP increase. After the increase, cost growth fell by 73% to 0.15 percentage points per month (-0.40; P = .003). Compared with the overall Medicaid population, cost growth for people with the selected chronic illnesses was significantly greater before the SNAP increase, as was the decline in growth afterward. Reduced hospital admissions after the SNAP increase drove the cost declines.

CONCLUSIONS

Medicaid cost growth fell in Massachusetts after SNAP benefits increased, especially for people with chronic illnesses with high sensitivity to food insecurity.

Evaluation of older adults hospitalized with a diagnosis of failure to thrive

BACKGROUND

older adults are sometimes hospitalized with the admission diagnosis of failure to thrive (FTT), often because they are not felt safe to be discharged back to their current living arrangement. It is unclear if this diagnosis indicates primarily a social admission or suggests an acute medical deterioration. The objective of this study was to explore the level of acuity and medical investigations commonly conducted among older hospitalized adults with a diagnosis of FTT.

METHODS

We conducted a retrospective cohort study at three hospitals in Calgary, Alberta. Data were extracted from the electronic medical records of the 603 admissions of patients 65 years or older with a diagnosis of FTT between January 2010 and January 2011. Markers of medical acuity were evaluated.

RESULTS

The vast majority of patients had short hospital stays. Specialist physicians were consulted for 323 cases (54%). Allied health-care professionals were consulted in 151 cases (25%). While in hospital, patients underwent extensive investigations, including CT scans, ultrasounds, and echo-cardiograms. Many patients received IV fluids (71%) and IV antibiotics (35%).

CONCLUSIONS

The data suggest that acute illnesses, and not social factors, were the primary reason for admission among those given a diagnosis of FTT.

Identifying failure to thrive in the long term care setting

INTRODUCTION AND RATIONALE

Geriatric failure to thrive (GFTT) is commonly encountered in the long term care (LTC) setting. This syndrome of unexplained functional decline can be approached in a methodical manner. The updated Minimum Data Set (MDS) 3.0, now implemented in almost all skilled nursing facilities, includes pertinent clinical information that could be used to identify residents who manifest GFTT. A screening tool using data from the MDS 3.0 could be used by LTC providers to evaluate LTC residents.

METHODS

A literature review was completed to identify articles focused on (1) GFTT in the LTC setting and (2) tools to identify GFTT. Common components of GFTT were matched with items collected as part of the MDS 3.0 with a goal to determine its utility as a screening tool to identify GFTT in the LTC setting.

OUTCOMES AND DISCUSSION

The MDS 3.0 includes assessment of numerous components commonly observed in patients with GFTT. By using clinically validated tools, the MDS 3.0 may assist in the recognition of LTC residents with or at risk for GFTT. Once GFTT is recognized, the LTC interdisciplinary team can then identify potentially reversible causes, set goals of care, and develop a comprehensive care plan that may include diagnostic measures, curative interventions, and/or palliative measures individualized to the resident.

Assessing Challenges in End-of-Life Conversations With Elderly Patients With Multiple Morbidities

Introduction: This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer). Methods: Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation. Results: Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach. Conclusion: Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.