First-generation versus third-generation comprehensive geriatric assessment instruments in the acute hospital setting: a comparison of the Minimum Geriatric Screening Tools (MGST) and the interRAI Acute Care (interRAI AC)

Hospital Complications and Frailty in Mexican Older Adults: An Emergency Care Cohort Analysis

Objectives: To describe the association of frailty level on admittance to the Emergency Department (ED) with various hospital complications including delirium, low phase angle, and low handgrip strength.

Design: Prospective cohort.

Setting: ED rooms of two public general hospitals in Mexico City.

Participants: A total of 548 persons 60 years or older who were admitted to the ED and who were alive during follow-up testing at home were included.

Measurements: A 32-item frailty index (FI) was measured on admission to the ED. Outcome measures included delirium, phase angle, and hand grip strength measured during different stages of the hospitalization (i.e., from admission to the ED through to follow-up at home).

Results: From this final sample, mean age was 76 years (± SD 7.2) and 58.4% (n = 320) were women. Mean waiting time in the ED was 5.1 h (± SD 6.2), the average stay in the ED was 99.9 (±68.2) h, and 274 subjects (50%) were admitted to a general ward after ED admission. FI was not associated with phase angle and was negatively associated with handgrip strength at admission to ED (β = −3.97, confidence interval [CI] 95% −5.56 −2.38, p < 0.001), discharge from ED (β = −3.94, CI 95% −5.97 −1.90, p < 0.001), and discharge from hospital (β = −4.93, CI 95% −7.68 −2.18, p = 0.01). FI was positively associated with delirium (β = 3.68, CI 95% 1.53–5.83, p < 0.01).

Conclusion: Higher frailty at ED admission was associated with lower hand grip strength and delirium during hospitalization in Mexican older adults.

"Establishing the criterion validity of the interRAI Check-Up Self-Report instrument"

Background

Low and middle-income countries have growing older populations and could benefit from the use of multi-domain geriatric assessments in overcoming the challenge of providing quality health services to older persons. This paper reports on the outcomes of a study carried out in Cape Town, South Africa on the validity of the interRAI Check-Up Self-Report instrument, a multi-domain assessment instrument designed to screen older persons in primary health settings. This is the first criterion validity study of the instrument. The instrument is designed to identify specific health problems and needs, including psychosocial or cognition problems and issues related to functional decline. The interRAI Check-Up Self-Report is designed to be compatible with the clinician administered instruments in the interRAI suite of assessments, but the validity of the instrument against clinician ratings has not yet been established. We therefore sought to establish whether community health workers, rather than trained healthcare professionals could reliably administer the self-report instrument to older persons.

Methods

We evaluated the criterion validity of the self-report instrument through comparison to assessments completed by a clinician assessor. A total of 112 participants, aged 60 or older were recruited from 7 seniors clubs in Khayelitsha, Cape Town. Each participant was assessed by one of two previously untrained, non-healthcare personnel using the Check-Up Self-report version and again by a trained assessor using the clinician version of the interRAI Check-Up within 48 h. Our analyses focused on the degree of agreement between the self-reported and clinician-rated versions of the Check-Up based on the simple or weighted kappa values for the two types of ratings. Binary variables used simple kappas, and ordinal variables with three or more levels were examined using weighted kappas with Fleiss-Cohen weights.

Results

Based on Cohen’s Kappa values, we were able to establish that high levels of agreement existed between clinical assessors and lay interviewers, indicating that the instrument can be validly administered by community health workers without formal healthcare training. 13% of items had kappa values ranging between 0.10 and 0.39; 51% of items had kappa values between 0.4 and 0.69; and 36% of items had values of between 0.70 and 1.00.

Conclusion

Our findings indicate that there is potential for the Check-Up Self-Report instrument to be implemented in under-resourced health systems such as South Africa’s.

Reliability and validity of the Mandarin version of the Continuity Assessment Record and Evaluation for older people who are transferred between hospitals and nursing homes in China

To date, assessment tools for older people are different between hospitals and nursing homes in China. The difference between assessment tools can lead to poor communication of information between hospitals and nursing homes, which causes discontinuity of care and adverse outcomes when older people are transferred between these different settings. Continuity Assessment Record and Evaluation (CARE) is a comprehensive geriatric assessment tool developed in the United States of America. This study aimed to evaluate the reliability and validity of the Mandarin Version of CARE for older people who are transferred between hospitals and nursing homes. Using a convenience sampling method, 120 older people in hospitals and 120 older people in nursing homes in Shanghai were selected to test the internal consistency, interrater reliability and criterion-related validity of CARE from May to November 2017. When used among hospital, 70.0% (7/10) of the subscales had a Cronbach's alpha coefficients of greater than 0.7, 94.3% (50/53) of the items had an intraclass correlation coefficient (ICC) of greater than 0.75. When used in nursing homes, 90.0% (9/10) of the subscales had a Cronbach's alpha coefficients of greater than 0.7, 94.3% (50/53) of the items had an ICC of greater than 0.75. For both settings, the correlation coefficients of the subscales with their corresponding instruments for criterion-related validity were all greater than 0.8 (p < .01). The Mandarin version of CARE exhibits good reliability and validity. It can be used as an assessment tool for transition between hospitals and nursing homes.

Frailty Index and functional level upon admission predict hospital outcomes: an interRAI-based cohort study of older patients in post-acute care hospitals

BACKGROUND

Geriatric assessment upon admission may reveal factors that contribute to adverse outcomes in hospitalized older patients. The purposes of this study were to derive a Frailty Index (FI-PAC) from the interRAI Post-Acute Care instrument (interRAI-PAC) and to analyse the predictive ability of the FI-PAC and interRAI scales for hospital outcomes.

METHODS

This retrospective cohort study was conducted by combining patient data from interRAI-PAC with discharge records from two post-acute care hospitals. The FI-PAC was derived from 57 variables that fulfilled the Frailty Index criteria. Associations of the FI-PAC and interRAI-PAC scales (ADLH for activities of daily living, CPS for cognition, DRS for mood, and CHESS for stability of health status) with hospital outcomes (prolonged hospital stay ≥90 days, emergency department admission during the stay, and in-hospital mortality) were analysed using logistic regression and ROC curves.

RESULTS

The cohort included 2188 patients (mean age (SD) 84.7 (6.3) years) who were hospitalized in two post-acute care hospitals. Most patients (n = 1691, 77%) were discharged and sent home. Their median length of stay was 35 days (interquartile range 18-87 days), and 409 patients (24%) had a prolonged hospital stay. During their stay, 204 patients (9%) were admitted to the emergency department and 231 patients (11%) died. The FI-PAC was normally distributed (mean (SD) 0.34 (0.15)). Each increase of 0.1 point in the FI-PAC increased the likelihood of prolonged hospital stay (odds ratio [95% CI] 1.91 [1.73─2.09]), emergency admission (1.24 [1.11─1.37]), and in-hospital death (1.82 [1.63─2.03]). The best instruments for predicting prolonged hospital stay and in-hospital mortality were the FI-PAC and the ADLH scale (AUC 0.75 vs 0.72 and 0.73 vs 0.73, respectively). There were no differences in the predictive abilities of interRAI scales and the FI-PAC for emergency department admission.

CONCLUSIONS

The Frailty Index derived from interRAI-PAC predicts adverse hospital outcomes. Its predictive ability was similar to that of the ADLH scale, whereas other interRAI-PAC scales had less predictive value. In clinical practice, assessment of functional ability is a simple way to assess a patient's prognosis.

Examining consensus for a standardised patient assessment in community paramedicine home visits: a RAND/UCLA-modified Delphi Study

OBJECTIVE

Community paramedicine programme are often designed to address repeated and non-urgent use of paramedic services by providing patients with alternatives to the traditional 'treat and transport' ambulance model of care. We sought to investigate the level of consensus that could be found by a panel of experts regarding appropriate health, social and environmental domains that should be assessed in community paramedicine home visit programme.

DESIGN

We applied the RAND/UCLA Appropriateness Method in a modified Delphi method to investigate the level of consensus on assessment domains for use in community paramedicine home visit programme.

SETTING AND PARTICIPANTS

We included a multi-national panel of 17 experts on community paramedicine and in-home assessment from multiple settings (paramedicine, primary care, mental health, home and community care, geriatric care).

MEASURES

A list of potential assessment categories was established after a targeted literature review and confirmed by panel members. Over multiple rounds, panel members scored the appropriateness of 48 assessment domains on a Likert scale from 0 (not appropriate) to 5 (very appropriate). Scores were then reviewed at an in-person meeting and a finalised list of assessment domains was generated.

RESULTS

After the preliminary round of scoring, all 48 assessment domains had scores that demonstrated consensus. Nine assessment domains (18.8%) demonstrated a wider range of rated appropriateness. No domains were found to be not appropriate. Achieving consensus about the appropriateness of assessment domains on the first round of scoring negated the need for subsequent rounds of scoring. The in-person meeting resulted in re-grouping assessment domains and adding an additional domain about urinary continence.

CONCLUSION

An international panel of experts with knowledge about in-home assessment by community paramedics demonstrated a high level of agreement on appropriate patient assessment domains for community paramedicine home visit programme. Community paramedicine home visit programme are likely to have similar patient populations. A standardised assessment instrument may be viable in multiple settings.

What do community paramedics assess? An environmental scan and content analysis of patient assessment in community paramedicine

Objectives

Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.

Methods

We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.

Results

A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.

Conclusion

Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.

Changes in the Use of Comprehensive Geriatric Assessment in Clinical Trials for Older Patients with Cancer over Time

BACKGROUND

The objective of this study was to describe the implementation of comprehensive geriatric assessment (CGA) in clinical trials dedicated to older patients before and after the creation of the International Society of Geriatric Oncology in the early 2000s.

SUBJECTS, MATERIALS, AND METHODS

All phase I, II, and III trials dedicated to the treatment of cancer among older patients published between 2001 and 2004 and between 2011 and 2014 were reviewed. We considered that a CGA was performed when the authors indicated an intention to do so in the Methods section of the article. We collected each geriatric domain assessed using a validated tool even in the absence of a clear CGA, including nutritional, functional, cognitive, and psychological status, comorbidity, comedication, overmedication, social status and support, and geriatric syndromes.

RESULTS

A total of 260 clinical trials dedicated to older patients were identified over the two time periods: 27 phase I, 193 phase II, and 40 phase III trials. CGA was used in 9% and 8% of phase II and III trials, respectively; it was never used in phase I trials. Performance status was reported in 67%, 79%, and 75% of phase I, II, and III trials, respectively. Functional assessment was reported in 4%, 11%, and 13% of phase I, II, and III trials, respectively. Between the two time periods, use of CGA increased from 1% to 11% (p = .0051) and assessment of functional status increased from 3% to 14% (p = .0094).

CONCLUSION

The use of CGA in trials dedicated to older patients increased significantly but remained insufficient.

IMPLICATIONS FOR PRACTICE

This article identifies the areas in which research efforts should be focused in order to offer physicians well-addressed clinical trials with results that can be extrapolated to daily practice.

A frailty index derived from a standardized comprehensive geriatric assessment predicts mortality and aged residential care admission

Background

Frailty in older adults is a condition characterised by a loss or reduction in physiological reserve resulting in increased clinical vulnerability. However, evidence suggests that frailty may be modifiable, and identifying frail older people could help better target specific health care interventions and services.

Methods

This was a regional longitudinal study to develop a frailty index for older adults living in Canterbury New Zealand. Participants included 5586 community dwelling older people that had an interRAI Minimum Data Set (MDS-HC) Home Care assessment completed between 2008 and 2012. The outcome measures were mortality and entry into aged residential care (ARC), after five years.

Results

Participants were aged between 65 and 101 (mean age was 82 years). The five-year mortality rate, including those who entered ARC, for this cohort was 67.1% (n = 3747). The relationship between the frailty index and both mortality and entry into ARC was significant (P < 0.001). At five years, 25.1% (n = 98) of people with a baseline frailty of < 0.1 had died compared with 28.2% (n = 22) of those with a frailty index of ≥0.5 (FS 5). Furthermore, 43.7% (n = 171) of people with a frailty index of < 0.1 were still living at home compared to 2.6% (n = 2) of those with a frailty index of ≥0.5.

Conclusion

A frailty index was created that predicts mortality, and admission into ARC. This index could help healthcare professionals and clinicians identify older people at risk of health decline and mortality, so that appropriate services and interventions may be put in place.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-1016-8) contains supplementary material, which is available to authorized users.

The Rest of the Story: A Qualitative Study of Complementing Standardized Assessment Data with Informal Interviews with Older Patients and Families

BACKGROUND

While standardized health assessments capture valuable information on patients' demographic and diagnostic characteristics, health conditions, and physical and mental functioning, they may not capture information of most relevance to individual patients and their families. Given that patients and their informal caregivers are the experts on that patient's unique context, it is important to ensure they are able to convey all relevant personal information to formal healthcare providers so that high-quality, patient-centered care may be delivered. This study aims to identify information that older patients and families consider important but that might not be included in standardized assessments.

METHODS

Transcripts were analyzed from 29 interviews relating to eight patients with hip fractures from three sites (large urban, smaller urban, rural) in two provinces in Canada. These interviews were conducted as part of a larger ethnographic study. Each transcript was analyzed by two researchers using content analysis. Results were reviewed in two focus group interviews with older adults and family caregivers. Identified themes were compared with items from two standardized assessments used in healthcare settings.

RESULTS

Three broad themes emerged from the qualitative analysis that were not covered in the standardized assessments: informal caregiver and family considerations, insider healthcare knowledge, and patients' healthcare attitudes and experiences. The importance of these themes was confirmed through focus group interviews. Focus group participants also emphasized the importance of conducting assessments in a patient-centered way and the importance of open-ended questions.

CONCLUSIONS

A less structured interview approach may yield information that would otherwise be missed in standardized assessments. Combining both sources could yield better-informed healthcare planning and quality-improvement efforts.

The geriatric management of frailty as paradigm of "The end of the disease era"

The sustainability of healthcare systems worldwide is threatened by the absolute and relative increase in the number of older persons. The traditional models of care (largely based on a disease-centered approach) are inadequate for a clinical world dominated by older individuals with multiple (chronic) comorbidities and mutually interacting syndromes. There is the need to shift the center of the medical intervention from the disease to the biological age of the individual. Thus, multiple medical specialties have started looking with some interest at concepts of geriatric medicine in order to better face the increased complexity (due to age-related conditions) of their average patient. In this scenario, special interest has been given to frailty, a condition characterized by the reduction of the individual's homeostatic reserves and increased vulnerability to stressors. Frailty may indeed represent the fulcrum to lever for reshaping the healthcare systems in order to make them more responsive to new clinical needs. However, the dissemination of the frailty concept across medical specialties requires a parallel and careful consideration around the currently undervalued role of geriatricians in our daily practice.

A Belgian Survey on Geriatric Assessment in Oncology Focusing on Large-Scale Implementation and Related Barriers and Facilitators

OBJECTIVES

The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate.

RESULTS

Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration.

CONCLUSION

Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.

Derivation of a frailty index from the interRAI acute care instrument

BACKGROUND

A better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care.

METHODS

1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis.

RESULTS

Variables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data. Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0-1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0. In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70-2.48]).

CONCLUSIONS

Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs. The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.

International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer

PURPOSE

To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer.

METHODS

SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care.

RESULTS

GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensity. The panel recommended that the following domains be evaluated in a GA: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. Although several combinations of tools and various models are available for implementation of GA in oncology practice, the expert panel could not endorse one over another.

CONCLUSION

There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.

International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer

PURPOSE

To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer.

METHODS

SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care.

RESULTS

GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensity. The panel recommended that the following domains be evaluated in a GA: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. Although several combinations of tools and various models are available for implementation of GA in oncology practice, the expert panel could not endorse one over another.

CONCLUSION

There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.

The interRAI Acute Care instrument incorporated in an eHealth system for standardized and web-based geriatric assessment: strengths, weaknesses, opportunities and threats in the acute hospital setting

Background

The interRAI Acute Care instrument is a multidimensional geriatric assessment system intended to determine a hospitalized older persons’ medical, psychosocial and functional capacity and needs. Its objective is to develop an overall plan for treatment and long-term follow-up based on a common set of standardized items that can be used in various care settings. A Belgian web-based software system (BelRAI-software) was developed to enable clinicians to interpret the output and to communicate the patients’ data across wards and care organizations. The purpose of the study is to evaluate the (dis)advantages of the implementation of the interRAI Acute Care instrument as a comprehensive geriatric assessment instrument in an acute hospital context.

Methods

In a cross-sectional multicenter study on four geriatric wards in three acute hospitals, trained clinical staff (nurses, occupational therapists, social workers, and geriatricians) assessed 410 inpatients in routine clinical practice. The BelRAI-system was evaluated by focus groups, observations, and questionnaires. The Strengths, Weaknesses, Opportunities and Threats were mapped (SWOT-analysis) and validated by the participants.

Results

The primary strengths of the BelRAI-system were a structured overview of the patients’ condition early after admission and the promotion of multidisciplinary assessment. Our study was a first attempt to transfer standardized data between home care organizations, nursing homes and hospitals and a way to centralize medical, allied health professionals and nursing data. With the BelRAI-software, privacy of data is guaranteed. Weaknesses are the time-consuming character of the process and the overlap with other assessment instruments or (electronic) registration forms. There is room for improving the user-friendliness and the efficiency of the software, which needs hospital-specific adaptations. Opportunities are a timely and systematic problem detection and continuity of care. An actual shortage of funding of personnel to coordinate the assessment process is the most important threat.

Conclusion

The BelRAI-software allows standardized transmural information transfer and the centralization of medical, allied health professionals and nursing data. It is strictly secured and follows strict privacy regulations, allowing hospitals to optimize (transmural) communication and interaction. However, weaknesses and threats exist and must be tackled in order to promote large scale implementation.

Convergent validity of the Cognitive Performance Scale of the interRAI acute care and the mini-mental state examination

OBJECTIVE

The Cognitive Performance Scale (CPS) is generated from five items of the interRAI/ Minimum Data Set instruments, a comprehensive geriatric assessment method. CPS was initially designed to assess cognition in residential care, where it has shown good psychometric performance. We evaluated the performance of the interRAI Acute Care in identifying cognitive impairment among patients hospitalized on acute geriatric wards.

METHODS

An observational study was conducted on two geriatric wards. Trained raters independently completed the interRAI Acute Care and the Mini-Mental State Examination (MMSE) in 97 inpatients (85 ± 5 years; 67% female). The level of agreement between CPS and MMSE was explored using comparisons of means, agreement coefficients, and diagnostic accuracy.

RESULTS

Cognitive impairment was present in 61% of the participants. Average MMSE scores were significantly different between groups with low CPS scores compared with those with high CPS scores (p <0.05). CPS explained only 48.8% of the variability in MMSE. Agreement in defining cognitively impaired subjects was moderate (percentage observed agreement, 68%; κ = 0.41). With MMSE score less than 24 as a gold standard, diagnostic accuracy of CPS was moderate (area under curve = 0.73), with low sensitivity, but excellent specificity. When lowering the MMSE cutoff to less than 18 and focusing on patients with severe cognitive impairment, CPS agreement coefficients and sensitivity increased but specificity decreased. Using education-adjusted MMSE cutoffs did not substantially affect the results.

CONCLUSION

CPS can be used for coarse triage between intact and severe cognitive impairment. Although promising results have been obtained in residential and community settings, our results suggest that CPS fails to differentiate across different levels of cognitive impairment in hospitalized geriatric patients.

Clinical changes in older adults during hospitalization: responsiveness of the interRAI acute care instrument

OBJECTIVES

To evaluate the responsiveness of the Minimum Data Set interRAI Acute Care (AC), a comprehensive geriatric assessment system, to detect clinical changes in patient status during hospital stays.

DESIGN

An explorative secondary data-analysis comparing prospectively collected data with the interRAI AC before hospitalization, upon admission, and at discharge.

SETTING

Clinicians from multiple disciplines in nine geriatric and eight nongeriatric wards of nine acute hospitals performed the assessment.

PARTICIPANTS

The interRAI AC was administered serially to 256 geriatric inpatients (aged 83.2 ± 5.2; 60% female).

MEASUREMENTS

Responsiveness (capacity to detect changes in patients) was calculated for the output scales on five domains: activities of daily living (ADLs), cognition, communication, depressive symptoms, and pain. Internal responsiveness was evaluated using the Friedman test and Guyatt technique.

RESULTS

Significant differences in clinical status were found for all five domains, based on the Friedman test. Post hoc tests revealed differences between each assessment period, except for cognition and communication from admission to discharge and for depressive symptoms from before admission to discharge. The Guyatt Responsiveness Index showed good to excellent capacity to detect longitudinal changes during hospitalization for cognition, communication, and pain and substantial performance for ADLs and depressive symptoms.

CONCLUSION

In older inpatients, fluctuations in ADLs, cognition, communication, depressive symptoms, and pain can be captured using the interRAI AC output scales, enabling clinicians to evaluate longitudinal changes from admission to discharge and to provide a comparison with patient status before the acute onset of the illness. These results support the use of these scales in geriatric and nongeriatric wards.

Translation and adaption of the interRAI Suite to local requirements in Belgian hospitals

Background

The interRAI Suite contains comprehensive geriatric assessment tools designed for various healthcare settings. Although each instrument is developed for a particular population, together they form an integrated health evaluation system. The interRAI Acute Care Minimum Data Set (interRAI AC) is tailored for hospitalized older persons. Our aim in this study was to translate and adapt the interRAI AC to the Belgian hospital context, where it can be used together with the interRAI Home Care (HC) and the interRAI Long Term Care Facility (LTCF).

Methods

A systematic, comprehensive, and rigorous 10-step approach was used to adapt the interRAI AC to local requirements. After linguistic translation by an official translator, five researchers assessed the translation for appropriate hospital jargon. Three researchers double-checked for translation accuracy and proposed additional items. A provisional version was converted into the three official languages of Belgium—Flemish, French, and German. Next, a multidisciplinary panel of nine experts judged item relevance to the Belgian care context and advised which country-specific items should be added. After these suggestions were incorporated into the interRAI AC, hospital staff from nine Flemish hospitals field-tested the tool in their practice. After evaluating field-test results, we compared the interRAI AC with Belgian versions of the interRAI HC and interRAI LTCF. Next, the Flemish, French, and German versions of the Belgian interRAI portfolio were harmonized. Finally, we submitted the Belgian interRAI AC to the interRAI organization for ratification.

Results

Eighteen administrative items of the interRAI AC were adapted to the Belgian healthcare context (e.g., usual residence, formal community services prior to admission). Fourteen items assessing the ‘informal caregiver’, and 17 items, including country-specific items, were added (e.g., advanced directive for euthanasia).

Conclusions

The interRAI AC was adapted to local requirements using a meticulous and recursive 10-step approach. As use of the interRAI Suite continues to grow worldwide and as it continues to expand to other care settings and populations, this procedure can guide future translations. This procedure might also be used by others facing similar challenges of complex translation and adaptation situations, where multidimensional instruments are used across multiple care settings in multiple languages.

Methods to assess the reliability of the interRAI Acute Care: a framework to guide clinimetric testing. Part II

The interRAI Acute Care is a comprehensive geriatric assessment tool that provides a holistic picture of complex and frail hospitalized older persons. It is designed to support holistic care planning and to transfer patient data across settings. Its usefulness in clinical decision making depends on the extent to which clinicians can rely on the patient data as accurate and meaningful indicators of patients functioning. But its multidimensional character implies challenges for clinimetric testing as some of the traditional analyses techniques cannot be unconditionally applied. The objective was to present an overview of methods to examine the reliability of the interRAI Acute Care. For each line of evidence, examples of hypotheses and research questions are listed.

Validity of the interRAI Acute Care based on test content: a multi-center study

BACKGROUND AND AIMS

The MDS inter- RAI Acute Care is a comprehensive geriatric assessment tool for hospitalized older persons. The aim was to examine its validity based on test content by use in daily clinical practice.

METHODS

Clinical staff of multiple disciplines assessed 256 older persons (83.2±5.2 years; 60% female) in a cross-sectional multicenter study in nine acute hospitals. Test content was empirically tested by frequency distribution of clinical deficits, missing, and invalid data. Item relevance was quantified by the content validity index (CVI) and modified kappa statistics (κ*) based on assessors' judgment.

RESULTS

Clinical deficits exceeded 30% in the majority of items (67%) across all assessment periods. Mean missing data for premorbid, admission, day-14 and discharge assessments were 9.7%, 5.3%, 29.3% and 13.7%, respectively. Invalid scores ranged from 3.9% to 26.7%. Of the 98 items, 82 had excellent CVI (≥0.78). Item relevance was excellent for 82 (κ*≥0.75), good for 9 (0.60≤κ*≤0.74) and fair for 3 items (0.40≤κ*<0.60). Item revision may optimize clinical relevance: removing 4 items with poor relevance would increase the overall CVI from 0.89 to 0.91, meeting the standard of excellent content validity (CVIaverage≥0.90).

CONCLUSIONS

Although the frequency distribution provides evidence that item selection of the interRAI Acute Care is appropriate for the targeted population, its use in a clinical context reveals a substantial number of missing and invalid data. To improve validity, training should pay specific attention to items with low compliance and invalid records. Software applications should also be designed to improve data quality.