Functional Decline in Hospitalized Older Adults: Can Nursing Make a Difference?

Mobility Loss in Hospitalized Adults Predicts Poor Clinical Outcomes

BACKGROUND

The Johns Hopkins Activity and Mobility Program is a systematic approach to measure and improve patient mobility.

PURPOSE

The purpose of this study was to evaluate the relationship between mobility loss and quality outcomes.

METHODS

A retrospective cohort study design was used. Patients were categorized into 3 groups (gain, loss, no change in mobility) using the Johns Hopkins Highest Level of Mobility (JH-HLM) scores. The association between mobility loss and falls risk, in-hospital mortality, delirium, discharge to a facility, length of stay, and 30 day readmissions were assessed.

RESULTS

Those who lost mobility were more at risk of being a high fall risk, in-hospital mortality, delirium, discharging to a facility, and had 48% longer lengths of stay. There was no association between mobility loss and 30-day readmissions.

CONCLUSIONS

Loss of mobility assessed using JH-HLM scores is associated with worse patient outcomes.

Revisiting the "Timed Up and Go" test: a 12-s cut-off can predict Hospitalization Associated Functional Decline in older adults

Early detection of functional decline, a major risk among hospitalized older adults, can facilitate interventions that could significantly reduce it. We aimed to examine the contribution of the Timed Up and Go (TUG) test in predicting Hospitalization Associated Functional Decline (HAFD) among older adults, able to independently ambulate before admission. We used a cross-sectional study design; a total of 310 older adults (age ≥ 65) hospitalized in internal medicine wards between December 2018 and August 2020 were included; exclusion criteria were inability to ambulate, a diagnosis restricting mobility, hospitalization for end-of-life care, or impaired cognition. The Modified Barthel Index was used to assess HAFD; it was administered at admission to evaluate patients' independence in activities of daily living 2 weeks prior hospitalization, and at discharge. The TUG test was performed on admission and to predict significant functional decline (defined by a reduction of three points or more in the Modified Barthel Index), while accounting for demographics, length of hospitalization, comorbidity burden (Charlson's comorbidity index), and cognitive function (ALFI-MMSE). Participants were divided into three groups according to their TUG score-under or over a cut-off score of 12 s, or inability to complete the test. Adjusting for age, comorbidity, cognitive ability, and duration of hospitalization, the group that performed the test in less than 12 s showed no statistically significant change in the Modified Barthel Index, therefore no significant HAFD. The other groups showed a statistically significant decline in function. Risk for significant HAFD is currently underestimated in clinical settings, limited to subjective assessment, and underused in the context of implementing early interventions to prevent HAFD. The TUG may support screening for those at risk of hospitalizing-associated functional decline and could help identify patients suitable for preventative interventions.

New horizons in hospital-associated deconditioning: a global condition of body and mind

Hospital-associated deconditioning is a broad term, which refers non-specifically to declines in any function of the body secondary to hospitalisation. Older people, particularly those living with frailty, are known to be at greatest risk. It has historically been most commonly used as a term to describe declines in muscle mass and function (i.e. acute sarcopenia). However, declines in physical function do not occur in isolation, and it is recognised that cognitive deconditioning (defined by delayed mental processing as part of a spectrum with fulminant delirium at one end) is commonly encountered by patients in hospital. Whilst the term 'deconditioning' is descriptive, it perhaps leads to under-emphasis on the inherent organ dysfunction that is associated, and also implies some ease of reversibility. Whilst deconditioning may be reversible with early intervention strategies, the long-term effects can be devastating. In this article, we summarise the most recent research on this topic including new promising interventions and describe our recommendations for implementation of tools such as the Frailty Care Bundle.

Implementation of Agile in healthcare: methodology for a multisite home hospital accelerator

BACKGROUND

The diffusion of innovation in healthcare is sluggish. Evidence-based care models and interventions take years to reach patients. We believe the healthcare community could deliver innovation to the bedside faster if it followed other sectors by employing an organisational framework for efficiently accomplishing work. Home hospital is an example of sluggish diffusion. This model provides hospital-level care in a patient's home instead of in a traditional hospital with equal or better outcomes. Home hospital uptake has steadily grown during the COVID-19 pandemic, yet barriers to launch remain for healthcare organisations, including access to expertise and implementation tools. The Home Hospital Early Adopters Accelerator was created to bring together a network of healthcare organisations to develop tools necessary for programme implementation.

METHODS

The accelerator used the Agile framework known as Scrum to rapidly coordinate work across many different specialised skill sets and blend individuals who had no experience with one another into efficient teams. Its goal was to take 40 weeks to develop 20 'knowledge products',or tools critical to the development of a home hospital programme such as workflows, inclusion criteria and protocols. We conducted a mixed-methods evaluation of the accelerator's implementation, measuring teams' productivity and experience.

RESULTS

18 healthcare organisations participated in the accelerator to produce the expected 20 knowledge products in only 32 working weeks, a 20% reduction in time. Nearly all (97.4%) participants agreed or strongly agreed the Scrum teams worked well together, and 96.8% felt the teams produced a high-quality product. Participants consistently remarked that the Scrum team developed products much faster than their respective organisational teams. The accelerator was not a panacea: it was challenging for some participants to become familiar with the Scrum framework and some participants struggled with balancing participation in the Accelerator with their job duties.

CONCLUSIONS

Implementation of an Agile-based accelerator that joined disparate healthcare organisations into teams equipped to create knowledge products for home hospitals proved both efficient and effective. We demonstrate that implementing an organisational framework to accomplish work is a valuable approach that may be transformative for the sector.

Implementation of the UMove Mobility Program to Promote Safe Patient Mobility and Reduce Falls in the Hospital Setting

The purpose of the current quality improvement (QI) project was to implement the UMove Early Mobility Program to engage patients in safe out of bed (OOB) activities and reduce falls, specifically focusing on toileting-related falls, during the hospital stay. Eight nursing units implemented the UMove program, including the UMove Mobility Screen (UMove MS), to select strategies to reduce toileting-related falls while increasing mobility. De-identified, unit-based data were collected from hospital reports. Nursing had a 95% documentation compliance rate for the UMove MS, and OOB activities and ambulation were documented at 50% and 57%, respectively. There was no statistical difference found in reducing toileting-related falls or sustaining increased OOB activities across the 15-month QI project. Toileting-related falls approached significance with a rate reduction from 1.77 pre-implementation to 0.23 at 6 months and no toileting-related falls at 12 months. Despite no significant findings, there is evidence that clinical changes occurred with nurses assessing and promoting mobility, while implementing strategies to reduce toileting-related falls. [Research in Gerontological Nursing, 17(1), 19-29.].

Factors Associated With Function-Focused Care Among Hospitalized Older Adults With Dementia

BACKGROUND

Function-focused care is an approach used to increase physical activity in hospitalized older adults with dementia.

OBJECTIVE

To explore factors associated with participation in function-focused care in this patient population.

METHODS

This was a cross-sectional descriptive study using baseline data from the first 294 participants in an ongoing study on testing function-focused care for acute care using the evidence integration triangle. Structural equation modeling was used for model testing.

RESULTS

The mean (SD) age of the study participants was 83.2 (8.0) years, and the majority were women (64%) and White (69%). Sixteen of the 29 hypothesized paths were significant and explained 25% of the variance in participation in function-focused care. Cognition, quality of care interactions, behavioral and psychological symptoms associated with dementia, physical resilience, comorbidities, tethers, and pain were all indirectly associated with function-focused care through function and/or pain. Tethers, function, and quality of care interactions were all directly associated with function-focused care. The χ2/df was 47.7/7, the normed fit index was 0.88, and the root mean square error of approximation was 0.14.

CONCLUSION

For hospitalized patients with dementia, the focus of care should be on treating pain and behavioral symptoms, reducing the use of tethers, and improving the quality of care interactions in order to optimize physical resilience, function, and participation in function-focused care.

Fast thinking: How unconscious bias and binary language contribute to rationing of care to older persons

BACKGROUND

Binary or categorical thinking is a way of thinking in which the brain unconsciously sorts the masses of information it receives into categories. This helps us to quickly process information and keeps us safe through pattern recognition of possible threats. However, it can also be influenced by unconscious and conscious biases that inform our judgements of other people and situations.

OBJECTIVES

To examine nursing practice with older people through the lens of unconscious bias.

METHODS

In this critical analysis, using Kahneman's fast and slow thinking, we argue that nurses working with hospitalised older people often rely on thinking quickly in hectic work environments, which can contribute to unconscious and conscious bias, use of binary language to describe older persons and nursing tasks, and ultimately rationing of care.

RESULTS

Binary language describes older persons and their care simplistically as nursing tasks. A person is either heavy or light, continent or incontinent, confused or orientated. Although these descriptions are informed in part by nurses' experiences, they also reflect conscious and unconscious biases that nurses hold towards older patients or nursing tasks. We draw on explanations of fast (intuitive) and slow (analytical) to explain how nurses gravitate to thinking fast as a survival mechanism in environments where they are not supported or encouraged to think slow.

CONCLUSIONS

Nurses survival efforts in getting through the shift using fast thinking, which can be influenced by unconscious and conscious biases, can lead to use of shortcuts and the rationing of care. We believe that it is of paramount importance that nurses be encouraged and supported to think slowly and analytically in their clinical practice.

IMPLICATIONS FOR PRACTICE

Implications Nurses can engage in journaling and reflecting on their practice with older people to examine possible unconscious bias. Managers can support reflective thinking by supporting nurses through staffing models and encouraging conversations about person-centered care in unit practices.

Testing Function Focused Care for Acute Care using the Evidence Integration Triangle: Protocol description

This manuscript provides the protocol for a National Institute of Aging-funded cluster randomized clinical trial that focuses on helping nurses in acute care to engage patients with dementia in physical activity while hospitalized using an approach referred to as function-focused care. Physical activity is defined as bodily movement produced by skeletal muscles resulting in the expenditure of energy and includes functional tasks such as bathing and dressing, leisure activity, ambulation, and moderate and vigorous intensity physical activity such as dancing, bike riding, or walking upstairs. The development of Function Focused Care for Acute Care (FFC-AC) was based on the Social Ecological Model and Social Cognitive Theory and includes four steps: (1) Environment and Policy Assessments; (2) Education; (3) Establishing Patient Goals; and (4) Mentoring and Motivating of Staff (all levels of nursing staff), Patients, and Families. Function-focused care activities include motivating older patients to participate in bed mobility; personal care activities such as bathing, dressing, ambulating as they are able; and other types of physical activities. The integration of the intervention among the nurses on the units is guided by the Evidence Integration Triangle (EIT), which includes the participation of a stakeholder team and practical outcome measures. The intervention is therefore referred to as FFC-AC-EIT. In addition to describing the protocol developed to test the effectiveness and feasibility of FFC-AC-EIT, a description of ways to overcome some of the barriers and challenges that can be encountered with this study is provided.

Progressing to Objective Measures of Daily Mobility in Hospitalized Older Adults

Accurate mobility assessment of hospitalized older adults is necessary to aid nurses in planning and providing appropriate mobility support; however, nurses cite lack of resources and time limitations as barriers. Accelerometry enables a detailed objective measurement of predominant hospital mobility activities in the older adult population, such as percent time sitting, and the sit-to-stand (STS) transition. The current exploratory study examined the use of a novel, unobtrusive accelerometry technique to obtain postural and STS metrics on 27 older adults during their hospital stay. Total device wear time in the hospital was 96.2%. Participants spent 60.3% time lying, 20.3% time sitting, 5.3% time standing, and 2% time stepping during hospitalization, and, on average, completed the STS transition 20 times (SD = 13) per 24-hour period. There were no participant complaints about wearing the device. Our exploratory study shows accelerometry provides automated, continuous data and may support accurate nursing assessment of patient mobility. [Journal of Gerontological Nursing, 48(5), 35-41.].

Implementation of the Frailty Care Bundle (FCB) to promote mobilisation, nutrition and cognitive engagement in older people in acute care settings: protocol for an implementation science study

Background: Older people are among the most vulnerable patients in acute care hospitals. The hospitalisation process can result in newly acquired functional or cognitive deficits termed hospital associated decline (HAD).  Prioritising fundamental care including mobilisation, nutrition, and cognitive engagement can reduce HAD risk. Aim: The Frailty Care Bundle (FCB) intervention aims to implement and evaluate evidence-based principles on early mobilisation, enhanced nutrition and increased cognitive engagement to prevent functional decline and HAD in older patients. Methods: A hybrid implementation science study will use a pragmatic prospective cohort design with a pre-post mixed methods evaluation to test the effect of the FCB on patient, staff, and health service outcomes.  The evaluation will include a description of the implementation process, intervention adaptations, and economic costs analysis. The protocol follows the Standards for Reporting Implementation Studies (StaRI). The intervention design and implementation strategy will utilise the behaviour change theory COM-B (capability, motivation, opportunity) and the Promoting Action on Research Implementation in Health Services (i-PARIHS). A clinical facilitator will use a co-production approach with staff. All patients will receive care as normal, the intervention is delivered at ward level and focuses on nurses and health care assistants (HCA) normative clinical practices. The intervention will be delivered in three hospitals on six wards including rehabilitation, acute trauma, medical and older adult wards. Evaluation: The evaluation will recruit a volunteer sample of 180 patients aged 65 years or older (pre 90; post 90 patients). The primary outcomes are measures of functional status (modified Barthel Index (MBI)) and mobilisation measured as average daily step count using accelerometers. Process data will include ward activity mapping, staff surveys and interviews and an economic cost-impact analysis. Conclusions: This is a complex intervention that involves ward and system level changes and has the potential to improve outcomes for older patients.

Awakening Canadians to ageism: a study protocol

Background

Making fun of growing older is considered socially acceptable, yet ageist humour reinforces negative stereotypes that growing old is linked with physical and mental deterioration, dependence, and less social value. Such stereotypes and discrimination affect the wellbeing of older people, the largest demographic of Canadians. While ageism extends throughout professions and social institutions, we expect nurses—the largest and most trusted group of healthcare professionals—to provide non-ageist care to older people. Unfortunately, nurses working with older people often embrace ageist beliefs and nursing education programs do not address sufficient anti-ageism content despite gerontological nursing standards and competencies.

Methods

To raise awareness of ageism in Canada, this quasi-experimental study will be supported by partnerships between older Canadians, advocacy organizations, and academic gerontological experts which will serve as an advisory group. The study, guided by social learning theory, will unfold in two parts. In Phase 1, we will use student nurses as a test case to determine if negative stereotypes and ageist perceptions can be addressed through three innovative e-learning activities. The activities employ gamification, videos, and simulations to: (1) provide accurate general information about older people, (2) model management of responsive behaviours in older people with cognitive impairment, and (3) dispel negative stereotypes about older people as dependent and incontinent. In Phase 2, the test case findings will be shared with the advisory group to develop a range of knowledge mobilization strategies to dispel ageism among healthcare professionals and the public. We will implement key short term strategies.

Discussion

Findings will generate knowledge on the effectiveness of the e-learning activities in improving student nurses’ perceptions about older people. The e-learning learning activities will help student nurses acquire much-needed gerontological knowledge and skills. The strength of this project is in its plan to engage a wide array of stakeholders who will mobilize the phase I findings and advocate for positive perspectives and accurate knowledge about aging—older Canadians, partner organizations (Canadian Gerontological Nurses Association, CanAge, AgeWell), and gerontological experts.

Nurse and Health Care Aide Knowledge of Urinary Continence Promotion and Management In Hospitalized Older People

PURPOSE

The aims of this study were to determine if there was a change in medical unit nursing staffs' knowledge about lower urinary tract symptoms following an education presentation and whether the education session met their learning needs.

DESIGN

Single-group, before-after study.

SUBJECTS AND SETTING

The study sample comprised 21 licensed nurses and 16 health care aides from 3 medical units in a tertiary care hospital in western Canada.

METHODS

Participants completed pre- and post-true/false questionnaires developed for the project to assess lower urinary tract symptom knowledge, and a questionnaire to determine whether the education session met staff learning needs.

RESULTS

Knowledge was moderate on the pretest in both groups, with licensed nurses showing a significant improvement after the education intervention. Health care aides did not have a significant change in knowledge; they persisted in their belief that incontinence is a normal change of aging.

CONCLUSIONS

Health care aides need targeted education and enhanced care processes to shift their knowledge and thinking about continence.

Functional Status among Polymedicated Geriatric Inpatients at Discharge: A Population-Based Hospital Register Analysis

This study explored and compared the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge. We used a cross-sectional registry of geriatric patients' hospital records from a multi-site public hospital center in Switzerland. The analysis included all inpatients aged 65 years old or more admitted between 1 January 2015 and 31 December 2017 (n = 53,690), of whom 67.5% were polymedicated at hospital discharge, 52.1% were women (n = 18,909), and 42.7% were 75-84 years old (n = 15,485). On average, the polymedicated patients' hospital lengths of stay were six days longer, they presented with more than three comorbidities, and they were prescribed more than nine medications at hospital discharge (p < 0.001). They showed more frequent general mobility decline (43.2% vs. 41.9%), gait disorders (46.2% vs. 43%), fatigue (48.6% vs. 43.4%) and dependence on lower-body care (49.7% vs. 47.6%), and presented a higher malnutrition risk (OR = 1.411; 95%CI 1.263-1.577; p < 0.001). However, the non-polymedicated inpatients had proportionally more physical and cognitive impairments. The comparison of the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge is important for clinicians trying to identify and monitor those who are most vulnerable to functional decline, and to design targeted strategies for the prevention of functional impairment and related adverse health outcomes.

Function-Focused Goal Attainment and Discharge Outcomes in Hospitalized Persons With Dementia

Hospitalized persons with dementia are at higher risk for functional decline and cognitive loss related to delirium. Family-centered, function-focused care (Fam-FFC) engages the family care partner in education and active participation in function-focused goal setting, implementation, and evaluation to support delirium prevention and abatement and return to baseline physical function. The purpose of the current study was to examine the association of function-focused goal attainment with two discharge outcomes, return to baseline physical function and delirium severity at discharge, in hospitalized persons with dementia. In the ongoing Fam-FFC clinical trial, the majority of goals (N = 433) developed by 134 care partner/patient dyads and nurses address mobility, cognitive stimulation, and self-care. Regression techniques demonstrated that goal attainment was significantly associated with return to baseline function (B = 0.826, Wald = 4.17 [1], p = 0.041) and lower delirium severity at discharge (B = 0.175, t = 2.239, p = 0.027). Results support the contribution of family engagement in promoting functional recovery of hospitalized persons with dementia. [Journal of Gerontological Nursing, 47(9), 13-20.].

Harnessing nursing to diminish ageism

BACKGROUND

The common practice of making fun of aging and older people demonstrates that ageism towards older people is socially acceptable. It is so accepted that even those of us who are aging or have moved into the 'third act' believe and fear the negative stereotypes that growing old is linked with physical and mental deterioration, dependence, and less social value. Ageism is evident in work places, family relationships, when older people purchase goods and services, in health and social institutions and extends throughout professions that work with older people.

OBJECTIVES

We explore how nurses-the largest group of healthcare professions- may be inadvertently perpetuating negative perceptions about older people in nursing practice, nursing education, and through common misconceptions about what gerontological nursing means.

METHODS

This is discussion paper using the literature.

RESULTS

We suggest that nursing education is well situated to diminish negative perspectives of ageing by incorporating theories of life-course and harmonious aging into the holistic perspective of individuals that nursing is well known for.

CONCLUSIONS

Greater understanding about the diversity of ageing and the context that have influenced older persons could encourage nurses to treat them holistically with dignity, which would ultimately improve older people's experiences. Improving older persons' experiences is like paying it forward, as we all are ageing and if we are to have a different experience when we are old, it is necessary to diminish stereotypes about ageing, and work towards inclusion of older people in social and healthcare institutions.

IMPLICATIONS FOR PRACTICE

It is important for nurses, particularly those in nursing education, to support the incorporation of a life course and harmonious view of aging in which the social, political, and environmental context of individuals are viewed as part of the difference of ageing.

Systematic review of interventions targeting fundamental care to reduce hospital-associated decline in older patients

AIMS

To examine the effectiveness of targeted nursing interventions on mobilization, nutrition and cognitive engagement to reduce functional and hospital-associated decline (HAD) in older patients.

DESIGN

Systematic review of experimental studies using randomized and quasi-experimental designs.

DATA SOURCES

We searched electronic databases CINAHL, MEDLINE, EMBASE, Cochrane library, google scholar and BMJ quality reports from January 2009 to February 2020.

REVIEW METHODS

We reviewed intervention studies that targeted ward nursing teams to increase mobilization, nutrition or cognitive engagement of older adults. Inclusion criteria included older patients, acute care (medical, surgical and older adult wards) and reporting patient level outcomes. Quality appraisal included the Joanna Briggs Critical Appraisal Checklist for Quasi-Experimental Studies.

RESULTS

From 1729 papers, 18 studies using quasi-experimental and pre-post designs were selected. Study heterogeneity necessitated a narrative synthesis. The quality of evidence was low to moderate. All studies used multicomponent strategies, and 10 studies used evidence translation frameworks to align interventions to local barriers. Overall, 74% (n = 14) of studies reported a significant improvement in the stated primary outcome. Eight studies reported a significant increase in mobilization (e.g., sitting in a chair or walking), and four reported improved functional outcomes. Five studies improved nutrition outcomes (e.g., protein or energy intake), and three studies reported a significant reduction in delirium.

CONCLUSION

Acknowledging methodological limitations, the evidence indicates that nursing teams using evidence-translation frameworks can improve mobilization, nutrition and cognitive engagement in acute care settings. Future research requires higher-quality pragmatic trial designs, standardized outcomes, staff co-designed interventions, evidence-translation frameworks and patient engagement to make more confident inference about effectiveness.

IMPACT

Nursing teams with the support of hospital management have to address ward and system barriers to prioritize fundamental care to improve patient outcomes. There is sufficient evidence on multicomponent interventions and implementation strategies to inform nurse-led quality improvement.

Fall Prevention and Injury Reduction Utilizing Virtual Sitters in Hospitalized Patients: A Literature Review

Falls and fall-associated injuries continue to occur in hospitals worldwide. Video monitoring using virtual sitters is a novel, cost-effective concept that has emerged as an intervention to address falls and maintain safety for hospitalized patients. This literature review examines the evidence regarding hospital-associated falls and fall-related injuries when video monitoring and virtual sitters were included as an intervention. Ten observational studies and two quasi-experimental studies (N = 12) were identified for inclusion from the Cumulative Index of Nursing and Allied Health Literature, Scopus, and PubMed databases. Overall, current evidence is focused on fall rates and cost savings. Eight studies demonstrated a fall reduction and the remaining three showed no statistical difference in fall rates with the use of video surveillance or virtual sitters. Cost savings for these interventions are based on the transition from 1:1 observation to virtual sitters; all 12 studies reported decreased overall costs transitioning to virtual sitters. Small sample size and limited studies are the primary limitations of current published evidence. As the novel clinical practice evolves and more hospitals are equipped with video capability, future research with virtual sitters should include expanded patient populations, a focus on fall-related injuries, and examinations of staff safety.

Nurses' perceptions of their role with respect to promoting physical activity in adult patients: a systematic review

AIMS AND OBJECTIVES

To identify the nurses' perceptions of their role with respect to promoting physical activity in adult patients and factors related to this role perceptions.

BACKGROUND

Ageing and chronic diseases are often accompanied by a decrease in physical activity. Nurses are in an excellent position to promote physical activity, because of their close and frequent interactions with patients. However, they often fail to actively stimulate patients to physical activity due to a lack of time, competing priorities and their focus on acute problems. Unclear was how nurses view their professional role in the promotion of physical activity.

DESIGN

Systematic literature review.

METHODS

PubMed, COCHRANE and CINAHL EBSCO were searched for papers published from 2006 to September 2019. Two reviewers independently assessed the methodological quality, using MMAT criteria. Thematic synthesis was used to analyse the data. The PRISMA statement was followed for reporting.

RESULTS

Overall, 10 quantitative, eight qualitative and one mixed methods study were included in the review. Analyses of these studies resulted in six themes: (1) active and professional role; (2) the recognised importance; (3) fear of patient falling; (4) patient's present health and need; (5) interdisciplinary context and responsibility; and (6) nurses' knowledge.

CONCLUSIONS

Nurses perceive they have an active role in the promotion of physical activity and consider it as important and part of their professional role. Clear guidance increased education and stronger awareness of guidelines might enable nurses to translate their perceived role into daily practice. This will enhance professional fulfilment as well as patients' physical activity.

RELEVANCE TO CLINICAL PRACTICE

The findings guide the development of interventions that aim to improve nursing care with respect to the promotion of physical activity and help managers and educators to provide appropriate resources and education.

Improving the assessment and documentation of patient mobility using a quality improvement framework

OBJECTIVE

To implement a system for assessing and documenting patient mobility in an inpatient geriatric unit using a quality improvement framework.

METHODS

Whiteboards incorporating the Johns Hopkins Highest Level of Mobility scale were placed on each door of the unit. Staff were trained to assess and document patient mobility, and documentation compliance was measured. Nurses were surveyed to assess perceived burden of the system. Fall rates were calculated and analyzed for change from baseline.

RESULTS

Median daily documentation rates reached 79% by the end of the project. Surveys indicated a low perceived burden of the system. Fall rates did not increase when compared to the previous year baseline (p = 0.80) and the analogous time frames during the previous two years (p = 0.84).

CONCLUSION

A quality improvement framework may be used to improve mobility assessment and documentation in a geriatric unit without increasing patient falls or nursing burden.

Older Persons and Nursing Staff's Perspectives on Continence Care in Rehabilitation: A Qualitative Study

PURPOSE

The aim of the study was to understand continence care in geriatric rehabilitation from the perspectives of older persons and nursing staff.

DESIGN

This is a qualitative descriptive study.

METHODS

Ten patients and 10 nursing staff participated in semistructured interviews. Observations of care were recorded in field notes. Content analysis was used to develop themes of patient and nursing staff perspectives.

FINDINGS

Three themes were developed: Perceptions of Assessment, Continence Management, and Rehab: The Repair Shop. Patients had limited insight into continence assessment and management by nursing staff. For older persons, incontinence was embarrassing and created dependence; independence in toileting meant gaining control. Staff viewed continence as an important part of rehabilitation nursing but focused on containment and regular toileting, with patients seeing absorbent pads as commonly suggested.

CONCLUSIONS

Continence care approaches that engage older persons during rehabilitation are needed.

CLINICAL RELEVANCE

Restoration of continence through patient-centered care is core to older person rehabilitation.

Rural Perceptions of Acute Care at Home: A Qualitative Analysis

PURPOSE

Hospital-level care at home in urban areas delivers low-cost, high-quality care. Few have attempted to deliver home hospital care in a rural environment, where traditional hospitals are often less equipped to deliver high-quality care. Little is known about rural clinicians' and patients' perceptions regarding rural home hospital care and how the urban model might be adapted to fit rural circumstances.

METHODS

We conducted semistructured qualitative interviews in the United States with a national purposive sample of practicing rural clinicians, a focus group with clinicians who care for rural patients, and interviews with rural patients. We coded these qualitative data into domains and subdomains.

FINDINGS

We identified 4 domains: (1) current state of rural health care, (2) attitudes toward rural home hospital, (3) perceived barriers to implementing rural home hospital, and (4) perceived facilitators to implementing rural home hospital. Participants expressed challenges with current rural health care, including inefficient care coupled with poor access. Most felt rural home hospital care could offer benefits, including comfort, timeliness, and downstream outcomes such as readmission rate reduction. Rural patients were open to receiving acute care in their homes. Potential barriers included geographic accessibility, Internet connectivity, rural hospital politics, the culture of hospitalization, and the availability of skilled human resources.

CONCLUSIONS

Significant interest and optimism exist surrounding rural home hospital despite perceived barriers. Designing for and testing adaptations to the urban model will likely optimize benefits and minimize threats to a potential intervention.

Effects of a Person Centered Dementia Training Program in Greek Hospital Staff-Implementation and Evaluation

People with Dementia (PwD) are frequently admitted in general hospitals. However, health care professionals have lack of dementia knowledge, negative attitudes toward dementia, and lack of confidence in caring those patients. The aim of this study is to develop, implement and evaluate a dementia staff training program in Greek general hospitals. It was a repeated-measures research design. Fourteen (14) two-day workshops were conducted, consisting of six targeted and interactive modules. Staff members (N = 242) attended the program and were assessed according to (1) individual performance: questionnaires about attitudes towards dementia, confidence in care, knowledge about dementia and anxiety before, immediately after the training and three months later, (2) an overall training evaluation immediately after the training and (3) an evaluation of training implementation three months later. Positive attitudes towards dementia, improvement of confidence in care and decrease of feeling of anxiety as a trait, were sustained over time. Knowledge about dementia also increased after the training and sustained, with, however, a slight decrease over time. A well applied training program seems to provide the basis of a better care in PwD during hospitalization. However, changes in the organizational level and a transformation of care culture are necessary for training sustainability over time.

Sequential chemotherapy after definitive radiotherapy in markedly elderly patients with advanced esophageal cancer

Background

Concurrent chemoradiotherapy (CCRT) is the standard treatment for advanced esophageal cancer, but it may be more invasive in the elderly and definitive radiotherapy (RT) alone may be selected. This study assessed the significance of sequential chemoradiotherapy (SCRT) in elderly esophageal cancer patients.

Methods

We reviewed 87 patients aged 75 years and older, who were treated using definitive radiotherapy without concurrent chemotherapy for esophageal cancer. A total dose ranging from 50.4 to 63 Gy (median, 58.8) was delivered to the primary lesion and the involved lymph nodes. This study compared patients who received SCRT with those who received RT alone among 40 patients with stage III or IVA cancer. Descriptive statistics were calculated using Cox proportional hazards regression analysis and the generalized Wilcoxon test.

Results

The total progression-free survival (TPFS), progression-free survival outside the irradiation field, and overall survival were significantly longer after SCRT (n = 15) than after definitive RT alone (n = 25; P = 0.0041 and 0.0098), whereas the progression-free survival in the irradiation field was not significantly different between the two groups. The TPFS was significantly shorter in patients who received RT alone than in those who received SCRT (P = 0.0372). There were no grade 4 or higher adverse events in the patients who received SCRT.

Conclusion

SCRT was associated with a reduced relapse rate, suggesting that it should be considered for markedly elderly patients with advanced esophageal cancer.

Nursing faculty and students' perspectives of how students learn to work with older people

BACKGROUND

Despite efforts to incorporate information about older people in pre-licensure nursing programs, there are inconsistent results from studies examining student nurses' perceptions towards the aging population. There is research suggesting that healthcare settings and nursing practice is perpetuating negative perspectives towards older people.

OBJECTIVE

To gain an understanding of how social contexts are influencing student nurses' experiences when learning to work with older people.

DESIGN

Descriptive case study guided by the theoretical framework of social learning theory.

SETTING

A university in Western Canada that offers a pre-licensure nursing program.

PARTICIPANTS

28 student nurses and 13 faculty in the nursing program.

METHODS

Participant interviews and focus groups were conducted with nursing faculty and students.

RESULTS

Key findings from this study are that students' previous experiences with older people, through family or work experiences, and their first clinical experience in long- term care negatively influenced their perceptions about working with older people. Clinical nurses and faculty influenced students' perceptions about nursing practice with older people, sometimes in subtle ways, underscoring that students are learning from what they see and hear in practice. Students were ill-prepared for the complexity of the aging population, particularly those with cognitive impairment.

CONCLUSIONS

Learning activities that engage students in active learning, such as simulation, providing students with a positive lexicon of how to describe older patients, and more overt attention to the perspectives students and faculty bring to the learning environment need to be carefully explored. Meaningful learning experiences with older people in multiple contexts are needed to thoughtfully plan how to disrupt negative perceptions that might emerge through the nursing education program.

Association of functional status and hospital-acquired functional decline with 30-day outcomes in medical inpatients: A prospective cohort study

BACKGROUND

There is growing evidence that patients with functional decline are at increased risk of readmission, mortality and institutionalization. Instruments to measure the status of self-care could provide important information for efficient care planning. The widely used Self Care Index serves as an indicator for the severity of nursing dependency. To date, no evidence is available on the association of the instrument with rehospitalization, mortality and institutionalization.

OBJECTIVES

To examine the association of functional status measures (Self Care Index on admission, at discharge and functional decline) with 30-day mortality, readmission and institutionalization in hospitalized non-surgical patients.

DESIGN

Prospective cohort study.

PARTICIPANTS

We included 4540 emergency medical patients at a single hospital in Switzerland.

METHODS

Primary outcome was 30-day mortality rate; secondary outcomes were 30-day readmission and institutionalization. We analyzed the association of the functional status with the binary endpoints using logistic regression models and C-statistics for discrimination.

RESULTS

All of the examined measures were significant predictors of overall 30-day mortality; Self Care Index on admission: adj. OR: 0.90 (95% CI: 0.87-0.92); Self Care Index at discharge: adj. OR: 0.86 (95% CI: 0.83-0.88); functional decline: adj. OR: 1.22 (95% CI: 1.14-1.31) and all Self Care Index single items. A combined model (functional status on admission and functional decline during hospitalization) showed a good accuracy with regard to the AUC: adj. AUC: 0.80 (95% CI: 0.74-0.86).

CONCLUSIONS

Several functional measures were associated with 30-day mortality. Self Care Index total score, five single items and a combined model showed the best performance.

Promotion of mobility among hospitalised older adults: An exploratory study on perceptions of patients, carers and nurses

BACKGROUND

Hospitalisation of an older adult due to acute medical illness can result in adverse events and accelerate loss of independence despite recovery from the illness. Promoting mobility during hospitalisation can help to mitigate the risks of functional decline. Understanding the perspectives on the barriers and the maintenance of mobility is essential in the development of effective strategies.

AIMS

To explore the perceptions of patients and their carers, as well as the nurses on promotion of mobility among hospitalised adult older patients.

METHODS

A qualitative descriptive study design with purposive and convenience sampling approach was undertaken. A total of fourteen patients, six carers and ten nurses from a general medical ward of an acute care tertiary public hospital in Singapore were recruited over the period of November 2017 to February 2018. Face to face semi-structured interviews were conducted and audio-recorded. The interview transcripts were coded and an inductive content analysis approach was adopted to generate categories of sub-themes and themes through the open coding process.

RESULTS

Four main themes were generated: (1) perceived and induced fear of falling; (2) challenges in initiation of mobility; (3) influence of premorbid status and physical condition on activity level; and (4) strategies to promote mobility.

CONCLUSION

Recognition of the importance of mobility as well as the detrimental effects of prolonged bed rest during hospitalization is an essential first step toward developing successful interventions to promote mobility in the Asian context. Improvements need to be made to help overcome the various barriers and challenges in the mobilization of the older patients in the acute care settings. Nurses and other members of the care team can help to increase the confidence of patients and among family carers (in providing assistance during mobility) by role modelling and provision of walking aids as well as risk-based education.

Student Nurses’ Perceptions About Older People

Educating nursing students about the ageing population is situated within negative societal, heath care and nursing perceptions. A cross-sectional design using Burbank’s perceptions towards older people scale was used to survey students in a pre-licensure nursing program in western Canada. Findings revealed that students’ perceptions about older people were lower in the third year of the nursing program and after four clinical experiences. We suggest that students’ first experiences in long-term care settings, in which they learn to provide basic care to older people, be balanced with experiences of older people in a variety of settings. Such experiences would allow students to develop the knowledge and skill needed to work with an ageing population with complex healthcare needs. More research is needed to better understand students’ experiences and perceptions about where in the program more learning strategies about how to best work with older people would be helpful.

Older Adults With Hip Arthroplasty: An Individualized Transitional Care Program

BACKGROUND

Most older adults with hip fracture surgery experience functional decline (FD), causing devastating outcomes. However, few studies have examined the effects of nursing interventions to reduce FD for them.

PURPOSE

The aim of the study was to evaluate an individualized transitional care program (ITCP) to reduce FD for older adults with hip arthroplasty.

METHODS

The study was quasiexperimental, with a nonequivalent control group design. A total of 37 participants scheduled for hip arthroplasty were recruited-21 in the experimental and 16 in the control group.

FINDINGS

Two weeks following surgery (i.e., just prior to discharge), the ITCP group displayed less fear of falling than the usual care group. Moreover, the experimental group displayed objectively less FD with increased activities of daily living and Timed Up and Go scores, 6 weeks after hip arthroplasty.

CONCLUSIONS

This study provides evidence of the effectiveness of nurse-led rehabilitative practices to reduce FD in older adults with hip arthroplasty.

CLINICAL RELEVANCE

The ITCP promoted individual physical functioning for older adults with hip arthroplasty. This study results can aid healthy transitions of elderly patients with other various diseases.

The feasibility of implementing education on older person care to practice on medical units: Nurses' perceptions and the influence of practice context

AIM

As part of a larger primary study on evidence-informed practice with hospitalised older people, we aimed to (a) examine nursing staffs' perceptions of the interactive geriatric educational intervention and to explore how perceptions of their work context may influence their ability to enact the evidence-informed assessment and care approaches discussed during the educational sessions and (b) compare differences in perceptions of context between RNs, LPNs and HCAs.

METHOD

A survey-based evaluation that used both closed and open-ended questions was conducted as part of an interactive educational intervention on cognitive impairment and managing responsive behaviours. Data were gathered on participants' perceptions of the education intervention and organisational context.

RESULTS

Findings from this study suggest when education is tailored to nurses' articulated educational needs, it is well received; however, barriers to implementation exist. Assessment of the context by using a standardised survey tool to get the nursing staffs' perceptions of organisational context revealed strengths in leadership support and day-to-day interactions with other nurses and healthcare professionals, but potential barriers related to lack of facilitation to transfer new knowledge into practice existed.

CONCLUSION

Providing evidence-based education related to care of older patients and evaluating nursing staffs' perceptions of the education and their context has laid the groundwork for a long-term relationship with the managers and nursing staff on the participating medical units. Further investigation about how best to incorporate the facilitator role into the medical units to support evidence-based practices with older patients is warranted.  IMPLICATIONS FOR PRACTICE: While nurses are receptive to new knowledge, the unpredictable workload of acute care creates challenges to implementing this new knowledge. Assessment of contextual factors that influence evidence-informed practice facilitates planning for implementation of new knowledge and support practice change.

Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review

BACKGROUND

Frequent geriatric users of emergency departments (EDs) constitute a small group of individuals accounting for a disproportionately high number of ED visits. In addition to overcrowding, this situation might result in a less appropriate response to health needs and negative health impacts. Geriatric patients turn to EDs for a variety of reasons. A better understanding of the variables associated with frequent ED use will help implement interventions best suited for their needs.

OBJECTIVE

This review aimed at identifying variables associated with frequent ED use by older adults.

METHODS

For this systematic review, we searched Medline, CINAHL, Healthstar, and PsyINFO (before June 2018). Articles written in English or French meeting these criteria were included: targeting a population aged 65 years or older, reporting on frequent ED use, using an observational study design and multivariate regression analysis. The search was supplemented by manually examining the reference lists of relevant studies. Independent reviewers identified articles for inclusion, extracted data, and assessed quality with the JBI Critical Appraisal Checklist for Studies Reporting Prevalence. A narrative synthesis was done to combine the study results. A sensitivity analysis was performed to evaluate the effect of removing the studies not meeting the quality criteria.

RESULTS

Out of 5096 references, 8 met our inclusion criteria. A high number of past hospital and ED admissions, living in a rural area adjacent to an urban center, low income, a high number of prescribed drugs, and a history of heart disease were associated with frequent ED use among older adults. In addition, having a principal-care physician and living in a remote rural area were associated with fewer ED visits. Some variables recognized in the literature as influencing ED use among older adults received scant consideration, such as comorbidity, dementia, and considerations related to primary-care and community settings.

CONCLUSION

Further studies should bridge the gap in understanding and give a more global portrait by adding important personal variables such as dementia, organizational variables such as use of community and primary care, and contextual variables such as social and economic frailty.

Barriers and facilitators to adopting functional maintenance initiatives for acutely hospitalised older adults

Purpose: To determine perceived barriers and facilitators to adopting and sustaining functional maintenance initiatives for acutely hospitalised older adults.Methods: A qualitative descriptive study using semi-structured interviews and initiative observations was conducted at five international and four Victorian acute hospitals. Purposive snowball sampling was used to recruit clinical, research, managerial, and volunteer staff who were involved in implementing and/or sustaining the initiatives. Emergent themes from audio-recorded interviews were developed and categorised as staff-perceived barriers or facilitators to adopting and sustaining initiatives using inductive thematic analysis.Results: Twenty-seven medical, nursing, allied health, and volunteer staff participated in interviews. Staff resistance and turnover, especially the loss of staff considered to be change drivers, were commonly reported barriers. A lack of professional autonomy was perceived to threaten longevity in allied health assistant led initiatives. Facilitators included support from change drivers, use of collaborative approaches and opinion leaders, integration of initiatives into usual care, alignment with institutional priorities, use of "internal" evidence to justify ongoing institutional investment, and use of an accompanying training and evaluation strategy.Conclusions: Successful adoption and sustainability of functional maintenance initiatives for acutely hospitalised older adults are influenced by a range of "non-clinical" factors, such as the ongoing effectiveness of change drivers. These factors should be considered when deciding upon future innovations to address functional decline and its associated economic impact.IMPLICATIONS FOR REHABILITATIONConsidering barriers and facilitators to successful adoption of functional maintenance initiatives is important for implementing evidence-based practice targeting the prevention of functional decline in acutely hospitalised older adults.Change drivers who remain actively involved are core facilitators of successful functional maintenance initiative adoption.Credible "internal" evaluation data are essential for ongoing sustainability of functional maintenance initiatives.Continual staff training is a key feature of successful functional maintenance initiatives.Perceived financial barriers to adopting functional maintenance initiatives can be overcome by other facilitating influences.

Psychometric testing of the Older Patients in Acute Care Survey (OPACS) in Australian final year nursing students

AIM

To assess the internal reliability and validity (content and criterion) of the Older Patients in Acute Care Survey (OPACS) as a measure of nurses' knowledge, attitudes and practices regarding care of older hospitalized patients in Australia.

DESIGN

Cross-sectional survey.

METHOD

A convenience sample of final year nursing students at an Australian university in October 2014 completed the OPACS (N = 191). Internal reliability was assessed using Cronbach's alpha, content validity using exploratory factor analysis and criterion validity using correlations between the OPACS and Palmore's Facts on Aging Quiz and the Caring Efficacy Scale.

RESULTS

Despite good internal reliability on both OPACS subscales, exploratory factor analysis of the 36 items representing behaviours and the 50 items on knowledge and attitudes failed to load strongly on their corresponding factors. Analyses of criterion validity suggested the OPACS scales are measures of attitude.

Development of a Comprehensive Geriatric Assessment Led by Geriatric Nurse Consultants: A Feasibility Study

Hospitalized older adults are at high risk for complications, leading to negative outcomes such as longer lengths of stay, hospital readmissions, and functional and cognitive decline. Comprehensive Geriatric Assessment (CGA) models are effective in mitigating these syndromes but are not widespread. Nurses with expertise in gerontology who can provide consultation and care coordination can improve care processes and clinical outcomes. This pilot study capitalized on the role of the geriatric nurse consultant (GNC) to develop, implement, and test the feasibility, acceptability, and utility of a GNC-led CGA. Through repeated applications with hospitalized patients, this study demonstrated that GNCs could complete a CGA and identify clinically actionable findings. This study also uncovered clinical geriatric concerns that would not have otherwise been identified via traditional nursing assessments. The results highlight contribution of a GNC-led CGA as a mechanism to support care process improvements to address common geriatric concerns in the acute care setting. [Journal of Gerontological Nursing, 44(12), 25-34.].

Optimizing Function and Physical Activity in Hospitalized Older Adults to Prevent Functional Decline and Falls

Physical activity, defined as bodily movement that expends energy including such things as bed mobility, transfers, bathing, dressing, and walking, has a positive impact on physical and psychosocial outcomes among older adults during their hospitalization and the post hospitalization recovery period. Despite benefits, physical activity is not the focus of care in the acute care setting. Further there are many barriers to engaging patients in physical activity and fall prevention activities including patient, family and provider beliefs, environmental challenges and limitations, hospital policies, and medical and nursing interventions. This paper provides an overview of falls and physical activity prevalence among acute care patients, challenges to engaging patients in physical activity and falls prevention activities and innovative approaches to increase physical activity and prevent falls among older hospitalized patients.

Improving Functional Assessment in Older Adults Transitioning From Hospital to Home

PURPOSE/OBJECTIVES

The purpose of this article is to highlight how scientists have assessed all components of functional status in older adults transitioning from hospital to home to date, discuss ways of improving assessment of functional status, and discuss implications for case management research and practice.

PRIMARY PRACTICE SETTING(S)

This article focuses on case management of older adults transitioning from hospital to home.

FINDINGS/CONCLUSIONS

There any many ways to assess functional status, including basic activities of daily living (BADL), instrumental activities of daily living (IADL), and other nonphysical domains of function such as leisure, social, and productive activities. However, assessment of function in older adults transitioning from hospital to home is primarily limited to BADL. Nonphysical domains of functional status have been linked to important outcomes in community-dwelling older adults and could give clinicians and researchers a better understanding of how older adults are functioning, as well as allow for earlier recognition of those who are beginning to experience functional decline.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

In case management, it is important to ask older adults about goals regarding their functional status and how they think about their functioning in the hospital and at home. Early identification of older adults' functional goals while in the hospital is the first step toward regaining their ideal or premorbid function after discharge to home. To best determine baseline functional status, we may need to consider assessments that can measure multiple domains of functioning in older adults, such as the Sickness Impact Profile. Gaining a more comprehensive understanding and assessment of functional status for hospitalized older adults would help inform discharge destinations and improve transitions in care.

Nursing practice with hospitalised older people: Safety and harm

BACKGROUND

Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood.

METHODS

An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people.

RESULTS

The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people.

CONCLUSIONS

This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority.

IMPLICATIONS FOR PRACTICE

Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.

The educational needs of nursing staff when working with hospitalised older people

OBJECTIVES

To examine nursing staffs' geriatric knowledge, perceptions about interprofessional collaboration and patient-centred care, and perceived learning needs related to working with hospitalised older people.

METHOD

A triangulation mixed methods design was used. A survey was administered to nursing staff that contained the Knowledge About Older Patients Quiz, the patient-centered Care measure and the Modified Index of Interdisciplinary Collaboration measure. Interviews were conducted to understand nursing staffs' learning needs. Survey data were analysed using descriptive statistics. Interview data were analysed using content analysis. Survey and interview data were then compared and contrasted.

RESULTS

Twenty-two nursing staff (response rate 26%) completed surveys and 14 participated in interviews. The mean knowledge about older patients score was 22.95, indicating moderately high gerontological knowledge. The mean scores on the patient-centered Care measure and Modified Index of Interdisciplinary Collaboration were moderately high at 3.75 and 3.86, respectively. Themes developed from analysis of the interview data were as follows: complex vulnerable population, clinical care concerns and working as a team. In spite of scores on knowledge surveys, nursing staff identified learning needs related to managing the responsive behaviours of older patients with cognitive impairment, chemical and physical restraints, mobility and continence.

CONCLUSIONS

There was an incongruence between survey and interview data as nursing staff reported gaps in their knowledge despite moderately high scores on the Knowledge about Older People Quiz. Further research is needed to understand additional factors that influence nurses' educational needs.

Predicting excess cost for older inpatients with clinical complexity: A retrospective cohort study examining cognition, comorbidities and complications

BACKGROUND

Hospital-acquired complications increase length of stay and contribute to poorer patient outcomes. Older adults are known to be at risk for four key hospital-acquired complications (pressure injuries, pneumonia, urinary tract infections and delirium). These complications have been identified as sensitive to nursing characteristics such as staffing levels and level of education. The cost of these complications compared to the cost of admission severity, dementia, other comorbidities or age has not been established.

METHOD

To investigate costs associated with nurse-sensitive hospital-acquired complications in an older patient population 157,178 overnight public hospital episodes for all patients over age 50 from one Australian state, 2006/07 were examined. A retrospective cohort study design with linear regression analysis provided modelling of length-of-stay costs. Explanatory variables included patient age, sex, comorbidities, admission severity, dementia status, surgical status and four complications. Extra costs were based on above-average length-of-stay for each patient's Diagnosis Related Group from hospital discharge data.

RESULTS

For adults over 50 who have length of stay longer than average for their diagnostic condition, comorbid dementia predicts an extra cost of A$874, (US$1,247); any one of four key complications predicts A$812 (US$1,159); each increase in admission severity score predicts A$295 ($US421); each additional comorbidity predicts A$259 (US$370), and for each year of age above 50 predicts A$20 (US$29) (all estimates significant at p<0.0001).

DISCUSSION

Hospital-acquired complications and dementia cost more than other kinds of inpatient complexity, but admission severity is a better predictor of excess cost. Because complications are potentially preventable and dementia care in hospitals can be improved, risk-reduction strategies for common complications, particularly for patients with dementia could be cost effective.

CONCLUSIONS

Complications and dementia were found to cost more than other kinds of inpatient complexity.

Identifying Factors Associated With Mobility Decline Among Hospitalized Older Adults

Hospitalization can negatively affect mobility among older adults. Early detection of older patients most at risk for mobility decline can lead to early intervention and prevention of mobility loss. This study's purpose was to identify factors from the International Classification of Functioning, Disability, and Health associated with mobility decline among hospitalized elders. We conducted a secondary analysis of data from 959 hospitalized adults age 65 and older. We estimated the effects of health conditions and environmental and personal factors on mobility decline using logistic regression. Almost half of the sample declined in mobility function during hospitalization. Younger age, longer length of hospital stay, having a hearing impairment, and non-emergency admit type were associated with mobility decline, after adjusting for covariates. Findings may be used to develop an evidence-based, risk-determination tool for hospitalized elders. Future research should focus on individual, environmental, and policy-based interventions promoting physical activity in the hospital.

Assessment of Physical Activity of Hospitalised Older Adults: A Systematic Review

BACKGROUND

The assessment of physical activity levels of hospitalised older people requires accurate and reliable measures. Physical activities that older people in hospital commonly engage in include exercises and walking. Measurement of physical activity levels of older inpatients is essential to evaluate the impact of interventions to improve physical activity levels and to determine associations between physical activity in hospital and other health-related outcome measures.

OBJECTIVE

To determine which measures are used to measure physical activity of older people in hospital, and to describe their properties and applications.

METHOD

A systematic review of four databases: Medline, Embase, CINAHL and AMED was conducted for papers published from 1996 to 2016. Inclusion criteria were participants aged ≥ 65 years and studies which included measures of physical activity in the acute medical inpatient setting. Studies which specifically assessed the activity levels of surgical patients or patients with neurological conditions such as stroke or brain injury were excluded. All study designs were included in the review.

RESULTS

18 studies were included from 127 articles selected for full review. 15 studies used objective measures to measure the physical activity of older inpatients: 11 studies used accelerometers and four used direct systematic observations. Seven accelerometers were identified including the StepWatch Activity Monitor, activPAL, GENEActiv, Kenz Lifecorder EX, Actiwatch-L, Tractivity and AugmenTech Inc. Pittsburgh accelerometer. Three studies used a subjective measure (interviews with nurses and patients) to classify patients into low, intermediate and high mobility groups. The StepWatch Activity Monitor was reported to be most accurate at step-counting in patients with slow gait speed or altered gait. The activPAL was reported to be highly accurate at classifying postures.

CONCLUSION

Physical activity levels of older inpatients can be measured using accelerometers. The accuracy of the accelerometers varies between devices and population-specific validation studies are needed to determine their suitability in measuring physical activity levels of hospitalised older people. Subjective measures are less accurate but can be a practical way of measuring physical activity in a larger group of patients.

Nutritional and Functional Status in Newly Hospitalized Older Patients Who are Not Underweight

Although malnutrition is commonly associated with being underweight, it occurs whenever nutrient intakes are inadequate, regardless of current body weight. The aim of the study was to determine nutritional status as a predictor of functional status among older patients without underweight according to body mass index (BMI) at hospital admission. This cross-sectional study enrolled 90 patients aged ≥65 years (mean age 78.1 ± 6.4). Assessments included basic and Instrumental Activities of Daily Living (bADL, IADL), Mini Nutritional Assessment (MNA), and BMI. Most of respondents were at risk of malnutrition (46%) or malnutrition (17%) according to MNA. Patients with/at risk of malnutrition had lower scores in bADL (p = 0.020), IADL (p = 0.010) and MNA (p < 0.001). Scores for bADL and IADL positively correlated with MNA (r = 0.34, r = 0.42, respectively) and negatively with age (r = -0.33, r = -0.21). MNA scores were also significant predictors of staying independence in bADL (β = 0.53, p < 0.001) and IADL (β = 0.45, p < 0.001) in regression analysis. Our findings indicated that most older patients with normal/elevated BMI were malnourished or at risk of malnutrition and experienced functional limitations in ADL at admission to hospital. In this population, nutritional status estimated by MNA appears to be one of the most important factors in predicting functional status of older adults who are not underweight.

Feasibility and Efficacy of Function-Focused Care for Orthopedic Trauma Patients

To overcome challenges associated with optimizing function and physical activity among hospitalized older adults, we developed function-focused care for acute care (FFC-AC). The purpose of this study was to test the feasibility and preliminary effectiveness of this intervention. We hypothesized that hospitalized trauma patients exposed to FFC-AC would (1) maintain or improve function, spend more time in physical activity, and have fewer adverse events between admission and discharge; and (2) maintain or improve function, have less fear of falling, fewer depressive symptoms, less pain, be more physically resilient, and be less likely to experience adverse events at 1 month postdischarge compared with those exposed to FFC-education only (EO). FFC-AC was implemented by a research function-focused care nurse who worked on the participating units for 20 hr a week for 16 months to implement the three components of FFC-AC. The sample included 89 older orthopedic trauma patients the majority of whom were female (N = 59, 66%), white (N = 82, 92%), and not married (N = 53, 59%). At discharge and/or 30 days postdischarge, participants in the treatment site showed greater improvement in function, less fear of falling, and better physical resilience when compared with those in the FFC-EO site. Future research is needed to continue to work on engaging staff in function-focused care approaches and optimizing the hospital environment and policies to support nurses in this type of care approach.

Functional trajectories of older patients admitted to an Acute Care Unit for Elders

AIMS AND OBJECTIVES

To describe the functional trajectories of older medical inpatients and to identify factors associated with overall and in-hospital functional decline.

BACKGROUND

Functional decline during a hospital stay is an important clinical outcome because independence remains a major determinant of older persons' quality of life and health care demands.

DESIGN AND METHODS

Participants (n = 189) were admitted to the Acute Care Unit for Elders of a Swiss academic hospital and were aged 65 years and older. Performance in basic activities of daily living at home (self-reported), at hospital admission (observed) and at discharge (observed) was collected. Differences in scores for basic activities daily living between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline. Predictors of in-hospital and overall decline were identified using bivariate and multivariate logistic regression analyses.

RESULTS

Pre-admission, in-hospital and overall functional decline occurred in 56.1%, 17.5% and 43.4% of the participants, respectively. In contrast, in-hospital functional improvement occurred in 40.2% of the participants. No predictors of pre-admission decline were identified, whereas pre-admission performance in instrumental activities of daily living was associated with in-hospital decline. Male gender and in-hospital delirium were associated with overall functional decline.

CONCLUSIONS

Most older inpatients experienced functional decline before their hospital admission, but only a minority experienced decline during their stay. Importantly, delirium was a strong predictor of overall functional decline.

IMPLICATIONS FOR PRACTICE

Low performance in instrumental activities of daily living prior to admission and delirium occurrence identified older patients at higher risk for in-hospital and overall functional decline. Gerontological nurses should play a key role in identifying these patients to provide preventative interventions and recovery care to preserve or restore their functional independence.

Activities of daily living trajectories among institutionalised older adults: A prospective study

AIMS AND OBJECTIVES

To examine activities of daily living trajectory groups among older residents in Taiwan, and to determine the relative risks of demographic characteristics and health status in explaining the trajectory group of activities of daily living.

BACKGROUND

Activity of daily living is a crucial indicator of health status for institutionalised older adults. activities of daily living is a dynamic process and has differences in trajectory groups.

DESIGN

This study was a 3-year longitudinal analysis of long-term care facility residents in Taiwan.

METHODS

A total of 364 older residents completed the entire research process. We used group-based trajectory modelling and multinomial logistic models for statistical analysis.

RESULTS

The result of this study revealed that three activities of daily living trajectory groups among older residents exhibited high dependency with gradually declining function (Group 1, 22.53%), low dependency with gradually declining function (Group 2, 43.13%) and persistent independent function (Group 3, 34.34%). Compared with Group 3, Group 1 was related to the following potential risk factors: older age, female, nonmainland China born and a married status. After considering resident health status in the analysis, three significant factors emerged for Group 1: the number of chronic diseases (odds ratio = 2.45), depressive symptoms (odds ratio = 1.71) and cognitive status (odds ratio = 83.11). Compared with Group 3, Group 2 was related to older age. After adding resident health status to the analysis, two significant factors of Group 2 emerged: the number of chronic diseases (odds ratio = 1.68) and depressive symptoms (odds ratio = 1.74).

CONCLUSION

The findings of this study indicated that health factors, including the number of chronic diseases, cognitive status and depressive symptoms, were more likely to contribute to the development of a decline pattern of activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

Appropriate exercise programmes and physical activities, according to residents' personal characteristics and activities of daily living status, is crucial for improving physical functioning, alleviating depression and cognitive defects in institutionalised older adults.