Sleep in Hospitalized Older Adults

Psychometric validation of the Hospital Stress Questionnaire

BACKGROUND

Psychological stress experienced by inpatients has been shown to be associated with poorer post-hospital outcomes. Research that explores and intervenes to address in-hospital stress and ameliorate negative patient outcomes requires a valid measurement tool. The Hospital Stress Questionnaire (HSQ) was developed for this purpose. The aims of the current study were to psychometrically validate the HSQ, identify latent factors, reduce the number of items within the HSQ, and explore the psychometric properties of longer and shorter versions of the scale.

METHODS

A nationally representative sample of recent NHS hospital inpatients (N =  660; mean age =  54.0, range =  18-97) completed the HSQ within a survey of patient experiences; 32 of which completed the measure a second time two weeks later. Factor structure, convergent validity, known-groups validity, predictive validity, and test-retest reliability were assessed.

RESULTS

Seven domains of in-hospital stress were identified: quality of care, away from home, inconvenienced, health anxiety, negative effects of treatment, ward environment, and disrupted patient experience. Long (55 items), medium (28 items), and short (10 items) versions of the measure were produced, all exhibiting excellent psychometric properties. The highest rated stressor was "poor sleep".

CONCLUSION

The HSQ is a valid and reliable tool, now available to be used by researchers and clinicians. It has potential to be used in intervention studies to reduce in-hospital stress, and to identify patients most at risk of the effects of post-hospital syndrome.

Preoperative Sleep Deprivation Exacerbates Anesthesia/Surgery-induced Abnormal GABAergic Neurotransmission and Neuronal Damage in the Hippocampus in Aged Mice

Older adults with anesthesia and surgery often suffer from postoperative cognitive dysfunction (POCD), which puts a heavy burden on rehabilitation. Preoperative sleep disorder, a common phenomenon in elderly anesthesia patients, is closely associated with POCD, but the underlying mechanism is still not fully understood. Hippocampal gamma-aminobutyric acid (GABA)ergic neurotransmission has been reported to play an important role in sleep disorder and cognitive impairment. The aim of this study was to elucidate the effect of preoperative acute sleep deprivation (SD) on anesthesia/surgery-induced POCD and the potential mechanism of hippocampal GABAergic neurotransmission. In the aged (18-20-month-old) male mice, we used a rotating rod to deprive sleep for 24 h and induced a POCD model using sevoflurane exposure combined with laparotomy exploration. A sequential set of behavioral tests, including open field test (OFT), Y-maze, and novel object recognition (NOR), was conducted to assess cognitive performances. In vivo magnetic resonance imaging (MRI) technique was used to observe hippocampal axonal microstructural changes. The levels of GABAergic neurotransmitter markers glutamic acid decarboxylase (GAD) 67, vesicular GABA transporter (VGAT), GABA transporter (GAT)-1, and GABA in the hippocampus were detected with enzyme-linked immunosorbent assay (ELISA). The reactivity of GABAergic neurons and neuronal damage in different subregions of the hippocampus were observed by immunofluorescence and Nissl staining, respectively. Compared the anesthesia/surgery (A/S) mice, 24-h SD combined with A/S induced shorter stay time in the central area of the open field, less the percent of novel arm preference in the Y maze, and lower recognition index in the NOR, as well as significantly enhanced hippocampal GABAergic neurotransmission, decreased hippocampal axonal integrity and density, and increased GAD67 reactivity and reduced the number of neurons in hippocampal CA1. Preoperative 24-h SD exacerbated anesthesia/surgery-induced POCD in aged mice, with the cumulative effect of abnormal GABAergic neurotransmission and neuronal damage in the hippocampus.

Optimizing Sleep Disorder Management in Hospitalized Patients: Practical Approach for Healthcare Providers

PURPOSE

To provide a comprehensive review of sleep disturbances in hospitalized patients, focusing on a case-based approach to illustrate the multifaceted nature of this clinical challenge.

METHOD

An extensive review of related literature was conducted to determine the common causes of sleep disturbances in hospitalized patients, such as environmental, medical, psychological, and physiological factors. The case of Mrs. Z was used to illustrate how these factors interact in a clinical setting.

FINDINGS

The study revealed a high prevalence of sleep disturbances in hospitalized patients, which can lead to significant adverse outcomes. A multidisciplinary approach involving physicians, nurses, pharmacists, and other healthcare professionals is essential to effectively manage sleep disorders due to the interplay of various factors. Nonpharmacological interventions are fundamental to a comprehensive sleep management plan. Pharmacotherapy may sometimes be necessary to improve sleep quality and duration.

CONCLUSION

Health professionals can significantly enhance the sleep quality of hospitalized piatients by understanding the value of sleep and providing evidence-based strategies for improvement. In return, this improves patient outcomes, reduces healthcare costs, and advances general patient satisfaction.

Alterations in hippocampal somatostatin interneurons, GABAergic metabolism, and ASL perfusion in an aged male mouse model of POCD aggravated by sleep fragmentation

Sleep fragmentation (SF) is increasingly recognized as a contributing factor to postoperative cognitive dysfunction (POCD). Given the critical roles of somatostatin (SST) interneurons, associated gamma-aminobutyric acid (GABA)ergic neurotransmitters, and hippocampal perfusion in sleep-related cognition, this study examined changes in these mechanisms in preoperative SF affecting POCD induced by anesthesia/surgery in aged male mice. The Morris water maze (MWM), novel object recognition (NOR), and Y maze tests were utilized to evaluate POCD. Arterial spin labeling (ASL) was employed to measure hippocampal regional cerebral blood flow (rCBF). In vitro assays quantified the levels of GABAergic metabolites-such as SST, neuropeptide Y (NPY), glutamic acid decarboxylase 1 (GAD1), vesicular GABA transporter (VGAT), and GABA and the distribution of SST interneurons in the hippocampus through enzyme-linked immunosorbent assay and immunofluorescence. Preoperative 24-h SF exacerbated anesthesia/surgery-induced spatial memory impairments observed in the MWM, NOR, and Y maze tests. Preoperative 24-h SF significantly increased the number of SST interneurons in hippocampal CA1, elevated hippocampal levels of SST, NPY, GAD1, and GABA, and reduced the rCBF. Preoperative SF aggravated POCD in aged male mice, with an increased number of SST interneurons in hippocampal CA1, elevated hippocampal GABAergic metabolites, and a further reduction in rCBF.

Effectiveness of a Multifaceted Implementation Strategy to Increase Equitable Hospital at Home Utilization: An Interrupted Time Series Analysis

BACKGROUND

The number of Hospital-at-Home (HaH) programs rapidly increased during the COVID-19 pandemic and after issuance of Centers for Medicare and Medicaid Services' (CMS) Acute Hospital Care at Home (AHCaH) waiver. However, there remains little evidence on effective strategies to equitably expand HaH utilization.

OBJECTIVE

Evaluate the effects of a multifaceted implementation strategy on HaH utilization over time.

DESIGN

Before and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.

PARTICIPANTS

Between December 2021 and December 2022, we identified adults hospitalized at six hospitals in North Carolina approved by CMS to participate in the AHCaH waiver program. Eligible adults met criteria for HaH transfer (HaH-eligible clinical condition, qualifying home environment). We conducted semi-structured interviews with 12 HaH patients and 10 referring clinicians.

INTERVENTIONS

Two strategies were studied. The discrete implementation strategy (weeks 1-12) included clinician-directed educational outreach. The multifaceted implementation strategy (weeks 13-54) included ongoing clinician-directed educational outreach, local HaH assistance via nurse navigators, involvement of clinical service line executives, and individualized audit and feedback.

MEASURES

We assessed weekly averaged HaH capacity utilization, weekly counts of unique referring providers, and patient characteristics. We analyzed themes from qualitative data to determine barriers and facilitators to HaH use.

RESULTS

Our evaluation showed week-to-week increases in HaH capacity utilization during the multifaceted implementation strategy period, compared to discrete-period trends (slope-change odds ratio-1.02, 1.01-1.04). Counts of referring providers also increased week to week, compared to discrete-period trends (slope-change means ratio-1.05, 1.03-1.07). The increase in HaH utilization was largest among rural residents (11 to 34%). Barriers included HaH-related information gaps and referral challenges; facilitators included patient-centeredness of HaH care.

CONCLUSIONS

A multifaceted implementation strategy was associated with increased HaH capacity utilization, provider adoption, and patient diversity. Health systems may consider similar, contextually relevant multicomponent approaches to equitably expand HaH.

Melanin-Concentrating Hormone Is Associated With Delayed Neurocognitive Recovery in Older Adult Patients With Preoperative Sleep Disorders Undergoing Spinal Anesthesia

BACKGROUND

Aging and preoperative sleep disorders are the main risk factors affecting postoperative cognitive outcomes. However, the pathogenesis of delayed neurocognitive recovery after surgery remains ambiguous, and there is still a lack of potential biomarkers for delayed neurocognitive recovery in older adult patients with preoperative sleep disorders. Our study aimed to explore the relationship between melanin-concentrating hormone (MCH) and delayed neurocognitive recovery early after surgery in older adult patients with preoperative sleep disorders.

METHODS

In this monocentric prospective observational study, 156 older adult patients (aged 65 years or older) with preoperative sleep disorders undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) were included at an academic medical center in Inner Mongolia, China, from October 2021 to November 2022, and all patients underwent spinal anesthesia. The Pittsburgh Sleep Quality Index (PSQI) was applied to assess the preoperative sleep quality of all patients, and preoperative sleep disorders were defined as a score of PSQI >5. We measured the levels of cerebrospinal fluid (CSF) MCH and plasma MCH of all patients. The primary outcome was delayed neurocognitive recovery early after surgery. All patients received cognitive function assessment through the Montreal Cognitive Assessment (MoCA) 1 day before and 7 days after surgery (postoperative day 7 [POD7]). Delayed neurocognitive recovery was defined as a score of POD7 MoCA <26. The potential confounders included variables with P < .2 in the univariate logistic analysis, as well as the important risk factors of delayed neurocognitive recovery reported in the literature. Multivariable logistic regression model based on the Enter method assessed the association of MCH and delayed neurocognitive recovery in older adult patients with preoperative sleep disorders.

RESULTS

Fifty-nine (37.8%) older adult patients with preoperative sleep disorders experienced delayed neurocognitive recovery at POD7. Increase in CSF MCH levels (odds ratio [OR] for an increase of 1 pg/mL = 1.16, 95% confidence interval [CI], 1.09-1.23, P < .001) and decrease in plasma MCH levels (OR for an increase of 1 pg/mL = 0.92, 95% CI, 0.86-0.98, P = .003) were associated with delayed neurocognitive recovery, after adjusting for age, sex, education, baseline MoCA scores, American Society of Anesthesiologists (ASA) grade, and coronary heart disease (CHD).

CONCLUSIONS

In older adult patients with preoperative sleep disorders, MCH is associated with the occurrence of delayed neurocognitive recovery after surgery. Preoperative testing of CSF MCH or plasma MCH may increase the likelihood of identifying the high-risk population for delayed neurocognitive recovery in older adult patients with preoperative sleep disorders.

Self-Completion Questionnaire on Sleep Evaluation in Patients Undergoing Oxaliplatin Therapy: An Observational Study

Sleep is a fundamental human need; sleep disruption, in fact, causes an increase in the activity of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, metabolic effects, changes in circadian rhythms, and pro-inflammatory responses. The scientific literature is finally starting to pay attention to the central role of sleep alterations in patients health. Oxaliplatin is extensively used for the treatment of gastrointestinal cancer and other malignancies, with an increased frequency of use in recent years. This study aims to understand the effects of sleep complaints on health and quality of life in cancer patients treated with oxaliplatin. A study has been conducted through the creation and distribution of questionnaires to patients to investigate their complaints about sleep quality. We observed significant differences between males and females in evaluating sleep hygiene scores, the Pittsburgh Sleep Quality Index, and previous difficulty sleeping. Moreover, in females, stress, worries, and anxiety seem to play a negative role in the sleep hygiene score. The obtained results could improve the interest of healthcare personnel and caregivers in sleep quality in patients undergoing chemotherapy.

Neurometabolic and structural alterations of medial septum and hippocampal CA1 in a model of post-operative sleep fragmentation in aged mice: a study combining 1H-MRS and DTI

Post-operative sleep disturbance is a common feature of elderly surgical patients, and sleep fragmentation (SF) is closely related to post-operative cognitive dysfunction (POCD). SF is characterized by sleep interruption, increased number of awakenings and sleep structure destruction, similar to obstructive sleep apnea (OSA). Research shows that sleep interruption can change neurotransmitter metabolism and structural connectivity in sleep and cognitive brain regions, of which the medial septum and hippocampal CA1 are key brain regions connecting sleep and cognitive processes. Proton magnetic resonance spectroscopy (1H-MRS) is a non-invasive method for the evaluation of neurometabolic abnormalities. Diffusion tensor imaging (DTI) realizes the observation of structural integrity and connectivity of brain regions of interest in vivo. However, it is unclear whether post-operative SF induces harmful changes in neurotransmitters and structures of the key brain regions and their contribution to POCD. In this study, we evaluated the effects of post-operative SF on neurotransmitter metabolism and structural integrity of medial septum and hippocampal CA1 in aged C57BL/6J male mice. The animals received a 24-h SF procedure after isoflurane anesthesia and right carotid artery exposure surgery. 1H-MRS results showed after post-operative SF, the glutamate (Glu)/creatine (Cr) and glutamate + glutamine (Glx)/Cr ratios increased in the medial septum and hippocampal CA1, while the NAA/Cr ratio decreased in the hippocampal CA1. DTI results showed post-operative SF decreased the fractional anisotropy (FA) of white matter fibers in the hippocampal CA1, while the medial septum was not affected. Moreover, post-operative SF aggravated subsequent Y-maze and novel object recognition performances accompanied by abnormal enhancement of glutamatergic metabolism signal. This study suggests that 24-h SF induces hyperglutamate metabolism level and microstructural connectivity damage in sleep and cognitive brain regions in aged mice, which may be involved in the pathophysiological process of POCD.

Approaching person-centered clinical practice: A cluster analysis of older inpatients utilizing the measurements of intrinsic capacity

Background

Maintaining the intrinsic capacity (IC) of older inpatients is a novel view in providing person-centered treatments in clinical practice. Uncertainty remains regarding the primary nature of IC among older hospitalized patients.

Objectives

We aimed to understand the status of IC among older inpatients by a cluster analysis based on IC measurements.

Methods

This is a cross-sectional study conducted in the geriatric department of Beijing Hospital in China. Older inpatients who were older than 60 years and who underwent comprehensive geriatric assessments were included. The inpatients were classified into subgroups based on 13 measurements of IC according to unsupervised methods (K-means cluster analysis and t-SNE). Subgroup differences were investigated for domains of IC, age, sex, frailty, activities of daily living, and falls.

Results

A total of 909 inpatients with a mean age of 76.6 years were included. Almost 98% of the inpatients showed IC impairment. Locomotion impairment was the most prevalent problem (91.1%), followed by sensory impairment (61.4%), psychological impairment (57.3%), cognition decline (30.7%), and vitality problem (29.2%). A total of five clusters were obtained by classification: Cluster 1 (56.6% of the participants) showed high IC with fair impairment of locomotion and vision; clusters 2 and 3 (37.8 % of the participants) had additional impairment of sleep in the psychological domain; clusters 4 and 5 (5.6% of the participants) represented a severe loss of all the IC domains; and clusters 1-5 showed a gradual decline in the IC score and were significantly associated with increased age, frailty, decreased activities of daily living, and falls. Significant correlations among the domains were observed; the locomotion domain showed the strongest links to the others in network analysis.

Conclusions

Great declines in IC and disparities between IC domains were found in older inpatients. IC-based primary assessment and classification enabled us to identify the variation of functional abilities among the older inpatients, which is pivotal for designing integrated treatment or care models in clinical practice.