Problems of older adults living alone after hospitalization

Solitary living worsens the continuation of adjuvant chemotherapy for gastric cancer

BACKGROUND

No studies have reported the effect of solitary living on adjuvant chemotherapy continuation in patients with gastric cancer. This study aimed to investigate the influence of solitary living on the efficacy of adjuvant chemotherapy after curative gastrectomy.

METHODS

We enrolled 155 patients with pathological stage II/III gastric cancer who underwent gastrectomy and adjuvant chemotherapy between January 2013 and March 2020. The patients were divided into two groups according to their living conditions, the solitary group (n = 34) versus the non-solitary group (n = 121). Clinicopathological features, predictive factors for the continuation of adjuvant chemotherapy, and long-term survival were compared between the two groups.

RESULTS

The median body weight loss (BWL) at one month after surgery (8.9% vs. 7.0%, p = 0.01), and the rates of failure to continue six courses of chemotherapy were higher in the solitary group (41.2% vs. 14.9%, p = 0.002) than in the non-solitary group. Multivariate analysis revealed that solitary living was an independent predictive factor for discontinuing adjuvant chemotherapy (odds ratio 3.36, 95% confidence interval [CI; 1.32-8.58], p = 0.01) as well as 10% BWL at one month after surgery (odds ratio 3.99, 95% CI [1.57-10.2], p = 0.004). The relapse-free survival was significantly worse in the solitary group (p = 0.03).

CONCLUSIONS

Solitary living may be an independent risk factor for discontinuation of adjuvant chemotherapy in patients with gastric cancer. It is necessary to examine whether social and medical support organized by medical institutes and the government improves the continuation of adjuvant chemotherapy in patients living alone.

Depressive symptoms among older empty nesters in China: the moderating effects of social contact and contact with one's children

OBJECTIVES

Mental health for older people has become a major social concern. Literature has shown that older people, especially when they become empty nesters-when a parent lives alone or lives with his/her spouse after the youngest child leaves home-may start to develop various mental health problems due to reduced contacts with their children.

Using fixed-effects, multivariate regression with a difference-in-differences approach and propensity score matching, this paper examines the relationship between being an empty nester and mental health among older people in China, and the moderating effects of social contact and contact with one's children in terms of mental health. Our data come from the China Health and Retirement Longitudinal Study of 2011, 2013, 2015 and 2018.

RESULTS

We found that, in the short term, the mental health of older people may not be affected after they became empty nesters. But in the longer term, if they did not have regular contact with their children, their mental health would deteriorate with time. Social contact, especially cognitive activities, was beneficial to the mental health of the older empty nesters. We also found that for older empty nesters with disabilities, frequent social contact and contact with their children were more important.

CONCLUSION

We urge the government to promote community-based social activities for older people, especially for those with functional limitations.

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

Association of Social Support With Functional Outcomes in Older Adults Who Live Alone

IMPORTANCE

Older adults who live alone are at risk for poor health outcomes. Whether social support mitigates the risk of living alone, particularly when facing a sudden change in health, has not been adequately reported.

OBJECTIVE

To assess if identifiable support buffers the vulnerability of a health shock while living alone.

DESIGN, SETTING, AND PARTICIPANTS

In this longitudinal, prospective, nationally representative cohort study from the Health and Retirement Study (enrollment March 2006 to April 2015), 4772 community-dwelling older adults 65 years or older who lived alone in the community and could complete activities of daily living (ADLs) and instrumental ADLs independently were followed up biennially through April 2018. Statistical analysis was completed from May 2020 to March 2021.

EXPOSURES

Identifiable support (ie, can the participant identify a relative/friend who could help with personal care if needed), health shock (ie, hospitalization, new diagnosis of cancer, stroke, heart attack), and interaction (multiplicative and additive) between the 2 exposures.

MAIN OUTCOMES AND MEASURES

The primary outcomes were incident ADL dependency, prolonged nursing home stay (≥30 days), and death.

RESULTS

Of 4772 older adults (median [IQR] age, 73 [68-81] years; 3398 [71%] women) who lived alone, at baseline, 1813 (38%) could not identify support, and 3013 (63%) experienced a health shock during the study. Support was associated with a lower risk of a prolonged nursing home stay at 2 years (predicted probability, 6.7% vs 5.2%; P = .002). Absent a health shock, support was not associated with a prolonged nursing home stay (predicted probability over 2 years, 1.9% vs 1.4%; P = .21). However, in the presence of a health shock, support was associated with a lower risk of a prolonged nursing home stay (predicted probability over 2 years, 14.2% vs 10.9%; P = .002). Support was not associated with incident ADL dependence or death.

CONCLUSIONS AND RELEVANCE

In this longitudinal cohort study among older adults who live alone, identifiable support was associated with a lower risk of a prolonged nursing home stay in the setting of a health shock.

Effectiveness of a community-based integrated care ward (CICW) on 90-day readmission among the elderly people: a retrospective cohort study of a rural area in Japan

Objective: Community-based integrated care wards (CICW) play a role in supporting the return of patients to their homes. However, studies investigating the readmission risk associated with CICW are lacking. To investigate the influence of CICW on readmission, we conducted a retrospective cohort study among Japanese elderly people.

Materials and Methods: This study used data from the Diagnosis Procedure Combination (DPC) and medical records of the Hamada Medical Center, Shimane Prefecture in 2014–2019. The number of subjects and readmission in each hospitalization case (general ward only [GW] and CICW) were 1,521 and 416 subjects and 152 and 49 cases, respectively. We selected the hospitalization cases for heart failure (I30–I52), ischemic heart disease (I20–I25), pneumonia (J09–J18), chronic lower respiratory tract diseases (J40–J47), intestinal diseases (K55–K64), cerebrovascular disease (I60–I69), gallbladder, bile duct, and pancreatic diseases (K80–K87) from the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The hazard ratios (HRs) and 95% confidence intervals (CIs) for readmission via a CICW were estimated using a multivariate Cox proportional hazards model.

Results: The HRs for readmission associated with CICW were not different between the shorter and longer durations, considering the percentage of CICW stay. Compared with GW cases, the HR of CICW cases was 0.40 (95% CI, 0.17–0.92) in coordination with outside agencies of hospital discharge support. While the HR of GW cases was 2.35 (95% CI 1.01–5.47), a significantly increased risk was observed in people living alone. A similar risk was not observed in CICW cases with the HR of 0.56 (95% CI 0.15–2.07).

Conclusion: The present study observed decreased risk of readmission among the patients discharged from CICW, compared to GW. Further research is required to clarify the causal factors for this decreased risk.

Predictors of happiness among older Korean women living alone

AIM

The level of happiness of older adults is associated with their psychosocial and physical health. Currently, little is known about the predictors of happiness among older women living alone in the community. The present study aimed to identify these predictors.

METHODS

This was a cross-sectional descriptive study of older women who were living alone and were registered with a social welfare center in an old urban area in South Korea. We designated various demographic factors along with health-related information, perceived self-esteem and depressive symptoms as independent variables predicting happiness. Descriptive statistics and multivariate analysis were carried out.

RESULTS

In total, 154 participants were recruited. They showed a moderate level of happiness. Furthermore, happiness was negatively correlated with the number of comorbidities, presence of pain and depressive symptoms, but positively correlated with self-esteem. The final model in hierarchical regression showed that depressive symptoms were powerful predictors of happiness after controlling the covariates and accounted for approximately 76.7% of the total variances.

CONCLUSIONS

The happiness of older women living alone was associated with their self-esteem and depressive symptoms. Interventions aimed at reducing depressive symptoms and improving self-esteem should be developed and applied to this population. Geriatr Gerontol Int 2019; 19: 352-356.

Risk of Social Isolation among Older Patients: What Factors Affect the Availability of Family, Friends, and Neighbors upon Hospitalization?

OBJECTIVES

To examine the prevalence of social isolation among older patients admitted to a hospital, and the effects of sociodemographic and health-related factors on the availability of their family, friends, and neighbor networks.

METHODS

Analyses are based on interviews with a sample of 2,449 older patients admitted to an urban academic medical center in the United States. A nine-item version of Lubben's Social Network Scale was developed and used to assess the availability of different social networks.

RESULTS

About 47% of the sample was at risk of social isolation. The oldest old and non-White older adults showed greater risk. The availability of family networks was associated with age, sex, marital status, and prior hospitalization; friend networks with age, race, education, prior hospitalization, and functional limitations; neighbor networks with race, education, marital status, and functional limitations.

CONCLUSIONS

The risk of social isolation and the availability of social support for hospitalized older adults varies by both patient and network characteristics. Health professionals should attend to this risk and the factors associated with such risk.

CLINICAL IMPLICATIONS

By assessing the availability of various types and frequency of support among older patients, health professionals can better identify those who may need additional support after discharge. Such information should be used in discharge planning to help prevent unnecessary complications and potential readmission.

Hospitalization and associated factors in people with Alzheimer's disease residing in a long-term care facility in southern Taiwan

AIM

It has been reported that many people with dementia require hospitalizations. The objective of the present study was to determine predictive factors for hospitalizations in people with dementia.

METHODS

A total of 70 individuals with dementia living in a veterans' home in southern Taiwan were consecutively enrolled. During prospective follow up, all hospitalization events were recorded.

RESULTS

The mean age of residents with dementia was 86.1 ± 4.0 years, and the mean follow-up time for this population was 2.2 ± 1.1 years. Among individuals, 62.9% suffered from malnutrition or were at risk of malnutrition (minimal nutritional assessment-short form score ≤11), and 8.6% of individuals had a body mass index of <18.5 Kg/m² . There were 52 (74.3%) individuals who had previously fallen. Overall, 51 of 70 residents were hospitalized during the follow-up period. In those individuals with previous falls, there was a significantly increased risk of hospitalization (odds ratio 5.61, 95% CI 1.18-26.7). Furthermore, three factors were significantly associated with the risk of fall, including handgrip strength, malnutrition and Mini-Mental State Examination score.

CONCLUSIONS

The results of the present study showed that hospitalization was a frequent event in residents with dementia living in a long-term care facility. The major predictor for hospital admission was history of a previous fall. Screening those with dementia for history of injurious falls and associated risk factors for falling could help identify those at risk of hospitalization, thus necessitating a comprehensive intervention to reduce hospitalization. Geriatr Gerontol Int 2017; 17 (Suppl. 1): 50-56.

Occupational Therapy Predischarge Home Visits in Acute Hospital Care: A Randomized Trial

OBJECTIVES

To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care.

DESIGN

Randomized controlled trial.

SETTING

Acute and medical wards.

PARTICIPANTS

Individuals aged 70 and older (N = 400).

MEASUREMENTS

Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)).

RESULTS

Occupational therapist recommendations differed significantly between groups (P < .001) (HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale (NEADL): β = -0.17, 95% confidence interval (CI) = -0.99-0.66) or participation (LLDI-Frequency: β = -0.23, 95% CI = -2.05-1.59; LLDI-Limitation: β = -0.14, 95% CI = -2.86-2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions (HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male (P = .03) or having lower perceived participation because of physical problems (P = .04) resulted in higher risk of unplanned readmissions.

CONCLUSION

HOME discharge planning, which had a strong emphasis on task modification, well-being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation.

An Analysis on Sensor Locations of the Human Body for Wearable Fall Detection Devices: Principles and Practice

Wearable devices for fall detection have received attention in academia and industry, because falls are very dangerous, especially for elderly people, and if immediate aid is not provided, it may result in death. However, some predictive devices are not easily worn by elderly people. In this work, a huge dataset, including 2520 tests, is employed to determine the best sensor placement location on the body and to reduce the number of sensor nodes for device ergonomics. During the tests, the volunteer’s movements are recorded with six groups of sensors each with a triaxial (accelerometer, gyroscope and magnetometer) sensor, which is placed tightly on different parts of the body with special straps: head, chest, waist, right-wrist, right-thigh and right-ankle. The accuracy of individual sensor groups with their location is investigated with six machine learning techniques, namely the k-nearest neighbor (k-NN) classifier, Bayesian decision making (BDM), support vector machines (SVM), least squares method (LSM), dynamic time warping (DTW) and artificial neural networks (ANNs). Each technique is applied to single, double, triple, quadruple, quintuple and sextuple sensor configurations. These configurations create 63 different combinations, and for six machine learning techniques, a total of 63 × 6 = 378 combinations is investigated. As a result, the waist region is found to be the most suitable location for sensor placement on the body with 99.96% fall detection sensitivity by using the k-NN classifier, whereas the best sensitivity achieved by the wrist sensor is 97.37%, despite this location being highly preferred for today’s wearable applications.

The effect of living alone on the costs and benefits of surgery amongst older people

Older people who live alone are a growing, high-cost group for health and social services. The literature on how living alone affects health and the costs and benefits of healthcare has focused on crude measures of health and utilisation and gives little consideration to other cost determinants and aspects of patient experience. We study the effect of living alone at each stage along an entire treatment pathway using a large dataset which provides information on pre-treatment experience, treatment benefits and costs of surgery for 105,843 patients receiving elective hip and knee replacements in England in 2009 and 2010. We find that patients who live alone are healthier prior to treatment and experience the same gains from treatment. However, living alone is associated with a 9.2% longer length of in-hospital stay and increased probabilities of readmission and discharge to expensive destinations. These increase the costs per patient by £179.88 (3.12%) and amount to an additional £4.9 million per annum. A lack of post-discharge support for those living alone is likely to be a key driver of these additional costs.

A Model of Risk Reduction for Older Adults Vulnerable to Nursing Home Placement

Because of the cost of nursing home care and desire of older adults to stay in their homes, it is important for health care providers to understand the factors that place older adults at risk for nursing home placement. This integrative review of 12 years of research, as published in 148 articles, explores the risk factors for nursing home placement of older adults. Using the framework of the vulnerable populations conceptual model developed by Flaskerud and Winslow (1998), we explored factors related to resource availability, relative risks, and health status. Important factors include socioeconomic status, having a caregiver, the availability and use of home- and community-based support services, race, acute illness particularly if hospitalization is required, medications, dementia, multiple chronic conditions, functional disability, and falls. Few intervention studies were identified. Development of evidence-based interventions and creation of policies to address modifiable risk factors are important next steps.

Functional decline in older adults one year after hospitalization

We studied the change in personal ability to perform the activities of daily living (P-ADL) one year after hospitalization (T2) of patients at least 65 years old at baseline (T1). The study included 363 (175 men) medical inpatients with age range 65-98 (mean 80.2, SD 7.5) years. Information was collected at baseline and at a 12 month follow-up using Lawton and Brody's physical self-maintenance scale (PSMS) (termed the P-ADL score), as the dependent variable, and the mini-mental state examination (MMSE), the hospital anxiety and depression scale (HAD) and the WHOQOL-BREF questionnaire as independent variables. For the total sample, the mean P-ADL was significantly worsened from T1 to T2 (mean change 0.5, SD 2.8; p<0.01). In a fully adjusted linear regression analysis, worsened P-ADL from T1 to T2 was independently associated with cognitive impairment at T1, increasing cognitive impairment from T1 to T2, the tendency to fall between T1 and T2, increase in depressive symptoms from T1 to T2, poor physical QOL at T1 and change toward a poorer QOL from T1 to T2. In conclusion, worse P-ADL at T2 was, independently of age and baseline P-ADL, associated with impaired cognitive function and QOL related to physical ability at baseline, as well as worsening depression, cognition and QOL from T1 to T2. Our findings highlight the importance of applying results from screening measures of cognitive function and emotional health when planning care for older people after hospitalization.

Traumatic brain injury and post-acute decline: what role does environmental enrichment play? A scoping review

Objectives: While a growing number of studies provide evidence of neural and cognitive decline in traumatic brain injury (TBI) survivors during the post-acute stages of injury, there is limited research as of yet on environmental factors that may influence this decline. The purposes of this paper, therefore, are to (1) examine evidence that environmental enrichment (EE) can influence long-term outcome following TBI, and (2) examine the nature of post-acute environments, whether they vary in degree of EE, and what impact these variations have on outcomes.

Methods: We conducted a scoping review to identify studies on EE in animals and humans, and post-discharge experiences that relate to barriers to recovery.

Results: One hundred and twenty-three articles that met inclusion criteria demonstrated the benefits of EE on brain and behavior in healthy and brain-injured animals and humans. Nineteen papers on post-discharge experiences revealed that variables such as insurance coverage, financial, and social support, home therapy, and transition from hospital to home, can have an impact on clinical outcomes.

Conclusion: There is evidence to suggest that lack of EE, whether from lack of resources or limited ability to engage in such environments, may play a role in post-acute cognitive and neural decline. Maximizing EE in the post-acute stages of TBI may improve long-term outcomes for the individual, their family and society.

Occupational therapy discharge planning for older adults: a protocol for a randomised trial and economic evaluation

BACKGROUND

Decreased functional ability is common in older adults after hospitalisation. Lower levels of functional ability increase the risk of hospital readmission and nursing care facility admission. Discharge planning across the hospital and community interface is suggested to increase functional ability and decrease hospital length of stay and hospital readmission. However evidence is limited and the benefits of occupational therapists providing this service has not been investigated.This randomised trial will investigate the clinical effectiveness of a discharge planning program in reducing functional difficulties of older adults post-discharge. This trial will also examine the cost of the intervention and cost effectiveness when compared to in-hospital discharge planning.

METHODS/DESIGN

400 participants admitted to participating hospitals will be recruited. Participants will be 70 years of age and over, have no significant cognitive impairment and be independently mobile at discharge. This study protocol was approved by the ethics committee of Ryde Rehabilitation Human Research Ethics Committee, Western Sydney Local Health District (Westmead Campus) Human Research Ethics Committee, Alfred Health Human Research ethics committee for the randomised trial and NSW Population and Health Service Human Research Ethics Committee for data linkage. Participants will provide informed written consent.Participants will be randomly allocated to the intervention or control group. The intervention group will receive discharge planning therapies primarily within their home environment while the control group will receive an in-hospital consultation, both provided by trained occupational therapists. Primary outcome measures will be the Nottingham Extended Activities of Daily Living Scale (NEADL) and the Late Life Disability Index (LLDI) which will measure functional independence, and participation and limitation in daily life activities.

DISCUSSION

This trial will investigate the effectiveness and cost effectiveness of occupational therapy discharge planning in reducing functional difficulties. Results will have a direct impact on healthcare practice and policy.

TRIAL REGISTRATION

ACTRN12611000615987.

Community supports used by older people post hospital discharge

Community support in the post-discharge period is of importance, as difficulties managing at home can lead to readmission to hospital (Strunin et. al, 2007; Arbaje et al, 2009). There is evidence that support from family in the community is perceived to be the best option by older people (McCann and Evans 2002; Themessl-Huber et. al, 2007). However, during the transition from hospital to home gaps may occur in the continuity of support, with the potential for poor outcomes. Knowledge about how older people interact with supports in their communities is therefore important to inform health and social care policy and provision. This article presents the results of a southern Irish study to examine the use of informal and formal supports and services by older people in the post discharge period. Recommendations for practice and further research are included.

Home food environment of older adults transitioning from hospital to home

Only anecdotal information is known about foods available in the home of hospital-discharged older adults. This study describes the home food environment of this population and examines associations between health/nutrition risk factors and ability to shop and prepare meals. Data were collected from 512 hospital-discharged older adults residing in 6 U.S. states; food available within the home was assessed. Most households had a variety of food present; however, 20% of households lacked fresh fruit, 15% lacked fresh vegetables, and 35% had no fresh meat. About 35% of participants reported an inability to both prepare meals and shop for food. Among those unable to do both activities, the prevalence of depressive symptoms, food-related anxiety, and poor self-rated health was significantly (p < 0.01) higher than those able to do both activities. Homebound older adults may face additional challenges to recuperation from illness based on inability to prepare meals, regardless of availability of food following hospital discharge.

Use of an innovative model to evaluate mobility in seniors with lower-limb amputations of vascular origin: a pilot study

BACKGROUND

The mobility of older individuals has often been only partially assessed, without considering all important aspects such as potential (available) versus effective (used) mobilities and the physical and psychosocial factors that modulate them. This study proposes a new model for evaluating mobility that considers all important aspects, applied here to lower-limb amputees with vascular origin. This model integrates the concepts of potential mobility (e.g. balance, speed of movement), effective mobility (e.g. life habits, movements in living areas) and factors that modulate these two types of mobility (e.g. strength, sensitivity, social support, depression). The main objective was to characterize potential and effective mobility as well as mobility modulators in a small sample of people with lower-limb amputations of vascular origin with different characteristics. The second objective of this pilot study was to assess the feasibility of measuring all variables in the model in a residential context.

METHODS

An observational and transversal design was used with a heterogeneous sample of 10 participants with a lower-limb amputation of vascular origin, aged 51 to 83, assessed between eight and 18 months after discharge from an acute care hospital. A questionnaire of participant characteristics and 16 reliable and valid measurements were used.

RESULTS

The results show that the potential mobility indicators do not accurately predict effective mobility, i.e., participants who perform well on traditional measures done in the laboratory or clinic are not always those who perform well in the real world. The model generated 4 different profiles (categories) of participants ranging from reduced to excellent potential mobility and low to excellent effective mobility, and characterized the modulating factors. The evaluations were acceptable in terms of the time taken (three hours) and the overall measurements, with a few exceptions, which were modified to optimize the data collected and the classification of the participants. For the population assessed, the results showed that some of the negative modulators (particularly living alone, no rehabilitation, pain, limited social support, poor muscle strength) played an important role in reducing effective mobility.

CONCLUSION

The first use of the model revealed interesting data that add to our understanding of important aspects linked to potential and effective mobility as well as modulators. The feasibility of measuring all variables in the model in a residential context was demonstrated. A study with a large number of participants is now warranted to rigorously characterize mobility levels of lower-limb amputees with vascular origin.

Effectiveness of a video-based exercise programme to reduce falls and improve health-related quality of life among older adults discharged from hospital: a pilot randomized controlled trial

OBJECTIVE

Falls, loss of health-related quality of life and physical capacity, reduced participation in activities of daily living, and increased fear of falling are all potential outcomes for older adults discharged from hospital. A low-cost video based exercise programme may address this.

DESIGN

This study was a randomized controlled trial with blinded outcomes assessment and a six-month follow-up.

SUBJECTS AND SETTING

Participants were older adults (>65 years) using a mobility aid discharged from a tertiary hospital in Brisbane, Australia, without referral for community-based rehabilitation services.

INTERVENTION

A digital video disk-based programme encompassing six exercise types each with six levels of difficulty. A home visit from a project physiotherapist was conducted to ensure patient safety. Control group patients received usual care.

MAIN MEASURES

Falls, health-related quality of life, participation in activities of daily living, physical capacity and fear of falling.

RESULTS

Study participants (n = 53, 19 intervention, 34 control) experienced decreasing health-related quality of life, several falls (72), and lower levels of participation in activities of daily living over the six-month follow-up. The intervention group did not differ significantly from the control group in terms of the outcomes examined, though a non-significant reduction in the rate of falls was observed. Intervention group participants complied with the exercise programme well during the first two weeks following discharge from hospital but then reduced their compliance levels thereafter.

CONCLUSIONS

The intervention may be beneficial for reducing the rate of falls in this patient population though further research with a larger sample size is indicated.

Predictors for institutionalization and prosthetic ambulation after major lower extremity amputation during an eight-year follow-up

BACKGROUND AND AIMS

Major lower extremity amputation (LEA) leads to great loss in mobility, exposing old people to the risk of losing their independent living status. This study applies predictors for institutionalization and considers prosthesis use by major lower leg amputees with peripheral arterial disease (PAD).

METHODS

119 PAD patients admitted from home (mean age 73.6, SD 11.5 years, 48% men) underwent their first major LEA, 1998- 2002, and survived at least one month after the operation. Logistic regression analysis was run to clarify institutionalization predictors. Prosthesis use and ambulatory capacity were recorded during the follow-up.

RESULTS

Older age, living alone, and unilateral above-knee amputation (AKA) or bilateral amputation predicted institutionalization. Of prosthesis users, 69% (27/39) were younger than 75 and 44% (17/39) were able to walk both in- and outdoors. Reasons for not receiving a prosthesis after amputation were: 1) short expected survival; 2) old age, combined with unilateral AKA or bilateral amputation; 3) unilateral AKA or bilateral amputation and a comorbid condition such as hemiparesis, paraplegia, uremia, dementia, or alcohol misuse. After one year, 72% (36/50) of amputees who were able to return home and 9% (3/32) of amputees in institutional care used a prosthesis.

CONCLUSION

The majority of amputated patients cannot return home after their first LEA. Comorbid conditions particularly influencing functional capacity also hinder ambulation with a prosthesis.

From hospital to home: assessing the transitional care needs of vulnerable seniors

PURPOSE

This qualitative study assessed the needs of patients and caregivers during the transition from hospital to home. We specifically identified unmet needs of ethnic minorities, recent immigrants, and seniors with limited English proficiency (LEP). Findings are translated into recommendations for improving services to these groups during health care transitions.

DESIGN AND METHODS

This needs assessment included extensive analysis of qualitative data collected from 20 language-, culture-, and ethnic-specific focus groups with caregivers who recently assisted a senior after a hospital discharge. Findings from these focus groups were supplemented by 5 in-depth, longitudinal case studies of recently hospitalized seniors and their caregivers.

RESULTS

Inadequate information and training at discharge were themes that spanned all groups, despite ethnicity or language. Additional unmet needs were identified for ethnic minorities, those with LEP, and recent immigrants, including lower levels of social support than might be expected, lack of linguistically appropriate information and services, and cultural and financial barriers to using long-term care services.

IMPLICATIONS

As ethnic diversity increases among older Americans, it will become increasingly important to design health care services to meet the needs of diverse groups. Recommendations include assessments of informal care, bilingual information and services, partnerships with community agencies providing culturally competent services, and expansion of home- and community-based services to near-poor seniors.

Recovery of activities of daily living in older adults after hospitalization for acute medical illness

OBJECTIVES

To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge.

DESIGN

Observational.

SETTING

Tertiary care hospital, community teaching hospital.

PARTICIPANTS

Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998).

MEASUREMENTS

Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point.

RESULTS

By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover.

CONCLUSION

For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.

Coping Difficulties After Hospitalization

Coping difficulties of 113 adults 3 weeks after hospital discharge were identified using the Post-Discharge Coping Difficulty Scale and a brief focused telephone interview (11-item guide). Overall, low difficulty scores were reported ( M = 23.9, SD = 18.2, range = 0 to 100). Qualitative data reveal specific coping difficulties in the categories of stressors, specific difficulties, caring for self, managing the condition, family, advice needed, contact with the health care system, and what they wished they knew before discharge. A core theme of biographical reconstruction emerged.

A research and policy agenda for transitions from nursing homes to home

More than 1 million adults make the transition from nursing homes to the community every year, often using formal health services including Medicare Part A skilled home health care. Although the need for discharge planning is well described, and the risks associated with care transitions are increasingly recognized, there is very limited information about the process and outcomes as patients move from nursing home to home. This paper reviews pertinent published data and health services research as background information and outlines a research agenda for studying these important transitions.

Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review

BACKGROUND

Many patients encounter a variety of problems after discharge from hospital and many discharge (planning and support) interventions have been developed and studied. These primary studies have already been synthesized in several literature reviews with conflicting conclusions. We therefore set out a systematic review of the reviews examining discharge interventions. The objective was to synthesize the evidence presented in literature on the effectiveness of interventions aimed to reduce post-discharge problems in adults discharged home from an acute general care hospital.

METHODS

A comprehensive search of seventeen literature databases and twenty-five websites was performed for the period 1994-2004 to find relevant reviews. A three-stage inclusion process consisting of initial sifting, checking full-text papers on inclusion criteria, and methodological assessment, was performed independently by two reviewers. Data on effects were synthesized by use of narrative and tabular methods.

RESULTS

Fifteen systematic reviews met our inclusion criteria. All reviews had to deal with considerable heterogeneity in interventions, populations and outcomes, making synthesizing and pooling difficult. Although a statistical significant effect was occasionally found, most review authors reached no firm conclusions that the discharge interventions they studied were effective. We found limited evidence that some interventions may improve knowledge of patients, may help in keeping patients at home or may reduce readmissions to hospital. Interventions that combine discharge planning and discharge support tend to lead to the greatest effects. There is little evidence that discharge interventions have an impact on length of stay, discharge destination or dependency at discharge. We found no evidence that discharge interventions have a positive impact on the physical status of patients after discharge, on health care use after discharge, or on costs.

CONCLUSION

Based on fifteen high quality systematic reviews, there is some evidence that some interventions may have a positive impact, particularly those with educational components and those that combine pre-discharge and post-discharge interventions. However, on the whole there is only limited summarized evidence that discharge planning and discharge support interventions have a positive impact on patient status at hospital discharge, on patient functioning after discharge, on health care use after discharge, or on costs.

Determining predictors of delayed recovery and the need for transitional cardiac rehabilitation after cardiac surgery

PURPOSE

To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery.

DATA SOURCES

A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home.

CONCLUSIONS

Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services.

IMPLICATIONS FOR PRACTICE

Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment.

Functional decline in hospitalized older adults

In older adults who are hospitalized, functional decline can occur in a matter of days. This devastating outcome is a common result of the older adult's "cascade to dependency," in which normal aging changes--combined with bed rest or immobility--result in irreversible physiologic changes, poor outcomes at discharge, and for many, placement in a nursing home. Routine walking schedules, activities to prevent sensory deprivation, and timely hospital discharge are among the interventions that can help prevent functional decline.

Living alone and outpatient care use by older veterans

In nonveteran older adults, living alone influences outpatient care use, but its importance in the veteran population has not been well studied. The aims of this study are to describe the use of outpatient care by older veterans who live alone versus those who live with others and determine whether living alone influences outpatient use by older veterans. The data come from the 2001 Veteran Identity Program Survey designed to measure Department of Veterans Affairs (VA) and non-VA outpatient care use. Univariate and bivariate analyses were conducted to examine distributional properties, associations, and subgroup differences in outpatient care use. Poisson regression was used to assess the role of living alone on outpatient care use, controlling for predisposing, other enabling, and need factors. Results found that older veterans who use the VA, whether they live alone or not, have similar numbers of VA outpatient visits. Older veterans who use VA and non-VA facilities and who live alone have greater total outpatient visits than those who live with others. Regression results indicate that living alone is a predictor of VA routine medical visits, VA prescription refill visits, and total VA and non-VA outpatient visits but does not influence VA emergency room visits. These findings suggest that living alone is associated with differences in outpatient care use by older veterans. It is important for the VA to understand this relationship with the aim of developing interventions to improve access, effectiveness, and efficiency of health services for older veterans.

The Efficacy of a Home-Based Nursing Program in Diabetic Control of Elderly People with Diabetes Mellitus Living Alone

The purpose of this study was to evaluate the efficacy of a home-based nursing program in the diabetic control of elderly people with diabetes mellitus living alone. Patients meeting the sampling criteria were recruited from a medical center and 10 health centers in Taipei for this quasi-experimental study. By matching the effects of age, sex, education, and history of diabetes, subjects were assigned semirandomly to two groups based on the intensity of home-based nursing care visitations. Group I was defined as daily visits to supervise diet, exercise, medication, and self-monitoring blood sugar (n = 15) and Group II as weekly visits to supervise diet, exercise, medication education, and self-monitoring blood sugar (n = 15). Patients who agreed only to receive blood examination were assigned to the control group (n = 14). The results of the study showed that reductions in fasting blood sugar, postmeal blood sugar, and hemoglobin A1c (HbA1c) in Groups I and II were significantly greater than those in the control group. The reduction in the total cholesterol and low-density lipoprotein in Groups I and II was significantly greater than that in the control group. There were no significant differences among the three groups in the improvement of high-density lipoprotein (HDL) and triglycerides (TGs). Group I revealed a significantly greater weight reduction compared to Group II. There was no significant difference between Groups I and II in the improvements of diabetes knowledge, depression level, or quality of life. From the research findings, based on cost-effectiveness, it is recommend that Program II be implemented.

Hospital to home: Improving internal medicine residents' understanding of the needs of older persons after a hospital stay

Physicians-in-training discharge many older patients from the hospital, but few have any knowledge of what happens to the patients they send home, of how discharge plans are applied, or of the difficulties patients and their families face. The authors describe a pilot program, Hospital to Home, at the University of Rochester School of Medicine and Dentistry's internal medicine residency program, which uses home visits as an educational tool in geriatrics training. The program was begun in July 2001, and 23 residents have participated. Home visits expose residents in their first-year geriatrics rotation to the elements and outcomes of discharge planning and create a heightened awareness of the needs of older persons recently discharged from the hospital. The home visits are videotaped, and the residents present a videoconference based on the visits, which are attended by internal medicine residents, family medicine residents, and medical students. The authors describe the three-part Hospital to Home program, three vignettes that highlight learning experiences, and the residents' feedback about the experience and the use of audiovisual recording for education.

Influence of social support on cognitive function in the elderly

BACKGROUND

Social support is important in daily activities of the elderly. This study tests the hypothesis that there is an association between social support and cognitive function among the elderly in a community setting.

METHODS

Face-to-face interviews were conducted in a cross-sectional stratified random sample of 4,993 elderly (> or =65 years) city residents. Using multiple regression analysis, we investigated the influence of social support on cognitive function.

RESULTS

12% were over 80 years old. 53.28% were men. 67.14% were married. Higher Short Portable Mental Status Questionnaire (SPMSQ) scores (higher score means better cognitive function) were associated with strong social support, as measured by marital status and perceived positive support from friends. Lower cognitive function was associated with older and with female respondents. Only instrumental activities of daily living (IADL) were statistically and negatively related to SPMSQ. Lower functional status was associated with lower cognitive function. Elders with grade school educations had lower SPMSQ scores than did elders with high school educations.

CONCLUSIONS

In Taiwan, higher cognitive function in community-living elderly was associated with increased social support. Life-style management should provide social activities for the elderly to promote a better quality of life.