Early evaluation of the risk of functional decline following hospitalization of older patients: development of a predictive tool

Caring and Health of Close Family Members of Frail Older Persons Recently Discharged from Acute Hospital Care: A Comparative Cross-Sectional Study

Multimorbidity in older people is strongly linked to the need for acute hospital care, and caregiving activities usually become more complex after patients are discharged from hospital. This may negatively impact the health of close family members, although this has not been comprehensively investigated. This study aimed to explore the general and mental health of close family members caring for frail older (>65) persons recently discharged from acute hospital care, making assessments in terms of gender, relationship to the older person, and aspects of caring. A comparative cross-sectional study was conducted involving 360 close family members caring for frail older persons recently discharged from hospital. The statistical analyses included subgroup comparisons and associations to caring were examined. Half of the family members reported that their general and mental health was poor, with spouses reporting the poorest health. Female participants had significantly more severe anxiety, while males had significantly more severe depression. Providing care for more than six hours per week was associated with poor general health (OR 2.31) and depression (OR 2.59). Feelings of powerless were associated with poor general health (OR 2.63), anxiety (6.95), and depression (3.29). This knowledge may provide healthcare professionals with better tools in order to individualise support, preventing family members from exceeding their resources during these demanding periods.

Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol

BACKGROUND

Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions.

METHOD

We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat.

DISCUSSION

To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions.

TRIAL REGISTRATION

www.

CLINICALTRIALS

org NCT05546073 (Date of registration: September 19th, 2022).

Multi-Year Retrospective Analysis of Mortality and Readmissions Correlated with STOPP/START and the American Geriatric Society Beers Criteria Applied to Calgary Hospital Admissions

Introduction: The goals of this retrospective cohort study of 129,443 persons admitted to Calgary acute care hospitals from 2013 to 2021 were to ascertain correlations of "potentially inappropriate medications" (PIMs), "potential prescribing omissions" (PPOs), and other risk factors with readmissions and mortality. Methods: Processing and analysis codes were built in Oracle Database 19c (PL/SQL), R, and Excel. Results: The percentage of patients dying during their hospital stay rose from 3.03% during the first admission to 7.2% during the sixth admission. The percentage of patients dying within 6 months of discharge rose from 9.4% after the first admission to 24.9% after the sixth admission. Odds ratios were adjusted for age, gender, and comorbidities, and for readmission, they were the post-admission number of medications (1.16; 1.12-1.12), STOPP PIMs (1.16; 1.15-1.16), AGS Beers PIMs (1.11; 1.11-1.11), and START omissions not corrected with a prescription (1.39; 1.35-1.42). The odds ratios for readmissions for the second to thirty-ninth admission were consistently higher if START PPOs were not corrected for the second (1.41; 1.36-1.46), third (1.41;1.35-1.48), fourth (1.35; 1.28-1.44), fifth (1.38; 1.28-1.49), sixth (1.47; 1.34-1.62), and seventh admission to thirty-ninth admission (1.23; 1.14-1.34). The odds ratios for mortality were post-admission number of medications (1.04; 1.04-1.05), STOPP PIMs (0.99; 0.96-1.00), AGS Beers PIMs (1.08; 1.07-1.08), and START omissions not corrected with a prescription (1.56; 1.50-1.63). START omissions for all admissions corrected with a prescription by a hospital physician correlated with a dramatic reduction in mortality (0.51; 0.49-0.53) within six months of discharge. This was also true for the second (0.52; 0.50-0.55), fourth (0.56; 0.52-0.61), fifth (0.63; 0.57-0.68), sixth (0.68; 0.61-0.76), and seventh admission to thirty-ninth admission (0.71; 0.65-0.78). Conclusions: "Potential prescribing omissions" (PPOs) consisted mostly of needed cardiac medications. These omissions occurred before the first admission of this cohort, and many persisted through their readmissions and discharges. Therefore, these omissions should be corrected in the community before admission by family physicians, in the hospital by hospital physicians, and if they continue after discharge by teams of family physicians, pharmacists, and nurses. These community teams should also meet with patients and focus on patients' understanding of their illnesses, medications, PPOs, and ability for self-care.

How Can We Best Measure Frailty in Cardiosurgical Patients?

BACKGROUND

Frailty is gaining importance in cardiothoracic surgery and is a risk factor for adverse outcomes and mortality. Various frailty scores have since been developed, but there is no consensus which to use for cardiac surgery.

METHODS

In an all-comer prospective study of patients presenting for cardiac surgery, we assessed frailty and analyzed complication rates in hospital and 1-year mortality, as well as laboratory markers before and after surgery.

RESULTS

246 included patients were analyzed. A total of 16 patients (6.5%) were frail, and 130 patients (52.85%) were pre-frail, summarized in the frail group (FRAIL) and compared to the non-frail patients (NON-FRAIL). The mean age was 66.5 ± 9.05 years, 21.14% female. The in-hospital mortality rate was 4.88% and the 1-year mortality rate was 6.1%. FRAIL patients stayed longer in hospital (FRAIL 15.53 ± 8.5 days vs. NON-FRAIL 13.71 ± 8.94 days, p = 0.004) and in intensive/intermediate care units (ITS/IMC) (FRAIL 5.4 ± 4.33 days vs. NON-FRAIL 4.86 ± 4.78 days, p = 0.014). The 6 min walk (6 MW) (317.92 ± 94.17 m vs. 387.08 ± 93.43 m, p = 0.006), mini mental status (MMS) (25.72 ± 4.36 vs. 27.71 ± 1.9, p = 0.048) and clinical frail scale (3.65 ± 1.32 vs. 2.82 ± 0.86, p = 0.005) scores differed between patients who died within the first year after surgery compared to those who survived this period. In-hospital stay correlated with timed up-and-go (TUG) (TAU: 0.094, p = 0.037), Barthel index (TAU-0.114, p = 0.032), hand grip strength (TAU-0.173, p < 0.001), and EuroSCORE II (TAU 0.119, p = 0.008). ICU/IMC stay duration correlated with TUG (TAU 0.186, p < 0.001), 6 MW (TAU-0.149, p = 0.002), and hand grip strength (TAU-0.22, p < 0.001). FRAIL patients had post-operatively altered levels of plasma-redox-biomarkers and fat-soluble micronutrients.

CONCLUSIONS

frailty parameters with the highest predictive value as well as ease of use could be added to the EuroSCORE.

The relationship between pre-surgery self-rated health and changes in functional and mental health in older adults: insights from a prospective observational study

BACKGROUND

Elective surgeries are among the most common health stressors in later life and put a significant risk at functional and mental health, making them an important target of research into healthy aging and physical resilience. Large-scale longitudinal research mostly conducted in non-clinical samples provided support of the predictive value of self-rated health (SRH) for both functional and mental health. Thus, SRH may have the potential to predict favorable adaptation processes after significant health stressors, that is, physical resilience. So far, a study examining the interplay between SRH, functional and mental health and their relative importance for health changes in the context of health stressors was missing. The present study aimed at addressing this gap.

METHODS

We used prospective data of 1,580 inpatients (794 complete cases) aged 70 years or older of the PAWEL study, collected between October 2017 and May 2019 in Germany. Our analyses were based on SRH, functional health (Barthel Index) and self-reported mental health problems (PHQ-4) before and 12 months after major elective surgery. To examine changes and interrelationships in these health indicators, bivariate latent change score (BLCS) models were applied.

RESULTS

Our analyses provided evidence for improvements of SRH, functional and mental health from pre-to-post surgery. BLCS models based on complete cases and the total sample pointed to a complex interplay of SRH, functional health and mental health with bidirectional coupling effects. Better pre-surgery SRH was associated with improvements in functional and mental health, and better pre-surgery functional health and mental health were associated with improvements in SRH from pre-to-post surgery. Effects of pre-surgery SRH on changes in functional health were smaller than those of functional health on changes in SRH.

CONCLUSIONS

Meaningful changes of SRH, functional and mental health and their interplay could be depicted for the first time in a clinical setting. Our findings provide preliminary support for SRH as a physical resilience factor being associated with improvements in other health indicators after health stressors. Longitudinal studies with more timepoints are needed to fully understand the predictive value of SRH for multidimensional health.

TRIAL REGISTRATION

PAWEL study, German Clinical Trials Register, number DRKS00013311. Registered 10 November 2017 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013311 .

Sensitivity and specificity of three screening tools for frailty in hospitalized older adults

AIM

To determine the test accuracy, including sensitivity, specificity, positive predictive value, negative predictive value and area under curve, of three frailty screening tools in identifying the risk of frail outcomes among hospitalized older patients.

DESIGN

Prospective longitudinal study.

METHODS

The screening tools [Frail-PPS (Frail-Physical, Psychological and Social), Frailty Assessment Measure (FAM), and Identification of seniors at-risk hospitalized patients (ISAR-HP)] were administered by ward nurses to patients aged 65 years and older within 24 h of admission to an acute hospital. Sensitivity, specificity, positive predictive value, negative predictive value and area under curve analysis of the three tools in the context of three frail outcomes, (a) functional decline at three months after discharge-defined as a decline of at least one point on the Katz Index, (ii) requiring a full-time caregiver upon discharge, and (iii) death by three months after discharge, was assessed.

RESULTS

Of 366 patients enrolled in the study, 78 (21.3%) experienced one or more frail outcomes, with 65 (17.76%) experiencing functional decline, 61 (16.67%) requiring a full-time caregiver upon discharge and 8 (2.19%) dying by three months. Frail-PPS had sensitivity 12.5% to 31.4% and specificity 91.2% to 94.8%, varying by the considered frail outcome. Similarly, FAM had sensitivity 12.5% to 29.4% and specificity 90.9% to 94.1%, and ISAR-HP had sensitivity 2.9% to 19.2% and specificity 92.2% to 99.1%. positive predictive value of the FAM, Frail-PPS and ISAR-HP ranged from 3.0 to 45.5%, 3.1 to 50.0% and 3.9 to 23.6% respectively, while their negative predictive value ranged from 87.1% to 97.9%, 87.7% to 97.9% and 92.2% to 99.4% respectively. The area under curve values were moderate for the Frail-PPS (0.56 to 0.75), FAM (0.58 to 0.70) and ISAR-HP (0.71 to 0.77) for the three outcomes.

CONCLUSIONS

With high specificity and negative predictive values, as well as low sensitivity, FAM and Frail-PPS may be beneficial in identifying older individuals who are not frail, minimizing unnecessary further assessment and intervention.

Differential utility of various frailty diagnostic tools in non-geriatric hospital departments of several countries: A longitudinal study

BACKGROUND

There is limited knowledge on the performance of different frailty scales in clinical settings. We sought to evaluate in non-geriatric hospital departments the feasibility, agreement and predictive ability for adverse events after 1 year follow-up of several frailty assessment tools.

METHODS

Longitudinal study with 667 older adults recruited from five hospitals in three different countries (Spain, Italy and United Kingdom). Participants were older than 75 years attending the emergency room, cardiology and surgery departments. Frailty scales used were Frailty Phenotype (FP), FRAIL scale, Tilburg and Groningen Frailty Indicators, and Clinical Frailty Scale (CFS). Analyses included the prevalence of frailty, degree of agreement between tools, feasibility and prognostic value for hospital readmission, worsening of disability and mortality, by tool and setting.

RESULTS

Emergency Room and cardiology were the settings with the highest frailty prevalence, varying by tool between 40.4% and 67.2%; elective surgery was the one with the lowest prevalence (between 13.2% and 38.2%). The tools showed a fair to moderate agreement. FP showed the lowest feasibility, especially in urgent surgery (35.6%). FRAIL, CFS and FP predicted mortality and readmissions in several settings, but disability worsening only in cardiology.

CONCLUSIONS

Frailty is a highly frequent condition in older people attending non-geriatric hospital departments. We recommend that based upon their current feasibility and predictive ability, the FRAIL scale, CFS and FP should be preferentially used in these settings. The low concordance among the tools and differences in prevalence reported and predictive ability suggest the existence of different subtypes of frailty.

Investigating the relationship between specific executive functions and functional decline among community-dwelling older adults: results from a prospective pilot study

BACKGROUND

As cognitive functions and, more specifically, executive functions (EF) seem to influence autonomy among the elderly, we investigated the role of each of the five EF sub-components (inhibition, spontaneous flexibility, reactive flexibility, planning, and updating in working memory) for the risk of functional decline.

METHOD

A total of 137 community-dwelling participants over 75 years of age were included in a prospective cohort study and assigned to three groups: individuals with neuro-degenerative cognitive disorders, those having cognitive disorders with non-degenerative aetiology, and a control group without any cognitive problems. We measured each EF sub-component and assessed functional decline by evaluating basic (b-ADL) and instrumental activities of daily living (i-ADL) at baseline and 6 months later. We conducted three separate multiple logistic regression models to examine the extent to which the five EF facets predicted overall functional decline at the end of the follow-up period.

RESULTS

We found that people who exhibited a decline in b-ADLs or/and i-ADLs over 6 months had worse performance on inhibition and two flexibility tasks than those who did not experience a decline. The results suggest that decliners have more difficulties in managing unforeseen events. Inhibition and updating in working memory predicted a decline in b-ADL while spontaneous and reactive flexibilities predicted a decline in i-ADL.

CONCLUSION

In our sample, specific executive dysfunctions were associated with a decline in functional status. With respect to the risk of decline in b-ADL, deficits in inhibition may represent a risk factor, as it regulates over-learned activities. Bothtypes of flexibility, which allow the shifting and generating of adaptive responses, predicted decline in i-ADL. In sum, paying more attention to particular EF profiles would help clinicians to anticipate some aspects of functional decline.

Association between multimorbidity and hospitalization in older adults: systematic review and meta-analysis

Background

Multimorbidity is defined as the presence of multiple chronic conditions in the same individual. Multimorbidity is more prevalent in older adults and can lead to several adverse health outcomes.

Methods

We systematically reviewed evidence from observational studies to verify the association between multimorbidity and hospitalization in older adults. Furthermore, we also aimed to identify whether it changes according to gender, advanced age, institutionalization, and wealth of the country of residence. We searched the PubMed, Embase and Scopus databases from December 2020 to April 2021. The analysed outcomes were as follows: hospitalization, length of stay and hospital readmission.

Results

Of the 6,948 studies identified in the databases, 33 were included in this review. From the meta-analysis results, it was found that multimorbidity, regardless of the country’s wealth, was linked to hospitalization in older adults (OR = 2.52, CI 95% = 1.87–3.38). Both definitions of multimorbidity, ≥2 (OR = 2.35, 95% CI = 1.34–4.12) and ≥3 morbidities (OR = 2.52, 95% CI = 1.87–3.38), were associated with hospitalization. Regardless of gender, multimorbidity was associated with hospitalization (OR = 1.98, 95% CI = 1.67–2.34) and with readmission (OR = 1.07, 95% CI = 1.04–1.09). However, it was not possible to verify the association between multimorbidity and length of stay.

Conclusions

Multimorbidity was linked to a higher hospitalization risk, and this risk was not affected by the country’s wealth and patient’s gender. Multimorbidity was also linked to a higher hospital readmission rate in older adults. PROSPERO Registration (Registration number: CRD42021229328).

Validation of Screening Tools for Predicting the Risk of Functional Decline in Hospitalized Elderly Patients

BACKGROUND

Functional decline and increased dependence on others are common health issues among hospitalized elderly patients. However, a well-validated screening tool for predicting functional decline in elderly patients is still lacking. The current study therefore aimed to evaluate and compare the diagnostic accuracy of the Identification of Seniors at Risk-Hospitalized Patients (ISAR-HP), Variable Indicative of Placement Risk (VIP), and Score Hospitalier d' Evaluation du Risque de Perte d'Autonomie (SHERPA) in predicting functional decline 30 days after discharge in older patients admitted to an acute hospital ward.

METHODS

A prospective, longitudinal study was conducted in 197 elderly inpatients at the internal medicine ward of a teaching hospital in central Taiwan. Data were collected twice, first within 48 h after hospitalization and second via a telephone interview 30 days after hospital discharge. Variables included demographic data, Barthel Index of activities of daily living (ADL), and screening instruments. The Barthel Index was used to measure functional disability. Functional decline was defined as a decline of at least five points on the Barthel Index 30 days after discharge compared to that at pre-admission.

RESULTS

Patients had a mean age of 77.7 years, with 55.7% being female. Functional decline was observed in 39.1% of all patients. The best cutoff point, sensitivity, specificity, and area under the receiver operating characteristic curve were 2.5, 96.1%, 52.5%, and 0.751 for ISAR-HP; 1.5, 83.1%, 62.5%, and 0.761 for VIP; and 4.75, 89.6%, 54.2%, and 0.758 for SHERPA, respectively.

CONCLUSIONS

All three instruments showed moderate diagnostic accuracy as indicated by their best cutoff points. Therefore, the results presented herein can guide health care professionals in selecting the appropriate assessment tool for predicting functional decline among hospitalized elderly patients in a clinical setting.

Hospital-associated deconditioning: Not only physical, but also cognitive

INTRODUCTION

Hospital-associated deconditioning (HAD) or post-hospital syndrome is well recognized as reduced functional performance after an acute hospitalization. Recommendations for the management of HAD are still lacking, partly due to a poor understanding of the underlying processes. We aimed to review existing data on risk factors, pathophysiology, measurement tools, and potential interventions.

MATERIALS AND METHODS

We conducted a systematic review from bibliographical databases in English, Spanish and French with keywords such as 'post-hospitalization syndrome' or 'deconditioning'. We selected studies that included people aged 60 years or older. Three researchers independently selected articles and assessed their quality.

RESULTS

From 4421 articles initially retrieved, we included 94 studies. Most were related to risk factors, trajectories and measures, and focused on the physical aspects of deconditioning. Risk factors for HAD included age, nutritional status, mobility, and pre-admission functional status, but also cognitive impairment and depression. Regarding interventions, almost all studies were devoted to physical rehabilitation and environmental modifications. Only one study focused on cognitive stimulation.

DISCUSSION

In the last decade, studies on HAD have mostly focused on the physical domain. However, neurological changes may also play a role in the pathophysiology of HAD. Beyond physical interventions, cognitive rehabilitation and neurological interventions should also be evaluated to improve deconditioning prevention and treatment in the hospital setting.

SPPB as a predictor of functional loss of hospitalized older adults

Abstract Introduction: Immobility is associated with adverse outcomes such as loss of functional capacity and longer hospitalization. Objective: To assess intra-hospital mobility at admission as a predictor of loss of functional capacity during older adults´ hospitalization. Methods: A prospective cohort study was conducted, and personal and hospital related risk factors were assessed at admission and discharge. To determine whether Short Physical Performance Battery (SPPB) on admission could predict loss of functional capacity during hospitalization, a ROC curve was performed and area under the curve (AUC) was calculated. Binary logistic regression models were used to identify predictors of loss of functional capacity. Model 1 contained only SPPB. Model 2 SPPB was matched with age, sex, instrumental activity of daily living (IADL), cognition, depression and surgery. Data were entered into SPSS version 18.0. Results: 1,191 patients were included with a mean age of 70.02 (± 7.34). SPPB cutoff point of 6.5 (sensitivity 62%, specificity 54%) identified 593 (49.8%) patients at risk for functional loss. In logistic regression, SPPB alone showed prediction of functional loss (p < 0.001, OR 1.8, 95% CI = 1.5-2.5) between admission and discharge. Model 1 explained between 22 to 32% of the variation in functional capacity. In Model 2, three variables contributed to the loss. SPPB 6.5 increased 1.8 times (95% CI = 1.3-2.4), being a woman increased 1.4 times (95% CI = 1.0-1.8) and not having surgery increased 2 times (95% CI = 1.4-2.8) the chance of having functional loss during hospitalization. Conclusion: SPPB is a good instrument to predict loss of functional capacity in hospitalized older adults.

The opinions and experiences of nurses on frailty screening among older hospitalized patients. An exploratory study

Background

Routine screening for frailty at admission by nurses may be useful to detect geriatric risks and problems at an early stage. However, the added value of this screening is not clear yet. Information about the opinions and attitudes of nurses towards this screening is also lacking. As they have a crucial role in conducting this screening, an exploratory study was performed to examine hospital nurses’ opinions and perspectives about this screening and how it influences their daily work.

Methods

A qualitative, exploratory approach was employed, using semi-structured interviews with 13 nurses working on different general medical wards (surgical and internal medicine) in three Dutch hospitals. Frailty screening had been implemented for several years in these hospitals.

Results

The participating nurses reported that frailty screening can be useful to structure their work, create more awareness of frail older patients and as starting point for pro-active nursing care. At the same time, they assess their clinical view as more important than the results of a standard screening tool. The nurses hardly used the overall screening scores, but were particularly interested in information regarding specific items, such as delirium or fall risk. Screening results are partly embedded systematically and in daily nursing care, e.g., in team briefings or during transfer of patients to other wards. The majority of the nurses had received little training about the background of frailty screening and the use of screening tools.

Conclusions

Most nurses stated that frailty screening tools are helpful in daily practice. However, nurses did not use the frailty screening tools in the referred way; tools were particularly used to evaluate patients on separate items of the tool instead of the summative score of the tool. When frailty screening tools are implemented in daily practice, training needs to be focused on. Additional research in this field is necessary to gain more insight into nurses’ opinions on frailty screening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02586-z.

Effects of a nurse–occupational therapist meeting on function and motivation in hospitalized elderly patients: A pilot randomized control trial

Introduction

This pilot randomized controlled trial assessed the effectiveness of a nurse–occupational therapist meeting on improving motor and social-cognitive functions, as well as motivation, in a subacute hospital setting.

Methods

Participants were randomized to a weekly multidisciplinary team meeting group (‘control’, n = 20) or a nurse–occupational therapist meeting group (‘intervention’, n = 18). Medical care plans in both groups were discussed in the weekly meeting. In addition, the details of daily life problems for the intervention patients were discussed in the nurse–occupational therapist meeting. Outcome measures included motor and social-cognitive functions assessed by the Functional Independence Measure and motivation assessed by the Vitality Index. Assessment time points were at admission and discharge.

Results

In the intervention group, additional improvements were found in the Functional Independence Measure cognitive ( p = 0.048, r = 0.32) and the Vitality Index ( p = 0.027, r = 0.36), whereas the Functional Independence Measure motor was improved in both groups ( p ≤ 0.018, r ≥ 0.52).

Conclusion

We found significant improvement in motor function in both groups and additional improvements in social-cognitive function and motivation in the intervention group. These observations suggest that collaborative practice between nurses and occupational therapists could improve functions underlying independent daily life in hospitalized elderly patients.

Trajectories and Predictors of Functional Capacity Decline in Older Adults From a Brazilian Northeastern Hospital

BACKGROUND AND PURPOSE

Older adults face increased risk of loss of functional capacity both before and during hospitalization, so identifying older adults at risk for loss in functional capacity during hospitalization would help researchers and clinicians make informed decisions. This study aims to evaluate functional changes from preadmission (baseline) until discharge of hospitalized older adults and identify predictors of loss in functional capacity.

METHODS

This is a prospective cohort study conducted at a tertiary care hospital in Natal, Brazil, and enrolled all consecutive patients aged 60 years and older between January 1, 2014, and April 30, 2015. Independent variables included personal characteristics, instrumental activities of daily living (IADL) (evaluated by the Lawton and Brody scale), cognition (evaluated by the Leganés cognitive test), depression (assessed by the Geriatric Depression Scale-15), and in-hospital mobility (evaluated by the Short Physical Performance Battery). The dependent variable functional capacity was assessed by the Katz scale. These instruments were applied at 2 different times: upon admission (within first 24 hours) and at discharge (12-24 hours before). Functional trajectories were defined as the course of functioning from preadmission until discharge using functional capacity data. A multivariate analysis with generalized estimating equation estimated the longitudinal changes in functional capacity.

RESULTS AND DISCUSSION

The final sample consisted of 1191 older adults and 53.9% were less than 70 years of age. Regarding changes in functional capacity, 52.5% of the older adults presented worse functional capacity at discharge than at baseline. Being dependent for IADL instrumental daily living activities, the presence of depressive symptoms, low levels of cognition, and in-hospital mobility were risk factors for greater loss in functional capacity during a hospitalization event.

CONCLUSION

Hospitalization events may be catastrophic for functional capacity in older adults in Brazil. Functional, cognitive, and emotional status and in-hospital mobility must be carefully assessed at hospital admission and monitored during hospitalization. Effective strategies for preventing loss in functional capacity in older people must improve in the Brazilian hospital system.

What is the impact of multimorbidity on the risk of hospitalisation in older adults? A systematic review study protocol

INTRODUCTION

The development of multiple coexisting chronic diseases (multimorbidity) is increasing globally, along with the percentage of older adults affected by it. Multimorbidity is associated with the concomitant use of multiple medications, a greater possibility of adverse effects, and increased risk of hospitalisation. Therefore, this systematic review study protocol aims to analyse the impact of multimorbidity on the occurrence of hospitalisation in older adults and assess whether this impact changes according to factors such as sex, age, institutionalisation and socioeconomic status. This study will also review the average length of hospital stay and the occurrence of hospital readmission.

METHODS AND ANALYSIS

A systematic review of the literature will be carried out using the PubMed, Embase and Scopus databases. The inclusion criteria will incorporate cross-sectional, cohort and case-control studies that analysed the association between multimorbidity (defined as the presence of ≥2 and/or ≥3 chronic conditions and complex multimorbidity) and hospitalisation (yes/no, days of hospitalisation and number of readmissions) in older adults (aged ≥60 years or >65 years). Effect measures will be quantified, including ORs, prevalence ratios, HRs and relative risk, along with their associated 95% CI. The overall aim of this study is to widen knowledge and to raise reflections about the association between multimorbidity and hospitalisation in older adults. Ultimately, its findings may contribute to improvements in public health policies resulting in cost reductions across healthcare systems.

ETHICS AND DISSEMINATION

Ethical approval is not required. The results will be disseminated via submission for publication to a peer-reviewed journal when complete.

PROSPERO REGISTRATION NUMBER

CRD42021229328.

Developing a predictive model for hospital-associated disability among older patients hospitalized for an acute illness: the HAD-FREE Score

PURPOSE

To develop a predictive model to identify hospitalized older patients at risk of functional decline.

METHODS

This retrospective cohort study recruited participants aged 65 years and over admitted to internal medicine wards of a tertiary medical center in Taiwan during May to October 2017 for developing predictive model (n = 1698) and those admitted during November to December 2017 for validation study (n = 530) of the model. Demographic data, geriatric assessments and hospital conditions (admission route and length of hospital stay) were collected for analysis.

RESULTS

Overall, of the 1698 participants (mean age 75.8 ± 7.9 years, 60.9% male) enrolled in the development study, 20.1% had functional decline. Results of multivariate logistic regression showed that older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥ 5 days were independent predictive factors for decline. A scoring system, HAD-FREE Score, constructed from the above predictive factors ranged from 0 to 18 points and ≥ 6 points was chosen as the cut-off point. The area under the receiver operating characteristic analysis was 0.748 (95% confidence interval: 0.720-0.776), the sensitivity was 65.3% and the specificity was 71.3%. Validation of the HAD-FREE Score showed moderate discriminative ability in the validation study.

CONCLUSION

A HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. This scoring system can be the basis of an automatic dynamic tracking within the electronic medical record to identify those older patients at risk of functional decline during hospitalization.

Self-Care Index and Post-Acute Care Discharge Score to Predict Discharge Destination of Adult Medical Inpatients: Protocol for a Multicenter Validation Study

BACKGROUND

Delays in patient discharge can not only lead to deterioration, especially among geriatric patients, but also incorporate unnecessary resources at the hospital level. Many of these delays and their negative impact may be preventable by early focused screening to identify patients at risk for transfer to a post-acute care facility. Early interprofessional discharge planning is crucial in order to fit the appropriate individual discharge destination. While prediction of discharge to a post-acute care facility using post-acute care discharge score, the self-care index, and a combination of both has been shown in a single-center pilot study, an external validation is still missing.

OBJECTIVE

This paper outlines the study protocol and methodology currently being used to replicate the previous pilot findings and determine whether the post-acute care discharge score, the self-care index, or the combination of both can reliably identify patients requiring transfer to post-acute care facilities.

METHODS

This study will use prospective data involving all phases of the quasi-experimental study "In-HospiTOOL" conducted at 7 Swiss hospitals in urban and rural areas. During an 18-month period, consecutive adult medical patients admitted to the hospitals through the emergency department will be included. We aim to include 6000 patients based on sample size calculation. These data will enable a prospective external validation of the prediction instruments.

RESULTS

We expect to gain more insight into the predictive capability of the above-mentioned prediction instruments. This approach will allow us to get important information about the generalizability of the three different models. The study was approved by the institutional review board on November 21, 2016, and funded in May 2020. Expected results are planned to be published in spring 2021.

CONCLUSIONS

This study will provide evidence on prognostic properties, comparative performance, reliability of scoring, and suitability of the instruments for the screening purpose in order to be able to recommend application in clinical practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21447.

Assessment of the measurement properties of the Brazilian versions of the Functional Status Score for the ICU and the Functional Independence Measure in critically ill patients in the intensive care unit

Objective

To compare the measurement properties (internal consistency, intra and interrater reliability, construct validity, and ceiling and floor effects) of the Functional Status Score for the ICU (FSS-ICU) and the Functional Independence Measure (FIM-motor domain).

Methods

In this study of measurement properties, the FSS-ICU and FIM were applied to 100 patients (72.1 ± 15.9 years; 53% male; Sequential Organ Failure Assessment = 11.0 ± 3.5 points, Simplified Acute Physiology Score 3 = 50.2 ± 16.8 points) in an intensive care unit at baseline and after 2 hours by physiotherapist 1 (test and retest) and 30 minutes after baseline by physiotherapist 2. The measurement properties evaluated were internal consistency (Cronbach's alpha), intra- and interrater reliability (intraclass correlation coefficient), agreement (standard error of measurement) and minimum detectable change at a 90% confidence level, ceiling and floor effects (frequency of maximum and minimum scores) and construct validity (Pearson's correlation).

Results

The FSS-ICU and FIM presented adequate internal consistency (Cronbach's alpha, FSS-ICU = 0.95 and FIM = 0.86), intra-and interrater reliability for overall FSS-ICU and FIM score (ICC > 0.75), agreement (minimum detectable change at a 90% confidence level: FSS-ICU and FIM = 1.0 point; standard error of measurement: FSS-ICU = 2% and FIM = 1%) and construct validity (r = 0.94; p < 0.001). However, the FSS-ICU and FIM presented ceiling effects (maximum score for 16% of patients for the FSS-ICU and 18% for the FIM).

Conclusion

The FSS-ICU and FIM present adequate measurement properties to assess functionality in critically ill patients, although they present ceiling effects.

Factors Associated With Hospitalization Before the Start of Long-Term Care Among Elderly Disabled People

The growing number of elderly people with functional limitations, cognitive impairment, and disability is an organizational challenge for the health care sector. This study investigated the factors associated with hospitalization in the period between evaluation and the start of a long-term care (LTC) program for patients on the waiting list. A population-based historical cohort study was performed using data extracted from different administrative databases. The cohort included disabled individuals 65 years and older who were evaluated for entrance into an LTC program between January 1, 2012, and December 31, 2013, in Tuscany, Italy. The sample consisted of 11,429 subjects. The characteristics positively associated with hospital admission were residence zone {urban incidence rate ratio (IRR) = 0.83 (95% confidence interval [CI] 0.74-0.94)}, number of prescribed drugs IRR = 1.01 (95% CI 1.00-1.02), a Charlson Comorbidity Index of 2 IRR = 1.44 (95% CI 1.26-1.64), and lower social conditions IRR = 0.99 (95% CI 0.98-1.00). The rate of hospitalization for patients with heart failure, chronic obstructive pulmonary disease, and dementia was higher than for patients without these diseases. Our results indicate that it may be possible to predict factors that can lead to hospitalization before the start of an LTC program.

ADL recovery trajectory after discharge and its predictors among baseline-independent older inpatients

Background

Among the previous studies about the ADL recovery and its predictors, the researches and resources used to study and protect the baseline-independent older patients from being permanently ADL-dependent was few. We aimed to describe the level of activities of daily living (ADL) at discharge and ADL change within 6 months after discharge in older patients who were ADL-independent before admission but became dependent because of acute illness, and to identify the predictors of early rehabilitation,so as to provide the basis to early intervention.

Methods

Stratified cluster sampling was used to recruit 520 hospitalised older patients who were ADL-independent from departments of internal medicine at two tertiary hospitals from August 2017 to May 2018. Demographics, clinical data, and ADL status at 1, 3, and 6 months after discharge were collected. Data were analysed using descriptive statistics, Student’s t-test, Pearson’s chi-square test,Spearman’s correlation analysis, binary logistic regression analysis, and receiver operating characteristic (ROC) curve analysis.

Results

There were 403 out of 520 patients completing the 6-month follow-up, and 229 (56.8%) regained independence at 6 months after discharge. There was an overall increasing trend in ADL with time. The recovery rate was the highest within the first month after discharge, gradually declined after 1 month, and changed less obviously from 3 to 6 months after discharge (p < 0.001). ADL score at discharge (OR = 1.034, p < 0.001), age (OR = 0.269, p = 0.001), post-discharge residence (OR = 0.390, p < 0.05), and cognition status at discharge (OR = 1.685, p < 0.05) were predictors of ADL recovery. The area under the curve of the four predictors combined was 0.763 (p < 0.001).

Conclusion

Studying ADL recovery rate and its predicting indicators of the baseline independent inpatients at different time points provide a theoretical reference for the formulation of nursing plans and allocation of care resources.

Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation

OBJECTIVES

Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed.

DESIGN

Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA.

SETTING

Tertiary-care hospital, France.

SUBJECTS AND MEASUREMENTS

The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients.

RESULTS

Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs.

CONCLUSIONS

As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.

SPMSQ for risk stratification of older patients in the emergency department : An exploratory prospective cohort study

Background

Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated.

Objective

To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality).

Method

This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment.

Results

The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact.

Conclusion

For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.

Electronic supplementary material

The online version of this article (10.1007/s00391-019-01626-z) contains supplementary material, which is available to authorized users.

Prescribed Exercise With Compression vs Compression Alone in Treating Patients With Venous Leg Ulcers: A Systematic Review and Meta-analysis

Importance

Exercise is recommended as an adjuvant treatment for venous leg ulceration (VLU) to improve calf muscle pump function. However, the association of exercise with VLU healing has not been properly aggregated, and the effectiveness of different exercise interventions has not been characterized.

Objective

To summarize the association of different exercise interventions with VLU healing when used as an adjuvant to any form of compression.

Data Sources

The Cochrane Controlled Trials Register, MEDLINE, Embase, CINAHL, PsycInfo, and SCOPUS databases were searched through October 9, 2017.

Study Selection

Randomized clinical trials (RCTs) of any exercise compared with no exercise in participants with VLU were included, where compression was used as standard therapy and a healing outcome was reported. Independent title screening and full text review by 2 authors (A.J., J.S.) with appeal to a third author (J.P.) if disagreement was unresolved. Of the 519 articles screened, a total of 6 (1.2%) studies met the inclusion criteria for systematic review, including 5 for meta-analysis.

Data Extraction and Synthesis

Independent quality assessment for Cochrane risk of bias and data extraction by 2 authors with appeal to third author if disagreement unresolved (PRISMA). Data pooled using fixed effects model.

Main Outcomes and Measures

The a priori primary outcome was any healing outcome (proportion healed, time to healing, or change in ulcer area). Secondary outcomes (adverse events, costs, and health-related quality of life) were only collected if a primary outcome was reported.

Results

Six RCTs were identified and 5 (190 participants) met inclusion criteria for meta-analysis. The exercise interventions were progressive resistance exercise alone (2 RCTs, 53 participants) or combined with prescribed physical activity (2 RCTs, 102 participants), walking only (1 RCT, 35 participants), or ankle exercises (1 RCT, 40 participants). Overall, exercise was associated with increased VLU healing at 12 weeks although the effect was imprecise (additional 14 cases healed per 100 patients; 95% CI, 1-27 cases per 100; P = .04). The combination of progressive resistance exercise plus prescribed physical activity appeared to be most effective, again with imprecision (additional 27 cases healed per 100 patients; 95% CI, 9-45 cases per 100; P = .004).

Conclusions and Relevance

The evidence base may now be sufficiently suggestive for clinicians to consider recommending simple progressive resistance and aerobic activity to suitable patients with VLU while further research is produced.

A pilot study to investigate the feasibility of the modified Blaylock Tool for Occupational Therapy Referral (MBTOTR) for use by nurses in acute care

PURPOSE

Patients in acute care settings may have limitations in their functional capacity associated with multiple morbidities. Occupational therapy can address factors affecting functional decline, and early and accurate identification of patients requiring occupational therapy referral can facilitate safe discharge. This study aimed to investigate the feasibility of the Modified Blaylock Tool for Occupational Therapy Referral to identify the characteristics of patients who would potentially require occupational therapy referral, for use by acute care nurses.

METHODS

A cross-sectional study was conducted using mixed methods. The Modified Blaylock Tool for Occupational Therapy Referral was completed for 305 patients by six acute care nurses across three clinical areas in an acute hospital setting. Data were analyzed using descriptive and non-parametric statistics. Semi-structured interviews were then conducted with these six nurses to understand their perspectives of their use of the Modified Blaylock Tool for Occupational Therapy Referral.

RESULTS

Nearly half (45%) of the assessed patients had Modified Blaylock Tool for Occupational Therapy Referral scores recommending occupational therapy referral. Items associated with risk of functional decline were mobility, memory and recent hospital admissions. Barriers to referral included resource limitations, lack of visibility, poor understanding of occupational therapy and lack of holistic assessment of patients.

CONCLUSION

The Modified Blaylock Tool for Occupational Therapy Referral could be used by nurses to identify acute care patients at risk of functional decline. Future research should include larger and longitudinal studies to validate the Modified Blaylock Tool for Occupational Therapy Referral further. Implications for rehabilitation The Modified Blaylock Tool for Occupational Therapy Referral could be used by nurses to identify acute care patients at risk of functional decline. This allows the early and accurate identification of patients requiring occupational therapy referral to facilitate safe discharge from acute care.

[Functional decline risk in elderly patients not institutionalized]

OBJECTIVE

To assess the risk of functional decline (DF) by using several prediction scales.

MATERIAL AND METHODS

A multicentre, observational, cross-sectional study was conducted on a population of 70 years or more in the health area of ??Toledo. Institutionalised, terminal ill, and patients dependent for three or more basic activities of daily life, were excluded. The sample (480 patients) was calculated for an estimated DF prevalence of 15%, accuracy 2%, confidence level 95%, and 10% of estimated losses. Stratified sampling; first by conglomerates (Health Centres) and then systematic sampling (1/15) by list of patients ordered by age. Response rate: 98%.

VARIABLES

Sociodemographic, morbidity, questionnaires to assess the functional capacity for basic activities (Katz index), and tools (Lawton-Brody index) of daily life and risk prediction rules of DF (SHERPA, TRST, ISAR-PC and Inouye). Approved by the Clinical Research Ethics Committee of Toledo.

RESULTS

The mean age was 77.94 (SD: 6.27), with 54.4% women. Mean number of illnesses: 4.38 (SD: 2.17) and drugs: 5.57 (SD: 3.35). Risk of DF according to the prediction rules: SHERPA: 32.7% (95% CI: 28.52-36.88) (slight risk: 17.2% [95% CI: 13.83-20.57]; moderate: 9.7% [95% CI: 7.06-12.34] and high: 5.8% [95% CI: 3.72-7.88]); TRST: 42% (95% CI: 37.6-46.4); ISAR-PC: 75.4% (95% CI: 71.14-78.86); Inouye: 49.3% (95% CI: 44.84-53.76) (mean risk: 44.5% [95% CI: 40.07-48.93], and high: risk 4.8% [95% CI: 2.89-6.71]).

CONCLUSIONS

A significant percentage of patients are at risk of DF, but there is a wide variation between the different rules. In general, the risk is lower than that found in other studies, and it is necessary to validate new rules adapted to our environment.

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.

A Proposal for the Retrospective Identification and Categorization of Older People With Functional Impairments in Scientific Studies-Recommendations of the Medication and Quality of Life in Frail Older Persons (MedQoL) Research Group

When treating older adults, a main factor to consider is physical frailty. Because specific assessments in clinical trials are frequently lacking, critical appraisal of treatment evidence with respect to functional status is challenging. Our aim was to identify and categorize assessments for functional status given in clinical trials in older adults to allow for a retrospective characterization and indirect comparison of treatment evidence from these cohorts. We conducted 4 separate systematic reviews of randomized and nonrandomized controlled clinical trials in older people with hypertension, diabetes, depression, and dementia. All assessments identified that reflected functional status were analyzed. Assessments were categorized across 4 different functional status levels. These levels span from functionally not impaired, slightly impaired, significantly impaired, to severely impaired/disabled. If available from the literature, cut-offs for these 4 functioning levels were extracted. If not, or if the existing cut-offs did not match the predefined functional levels, cut-off points were defined by an expert group composed of geriatricians, pharmacists, pharmacologists, neurologists, psychiatrists, and epidemiologists using a patient-centered approach. We identified 51 instruments that included measures of functional status. Although some of the assessments had clearly defined cut-offs across our predefined categories, many others did not. In most cases, no cut-offs existed for slightly impaired or severely impaired older adults. Missing cut-offs or values to adjust were determined by the expert group and are presented as described. The functional status assessments that were identified and operationalized across 4 functional levels could now be used for a retrospective characterization of functional status in randomized controlled trials and observational studies. Allocated categories only serve as approximations and should be validated head-to-head in future studies. Moreover, as general standard, upcoming studies involving older adults should include and explicitly report functional impairment as a baseline characteristic of all participants enrolled.

Hospital Discharge Decisions Concerning Older Patients: Understanding the Underlying Process

ABSTRACTWe aimed to understand clinical decision-making processes that influence the orientation of older patients after hospital discharge. We compared discharge decisions (i.e., discharge home, or nursing home stay) of the hospital team with those of an expert panel. Both panel and hospital team made their decisions independently. The blind study included 102 patients (mean age: 83.13 ± 6.74). There is a statistically significant difference between expert and hospital team decisions (p &lt; .001; kappa coefficient: 0.468). Panel decisions were more closely associated with isolation (p = .018), reliable caregivers (p = .004), social problems (p = .001), and behavioural symptoms perceived as aggressive (p = .001). Both decision processes considered refusal of care (p = 0,025 and 0.016 respectively) and social problems (p = .001 and &lt; 0.001 respectively). Discharge planning models differ depending on the country, team and patient's condition. Our study suggests more precise evaluation of patients' needs.

Factors associated with 1-year mortality after discharge for acute stroke: what matters?

OBJECTIVE

To evaluate factors associated with 1-year mortality after discharge for acute stroke.

METHODS

In this retrospective cohort study, we studied 305 patients with ischemic stroke or intracerebral hemorrhage discharged in 2010/2011. We linked Get With The Guidelines®-Stroke clinical data with New York State administrative data and used multivariate regression models to examine variables related to 1-year all-cause mortality poststroke.

RESULTS

The mean age was 68.6 ± 14.8 years and 51.1% were women. A total of 146 (47.9%) were discharged directly home, 96 (31.5%) to inpatient rehabilitation facilities (IRFs), and 63 (20.7%) to skilled nursing facilities (SNFs). Overall, 24 (7.9%) patients died within 1-year post-discharge. Older age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), higher National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.10, 95% CI 1.03-1.17), and discharge destination (IRF vs. home, OR 0.10, 95% CI 0.01-0.94; and SNF vs. home, OR 2.22, 95% CI 0.71-6.95) were factors associated with 1-year all-cause mortality. When ambulation status at discharge was added to the model, ambulation with assistance and non-ambulation were significantly associated with mortality (ambulatory with assistance vs. ambulatory, OR 9.42, 95% CI 1.87-47.61; nonambulatory vs. ambulatory, OR 12.65, 95% CI 1.89-84.89).

CONCLUSIONS

While age and NIHSS on admission are important predictors of long-term outcomes, factors at discharge - ambulation status at discharge and discharge destination - are associated with 1-year mortality post-discharge for acute stroke and therefore could represent therapeutic targets to improve long-term survival in future studies.

Clinical utility of scores on the Blaylock Risk Assessment Screen (BRASS): An analysis of administrative data

PURPOSE

Project was undertaken to examine the utility of the Blaylock Risk Assessment Screen (BRASS) in identifying patients who may experience discharge complications as indicated by longer hospital stays or readmission within 30-days of a discharge to home.

BACKGROUND

Before measures can be put in place to facilitate discharge planning and to prevent unplanned readmission by recently discharged patients, those at risk of such events must be identified.

METHODS

Project involved an analysis of 13-months of administrative data from one tertiary care hospital. Utility of the BRASS was examined in terms of its sensitivity and specificity as well as its positive and negative predictive values.

RESULTS

Majority (83%) of hospital discharges were to home. Approximately 7% of patients experienced at least one readmission within 30-days of being discharged to home. Using scores of 10 or higher as an indicator of risk, BRASS exhibited a high degree of specificity suggesting it is useful for 'ruling in' those who have the outcomes-of-interest. However low sensitivity indicates many who experienced the outcomes were incorrectly classified by the BRASS as low risk. The low positive predictive value for 30-day readmission also suggests many who were classified by the BRASS as being 'at risk' were not readmitted.

CONCLUSION

The observed rate of 30-day readmission is likely conservative as the analysis involved data from only one acute care facility. One explanation for the low positive predictive value for 30-day readmission is that completion of the BRASS on admission enabled the implementation of preventive measures.

Development and validation of a prediction model for functional decline in older medical inpatients

OBJECTIVE

To prevent functional decline in older inpatients, identification of high-risk patients is crucial. The aim of this study was to develop and validate a prediction model to assess the risk of functional decline in older medical inpatients.

METHODS

In this retrospective cohort study, patients ≥65 years admitted acutely to medical wards were included. The healthcare database of 246 acute care hospitals (n = 229,913) was used for derivation, and two acute care hospitals (n = 1767 and 5443, respectively) were used for validation. Data were collected using a national administrative claims and discharge database. Functional decline was defined as a decline of the Katz score at discharge compared with on admission.

RESULTS

About 6% of patients in the derivation cohort and 9% and 2% in each validation cohort developed functional decline. A model with 7 items, age, body mass index, living in a nursing home, ambulance use, need for assistance in walking, dementia, and bedsore, was developed. On internal validation, it demonstrated a c-statistic of 0.77 (95% confidence interval (CI) = 0.767-0.771) and good fit on the calibration plot. On external validation, the c-statistics were 0.79 (95% CI = 0.77-0.81) and 0.75 (95% CI = 0.73-0.77) for each cohort, respectively. Calibration plots showed good fit in one cohort and overestimation in the other one.

CONCLUSIONS

A prediction model for functional decline in older medical inpatients was derived and validated. It is expected that use of the model would lead to early identification of high-risk patients and introducing early intervention.

BRASS score and complex discharge: a pilot study

Aims:

A highly functional continuity of patient care, which is linked to the reduction of the risk of long-term hospitalization, above all for ‘at-risk’ patients. Research into an objective, reliable instrument for redirecting individual results to organizational aims to extend the entire country, is a fundamental step to move from a reactive assistance approach to a pro-active one.

Methods:

An observational and descriptive retrospective study was carried out July - November 2014 in two Italian state hospitals, completing the BRASS Index within 48/72 hours of admission.

Results:

The study group consisted of 122 inpatients. A correlation presented itself, albeit low (ρ=0.05191), between age and the number of ‘revolving door’ admissions; a medium correlation (ρ=0.485131) between age and risk band (according to BRASS).

Conclusions:

The BRASS Index is straightforward and swift, and can prove a valuable tool in directing nurses’ attention to those patients most at risk of prolonged hospitalization. (www.actabiomedica.it)

[Functional impairment associated with cognitive impairment in hospitalised elderly]

INTRODUCTION

The aim of this study was to analyse the effect of cognitive impairment on functional decline in hospitalised patients aged ≥60 years.

METHODS

Measurements at admission included demographic data, Charlson's comorbidity index, and cognitive impairment (according to education level). Data were also collected on hospital length of stay, depression, and delirium developed during hospitalisation. The outcome, Barthel Index (BI), was measured at admission, discharge, and 1-month post-discharge. Patients with BI≤75 at admission (n=54) or with a missing BI value were excluded (n=1). Multivariate logistic regression analyses were conducted to explore predictive factors with functional decline (BI≤75) from admission to discharge, and 1-month later.

RESULTS

Of the 133 patients included, 24.8% and 19.6% had a BI≤75 at discharge and at 1-month, respectively. Compared with men, women had more than double risk for functional decline at discharge and 1-month (P<.05). Compared with those without delirium and without cognitive impairment, those with delirium and cognitive impairment had an increased risk for functional decline (BI≤75) at discharge (OR 5.15, 95% CI; 1.94-13.67), and at 1-month (OR 6.26, 95% CI; 2.30-17.03). Similarly, those with comorbidity (≥2) had increased functional decline at discharge (OR 2.36, 95% CI; 1.14-4.87), and at 1-month after discharge (OR 2.71, 95% CI; 1.25-5.89).

CONCLUSION

Delirium during hospitalisation, together with cognitive impairment on admission, was a strong predictor of functional decline.

Caregivers' misperception of the severity of hip fractures

PURPOSE

The aim of our study was to evaluate how the caregiver of a hip fracture patient perceives the patient's health status and autonomy in the period immediately preceding the acute event and whether these judgments are actually in line with the prognosis predicted by the medical team caring for the patient in the rehabilitation structure.

PATIENTS AND METHODS

We enrolled 147 patients of both sexes, aged ≥65 years, who were referred to our center following surgical treatment of hip fractures of various nature. At the beginning of the rehabilitation program, each patient's caregiver was asked to complete the Blaylock Risk Assessment Screening Score (BRASS) questionnaire. The same questionnaire was compiled contemporaneously by the doctor taking care of the patient.

RESULTS

Analysis of the data shows that the caregivers tend to assign lower scores than the doctor, with a mean difference in agreement with the Bland-Altman plot of -2.43, 95% CI=-2.93 to -1.93, t-test P<0.001. Furthermore, differences in objectivity emerge in the evaluation of the clinical problems of the patient in a borderline clinical condition.

CONCLUSION

This study revealed that caregivers systematically misperceive the clinical situation of hip fracture patients prior to the acute event. Altered perception of such an important factor can lead to a general lack of satisfaction with the outcome achieved by the patient at the end of the rehabilitation process. We therefore believe that an adequate, effective communication between the people making up the health care team and the patient's social and family network is the foundation of the rehabilitation process. It is precisely on this foundation that the individual's care and assistance need to be assembled.

Measurement of function in older adults transitioning from hospital to home: an integrative review

Older adults often experience decline in functional status during the transition from hospital to home. In order to determine the effectiveness of interventions to prevent functional decline, researchers must have instruments that are reliable and valid for use with older adults. The purpose of this integrative review is to: (1) summarize the research uses and methods of administering functional status instruments when investigating older adults transitioning from hospital to home, (2) examine the development and existing psychometric testing of the instruments, and (3) discuss gaps and implications for future research. The authors conducted an integrative review of forty research studies that assessed functional status in older adults transitioning from hospital to home. This review reveals important gaps in the functional status instruments' psychometric testing, including limited testing to support their validity and reliability when administered by self-report and limited evidence supporting their ability to detect change over time.

Report by the Spanish Foundation of the Brain on the social impact of Alzheimer disease and other types of dementia

INTRODUCTION

Knowledge of the socioeconomic impact of dementia-related disorders is essential for appropriate management of healthcare resources and for raising social awareness.

METHODS

We performed a literature review of the published evidence on the epidemiology, morbidity, mortality, associated disability and dependence, and economic impact of dementia and Alzheimer disease (AD) in Spain.

CONCLUSIONS

Most population studies of patients older than 65 report prevalence rates ranging from 4% to 9%. Prevalence of dementia and AD is higher in women for nearly every age group. AD is the most common cause of dementia (50%-70% of all cases). Dementia is associated with increased morbidity, mortality, disability, and dependence, and results in a considerable decrease in quality of life and survival. Around 80% of all patients with dementia are cared for by their families, which cover a mean of 87% of the total economic cost, resulting in considerable economic and health burden on caregivers and loss of quality of life. The economic impact of dementia is huge and difficult to evaluate due to the combination of direct and indirect costs. More comprehensive programmes should be developed and resources dedicated to research, prevention, early diagnosis, multidimensional treatment, and multidisciplinary management of these patients in order to reduce the health, social, and economic burden of dementia.

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.

Recognising older frail patients near the end of life: What next?

Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor -pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.

Can we predict functional decline in hospitalized older people admitted through the emergency department? Reanalysis of a predictive tool ten years after its conception

Background

In the Emergency Department (ED), early and rapid identification of older people at risk of adverse outcomes, who could best benefit from complex geriatric intervention, would avoid wasting time, especially in terms of prevention of adverse outcomes, and ensure optimal orientation of vulnerable patients. We wanted to test the predictive ability of a screening tool assessing risk of functional decline (FD), named SHERPA, 10 years after its conception, and to assess the added value of other clinical or biological factors associated with FD.

Methods

A prospective cohort study of older patients (n = 305, ≥ 75 years) admitted through the emergency department, for at least 48 h in non-geriatric wards (mean age 82.5 ± 4.9, 55% women). SHERPA variables (i.e. age, pre-admission instrumental Activity of Daily Living (ADL) status, falls within a year, self-rated health and 21-point MMSE) were collected within 48 h of admission, along with socio-demographic, medical and biological data. Functional status was followed at 3 months by phone. FD was defined as a decrease at 3 months of at least one point in the pre-admission basic ADL score. Predictive ability of SHERPA was assessed using c-statistic, predictive values and likelihood ratios. Measures of discrimination improvement were Net Reclassification Improvement and Integrated Discrimination Improvement.

Results

One hundred and five patients (34%) developed 3-month FD. Predictive ability of SHERPA decreased dramatically over 10 years (c = 0.73 vs. 0.64). Only two of its constitutive variables, i.e. falls and instrumental ADL, were significant in logistic regression analysis for functional decline, while 21-point MMSE was kept in the model for clinical relevance. Demographic, comorbidity or laboratory data available upon admission did not improve the SHERPA predictive yield.

Conclusions

Prediction of FD with SHERPA is difficult, but predictive factors, i.e. falls, pre-existing functional limitation and cognitive impairment, stay consistent across time and with literature. As accuracy of SHERPA and others existing screening tools for FD is moderate, using these predictors as flags instead of using composite scales can be a way to screen for high-risk patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0498-0) contains supplementary material, which is available to authorized users.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Mobility decline in patients hospitalized in an intensive care unit

Objective

To evaluate the variation in mobility during hospitalization in an intensive care unit and its association with hospital mortality.

Methods

This prospective study was conducted in an intensive care unit. The inclusion criteria included patients admitted with an independence score of ≥ 4 for both bed-chair transfer and locomotion, with the score based on the Functional Independence Measure. Patients with cardiac arrest and/or those who died during hospitalization were excluded. To measure the loss of mobility, the value obtained at discharge was calculated and subtracted from the value obtained on admission, which was then divided by the admission score and recorded as a percentage.

Results

The comparison of these two variables indicated that the loss of mobility during hospitalization was 14.3% (p < 0.001). Loss of mobility was greater in patients hospitalized for more than 48 hours in the intensive care unit (p < 0.02) and in patients who used vasopressor drugs (p = 0.041). However, the comparison between subjects aged 60 years or older and those younger than 60 years indicated no significant differences in the loss of mobility (p = 0.332), reason for hospitalization (p = 0.265), SAPS 3 score (p = 0.224), use of mechanical ventilation (p = 0.117), or hospital mortality (p = 0.063).

Conclusion

There was loss of mobility during hospitalization in the intensive care unit. This loss was greater in patients who were hospitalized for more than 48 hours and in those who used vasopressors; however, the causal and prognostic factors associated with this decline need to be elucidated.

The Impact of Introducing Restorative Care on Client Outcomes and Health System Effectiveness in an Integrated Health Authority

To support the transition from hospital to community for adults 65 years and older, a restorative care unit was introduced within a regional health authority in Newfoundland and Labrador. A pre-post study design was used to evaluate the impacts of restorative care. This article describes the impact of restorative care on client outcomes and health system utilization. All patients discharged from restorative care during the first year of operation were included in the study. A total of 54 clients were discharged during the first year, with 70% being discharged to a community setting. Consistent with previous studies, statistically significant improvements were noted in function as measured using the modified Barthel Index of Activities of Daily Living and fear of falling as measured using the Fall Efficacy Scale–International. The number of alternate level of care patients in acute care and their length of acute care stay did not decrease during our study period. However, an interesting change was observed: The number of applications for long-term care initiated in acute care decreased. Further examination of the long-term outcomes of discharged patients and of the factors influencing health system outcomes is suggested.

Functional status decline in older patients with breast and colorectal cancer after cancer treatment: A prospective cohort study

OBJECTIVES

The aim of the present study was to disentangle the impact of age and that of cancer diagnosis and treatment on functional status (FS) decline in older patients with cancer.

MATERIALS AND METHODS

Patients with breast and colorectal cancer aged 50-69years and aged ≥70years who had undergone surgery, and older patients without cancer aged ≥70years were included. FS was assessed at baseline and after 12months follow-up, using the Katz index for activities of daily living (ADL) and the Lawton scale for instrumental activities of daily living (IADL). FS decline was defined as ≥1 point decrease on the ADL or IADL scale from baseline to 12months follow-up.

RESULTS

In total, 179 older patients with cancer (≥ 70years), 341 younger patients with cancer (50-69years) and 317 older patients without cancer (≥ 70years) were included. FS decline was found in 43.6%, 24.6% and 28.1% of the groups, respectively. FS decline was significantly worse in older compared to younger patients with cancer receiving no chemotherapy (44.5% versus 17.6%, p<0.001), but not for those who did receive chemotherapy (39.4% versus 30.8%, p=0.33). Among the patients with cancer, FS decline was significantly associated with older age (OR 2.63), female sex (OR 3.72), colorectal cancer (OR 2.81), polypharmacy (OR 2.10) and, inversely, with baseline ADL dependency (OR 0.44).

CONCLUSION

Cancer treatment, and older age are important predictors of FS decline. The relation of baseline ADL dependency and chemotherapy with FS decline suggest that the fittest of the older patients with cancer were selected for chemotherapy.