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

Factors involved in the development of hospital-acquired conditions in older patients in acute care settings: a scoping review

BACKGROUND

Older patients hospitalized in acute care settings are at significant risk of presenting hospital-acquired conditions. Healthcare professionals should consider many factors involved in the development of such conditions, including factors related to the patients, as well as those related to the processes of care and the structure of hospitals. The aim of this study was to describe and identify the factors involved in the development of hospital-acquired conditions in older patients in acute care settings.

METHODS

A scoping review was performed based on a structured search in eight databases in September 2022. Data were extracted with an extraction tool and classified into categories. Mapping and a narrative summary were used to synthetize data.

RESULTS

A total of 237 articles were included in the scoping review. Functional decline and delirium were the most frequent hospital-acquired conditions studied. Among all categories, factors related to the patients provided most of the data, whereas factors related to the processes of care and the structure of hospitals were less frequently explored. In most articles, one or two categories of factors were retrieved; fewer articles examined factors among three categories. Personal factors, medications, and the human and work environment were the most frequent subcategories of factors retrieved, whereas social factors, hydration and nutrition, and organizational factors were less common.

CONCLUSIONS

The development of hospital-acquired conditions in older patients in acute care settings involves many factors related to the patients, as well as to the processes of care and the structure of hospitals. Prevention of hospital-acquired conditions must involve to consider the complexities of older patients and of acute care hospitals. Not considering all categories of factors might affect the implementation of new practices of care and interventions.

Risk factors for hospitalization-associated disability among older patients: A systematic review and meta-analysis

BACKGROUND

The outcomes of older patients are significantly limited by hospitalization-associated disability (HAD), and there are currently few available management options for HAD. This review aimed to identify and quantify the risk factors for HAD, to provide reliable evidence for developing a HAD prevention program centered on risk factor management among older patients.

METHODS

The MEDLINE, Embase, PsycINFO, CINAHL, and PubMed databases were searched in March 2024 to identify cross-sectional and cohort studies that used multivariable analysis to examine risk factors for HAD among older patients.

RESULTS

We screened 883 studies, 21 of which met our inclusion criteria. Our findings revealed a substantial association between various risk factors and HAD among older patients. Specifically, advanced age, female sex, Caucasian ethnicity, comorbidity burden, better activities of daily living at admission, dementia diagnosis, and longer lengths of stay were significant risk factors for HAD. Furthermore, frailty, poor physical function, immobility, and delirium were identified as confirmed risk factors for HAD among older patients.

CONCLUSIONS

This review provided a comprehensive synthesis of available evidence on risk factors for HAD among older patients, serving as a valuable guide for the development of HAD prevention strategies both prior to and during hospitalization.

Home-based Rehabilitation After Inpatient Rehabilitation: Utilization Rate and Characteristics of Referred Patients

OBJECTIVE

To determine the utilization rate of a home-based rehabilitation program after an inpatient rehabilitation stay, and to investigate the profile of users.

DESIGN

Observational study.

SETTING

Inpatient rehabilitation facility in a tertiary hospital.

PARTICIPANTS

Older patients (N=1913) discharged home between June 2018 and May 2021, after an inpatient rehabilitation stay.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge to home-based rehabilitation.

RESULTS

Over the study period, 296 (15.5%) patients were discharged to home-based rehabilitation. Compared with the others, home-based rehabilitation patients were more frequently women (69.6% vs 61.5%; P=.008), and admitted after orthopedic surgery (elective or for fracture) (30.1% vs 16.1%; P<.001). They had worse functional performance at admission (mean Functional Independence Measure self-care score: 27.8±7.3 vs 30.8±6.7; P<.001), but greater gain in self-care during their inpatient stay (5.0±4.8 vs 4.4±4.7; P=.038). In multivariable analysis, being a woman (adjusted odds ratio [adjOR], 1.36; 95% confidence interval [CI], 1.01-1.82; P=.040), being admitted after orthopedic surgery (adjOR, 2.32; 95% CI, 1.64-3.27; P<.001), being admitted for gait disorders or falls (adjOR, 1.38; 95% CI, 1.01-1.88; P=.039), and showing greater gain in mobility during the inpatient stay (adjOR, 1.12; 95% CI, 1.07-1.17; P<.001) remained associated with discharge to home-based rehabilitation. In contrast, higher mobility at discharge decreased the odds of discharge to home-based rehabilitation (adjOR, 0.87; 95% CI, 0.83-0.91; P<.001).

CONCLUSIONS

One in 6 patients benefited from home-based rehabilitation after their inpatient stay. Although these patients had poorer functional performance at admission and discharge, they showed greater mobility improvement during their inpatient stay, suggesting that their good recovery potential was a key determinant of their orientation toward home-based rehabilitation.

Theory-driven assessment of intentions and behaviours related to mobility of older inpatients: a survey of patients and healthcare professionals

BACKGROUND

Low mobility of patients during hospitalisation is associated with adverse outcomes. To successfully change behaviours related to mobility of older hospitalised patients, we need to better understand the mechanisms underlying patient and healthcare professional behaviours. In this study, we thus assessed patient- and healthcare professional-reported intentions and behaviours related to mobility of older patients hospitalised on an acute medical ward, based on a theoretical framework - the Health Action Process Approach (HAPA) model - and on additional barriers and facilitators to mobility.

METHODS

We conducted a cross-sectional survey in April 2022 among patients aged ≥60 years recently hospitalised on an an acute medical ward of one of three hospitals of different language/cultural regions of Switzerland, and healthcare professionals (physicians, nurses/nursing assistants, physiotherapists) working on those wards. The survey assessed the HAPA model and additional barriers and facilitators to patient mobility at hospital, as previously identified in the literature. The target behaviour studied was "to move as much as possible during hospitalisation" for patients and "to ensure my patients move as much as possible during hospitalisation" for healthcare professionals. We conducted hierarchical linear regressions to determine factors associated with the self-reported intention to perform the behaviour and with the self-reported behaviour itself.

RESULTS

A total of 142 healthcare professionals (61 physicians, 59 nurses, 22 physiotherapists) and 200 patients (mean age 74 years) completed the survey. Patients with higher intention to move as much as possible during hospitalisation scored significantly higher on factual knowledge, outcome expectancies and risk perception. Healthcare professionals with higher intention to ensure that their patients move as much as possible during hospitalisation scored higher on action knowledge, outcome expectancies and risk perception. The more the patients reported that they moved as much as possible during hospitalisation, the higher their action knowledge and action control. The more healthcare professionals reported that they ensure that patients move as much as possible during hospitalisation, the higher they scored on factual knowledge, role perception, planning and action control.

CONCLUSIONS

factual and action knowledge, self-efficacy, outcome expectancies, risk perception, planning and action control were identified as important drivers of patient- and healthcare professional-reported intentions and behaviours related to inpatient mobility. These parameters can be addressed through behaviour-change interventions and should be considered in future interventions to successfully implement practice changes, with the goal of improving mobility of older patients during hospitalisation, and thus the outcomes of this particularly vulnerable population.

Relationship between average daily rehabilitation time and decline in instrumental activity of daily living among older patients with heart failure: A preliminary analysis of a multicenter cohort study, SURUGA-CARE

Background

Limitation of instrumental activity of daily living (IADL) is independently associated with an adverse prognosis in older heart failure (HF) patients.

Aims

This multicenter study aims to examine the relationship between average daily rehabilitation time (ADRT) and risk of IADL decline during acute hospitalization in older patients with HF.

Methods

Four hundred eleven older patients who were hospitalized due to acute HF and underwent rehabilitation were divided into three groups based on the tertile of the ADRT: short, intermediate, and long groups. IADL was assessed by the National Center for Geriatrics and Gerontology Activities of Daily Living (NCGG-ADL) scale. Change in NCGG-ADL (Δ NCGG-ADL) was calculated by subtracting the pre-hospitalization score from the at-discharge score and IADL decline was defined as Δ NCGG-ADL < = −1 point. Logistic regression analysis was carried out examining the association between ADRT and occurrence of IADL decline.

Results

The ADRT was 23.9, 32.0, and 38.6 minutes in short, intermediate, and long group, respectively. The proportion of patients with IADL decline during hospitalization was 21% among all subjects and short group had the highest proportion of IADL decline (33%) and long group had the lowest proportion (14%). The long group had significantly lower odds of IADL decline compared with the short group (OR:0.475, 95% CI:0.231–0.975, P = 0.042). Among the items of NCGG-ADL scale, significant decreases in the “go out by oneself”, “travel using a bus or train”, “shop for necessities”, “vacuum”, and “manage medication” were observed at discharge compared to pre-hospitalization in the short group (p<0.01, p<0.01, p<0.01, p<0.05, and p<0.05).

Conclusions

The present study demonstrated that short of ADRT may be associated with the risk of IADL decline during hospitalization in older patients with HF.

Hospitalized older adult: predictors of functional decline

OBJECTIVE

to identify the predictors of functional decline in hospitalized individuals aged 70 or over, between: baseline and discharge; discharge and follow-up, and baseline and three-month follow-up.

METHOD

a prospective cohort study conducted in internal medicine services. A questionnaire was applied (clinical and demographic variables, and predictors of functional decline) at three moments. The predictors were determined using the binary logistic regression model.

RESULTS

the sample included 101 patients, 53.3% female, mean age of 82.47 ± 6.57 years old. The predictors that most contributed to decline in hospitalization were the following: previous hospitalization (OR=1.8), access to social support (OR=4.86), cognitive deficit (OR=6.35), mechanical restraint (OR=7.82), and not having a partner (OR=4.34). Age (OR=1.18) and medical diagnosis (OR=0.10) were the predictors between discharge and follow-up. Being older, delirium during hospitalization (OR=5.92), and presenting risk of functional decline (OR=5.53) were predictors of decline between the baseline and follow-up.

CONCLUSION

the most relevant predictors were age, previous hospitalization, cognitive deficit, restraint, social support, not having a partner, and delirium. Carrying out interventions aimed at minimizing the impact of these predictors can be an important contribution in the prevention of functional decline.

Effects of a nursing care program focused on basic self-care in older acute medical in-patients: a randomized controlled trial

Background

Acute illness and hospitalization are often associated with decreased independence in basic activities of daily living. The aim of this study was to test the hypothesis that a nursing care program focused on basic self-care (N_BSC) improves functional outcomes in older patients admitted to an acute medical unit.

Methods

This was a 2-group randomized controlled trial with repeated measures: 182 older patients admitted to an acute medical unit were randomly allocated to the usual care group (n = 91) and intervention group (n = 91). The intervention consisted of nursing care centered on basic self-care that includes promotion of daily walking and all daytime meals seated, out of bed. The main outcome was changes in the number of independent basic activities of daily living (BADL) from 2 weeks before admission (baseline) to discharge.

Results

There was significant effect of the N_BSC on the outcomes. Changes from baseline to discharge in the number of independent BADL differ significantly between the intervention and usual care group. Intervention group patients were discharged with a superior functional status than usual care group. On discharge they were able to perform independently 2.93 BADL, whereas usual care patients performed independently 1.90 BADL (P < .001).

Conclusions

N_BSC for hospitalized older adults was feasible and program participants were discharged with better functional status than a clinically similar comparison group. N_BSC could be readily adapted for use in other hospitals and warrants further evaluation as a potential new tool for improving outcomes for hospitalized older patients.

Functional trajectories of older acute medical inpatients

OBJECTIVES

To describe the changes in basic activities of daily living (BADL) function before and during hospital admission in older patients admitted to an acute medical unit and to assess the effect of age on loss of BADL function.

METHODS

Prospective observational study. The study included 91 patients aged 65 and older consecutively admitted to an acute medical unit of an urban public teaching hospital in Portugal, between May and September 2017. Functional status was measured at three times: at hospital admission; at about 2 weeks before hospital admission (baseline); an on the discharge day. The functional condition was evaluated using the Katz index. Differences in scores for BADL between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline.

RESULTS

Pre-admission, in-hospital and overall functional decline occurred in 78.0%, 4.4% and 63.7% of the participants, respectively. In contrast, in-hospital functional improvement occurred in a minority of the patients (14.3%). Hospitalized older people are discharged with BADL function that is worse than their baseline function. The oldest patients are at high risk of poorer functional outcomes because they are less likely to recover BADL function lost before admission.

CONCLUSION

These results emphasize the overriding need for implementing in-hospital processes to prevent functional decline and enhance functional recovery. This study also highlights the need for nurses to closely monitor the functional status of hospitalized older people, particularly in oldest-old patients.

Effects of a nursing care program on functional outcomes in older acute medical in-patients: protocol for a randomized controlled trial

Background:

Hospitalization often leads to long periods of bed rest and inactivity which is associated with an increase in length of hospital stay, loss of capacity for basic self-care and discharge into a nursing home.

Objective:

This trial aims to verify if a nursing care program centered on basic self-care and predefined physical activity, improves functional outcomes in older hospitalized patients.

Methods:

This is a 2-group randomized controlled trial with repeated measures: 182 older acute medical patients will be blindly randomly allocated to the control group (n = 91) or intervention group (n = 91). The intervention will consist of nursing care intervention centered on basic self-care that includes a twice daily walking training, plus privileging pre-established trips to the toilet by walking and all daytime meals seated, off the bed. The main outcome was changes in the number of independent activities of daily living from 2 weeks before admission (baseline) to discharge. Trial registration: ClinicalTrials.gov (Identifier NCT03106064).

Results:

This intervention has the potential to change the outcomes of the older patient in the acute setting.

Conclusion:

The loss of independence in self-care is determinant in future health care needs. If our hypothesis is correct and demonstrate that this nursing care program centered on basic self-care for older acute medical patients improves functional outcomes, a change in the paradigmatic organization of hospital care may be justifiable.

Basic self-care in older acute medical in-patients: a retrospective cohort study

Background:

Older patients hospitalized for acute illness are vulnerable to decline in basic self-care. This functional decline determines future health needs and can lead to negative health outcomes.

Aim:

To compare basic self-care needs in older acute medical in-patients between admission and discharge using the Nursing Patient Classification System data.

Design:

Single-center, observational, and retrospective cohort study.

Methods:

Data were collected between April 2015 and April 2016 and included 384 patients aged 65 or older admitted to a medical ward of a 580-bed teaching hospital in Portugal. Significant differences between groups of patients were assessed by analysis of variance and Kruskal–Wallis for continuous variables and by chi-squared test for categorical variables. Significant changes in the level of dependence were analyzed using McNemar–Bowker test.

Results:

The mean age of the patients was 79.93 years (SD = 7.49) and the majority were women (57.3%). There were no gender differences in length of stay. Oldest-old patients presented higher percentages of dependence on basic self-care, both at admission and at discharge. Younger-old patients improves in hygiene and personal care, toilet use, and movement (P < .01). However, it is also this group of patients who have the highest percentages of deterioration in eating (P = .129), toilet use, and movement (P < .001).

Conclusion:

All patients are vulnerable to decline in basic self-care regardless their age. Use Nursing Patient Classification Systems to track progress in basic self-care between admission and discharge in older acute medical patients is an innovative and valid methodology. Based on the needs of nursing care, we were able to characterize older patients’ needs and achieve health outcomes.