Predictors of falls and hospital admissions in people with cognitive impairment in day-care: role of multimorbidity, polypharmacy, and potentially inappropriate medication

General practitioner-based interventions to reduce hospital admissions in patients with multimorbidity living at home - A rapid review

BACKGROUND

Multimorbidity is a common health problem among patients treated in GP practices and often associated with an increased risk of hospitalization. The aim of this review was to identify GP-based interventions to reduce hospitalization in patients with multimorbidity who were evaluated in randomized controlled trials.

METHODS

For the rapid review, the databases Medline and CENTRAL were systematically searched for randomized controlled trials evaluating an effect of GP-based interventions on the duration or frequency of hospitalization in adult patients with multimorbidity living at home. The interventions and their effects were described narratively.

RESULTS

From 2,260 hits in the database searches, 15 studies could be included. The interventions identified included, amongst others, interdisciplinary cooperation, training of GPs and other practice staff, and increased patient centeredness. Hospital admissions were reported in 13 studies, and the number of days spent in hospital was reported in six studies. Two studies found a significant reduction in hospitalization.

CONCLUSIONS

While most interventions were not effective, there were also two GP-based interventions for patients with multimorbidity which focused on the patients' individual situation and contributed to avoiding hospitalization. However, more studies are needed to make reliable statements on the effectiveness of various measures.

One-Year Changes in Depressive Symptoms and Cognitive Function Among Brazilian Older Adults Attending Primary Care

Background: Aging is a global phenomenon closely associated with changes in cognitive function and mental health. These conditions substantially burden public health systems and adversely affect the quality of life of older adults. This study aimed to examine changes in depressive symptoms and cognitive function over a 12-month follow-up period in a cohort of Brazilian older adults attending primary care. Methods: This observational longitudinal study included a randomized sample of individuals aged ≥60 years residing in São Paulo, Brazil, and registered at a Primary Healthcare Unit (PHU). Data collection involved administering a sociodemographic and health questionnaire along with two validated instruments: the Geriatric Depression Scale-15 (GDS-15) and the Mini-Mental State Examination (MMSE). Linear regression models were used for the analyses. Results: A total of 368 older adults were included, with 63% being men and a mean age of 74.65 years. After one year, depressive symptoms showed a notable increase, with the mean GDS-15 score rising from 5.97 to 7.48 (Cohen-d = 0.542). Likewise, there was a decrease in the mean MMSE score ranging from 19.11 to 18.88 (Cohen-d = 0.216). Adjusted regression analyses revealed that depressive symptoms at baseline (B = 0.696; p = 0.048; R2 = 0.19) and cognitive function at baseline (B = 0.444; p < 0.001; R2 = 0.26) were predictive of their respective deteriorations over the follow-up period. Conclusions: Depressive symptoms and cognitive decline place a significant burden on public health systems in aging societies. These findings underscore the importance of continuous monitoring and early intervention strategies to mitigate their impact and enhance the quality of life for older adults.

Comparing Different Implementation Strategies for Collaborative Dementia Care Management in Terms of Patients' Characteristics, Unmet Needs, and the Impact on Quality of Life and Costs in Germany

OBJECTIVE

To compare the implementation of collaborative dementia care management (cDCM) across two settings regarding patients' characteristics, unmet needs, and the impact on health-related quality of life (HRQoL) and costs.

METHODS

This analysis was based on data from the DCM:IMPact study, implementing cDCM in a physician network (n = 22 practices) and two day care centers (DCC) for community-dwelling persons with dementia over 6 months in Germany. Participants completed comprehensive assessments at baseline and 6 months after, soliciting sociodemographic and clinical characteristics, unmet needs, HRQoL and healthcare resource utilization. Patient characteristics and unmet needs were analyzed descriptively, and the impact of cDCM on costs and HRQoL was assessed using multivariable regression models.

RESULTS

At baseline, patients from the physician network (n = 46) exhibited more pronounced neuropsychiatric symptoms (NPI mean score 14 versus 10, p = 0.075), were more frequently diagnosed with dementia (76% versus 56%, p = 0.040), were less likely assigned a care level by the long-term care insurance (63% versus 91%, p ≤ 0.001) to access formal care services and had more unmet needs (12.8 versus 11.0, p ≤ 0.001), especially for social care services than DCC patients (n = 57). After 6 months, the adjusted means indicated that cDCM implemented in the physician network was more effective [EQ-5D-5L utility score; 0.061; 95% confidence interval (CI) - 0.032 to 0.153] and less costly (- 5950€; 95% CI - 8415€ to - 3485€) than cDCM implemented in DCC.

CONCLUSIONS

Patients and the healthcare system may benefit more when cDCM is implemented in physician networks. However, patient characteristics indicated two samples with specific conditions and various unmet needs using different ways of accessing healthcare, demonstrating the need for cDCM in both settings, which must be considered when implementing cDCM to integrate the respective sectors efficiently.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00025074. Registered 16 April 2021-retrospectively registered.

Multimorbidity, medications, and their association with falls, physical activity, and cognitive functions in older adults: multicenter study in Sri Lanka

This study was aimed to examine the prevalence and associations between multimorbidity, polypharmacy, Falls Risk Increasing Drugs use (FRIDs), Anti Cholinergic Burden (ACB), and adverse health outcomes in older adults attending medical clinics. A cross-sectional study was conducted among 704 older adults attending medical clinics in four tertiary care hospitals. The mean (SD) age of study participants was 73 (5.5) years, and the majority were females (58.7%). Patients 305 (43.5%) reported at least one fall after age of 65 while 220 (31.3%) reported falls in the previous 12 months and 90 (12.8%) reported recurrent falls. The prevalence of multimorbidity was 77.4% while polypharmacy was seen in 51.2%. The use of at least one FRID was seen in 70.5% patients while higher ACB was seen in 5.4%. Multimorbidity, polypharmacy, use of FRIDs and ACB were not associated with negative health outcome (p > 0.05). Polypharmacy, however, was associated with high ACB (p < 0.001). This study highlights a high prevalence of multimorbidity and polypharmacy among older people in clinical settings. However, negative associations between drugs and multimorbidity with adverse health outcomes indicate that these relationships are complex, potentially influenced by other factors such as poor drug compliance, which can lead to falls.

Impact of Polypharmacy on Symptoms and Health Outcomes in Older Adults With and Without Alzheimer's Disease and Related Dementias

BACKGROUND

There is a critical gap in understanding the symptom experience and health outcomes of older adults with and without Alzheimer's Disease and related dementias (ADRD) and polypharmacy (PPY). The primary aim of the study was to compare the number of symptoms experienced over time in older adults with and without ADRD by polypharmacy status. The secondary aim was to examine the trajectory of physical function and health outcomes over time in each group.

METHODS

This study utilized longitudinal data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries from 2016-2019. The sample was separated into four groups (N = 2,052): neither ADRD or PPY (n = 1,048), PPY only (n = 761), ADRD only (n = 116), and both ADRD and PPY(n = 127).

RESULTS

The overall sample was predominately female (57.9%), White (70.9%), aged 84 or younger (75%), married (46%), and had some college or a college degree (50%). Participants with both ADRD and PPY experienced more symptoms on average, had higher odds of falls, hospitalizations, and mortality than all other groups. Older adults with both ADRD and PPY had lower physical function, needed more assistance with activities of daily living and higher assistive device utilization compared to the other three groups.

CONCLUSIONS

Findings indicate that older adults with both ADRD and PPY experience more symptoms, negative health outcomes and physical function decline that can negatively impact their quality of life. Further research is needed to identify strategies for reducing PPY in people with ADRD.

Association between continuity of care and inappropriate prescribing in outpatient care in Germany: a cross-sectional analysis conducted as part of the LoChro trial

OBJECTIVES

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients.

DESIGN

Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC.

SETTING

Southern Germany, outpatient setting.

PARTICIPANTS

321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool.

PRIMARY OUTCOMES

Numbers of PIMs and PPOs.

RESULTS

The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337).

CONCLUSION

The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904.

Effect of chronic pain on the occurrence of falls in older adults with disabilities: a prospective cohort study

BACKGROUND

The relationship between chronic pain and the occurrence of falls in healthy older adults has been clarified in previous studies, but its relationship in older adults with disabilities has not.

OBJECTIVE

This study aimed to determine whether chronic pain is related to the occurrence of falls in older adults with disabilities.

METHODS

The participants were 101 older adults above 65 years old who used long-term care insurance services in Japan. Of these, 30 were fallers and 71 were non-fallers. Chronic pain, defined as pain lasting more than three months, was assessed using questionnaires, and the falls' occurrence was followed up for six months using a fall calendar. Logistic regression analysis was used to analyze the data, with falls as the dependent variable, chronic pain as the independent variable, and age, sex, body mass index, number of drugs, sleep disorders, and depression as covariates.

RESULTS

After adjusting for covariates, chronic pain significantly influenced the occurrence of falls (odds ratio: 3.168, 95% confidence interval: 1.057-9.495, p = .04).

CONCLUSION

Chronic pain was related to the occurrence of falls in older adults with disabilities. There is a need to focus on chronic pain presence in falls' prevention among older adults with disabilities.

Meta-Analysis-Based Comparison of Annual Fall Risk between Older Adults with Alzheimer's Disease and Mild Cognitive Impairment

Background

Falls are a primary cause of injuries and hospitalization in older adults. It has been reported that cognitive impairments and dementia can increase fall risk in the older population; however, it remains unknown if fall risk differs among subgroups of dementia. This meta-analysis summarized previous studies reporting the annual fall risk of people with Alzheimer's disease (AD) or mild cognitive impairment (MCI) and compared the fall risk between these two groups of people with dementia.

Methods

Thirty-five studies enrolling 7844 older adults with AD or MCI were included. The annual fall prevalence and average number of falls of the included studies were meta-analyzed and compared by random-effects models with inverse variance weights.

Results

The annual fall prevalence in people with AD (43.55%) was significantly higher than MCI (35.26%, p < 0.001). A χ2 test indicated that the pooled fall prevalence is significantly higher in people with AD than MCI χ2 = 158.403, p < 0.001). Additionally, the yearly average number of falls in AD was higher than in MCI (1.30 vs 0.77 falls/person).

Conclusions

The results showed that older people with AD experience a higher annual fall prevalence with a larger number of falls than older adults with MCI. The results suggested that the fall risk measurements should be reported separately between people with AD and MCI. The findings could provide preliminary guidance for the identification of individuals with dementia who experience a high fall risk.

Old-age mental telehealth services at primary healthcare centers in low- resource areas in Greece: design, iterative development and single-site pilot study findings

BACKGROUND

Even though communities in low-resource areas across the globe are aging, older adult mental and cognitive health services remain mainly embedded in tertiary- or secondary hospital settings, and thus not easily accessible by older adults living in such communities. Here, the iterative development of INTegRated InterveNtion of pSychogerIatric Care (INTRINSIC) services addressing the mental and cognitive healthcare needs of older adults residing in low-resource areas of Greece is depicted.

METHODS

INTRINSIC was developed and piloted in three iterative phases: (i) INTRINSIC initial version conceptualization; (ii) A 5-year field testing in Andros island; and (iii) Extending the services. The INTRINSIC initial version relied on a digital platform enabling videoconferencing, a flexible battery of diagnostic tools, pharmacological treatment and psychosocial support and the active involvement of local communities in service shaping.

RESULTS

Ιn 61% of the 119 participants of the pilot study, new diagnoses of mental and/or neurocognitive disorders were established. INTRINSIC resulted in a significant reduction in the distance travelled and time spent to visit mental and cognitive healthcare services. Participation was prematurely terminated due to dissatisfaction, lack of interest or insight in 13 cases (11%). Based on feedback and gained experiences, a new digital platform, facilitating e-training of healthcare professionals and public awareness raising, and a risk factor surveillance system were created, while INTRINSIC services were extended to incorporate a standardized sensory assessment and the modified problem adaptation therapy.

CONCLUSION

The INTRINSIC model may be a pragmatic strategy to improve access of older adults with mental and cognitive disorders living in low-resource areas to healthcare services.