Cognitive decline after hospitalization in a community population of older persons

Movement is muscle in hospitalized adults

Physical inactivity is a major public health concern, but for hospitalized adults, the results of immobility are even more alarming. The "trauma of hospitalization" is a syndrome that refers to the collective impact of immobility, sleep deficits, and malnutrition associated with hospitalization and contributes to functional deficits. Functional decline is a modifiable and preventable risk factor. Nursing, at the center of patient care, is poised to coordinate the patient's mobility activities. Multiple steps to stave off functional decline to improve health outcomes for older adults are in the control of nurses and nursing practice and reflect the goals of the NICHE practice model.

Short-Term, Community-Based, Slow-Stream Rehabilitation Program for Older Adults Transitioning from Hospital to Home: A Mixed Methods Program Evaluation

Introduction

Shortened hospital stays have shifted the burden of care for older adults to community, informal (ie, family, caregiver) and formal post-acute care and services, highlighting the need for effective post-hospital stay services and programs. As there is a dearth of information related to community-based, slow-stream rehabilitation program models for older adults transitioning from hospital to home in the Canadian context, the paper describes a mixed methods evaluation of such a program.

Materials and Methods

A mixed methods program evaluation, with process- and outcome-related elements, included 1) review and analysis of program documents; 2) observations to examine fidelity. Observation data were coded and summarized using descriptive statistics. Coded information and data were compared to document review data; 3) quantitative assessment of pre-post changes in physical, social, and psychological outcome measure and instrument scores using descriptive statistics, paired t-tests and confidence intervals (p = 0.05); and 4) exploration of acceptability through interviews and focus groups with 41 of the older adult participants and 17 family caregivers. Thematic analysis was used to examine focus group and interview transcripts.

Results

Observational data indicated alignment with the program document information overall. Statistically and clinically significant positive trends in improvement for physical outcome measure scores were observed (6-minute Walk Test, Life Space Assessment, Short Physical Performance Battery, Rapid Assessment of Physical Activity). Participants and family caregivers identified several positives and benefits of the program, ie, improvement in physical, social and mental well-being, decreased caregiver burden; and areas for improvement ie, need for more information about the program prior to enrollment and individualization, several of which aligned with the observation and quantitative data.

Discussion/Conclusion

This mixed methods program evaluation provided a detailed description of a community-based, slow-stream rehabilitation program for older adults who are transitioning to home post-hospital stay and its participants. Evidence of program fidelity, acceptability, and positive trends in improvement in physical outcome measure scores were found. Information about program strengths and areas for improvement can be used by stakeholders to inform program refinement and enhancement.

The spectrum of hospitalization-associated harm in the elderly

Acutely ill patients are not infrequently referred to the hospital and admitted, when they could be diagnosed and managed in the ambulatory setting or by hospital-level care at home. Avoidable admissions are particularly regrettable when the wide spectrum of hospitalization-associated patient harm is considered. It includes acute discomfort to the patient due to multiple disturbing hospital stressors; an emotional trauma; the burden of multiple redundant tests begetting false-positive and incidental findings triggering further testing and cascades; highly prevalent adverse events and serious harm associated with medical care, such as nosocomial infections, delirium, falls, and adverse drug events; and a complex array of post-discharge complications including significant physical and functional decline; cognitive decline; flawed transitions of care; common post-discharge adverse events; and a substantial risk of readmission, restarting the vicious cycle and compromising patient well-being, safety, and outcomes. Elderly patients are especially vulnerable, but in-hospital patient harm is not limited to older adults and is associated with increased length of stay, escalating costs, and mortality. The myriad types of harm that often accompany hospital admission is often not fully appreciated. Better awareness may result in better preventive strategies, in finding alternatives to hospital admission in some cases, and may contribute towards an improved patient experience and safety when hospitalization is mandatory, and the provision of enhanced care in the vulnerable post-discharge period.

Effectiveness of intervention package on knowledge and attitude regarding functional needs and quality of life of elderly patients with psychiatric illness, among nursing interns

OBJECTIVE

To develop and assess the effectiveness of the intervention package on knowledge and attitude regarding meeting the functional needs and improving the quality of life of elderly patients with psychiatric illness, among nursing interns.

MATERIALS AND METHODS

The study was carried out among 60 nursing interns of a tertiary government mental health setting. After the pretest, the educational intervention package on functional needs and quality of life of elderly patients with psychiatric illness was administered to the study group in four sessions. Posttest data collection was performed using the same questionnaires after 2 weeks after the last session.

RESULTS

There was a statistically significant improvement in the knowledge and attitude of nursing students following the sessions of the intervention package. Pretest data showed that there is a positive correlation between the knowledge and attitude of study subjects. Overall knowledge has significantly improved after attending the intervention program (Z = 6.701, P < 0.001). Moreover, the overall attitude level has significantly improved after attending the intervention program (Z = 6.741, P < 0.001).

CONCLUSION

The educational intervention package on functional needs and quality of life of elderly patients with psychiatric illness was effective in improving the knowledge and attitude regarding functional needs and quality of life of elderly patients with psychiatric illness, among nursing interns. Similar packages may be incorporated into the nursing curriculum in training future nurses for their better practice in this area.

Caregivers’ experience with Tele-Savvy Caregiver Program post-hospitalization

Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.

Association of neurocognitive function with psychiatric hospitalization and socio-demographic conditions in individuals with bipolar and major depressive disorders

Background

Neurocognitive impairments are associated with poor clinical and employment outcomes in individuals with affective disorders. However, little is known about their associations with long-term clinical outcomes such as psychiatric hospitalizations, and with socio-demographic indicators other than employment. In the largest longitudinal study of neurocognition in affective disorders to date, we investigate the role of neurocognitive impairments on psychiatric hospitalizations and socio-demographic conditions.

Methods

The study included 518 individuals with bipolar or major depressive disorder. Neurocognitive assessments covered executive function and verbal memory domains. Longitudinal data on psychiatric hospitalization and socio-demographic conditions (employment, cohabitation, and marital status) for up to 11 years were obtained using National population-based registers. The primary and secondary outcomes were psychiatric hospitalizations (n = 398) and worsening of socio-demographic conditions (n = 518), in the follow-up period since study inclusion, respectively. Cox regression models were used to examine the association of neurocognition with future psychiatric hospitalizations and the worsening of socio-demographic conditions.

Findings

Clinically significant impairment in verbal memory (z-score ≤ -1; defined by the ISBD Cognition Task Force), but not in executive function, was associated with a higher risk of future hospitalization, when adjusted for age, sex, hospitalization in the year preceding inclusion, depression severity, diagnosis, and type of clinical trial (HR = 1.84, 95% CI:1.05-3.25, p = 0.034; n = 398). The results remained significant even after accounting for illness duration. Neurocognitive impairments were not associated with the worsening of socio-demographic conditions (p ≥ 0.17; n = 518).

Interpretation

Promoting neurocognitive function, especially verbal memory, may mitigate the risk of future psychiatric hospitalization in individuals with affective disorders.

Funding

Lundbeckfonden (R279-2018-1145).

Effects of a financial incentive scheme for dementia care on medical and long-term care expenditures: A propensity score-matched analysis using LIFE study data

OBJECTIVE

Japan introduced a financial incentive scheme in April 2016 to improve hospital-based dementia care, but its effectiveness remains unclear. This study aimed to investigate the scheme's impact on medical and long-term care (LTC) expenditures, as well as on changes in care needs levels and daily living independence levels among older persons one year after hospital discharge.

METHODS

We linked medical and LTC claims databases, and retrospectively identified patients who received LTC needs certification and daily living independence assessments in Fukuoka, Japan. Case patients (received care under the new scheme) were those admitted from April 2016 to March 2018, and control patients were those admitted from April 2014 to March 2016 (before the scheme was implemented). Through propensity score matching, we identified 260 case patients and 260 control patients, and compared using t-tests, and chi-square tests.

RESULTS

The analyses found no significant differences between the case and control groups in medical expenditure (US$26,685 vs US$24,823, P = 0.37), LTC expenditure (US$16,870 vs US$14,374, P = 0.08), daily living independence level changes (26.5% vs 20.4%, P = 0.12), or care needs level changes (36.9% vs 30%, P = 0.11).

CONCLUSIONS

The financial incentive scheme for dementia care did not demonstrate any beneficial effects on patients' healthcare expenditures or health conditions. Further studies are needed to examine the scheme's long-term effects.

In-hospital stress and patient outcomes: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients are exposed to high levels of stress during hospitalisation that may increase susceptibility to major adverse health events post-hospitalisation (known as post-hospital syndrome). However, the existing evidence base has not been reviewed and the magnitude of this relationship remains unknown. Therefore, the aim of the current systematic review and meta-analysis was to: 1) synthesise existing evidence and to determine the strength of the relationship between in-hospital stress and patient outcomes, and 2) determine if this relationship differs between (i) in-hospital vs post-hospital outcomes, and (ii) subjective vs objective outcome measures.

METHODS

A systematic search of MEDLINE, EMBASE, PsychINFO, CINAHL, and Web of Science from inception to February 2023 was conducted. Included studies reported a measure of perceived and appraised stress while in hospital, and at least one patient outcome. A random-effects model was generated to pool correlations (Pearson's r), followed by sub-group and sensitivity analyses. The study protocol was preregistered on PROSPERO (CRD42021237017).

RESULTS

A total of 10 studies, comprising 16 effects and 1,832 patients, satisfied the eligibility criteria and were included. A small-to-medium association was found: as in-hospital stress increased, patient outcomes deteriorated (r = 0.19; 95% CI: 0.12-0.26; I2 = 63.6; p < 0.001). This association was significantly stronger for (i) in-hospital versus post-hospital outcomes, and (ii) subjective versus objective outcome measures. Sensitivity analyses indicated that our findings were robust.

CONCLUSIONS

Higher levels of psychological stress experienced by hospital inpatients are associated with poorer patient outcomes. However, more high-quality, larger scale studies are required to better understand the association between in-hospital stressors and adverse outcomes.

Is hospitalization a risk factor for cognitive decline in older age adults?

OBJECTIVES

Many studies document cognitive decline following specific types of acute illness hospitalizations (AIH) such as surgery, critical care, or those complicated by delirium. However, cognitive decline may be a complication following all types of AIH. This systematic review will summarize longitudinal observational studies documenting cognitive changes following AIH in the majority admitted population and conduct meta-analysis (MA) to assess the quantitative effect of AIH on post-hospitalization cognitive decline (PHCD).

METHODS

We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Selection criteria were defined to identify studies of older age adults exposed to AIH with cognitive measures. 6566 titles were screened. 46 reports were reviewed qualitatively, of which seven contributed data to the MA. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

The qualitative review suggested increased cognitive decline following AIH, but several reports were particularly vulnerable to bias. Domain-specific outcomes following AIH included declines in memory and processing speed. Increasing age and the severity of illness were the most consistent risk factors for PHCD. PHCD was supported by MA of seven eligible studies with 41,453 participants (Cohen's d = -0.25, 95% CI [-0.02, -0.49] I² 35%).

CONCLUSIONS

There is preliminary evidence that AIH exposure accelerates or triggers cognitive decline in the elderly patient. PHCD reported in specific contexts could be subsets of a larger phenomenon and caused by overlapping mechanisms. Future research must clarify the trajectory, clinical significance, and etiology of PHCD: a priority in the face of an aging population with increasing rates of both cognitive impairment and hospitalization.

Warning Signs of Acute Infectious Disease-Related Illness in Persons Living With Dementia: Perspectives of Primary Care Providers, Adult Day Service Center Staff, and Family Care Partners

In the current study, we conducted one-on-one interviews with primary care providers (PCPs) and family care partners (FCPs) and held focus groups with interdisciplinary adult day service center (ADSC) staff to understand the perspectives of care providers across community settings regarding early warning signs of acute illnesses in persons living with dementia (PLWD). We used content analysis to analyze qualitative data. Warning signs of acute illnesses in PLWD fell into one of five categories, including new onset changes in (a) physical functions, (b) moods or behaviors (psychological), (c) social interactions, (d) speech, or (e) appearance. FCPs (n = 11) focused on physical changes, whereas ADSC staff (n = 33) emphasized changes in speech and social interactions in addition to the other categories. Although ADSC staff and PCPs (n = 22) focused on changes in functions and moods, each group described these changes differently. ADSC staff possess rich information that can be used to identify acute changes in PLWD and describe a broader range of warning signs compared to PCPs and FCPs. FCPs may benefit from further training in distinguishing between normal disease progression and acute illness. Future research should focus on the implementation of standardized tools across community-based care providers to simplify the identification and reporting of early warning signs in PLWD. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

The contribution of functional cognition screening during acute illness hospitalization of older adults in predicting participation in daily life after discharge

Background

Cognitive assessment in acutely hospitalized older adults is mainly limited to neuropsychological screening measures of global cognition. Performance-based assessments of functional cognition better indicate functioning in real-life situations. However, their predictive validity has been less studied in acute hospital settings. The aim of this study was to explore the unique contribution of functional cognition screening during acute illness hospitalization in predicting participation of older adults one and three months after discharge beyond traditional neuropsychological measures.

Methods

This prospective longitudinal study included 84 older adults ≥ 65 years hospitalized in internal medicine wards due to acute illness, followed by home visits at one month and telephone interviews at three months (n = 77). Participation in instrumental activities of daily living, social and leisure activities was measured by the Activity Card Sort. In-hospital factors included cognitive status (telephone version of the Mini-Mental State Examination, Color Trails Test), functional cognition screening (medication sorting task from the alternative Executive Function Performance Test), emotional status (Hospital Anxiety and Depression scale), functional decline during hospitalization (modified Barthel index), length of hospital stay, the severity of the acute illness, symptoms severity and comorbidities.

Results

Functional cognition outperformed the neuropsychological measures in predicting participation declines in a sample of relatively high-functioning older adults. According to a hierarchical multiple linear regression analysis, the overall model explained 28.4% of the variance in participation after one month and 19.5% after three months. Age and gender explained 18.6% of the variance after one month and 13.5% after three months. The medication sorting task explained an additional 5.5% of the variance of participation after one month and 5.1% after three months, beyond age and gender. Length of stay and the Color Trails Test were not significant contributors to the change in participation.

Conclusions

By incorporating functional cognition into acute settings, healthcare professionals would be able to better detect older adults with mild executive dysfunctions who are at risk for participation declines. Early identification of executive dysfunctions can improve continuity of care and planning of tailored post-discharge rehabilitation services, especially for high-functioning older adults, a mostly overlooked population in acute settings. The results support the use of functional cognition screening measure of medication management ability in acute settings.

Psychobiological Evaluation of Day Clinic Treatment for People Living With Dementia – Feasibility and Pilot Analyses

Background

Hospitalization is often stressful and burdensome for people living with dementia (PwD) and their informal caregivers (ICs). Day clinic treatment may provide a suitable alternative, but is often precluded by a diagnosis of dementia. Furthermore, it is often caregiver-based ratings that measure treatment success as the validity of self-reports in PwD is critically discussed. We therefore set out to examine the feasibility of psychobiological stress measures in PwD and ICs and to evaluate treatment trajectories considering both the day clinic context and the daily life of the dyads.

Method

A total of 40 dyads of PwD (mean age: 78.15 ± 6.80) and their ICs (mean age: 63.85 ± 13.09) completed paper-and-pencil questionnaires (covering stress, depressive symptoms, and caregiver burden among others) in addition to the measurement of hair cortisol concentrations (HCC) at admission, discharge, and follow-up 6 months after day clinic treatment. As part of an ambulatory assessment, for 2 days at the beginning and 2 days at the end of the day clinic treatment, PwD and ICs collected six saliva samples per day for the analysis of salivary cortisol (sCort) and alpha-amylase (sAA).

Results

Paper-and-pencil questionnaires and HCC assessments were more feasible than the ambulatory assessment. We found discrepancies between subjective and physiological markers of stress in PwD. Whereas HCC decreased over time, self-reported stress increased. Child–parent dyads reported decreases in neuropsychiatric symptoms, associated burden, and self-reported stress from admission to follow-up. In daily life, both PwD and ICs showed characteristic diurnal profiles of sAA and sCort, however, we found no differences in summary indicators of salivary stress markers over time.

Discussion

The psychobiological evaluation was feasible and added informative value, underlining the potential of physiological stress markers to complement self-reports on stress in PwD and to objectively evaluate treatment trajectories. In this sample, HCC was more feasible and acceptable as biological marker of stress compared to saliva samples. Concerning treatment trajectories, differential effects on the dyads were found, with child–parent dyads benefiting more from day clinic treatment compared to spousal dyads.

Surgical Hospitalization Is Not Associated With Cognitive Trajectory Over 6 Years in Healthy Older Australians

OBJECTIVE

The aim was to investigate the association of cognitive trajectories and overnight surgical hospitalization in older adults, while controlling for and comparing with the association with acute medical hospitalizations.

DESIGN

This is a secondary analysis of data from a population-based, longitudinal cohort study of older Australians.

SETTING AND PARTICIPANTS

Cognition was assessed with 4 biennial waves of prospective neuropsychological data from 1026 Sydney Memory and Aging Study participants age 70 to 90 years at baseline. Hospitalization exposure was obtained from 10 years of electronically linked data from the New South Wales Admitted Patient Data Collection.

METHODS

Latent growth curve modeling estimated global cognition z score baseline and slope over 6 years, and the effects of contemporaneous surgical and medical hospitalization predictors while controlling for potential demographic and comorbidity confounders.

RESULTS

After controlling for confounding variables, this analysis showed that overnight surgical hospitalizations were not associated with worse baseline global cognition or accelerated cognitive decline over 6 years. This was despite this cohort having more surgeries and more complex surgeries compared with Australian data for overnight hospitalizations in over 70-year-olds. Conversely, recent medical hospitalizations were associated with accelerated cognitive decline.

CONCLUSIONS AND IMPLICATIONS

This analysis finds that surgery and anesthesia are unlikely to be risk factors for medium to long-term global cognitive decline in healthy older adults, while controlling for contemporaneous medical hospitalizations. These findings are contrary to prior conclusions from several surgical studies that may have been impeded by insufficient comparison groups. They are, however, consistent with recent population-based studies suggesting surgery has minimal association with cognitive decline in the medium to long-term. Future research needs to clarify the association of surgical hospitalization with the full spectrum of cognitive outcomes including subjective cognitive complaints and dementia, and importantly, how these cognitive outcomes correlate with clinically significant functional changes.

Effects of Physical Exercise on the Incidence of Delirium and Cognitive Function in Acutely Hospitalized Older Adults: A Systematic Review with Meta-Analysis

BACKGROUND

Acute care hospitalization increases the likelihood of developing cognitive impairment and delirium in older adults.

OBJECTIVE

To summarize evidence about the effectiveness of exercise and physical rehabilitation interventions on the incidence of delirium and cognitive impairment in acutely hospitalized older patients.

METHODS

Relevant articles were systematically searched (PubMed, Web of Science, and CINHAL databases) until 26 August 2021. Randomized and nonrandomized controlled trials of in-hospital physical exercise interventions and rehabilitation programs compared to usual care performed for older patients (>  65 years) hospitalized for an acute medical condition were selected. The primary endpoints were changes in the incidence of delirium and cognition during acute hospitalization. The secondary endpoints included functional independence, psychological measures, well-being status, length of hospital stay, transfer after discharge, fall occurrence, hospital readmissions, and mortality rate. The endpoints were evaluated at different time points (at admission, at discharge, and after discharge).

RESULTS

Eleven studies from 8 trials (n = 3,646) were included. The methodological quality of the studies was mostly high. None of the studies reported any adverse events related to the intervention. Early rehabilitation improved cognitive function at 3 months postdischarge (Hedge's g = 0.33, 95% confidence interval [CI] 0.19 to 0.46, p <  0.001). No between-group differences were found for incident delirium and cognitive impairment during hospitalization (all p >  0.05).

CONCLUSION

In-hospital physical exercise and early rehabilitation programs seem to be safe and effective interventions for enhancing cognitive function after discharge in older patients hospitalized for an acute medical condition. However, no potential benefits were obtained over usual hospital care for the incidence of delirium.

Overall and cause-specific hospitalisation and death after COVID-19 hospitalisation in England: A cohort study using linked primary care, secondary care, and death registration data in the OpenSAFELY platform

BACKGROUND

There is concern about medium to long-term adverse outcomes following acute Coronavirus Disease 2019 (COVID-19), but little relevant evidence exists. We aimed to investigate whether risks of hospital admission and death, overall and by specific cause, are raised following discharge from a COVID-19 hospitalisation.

METHODS AND FINDINGS

With the approval of NHS-England, we conducted a cohort study, using linked primary care and hospital data in OpenSAFELY to compare risks of hospital admission and death, overall and by specific cause, between people discharged from COVID-19 hospitalisation (February to December 2020) and surviving at least 1 week, and (i) demographically matched controls from the 2019 general population; and (ii) people discharged from influenza hospitalisation in 2017 to 2019. We used Cox regression adjusted for age, sex, ethnicity, obesity, smoking status, deprivation, and comorbidities considered potential risk factors for severe COVID-19 outcomes. We included 24,673 postdischarge COVID-19 patients, 123,362 general population controls, and 16,058 influenza controls, followed for ≤315 days. COVID-19 patients had median age of 66 years, 13,733 (56%) were male, and 19,061 (77%) were of white ethnicity. Overall risk of hospitalisation or death (30,968 events) was higher in the COVID-19 group than general population controls (fully adjusted hazard ratio [aHR] 2.22, 2.14 to 2.30, p < 0.001) but slightly lower than the influenza group (aHR 0.95, 0.91 to 0.98, p = 0.004). All-cause mortality (7,439 events) was highest in the COVID-19 group (aHR 4.82, 4.48 to 5.19 versus general population controls [p < 0.001] and 1.74, 1.61 to 1.88 versus influenza controls [p < 0.001]). Risks for cause-specific outcomes were higher in COVID-19 survivors than in general population controls and largely similar or lower in COVID-19 compared with influenza patients. However, COVID-19 patients were more likely than influenza patients to be readmitted or die due to their initial infection or other lower respiratory tract infection (aHR 1.37, 1.22 to 1.54, p < 0.001) and to experience mental health or cognitive-related admission or death (aHR 1.37, 1.02 to 1.84, p = 0.039); in particular, COVID-19 survivors with preexisting dementia had higher risk of dementia hospitalisation or death (age- and sex-adjusted HR 2.47, 1.37 to 4.44, p = 0.002). Limitations of our study were that reasons for hospitalisation or death may have been misclassified in some cases due to inconsistent use of codes, and we did not have data to distinguish COVID-19 variants.

CONCLUSIONS

In this study, we observed that people discharged from a COVID-19 hospital admission had markedly higher risks for rehospitalisation and death than the general population, suggesting a substantial extra burden on healthcare. Most risks were similar to those observed after influenza hospitalisations, but COVID-19 patients had higher risks of all-cause mortality, readmission or death due to the initial infection, and dementia death, highlighting the importance of postdischarge monitoring.

Using machine learning to reduce unnecessary rehospitalization of cardiovascular patients in Saudi Arabia

OBJECTIVES

Patient readmission is a costly and preventable burden on healthcare systems. The main objective of this study was to develop a machine-learning classification model to identify cardiovascular patients with a high risk of readmission.

METHODS

Inpatient data were collected from 48 Ministry of Health hospitals (MOH) in Saudi Arabia from 2016 to 2019. Cardiovascular disease (CVD)-related diagnoses were defined as congestive heart failure (HF), ischemic heart disease (IHD), cardiac arrhythmias (CA), and valvular diseases (VD). Hospitalization days, daily hospitalization price, and the price of each basic and medical service provided were used to calculate the healthcare utilization cost. We employed a Python machine-learning model to identify all-cause 30-day CVD-related readmissions using the International Classification of Diseases, Revision 10 classification system (ICD10) as the gold standard. Demographics, comorbidities, and healthcare utilization were used as the independent variables.

RESULTS

From 2016 to 2019, we identified 403,032 hospitalized patients from 48 hospitals in 13 administrative regions of Saudi Arabia. Out of these patients, 17,461 had a history of hospital admission for cardiovascular reasons. The total direct cost of overall hospitalizations was 1.6 B international dollars (I$) with an average of I$ 3,156 per hospitalization, whereas CVD-related readmission costs were estimated to be I$ 14.9 M, with an average of I$ 7,600 per readmission. Finally, an empirical approach was followed to test several algorithms to identify patients at high risk of readmission. The comparison indicated that the decision-tree algorithm correctly classified 2,336 instances (926 readmitted and 1,410 not readmitted) and showed a higher F1 score than other models (64%), with a recall of 71% and precision of 57%.

CONCLUSION

This study identified IHD as the most prevalent CVD, and hypertension and diabetes were found to be the most common comorbidities among hospitalized CVD patients. Compared to general encounters, readmission encounters were nearly two times higher on average among the study population. Furthermore, we concluded that a machine-learning model can be used to identify CVD patients at a high risk of readmission. Further research is required to develop more accurate models based on clinical notes and laboratory results.

Hospitalisation without delirium is not associated with cognitive decline in a population-based sample of older people-results from a nested, longitudinal cohort study

BACKGROUND

Acute hospitalisation and delirium have individually been shown to adversely affect trajectories of cognitive decline but have not previously been considered together. This work aimed to explore the impact on cognition of hospital admission with and without delirium, compared to a control group with no hospital admissions.

METHODS

The Delirium and Cognitive Impact in Dementia (DECIDE) study was nested within the Cognitive Function and Ageing Study II (CFAS II)-Newcastle cohort. CFAS II participants completed two baseline interviews, including the Mini-Mental State Examination (MMSE). During 2016, surviving participants from CFAS II-Newcastle were recruited to DECIDE on admission to hospital. Participants were reviewed daily to determine delirium status.During 2017, all DECIDE participants and age, sex and years of education matched controls without hospital admissions during 2016 were invited to repeat the CFAS II interview. Delirium was excluded in the control group using the Informant Assessment of Geriatric Delirium Scale (i-AGeD). Linear mixed effects modelling determined predictors of cognitive decline.

RESULTS

During 2016, 82 of 205 (40%) DECIDE participants had at least one episode of delirium. At 1 year, 135 of 205 hospitalised participants completed an interview along with 100 controls. No controls experienced delirium (i-AGeD>4). Delirium was associated with a faster rate of cognitive decline compared to those without delirium (β = -2.2, P < 0.001), but number of hospital admissions was not (P = 0.447).

CONCLUSIONS

These results suggest that delirium during hospitalisation rather than hospitalisation per se is a risk factor for future cognitive decline, emphasising the need for dementia prevention studies that focus on delirium intervention.

Genetic risk, adherence to a healthy lifestyle, and cognitive decline in African Americans and European Americans

INTRODUCTION

We investigated the role of genetic risk and adherence to lifestyle factors on cognitive decline in African Americans and European Americans.

METHODS

Using data from the Chicago Health and Aging Project (1993-2012; n = 3874), we defined the genetic risk based on presence of apolipoprotein E (APOE) ε 4 allele and determined a healthy lifestyle using a scoring of five factors: non-smoking, exercising, being cognitively active, having a high-quality diet, and limiting alcohol use. We used linear mixed-effects models to estimate cognitive decline by genetic risk and lifestyle score.

RESULTS

APOE  ε 4 allele was associated with faster cognitive decline in both races. However, within APOE  ε 4 carriers, adherence to a healthy lifestyle (eg., 4 to 5 healthy factors) was associated with a slower cognitive decline by 0.023 (95% confidence interval [CI] 0.004, 0.042) units/year in African Americans and 0.044 (95% CI 0.008, 0.080) units/year in European Americans.

DISCUSSION

A healthy lifestyle was associated with a slower cognitive decline in African and European Americans.

Impact of delayed device re-implantation on outcomes of patients with cardiovascular implantable electronic device related infective endocarditis

BACKGROUND

Optimal timing of cardiovascular implantable electronic device (CIED) re-implantation following device removal due to infection is undefined. Multinational guidelines reflect this and include no specific recommendation for this timing, while others have recommended waiting at least 14 days in cases of CIED related infective endocarditis (CIED-IE). The current work seeks to clarify this issue.

METHODS

We retrospectively reviewed institutional data at Mayo Clinic, Minnesota of patients aged ≥ 18 years who developed CIED-IE from January 1, 1991 to February 1, 2016. CIED-IE was defined as echocardiogram reported device lead or valvular vegetation. Regression analyses were used to relate the risk of clinical outcomes to the interval between CIED removal and re-implantation and the location of vegetations.

RESULTS

A total of 109 patients met study inclusion criteria. A majority (68.8%) of patients were men and the median age was 68.0 years. Transoesophageal echocardiogram (TEE) was performed in 95.4% of patients, with valve vegetations detected in 33.9% (n = 37). Survival analysis comparing patients in whom device re-implantation was < 14 days vs. ≥14 days, and further categorized by those with and without valve vegetation, showed a significant difference (P = 0.028); patients with valve vegetation and reimplantation interval < 14 days had the lowest (58.7%) 12-month survival. When adjusted for valve vegetation, longer time interval for reimplantation trended toward increased hospital length of stay (P = 0.079).

CONCLUSION

Our findings suggest that the recommended 14-day delay between CIED extraction and re-implantation in CIED-IE patients is associated with a survival benefit, but longer length of hospital stay following re-implantation.

Real-World Experience of Talimogene Laherparepvec (T-VEC) in Old and Oldest-Old Patients with Melanoma: A Retrospective Single Center Study

Purpose

Rising melanoma incidences lead to an increasing need for individual therapy strategies in old patients. Talimogene laherparepvec (T-VEC) is a modified herpes simplex virus, approved for the local treatment of unresectable metastatic melanoma. Since data on the efficacy and safety of geriatric patients are sparse, this study was conducted to gain further real-world experience in the treatment of old and oldest-old patients with T-VEC and to obtain data on therapy costs in this population in Germany.

Patients and Methods

We performed a retrospective analysis, including all patients with a minimum age of 75 years who were treated with T-VEC from August 2016 to September 2020 in the Skin Cancer Center of the University Hospital Frankfurt, Germany. Patient clinicopathological data, treatment responses, toxicities, treatment-specific data and therapy costs were assessed.

Results

Twelve patients with a median age of 83 years (75-89 years) at the start of treatment were identified. By the end of the study, three (25%) patients experienced complete remission (CR), four (33%) experienced partial response (PR), two patients (17%) remained at stable disease (SD) and three (25%) patients suffered from progressive disease (PD). Overall response rate was 58.3%, and durable response rate was 41.7%. There were no treatment-related adverse events grade 3 or higher. The median duration of treatment was seventeen weeks (3-57 weeks). Median medication costs in the patients who had completed treatment (n=10) were calculated to be 27,325 Euros in Germany.

Conclusion

This study provides further evidence for an effective use of T-VEC in old and oldest-old patients. The low rate of adverse events seems to be favorable compared to other systemic melanoma therapies. Furthermore, duration of treatment was short and therapy costs were lower than would have been expected from clinical trial data. Altogether, these data encourage the use of T-VEC in this special patient cohort.

Recurrent delirium over 12 months predicts dementia: results of the Delirium and Cognitive Impact in Dementia (DECIDE) study

Background

Delirium is common, distressing and associated with poor outcomes. Previous studies investigating the impact of delirium on cognitive outcomes have been limited by incomplete ascertainment of baseline cognition or lack of prospective delirium assessments. This study quantified the association between delirium and cognitive function over time by prospectively ascertaining delirium in a cohort aged ≥ 65 years in whom baseline cognition had previously been established.

Methods

For 12 months, we assessed participants from the Cognitive Function and Ageing Study II-Newcastle for delirium daily during hospital admissions. At 1-year, we assessed cognitive decline and dementia in those with and without delirium. We evaluated the effect of delirium (including its duration and number of episodes) on cognitive function over time, independently of baseline cognition and illness severity.

Results

Eighty two of 205 participants recruited developed delirium in hospital (40%). One-year outcome data were available for 173 participants: 18 had a new dementia diagnosis, 38 had died. Delirium was associated with cognitive decline (−1.8 Mini-Mental State Examination points [95% CI –3.5 to –0.2]) and an increased risk of new dementia diagnosis at follow up (OR 8.8 [95% CI 1.9–41.4]). More than one episode and more days with delirium (>5 days) were associated with worse cognitive outcomes.

Conclusions

Delirium increases risk of future cognitive decline and dementia, independent of illness severity and baseline cognition, with more episodes associated with worse cognitive outcomes. Given that delirium has been shown to be preventable in some cases, we propose that delirium is a potentially modifiable risk factor for dementia.

Association of Infection-Related Hospitalization With Cognitive Impairment Among Nursing Home Residents

IMPORTANCE

Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown.

OBJECTIVE

To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020.

EXPOSURE

Infection-related hospitalization lasting 1 to 14 days.

MAIN OUTCOMES AND MEASURES

Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment).

RESULTS

Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P < .001), or 3%. The increase in scores was greatest among residents aged 85 years or older vs younger residents by approximately 0.022 CFS points (95% CI, 0.004-0.040 points; P < .05). The prevalence of severe cognitive impairment increased by 1.6 percentage points (95% CI, 1.2-2.0 percentage points; P < .001), or 18%; the increases were observed among individuals with ADRD but not among those without it. After an infection-related hospitalization, cognition among residents who had experienced sepsis declined more than for residents who had not by about 0.02 CFS points (95% CI, 0.00-0.04 points; P < .05). All observed differences persisted without an accelerated rate of decline for at least 6 quarters after infection-related hospitalization. No differences were observed by sex.

CONCLUSIONS AND RELEVANCE

In this cohort study, infection-related hospitalization was associated with immediate and persistent cognitive decline among nursing home residents, with the largest increase in CFS scores among older residents, those with ADRD, and those who had experienced sepsis. Identification of NH residents at risk of worsened cognition after an infection-related hospitalization may help to ensure that their care needs are addressed to prevent further cognitive decline.

Gait Speed and Instrumental Activities of Daily Living in Older Adults After Hospitalization: A Longitudinal Population-Based Study

BACKGROUND

Hospitalization can impair physical and functional status of older adults, but it is unclear whether these deficits are transient or chronic. This study determined the association between hospitalization of older adults and changes in long-term longitudinal trajectories of two measures of physical and functional status: gait speed (GS) and Instrumental Activities of Daily Living measured with Functional Activities Questionnaire (FAQ).

METHODS

Linear mixed effects models assessed the association between hospitalization (non-elective vs. elective, and surgical vs. medical) and outcomes of GS and FAQ score in participants (>60 years old) enrolled in the Mayo Clinic Study of Aging who had longitudinal assessments.

RESULTS

Of 4,902 participants, 1,879 had ≥1 hospital admission. Median GS at enrollment was 1.1 m/s. The slope of the annual decline in GS before hospitalization was -0.015 m/s. The parameter estimate [95%CI] for additional annual change in GS trajectory after hospitalization was -0.009 [-0.011 to -0.006] m/s, P<0.001. The accelerated GS decline was greater for medical vs. surgical hospitalizations (-0.010 vs. -0.003 m/s, P=0.005), and non-elective vs. elective hospitalizations (-0.011 vs -0.006 m/s, P=0.067). The odds of a worsening FAQ-score increased on average by 4% per year. Following hospitalization, odds of FAQ-score worsening further increased (multiplicative annual increase in odds ratio per year [95%C] following hospitalization was 1.05 [1.03, 1.07], P<0.001).

CONCLUSIONS

Hospitalization of older adults is associated with accelerated long-term decline in GS and functional limitations, especially after non-elective admissions and those for medical indications. However, for most well-functioning participants these changes have little clinical significance.

Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

BACKGROUND

Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission.

AIM

To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness.

DESIGN

Pre- and post-cohort study.

METHODS

Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS).

RESULTS

There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4-24.0] days compared to 18.2 (95% CI 14.6-21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030).

CONCLUSION

This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative

BACKGROUND/OBJECTIVES

Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated.

DESIGN

We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status.

SETTING

Participating NFs during fiscal years 2017 to 2018.

PARTICIPANTS

There were 47,202 long-stay NF residents from 260 facilities in seven states.

INTERVENTION

CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform.

MEASUREMENTS

Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions.

RESULTS

Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital.

CONCLUSION

Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Association of Hospitalization with Long-Term Cognitive Trajectories in Older Adults

IMPORTANCE

Hospitalizations are associated with cognitive decline in older adults.

OBJECTIVE

To determine the association between hospitalization characteristics and the trajectory of cognitive function in older adults.

DESIGN

Population-based longitudinal study of cognitive aging.

SETTING

Olmsted Medical Center and Mayo Clinic, the only centers in Olmsted County, Minnesota, with hospitalization capacity.

PARTICIPANTS

Individuals without dementia at baseline, with consecutive cognitive assessments from 2004 through 2017, and at least one visit after the age of 60.

MEASUREMENTS

The primary outcome was longitudinal changes in global cognitive z-score. Secondary outcomes were changes in four cognitive domains: memory, attention/executive function, language, and visuospatial skills. Hospitalization characteristics analyzed included elective versus nonelective, medical versus surgical, critical care versus no critical care admission, and long versus short duration admissions.

RESULTS

Of 4,587 participants, 1,622 had 1 and more hospital admission. Before hospitalization, the average slope of the global z-score was -0.031 units/year. After hospitalization, the rate of annual global z-score accelerated by -0.051 (95% CI = -0.057, -0.045) units, P < .001, resulting in an estimated annual slope after the first hospitalization of -0.082. The accelerated decline was found in all four cognitive domains (memory, visuospatial, language, and executive, all P < .001). The acceleration of the decline in global z-score following hospitalization was greater for medical compared to surgical hospitalizations (slope change following hospitalization = -0.064 vs -0.034 for medical vs surgical, P < .001), and nonelective compared to elective admissions (slope change following hospitalization = -0.075 vs -0.037 for nonelective vs elective, P < .001). The acceleration of cognitive decline was not different for hospitalization with intensive care unit admission versus not.

CONCLUSIONS

Hospitalization of older adults is associated with accelerated decline of global and domain-specific cognitive domains, with the rate of decline dependent upon type of admission. The clinical impact of this accelerated decline will depend on the individual's baseline cognitive reserve and expected longevity.

Determinants of participation in a post-hospitalization physical exercise program for older adults

Background

Older patients often experience a decline in physical function and cognitive status after hospitalization. Although interventions involving physical exercise are effective in improving functional performance, participation in physical exercise interventions among older individuals is low. We aimed to identify factors that contribute to exercise refusal among post-hospitalized older patients.

Methods

A cross-sectional study of recruitment data from a randomized controlled trial was conducted involving 495 hospitalized people ≥70 years old. Sociodemographic and clinical data were obtained from the Basque Public Health System database. We determined physical function with the Short Physical Performance Battery (SPPB), nutritional status with the Mini-Nutritional Assessment, frailty according to the Fried phenotype criteria, and cognitive function with the Short Portable Mental Status Questionnaire (SPMSQ). Student’s t, Mann-Whitney U, or chi-squared tests were applied for bivariate analysis. Parameters significantly associated with participation were introduced in a logistic multivariate regression model.

Results

Among the analyzed patients, 88.8% declined participation in the physical exercise program. Multivariate regression revealed that older age (OR: 1.13; 95% CI: 1.07–1.19), poor nutritional status (OR: 0.81; 95% CI: 0.69–0.95), and reduced home accessibility (OR: 0.27; 95% CI: 0.08–0.94) were predictors of participation refusal. Moreover, patients who declined participation had worse performance on the SPPB (P < 0.05) and its tests of balance, leg strength, and walking speed (P < 0.05). No differences were found between groups in other variables.

Conclusions

This study confirms low participation of older adults in a post-hospitalization physical exercise program. Non-participation was associated with increased age, poor nutritional status, and reduced home accessibility. Our findings support the need for intervention design that accounts for these factors to increase older patient participation in beneficial exercise programs.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12619000093189, (date: January 22, 2019, retrospectively registered).

Do Caregiving Factors Affect Hospitalization Risk Among Disabled Older Adults?

BACKGROUND/OBJECTIVES

Hospitalization is common among older adults with disability, many of whom receive help from a caregiver and have dementia. Our objective was to evaluate the association between caregiver factors and risk of hospitalization and whether associations differ by dementia status.

DESIGN

Longitudinal observational study.

SETTING

The 1999 and 2004 National Long-Term Care Survey and the 2011 and 2015 National Health and Aging Trends Study, linked caregiver surveys, and Medicare claims.

PARTICIPANTS

A total of 2,589 community-living Medicare fee-for-service beneficiaries, aged 65 years or older (mean age = 79 years; 63% women; 31% with dementia), with self-care or mobility disability and their primary family or unpaid caregiver.

MEASUREMENTS

Self-reported characteristics of older adults and their caregivers were assessed from older adult and caregiver survey interviews. Older adult hospitalization over the subsequent 12 months was identified in Medicare claims. Multivariable Cox proportional hazards models adjusted for older adult characteristics and were stratified by dementia status.

RESULTS

In this nationally representative cohort, 38% of older adults with disabilities were hospitalized over 12 months following interview. Increased hospitalization risk was associated with having a primary caregiver who helped with healthcare tasks (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI) = 1.05-1.40), reported physical strain (aHR = 1.21; 95% CI = 1.04-1.42), and provided more than 40 hours of care weekly (aHR = 1.26; 95% CI = 1.04-1.54 vs ≤20 hours). Having a caregiver who had helped for 4 years or longer (vs <1 year) was associated with 38% lower risk of hospitalization (aHR = 0.62; 95% CI = 0.49-0.79). Older adults with and without dementia had similar rates of hospitalization (39.5% vs 37.3%; P = .4), and caregiving factors were similarly associated with hospitalization regardless of older adults' dementia status.

CONCLUSION

Select caregiving characteristics are associated with hospitalization risk among older adults with disability. Hospitalization risk reduction strategies may benefit from understanding and addressing caregiving circumstances.

Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients

Aim

Polypharmacy in elderly people is a social issue and has been reported to cause not only drug adverse events, but also falls, dysfunction and cognitive decline. Those events may trigger prolonged length of hospitalization. Therefore, the aim of this study was to investigate whether polypharmacy has a prolonging effect on hospitalization.

Methods

The study subjects were 584 patients in a university hospital in Japan who had been admitted for hepatectomy, pancreaticoduodenectomy, gastrectomy or colectomy, and to whom clinical pathways had been applied. In this study, polypharmacy was defined as taking five or more regular oral medications, and prolonged hospitalization was defined as hospitalization longer than that determined by the clinical pathway. Multiple logistic regression analysis was performed to investigate whether polypharmacy affects the length of hospitalization.

Results

The subjects were 348 males and 236 females, mean ± SD age of 65.8 ± 12.9 years. Among all subjects, 228 (39.0%) were receiving polypharmacy at admission, and the number of patients with prolonged hospitalization was 262 (44.9%). Multiple logistic regression analysis revealed that the following variables were significantly associated with prolonged hospitalization; polypharmacy (odds ratio = 1.532; 95% confidence interval = 1.010–2.327), age 50–59; 2.971 (1.216–7.7758), age 60–69; 2.405 (1.059–5.909), organ pancreas; 0.298 (0.122–0.708), operation time ≥386 min; 2.050 (1.233–3.432), intraoperative bleeding volume ≥401 mL; 2.440 (1.489–4.038), postoperative delirium; 2.395 (1.240–4.734), postoperative infection; 10.715 (4.270–33.059).

Conclusion

The current study revealed that polypharmacy at admission was an independent factor for prolonged hospitalization. In future, measures against polypharmacy are required, collaborating with outpatient clinics, family doctors and dispensing pharmacies. Geriatr Gerontol Int 2020; 20: 1085–1090..

Dietary Diversity Is Associated With Memory Status in Chinese Adults: A Prospective Study

BACKGROUND AND AIM

Subjective memory complaints are common in elderly people. Nutrition plays an important role in keeping brain health, however, the evidence on dietary diversity and subjective memory status is limited. This study aimed to investigate the effect of dietary diversity score (DDS) on memory status in Chinese adults in a prospective cohort study.

METHODS

Data of the China Health and Nutrition Survey was used in this study. A total of 4356 participants aged 50 years or older were enrolled in the analysis. DDS was calculated based on the dietary recall data collected in the wave of 2011. Information on self-report memory status (OK, good, or bad) and memory change in the past 12 months (stayed the same, improved, or deteriorated) were obtained from the wave of 2015. A memory score was calculated based on a subset of items of the Telephone Interview for Cognitive Status-modified. Multinomial logistic regression models were used to estimate the associations of DDS with memory status and memory change, and linear regression models were carried out to estimate the association between DDS and memory score.

RESULTS

In the study population, the percentages of participants who thought their memory was OK, bad, and good were 43.3, 24.3, and 32.4%, respectively. There were 1.4% of participants reported memory improvement in the past 12 months and 47.2% reported memory decline. Average memory score among participants was 12.8 ± 6.1. Compared with participants who thought their memory was OK, a higher DDS was associated with self-reported good memory (Odds Ratio [OR] 1.15, 95%CI 1.07-1.24) and inversely associated with bad memory (OR 0.82, 95%CI 0.75-0.89). In subgroup analysis, however, in participants aged 65 years and above, the association between DDS and self-reported good memory was insignificant (OR 1.09, 95%CI 0.94-1.25). Compared with participants whose memory stayed the same, higher DDS was inversely associated with memory decline (OR 0.85, 95%CI 0.80-0.91). Besides, higher DDS was associated with higher memory score (β 0.74, 95%CI 0.56-0.91).

CONCLUSION

This study revealed that higher DDS was associated with better memory status and was inversely associated with self-reported memory decline in Chinese adults.

Effects of exercise interventions on the functional status of acutely hospitalised older adults: A systematic review and meta-analysis

BACKGROUND

Acute hospitalisation can have adverse effects in older adults, notably functional decline. We aimed to summarize evidence on the effects of exercise interventions in acutely hospitalised older adults.

METHODS

Relevant articles were systematically searched (PubMed, Web of Science, Rehabilitation & Sports Medicine Source, and EMBASE) until 19^th March 2020. Randomized controlled trials (RCTs) of in-hospital exercise interventions versus usual care conducted in older adults (>60yrs) hospitalised for an acute medical condition were included. Methodological quality of the studies was assessed with the PEDro scale. Primary outcomes included functional independence and physical performance. Intervention effects were also assessed for other major outcomes (length of hospital stay, incidence of readmission, and mortality). A meta-analysis was conducted when ≥3 studies analysed the same outcome.

RESULTS

Fifteen studies from 12 RCTs (n = 1748) were included. Methodological quality of the studies was overall high. None of the studies reported any adverse event related to the intervention. Exercise interventions improved functional independence at discharge (standardized mean difference [SMD] = 0.64, 95% confidence interval = 0.19-1.08) and 1-3 months post-discharge (SMD = 0.29, 95%CI = 0.13-0.43), as well as physical performance (SMD = 0.57, 95%CI = 0.18-0.95). No between-group differences were found for length of hospital stay or risk of readmission or mortality (all p > 0.05).

CONCLUSIONS

In-hospital supervised exercise interventions seem overall safe and effective for improving - or attenuating the decline of - functional independence and physical performance in acutely hospitalised older adults. The clinical relevance of these findings remains to be confirmed in future research.

The Changes in Medication Prescribing Among the Older People with Cognitive Impairment in the Acute Care Setting

PURPOSE

Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period.

PATIENTS AND METHODS

Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses.

RESULTS

The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI.

CONCLUSION

The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.

Is hospitalisation a risk factor for cognitive decline in the elderly?

PURPOSE OF REVIEW

Cognitive decline is frequently reported after hospitalisation in the contexts of surgery, delirium and critical care. The question not adequately addressed is whether all types of acute hospitalisations increase the risk of cognitive decline. As acute hospitalisations are common in the elderly, who are also vulnerable to cognitive decline, this possible association is of significant concern.

RECENT FINDINGS

This review summarises cognitive outcomes from recent observational studies investigating acute hospitalisation (emergent and elective) in older age adults. Studies were identified from searching Medline, Embase and PsycINFO databases and citations lists. The highest incidence of cognitive decline has been reported following critical care admissions and admissions complicated by delirium, although all types of acute hospitalisations are implicated. Age is the most consistent risk factor for cognitive decline. Several etiological and therapeutic aspects are being investigated, particularly the measurement of inflammatory biomarkers and treatment with anti-inflammatory medications.

SUMMARY

Acute hospitalisation for any reason appears to increase the risk of cognitive decline in older adults, but the cause remains elusive. Future research must clarify the nature and modifiers of posthospitalisation cognitive change, a priority in the face of an ageing population.

Effect of income on length of stay in a hospital or long-term care facility among older adults with dementia in Japan

OBJECTIVE

We aimed to ascertain the degree of influence of income disparity among older people with newly developed dementia on the probability and duration of stay in a hospital or long-term care facility and the degree of influence on medical expenses for hospitalization and care costs.

METHODS

This was a retrospective cohort study. Study participants included 12 829 individuals aged 75 years or older not diagnosed with dementia between April 2012 and March 2013 but newly diagnosed with dementia between April 2013 and March 2014. Participants were categorized according to income. We evaluated the associations of income with the probability and duration of stay in a hospital or long-term care facility and the costs for hospitalization and care.

RESULTS

In the adjusted analyses, high-income individuals had a lower probability of admission to a hospital or long-term care facility than middle- and high-income individuals. In all hospitals, low-income individuals had the longest duration of stay, but in long-term care facilities, income categories varied by facility type. Medical expenses for hospitalization and care costs were highest in the low-income group.

CONCLUSION

Income category affects the probability and duration of stay in the hospital or a long-term care facility, as well as expenses for hospitalization and care. It is necessary to consider a policy to enable low-income older patients with dementia to continue living at home.

Multicomponent Physical Exercise in Older Adults after Hospitalization: A Randomized Controlled Trial Comparing Short- vs. Long-Term Group-Based Interventions

Multicomponent physical exercise is effective in curbing the effect of hospitalization in older adults. However, it is not well established which characteristics of the exercise interventions would optimize intervention sustainability and efficacy. This study compared the effects of two group-based multicomponent exercise interventions of different lengths in older adults after hospitalization. Fifty-five participants were randomly assigned to a short-term group-based branch (SGB, n = 27) or to a long-term group-based branch (LGB, n = 28). The SGB participated in a six-week multicomponent group-based exercise-training program followed by 18 weeks of home-based exercise. The LGB completed 12 weeks of each phase. Physical function, physical activity, quality of life, anthropometrics, and nutritional status were assessed at baseline, after 12 weeks, and after 24 weeks of intervention. Both groups improved physical function and nutritional status and increased physical activity after 12 weeks of intervention (paired student’s t-test, p < 0.01), and maintained the positive effects during the following 12 weeks. No group-by-time interaction was observed in any of the studied variables using mixed-model ANOVA. Based on these findings, we determined that 6 weeks of a group-based exercise intervention caused similar functional and nutritional benefits to a longer group-based intervention of 12 weeks when both are continued at home until 24 weeks.

Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey

BACKGROUND

Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany.

METHODS

A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested.

RESULTS

486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement.

CONCLUSIONS

Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.

Hospitalization, Alzheimer's Disease and Related Neuropathologies, and Cognitive Decline

Objective

To test the hypothesis that Alzheimer's disease and related neuropathologies contribute to the association between hospitalization and cognitive decline in old age.

Methods

As part of a longitudinal clinical–pathologic cohort study, 526 older persons (mean age at death = 90.9 years, 71% female) without dementia at baseline completed annual cognitive testing and were autopsied at death. Hospitalization information was obtained from linked Medicare claims records. Neuropathologic examination assessed β‐amyloid burden, tau tangle density, neocortical Lewy bodies, hippocampal sclerosis, chronic gross and microscopic cerebral infarcts, and transactive response DNA binding protein 43 kDa.

Results

Over a mean of 5.1 years, a total of 1,383 hospitalizations occurred, and the mean annual rate of hospitalization was 0.5 (standard deviation = 0.6, median = 0.4). Higher rate of hospitalization was not directly related to higher burden for any of the neuropathologic markers. Higher rate of hospitalization was associated with more rapid cognitive decline (estimate = −0.042, standard error [SE] = 0.012, p < 0.001), and after controlling for all 7 neuropathologic markers, the association was essentially the same (estimate = −0.040, SE = 0.013, p = 0.002). In a multivariable model with 3‐way interactions of neuropathologic markers with hospitalization rate and time, the association between hospitalization rate and faster cognitive decline was greater in persons with more tangle pathology (estimate for interaction = −0.007, SE = 0.002, p = 0.002) and in persons with neocortical Lewy bodies (estimate for interaction = −0.117, SE = 0.042, p = 0.005).

Interpretation

Older persons with more hospitalizations experienced faster rates of cognitive decline, and this association was more pronounced in persons with more tau tangle density and with neocortical Lewy body pathologies. ANN NEUROL 2019;86:844–852

Improvement During Inpatient Rehabilitation Among Older Adults With Guillain-Barré Syndrome, Multiple Sclerosis, Parkinson Disease, and Stroke

OBJECTIVE

The aim of the study was to quantify the improvement in independence experienced by patients with the following diagnoses: Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke after inpatient rehabilitation.

DESIGN

Subjects who were admitted to inpatient rehabilitation hospitals in 2012-2013 with an incident diagnosis of the following: Guillain-Barré syndrome (n = 1079), multiple sclerosis (n = 1438), Parkinson disease (n = 11,834), or stroke (n = 131,313), were included. The main outcome measure was improvement in Functional Independence Measure scores on self-care, mobility, and cognition during inpatient rehabilitation. We estimated percent improvement from a linear mixed-effects model adjusted for patients' age, sex, race/ethnicity, comorbidity count, diagnostic group (Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke), and admission score.

RESULTS

All patient diagnostic groups receiving inpatient rehabilitation improved across all three domains. The largest adjusted percent improvements were observed in the mobility domain and the smallest in the cognition domain for all groups. Percent improvement in mobility ranged from 84.9% (multiple sclerosis) to 144.0% (Guillain-Barré syndrome), self-care from 49.5% (multiple sclerosis) to 84.1% (Guillain-Barré syndrome), and cognition from 34.0% (Parkinson disease) to 51.7% (Guillain-Barré syndrome). Patients with Guillain-Barré syndrome demonstrated the greatest percent improvement across all three domains.

CONCLUSIONS

Patients with Guillain-Barré syndrome, multiple sclerosis, Parkinson disease, and stroke should improve during inpatient rehabilitation but anticipated outcomes for patients with Guillain-Barré syndrome should be even higher.

Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study

BACKGROUND

Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD.

OBJECTIVE

To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD.

METHODS

We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models.

RESULTS

Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records.

CONCLUSIONS

Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.

Successful stent implantation in a rural area on a patient with superior vena cava syndrome through specialist intervention: a case report

Superior vena cava syndrome (SVCS), which is characterized by facial edema and congestion of the head, upper extremities, and neck, is a life-threatening oncologic emergency. Although a combination of chemotherapy and radiation therapy has been considered as the standard treatment for SVCS, stent implantation to the superior vena cava (SVC) has been recently developed to alleviate edema or dyspnea caused by SVCS. On the other hand, stent implantation to the SVC requires skilled interventional cardiologists or radiologists. In general, those specialists reside in university hospitals or large hospitals in an urban area. In this case report, an 86-year-old man underwent stent implantation to a stenosed SVC in a rural area. Because the patient refused the transfer to the core, urban hospital, we invited a skilled interventional cardiologist from the core hospital and performed stent implantation to the SVC in a small, rural hospital. It is generally difficult to perform stent implantation for SVCS in a small hospital, because skilled operators in the field of interventional cardiology or radiology do not usually perform operations in smaller facilities. Our case indicates the importance of cooperation between rural generalists and urban specialists.

Feasibility and utility of a cognitive screening for risk stratification in hospitalized older patients

OBJECTIVES

To determine whether the Mini-Cog can be applied by nursing staff to hospitalized elderly patients for cognitive impairment associated risk stratification.

METHODS

This explorative prospective multicenter cohort study was carried out among 2522 patients aged 70 and older, hospitalized due to physical illness in eight hospitals in Rhineland-Palatinate, Germany. All patients were asked to conduct the Mini-Cog at the day of admission and were clustered into low-performance, intermediate-performance, and good-performance categories by trained nursing staff and two experienced geronto-psychiatrists as gold standard. Complications in the course of the treatment were monitored.

RESULTS

The Mini-Cog was conducted in 1398 (54%) out of 2522 eligible patients. Mini-Cog scores assessed by nursing staff differed from the gold standard in 327 cases (23.9%). According to the area under the curve (AUC), nursing staff identified cognitively low-performing patients almost as well as the geronto-psychiatrists (AUC = 0.862; 95% CI, 0.83-0.89; P < 0.001, accuracy 89.6%). Overall, 241 (17.6%) patients were classified as low performing. These patients had a significantly higher probability of suffering from at least one complication (odds ratio [OR] = 3.13; 95% CI, 2.09-4.70; calculated by a logistic regression model, adjusted for age), and they had a higher probability to show behavioral symptoms.

CONCLUSION

Even under naturalistic conditions, nursing staff detected cognitively low-performing inpatients with the Mini-Cog. Using this short screening instrument should enable to predict complications of hospitalized older patients associated with cognitive impairment, a precondition to implement targeted care for this vulnerable patient group.

Don't go there - It's not a nice place: Older adults' experiences of delirium

Delirium is a common neuropsychiatric disorder that causes fluctuations in consciousness and attention, impairments in cognitive functioning and information processing, and changes in how individuals perceive what is going on around them. Delirium is associated with increased mortality, ongoing impairment in cognitive functioning, and a high possibility of discharge to residential care. The experience of delirium may be distressing for the patient and their family. Despite the frequency of delirium in hospitalized elderly patients, there is a dearth of literature that examines their experience of this phenomenon, and how it affects individuals as they continue their lives. This study uses descriptive qualitative methodology to explore the question: 'What is the experience of delirium for older adults during hospitalisation?' Data were collected from older adults who had received hospital care in a tertiary general hospital setting. Seven participants were recruited between January and June 2017. Semi-structured individual interviews were used to gather data which was analysed using content analysis. Four themes were identified. These were sense of confusion, disrupted sense of autonomy, perceptual disturbances, and emotional response. Participants exercised agency in the way they responded to these experiences. The study highlighted the need for delirium prevention, and education to improve nurses' recognition, understanding, and management of delirium. In particular, there is a need for nurses to attend to the psychological and emotional experience of delirium.

Association of Financial Literacy With Hospitalization in Community-dwelling Older Adults

BACKGROUND

Lowering the likelihood of hospitalization in older adults is a major public health goal for modern health care systems. Emerging data suggest that financial literacy is an important determinant of health outcomes in old age, but the relationship with hospitalization has not been explored.

OBJECTIVE

To test the hypothesis that better financial literacy is related to lower risk of hospitalization in older persons.

DESIGN

Prospective cohort study.

PARTICIPANTS

Data came from community-dwelling older adults (n=388) without dementia enrolled in the Rush Memory and Aging Project.

MAIN MEASURES

Participants underwent detailed assessment of financial literacy and cognition. Data on hospitalizations were obtained from linked Medicare claims records (MedPAR file).

RESULTS

Over an average of 1.8 years, 117 participants (30%) were hospitalized, and a third of those hospitalized experienced multiple hospitalizations. In a modified Poisson regression model adjusted for age, sex, education, and cognition, better financial literacy was associated with lower risk of hospitalization. In a model further adjusted for income, physical activity, body mass index, smoking, social network size, chronic conditions, basic and instrumental activities of daily living disability, and depressive symptoms, the association was unchanged. Secondary analyses showed the association was primarily driven by conceptual knowledge rather than numeracy.

CONCLUSIONS

Higher financial literacy is related to a lower risk of hospitalization in older persons without dementia, after adjusting for cognitive, health, functional, and socioeconomic factors. The ability to understand and utilize financial concepts may represent a potentially modifiable risk factor for hospitalization in later life.

Resident-Level Factors Associated with Hospitalization Rates for Newly Admitted Long-Term Care Residents in Canada: A Retrospective Cohort Study

Chez les résidents en soins de longue durée (SLD), l’hospitalisation peut amener des complications telles que le déclin fonctionnel. L’objectif de notre étude était d’examiner l’association entre les données démographiques et de santé et le taux d’hospitalisation des résidents nouvellement admis en SLD. Nous avons mené une étude de cohorte rétrospective incluant tous les centres de SLD de six provinces et d’un territoire du Canada, à l’aide des données de la RAI-MDS 2.0 et de la Discharge Abstract Database. Nous avons inclus les résidents nouvellement admis ayant eu une évaluation entre le 1er janvier et le 31 décembre 2013 (n = 37 998). Les résidents de sexe masculin avec une santé plus instable et une déficience fonctionnelle de modérée à grave présentaient des taux d’hospitalisation plus élevés, tandis que les résidents avec une déficience cognitive de modérée à grave avaient des taux moindres. Les résultats de notre étude pourraient contribuer à l’identification des résidents nouvellement admis qui seraient plus à risque d’hospitalisation et à l’élaboration de stratégies préventives plus ciblées, incluant la réadaptation, la planification préalable de soins, les soins palliatifs et les services gériatriques spécialisés.