309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Background

Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty.

Methods

All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons.

Results

Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age >75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465).

Conclusion

There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

319 CAN INDEX BARTHEL SCORE AT EMERGENCY DEPARTMENT PRESENTATION PREDICT ADVERSE OUTCOMES AMONG OLDER ADULTS AT 30 DAYS AND 6 MONTHS?

Background

Frailty is acknowledged as a significant syndrome particularly in the older population. Monitoring frailty in late life aetiology and recognising the value of frailty as a marker of risk for adverse health outcomes is vital and ensures the identification of opportunities for intervention with this cohort in clinical practice. The aim of this prospective cohort study is to examine if an index Barthel Score at Emergency Department presentation predicts adverse outcomes among older adults at 30 days and 6 months.

Methods

Six-hundred and fifty older adults (≥65 years) attending a university model 4 hospital ED were recruited. Baseline evaluation included the Barthel Index. Adverse outcomes (hospital readmission or death) were recorded by a research nurse at 30 days and 6 months, blinded to Barthel score. Descriptive statistics were used to profile the population and report the incidence of adverse outcomes.

Results

At 30 days, 61 older adults had either being admitted to hospital (n=28) or died (n=33) and at 180 days a further 72 had been admitted (n=43) or died (n=29). A total of 29% (n=189) of the population had a Barthel score of ≤15 indicating moderate dependency. Of this cohort, 70% had an adverse outcome-readmitted or died within 180 days.

Conclusion

It may be worth looking at introducing the Barthel Index as a routine measure of activity for older adults presenting to the ED. This tool demonstrates an increased risk of adverse outcomes among older adults who present with moderate dependency. Early intervention either in the hospital or community setting with this ‘at risk’ cohort may serve to reduce adverse outcomes among this group.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

236 PREDICTORS OF ADVERSE OUTCOMES IN OLDER PATIENTS DISCHARGED DIRECTLY FROM THE EMERGENCY DEPARTMENT

Background

Over 40% of older patients are discharged directly from the Emergency Department (ED) and this cohort is at increased risk of adverse outcomes.

The purpose of this study was to explore the factors that predict future adverse outcomes in this cohort to inform practice, resource planning and policy.

Methods

A secondary analysis of the OPTIMEND, a single-centre, randomized-controlled trial was completed. OPTIMEND examined the effectiveness of an intervention by a team of Health and Social Care Professionals along with usual care and compared this to standard ED care alone (Dec 2018-May 2019). The inclusion criteria were adults aged 65 years and over presenting to the ED at a University Teaching Hospital with medical complaints and a Manchester Triage System category 2–5.

Results

220 patients were included (median age 79 years; 62% female). Median length of stay in ED was 5.5 hrs. 70 patients re-attended the ED within 6 months with 43 re-hospitalised within 6 months. 9 patients died within six months of discharge.

Multivariant logistic regression was completed. Age was the only independent predictor of mortality within six months of discharge {Odds Ratio (OR) 1.15, p = 0.044}. Past hospitalisation (<6 months) was associated with a lower likelihood of ED re-attendance, and rehospitalization within six months of discharge (OR: 0.452 p = 0.022; OR:0.442, p = 0.046; respectively). Clinical Frailty Score was associated with a significantly higher likelihood of rehospitalization (OR:1.48, p = 0.031) but not with ED revisits (OR: 1.235, p = 0.165).

Conclusion

Older people have a high ED re-attendance rate of 33% after an index visit with 20% hospitalized subsequently. Frailty is a significant predictor of rehospitalisation. Rapid and targeted intervention for frail patients who reattend the ED should be a priority for the integrated care program to enhance admission avoidance.

The FIM instrument to identify patients at risk of falling in geriatric wards: a 10-year retrospective study

OBJECTIVES

the main objective was to evaluate if the admission functional independence measure (FIM) score could be used to predict the risk of falls in geriatric inpatients.

DESIGN

a 10-year retrospective study was performed.

SETTING

the study was conducted in a 298-bed geriatric teaching hospital in Geneva, Switzerland.

SUBJECTS

all patients discharged from the hospital from 1 January 1997 to 31 December 2006 were selected.

MAIN OUTCOME MEASURES

measures used were FIM scores at admission using the FIM instrument and number of falls extracted from the institution's fall report forms.

RESULTS

during the study period, there were 23,966 hospital stays. A total of 8,254 falls occurred. Of these, 7,995 falls were linked to 4,651 stays. Falls were recorded in 19.4% of hospital stays, with a mean incidence of 7.84 falls per 1,000 patients-days. Although there was a statistically significant relationship between total FIM score, its subscales, and the risk of falling, the sensitivity, specificity, positive predictive value and negative predictive value obtained with receiver operating characteristic curves were insufficient to permit fall prediction. This might be due in part to a non-linear relationship between FIM score and fall risk.

CONCLUSION

in this study, the FIM instrument was found to be unable to predict risk of falls in general geriatric wards.

Cardiac operations in patients with low-grade small lymphocytic malignancies

BACKGROUND

Low-grade small lymphocytic (B cell) malignancies (encompassing chronic lymphocytic leukemia and some types of non-Hodgkin lymphoma) are diseases of the elderly. Open cardiac procedures are known to have increased risk of postoperative infection and other morbidities in these immunodeficient patients. Outcome of open cardiac procedures in these patients was reviewed retrospectively.

PATIENTS

Thirteen patients (aged 58-82 years, 11 men, 2 women) with these lymphocytopathologic diseases (8 with chronic lymphocytic leukemia and 5 with non-Hodgkin lymphoma) underwent cardiac operations between January 1977 and June 1998. Mean age was 72 +/- 2.1 years. Isolated coronary artery bypass grafting was performed in 11 and combined procedures and double valve replacement were performed in 1 each. Preoperatively, 9 patients were in a low-risk clinical stage. Mean preoperative duration of lymphocytopathologic disease was 6.1 +/- 1.6 years. Mean preoperative New York Heart Association functional class was 2.8.

RESULTS

There was no operative death. Average stay in the intensive care unit was 41.4 +/- 8.6 hours. Postoperative leg and superficial sternal wound infections were encountered in 3 patients. Average postoperative hospital stay was 10.0 +/- 1.7 days. During the follow-up up to 72 months, 1 patient underwent a second cardiac operation. There was 1 late death 4 years later. Coronary stenting was done in 1 patient and a cardioverter-defibrillator was implanted in another patient for recurrent angina. Three patients underwent chemotherapy. Cardiac and lymphocytopathologic status remained stable in others.

CONCLUSIONS

Acceptable outcome may be anticipated after cardiac operations in patients with low-grade chronic lymphocytic leukemia and non-Hodgkin lymphoma in early stages. However, the possibility of infection and progression of cardiac and lymphocytopathologic status in these patients should call for caution.

Cardiac reoperations in octogenerians

OBJECTIVE

In recent years, satisfactory outcome of primary cardiac operation in octogenerians and increased ageing of cardiac surgical population in western hospitals have led to increased expectations and referrals for reoperation. Outcome of reoperation in this aged subset was analysed.

METHODS

Consecutive 18 octogenerians (mean age 81.2 years, 10 men, eight women) undergoing cardiac reoperations from November 1989 through August 1998 were retrospectively reviewed.

RESULTS

They represented 6.2% of all octogenerian cardiac surgical patients and 2.7% of all reoperations during the same period. Mean preoperative NYHA class was 3.4 and Parsonnet score was 29.4. The interval to reoperation was 114.5+/-11.96 (4-188) months. Priority was urgent in 11 and elective in seven patients. The procedures included four AVRs, five MVRs (including two associated TVAs), six CABGs and one each of MVR with CABG, AVR with CABG and AVR, MVR and CABG. Average graft/patient was 2.3. Mean ICU stay was 4.6+/-1.5 (1-28) days. There was one hospital death (5.5%) on 18 pod after MVR in an 83-year-old woman. Mean postoperative stay was 20.2+/-5.13 (8-93) days. There were three late deaths (17.6%)--at 32 months after MVR, at 44 and 63 months after CABG. Long-term survivors were 90% among men and 50% among women who were followed up for 42.7+/-6.9 (9-93) months. Mean Karnofsky score in survivors at 1 year of follow-up was 78.5+/-2.9. Despite continued medication in all survivors, mean current NYHA is 1.9 and most have improved lifestyle.

CONCLUSIONS

Satisfactory outcome may be expected after cardiac reoperations in highly selected octogenerians. However, increased procedural risks, complications, hospital stay and slower convalescence during early follow-up may be anticipated, and will indicate very careful screening. These results indicate a need to reconsider the treatment policy in primary operation with regard to choice of graft conduits and prosthetic valves in other elderly patients.

Functional assessment in partial hospitalization: clinical and administrative applications and implications after one year's utilization of the Framingham Functional Assessment Scale

This paper presents the use of functional assessment as one response to the growing need for objective measures of outcome in psychiatric treatment. The Framingham Functional Assessment Scale was developed in 1979 as a functional assessment measure to form the basis of a client-oriented cost-outcome system for Medicaid reimbursement in Massachusetts. Clinical and administrative findings from 1 year's utilization of the scale are presented. Level of functioning (LOF) scores in a sample of 45 clients are analyzed to determine the amount of LOF change that occurred during the course of an intensive, 13-week, day-treatment program. Trends and patterns of LOF change are described. Utilization of functional assessment input/outcome data in administrative decision making is discussed, in light of increasing economic constraints in mental-health programs and concomitant demands for service accountability.