Recognition of cognitive dysfunction in hospitalised older patients: a flash mob study

BACKGROUND

It is important that healthcare professionals recognise cognitive dysfunction in hospitalised older patients in order to address associated care needs, such as enhanced involvement of relatives and extra cognitive and functional support. However, studies analysing medical records suggest that healthcare professionals have low awareness of cognitive dysfunction in hospitalised older patients. In this study, we investigated the prevalence of cognitive dysfunction in hospitalised older patients, the percentage of patients in which cognitive dysfunction was recognised by healthcare professionals, and which variables were associated with recognition.

METHODS

A multicentre, nationwide, cross-sectional observational study was conducted on a single day using a flash mob study design in thirteen university and general hospitals in the Netherlands. Cognitive function was assessed in hospitalised patients aged ≥ 65 years old, who were admitted to medical and surgical wards. A Mini-Cog score of < 3 out of 5 indicated cognitive dysfunction. The attending nurses and physicians were asked whether they suspected cognitive dysfunction in their patient. Variables associated with recognition of cognitive dysfunction were assessed using multilevel and multivariable logistic regression analyses.

RESULTS

347 of 757 enrolled patients (46%) showed cognitive dysfunction. Cognitive dysfunction was recognised by attending nurses in 137 of 323 patients (42%) and by physicians in 156 patients (48%). In 135 patients (42%), cognitive dysfunction was not recognised by either the attending nurse or physician. Recognition of cognitive dysfunction was better at a lower Mini-Cog score, with the best recognition in patients with the lowest scores. Patients with a Mini-Cog score < 3 were best recognised in the geriatric department (69% by nurses and 72% by physicians).

CONCLUSION

Cognitive dysfunction is common in hospitalised older patients and is poorly recognised by healthcare professionals. This study highlights the need to improve recognition of cognitive dysfunction in hospitalised older patients, particularly in individuals with less apparent cognitive dysfunction. The high proportion of older patients with cognitive dysfunction suggests that it may be beneficial to provide care tailored to cognitive dysfunction for all hospitalised older patients.

Development of a practical guideline for person centred goal setting in geriatric rehabilitation: a participatory action research

PURPOSE

To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting.

METHODS

Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline.

RESULTS

In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously.

CONCLUSION

In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

CO-CREATING A GUIDELINE FOR MANAGING CHALLENGING BEHAVIOR OF MIGRANTS WITH DEMENTIA AT HOME

Challenging behaviour is common in people with dementia at home. Nurses guide people with dementia and their informal caregivers managing challenging behaviour. However, common nursing guidelines for challenging behaviour in home care are unsuitable to the situation of migrants with dementia. We started a co-creation project with home care nurses, dementia case managers, informal caregivers of migrant background and student nurses as co-researchers that aims to develop an appropriate guideline. Semi-structured interviews at the start explored the current experiences with challenging behaviour. Interview results informed several working sessions where we discussed the results and used creative working methods such as role play to develop a first prototype of the guideline. The prototype was implemented in the daily practice of six home care teams and followed up during reflection meetings with our co-researchers. Our guideline puts special attention to getting familiar with each other before taking steps in managing challenging behaviour.

The role of the Sunfrail tool in the screening of frailty and in integrated community-hospital care pathways: a retrospective observational study

Background

One of the most problematic expression of ageing is frailty, and an approach based on its early identification is mandatory. The Sunfrail-tool (ST), a 9-item questionnaire, is a promising instrument for screening frailty.

Aims

To assess the diagnostic accuracy and the construct validity between the ST and a Comprehensive Geriatric Assessment (CGA), composed by six tests representative of the bio-psycho-social model of frailty;

To verify the discriminating power of five key-questions of the ST;

To investigate the role of the ST in a clinical-pathway of falls’ prevention.

Methods

In this retrospective study, we enrolled 235 patients from the Frailty-Multimorbidity Lab of the University-Hospital of Parma. The STs’ answers were obtained from the patient’s clinical information. A patient was considered frail if at least one of the CGAs’ tests resulted positive.

Results

The ST was associated with the CGA’s judgement with an Area Under the Curve of 0.691 (CI 95%: 0.591–0.791). Each CGA’s test was associated with the ST total score. The five key-question showed a potential discriminating power in the CGA’s tests of the corresponding domains. The fall-related question of the ST was significantly associated with the Short Physical Performance Battery total score (OR: 0.839, CI 95%: 0.766–0.918), a proxy of the risk of falling.

Discussion

The results suggest that the ST can capture the complexity of frailty. The ST showed a good discriminating power, and it can guide a second-level assessment to key frailty domains and/or clinical pathways.

Conclusions

The ST is a valid and easy-to-use instrument for the screening of frailty.

Known in the nursing home: development and evaluation of a digital person-centered artistic photo-activity intervention to promote social interaction between residents with dementia, and their formal and informal carers

BACKGROUND

To address the lack of social interaction and meaningful activities for persons with dementia (PWD) in nursing homes an artistic Photo-Activity was designed. The present study aims to develop a digital version of the Photo-Activity and to investigate its implementation and impact on nursing home residents with advanced dementia, and their (in)formal carers.

METHODS

First, within a user-participatory design, a digital-app version of the Photo-Activity will be developed and pilot-tested, in co-creation with (in)formal carers and PWD. Next, the feasibility and effectiveness of the Photo-Activity versus a control activity will be explored in a randomized controlled trial with nursing home residents (N=90), and their (in)formal carers. Residents will be offered the Photo-Activity or the control activity by (in)formal carers during one month. Measurements will be conducted by independent assessors at baseline (T0), after one month (T1) and at follow up, two weeks after T1 (T2). Qualitative and quantitative methods will be used to investigate the effects of the intervention on mood, social interaction and quality of life of the PWD, sense of competence of informal carers, empathy and personal attitude of the formal carers, and quality of the relationship between the PWD, and their (in)formal carers. In addition, a process evaluation will be carried out by means of semi-structured interviews with the participating residents and (in)formal carers. Finally, an implementation package based on the process evaluation will be developed, allowing the scaling up of the intervention to other care institutions.

DISCUSSION

Results of the trial will be available for dissemination by Spring 2023. The digital Photo-Activity is expected to promote meaningful connections between the resident with dementia, and their (in)formal carers through the facilitation of person-centered conversations.

TRIAL REGISTRATION

Netherlands Trial Register: NL9219 ; registered (21 January 2021); NTR (trialregister.nl).

Goal-setting in geriatric rehabilitation: Can the nursing profession meet patients' needs? A narrative review

STUDY OBJECTIVE

To provide an overview of patients' needs concerning goal-setting, and indications of how those needs can be met by nurses.

METHODS

A narrative review. Pubmed and Cinahl were searched through March 1, 2020 for: patients' experiences concerning goal-setting and the role of nursing in rehabilitation. Additional articles were found through snowballing. A total of 22 articles were reviewed on patients' experiences, and 12 on the nursing role.

RESULTS

Patients need to be prepared for collaborating in goal-setting and to receive an explanation about their part in that process. The multiplicity of disciplines may cloud patients' understanding of the process. The nurse's planning of the rehabilitation process should be aimed at resolving this issue. Goals need to be meaningful, and patients need support in attaining them. The interpretive, integrative, and consoling functions of Kirkevold's nursing role are suitable to meet these needs.

CONCLUSIONS

Both the literature about patients' needs regarding goal-setting and the nursing role make clear that the way nurses work in rehabilitation can gain in clarity. Strengthening the role of nurses will improve the goal-setting process for patients. Interprofessional collaboration, clear work procedures, continuity of care, time and trust, and the physical environment all are important to reinforce this role.

A Comparison of Different Modelling Techniques in Predicting Mortality with the Tilburg Frailty Indicator (Preprint)

Background

Objective

Methods

Results

Conclusions

Coexisting Frailty With Heart Failure

People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.

Heart Failure and Problems with Frailty Syndrome: Why it is Time to Care About Frailty Syndrome in Heart Failure

Frailty syndrome (FS) is an independent predictor of mortality in cardiovascular disease and is found in 15–74% of patients with heart failure (HF). The syndrome has a complex, multidimensional aetiology and contributes to adverse outcomes. Proper FS diagnosis and treatment determine prognosis and support the evaluation of treatment outcomes. Routine FS assessment for HF patients should be included in daily clinical practice as an important prognostic factor within a holistic process of diagnosis and treatment. Multidisciplinary team members, particularly nurses, play an important role in FS assessment in hospital and primary care settings, and in the home care environment. Raising awareness of concurrent FS in patients with HF patients and promoting targeted interventions may contribute to a decreased risk of adverse events, and a better prognosis and quality of life.

Frailty Syndrome: Nursing Interventions

Background

Frailty syndrome is now becoming a challenge for multidisciplinary teams. Frailty assessment in elderly patients is recommended due to the associated cascade of irreversible alterations that ultimately result in disability.

Aims

The purpose of this article is to identify interventions, which can be implemented and performed by nurses as part of a multidisciplinary plan. Nursing strategies related to nutrition, polypharmacy, adherence to treatment, falls, exercise, and mood and cognitive intervention are described.

Design

Discussion paper.

Data sources

Relevant and up-to-date literature from PubMed, MEDLINE, and Scopus databases regarding the selected issues, such as nutritional status, polypharmacy, falls, physical activity, and cognitive functions.

Conclusion

Frailty is considered preventable or even reversible with the appropriate interventions, which can help maintain or even restore physical abilities, cognitive function, or nutritional status in frail elderly patients. Hence, the nursing interventions are significant in clinical practice and should be implemented for frail patients.

Implications for nursing

Health-care providers, especially nurses, in their clinical practice should recognize not only elderly patients but also elderly patients with concurrent frailty, requiring intensified therapeutic interventions tailored to their individual needs. Frailty syndrome is undoubtedly a challenge for multidisciplinary teams providing health care for geriatric patients.

Hypertension and Frailty Syndrome in Old Age: Current Perspectives

Hypertension is both a health problem and a financial one globally. It affects nearly 30 % of the general population. Elderly people, aged ≥65 years, are a special group of hypertensive patients. In this group, the overall prevalence of the disease reaches 60 %, rising to 70 % in those aged ≥80 years. In the elderly population, isolated systolic hypertension is quite common. High systolic blood pressure is associated with an increased risk of cardiovascular disease, cerebrovascular disease, peripheral artery disease, cognitive impairment and kidney disease. Considering the physiological changes resulting from ageing alongside multiple comorbidities, treatment of hypertension in elderly patients poses a significant challenge to treatment teams. Progressive disability with regard to the activities of daily life, more frequent hospitalisations and low quality of life are often seen in elderly patients. There is discussion in the literature regarding frailty syndrome associated with old age. Frailty is understood to involve decreased resistance to stressors, depleted adaptive and physiological reserves of a number of organs, endocrine dysregulation and immune dysfunction. The primary dilemma concerning frailty is whether it should only be defined on the basis of physical factors, or whether psychological and social factors should also be included. Proper nutrition and motor rehabilitation should be prioritised in care for frail patients. The risk of orthostatic hypotension is a significant issue in elderly patients. It results from an autonomic nervous system dysfunction and involves maladjustment of the cardiovascular system to sudden changes in the position of the body. Other significant issues in elderly patients include polypharmacy, increased risk of falls and cognitive impairment. Chronic diseases, including hypertension, deteriorate baroreceptor function and result in irreversible changes in cerebral and coronary circulation. Concurrent frailty or other components of geriatric syndrome in elderly patients are associated with a worse perception of health, an increased number of comorbidities and social isolation of the patient. It may also interfere with treatment adherence. Identifying causes of non-adherence to pharmaceutical treatment is a key factor in planning therapeutic interventions aimed at increasing control, preventing complications, and improving long-term outcomes and any adverse effects of treatment. Diagnosis of frailty and awareness of the associated difficulties in adhering to treatment may allow targeting of those elderly patients who have a poorer prognosis or may be at risk of complications from untreated or undertreated hypertension, and for the planning of interventions to improve hypertension control.

Predictive Value of Gait Speed and Frailty Indicators on Survival Time and Time Until Discharge to Home in Ambulant Older Patients in a Specialized Rehabilitation Center

BACKGROUND AND PURPOSE

"Frailty" is a frequently used term in both scientific research and clinical practice, but it has proven to be difficult to recognize and measure frailty. In this study, we aim to identify variables related to frailty as simple and unambiguous predictors of time until discharge to home and until mortality for ambulant individuals residing in a rehabilitation center for older people.

METHODS

This was a longitudinal cohort study. We included data on people admitted to a Dutch rehabilitation center for older people between September 15, 2013, and September 10, 2014 (n = 389). At admission, we collected data regarding participants' demography, details of their admission and origin as well as their gait speed. We also asked both participants and their physiotherapists whether the patients experienced problems as a consequence of fatigue, mobility, balance, or unintentional weight loss (yes/no), which are considered to be indicators of frailty. Date of discharge or death was recorded upon occurrence. We used survival analyses to establish associations between frailty indicators and gait speed with time until death and time until discharge to home.

RESULTS AND DISCUSSION

We found associations between patients' and physiotherapists' reports regarding indicators of frailty with mortality and discharge to home. Although patients' and physiotherapists' scores were strongly correlated, the physiotherapists' scores proved to be more accurate in predicting time until discharge to home and mortality. Time until death was best predicted by the physiotherapists' report that a patient was fatigued (hazard ratio = 4.09; 95% confidence interval = 1.41-11.83; P < .01). Time until discharge to home was strongly related to physiotherapists' reports of unintentional weight loss in the patient (hazard ratio = 0.67; 95% confidence interval = 0.48-0.95; P < .05). We did not find a relationship between gait speed and time until death and discharge to home.

CONCLUSIONS

Simple yes/no reports by physiotherapists at the time of admission regarding patients feeling fatigued and losing weight unintentionally showed strong associations with time until death and time until discharge to home. These simple questions could be used for screening at admission to identify people at risk of prolonged rehabilitation and mortality.

The comprehensive frailty assessment instrument: development, validity and reliability

Population aging forces governments to change their policy on elderly care. Older people, even if they are frail and disabled, are motivated to stay in their own homes and environment for as long as possible. Consequently, the early detection of frail older persons is appropriate to avoid adverse outcomes. Several instruments to detect frailty exist, but none use environmental indicators. This study addresses the development and psychometric properties of the Comprehensive Frailty Assessment Instrument (CFAI). This new self-reporting instrument includes physical, psychological, social and environmental domains. The CFAI showed good fit indices and a high reliability. The underlying structure of the CFAI demonstrates the multidisciplinary nature of frailty. Using the CFAI can stimulate nurses and other community healthcare providers toward a more holistic approach of frailty and can guide them to take appropriate interventions to prevent adverse outcomes such as disabilities or hospitalization.