Best practice interventions to improve the management of older people in acute care settings: a literature review

Persistent cognitive decline in older hospitalized patients in Taiwan

AIM

This paper is a report of a study conducted to determine the prevalence and predictors of persistent and transient cognitive decline in older hospitalized patients over 6 months after hospital discharge.

BACKGROUND

Cognitive decline occurs in 16-35.5% of older hospitalized patients, but this decline may be persistent rather than transient. Distinguishing persistent from transient cognitive decline is clinically useful.

METHODS

For this prospective cohort study, 291 older patients were recruited from five medical and surgical units at a tertiary medical centre in Taiwan between 2004 and 2006. Participants were assessed for cognitive status by scores on the Mini-Mental State Examination at admission, discharge, 3 and 6 months postdischarge. Persistent cognitive decline was defined as continuing score reduction and > or =3-point reduction 6 months postdischarge. Transient decline was defined as > or = 3-point reduction at some stage, with a total decline < 3 points 6 months postdischarge. Findings. The cognitive status of the majority of participants (57.4%, n = 167) decreased > or =3 points during follow-up. Of these decliners, 59 (35.3%) had persistent cognitive decline, with an average 5.32-point reduction 6 months postdischarge. Forty-six (27.5%) participants experienced transient cognitive decline. After multiple adjustments in logistic regression analysis, persistent decline was predicted by no in-hospital functional decline (OR = 0.16, P = 0.002), more re-admissions after discharge (OR = 2.42, P = 0.020), and older age (OR = 1.09, P = 0.048).

CONCLUSION

A new perspective is needed on discharge planning on patients at risk for persistent cognitive decline. Nurses can oversee the delivery of care, identify cognitive decline, refer patients, and educate families on strategies to enhance cognitive functioning for their aging relatives.

Short-term geriatric assessment units: 30 years later

Background

The increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them.

Methods

In 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their unit's operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile.

Results

Overall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAU's operation.

Conclusions

The GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAU's primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review

AIM

This paper is a report of a literature review conducted to analyse data from published studies reporting nursing interventions targeted at older attendees of emergency departments (EDs), and to provide a critical appraisal of the evidence concerning their effectiveness.

BACKGROUND

Attendance at hospital EDs by older persons presents opportunities for targeted interventions to address actual and potential problems associated with or in addition to the presenting problem. The evidence concerning the effectiveness of such interventions is mixed.

DATA SOURCES

Studies were retrieved from a systematic search of published works indexed in CINAHL, MEDLINE (PubMed), Science Direct and the Cochrane Central Register of Controlled Trials (CENTRAL).

METHODS

A systematic review of effectiveness was conducted using the Cochrane Effective Practice and Organisation of Care guidelines and a narrative synthesis approach for data handling and presentation. The review period was 1992 to 31 August 2008.

RESULTS

Nursing assessment and referral interventions have demonstrated effectiveness in reducing service use and improving physical function, but have failed to demonstrate statistically significant effects on predicted patient and/or health systems outcomes.

CONCLUSION

The evidence of the effectiveness of gerontologically informed nursing assessment and referral interventions in EDs must be accepted with caution, as not all studies demonstrated effectiveness in predicted patient and/or health systems outcomes, and the testing of complex social interventions in randomized clinical trials is inherently problematic. Further evidence of the effectiveness of nursing interventions is required, and such evidence might be usefully demonstrated using pragmatic, as opposed to explanatory, trials.

The Nursing Practice Environment and Nurse-Perceived Quality of Geriatric Care in Hospitals

The relationships between general and geriatric-specific nursing practice environments (NPEs) and nurse-perceived quality of geriatric care in hospitals were examined using the Nurses Improving Care for Healthsystems Elders benchmarking database. The overall general NPE was negatively related, but the overall geriatric-specific NPE was positively related to quality of geriatric care. Among five subdomains of the general NPE measured by the Practice Environment Scale of the Nursing Work Index, Nurse Participation in Hospital Affairs was positively related to quality of geriatric care, whereas two subdomains were not significant, and another two were negatively related to quality of geriatric care. All three subdomains of the geriatric-specific NPE measured by the Geriatric Nursing Practice Environment scale were positively related to quality of geriatric care when adjusting for general NPE. These findings suggest geriatric-specific organizational support combined with nurse involvement in hospital decision making is critical for delivering quality geriatric care.