Factors affecting survival of elderly nursing home residents

Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER)

OBJECTIVES

To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents.

DESIGN

Modified stepped-wedge unit-level intervention.

SETTING AND PARTICIPANTS

Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs.

METHODS

Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2.

RESULTS

There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2.

CONCLUSIONS AND IMPLICATIONS

SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.

Mortality in nursing home residents stratified according to subtype of dementia: a longitudinal study over three years

Background

There are several subtypes of dementia caused by different pathophysiology and with different clinical characteristics. Irrespective subtype, the disease is progressive, eventually leading to the need for care and supervision on a 24/7 basis, often provided in nursing homes (NH). The progression rate and course of the disease might vary according to subtype. The aim of this study was to explore whether the mortality rate for NH residents varied according to the subtype of dementia.

Methods

NH residents were followed from admission to NH over a period of 36 months or until death with annual follow-up examinations. Demographic and clinical data were collected. The diagnosis of dementia and its subtype at baseline (BL) were set according to international accepted criteria. Kaplan-Meier analysis was performed to estimate median survival time. A Cox regression model was estimated to assess the impact of dementia diagnosis and demographic and clinical variables on mortality.

Results

A total of 1349 participants were included. When compared to persons with Alzheimer’s disease (AD), persons with frontotemporal dementia (FTD) and dementia with Lewy bodies or Parkinson’s disease dementia (DLB/PDD) were younger and had more neuropsychiatric symptoms. Median survival for the total sample was 2.3 years (95% confidence interval: 2.2–2.5). When compared to persons with AD, having no dementia or unspecified dementia was associated with higher mortality, while we found similar mortality in other subtypes of dementia. Higher age, male gender, poorer general health, higher dependency in activities of daily living, and more affective symptoms were associated with higher mortality.

Conclusion

Mortality did not differ across the subtypes of dementia, except in persons with unspecified dementia or without dementia, where we found a higher mortality. With a median survival of 2.3 years, NH residents are in the last stage of their lives and care and medical follow-up should focus on a palliative approach. However, identifying the subtype of dementia might help carers to better understand and address neuropsychiatric symptoms and to customize medical treatment.

Explanatory survival model for nursing home residents- a 9-year retrospective cohort study

PURPOSE

There is a gap in the literature regarding the analysis of long-term survival and mortality risk factors among disabled and multimorbid institutionalized populations. The study aimed to analyze 9-year survival, investigate mortality factors, and develop an explanatory survival model for nursing home residents.

MATERIALS AND METHODS

A retrospective cohort study with a 9-year follow-up (2009-2018) was conducted among 96 residents of a nursing home with Barthel index ≤ 40. The study was based on baseline measurements performed in 2009, which included results obtained on geriatric scales: Mini Nutritional Assessment Short-Form (MNA-SF) and Abbreviated Mental Test Score (AMTS). Information on demographics, comorbidities, pharmacotherapy, transfers and deaths came from medical records. Kaplan-Meier curves were used to estimate and present survival data. Factors associated with mortality were determined using Cox proportional hazard models.

RESULTS

The median survival was 2.9 years. Mortality during the follow-up period was 83%. Kaplan-Meier curves showed that residents with normal nutritional status (p = 0.002) and taking aspirin (p = 0.005) had a better 9-year survival. The multivariable Cox regression model revealed that the risk of mortality (Hazard Ratio, HR) increased in older age (HR=1.04), male gender (HR=2.08), with risk of malnutrition (HR=3.91), malnutrition (HR=4.84), and presence of urinary incontinence (HR=2.14). The aspirin use was the strongest protective factor against death (HR=0.40).

CONCLUSION

The aspirin use was associated with better long-term survival for nursing home residents. Factors associated with higher mortality among residents include older age, male gender, poor nutritional status, and urinary incontinence.

BRIEF SUMMARY

We are the first to report the beneficial effects of a low-dose of aspirin on the long-term survival of disabled, institutionalized populations with multimorbidity. Furthermore, this study presents an explanatory model of survival for nursing home residents and identifies the long-term mortality risk factors among disabled residents with multimorbidity.

Impact of morbidity on care need increase and mortality in nursing homes: a retrospective longitudinal study using administrative claims data

Background

A growing number of older people are care dependent and live in nursing homes, which accounts for the majority of long-term-care spending. Specific medical conditions and resident characteristics may serve as risk factors predicting negative health outcomes. We investigated the association between the risk of increasing care need and chronic medical conditions among nursing home residents, allowing for the competing risk of mortality.

Methods

In this retrospective longitudinal study based on health insurance claims data, we investigated 20,485 older adults (≥65 years) admitted to German nursing homes between April 2007 and March 2014 with care need level 1 or 2 (according to the three level classification of the German long-term care insurance). This classification is based on required daily time needed for assistance. The outcome was care level change. Medical conditions were determined according to 31 Charlson and Elixhauser conditions. Competing risks analyses were applied to identify chronic medical conditions associated with risk of care level change and mortality.

Results

The probability for care level change and mortality acted in opposite directions. Dementia was associated with increased probability of care level change compared to other conditions. Patients who had cancer, myocardial infarction, congestive heart failure, cardiac arrhythmias, renal failure, chronic pulmonary disease, weight loss, or recent hospitalization were more likely to die, as well as residents with paralysis and obesity when admitted with care level 2.

Conclusion

This paper identified risk groups of nursing home residents which are particularly prone to increasing care need or mortality. This enables focusing on these risk group to offer prevention or special treatment. Moreover, residents seemed to follow specific trajectories depending on their medical conditions. Some were more prone to increased care need while others had a high risk of mortality instead. Several conditions were neither related to increased care need nor mortality, e.g., valvular, cerebrovascular or liver disease, peripheral vascular disorder, blood loss anemia, depression, drug abuse and psychosis. Knowledge of functional status trajectories of residents over time after nursing home admission can help decision-makers when planning and preparing future care provision strategies (e.g., planning of staffing, physical equipment and financial resources).

Interventions that support major life transitions in older adulthood: a systematic review

ABSTRACTBackground:Major life transitions can negatively impact the emotional well-being of older people. This study examined the effectiveness of interventions that target the three most common transitions in later life, namely bereavement, retirement, and relocation.

METHODS

A systematic search was performed via MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, and reference lists of retrieved non-randomized and randomized controlled trials (RCTs) in English that studied the effectiveness of interventions addressing the three transitions in those &gt;50 years of age. Two researchers independently selected the publications, piloted the data extraction form, and critically appraised studies specific to transition type and study design.

RESULTS

A total of 11 studies (bereavement: 7; retirement: 2; relocation: 2) of 8 unique interventions met the inclusion criteria of which nine were RCTs and two were of quasi-experimental designs were reviewed. Six studies were group-based interventions, three studies used individualized sessions, and one intervention used a combination of group and individualized programming. Group size varied (20-32 participants), as did qualifications of those administering the interventions. The methodological quality of included studies was weak. Findings suggest that group-based approaches provided by trained personnel can mitigate the negative health-related consequences associated with major transitions in later life.

CONCLUSION

Evidence concerning interventions that address mental health challenges associated with these major transitions is limited. Future research should better characterize participants at study outset and use validated measures to capture effectiveness. Use of peer mentorship to navigate such transitions is promising, but given the small number of studies and their methodological weaknesses, further research on effectiveness is warranted.

Mortality in nursing home residents: A longitudinal study over three years

OBJECTIVE

Nursing home (NH) stay is the highest level of formal care. With the expected demographic changes ahead, the need for NH placement will put an increasing socioeconomic strain on the society. Survival in NHs and factors predicting survival are important knowledge in order to evaluate NH admission policies and plan future NH capacity.

METHODS

We followed 690 NH residents included at admission to NH over a period of three years. Participants were examined at baseline (BL) and every six months. Demographic and clinical data were collected, including comorbidity, severity of cognitive impairment, dependency in activities of daily living (ADL) and neuropsychiatric symptoms. Median survival was calculated by the Kaplan-Meier analysis, and factors associated with mortality were identified by Cox models with baseline and time-dependent covariates.

RESULTS

Median survival in NH was 2.2 years (95% confidence interval [CI]: 1.9-2.4). Yearly mortality rate throughout the three-year observation period was 31.8%. Mortality was associated with higher age and comorbidity at BL, and more severe dementia, higher ADL-dependency, less severe psychotic symptoms, and a lower BMI throughout the study period. Of the organizational variables, living on a ward with more residents resulted in a higher risk of mortality.

CONCLUSION

In conclusion, the NH mortality rate remained stable throughout the three-year study period with about one third of the residents deceasing each year. Individual resident characteristics appeared to be more important than organizational variables for predicting mortality risk. The finding of an association between ward size and mortality risk deserves further investigation in future studies.

Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia

PURPOSE

The proportion of deaths occurring in nursing homes is increasing and end of life hospitalizations in residents are common. This study aimed to obtain the time from nursing home admission to death and the frequency of hospitalizations prior to death among residents with and without dementia.

METHODS

This retrospective cohort study analyzed claims data of 127,227 nursing home residents aged 65 years and older newly admitted to a nursing home between 2010 and 2014. We analyzed hospitalizations during the last year of life and assessed mortality rates per 100 person-years. Factors potentially associated with time to death were analyzed in Cox proportional hazard models.

RESULTS

The median time from nursing home admission to death was 777 and 635 days in residents with and without dementia, respectively. Being male, older age and a higher level of care decreased the survival time. Sex and age had a higher influence on survival time in residents with dementia, whereas level of care was found to have a higher influence in residents without dementia. Half of the residents of both groups were hospitalized during the last month and about 37% during the last week before death. Leading causes of hospitalizations were infections (with dementia: 20.6% vs. without dementia: 17.2%) and cardiovascular diseases (with dementia: 16.6% vs. without dementia: 19.0%).

CONCLUSIONS

A high proportion of residents with and without dementia are hospitalized shortly before death. There should be an open debate about the appropriateness of hospitalizing nursing home residents especially those with dementia near death.

Use of medicines in nursing homes for older people

The National Health Service (NHS) spent £10 billion (40%) of its total budget on people aged 65 and over in 1998/1999. The profile of the health and social care of older people has been raised recently by the publication of the National Service Framework (NSF) for Older People (Department of Health, 2001). The NSF contains standards that older people can expect when they receive health and social care (Box 1). The document also discusses in detail medication management issues in older people. Its two aims in this area are to ensure that older people gain the maximum benefit from their medication in order to maintain or improve quality and duration of life, and do not suffer unnecessarily from illness caused by excessive, inappropriate or inadequate consumption of medicines.

Sleep and Long-Term Care

Long-term care (LTC) involves a range of support and services for people with chronic illness and disabilities who can not perform activities of daily living independently. Poor sleep increases the risk of LTC placement, and sleep disturbance is extremely common among LTC residents. The identification and management of sleep disturbance in LTC residents is a vital, but perhaps underappreciated, aspect of offering high-quality care for this already compromised population. This review describes the nature and consequences of sleep disturbances in LTC, clinical assessment and management of sleep disturbances in LTC, and implications for future research and clinical practice.

Association of Hospital Admission Risk Profile Score with Mortality in Hospitalized Older Adults

OBJECTIVES

To evaluate the association of the Hospital Admission Risk Profile (HARP) score with mortality after discharge in a population of hospitalized older adults.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Hospitalized patients aged 70 years or older.

MEASUREMENTS

Patient age at the time of admission, modified Folstein Mini-Mental Status Exam score, and self-reported instrumental activities of daily living 2 weeks prior to admission were used to calculate a HARP score. The primary outcome assessed was overall mortality up to 365 days after hospital discharge. Cox proportional hazard analyses evaluated the association between HARP score and mortality adjusting for age, sex, and comorbidities associated with increased mortality.

RESULTS

Of the 474 patients, 165 (34.8%) had a low HARP score, 177 (37.4%) had an intermediate, and 132 (27.8%) had a high score. HARP score was not associated with differences in 30-day readmission rates. High HARP score patients had higher mortality when compared to patients with low HARP scores at all time frames (30 days: 12.9% vs 1.8%, p < .05; 90 days: 19.7% vs 4.8%, p < .05; 365 days: 34.8% vs 16.9%, p < .05). In fully adjusted Cox proportional models, patients with high HARP scores had a 3.5 times higher odds of mortality when compared to low HARP score patients.

CONCLUSION

The HARP score is a simple and easy to use instrument that identifies patients at increased risk for mortality after hospital discharge. Early identification of patients at increased risk for mortality has the potential to help guide treatment decisions following hospital discharge and provides additional information to providers and patients for shared decision making and may help in clarifying and achieving patient and family goals of care.

Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process

Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.

The association between the utilization of long-term care services and mortality in elderly Koreans

It is necessary to confirm the effect of long-term care insurance (LTCI) by identifying changes in mortality, whether benefits are used or not, as well as the effects of in-home and institutional services on mortality. The goal of this study was to identify the association between service use and the mortality rate in elderly Koreans. We used Cox proportional hazard regression models and the Kaplan-Meier survival curve method to estimate the hazard ratio and survival probability for death while adjusting for covariates. We detected a 27.8% mortality rate at the 40-month follow-up period. Male gender, advanced age and activities of daily living were risk factors for mortality. In all models, the hazard ratio of participant death of those using long-term care services was significantly lower than for those who did not use these services. Among the service users, the hazard ratio for participant death of institutional service users was significantly higher than it was for in-home service users. This study also identified the impact of the transition from in-home services to institutional services. A primary goal of LTCI is to promote health and life stabilization in the elderly. To both delay and prevent institutionalization, it is necessary to develop assistive devices and effective in-home services and ensure access of these for elderly patients.

Differences in predictors of 5-year survival over a 10-year period in two cohorts of elderly nursing home residents in Sweden

AIM

The aim was to compare 5-year survival in two included cohorts (from year 2000 and year 2007) of 249 nursing home residents (NHR) in this retrospective, comparative study.

METHODS

The cohorts were compared regarding chronic diseases, medication, physical/cognitive/nutritional status, body mass index, body temperature and 5-year mortality. Factors correlated with 5-year survival were determined using Cox regression analysis.

RESULTS

In average, cohort 2007 survived 31 ± 16 months and cohort 2000, 38 ± 13 months, p < 0.001. Dementia, ageing and circulatory failure were more common as cause of death 2007, while stroke, chronic obstructive pulmonary disease (COPD) and pneumonia were less common, compared with 2000. NHR belonging to cohort 2007 were significantly older when admitted to nursing homes (NH), more dependent in activities of daily living (ADL), had dementia, stroke, autoimmune disease and treatment with antidepressants, while malnutrition and treatment with paracetamol were more common 2000. In 2000, medication with antidepressants, the presence of stroke and diabetes, irrespective of gender, and in women cardiovascular disease, two to threefold significantly increased survival, while autoimmune disease, influenza vaccination and dependency in ADL decreased survival. In 2007, maintaining BMI, irrespective of gender, and autoimmune disease and COPD in women significantly increased survival, while malnutrition, influenza vaccination, dependency in ADL and medication with sedatives/tranquillisers or paracetamol severely reduced survival.

CONCLUSIONS

The present results indicate a trend that individuals are older and frailer when admitted to NH and that survival time after admission has been shortened. Hence, the need of daily support and care has increased, irrespective of housing. Also, predictors of survival, possible to influence, have changed.

Mortality in older care home residents in England and Wales

BACKGROUND

mortality in UK care homes is not well described.

OBJECTIVE

to describe 1-year mortality and predictors in older care home residents compared with community residents.

METHOD

cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009.

RESULTS

a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes.

CONCLUSIONS

older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

Evening cortisol is associated with intra-individual instability in daytime napping in nursing home residents with dementia: an allostatic load perspective

BACKGROUND

Circadian rhythm disruption, reflected in alterations in sleep-wake activity and daytime napping behavior, is consistently reported in nursing home (NH) residents with dementia. This disruption may be reflected in day-to-day instability. The concept of allostatic load (AL), a measure of cumulative biological burden over a lifetime, may be a helpful model for understanding cortisol diurnal rhythm and daytime napping activity in this population. The purpose of this study was to examine the association between intra-individual daytime napping episodes and basal cortisol diurnal rhythm in NH residents with dementia in the context of AL.

METHOD

U sing a within-individual longitudinal design (N = 51), the authors observed and recorded daytime napping activity every 20 min for 10 hr per day across 4 consecutive days. The authors obtained saliva samples 4 times each day (upon participants' waking and within 1 hr, 6 hr, and 12 hr of participants' wake time) for cortisol analysis.

RESULTS

The authors categorized participants as high changers (HCs; day-to-day instability in napping activity) or low changers (LCs; day-to-day stability). There were no significant differences in resident characteristics between groups. There was a significant difference between HCs and LCs in napping episodes (F = 4.86, p = .03), with an interaction effect of evening cortisol on napping episodes in the HC group (F = 10.161, p = .001).

CONCLUSIONS

NH residents with unstable day-to-day napping episodes are more responsive to alterations in evening cortisol, an index of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. They may also be more amenable to environmental intervention, an avenue for further research.

Predicting mortality of residents at admission to nursing home: a longitudinal cohort study

Background

An increasing numbers of deaths occur in nursing homes. Knowledge of the course of development over the years in death rates and predictors of mortality is important for officials responsible for organizing care to be able to ensure that staff is knowledgeable in the areas of care needed. The aim of this study was to investigate the time from residents' admission to Icelandic nursing homes to death and the predictive power of demographic variables, health status (health stability, pain, depression and cognitive performance) and functional profile (ADL and social engagement) for 3-year mortality in yearly cohorts from 1996-2006.

Methods

The samples consisted of residents (N = 2206) admitted to nursing homes in Iceland in 1996-2006, who were assessed once at baseline with a Minimum Data Set (MDS) within 90 days of their admittance to the nursing home. The follow-up time for survival of each cohort was 36 months from admission. Based on Kaplan-Meier analysis (log rank test) and non-parametric correlation analyses (Spearman's rho), variables associated with survival time with a p-value < 0.05 were entered into a multivariate Cox regression model.

Results

The median survival time was 31 months, and no significant difference was detected in the mortality rate between cohorts. Age, gender (HR 1.52), place admitted from (HR 1.27), ADL functioning (HR 1.33-1.80), health stability (HR 1.61-16.12) and ability to engage in social activities (HR 1.51-1.65) were significant predictors of mortality. A total of 28.8% of residents died within a year, 43.4% within two years and 53.1% of the residents died within 3 years.

Conclusion

It is noteworthy that despite financial constraints, the mortality rate did not change over the study period. Health stability was a strong predictor of mortality, in addition to ADL performance. Considering these variables is thus valuable when deciding on the type of service an elderly person needs. The mortality rate showed that more than 50% died within 3 years, and almost a third of the residents may have needed palliative care within a year of admission. Considering the short survival time from admission, it seems relevant that staff is trained in providing palliative care as much as restorative care.

Sleep in care homes

Sleep problems in older adults are common and disturbance in sleep is associated with increased mortality. These problems are more pronounced in the care home population because of institutional factors and a high prevalence of frailty and co-morbidity. This article reviews the randomized controlled trials undertaken to address sleep problems in care homes. These suggest that stand-alone therapies – oral melatonin and light therapy – have no effect on sleep but that combination treatments – physical exercise plus sleep hygiene, physical exercise plus sleep hygiene plus light and melatonin plus light – may have positive effects. These effects are more marked for daytime arousal than nocturnal sleep. Practical considerations for care homes are how to maximize light exposure, incorporate exercise into daily routines and minimize night-time disruption for residents. Trials undertaken so far are compromised by small sample size and inappropriate randomization strategies and further research is therefore required.

Gender differences in predictors of nursing home placement in the elderly: a systematic review

BACKGROUND

In recent decades a substantial number of studies have examined predictors of nursing home placement (NHP) in the elderly. This study provides a systematic review of gender-differences in predictors of NHP from population-based, longitudinal studies worldwide.

METHODS

Relevant articles were identified by a systematic search of literature. The articles based on prospective studies with representative samples of community-living elders identified predictors by gender-specific multivariate analyses.

RESULTS

Eleven studies were identified. We found gender differences in the prediction of NHP for marital status, living situation, housing and car availability and urinary incontinence. For both genders the risk of NHP did not differ substantially for age, functional impairment, cognitive impairment, dementia, and depression. The male to female ratio of admission rates ranged between 1 to 1.4 and 1 to 1.6.

CONCLUSIONS

Only a few studies analyzed gender-specific predictors of NHP, probably owing to the associated statistical difficulties. However, gender differences in prediction of NHP do actually exist, and this should encourage further research activities in this area using appropriate statistical methods.

A Census-based longitudinal study of variations in survival amongst residents of nursing and residential homes in Northern Ireland

BACKGROUND

despite the intensive services provided to residents of care homes, information on death rates is not routinely available for this population in the UK.

OBJECTIVE

to quantify mortality rates across the care home population of Northern Ireland, and assess variation by type of care home and resident characteristics.

DESIGN

a prospective, Census-based cohort study, with 5-year follow-up.

PARTICIPANTS

all 9,072 residents of care homes for people aged 65 and over at the time of the 2001 census with a special emphasis on the 2,112 residents admitted during the year preceding census day.

MEASUREMENTS

age, sex, self-reported health, marital status, residence (not in care home, residential home, dual registered home, nursing home), elderly mentally infirm care provision.

RESULTS

the median survival among nursing home residents was 2.33 years (95% CI 2.25-2.59), for dual registered homes 2.75 (95% CI 2.42-3.17) and for residential homes 4.51 (95% CI 3.92-4.92) years. Age, sex and self-reported health showed weaker associations in the sicker populations in nursing homes compared to those in residential care or among the non-institutionalised.

CONCLUSIONS

the high mortality in care homes indicates that places in care homes are reserved for the most severely ill and dependent. Death rates may not be an appropriate care quality measure for this population, but may serve as a useful adjunct for clinical staff and the planning of care home provision.

Survival prediction in nursing home residents using the Minimum Data Set subscales: ADL Self-Performance Hierarchy, Cognitive Performance and the Changes in Health, End-stage disease and Symptoms and Signs scales

BACKGROUND

With the intention to aid planning for elderly focused public health and residential care needs in rapidly aging societies, a simple model using only age, gender and three Minimum Data Set (MDS) subscales (MDS-ADL Self-Performance Hierarchy, MDS-Cognitive Performance and the MDS-Changes in Health, End-stage disease and Symptoms and Signs scales) was used to estimate long-term survival of older people moving into nursing homes.

METHODS

A total of 1820 nursing home residents were assessed by the MDS 2.0 and their mortality status 5 years later was used to develop a survival prediction model.

RESULT

In December 2006, 54.2% of subjects were dead. Older age at nursing home admission (HR = 1.036 per 1-year increment, 95% CI 1.028-1.045), men (HR = 1.895, 95% CI 1.651-2.175), higher impairment level according to the MDS-ADL (HR = 1.135 per 1-unit increment, 95% CI 1.099-1.173) and MDS-CPS (HR = 1.077 per 1-unit increment, 95% CI 1.033-1.123), and more frail on the MDS-CHESS (HR = 1.150 per 1-unit increment, 95% CI 1.042-1.268), were all independent predictors of shorter survival after nursing home admission in multivariate analysis. Survival function was derived from the fitted Cox regression model. Survival time of nursing home residents with different combinations of risk factors were estimated through the survival function.

CONCLUSION

The MDS-ADL, MDS-CPS and MDS-CHESS scales, in addition to age and gender, provide prognostic information in terms of survival time after institutionalization. The model may be useful for health care and residential care planning in an ageing community.

Sleep disturbances in long-term care

Nighttime sleep disruption is characteristic of long-term care residents, is typically accompanied by daytime sleepiness, and may be caused by a multitude of factors. Causal factors include medical and psychiatric illness, medications, circadian rhythm abnormalities, sleep disordered breathing and other primary sleep disorders, environmental factors, and lifestyle habits. There is some suggestion that these factors are amenable to treatment; however, further research on the implementation of treatments within the long-term care setting is needed. Additional work is also needed to understand the administrative and policy factors that might lead to systemic changes in how sleep is viewed and sleep problems are addressed in long-term care settings.

The effect of chronic disorders on sleep in the elderly

Sleep disorders are increasingly common as people age. Along with the numerous physiologic changes that occur with aging, sleep patterns are also altered. Inability to get to sleep, shorter sleep times, and changes in the normal circadian patterns can have an impact on an individual's overall well being. In addition, many common chronic conditions, such as chronic obstructive pulmonary disease, diabetes, dementia, chronic pain, and cancer, that are more common in the elderly, can also have significant effects on sleep and increase the prevalence of insomnia as compared with the general population. This is a result not only of the chronic medical illnesses themselves, but of the psychologic and social factors associated with the disease processes.

Depressed mood, cognitive impairment, and survival in older people admitted to care homes in England

OBJECTIVE

To investigate psychiatric morbidity, cognitive impairment, dependency, and survival in residents newly admitted to care homes.

METHODS

A total of 308 older people were assessed using measures of cognitive impairment and depressive symptomatology, and interviewable residents completed a quality-of-life interview. Dependency levels were assessed by interviews with staff and medication data were collected from home records. Follow-up assessments were carried out at five and nine months. A telephone follow-up approximately 12 months later augmented the survival data.

RESULTS

Of residents whose outcomes were known, 73% survived throughout the nine-month study period. Residents who died before the five-month follow-up had higher scores on the depression measure than those surviving longer. Reduced survival was predicted by greater dependency at baseline. Of 188 surviving residents, 63 (38%) were classified as depressed at baseline. Twenty-seven (43%) of the latter were still classed as depressed at five and nine months. Just 19% of residents rated as depressed at baseline were prescribed antidepressant medication, increasing to 26% at each follow-up. There was significant coexistence of cognitive impairment and depressive symptomatology.

CONCLUSION

High levels of mortality, psychiatric morbidity, and chronicity of depressed mood among residents requires care homes to improve access to specialist resources such as geriatric consultation, old-age psychiatry, occupational therapy, and physiotherapy. Findings suggest that future care standards should include external factors, such as the extent of access to relevant specialist services for vulnerable older people.

Gender differences in predictors of survival in elderly nursing-home residents: a 3-year follow up

This study focus on predicting factors of survival possible to modify by nursing care, and the incidence and mortality rate of nursing-home-acquired pneumonia, allocated to 1, 2 and 3 years of follow ups. The residents consisted of 156 women and 78 men living in special housing for the elderly. Data on chronic disease and medication were obtained at baseline, and activities of daily living (ADL) status, nutritional status and body temperature were assessed. The incidence of pneumonia was noted prospectively for 1 year and retrospectively for the following 2 years. Predictive factors for survival were explored by Cox hazard regression analysis. The results showed that age, functional and cognitive impairment were predictors of mortality irrespective of gender, while poor nutritional status in women and chronic obstructive pulmonary disease, heart disease and medication with sedatives in men were gender-specific predictors. ADL correlated positively with dementia and negatively with S-albumin irrespective of gender, while malnutrition correlated positively with ADL in women and positively with chronic obstructive pulmonary disease in men. To promote the quality of daily living in elderly individuals, it is of importance to improve the capabilities in daily functions and nutritional status, especially in women with functional impairment, and to prevent anxiety particularly in men. The findings also clarify that pneumonia is as common as cerebral vascular insult and heart failure as cause of death in this population.

Discharge to Home Rates Are Significantly Lower for Octogenarians Undergoing Coronary Artery Bypass Graft Surgery

BACKGROUND

The incidence of coronary artery bypass graft surgery (CABG) performed in elderly patients has been increasing over recent years. We sought to evaluate clinical outcomes of octogenarians undergoing CABG using an audited state-wide mandatory database.

METHODS

New York State Department of Health's Cardiac Reporting System was analyzed from 1998 to 2002. In all, 88,154 patients undergoing isolated CABG were identified. Patients were divided into four age groups: less than 50 years (group 1, n = 6,527), 50 to 64 years (group 2, n = 30,088), 65 to 79 years (group 3, n = 43,369), and 80 years and above (group 4, n = 8,170).

RESULTS

Of all patients, 9.3% were octogenarians. In addition to marginally worse coronary artery disease, octogenarians generally manifested a higher incidence of preoperative risk factors such as cerebrovascular disease, peripheral vascular disease, and congestive heart failure compared with younger patients at baseline. Both length of hospital stay and in-hospital mortality rate were significantly higher among octogenarians. The incidence of postoperative complications was higher among octogenarians. Multivariate analysis demonstrated renal failure requiring dialysis (odds ratio [OR] = 4.4), myocardial infarction within 6 hours before surgery (OR = 3.6), chronic obstructive pulmonary disease (OR = 1.7), congestive heart failure at admission (OR = 1.7), emergent operation (OR = 1.6), Canadian Cardiovascular Society functional class IV (OR = 1.5), hypertension (OR = 1.4), and low ejection fraction (OR = 0.98) to be significant independent predictors of in-hospital mortality of octogenarians. Discharge to home rates were significantly lower for octogenarians.

CONCLUSIONS

Although early outcomes in octogenarians are acceptable, these factors alone are not sufficient to reflect overall success of CABG in these patients, given the strikingly lower discharge to home rates. Attention to full functional recovery in octogenarians is essential.

Nursing home institutionalization: a source of eustress or distress for the elderly?

OBJECTIVE

To investigate why elderly persons moved to a nursing home and detect any change in their psychopathological and cognitive profile, dependency and perceived QOL.

METHOD

We considered 100 elderly consecutively admitted to a nursing home, within 1 week of admission and 6 months later. Data were collected from medical and nursing records (medical and psychiatric history, ADL), interviews (MMSE, reasons for admission) and self-report instruments (GDS, BSI, WHOQOL-brief).

RESULTS

At admission, 68 subjects were able to participate in the survey and agreed to take part. Only 5.9% (n = 4) had moved to the nursing home by their own choice, 26.5% (n = 18) because they were lonely and 36.7% (n = 25) because they had no caregiver available. The reasons for admission reported by the interviewed residents only partly corresponded with the ones noted in their records. Twenty-six subjects had an MMSE score >or= 18 and agreed to undertake complete assessment. The scores of 20 of the 26 subjects exceeded the cut-off on the GDS and five of the nine BSI subscales. During the follow-up period, 19 of the 68 originally assessed residents died (33 of the entire sample of 100) and one refused to continue to take part in the survey. The mean MMSE and ADL scores of the 48 survivors decreased from 16.87 (SD +/- 7.32) to 14.27 (SD +/- 7.24; t = 4.89, p < 0.000) and from 8.22 (SD +/- 3.55) to 6.39 (SD +/- 3.56; t = 5.34, p < 0.000), respectively. The scores achieved on GDI and BSI subscales worsened in 20 survivors with MMSE >or= 18. The score achieved on the QOL physical health domain also worsened. Comparison of the subjects who died and survived during the follow-up period showed a significant difference in terms of ADL (6.60 SD +/- 4.221 vs 3.64 SD +/- 3.773 F = 11.639; p < 0.001).

CONCLUSION

The 68 original participants expressed feelings of loneliness and marginalization, but these experiences were not noted in their personal records. Most subjects presented psychiatric symptoms and cognitive decline. After 6 months, the clinical condition of the sample, particularly the females, had worsened, with a 33% mortality rate. This suggests that moving to a nursing home did not bring about improvement or stabilization; rather, psychiatric symptoms worsened and quality of life was perceived more poorly.

Daytime sleeping, sleep disturbance, and circadian rhythms in the nursing home

OBJECTIVE

This study reports the frequency of abnormal daytime sleeping and identifies factors related to daytime sleeping, nighttime sleep disturbance, and circadian rhythm abnormalities among nursing home residents.

METHODS

The authors conducted secondary analysis of data collected under usual care conditions within a nonpharmacologic sleep intervention trial. All residents from four Los Angeles nursing homes were screened for daytime sleeping (asleep>or=15% of observations, 9:00 am-5:00 pm). Consenting residents with daytime sleeping had two nights of wrist actigraphy to assess nighttime sleep disturbance (asleep<80%, 10:00 pm-6:00 am). Residents with nighttime sleep disturbance completed an additional 72-hour wrist actigraphy recording to assess circadian activity rhythms and light exposure.

RESULTS

Sixty-nine percent of 492 observed residents had daytime sleeping, of whom 60% also had disturbed nighttime sleep. Sleep disturbance and daytime sleeping were rarely documented in medical records. Residents spent one-third of the day in their rooms, typically in bed, and were seldom outdoors or exposed to bright light. More time in bed and less social activity were significant predictors of daytime sleepiness. Ninety-seven percent of residents assessed had abnormal circadian rhythms. More daytime sleeping and less nighttime sleep were associated with weaker circadian activity rhythms. Later circadian rhythm acrophase (peak) was associated with more bright light exposure.

CONCLUSION

Daytime sleepiness, nighttime sleep disturbance, and abnormal circadian rhythms were common in nursing home residents. Modifiable factors (e.g., time in bed) are associated with sleep/wake abnormalities. Mental health specialists should consider the complexity of factors causing sleep problems in nursing home residents.

Obesity and Mortality in Elderly Nursing Home Residents

BACKGROUND

The increasing prevalence of obese Americans over the last several decades has been well documented. A number of studies have analyzed the relationship of obesity and mortality in community-dwelling elderly persons, but little work has analyzed this issue within the institutionalized elderly population.

METHODS

In an analysis of the 1996 Medical Expenditures Panel Study, we used logistic regression methods to examine the excess mortality associated with obesity, as defined by body mass index (BMI), over calendar year 1996 for existing and new nursing home residents.

RESULTS

Across the total sample of existing and new residents, there was not a statistically significant difference in mortality for "obese" (BMI > 28 kg/m2) nursing home residents (odds ratio [OR] 0.89; 95% confidence interval [CI], 0.67-1.17) compared to the "normal" group, but obesity was associated with significantly less mortality among existing residents (OR 0.75; 95% CI, 0.57-0.98). For "thin" (BMI < 19 kg/m2) nursing home residents, there was significantly higher mortality among both current residents (OR 1.40; 95% CI, 1.11-1.77) and new admissions (OR 1.63; 95% CI, 1.17-2.28). For "very obese" (BMI > 35 kg/m2) individuals, there was a significantly higher mortality among new admissions (OR 1.75; 95% CI, 1.10-2.80), but not existing residents (OR 0.67; 95% CI, 0.38-1.15). These effects persisted for "very obese" individuals (BMI > 40 kg/m2).

CONCLUSIONS

Very obese nursing home residents experience higher mortality early in their stay, but this association diminishes over time with some evidence suggesting that a higher BMI may be protective among long-stay residents.

Randomized, controlled trial of a nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents

OBJECTIVES

Abnormal sleep/wake patterns are common in nursing home residents. Lifestyle and environmental factors likely contribute to these poor sleep patterns. The objective of this study was to test a multidimensional, nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents.

DESIGN

Randomized, controlled trial.

SETTING

Four nursing homes in the Los Angeles area.

PARTICIPANTS

Residents were screened for excessive daytime sleeping (asleep > or = 15% of daytime observations) and nighttime sleep disruption (asleep < 80% of nighttime hours, according to wrist actigraphy). Four hundred ninety-two residents were screened; 339 had excessive daytime sleeping. Of these, 133 had nighttime sleep disruption and consented to participate; 120 completed baseline assessments, and 118 (77% female, mean age 86.9, 90% non-Hispanic white) were randomized to intervention versus usual care.

INTERVENTION

Five consecutive days and nights of efforts to decrease daytime in-bed time, 30 minutes or more of daily sunlight exposure, increased physical activity, structured bedtime routine, and efforts to decrease nighttime noise and light.

MEASUREMENTS

Seventy-two consecutive hours of wrist actigraphy (nighttime sleep) and structured behavioral observations (daytime sleep and participation in social and physical activities and social conversation) at baseline and repeated at follow-up while the intervention or usual care condition was in place.

RESULTS

The only effect on nighttime sleep was a modest decrease in mean duration of nighttime awakenings in intervention participants (10.6 minutes at baseline, 9.8 minutes at follow-up) versus an increase in controls (9.8 minutes at baseline, 13.8 minutes at follow-up) (F=4.27, P=.04). There were no significant effects on percentage of nighttime sleep or number of nighttime awakenings. There was a significant decrease in daytime sleeping in intervention participants (32% of daytime observations asleep at baseline, 21% at follow-up), with no change in controls (32% at baseline, 30% at follow-up; F=20.68, P<.001). Intervention participants had increased participation in social (F=22.42, P<.001) and physical (F=12.65, P=.001) activities and social conversation (F=5.04, P=.03).

CONCLUSION

A multidimensional, nonpharmacological intervention into lifestyle and environmental factors that likely contribute to abnormal sleep/wake patterns in nursing home residents resulted in decreased daytime sleeping and increased participation in social and physical activities and social conversation. Nonpharmacological interventions should be considered in the management of abnormal sleep/wake patterns in nursing home residents. The main effect may be a significant decrease in daytime sleeping, which may translate to an improvement in quality of life.

Comorbidity and 1-year mortality risks in nursing home residents

OBJECTIVES

To investigate the effect of chronic diseases and disease combinations on 1-year mortality in nursing home residents.

DESIGN

Retrospective cohort study using electronically submitted Minimum Data Set (MDS) information and Missouri death certificate data.

SETTING

Five hundred twenty-two nursing homes in Missouri.

PARTICIPANTS

Forty-three thousand five hundred ten nursing home residents with a full MDS assessment in 1999.

MEASUREMENTS

Information about chronic diseases, age, sex, and performance in activities of daily living (ADLs) available from the first full MDS 2.0 assessment in 1999; death within 1 year after the first full MDS-assessment in 1999.

RESULTS

After adjustment for age and sex, eight variables were predictive for 1-year mortality: seven chronic diseases (dementia, cancer, heart failure, renal failure, emphysema/chronic obstructive pulmonary disease, diabetes mellitus, and anemia) and an interaction variable containing age and cancer. Adding terms for disease combinations (e.g., diabetes mellitus and heart failure) did not enhance survival prediction. When there was also adjustment for ADL performance as measured using the MDS-ADL Short Form, dementia and anemia were not included, because they had no prognostic value above that of the other variables.

CONCLUSION

Several chronic diseases were associated with 1-year mortality in the institutionalized elderly after adjustment for ADL performance, age, and sex. Evidence of a synergistic effect of disease combinations on mortality is lacking.

An attempt to determine the benefits of a 'home-for-life' principle in residential care for people with dementia and behavioural problems: a comparative cohort study

It is not clear whether moving individuals with dementia and behavioural problems as part of a rehabilitation and relocation ('intermediate care', IC) nursing home model worsens behaviour, compared with a 'home for life' philosophy. We studied this in contiguous services with the same formal admission criteria but different models of subsequent care. 37 patients admitted to 'homes for life' and 24 to IC homes were followed up for 1 year using the BEHAVE-AD. Scores were lower at baseline in the IC group. Both groups deteriorated over the year, although more in IC patients (trend), and those actually moving home were worse after the move. Use of neuroleptic medication increased significantly in the IC group. Our results confirm previous studies of the disruptive effects of re-location for patients with severe dementia but do not suggest major differences between the two models of care.

Protocol for the successful treatment of pressure ulcers

Bed-bound patients with pressure ulcers are almost twice as likely to die as are those without pressure ulcers. If pressure ulcers are treated with a comprehensive regimen upon early recognition, nearly all stage IV ulcers can be avoided. Furthermore, such a regimen can significantly reduce the comorbidities, mortalities, and costs of treatments resulting from stage IV ulcers. The costs of treatments for comorbidities after the ulcer progresses to stage IV far outweigh the costs for early treatment of the ulcer before it progresses beyond the early stages. We describe herein the 4 stages of pressure ulcers, as well as the pathogeneses, costs, and complications associated with these wounds. A comprehensive 12-step detailed protocol for treatment of pressure ulcers is described; this includes recognizing that every patient with limited mobility is at risk for developing a sacral, ischial, trochanteric, or heel ulcer; daily assessment of the skin; objective measurement of every wound; immediate initiation of a treatment protocol; mechanical debridement of all nonviable tissue; establishment of a moist wound-healing environment; nutritional supplementation for malnourished patients; pressure relief for the wound; elimination of drainage and cellulitus; biological therapy for patients whose wounds fail to respond to more traditional therapies; physical therapy; and palliative care. Availability of the described treatment modalities, in combination with early recognition and regular monitoring, ensures rapid healing and minimizes morbidity, mortality, and costs.

Cardiac surgery for octogenarians: is it an informed decision?

BACKGROUND

Cardiac surgery is frequently performed to palliate cardiovascular symptoms in patients who are octogenarians, without controlled clinical trials to support its benefits. We hypothesized that death or discharge to a nursing care facility after cardiac surgery is similar in patients who are octogenarians and younger patients.

METHODS

We conducted an inception cohort study in a tertiary care teaching hospital in patients who had undergone coronary grafting, valve surgery, or both over 36 months before. We collected data on preoperative disease, operation characteristics, postoperative complications, and outcome at hospital discharge.

RESULTS

Of 783 patients who had cardiac surgery, 96 were octogenarians. Female sex, pulmonary hypertension, previous malignancy, cerebral vascular disease, valvular heart disease, and congestive heart failure were more frequent in patients who were octogenarians than in younger patients. Operative characteristics were similar in both age groups, except there were more frequent valve or combined with coronary grafts surgery and surgical re-exploration in octogenarians. The rate of postoperative complications including cardiovascular, neurological, renal, and nosocomial infections were higher in patients who were octogenarians than younger patients. Death or discharge to a nursing care facility was more frequent in patients who were octogenarians than younger patients (53% vs 14%, P <.002). Age > or =80 years, female sex, congestive heart failure, and surgical re-exploration were independent predictors for death or discharge to a nursing care facility after cardiac surgery.

CONCLUSIONS

The rate of death or discharge to nursing care facility after cardiac surgery was high among patients who were octogenarians. Current operative outcome end points do not reflect such important differences between patients who are octogenarians and younger patients. Informed discussion of treatment options, potential for discharge to a nursing care facility, and quality of life expectations should precede a decision to undergo cardiac surgery in patients who are octogenarians. Randomized clinical trials of medical versus surgical palliation of cardiovascular symptoms in patients who are octogenarians are needed to justify cost-effectiveness and guide better use of relatively scarce Medicare resources.

Natural history of change in physical function among long-stay nursing home residents

BACKGROUND

Few longitudinal studies exist to guide clinicians or administrators on what functional outcomes can be expected among nursing home residents with different levels of cognitive impairment. Extrapolating from cross-sectional studies or from longitudinal studies of community-dwelling residents may provide misleading estimates of prognosis, hindering efforts to target preventive care.

OBJECTIVE

To describe patterns of change in physical function on a quarterly basis over 1 year among long-stay nursing home residents grouped according to their level of cognitive impairment on admission.

METHOD

Retrospective analysis of activities of daily living dependence ratings were based on quarterly MDS+ assessments from 76,016 long-stay residents admitted to nursing homes during calendar years 1993 through 1996 in five states participating in the National Case Mix and Quality and Demonstration Project. Residents were stratified by level of cognitive impairment on admission using a 7-level Cognitive Performance Scale. The activities of daily living dependence was measured by a 20 point scale. Mean activities of daily living scores on admission to the hospital and at four quarterly intervals following admission were compared across cognitive impairment levels and by state of residence.

RESULTS

A change in activities of daily living dependence over 1 year in most groups averaged 1 point or less. Three patterns of activities of daily living dependence were identified consistently across five states. Those with mild cognitive impairment on admission showed an initial reduction in dependence followed by slow increase; those with moderately severe impairment showed slow linear increased dependence; and those with severe cognitive impairment showed an initial improvement in dependence, followed by stability.

CONCLUSION

More complex statistical models that take into account comorbid conditions at baseline, in addition to cognitive performance, might identify subgroups of nursing home residents who are at risk for rapid decline. Ways to better characterize declines in function are needed, otherwise relatively large samples will be required for intervention trials.

Mortality-related factors and 1-year survival in nursing home residents

OBJECTIVES

To identify factors associated with 1-year mortality in newly admitted and long-stay (in nursing home longer than 1 year) nursing home residents by linking Minimum Data Set (MDS) information with data from the National Death Index and use these factors to create a useful tool for estimating risk levels for 1-year mortality.

DESIGN

Retrospective cohort study with development and validation cohorts.

SETTING

All 643 Medicare and Medicaid certified nursing homes in New York State during the study period.

PARTICIPANTS

The study included data on residents collected during full MDS assessments from June 1994 through December 1997. A total of 100,669 nursing home residents met the inclusion criteria for the newly admitted resident analysis. The newly admitted development cohort included 60,341 residents, and the newly admitted validation cohort included 40,328 residents. A total of 36,125 nursing home residents met inclusion criteria for the long-stay (residing in nursing home>1 year) cohort. The long-stay development cohort included 22,749 residents, and the long-stay validation cohort included 15,068 residents.

MEASUREMENTS

The analytical approach was similar for the newly admitted and long-stay resident cohorts. Resident characteristics that were considered potential risk factors for mortality were examined individually in bivariate proportional hazards models, and factors with P <.05 were entered into a proportional hazards regression stepwise model. The strongest factors based on their chi-square values were selected for entry into a multivariate proportional hazards analysis. Hazard ratios (HRs), 95% confidence intervals, and P-values were derived from this model. A mortality risk index score was created for each resident by summing the value of each HR in the multivariate model for those who had the risk factor. A sensitivity analysis was performed to determine the effect of residents with an unknown death status. A similar analysis was performed on the validation cohort to validate the original results.

RESULTS

Major factors associated with 1-year mortality were identified in both the newly admitted and long-stay cohorts. In both newly admitted and long-stay residents, a higher mortality risk index score was associated with increased 1-year mortality in both the development and validation cohorts.

CONCLUSIONS

MDS data can identify major factors associated with 1-year mortality in newly admitted and long-stay nursing home residents. These factors can be used to stratify residents into risk categories for 1-year mortality. This information could be important to residents, their families, and their physicians when developing care plans, as well as to agencies interested in healthcare resource planning.

Adverse outcomes in older hospitalized patients: the role of multidimensional geriatric assessment

BACKGROUND AND AIMS

This study was carried out to detect the incidence of adverse outcomes in hospitalized older patients and the role of multidimensional assessment in identifying predictors of adverse outcomes, which include in-hospital mortality and the need for admission to rehabilitation units or nursing homes after hospital discharge.

METHODS

923 patients at least 65 years old (mean age 78.7 +/- 7.2, 49% women) admitted to the acute care geriatric ward of an internal medicine department were included in the study. On admission, each patient underwent a comprehensive medical, functional, neuropsychological, sociodemographic and nutritional assessment.

RESULTS

Incidence of mortality and other adverse outcomes was 6 and 16%, respectively. In-hospital mortality was independently predicted by older age (OR per year: 1.07, 95% CI: 1.02-1.12), male gender (OR: 3.97, 1.99-7.95), higher comorbidity (OR: 2.09, 1.01-4.33), higher heart rate (OR: 2.87, 1.30-6.35), lower systolic blood pressure (OR: 2.22, 1.03-4.81), lower serum albumin values (OR: 3.20, 1.63-6.29) and a lower MMSE score at hospital admission (OR: 5.51, 2.34-12.9). Adverse outcomes were independently predicted by older age (OR per year: 1.03, 1.01-1.06), higher comorbidity (OR: 2.00, 1.35-2.94), lower serum albumin values (OR: 2.57, 1.69-3.90) and a lower admission MMSE score (OR: 2.49, 1.68-3.71).

CONCLUSIONS

A multidimensional geriatric assessment should be comprised of simple parameters available early, like serum albumin and MMSE score, that are predictive of adverse outcomes in older hospitalized patients, along with other health Indicators (comorbidity, heart rate and blood pressure).