Effect of Early Rehabilitation by Physical Therapists on In-hospital Mortality After Aspiration Pneumonia in the Elderly

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

PURPOSE

Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia.

METHODS

We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors.

RESULTS

803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death.

CONCLUSION

The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient.

Relationship of Age And Mobility Levels During Physical Rehabilitation With Clinical Outcomes in Critical Illness

Objective

To determine whether age, mobility level, and change in mobility level across the first 3 physical rehabilitation sessions associate with clinical outcomes of patients who are critically ill.

Design

Retrospective, observational cohort study.

Setting

Medical Intensive Care Unit (MICU).

Participants

Hospitalized adults (n = 132) who received 3 or more, consecutive rehabilitation sessions in the MICU.

Interventions

Not applicable.

Measurements and Main Results

Sample included 132 patients with 60 (45%) classified as younger (18-59 years) and 72 (55%) as older (60+ years). The most common diagnosis was sepsis/septicemia (32.6%). Older relative to younger patients had a significantly slower rate of improvement in ICU Mobility Scale (IMS) scores across rehabilitation sessions (mean slope coefficient 0.3 vs 0.6 points, P<.001), were less likely to be discharged to home (30.6% vs 55.0%, P=.005), and were more likely to die within 12 months (41.7% vs 25.0%, P=.046). Covariate-adjusted models indicated greater early improvement in IMS scores were associated with discharge home (P=.005). Longer time to first rehabilitation session, lower initial IMS scores, and slower improvement in IMS scores were associated with increased ICU days (all P<.03).

Conclusion

Older age and not achieving the mobility milestone of sitting at edge of bed or limited progression of mobility across sessions is associated with poor patient outcomes. Our findings suggest that age and mobility level contribute to outcome prognostication, and can aide in clinical phenotyping and rehabilitative service allocation.

Comparison of the thickness of the erector spinae muscles between aspiration pneumonia and bacterial pneumonia patients

BACKGROUND AND AIMS

Aspiration pneumonia is generally associated with deterioration of skeletal muscle mass, which is usually evaluated by the erector spinae muscle cross-sectional area (ESMCSA); however, no report has assessed ESMCSA in patients with aspiration pneumonia. Furthermore, erector spinae muscle thickness (ESMT) was developed to be easier to measure than ESMCSA. Therefore, this study investigated the relationship between ESMT and ESMCSA in aspiration pneumonia patients compared to bacterial pneumonia patients.

METHODS

We retrospectively collected data for 164 patients with aspiration pneumonia and 480 patients with bacterial pneumonia who were hospitalized at Fukujuji Hospital between September 2018 and May 2022. We assessed the correlations between ESMCSA and ESMT and compared the data between the two groups.

RESULTS

ESMT had a strong, proportional relationship with ESMCSA in all patients (r = 0.908, p < 0.001) and those with aspiration pneumonia (r = 0.896, p < 0.001). ESMCSA (median 671.8 mm2 [range 164.0-1636.7] vs. median 1057.0 mm2 [range 161.3-2412.5], p < 0.001) and ESMT (median 17.1 mm [range 6.95-34.4] vs. median 23.8 mm [range 6.95-43.7], p < 0.001) were significantly lower in patients with aspiration pneumonia. A multivariate analysis of aspiration pneumonia diagnosis showed significant independent differences from bacterial pneumonia in ESMCSA (odds ratio 0.998 [95% CI: 0.996-0.999], p = 0.001) and ESMT (odds ratio 0.90 [95% CI: 0.84-0.96], p = 0.002).

CONCLUSION

This study demonstrates a strong correlation between ESMCSA and ESMT. ESMT can be more easily used to evaluate skeletal muscle mass and can help in diagnosing aspiration pneumonia.

Association between physical therapy frequency and postacute care for a national cohort of patients hospitalized with pneumonia

BACKGROUND

Annually more than 300,000 patients hospitalized for pneumonia need postacute care. Patients and systems prefer home discharge, but physical limitations often necessitate postacute care. It is unknown whether frequency of physical therapy in the hospital affects postacute care discharges.

OBJECTIVE

Examine the relationship between physical therapy visit frequency and disposition among a national sample of patients hospitalized with pneumonia.

DESIGNS

Observational cohort study.

SETTING

Acute care hospital.

PARTICIPANTS

Adult patients with primary diagnosis of pneumonia in the Premier Data Set who received physical therapy in the hospital during a 5-day window, with therapy on at least days 1 and 5.

INTERVENTION

Physical therapy visit frequency.

MAIN OUTCOME AND MEASURES

Discharge disposition (home or postacute care).

RESULTS

We included 18,886 patients from 595 hospitals. Just over half were discharged home (n = 9638; 51.0%) and 558 (2.95%) died. Patients getting more frequent therapy were older, non-Hispanic white, treated in small non-teaching rural hospitals in the West, Midwest, or South, and had fewer severe illness indicators. In adjusted models, patients who received physical therapy on 100% of days were 7% [(95% confidence interval, 4.3-9.7), p < .0001] more likely to go home than patients who received physical therapy on 40% of days. As a falsification test, we found that there was no relationship between physical therapy frequency and all-cause mortality. Physical therapy visit frequency was positively associated with discharge to home. Increasing visit frequency of physical therapy in hospitals might reduce the need for postacute care, but randomized controlled trials are needed to confirm the effect.

Association between additional weekend rehabilitation and in-hospital mortality in patients with hip fractures

Aims

The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

Methods

A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups.

Results

The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group.

Conclusion

Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted.

Long-Term Survival After Aspiration Pneumonia in Older Inpatients: A Comparative Study

OBJECTIVES

Aspiration pneumonia (AsP), a leading cause of death in older people, remains poorly studied. We aimed to evaluate short- and long-term prognosis after AsP in older inpatients.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All consecutive patients aged ≥75 years hospitalized in a 62-bed acute geriatric unit during a 1-year period.

METHODS

We compared clinical characteristics and overall 2-year survival between patients with a main diagnosis of AsP, patients with other types of acute pneumonia (non-AsP), and patients hospitalized for another cause.

RESULTS

Among the 1774 patients hospitalized over 1 year (median age: 87 years, 41% female), 125 (7%) had a primary diagnosis of acute pneumonia, of whom 39 (31%) had AsP and 86 (69%) non-AsP. Patients with AsP were more frequently male, lived more frequently in a nursing home, and had a more frequent history of stroke or neurocognitive disorders. Mortality rates were much higher after AsP, reaching 31% at 30 days (vs 15% after Non-AsP and 11% in the rest of the cohort, P < .001), and 69% 2 years after admission (vs 56% and 49%, P < .001). After adjustment for confounders, AsP was significantly associated with mortality but non-AsP was not [adjusted hazard ratio (95% CI): 3.09 (1.72-5.57) at 30 days and 1.67 (1.13-2.45) at 2 years for AsP; 1.36 (0.77-2.39) and 1.14 (0.85-1.52) for non-AsP]. However, among patients who survived at 30 days, mortality did not significantly differ between the 3 groups (P = .1).

CONCLUSIONS AND IMPLICATIONS

In an unselected cohort of patients hospitalized in an acute geriatric unit, a third of AsP patients died within the first month after admission. However, among those surviving at 30 days, long-term mortality did not significantly differ from the rest of the cohort. These findings underline the importance of optimizing the early management of AsP.

Clinical decision-making using an assessment protocol of swallowing function after aspiration pneumonia: a comparative retrospective study

Objective: Aspiration pneumonia is a challenge in Japan, with many elderly citizens; however, there are insufficient experts on swallowing. Non-expert doctors may suspend oral intake for an overly long period because of the fear of further aspiration. We devised and modified an assessment protocol for swallowing function with reference to the Japanese and American practical guidelines for dysphagia. This study aimed to demonstrate clinical decision-making using the protocol by reporting the results of decisions on the safe and timely restart of adequate food intake for patients with aspiration pneumonia. Patients and Methods: This comparative retrospective study included 101 patients hospitalized with aspiration pneumonia between April 2015 and November 2017. We compared the parameters of patients for whom decisions on resumption of oral intake were aided by our protocol against those of patients from the previous year when the protocol was not used. We counted the days until either resumption of oral intake or events of aspiration/choking. Results: The duration of days until oral intake in the two groups was 1.64 ± 2.34 days in the protocol group (56 patients) and 2.09 ± 2.30 days in the control group (45 patients) (P=0.52). The adverse events of aspiration/choking were less frequent in the protocol group (5 vs. 15, odds ratio (OR) 0.32, P<0.001) as compared to the control group. The protocol group showed a significant reduction in aspiration/choking (OR 0.19, P<0.01). Conclusion: Clinical decision-making based on the protocol seems to help non-expert doctors make informed decisions regarding resuming oral intake after aspiration pneumonia.

Metabolic and ventilatory changes during postural change from the supine position to the reclining position in bedridden older patients

The prevention of pneumonia in bedridden older patients is important, and its recurrence in these patients is a relevant issue. Patients who are bedridden and inactive, and have dysphagia are considered to be at risk for pneumonia. Efforts to reduce the bedridden state and low activity may be necessary to reduce the risk of developing pneumonia in bedridden older patients. This study aimed to clarify the effects of postural change from the supine position to the reclining position on metabolic and ventilatory parameters and on safety in bedridden older patients. Using a breath gas analyzer and other tools, we assessed the following 3 positions: lying on the back (supine), resting in the Fowler position (Fowler), and resting in an 80° recline wheelchair (80°). Measurements were oxygen uptake, carbon dioxide output, gas exchange ratio, tidal volume (VT), minute volume, respiratory rate, inspiratory time, expiratory time, total respiratory time, mean inspiratory flow, metabolic equivalents, end-expiratory oxygen, and end-expiratory carbon dioxide as well as various vital signs. The study analysis included 19 bedridden participants. The change in oxygen uptake driven by changing the posture from the supine position to the Fowler position was as small as 10.8 mL/minute. VT significantly increased from the supine position (398.4 ± 111.2 mL) to the Fowler position (426.9 ± 106.8 mL) (P  = .037) and then showed a decreasing trend in the 80° position (416.8 ± 92.5 mL). For bedridden older patients, sitting in a wheelchair is a very low-impact physical activity, similar to that in normal people. The VT of bedridden older patients was maximal in the Fowler position, and the ventilatory volume did not increase with an increasing reclining angle, unlike that in normal people. These findings suggest that appropriate reclining postures in clinical situations can promote an increase in the ventilatory rate in bedridden older patients.

Early physical rehabilitation effectiveness in frail older patients hospitalized for community-acquired pneumonia: analysis of a nationwide database in Japan

BACKGROUND

Frailty is a significant predictor of prognosis in older patients with community-acquired pneumonia (CAP). No effective therapy has been reported in frail patients with CAP, with frailty determined using the Hospital Frailty Risk Score (HFRS).

AIMS

To investigate whether early physical rehabilitation intervention would effectively minimize adverse outcomes in frail older patients (determined using the HFRS) hospitalized for CAP.

METHODS

This retrospective cohort analysis involved patients with CAP aged ≥ 65 years enrolled in the Japanese Diagnostic Procedure Combination Database between 2014 and 2020 and assessed as being frail. We compared 30-day mortality and readmission rates for patients who did and who did not receive physical rehabilitation within three days of admission and evaluated the association between outcomes and receiving early physical rehabilitation using Cox regression models and inverse probability weighting (IPW) for sensitivity analysis.

RESULTS

The analysis involved 31,133 frail older patients hospitalized for CAP (mean age 84.3 ± 6.3 years; females, 49.1%), including 11,515 (37.0%) who received early physical rehabilitation. Cox regression analysis showed that early physical rehabilitation intervention was inversely associated with 30-day mortality and readmission rates. The IPW model also showed similar results.

DISCUSSION

Early physical rehabilitation was associated with reduced risks of 30-day mortality, overall in-hospital mortality, and 30-day readmission rates in frail older patients with CAP.

CONCLUSIONS

Early physical rehabilitation in frail older patients hospitalized for CAP may improve outcomes. This finding highlights the importance of simultaneously introducing the HFRS and early physical rehabilitation intervention into clinical practice for frail older patients with CAP.

Usefulness of the Modified Frailty Index for Predicting Pneumonia Occurrence After Esophagectomy

Background

Esophagectomy is an invasive and complication-prone surgical procedure. Therefore, a tool that can predict the occurrence of postoperative complications may be useful for perioperative management. In this study, we investigated whether the modified frailty index (mFI) could be a useful tool for predicting the postoperative complications of esophagectomy.

Methods

In this study, 162 patients who underwent curative esophagectomy for esophageal squamous cell carcinoma from 2004 to 2019 at our institution were included. The patients were divided into the high mFI (≥ 0.27) and low mFI (< 0.27) groups, and the short-term postoperative outcomes of each group were examined retrospectively.

Results

Regarding background factors, age and the American Society of Anesthesiologists physical status classification were significantly higher in the high mFI group (P = 0.049 and P = 0.002, respectively); however, the other items were not significantly different between the two groups. Regarding surgical outcomes, no significant differences in operative time, blood loss, and hospital stay were observed between the two groups. Regarding postoperative complications, pneumonia was significantly more common in the high mFI group (P = 0.035). In multivariate analysis, high mFI (P = 0.034) was an independent predictor of pneumonia, along with operative time ≥ 613 min (P = 0.03) and preoperative BMI < 20.48 (P = 0.006).

Conclusion

The mFI is useful for predicting pneumonia after esophagectomy.

Association Between Delayed Discharge From Acute Care and Rehabilitation Outcomes and Length of Stay: A Retrospective Cohort Study

OBJECTIVE

To examine the association between discharge delays from acute to rehabilitation care because of capacity strain in the rehabilitation units, patient length of stay (LOS), and functional outcomes in rehabilitation.

DESIGN

Retrospective cohort study using an instrumental variable to remove potential biases because of unobserved patient characteristics.

SETTING

Two campuses of a hospital network providing inpatient acute and rehabilitation care.

PARTICIPANTS

Patients admitted to and discharged from acute care categories of Medicine and Neurology/Musculoskeletal (Neuro/MSK) and subsequently admitted to and discharged from inpatient rehabilitation between 2013 and 2019 (N=10486).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Rehabilitation LOS, FIM scores at admission and discharge, and rehabilitation efficiency defined as FIM score improvement per day of rehabilitation.

RESULTS

The final cohort contained 3690 records for Medicine and 1733 for Neuro/MSK categories. For Medicine, 1 additional day of delayed discharge was associated with an average 5.1% (95% confidence interval [CI], 3%-7.3%) increase in rehabilitation LOS and 0.08 (95% CI, 0.03-0.13) reduction in rehabilitation efficiency. For Neuro/MSK, 1 additional day of delayed discharge was associated with an average 11.6% (95% CI, 2.8%-20.4%) increase in rehabilitation LOS and 0.08 (95% CI, -0.07 to 0.23) reduction in rehabilitation efficiency.

CONCLUSIONS

Delayed discharge from acute care to rehabilitation because of capacity strain in rehabilitation had a strong association with prolonged LOS in rehabilitation. An important policy implication of this "cascading" effect of delays is that reducing capacity strain in rehabilitation could be highly effective in reducing discharge delays from acute care and improving rehabilitation efficiency.

The concept of aggressive nutrition therapy and clinical indication: A position paper

Aggressive nutrition therapy is a nutritional management method that sets energy intake requirements by adding the amount of energy accumulated to energy consumption. It is used to treat patients with undernutrition and sarcopenia. However, evidence for aggressive nutrition therapy is insufficient, and validation through high-quality clinical research is essential. Therefore, this paper aimed to clarify the concept of aggressive nutrition therapy, present indications and contraindications; and describe the effects, limitations, and the need to individualize aggressive nutrition therapy for different pathological conditions. Aggressive nutrition therapy should be accompanied by the etiology of undernutrition, sarcopenia, and nutritional metabolism in various states. In addition to calculating nutritional requirements, the nutritional management methods of oral intake, tube feeding, and parenteral nutrition should be appropriately selected. A nutrition plan with the amount of energy accumulated should also be a vital issue. This position paper was authored by the Registered Dietitian Subcommittee of the Japanese Association of Rehabilitation Nutrition and was approved by the Japanese Association of Rehabilitation Nutrition.

Is rehabilitation effective in preventing decreased functional status after community-acquired pneumonia in elderly patients? Results from a multicentre, retrospective observational study

OBJECTIVES

This study was designed to evaluate the effect of rehabilitation in preventing decreased functional status (FS) after community-acquired pneumonia (CAP) in elderly patients.

DESIGN

This was a retrospective observational study.

SETTING

Multicentre study was conducted in two medical facilities from January 2016 to December 2018.

PARTICIPANTS

Hospitalised patients with CAP aged over 64 years were enrolled. FS was assessed by the Barthel Index (BI) (range, 0-100, in 5-point increments) at admission and before discharge and graded into three categories: independent, BI 80-100; semidependent, BI 30-75; and dependent, BI 0-25. Multivariable analysis of factors contributing to decreased FS was conducted with two groups: with a decrease of at least one category (decreased group) or without a decrease of category (maintained group).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the effect of rehabilitation in preventing decreased FS. The secondary outcomes were factors associated with decreased FS.

RESULTS

The maintained and decreased groups included 400 and 138 patients, respectively. A high frequency of rehabilitation therapy was observed in the decreased group (189 (47.3%) vs 104 (75.4%); p<0.001). Multivariable analysis showed that the factors affecting FS were aspiration pneumonia, Pneumonia Severity Index (PSI) category V, length of stay and age (OR 2.66, 95% CI 1.58 to 4.49; OR 1.92, 95% CI 1.29 to 3.44; OR 1.05, 95% CI 1.04 to 1.07; and OR 1.05, 95% CI 1.02 to 1.09, respectively). After adjusting for factors contributing to decreased FS, rehabilitation showed a limited effect in preventing decreased FS in 166 matched pairs by McNemar's test (p=0.327).

CONCLUSIONS

Aspiration and PSI played important roles in reducing FS. The effect of rehabilitation remains unclear in CAP.

TRIAL REGISTRATION NUMBER

UMIN000046362.

Incidence and risk factors for postoperative pneumonia following surgically treated hip fracture in geriatric patients: a retrospective cohort study

Objective

Large sample investigations for risk factors for pneumonia in elderly patients after hip fracture surgeries are lacking. The purpose of this study is to determine the incidence and risk factors for postoperative pneumonia in geriatric patients following hip fracture operations.

Methods

A retrospective study of incidence and risk factors in a tertiary referral center between 2016 and 2020 was conducted. Geriatric patients who developed postoperative pneumonia after surgeries of hip fracture during hospitalization stay were defined as cases and those without as controls. Multivariate logistic regression model was used to evaluate risk factors for postoperative pneumonia.

Results

This study included 3147 patients, and 182 developed postoperative pneumonia, denoting the rate of 5.8%. In the multivariate analyses, age (OR 1.04; 95% CI 1.02–1.06), sex (males) (OR 2.27; 95% CI 1.64–3.13), respiratory disease (OR 3.74; 95% CI 2.32–6.04), heart disease (OR 1.68; 95% CI 1.14–2.47), cerebrovascular disease (OR 1.58; 95% CI 1.11–2.27), liver disease (OR 2.61; 95% CI 1.33–5.15), preoperative stay (OR 1.08; 95% CI 1.05–1.11) and general anesthesia (OR 1.61; 95% CI 1.15–2.27) were identified as independent risk factors for postoperative pneumonia.

Conclusions

This study identified several risk factors for pneumonia in geriatric patients after hip fracture operations, providing a viable preventive strategy for optimizing clinical conditions for reduction of postoperative pneumonia.

Effects of fluid and drinking on pneumonia mortality in older adults: A systematic review and meta-analysis

Background and aims

Methods

Results

Conclusions

Effects of Cough Training and Inspiratory Muscle Training on Cough Strength in Older Adults: A Randomized Controlled Trial

PURPOSE

While the need for preventive strategies to reduce the incidence of aspiration pneumonia has been indicated, it is also important to investigate effective training methods to improve cough function, which is associated with the development of aspiration pneumonia. This study aimed to investigate whether a 4-week home-based unsupervised cough training (CT) or inspiratory muscle training (IMT) program was effective in improving cough strength in older adults.

METHODS

Fifty-three ambulatory older adults without airflow limitations were randomly assigned to one of three groups: a CT group (n = 18), an IMT group (n = 18), or a control group (n = 17). The CT and IMT groups performed home-based unsupervised training with a device for 4 weeks. Cough strength (cough peak flow), forced vital capacity, and respiratory muscle strength were assessed at the 4-week and 16-week follow-up. Intention-to-treat analyses were performed to investigate differences between the three groups using linear mixed models.

RESULTS

At the 4-week follow-up, the CT group showed significant increases in cough peak flow and forced vital capacity compared with the control group, while the IMT group showed significant increases in inspiratory muscle strength compared with the cough training and control groups. At the 16-week follow-up, the CT group showed a significant increase in cough peak flow compared with the IMT group.

CONCLUSION

These preliminary results suggest that a 4-week home-based CT program may have short-term effectiveness in improving cough peak flow in ambulatory older adults.

TRIAL REGISTRATION

This trial was registered on UMIN-CTR on 01/05/2018 (UMIN000031656).

Six-month outcomes and effect of pulmonary rehabilitation among patients hospitalized with COVID-19: a retrospective cohort study

BACKGROUND

Patients appear to maintain sequelae post-coronavirus disease 2019 (COVID-19) affecting daily life and physical health. We investigated the changes in and the effects of pulmonary rehabilitation (PR) on exercise capacity and immunology six months after COVID-19 hospitalization.

METHODS

This retrospective cohort reviewed 233 COVID-19 patients admitted from 17 January 2020 to 29 February 2020. Ninety-eight patients who completed 2-week and 6-month follow-ups and tests were included. Among 98 patients, 27 completed at least five sessions of PR at the First Hospital of Changsha, China, during the 6-month convalescence were allocated to the PR group; the reminder who had not performed any PR were assigned to the control group. The primary outcome was the change in six-minute walk distance (6-MWD) between the 2-week and 6-month follow-ups, which was assessed via analysis of covariance with a covariate of propensity score that adjusted for the potential confounders. Secondary outcomes were the changes in 6-MWD, SARS-CoV-2 immunoglobulins, T-lymphocytes and blood chemistry, which were evaluated via paired tests.

RESULTS

Participants' ages ranged from 19 to 84 years (M = 47, standard deviation (SD)=15) 45.9% identified as male. During the 6-month convalescence, 6-MWD increased 27.0%, with a mean [95% CI] of 113 [92-134] m (p < .001). SARS-CoV-2 IgG and IgM decreased 33.3% (p = .002) and 43.8% (p = .009), CD4+ T cells increased 7.9% (p = .04), and the majority of blood chemistry significantly changed. The patients in the PR group acquired a greater increase in 6-MWD than those in control (unadjusted, 194 [167-221] m, p < .001; adjusted, 123 [68-181] m, p < .001), dose-responsiveness of PR on 6-MWD was observed (p < .001). No differences in immunity variables and blood chemistry were observed between groups.

CONCLUSIONS

These findings suggest PR may be a strategy to promote the improvement of exercise capacity after COVID-19.

Early walking time is associated with recovery of activities of daily living during hospitalization in older patients with community-acquired pneumonia: A single-center prospective study

AIM

Pneumonia is a common disease with a high mortality rate among older adults that is associated with a decline in activities of daily living (ADL) during hospitalization. The aims of this study were to investigate the following: (i) early physical activity time among older patients hospitalized with community-acquired pneumonia; and (ii) the association of physical activity time with the recovery of ADL.

METHODS

A prospective observational study was carried out in patients aged ≥65 years hospitalized with community acquired pneumonia. We measured the time spent standing and walking as physical activity time using the activPAL accelerometer from the third to the ninth day of admission. Patients underwent rehabilitation during their hospitalization, and rehabilitation effectiveness was calculated using the motor Functional Independence Measure on admission and at day 10. We used stepwise multiple regression to examine the relationship between physical activity time and rehabilitation effectiveness.

RESULTS

A total of 87 patients were included in the analysis. Median (interquartile range) physical activity time was 69 min/day (43-103 min/day). In the multiple regression model, a greater daily walking time, higher cognitive and physical function, and ADL at admission were independently associated with rehabilitation effectiveness (adjusted R²  = 0.32, P < 0.0001). For every increase of 10 min/day of walking time, ADL improved by 7.8% (B = 7.8, 95% CI 1.3-14.2, P = 0.02).

CONCLUSIONS

Older patients hospitalized with community-acquired pneumonia have low levels of physical activity, and increasing early walking time might be an effective strategy to accelerate the recovery of ADL. Geriatr Gerontol Int 2021; ••: ••-••.

Effect of parenteral energy or amino acid doses on in-hospital mortality, among patients with aspiration pneumonia: a cohort medical claims database study

Background

This study examined the association between parenteral energy/amino acid doses and in-hospital mortality among inpatients on long-term nil per os (NPO) status, using a medical claims database in Japan.

Methods

Hospitalized patients with aspiration pneumonia, aged 65 and older, and on more than 7-day NPO status were identified in a medical claims database between January 2013 and December 2018. Using multivariate logistic regression and regression analyses, we examined the association between mean parenteral energy/amino acid doses and in-hospital mortality, and secondarily, the association between prognosis (in-hospital mortality, inability to receive full oral intake, readmission, and hospital stay length) and 4 groups of mean amino acid doses (no dose: 0 g/kg/day; very low dose: >0, ≤0.3 g/kg/day; low dose: >0.3, ≤0.6 g/kg/day; moderate dose: >0.6 g/kg/day).

Results

The analysis population included 20 457 inpatients (≥80 years: 78.3%). In total, 5 920 mortalities were recorded. Increased amino acid doses were significantly associated with reduced in-hospital mortality (p < .001). With a no dose reference level, the odds ratios (95% confidence interval) of in-hospital mortality adjusted for potential confounders were 0.78 (0.72–0.85), 0.74 (0.67–0.82), and 0.69 (0.59–0.81) for very low, low, and moderate amino acid doses, respectively. Additionally, patients prescribed amino acid dose levels more than 0.6 g/kg/day had shorter hospitalization periods than those prescribed none.

Conclusions

Increased amino acid doses were associated with reduced in-hospital mortality. Sufficient amino acid administration is recommended for patients with aspiration pneumonia requiring NPO status.

[Factors influencing the survival prognosis in older adults]

AIM

The present study examined the predictive factors for the survival prognosis in older adults.

METHODS

The subjects were 431 patients (75-99 years old) who visited our hospital between April 2016 and March 2019. Multivariate analyses were conducted to clarify the survival prognosis (P <0.05).

RESULTS

In a Cox regression analysis, the significant factors for the survival were the age (hazard ratio [HR] 1.050, 95% confidence interval [CI] 1.014-1.087), Charlson comorbidity index (CCI) (low vs. medium: HR 0.106, 95% CI 0.032-0.353; low vs. high: HR 0.244, 95% CI 0.150-0.398; low vs. very high: HR 0.514, 95% CI 0.326-0.809), pre-hospitalized gait (HR 1.861, 95% CI 1.158-2.988), sitting at discharge (HR 0.429, 95% CI 0.277-0.663), subcutaneous adipose tissue index (SATI) (HR 0.988, 95% CI 0.979-0.997) and modified controlling nutritional status (m-CONUT) (normal vs. light: HR 0.114, 95% CI 0.042-0.311; normal vs. moderate: HR 0.235, 95% CI 0.110-0.502; normal vs. severe: HR 0.351, 95% CI 0.166-0.741). In decision tree analyses, the significant factors for the 1-year survival were a CCI of low >medium >high-very high, body mass index of >20.7 kg/m², m-CONUT of normal-light >moderate-severe and sitting at discharge, and those for the 2-year survival were sitting at discharge, a SATI of >43.9 cm²m^-2, a CCI of low-medium >high-very high, male <female and m-CONUT of normal-light >moderate-severe.

CONCLUSIONS

High SATI and body mass index values appeared to be associated with better survival outcomes.

Impact of physical frailty on the clinical outcomes of older patients hospitalized for pneumonia

AIM

This study aimed to assess the association between physical frailty and clinical outcomes among older patients hospitalized for pneumonia.

METHODS

This study examined 852 consecutive patients hospitalized for pneumonia between October 2018 and September 2020. Patients who were <65 years old, scheduled for admission, did not receive inpatient rehabilitation, or died during admission were excluded. A short physical performance battery (SPPB) test was performed by physical therapists upon discharge. The primary outcome measure was a composite endpoint of readmission or mortality due to any cause within 6 months of discharge.

RESULTS

In total, 521 patients (median age, 80 years; interquartile range, 74-86 years) were included in the analyses, and were divided into the following two groups: robust group with SPPB scores >9 (n = 150), and physical frailty group with SPPB scores ≤9 (n = 371). Of these, 346 (66.4%) patients were men; and the median SPPB score was 6 (interquartile range, 1-10). During the median follow-up period of 53 days (interquartile range, 4-180 days), 92 (17.6%) patients were readmitted and 25 (4.8%) patients died. Patients with physical frailty were at an increased risk for the primary endpoint (hazard ratio, 2.21; 95% confidence interval, 1.44-3.41; P < 0.001); the risk remained significant after adjusting for multiple variables (adjusted hazard ratio, 1.70; 95% confidence interval, 1.05-2.74; P = 0.028).

CONCLUSIONS

Among older patients with pneumonia, physical frailty status at discharge was an independent risk factor for readmission and mortality within 6 months after initial discharge. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.

Pneumonia prevention in the elderly patients: the other sides

Pneumonia is one of the leading causes of morbidity and mortality from infection in elderly patients. The increased frequency of pneumonia among elderly subjects can be explained by the physiological changes linked to the progressive aging of the respiratory tree and the diminished immunological response. A spiral of event leads to frailty, infection and possible death; preventing pneumonia consists of controlling the risk factors. Dysphagia, which is associated with malnutrition and dehydration, is recognized as one of the major pathophysiological mechanism leading to pneumonia and its screening is crucial for the pneumonia risk assessment. The impairment in the oropharyngeal reflexes results in stagnation of foreign material in the lateral cavities of the pharynx which may then get aspirated repeatedly in the lungs and cause pneumonia. Pneumonia prevention starts with lifestyle modifications such as alcohol and tobacco cessation. A careful review of the risk-benefit of the prescribed medication is critical and adaptation may be required in elders with multiple morbidities. Respiratory physiotherapy and mobilization improve the functional status and hence may help reduce the risk of pneumonia. Maintaining teeth and masticatory efficiency is important if malnutrition and its consequences are to be avoided. Daily oral hygiene and regular professional removal of oral biofilm can prevent the onset of periodontitis and can avoid an oral environment favoring the colonization of respiratory pathogens than can then be aspirated into the lungs.

Risk and mortality of aspiration pneumonia in Parkinson's disease: a nationwide database study

This retrospective cohort study investigated the risk and mortality rate due to aspiration pneumonia in patients with Parkinson's disease (PD) using a nationwide database. We identified 10,159 newly diagnosed PD patients between 2004 and 2006, and four age- and sex-matched controls for each PD patient from the National Health Insurance Service database in Korea. We analyzed the relative risk of aspiration pneumonia and mortality after the first occurrence of aspiration pneumonia until 2017. Throughout the study period, PD patients showed a higher incidence of aspiration pneumonia than their matched controls (3.01 vs. 0.59 events per 1,000 person-years), and they were at an increased risk of aspiration pneumonia (hazard ratio = 4.21; 95% confidence interval, 3.87-4.58). After the first occurrence of aspiration pneumonia, the mortality rate of PD patients was 23.9% after one month, 65.2% after 1 year, and 91.8% after 5 years, while that of controls was 30.9%, 67.4%, and 88.9%, respectively. Patients with PD are at an increased risk of aspiration pneumonia, and approximately two-thirds of the patients die within a year after experiencing aspiration pneumonia. Further studies are warranted to prevent aspiration pneumonia and implement proper treatments to prevent death after aspiration pneumonia in patients with PD.

Nutritional management in inpatients with aspiration pneumonia: a cohort medical claims database study

BACKGROUND/OBJECTIVES

This study aimed to describe real-world nutrition management patterns among inpatients hospitalized for aspiration pneumonia, using a medical claims database in Japan.

METHODS

Patients aged ≥65 years hospitalized for aspiration pneumonia treatment were identified in a medical claims database between January 2013 and December 2018, to evaluate nutrition management initiation and adjustment timing, factors associated with >7-days nil per os (NPO) status, prescribed nutrition doses, and types of parenteral nutrition solutions. Patients who received oral intake or enteral nutrition on the day of admission (Day 1) were excluded.

RESULTS

The analysis population included 72,315 inpatients. The median (first quartile, third quartile) initiation date of oral nutrition intake was Day 4 (3, 7) and 65.1% of patients received oral nutrition intake by Day 7. Factors associated with >7-day NPO included sex, BMI, treatment years, Barthel Index score, Japan Coma Scale score, and oxygen inhalation on the day of hospital admission. Amongst NPO patients on Day 7, only 5.3% were prescribed the recommended doses of ≥20 kcal/kg; 6.4% were prescribed ≥1.0 g/kg amino acids, and 5.7% were prescribed fat energy ratio at ≥15% of non-protein calories. Commonly prescribed parenteral nutrition solutions on Day 7 were carbohydrate/electrolyte solutions (52.8%) and peripheral parenteral nutrition solutions (49.0%).

CONCLUSION

Prescribed parenteral energy, amino acids, and fat during the NPO period were lower than the recommended doses in the majority of patients. Prescribing recommended doses of each of these component nutrients may be beneficial when managing parenteral nutrition of patients during NPO.

Early mobilization and physical exercise in patients with COVID-19: A narrative literature review

BACKGROUND

Currently, little is known about early mobilization and exercise in individuals with COVID-19.

OBJECTIVE

To describe the indication and safety of early mobilization and exercises in mild to severe COVID-19 patients and to investigate the use of telerehabilitation to deliver exercise programs to these patients.

METHODS

This narrative literature review was conducted performing a comprehensive search of databases.

RESULTS

32 articles met the established criteria and the main findings were summarized and described, including indication, contraindication and recommendation for early rehabilitation and exercises prescription.

CONCLUSIONS

The literature suggests that early mobilization and physical exercise are beneficial for individuals with COVID-19. However, much of what has been published is based on expert opinion due to a lack of randomized trials, which are needed.

Swallowing evaluation by the Kuchikara Taberu Balance Chart and videoendscopic examination reveals that respiratory conditions, chewing, and position are strongly related to dysphagia

This study focused on the Kuchikara Taberu Balance Chart (KTBC) as a tool for swallowing function evaluation. To clarify the relationship between videoendoscopic (VE) examination of swallowing function and the KTBC, we compared median KTBC scores with and without laryngeal penetration identified by VE. Sixty-five patients with a mean age of 84.3 ± 7.9 years were examined at the Towada City Hospital. The patients were classified into groups based on laryngeal penetration, including 28 patients with and 37 patients without penetration. We found no significant differences in patient backgrounds. The median KTBC score (interquartile range) was 36.5 (31-44.5) in the group with laryngeal penetration and 42 (35-48.5) in the group without penetration, but the scores were not significantly different (level of statistical significance at α = 0.0036 determined by the Bonferroni correction method) when compared with the Mann-Whitney U test (36.5 vs. 42, z = -2.33, p = 0.020). The median respiratory condition (3 vs. 4, z = - 3.23; p < 0.0036), oral preparatory and propulsive phases (3 vs. 4, z = - 2.96; p < 0.0036), and position and endurance (1 vs. 3, z = - 3.25; p < 0.0036) scores were significantly lower in the group with laryngeal penetration. This study revealed a correlation between laryngeal penetration confirmed by VE and KTBC scores. Consequently, respiratory condition, oral preparatory and propulsive phases, and position and endurance may be useful as tools for the assessment of swallowing. In particular, we recommend adding respiratory status to dysphagia screening.

Effects of Early Dysphagia Rehabilitation by Speech-language-hearing Therapists on Patients with Severe Aspiration Pneumonia

Objective:

To clarify the effect of early dysphagia rehabilitation, early rehabilitation was started within 2 days of admission by speech-language-hearing therapists in patients with severe aspiration pneumonia.

Methods:

The subjects were inpatients with severe aspiration pneumonia (A-DROP≥3) admitted to our hospital between April 2014 and March 2019. We retrospectively investigated patient age, sex, A-DROP score, community-acquired or nursing- and healthcare-associated pneumonia, invasive and noninvasive ventilation, comorbidities, nutritional risk, admission from nursing home, discharge to nursing home, walking ability before admission and at discharge, Food Intake LEVEL Scale (FILS) score at the start of rehabilitation and at discharge, the achievement of oral intake, alternative nutrition in use at discharge, number of days from admission to the start of rehabilitation, and number of days from admission to oral intake. We compared the patient characteristics and rehabilitation outcomes between 159 patients who underwent early dysphagia rehabilitation and 67 patients who underwent later dysphagia rehabilitation. To assess the association between alternative nutrition at discharge and early dysphagia rehabilitation, binominal logistic regression analysis was performed.

Results:

Early dysphagia rehabilitation was significantly associated with shorter hospital stays, fewer discharges to nursing homes, higher likelihood of oral intake, the removal of alternative nutrition at discharge, fewer days from admission to oral intake, and higher FILS scores at discharge. Early dysphagia rehabilitation was significantly associated with no alternative nutrition at discharge in binominal logistic regression analysis (odds ratio 3.26; P <0.01).

Conclusions:

This study suggested that early dysphagia rehabilitation was effective in improving outcomes of severe aspiration pneumonia including the removal of alternative nutrition at discharge.

A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study

OBJECTIVES

To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs.

DESIGN

Retrospective preintervention and postintervention quality comparison study.

SETTINGS

Single tertiary community hospital with a 12-bed closed-mixed ICU.

PATIENTS

All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B).

INTERVENTION

Maebashi early mobilization protocol.

MEASUREMENTS AND MAIN RESULTS

Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13-0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $-5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum.

CONCLUSIONS

In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

Effectiveness of Early Versus Delayed Physical Rehabilitation on In-Hospital Mortality in Interstitial Pneumonia: A Retrospective Cohort Study

INTRODUCTION

Although early rehabilitation for acute inpatients is widely recommended, the effectiveness of early physical rehabilitation for interstitial pneumonia in the acute setting remains unclear.

OBJECTIVE

To investigate the impact of early rehabilitation on mortality in patients with interstitial pneumonia in the acute setting.

DESIGN

Retrospective cohort study used a hospital-based database created by the Japan Medical Data Center.

SETTING

Over 100 acute-care hospitals across Japan.

PARTICIPANTS

Inpatients hospitalized due to interstitial pneumonia from 2014 to 2018.

INTERVENTIONS

Early rehabilitation provided by physical therapists and/or occupational therapists within 2 day of admission.

MAIN OUTCOME MEASURES

Thirty- and 90-day in-hospital mortality.

RESULTS

Among the included inpatients, 847 (50%) underwent early rehabilitation. Mortality was significantly lower in the early rehabilitation group compared with the delayed rehabilitation group (30-day mortality: 6.8% vs 12.1%, 90-day mortality: 13.0% vs 19.8%). The differences were significant after propensity score adjustment using inverse probability weighting (30-day mortality: 7.6% vs 11.0%, 90-day mortality: 14.3% vs 18.0%).

CONCLUSION

Early rehabilitation was associated with decreased mortality in hospitalized patients with interstitial pneumonia.

Utility of the blood urea nitrogen to serum albumin ratio as a prognostic factor of mortality in aspiration pneumonia patients

PURPOSE

This study aimed to determine whether the blood urea nitrogen to serum albumin (B/A) ratio is a useful prognostic factor of mortality in patients with aspiration pneumonia.

METHODS

The study included patients with aspiration pneumonia who had been admitted to our hospital via the emergency department (ED) between January 1, 2014 and December 31, 2018. The 28-day mortality after the ED visits was the primary end point of this study. The data of the survivors and non-survivors were compared.

RESULTS

A final diagnosis of aspiration pneumonia was made for 443 patients during the study period. Significant differences were observed in age, respiratory rate, albumin levels, total protein levels, blood urea nitrogen levels, C-reactive protein levels, glucose, and Charlson comorbidity index scores between the survivor and non-survivor groups. Moreover, the B/A ratio was significantly higher in the non-survivor group than that in the survivor group. The area under the curve for the B/A ratio was 0.70 [95% confidence interval (CI) 0.65-0.74], 0.71 for the PSI (95% CI 0.67-0.76), 0.64 for CURB-65 (95% CI 0.60-0.69), and 0.65 for albumin (95% CI 0.60-0.70) on the receiver operating characteristic curve for predicting mortality within 28 days of the ED visit. Multivariable logistic regression analysis revealed that the B/A ratio (>7, OR 3.40, 95% CI 1.87-6.21, P < 0.001) was associated with mortality within 28 days of the ED visit.

CONCLUSION

The B/A ratio is a simple and potentially useful prognostic factor of mortality in aspiration pneumonia patients.

Investigation into the mobility of elderly patients with pneumonia using triaxial accelerometer data

OBJECTIVE

This study aimed to clarify the levels of physical activity of elderly pneumonia patients.

METHOD

This is a prospective observational study among pneumonia patients who were hospitalized in a clinic within a general and respiratory medicine hospital department, and community-dwelling elderly. Activity levels of 29 elderly patients with pneumonia who were aged >75 years (PP group), and 15 community-dwelling healthy elderly (CD group) were measured. Triaxial accelerometers were attached to the patients' left chest regions from 48 h until 7 days after hospitalization.

RESULTS

The time spent in the upright position was 320.0 min/day in the PP group and 729.0 min/day in the CD group. The time spent walking was 3.8 min/day in the PP group, and 71.0 min/day in the CD group. In the PP group, the times spent in the upright position and walking did not increase during the period studied, that is, from 48 h until 7 days after hospitalization.

CONCLUSION

The time spent in the upright position and walking among elderly patients with pneumonia did not increase, despite gradual improvement of the disease.

The effects of promoting oral intake using the Kuchi-kara Taberu index, a comprehensive feeding assistant tool, in older pneumonia patients: a cluster randomized controlled trial

Background

The multidisciplinary comprehensive care (MDCC) program promotes the improvement of oral intake for older patients. The Kuchi-kara Taberu (ingesting orally in Japanese, KT) index was developed to objectively assess patient conditions in the MDCC program. This trial examined the effects of the index in promoting oral intake in older patients with pneumonia.

Methods

A cluster randomized controlled trial was conducted in 10 local hospitals targeting older patients with pneumonia (≥65 years). Ten hospitals were allocated randomly to either the intervention or the control group. Both groups (each with five hospitals) received the MDCC program for oral feeding, which consisted of professional assessment, care, and treatment. The KT index was used by the intervention group, focusing on improving low score items. The primary outcome was determined using the Functional Oral Intake Scale (FOIS) at discharge or 1 month after admission.

Results

One hundred and twelve patients (46 women and 66 men) who participated from 10 hospitals, with a median age of 88 years (interquartile range [IQR], 80–91), were examined. The median FOIS level and the number of patients with oral intake (FOIS ≥ level 4) at discharge were 4 (IQR, 4–6) and 89 (79.5%), respectively. The duration of nil per os was 2 (IQR, 1–5) days. Clusters were not matched in the presence of Kuchi-kara Taberu Shiawase-wo Mamoru-kai-certified medical staff promoting oral intake in patients with dysphagia in each hospital. The median FOIS levels of 53 patients in the intervention group and 59 patients in the control group were 5 (IQR, 4–6) and 4 (IQR, 4–5), respectively, showing no statistically significant difference (P = 0.76). According to a multivariate analysis, the KT index had no positive effect on FOIS levels.

Conclusions

This trial was not able to demonstrate the usefulness of the KT index due to random assignment failure. However, both the intervention and control groups showed a high prevalence of oral intake (FOIS ≥ level 4) at discharge.

Trial registration

UMIN-Clinical Trial Registry, UMIN000025172, December 17, 2016.

Barium sulfate aspiration: Is early bronchioalveolar lavage a life-saving procedure?

Aspiration of barium sulfate is a well-known complication, occurring accidentally during contrast-enhanced examinations of the upper gastrointestinal system. Massive aspiration of contrast material causes mechanical obstruction that increases alveolar dead space leading to altered ventilation/perfusion (V/Q) ratio with secondary respiratory failure and death. The potential treatment strategies include early recognition of predisposing factors, pretreatment with antireflux medications, such as domperidone, correct choice of contrast media, and use of retroesophageal suction catheter during barium swallow study. We report a case of barium swallow aspiration, which was successfully managed by early institution of bronchioalveolar lavage (BAL) and positive pressure mechanical ventilation. Till date, BAL has not been recommended for the same, with studies showing it can worsen the clinical scenario.

The association of patient-reported improvement and rehabilitation characteristics with mortality

This study aims to investigate the association of patient-reported improvement and rehabilitation characteristics with mortality among older adults who received rehabilitation. To do so, a national sample of Medicare beneficiaries from the National Health and Aging Trends Study was examined. Among those who reported receiving rehabilitation services in the 2015 interview (N = 1,188), 4.2% were deceased at the 2016 follow-up interview. Mortality was more common among those who had received rehabilitation in nursing home or inpatient and in-home settings compared to outpatient rehabilitation settings. In multivariable analyses accounting for demographics and health status, patient-reported worsening of functioning during rehabilitation (OR=15.69; 95% CI: 1.84-133.45) and cardiovascular disease (OR=4.15; 95% CI: 1.41-12.17) were associated with mortality. Among older adults who received rehabilitation, 1 in 25 were deceased at follow-up. That patient-reported functioning is associated with mortality suggests that more systematically including patient-reported outcomes in rehabilitation care may be clinically pertinent.

Effect of Early Mobility as a Physiotherapy Treatment for Pneumonia: A Systematic Review and Meta-Analysis

Purpose: We conducted a systematic review of the effect of early mobility on length of stay (LOS), mortality, and clinical outcomes as a treatment for adults hospitalized with pneumonia. Method: An electronic search of four databases was conducted. Inclusion criteria were (1) acute medical condition of pneumonia in adults and (2) early mobility intervention. Quality appraisal was conducted using the Physiotherapy Evidence Database scale and the Newcastle-Ottawa Scale. Results: Four studies (three randomized controlled trials and one retrospective cohort study) met the inclusion criteria. Meta-analysis demonstrated that early mobility did not reduce the risk of mortality compared with usual care (risk ratio 0.9 [95% CI: 0.27, 2.97]; p = 0.86) but did reduce the mean LOS (-1.1 days [95% CI: 2.21, -0.04]; p = 0.04). Early mobility also did not affect the rate of hospital readmissions or emergency department visits. One study demonstrated an improvement in functional exercise capacity and quality of life related to physical function and faster completion of a measure of activities of daily living. Conclusions: Early mobility reduced LOS in adults hospitalized with community-acquired pneumonia, although there was no effect on mortality or rate of hospital readmissions. Further research is needed to determine the effect of early mobility in this population and establish guidelines.

Rehabilitation Nutrition for Iatrogenic Sarcopenia and Sarcopenic Dysphagia

Sarcopenia is a very important issue in rehabilitation medicine and nutritional care. The prevalence of sarcopenia in older people is approximately 50% in the rehabilitation setting, and also approximately 15% of inpatients without sarcopenia upon admission developed sarcopenia during hospitalization. There is a concern that secondary sarcopenia may occur iatrogenically during hospitalization. Iatrogenic sarcopenia is defined as sarcopenia caused by the activities of medical staff including doctors, nurses, or other health care professionals in healthcare facilities. Iatrogenic sarcopenia is categorized into activity-related, nutrition-related and disease-related-iatrogenic sarcopenia. Especially in acute phase hospitals, concentrating on the treatment of diseases with less attention to nutrition and activity is more likely to cause iatrogenic sarcopenia. Sarcopenic dysphagia is also an important aspect in rehabilitation medicine and nutritional care. Sarcopenic dysphagia is characterized by swallowing difficulty because of a loss of mass and function in whole-body skeletal and swallowing muscles. Sarcopenic dysphagia can be diagnosed using a 5-step algorithm for the condition. Iatrogenic sarcopenia and sarcopenic dysphagia are affected by nutrition, activity and diseases in a complex manner. Therefore, treatment of iatrogenic sarcopenia and sarcopenic dysphagia requires comprehensive interventions through nutrition management and rehabilitation. Rehabilitation nutrition is effective for preventing and treating iatrogenic sarcopenia and sarcopenic dysphagia. Rehabilitation nutrition can be practiced more effectively and comprehensively by using the rehabilitation nutrition care process, which is a systematic problem-solving method. Further research is required to verify the efficacy of rehabilitation nutrition for preventing or improving iatrogenic sarcopenia and/or sarcopenic dysphagia.

Association Between Early Rehabilitation for Mechanically Ventilated Intensive Care Unit Patients and Oral Ingestion

Objective

The present study examined the association between early rehabilitation for mechanically ventilated intensive care unit (ICU) patients and oral ingestion.

Method

Among 1055 consecutive patients who were transported to the study facility via ambulance, newly admitted to the ICU, and treated with rehabilitation during hospitalization, 234 were included in the current study. The patients were allocated to early rehabilitation and control groups to retrospectively examine the proportion able to orally ingest three meals per day, the period needed to achieve such independence, and course-related factors.

Results

A total of 77 matched pairs were selected using propensity score matching. Analysis using the Kaplan-Meier estimator revealed that the early rehabilitation group needed a markedly shorter period to achieve oral ingestion of three meals per day. There were significant differences between the groups in the periods from hospital admission to first physical therapy and to mobilization as well as differences in the frequency of delirium.

Conclusion

Early rehabilitation for mechanically ventilated ICU patients may facilitate earlier mobilization. It may also shorten the period needed to achieve oral ingestion of three meals per day by preventing complications such as delirium.

Multidisciplinary Comprehensive Care for Early Recommencement of Oral Intake in Older Adults With Severe Pneumonia

HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Multidisciplinary Comprehensive Care for Early Recommencement of Oral Intake in Older Adults With Severe Pneumonia" found on pages 21-29, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until September 30, 2019. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVES 1. Describe the effect of multidisciplinary comprehensive care (MDCC) on oral intake in older adults with severe pneumonia at the time of discharge. 2. Explore the impact of MDCC on the length of stay for hospitalized older adults with severe pneumonia. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The current study was designed to assess the effect of multidisciplinary comprehensive care (MDCC) on (a) oral intake at discharge and (b) hospital stay duration in older adult patients with severe pneumonia. Participants were divided into two groups: receiving and not receiving MDCC. MDCC comprises regular assessment of swallowing ability, aspiration risk management, improvement of oral hygiene, serving of nutritious texture-modified foods, and encouragement of early mobilization. The MDCC group (164 women, 206 men; mean age = 82.7, SD = 8.4 years) had severe pneumonia as well as high proportions of poor premorbid physical function and consciousness disturbance compared to the non-MDCC group (45 women, 56 men; mean age = 81.1, SD = 8.6 years). Nevertheless, MDCC was an independent determinant of hospital stay duration and oral intake (Functional Oral Intake Scale score ≥4) at discharge with Cox regression analysis (hazard ratio = 1.42, 95% confidence interval [1.09, 1.85]). MDCC may promote early oral intake and hospital discharge in older adults with severe pneumonia. [Journal of Gerontological Nursing, 42(10), 21-29.].

Outcomes after early and delayed rehabilitation for exacerbation of chronic obstructive pulmonary disease: a nationwide retrospective cohort study in Japan

Background

The effectiveness of early pulmonary rehabilitation (PR) for exacerbation of chronic obstructive pulmonary disease (COPD) remains controversial. The present study aimed to compare the outcomes between early and delayed PR for exacerbation of COPD, using a national inpatient database.

Methods

Using the Japanese Diagnosis Procedure Combination database, we examined patients who were transported to hospital for exacerbation of COPD, received PR during hospitalisation, and were discharged to their home. The patients were divided into those who received early PR (defined as PR starting within 48 h of admission) and those who received delayed PR. The outcomes included 90-day readmission, length of stay (LOS), and activities of daily living (Barthel index ≥15) at discharge. Multiple imputation was used for missing data. To assess the associations between early PR and the outcomes, we used risk-adjusted treatment effects and instrumental variable methods.

Results

We identified 12,572 eligible patients, including 8459 patients with delayed PR and 4113 with early PR. In the risk-adjusted treatment effect models, the early PR group had lower proportion of 90-day readmission (risk difference, −3.4%; 95% CI, −5.7% to −1.5%) and shorter LOS (−9.8 days; 95% CI, −10.8 days to −8.7 days) than the delayed PR group. There was no significant difference in activities of daily living at discharge between the two groups. The instrumental variable analyses showed similar results.

Conclusions

In this national database study, early PR was associated with reduced 90-day readmission and shortened LOS in patients with exacerbation of COPD.

Rehabilitative management for aspiration pneumonia in elderly patients

Aspiration pneumonia is a common disease that frequently occurs in elderly patients. Most patients with aspiration pneumonia have swallowing disability and develop hospital‐acquired disability. Frequently, patients have difficulty returning home, and they often require long‐term hospitalization. Recently, the effectiveness of rehabilitative management including physical, pulmonary, and dysphagia rehabilitation for aspiration pneumonia was reported. Several studies showed that early rehabilitation was associated with reduced mortality and early hospital discharge after aspiration pneumonia. Unnecessary “nil by mouth” directives associated with aspiration pneumonia at hospital admission resulted in adverse effects, including decline in swallowing ability and prolonged treatment duration. Rehabilitative management combined with appropriate nutrition is recommended to improve clinical outcomes, including physical and swallowing function in geriatric patients with aspiration pneumonia.

Time trends in incidence and outcomes of hospitalizations for aspiration pneumonia among elderly people in Spain (2003-2013)

BACKGROUND

Aspiration pneumonia (AP) is an infectious process causing high rates of mortality. The purpose of this study was: 1, to describe the incidence from 2003 to 2013 of AP hospitalizations; 2, to assess time trends in hospital outcomes variables, and; 3, to identify the factors independently associated with in-hospital mortality (IHM).

METHODS

A retrospective observational study using the Spanish National Hospital Database, with patients discharged between January 2003 and December 2013 was conducted. Inclusion criteria were: Subjects aged 75years or older whose medical diagnosis included AP events code according to the ICD-9-CM: 507.x in the primary diagnosis field. Patient variables, up to 14 discharge diagnoses per patient, and up to 20 procedures performed during the hospital stay (ICD-9-CM), Charlson Comorbidity Index, readmission, length of hospital stay (LOHS), and IHM were analyzed.

RESULTS

We included 111,319 admissions (53.13% women). LOHS decreased in both sexes (P<0.001) and was significantly higher in men (10.4±10.31 vs. 9.56±10.02days). Readmissions increased significantly in women during the study (13.94% in 2003 to 16.41% in 2013, P<0.001). In both sex, IHM was significantly higher in >94years old subjects (OR: 1.43, 95%CI 1.36-1.51) and in those with readmissions (OR: 1.20, 95%CI 1.15-1.23). For the entire population, time trend analyses showed a significant decrease in mortality from 2003 to 2013 (OR: 0.96, 95%CI 0.95-0.97).

CONCLUSIONS

Patients with AP are older, male, and have more comorbidities than those without AP. Over time, LOHS and IHM decreased in both sexes, but readmissions increased significantly in women.

Muscle Mass Loss Is a Potential Predictor of 90-Day Mortality in Older Adults with Aspiration Pneumonia

OBJECTIVES

To investigate the association between loss of muscle mass and aspiration pneumonia (AP).

DESIGN

Prospective observational cohort.

SETTING

Acute geriatric hospital.

PARTICIPANTS

Individuals admitted to the hospital for AP (N = 151; mean age 85.9; 49.7% male).

MEASUREMENTS

Appendicular skeletal muscle index (ASMI; appendicular skeletal muscle mass divided by height squared) was used to evaluate muscle mass. Data on age, sex, body mass index, Mini Nutritional Assessment-Short Form score, Barthel Index score, Charlson Comorbidity Index score, and pneumonia severity (Japanese version of the CURB-65 (C (confusion), U (blood urea nitrogen ≥20 mg/dL), R (respiratory rate ≥30 breaths/min), B (systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg), 65 (aged ≥65) severity score (A-DROP)) were obtained. Outcomes included 30- and 90-day mortality.

RESULTS

Mild, moderate, severe, and extremely severe AP were observed in 1.3%, 70.2%, 25.8%, and 2.6% of participants, respectively. On Kaplan-Meier analysis, participants in the lowest ASMI quartile for each sex were more likely to die than those in the other quartiles (log-lank test P = .005). Multivariate logistic analyses showed that ASMI and A-DROP were independent predictors of 90-day mortality; only A-DROP was a significant predictor of 30-day mortality (P < .001). Cox regression analysis also showed that the first ASMI quartile was independently associated with mortality (hazard ratio = 2.19; 95% confidence interval = 1.06-4.52; P = .03).

CONCLUSION

Low muscle mass is a potential predictor of long-term mortality in individuals with AP. Prospectively preventing muscle mass deterioration may be beneficial for recovery from AP in older adults.

Changes in physical function after hospitalization in patients with nursing and healthcare-associated pneumonia

To clarify the functional changes after hospitalization due to pneumonia in elderly Japanese patients, we investigated the changes in physical functioning, nutritional routes, and diet that occurred after hospitalization in patients with nursing and healthcare-associated pneumonia (NHCAP). We analyzed 405 patients with NHCAP and compared findings with 448 patients with community-acquired pneumonia (CAP). Among the NHCAP patients, 140 (34%) patients showed a decline in activities of daily living function between baseline and discharge. After hospital discharge, 149 (37%) NHCAP patients did not return to the same residence location compared with where they were living prior to hospital admission. The frequency of this outcome was significantly higher in NHCAP patients than in CAP patients (p < 0.0001). After 6 months' follow-up, of the patients who transferred to different hospitals, 41 (73%) patients with CAP had returned to their own home, but only 16 (20%) patients with NHCAP could return home (p < 0.0001). Rates of alteration of nutritional route and type of diet from oral nutrition were significantly higher in NHCAP patients compared with CAP patients (22% vs 4%, p < 0.0001). Our results demonstrated that approximately one-third of hospitalized patients with NHCAP showed a decline in physical function. In addition, approximately one-fifth of NHCAP patients had changed their route of nutrition and type of diet. Our results indicated that physicians should attach greater importance to preventative measures against NHCAP rather than relying on antibiotic therapy post-infection in the management of pneumonia in elderly patients in order to extend their healthy life expectancy.