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Rice HJ, Fernandes MB, Punia V, Rubinos C, Sivaraju A, Zafar SF. Predictors of follow-up care for critically-ill patients with seizures and epileptiform abnormalities on EEG monitoring. Clin Neurol Neurosurg 2024; 241:108275. [PMID: 38640778 PMCID: PMC11167629 DOI: 10.1016/j.clineuro.2024.108275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/20/2024] [Accepted: 04/04/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Post-hospitalization follow-up visits are crucial for preventing long-term complications. Patients with electrographic epileptiform abnormalities (EA) including seizures and periodic and rhythmic patterns are especially in need of follow-up for long-term seizure risk stratification and medication management. We sought to identify predictors of follow-up. METHODS This is a retrospective cohort study of all patients (age ≥ 18 years) admitted to intensive care units that underwent continuous EEG (cEEG) monitoring at a single center between 01/2016-12/2019. Patients with EAs were included. Clinical and demographic variables were recorded. Follow-up status was determined using visit records 6-month post discharge, and visits were stratified as outpatient follow-up, neurology follow-up, and inpatient readmission. Lasso feature selection analysis was performed. RESULTS 723 patients (53 % female, mean (std) age of 62.3 (16.4) years) were identified from cEEG records with 575 (79 %) surviving to discharge. Of those discharged, 450 (78 %) had outpatient follow-up, 316 (55 %) had a neurology follow-up, and 288 (50 %) were readmitted during the 6-month period. Discharge on antiseizure medications (ASM), younger age, admission to neurosurgery, and proximity to the hospital were predictors of neurology follow-up visits. Discharge on ASMs, along with longer length of stay, younger age, emergency admissions, and higher illness severity were predictors of readmission. SIGNIFICANCE ASMs at discharge, demographics (age, address), hospital care teams, and illness severity determine probability of follow-up. Parameters identified in this study may help healthcare systems develop interventions to improve care transitions for critically-ill patients with seizures and other EA.
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Affiliation(s)
- Hunter J Rice
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Marta Bento Fernandes
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Vineet Punia
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Clio Rubinos
- University of North Carolina, Chapel Hill, NC, United States
| | - Adithya Sivaraju
- Department of Neurology, Yale New Haven Hospital, Yale University, New Haven, CT, United States
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States; Center for Value-based Health Care and Sciences, Massachusetts General Hospital, Boston, MA, United States.
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Gettel CJ, Hastings SN, Biese KJ, Goldberg EM. Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population. Clin Geriatr Med 2023; 39:659-672. [PMID: 37798071 PMCID: PMC10716862 DOI: 10.1016/j.cger.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article describes emergency department (ED)-to-community care transitions for older adults and associated challenges, measurement, proven efficacious and effective interventions, and policy considerations. Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care and may benefit from targeted intervention implementation. Future efforts should target optimizing screening techniques to identify those at risk, developing and validating patient-centered outcome measures, and using policy and reimbursement levers to include transitional care management services for older adults within the ED setting.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519, USA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT 06519, USA.
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Box 3003, Durham, NC 27710, USA; Geriatric Research, Education, Clinical Center, Durham VA Health Care System, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin J Biese
- Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB #7594, Chapel Hill, NC 27599, USA; Department of Medicine, Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, 13001 East 17th Place, CB #C290, Aurora, CO 80045, USA
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Pomeroy ML, Cudjoe TKM, Cuellar AE, Ihara ES, Ornstein KA, Bollens-Lund E, Kotwal AA, Gimm GW. Association of Social Isolation With Hospitalization and Nursing Home Entry Among Community-Dwelling Older Adults. JAMA Intern Med 2023; 183:955-962. [PMID: 37486647 PMCID: PMC10366946 DOI: 10.1001/jamainternmed.2023.3064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/19/2023] [Indexed: 07/25/2023]
Abstract
Importance Social isolation is associated with adverse health outcomes, yet its implications for hospitalization and nursing home entry are not well understood. Objective To evaluate whether higher levels of social isolation are associated with overnight hospitalization, skilled nursing facility stays, and nursing home placement among a nationally representative sample of community-dwelling older adults after adjusting for key health and social characteristics, including loneliness and depressive symptoms. Design, Setting, and Participants This observational cohort study included 7 waves of longitudinal panel data from the Health and Retirement Study, with community-dwelling adults aged 65 years or older interviewed between March 1, 2006, and June 30, 2018 (11 517 respondents; 21 294 person-years). Data were analyzed from May 25, 2022, to May 4, 2023. Main Outcomes and Measures Social isolation was measured with a multidomain 6-item scale (range, 0-6, in which a higher score indicates greater isolation). Multivariate logistic regressions were performed on survey-weighted data to produce national estimates for the odds of self-reported hospitalization, skilled nursing facility stays, and nursing home placement over time. Results A total of 57% of this study's 11 517 participants were female, 43% were male, 8.4% were Black, 6.7% were Hispanic or Latino, 88.1% were White, 3.5% were other ("other" includes American Indian or Alaska Native, Asian or Pacific Islander, and other race, which has no further breakdown available because this variable was obtained directly from the Health and Retirement Study), and 58.2% were aged 65 to 74 years. Approximately 15% of community-dwelling older adults in the US experienced social isolation. Higher social isolation scores were significantly associated with increased odds of nursing home placement (odds ratio, 2.01; 95% CI, 1.21-3.32) and skilled nursing facility stays (odds ratio, 1.16; 95% CI, 1.06-1.28) during 2 years. With each point increase in an individual's social isolation score, the estimated probability of nursing home placement or a skilled nursing facility stay increased by 0.5 and 0.4 percentage points, respectively, during 2 years. Higher levels of social isolation were not associated with 2-year hospitalization rates. Conclusions and Relevance This cohort study found that social isolation was a significant risk factor for nursing home use among older adults. Efforts to deter or delay nursing home entry should seek to enhance social contact at home or in community settings. The design and assessment of interventions that optimize the social connections of older adults have the potential to improve their health trajectories and outcomes.
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Affiliation(s)
- Mary Louise Pomeroy
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Equity in Aging, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Thomas K. M. Cudjoe
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alison E. Cuellar
- Department of Health Administration and Policy, College of Public Health, George Mason University, Fairfax, Virginia
| | - Emily S. Ihara
- Department of Social Work, College of Public Health, George Mason University, Fairfax, Virginia
| | - Katherine A. Ornstein
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Equity in Aging, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, Mount Sinai Health System, New York, New York
| | - Ashwin A. Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Gilbert W. Gimm
- Department of Health Administration and Policy, College of Public Health, George Mason University, Fairfax, Virginia
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Dunnion M, Ryan A, Goode D, McIlfatrick S. Supporting older people following out of hours discharge from the Emergency Department: An integrative review of the literature. Int J Older People Nurs 2023; 18:e12529. [PMID: 36866513 DOI: 10.1111/opn.12529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND For many older people the emergency department (ED) is an important but sometimes difficult step in their healthcare journey. They often attend the ED with co and multi morbidities. Discharge home at evenings and weekends when post-discharge support services are limited can result in a delay or failure to follow through on their discharge plan leading to adverse health outcomes and in some cases, readmission to ED. OBJECTIVE The aim of this integrative review was to identify and appraise the support available to older people following discharge from the ED out of hours (OOH). METHODS For this review, out of hours referred to those times after 17.30 until 08.00 a.m. on Mondays to Fridays, all hours on weekends and public holidays. Whittemore and Knafl's (Journal of Advanced Nursing, 2005;52:546), framework was used to guide all stages of the review process. Articles were retrieved following a rigorous search of published works using various databases, the grey literature and hand search of the reference lists of the studies included. RESULTS In total 31 articles were included in the review. These comprised systematic reviews, randomised control studies, cohort studies and surveys. Main themes identified included processes that enable support, support provision by health and social care professionals and telephone follow-up. Results identified a significant dearth of out of hours discharge research and a strong recommendation for more concise and thorough research in this important area of care transition. CONCLUSION Older person discharge home from the ED presents an associated risk as previous research has identified frequent readmission and periods of ill health and dependency. Out of hours discharge can be even more problematic when it may be difficult to arrange support services and ensure continuity of care. Further work in this area is required, taking cognisance of the findings and recommendations identified in this review.
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Affiliation(s)
- Mary Dunnion
- School of Nursing, Department of Life and Health Science, Ulster University, Coleraine, UK
| | - Assumpta Ryan
- School of Nursing and Institute of Nursing and Health Research, Ulster University, Coleraine, UK
| | - Debbie Goode
- School of Nursing and Institute of Nursing and Health Research, Ulster University, Coleraine, UK
| | - Sonja McIlfatrick
- School of Nursing and Institute of Nursing and Health Research, Ulster University, Coleraine, UK
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Casson CA, Clanahan JM, Han BJ, Ferris C, Holden TR, Kushner BS, Holden SE. The efficacy of goal-directed recommendations in overcoming barriers to elective ventral hernia repair in older adults. Surgery 2023; 173:732-738. [PMID: 36280511 DOI: 10.1016/j.surg.2022.07.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although ventral hernias are common in older adults and can impair quality of life, multiple barriers exist that preclude ventral hernia repair. The goal of this study was to determine if older adults with ventral hernias achieve surgeon-directed goals to progress to an elective ventral hernia repair. METHODS Patients ≥60 years evaluated for a ventral hernia in a specialty clinic from January 2018 to August 2021 were retrospectively reviewed. Nonoperative candidates with modifiable risk factors were included. Data collected included specific barriers to ventral hernia repair and recommendations to address these barriers for future ventral hernia repair eligibility. Patients lost to follow-up were contacted by phone. RESULTS In total, 559 patients were evaluated, with 182 (32.6%) deemed nonoperative candidates with modifiable risk factors (median age 68 years, body mass index 38.2). Surgeon-directed recommendations included weight loss (53.8%), comorbidity management by a medical specialist (44.0%), and smoking cessation (19.2%). Ultimately, 45/182 patients (24.7%) met preoperative goals and progressed to elective ventral hernia repair. Alternatively, 5 patients (2.7%) required urgent/emergency surgical intervention. Importantly, 106/182 patients (58.2%) did not return to clinic after initial consultation. Of those contacted (n = 62), 35.5% reported failure to achieve optimization goals. Initial body mass index ≥40 and surgeon-recommended weight loss were associated with lack of patient follow-up (P = .01, P = .02) and progression to elective ventral hernia repair (P = .009, P = .005). CONCLUSION Nearly one-third of older adults evaluated for ventral hernias were nonoperative candidates, most often due to obesity, and over half of these patients were lost to follow-up. An increase in structured support is needed for patients to achieve surgeon-specified preoperative goals.
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Affiliation(s)
| | | | - Britta J Han
- Department of Surgery, Washington University, St. Louis, MO
| | - Chloe Ferris
- Department of Surgery, Washington University, St. Louis, MO
| | - Timothy R Holden
- Department of Medicine, Division of Geriatrics and Nutritional Science, Washington University, St. Louis, MO
| | | | - Sara E Holden
- Department of Surgery, Washington University, St. Louis, MO
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Sex-specific impacts of social isolation on loneliness, depressive symptoms, cognitive impairment, and biomarkers: Results from the social environment and biomarker of aging study. Arch Gerontol Geriatr 2023; 106:104872. [PMID: 36493576 DOI: 10.1016/j.archger.2022.104872] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/03/2022] [Accepted: 11/19/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To investigate sex-specific associations between social isolation and psychological outcomes and biomarkers among community-dwelling middle-aged and older adults using a nationally representative population-based cohort study. METHODS Data from 757 participants from the Social Environment and Biomarkers of Aging Study (SEBAS) were retrieved for analysis, and all participants were stratified by sex. The associations between social isolation and psychological outcomes (loneliness, depressive symptoms, and cognitive impairment) at the 4-year follow-up were examined by multivariate logistic regression models, and associations between social isolation and biomarkers at the 4-year follow-up were examined by multivariate generalized linear models (GLMs). RESULTS For men, social isolation was not associated with the development of loneliness. However, being married (adjusted odds ratio (aOR) 0.32 [95% confidence interval (CI) 0.13-0.74], p<0.001) was associated with a lower risk of loneliness, indicating potential protective effects of marriage for men. On the other hand, social isolation was associated with a 2-fold higher risk of loneliness in women (aOR 2.26 [1.01-5.09], p<0.001). Social isolation was not associated with depressive symptoms after adjusting for other demographics. For men, being married (aOR 0.51 [0.26-0.99], p<0.05) or having good self-reported health (aOR 0.44 [0.21-0.92], p<0.05) was protective against depressive symptoms. For women, only good self-reported health (aOR 0.30 [0.13-0.70], p<0.01) provided protective effects against depressive symptoms. Similarly, other demographic factors (being married and having a higher educational level) but not social isolation were associated with lower risks of cognitive impairment. No significant associations were noted between social isolation and selected biomarkers. CONCLUSIONS Sex-different associations between social isolation and loneliness were noted; the effects of demographic factors, such as being married, self-reported health status, and high education levels, on subsequent loneliness, depression, and cognitive function were also sex-different. Further intervention studies are needed to explore sex-specific approaches to deal with the interplay of social isolation, loneliness, psychological outcomes and other demographic factors.
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Kayser J, Wang X, Wu Z, Dimoji A, Xiang X. Layperson-Facilitated Internet-Delivered Cognitive Behavioral Therapy for Homebound Older Adults With Depression: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e44210. [PMID: 36811937 PMCID: PMC9996421 DOI: 10.2196/44210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Depression in older adults has serious biological, psychological, and social consequences. Homebound older adults experience a high burden of depression and significant barriers to accessing mental health treatments. Few interventions to address their specific needs have been developed. Existing treatment modalities can be challenging to scale up, are not tailored to unique population concerns, and require significant staffing support. Technology-assisted, layperson-facilitated psychotherapy has the potential to overcome these challenges. OBJECTIVE The aim of this study is to assess the efficacy of a layperson-facilitated internet-delivered cognitive behavioral therapy program tailored for homebound older adults. The novel intervention, Empower@Home, was developed based on user-centered design principles and partnerships between researchers, social service agencies, care recipients, and other stakeholders serving low-income homebound older adults. METHODS This 2-arm, 20-week pilot randomized controlled trial (RCT) with a waitlist control crossover design aims to enroll 70 community-dwelling older adults with elevated depressive symptoms. The treatment group will receive the 10-week intervention immediately, whereas the waitlist control group will cross over and receive the intervention after 10 weeks. This pilot is part of a multiphase project involving a single-group feasibility study (completed in December 2022). This project consists of a pilot RCT (described in this protocol) and an implementation feasibility study running in parallel with the pilot RCT. The primary clinical outcome of the pilot is the change in depressive symptoms after the intervention and at the 20-week postrandomization follow-up. Additional outcomes include acceptability, adherence, and changes in anxiety, social isolation, and quality of life. RESULTS Institutional review board approval was obtained for the proposed trial in April 2022. Recruitment for the pilot RCT began in January 2023 and is anticipated to end in September 2023. On completion of the pilot trial, we will examine the preliminary efficacy of the intervention on depression symptoms and other secondary clinical outcomes in an intention-to-treat analysis. CONCLUSIONS Although web-based cognitive behavioral therapy programs are available, most programs have low adherence and very few are tailored for older adults. Our intervention addresses this gap. Older adults, particularly those with mobility difficulties and multiple chronic health conditions, could benefit from internet-based psychotherapy. This approach can serve a pressing need in society while being cost-effective, scalable, and convenient. This pilot RCT builds on a completed single-group feasibility study by determining the preliminary effects of the intervention compared with a control condition. The findings will provide a foundation for a future fully-powered randomized controlled efficacy trial. If our intervention is found to be effective, implications extend to other digital mental health interventions and populations with physical disabilities and access restrictions who face persistent disparities in mental health. TRIAL REGISTRATION ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/44210.
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Affiliation(s)
- Jay Kayser
- School of Social Work, University of Michigan, Ann Arbor, MI, United States
| | - Xu Wang
- Computer Science and Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Zhenke Wu
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
| | - Asha Dimoji
- College of Literature, Science, and Arts, University of Michigan, Ann Arbor, MI, United States
| | - Xiaoling Xiang
- School of Social Work, University of Michigan, Ann Arbor, MI, United States
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Affiliation(s)
- Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan; Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan.
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The Impact of COVID-19 Protocols on the Continuity of Care for Patients with Hypertension. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031735. [PMID: 35162758 PMCID: PMC8835649 DOI: 10.3390/ijerph19031735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the continuity of care (COC) for patients with hypertension. Additionally, the factor of whether participants were treated via telemedicine was also considered. This study used the National Health Insurance and Medical Aid claims data of the Republic of Korea between 2019 and 2020. Multivariable regression analysis was performed to identify the differences in the number of visits and the most frequent provider continuity (MFPC) of hypertensive patients before and after the appearance of COVID-19 in Korea. Additional analysis was performed with data that excluded cases of patients who received telemedicine services. A total of 5,791,812 hypertensive patients were included in this study. The MFPC decreased by 0.0031 points after the appearance of COVID-19, and it showed the same decrease even when telemedicine cases were excluded. The number of outpatient clinic visit days decreased by 0.2930 days after the appearance of COVID-19. Without the telemedicine cases, the number of outpatient clinic visit days decreased by 0.3330 days after the appearance of COVID-19. Accordingly, the COVID-19 protocols did not affect hypertension patients’ COC but impacted the frequency of their outpatient visits. In other words, with or without telemedicine, the utilization of healthcare was not disrupted, but there was a significant difference in the volume of healthcare use depending on the inclusion of telemedicine cases.
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