The value of caregiver inclusive practices in geriatric transitions of care: A systematic review

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

A Methodological Approach for Documenting Multi-Component Interventions Targeting Family Caregivers

Managing the complex care needs of seriously ill patients transitioning from hospital to home can have detrimental effects on family caregivers (FCG). Multi-component interventions tailored to FCG needs are most effective at reducing caregiver burden, distress, and depression. However, gaps exist in determining best methods to assess, document, and analyze intervention components for FCGs. Common methods used to capture patient data during transitions in care may not be appropriate or allowed for FCG needs. As such, we present a methodological approach for electronically capturing, reporting, and analyzing multiple intervention components. This approach uses a standardized terminology and pathway for tailoring intervention components in real time while evaluating intervention effects across time. We use examples from a randomized controlled trial to illustrate the benefits of the current approach for analyzing the effectiveness of multi-component interventions in the context of caregiving research.

Transitional care interventions for supporting frail older adults discharged from hospitals: An umbrella review

Transitional care interventions have been shown to assist frail older adults; however, their true efficacy remains inconclusive. This umbrella review aimed (1) to summarize the components of transitional care interventions in support of frail older adults discharged from hospitals to community-based facilities that may have impacted healthcare outcomes and (2) to synthesize the impacts of these interventions. Systematic reviews published between January 2018 and September 2022 were screened using seven electronic databases. The review protocol followed the Joanna Briggs Institute Reviewers' Manual and was registered in the PROSPERO. Nine relevant systematic reviews were assessed for their methodological quality. Four of the measured primary healthcare outcomes improved as a result of transitional care interventions. In particular, evidence indicates that high-intensity transitional care or transitional care lasting at least one month can improve healthcare outcomes in frail older adults. Additional funding research and practical guidelines are warranted.

Assessing Family Caregiver Communication in Chronic Illness: Validation of the FCCT-CI

Background: Chronic illness care demands attention to the unique needs of family caregivers who support care at home, yet few tools exist for family caregiver assessment in the social domain of practice. Objectives: The Family Caregiver Communication Tool (FCCT) assesses caregiver communication as part of the family system and was originally developed for cancer caregivers. The aim of this study was to develop and psychometrically-validate a version of the FCCT for Chronic Illness (FCCT-CI). Methods: We revised the FCCT, including the generation of new items, and psychometrically tested it in 303 family caregivers recruited through Amazon Prime Panels. Item reduction through exploratory factor analysis was conducted, internal consistency was assessed using Cronbach's alpha, and concurrent validity was conducted to demonstrate correlation of the new scale with previously validated instruments. Results: A principal axis analysis with promax rotation initially revealed a five-factor structure of the 27 items initially tested, but, after statistical and theoretical reduction and refinement, a 10 item FCCT-CI emerged. Cronbach's alpha ranged from .74 to .86 for the FCCT-CI instrument. Concurrent validity was supported by bivariate correlation tests. Conclusions: The FCCT-CI is the first psychometrically tested scale designed to assess caregiver communication with chronically ill patients, family members, and palliative care providers about caregiving. The FCCT-CI scale includes but is not limited to cancer caregiving and palliative care contexts and has good reliability and validity. Palliative care providers can use this tool to assess, design, and test interventions to support family caregivers.