Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort

New horizons in the analysis of hospital readmissions of older adults

This short communication highlights analytical methods that can be usefully applied to the problem of hospital readmissions of older adults. The limitations of the models currently used in studies of hospital readmissions are described. In summary, analyses of hospital readmissions face two important methodological and statistical problems not accounted for by these currently used statistical models: the potential recurrence of readmissions, and death, a terminal event which absorbs the readmission process. Not addressing the issue raised by recurrent events and terminal event generates biased estimates. We discuss an approach for the analysis of hospital readmission risk and death in the same framework. Understanding the features of this kind of approaches is essential at a time when high-quality data on hospital readmission in older patients are becoming available to a large number of researchers. Models adapted for the analysis of recurrent and terminal events are presented, and their application to studies of hospital readmission are explained, with reference to two cohorts of several thousand older individuals.

Nutritional risk screening in a Danish university hospital is insufficient and may underestimate nutritional risk: A cross-sectional study

BACKGROUND

Disease-related-malnutrition predicts poor clinical outcomes in elderly patients, and screening is pivotal for identifying patients at nutritional risk. The present study aimed to investigate nutrition screening rates in electronic patient records and validate the scores given. A secondary aim was to investigate whether the proportion of patients at risk differed between patients where screening was documented and those where no screening was documented.

METHODS

This cross-sectional observational study was conducted in a Danish university hospital during November 2020. Patients aged 65 years or more admitted to a medical department were included. The Nutrition Risk Screening 2002 (NRS-2002) tool was used to identify patients at nutritional risk, both in routine clinical care, where data were collected retrospectively, and during a validation process in a random patient sample, where data were collected prospectively.

RESULTS

In total, 817 patients were admitted for more than 24 h. Of these, an NRS-2002 score was documented in 294 (36%), among whom 177 (60%) were at nutritional risk. In 146 patients where no score was documented, 88 (60%) were at risk. Validation was possible in 91 patients where a record-based score and a validated score were documented. The specificity of the record-based score was 100%, whereas the sensitivity was 75%, indicating that routine screening underestimated nutritional risk (p < 0.001, proportion difference 19%; 95% confidence interval = 10%-28%).

CONCLUSIONS

Electronic documentation does not solve issues about compliance with nutritional risk screening. In patients where screening was not documented, the occurrence of nutritional risk was similar, indicating that omission of screening is not related to the score.

Poor prognostic impact of delirium: especially on mortality and institutionalisation

The course of delirium is associated with increased hospital costs, healthcare complications, increased mortality, and long-term poor outcomes. Despite delirium being long recognised as one of the most important prognostic components of patients with illnesses, delirium remains poorly understood, effective management options are limited, and no effective treatment has yet been established. This review evaluated the effects of delirium on mortality, institutionalisation, and dementia in various situations to clarify its prognostic seriousness to elucidate important areas for clinical practice and future research. The effect of delirium on mortality in COVID-19 patients was similar to that in other diseases. The effect of delirium on mortality in patients with delirium between the ages of 18 and 65 may be higher than in those with delirium aged over 65, but studies are scarce. Promoting recognition of delirium at all ages is needed. With careful attention to the specific factors in younger patients that contribute to delirium, healthcare providers may be able to decrease the poor impact of delirium on clinical outcomes. Evaluation of the association between interventions for delirium such as sedation in present clinical practice and the prognosis of delirium is lacking, and further clinical studies are essential.

Risk Factors for Hospital Readmission and Death After Discharge of Older Adults from Acute Geriatric Units: Taking the Rank of Admission into Account

Objective

To analyze the impact of the number of hospital readmissions on the risks of further hospital readmission and death after adjustment for a range of risk factors.

Methods

We performed a multicentre prospective study of the DAMAGE cohort in the Hauts-de-France region of France. Patients aged 75 and over hospitalized initially in an acute geriatric unit (AGU) were included and followed up for 12 months. The risk of hospital readmission was analyzed using a Cox model, and its extension for recurrent events and the risk of death were analyzed using a Cox model for time-dependent variables.

Results

A total of 3081 patients were included (mean (SD) age: 86.4 (5.5)). In the multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital readmission rose progressively to 2.66 (1.44; 5.14), and the risk of death rose to 2.01 (1.23; 3.32) after five hospital admissions, relative to a patient with no hospital readmissions. The number of hospital readmissions during the follow-up period was the primary risk factor and the best predictor of the risk of hospital readmission and the risk of death.

Conclusion

Hospital readmission is the primary risk factor for further hospital readmissions and for death in older subjects discharged from an AGU.

Emergency hospital admissions among older adults living alone in the community

Background

Among older adults, living alone is often associated with higher risk of Emergency Department (ED) admissions. However, older adults living alone are very heterogeneous in terms of health. As more older adults choose to live independently, it remains unclear if the association between living alone and ED admissions is moderated by health status. We studied the association between living alone and ED admission outcomes (number of admissions, inpatient days and inpatient costs) among older adults with and without multimorbidity.

Methods

We used data from 16,785 individuals of the third follow-up of the Singapore Chinese Health Study, a population-based cohort of older Singapore Chinese (mean age: 73(61-96) years). Participants were interviewed face-to-face from 2014 to 2016 for sociodemographic/health factors and followed-up for one year on ED admission outcomes using Singapore Ministry of Health’s Mediclaim Database. We first applied multivariable logistic regression and two-part models to test if living alone is a risk factor for ED admission outcomes. We then ran stratified and joint effect analysis to examine if the associations between living alone and ED admission outcomes were moderated by multimorbidity.

Results

Compared to living with others, living alone was associated with higher odds of ED admission [Odds Ratio (OR) 1.28, 95 % Confidence Interval(CI) 1.08-1.51)], longer inpatient days (+0.61, 95 %CI 0.25-0.97) and higher inpatient costs (+322 USD, 95 %CI 54-591). The interaction effects of living arrangement and multimorbidity on ED admissions and inpatient costs were not statistically different, whereas the interaction between living arrangements and multimorbidity on inpatient days was borderline significant (p-value for interaction=0.050). Compared to those living with others and without multimorbidity, the relative mean increase was 1.13 inpatient days (95 %CI 0.39-1.86) for those living alone without multimorbidity, and 0.73 inpatient days ( 95 %CI 0.29-1.17) for those living alone with multimorbidity.

Conclusions

Older adults living alone were at higher risk of ED admission and higher inpatient costs regardless of multimorbidity, while those living alone without multimorbidity had the longest average inpatient days. To enable aging in place while avoiding ED admissions, interventions could provide instrumental support and regular health monitoring to older adults living alone, regardless of their health status.

Terms used by physicians when deciding to withhold treatment for older patients not having received palliative care in an acute geriatric care unit

PURPOSE

There are no guidelines or consensus statements on the terms to be used when discussing withholding of treatment for patients in acute geriatric care units and who have not received palliative care. The objective of the present study was to analyze the terms used in medical records to refer to the withholding of treatment for patients who died in an acute geriatric care unit and did not receive palliative care.

METHODS

We conducted an ambispective multicentre cohort study based on the DAMAGE study. Data on 53 patients who died in the acute geriatric care unit and who had not received palliative care were extracted from medical records. The verbatims referring to the withholding of treatment were analyzed in terms of keywords and then key concepts, as defined by several reviewers in a consensus-based approach.

RESULTS

The mean age of the patients was 86.4 years, 34.1% were male. Terms referring to the withholding of treatment were found for 25 of the 53 patients (47.2%). Most of the decisions on the withholding of treatment were recorded in the week following admission to the acute geriatric care unit. Our analysis of the terms identified 11 key concepts: treatment limitation, no resuscitation, withholding diagnostic procedures, justification of care, ethical considerations, disease progression, uncertainty, the patient's wishes, the family's wishes, patient's comfort, and collegiality. The terms used to describe key concepts varied markedly from one physician to another.

CONCLUSION

Decisions about the withholding of treatment are frequently noted in the medical records of patients who die in the acute geriatric care unit without having received palliative care. The broad variety of key concepts and differences in the choice of words highlight the need for standardized terms.

Importance of previous hospital stays on the risk of hospital re-admission in older adults: a real-life analysis of the PAERPA study population

BACKGROUND

consideration of the first hospital re-admission only and failure to take account of previous hospital stays, which are the two significant limitations when studying risk factors for hospital re-admission. The objective of the study was to use appropriate statistical models to analyse the impact of previous hospital stays on the risk of hospital re-admission among older patients.

METHODS

an exhaustive analysis of hospital discharge and health insurance data for a cohort of patients participating in the PAERPA ('Care Pathways for Elderly People at Risk of Loss of Personal Independence') project in the Hauts de France region of France. All patients aged 75 or over were included. All data on hospital re-admissions via the emergency department were extracted. The risk of unplanned hospital re-admission was estimated by applying a semiparametric frailty model, the risk of death by applying a time-dependent semiparametric Cox regression model.

RESULTS

a total of 24,500 patients (median [interquartile range] age: 81 [77-85]) were included between 1 January 2015 and 31 December 2017. In a multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital re-admission rose progressively from 1.8 (1.7-1.9) after one previous hospital stay to 3.0 (2.6-3.5) after five previous hospital stays. The relative risk [95%CI] of death rose slowly from 1.1 (1.07-1.11) after one previous hospital stay to 1.3 (1.1-1.5) after five previous hospital stays.

CONCLUSION

analyses of the risk of hospital re-admission in older adults must take account of the number of previous hospital stays. The risk of death should also be analysed.

A qualitative study of old patients' experiences of the quality of the health services in hospital and 30 days after hospitalization

Background

The number of people aged 80 years and above is projected to triple over the next 30 years. People in this age group normally have at least two chronic conditions. The impact of multimorbidity is often significantly greater than expected from the sum of the effects of each condition. The World Health Organization has indicated that healthcare systems must prepare for a change in the focus of clinical care for older people. The World Health Organization (WHO) defines healthcare quality as care that is effective, efficient, integrated, patient centered, equitable and safe. The degree to which healthcare quality can be defined as acceptable is determined by services’ ability to meet the needs of users and adapt to patients’ expectations and perceptions.

Method

We took a phenomenological perspective to explore older patients’ subjective experiences and conducted semistructured individual interviews. Eighteen patients (aged from 82 to 100 years) were interviewed twice after discharge from hospital. The interview transcriptions were analyzed thematically.

Results

The patients found their meetings with the health service to be complex and demanding. They reported attempting to restore a sense of security and meaning in everyday life, balancing their own needs against external requirements. Five overarching themes emerged from the interviews: hospital stay and the person behind the diagnosis, poor communication and coordination, life after discharge, relationship with their next of kin, and organizational and systemic determinants.

Conclusion

According to the WHO, to deliver quality healthcare, services must include all six of the dimensions listed above. Our findings show that they do not. Healthcare focused on measurable values and biomedical inquiries. Few opportunities for participation, scant information and suboptimal care coordination left the patients with a feeling of being in limbo, where they struggled to find balance in their everyday life. Further work must be done to ensure that integrated services are provided without a financial burden, centered on the needs and rights of older people.

Informal caregivers' views on the quality of healthcare services provided to older patients aged 80 or more in the hospital and 30 days after discharge

Background

In the European Union (EU), informal caregivers provide 60% of all care. Informal caregiving ranges from assistance with daily activities and provision of direct care to helping care recipients to navigate within complex healthcare and social services systems. While recent caregiver surveys document the impact of informal caregivers, systematic reviews show that they have unmet needs.

Because of the political desire to reduce the length of hospital stays, older patients are discharged from the hospital ‘quicker and sicker’ than before. The transition between different levels of the healthcare system and the period after hospital discharge is critical for elderly patients.

Caregivers’ perspectives on the quality of older patients’ care journeys between levels of the healthcare system may provide valuable information for healthcare providers and policymakers. This study aims to explore older patient’s informal caregivers’ views on healthcare quality in the hospital and in the first 30 days after hospitalisation.

Method

We conducted semi-structured individual interviews with 12 participants to explore and describe informal caregivers’ subjective experiences of providing care to older relatives. The interviews were then transcribed and analysed thematically.

Results

The analysis yielded the overarching theme ‘Informal caregivers – a health service alliance – quality contributor’, which was divided into four main themes: ‘Fast in, fast out’, ‘Scant information’, ‘Disclaimer of responsibility’ and ‘A struggle to secure professional care’. The healthcare system seemed to pay little attention to ensuring mutual understandings between those involved in discharge, treatment and coordination. The participants experienced that the healthcare providers’ main focus was on the patients’ diseases, although the health services are supposed to view patients holistically.

Conclusion

Based on the information given by informal caregivers, health services must take into account each person’s needs and preferences. To deliver quality healthcare, better coordination between inter-professional care teams and the persons they serve is necessary. Health professionals must strengthen the involvement of caregivers in transitions between care and healthcare. Future work should evaluate targeted strategies for formal caregivers to cooperate, support and empower family members as informal caregivers.

Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation

OBJECTIVES

Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed.

DESIGN

Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA.

SETTING

Tertiary-care hospital, France.

SUBJECTS AND MEASUREMENTS

The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients.

RESULTS

Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs.

CONCLUSIONS

As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.

Predictability of a modified Mini- Nutritional- Assessment version on six-month and one-year mortality in hospitalized geriatric patients: a comparative analysis

Recently we introduced a modified Mini Nutritional Assessment (MNA) Short Form (MNA-SF) and Long Form (MNA-SF) with operationalization of the ‘mobility’ and ‘neuropsychological problems’ items of the MNA using scores on Barthel Index mobility item and Mini Mental State Examination and Geriatric Depression Scale scores. We have now evaluated the abilities of this modified MNA-SF and MNA-LF to predict mortality in comparison with the standard MNA-SF and MNA-LF and the Nutritional Risk Screening 2002 (NRS 2002) and the Malnutrition Universal Screening Tool (MUST). A prospective analysis was performed in 240 hospitalised geriatric patients aged ≥ 65 years. Malnutrition and/or malnutrition risk were assessed using the modified MNA-SF and MNA-LF, the standard MNA-SF and MNA-LF, and the NRS 2002 and MUST. The modified MNA-SF and MNA-LF and the standard MNA-SF and MNA-LF assessments (all p < 0.05), but not NRS 2002 or MUST (all p ≥ 0.05), predicted six-month and/or one-year mortality. Prediction of six-month and/or one-year mortality by the modified MNA-SF was comparable with predictions by the standard MNA-SF and MNA-LF (all p ≥ 0.05). The modified MNA-LF showed better prediction of six-month and one-year mortality than the standard MNA-SF and MNA-LF (all p < 0.05). The modified MNA-LF (all adjusted p < 0.05), but none of the other instruments (all adjusted p ≥ 0.05), predicted six-month and one-year mortality independently of age, sex, frailty, comorbidity and ADL disability burden. The modified MNA-SF and MNA-LF emerged as potentially valuable tools for predicting mortality in patients hospitalised on geriatric wards.

Discharge Home From Hospital: How DIRE Can It Be?

Aim: An easy-to-use “DIRE” questionnaire tool was developed to predict an adverse event (AE) within 30 days following discharge from a hospital to the community, among frail elderly individuals aged 65+ years. Methods: Hospital-administered RAI-HC (Residential Assessment Instrument for Home Care) assessment data from 1,433 individuals were used to develop the tool. Results: The DIRE tool outperformed two other instruments that have been used to predict risk in similar populations. Furthermore, the DIRE index was validated on a hold-out sample and in a bootstrapping analysis. Discussion: In addition to its effectiveness in predicting an AE, the added advantages of the DIRE assessment is that only a small amount of data is required and the data are readily available to clinicians at the point of hospital discharge.

Can delirium research activity impact on routine delirium recognition? A prospective cohort study

OBJECTIVE

To assess if ongoing delirium research activity within an acute admissions unit impacts on prevalent delirium recognition.

DESIGN

Prospective cohort study.

SETTING

Single-site tertiary university teaching hospital.

PARTICIPANTS

125 patients with delirium, as diagnosed by an expert using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition reference criteria, were recruited to a prospective cohort study investigating use of informant tools to detect unrecognised dementia. This study evaluated recognition of delirium and documentation of delirium by medical staff.

INTERVENTIONS

The main study followed an observational design; the intervention discussed was the implementation of this study itself.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was recognition of delirium by the admitting medical team prior to study diagnosis. Secondary outcomes included recording of or description of delirium in discharge summaries, and factors which may be associated with unrecognised delirium.

RESULTS

Delirium recognition improved between the first half (48%) and second half (71%) of recruitment (p=0.01). There was no difference in recording of delirium or description of delirium in the text of discharge summaries.

CONCLUSION

Delirium research activity can improve recognition of delirium. This has the potential to improve patient outcomes.

Hospital outcomes of older people with cognitive impairment: An integrative review

OBJECTIVES

To summarise existing knowledge of outcomes of older hospital patients with cognitive impairment, including the type and frequency of outcomes reported, and the additional risk experienced by this patient group.

METHODS

Integrative literature review. Health care literature databases, reports, and policy documents on key websites were systematically searched. Papers describing the outcomes of older people with cognitive impairment during hospitalisation and at discharge were analysed and summarised using integrative methods.

RESULTS

One hundred four articles were included. A range of outcomes were identified, including those occurring during hospitalisation and at discharge. Older people with a dementia diagnosis were at higher risk from death in hospital, nursing home admission, long lengths of stay, as well as intermediate outcomes such as delirium, falls, dehydration, reduction in nutritional status, decline in physical and cognitive function, and new infections in hospital. Fewer studies examined the relationship of all-cause cognitive impairment with outcomes. Patient and carer experiences of hospital admission were often poor. Few studies collected data relating to hospital environment, eg, ward type or staffing levels, and acuity of illness was rarely described.

CONCLUSIONS

Older people with cognitive impairment have a higher risk of a variety of negative outcomes in hospital. Prevalent intermediate outcomes suggest that changes in care processes are required to ensure maintenance of fundamental care provision and greater attention to patient safety in this vulnerable group. More research is required to understand the most appropriate ways of doing this and how changes in these care processes are best implemented to improve hospital outcomes.

Thirty-day rehospitalizations among elderly patients with acute myocardial infarction: Impact of postdischarge ambulatory care

Rehospitalization after acute myocardial infarction (AMI) is common in elderly patients. It increases morbimortality and health care expenditures. The association between ambulatory care after discharge for AMI and rehospitalization has never been studied in France. We analyzed the impact of ambulatory care on rehospitalization of elderly patients (≥65 years) within 30 days after hospital discharge.We conducted a nationwide population-based study of elderly patients hospitalized with a main diagnosis of AMI in France between 2011 and 2013. We excluded patients hospitalized for AMI in the previous year and those who died during the index hospitalization or within 30 days after discharge. The primary outcome was the first all-cause 30-day rehospitalization in an acute care hospital. Individual and neighborhood-level variables were compared among rehospitalized and nonrehospitalized patients. Determinants of 30-day rehospitalization were identified using logistic regression models.Among the 624 eligible patients, 137 (22.0%) were rehospitalized within 30 days after discharge. In multivariate analyses, chronic kidney failure (odds ratio [OR] 1.88; 95% confidence interval [CI], 1.01-3.53) was an independent predictor of 30-day rehospitalization. We found no association among deprivation and spatial accessibility measures and 30-day rehospitalization. The purchase of lipid-lowering drugs prescription within 7 days after discharge was associated with a reduced risk of 30-day rehospitalization (OR 0.53; 95% CI, 0.36-0.79).This study highlights the role of coordination among hospital and primary care physicians in post-AMI discharge and follow-up among elderly patients. Specifically, targeted interventions to reduce 30-day rehospitalizations should focus on patients with comorbidities and use of prescription drugs after hospital discharge.

A high-protein diet during hospitalization is associated with an accelerated decrease in soluble urokinase plasminogen activator receptor levels in acutely ill elderly medical patients with SIRS

Acute illness and hospitalization in elderly individuals are often accompanied by the systemic inflammatory response syndrome (SIRS) and malnutrition, both associated with wasting and mortality. Nutritional support and resistance training were shown to increase muscle anabolism and reduce inflammation in healthy elderly. We hypothesized that nutritional support and resistance training would accelerate the resolution of inflammation in hospitalized elderly patients with SIRS. Acutely admitted patients aged >65 years with SIRS were randomized to an intervention consisting of a high-protein diet (1.7 g/kg per day) during hospitalization, and daily protein supplement (18.8 g) and 3 weekly resistance training sessions for 12 weeks after discharge (Intervention, n=14), or to standard-care (Control, n=15). Plasma levels of the inflammatory biomarkers soluble urokinase plasminogen activator receptor (suPAR), interleukin-6, C-reactive protein (CRP), and albumin were measured at admission, discharge, and 4 and 13 weeks after discharge. The Intervention group had an earlier decrease in suPAR levels than the Control group: -15.4% vs. +14.5%, P=.007 during hospitalization, and -2.4% vs. -28.6%, P=.007 between discharge and 4 weeks. There were no significant effects of the intervention on the other biomarkers. All biomarkers improved significantly between admission and 13 weeks, although with different kinetics (suPAR: -22%, interleukin-6: -86%, CRP: -89%, albumin: +11%). Nutritional support during hospitalization was associated with an accelerated decrease in suPAR levels, whereas the combined nutrition and resistance training intervention after discharge did not appear to affect the inflammatory state. Our results indicate that improved nutritional care during hospitalization may accelerate recovery in acutely ill elderly medical patients.

Establishing in-hospital geriatrics services in Africa: Insights from the University of Benin Teaching Hospital geriatrics project

Background:

Unawareness of the peculiar healthcare needs of the elderly and resource constraints may be some reasons why until recently, Nigerian hospitals have not been equipped with the human and infrastructural resources required to meet older adults’ special healthcare needs. There is paucity of specialized health services for the elderly in Africa. Nigeria, with a population of over 170 million, did not have any healthcare facility with dedicated services for the elderly until 2012. The University of Benin Teaching Hospital (UBTH) in Nigeria was established in 1973 and created its geriatrics unit in October 2013. A prepared environment and trained interdisciplinary teams are pivotal in providing effective healthcare services for the elderly. The ongoing UBTH geriatrics project aims to provide specialized interdisciplinary health services to older adults and to provide training and continuing professional development in geriatrics for healthcare staff. In developing our inpatient services, we adopted the acute care for elders (ACE) model and worked in tandem with the “ABCs” of implementing ACE units.

Results:

In the face of limited resources, it was possible to establish a functional geriatrics unit with a trained interdisciplinary team. Family participation is central in our practice. Since October 2013, residents and house officers in internal medicine have been undertaking 4- and 12-weekly rotations, respectively. There is also a robust academic program, which includes once-weekly geriatric pharmacotherapy seminars, once-weekly interdisciplinary seminars, and 2-weekly journal club meetings alternating with seminars on geriatric assessment tools.

Conclusions:

It is possible to establish geriatric services and achieve best practices in resource-limited settings by investing on improving available human resources and infrastructure. We also make recommendations for setting up similar services in other parts of Africa.

Nutritional Follow-Up after Discharge Prevents Readmission to Hospital - A Randomized Clinical Trial

OBJECTIVE

To compare the effects of two individualized nutritional follow-up intervention strategies (home visit or telephone consultation) with no follow-up, with regard to acute readmissions to hospital at two points in time, 30 and 90 days after discharge from hospital.

DESIGN

Randomized clinical trial with two intervention groups and one control group, and monitoring on readmission at 30 and 90 days after discharge.

SETTING

Intervention in the participants' homes after discharge from hospital.

PARTICIPANTS

Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: Upon discharge, the patients were stratified according to nutritional status (MNA), and assigned to one of three groups: 'home visit', 'telephone', or 'control' group.

INTERVENTION

Individualized nutritional counselling of the patient and the patient's daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patient's homes, or over the telephone. All patients received a diet plan on discharge. The control group received standard care, but no follow-up after discharge.

MEASUREMENTS

Information on readmissions to hospital and mortality at 30 and 90 days after discharge was obtained from electronic patient records. Intention-to-treat (ITT) and per-protocol (PP) analyses were carried out.

RESULTS

Two-hundred and eight participants were randomized, 73 to home visits, 68 to the telephone consultation group, and 67 to the control group. The mean age of the participants was 86.1 years. Home visit participants had a lower risk of readmission to hospital compared to control participants at 30 days after discharge (HR=0.4; 95% CI: 0.2-0.9, p=0.03) and 90 days after discharge (HR=0.4; 95% CI: 0.2-0.8, p<0.01). No significant difference was detected between the telephone consultation group and the control group, at either 30 days (HR=0.6, 95% CI: 0.3-1.3, p=0.18) or 90 days after discharge (HR=0.7, 95% CI: 0.4-1.3, p=0.23). The PP analysis revealed that the risk of readmission was significantly lower in the home visit group compared to the control group and the telephone consultation group compared to the control group, and this was evident at 30 days as well as at 90 days after discharge.

CONCLUSION

An individualized nutritional follow-up performed as home visits seems to reduce readmission to hospital 30 and 90 days after discharge. Intervention by telephone consultations may also prevent readmission, but only among participants who receive the full intervention.

Delirium Diagnostic and Screening Instruments in the Emergency Department: An Up-to-Date Systematic Review

BACKGROUND

Emergency care systems are at the core of modern healthcare and are the "point-of-entry/admission" into the hospital for many older/elderly patients. Among these, it is estimated that 15% to 30% will have delirium on admission and that over 50% will develop it during their stay. However, appropriate delirium diagnostic and screening still remains a critical area of need. The goal of this review is to update the field, exploring target areas in screening methods for delirium in the Emergency Department (ED), and/or acute care units, in the older population.

METHODS

A systematic review was conducted to search screening/diagnostic methods for delirium in the ED and/or acute care units within the ED.

RESULTS

Seven different scales were identified. Of the identified instruments, the Confusion Assessment Method (CAM) for the Intense Care Unit (CAM-ICU) was the most widely used. Of note, a brief two-step approach for delirium surveillance was defined with the Delirium Triage Screen (DTS) and the Brief Confusion Assessment Method (bCAM), and the diagnostic accuracy of the Richmond Agitation-Sedation Scale (RASS) for delirium had a good sensitivity and specificity in older patients.

CONCLUSION

The CAM-ICU appears as the potential reference standard for use in the ED, but research in a global approach of evaluation of actual and past cognitive changes is still warranted.

Predictive factors for early unplanned rehospitalization of older adults after an ED visit: role of the caregiver burden

BACKGROUND AND AIMS

For older adults, an Emergency Department (ED) visit represents a period of vulnerability that extends beyond the visit itself. This study aimed to determine the impact of the role of caregiver, and geriatric conditions of patients on early unplanned rehospitalization (EUR) within 3 months after an ED visit.

METHODS

This prospective longitudinal experimental study included consecutively 173 patients aged 75 and older admitted in an ED over a 2-week period (18.7% of the total visits). Only older patients having a caregiver were analyzed (78.0%, n = 135). Medical conditions and a comprehensive geriatric assessment were recorded for each patient. All caregivers were interviewed about their tasks and emotional impact using the short Zarit Burden Inventory. Three months after, patients or their caregivers were called about the vital status, and EUR of patients.

RESULTS

Among the patients included, 64.2% had an EUR and 28.9% of their caregivers reported a high level of burden. EUR was strongly associated with a high caregiver burden (OR 8.7, 95% CI 1.5-49.8). No association was found for patient's medical or geriatric status. Caregivers reported a significantly high burden when patients were malnourished, or were at risk of adverse health outcomes based on the ISAR scale, and when they had greater disabilities in IADLs and ADLs, or cognitive impairments.

CONCLUSIONS

Many hospital readmissions after an ED visit may be preventable by identifying caregiver's high burden. Reasons that lead to this high burden should be checked at the first visit.

Predictive validity of the identification of seniors at risk screening tool in a German emergency department setting

BACKGROUND

The identification of patients at high risk for adverse outcomes [death, unplanned readmission to emergency department (ED)/hospital, functional decline] plays an important role in emergency medicine. The Identification of Seniors at Risk (ISAR) instrument is one of the most commonly used and best-validated screening tools. As to the authors' knowledge so far there are no data on any screening tool for the identification of older patients at risk for a negative outcome in Germany.

OBJECTIVES

To evaluate the validity of the ISAR screening tool in a German ED.

DESIGN

This was a prospective single-center observational cohort study in an ED of an urban university-affiliated hospital. Participants were 520 patients aged ≥75 years consecutively admitted to the ED.

MEASUREMENTS

The German version of the ISAR screening tool was administered directly after triage of the patients. Follow-up telephone interviews to assess outcome variables were conducted 28 and 180 days after the index visit in the ED. The primary end point was death from any cause or hospitalization or recurrent ED visit or change of residency into a long-term care facility on day 28 after the index ED visit.

RESULTS

The mean age ± SD was 82.8 ± 5.0 years. According to ISAR, 425 patients (81.7%) scored ≥2 points, and 315 patients (60.5%) scored ≥3 points. The combined primary end point was observed in 250 of 520 patients (48.1%) on day 28 and in 260 patients (50.0%) on day 180. Using a continuous ISAR score the area under the curve on day 28 was 0.621 (95% confidence interval, CI 0.573-0.669) and 0.661 (95% CI 0.615-0.708) on day 180, respectively.

CONCLUSION

The German version of the ISAR screening tool acceptably identified elderly patients in the ED with an increased risk of a negative outcome. Using the cutoff ≥3 points instead of ≥2 points yielded better overall results.