Relationship between hospitalization and functional and cognitive impairment in hospitalized older adults patients

Impact of the End PJ Paralysis interventions on patient health outcomes at the participating hospitals in Alberta, Canada

PURPOSE

Multiple hospitals in Alberta implemented the End PJ Paralysis - a multicomponent inpatient ambulation initiative aimed at preventing the adverse physical and psychological effects patients experience due to low mobility during admission. To inform a scale-up strategy, this study assessed the impact of the initiative based on select process and outcome measures.

MATERIALS AND METHODS

Clinical and administrative data were obtained from the hospital Discharge Abstract Database, Research Electronic Data Capture (Redcaps), and Reporting and Learning System for Patient Safety. The variables explored were length of stay, inpatient falls, discharge disposition, pressure injury, patient ambulation, and patient dressed rates. We then used the Interrupted Time Series design for impact analysis.

RESULTS

The analysis included discharge abstracts for 32,884 patients and the results showed significant improvements in outcomes at the participating units. The length of stay and inpatient falls were reduced immediately by 1.8 days (B2=-1.80, p = 0.044, 95% CI [-3.54, -0.05]), and 2.2 events (B2=-2.22, p = 005, 95% CI [-3.75, -0.69]). The percentage of patients discharged home increased overtime (B2=.39, p=.006, 95% CI [.11, .66]). Mobilization and dressed rates also improved.

CONCLUSIONS

The findings imply the interventions safely mitigated the risk of immobility-induced complications, including deconditioning and hospital-acquired disability.

Bed flow priorities and the spatial and temporal dimensions of rural older adult care

Despite prior research that examines the spatial and temporal dimensions of older adult care, there is disparate research on the influence of patient flow priorities on older adult care over time and place. Drawing on a qualitative case study of rural older adult transitions in care in the Canadian context we examine how patient flow prioritization undervalues older patients' needs and the local contexts in which care is provided. Certainly, accounting for the spatial and temporal dimensions of older adult care has broader implications that will enhance future research, policy and practice. Policy makers, researchers and clinicians may then use these recommendations as a stepping stone to align the health care system with the older populations that they serve.

Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults' transitions into long-term care

BACKGROUND

Establishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum.

METHODS

We performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process.

RESULTS

The findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care.

CONCLUSIONS

We emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.

Promoting Safe Mobility Strategies for partnering with caregivers to maximize older adults' functional ability

This article is the fifth in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Olson,L.M., et al. Promote Safe Mobility. Am J Nurs 2022; 122(7): 46-52.

Preserving independence among under-resourced older adults in the Southeastern United States: existing barriers and potential strategies for research

Disability prevention and preservation of independence is crucial for successful aging of older adults. To date, relatively little is known regarding disparities in independent aging in a disadvantaged older adult population despite widely recognized health disparities reported in other populations and disciplines. In the U.S., the Southeastern region also known as “the Deep South”, is an economically and culturally unique region ravaged by pervasive health disparities – thus it is critical to evaluate barriers to independent aging in this region along with strategies to overcome these barriers. The objective of this narrative review is to highlight unique barriers to independent aging in the Deep South and to acknowledge gaps and potential strategies and opportunities to fill these gaps. We have synthesized findings of literature retrieved from searches of computerized databases and authoritative texts. Ultimately, this review aims to facilitate discussion and future research that will help to address the unique challenges to the preservation of independence among older adults in the Deep South region.

Measuring medically unjustified hospitalizations in Switzerland

Background

Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics.

Methods

The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. “unjustified” and “sometimes justified” stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse).

Results

Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for “unjustified stays” and 17% for “sometimes justified stays”. Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions’ monitoring, pain management, falls prevention, and specialized at-home services that should be offered.

Conclusion

We recommend using “unjustified stays” and “sometimes justified stays” indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07569-3.

Effects of game-based interventions on functional capacity in acutely hospitalised older adults: results of an open-label non-randomised clinical trial

BACKGROUND

Hospitalisation-associated disability due to reduced physical activity levels and prolonged bedrest episodes are highly prevalent in older adults.

OBJECTIVE

To assess the effect of gamified interventions on functional capacity in hospitalised older adults.

METHODS

A three-armed non-randomised controlled trial with two experimental intervention groups and a control group was conducted in a tertiary public hospital in Navarre, Spain. Participants were allocated to a simple gamification group (SGG) (n = 21), a technology-based gamification group (TGG) (n = 23) or a control group (CG) (n = 26). The end points were changes in functional capacity, muscle strength, cognition, mood status and quality of life.

RESULTS

Seventy patients (mean age 86.01 ± 4.27 years old) were included in the study; 29 (41.4%) were women. At discharge, compared to CG, a mean increase of 1.47 points (95%CI, 0.15-2.80 points) and 2.69 points (95%CI, 1.32-4.06 points) was observed (SGG and TGG, respectively) in the SPPB test; as well as an increase of 5.28 points (95%CI, 0.70-9.76 points) in the Barthel Index and 2.03 kg (95%CI, 0.33-3.72 kg) in handgrip strength in the TGG. Regression mediation analyses demonstrated that muscle strength changes (β = 1.30; 95%CI, 0.45-2.14; indirect effect 0.864; 95%CI, 0.09-1.90) significantly mediated the TGG effect on the SPPB score.

CONCLUSIONS

The TGG intervention programme may provide significant benefits in physical and muscle function over usual care and seems to reverse the functional decline frequently associated with acute hospitalisation in older adults.

Hospitalized older adult: predictors of functional decline

OBJECTIVE

to identify the predictors of functional decline in hospitalized individuals aged 70 or over, between: baseline and discharge; discharge and follow-up, and baseline and three-month follow-up.

METHOD

a prospective cohort study conducted in internal medicine services. A questionnaire was applied (clinical and demographic variables, and predictors of functional decline) at three moments. The predictors were determined using the binary logistic regression model.

RESULTS

the sample included 101 patients, 53.3% female, mean age of 82.47 ± 6.57 years old. The predictors that most contributed to decline in hospitalization were the following: previous hospitalization (OR=1.8), access to social support (OR=4.86), cognitive deficit (OR=6.35), mechanical restraint (OR=7.82), and not having a partner (OR=4.34). Age (OR=1.18) and medical diagnosis (OR=0.10) were the predictors between discharge and follow-up. Being older, delirium during hospitalization (OR=5.92), and presenting risk of functional decline (OR=5.53) were predictors of decline between the baseline and follow-up.

CONCLUSION

the most relevant predictors were age, previous hospitalization, cognitive deficit, restraint, social support, not having a partner, and delirium. Carrying out interventions aimed at minimizing the impact of these predictors can be an important contribution in the prevention of functional decline.

Internação hospitalar de pessoas idosas de um grande centro urbano brasileiro e seus fatores associados

Resumo Objetivo Avaliar a frequência de Internação Hospitalar (IH) nos últimos doze meses em pessoas idosas atendidos na Atenção Primária à Saúde (APS) e seus fatores associados por meio de uma Avaliação Geriátrica Ampla (AGA). Métodos Estudo transversal, com amostra aleatória de 400 pessoas idosas atendidas em uma Unidade Básica de Saúde (UBS). A avaliação da frequência de IH por pelo menos 24 horas foi autorreferida (sim; não). Utilizou-se questionário sociodemográfico e de saúde, instrumentos para avaliar as atividades básicas e instrumentais da vida diária, status cognitivo, sintomas depressivos, queda e medo de cair. A regressão logística múltipla foi utilizada para investigar os fatores associados à IH. Resultados A média de idade foi de 75,23 (±8,53), 63,2% dos participantes eram do sexo feminino, 62,6% relataram um estado de saúde ruim/razoável e 38% relataram hospitalização nos últimos doze meses. Idade mais avançada, com pior percepção de saúde, doenças crônicas, uso diário de medicamentos, dependentes para as atividades básicas e instrumentais da vida diária, comprometimento do status cognitivo e queda no ano anterior demonstraram associação com a hospitalização. Saber ler e escrever foi associado com menor risco de hospitalização. Conclusão A frequência de IH de pessoas idosas atendidas em UBS foi alta e foi associada a fatores modificáveis e não modificáveis, indicando que a abordagem multidimensional é uma ferramenta importante no cuidado da pessoa idosa na atenção primária à saúde.

COVID-19: Short and Long-Term Effects of Hospitalization on Muscular Weakness in the Elderly

The COVID-19 pandemic has recently been the cause of a global public health emergency. Frequently, elderly patients experience a marked loss of muscle mass and strength during hospitalization, resulting in a significant functional decline. This paper describes the impact of prolonged immobilization and current pharmacological treatments on muscular metabolism. In addition, the scientific evidence for an early strength intervention, neuromuscular electrical stimulation or the application of heat therapy during hospitalization to help prevent COVID-19 functional sequels is analyzed. This review remarks the need to: (1) determine which potential pharmacological interventions have a negative impact on muscle quality and quantity; (2) define a feasible and reliable pharmacological protocol to achieve a balance between desired and undesired medication effects in the treatment of this novel disease; (3) implement practical strategies to reduce muscle weakness during bed rest hospitalization and (4) develop a specific, early and safe protocol-based care of functional interventions for older adults affected by COVID-19 during and after hospitalization.

Facilitating transcatheter aortic valve implantation in the era of COVID-19: Recommendations for programmes

The COVID-19 pandemic continues to significantly impact the treatment of people living with aortic stenosis, and access to transcatheter aortic valve implantation. Transcatheter aortic valve implantation (TAVI) programmes require unique coordinated processes that are currently experiencing multiple disruptions and are guided by rapidly evolving protocols. We present a series of recommendations for TAVI programmes to adapt to the new demands, based on recent evidence and the international expertise of nurse leaders and collaborators in this field. Although recommended in most guidelines, the uptake of the role of the TAVI programme nurse is uneven across international regions. COVID-19 is further highlighting why a nurse-led central point of coordination and communication is a vital asset for patients and programmes. We propose an alternative streamlined evaluation pathway to minimize patients' pre-procedure exposure to the hospital environment while ensuring appropriate treatment decision and shared decision-making. The competing demands created by COVID-19 require vigilant wait list management, with risk stratification, telephone surveillance and optimized triage and prioritization. A minimalist approach with close scrutiny of all parts of the procedure has become an imperative to avoid any complications and ensure patients' accelerated recovery. Lastly, we outline a nurse-led protocol of rapid mobilization and reconditioning as an effective strategy to facilitate safe next-day discharge home. As the pandemic abates, TAVI programmes must facilitate access to care without compromising patient safety, enable hospitals to manage the competing demands created by COVID-19 and establish new processes to support patients living with valvular heart disease.

Factors associated with the frequency of medical consultations by older adults: a national study

OBJECTIVE

To analyze factors associated with the high frequency of medical consultations (five or more consultations) among older adult participants of the National Health Survey - 2013.

METHOD

A quantitative cross-sectional study conducted with data from individuals aged 60 years and over (n = 19,503). The outcome variable came from the question: 'How many times have you consulted the doctor in the last 12 months? Fifty-seven (57) independent variables were listed. The Waikato Environment for Knowledge Analysis software program was used in the analysis. The data set was balanced and the dimensionality reduction test was performed. The variables which were strongly related to the dependent variable were analyzed using logistic regression.

RESULTS

The independent variables listed were strongly related to the outcome variables: female gender, negative self-perception of health condition, inability to perform usual activities for health reasons, diagnosis of chronic disease, seeking health services for health-related care, and hospitalization.

CONCLUSION

The results reflect the relevance of expanding and qualifying services through effective prevention, protection and health promotion actions.

[Functional difficulty among elderly Brazilians: a study based on the National Health Survey (PNS - 2013)]

The objective of this study was to study the factors that present a high degree of association with functional difficulties among the elderly. A cross-sectional, quantitative study was conducted among individuals aged 60 years or older (n = 23,815). Two dependent variables were considered: Basic Activity of Daily Living and Instrumental Activity of Daily Living, and 42 independent variables related to sociodemographic issues, general health, oral health and the use of health services. For the analysis, the Waikato Environment for Knowledge Analysis software was used. Data set balancing and the dimensionality reduction test were performed through 10-fold cross-validation and lastly, the variables related to the dependent variables were evaluated through logistic regression. Eight variables had a strong association with functional difficulties among the elderly, related to physical aspects, intrinsic factors, social relations, literacy and the use of health services. The results obtained enable the bolstering of planning and execution of strategies in public health, directed to the elderly population, avoiding or minimizing situations of functional difficulty.

Concepts in Practice: Geriatric Emergency Departments

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Links between meaning in life and physical quality of life after rehabilitation: Mediating effects of positive experiences with physical exercises and mobility

BACKGROUND

Indicators of emotional processes (positive experiences with physical exercises) and functional processes (mobility) were previously found to be associated with positive cognitive resources (meaning in life), and the key outcome in the rehabilitation, namely physical quality of life (QOL). Yet, the mediating roles of such processes were not tested. Therefore, this prospective study investigated whether the relationship between meaning in life and physical QOL was mediated by positive experiences with physical exercises and mobility.

METHODS

Prospective data were collected at two measurement points, 1 month apart. A total of N = 339 participants (aged 19-84 years old, 57.9% women) provided data at Time 1 (T1) at the beginning of inpatient rehabilitation from central nervous system diseases (CNSD, e.g., stroke; n = 89) or musculoskeletal system diseases (MSD, e.g., dorsopathies; n = 250), and n = 234 at Time 2 (T2, the end of rehabilitation; 4 weeks after T1). Mediation analysis with meaning in life as predictor (T1), positive experiences with physical exercises and mobility as sequential mediators (T2), and physical QOL (T2) as the outcome was conducted.

RESULTS

Higher meaning in life (T1) predicted more positive experiences with physical exercises (T2), which were associated with a higher level of mobility (T2), which in turn was associated with better physical quality of life (T2).

CONCLUSIONS

Meaning in life at the beginning of inpatient rehabilitation may trigger positive experiences with physical exercises and functional changes in mobility levels, leading to better physical quality of life. Screening for low meaning in life may allow to identify patients who are at risk for a lack of improvement of mobility and physical quality of life during rehabilitation.

Emergency Department Observation Unit Utilization Among Older Patients With Chest Pain

BACKGROUND

Although some emergency department observation units (EDOUs) may exclude patients over 65 years old, our EDOU accepts patients up to 79 years old. We assessed the utilization of our EDOU by older patients (those 65-79 years old).

METHODS

We prospectively enrolled emergency department (ED) patients with chest pain. We gathered baseline data at the time of ED presentation and tracked outcomes related to the ED stay, EDOU, and/or inpatient admission. Our primary outcome included EDOU placement among older patients. Our secondary outcome was the rate of major adverse cardiac events [MACE: myocardial infarction, stent, coronary artery bypass graft, and death].

RESULTS

Over the 5-year study period, we evaluated 2242 ED patients with chest pain, of whom 19.4% (95% confidence interval, 17.8%-21.1%) were 65-79 years old. Older patients were more likely to be placed in the EDOU after the ED visit (45.8% vs. 36.6%; P = 0.001) and more likely to be admitted to an inpatient unit from the ED (31.8% vs. 17.9%;P < 0.001) than those under 65 years old. The overall MACE rate was similar between admitted older patients and those in the EDOU: 5.9% versus 4.3% (P = 0.57). Of the admitted older patients, 30.4% (95% confidence interval, 22.3%-39.9%) were low risk and there were no cases of MACE in this group.

CONCLUSIONS

In an EDOU that allows older patients, we noted substantial utilization by these patients for the evaluation of chest pain. The characteristics of admitted older patients suggest the potential for even greater EDOU utilization in this group.

Diet and Activity Assessments and Interventions Using Technology in Older Adults

This paper reports on the findings and recommendations specific to older adults from the "Tech Summit: Innovative Tools for Assessing Diet and Physical Activity for Health Promotion" forum organized by the North American branch of the International Life Sciences Institute. The summit aimed to investigate current and emerging challenges related to improving energy balance behavior assessment and intervention via technology. The current manuscript focuses on how novel technologies are applied in older adult populations and enumerated the barriers and facilitators to using technology within this population. Given the multiple applications for technology in this population, including the ability to monitor health events and behaviors in real time, technology presents an innovative method to aid with the changes associated with aging. Although older adults are often perceived as lacking interest in and ability to adopt technologies, recent studies show they are comfortable adopting technology and user uptake is high with proper training and guided facilitation. Finally, the conclusions suggest recommendations for future research, including the need for larger trials with clinical outcomes and more research using end-user design that includes older adults as technology partners who are part of the design process.

THEME INFORMATION

This article is part of a theme issue entitled Innovative Tools for Assessing Diet and Physical Activity for Health Promotion, which is sponsored by the North American branch of the International Life Sciences Institute.

Factors associated with the hospitalization of the elderly: a national study

Abstract Objective :to analyze the factors associated with hospitalization among the Brazilian elderly based on multidimensional methodology. Method: a cross-sectional, quantitative study was performed with data from the National Health Survey (2013) population-based study. The sample was composed of 23,815 individuals over the age of 60 years. Hospitalization was considered the outcome variable and 53 independent variables were included, relating to: sociodemographic characteristics; limitations and illness; difficulties in performing basic and instrumental activities of daily living; use of health services and medical emergencies. Results: it was found that 10% of the elderly were hospitalized in the previous year. This event was related to: a negative self-perception of health (OR = 1.35); stopping performing any of their usual activities due to health reasons (OR = 2.14); difficulty going to the doctor (OR = 1.65) or walking alone (OR = 1.55); a recent search for a site, service or health professional for health-related care (OR = 1.47); increased frequency of annual medical visits (OR = 2.93) and household emergency (OR = 5.40). Conclusion: the results reinforce the fact that multiple factors are associated with the hospitalization of the elderly. The analysis of these associations has the potential to make health professionals and administrators aware of the need to improve health care for the elderly and to assist in the organization and planning of the actions of the entire health service network.

Medical Complications Predict Cognitive Decline in Nondemented Hip Fracture Patients-Results of a Prospective Observational Study

OBJECTIVE

The aim of this study was to identify factors that are associated with cognitive decline in the long-term follow-up after hip fractures in previously nondemented patients.

METHODS

A consecutive series of 402 patients with hip fractures admitted to our university hospital were analyzed. After exclusion of all patients with preexisting dementia, 266 patients were included, of which 188 could be examined 6 months after surgery. Additional to several demographic data, cognitive ability was assessed using the Mini-Mental State Examination (MMSE). Patients with 19 or less points on the MMSE were considered demented. Furthermore, geriatric scores were recorded, as well as perioperative medical complications. Mini-Mental State Examination was performed again 6 months after surgery.

RESULTS

Of 188 previously nondemented patients, 12 (6.4%) patients showed a cognitive decline during the 6 months of follow-up. Multivariate regression analysis showed that age ( P = .040) and medical complications ( P = .048) were the only significant independent influencing factors for cognitive decline.

CONCLUSIONS

In our patient population, the incidence of dementia exceeded the average age-appropriate cognitive decline. Significant independent influencing factors for cognitive decline were age and medical complications.