Predictors of hospital contact by very elderly people: a pilot study from a cohort of people aged 75 years and over

Self-rated health as a predictor of hospitalizations in patients with bipolar disorder or major depressive disorder: A prospective cohort study of the UK Biobank

BACKGROUND

To determine the association between self-rated health (SRH) and subsequent all-cause hospitalizations in patients with bipolar disorder (BD) or major depression (MDD).

METHODS

We conducted a prospective cohort study on people with BD or MDD in the UK from 2006 to 2010 using UK Biobank touchscreen questionnaire data and linked administrative health databases. The association between SRH and 2-year all-cause hospitalizations was assessed using proportional hazard regression after adjustment for sociodemographics, lifestyle behaviors, previous hospitalization use, the Elixhauser comorbidity index, and environmental factors.

RESULTS

A total of 29,966 participants were identified, experiencing 10,279 hospitalization events. Among the cohort, the average age was 55.88 (SD 8.01) years, 64.02 % were female, and 3029 (10.11 %), 15,972 (53.30 %), 8313 (27.74 %), and 2652 (8.85 %) reported excellent, good, fair, and poor SRH, respectively. Among patients reporting poor SRH, 54.19 % had a hospitalization event within 2 years compared with 22.65 % for those having excellent SRH. In the adjusted analysis, patients with good, fair, and poor SRH had 1.31 (95 % CI 1.21-1.42), 1.82 (95 % CI 1.68-1.98), and 2.45 (95 % CI 2.22, 2.70) higher hazards of hospitalization, respectively, than those with excellent SRH.

LIMITATIONS

Selection bias can exist as our cohort cannot fully represent all the BD and MDD cases in the UK. Moreover, the causality is questionable.

CONCLUSION

SRH was independently associated with subsequent all-cause hospitalizations in patients with BD or MDD. This large study underscores the need for proactive SRH screening in this population, which might inform resource allocation in clinical care and enhance high-risk population detection.

Use of Services by People Living Alone With Cognitive Impairment: A Systematic Review

BACKGROUND AND OBJECTIVES

Formal supports and social services are essential to people living alone with cognitive impairment (PLACI) because they are at risk of negative health outcomes and lack cohabitants who may support them with cognitively demanding tasks. To further our understanding of this critical and worldwide issue, we conducted a systematic review to understand whether, and how, PLACI access and use essential formal supports and services.

RESEARCH DESIGN AND METHODS

We searched 6 databases (PubMed, Embase, PsycINFO, CINAHL, Web of Science, and Sociological Abstracts) to identify quantitative and mixed-method literature on formal service use among PLACI. The initial search was conducted in 2018 and updated in 2020.

RESULTS

We identified 32 studies published between 1992 and 2019, representing 13 countries, that met our criteria: 16 reported on health services and 26 on social services. Most studies compared PLACI with people with cognitive impairment living with others. Health service use was lower or similar among PLACI, as opposed to counterparts living with others. Most studies reported a higher use of social services (e.g., home services) among PLACI than those living with others. Overall use of essential home service among PLACI was higher in Europe than in the United States, a country where large portions of PLACI were reported receiving no formal services.

DISCUSSION AND IMPLICATIONS

We identified wide variability among countries and major gaps in service use. Results for use of health services were mixed, although our findings suggest that PLACI may have fewer physician visits than counterparts living with others. Our findings suggest that varying policies and budgets for these services among countries may have affected our findings. We encourage researchers to evaluate and compare the influence of social policies in the well-being of PLACI. We also encourage policy makers to prioritize the needs of PLACI in national dementia strategies.

A Report of an Investigation of End-of-Life Care Practices in Health Care Facilities and the Influences on those Practices

In 1992, 82.2% of deaths in Alberta occurred in acute care hospitals or continuing care facilities. This paper outlines the end-of-life care of adult in patients who died that year in four such facilities (n=137). CPR was an infrequent end-of-life treatment modality (2.9%), in stark contrast to the extensive use of other medical technologies. Almost every inpatient (94.2%) died with one or more technologies in continuous operation. Although reasons were infrequently given, the desire to promote patient comfort was the most frequent influence on end-of-life technology use. The findings of this study raise issues for debate and further investigation. Chief among these issues is whether or not medical technologies promote comfort during the dying process.

A population-based comparison of the use of acute healthcare services by older adults with and without mental illness diagnoses

Older adults with mental illness (MI) are a highly vulnerable population and need to be provided healthcare services in a timely and thorough way. Compared with older adults without MI, older adults with MI spend a great deal of time being hospitalized and hence costing millions of dollars because the care they need is often overlooked and/or not provided. While they end up spending too much time in hospital, in the emergency department and getting readmitted to hospital because of their MI, this could have been prevented or lessened if an adequate assessment and treatment regime was done by clinicians who were well informed on the topic of older adults' mental health. Older adults with MI are also more likely to leave hospital for long-term care settings, to die and to have more sickness compared with older adults who do not have MI. Further, they are also more likely to be admitted to hospital on an urgent, unplanned basis. How older adults with MI use acute hospitals is important for psychiatric nurses to know and understand, as they can help to provide the care needed so they do not have to be in hospital for long periods of time. Psychiatric nurses can share much support and information on making sure older adults with MI are accurately care for when needed. To explore and compare predictors of hospital length of stay (LOS), acute LOS (ALOS), emergency room (ER) wait times, rate of readmission (ROR) and costs of inpatient hospital care for older adults with and without mental illness (MI) diagnoses in the province of Newfoundland and Labrador (NL). This descriptive-comparative study used aggregate population level data of 12,283 people aged 65 years and older admitted to an acute care hospital in the province of NL. A total of 8.3% of hospitalized older adults had MI diagnoses. Older adults with MI diagnoses had a significantly longer LOS, ALOS, ROR, ER wait time and costs compared with older adults without MI diagnoses, after controlling for medical co-morbidities. Key variables such as patient demographics, admission indicators, discharge indicators and other medical co-morbidities had differential impacts on observed service use. While only a small percentage of hospitalized older adults had MI diagnoses, the use and cost of acute hospitalizations was significantly greater than that of older adults without MI diagnoses.

Trends in the Utilization of Specific Health Care Services among Older Manitobans: 1985 to 2000

This paper examines 16-year trends in the utilization of hospital and physician services by Manitobans aged 75 and more, using data from the Manitoba Population Health Research Data Repository. Trends are examined across five measures of hospital services (separations, short-stay days, long-stay days, cataract surgeries, and hip/knee replacements) and two measures of physician care (overall visit rate, and proportion having seven or more visits). Results show changes in the utilization of these services among older adults living in Manitoba over time, with the extent of change varying with the service under consideration, age, and location of residence. Previously large utilization differentials are shown to be shrinking; for example, cataract surgery rates across regions and physician visit rates by age. For other services, such as the rates of hip or knee replacement surgery, the differences across regions are increasing. Findings indicate that global generalizations about the impact of older adults on the health care system are subject to question, as regional differences and differences between age groups (75–84, 85+) can be significant.

Risk factors for incident dementia in England and Wales: The Medical Research Council Cognitive Function and Ageing Study. A population-based nested case-control study

OBJECTIVE

To investigate a number of prospectively collected factors (sociodemographic, medical and behavioural) and their association with incident dementia in a population-based cohort.

DESIGN

Nested case-control analysis (at 2 and 6 years) of a population-based cohort study.

SETTING

Individuals aged 65 years and above from five centres in England and Wales: two rural (Cambridgeshire and Gwynedd) and three urban (Nottingham, Newcastle and Oxford).

PARTICIPANTS

A total of 4,075 individuals from a detailed assessment group, with risk measured at baseline.

MAIN OUTCOME MEASURE

Incident dementia at 2 and 6 years.

METHODS

Logistic regression was used to calculate crude odds ratios (ORs) for various risk factors and ORs adjusted for age, sex, education and social class.

RESULTS

Age (90+ versus 65-69 years OR = 25.6, 95% confidence interval (CI) = 11.6-56.9) and sex (women versus men OR = 1.6, 95% CI = 1.1-2.4) were directly associated with dementia, with a trend by years of education (P(trend) = 0.02) but not social class. Poor self-perceived health (versus good) increased the risk for incident dementia (OR = 3.9, 95% CI = 2.2-6.9). Alcohol and smoking (never, past and current) were neither strongly protective nor predictive. Stroke was strongly related to incident dementia (OR = 2.1, 95% CI = 1.1-4.2), as was Parkinson's disease (OR = 3.5, 95% CI = 1.3-9.3), and exposure to general anaesthesia (GA) was inversely associated with dementia development (OR = 0.6, 95% CI = 0.4-0.9, with a trend with increasing GA exposure; P = 0.003).

CONCLUSION

In this large multicentre and long-term population-based study, some well-known risk factors for dementia, of vascular and Alzheimer's type, are confirmed but not others. The association between self-perceived health-a robust predictor of later health outcomes-and incident dementia, independently of other potential risks, warrants further study.

Repeated hospitalizations and self-rated health among the elderly: a multivariate failure time analysis

The purpose of this study was to determine to what extent a single measure, self-rated health (SRH), independently predicts long-term hospitalizations due to all causes and to cardiovascular diseases by using both the standard Cox proportional hazards model and a more robust events model. The study cohort consisted of 2,812 elderly subjects residing in New Haven, Connecticut, who were followed from 1982 to 1996 as part of the Established Populations for Epidemiologic Study of the Elderly. After adjustment for baseline risk factors, using the Cox model, a favorable SRH was associated with a significantly lowered risk for a first hospitalization for all causes (risk ratio (RR) = 0.850, 95% confidence interval (CI): 0.774, 0.934) and congestive heart failure (RR = 0.599, 95% CI: 0.426, 0.841) but not for myocardial infarction (RR = 0.882, 95% CI: 0.565, 1.379). With the adjusted robust events model, a positive SRH was associated with a decreased risk in both a first (RR = 0.813, 95% CI: 0.744, 0.889) and a second (RR = 0.870, 95% CI: 0.782, 0.968) hospitalization for any cause. These results indicate that a single measurement of SRH predicts long-term patterns of hospitalization, especially for heart failure, among older adults.

Extent and determinants of hospitalization in a cohort of older disabled people

OBJECTIVES

The purpose of this prospective cohort study was to determine the extent and determinants of hospitalization in a population sample of older disabled people.

DESIGN

A longitudinal cohort study.

SETTING

Noninstitutionalized disabled people in the region of Augsburg, South Germany.

PARTICIPANTS

The study population included 2427 persons, aged 60 years and older, who, between 1991 and 1993, applied for benefits from the statutory health insurance system provided to the most severely handicapped noninstitutionalized persons.

MEASUREMENTS

Baseline variables were derived from a standardized medical examination. Information about hospitalization and mortality until June 30, 1996, was extracted from records of the pertinent health insurance plan. Rate ratios (RRs) of hospitalization were derived from a multivariable Poisson regression model corrected for the correlation of multiple hospitalizations for each person.

RESULTS

The overall absolute hospitalization rate was 6.7 hospitalizations per 10 person-years at risk, with a mean length of stay per hospitalization of 19.2 days. Multivariable analysis showed an inverse association of age and hospitalization. Persons cared for primarily by their children had a lower rate of hospitalization (RR = 0.83) than persons relying mainly on professional home care. Medical causes of disability and dependency with respect to activities of daily living were unrelated to the hospitalization rate. A total of 1415 persons (58.3%) died during follow-up. The rate of hospitalization was twice as high among these subjects compared with others. The hospitalization rate increased rapidly during the last year of life, with a peak increase in the last 3 months.

CONCLUSIONS

This study expands the current inadequate database on hospitalization in Europe. Further expansion is necessary for the efficient allocation of medical resources to older people, a group steadily increasing in numbers.

Costs of formal care for frail older people in England: the resource implications study of the MRC cognitive function and ageing study (RIS MRC CFAS)

The aim of this paper is to quantify service use and costs of supporting frail older people at home in the community, using data collected in a longitudinal multicentre stratified randomised study for 1055 mentally frail, physically frail, and mentally and physically frail subjects. Average costs per person per week were found to total 64.45 Pounds Sterling, with a small number of services accounting for a large proportion of the total costs. The level of services offered by the nonstatutory voluntary and private sectors was found to be small. To highlight issues for policy makers, the extent of cost variations between a number of different subgroups were calculated. These bivariate analyses revealed substantial variation in costs, especially according to household structure, type of frailty, whether admission to continuing care accommodation occurred and survival. Multiple regression analysis demonstrated that 26% of the variation in log average weekly costs could be explained by a number of socio-demographic and health status variables. A particularly close relationship was observed between costs and whether admission to continuing care accommodation occurred, highlighting a need for policy-makers to examine the nature and scale of provision of alternative community based care packages. The results demonstrate that descriptive cost data such as those presented can provide information useful to the planning process, enabling more informed choices to be made over the provision of services for particular groups of people.

Predictors of repeat emergency department visits by elders

OBJECTIVE

To determine which characteristics of older patients who use a hospital ED are associated with repeat visits during the 90 days following the index visit.

METHODS

The study was conducted in the ED of a 400-bed university-affiliated acute care community hospital in Montreal. Patients aged > or = 75 years who visited the ED between 08:00 and and 16:00 on a convenience sample of days over an 8-week period (July and August 1994) were assessed using a questionnaire, physical and cognitive status instruments, and a functional problem checklist. The hospital's administrative database was used to identify repeat visits during the 90 days following the ED visit. The representativeness of the sample was assessed by analyses of ED visits made by 4,466 persons aged > or = 65 years during a 12-month period (September 1993 to August 1994) using the hospital's administrative database.

RESULTS

256 patients aged > or = 75 years visited the ED during the study period and 167 were assessed. Of these, 54 (32%) were admitted to the hospital. Among the 113 patients released from the ED, 27 (24%) made repeat visits during the next 90 days. In univariate analyses, repeat visits were significantly associated with the number of functional problems, cognitive impairment, and previous ED visits. In multiple logistic regression, male gender, living alone, and number of functional problems were independent predictors of repeat visits. In the administrative data analyses, nighttime arrival to the ED for the index visit was significantly associated with repeat visits.

CONCLUSIONS

Self-reported risk factors can help to identify a group of elders likely to make repeated ED visits; the development of a screening instrument incorporating questions on these problems and implementation of appropriate interventions might improve these patients' quality of life and reduce the demand for further ED care in this age group.

Prevalence of cognitive impairment in the hospitalized elderly

Surveys of older populations reveal rates of senile dementia varying from 5.2% to 25%. The specialist branch of psychiatry dealing with the elderly advocates that services for these patients and their carers should predominantly be based outside hospital. The following study was conducted in Limerick, Ireland before the arrival of a consultant in old age psychiatry and associated services. Its aim was to assess the extent to which the patients with dementing disorders were using hospital facilities other than those in psychiatric wards. The study assessed 371 patients aged 65 years and over in various medical and surgical units. The Mini Mental State Examination was performed on all patients. Patients with scores of 23/31 or less were considered to have significant cognitive impairment and those with 16 or less to have severe impairment. As mental performance can be impaired by acute illness, methods were used to avoid such patients being wrongly labelled as suffering from dementia. In the acute hospital 112 patients with an average age of 74.7 years were examined and 22.3% of these had significant cognitive impairment. These patients were predominantly sited on medical wards. On acute medical wards 31% of older patients had significant impairment compared to only 7.3% on the surgical wards. In the orthopaedic unit 15.8% of the elderly had evidence of cognitive impairment. In hospitals specializing in continuing care of the elderly the proportion was 70.6% and of these 46% were severely impaired. We conclude that in the absence of specialized dementia services for the elderly, medical beds both in the acute and long-stay sector will be used for these patients more than their medical needs might otherwise require.

Predictors of mortality in the prospective Dubbo study of Australian elderly

BACKGROUND

A prospective study in non-institutionalised Australian elderly 60 years and over commenced in Dubbo, NSW in 1988.

AIM

To examine clinical and socio-demographic predictors of all-causes mortality.

METHODS

The data were derived from a community-based sample comprising 1236 men and 1569 women followed for a median period of 62 months.

RESULTS

Two hundred and thirty five men (19%) and 184 women (12%) died, 46% of male and 53% of female deaths respectively related to cardiovascular disease. In a proportional hazards model, the significant predictors of mortality were: older age, being married (relative risk [RR] = 0.71 for men, 0.74 for women), current smoking for men (RR = 3.11), taking more than three alcoholic drinks per day for men (RR = 0.37), prior coronary heart disease for men (RR = 1.36), severe hypertension for women (RR = 1.99), use of anti-hypertensive medication for men (RR = 1.74), diabetes for men (RR = 1.62), poor-fair self-rated health for women (RR = 1.74) and physical disability for men (RR = 1.72). Serum cholesterol was associated with mortality in a 'J-shaped' relationship in men and in a reciprocal relationship in women. Blood pressure predicted mortality in an incremental fashion below 75 years, but in older subjects lower pressure was associated with excess mortality.

CONCLUSION

Some predictors of mortality in the well elderly have been identified and a more extended period of follow-up will possibly resolve contradictory findings in some areas.