Acute hospital care for frail older people

Outcomes of Care by Geriatricians and Non-geriatricians in an Academic Hospital

Introduction

While hospitalist and internist inpatient care models dominate the landscape in many countries, geriatricians and internists are at the frontlines managing hospitalized older adults in countries such as Singapore and the United Kingdom. The primary aim of this study was to determine outcomes for older patients cared for by geriatricians compared with non-geriatrician-led care teams.

Materials and Methods

A retrospective cohort study of 1,486 Internal Medicine patients aged ≥75 years admitted between April and September 2021 was conducted. They were either under geriatrician or non-geriatrician (internists or specialty physicians) care. Data on demographics, primary diagnosis, comorbidities, mortality, readmission rate, Hospital Frailty Risk Score (HFRS), Age-adjusted Charlson Comorbidity Index, Length of Stay (LOS), and cost of hospital stay were obtained from the hospital database and analyzed.

Results

The mean age of patients was 84.0 ± 6.3 years, 860 (57.9%) females, 1,183 (79.6%) of Chinese ethnicity, and 902 (60.7%) under the care of geriatricians. Patients under geriatrician were significantly older and had a higher prevalence of frailty, dementia, and stroke, whereas patients under non-geriatrician had a higher prevalence of diabetes and hypertension. Delirium as the primary diagnosis was significantly higher among patients under geriatrician care. Geriatrician-led care model was associated with shorter LOS, lower cost, similar inpatient mortality, and 30-day readmission rates. LOS and cost were lower for patients under geriatrician care regardless of frailty status but significant only for low and intermediate frailty groups. Geriatrician-led care was associated with significantly lower extended hospital stay (OR 0.73; 95% CI 0.56–0.95) and extended cost (OR 0.69; 95% CI 0.54–0.95).

Conclusion

Geriatrician-led care model showed shorter LOS, lower cost, and was associated with lower odds of extended LOS and cost.

Understanding the knowledge and engagement of facilities management with dementia-friendly design in Irish hospitals: an exploratory study

Purpose

This exploratory study stems from research conducted between 2015–2018 focussing on dementia-friendly design (DFD) in hospitals (Grey T. et al. 2018). Specifically, this study focusses on facilities management (FM) staff in Irish hospitals to gain a preliminary understanding of the level of knowledge and engagement of FM in the implementation of dementia-friendly hospital (DFH) design.

Design/methodology/approach

A mixed-methods approach based on a series of ad hoc semi-structured interviews, and an online survey. The aims were, namely, assess the extent of FM engagement in hospital works; measure the level of awareness regarding DFD; and identify facilitators and barriers to DFD in hospital settings. Participants (74) comprised FM staff in 35 Irish acute care hospitals. The research findings are based on thematic analysis of ad hoc semi-structured interviews (participants, n = 4) and survey responses (participants, n = 13).

Findings

While FM staff reported to possess important knowledge for building DFH, they also mentioned a lack of engagement of FM in design processes and hospital works.

Practical implications

The research has gained insight into the role of FM in promoting a dementia-friendly approach. Lack of or poor engagement of FM in design processes and hospital works means not fully tapping into rich expertise that would be invaluable in the development, implementation and maintenance of DFH. Universal design is a key driver for facilitating their engagement in the design, implementation and maintenance of DFH environments.

Originality/value

This is the first study exploring the role of FM in supporting a DFD approach in acute care hospitals.

Do premorbid characteristics of home care clients predict delayed discharges in acute care hospitals: a retrospective cohort study in Ontario and British Columbia, Canada

BACKGROUND

Improved identification of patients with complex needs early during hospitalisation may help target individuals at risk of delayed discharge with interventions to prevent iatrogenic complications, reduce length of stay and increase the likelihood of a successful discharge home.

METHODS

In this retrospective cohort study, we linked home care assessment records based on the Resident Assessment Instrument for Home Care (RAI-HC) of 210 931 hospitalised patients with their Discharge Abstract Database records. We then undertook multivariable logistic regression analyses to identify preadmission predictive factors for delayed discharge from hospital.

RESULTS

Characteristics that predicted delayed discharge included advanced age (OR: 2.72, 95% CI 2.55 to 2.90), social vulnerability (OR: 1.27, 95% CI 1.08 to 1.49), Parkinsonism (OR: 1.34, 95% CI 1.28 to 1.41) Alzheimer's disease and related dementias (OR: 1.27, 95% CI 1.23 to 1.31), need for long-term care facility services (OR: 2.08, 95% CI 1.96 to 2.21), difficulty in performing activities of daily living and instrumental activities of daily living, falls (OR: 1.16, 95% CI 1.12 to 1.19) and problematic behaviours such as wandering (OR: 1.29, 95% CI 1.22 to 1.38).

CONCLUSION

Predicting delayed discharge prior to or on admission is possible. Characteristics associated with delayed discharge and inability to return home are easily identified using existing interRAI home care assessments, which can then facilitate the targeting of pre-emptive interventions immediately on hospital admission.

Frailty as a predictor of adverse outcomes in hospitalized older adults: A systematic review and meta-analysis

Frailty syndrome is prevalent among hospitalized older adults as are the occurrence of adverse outcomes. This systematic review and meta-analysis investigated whether frailty in older adults at hospital admission predicts adverse outcomes. Manual (ProQuest, conferences annals and references) and electronic searches (PUBMED, EMBASE, Web of Science, Lilacs, CINAHL, PsycINFO and Google Scholar) were performed. We included prospective studies of hospitalized older adults. Primary outcomes were functional decline at hospital discharge and mortality after discharge. Other data were considered secondary outcomes. Methodological quality was evaluated by the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Twenty-eight papers were included, corresponding to 19 cohorts (5 cohorts for functional decline and 16 for mortality), with moderate to good methodological quality. Being frail [RR: 1.32 (95%CI: 1.04; 1.67)] and pre-frail [RR: 1.51 (95%CI: 1.05; 2.17)] are risk factors for functional decline compared with being nonfrail. Frail individuals had a relative risk for in-hospital mortality and mortality in medium- and long-term compared to nonfrail (in-hospital RR: 8.20, medium RR: 9.49 and long RR: 7.94) and pre-frail (in-hospital RR: 3.19, medium RR: 3.31 and long RR: 3.72). The overall mortality risk in frail individuals is 3.49 and 2.14 times compared to nonfrail and pre-frail, respectively. Length of hospital stay was higher for frail older adults (13.5 days) compared with pre-frail (10.5 days) and nonfrail (8.3 days). Therefore, being frail at hospital admission is a risk factor for in-hospital mortality, long hospital stay, functional decline at hospital discharge, and mortality in the medium- and long-term.

Dementia Friendly Hospital Design: Key Issues for Patients and Accompanying Persons in an Irish Acute Care Public Hospital

OBJECTIVES

Research was conducted to investigate the impact of the hospital environment on older people including patients with dementia and their accompanying persons (APs). The article presents key research findings in the case study hospital.

BACKGROUND

For many patients, the hospital is challenging due to the busy, unfamiliar, and stressful nature of the environment. For a person with dementia, the hospital experience can be exacerbated by cognitive impairment and behavioral or psychological symptoms and can therefore prove to be a frightening, distressing, and disorientating place.

METHOD

The findings are based on a stakeholder engagement process where the research team spent approximately 150 hr observing within the hospital, administered 95 questionnaires to patients and/or APs, and conducted 12 structured interviews with patients and APs. A thematic analysis was employed to analyze and generate key themes emerging from the process.

RESULTS

Themes were grouped into overarching issues and design issues across spatial scales.

CONCLUSION

This research confirms the negative impact of the acute hospital setting on older people with cognitive impairments including dementia and delirium. The multiple perspectives captured in this study, including most importantly people with dementia, ensure that stakeholder needs can be used to inform the design of the hospital environment. The research points to the value of understanding the lived experience of the person with dementia and APs. The voices of patients, particularly persons with dementia and their APs, are a crucial element in helping hospitals to fulfill their role as caregiving and healing facilities.

Patient-directed self-management of pain (PaDSMaP) compared to treatment as usual following total knee replacement; a randomised controlled trial

Background

Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor.

The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)).

Methods

A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis.

Results

ITT analysis did not detect any significant differences between the two groups’ pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, − 1.1). One patient in the self-medicating group over-medicated but suffered no harm.

Conclusion

Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication.

Trial Registration

ISRCTN10868989. Registered 22 March 2012, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3146-2) contains supplementary material, which is available to authorized users.

Results from the third Scottish National Prevalence Survey: is a population health approach now needed to prevent healthcare-associated infections?

BACKGROUND

Healthcare-associated infections (HCAIs) are a major public health concern and a significant cause of morbidity and mortality. A robust and current evidence base that is specific to local, national and Europe-wide settings is necessary to inform the development of strategies to reduce HCAI and contain antimicrobial resistance.

AIM

To measure the prevalence of HCAI and antimicrobial prescribing and identify key priority areas for interventions to reduce the burden of infection.

METHODS

A national rolling point-prevalence survey (PPS) in National Health Service (NHS) acute, NHS non-acute, NHS paediatric, and independent hospitals was carried out between September and November 2016 using the European Centre for Disease Prevention and Control protocol designed for the European PPS.

FINDINGS

The prevalence of HCAI was 4.6%, 2.7%, and 3.2% in acute adults, paediatric and non-acute patient groups, respectively. The most frequent HCAI types reported in adult patients were urinary tract infection and pneumonia. The prevalence of antimicrobial prescribing was 35.7%, 29.3%, and 13.8% in acute adults, paediatric, and non-acute patient groups, respectively. Respiratory, skin and soft tissue, gastrointestinal, and urinary tract infections were the most common infections being treated at the time of survey.

CONCLUSION

HCAI continues to be a public health concern in Scotland. Urinary tract infection and pneumonia continue to place a significant burden on patients and on healthcare delivery, including those that develop in the community and require hospital admission. A broader population health approach which focuses on reducing the risk of infection upstream would reduce these infections in both community and hospital settings.

Evaluation of frailty and influencing factors in old people in hospital institution: Evidence for a phenotype of frailty

We assessed the frailty status of inpatients and analyzed the factors influencing frailty status to explore the reasons for frailty and identify feasible intervention strategies.A total of 1494 geriatric patients aged ≥60 years were recruited as subjects. All patients were hospitalized between September 2014 and August 2015 in the internal medicine units of 3 hospitals in Chongqing and Zunyi in the southwestern area of China. Patients' frailty status was evaluated using the Phenotype of Frailty scale, via face-to-face interviews coupled with physical examinations using simple equipment.Of the 1494 cases, 1400 (93.71%) were eligible for analysis. Participants' mean age was 75.52 ± 9.28 years. The overall prevalence of frailty was 18.0%, and was higher for frail females (9.4%) than males (8.6%). Increasing age and body mass index, low income (<1000 Ren Min Bi for per month), poor self-rated health, cognitive impairment, depression, polypharmacy (≥5 medications), disability, and a history of fall in the past 1 year were independently significantly correlated with frailty (P < .05 for each comparison).Numerous factors were associated with frailty. As treatment for frailty is focused on prevention in this study, intervention strategies should target a comprehensive list of physiological and psychological aspects of the older people.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Supportive care for older people with frailty in hospital: An integrative review

BACKGROUND

Growing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care.

AIM

To identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation.

DESIGN

An integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term 'supportive care'. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken.

DATA SOURCES

Literature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n=52) were integrated using synthesis of themes.

RESULTS

Relevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings.

CONCLUSION

The findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.

Death is not the only healthcare outcome important to patients

Unfortunately throughout history there have been wide variations in the way death has been handled by the medical profession in different times and places, and even today within the same hospital there are big difference between what doctors say they do and what actually happens. It is not currently possible to determine when severely ill patients become irreversibly unsalvageable and when attempts at resuscitation after death are futile. Without this knowledge it is impossible to honestly advise patients and their loved ones. There is little data available to show what proportions of patients are less sick or feel better on discharge from hospital than they were on admission and no robust systems for predicting such outcomes. Death is not the only healthcare outcome important to patients. Regaining or preserving health is the ultimate goal for patients, yet most hospital outcomes are reported only in terms of mortality. Developing models that predict a good clinical outcome may be more clinically useful than those that predict death. Patients are more likely to want to know their chances of getting better than their chances of dying. Also expressing treatment options in terms of its benefits (i.e. the chance of getting better) versus the risks (i.e. the chances the treatment will kill you) may be far more acceptable to patients than providing their risks versus the chance that they are going to die anyway.

A Review of Risk Factors for Cognitive Impairment in Stroke Survivors

In this review, we aimed to identify the risk factors that may influence cognitive impairment among stroke survivors, namely, demographic, clinical, psychological, and physical determinants. A search from Medline, Scopus, and ISI Web of Science databases was conducted for papers published from year 2004 to 2015 related to risk factors of cognitive impairment among adult stroke survivors. A total of 1931 articles were retrieved, but only 27 articles met the criteria and were reviewed. In more than half of the articles it was found that demographical variables that include age, education level, and history of stroke were significant risk factors of cognitive impairment among stroke survivors. The review also indicated that diabetes mellitus, hypertension, types of stroke and affected region of brain, and stroke characteristics (e.g., size and location of infarctions) were clinical determinants that affected cognitive status. In addition, the presence of emotional disturbances mainly depressive symptoms showed significant effects on cognition. Independent relationships between cognition and functional impairment were also identified as determinants in a few studies. This review provided information on the possible risk factors of cognitive impairment in stroke survivors. This information may be beneficial in the prevention and management strategy of cognitive impairments among stroke survivors.

Recovery coaching in an acute older people rehabiliation ward

Our patient, carer, and staff feedback clearly tells us that elderly patients are frequently disempowered by acute care provision, environments, and attitudes. This debilitates individuals mentally and physically, reducing their independent functioning, and may mean that they require prolonged care or are unfit to return home.

We developed the concept of “recovery coaching” to support acute inpatient elderly care rehabilitation. We designed a training intervention to achieve “coaching conversations” between our staff and our patients.

Data were collected from 46 participants; 22 in the pre-intervention stage and 24 in the post-intervention stage. For the post-intervention patients, mean scores indicated that there was slightly higher increase in the patient's independence in terms of their Barthel (ADL) scores and that they reported higher feelings of self-efficacy. For this patient group it was also found that more returned home with the same level of care as on their admission, and that fewer patients required residential care placements at discharge.

This innovative intervention allowed us to challenge the fundamental basis of “I do it for you” to “I will do it with you”, allowing the patient to become an integral partner in their health care.

Short-term outcomes of seniors aged 80 years and older with acute illness: hospitalist care by geriatricians and other internists compared

BACKGROUND

Although acute geriatric units have improved the outcomes of hospitalized seniors, it is uncertain as to whether hospitalist care by geriatricians outside of these units confers similar benefit.

OBJECTIVE

To determine whether hospitalist care by geriatricians reduces short-term mortality and readmission, and length of stay (LOS) for seniors aged 80 years and older with acute medical illnesses compared with care by other internists.

DESIGN

Retrospective cohort study using administrative and chart review data on demographic, admission-related, and clinical information of hospital episodes.

SETTING

General internal medicine department of an acute-care hospital in Singapore from 2005 to 2008.

PATIENTS

Seniors aged 80 years and older with specific focus on 2 subgroups with premorbid functional impairment and acute geriatric syndromes.

INTERVENTION

Hospitalist care by geriatricians compared with care by other internists.

MEASURES

Hospital mortality, 30-day mortality or readmission, and LOS.

RESULTS

For 1944 hospital episodes (intervention: 968, control: 976), there was a nonsignificant trend toward lower hospital mortality (15.5% vs 16.9%) but not 30-day mortality or readmission, or LOS for care by geriatricians compared with care by other internists. A marginally stronger trend toward lower hospital mortality for care by geriatricians among those with acute geriatric syndromes (20.2% vs 23.1%) was observed. Similar treatment effects were found after adjustment for demographic, admission-related, and clinical factors.

CONCLUSIONS

For seniors aged 80 years and over with acute medical illness, hospitalist care by geriatricians did not significantly reduce short-term mortality, readmission, or LOS, compared with care by other internists.

Early re-presentation to hospital after discharge from an acute medical unit: perspectives of older patients, their family caregivers and health professionals

AIMS AND OBJECTIVES

To explore the perceptions of older patients who re-presented to hospital within 28 days of discharge from an acute medical unit (AMU), their family caregivers and appropriately experienced health professionals.

BACKGROUND

Hospitals are increasingly using AMUs to provide rapid assessment and treatment for medical patients. Evidence of efficacy is building, however in-depth exploration of the experiences of older patients who re-present to hospital soon after discharge from an AMU, and those who care for them, appears to be lacking.

DESIGN

A qualitative, descriptive design was used.

METHODS

In 2007, our team purposively sampled older patients who re-presented to hospital within 28 days of discharge from an AMU (n = 12), family caregivers (n = 15), and health professionals (n = 35). Data were collected using semi-structured interviews and subjected to thematic content analysis.

RESULTS

Four themes emerged: the health trajectory, communication challenges, discharge readiness and the decision to return. Re-presentation to hospital was seen as part of a declining health trajectory. The AMU was viewed as treating acute illness well, however patients and family caregivers left hospital with limited understanding of underlying health problems and, therefore, ill-prepared for future health crises.

CONCLUSION

There are clear benefits for older patients from AMUs, which expedite treatment for acute health crises. However, AMU discharge planning needs to consider patients' overall health status and likely future needs to optimise outcomes. Such a requirement is problematic in the context of acute time pressures.

RELEVANCE TO CLINICAL PRACTICE

To ensure prompt and expert attention to key aspects of discharge planning for older people leaving AMUs, there is a role for in-depth clinical expertise in the care of older people facing deteriorating life-limiting conditions. Therefore, a leadership role for nurses with geriatric and palliative care expertise, alongside medical and allied health professionals, merits attention in this context.

Characteristics of Patients Described as Sub-acute in an Acute Care Hospital

Les patients frêles et âgés souffrent de multiples besoins complexes qui souvent passent non-traitées dans un établissement de soins actifs. Ne pas reconnaître les géants gériatriques au sein de ces aînés frêles provoque des erreurs de classement de cette population. Cette étude a examiné des aînés malades “sub-aiguë” hospitalisés dans un hôpital de soins tertiaires. Bien qu’ils aient été identifiés comme n’étant plus gravement malades, tous les participants avaient besoin des soins medicaux actifs et/ou de soins infirmiers. Lorsque l’acuité de leur maladie est passée inaperçue, les patients âgés et fragiles ont été classés par erreur comme sub-aiguë. La majorité des participants ont souhaité être soignés chez eux ou à proximité. L’absence, dans notre système de soins de santé, des soins post-aigus, ainsi que l’aversion au risque de la part du personnel de l’hôpital, a abouti aux hospitalisations prolongées ou/et les patients étaient rélégués* dans les services existants (maisons de soins infirmiers) contre leur désir de rentrer chez eux.

Frailty is associated with longer hospital stay and increased mortality in hospitalized older patients

INTRODUCTION

With the onset of frailty, there is often a rapid, progressive, and self- perpetuating downward spiral towards death. Frailty has enormous impact on acute hospital care and has been shown to be a more effective predictor of mortality than conventional clinical measures.

METHODS

Hospitalized older patients admitted in medical wards at a teaching public hospital were studied to determine the prevalence of frailty; its association with anemia, congestive heart failure, clinically active tuberculosis and cognitive impairment; as well as its impact upon short-term outcome.

RESULTS

A total of 250 older hospitalized patients were included, and their frailty status was assessed using Fried's criteria. Of these, 83 (33.2%) patients were frail, with frailty found to be significantly associated with increasing age. A lower mean level of haemoglobin (p, 0.002), higher chance of congestive heart failure (p, <0.001), lower mean MMSE score (p, <0.001), was found in frail older patients. Frail subjects had a higher median hospital stay. There were total of 5 deaths, all among the frail group.

CONCLUSION

Our study showed that almost a third of hospitalized older patients are frail, and have anemia, higher frequency of CHF, cognitive impairment, longer hospital stay and higher mortality.

Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture

BACKGROUND

Hip fractures are common among frail elderly persons and often have serious consequences on function, mobility and mortality. Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment. However, studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment. The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics (DG) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery (DOS).

FINDINGS

A new clinical pathway for in-hospital treatment of hip fracture patients was developed. In this pathway patients were treated pre-and postoperatively in DG. Comprehensive geriatric assessment was performed as an interdisciplinary, multidimensional, systematic assessment of all patients focusing on each patient's capabilities and limitations as recommended in guidelines and systematic reviews. Identification and treatment of co-morbidities, pain relief, hydration, oxygenation, nutrition, elimination, prevention and management of delirium, assessment of falls and osteoporosis were emphasized. Discharge planning started as early as possible. Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital. Fracture specific treatment was based upon standard treatment for the hospital, expert opinions and a review of the literature.

CONCLUSION

A new treatment program for old hip fracture patients was developed, introduced and run in the DG, the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a randomised clinical trial.

Screening for cognitive impairment in older general hospital patients: comparison of the Six-Item Cognitive Impairment Test with the Mini-Mental State Examination

OBJECTIVE

To investigate the performance and usability of the Six-Item Cognitive Impairment Test (6CIT) as a screening instrument for cognitive impairment in older, general hospital inpatients/outpatients.

METHOD

In 253 general hospital patients aged ≥ 70 years, diagnostic accuracy of the 6CIT and time required to administer it were assessed using the Mini-Mental State Examination (MMSE) as the criterion standard.

RESULTS

The (negative) correlation between the 6CIT and the MMSE was very high (r = -0.82). Optimal comparability was found using a MMSE cutoff of ≤19 for lower and ≤23 for higher educated patients, at a cutoff of ≥11 on the 6CIT that was not sensitive to educational level. The sensitivity of the 6CIT was 0.90 and the specificity was 0.96, whereas the positive predictive value was 0.83 and the negative predictive value was 0.98. The area under the curve was 0.95. The mean administration time was 5.8 min for the MMSE and 2.5 min for the 6CIT (p ≤ 0.01).

CONCLUSIONS

Diagnostic accuracy of the 6CIT was high. As the 6CIT is not sensitive to educational level, does not require advanced language skills, only takes a few minutes to administer and is very easy to use, it appears to be a suitable screening instrument for cognitive impairment in older patients in the general hospital.

The prevalence of health care-associated infection in older people in acute care hospitals

OBJECTIVE

To determine the prevalence of health care-associated infection (HAI) in older people in acute care hospitals, detailing the specific types of HAI and specialties in which these are most prevalent.

DESIGN

Secondary analysis of the Scottish National Healthcare Associated Infection Prevalence Survey data set.

PATIENTS AND SETTING

All inpatients in acute care (n = 11,090) in all acute care hospitals in Scotland (n = 45).

RESULTS

The study found a linear relationship between prevalence of HAI and increasing age (P<.0001) in hospital inpatients in Scotland. Urinary tract infections and gastrointestinal infections represented the largest burden of HAI in the 75-84- and over-85-year age groups, and surgical-site infections represented the largest burden in inpatients under 75 years of age. The prevalence of urinary catheterization was higher in each of the over-65 age groups (P<.0001). Importantly, this study reveals that a high prevalence of HAI in inpatients over the age of 65 years is found across a range of specialties within acute hospital care. An increased prevalence of HAI was observed in medical, orthopedic, and surgical specialties.

CONCLUSIONS

HAI is an important outcome indicator of acute inpatient hospital care, and our analysis demonstrates that HAI prevalence increases linearly with increasing age (P<.0001). Focusing interventions on preventing urinary tract infection and gastrointestinal infections would have the biggest public health benefit. To ensure patient safety, the importance of age as a risk factor for HAI cannot be overemphasized to those working in all areas of acute care.

Use of the Mini Nutritional Assessment to detect frailty in hospitalised older people

OBJECTIVES

The aims of this study were to: (1) determine the prevalence of undernutrition and frailty in hospitalised elderly patients and (2) evaluate the efficacy of both the Mini-Nutritional Assessment (MNA) screening tool and the MNA short form (MNA-SF) in identifying frailty.

SETTING AND PARTICIPANTS

A convenient sample of 100 consecutive patients (75.0 % female) admitted to the Geriatric Evaluation and Management Unit (GEMU) at The Queen Elizabeth Hospital in South Australia.

MEASUREMENTS

Frailty status was determined using Fried's frailty criteria and nutritional status by the MNA and MNA-SF. Optimal cut-off scores to predict frailty were determined by Youden's Index, Receiver Operator Curves (ROC) and area under curve (AUC).

RESULTS

Undernutrition was common. Using the MNA, 40.0% of patients were malnourished and 44.0% were at risk of malnutrition. By Fried's classification, 66.0 % were frail, 30.0 % were pre-frail and 4.0 % robust. The MNA had a specificity of 0.912 and a sensitivity of 0.516 in predicting frailty using the recommended cut-off for malnourishment (< 17). The optimal MNA cut-off for frailty screening was <17.5 with a specificity of 0.912 and sensitivity of 0.591. The MNA-SF predicted frailty with specificity and sensitivity values of 0.794 and 0.636 respectively, using the standard cut-off of < 8. The optimal MNA-SF cut-off score for frailty was < 9, with specificity and sensitivity values of 0.765 and 0.803 respectively and was better than the optimum MNA cut-off in predicting frailty (Youden Index 0.568 vs. 0.503).

CONCLUSION

The quickly and easily administered MNA-SF appears to be a good tool for predicting both under-nutrition and frailty in elderly hospitalised people. Further studies would show whether the MNA-SF could also detect frailty in other populations of older people.

Health care transitions and the aging population: a framework for measuring the value of rapid rehabilitation

A study was undertaken to establish a framework to measure the value of rapid rehabilitation and identify indicators to quantify effective outcomes and efficient processes as health care services are delivered to the aging population across providers, services, and settings. The rapid rehabilitation protocol serving as intervention in this research provides patients (≥65 years old) the option to transition from the acute-care hospital, early in the continuum of care, to an outpatient, skilled nursing facility operated by a division of the hospital organization. A quasi-experimental, cross-sectional, retrospective study is designed to identify and quantify the relationships present in processes and outcomes inherent in health care transitions. Statistical analysis yields unexpected relationships with limited explanatory power for the selected indicators: length of stay, cost of care, discharge delays, 30-day readmissions, falls, and patient satisfaction. However, this research finds 4 imperatives for hospital and clinical leadership: (1) increase collaboration across providers, settings, and stakeholders; (2) educate workforce to optimize risk assessment of aging population; (3) standardize critical to quality measures as scientific foundation for management of services; (4) invest in technologies to ensure the integrity, validity, and reliability of information used to draw inferences about services, risk, and performance.

Reducing "iatrogenic disability" in the hospitalized frail elderly

BACKGROUND

Hospitalization is the first cause of functional decline in the elderly: 30 to 60% of elderly patients lose some independence in basic activities of daily living (ADL) during a stay in hospital. This loss of independence results from the acute condition that led to admission, but is also related to the mode of management.

OBJECTIVE

This paper is a review of the literature on functional decline in elderly hospitalized patients. It is the first stage in a project aiming to prevent dependence that is induced during the course of care.

METHODS

During a 2-day workshop in Monaco, a task force of 20 international experts discussed and defined the concept of "iatrogenic disability".

RESULTS

1- "Iatrogenic disability" was defined by the task force as the avoidable dependence which often occurs during the course of care. It involves three components that interact and have a cumulative effect: a) the patient's pre-existing frailty, b) the severity of the disorder that led to the patient's admission, and lastly c) the hospital structure and the process of care. 2- The prevention of "iatrogenic disability" involves successive stages. - becoming aware that hospitalization may induce dependence. Epidemiological studies have identified at-risk populations by the use of composite scores (HARP, ISAR, SHERPA, COMPRI, etc). - considering that functional decline is not a fatality. Quality references have already been defined. Interventions to prevent dependence in targeted populations have been set up: simple geriatric consultation teams, single-factor interventions (aimed for example at mobility, delirium, iatrogenic disorders) or multidomain interventions (such as GEM and ACE units, HELP, Fast Track, NICHE). These interventions are essentially centered on the patient's frailty and have limited results, as they take little account of the way the institution functions, which is not aimed at prevention of functional decline. The process of care reveals shortcomings: lack of geriatric knowledge, inadequate evaluation and management of functional status. The group suggests that interventions must not only identify at-risk patients so that they may benefit from specialized management, but they must also target the hospital structure and the process of care. This requires a graded "quality approach" and rethinking of the organization of the hospital around the elderly person.

Short-term geriatric assessment units: 30 years later

Background

The increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them.

Methods

In 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their unit's operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile.

Results

Overall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAU's operation.

Conclusions

The GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAU's primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

Dementia care in the acute district general hospital

Morbidity and mortality for any physical illness treated in hospital and complicated by dementia is increased. Length of stay is also prolonged for any physical illness and dementia. Poor uncoordinated hospital care contributes to increased rates of nursing home admissions. Improvement in acute sector care for dementia patients should have a higher priority. Enhanced communication with patients and carers, more attention to hydration and nutrition and improved environmental factors within the hospital would be a start. All NHS staff require an increased insight and training about the consequences of physical illness complicated with dementia.

[Hospital at home for acutely ill older]

The aging of population uses to evolve suffering from chronic diseases, many times in pluripathological shaped, which may engender frailty, disability and, as a last term, dependence. The aggravation of those and/or the appearance of others acute processes become the old people into a regular patient of our hospitals. The hospital at home (HaH) has showed that it may play an important role in the provision of range hospital cares to these patients, unimpaired of efficacy and security; but with indubitable benefits within the scope of their comfort (physical, psychical) and in the field of their functional condition. Available technical means at the present day and the staff's professionalism from these units make easier that any serious illness, medical or surgical, will be subsidiary in this type of attention sometime during their hospital care process. The HaH permits a more efficient rationalization of sanitary resources and should play an important role in the longed for interconnection between primary attention and specialized one.

Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis

OBJECTIVE

To assess the effectiveness of acute geriatric units compared with conventional care units in adults aged 65 or more admitted to hospital for acute medical disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, and the Cochrane Library up to 31 August 2008, and references from published literature. Review methods Randomised trials, non-randomised trials, and case-control studies were included. Exclusions were studies based on administrative databases, those that assessed care for a single disorder, those that evaluated acute and subacute care units, and those in which patients were admitted to the acute geriatric unit after three or more days of being admitted to hospital. Two investigators independently selected the studies and extracted the data.

RESULTS

11 studies were included of which five were randomised trials, four non-randomised trials, and two case-control studies. The randomised trials showed that compared with older people admitted to conventional care units those admitted to acute geriatric units had a lower risk of functional decline at discharge (combined odds ratio 0.82, 95% confidence interval 0.68 to 0.99) and were more likely to live at home after discharge (1.30, 1.11 to 1.52), with no differences in case fatality (0.83, 0.60 to 1.14). The global analysis of all studies, including non-randomised trials, showed similar results.

CONCLUSIONS

Care of people aged 65 or more with acute medical disorders in acute geriatric units produces a functional benefit compared with conventional hospital care, and increases the likelihood of living at home after discharge.

A comprehensive evaluation of elderly people discharged from an Emergency Department

Elderly people make extensive use of the Emergency Department (ED). After discharge from the ED, these patients are at high risk of short-term adverse outcomes such as functional decline, readmission to the ED, hospitalization and death. We investigated whether a comprehensive geriatric evaluation (CGE) and follow-up of the elderly discharged from the ED can provide them with better diagnosis and treatment, and thus reduce adverse outcomes. Out of 423 elderly patients over 75 years of age discharged from an ED we evaluated 222 of them. The patients were evaluated and treated, based on testing for physical, functional, cognitive and emotional status. A comparison was made between scale scores at baseline and 3 months later. We observed a significant improvement in physical and emotional status in all the studied patients, a significant improvement in behavioural status in the elderly patients with cognitive dysfunction, and a reduction of distress in the caregivers of the elderly patients with cognitive dysfunction and behavioural disturbances. We also found that the rate of ED readmission or hospitalization was lower than in the 3 months preceding the CGE. The experience of older patients with the ED system can be greatly improved if their complex needs are given due attention by developing interdisciplinary programs between emergency physicians, geriatricians, and primary care physicians.

Preventing falls and falls-injuries in hospitals and long-term care facilities

Falls are predominantly a problem of older people. In the UK, people over 65 currently account for around 60% of admissions and 70% of bed days in hospitals. There are approximately half a million older people in long-term care settings – many with frailty and multiple long-term conditions. The proportion of the population over 65 years is predicted to rise 25% by 2025, and that over 80 by 50%, with a similar increase in those with dependence for two or more activities of daily living. Despite policies to drive care to the community, it is likely that the proportion of older people in hospitals and care homes will therefore increase. Accidental falls are the commonest reported patient/resident safety incidents. Similar demographic trends can be seen in all developed nations, so that the growing problem of fall prevention in institutions is a global challenge. There has been far more focus in falls-prevention research on older people in ‘community’ settings, but falls are a pressing issue for hospitals and care homes, and a threat to the safety of patients and residents, even if a relatively small percentage of the population is in those settings at any one time.