Elderly patients with cognitive impairment have a high risk for functional decline during hospitalization: The GIFA Study

Hemoglobin levels and cognitive trajectory: unveiling prognostic insights in post-stroke geriatric cohort

PURPOSE

Evidence is scarce regarding the association between anemia and alterations in cognitive level among hospitalized older patients. We aimed to evaluate the associations between baseline hemoglobin (Hb) levels and changes in cognitive level in patients undergoing rehabilitation after stroke.

METHODS

A retrospective cohort study was conducted, encompassing consecutively hospitalized post-stroke patients. Data on serum Hb levels were extracted from medical records, specifically tests conducted within 24 hours of admission. Primary outcomes included discharge scores for cognitive function assessed by the cognitive domain of the Functional Independence Measure (FIM-cognition) and the corresponding change in FIM-cognition during hospitalization. Another outcome measure was the length of hospital stay. Multivariate linear regression analyses were employed to assess the association between Hb levels at admission and the designated outcomes, adjusting for potential confounding factors.

RESULTS

Data from 955 patients (mean age 73.2 years; 53.6% men) were included in the analysis. The median Hb level at admission was 13.3 [11.9, 14.5] g/dL. After fully adjusting for confounding factors, the baseline Hb level was significantly and positively associated with FIM-cognition at discharge (β = 0.045, p = 0.025) and its gain (β = 0.073, p = 0.025). Further, the baseline Hb level was independently and negatively associated with length of hospital stay (β = -0.013, p = 0.026).

CONCLUSION

Elevated baseline Hb levels are correlated with preserved cognitive level and shorter hospital stays in post-stroke patients. Evaluating anemia at the outset serves as a crucial prognostic indicator.

Hospitalisations before and after entry into a residential aged care facility: An interrupted time series analysis

OBJECTIVE

Hospitalisations are an important indicator of safety and quality of care in residential aged care facilities (RACFs). This study aimed to investigate changes in hospital use 12 months before and 12 months after RACF entry using routinely collected data from 25 Australian RACFs.

METHODS

This was a retrospective longitudinal cohort study using linked aged care provider and hospital record data. The sample comprised 1029 residents living in an aged care facility between July 2014 and December 2019 who had stayed a minimum of 12 months in an RACF. The outcome measures were all-cause hospitalisations and fall-related hospitalisations. We applied an interrupted time series analysis using segmented regression to examine changes in both outcome measures over time. Stratified analyses were conducted by gender and dementia status.

RESULTS

The rate of all-cause hospitalisations increased dramatically over the 12 months before RACF entry, from 97 per 1000 residents per month 12 months prior to RACF admission to 303 per 1000 residents at the second month prior to RACF entry. All-cause hospitalisations then decreased considerably to 55 per 1000 residents upon RACF admission and stabilised across the next 12 months. Such trajectories were also observed in fall-related hospitalisations and were consistent for gender and dementia status.

CONCLUSIONS

In this study, hospitalisation rates decreased significantly after RACF entry, and such reductions were maintained for residents who stayed for 12 months in RACFs. Multiple hospital admissions are likely to precipitate entry into RACF. Additional investigation of how community-based services can be successful in reducing the escalating hospitalisations is needed.

The Association of Cognitive Impairment With Depressive Symptoms, Function, and Pain in Hospitalized Older Patients With Dementia

This study examined the associations between cognition and depressive symptoms, function, and pain among hospitalized older patients with dementia. We utilized baseline data of 461 hospitalized older patients with dementia who participated in an intervention study implementing Family-centered Function-focused Care (Fam-FFC) and conducted stepwise linear regression. On average, the participants (males = 189; 41% and females = 272; 59%) were 81.64 years old (Standard Deviation, SD = 8.38). There was a statistically significant association of cognition with depressive symptoms (b = -0.184, p < .001), functional status (b = 1.324, p < .001), and pain (b = -0.045, p < .001) when controlling for covariates. This study utilized a large sample of a relatively underrepresented population, hospitalized older adults with dementia, and addressed a topic with great clinical significance. Specific focus on testing and implementing best practices or interventions to support the clinical outcomes, and the cognitive function of hospitalized older adults with dementia is warranted in both practice and research.

Caring for Informal Dementia Caregivers and Their Loved Ones Via the HOMeCARE Exercise and Mindfulness for Health Program (HOMeCARE): A Randomized, Single-Blind, Controlled Trial

Objective: To investigate the effects of a dyadic intervention of mindfulness-based stress reduction (MBSR) for informal dementia caregivers and home-based balance and progressive resistance training (PRT) for their loved ones. Methods: The study was a two arm, randomized, controlled, single-blinded, parallel-group trial. Dyads were randomized to an intervention group: an 8-week MBSR course (daily) and an 8-week PRT and balance training (3 days/week) for their loved ones or a waiting list control group. Results: Nine dyads were randomized [caregivers: median age 75 (40-81) years, loved ones: 77 (73-88) years]. The intervention significantly improved caregiver mindfulness [relative effect size (95% confidence interval) 1.35 (-0.10, 2.81); p = .009] and functional mobility in their loved ones [mean difference (95% confidence interval) 1.53 (-3.09, 6.14)] with no significant effects on caregiver burden [relative effect size (95% confidence interval) 0.22 (-1.09, 1.54); p = .622]. Conclusion: The study appeared feasible in the home environment and future large and longer trials should test the efficacy of a more abbreviated MBSR intervention and to optimize adoption and sustain adherence over time. Trial registry name: HOMeCare: Caring for the Dementia Caregiver and their Loved One via the HOMeCare Exercise and Mindfulness for Health Program Trial URL: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12617000347369 Registration number: ACTRN12617000347369.

The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review

Background

Older adults with cognitive impairment are frequently hospitalized and discharged to facility-based transitional care programs (TCPs). However, it is unknown whether TCPs are effective in improving their functional status and promoting discharge home rather than to long-term care. The aims of this systematic review were to examine the effectiveness of facility-based TCPs on functional status, patient and health services outcomes for older adults (≥ 65 years) with cognitive impairment and to determine what proportion post TCP are discharged home compared to long-term care.

Methods

The Joanna Briggs Institute Critical Appraisal Manual for Evidence Synthesis was used to guide the methodology for this review. The protocol was published in PROSPERO (registration number CRD42021257870). MEDLINE, CINAHL, PsycINFO, the Cochrane Library, and EMBASE databases, and ClinicalTrials.gov and the World Health Organization Trials Registry were searched for English publications. Studies that met the following criteria were included: community-dwelling older adults ≥ 65 years who participated in facility-based TCPs and included functional status and/or discharge destination outcomes. Studies with participants from nursing homes and involved rehabilitation programs or transitional care in the home or in acute care, were excluded. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Results are in narrative form.

Results

Twenty-two studies (18 cohort and four cross sectional studies) involving 4,013,935 participants met inclusion criteria. The quality of the studies was mostly moderate to good. Improvement in activities of daily living (ADLs) was reported in eight of 13 studies. Between 24.4%-68% of participants were discharged home, 20–43.9% were hospitalized, and 4.1–40% transitioned to long-term care. Review limitations included the inability to perform meta-analysis due to heterogeneity of outcome measurement tools, measurement times, and patient populations.

Conclusions

Facility-based TCPs are associated with improvements in ADLs and generally result in a greater percentage of participants with cognitive impairment going home rather than to long-term care. However, gains in function were not as great as for those without cognitive impairment. Future research should employ consistent outcome measurement tools to facilitate meta-analyses. The level of evidence is level III-2 according to the National Health and Medical Research Council for cohort and cross-sectional studies.

Functional trajectories associated with acute illness and hospitalization in oldest old patients: Impact on mortality

Background: The literature pays low attention to functional changes during acute illness in older patients. Our main objectives were to separately describe the different functional changes occurring before and after hospital admission in oldest old medical patients, to investigate their association with mortality, and identify predictors associated with in-hospital failure to recover function.

Methods: Secondary analysis of data from a prospective cohort study conducted in a tertiary teaching hospital. The study followed the STROBE criteria. The sample included 604 consecutive patients aged 65 or older hospitalized for acute illness, discharged alive, and not fully dependent at baseline. Activities of daily living measured at baseline, admission, and discharge were used to classify patients into four functional trajectories depending on whether they decline or remain stable between baseline and admission (prehospital) and whether they decline, remain stable, or recover baseline function between admission and discharge (in-hospital). Multivariate models were used to test the association between functional trajectories with mortality, and predictors for in-hospital recovery.

Results: Functional trajectories were: “stable-stable” (18%); “decline-recovery” (18%); “decline-no recovery” (53%); “in-hospital decline” (11%). Prehospital decline occurred in 75% and 64% were discharged with worse function than baseline. “In-hospital decline” and “decline-no recovery” trajectories were independently associated with higher 6- and 12-month mortality. Extent of prehospital decline and dementia were predictors of failure to in-hospital recovery.

Conclusion: In acutely ill older people, differentiating between prehospital and in-hospital functional changes has prognostic implications. Lack of functional regain at discharge is associated with higher mortality at 6- and 12-months.

Comparing emergency department use among individuals with varying levels of cognitive impairment

INTRODUCTION

As the population ages, Alzheimer's disease and related dementias (ADRD) are becoming increasingly common in patients presenting to the emergency department (ED). This study compares the frequency of ED use among a cohort of individuals with well-defined cognitive performance (cognitively intact, mild cognitive impairment (MCI), and ADRD).

METHODS

We performed a retrospective cohort study of English-speaking, community-dwelling individuals evaluated at four health system-based multidisciplinary memory clinics from 2014-2016. We obtained demographic and clinical data, including neuropsychological testing results, through chart review and linkage to electronic health record data. We characterized the frequency and quantity of ED use within one year (6 months before and after) of cognitive evaluation and compared ED use between the three groups using bivariate and multivariate approaches.

RESULTS

Of the 779 eligible patients, 89 were diagnosed as cognitively intact, 372 as MCI, and 318 as ADRD. The proportion of subjects with any annual ED use did not increase significantly with greater cognitive impairment: cognitively intact (16.9%), MCI (26.1%), and ADRD (28.9%) (p = 0.072). Average number of ED visits increased similarly: cognitively intact (0.27, SD 0.72), MCI (0.41, SD 0.91), and ADRD (0.55, SD 1.25) (p = 0.059). Multivariate logistic regression results showed that patients with MCI (odds ratio (OR) 1.62; CI = 0.87-3.00) and ADRD (OR 1.84; CI = 0.98-3.46) did not significantly differ from cognitively intact adults in any ED use. Multivariate negative binomial regression found patients with MCI (incidence rate ratio (IRR) 1.38; CI = 0.79-2.41) and ADRD (IRR 1.76, CI = 1.00-3.10) had elevated but non-significant risk of an ED visit compared to cognitively intact individuals.

CONCLUSION

Though there was no significant difference in ED use in this small sample from one health system, our estimates are comparable to other published work. Results suggested a trend towards higher utilization among adults with MCI or ADRD compared to those who were cognitively intact. We must confirm our findings in other settings to better understand how to optimize systems of acute illness care for individuals with MCI and ADRD.

Hospital-associated deconditioning: Not only physical, but also cognitive

INTRODUCTION

Hospital-associated deconditioning (HAD) or post-hospital syndrome is well recognized as reduced functional performance after an acute hospitalization. Recommendations for the management of HAD are still lacking, partly due to a poor understanding of the underlying processes. We aimed to review existing data on risk factors, pathophysiology, measurement tools, and potential interventions.

MATERIALS AND METHODS

We conducted a systematic review from bibliographical databases in English, Spanish and French with keywords such as 'post-hospitalization syndrome' or 'deconditioning'. We selected studies that included people aged 60 years or older. Three researchers independently selected articles and assessed their quality.

RESULTS

From 4421 articles initially retrieved, we included 94 studies. Most were related to risk factors, trajectories and measures, and focused on the physical aspects of deconditioning. Risk factors for HAD included age, nutritional status, mobility, and pre-admission functional status, but also cognitive impairment and depression. Regarding interventions, almost all studies were devoted to physical rehabilitation and environmental modifications. Only one study focused on cognitive stimulation.

DISCUSSION

In the last decade, studies on HAD have mostly focused on the physical domain. However, neurological changes may also play a role in the pathophysiology of HAD. Beyond physical interventions, cognitive rehabilitation and neurological interventions should also be evaluated to improve deconditioning prevention and treatment in the hospital setting.

Patient-related risk factors for in-hospital functional decline in older adults: A systematic review and meta-analysis

BACKGROUND

Functional decline (FD) is a common and serious problem among hospitalised older adults.

OBJECTIVE

This systematic review and meta-analysis aims to identify patient-related risk factors for in-hospital FD in older adults.

METHODS

Previous reviews on this topic (1970-2007) and the databases PubMed, Embase, and CINAHL (January 2007-December 2020) were searched. Reference lists of included articles were screened. Studies investigating patient-related risk factors for FD from (pre)admission to discharge in older adults admitted to an acute geriatric or internal medical unit were included. Study quality was assessed using the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using random-effects models. The quality of evidence was assessed using GRADE.

RESULTS

Twenty-nine studies met the inclusion criteria. Statistically significant risk factors were living in a nursing home (OR, 2.42; 95% CI, 1.29-4.52), impairment in instrumental activities of daily living (OR, 2.08; 95% CI, 1.51-2.86), history of falls (OR, 1.71; 95% CI, 1.00-2.92), cognitive impairment (OR, 1.83; 95% CI, 1.56-2.14), dementia (OR, 1.71; 95% CI, 1.23-2.38), delirium (OR, 2.34; 95% CI, 1.88-2.93), (risk of) malnutrition (OR, 1.76; 95% CI, 1.03-3.03), hypoalbuminemia (OR, 1.79; 95% CI, 1.36-2.36), comorbidity (OR, 1.09; 95% CI, 1.03-1.16), and the presence of pressure ulcers (OR, 3.33; 95% CI, 1.82-6.09). The narrative synthesis suggested prehospital FD, needing assistance with walking, and low body mass index as additional risk factors.

CONCLUSIONS

Several patient-related risk factors for in-hospital FD were identified that can be used at hospital admission to identify older patients at risk of FD.

Acute care utilization risk among older adults living undiagnosed or unaware of dementia

BACKGROUND

Dementia is associated with increased risk of hospitalization and emergency department (ED) visits. Many persons with dementia are undiagnosed or unaware of their diagnosis, however. Our objective was to determine whether undiagnosed dementia or unawareness affects risk of hospitalization or ED visits.

METHODS

Retrospective longitudinal cohort study of 3537 community-living adults age ≥65 enrolled in the 2011-2017 National Health and Aging Trends Study with linked fee-for-service Medicare claims. Using self or proxy reported diagnosis, proxy dementia screening questionnaire, cognitive testing, and Medicare claims diagnosis, participants were classified as having (1) no dementia or dementia, for which they were classified as (2) undiagnosed, (3) diagnosed but unaware, or (4) diagnosed and aware. Proportional hazards models evaluated all-cause and potentially preventable hospitalization and ED visit risk by time-varying dementia status, adjusting for older adult characteristics.

RESULTS

Most participants (n = 2879) had no dementia at baseline. Among participants with dementia at baseline (n = 658), 187 were undiagnosed, 300 diagnosed but unaware, and 171 diagnosed and aware. In multivariable adjusted proportional hazards models, persons with undiagnosed dementia had lower risk of hospitalization and ED visits compared to persons diagnosed and aware (all-cause hospitalization aHR 0.59 [0.44, 0.79] and ED visit aHR 0.63 [0.47, 0.85]) and similar risks of these outcomes compared to persons without dementia. Individuals diagnosed but unaware had greater risk compared to those without dementia: aHR 1.37 (1.18, 1.59) for all-cause hospitalization and 1.48 (1.28, 1.71) for ED visits; they experienced risk comparable to individuals diagnosed and aware.

CONCLUSION

Older adults with undiagnosed dementia are not at increased risk of acute care utilization after accounting for differences in other characteristics. Individuals unaware of diagnosed dementia demonstrate risk similar to individuals aware of the diagnosis. Increasing diagnosis alone may not affect acute care utilization. The role of awareness warrants further investigation.

Age-specific rates of hospital transfers in long-stay nursing home residents

INTRODUCTION

hospital transfers and admissions are critical events in the care of nursing home residents. We sought to determine hospital transfer rates at different ages.

METHODS

a cohort of 1,187 long-stay nursing home residents who had participated in a Centers for Medicare and Medicaid demonstration project. We analysed the number of hospital transfers of the study participants recorded by the Minimum Data Set. Using a modern regression technique, we depicted the annual rate of hospital transfers as a smooth function of age.

RESULTS

transfer rates declined with age in a nonlinear fashion. Rates were the highest among residents younger than 60 years of age (1.30-2.15 transfers per year), relatively stable between 60 and 80 (1.17-1.30 transfers per year) and lower in those older than 80 (0.77-1.17 transfers per year). Factors associated with increased risk of transfers included prior diagnoses of hip fracture (annual incidence rate ratio or IRR: 2.057, 95% confidence interval (CI): [1.240, 3.412]), dialysis (IRR: 1.717, 95% CI: [1.313, 2.246]), urinary tract infection (IRR: 1.755, 95% CI: [1.361, 2.264]), pneumonia (IRR: 1.501, 95% CI: [1.072, 2.104]), daily pain (IRR: 1.297, 95% CI: [1.055,1.594]), anaemia (IRR: 1.229, 95% CI [1.068, 1.414]) and chronic obstructive pulmonary disease (IRR: 1.168, 95% CI: [1.010,1.352]). Transfer rates were lower in residents who had orders reflecting preferences for comfort care (IRR: 0.79, 95% CI: [0.665, 0.936]).

DISCUSSION

younger nursing home residents may require specialised interventions to reduce hospital transfers; declining transfer rates with the oldest age groups may reflect preferences for comfort-focused care.

Gait changes over time in hospitalized older adults with advanced dementia: Predictors of mobility change

People with dementia are at risk of mobility decline. In this study, we measured changes in quantitative gait measures over a maximum 10-week period during the course of a psychogeriatric admission in older adults with dementia, with the aims to describe mobility changes over the duration of the admission, and to determine which factors were associated with this change. Fifty-four individuals admitted to a specialized dementia inpatient unit participated in this study. A vision-based markerless motion capture system was used to record participants' natural gait. Mixed effect models were developed with gait measures as the dependent variables and clinical and demographic variables as predictors. We found that gait stability, step time, and step length decreased, and step time variability and step length variability increased over 10 weeks. Gait stability of men decreased more than that of women, associated with an increased sacrum mediolateral range of motion over time. In addition, the sacrum mediolateral range of motion decreased in those with mild neuropsychiatric symptoms over 10 weeks, but increased in those with more severe neuropsychiatric symptoms. Our study provides evidence of worsening of gait mechanics and control over the course of a hospitalization in older adults with dementia. Quantitative gait monitoring in hospital environments may provide opportunities to intervene to prevent adverse events, decelerate mobility decline, and monitor rehabilitation outcomes.

Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity

The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia’s aged care system with a human rights approach.

Prevalence and predictors of hospital-acquired functional decline in patients with sepsis admitted to the intensive care unit

Although sepsis is known to cause functional decline, the prevalence and predictors of hospital-acquired functional decline (HAFD) in patients with sepsis are unclear. The purpose of this study was to investigate the prevalence and predictors of HAFD in patients with sepsis admitted to the ICU. This study is a single-center retrospective observational study from January 2014 to December 2019. We included all consecutive patients with sepsis who received rehabilitation in our ICU. The primary outcome was HAFD, which was defined as a decrease in at least five points of the Barthel index mobility score from prehospital to hospital discharge. We described the prevalence of HAFD and investigated the predictors of HAFD using the multivariate logistic regression analysis adjusting for potential confounders. Among 134 patients, 57 patients (42.5%) had HAFD. The longer time to initial ambulation and lower prehospital walking ability were associated with HAFD (adjusted odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.10 and adjusted OR 0.79; 95% CI, 0.66-0.95, respectively). In conclusion, nearly half of the patients with sepsis who received rehabilitation developed HAFD. Lower functional status prior to hospitalization and the longer time to initial ambulation was associated with HAFD, indicating the potential importance of early ambulation among septic patients in the ICU.

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Construct Validity, Test-Retest Reliability, Sensitivity to Change, and Feasibility of the Patient-Specific Functional Scale in Acutely Hospitalized Older Patients With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

The Patient-Specific Functional Scale (PSFS) as an individualized patient-reported outcome measure may allow to assess limitations and changes in self-determined functional activities most important to an older patient in the acute care setting. However, its clinimetric properties have not yet been evaluated in these patients. The study aimed to investigate the construct validity, test-retest reliability, sensitivity to change, and feasibility of the PSFS in acutely hospitalized older patients with and without cognitive impairment (CI).

METHODS

The clinimetric properties of the PSFS were investigated by secondary data analysis from a prospective observational cohort study examining physical activity and mobility in acutely hospitalized older patients. In this analysis, 120 older patients-83.0 (6.4) years-with (Mini-Mental State Examination [MMSE] 18-23, n = 52) and without CI (MMSE ≥24, n = 68) receiving early multidisciplinary geriatric rehabilitation in acute care were included. Construct validity was assessed by Spearman correlations (rs) with the Activity-specific Balance Confidence Scale (ABC-6), Short Falls Efficacy Scale-International (Short FES-I), EuroQoL-5 Dimensions (EQ-5D), Short Physical Performance Battery (SPPB), de Morton Mobility Index (DEMMI), and Barthel Index (BI); test-retest reliability within 24 hours by intraclass correlation coefficients (ICCs); sensitivity to change by standardized response means (SRMs) calculated for treatment effects, and feasibility by completion rates/times and floor/ceiling effects.

RESULTS

The PSFS showed fair to moderate correlations with all construct variables in patients with CI (rs = 0.31 to 0.53). In patients without CI, correlations were fair for the ABC-6, FES-I, EQ-5D, and BI (rs = |0.27 to 0.36|), but low for the SPPB and DEMMI (rs = -0.04 to 0.14). Test-retest reliability (both: ICC = 0.76) and sensitivity to change (CI: SRM = 1.10, non-CI: SRM = 0.89) were excellent in both subgroups. Excellent feasibility was documented by high completion rates (>94%), brief completion times (<8 min), and no floor/ceiling effects in both subgroups.

CONCLUSIONS

The PSFS has adequate clinimetric properties for assessing patient-specific functional limitations and changes in acutely hospitalized older patients with and without CI. It might be an appropriate complement to traditional functional scales to enhance patient-centeredness in clinical geriatric assessment.

Predictors of Functional Decline in Nursing Home Residents: The Shelter Project

BACKGROUND

The aim of our study was to identify independent predictors of functional decline in older nursing home (NH) residents, taking into account both resident and facility characteristics.

METHODS

Longitudinal observational study involving 1,760 older (≥65 y) residents of NH participating in the SHELTER* study (57 NH in eight countries). All residents underwent a comprehensive geriatric assessment using the interRAI LTCF. Functional decline was defined as an increase of at least one point in the MDS Long Form ADL scale during a 1 year follow-up. Facility and country effects were taken into account.

RESULTS

During the study period 891 (50.6%), NH residents experienced ADL decline. Residents experiencing ADL decline were older, had lower disability at baseline, were more frequently affected by severe dementia and by urinary incontinence, and used more antipsychotics. In the mixed-effect logistic regression model, factors independently associated with a higher risk of functional decline were dementia and urinary incontinence, whereas the presence of a geriatrician was a protective factor.

CONCLUSIONS

Both resident and facility characteristics are associated with the risk of functional decline in NH residents. Increasing the quality of healthcare by involving a geriatrician in residents' care might be an important strategy to improve the outcome of this vulnerable population.

Dementia and the risk of short-term readmission and mortality after a pneumonia admission

BACKGROUND

At time of discharge after a pneumonia admission, care planning for older persons with dementia is essential. However, care planning is limited by lack of knowledge on the short-term prognosis.

AIM

To investigate 30-day mortality and readmission after hospital discharge for pneumonia in persons with versus without dementia, and to investigate how these associations vary with age, time since discharge, and medication use.

METHODS

Using the Danish registries, we investigated 30-day mortality and readmission in persons (+65 years) discharged after pneumonia in 2000-2016 (N = 298,872). Adjusted mortality rate ratios (aMRRs) and incidence rate ratios (aIRRs) were calculated for persons with versus without dementia, and we investigated if these associations varied with use of benzodiazepines, opioids, and antipsychotics, and with age and time since discharge.

RESULTS

Among 25,948 persons with dementia, 4,524 died and 5,694 were readmitted within 30 days. The risk of 30-day mortality was 129% higher (95% CI 2.21-2.37) in persons with versus without dementia after adjustment for sociodemographic characteristics, admission-related factors, and comorbidities. Further, the highest mortality risk was found in persons with both dementia and use of antipsychotics (aMRR: 3.39, 95% CI 3.19-3.59); 16% of deaths in this group could not be explained by the independent effect of each exposure. In those with dementia, the highest aMRRs were found for the youngest and for the first days after discharge. The risk of 30-day readmission was 7% higher (95% CI 1.04-1.10) in persons with versus without dementia. In those with dementia, the highest aIRRs were found for the first days after discharge.

CONCLUSIONS

Dementia was associated with higher short-term mortality after pneumonia, especially in users of antipsychotics, and with slightly higher readmission, especially in the first days after discharge. This is essential knowledge in the care planning for persons with dementia who are discharged after a pneumonia admission.

Association of Co-occurring Dementia and Self-reported Visual Impairment With Activity Limitations in Older Adults

Importance

The number of older adults with visual impairment (VI) and dementia is projected to increase in the US because of the aging of the population. Dementia and VI commonly co-occur and are each independently associated with disability. To care for an aging population, it may be important to characterize the association of coexisting dementia and self-reported VI on daily functioning.

Objective

To evaluate the association of co-occurring dementia and self-reported VI on daily functioning.

Design, Setting, and Participants

This cross-sectional analysis of a nationally representative cohort study used data from the National Health and Aging Trends Study (NHATS), an annual study of US adults 65 years and older. Participants in the 2015 survey with complete data on outcomes, associated factors, and covariates were included in this study. Data analysis took place from January 2019 to November 2019.

Main Outcomes and Measures

Multivariable Poisson regression was used to model the independent associations and interaction of dementia and self-reported VI status on 3 functional activity scales (self-care, mobility, and household activities). Marginal predicted proportions were calculated. Analyses were adjusted for sociodemographic and medical factors and accounted for the complex survey design.

Results

A total of 7124 participants were included. The weighted proportion of female respondents was 55.3% (95% CI, 54.0%-56.6%), and 56.1% (95% CI, 54.1%-58.1%) were between 65 and 74 years old. Self-reported VI was present in 8.6% (95% CI, 7.8%-9.3%) of participants, while 8.3% (95% CI, 7.8%-8.9%) had possible dementia and 6.3% (95% CI, 5.7%-6.9%) had probable dementia. Self-reported VI was associated with an expected decrease in mobility score of 14.7% (functional scale scores: no VI, 10.82 vs VI, 9.23), self-care score of 9.5% (no VI, 14.54 vs VI, 13.16), and household activity score of 15.2% (no VI, 18.23 vs VI, 15.45), while probable dementia was associated with expected decreases of 27.8% (no dementia, 10.82 vs probable dementia, 7.81), 22.9% (no dementia, 14.54 vs probable dementia, 11.20), and 34.7% (no dementia, 18.23 vs probable dementia, 11.90), respectively. Among those with probable dementia and self-reported VI, there was an expected decrease in mobility score of 50.1% (functional ability scores: no VI and no dementia, 10.82 vs VI and probable dementia, 5.40), self-care score of 42.4% (no VI and no dementia, 14.54 vs VI and probable dementia, 8.38), and household activity score of 52.4% (no VI and no dementia, 18.23 vs VI and probable dementia, 8.68), suggesting that respondents with co-occurring dementia and self-reported VI had lower functional activity scores than would be associated with the independent contributions of these conditions.

Conclusions and Relevance

Older adults with both dementia and self-reported VI may be at high risk for disability, and their co-occurrence may potentiate this risk. These findings suggest that the growing population of older adults with both visual impairment and dementia may benefit from interventions to maximize vision and cognition and promote functioning and independence.

Associação entre limitação funcional e deficit cognitivo em pacientes idosos hospitalizados

Resumo Introdução A hospitalização é reconhecida como um fator de risco para o declínio funcional do idoso, bem como para o declínio cognitivo. Entretanto, a associação entre essas variáveis ainda não é bem estabelecida, sobretudo no contexto hospitalar. Objetivo Verificar a associação entre deficit cognitivo e limitação funcional em atividades básicas da vida diária entre idosos hospitalizados. Método Estudo seccional, com idosos internados em dois hospitais públicos. Foi verificada a presença de deficit cognitivo por meio do teste de rastreio Mini Exame do Estado Mental e a presença de limitação funcional pelo Índice Katz para Atividades Básicas de Vida Diária. Foi realizada análise descritiva da amostra e regressão logística, estimando-se os valores de odds ratio e respectivos intervalos de confiança (95%). Resultados A prevalência de deficit cognitivo foi de 51,5% (IC95%, 41,6-61,4) e 37,6% dos idosos apresentaram dependência em uma ou mais atividades básicas de vida diária. Os resultados mostraram que tanto o número de atividades comprometidas (p=0,002) quanto a classificação final do índice Katz (p=0,001) foram diferentes estatisticamente entre os grupos de idosos com e sem deficit cognitivo. Entre os idosos que eram dependentes parciais para as atividades, 14,9% apresentaram deficit cognitivo; já entre aqueles que eram dependentes totais, o valor foi de 13,9%. Os idosos dependentes nas atividades apresentaram 5,08 vezes (IC95%, 1,84-14,01) maior chance de deficit cognitivo. Conclusão: O deficit cognitivo foi associado à limitação funcional e os resultados colaboraram no direcionamento da sistematização da assistência precoce direcionada, a fim de minimizar perdas cognitivas e funcionais na hospitalização.

A Predictive Model of Intrinsic Factors Associated with Long-Stay Nursing Home Care After Hospitalization

We aimed to build a predictive model with intrinsic factors measured upon admission to skilled nursing facilities (SNFs) post-acute care (PAC) to identify older adults transferred from SNFs to long-term care (LTC) instead of home. We analyzed data from Massachusetts in 23,662 persons admitted to SNFs from PAC in 2013. Explanatory logistic regression analysis identified single "intrinsic predictors" related to LTC placement. To assess overfitting, the logistic regression predictive model was cross-validated and evaluated by its receiver operating characteristic (ROC) curve. A 12-variable predictive model with "intrinsic predictors" demonstrated both high in-sample and out-of-sample predictive accuracy in the receiver operating characteristic ROC and area under the ROC among patients at risk of LTC placement. This predictive model may be used for early identification of patients at risk for LTC after hospitalization in order to support targeted rehabilitative approaches and resource planning.

A Cognitive-Based Board Game With Augmented Reality for Older Adults: Development and Usability Study

Background

Older adults in Taiwan are advised to adopt regular physical and social activities for the maintenance of their cognitive and physical health. Games offer a means of engaging older individuals in these activities. For this study, a collaborative cognitive-based board game, Nostalgic Seekers, was designed and developed with augmented reality technology to support cognitive engagement in older adults.

Objective

A user study of the board game was conducted to understand how the game facilitates communication, problem solving, and emotional response in older players and whether augmented reality is a suitable technology in game design for these players.

Methods

A total of 23 participants aged 50 to 59 years were recruited to play and evaluate the game. In each session, participants’ interactions were observed and recorded, then analyzed through Bales’ interaction process analysis. Following each session, participants were interviewed to provide feedback on their experience.

Results

The quantitative analysis results showed that the participants engaged in task-oriented communication more frequently than social-emotional communication during the game. In particular, there was a high number of answers relative to questions. The analysis also showed a significant positive correlation between task-oriented acts and the game score. Qualitative analysis indicated that participants found the experience of playing the game enjoyable, nostalgic objects triggered positive emotional responses, and augmented reality technology was widely accepted by participants and provided effective engagement in the game.

Conclusions

Nostalgic Seekers provided cognitive exercise and social engagement to players and demonstrated the positive potential of integrating augmented reality technology into cognitive-based games for older adults. Future game designs could explore strategies for regular and continuous engagement.

Validation of the interview-based life-space assessment in institutionalized settings (LSA-IS) for older persons with and without cognitive impairment

BACKGROUND

Self-reported life-space assessment methods so far focus on community-dwelling persons, with a lack of validated assessment methods for institutionalized settings. This study evaluated construct validity, test-retest reliability, sensitivity to change, and feasibility of a new Life-Space Assessment for Institutionalized Settings (LSA-IS) in geriatric patients.

METHODS

Psychometric properties of the LSA-IS in 119 hospitalized geriatric patients (83.0 ± 6.2 years) with and without cognitive impairment (CI) [Mini-Mental State Examination: 22.4 ± 4.9 scores] were evaluated within a comprehensive validation design. For the total group and subgroups according to cognitive status, construct validity was assessed by calculating Spearman's rank correlation coefficients (rho) with established construct variables, test-retest reliability by intra-class correlation coefficients (ICCs), sensitivity to change by standardized response means (SRMs) calculated for effects of early ward-based rehabilitation during hospital stay.

RESULTS

The LSA-IS (total score) demonstrated good test-retest reliability (ICC = .704), and large sensitivity to change (SRM = .806), while construct validity was small to high indicated by significant correlations of the LSA-IS to construct variables (rho = .208-716), depending on relative construct association. On average results of LSA-IS sub-scores confirmed results of the total score. Subgroups according to cognitive status did not differ for most analyzed variables. A completion rate of 100% and a completion time of 3.2 ± 1.2 min documented excellent feasibility.

CONCLUSIONS

The interview-based LSA-IS has proven to be valid, reliable, sensitive, and feasible in hospitalized, multi-morbid, geriatric patients with and without CI documenting good psychometric properties for institutionalized settings.

TRIAL REGISTRATION

DRKS00016028.

Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia

Objectives

Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia.

Design

Retrospective cohort study.

Setting and Participants

Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia.

Methods

Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS.

Results

In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome.

Conclusions and Implications

Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BACKGROUND

In some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.

METHODS

We used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.

RESULTS

Among the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80-88] had available ADL scores at baseline (median score 7 [IQR 4-10]) and at discharge (median 9 [6-12]). Median CIRS-G score was 11 [8-13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27-7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17-8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4-37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83-6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.

CONCLUSION

Baseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.

Nurses' perceptions of their role in functional focused care in hospitalised older people: An integrated review

AIM

The aim of this integrative review was to identify nurses' perspectives of their role in influencing the functional status of hospitalised older people.

METHODS

An integrative review using Whittemore and Knafls' method was conducted using EBSCOhost CINAHL, Ovid MEDLINE(R), EBSCOhost, Social Gerontology, Cochrane Database of Systematic Reviews and ProQuest Dissertations & Theses data bases. Only studies with nurses' perspectives, or beliefs about their role in function-focused care were included. Content analysis was used to develop the themes nurses' role in function-focused care and barriers to functional care.

RESULTS

The review found 12 relevant articles. Nurses believed that they were responsible for function-focused care, yet functional care tasks were often missed. Organisational contexts created many barriers to providing function-focused care for patients. Nurses felt powerless to address these overarching problems in their organisations.

CONCLUSION

Nurses understand the importance of functional care yet often fail to carry out functional care interventions. Lack of organisational support creates a workplace that is short on staff, time and equipment and does not prioritise functional care needs. Nurse leaders and healthcare organisations need to reprioritise function-focused care for the good of patients, families and healthcare budgets.

Does Alzheimer's Disease and Related Dementias Modify Delirium Severity and Hospital Outcomes?

OBJECTIVES

We examined the association between delirium severity and outcomes of delirium among persons with and without Alzheimer's disease and related dementias (ADRD).

DESIGN

Prospective cohort study.

SETTING

Academic tertiary medical center.

PARTICIPANTS

A total of 352 medical and surgical patients.

MEASUREMENTS

Delirium incidence and severity were rated daily using the Confusion Assessment Method (CAM) and CAM-Severity (CAM-S) score during hospitalization. Severe delirium was defined as a CAM-S Short Form score in the highest tertile (3-7 points out of 7). ADRD status was determined by a clinical consensus process. Clinical outcomes included prolonged length of stay (>6 d), discharge to post-acute nursing facility, any decline in activities of daily living (ADLs) at 1 month from prehospital baseline, ongoing nursing facility stay, and mortality.

RESULTS

Patients with ADRD (n = 85 [24%]) had a significantly higher relative risk (RR) for incident delirium (RR = 2.31; 95% confidence interval [CI] = 1.64-3.28) and higher peak CAM-S scores (mean difference = 1.24 points; CI = .83-1.65; P < .001). Among patients with ADRD, severe delirium significantly increased the RR for nursing facility stay (RR = 2.22; CI = 1.05-4.69; P = .04) and increased the RR for mortality (RR = 2.10; CI = .89-4.98; P = .09). Among patients without ADRD, severe delirium was associated with a significantly increased risk for all poor outcomes except mortality including prolonged length of stay in the hospital (RR = 1.47; CI = 1.18-1.82) and discharge to a post-acute nursing facility (RR = 2.17; CI = 1.58-2.98) plus decline in ADLs (RR = 1.30; CI = 1.05-1.60) and nursing facility stay at 1 month (RR = 1.93; CI = 1.31-2.83).

CONCLUSION

Severe delirium is associated with increased risk for poor clinical outcomes in patients with and without ADRD. In both groups, severe delirium increased risk of nursing home placement. In patients with ADRD, delirium was more severe and associated with a trend toward increased mortality at 1 month. Although the increased risk remains substantial by RR, the study had limited power to examine the rarer outcome of death. J Am Geriatr Soc 68:1722-1730, 2020.

Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015

OBJECTIVES

We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays.

STUDY DESIGN

Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included.

MAIN OUTCOME MEASURES

We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates.

RESULTS

A total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006-2007 to 28.3 % in 2014-2015 (OR 0.86; 95 % CI 0.75-0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses.

CONCLUSIONS

End-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

Background

Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement.

Methods

Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests.

Results

We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492).

Conclusions

A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey

BACKGROUND

Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany.

METHODS

A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested.

RESULTS

486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement.

CONCLUSIONS

Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.

Alzheimer's disease medication and outcomes of hospitalisation among patients with dementia

AIMS

The use of Alzheimer disease medication for the treatment of dementia symptoms has shown significant benefits with regards to functional and cognitive outcomes as well as nursing home placement (NHP) and mortality. Hospitalisations in these patient groups are characterised by extended length of stays (LOS), frequent readmissions, frequent NHP and high-mortality rates. The impact of Alzheimer disease medication on the aforementioned outcomes remains still unknown. This study assessed the association of Alzheimer disease medication with outcomes of hospitalisation among patients with Alzheimer disease and other forms of dementia.

METHODS

A dynamic retrospective cohort study from 2004 to 2015 was conducted which claims data from a German health insurance company. People with dementia (PWD) were identified using ICD-10 codes and diagnostic measures. The main predictor of interest was the use of Alzheimer disease medication. Hospitalisation outcomes included LOS, readmissions, NHP and mortality during and after hospitalisation across four hospitalisations. Confounding was addressed using a propensity score throughout all analyses.

RESULTS

A total of 1380 users of Alzheimer disease medication and 6730 non-users were identified. The use of Alzheimer disease medication was associated with significantly shorter LOS during the first hospitalisations with estimates for the second, third and fourth showed a tendency towards shorter hospital stays. In addition, current users of Alzheimer disease medication had a lower risk of hospital readmission after the first two hospitalisations. These associations were not significant for the third and fourth hospitalisations. Post-hospitalisation NHP and mortality rates also tended to be lower among current users than among non-users but differences did not reach statistical significance.

CONCLUSIONS

Our results indicate that Alzheimer disease medication might contribute to a reduction of the LOS and the number of readmissions in PWD.

Nurses' emotional tone toward older inpatients: Do cognitive impairment and acute hospital setting matter?

The emotional tone of nurses' voice toward residents has been characterized as overly controlling and less person-centered. However, it is unclear whether this critical imbalance also applies to acutely ill older patients, who represent a major subgroup in acute hospitals. We therefore examined nurses' emotional tone in this setting, contrasting care interactions with severely cognitively impaired (CI) versus cognitively unimpaired older patients. Furthermore, we included a general versus a geriatric acute hospital to examine the role of different hospital environments. A mixed-methods design combining audio-recordings with standardized interviews was used. Audio-recorded clips of care interactions between 34 registered nurses (M _age = 38.9 years, SD = 12.3 years) and 92 patients (M _age = 83.4 years, SD = 6.1 years; 50% with CI) were evaluated by 12 naïve raters (M _age = 32.8 years, SD = 9.3 years). Based on their impressions of the vocal qualities, raters judged nurses' emotional tone by an established procedure which allows to differentiate between a person-centered and a controlling tone (Cronbach's α = .98 for both subscales). Overall, findings revealed that nurses used rather person-centered tones. However, nurses' tone was rated as more controlling for CI patients and in the geriatric hospital. When controlling for patients' functional status, both effects lost significance. To our knowledge, this is the first study that examined nurses' emotional tone in the acute hospital setting. Findings suggest that overall functional status of older patients may play a more important role for emotional tone in care interactions than CI and setting differences.

Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study

BACKGROUND

Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD.

OBJECTIVE

To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD.

METHODS

We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models.

RESULTS

Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records.

CONCLUSIONS

Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.

Post-Acute Care as a Key Component in a Healthcare System for Older Adults

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Geriatric Palliative Care

In the geriatric age group, few studies demonstrate the efficacy of aggressive treatment. Often, a more palliative approach is wanted; such an approach can lead to better quality of life and even a longer life. The author discusses the limits of medical interventions in the elderly, the paucity of data, and the benefits of palliation in certain medical conditions, including dementia, Parkinson, depression, arthritis, congestive heart failure, and pneumonia. The role of frailty is addressed; specific goals of palliative care are delineated, such as reduction of polypharmacy, fall prevention, pain reduction, and the central role of a primary care provider.

Dying in hospital among nursing home residents with and without dementia in Germany

OBJECTIVES

Nursing home residents (NHR) often suffer from dementia. As end-of-life care of NHR with dementia and without might differ, our aim was to investigate patterns of in-hospital deaths in NHR with and without dementia.

DESIGN

Retrospective observational study.

SETTING

German nursing homes.

PARTICIPANTS

Deceased NHR.

MEASUREMENTS

Using data of a large German health insurance fund, we included NHR aged 65+ years who died between January 1, 2010, and December 31, 2014. We assessed proportions of in-hospital deaths stratified by dementia status as well as by age, sex, level of care and length of stay. Multiple logistic regression models were applied to explore the association of these variables with in-hospital death.

RESULTS

Data on 67,328 decedents were included (mean age 85.3 years, 69.8% female), of whom 43.1% suffered from dementia. Overall, 29.5% died in hospital, with similar figures found for those with dementia (29.2%) and those without (29.8%). Differences between NHR with and without dementia were noticeable regarding age and length of stay. In those with dementia, the proportion of in-hospital deaths decreased linearly with age from 37.0%-20.2% (65-74 to 95+ years). These results are supported by the multivariate analyses. The terminal hospital stay was up to 3 days in 32.6%. This length did not differ by dementia status.

CONCLUSIONS

Germany has a high proportion of NHR in-hospital deaths. Surprisingly, we found no differences in these figures between NHR with and without dementia, although predictors for in-hospital death seem to differ between these groups.

Systems Delivery Innovation for Alzheimer Disease

OBJECTIVE

The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.

METHODS

Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.

RESULTS

After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).

CONCLUSION

A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

Length of hospital stay and dementia: A systematic review of observational studies

OBJECTIVE

Hospitalizations of people with dementia (PWD) are often accompanied by complications or functional loss and can lead to adverse outcomes. Unsystematic findings suggest an influence of comorbidities on the extent of differences in the length of hospital stay (LOS). This systematic review aimed to identify and evaluate all studies reporting LOS in PWD as compared to PwoD in general hospitals.

METHODS

A systematic review of observational studies using PubMed and ISI Web of Knowledge. Inclusion criteria comprised original studies written in English or German, assessment of diagnosis of dementia, measurement of LOS, and comparison of people with and without dementia.

RESULTS

Fifty-two of 60 studies reported a longer hospitalization time for PWD compared to PwoD. The extent of the difference in LOS varied between and within countries as well as by type of primary morbidity (eg, injuries, cardiovascular diseases). The range of the LOS difference for studies without restriction to a primary morbidity was -2 to +22 days after matching or adjustment for a variable number and selection of potentially relevant covariates. For studies with injuries/fractures/medical procedures and infectious/vascular disease as the primary morbidity, the range was -2.9 to +12.4 and -11.2 to +21.8 days, respectively.

CONCLUSIONS

The majority of studies reported a longer hospitalization of PWD compared to PwoD. Length of hospital stay seems to be influenced by a variety of medical, social, organizational factors, including reasons for hospital admission, whose role should be explored in detail in further research.

Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia

PURPOSE

The proportion of deaths occurring in nursing homes is increasing and end of life hospitalizations in residents are common. This study aimed to obtain the time from nursing home admission to death and the frequency of hospitalizations prior to death among residents with and without dementia.

METHODS

This retrospective cohort study analyzed claims data of 127,227 nursing home residents aged 65 years and older newly admitted to a nursing home between 2010 and 2014. We analyzed hospitalizations during the last year of life and assessed mortality rates per 100 person-years. Factors potentially associated with time to death were analyzed in Cox proportional hazard models.

RESULTS

The median time from nursing home admission to death was 777 and 635 days in residents with and without dementia, respectively. Being male, older age and a higher level of care decreased the survival time. Sex and age had a higher influence on survival time in residents with dementia, whereas level of care was found to have a higher influence in residents without dementia. Half of the residents of both groups were hospitalized during the last month and about 37% during the last week before death. Leading causes of hospitalizations were infections (with dementia: 20.6% vs. without dementia: 17.2%) and cardiovascular diseases (with dementia: 16.6% vs. without dementia: 19.0%).

CONCLUSIONS

A high proportion of residents with and without dementia are hospitalized shortly before death. There should be an open debate about the appropriateness of hospitalizing nursing home residents especially those with dementia near death.

Outcomes of Patients With Syncope and Suspected Dementia

OBJECTIVES

Syncope and near-syncope are common in patients with dementia and a leading cause of emergency department (ED) evaluation and subsequent hospitalization. The objective of this study was to describe the clinical trajectory and short-term outcomes of patients who presented to the ED with syncope or near-syncope and were assessed by their ED provider to have dementia.

METHODS

This multisite prospective cohort study included patients 60 years of age or older who presented to the ED with syncope or near-syncope between 2013 and 2016. We analyzed a subcohort of 279 patients who were identified by the treating ED provider to have baseline dementia. We collected comprehensive patient-level, utilization, and outcomes data through interviews, provider surveys, and chart abstraction. Outcome measures included serious conditions related to syncope and death.

RESULTS

Overall, 221 patients (79%) were hospitalized with a median length of stay of 2.1 days. A total of 46 patients (16%) were diagnosed with a serious condition in the ED. Of the 179 hospitalized patients who did not have a serious condition identified in the ED, 14 (7.8%) were subsequently diagnosed with a serious condition during the hospitalization, and an additional 12 patients (6.7%) were diagnosed postdischarge within 30 days of the index ED visit. There were seven deaths (2.5%) overall, none of which were cardiac-related. No patients who were discharged from the ED died or had a serious condition in the subsequent 30 days.

CONCLUSIONS

Patients with perceived dementia who presented to the ED with syncope or near-syncope were frequently hospitalized. The diagnosis of a serious condition was uncommon if not identified during the initial ED assessment. Given the known iatrogenic risks of hospitalization for patients with dementia, future investigation of the impact of goals of care discussions on reducing potentially preventable, futile, or unwanted hospitalizations while improving goal-concordant care is warranted.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A retrospective analysis of care in patients with dementia hospitalized at a tertiary medical center

BACKGROUND

Hospitalization is an opportunity to address various aspects related to management of dementia, including the goals of care to avoid futile care. We studied the prevalence of these factors when patients with dementia are hospitalized.

DESIGN

One hundred and thirty-one charts of patients with dementia admitted to a single university-based hospital were retrospectively reviewed. Data were collected and analyzed for age, gender, the severity of dementia, co-morbidities, co-existing vascular dementia, reversible causes of dementia, mental status scores, medications, consultations, procedures, complications, availability of advance directives, decision-maker, code status, and goals of care discussion.

RESULTS

In patients with dementia, co-morbidities and vascular disease burden were frequent. When these patients were hospitalized, use of psychotropic medications, invasive procedures, and multi-specialty consultations was common. Tests of mental status, screening for reversible causes, and use of FDA-approved medications for dementia is less common. Despite the lack of advance directives, goals of care were infrequently discussed. When goals of care were discussed, proxy decision-maker preferred palliative care and long-term institutionalization on discharge.

CONCLUSION

Goals of care and other aspects of management are not fully addressed in hospitalized patients with dementia.

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

OBJECTIVES

To study changes in the cognitive status and dependency of patients aged over 65 years during hospitalization for bone fracture and how these changes relate to the total number of days of admission and absolute rest during hospitalization. Along with cognitive decline, musculoskeletal disorders are considered key factors in this patient population. As well as requiring hospital admission and/or surgical treatment, fractures increase the risk factors that contribute to disability and dependency in older adults.

METHOD

A longitudinal case-series study with repeated follow-up assessments was conducted. The sample consisted of 259 older adults. The following tests were administered: Barthel index, Lawton-Brody's scale, Phototest, and informant questionnaire on cognitive decline in the elderly.

RESULTS

The main variable which fosters functional dependency, cognitive decline, and functional loss and diminishes functional gain (both in the hospital and at home) is the number of days of bed rest during hospitalization.

CONCLUSIONS

The present study reveals that the greater impact on levels of functional dependency and cognitive decline comes from the patient's days of bed rest in hospital, rather than the total days of hospitalization. These findings could be taken into consideration when discussing post-discharge functional recovery.