Adverse clinical events and mortality during hospitalization and 3 months after discharge in cognitively impaired elderly patients

Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors

BACKGROUND

Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes.

METHODS

In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes.

RESULTS

Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts.

CONCLUSIONS

Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial

INTRODUCTION

The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown.

METHODS

Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery.

RESULTS

Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment.

DISCUSSION

Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.

Outcomes and Predictors of In-Hospital Mortality among Older Patients with Dementia

Dementia is associated with high rates of admission to hospital, due to acute illness, and in-hospital mortality. The study aimed to investigate the impact of dementia on in-hospital mortality and identify the predictors of in-hospital mortality in these patients. This was a retrospective study evaluating all the patients ≥65 years consecutively admitted to our Emergency Department (ED). We compared the clinical outcomes of the patients with dementia at ED admission with those who did not have dementia, using a propensity score-matched (PSM) paired cohort of controls. The patients were matched for age, sex, Charlson Comorbidity Index value, and clinical severity at presentation (based on NEWS ≥ 5). The primary study endpoint was all-cause in-hospital death. After the PSM, a total of 7118 patients, 3559 with dementia and 3559 in the control group, were included in the study cohort. The mean age was 84 years, and 59.8% were females. The overall mortality rate was higher for the demented patients compared with the controls (18.7% vs. 16.0%, p = 0.002). The multivariate-adjusted hazard ratio (HR) showed that dementia was an independent risk factor for death (HR 1.13 [1.01−1.27]; p = 0.033). In the patients with dementia, respiratory failure (HR 3.08 [2.6−3.65]), acute renal failure (HR 1.64 [1.33−2.02]; p < 0.001), hemorrhagic stroke (HR 1.84 [1.38−2.44]; p < 0.001), and bloodstream infection (HR 1.41 [1.17−1.71]; p = 0.001) were significant predictors of worse outcomes. Finally, the comorbidities and severity of illness at ED admission negatively influenced survival among the patients with dementia (CCI HR 1.05 [1.01−1.1] p = 0.005; NEWS ≥ 5 HR 2.45 [1.88−3.2] p < 0.001). In conclusion, among the hospitalized older patients, dementia was associated with a higher risk of mortality. Furthermore, among the older patients with dementia, respiratory failure and bloodstream infections were independently associated with an increased risk of in-hospital mortality.

Utilisation of a Suite of Screening Tools to Determine Adverse Healthcare Outcomes in an Older Frail Population Admitted to a Community Virtual Ward

Risk stratification to assess healthcare outcomes among older people is challenging due to the interplay of multiple syndromes and conditions. Different short risk-screening tools can assist but the most useful instruments to predict responses and outcomes following interventions are unknown. We examined the relationship between a suite of screening tools and risk of adverse outcomes (pre-determined clinical 'decline' i.e., becoming 'unstable' or 'deteriorating' at 60-90 days, and institutionalisation, hospitalisation and death at 120 days), among community dwellers (n = 88) after admission to a single-centre, Irish, Community Virtual Ward (CVW). The mean age of patients was 82.8 (±6.4) years. Most were severely frail, with mean Clinical Frailty Scale (CFS) scores of 6.8 ± 1.33. Several instruments were useful in predicting 'decline' and other healthcare outcomes. After adjustment for age and gender, higher frailty levels, odds ratio (OR) 3.29, (p = 0.002), impaired cognition (Mini Mental State Examination; OR 4.23, p < 0.001), lower mobility (modified FIM) (OR 3.08, p < 0.001) and reduced functional level (Barthel Index; OR 6.39, p < 0.001) were significantly associated with clinical 'decline' at 90 days. Prolonged (>30 s) TUG times (OR 1.27, p = 0.023) and higher CFS scores (OR 2.29, p = 0.045) were associated with institutionalisation. Only TUG scores were associated with hospitalisation and only CFS, MMSE and Barthel scores at baseline were associated with mortality. Utilisation of a multidimensional suite of risk-screening tools across a range of domains measuring frailty, mobility and cognition can help predict clinical 'decline' for an already frail older population. Their association with other outcomes was less useful. A better understanding of the utility of these instruments in vulnerable populations will provide a framework to inform the impact of interventions and assist in decision-making and anticipatory care planning for older patients in CVW models.

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.

Association of cognitive impairment severity with potentially avoidable readmissions: A retrospective cohort study of 8897 older patients

INTRODUCTION

Understanding the association between cognitive impairment severity and potentially avoidable readmissions (PARs) in older patients may facilitate the identification of at-risk individuals who would benefit from readmission prevention measures.

METHODS

This retrospective cohort study was conducted using claims data linked with routinely collected cognitive impairment assessment results from a general acute care hospital in Tokyo, Japan. Patients were 65 years or age or older who were discharged from the subject hospital to home or a facility between July 2016 and September 2018.

RESULTS

A multivariable logistic regression analysis adjusted for covariates showed that the odds of PARs within 90 days to the subject hospital for patients with moderate and severe cognitive impairment were 1.418 times (95% confidence interval: 1.005-2.002) and 2.212 times (95% confidence interval: 1.206-4.058) higher, respectively, that for patients with normal cognition.

DISCUSSION

Older inpatients with later-stage cognitive impairment may represent a suitable target population for transitional care programs aimed at reducing readmissions.

Bone Fracture Enhanced Blood-Brain Barrier Breakdown in the Hippocampus and White Matter Damage of Stroke Mice

Background: Tibia fracture (BF) before stroke shortly causes long-term post-stroke memory dysfunction in mice. The mechanism is unclear. We hypothesize that BF enhances neuroinflammation and blood brain barrier (BBB) breakdown in the hippocampus and white matter (WM) damage. Methods: Mice were assigned to groups: BF, stroke, BF+stroke (BF 6 h before stroke) and sham. BBB integrity was analyzed 3 days after the surgeries and WM injury was analyzed 3 days and 8 weeks after the surgeries. Results: Stroke and BF+stroke groups had more activated microglia/macrophages and lower levels of claudin-5 in the ipsilateral hippocampi than the BF group. BF+stroke group had the highest number microglia/macrophages and the lowest level of claudin-5 among all groups and had fewer pericytes than BF group. Stroke and BF+stroke groups had smaller WM areas in the ipsilateral basal ganglia than the sham group 8 weeks after the injuries. The BF+stroke group also had smaller WM areas in the ipsilateral than sham and BF groups 3 days after the injuries and in the contralateral basal ganglia than stroke and BF groups 8 weeks after the injuries. Conclusions: BF exacerbates neuroinflammation and BBB leakage in the hippocampus and WM damage in basal ganglia, which could contribute to the long-lasting memory dysfunction in BF+stroke mice.

Risk Prediction for Adverse Outcomes for Frail Older Persons with Complex Healthcare and Social Care Needs Admitted to a Community Virtual Ward Model

Purpose

Population ageing is challenging healthcare systems with limited resources, necessitating the development of new care models to address the needs of older, frail community-dwellers. Community Virtual Wards (CVW) reduce adverse events in these patients. We examined the effect of an established CVW on pre-defined health trajectories (between “stable”, “deteriorating”, and “unstable” states) and characteristics that increased the likelihood of adverse healthcare outcomes (hospitalization, institutionalization and death).

Patients and Methods

We collected prospective data on frail patients admitted to a CVW in a single centre in Ireland. Relationships between risk scores, health states and adverse outcomes at 30, 60 and 90 days after admission were examined using multinomial regression analysis.

Results

In total, 88 community-dwellers, mean (±SD) age of 82.8 ±6.4 years, were included. Most were severely frail on the Rockwood Clinical Frailty Scale (mean 6.8/9 ±1.33). Reaching stability (“stable” state) within 30 days was a predictor for stability at 60 and 90 days and remaining at home. Stability was also associated with fewer care episodes (<2) (p=<0.001), a requirement for fewer healthcare professionals (HCP) (<7) (p<0.001) and lower risk of delirium (p<0.001). By contrast, being “unstable” at 60 days increased the numbers of HCP referrals (>7) and was predictive of more acute episodes (>2) and institutionalization or death (p<0.001). Predictors of adverse outcomes of either institutionalization or death included frailty status, function, mobility, nutrition, pressure ulcer risk and cognition.

Conclusion

A CVW model can provide a framework for monitoring and case management to support older people to remain at home or identify those at risk of institutional care. The use of defined health states helped to stratify those at lower or higher risk in an already high-risk frail population. Level of frailty, function, mobility, nutrition, pressure ulcer risks and cognition were predictive of remaining at home and reaching a level of stability or instability/deterioration and institutional care.

Fracture shortly before stroke in mice leads to hippocampus inflammation and long-lasting memory dysfunction

Cognitive impairment occurs in stroke and hip fracture patients. In mice, bone fracture (BF) exacerbates stroke-related neuronal damage and sensorimotor dysfunction. We hypothesize that BF exacerbates post-stroke cognitive impairment. Adult mice were randomly assigned into BF, stroke, BF+stroke (BF 6 h before stroke), and control (sham operated) groups. Memory function was evaluated weekly for eight weeks by Y maze test and at eight weeks post-surgeries by novel object recognition (NOR) test. The neuronal damage and inflammation in hippocampus were analyzed three days and eight weeks after the surgeries. In Y maze test, BF+stroke mice started making fewer alternations than controls two weeks after the surgeries. Significant difference between BF+stroke and stroke groups started at five weeks post-injury and continued to the end of the experiment. In NOR test, BF+stroke group spent less time on novel objective than that of other groups. Cx3cr1⁺ cells and CD68⁺ cells accumulated in the stratum lacunosum moleculare (SLM) on the ipsilateral side of stroke injury in stroke and BF+stroke mice. BF+stroke mice had a higher ratio of ipsilateral/contralateral Cx3cr1⁺ cell-density than that of stroke mice. Therefore, BF shortly before stroke exacerbates hippocampal inflammation and causes long-lasting memory dysfunction.

Cognitive impairment is independently associated with mortality, extended hospital stays and early readmission of older people with emergency hospital admissions: A retrospective cohort study

BACKGROUND

Older adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population.

OBJECTIVES

To determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes.

DESIGN

Retrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases.

SETTING

Large, acute district general hospital in England.

PARTICIPANTS

21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment.

METHODS

Multivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk.

RESULTS

Twenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17-1.55] with dementia; Odds Ratio 1.78 [1.52-2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48-1.86]; Odds Ratio 1.67 [1.46-1.90]); readmission (Odds Ratio 1.21 [1.04-1.40]; Odds Ratio 1.47 [1.25-1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76-0.83]; sub-hazard ratio 0.66 [0.63-0.69]).

CONCLUSIONS

Cognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population.

Polypharmacy in older people: lessons from 10 years of experience with the REPOSI register

As a consequence of population aging, we have witnessed in internal medicine hospital wards a progressive shift from a population of in-patients relatively young and mainly affected by a single ailment to one of ever older and more and more complex patients with multiple chronic diseases, followed as out-patients by many different specialists with poor integration and inevitably treated with multiple medications. Polypharmacy (defined as the chronic intake of five or more drugs) is associated with increased risks of drug-drug interactions and related adverse effects, prescription and intake errors, poor compliance, re-hospitalization and mortality. With this background, the Italian Society of Internal Medicine chose to start in 2008 a prospective register called REPOSI (REgistro POliterapie SIMI, Società Italiana di Medicina Interna) in internal medicine and geriatric hospital wards. The country wide register is an ongoing observatory on multimorbidity and polypharmacy in the oldest old, with the goal to improve prescription appropriateness and, thus to avoid potentially inappropriate medications. The main findings of the register, that has accrued so far, 7005 older patients throughout a 10 year period, are summarized herewith, with special emphasis on the main patterns of poor prescription appropriateness and related risks of adverse events.

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

ABSTRACT

To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients.

METHODS

Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy.

RESULTS

2493 patients, with median age 78-80 years (DK-Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7-8.6 vs. 5.8 95% CI 5.6-5.9) and Danish mean 7.1 (95% CI 6.6-7.5 vs. 5.5 95% CI 5.4-5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL's accuracy was only modest for in-hospital death prediction in either setting.

CONCLUSIONS

The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician's confidence in initiating earlier end-of-life discussions.

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.

Impact of Bone Fracture on Ischemic Stroke Recovery

Stroke is one of the most devastating complications of bone fracture, occurring in up to 4% of patients after surgical repair for hip fracture. Bone fracture and ischemic stroke have many common risk factors. The impact of bone fracture on stroke recovery has not drawn much attention in the research field. Bone fracture could occur in stroke patients at different times during the recovery phase, which steepens the trajectory of cognitive decline, greatly affects the quality of life, and causes a heavy burden on healthcare resources. In this paper, we reviewed the growing information on the pathophysiological mechanisms by which bone fracture may affect ischemic stroke recovery process.

Antipsychotic prescription and mortality in hospitalized older persons

BACKGROUND

Recent scientific reports have shown that older persons treated with antipsychotics for dementia-related behavioural symptoms have increased mortality. However, the impact of these drugs prescribed during hospitalization has rarely been assessed. We aimed to investigate whether antipsychotics are associated with an increased risk of mortality during hospitalization and at 3-month follow-up in elderly inpatients.

METHODS

We analyzed data gathered during two waves (2010 and 2012) by the REPOSI (Registro Politerapie Società Italiana Medicina Interna). All new prescriptions of antipsychotic drugs during hospitalization, whether maintained or discontinued at discharge, were collected, and logistic regression models were used to analyze their association with in-hospital and 3-month mortality. Covariates were age, sex, the Short Blessed Test (SBT) score, and the Cumulative Illness Rating Scale.

RESULTS

Among 2703 patients included in the study, 135 (5%) received new prescriptions for antipsychotic drugs. The most frequently prescribed antipsychotic during hospitalization and eventually maintained at discharge was haloperidol (38% and 36% of cases, respectively). Patients newly prescribed with antipsychotics were older and had a higher Cumulative Illness Rating Scale comorbidity index both at admission and at discharge compared to those who did not receive a prescription. Of those prescribed antipsychotics, 71% had an SBT score ≥10 (indicative of dementia), 12% had an SBT score of 5-9 (indicative of questionable dementia); and 17% had an SBT score <5 (indicative of normal cognition). In-hospital mortality was slightly higher in patients prescribed antipsychotic drugs (14.3% vs 9.4%; P = 0.109), but in multivariate analysis only male sex, older age, and higher SBT scores were significantly related to mortality during hospitalization. At 3-month follow-up, only male sex, older age, and higher SBT scores were associated with mortality.

CONCLUSION

We found that the prescription of antipsychotic drugs during hospitalization was not associated with in-hospital or follow-up mortality. Short-term antipsychotic prescriptions (for acutely ill patients) may have a different effect than long-term, repeated prescriptions.

Clinicians' perceptions and recognition of practice improvement strategies to prevent harms to older people in acute care hospitals

AIMS AND OBJECTIVES

Explore clinicians' perceptions of practice improvement strategies used to prevent harms to older people during acute hospitalisation.

BACKGROUND

Older people are vulnerable to many interrelated preventable harms during acute care hospitalisation. Improvement strategies recommend standardisation of practices to assist healthcare staff to mitigate risk; however, older people continue to suffer preventable harms in acute hospitals.

METHODS

A qualitative exploratory descriptive design was used to collect data using focus groups and individual interviews from a purposive sample of 33 participants. Participants represented a wide range of clinicians from four diverse healthcare organisations. Qualitative content analysis used a framework informed by common preventable harms derived from key literature and policy documents.

RESULTS

Participants' perceptions of practice improvement strategies varied depending on their role within their organisational hierarchy. Recognition of preventable harms was guided by standard risk assessment and management tools used in their organisations. Preventable harms relating to skin integrity and falls were universally recognised across all sites and roles. Alternatively, there was variability in participant recognition of preventable harms related to nutrition, continence, medications and cognition; pain was consistently overlooked as a contributor to preventable harms.

CONCLUSIONS

Hospital staff perceived standard clinical risk assessment and management tools as the main practice improvement strategy to prevent harms. These tools prompted staff recognition of preventable harms to older people during acute hospitalisation. Variability in the recognition of some preventable harms was attributed to variable use of standard assessment tools. Pain was unlikely to be recognised as contributing to preventable harms.

RELEVANCE TO CLINICAL PRACTICE

Clinical Risk Management tools may assist clinicians in recognising and responding to preventable harms to older people during hospitalisation. These tools provide critical resources for consistent and timely assessment and evaluation of risk for preventable harms.

In-hospital elderly mortality and associated factors in 12 Italian acute medical units: findings from an exploratory longitudinal study

BACKGROUND

Given the progressive demographic ageing of the population and the National Health System reforms affecting care at the bedside, a periodic re-evaluation of in-hospital mortality rates and associated factors is recommended.

AIMS

To describe the occurrence of in-hospital mortality among patients admitted to acute medical units and associated factors. Two hypotheses (H) were set as the basis of the study: patients have an increased likelihood to die H₁: at the weekend when less nursing care is offered; H₂: when they receive nursing care with a skill-mix in favour of Nursing Aides instead of Registered Nurses.

METHODS

Secondary analysis of a prospective study of patients >65 years consecutively admitted in 12 Italian medical units. Data on individual and nursing care variables were collected and its association with in-hospital mortality was analysed by stepwise logistic regression analysis.

RESULTS

In-hospital mortality occurrence was 6.8 %, and 37 % of the patients died during the weekend. The logistic regression model explained 34.3 % (R ²) of the variance of in-hospital mortality: patients were six times (95 % CI = 3.632-10.794) more likely at risk of dying at weekends; those with one or more AEDs admissions in the last 3 months were also at increased risk of dying (RR 1.360, 95 % CI = 1.024-1.806) as well as those receiving more care from family carers (RR = 1.017, 95 % CI = 1.009-1.025). At the nursing care level, those patient receiving less care by RNs at weekends were at increased risk of dying (RR = 2.236, 95 % CI = 1.270-3.937) while those receiving a higher skill-mix, thus indicating that more nursing care was offered by RNs instead of NAs were at less risk of dying (RR = 0.940, 95 % CI = 0.912-0.969).

CONCLUSIONS

Within the limitations of this secondary analysis, in addition to the role of some clinical factors, findings suggest redesigning acute care at weekends ensuring consistent care both at the hospital and at the nursing care levels.

Cognitive impairment and stroke in elderly patients

We reviewed current knowledge about the interaction between stroke and vascular risk factors and the development of cognitive impairment and dementia. Stroke is increasingly recognized as an important cause of cognitive problems and has been implicated in the development of both Alzheimer’s disease and vascular dementia. The prevalence of cognitive impairment after stroke is high, and their combined effects significantly increase the cost of care and health resource utilization, with reflections on hospital readmissions and increased mortality rates. There is also substantial evidence that vascular risk factors (such as hypertension, diabetes, obesity, dyslipidemia, and tobacco smoking) are independently associated with an increased risk of cognitive decline and dementia. Thus, a successful management of these factors, as well as optimal acute stroke management, might have a great impact on the development of cognitive impairment. Notwithstanding, the pathological link between cognitive impairment, stroke, and vascular risk factors is complex and still partially unclear so that further studies are needed to better elucidate the boundaries of this relationship. Many specific pharmacological treatments, including anticholinergic drugs and antihypertensive medications, and nonpharmacological approaches, such as diet, cognitive rehabilitation, and physical activity, have been studied for patients with vascular cognitive impairment, but the optimal care is still far away. Meanwhile, according to the most recent knowledge, optimal stroke care should also include cognitive assessment in the short and long term, and great efforts should be oriented toward a multidisciplinary approach, including quality-of-life assessment and support of caregivers.

Cognitive Impairment in Hospitalized Seniors

Cognitive disorders are highly prevalent in hospitalized seniors, and can be due to delirium, dementia, as well as other disorders. Hospitalization can have adverse cognitive effects, and cognitive dysfunction adversely affects hospital outcomes. In this article, the literature is reviewed on how hospitalization affects cognitive function and how cognitive impairment affects hospital outcomes. Possible interventions in cognitively impaired hospitalized seniors are reviewed.

Multimorbidity and polypharmacy in the elderly: lessons from REPOSI

The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists. Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient.

A prospective, multidimensional follow-up study of a geriatric hospitalised population: predictors of discharge and well-being

BACKGROUND AND AIMS

Ageing trends in populations are common amongst most European countries. One of the consequences of this trend is the increase of hospitalisation of elderly patients. To better manage the elderly population hospitalisation, it is crucial to obtain a better understanding of this population's clinical and functional conditions and their hospitalisation outcome predictors. The present prospective observational cohort study aimed at studying the variables considered predictive of the length of stay, of destination at discharge, of re-hospitalisation, and of mortality at 6 months of elderly (age >64 years, N = 329) admitted to ten geriatric units, having different missions (e.g., cognitive impairment and dementia; movement disorders; bone fractures and immobilisation syndrome; or stroke), of the St. John of God Order during a 4-month-long index period.

METHODS

The patients were monitored from the first day of hospitalisation through the discharge. Researchers filled in a "Patient Schedule" based on a comprehensive set of socio-demographic and clinical variables and standardised assessment tools. We used a standardised telephone interview to re-assess patients at the 6-month follow-up.

RESULTS

The BRASS score proved to be a better reliable predictor of length of stay (F = 3.9, p = 0.04) among all variables associated with higher risks of prolonged hospital stay and post-discharge problems. In addition, discharge destination was also predicted by the use of the Tinetti Scale score (OR = 0.95, 95 % CI 0.90-0.99), the Mini Mental State Examination (MMSE) score (OR = 0.1.07, 95 % CI 1.01-1.13) and by independence in daily activity as measured by the IADL scale (OR = 4.09, 95 % CI 1.46-11.44). Motor functioning resulted as a reliable predictor (OR = 2.67, 95 % CI 1.27-5.59) of re-hospitalisation in all the medical units. Lastly, female gender (OR = 0.28, 95 % CI 0.11-0.71) resulted as the only reliable variable associated with a lower mortality risk after discharge.

CONCLUSION

The variables related to the clinical and functional status were reliable predictors for length of stay, for discharge destination, and for re-hospitalisation among older patients admitted to ten geriatric units in Italy. Further research is needed to establish valid and reliable predictors of mortality risk, to develop effective preventive strategies in those vulnerable populations.