A randomized trial of geriatric liaison intervention in elderly medical inpatients

Exercise for acutely hospitalised older medical patients

BACKGROUND

Approximately 30% of hospitalised older adults experience hospital-associated functional decline. Exercise interventions that promote in-hospital activity may prevent deconditioning and thereby maintain physical function during hospitalisation. This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To evaluate the benefits and harms of exercise interventions for acutely hospitalised older medical inpatients on functional ability, quality of life (QoL), participant global assessment of success and adverse events compared to usual care or a sham-control intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was May 2021.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials evaluating an in-hospital exercise intervention in people aged 65 years or older admitted to hospital with a general medical condition. We excluded people admitted for elective reasons or surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our major outcomes were 1. independence with activities of daily living; 2. functional mobility; 3. new incidence of delirium during hospitalisation; 4. QoL; 5. number of falls during hospitalisation; 6. medical deterioration during hospitalisation and 7. participant global assessment of success. Our minor outcomes were 8. death during hospitalisation; 9. musculoskeletal injuries during hospitalisation; 10. hospital length of stay; 11. new institutionalisation at hospital discharge; 12. hospital readmission and 13. walking performance. We used GRADE to assess certainty of evidence for each major outcome. We categorised exercise interventions as: rehabilitation-related activities (interventions designed to increase physical activity or functional recovery, but did not follow a specified exercise protocol); structured exercise (interventions that included an exercise intervention protocol but did not include progressive resistance training); and progressive resistance exercise (interventions that included an element of progressive resistance training).

MAIN RESULTS

We included 24 studies (nine rehabilitation-related activity interventions, six structured exercise interventions and nine progressive resistance exercise interventions) with 7511 participants. All studies compared exercise interventions to usual care; two studies, in addition to usual care, used sham interventions. Mean ages ranged from 73 to 88 years, and 58% of participants were women. Several studies were at high risk of bias. The most common domain assessed at high risk of bias was measurement of the outcome, and five studies (21%) were at high risk of bias arising from the randomisation process. Exercise may have no clinically important effect on independence in activities of daily living at discharge from hospital compared to controls (16 studies, 5174 participants; low-certainty evidence). Five studies used the Barthel Index (scale: 0 to 100, higher scores representing greater independence). Mean scores at discharge in the control groups ranged from 42 to 96 points, and independence in activities of daily living was 1.8 points better (0.43 worse to 4.12 better) with exercise compared to controls. The minimally clinical important difference (MCID) is estimated to be 11 points. We are uncertain regarding the effect of exercise on functional mobility at discharge from the hospital compared to controls (8 studies, 2369 participants; very low-certainty evidence). Three studies used the Short Physical Performance Battery (SPPB) (scale: 0 to 12, higher scores representing better function) to measure functional mobility. Mean scores at discharge in the control groups ranged from 3.7 to 4.9 points on the SPPB, and the estimated effect of the exercise interventions was 0.78 points better (0.02 worse to 1.57 better). A change of 1 point on the SPPB represents an MCID. We are uncertain regarding the effect of exercise on the incidence of delirium during hospitalisation compared to controls (7 trials, 2088 participants; very low-certainty evidence). The incidence of delirium during hospitalisation was 88/1091 (81 per 1000) in the control group compared with 70/997 (73 per 1000; range 47 to 114) in the exercise group (RR 0.90, 95% CI 0.58 to 1.41). Exercise interventions may result in a small clinically unimportant improvement in QoL at discharge from the hospital compared to controls (4 studies, 875 participants; low-certainty evidence). Mean QoL on the EuroQol 5 Dimensions (EQ-5D) visual analogue scale (VAS) (scale: 0 to 100, higher scores representing better QoL) ranged between 48.9 and 64.7 in the control group at discharge from the hospital, and QoL was 6.04 points better (0.9 better to 11.18 better) with exercise. A change of 10 points on the EQ-5D VAS represents an MCID. No studies measured participant global assessment of success. Exercise interventions did not affect the risk of falls during hospitalisation (moderate-certainty evidence). The incidence of falls was 31/899 (34 per 1000) in the control group compared with 31/888 (34 per 1000; range 20 to 57) in the exercise group (RR 0.99, 95% CI 0.59 to 1.65). We are uncertain regarding the effect of exercise on the incidence of medical deterioration during hospitalisation (very low-certainty evidence). The incidence of medical deterioration in the control group was 101/1417 (71 per 1000) compared with 96/1313 (73 per 1000; range 44 to 120) in the exercise group (RR 1.02, 95% CI 0.62 to 1.68). Subgroup analyses by different intervention categories and by the use of a sham intervention were not meaningfully different from the main analyses.

AUTHORS' CONCLUSIONS

Exercise may make little difference to independence in activities of daily living or QoL, but probably does not result in more falls in older medical inpatients. We are uncertain about the effect of exercise on functional mobility, incidence of delirium and medical deterioration. Certainty of evidence was limited by risk of bias and inconsistency. Future primary research on the effect of exercise on acute hospitalisation could focus on more consistent and uniform reporting of participant's characteristics including their baseline level of functional ability, as well as exercise dose, intensity and adherence that may provide an insight into the reasons for the observed inconsistencies in findings.

Effectiveness of supervised and functional level-based exercise program in elderly inpatients: Randomised controlled trial

OBJECTIVE

The aim of this study was to compare the effectiveness of supervised and unsupervised functional level-based exercises program for elderly inpatients on physical activity, mobility, health-related quality of life and depression status.

DESIGN

A single-blinded randomised controlled trial.

SETTING

Internal medicine service.

SUBJECTS

Patients aged 65 years or older.

INTERVENTIONS

A supervised functional level-based exercise program was applied to the intervention group by a physiotherapist, for 40 min 5 times a week during their hospitalisation. Patients in the control group were asked to perform an unsupervised functional level-based exercise program which was described by the physiotherapist during the first visit.

MAIN MEASURES

Mobility, physical activity level and health-related quality of life were assessed at admission and discharge in both groups. Depression status was evaluated at admission and 3 months after discharge.

RESULTS

Sociodemographic features between intervention group (n = 62) and control group (n = 62) were similar. The intervention group showed a higher increment in mobility, physical activity level and quality of life scores than the control group (d = 0.62, p < 0.05; d = 0.57, p < 0.05; d = 1.12, p < 0.05 respectively). Inpatients in the intervention group, depression scores were lower 3 months after discharge (d = 0.42, p < 0.05). The length of stay in the hospital was not different between the groups.

CONCLUSIONS

A supervised functional level-based exercise program is more effective than an unsupervised functional level-based exercise program for mobility, physical activity, depression and quality of life in elderly inpatients. These positive contributions are seen within a short period like a 5 to 10 days stay in hospital.

TRIAL REGISTRATION

ClinicalTrials.gov(NCT03516032).

Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Proactive Consultation-Liaison Psychiatry: American Psychiatric Association Resource Document

In 2019, the American Psychiatric Association Council on Consultation-Liaison (C-L) Psychiatry convened a work group to develop a resource document on proactive C-L psychiatry. A draft of this document was reviewed by the Council in July 2020, and a revised version was approved by this Council in September 2020. The accepted version was subsequently reviewed by the American Psychiatric Association Council on Health Care Systems and Financing in November 2020. The final version was approved by the Joint Reference Committee on November 24, 2020, and received approval for publication by the Board of Trustees on December 12, 2020. This resource document describes the historical context and modern trends that have given rise to the model of proactive C-L psychiatry. Styled as an inpatient corollary to outpatient collaborative care models, proactive C-L provides a framework of mental health care delivery in the general hospital designed to enhance mental health services to a broad range of patients. Its 4 elements include systematic screening for active mental health concerns, proactive interventions tailored to individual patients, team-based care delivery, and care integration with primary teams and services. Studies have found that proactive C-L psychiatry is associated with reduced hospital length of stay, enhanced psychiatric service utilization, reduced time to psychiatric consultation, and improved provider and nurse satisfaction. These favorable results encourage further studies that replicate and build upon these findings. Additional outcomes such as patient experience, health outcomes, and readmission rates deserve investigation. Further studies are also needed to examine a broader array of team compositions and the potential value of proactive C-L psychiatry to different hospital settings such as community hospitals, surgery, and critical care.

Taking the Long View in an Inpatient Medical Unit: A Person-Centered, Integrated Team Approach for Patients With Severe Mental Illnesses

OBJECTIVE

Patients with severe mental illnesses and related conditions, such as substance misuse and suicide attempts, are among the highest utilizers of acute inpatient medical services. The objective of this study was to assess the impact of a specialized medical unit that uses a comprehensive biopsychosocial model to care for patients with severe mental illnesses.

METHODS

The study used administrative data to compare patients with severe mental illnesses admitted to a specialized unit with patients admitted to medically similar acute (non-intensive care) medical units in a tertiary academic medical center. With controls for sociodemographic variables, illness severity, and medical complexity, multivariate regression analyses compared utilization outcomes for patients from the specialized unit with outcomes from comparison units.

RESULTS

Patients on the specialized unit (N=2,077) were younger, had more mental disorder diagnoses, and were more likely to have less severe general medical illness and less medical complexity than patients from comparison units (N=12,824). Analyses of a subsample of patients with complex behavioral health diagnoses indicated that those on the specialized unit had a shorter average stay, higher odds of discharge to home, and lower odds of 30-day readmission, compared with those on comparison units.

CONCLUSIONS

Specialized units targeted to the needs of patients with serious mental illnesses can provide a moment of engagement when vulnerable patients are likely to benefit from more coordinated care. Findings suggest that a specialized unit that capitalizes on this moment of engagement and uses a biopsychosocial model of care can improve utilization outcomes.

Augmented exercise in hospital improves physical performance and reduces negative post hospitalization events: a randomized controlled trial

BACKGROUND

To measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting.

METHODS

This was a parallel single-blinded randomised controlled trial. Within 2 days of admission, older medical inpatients with an anticipated length of stay ≥3 days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. Until discharge, both groups received twice daily, Monday-to-Friday half-hour assisted exercises, assisted by a staff physiotherapist. The intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. Length of stay was the primary outcome measure. Blindly assessed secondary measures included readmissions within 3 months, and physical performance (Short Physical Performance Battery) and quality of life (EuroQOL-5D-5 L) at discharge and at 3 months. Time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation).

RESULTS

Of the 199 patients allocated, 190 patients' (aged 80 ± 7.5 years) data were analysed. Groups were comparable at baseline. In intention-to-treat analysis, length of stay did not differ between groups (HR 1.09 (95% CI, 0.77-1.56) p = 0.6). Physical performance was better in the intervention group at discharge (difference 0.88 (95% CI, 0.20-1.57) p = 0.01), but lost at follow-up (difference 0.45 (95% CI, - 0.43 - 1.33) p = 0.3). An improvement in quality of life was detected at follow-up in the intervention group (difference 0.28 (95% CI, 0.9-0.47) p = 0.004). Overall, fewer negative events occurred in the intervention group (OR 0.46 (95% CI 0.23-0.92) p = 0.03).

CONCLUSION

Improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. Its effect on length of stay remains unclear.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02463864, registered prospectively 26.05.2015.

A systematic review of proactive psychiatric consultation on hospital length of stay

OBJECTIVE

Roughly half of general hospital patients may have a psychiatric issue that impacts care, yet most of these are not recognized during hospital admission. Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes.

METHOD

We conducted a PRISMA systematic review of Pubmed, Embase, PsycINFO, and Cochrane Library for proactive models of psychiatric consultation to reduce hospital length of stay (LOS) in adult inpatients. For each study, we evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes.

RESULTS

Of the 12 included studies, the 8 whose screening was informed by clinicians with mental health care expertise or whose providers were integrated with primary services reported a reduction in LOS. Two of these also reported favorable cost-benefit analyses. All positive studies represent versions of either psychiatrists embedded within medical or surgical settings or a multidisciplinary team-based model.

CONCLUSIONS

Proactive CL psychiatry with clinically-informed screening and integrated care delivery appear to reduce LOS. Further studies are needed to explore a broader range of outcomes, hospital populations beyond hospital medicine, and additional benefits of proactive integrated mental health care in the general hospital.

Delirium: Medical Students' Knowledge and Effectiveness of Different Teaching Methods

OBJECTIVE

Medical schools are often blamed for inadequately training doctors on delirium. This study assesses the knowledge of medical students regarding delirium and evaluates different teaching methods for comparing learning outcomes.

METHODS

A video, a handout, and a video+handout were used as three different teaching methods. Students were randomly assigned to three groups and pre- and postintervention knowledge gains were compared. Interventions were held between 2015 and 2018 at the University of Heidelberg Medical School in Germany. Seventy-eight (video intervention 33; handout 26; video+handout 19) sixth-year medical students participated. Participants learned about delirium with the help of a video, a handout, and both a video+handout at the start of one-hour lectures dedicated to teaching about delirium. Pre- and postintervention questionnaires, comprising five multiple-choice questions and a self-estimated grade of knowledge about delirium, were used. Variables calculated were objective and subjective knowledge, recall, and accuracy of self-assessment. Microsoft Excel and analysis of covariance were used to analyze data.

RESULTS

Knowledge gains for all interventions were large (d>0.8) irrespective of gender. Post hoc comparison showed video and video+handout methods were more effective with high recall for video (92.8%). Students rated their knowledge as satisfactory, although they scored 11.4 out of 20. Preintervention knowledge level was correctly estimated by 31% of students, and postintervention by 40.3% students.

CONCLUSION

Teaching about delirium to medical students with a video resulted in better knowledge transfer and recall. Most medical students, particularly men, overestimated their knowledge about delirium.

Where next for delirium research?

Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.

Quality indicators for in-hospital geriatric co-management programmes: a systematic literature review and international Delphi study

OBJECTIVE

To find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes.

DESIGN

An international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers).

SETTING

Western Europe and the USA.

PARTICIPANTS

Thirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate).

MEASURES

Participants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method.

RESULTS

In the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications.

CONCLUSION

The indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis

Background

geriatric consultation teams have failed to impact clinical outcomes prompting geriatric co-management programmes to emerge as a promising strategy to manage frail patients on non-geriatric wards.

Objective

to conduct a systematic review of the effectiveness of in-hospital geriatric co-management.

Data sources

MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to 6 May 2016. Reference lists, trial registers and PubMed Central Citations were additionally searched.

Study selection

randomised controlled trials and quasi-experimental studies of in-hospital patients included in a geriatric co-management study. Two investigators performed the selection process independently.

Data extraction

standardised data extraction and assessment of risk of bias were performed independently by two investigators.

Results

twelve studies and 3,590 patients were included from six randomised and six quasi-experimental studies. Geriatric co-management improved functional status and reduced the number of patients with complications in three of the four studies, but studies had a high risk of bias and outcomes were measured heterogeneously and could not be pooled. Co-management reduced the length of stay (pooled mean difference, -1.88 days [95% CI, -2.44 to -1.33]; 11 studies) and may reduce in-hospital mortality (pooled odds ratio, 0.72 [95% CI, 0.50-1.03]; 7 studies). Meta-analysis identified no effect on the number of patients discharged home (5 studies), post-discharge mortality (3 studies) and readmission rate (4 studies).

Conclusions

there was low-quality evidence of a reduced length of stay and a reduced number of patients with complications, and very low-quality evidence of better functional status as a result of geriatric co-management.

The effect of exercise on outcomes for older acute medical inpatients compared with control or alternative treatments: a systematic review of randomized controlled trials

Objective: To determine the effect of exercise interventions for acutely hospitalized older medical patients on functional status and hospital outcomes.

Data sources: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PEDro, Current Contents and Sports Discus were searched until February 2006. Additional studies were identified through reference and citation tracking and contacting authors of eligible trials.

Review methods: Eligible studies were prospective randomized or pseudor and omized controlled trials comparing exercise for medical inpatients to alternate or no treatment controls. Of 3138 potentially relevant articles screened by two independent reviewers, seven randomized controlled trials and two pseudorandomized controlled trials were included. Two independent reviewers extracted data relating to patient and hospital outcomes and assessed the method quality.

Results: Pooled analysis of multidisciplinary interventions that included exercise indicated a significant increase in the proportion of patients discharged to home at hospital discharge (relative risk 1.08; 95% confidence interval (CI) 1.03 –1.14) and a small but important reduction in acute hospital length of stay (weighted mean difference – / 1.08 days; 95% CI – / 1.93 to – / 0.22) and total hospital costs (weighted mean difference – / US$280; 95% CI – / $493 to – / $65) compared with usual care. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay. The effect of exercise on functional outcome measures is unclear. There was no influence of exercise intervention on adverse events.

Conclusions: Multidisciplinary intervention that includes exercise improves patient and hospital outcomes for acutely hospitalized older medical patients.

A study protocol of a randomised controlled trial to measure the effects of an augmented prescribed exercise programme (APEP) for frail older medical patients in the acute setting

Background

Older adults experience functional decline in hospital leading to increased healthcare burden and morbidity. The benefits of augmented exercise in hospital remain uncertain. The aim of this trial is to measure the short and longer-term effects of augmented exercise for older medical in-patients on their physical performance, quality of life and health care utilisation.

Design & Methods

Two hundred and twenty older medical patients will be blindly randomly allocated to the intervention or sham groups. Both groups will receive usual care (including routine physiotherapy care) augmented by two daily exercise sessions. The sham group will receive stretching and relaxation exercises while the intervention group will receive tailored strengthening and balance exercises. Differences between groups will be measured at baseline, discharge, and three months. The primary outcome measure will be length of stay. The secondary outcome measures will be healthcare utilisation, activity (accelerometry), physical performance (Short Physical Performance Battery), falls history in hospital and quality of life (EQ-5D-5 L).

Discussion

This simple intervention has the potential to transform the outcomes of the older patient in the acute setting.

Trial registration

ClinicalTrials.gov Identifier: NCT02463864, registered 26.05.2015.

Long Term Outcomes of a Geriatric Liaison Intervention in Frail Elderly Cancer Patients

Background

The aim of this study was to evaluate the long term effects after discharge of a hospital-based geriatric liaison intervention to prevent postoperative delirium in frail elderly cancer patients treated with an elective surgical procedure for a solid tumour. In addition, the effect of a postoperative delirium on long term outcomes was examined.

Methods

A three month follow-up was performed in participants of the Liaison Intervention in Frail Elderly study, a multicentre, prospective, randomized, controlled trial. Patients were randomized to standard treatment or a geriatric liaison intervention. The intervention consisted of a preoperative geriatric consultation, an individual treatment plan targeted at risk factors for delirium and daily visits by a geriatric nurse during the hospital stay. The long term outcomes included: mortality, rehospitalisation, Activities of Daily Living (ADL) functioning, return to the independent pre-operative living situation, use of supportive care, cognitive functioning and health related quality of life.

Results

Data of 260 patients (intervention n = 127, Control n = 133) were analysed. There were no differences between the intervention group and usual-care group for any of the outcomes three months after discharge. The presence of postoperative delirium was associated with: an increased risk of decline in ADL functioning (OR: 2.65, 95% CI: 1.02–6.88), an increased use of supportive assistance (OR: 2.45, 95% CI: 1.02–5.87) and a decreased chance to return to the independent preoperative living situation (OR: 0.18, 95% CI: 0.07–0.49).

Conclusions

A hospital-based geriatric liaison intervention for the prevention of postoperative delirium in frail elderly cancer patients undergoing elective surgery for a solid tumour did not improve outcomes 3 months after discharge from hospital. The negative effect of a postoperative delirium on late outcome was confirmed.

Trial Registration

Nederlands Trial Register, Trial ID NTR 823.

Physical Activity and Early Rehabilitation in Hospitalized Elderly Medical Patients: Systematic Review of Randomized Clinical Trials

BACKGROUND

To critically review the effect of interventions incorporating exercise and early rehabilitation (physical therapy, occupational therapy, and physical activity) in the functional outcomes (i.e., active daily living tests, such as Barthel Index Scores, Timed-up-and go, mobility tests), and feasibility in hospitalized elderly medical patients.

DESIGN

Systematic review of the literature.

METHODS

A literature search was conducted using the following databases and medical resources from 1966 to January 2014: PubMed (Medline), PEDro, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews, Google Scholar, ClinicalTrials.gov, Clinical Evidence, SportsDiscus, EMBASE and UptoDate. Studies must have mentioned the effects of early rehabilitation on the above mentioned functional outcomes and feasibility. Data on the mortality, economic profile and average stay were also described.

RESULTS

From the 6564 manuscripts potentially related to exercise performance in hospitalized elderly patients, the review focused on 1086, and 17 articles were ultimately included. Regarding functional outcomes after discharge, four studies observed significant improvement in functional outcomes following early rehabilitation, even up to twelve months after discharge. Eight studies directly or indirectly assessed the economic impact of exercise intervention. Five of them did not show any increase in costs, while three concluded that the intervention was cost effective. No adverse effect related with the interventions were mentioned.

CONCLUSION

The introduction of an exercise program for hospitalized elderly patients may be feasible, and may not increase costs. Importantly, early rehabilitation may also improve the functional and healthcare.

Supporting dementia patients in hospital environments: health-related risks, needs and dedicated structures for patient care

The diagnostics and treatment of dementia are progressively gaining importance for European neurologists. Our hospital structures are poorly prepared for patients suffering from dementia. As a consequence of cognitive and physical deficits, dementia patients have an increased risk for serious complications and poor outcomes in hospital environments. In this review, the specific needs of dementia patients are outlined, describing how geriatricians, neurologists and psychiatrists may contribute to better patient care, e.g. with consultation or liaison services, geriatric wards, dedicated dementia wards or memory clinics in interaction with nurses, occupational therapists, physiotherapists, speech therapists, psychologists and social workers. Due to their multifaceted needs, dementia patients can most successfully be supported in clinical environments that closely integrate specialized inpatient, outpatient and primary care offers.

[Review of functional impairment associated with acute illness in the elderly]

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: a systematic review

Background

Old adults admitted to the hospital are at severe risk of functional loss during hospitalization. Early in-hospital physical rehabilitation programs appear to prevent functional loss in geriatric patients. The first aim of this review was to investigate the effect of early physical rehabilitation programs on physical functioning among geriatric patients acutely admitted to the hospital. The second aim was to evaluate the feasibility of early physical rehabilitation programs.

Methods

Two searches, one for physical functioning and one for feasibility, were conducted in PubMed, CINAHL, and EMBASE. Additional studies were identified through reference and citation tracking. To be included articles had to report on in-hospital early physical rehabilitation of patients aged 65 years and older with an outcome measure of physical functioning. Studies were excluded when the treatment was performed on specialized units other than geriatric units. Randomized controlled trials were included to examine the effect of early physical rehabilitation on physical functioning, length of stay and discharge destination. To investigate feasibility also non randomized controlled trials were added.

Results

Fifteen articles, reporting on 13 studies, described the effect on physical functioning. The early physical rehabilitation programs were classified in multidisciplinary programs with an exercise component and usual care with an exercise component. Multidisciplinary programs focussed more on facilitating discharge home and independent ADL, whereas exercise programs aimed at improving functional outcomes. At time of discharge patients who had participated in a multidisciplinary program or exercise program improved more on physical functional tests and were less likely to be discharged to a nursing home compared to patients receiving only usual care. In addition, multidisciplinary programs reduced the length of hospital stay significantly. Follow-up interventions improved physical functioning after discharge. The feasibility search yielded four articles. The feasibility results showed that early physical rehabilitation for acutely hospitalized old adults was safe. Adherence rates differed between studies and the recruitment of patients was sometimes challenging.

Conclusions

Early physical rehabilitation care for acutely hospitalized old adults leads to functional benefits and can be safely executed. Further research is needed to specifically quantify the physical component in early physical rehabilitation programs.

Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)

OBJECTIVE

To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment.

DESIGN

Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system.

SETTING

Large acute general hospital in the United Kingdom.

PARTICIPANTS

600 patients aged over 65 admitted for acute medical care, identified as "confused" on admission.

INTERVENTIONS

Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers.

PRIMARY OUTCOME

number of days spent at home over the 90 days after randomisation.

SECONDARY OUTCOMES

structured non-participant observations to ascertain patients' experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation.

RESULTS

There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference -12 to 24; P=0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (-9% to 4%), readmission 32% versus 35% (-10% to 5%), and new admission to care home 20% versus 28% (-16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (-6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P=0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P<0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P=0.004), and severe dissatisfaction was reduced (5% v 10%, -10% to 0%; P=0.05).

CONCLUSIONS

Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients' experience and carers' satisfaction might be more appropriate measures of success for frail older people approaching the end of life.

TRIAL REGISTRATION

Clinical Trials NCT01136148.

Identifying modifiable factors to improve quality for older adults in hospital: a scoping review

BACKGROUND

Traditional ways of viewing hospitalisation do not always recognise how elements within the hospital environment contribute to disability. Four theoretical dimensions of older adult-hospital environment fit have been proposed in previous research on elder-friendly hospitals: social climate, physical design, care systems and processes, policies and procedures; however, modifiable factors for each dimension are not yet identified.

DESIGN

Exploratory iterative design guided by Arksey and O'Malley (2005, International Journal of Social Research Methodology 8, 19) scoping review methodology.

METHOD

We undertook a scoping review of primary research related to hospitalised community-dwelling older adults. Keys search terms and criteria were used to identify relevant articles with modifiable factors extracted from articles meeting study criteria.

RESULTS

A total of 66 studies were included and evaluated for modifiable factor mapping. We were able to map all 66 studies to the four dimensions. The majority of included studies described care systems and processes, with little relating to social climate, physical design and policies and procedures. Thirty-nine potentially modifiable factors were identified and mapped to the theoretical dimensions according to four overarching themes: models of care; assessment of potential geriatric issues; targeting care to a specific clinical issue and supporting transitions home themes.

CONCLUSION

The dimensions of older adult-hospital fit help us to organise key features of an elder-friendly hospital and identify potentially modifiable factors. Although it makes intuitive sense to cluster and organise according to the dimensions to help with understanding, this tells us little about the synergy of interactions and hierarchical relationships. Our results highlight the importance of competent gerontological nursing in care for hospitalised older adults and the need for further understanding of the older adult and family as a unit of care.

IMPLICATIONS FOR PRACTICE

Registered nurses have a leadership role to ensure safe quality care for older people in hospital. This leadership role can be framed in interventions that focus on fixing the fit between what older people need and what the hospital environment provides. Modifiable factors for improvement are within the scope and competency of the registered nurse.

Delirium in elderly people: a review

The present review aims to highlight this intricate syndrome, regarding diagnosis, pathophysiology, etiology, prevention, and management in elderly people. The diagnosis of delirium is based on clinical observations, cognitive assessment, physical, and neurological examination. Clinically, delirium occurs in hyperactive, hypoactive, or mixed forms, based on psychomotor behavior. As an acute confusional state, it is characterized by a rapid onset of symptoms, fluctuating course and an altered level of consciousness, global disturbance of cognition or perceptual abnormalities, and evidence of a physical cause. Although pathophysiological mechanisms of delirium remain unclear, current evidence suggests that disruption of neurotransmission, inflammation, or acute stress responses might all contribute to the development of this ailment. It usually occurs as a result of a complex interaction of multiple risk factors, such as cognitive impairment/dementia and current medical or surgical disorder. Despite all of the above, delirium is frequently under-recognized and often misdiagnosed by health professionals. In particular, this happens due to its fluctuating nature, its overlap with dementia and the scarcity of routine formal cognitive assessment in general hospitals. It is also associated with multiple adverse outcomes that have been well documented, such as increased hospital stay, function/cognitive decline, institutionalization and mortality. In this context, the early identification of delirium is essential. Timely and optimal management of people with delirium should be performed with identification of any possible underlying causes, dealing with a suitable care environment and improving education of health professionals. All these can be important factors, which contribute to a decrease in adverse outcomes associated with delirium.

Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial

BACKGROUND

Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.

OBJECTIVE

Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.

DESIGN

A randomized controlled clinical trial.

SETTING

A public hospital in Indianapolis.

POPULATION

A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.

INTERVENTION

A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.

MEASUREMENTS

Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.

RESULTS

Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).

CONCLUSION

A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.

Discharge diagnosis and comorbidity profile in hospitalized older patients with dementia

OBJECTIVES

The aim of this study was to investigate the principal discharge diagnosis and related comorbidity in hospitalized older patients affected by dementia.

METHODS

Data from 51,838 consecutive computerized discharge records of the St. Anna University Hospital (Ferrara, Italy) were analyzed. Records included only subjects aged ≥60 years. Number of admissions, length of stay in hospital, primary and secondary discharge diagnosis (by ICD-9-CM code), number of procedures, and possible death were evaluated.

RESULTS

Demented patients represented 8.6% of the sample (4466 individuals) and were older and more likely to be female patients compared with controls (47,372 individuals); they were characterized by higher number of admissions to hospital, instrumental clinical investigations, secondary diagnoses, and mortality rate. Among the primary diagnoses, a higher prevalence of cerebrovascular disease, pneumonia, and hip fracture was observed in demented patients. Furthermore, pulmonary embolism, renal failure, septicemia, and urinary infections were frequently reported in demented patients, but not in controls. As regards secondary diagnoses, dementia was associated with an increased risk of delirium, muscular atrophy and immobilization, dehydration, cystitis, and pressure ulcers, whereas the risk for other conditions, including cancer, was reduced.

CONCLUSIONS

Among older patients, dementia was associated with higher rate of admissions to hospital and mortality. Discharge diagnoses were sensibly different according to the presence of dementia; in particular, a greater load and a different kind of comorbidity were observed in demented patients. On the whole, our data suggest that the adequate management of demented outpatients might help to reduce hospitalization.

Joint geriatric and psychiatric wards: a review of the literature

Joint geriatric/psychiatric wards are a potential solution to improving care of older patients with both psychiatric and medical illnesses in acute hospitals. A literature search using Medline, PsycINFO, Embase and CINAHL between 1980 and 2010 was carried out for information about joint wards for older people. Thirteen relevant papers were identified. These wards share common characteristics and there is evidence that they may reduce length of stay and be cost-effective, but there are no high-quality randomised controlled trials. Further research is needed, particularly regarding cost-effectiveness.

Discharge planning from hospital to home for elderly patients: a meta-analysis

In the present healthcare environment, budget cuts, staff shortages, and resource limitations are grave concerns. The elderly in particular consume a considerable proportion of hospital resources. Thus, the discharge planner's role, particularly with respect to elderly patients, is extremely important. In this systematic review recent (within the last 10 years) randomized, controlled or quasi-experimental trials of discharge planning (DP) from hospital to home of patients age 65 years or older were examined. The most important finding was the paucity of investigations by social work professionals. A second important finding was the lack of appropriate reporting of methods and results. Where data were provided, an effect size was computed for statistically significant results (overall mean d = 0.51, SD 0.35). Large effects were noted for patient satisfaction, while moderate effects were evident for patients' quality of life and readmission rates. The integration and evaluation of current knowledge in this field may inform further research and may lead to the advancement of clinical practice and new policy development, with the ultimate goal of improving the quality of patient care and the quality of patient outcomes. The implications for social work clinicians and researchers are discussed.

Long-term patients' outcomes after intermediate care at a community hospital for elderly patients: 12-month follow-up of a randomized controlled trial

BACKGROUND

Developing a better understanding of if, and when, patients need care at a general hospital is an urgent challenge, as the proportion of general hospital beds being occupied by older patients is continuously increasing.

METHODS

In a randomized controlled trial, of 142 patients aged 60 years or more admitted to a city general hospital due to acute illness or exacerbation of a chronic disease, 72 (intervention group) were randomized to intermediate care at a community hospital, and 70 (general hospital group) to further general hospital care. The patients were followed up for 12 months. The need for long-term home care and nursing homes, mortality and the number of admissions and days in general hospital for all diseases were monitored.

RESULTS

Thirty-five patients, 13 (18.1%) of the patients included in the intervention group and 22 (31.4%) in the general hospital group, died within 12 months (p=0.03). Patients in the intervention group were observed for a longer period of time than those in the general hospital group; 335.7 (95% confidence interval (CI) 312.0-359.4) vs. 292.8 (95% CI 264.1-321.5) days (p=0.01). There were statistically no differences in the need for long-term primary-level care or in the number of admissions or days spent in general hospital beds.

CONCLUSIONS

Intermediate care at the community hospital in Trondheim is an equal alternative to ordinary prolonged care at the city general hospital, as fewer patients were in need of community care services, and significantly fewer patients died during the 12-month follow-up time.

Best practice interventions to improve the management of older people in acute care settings: a literature review

AIM

This paper is a report of a literature review of experimental evidence describing interventions to manage the older adult in the acute care hospital setting.

BACKGROUND

Older people are increasingly being cared for in a system largely geared towards acute care. This approach is often inadequate to meet the needs of older patients with chronic and complex conditions. In response to these challenges, evidence-based interventions are required to improve health outcomes.

METHOD

The MEDLINE and CINAHL databases and the Internet were searched using the keywords elderly, older, geriatric and aged care. Studies published between 1985 and 2006 were included if they reported, in English, a controlled trial of an intervention designed to improve the management of older adults in the acute care setting. The findings were synthesized using the method of a modified integrative literature review.

FINDINGS

Only 26 controlled trials met the inclusion criteria. The following elements of interventions appear critical in providing optimal health outcomes for older people admitted to acute care: (1) a team approach to care delivery either directly in a designated unit for older patients or indirectly using gerontological expertise in a consultancy model; (2) targeted assessment techniques to prevent complications; (3) an increased emphasis on discharge planning and (4) enhanced communication between care providers across the care continuum.

CONCLUSION

A multidisciplinary team approach, using gerontological expertise, in acute care settings is recommended to improve the care of older patients. Care delivery should occur in a specially designed unit, with communication strategies that emphasize discharge planning.

Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial

Background

Demographic changes together with an increasing demand among older people for hospital beds and other health services make allocation of resources to the most efficient care level a vital issue. The aim of this trial was to study the efficacy of intermediate care at a community hospital compared to standard prolonged care at a general hospital.

Methods

In a randomised controlled trial 142 patients aged 60 or more admitted to a general hospital due to acute illness or exacerbation of a chronic disease 72 (intervention group) were randomised to intermediate care at a community hospital and 70 (general hospital group) to further general hospital care.

Results

In the intervention group 14 patients (19.4%) were readmitted for the same disease compared to 25 patients (35.7%) in the general hospital group (p = 0.03). After 26 weeks 18 (25.0%) patients in the intervention group were independent of community care compared to seven (10.0%) in the general hospital group (p = 0.02). There were an insignificant reduction in the number of deaths and an insignificant increase in the number of days with inward care in the intervention group. The number of patients admitted to long-term nursing homes from the intervention group was insignificantly higher than from the general hospital group.

Conclusion

Intermediate care at a community hospital significantly decreased the number of readmissions for the same disease to general hospital, and a significantly higher number of patients were independent of community care after 26 weeks of follow-up, without any increase in mortality and number of days in institutions.

Exercise for acutely hospitalised older medical patients

BACKGROUND

A high incidence of functional decline (deterioration in physical or cognitive function) during hospitalisation of older adults is reported. The role of exercise in preventing these deconditioning effects is unclear.

OBJECTIVES

To determine the effect of exercise interventions for acutely hospitalised older medical patients on functional status, adverse events and hospital outcomes.

SEARCH STRATEGY

We searched MEDLINE (1966-Feb 2006), CINAHL (1982-Feb 2006), EMBASE (1988 to Feb 2006), Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), PEDro (1929- Feb 2006), Current Contents (1993- Feb 2006) and Sports Discus (1830-Feb 2006). The Journal of the American Geriatrics Society was hand searched. Additional studies were identified through reference and citation tracking, personal communications with a content expert and contacting authors of eligible trials. There was no language restriction.

SELECTION CRITERIA

Eligible studies were prospective randomised controlled trials (RCT) or prospective controlled clinical trials (CCT) comparing exercise for acutely hospitalised older medical patients to usual care or no treatment controls.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data relating to patient and hospital outcomes and assessed the method quality of included studies. Data were pooled in meta-analysis using the relative risk (RR) and absolute risk reduction (ARR) for dichotomous outcomes and the standardised mean difference (SMD) or the weighted mean difference (WMD) for continuous outcomes.

MAIN RESULTS

Of 3138 potentially relevant articles screened, 7 randomised controlled trials and 2 controlled clinical trials were included. The effect of exercise on functional outcome measures is unclear. No intervention effect was found on adverse events. Pooled analysis of multidisciplinary interventions that included exercise indicated a small significant increase in the proportion of patients discharged to home at hospital discharge (Relative Risk 1.08, 95% CI 1.03 to 1.14 and Numbers Needed to Treat 16, 95% CI 11 to 43) and a small but important reduction in acute hospital length of stay (weighted mean difference, -1.08 days, 95% CI -1.93 to -0.22) and total hospital costs (weighted mean difference, -US$278.65, 95% CI -491.85 to -65.44) compared to usual care. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay.

AUTHORS' CONCLUSIONS

There is 'silver' level evidence (www.cochranemsk.org) that multidisciplinary intervention that includes exercise may increase the proportion of patients discharged to home and reduce length and cost of hospital stay for acutely hospitalised older medical patients.

Treatment and Prevention of Depression After Surgery for Hip Fracture in Older People: Randomized, Controlled Trials

OBJECTIVES

To evaluate the effect of a psychiatric intervention in treating depression (treatment study) and the effect of a psychological treatment in preventing depression (prevention study) after hip fracture in older people.

DESIGN

Two linked randomized, controlled trials.

SETTING

Orthopedic units in Manchester, England.

PARTICIPANTS

Two hundred ninety-three older people who had undergone surgery for a fractured hip: 121 in the treatment study and 172 in the prevention study.

MEASUREMENTS

The Geriatric Depression Scale and Hospital Anxiety and Depression Scale for mood, functional tests for mobility and pain measures.

RESULTS

There was a slight reduction in depressive symptoms in the active arm of the treatment study. In the prevention study, there was no significant difference in incident depression between the psychological intervention and treatment as usual. There were no differences in the functional and pain outcomes.

CONCLUSION

The results from these two randomized, controlled trials show that, after hip fracture surgery, no statistically significant benefits can be achieved from a psychiatric intervention in people who are depressed or a psychological intervention to prevent the onset of depression.

The importance of knowledge transfer between specialist and generic services in improving health care: a cross-national study of dementia care in England and The Netherlands

Knowledge transfer (KT) between specialist and generic services is widely seen as an important strategy for improving the quality of integrated dementia care. This article elaborates on intra- and inter-organizational features associated with successful KT. A provisional conceptual framework is suggested, based on literature about inter-organizational networks and knowledge management. Professional and organizational cultures, domain perceptions, perceived dependency and the availability of resources are suggested as significant influences upon the motivation and perceived capacity to engage in KT. Personal and organizational continuity is identified as an important process quality. Data from four local case studies in England and The Netherlands are used to develop and specify the provisional framework. A conceptual model is built to explain the relative success or failure of KT.

Models of integrated care

This article describes the range of options for integrating medicine and psychiatry, with a focus on the advantages and limitations of each model. The models were developed in different countries with specific health care cultures. This article illustrates the range of in- and outpatient options as currently practiced, with case reports from practitioners when possible, and describes qualifications for practicing in each model, the settings, the patient populations, the relevant financial issues, and the advantages and disadvantages of practicing in each model. It closes with comments on the next steps for advancing integrated care and the barriers to be overcome.

Epidemiologic trends and costs of fragmentation

The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.

Cognitive impairment is the major risk factor for development of geriatric syndromes during hospitalization: results from the GIFA study

OBJECTIVE

To detect the main factors associated with the occurrence of specific geriatric syndromes (namely pressure sores, fecal incontinence, urinary incontinence and falls) in elderly patients during hospitalization.

DESIGN

Observational prospective study.

SETTING

Eighty-one community and university hospitals throughout Italy.

PARTICIPANTS

13,729 patients aged 65 years and more, consecutively admitted to medical or geriatric acute wards during 20 months in the period between 1991 and 1998.

MEASUREMENTS

Occurrence of pressure sores, fecal incontinence, urinary incontinence and falls during the stay in hospital.

RESULTS

Pressure sores were already present in 3% of hospitalized subjects, fecal incontinence in 7.3%, while urinary incontinence, evaluated on a subgroup of total population (4,268 subjects), had a prevalence of 22.3%. During hospitalization (mean stay of 15 days), 74 subjects developed new pressure sores, 55 became fecal and 35 urinary incontinent, and 279 subjects had at least one episode of fall. In multivariate analyses, cognitive impairment, advanced age (85+ years), length of stay (more than 3 weeks) and severe disability were the main independent predictors of development of the four geriatric syndromes, with cognitive impairment as the most significant risk factor for all the four outcomes (OR 4.9, 95% CI 2.4-9.9 for pressure sores; OR 6.3, 95% CI 3.0-13.0 for fecal incontinence; OR 5.3, 95% CI 2.3-12.0 for urinary incontinence; OR 1.6, 95% CI 1.2-2.3 for falls).

CONCLUSION

Very old people have a significant increased risk of several geriatric syndromes during the stay in hospital, particularly if it is long and they are cognitively impaired. A standardized comprehensive geriatric evaluation at admission could be helpful in detecting all subjects at risk and preventing the development of hospital-acquired geriatric syndromes.

A comparative study of dementia care in England and the Netherlands using neo-institutionalist perspectives

In this article, the authors compare dementia care in England and the Netherlands. They used qualitative methods to explore recommended standards of service provision and perceived achievements in mainstream care. They found some similarities in recommended standards and in major shortcomings in mainstream services: notably, weaknesses of generic services in supporting patients and carers, and failure to achieve integrated care. Priorities regarding service provision differed. Whereas in England, a social model of care was used to encourage empowerment of both the person with dementia and the carer, Dutch care professionals focused more on "warm care concepts" and on support of the carer rather than the patient. The balance between community care and institutional care also differed. The authors used neo-institutionalist concepts to explore these similarities and differences as embedded in the (historically developed) structural and cultural contexts of the respective health and social care systems.

Longitudinal Study of Inpatients Admitted to a General Activation Service: Variables That Predict Discharge to a Patient’s Discharge Goal Location

OBJECTIVE

To determine which sociodemographic and clinical characteristics of patients admitted to a general activation service (GAS) are predictive of discharge to patients' discharge goal locations (DGLs).

DESIGN

Prospective cohort study.

SETTING

Rehabilitation and complex continuing care hospital in southern Ontario, Canada.

PARTICIPANTS

Patients admitted from January 2000 to December 2002 (N=154).

INTERVENTION

The GAS.

MAIN OUTCOME MEASURE

Patients indicated on their service applications where they wanted to be discharged. This is termed the DGL.

RESULTS

Fifty-three percent of the sample were discharged to their DGLs. Ninety-eight percent of these patients were discharged by 9 months. Eighty-seven percent who were discharged to their DGLs were discharged to their own home. Predictors of being discharged to the DGL were better activities of daily living scores, good vision, and having sufficient help at home. Expert clinician opinion of the likelihood of each patient being discharged to his/her DGL, based on initial assessment, was also predictive of each patient's eventual discharge to his/her DGL.

CONCLUSIONS

The GAS has a 53% success rate in discharging patients to their DGLs. Variables have been identified that should be useful in predicting whether patients will be discharged to their DGLs. Our findings are meaningful and informative in determining future admission criteria for the service.