Optimising care of the hospitalised elderly. A literature review and suggestions for future research

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.

The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

BACKGROUND

The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care.

OBJECTIVE

To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases

METHOD

A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest.

MAIN FINDINGS

Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. MAIN STUDY LIMITATION: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions.

CONCLUSIONS

The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.

Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review

RATIONALE, AIMS AND OBJECTIVES

Unplanned hospital readmissions of elderly people represent an increasing burden on health care systems. This burden could theoretically be reduced by adequate preventive interventions, although there is uncertainty about the effectiveness of different types of interventions. The objective of this systematic review was to identify interventions that effectively reduce the risk of hospital readmissions in patients of 75 years and older, and to assess the role of home follow-up.

METHODS

We searched studies in MEDLINE, CINAHL, CENTRAL and seven other electronic databases up to October 2007, and we updated the MEDLINE search in October 2009. Clinical trials (randomized or controlled) evaluating the effectiveness of an intervention aimed at reducing readmissions in elderly patients were selected. Quality was assessed using the SIGN tool and the information extracted is presented in text and tables.

RESULTS

Thirty-two clinical trials were included and they were divided into two groups: in-hospital interventions (17 studies) and interventions with home follow-up (15 studies). A positive effect of the intervention evaluated on the readmission outcome was found in three studies from the first group and in seven from the second group.

CONCLUSIONS

Most of the interventions evaluated did not have any effect on the readmission of elderly patients. However, those interventions that included home care components seem to be more likely to reduce readmissions in the elderly.

The hospital-based, post-acute geriatric evaluation and management unit: the experience of the acute geriatric unit in Trieste

In 2005, the Azienda Ospedaliero-Universitaria of Trieste (AOUT) activated the hospital-based post-acute geriatric evaluation and management unit (PAGEMU). The purpose of the study is to illustrate the activities of the PAGEMU, and to evaluate the effects of personalized and multidisciplinary care on geriatric inpatients. The evaluation for admission in PAGEMU included general admitting criteria, co-morbidity, autonomy, and assessment of the patient's pre-morbid functional status. During the stay, inpatients completed their treatment plan, comprehensive geriatric assessment was carried out, and rehabilitation and nutritional interventions were implemented. If necessary, a new diagnostic-therapeutic plan was provided. A number of 826 patients were evaluated for admission in PAGEMU (612 patients from surgical departments and 214 from medical wards). The mean length of stay was 19.55 days. Re-evaluation of patients at discharge showed a statistically significant improvement in co-morbidity and in self-sufficiency, not in cognitive or mood status. PAGEMU is a valid model both for patient-oriented and for management-oriented objectives, shortening the length of stay in acute care settings and increasing hospital turnover.

Should geriatric medicine remain a specialty? No

The development of geriatricshas greatly improved care for older people. Leon Flicker (doi: 10.1136/bmj.39538.481273.AD) believesspecialist care remains important for this vulnerable group,butC P Denaro and A Mudge argue that age divisions are no longer relevant

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.

State of the art in geriatric rehabilitation. Part I: review of frailty and comprehensive geriatric assessment

OBJECTIVES

To increase recognition of geriatric rehabilitation and to provide recommendations for practice and future research.

DATA SOURCES

A CINAHL and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search used the Cochrane database.

STUDY SELECTION

One author reviewed the reference for relevance and another for quality. A total of 336 articles were selected. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports.

DATA EXTRACTION

The following major geriatric rehabilitation subtopics were identified: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. Part I describes the first 5 subtopics on concepts and processes in geriatric rehabilitation. Part II focuses on the latter 5 subtopics of common clinical problems in frail older persons. A level-of-evidence framework was used to review the literature. Level 1 evidence was a randomized controlled trial (RCT) or a meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts or descriptive studies.

DATA SYNTHESIS

Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic. In cases in which several articles were written on the same topic and drew similar conclusions, the authors chose those articles with the strongest level of evidence, reducing the total number of references.

CONCLUSIONS

Frail elderly patients should be screened for rehabilitation potential. Standardized tools are recommended to aid diagnosis, assessment, and outcome measurement. The team approach to geriatric rehabilitation should be interdisciplinary and use a comprehensive geriatric assessment. Medication reviews and self-medication programs may be beneficial. Future research should address cost effectiveness, consensus on outcome measures, which components of geriatric rehabilitation are most effective, screening, and what outcomes are sustainable.

State of the art in geriatric rehabilitation. Part II: clinical challenges

OBJECTIVES

To examine common clinical problems in geriatric rehabilitation and to make recommendations for current practice based on evidence from the literature.

DATA SOURCES

A CINAHL database and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search was completed by using the Cochrane database.

STUDY SELECTION

One author reviewed the references for relevance and another for quality. A total of 336 articles were considered relevant. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports on a small number of patients.

DATA EXTRACTION

The following areas were the major geriatric rehabilitation subtopics identified in the search: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. This article focuses on the latter 5 subtopics. The literature was reviewed by using a level-of-evidence framework. Level 1 evidence was a randomized controlled trial (RCT) or meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts, descriptive studies, or reports of expert committees.

DATA SYNTHESIS

Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic according to the level of evidence in the specific area. In cases in which several articles were written on a topic with similar conclusions, we selected the articles with the strongest level of evidence, thereby reducing the total number of references.

CONCLUSIONS

Frail older patients with hip fracture should receive geriatric rehabilitation. They should also be screened for nutrition, cognition, and depression. Older persons should receive nutritional supplementation when malnourished. If severe dysphagia occurs in stroke patients, gastrostomy tube feeding is superior to nasogastric tube feeding.

Pre-discharge home visits with older people: time to review practice

The present review paper uses the available evidence to make a case for a reconsideration of the practice of undertaking pre-discharge home visits with frail older people as part of decisions regarding a return home. This practice is embedded into the routine activity of acute medical wards for older people and occupies a large proportion of the time of hospital employed therapy staff, with consequent financial and resource implications. Assessments are often conducted to provide information on safe discharge rather than being located in the interests of the older person and their carer. The introduction of a new range of services bridging hospital and home raises the need for an urgent, critical appraisal of this practice.