Trajectories and predictors of functional decline of hospitalised older patients

Exploring trajectories of functional decline and recovery among older adults: a data-driven approach

Independently performing activities of daily living (ADLs) is vital for maintaining one's quality of life. Losing this ability can significantly impact an individual's overall health status, including their mental health and social well-being. Aging is an important factor contributing to the loss of ADL abilities, and our study focuses on investigating the trajectories of functional decline and recovery in older adults. Employing trajectory analytics methodologies, this research delves into the intricate dynamics of ADL pathways, unveiling their complexity, diversity, and inherent characteristics. The study leverages a substantial dataset encompassing ADL assessments of nursing home residents with diverse disability profiles in the United States. The investigation begins by transforming these assessments into sequences of disability combinations, followed by applying various statistical measures, indicators, and visual analytics. Valuable insights are gained into the typical disability states, transitions, and patterns over time. The results also indicate that while predicting the progression of ADL disabilities presents manageable challenges, the duration of these states proves more complicated. Our findings hold significant potential for improving healthcare decision-making by enabling clinicians to anticipate possible patterns, develop targeted and effective interventions that support older patients in preserving their independence, and enhance overall care quality.

Delirium Severity and Physical Function in Hospitalized Persons Living With Dementia: Moderation by Age, Sex, and Race

OBJECTIVE

This study investigated whether demographic characteristics (age, sex, and race) moderated delirium severity as a predictor of physical function in hospitalized persons living with dementia.

METHODS

The sample consisted of 351 patients enrolled in a randomized controlled trial (Function Focused Care for Acute Care Using the Evidence Integration Triangle). Preliminary analysis was conducted to assess the main effect, and multiple linear regression was used to examine the moderating effect of demographic characteristics between delirium severity and physical function.

RESULTS

Both age and sex were found to have significant moderating effects on the relationship between delirium severity and physical function (β = 2.22; P = 0.02 and β = 1.34; P = 0.04, respectively). Older adults aged 85 years or older with higher levels of delirium severity reported lower levels of physical function compared with older adults aged 65 to 84 years. Males with higher levels of delirium severity reported lower levels of physical function compared with females. Race did not significantly moderate the association between delirium severity and physical function (β = 0.22; P = 0.90).

CONCLUSIONS

Our findings suggest that age and sex may have differential effects on physical function across different levels of delirium severity in hospitalized persons living with dementia.

Gender, Pain, and Function Associated With Physical Activity After Hospitalization in Persons Living With Dementia

BACKGROUND

The purpose of this study was to identify factors that are associated with physical activity after hospitalization in persons living with dementia.

METHODS

Multiple linear regressions were conducted to test factors associated with objective activity levels (sedentary, low, moderate, and vigorous) among 244 patients living with dementia from a randomized controlled trial.

RESULTS

Within 48 hours of hospital discharge, time in sedentary behavior was associated with increased pain (β=0.164, P =0.015). Time in low activity was associated with less pain (β=-0.130, P =0.049) and higher physical function (β=0.300, P =<0.001). Time in moderate activity was associated with increased physical function (β=0.190, P =0.008) and male gender (β=0.155, P =0.016). No significant associations of potential factors were found with time in vigorous activity.

CONCLUSIONS

Our findings suggest that managing or reducing pain, encouraging individual functional level, and gender could influence time spent in physical activity after acute hospitalization in persons living with dementia.

A scoping review of unpaid caregivers' experiences during older adults' hospital-to-home transitions

The objective of this scoping review is to examine current evidence regarding unpaid/family caregivers' experiences during older adults' hospital-to-home transitions to identify gaps and opportunities to involve caregivers in transitional care improvement efforts. Eligible articles focused on caregiver experience, outcomes, or interventions during older adults' hospital-to-home transitions. Our review identified several descriptive studies focused on exploring the caregiver experience of older adult hospital-to-home transitions and caregiver outcomes (such as preparedness, strain, burden, health, and well-being). Qualitative studies revealed challenges at multiple levels, including individual, interpersonal, and systemic. Few interventions have targeted or included caregivers to improve discharge education and address support needs during the transition. Future work should target underrepresented and marginalized groups of caregivers, and caregivers' collaboration with community-based services, social networks, or professional services. Work remains in developing and implementing interventions to support both older adult and caregiver needs.

Development of a Clinical Prediction Rule for Adverse Events in Multimorbid Patients in Emergency and Hospitalisation

(1) Background: There is currently a global consensus that the quality of comprehensive care for acutely hospitalised elderly people should include addressing functionality and mobility, cognitive status, prevention of pressure ulcers, urinary incontinence, falls and delirium, as well as pain control and medication-related problems. The aim of this study is to develop and validate a clinical prediction rule for multimorbid patients admitted to an acute care hospital unit for any of the five adverse events included in our vulnerability pentad: falls, pressure ulcers, urinary incontinence, pain and delirium. (2) Methods: Longitudinal analytical clinimetric study, with two cohorts. The study population will consist of multimorbid patients hospitalised for acute care, referred from the Emergency Room. A clinical prediction rule will be proposed, incorporating predictive factors of these five adverse outcomes described. This study has received funding, awarded in November 2020 (PI-0107-2020), and was approved in October 2019 by the Research Ethics Committee ″Costa del Sol″. (3) Conclusions: Preventing adverse events in hospitalised patients is particularly important for those with multimorbidity. By applying a clinical prediction rule to detect specific risks, an estimate can be obtained of their probability of occurrence.

Functional status of community-dwelling older adults after inpatient rehabilitation

Background/aims:

Factors that influence functional ability in older adults after rehabilitation are not well understood. The aim of this study was to investigate how older people function in their community after being discharged from inpatient rehabilitation.

Methods

A cross-sectional study was undertaken of community-dwelling older adults (n=86, 75 ± 6 years) discharged from rehabilitation in the previous 12 months. Basic functional independence was assessed using the Functional Independence Measure and complex functional independence was assessed using the Frenchay Activities Index. Multiple regression analyses were conducted to assess any association between predetermined factors and function.

Results

Functional Independence Measure scores and physical activity levels after being discharged accounted for 50% of the variance in basic function (R2=0.50, F=40.75, P<0.001). Frenchay Activities Index scores, physical activity, age, sex and migrant status accounted for 68% of variance in complex function (R2=0.68, F=29.75, P<0.001).

Conclusions

Clinicians are encouraged to implement strategies to improve function at discharge from rehabilitation and to promote physical activity among older people at risk of poor function following rehabilitation.

Determinants of trajectories of fatigability and mobility among older medical patients during and after hospitalization; an explorative study

Background

Fatigability is an important marker of functional decline in community dwelling older people, yet its relationship with functional decline after hospitalization is unclear. The objectives of this study were to identify trajectories of fatigability and mobility over time and to examine the association between demographic and clinical characteristics and these trajectories in medical patients aged 70 years and older admitted to a Dutch tertiary care teaching hospital.

Methods

In this prospective cohort study with baseline (in-hospital), discharge, three-, and six-months post discharge follow-up measurements, fatigability was assessed by the physical subscale of the Pittsburgh Fatigability Scale (PFS). Mobility was assessed by the De Morton Mobility Index (DEMMI). Group-based trajectory modeling was used to identify joint trajectories of fatigability and mobility. Covariates included demographic (age, sex, living situation, education) and clinical characteristics (functional status, frailty status, depression, comorbidity, length of hospital stay).

Results

Among 44 patients, three distinct fatigability trajectories and two mobility trajectories were identified over the course from hospital admission up to six months after discharge. Subsequently, three joint trajectories were identified, including low fatigability and high mobility (11%), improving fatigability and high mobility (52%), and high fatigability and low mobility (36%). Controlling for baseline functional status, patients with a lower comorbidity score (OR: 0.27, 95%CI 0.10; 0.74) and higher frailty status (OR: 1.36, 95%CI: 1.07; 1.74) were more likely to be a member of the high fatigability and low mobility trajectories.

Conclusions

From hospital admission up to six months after discharge, three distinct trajectories of fatigability and mobility were identified among older medical patients. Our results should be interpreted with caution due to the small sample size, but may inspire other researchers to determine the value of fatigability assessment in identifying older medical patients at risk for developing mobility problems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02714-9.

Physical Resilience in Daily Functioning Among Acutely Ill Hospitalized Older Adults: The Hospital-ADL Study

OBJECTIVES

Insight into older adults' physical resilience is needed to predict functional recovery after hospitalization. We assessed functional trajectories in response to acute illness and subsequent hospitalization and investigated baseline variables and dynamic variables associated with these trajectories.

DESIGN

Prospective observational cohort study (Hospitalization-Associated Disability and impact on daily Life Study).

SETTING AND PARTICIPANTS

This study included 207 older adults (aged 79.8 ± 6.9 years, 49% female, 57% frail) acutely hospitalized in 6 Dutch hospitals.

METHODS

Functional disability was assessed using the 15-item modified activities of daily living index retrospectively 2 weeks before admission, and prospectively from admission up to 3 months after discharge. Baseline variables including frailty, somatic, physical, and psychosocial factors were assessed at admission. Dynamic variables (step count, pain, fatigue, and fear of falling) were continuously or repeatedly assessed during hospitalization. We performed individual spline modeling using random effects. Baseline variables and within-person mean levels and variability in the dynamic variables were assessed as predictors of functional trajectories.

RESULTS

Functional disability significantly increased before admission and decreased from admission to 3 months post discharge. Frail participants had a significantly higher increase in functional disability before admission compared with nonfrail participants. Lower step count, higher pain scores, and higher within-person variability in fear of falling were significantly associated with higher increase in functional disability before admission. Higher within-person variability in fear of falling was associated with more recovery.

CONCLUSIONS AND IMPLICATIONS

Older adults increase in functional disability before hospitalization and start to recover from admission onward. Frailty and dynamic variables are associated with a higher increase in functional disability after acute illness. Our findings give more insight into older adults' physical resilience, which may improve the prediction of functional recovery and may improve therapeutic decision-making and rehabilitation strategies to improve functional recovery after acute hospitalization.

Telerehabilitation program for older adults on a waiting list for physical therapy after hospital discharge: study protocol for a pragmatic randomized trial protocol

BACKGROUND

Delays in starting physical therapy after hospital discharge worsen deconditioning in older adults. Intervening quickly can minimize the negative effects of deconditioning. Telerehabilitation is a strategy that increases access to rehabilitation, improves clinical outcomes, and reduces costs. This paper presents the protocol for a pragmatic clinical trial that aims to determine the effectiveness and cost-effectiveness of a multi-component intervention offered by telerehabilitation for discharged older adults awaiting physical therapy for any specific medical condition.

METHODS

This is a pragmatic randomized controlled clinical trial with two groups: telerehabilitation and control. Participants (n=230) will be recruited among individuals discharged from hospitals who are in the public healthcare system physical therapy waiting lists. The telerehabilitation group will receive a smartphone app with a personalized program (based on individual's functional ability) of resistance, balance, and daily activity training exercises. The intervention will be implemented at the individuals' homes. This group will be monitored weekly by phone and monthly through a face-to-face meeting until they start physical therapy. The control group will adhere to the public healthcare system's usual flow and will be monitored weekly by telephone until they start physical therapy. The primary outcome will be a physical function (Timed Up and Go and 30-s Chair Stand Test). The measurements will take place in baseline, start, and discharge of outpatient physical therapy. The economic evaluations will be performed from the perspective of society and the Brazilian public healthcare system.

DISCUSSION

The study will produce evidence on the effectiveness and cost-effectiveness of multi-component telerehabilitation intervention for discharged older adult patients awaiting physical therapy, providing input that can aid the implementation of similar proposals in other patient groups.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC), RBR-9243v7 . Registered on 24 August 2020.

The Role of Frailty in Predicting 3 and 6 Months Functional Decline in Hospitalized Older Adults: Findings from a Secondary Analysis

Frailty represents one of the most relevant geriatric syndromes in the 21st century and is a predictor of adverse outcomes in hospitalized older adult, such as, functional decline (FD). This study aimed to examine if frailty, evaluated with the Frailty Index (FI), can predict FD during and after hospitalization (3 and 6 months). Secondary data analysis of a prospective cohort study of 101 hospitalized older adults was performed. The primary outcome was FD at discharge, 3 and 6 months. The FI was created from an original database using 40 health deficits. Functional decline models for each time-point were examined using a binary logistic regression. The prevalence of frailty was 57.4% with an average score of 0.25 (±0.11). Frail patients had significant and higher values for functional decline and social support for all time periods and more hospital readmission in the 3 month period. Multivariable regression analysis showed that FI was a predictor of functional decline at discharge (OR = 1.07, 95% CI = 1.02–1.14) and 3-month (OR = 1.05, 95% CI = 1.01–1.09) but not 6-month (OR = 1.03, 95% CI = 0.99–1.09) follow-up. Findings suggest that frailty at admission of hospitalized older adults can predict functional decline at discharge and 3 months post-discharge.

A scoping review of interventions for older adults transitioning from hospital to home

BACKGROUND/OBJECTIVES

Older adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication management and may miss key components. The objective of this study is to examine the current scope of hospital-to-home transitional care interventions that impact health-related outcomes and to examine other key components including engagement by older adults and their caregivers.

DESIGN

Scoping review.

METHODS

Eligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results.

RESULTS

Five hundred sixty-seven records were identified by title. Forty-four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self-management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality.

CONCLUSION

To improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver-reported needs and their well-being.

A systematic review of the physical activity levels of acutely ill older adults in Hospital At Home settings: an under-researched field

PURPOSE

The purpose of this review was to identify, evaluate and synthesise existing evidence reporting the physical activity levels of acutely ill older patients in a 'Hospital At Home' setting and compare this to patients with similar characteristics treated in a traditional hospital inpatient setting. Functional changes and any adverse outcomes due to physical activity (e.g. falls) in both settings where PA was reported or recorded were also evaluated as secondary outcomes.

METHODS

A search strategy was devised for the MEDLINE, CINAHL, AMed, PEDRO, OT Seeker and Cochrane databases. Search results were title, abstract and full-text reviewed by two independent researchers. Data were extracted from included articles using a custom form and assessed for quality and risk of bias using the Appraisal Tool for Cross-Sectional Studies.

RESULTS

No studies set in the Hospital at Home environments were identified. 16 hospital inpatient studies met the criteria for inclusion. Older patients managed in inpatient settings that would be eligible for Hospital at Home services spent 6.6% of their day active and undertook only 881.8 daily steps. Functional change was reported in four studies with both improvement and decline during admission reported.

CONCLUSION

There is a lack of published research on the physical activity levels of acutely-ill older adults in Hospital at Home settings. This review has identified a baseline level of activity for older acutely ill patients that would be suitable for Hospital at Home treatment. This data could be used as a basis of comparison in future hospital at home studies, which should also include functional change outcomes to further explore the relationship between physical inactivity and functional decline.

Nurses' experiences with an inpatient geriatric consulting service at a Midwestern Veterans' hospital: The elder veteran program

This qualitative project used conventional content analysis of interview data to examine nurses' experience with and perception of the Elder Veteran Program, an inpatient geriatric consulting service, at a midwestern Veterans' hospital. Nurses were recruited from nursing units utilizing the program and completed individual interviews (N = 10). Participants described the impact of the program within four categories: providing comprehensive care to patients, contributing to individual growth of nurses, promoting team-based care, and as a resource. Participants described several barriers and facilitators to implementation of the program on their unit, including workload and time, shifts and availability of program staff, perceived need, inclusion criteria, perception of program staff, education of nurses, communication, and the inpatient environment. This project provides opportunities for further examination of healthcare providers' experience with inpatient geriatric programs, how those experiences may relate to effectiveness of programs, and important areas of support for hospital staff.

Hospitalized older adult: predictors of functional decline

OBJECTIVE

to identify the predictors of functional decline in hospitalized individuals aged 70 or over, between: baseline and discharge; discharge and follow-up, and baseline and three-month follow-up.

METHOD

a prospective cohort study conducted in internal medicine services. A questionnaire was applied (clinical and demographic variables, and predictors of functional decline) at three moments. The predictors were determined using the binary logistic regression model.

RESULTS

the sample included 101 patients, 53.3% female, mean age of 82.47 ± 6.57 years old. The predictors that most contributed to decline in hospitalization were the following: previous hospitalization (OR=1.8), access to social support (OR=4.86), cognitive deficit (OR=6.35), mechanical restraint (OR=7.82), and not having a partner (OR=4.34). Age (OR=1.18) and medical diagnosis (OR=0.10) were the predictors between discharge and follow-up. Being older, delirium during hospitalization (OR=5.92), and presenting risk of functional decline (OR=5.53) were predictors of decline between the baseline and follow-up.

CONCLUSION

the most relevant predictors were age, previous hospitalization, cognitive deficit, restraint, social support, not having a partner, and delirium. Carrying out interventions aimed at minimizing the impact of these predictors can be an important contribution in the prevention of functional decline.

Getting Back to Normal: A Grounded Theory Study of Function in Post-hospitalized Older Adults

BACKGROUND AND OBJECTIVES

The literature on transitions after hospitalization is based on a medicalized model focusing primarily on medication management and readmission, but little is known about the process older adults engage in to maintain their normal life posthealth event or how older adults define what the transition is. This grounded theory study aimed to describe how older adults understand and define a transition process, what actions they take based on their understanding, and what consequences they experience as they transition.

RESEARCH DESIGN AND METHODS

Adults aged 65 and older discharged from a large Midwestern teaching hospital (N = 14) were interviewed using in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding.

RESULTS

All participants described the process of transition as moving from a state of normal function to loss, and then working back to a normal state. A conceptual model was developed to illustrate the complexity of movement related to how older adults understand and manage the transition. All participants described starting out being normal until they experienced a major health event (acute or chronic illness). Losing normal involved experiencing a lower level of function both inside and outside the home. Working back to normal was accomplished by two different pathways: those "working to regain" focused on getting back to the level they were at prior to the major health event, whereas those "working to maintain" often involved redefining a new normal. The consequences of the two pathways were quite different, with those working to maintain describing several negative consequences.

DISCUSSION AND IMPLICATIONS

This study provides a detailed understanding of how older adults transition and the complexity of that transition. Findings provide a foundation for broadening our understanding of function beyond typical activities of daily living and reveal a more complex transition process that can span months to years.

ADL recovery trajectory after discharge and its predictors among baseline-independent older inpatients

Background

Among the previous studies about the ADL recovery and its predictors, the researches and resources used to study and protect the baseline-independent older patients from being permanently ADL-dependent was few. We aimed to describe the level of activities of daily living (ADL) at discharge and ADL change within 6 months after discharge in older patients who were ADL-independent before admission but became dependent because of acute illness, and to identify the predictors of early rehabilitation,so as to provide the basis to early intervention.

Methods

Stratified cluster sampling was used to recruit 520 hospitalised older patients who were ADL-independent from departments of internal medicine at two tertiary hospitals from August 2017 to May 2018. Demographics, clinical data, and ADL status at 1, 3, and 6 months after discharge were collected. Data were analysed using descriptive statistics, Student’s t-test, Pearson’s chi-square test,Spearman’s correlation analysis, binary logistic regression analysis, and receiver operating characteristic (ROC) curve analysis.

Results

There were 403 out of 520 patients completing the 6-month follow-up, and 229 (56.8%) regained independence at 6 months after discharge. There was an overall increasing trend in ADL with time. The recovery rate was the highest within the first month after discharge, gradually declined after 1 month, and changed less obviously from 3 to 6 months after discharge (p < 0.001). ADL score at discharge (OR = 1.034, p < 0.001), age (OR = 0.269, p = 0.001), post-discharge residence (OR = 0.390, p < 0.05), and cognition status at discharge (OR = 1.685, p < 0.05) were predictors of ADL recovery. The area under the curve of the four predictors combined was 0.763 (p < 0.001).

Conclusion

Studying ADL recovery rate and its predicting indicators of the baseline independent inpatients at different time points provide a theoretical reference for the formulation of nursing plans and allocation of care resources.

Effectiveness of a simplified reablement program to minimize functional decline in hospitalized older patients

AIM

To examine the effects of a simplified reablement program on physical function and quality of life in hospitalized older patients.

METHODS

The randomized controlled trial enrolled 114 older patients aged ≥65 years who, 2 weeks before admission, had been able to walk independently. Patients randomized to the reablement group received supervision and assistance to carry out the simplified reablement program 30 min daily during their hospital stay. Patients in the reminding group received only oral encouragement to continue the reablement program for 30 min daily. The control group received only usual care that included medical intervention consistent with the patient's diagnosis. The main outcome was improvement in physical function, including the modified version of the Katz Activities of Daily Living (ADL) score, Timed Up and Go test (TUG) and Hand Grip Strength (HGS). Secondary outcomes included the EuroQoL 5 Dimension (EQ-5D) Questionnaire and Visual Analog Scale (VAS).

RESULTS

The intervention had no significant effect on the Katz ADL score. However, a significant within-group improvement in TUG occurred in the reminding group and reablement group. In addition, a significant time-dependent improvement in HGS occurred only in the reablement group. With respect to secondary outcomes, the EQ5D score improved significantly only in the reablement group at 3 months after discharge.

CONCLUSIONS

The simplified reablement program may be beneficial to optimize physical function and improve quality of life in hospitalized older patients. It is recommended that health professionals should assist or encourage older patients to do simplified reablement during their hospital stay. Geriatr Gerontol Int 2020; 20: 436-442.

Strategies older adults use in their work to get back to normal following hospitalization

Loss of function is a significant concern among hospitalized older adults, and prior research suggests they engage in dedicated work to regain "normal" function following hospitalization. This paper aims to describe the strategies older adults use to return to normal function and the conditions that influence their ability to do so. Recently discharged adults aged 65 and older (N = 14) completed in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding. Participants described strategies they used to regain their normal function following hospitalization: doing exercises, expanding physical space, resuming activities and daily cares, and tracking improvement with benchmarks. Several conditions, such as presence of informal and formal support, perceived threats, and poor physical or physiologic function, acted as barriers and facilitators to participants' ability to work back to normal function. Findings increase our understanding of patients' work to regain normal function and have important implications for practice.

Improving Functional Assessment in Older Adults Transitioning From Hospital to Home

PURPOSE/OBJECTIVES

The purpose of this article is to highlight how scientists have assessed all components of functional status in older adults transitioning from hospital to home to date, discuss ways of improving assessment of functional status, and discuss implications for case management research and practice.

PRIMARY PRACTICE SETTING(S)

This article focuses on case management of older adults transitioning from hospital to home.

FINDINGS/CONCLUSIONS

There any many ways to assess functional status, including basic activities of daily living (BADL), instrumental activities of daily living (IADL), and other nonphysical domains of function such as leisure, social, and productive activities. However, assessment of function in older adults transitioning from hospital to home is primarily limited to BADL. Nonphysical domains of functional status have been linked to important outcomes in community-dwelling older adults and could give clinicians and researchers a better understanding of how older adults are functioning, as well as allow for earlier recognition of those who are beginning to experience functional decline.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

In case management, it is important to ask older adults about goals regarding their functional status and how they think about their functioning in the hospital and at home. Early identification of older adults' functional goals while in the hospital is the first step toward regaining their ideal or premorbid function after discharge to home. To best determine baseline functional status, we may need to consider assessments that can measure multiple domains of functioning in older adults, such as the Sickness Impact Profile. Gaining a more comprehensive understanding and assessment of functional status for hospitalized older adults would help inform discharge destinations and improve transitions in care.

Compassionate care intervention for hospital nursing teams caring for older people: a pilot cluster randomised controlled trial

OBJECTIVE

Compassionate care continues to be a focus for national and international attention, but the existing evidence base lacks the experimental methodology necessary to guide the selection of effective interventions for practice. This study aimed to evaluate the Creating Learning Environments for Compassionate Care (CLECC) intervention in improving compassionate care.

SETTING

Ward nursing teams (clusters) in two English National Health Service hospitals randomised to intervention (n=4) or control (n=2). Intervention wards comprised two medicines for older people (MOPs) wards and two medical/surgical wards. Control wards were both MOPs.

PARTICIPANTS

Data collected from 627 patients and 178 staff.

EXCLUSION CRITERIA

reverse barrier nursed, critically ill, palliative or non-English speaking. All other patients and all nursing staff and Health Care Assistant HCAs were invited to participant, agency and bank staff were excluded.

INTERVENTION

CLECC, a workplace intervention focused on developing sustainable leadership and work-team practices to support the delivery of compassionate care.

CONTROL

No educational activity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary-Quality of Interaction Schedule (QuIS) for observed staff-patient interactions. Secondary-patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy).

RESULTS

Trial proceeded as per protocol, randomisation was acceptable. Some but not all blinding strategies were successful. QuIS observations achieved 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more total positive (78% vs 74%) and less total negative (8% vs 11%) QuIS ratings for intervention wards versus control wards. Sixty-three per cent of intervention ward patients scored lowest (ie, more negative) scores on PEECH connection subscale, versus 79% of control. This was not a statistically significant difference. No statistically significant differences in nursing empathy were observed.

CONCLUSIONS

Use of experimental methods is feasible. The use of structured observation of staff-patient interaction quality is a promising outcome measure inclusive of hard to reach groups.

TRIAL REGISTRATION NUMBER

ISRCTN16789770.

Measurement of function in older adults transitioning from hospital to home: an integrative review

Older adults often experience decline in functional status during the transition from hospital to home. In order to determine the effectiveness of interventions to prevent functional decline, researchers must have instruments that are reliable and valid for use with older adults. The purpose of this integrative review is to: (1) summarize the research uses and methods of administering functional status instruments when investigating older adults transitioning from hospital to home, (2) examine the development and existing psychometric testing of the instruments, and (3) discuss gaps and implications for future research. The authors conducted an integrative review of forty research studies that assessed functional status in older adults transitioning from hospital to home. This review reveals important gaps in the functional status instruments' psychometric testing, including limited testing to support their validity and reliability when administered by self-report and limited evidence supporting their ability to detect change over time.

Relationship between engagement and level of functional status in older adults

Functional status is an important component of quality of life for older adults and for their caregivers. Factors associated with level of functional status include age, comorbidity, cognitive status, depression, social support, and activity. Of the types of activity linked with functional status, the strongest evidence is for physical exercise, with weaker evidence for social and productive activity. Engagement is a construct including motivation, commitment, and participation.

Functional trajectories of older patients admitted to an Acute Care Unit for Elders

AIMS AND OBJECTIVES

To describe the functional trajectories of older medical inpatients and to identify factors associated with overall and in-hospital functional decline.

BACKGROUND

Functional decline during a hospital stay is an important clinical outcome because independence remains a major determinant of older persons' quality of life and health care demands.

DESIGN AND METHODS

Participants (n = 189) were admitted to the Acute Care Unit for Elders of a Swiss academic hospital and were aged 65 years and older. Performance in basic activities of daily living at home (self-reported), at hospital admission (observed) and at discharge (observed) was collected. Differences in scores for basic activities daily living between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline. Predictors of in-hospital and overall decline were identified using bivariate and multivariate logistic regression analyses.

RESULTS

Pre-admission, in-hospital and overall functional decline occurred in 56.1%, 17.5% and 43.4% of the participants, respectively. In contrast, in-hospital functional improvement occurred in 40.2% of the participants. No predictors of pre-admission decline were identified, whereas pre-admission performance in instrumental activities of daily living was associated with in-hospital decline. Male gender and in-hospital delirium were associated with overall functional decline.

CONCLUSIONS

Most older inpatients experienced functional decline before their hospital admission, but only a minority experienced decline during their stay. Importantly, delirium was a strong predictor of overall functional decline.

IMPLICATIONS FOR PRACTICE

Low performance in instrumental activities of daily living prior to admission and delirium occurrence identified older patients at higher risk for in-hospital and overall functional decline. Gerontological nurses should play a key role in identifying these patients to provide preventative interventions and recovery care to preserve or restore their functional independence.

Diagnostic validity of the STRATIFY and Downton instruments for evaluating the risk of falls by hospitalised acute-care patients: a multicentre longitudinal study

Background

Falls are major adverse events in hospitals. The appropriateness of using risk assessment instruments for falls in hospitals has recently been questioned, although the research performed in this respect presents some methodological shortcomings. The purpose of the present study is to evaluate the accuracy of the Downton and STRATIFY instruments to determine the risk of falls and to predict their incidence in acute care hospitals in the public health system in Andalusia (Spain).

Methods

A longitudinal, multicentre prospective study was made of a cohort of patients recruited between May 2014 and March 2016. The risk of falls was assessed using each of the above instruments during the first 24 h after hospital admittance, with later re-evaluations every 72 h until discharge. Descriptive statistics were obtained, bivariate and multivariate analysis were performed. The diagnostic validity of the process was assessed by calculations of sensitivity, specificity, positive and negative predictive values and ratios of positive and negative likelihood. ROC curve analysis was performed for both instruments.

Results

For this study, 1247 patients were recruited, of whom 977 completed all the follow-up assessments. Twenty-three of these patients (2.35%) suffered 24 falls. ROC curve analysis showed that the optimal cut-off point for each assessment instrument was below that described by the authors: AUC STRATIFY = 0.69 (95% CI: 0.57–0.8); AUC Downton = 0.6 (95% CI: 0.48–0.72). With a cut-off point of 1, the sensitivity of STRATIFY was 47.6% and its specificity, 85%. With a cut-off point of 2, Downton presented a sensitivity of 66.7% and a specificity of 55.3%.

Conclusions

The Downton and STRATIFY falls risk assessment instruments presented little utility as means of detecting the risk of falls among a sample of adult patients admitted to acute care hospitals. Fall prevention in hospitals should be based on the study of individual risk factors.

Hospital-acquired functional decline in older patients cared for in acute medical wards and predictors: Findings from a multicentre longitudinal study

Describing the trajectories of hospital-associated functional decline in older patients admitted to acute medical units and identifying predictors at the individual, nursing, and hospital levels, were the aims of the study. A longitudinal survey among 12 acute medical units in which 1464 patients were consecutively enrolled and evaluated using the Barthel Index (BI), was performed. Functional decline was defined as a decrease in the BI of at least 5 points from admission to discharge. In all, 17.1% participants (n = 251) demonstrated functional decline. In accordance with multiple logistic regression analysis, 28.8% (R(2)) of the variance in the functional decline was explained by: confusion/disorientation (RR = 4.684; 95% CI = 3.144-6.978), admission from nursing homes (RR = 2.464; 95% CI = 1.642-3.697), daily care expressed in minutes offered by nursing aides (RR = 1.535; 95% CI = 1.275-1.849), higher workforce skill-mix (RR = 2.221; 95% CI = 1.763-2.797), bladder catheter insertion (RR = 1.599; 95% CI = 1.128-2.268), and higher BI score at admission (RR = 1.019; 95% CI = 1.014-1.024). Increasing the amount of care delivered by competent nurses-having a bachelors degree-providing and supervising direct-care activities, may reduce the occurrence of functional decline in older patients admitted to medical units.

From research to reality: minimizing the effects of hospitalization on older adults

This review examines ways to decrease preventable effects of hospitalization on older adults in acute care medical (non-geriatric) units, with a focus on the Israeli experience at the Rambam Health Care Campus, a large tertiary care hospital in northern Israel. Hospitalization of older adults is often followed by an irreversible decline in functional status affecting their quality of life and well-being after discharge. Functional decline is often related to avoidable effects of in-hospital procedures not caused by the patient's acute disease. In this article we review the literature relating to the recognized effects of hospitalization on older adults, pre-hospitalization risk factors, and intervention models for hospitalized older adults. In addition, this article describes an Israeli comprehensive research study, the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), and outlines the design of a combined intervention model being implemented at the Rambam Health Care Campus. The majority of the reviewed studies identified preadmission personal risk factors and psychosocial risk factors. In-hospital restricted mobility, under-nutrition care, over-use of continence devices, polypharmacy, and environmental factors were also identified as avoidable processes. Israeli research supported the findings that preadmission risk factors together with in-hospital processes account for functional decline. Different models of care have been developed to maintain functional status. Much can be achieved by interdisciplinary teams oriented to the needs of hospitalized elderly in making an impact on hospital processes and continuity of care. It is the responsibility of health care policy-makers, managers, clinicians, and researchers to pursue effective interventions to reduce preventable hospitalization-associated disability.

Circumstances and causes of falls by patients at a Spanish acute care hospital

RATIONALE, AIMS AND OBJECTIVES

A major problem in hospitals is that of falls, which can seriously reduce patients' quality of life. Fall rates vary considerably depending on health care practices, the hospital environment and the measurement method used. The aim of this study was to determine the characteristics of hospitalized acute patients who suffer falls, by analysing the distribution and the profile of these patients.

METHODS

This is an analytic cross-sectional study conducted at a Spanish hospital. All patients who suffered a fall during hospitalization in 2011 were studied by analysing the computerized register of falls. Downton index, circumstances and consequences of falls were analysed. Descriptive statistics, bivariate analysis and logistic regression analysis were performed.

RESULTS

The frequency of falls was 0.64%. The rate of falls increased with age (mean age: 71.06 years). The highest percentage occurred among patients in the medical care area (63.7%). The probability of suffering a fall was 1.33 times higher among men than women. Differences in age, type of risk of fall and circumstances were found, depending on the type of hospitalization. Multivariate analysis revealed that patients in the medical care area suffered more falls with consequences: 7.01 [95% confidence interval (CI): 1.34-36.79], as did the patients classified as 'low risk': 2.40 (CI 95%: 1.02-5.65).

CONCLUSIONS

Falls have diverse causes. Determining these circumstances can contribute to promoting a culture of prevention and to reducing the injuries provoked by falls. Notification procedures should be standardized in order to enable comparisons among different environments.