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Persaud E, Nissley C, Piasecki E, Quinn C. Transition of Care for Older Adults Undergoing General Surgery. Crit Care Nurs Clin North Am 2023; 35:453-467. [PMID: 37838418 DOI: 10.1016/j.cnc.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
The demand for surgical intervention and hospitalization is expected to increase with the growth of the older adult population. Despite advances in technology and minimally invasive surgical procedures, the needs of the older adult in the perioperative period are unique. Transitions of care from the decision to support surgery through surgical intervention, subsequent hospitalization, and postacute discharge must be supported to achieve optimal patient outcomes. The clinical nurse specialist is well suited to address care delivery and assure implementation of best practices across the continuum.
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Affiliation(s)
- Elissa Persaud
- Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5866, USA.
| | - Courtney Nissley
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
| | - Eric Piasecki
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
| | - Carrie Quinn
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
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2
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Fan L, Xue H, Wang Q, Yan Y, Du W. Development and Validation of a Nomogram for Predicting Risk of Emergency Department Revisits in Chinese Older Patients. Healthc Policy 2022; 15:2283-2295. [PMID: 36510569 PMCID: PMC9738955 DOI: 10.2147/rmhp.s391731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022] Open
Abstract
Objective The identification of older patients at risk of repeated emergency department (ED) visits is crucial for managing preventable adverse outcomes. This study aims to identify risk factors associated with ED revisits and to develop and validate a nomogram for predicting risk of geriatric ED revisits. Methods This was a cohort study comprising 553 older patients, who attended the two tertiary hospitals EDs in China from August 2018 to February 2019 and were prospectively followed for any unplanned revisit within 1 year after discharge. Patients were randomly assigned to a training or validation set at a ratio of 2:1. Stepwise selection procedure was applied to select factors associated with ED revisits for inclusion in a multivariable logistic model from which a nomogram was elaborated. Discrimination, calibration and clinical utility of the nomogram were assessed using C-statistic, calibration plot, Hosmer-Lemeshow test, and decision curve analysis (DCA). Results The final nomogram included four predictors for ED revisits: age, BMI, frailty and polypharmacy. Older patients having revisits were more likely to be frail (OR = 1.17, p = 0.031), have polypharmacy (OR = 1.69, p = 0.049) or BMI <18.5 kg/m2 (OR = 2.45, p = 0.025), and were less likely to be older than 90 years (OR = 0.21, p = 0.002). The nomogram demonstrated acceptable discrimination ability in the training (C-index = 0.661) and validation sets (C-index = 0.651), satisfactory calibration (p > 0.05), and good clinical applicability. Conclusion A nomogram incorporating four obtainable variables was constructed to individualize ED readmission risk in older patients. These patients may benefit from early triage and better-targeted care if considering the nomogram as a clinical decision aid.
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Affiliation(s)
- Lijun Fan
- School of Public Health, Southeast University, Nanjing, People’s Republic of China,School of Public Health, Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Hui Xue
- School of Public Health, Southeast University, Nanjing, People’s Republic of China
| | - Qian Wang
- Guangdong Provincial Geriatrics Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Yuhan Yan
- General Hospital of Eastern Theater Command, Nanjing, People’s Republic of China,Yuhan Yan, General Hospital of Eastern Theater Command, Nanjing, 210009, People’s Republic of China, Email
| | - Wei Du
- School of Public Health, Southeast University, Nanjing, People’s Republic of China,Correspondence: Wei Du, School of Public Health, Southeast University, Nanjing, 210009, People’s Republic of China, Email
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3
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Carter B, Keevil VL, Anand A, Osuafor CN, Goudie RJB, Preller J, Lowry M, Clunie S, Shenkin SD, McCarthy K, Hewitt J, Quinn TJ. The Prognostic and Discriminatory Utility of the Clinical Frailty Scale and Modified Frailty Index Compared to Age. Geriatrics (Basel) 2022; 7:geriatrics7050087. [PMID: 36136796 PMCID: PMC9498791 DOI: 10.3390/geriatrics7050087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/12/2022] [Accepted: 08/21/2022] [Indexed: 02/08/2023] Open
Abstract
Background: There is no consensus on the optimal method for the assessment of frailty. We compared the prognostic utility of two approaches (modified Frailty Index [mFI], Clinical Frailty Scale [CFS]) in older adults (≥65 years) hospitalised with COVID-19 versus age. Methods: We used a test and validation cohort that enrolled participants hospitalised with COVID-19 between 27 February and 30 June 2020. Multivariable mixed-effects logistic modelling was undertaken, with 28-day mortality as the primary outcome. Nested models were compared between a base model, age and frailty assessments using likelihood ratio testing (LRT) and an area under the receiver operating curves (AUROC). Results: The primary cohort enrolled 998 participants from 13 centres. The median age was 80 (range:65−101), 453 (45%) were female, and 377 (37.8%) died within 28 days. The sample was replicated in a validation cohort of two additional centres (n = 672) with similar characteristics. In the primary cohort, both mFI and CFS were associated with mortality in the base models. There was improved precision when fitting CFS to the base model +mFI (LRT = 25.87, p < 0.001); however, there was no improvement when fitting mFI to the base model +CFS (LRT = 1.99, p = 0.16). AUROC suggested increased discrimination when fitting CFS compared to age (p = 0.02) and age +mFI (p = 0.03). In contrast, the mFI offered no improved discrimination in any comparison (p > 0.05). Similar findings were seen in the validation cohort. Conclusions: These observations suggest the CFS has superior prognostic value to mFI in predicting mortality following COVID-19. Our data do not support the use of the mFI as a tool to aid clinical decision-making and prognosis.
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Affiliation(s)
- Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Victoria L. Keevil
- Department of Medicine for the Elderly, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Atul Anand
- Centre for Cardiovascular Science, Queens Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Christopher N. Osuafor
- Department of Medicine for the Elderly, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Robert J. B. Goudie
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge CB2 0SR, UK
| | - Jacobus Preller
- Department of Acute Internal Medicine and Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Matthew Lowry
- Geriatric Medicine, Usher Institute, University of Edinburgh; Edinburgh EH16 4UX, UK
| | - Sarah Clunie
- Geriatric Medicine, Usher Institute, University of Edinburgh; Edinburgh EH16 4UX, UK
| | - Susan D. Shenkin
- Geriatric Medicine, Usher Institute, University of Edinburgh; Edinburgh EH16 4UX, UK
| | - Kathryn McCarthy
- Department of Surgery and Care of the Elderly, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Jonathan Hewitt
- Division of Population Medicine, Cardiff University, Cardiff CF10 3AT, UK
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
- Correspondence:
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Occurrence and outcomes of possible superadded infections in older adults with COVID-19-cohort study. Eur Geriatr Med 2022; 13:1161-1167. [PMID: 35829905 PMCID: PMC9553794 DOI: 10.1007/s41999-022-00675-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022]
Abstract
Aim To investigate the outcomes and prevalence of superadded infections in older adults with COVID-19. Findings Possible superadded infection is common in older adults hospitalized with COVID-19 and was associated with longer inpatient stay and higher mortality. Message Clinicians should have a low threshold to assess for other sources of infection in older adults with COVID-19. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00675-9. Purpose Current guidance discourages use of antibiotics in COVID-19. However, in older adults, superadded infection may be common and require treatment. Our aim was to investigate the occurrence and outcomes from possible superadded infections, occurring within 2 weeks of hospitalization, in older adults with COVID-19. Methods This was a single centre, observational cohort study. We collected data from patients admitted to older adult wards who had tested positive for the Sars-CoV-2 virus on viral PCR between 1st October and 1st December 2020. The primary outcome was inpatient death occurring within 90 days of COVID-19 diagnosis. The secondary outcome was length of stay in hospital. Associations were described using univariable and multivariable models, and time to event data. Results Of 266 patients with COVID-19, 43% (115) had evidence of superadded infections (91 with positive bacterial cultures and 36 instances of radiological lobar consolidation). Patients with superadded infections were more likely to die (45.2 versus 30.7%, p = 0.020) and had an increased length of stay (23 versus 18 days, p = 0.026). Conclusions Recommendations to avoid antibiotics in COVID-19 may not be applicable to an older adult population. Assessing for possible superadded infections is warranted in this group. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00675-9.
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Dewhurst F, Stow D, Paes P, Frew K, Hanratty B. Clinical frailty and performance scale translation in palliative care: scoping review. BMJ Support Palliat Care 2022; 12:bmjspcare-2022-003658. [PMID: 35649714 DOI: 10.1136/bmjspcare-2022-003658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Frailty is associated with advancing age and increases the risk of adverse outcomes and death. Routine assessment of frailty is becoming more common in a number of healthcare settings, but not in palliative care, where performance scales (eg, the Australia-modified Karnofsky Performance Status Scale (AKPS)) are more commonly employed. A shared understanding of performance and frailty measures could aid interspecialty collaboration in both end-of-life care research and clinical practice. AIMS To identify and synthesise evidence comparing measures of performance routinely collected in palliative care with the Clinical Frailty Scale (CFS), and create a conversion chart to support interspecialty communication. METHODS A scoping literature review with comprehensive searches of PubMed, Web of Science, Ovid SP, the Cochrane Library and reference lists. Eligible articles compared the CFS with the AKPS, Palliative Performance Scale (PPS), Karnofsky Performance Scale or Eastern Cooperative Oncology Group Performance Status or compared these performance scales, in patients aged >18 in any setting. RESULTS Searches retrieved 3124 articles. Two articles directly compared CFS to the PPS. Thirteen studies translated between different performance scores, facilitating subsequent conversion to CFS, specifically: AKPS/PPS 10/20=very severe frailty, AKPS/PPS 30=severe frailty, AKPS/PPS 40/50=moderate frailty, AKPS/PPS60=mild frailty. CONCLUSION We present a tool for converting between the CFS and performance measures commonly used in palliative care. A small number of studies provided evidence for the direct translation between CFS and the PPS. Therefore, more primary evidence is needed from a wider range of population settings, and performance measures to support this conversion.
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Affiliation(s)
- Felicity Dewhurst
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- Palliative Medicine, St Oswald's Hospice, Newcastle upon Tyne, UK
| | - Daniel Stow
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Paul Paes
- Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine Frew
- Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Barbara Hanratty
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
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The Diagnostic Accuracy and Clinimetric Properties of Screening Instruments to Identify Frail Older Adults Attending Emergency Departments: A Protocol for a Mixed Methods Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031380. [PMID: 35162397 PMCID: PMC8834939 DOI: 10.3390/ijerph19031380] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 01/23/2023]
Abstract
Background: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. Methods: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. Conclusion: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.
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Liu X, Le MK, Lim AYC, Koh EJ, Nguyen TN, Malik NA, Lien CTC, Lee JE, Au LSY, Low JAYH, Wee SL. Perspectives on frailty screening, management and its implementation among acute care providers in Singapore: a qualitative study. BMC Geriatr 2022; 22:58. [PMID: 35039007 PMCID: PMC8762449 DOI: 10.1186/s12877-021-02686-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND COVID-19 pandemic has reminded how older adults with frailty are particularly exposed to adverse outcomes. In the acute care setting, consideration of evidence-based practice related to frailty screening and management is needed to improve the care provided to aging populations. It is important to assess for frailty in acute care so as to establish treatment priorities and goals for the individual. Our study explored understanding on frailty and practice of frailty screening among different acute care professionals in Singapore, and identify barriers and facilitators concerning frailty screening and its implementation. METHODS A qualitative study using focus group discussion among nurses and individual interviews among physicians from four departments (Accident & Emergency, Anesthesia, General Surgery, Orthopedics) in three acute hospitals from the three public health clusters in Singapore. Participants were recruited through purposive sampling of specific clinicians seeing a high proportion of older patients at the hospitals. Thematic analysis of the data was performed using NVIVO 12.0. RESULTS Frailty was mainly but inadequately understood as a physical and age-related concept. Screening for frailty in acute care was considered important to identify high risk patients, to implement targeted treatment and care, and to support decision making and prognosis estimation. Specific issues related to screening, management and implementation were identified: cooperation from patient/caregivers, acceptance from healthcare workers/hospital managers, need for dedicated resources, guidelines for follow-up management and consensus on the scope of measurement for different specialties. CONCLUSION Our findings indicated the need for 1) frailty-related education program for patients/care givers and stakeholders 2) inter-professional collaboration to develop integrated approach for screening and management of hospital patients with frailty and 3) hospital-wide consensus to adopt a common frailty screening tool.
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Affiliation(s)
- Xiao Liu
- Geriatric Education and Research Institute, Yishun, Singapore
| | - Mai Khanh Le
- Geriatric Education and Research Institute, Yishun, Singapore
| | | | - Emily Jiali Koh
- Geriatric Education and Research Institute, Yishun, Singapore
| | - Tu Ngoc Nguyen
- Geriatric Education and Research Institute, Yishun, Singapore
| | | | | | - Jer En Lee
- Woodlands Health Campus, Yishun, Singapore
| | | | - James Alvin Yiew Hock Low
- Geriatric Education and Research Institute, Yishun, Singapore
- Khoo Teck Puat Hospital, Yishun, Singapore
| | - Shiou Liang Wee
- Geriatric Education and Research Institute, Yishun, Singapore.
- Health and Social Sciences Cluster, Singapore Institute of Technology, Dover, Singapore.
- , Yishun, Singapore.
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8
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Sarkar S, MacLeod JB, Hassan A, Dutton DJ, Brunt KR, Légaré JF. An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costs. JTCVS OPEN 2021; 8:491-502. [PMID: 36004086 PMCID: PMC9390592 DOI: 10.1016/j.xjon.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 10/19/2021] [Indexed: 10/29/2022]
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9
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Mooijaart SP, Nickel CH, Conroy SP, Lucke JA, van Tol LS, Olthof M, Blomaard LC, Buurman BM, Dundar ZD, de Groot B, Gasperini B, Heeren P, Karamercan MA, McNamara R, Mitchell A, van Oppen JD, Martin Sanchez FJ, Schoon Y, Singler K, Spode R, Skúldóttir S, Thorrsteindottir T, van der Velde M, Wallace J. A European Research Agenda for Geriatric Emergency Medicine: a modified Delphi study. Eur Geriatr Med 2021; 12:413-422. [PMID: 33219983 PMCID: PMC7990812 DOI: 10.1007/s41999-020-00426-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/29/2020] [Indexed: 11/01/2022]
Abstract
PURPOSE Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe. METHODS A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions. RESULTS In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED? CONCLUSION This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.
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Affiliation(s)
- Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
- Institute for Evidence-Based Medicine for Older People (IEMO), Leiden, The Netherlands.
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jacinta A Lucke
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Lisa S van Tol
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Mareline Olthof
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Laura C Blomaard
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Bianca M Buurman
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Zerrin D Dundar
- Department of Emergency Medicine, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Beatrice Gasperini
- Department of Geriatrics and Rehabilitation, Santa Croce Hospital, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Fano, Italy
| | - Pieter Heeren
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Mehmet A Karamercan
- Department of Emergency Medicine, Gazi University School of Medicine, Ankara, Turkey
| | - Rosa McNamara
- Department of Emergency Medicine, St. Vincent University Hospital, Dublin, Ireland
| | - Aine Mitchell
- Department of Emergency Medicine, Sligo University Hospital, Sligo, Ireland
| | - James D van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - F Javier Martin Sanchez
- Emergency Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Madrid, Spain
| | - Yvonne Schoon
- Department of Emergency Medicine and Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Katrin Singler
- Department of Geriatrics, Klinikum Nürnberg, Paracelsus Private, Medical University, Nuremberg, Germany
| | - Renan Spode
- Department of Emergency Medicine, Charité University Hospital, Berlin, Germany
| | - Sigrun Skúldóttir
- Research Institute in Emergency Care, Landspitali National University Hospital of Iceland, Reykjavík, Iceland
- The Icelandic Gerontological Research Institute, Reykjavík, Iceland
| | - Thordis Thorrsteindottir
- Research Institute in Emergency Care, Landspitali National University Hospital of Iceland, Reykjavík, Iceland
| | | | - James Wallace
- Emergency Department, Warrington and Halton Hospitals NHS Teaching Trust, Warrington, England, UK
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10
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Improving the care for older emergency department patients: the Acutely Presenting Older Patient study. Z Gerontol Geriatr 2021; 54:97-98. [PMID: 33693970 PMCID: PMC7945600 DOI: 10.1007/s00391-021-01856-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/20/2021] [Indexed: 10/26/2022]
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Etkind SN, Lovell N, Bone AE, Guo P, Nicholson C, Murtagh FEM, Higginson IJ. The stability of care preferences following acute illness: a mixed methods prospective cohort study of frail older people. BMC Geriatr 2020; 20:370. [PMID: 32993526 PMCID: PMC7523327 DOI: 10.1186/s12877-020-01725-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/19/2020] [Indexed: 11/16/2022] Open
Abstract
Background Patient preferences are integral to person-centred care, but preference stability is poorly understood in older people, who may experience fluctuant illness trajectories with episodes of acute illness. We aimed to describe, and explore influences on the stability of care preferences in frail older people following recent acute illness. Methods Mixed-methods prospective cohort study with dominant qualitative component, parallel data collection and six-month follow up. Study population: age ≥ 65, Rockwood Clinical Frailty score ≥ 5, recent acute illness requiring acute assessment/hospitalisation. Participants rated the importance of six preferences (to extend life, improve quality of life, remain independent, be comfortable, support ‘those close to me’, and stay out of hospital) at baseline, 12 and 24 weeks using a 0–4 scale, and ranked the most important. A maximum-variation sub-sample additionally contributed serial in-depth qualitative interviews. We described preference stability using frequencies and proportions, and undertook thematic analysis to explore influences on preference stability. Results 90/192 (45%) of potential participants consented. 82/90 (91%) answered the baseline questionnaire; median age 84, 63% female. Seventeen undertook qualitative interviews. Most participants consistently rated five of the six preferences as important (range 68–89%). ‘Extend life’ was rated important by fewer participants (32–43%). Importance ratings were stable in 61–86% of cases. The preference ranked most important was unstable in 82% of participants. Preference stability was supported by five influences: the presence of family support; both positive or negative care experiences; preferences being concordant with underlying values; where there was slowness of recovery from illness; and when preferences linked to long term goals. Preference change was related to changes in health awareness, or life events; if preferences were specific to a particular context, or multiple concurrent preferences existed, these were also more liable to change. Conclusions Preferences were largely stable following acute illness. Stability was reinforced by care experiences and the presence of family support. Where preferences were unstable, this usually related to changing health awareness. Consideration of these influences during preference elicitation or advance care planning will support delivery of responsive care to meet preferences. Obtaining longer-term data across diverse ethnic groups is needed in future research.
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Affiliation(s)
- S N Etkind
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Bessemer Road, London, SE59PJ, UK. .,Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - N Lovell
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Bessemer Road, London, SE59PJ, UK
| | - A E Bone
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Bessemer Road, London, SE59PJ, UK
| | - P Guo
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Bessemer Road, London, SE59PJ, UK.,School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - C Nicholson
- St Christopher's Hospice, London, UK.,University of Surrey, Faculty of Health and Medical Sciences, Guildford, UK
| | - F E M Murtagh
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Bessemer Road, London, SE59PJ, UK.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - I J Higginson
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Bessemer Road, London, SE59PJ, UK.,King's College Hospitals NHS Foundation Trust, London, UK
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12
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Carpenter CR, Mooijaart SP. Geriatric Screeners 2.0: Time for a Paradigm Shift in Emergency Department Vulnerability Research. J Am Geriatr Soc 2020; 68:1402-1405. [DOI: 10.1111/jgs.16502] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/11/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Christopher R. Carpenter
- Department of Emergency MedicineWashington University in St. Louis School of Medicine, Emergency Care Research Core St. Louis Missouri USA
| | - Simon P. Mooijaart
- Department of Geriatrics and GerontologyLeiden University Medical Center Leiden The Netherlands
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13
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Gee SB, Cheung G, Bergler U, Jamieson H. "There's More to Frail than That": Older New Zealanders and Health Professionals Talk about Frailty. J Aging Res 2019; 2019:2573239. [PMID: 31915552 PMCID: PMC6930781 DOI: 10.1155/2019/2573239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/15/2019] [Accepted: 10/26/2019] [Indexed: 11/17/2022] Open
Abstract
There is general agreement that frailty is common and important in later life, but there is less agreement about what frailty is. Little is known about the extent to which practicing health professionals and older people hold a mutual understanding of frailty. Focus groups were held to engage older people and health professionals in discussion about what made them think that someone was frail. Eighteen older people took part across three focus groups, and se'venteen health professionals took part across another three focus groups. Both the health professionals and the older people talked about the experience of frailty as an interplay of physical, psychological, and social dimensions. Older people with frailty were seen as needing help and being vulnerable to adverse outcomes, but accepting help was positioned by older people as an adaptive choice. The experience of frailty was described as being mediated by the individual's psychological mindset, highlighting the importance of approaches that recognise strengths and resilience. A broader and more balanced understanding of frailty may help create more rounded and appropriate approaches to assessment and management.
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Affiliation(s)
- Susan B. Gee
- University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand
| | - Gary Cheung
- University of Auckland, Auckland 1023, New Zealand
| | - Ulrich Bergler
- University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand
| | - Hamish Jamieson
- University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand
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14
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McGrath J, Almeida P, Law R. The Whittington Frailty Pathway: improving access to comprehensive geriatric assessment: an interdisciplinary quality improvement project. BMJ Open Qual 2019; 8:e000798. [PMID: 31803856 PMCID: PMC6887502 DOI: 10.1136/bmjoq-2019-000798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/16/2019] [Accepted: 11/01/2019] [Indexed: 11/13/2022] Open
Abstract
National guidelines mandate identification and tailored management of patients living with frailty who attend the acute hospital setting. We describe using quality improvement (QI) techniques to embed a system that allowed identification of frailty in older patients attending the emergency department (ED), creation of a clinical pathway to facilitate comprehensive geriatric assessment and appropriate same-day discharge of suitable patients. Integration of Clinical Frailty Scale (CFS) scoring within an electronic record system, a continuing programme of education and awareness, and dedicated project staff allows patients to be identified for an ambulatory frailty pathway. Our results show a sustained improvement over 9 months of the project, with 73% of patients over the age of 75 years presenting to ED by ambulance now receiving a CFS score. Over 300 patients have been identified, transferred to ambulatory care and treated via a new frailty pathway, with an admission rate for this cohort of 14%, compared with an overall admission rate of 50% for patients over 75 years. We report a decrease in overall ED admission of 1%. Analysis of patients discharged through this same-day pathway showed a 7-day ED reattendance rate of 15.1% and a 30-day readmission rate of 18.9%, which are comparable with current pathways. Consultant review estimated 87% of patients to have avoided a longer admission. Patient and staff satisfaction indicates this pathway to be feasible and acceptable to users. Our data suggest an ambulatory frailty pathway can deliver significant admission avoidance while maintaining low readmission rates. Similar schemes in other hospitals should consider using QI approaches to implementation of frailty pathways.
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Affiliation(s)
- John McGrath
- Islington GP Federation, NHS Islington CCG, London, UK.,Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
| | - Paula Almeida
- Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
| | - Ruth Law
- Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
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15
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Affiliation(s)
- Ruth Benson
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Gordon McGregor
- Centre for Sport, Exercise & Life Sciences, Coventry University, Coventry, UK
| | - Mishkat Shehata
- Unit of Academic Primary Care, University of Warwick, Coventry, UK
| | - Christopher Imray
- Warwick Medical School, Coventry University and Exeter University, UK
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16
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Taylor-Rowan M, Cuthbertson G, Keir R, Shaw R, Drozdowska B, Elliott E, Stott D, Quinn TJ. The prevalence of frailty among acute stroke patients, and evaluation of method of assessment. Clin Rehabil 2019; 33:1688-1696. [DOI: 10.1177/0269215519841417] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objective:We aimed to determine prevalence of pre-stroke frailty in acute stroke and describe validity of a Frailty Index–based assessment.Design:Cross-sectional.Setting:Single UK urban teaching hospital.Subjects:Consecutive acute stroke unit admissions, recruited in four waves (May 2016–August 2018). We performed the assessments within first week and attempted to include all admissions.Main measures:Our primary measure was a Frailty Index, based on cumulative disorders. A proportion of participants were also assessed with the ‘Frail non-disabled’ questionnaire. We evaluated concurrent validity of Frailty Index against variables associated with frailty in non-stroke populations. We described predictive validity of Frailty Index for stroke severity and delirium. We described convergent validity, quantifying agreement between frailty assessments and a measure of pre-stroke disability (modified Rankin Scale) using kappa statistics and correlations.Results:We included 546 patients. A Frailty Index–defined frailty syndrome was observed in 427 of 545 patients (78%), of whom, 151 (28%) had frank frailty and 276 (51%) were pre-frail. Phenotypic frailty was observed in 72 of 258 patients (28%). We demonstrated concurrent validity via significant associations with all variables (all p < 0.01). We demonstrated predictive validity for stroke severity and delirium ( p < 0.01). Agreement between the frailty measures was poor (kappa = –0.06) and convergent validity was moderate (Frail non-disabled ‘Cramer’s V’ = 0.25; modified Rankin Scale ‘Cramer’s V’ = 0.47).Conclusion:Frailty is present in around one in four patients with acute stroke; if pre-frailty is included, then a frailty syndrome is seen in three out of four patients. The Frailty Index is a valid measure of frailty in stroke; however, there is little agreement between this scale and other measurements of frailty.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Gillian Cuthbertson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ruth Keir
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Robert Shaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Bogna Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emma Elliott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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17
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Thompsell AAB, Sachdev K, Das-Munshi J, Rao T. Substance misuse in older adults with frailty. BMJ 2019; 364:l958. [PMID: 30846428 DOI: 10.1136/bmj.l958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Kapila Sachdev
- Tower Hamlets Centre for Mental Health, Robinson Centre, Mile End Hospital, London, UK
| | - Jayati Das-Munshi
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
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