Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP)

Machine learning models for identifying pre-frailty in community dwelling older adults

Background

There is increasing evidence that pre-frailty manifests as early as middle age. Understanding the factors contributing to an early trajectory from good health to pre-frailty in middle aged and older adults is needed to inform timely preventive primary care interventions to mitigate early decline and future frailty.

Methods

A cohort of 656 independent community dwelling adults, aged 40–75 years, living in South Australia, undertook a comprehensive health assessment as part of the Inspiring Health cross-sectional observational study. Secondary analysis was completed using machine learning models to identify factors common amongst participants identified as not frail or pre-frail using the Clinical Frailty Scale (CFS) and Fried Frailty Phenotype (FFP). A correlation-based feature selection was used to identify factors associated with pre-frailty classification. Four machine learning models were used to derive the prediction models for classification of not frail and pre-frail. The class discrimination capability of the machine learning algorithms was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision, F1-score and accuracy.

Results

Two stages of feature selection were performed. The first stage included 78 physiologic, anthropometric, environmental, social and lifestyle variables. A follow-up analysis with a narrower set of 63 variables was then conducted with physiologic factors associated with the FFP associated features removed, to uncover indirect indicators connected with pre-frailty. In addition to the expected physiologic measures, a range of anthropometric, environmental, social and lifestyle variables were found to be associated with pre-frailty outcomes for the cohort. With FFP variables removed, machine learning (ML) models found higher BMI and lower muscle mass, poorer grip strength and balance, higher levels of distress, poor quality sleep, shortness of breath and incontinence were associated with being classified as pre-frail. The machine learning models achieved an AUC score up to 0.817 and 0.722 for FFP and CFS respectively for predicting pre-frailty. With feature selection, the performance of ML models improved by up to + 7.4% for FFP and up to + 7.9% for CFS.

Conclusions

The results of this study indicate that machine learning methods are well suited for predicting pre-frailty and indicate a range of factors that may be useful to include in targeted health assessments to identify pre-frailty in middle aged and older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03475-9.

Nursing, frailty, functional decline and models of care in relation to older people receiving long-term care: a scoping review protocol

INTRODUCTION

Older people receiving healthcare in long-term care contexts (eg, home healthcare, sheltered housing and nursing home contexts) are especially vulnerable to developing frailty and functional decline. Considering the negative effects associated with these conditions and the possibility of preventing them from progressing, it is vital that nurses possess a broad knowledge base related to them. Particularly as prevention related to these conditions lies well within their remit. Such knowledge could guide the development of effective models of care, ensuring continuity and, hence, quality of care. Our objective will be to review published literature on existing models of care targeting frailty and/or functional decline and how these conditions are described by older people themselves, significant others and nurses in relation to long-term care.

METHODS AND ANALYSIS

The scoping review will be conducted in accordance with Arksey and O'Malley's methodological framework. Recent methodological developments will be considered. PubMed, CINAHL and PsycINFO will be searched. Eligibility criteria will be peer-reviewed papers and written in English. All types of study designs will be eligible and included papers will be quality and ethically assessed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Protocol checklist for protocols and the PRISMA for Scoping Reviews checklist were followed in this paper.

ETHICS AND DISSEMINATION

As the study outlined in this protocol is a scoping review, no ethics approval was needed for this protocol nor for the upcoming study. The findings will be published in an open-access, peer-reviewed journal. Additionally, the findings will guide a research project following the Medical Research Council's framework for developing and evaluating complex interventions. Thus, supporting us in developing a model of care related to the detection and prevention of frailty and/or functional decline among older people in a long-term care context.

Development and validation of the geriatric trauma frailty index for geriatric trauma patients based on electronic hospital records

BACKGROUND

Globally, geriatric patients are the dominant population requiring global medical care. We established a frailty index for geriatric trauma patients by retrospectively analysing electronic hospital records to identify patients with frailty characteristics and poor prognostic outcomes.

METHOD

Data were obtained from 2016 US National Emergency Department Sample and Shanghai Trauma Emergency Medical Association (2015-18). Overall, 141,267 hospitalised geriatric trauma patients (age ≥ 65 years) were included. We used a three-step method to construct geriatric trauma frailty index (GTFI) based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic codes. Systematic cluster analysis was used. The accuracy of GTFI was verified in national validation cohort, and its applicability to Chinese patients was assessed in local validation cohort.

RESULTS

In development cohort (n = 28,179), frail patients had longer lengths of stay and higher Charlson co-morbidity index than non-frail patients (18.2 ± 12.4 days, 5.59 ± 2.0 versus 5.3 ± 5.3 days, 5.33 ± 1.8, respectively). In national validation cohort (n = 113,089), frail patients had longer lengths of stay (8.5 ± 8.8 days versus 4.5 ± 3.1 days) and higher in-hospital mortality than non-frail patients (2,795, 11.69% versus 589, 0.66%). Areas under the curves for GTFI for length of stay (>14 days) and in-hospital mortality were 0.848 (0.841, 0.854) and 0.885 (0.880, 0.891) in national validation cohort, and were 0.791 (0.779, 0.804) and 0.903 (0.885, 0.922) in local validation cohort (n = 14,827).

CONCLUSIONS

The GTFI helps hospitals and emergency departments to identify geriatric trauma patients with poor prognostic outcomes, and has been proven to be useful in China.

Gait changes over time in hospitalized older adults with advanced dementia: Predictors of mobility change

People with dementia are at risk of mobility decline. In this study, we measured changes in quantitative gait measures over a maximum 10-week period during the course of a psychogeriatric admission in older adults with dementia, with the aims to describe mobility changes over the duration of the admission, and to determine which factors were associated with this change. Fifty-four individuals admitted to a specialized dementia inpatient unit participated in this study. A vision-based markerless motion capture system was used to record participants’ natural gait. Mixed effect models were developed with gait measures as the dependent variables and clinical and demographic variables as predictors. We found that gait stability, step time, and step length decreased, and step time variability and step length variability increased over 10 weeks. Gait stability of men decreased more than that of women, associated with an increased sacrum mediolateral range of motion over time. In addition, the sacrum mediolateral range of motion decreased in those with mild neuropsychiatric symptoms over 10 weeks, but increased in those with more severe neuropsychiatric symptoms. Our study provides evidence of worsening of gait mechanics and control over the course of a hospitalization in older adults with dementia. Quantitative gait monitoring in hospital environments may provide opportunities to intervene to prevent adverse events, decelerate mobility decline, and monitor rehabilitation outcomes.

Flucloxacillin-induced liver injury in elderly patient

Flucloxacillin is a penicillin antibiotic used as first-line treatment for soft tissue infections caused by Staphylococcus aureus It is used frequently in the elderly and is an established cause of cholestatic liver injury. Risk factors for cholestasis include prolonged duration of treatment, female sex and older age. Elderly patients are also more likely to suffer from comorbidities and polypharmacy, which increases the incidence of drug-induced liver injury and hospitalisation, which in turn can lead to irreversible deterioration in functional baseline. Our case report aims to raise awareness of flucloxacillin-induced liver injury in elderly patients and to encourage the use of alternative treatments and/or limited duration. We advocate for further research into individualised treatments and new diagnostic techniques in patients with painless jaundice based on their genotype.

Internal medicine patients admitted without COVID-19 during the outbreak

BACKGROUND

The first case of COVID-19 in Israel was reported on February 21, 2020. Shaare Zedek (SZ), a 1000-bed tertiary care medical centre in Jerusalem, Israel, cared for a significant number of these patients. While attention focused on COVID-19 patients, uninfected patients were admitted to decreasing numbers of available internal medicine (IM) beds as IM departments were converted to COVID-19 isolation wards. As a result of the increase in COVID-19 patients, closure of IM wards, re-assignment of staff and dynamic changes in available community placement options, we investigated the impact of the outbreak on IM patient not admitted for COVID-19.

METHODS

We reviewed IM admissions during March 15-April 30, 2020 for patients without COVID-19. Characteristics assessed included number of admissions, age, length of stay, mortality rate, number of discharges, number discharged home and functional status of the patients. Data were compared with the previous 3 years (2017-2019) during the same time period.

RESULTS

During March 15-April 30, 2020 there were 409 patients admitted to IM compared with a mean of 557 over the previous 3 years. Fewer patients were admitted to the ED and the IM wards during the outbreak. There was no significant difference between the two groups with regards to gender, in-hospital mortality rate, number discharged, number discharged home and patient functional level. Patients admitted during the outbreak to IM were younger (74.85 vs 76.86 years) and had a mean shorter hospital length of stay (5.12 vs 7.63 days) compared with the previous 3 years.

CONCLUSION

While the characteristics of patients admitted to IM during the outbreak were similar, hospital length of stay was significantly shorter. Internal management processes, as well as patient preferences may have contributed to this observation. An infectious disease outbreak may have a significant effect on uninfected admitted patients.

Risk indices that predict in-hospital mortality of elderly patients

Background/aim

Mortality in the elderly population tends to be higher than in all other age groups; the risk factors that predict mortality among those in this age cohort are not fully understood. This large-scale clinical study aimed to identify effective risk factors that predict mortality in the elderly population with a particular focus on age and hospitalization status.

Material and methods

We retrospectively analyzed outcomes from patients with clinical follow-up between July 2015 and January 2020 at 29 Mayıs State Hospital, Ankara, Turkey. Patient records with missing or ambiguous data were excluded. Age, sex, length of hospital stay, comorbidities, consultation requests and diagnoses that include infectious diseases were evaluated for their role in predicting in-hospital mortality using binary logistic regression analysis. Primary outcomes focused on factors that had an impact on overall in-hospital mortality in the elderly population.

Results

Our study included 11,430 patients; of this group, 39.9% were elderly, which we defined as 65 years of age or older. Risk factors for in-hospital mortality in this cohort included consultation requests (AOR = 1.95, CI (1.53–2.49), P < 0.001) and length of hospital stay of ≥4 days (AOR = 2.49, CI (1.90–3.26), P < 0.001).

Conclusion

Elderly patients are at significantly higher risk for in-hospital mortality than are younger patients. Among the factors that may be used to predict the risk of in-hospital mortality in the elderly patient cohort, the most important factor is the length of hospital stay.

Integrating functional ageing into daily clinical practice

The analysis of the ageing trajectory clearly demonstrates the constant involvement of functional ability in daily life, from its development in youth, to its preservation through midlife into very old age. While maintaining function appears to be largely related to persistent regular exercise, the risk factors for functional decline are extremely diverse, ranging from a decrease or discontinuation of physical activity, to nutritional/metabolic disturbances, chronic diseases and unfavourable socio-demographic and socio-economic contexts. Prevention of functional decline is a major public health challenge, both for individuals and for society as a whole, and needs to be urgently addressed. Engaging citizens to be conscious of their responsibility for, and role in their own ageing process is equally as important as reinforcing the involvement of society in promoting healthy ageing through enhanced basic and health education, promotion of a healthy diet, long term practice of moderate physical activity, and the continual battle against deleterious life habits and behaviours. The success of these combined actions would be quite simply demonstrated by a change from the current pandemics of morbidity, to the compression of disability, which is expected by all.

Working Collaboratively: Outcomes of Geriatrician Input in Older Patients Undergoing Emergency Laparotomy in a District General Hospital

With the increasing median age of survival in the UK, there is an increased burden on the provision of medical and surgical care to the population. The 2010 National Confidential Enquiry into Patient Outcome and Death report, "An Age Old Problem," emphasizes the early involvement of surgical and geriatric consultant input to improve perioperative care in older patients. This study describes the development of a Geriatric Surgical Liaison Service aimed at providing consultant-led geriatrician support to improve the outcomes of older patients undergoing Emergency Laparotomy (EL). The primary outcome is the reduction in length of stay (LOS) compared to baseline data prior to geriatrician involvement. The service was designed to include one clinical session involving a consultant geriatrician and two and a half days with a junior doctor in a week. Data was collected prospectively from February 2018 till July 2018 for surgical patients aged ≥ 70 years, who underwent EL, had an inpatient stay of more than seven days, and who were diagnosed with delirium or incurred inpatient falls (intervention group). Baseline data, prior to geriatrician involvement, were collected retrospectively for EL patients aged ≥ 70 years from December 2015 until May 2016. Length of stay and 30-day mortality were also compared between the two cohorts undergoing EL. A total of 69 patients were included in the intervention group; 45 patients underwent EL and their mean LOS was 17.5 days, which was reduced from 22.5 days prior to geriatrician involvement (n=57). There was no difference in median length of stay and 30-day mortality between the retrospective baseline group and the intervention groups. In the intervention group, 8.5% of patients had a new medical diagnosis and 26.8% of patients were offered follow-ups. Although statistically not significant (p=0.40), a shorter stay in hospital by five days can potentially have a positive impact on patient outcomes by reducing psychosocial, cognitive, and functional deconditioning. This would also improve patient flow, release capacity, and waiting times and would be of benefit to the financially strained National Health Service (NHS). Overall, our study suggests that a collaborative, consultant-led geriatric service can improve the management of older surgical patients by potentially reducing length of stay, identifying high-risk patients, and facilitating early and appropriate specialty input alongside adequate and required outpatient follow-up.

Dependent person in self-care: analysis of care needs

BACKGROUND

The aim of this study was to assess the self-care dependency levels of the dependent person at the time of home discharge and its relationship between (1) the degree of dependency of each self-care domain; (2) the previous dependency levels; and (3) the gender of the dependent person. It also aims to assess the relationship between the degree of dependency of each self-care domain, the length of admission, the length of dependency and the age of the dependent person at the time of discharge.

METHODS

A cross-sectional study was conducted. The sample comprised hospitalised adults and elderly in the medical services of a Portuguese hospital during the months of March, April and May of 2018. The data were collected by an interview conducted at the time of home discharge from the hospital medical ward.

RESULTS

The average age of dependent people of the sample is 80.7 years (±10.1) with the majority being women (51.7%), with no statistical difference in the mean age according to gender (U = 2205.500; p > 0.05). They were hospitalised on average 11.4 days (±33.2), most of them (44.0%) due to respiratory problems (85% of which were due to pneumonia). There were no statistically significant differences between the length of the hospital stay, the length of dependency and the participants' gender (U = 2200.500, p > 0.05; U = 1688.000, p > 0.05). Medication intake was the highest dependency domain amongst participants (41.3%), followed by instrumental activities of daily living (40.6%) and bathing (39.9%).

CONCLUSION

The amount of support required may vary according to the domain that the person is dependent. Thus, it is important to use a robust and reliable assessment tool that will be able to assess the degree of dependency on the various domains of self-care.

Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study

BACKGROUND

Older people are increasing users of health care globally. We aimed to establish whether older people with characteristics of frailty and who are at risk of adverse health-care outcomes could be identified using routinely collected data.

METHODS

A three-step approach was used to develop and validate a Hospital Frailty Risk Score from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes. First, we carried out a cluster analysis to identify a group of older people (≥75 years) admitted to hospital who had high resource use and diagnoses associated with frailty. Second, we created a Hospital Frailty Risk Score based on ICD-10 codes that characterised this group. Third, in separate cohorts, we tested how well the score predicted adverse outcomes and whether it identified similar groups as other frailty tools.

FINDINGS

In the development cohort (n=22 139), older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use (33·6 bed-days over 2 years compared with 23·0 bed-days for the group with the next highest number of bed-days). In the national validation cohort (n=1 013 590), compared with the 429 762 (42·4%) patients with the lowest risk scores, the 202 718 (20·0%) patients with the highest Hospital Frailty Risk Scores had increased odds of 30-day mortality (odds ratio 1·71, 95% CI 1·68-1·75), long hospital stay (6·03, 5·92-6·10), and 30-day readmission (1·48, 1·46-1·50). The c statistics (ie, model discrimination) between individuals for these three outcomes were 0·60, 0·68, and 0·56, respectively. The Hospital Frailty Risk Score showed fair overlap with dichotomised Fried and Rockwood scales (kappa scores 0·22, 95% CI 0·15-0·30 and 0·30, 0·22-0·38, respectively) and moderate agreement with the Rockwood Frailty Index (Pearson's correlation coefficient 0·41, 95% CI 0·38-0·47).

INTERPRETATION

The Hospital Frailty Risk Score provides hospitals and health systems with a low-cost, systematic way to screen for frailty and identify a group of patients who are at greater risk of adverse outcomes and for whom a frailty-attuned approach might be useful.

FUNDING

National Institute for Health Research.

Integrated Care Approaches Used for Transitions from Hospital to Community Care: A Scoping Review

ABSTRACTIntegrated care is a promising approach for improving care transitions for older adults, but this concept is inconsistently defined and applied. This scoping review describes the size and nature of literature on integrated care initiatives for transitions from hospital to community care for older adults (aged 65 and older) and how this literature conceptualizes integrated care. A systematic search of literature from the past 10 years yielded 899 documents that were screened for inclusion by two reviewers. Of the 48 included documents, there were 26 journal articles and 22 grey literature documents. Analysis included descriptive statistics and a content analysis approach to summarize features of the integrated care initiatives. Results suggest that clinical and service delivery integration is being targeted rather than integration of funding, administration, and/or organization. To promote international comparison of integrated care initiatives aiming to improve care transitions, detailed descriptions of organizational context are also needed.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person's pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions.

Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation.

Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person's Pathway

We addressed the research question “what factors enable the successful development and implementation of a frail older person’s pathway within the acute setting”. A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person’s pathway.

Relationship between hospitalization and functional and cognitive impairment in hospitalized older adults patients

OBJECTIVES

To study changes in the cognitive status and dependency of patients aged over 65 years during hospitalization for bone fracture and how these changes relate to the total number of days of admission and absolute rest during hospitalization. Along with cognitive decline, musculoskeletal disorders are considered key factors in this patient population. As well as requiring hospital admission and/or surgical treatment, fractures increase the risk factors that contribute to disability and dependency in older adults.

METHOD

A longitudinal case-series study with repeated follow-up assessments was conducted. The sample consisted of 259 older adults. The following tests were administered: Barthel index, Lawton-Brody's scale, Phototest, and informant questionnaire on cognitive decline in the elderly.

RESULTS

The main variable which fosters functional dependency, cognitive decline, and functional loss and diminishes functional gain (both in the hospital and at home) is the number of days of bed rest during hospitalization.

CONCLUSIONS

The present study reveals that the greater impact on levels of functional dependency and cognitive decline comes from the patient's days of bed rest in hospital, rather than the total days of hospitalization. These findings could be taken into consideration when discussing post-discharge functional recovery.

Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred

BACKGROUND

The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2-0.6]), lower depression (Geriatric Depression Scale 15; -0.9 [95% -1.1 to -0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8-8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care 'as usual'.

METHODS

We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components.

RESULTS

The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by geriatricians, geriatric nurses, and PReCaP case managers in hospital A. Yet hospital B consultative psychiatric nurses provide similar consultation services. The combination of standardized procedures, formalized communication channels, and advanced computerization contributes significantly to geriatric care in hospital B. Nevertheless, a small size hospital (hospital C) provides informal opportunities for information sharing and decision making, which are essential in geriatric care, given its multidisciplinary nature.

CONCLUSIONS

Geriatric care for patients with multimorbidity requires a multidisciplinary approach in a geriatric unit. Geriatric care, which integrates medical and reactivation treatment, by means of early screening of risk factors for functional decline, promotion of physical activity, and adequate discharge planning, potentially reduces the incidence of functional decline in elderly patients. Yet low treatment fidelity played a major role in the ineffective implementation of the PReCaP. Treatment fidelity issues are caused by various factors, including the complexity of projects, limited attention for implementation, and inadequate interdisciplinary communication. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.

[Counseling and preventive action in elderly population in hospitals and residences in Spain]

Objetivos

Conocer el perfil sociosanitario de los pacientes mayores atendidos en consultas; conocer las acciones preventivas que se llevan a cabo, de forma rutinaria, en hospitales, residencias geriátricas y otros centros asistenciales en España.

Diseño

Estudio descriptivo transversal, basado en un cuestionario a médicos que atienden a población mayor de 65 años en España (2013).

Emplazamiento

Centros de diferentes comunidades autónomas en España.

Participantes: Un total de 420 médicos de hospitales, residencias y otros centros. Se obtuvieron datos de 840 consultas a pacientes geriátricos.

Mediciones principales

Variables principales de resultados: dependencia, comorbilidad, motivo de consulta, actuación en consulta y recomendación de estilos de vida saludable. Factor asociado, tipo de institución en la que se atendió al paciente. Análisis de prevalencias y diferencias con Chi-cuadrado.

Resultados

El 66,7% presentaban dependencia, siendo mayor entre las mujeres: 68,9% vs 62,4% (p = 0,055). El 88,6% de mujeres atendidas con 85 o más años presentaban comorbilidad, mientras que en hombres de ese mismo grupo de edad eran un 79,8%. Solo un 6,6% de pacientes con comorbilidad recibieron recomendaciones saludables durante la consulta. El 79,6% de pacientes atendidos en hospitales recibieron recomendaciones de estilo de vida saludable, mientras que en las residencias geriátricas las recibieron el 59,62% de los pacientes (p < 0,001).

Conclusiones

Se detecta una escasa acción preventiva y de promoción de la salud hacia las personas mayores, con diferencias entre hospitales y residencias geriátricas. Parece necesario incentivar la actitud promotora de salud y las intervenciones preventivas en la práctica clínica gerontológica.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

Background

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

Methods

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

Results

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

Conclusion

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

BACKGROUND

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

METHODS

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

RESULTS

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

CONCLUSION

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.

Physical activity in non-frail and frail older adults

Introduction

Physical activity (PA) is important for healthy ageing. Better insight into objectively measured PA levels in older adults is needed, since most previous studies employed self-report measures for PA assessment, which are associated with overestimation of PA.

Aim

This study aimed to provide insight in objectively measured indoor and outdoor PA of older adults, and in PA differences by frailty levels.

Methods

Data were collected among non-frail (N = 74) and frail (N = 10) subjects, aged 65 to 89 years. PA, measured for seven days with accelerometers and GPS-devices, was categorized into three levels of intensity (sedentary, light, and moderate-to-vigorous PA).

Results

Older adults spent most time in sedentary and light PA. Subjects spent 84.7%, 15.1% and 0.2% per day in sedentary, light and moderate-to-vigorous PA respectively. On average, older adults spent 9.8 (SD 23.7) minutes per week in moderate-to-vigorous activity, and 747.0 (SD 389.6) minutes per week in light activity. None of the subjects met the WHO recommendations of 150 weekly minutes of moderate-to-vigorous PA. Age-, sex- and health status-adjusted results revealed no differences in PA between non-frail and frail older adults. Subjects spent significantly more sedentary time at home, than not at home. Non-frail subjects spent significantly more time not at home during moderate-to-vigorous activities, than at home.

Conclusions

Objective assessment of PA in older adults revealed that most PA was of light intensity, and time spent in moderate-to-vigorous PA was very low. None of the older adults met the World Health Organization recommendations for PA. These levels of MVPA are much lower than generally reported based on self-reported PA. Future studies should employ objective methods, and age specific thresholds for healthy PA levels in older adults are needed. These results emphasize the need for effective strategies for healthy PA levels for the growing proportion of older adults.

Early indications that low mental quality of life scores in recently unwell older people predict downstream functional decline

Background

Accurately detecting markers of early functional decline (FD) are essential to support older people to successfully age in place; however, these markers are poorly understood. We tested the hypothesis that compromised mental quality of life after a minor health crisis could be an early predictor of FD.

Methods

This longitudinal observational cohort study was conducted in the emergency department (ED) of a large Australian hospital and in the community. Data were collected from 148 community-dwelling people aged 65+ years, who provided data at recruitment (baseline), and at 1 month and 3 months post discharge from the ED. Short Form-12 mental quality of life component scores (MCS) were regressed with patient descriptors taken at baseline (age, sex, socioeconomic status, education, Mini-Mental State Examination, and primary language), and over-time estimates of FD taken at baseline, and at 1 and 3 months post discharge (instrumental activities of daily living, frequency of falls and hospitalizations, use of gait aids, receipt of community services, living status, and requiring a carer).

Results

MCS at 1 month (MCS1) post ED discharge was significantly associated with instrumental activities of daily living at 1 (r=0.45, P<0.001) and 3 months (r=0.401, P=0.001) post ED discharge, but not at baseline (r=0.010, P>0.05). Subjects with lower than the population median MCS showed a significant linear decline in total instrumental activities of daily living scores over 3 months (P=0.025). There was no linear trend over time in the relationship between MCS1 with frequency of falls (P=0.20) or hospitalizations (P=0.42); however, there was a significant difference at 3 months post ED discharge for falls (P=0.036) and hospitalizations (P=0.039) between low and high MCS1 groups. There were no significant confounders.

Conclusion

Low MCS scores 1 month after a minor health crisis appear to significantly predict downstream FD. This finding needs to be tested in a larger sample.

Evaluation of the Prevention and Reactivation Care Program (PreCaP) for the hospitalized elderly: a prospective nonrandomized controlled trial

Background

The hospitalized elderly are at risk of functional decline. We evaluated the effects and care costs of a specialized geriatric rehabilitation program aimed at preventing functional decline among at-risk hospitalized elderly.

Methods

The prospective nonrandomized controlled trial reported here was performed in three hospitals in the Netherlands. One hospital implemented the Prevention and Reactivation Care Program (PReCaP), while two other hospitals providing usual care served as control settings. Within the PReCaP hospital we compared patients pre-implementation with patients post-implementation of the PReCaP (“within-hospital analysis”), while our nonrandomized controlled trial compared patients of the PReCaP hospital post-implementation with patients from the two control hospitals providing usual care (“between-hospital analysis”). Hospitalized patients 65 years or older and at risk of functional decline were interviewed at baseline and at 3 and 12 months using validated questionnaires to score functioning, depression, and health-related quality of life (HRQoL). We estimated costs per unit of care from hospital information systems and national data sources. We used adjusted general linear mixed models to analyze functioning and HRQoL.

Results

Between-hospital analysis showed no difference in activities of daily living (ADL) or instrumental activities of daily living (IADL) between PReCaP patients and control groups. PReCaP patients did have slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2–0.6]), lower depression (Geriatric Depression Scale 15; −0.9 [95% −1.1 to −0.6]) and higher perceived health (Short-Form 20; 5.6 [95% CI 2.8–8.4]) than control patients. Analyses within the PReCaP hospital comparing patients pre-and post-implementation of the PReCaP showed no improvement over time in functioning, depression, and HRQoL. One-year health care costs were higher for PReCaP patients, both for the within-hospital analysis (+€7,000) and the between-hospital analysis (+€2,500).

Conclusion

We did not find any effect of the PReCaP on ADL and IADL. The PReCaP may possibly provide some benefits to hospitalized patients at risk of functional decline with respect to cognitive functioning, depression, and perceived health. Further evaluations of integrated intervention programs to limit functional decline are therefore required.

Characteristics of residential areas and transportational walking among frail and non-frail Dutch elderly: does the size of the area matter?

Background

A residential area supportive for walking may facilitate elderly to live longer independently. However, current evidence on area characteristics potentially important for walking among older persons is mixed. This study hypothesized that the importance of area characteristics for transportational walking depends on the size of the area characteristics measured, and older person’s frailty level.

Methods

The study population consisted of 408 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighborhood (ELANE) study in 2011–2012. Characteristics (aesthetics, functional features, safety, and destinations) of areas surrounding participants’ residences ranging from a buffer of 400 meters up to 1600 meters (based on walking path networks) were linked with self-reported transportational walking using linear regression analyses. In addition, interaction effects between frailty level and area characteristics were tested.

Results

An increase in functional features (e.g. presence of sidewalks and benches) within a 400 meter buffer, in aesthetics (e.g. absence of litter and graffiti) within 800 and 1200 meter buffers, and an increase of one destination per buffer of 400 and 800 meters were associated with more transportational walking, up to 2.89 minutes per two weeks (CI 1.07-7.32; p < 0.05). No differences were found between frail and non-frail elderly.

Conclusions

Better functional and aesthetic features, and more destinations in the residential area of community-dwelling older persons were associated with more transportational walking. The importance of area characteristics for transportational walking differs by area size, but not by frailty level. Neighbourhood improvements may increase transportational walking among older persons, thereby contributing to living longer independently.

Situational awareness, relational coordination and integrated care delivery to hospitalized elderly in the Netherlands: a comparison between hospitals

BACKGROUND

It is known that interprofessional collaboration is crucial for integrated care delivery, yet we are still unclear about the underlying mechanisms explaining effectiveness of integrated care delivery to older patients. In addition, we lack research comparing integrated care delivery between hospitals. Therefore, this study aims to (i) provide insight into the underlying components 'relational coordination' and 'situational awareness' of integrated care delivery and the role of team and organizational context in integrated care delivery; and (ii) compare situational awareness, relational coordination, and integrated care delivery of different hospitals in the Netherlands.

METHODS

This cross-sectional study took place in 2012 among professionals from three different hospitals involved in the delivery of care to older patients. A total of 215 professionals filled in the questionnaire (42% response rate).Descriptive statistics and paired-sample t-tests were used to investigate the level of situational awareness, relational coordination, and integrated care delivery in the three different hospitals. Correlation and multilevel analyses were used to investigate the relationship between background characteristics, team context, organizational context, situational awareness, relational coordination and integrated care delivery.

RESULTS

No differences in background characteristics, team context, organizational context, situational awareness, relational coordination and integrated care delivery were found among the three hospitals. Correlational analysis revealed that situational awareness (r = 0.30; p < 0.01), relational coordination (r = 0.17; p < 0.05), team climate (r = 0.29; p < 0.01), formal internal communication (r = 0.46; p < 0.01), and informal internal communication (r = 0.36; p < 0.01) were positively associated with integrated care delivery. Stepwise multilevel analyses showed that formal internal communication (p < 0.001) and situational awareness (p < 0.01) were associated with integrated care delivery. Team climate was not significantly associated with integrated care delivery when situational awareness and relational coordination were included in the equation. Thus situational awareness acted as mediator between team climate and integrated care delivery among professionals delivering care to older hospitalized patients.

CONCLUSIONS

The results of this study show the importance of formal internal communication and situational awareness for quality of care delivery to hospitalized older patients.

The importance of multidisciplinary teamwork and team climate for relational coordination among teams delivering care to older patients

Aim

To identify predictors of relational coordination among professionals delivering care to older patients.

Background

Relational coordination is known to enhance quality of care in hospitals. The underlying mechanisms, however, remain poorly understood.

Design

This cross-sectional study was part of a larger evaluation study examining the opportunity to prevent loss of function in older patients due to hospitalization in the Netherlands.

Methods

This study was performed in spring 2010 among team members delivering care to older hospitalized patients (192 respondents; 44% response rate) in one hospital. Relational coordination was measured by the Relational Coordination survey; team climate by the Team Climate Inventory and questions were asked about participation in multidisciplinary team meetings and disciplines represented in these meetings. To account for the hierarchical structure, a multilevel analysis was performed.

Results

Correlation analysis revealed a positive relationship among being female, being a nurse and relational coordination; medical specialists showed a negative relationship. The number of disciplines represented during multidisciplinary team meetings and team climate were positively related with relational coordination. The multilevel analysis showed a positive relationship between the number of disciplines represented during multidisciplinary team meetings and team climate with relational coordination.

Conclusions

The enhancement of team climate and attendance of diverse professionals during multidisciplinary team meetings are expected to improve relational coordination. Furthermore, this study underscores the importance of enhancing relational coordination between medical specialists and other professionals.

The Prevention and Reactivation Care Program: intervention fidelity matters

BACKGROUND

The Prevention and Reactivation Care Program (PReCaP) entails an innovative multidisciplinary, integrated and goal oriented approach aimed at reducing hospital related functional decline among elderly patients. Despite calls for process evaluation as an essential component of clinical trials in the geriatric care field, studies assessing fidelity lag behind the number of effect studies. The threefold purpose of this study was (1) to systematically assess intervention fidelity of the hospital phase of the PReCaP in the first year of the intervention delivery; (2) to improve our understanding of the moderating factors and modifications affecting intervention fidelity; and (3) to explore the feasibility of the PReCaP fidelity assessment in view of the modifications.

METHODS

Based on the PReCaP description we developed a fidelity instrument incorporating nineteen (n=19) intervention components. A combination of data collection methods was utilized, i.e. data collection from patient records and individual Goal Attainment Scaling care plans, in-depth interviews with stakeholders, and non-participant observations. Descriptive analysis was performed to obtain levels of fidelity of each of the nineteen PReCaP components. Moderating factors were identified by using the Conceptual Framework for Implementation Fidelity.

RESULTS

Ten of the nineteen intervention components were always or often delivered to the group of twenty elderly patients. Moderating factors, such as facilitating strategies and context were useful in explaining the non- or low-adherence of particular intervention components.

CONCLUSIONS

Fidelity assessment was carried out to evaluate the adherence to the PReCaP in the Vlietland Ziekenhuis in the Netherlands. Given that the fidelity was assessed in the first year of PReCaP implementation it was commendable that ten of the nineteen intervention components were performed always or often. The adequate delivery of the intervention components strongly depended on various moderating factors. Since the intervention is still developing and undergoing continuous modifications, it has been concluded that the fidelity criteria should evolve with the modified intervention. Furthermore, repeated intervention fidelity assessments will be necessary to ensure a valid and reliable fidelity assessment of the PReCaP.

TRIAL REGISTRATION

The Netherlands National Trial Register: NTR2317.