Multi-Morbidity in Hospitalised Older Patients: Who Are the Complex Elderly?

Stakeholders' experiences of comprehensive geriatric assessment in an inpatient hospital setting: a qualitative systematic review and meta-ethnography

BACKGROUND

Comprehensive geriatric assessment (CGA) is considered the gold standard approach to improving a range of outcomes for older adults living with frailty admitted to hospital. To date, research has predominantly focused on quantitative syntheses of the international evidence with limited focus on qualitative synthesis of stakeholder perspectives. This review aims to resolve this research gap by identifying and synthesising qualitative studies reporting multiple stakeholders' experiences of inpatient CGA.

METHODS

A systematic search of five electronic databases was conducted. Qualitative or mixed methods studies that included qualitative findings on the experiences of CGA in an inpatient hospital setting from the perspective of healthcare professionals (HCP), older adults, and those important to them were included. The protocol was registered on PROSPERO (Registration: CRD42021283167) and the 10-item Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of included studies. Results were synthesised as a meta-ethnography.

RESULTS

Eleven studies, which reported on the experiences of 153 HCPs, 91 older adults and 57 caregivers were included. The studies dated from 2011 to 2021 and three key themes were identified: (1) HCPs, older adults and caregivers report conflicting views on CGA as a holistic process, (2) most HCPs, but only some older adults and caregivers view CGA goalsetting and care planning as collaborative, and (3) all stakeholders value care continuity during the transition from hospital to home but often fail to achieve it.

CONCLUSION

While HCPs, older adults, and caregivers' values and ambitions related to CGA broadly align, their experiences often differ. The identified themes highlight organisational and relational factors, which positively and negatively influence CGA practices and processes in an inpatient hospital setting.

The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study

The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.

Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Background

We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design.

Objective(s), study design, settings and participants

Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions.

Results

A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality.

Limitations

Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly.

Conclusions

We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people.

Future work

Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs.

Study registrations

This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.

Hospital utilisation in Australia, 1993-2020, with a focus on use by people over 75 years of age: a review of AIHW data

OBJECTIVES

To assess Australian hospital utilisation, 1993-2020, with a focus on use by people aged 75 years or more.

DESIGN

Review of Australian Institute of Health and Welfare (AIHW) hospital utilisation data.

SETTING, PARTICIPANTS

Tertiary data from all Australian public and private hospitals for the financial years 1993-94 to 2019-20.

MAIN OUTCOME MEASURES

Numbers and population-based rates of hospital separations and bed utilisation (bed-days) (all and multiple day admissions) and mean hospital length of day (multiple day admissions), overall and by age group (under 65 years, 65-74 years, 75 years or more).

RESULTS

Between 1993-94 and 2019-20, the Australian population grew by 44%; the number of people aged 75 years or more increased from 4.6% to 6.9% of the population. The annual number of hospital separations increased from 4.61 million to 11.33 million (146% increase); the annual hospital separation rate increased from 261 to 435 per 1000 people (66% increase), most markedly for people aged 75 years or more (from 745 to 1441 per 1000 people; 94% increase). Total bed utilisation increased from 21.0 million to 29.9 million bed-days (42% increase), but the bed utilisation rate did not change markedly (1993-94, 1192 bed-days per 1000 people; 2019-20, 1179 bed-days per 1000 people), primarily because the mean hospital length of stay for multiple day admissions declined from 6.6 days to 5.4 days; for people aged 75 years or more it declined from 12.2 to 7.1 days. However, declines in stay length have slowed markedly since 2017-18. Total bed utilisation was 16.8% lower than projected from 1993-94 rates, and was 37.3% lower for people aged 75 years or more.

CONCLUSION

Hospital bed utilisation rates declined although admission rates increased during 1993-94 to 2019-20; the proportion of beds occupied by people aged 75 years or more increased slightly during this period. Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy.

Outcomes of Care by Geriatricians and Non-geriatricians in an Academic Hospital

Introduction

While hospitalist and internist inpatient care models dominate the landscape in many countries, geriatricians and internists are at the frontlines managing hospitalized older adults in countries such as Singapore and the United Kingdom. The primary aim of this study was to determine outcomes for older patients cared for by geriatricians compared with non-geriatrician-led care teams.

Materials and Methods

A retrospective cohort study of 1,486 Internal Medicine patients aged ≥75 years admitted between April and September 2021 was conducted. They were either under geriatrician or non-geriatrician (internists or specialty physicians) care. Data on demographics, primary diagnosis, comorbidities, mortality, readmission rate, Hospital Frailty Risk Score (HFRS), Age-adjusted Charlson Comorbidity Index, Length of Stay (LOS), and cost of hospital stay were obtained from the hospital database and analyzed.

Results

The mean age of patients was 84.0 ± 6.3 years, 860 (57.9%) females, 1,183 (79.6%) of Chinese ethnicity, and 902 (60.7%) under the care of geriatricians. Patients under geriatrician were significantly older and had a higher prevalence of frailty, dementia, and stroke, whereas patients under non-geriatrician had a higher prevalence of diabetes and hypertension. Delirium as the primary diagnosis was significantly higher among patients under geriatrician care. Geriatrician-led care model was associated with shorter LOS, lower cost, similar inpatient mortality, and 30-day readmission rates. LOS and cost were lower for patients under geriatrician care regardless of frailty status but significant only for low and intermediate frailty groups. Geriatrician-led care was associated with significantly lower extended hospital stay (OR 0.73; 95% CI 0.56–0.95) and extended cost (OR 0.69; 95% CI 0.54–0.95).

Conclusion

Geriatrician-led care model showed shorter LOS, lower cost, and was associated with lower odds of extended LOS and cost.

Comparison between attention and experiences of chronic complex patients: A multicentric study

The aim of this research is to explore and analyse the functional status and experiences of complex patients located at levels 3-4 of the risk pyramid of the chronic care model in primary care, within the hospital system of two regions in Spain. The design was a mixed design (COREQ). The participants were enrolled in programs for chronic complex patients and their caregivers. Sociodemographic variables were gathered, together with the following measures: the Barthel test, the Mini mental test, the Zarit questionnaire, the IEXPAC scale and the Braden scale. A semi-structured interview was conducted individually with patients in order to explore their experiences and narrative on the process of their illness and the support they had received. The sample comprised 206 chronic pluripathological patients, of whom 103 were from Cantabria and a further 103 were from Mallorca. The patient profile in both regions was very similar. There was an equal distribution across both gender and the patients were over 78 years old. They all had a basic (primary) education, an average income and required moderate physical dependence, receiving assistance primarily from their children. The qualitative analysis highlighted patients' awareness of the illness and their concern for the future, noting that, overall, patients were satisfied with the care provided by their caregivers and the health system. We can conclude that is the first multicentric study of these characteristics conducted in Spain, despite it being the country with the second largest ageing population in the world. It is important to test new organisational models with differentiating areas of advanced clinical practice in primary care, whereby both patients and their caregivers can be co-responsible within the care process.

Congestive heart failure and comorbidity as determinants of colorectal cancer perioperative outcomes

There has been an increase in surgical interventions in frailer elderly with concomitant chronic diseases. The purpose of this paper was to evaluate the impact of aging and comorbidities on outcomes in patients who underwent surgery for the treatment of colorectal cancer (CRC) in Veneto Region (Northeastern Italy). This is a retrospective cohort study in patients ≥ 40 years who underwent elective or urgent CRC surgical resection between January 2013 and December 2015. Independent variables included: age, sex, and comorbidities. We analyzed variables associated with the surgical procedure, such as stoma creation, hospitalization during the year before the index surgery, the surgical approach used, the American Society of Anesthesiologists (ASA) score, and the Charlson Comorbidity Index score. Eight thousand four hundred and forty-seven patients with CRC underwent surgical resection. Patient age affected both pre- and post-resection LOS as well as the overall survival (OS); however, it did not affect the 30-day readmission and reoperation rates. Multivariate analysis showed that age represented a risk factor for longer preoperative and postoperative LOS as well as for 30-day and 365-day mortality, but it was not associated with an increased risk of 30-day reoperation and 30-day readmission. Chronic Heart Failure increased the 30-day mortality risk by four times, the preoperative LOS by 51%, and the postoperative LOS by 33%. Chronic renal failure was associated with a 74% higher 30-day readmission rate. Advanced age and comorbidities require a careful preoperative evaluation and appropriate perioperative management to improve surgical outcomes in older patients undergoing elective or urgent CRC resection.

Effectiveness of acute geriatric unit care on functional decline, clinical and process outcomes among hospitalised older adults with acute medical complaints: a systematic review and meta-analysis

Background

the aim of this systematic review and meta-analysis was to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints.

Methods

MEDLINE, CINAHL, CENTRAL and Embase databases were systematically searched from 2008 to February 2022. Screening, data extraction and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence. The primary outcome was incidence of functional decline between baseline 2-week prehospital admission status and discharge and at follow-up.

Results

11 trials recruiting 7,496 participants across three countries were included. AGU care resulted in a reduction in functional decline at 6-month follow-up (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.66–0.93; moderate certainty evidence) and an increased probability of living at home at 3-month follow-up (RR 1.06, 95% CI 0.99–1.13; high certainty evidence). AGU care resulted in little or no difference in functional decline at hospital discharge or at 3-month follow-up, length of hospital stay, costs, the probability of living at home at discharge, mortality, hospital readmission, cognitive function or patient satisfaction.

Conclusions

AGU care improves clinical and process outcomes for hospitalised older adults with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures.

Commentary on the EMA reflection paper on the pharmaceutical development of medicines for use in the older population

Older people are often affected by impaired organ and bodily functions resulting in multimorbidity and polypharmacy, turning them into the main user group of many medicines. Very often, medicines have not specifically been developed for older people, causing practical medication problems for them like limited availability of easy to swallow formulations, easy to open packaging and dosing instructions for enteral administration. In 2020, the European Medicines Agency (EMA) published a reflection paper 'Pharmaceutical development of medicines for use in the older population', which discusses how the emerging needs of an ageing European population can be addressed by medicines regulation. The paper intends to help industry to better consider the needs of older people during pharmaceutical/clinical medicines development by summarising data on the most relevant topics, providing early suggestions on how to move forward and prompting expert discussions and studies into knowledge gaps. Topics include patient acceptability, (dis)advantages of an administration route, formulation, dosage form, packaging, dosing device and user instruction. While the paper is directed at older people and the pharmaceutical industry, the reflections are also relevant to younger patients with similar disease-related needs and of value to other stakeholders parties, e.g., healthcare professionals, academics, patients and caregivers, as the paper makes clear what can be expected from industry and where collaborative work is needed. This commentary provides an overview of the different steps in the development of the reflection paper, discusses points considered most controversial and/or subject to (multidisciplinary) expert discussions and indicates their value for real world clinical practice.

Integrated primary care and social services for older adults with multimorbidity in England: a scoping review

BACKGROUND

As the prevalence of older adults with multimorbidity increases, greater integration of services is necessary to manage the physical and psycho-social needs of this cohort. This study describes and summarises current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England.

METHODS

A scoping review was conducted involving systematic searches of a range of electronic academic and policy databases. Articles were screened and extracted in duplicate by two independent reviewers. Data were extracted onto a charting sheet and thematic synthesis was used to summarise findings. Articles were included if published in English and related to primary care, social care and multimorbidity in older adults in England. Conceptually, the review was framed using the Rainbow Model of Integrated Care.

RESULTS

The search yielded 7656 articles of which 84 were included. Three themes were identified: (1) a focus on individual level services rather than multi-level or multi-sector integration, with an increasing emphasis on the need to consider broader determinants of population health as critical to integrated care for older adults with multimorbidity; (2) the need for policymakers to allow time for integration to embed, to enable new structures and relationships to develop and mature; and (3) the inherent tension between top-down and bottom-up driven approaches to integrated care requires a whole-systems structure, while allowing for local flexibilities.

CONCLUSIONS

There is limited evidence of multi-level and multi-sector integration of services for older adults with multimorbidity in England. The literature increasingly acknowledges wider determinants of population health that are likely to require integration beyond primary care and social services. Improving clinical care in one or two sectors may not be as effective as simultaneously improving the organisation or design across services as one single system of provision. This may take time to establish and will require local input.

Factors associated to multimorbidity in inpatient elderly according to sociodemographic characteristics, lifestyle and use of services

Introduction: Aging is a physiological process associated to decreased functional capacity and the presence of diseases, especially chronic noncommunicable diseases. Objective: To analyze the prevalence and factors associated to the multimorbidity of elderly in a teaching hospital, according to sociodemographic characteristics, lifestyle and use of services in the health care network. Methods: Descriptive and inferential cross-sectional study, conducted with 144 hospitalized patients 60 years of age or more, from January to June 2018, in a university hospital in the state of Paraná. Data were collected 30 days after hospital discharge by telephone interview. The dependent variable was the occurrence of multimorbidity and the independent variables were: sociodemographic characteristics, lifestyle and use of hospital health services. Logistic regression analysis was performed. Results: It was found that 55% of the elderly had multimorbidity. The elderly who were more chances to have multimorbidity where there low education (OR=16.29; CI:2.75-96.42), non-white (OR=2.34; CI:1.00-5.50) hospitalized longer (4 to 7 days: OR=6.91; CI:2.40-19.96; more than 7 days: OR=3.03; CI:1.00-9.22), who scheduled to return to the hospital (OR=18.99; CI: 1.30-277.87), and that after discharge they needed help from someone to follow the medical recommendations (OR=3.16; CI:1.38-7.22). Conclusion: It was identified a high prevalence of multimorbidity, and important factors associated to multimorbidity in hospitalized elderly, with emphasis on education; color; hospitalization time; scheduling of return to hospital after discharge; need for help from someone (family member/caregiver), without post-discharge, to follow medical recommendations.

In-Hospital Clinical Outcomes in Patients with Fragility Fractures of the Lumbar Spine, Thoracic Spine, and Pelvic Ring: A Comparison of Data before and after Certification as a DGU® Geriatric Trauma Centre

Background and Objectives: The implementation of orthogeriatric co-management (OGCM) reflects the demand for interdisciplinary collaborations due to the increasing comorbidities of geriatric trauma patients. This study aimed to assess clinical in-hospital outcomes in lumbar spine, thoracic spine, and pelvic ring fragility fracture patients before and after the implementation of a Geriatric Trauma Centre (GTC) certified by the German Trauma Society (DGU^®). Materials and Methods: In this observational, retrospective cohort study, geriatric trauma patients (>70 years of age) were stratified into either a pre-GTC group (hospital admission between 1 January 2012 and 31 December 2013) or a post-GTC group (hospital admission between 1 January 2017 and 31 December 2018). Patients’ pre-injury medical complexity was measured by ASA class (American Society of Anaesthesiologists classification), the use of anticoagulant medication, and the ACCI (Age-adjusted Charlson Comorbidity Index). Outcome parameters were patients’ in-hospital length of stay (LOS) and mortality rates, as well as new in-hospital findings and diagnoses. Further, the necessity of deviation from initial management plans due to complications was assessed using the Adapted Clavien–Dindo Scoring System in Trauma (ACDiT score of ≥1). Results: Patients in the post-GTC group (n = 111) were older (median age 82.0 years) compared to the pre-GTC group (n = 108, median age 80.0 years, p = 0.016). No differences were found in sex, body mass index, ASA class, or ACCI (all p > 0.05). Patients in the post-GTC group used vitamin K antagonists or direct oral anticoagulants more frequently (21.3% versus 10.8%). The incidence of non-surgical treatment and mortality was comparable between groups, while LOS tended to be shorter in the post-GTC group (7.0 days versus 9.0 days, p = 0.076). In the post-GTC group, the detection of urinary tract infections (UTI) increased (35.2% versus 16.2%, p = 0.001), and the delirium diagnoses tended to increase (13.0% versus 6.3%, p = 0.094), while an ACDiT score of ≥1 was comparable between groups (p = 0.169). Conclusions: In this study including lumbar spine, thoracic spine, and pelvic ring geriatric fragility fractures, patients in the post-GTC group were more medically complex. More UTIs and the tendency for increased delirium detection was observed in the post-GTC group, likely due to improved diagnostic testing. Nonetheless, the necessity of deviation from initial management plans (ACDiT score of ≥1) was comparable between groups, potentially a positive result of OGCM.

Admission criteria for a cardiovascular short stay unit: a retrospective analysis on a pilot unit

Rapid intensive observation (RIO) units have been created to guarantee high standards of care in a sustainable health-care system. Within short stay units (SSUs), which are a subgroup of RIOs, only rapidly manageable patients should be admitted. Physicians are unable to predict the length of stay (LOS) as objective criteria to make such a prediction are missing. A retrospective observational study was carried out to identify the objective criteria for admission within a cardiovascular care-oriented SSU. Over a period of 317 days, 340 patients (age 69.4 ± 14.7 years) were admitted to a pilot SSU within our internal medicine department. The most frequent diagnoses were chest pain (45.9%), syncope (12.9%), and supraventricular arrhythmias (11.2%). The median LOS was 4 days (quartile 1:3; quartile 3:7). Predictors of LOS ≤ 96 h were age < 80, hemoglobin > 115 g/L, estimated glomerular filtration rate > 45 mL/min/1.73 m², Charlson Comorbidity Index < 3, Barthel Index > 40, diagnosis of chest pain, syncope, supraventricular arrhythmias, or acute heart failure. The HEART (history, ECG, age, risk factors, troponin) score was found to be excellent in risk stratification of patients admitted for chest pain. Blood tests and anamnestic variables can be used to predict the LOS and thus SSU admission. The HEART score may help in the classification of patients with chest pain admitted to an SSU.

Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review

INTRODUCTION

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints.

DESIGN

Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper.

PROSPERO REGISTRATION NUMBER

CRD42021237633.

Identifying longitudinal clusters of multimorbidity in an urban setting: A population-based cross-sectional study

Background

Globally, there is increasing research on clusters of multimorbidity, but few studies have investigated multimorbidity in urban contexts characterised by a young, multi-ethnic, deprived populations. This study identified clusters of associative multimorbidity in an urban setting.

Methods

This is a population-based retrospective cross-sectional study using electronic health records of all adults aged 18 years and over, registered between April 2005 to May 2020 in general practices in one inner London borough. Multiple correspondence analysis and cluster analysis was used to identify groups of multimorbidity from 32 long-term conditions (LTCs).

Results

The population included 41 general practices with 826,936 patients registered between 2005 and 2020, with mean age 40 (SD15·6) years. The prevalence of multimorbidity was 21% (n = 174,881), with the median number of conditions being three and increasing with age. Analysis identified five consistent LTC clusters: 1) anxiety and depression (Ratio of within- to between- sum of squares (WSS/BSS <0·01 to <0·01); 2) heart failure, atrial fibrillation, chronic kidney disease (CKD), chronic heart disease (CHD), stroke/transient ischaemic attack (TIA), peripheral arterial disease (PAD), dementia and osteoporosis (WSS/BSS 0·09 to 0·12); 3) osteoarthritis, cancer, chronic pain, hypertension and diabetes (0·05 to 0·06); 4) chronic liver disease and viral hepatitis (WSS/BSS 0·02 to 0·03); 5) substance dependency, alcohol dependency and HIV (WSS/BSS 0·37 to 0·55).

Interpretation

Mental health problems, pain, and at-risk behaviours leading to cardiovascular diseases are the important clusters identified in this young, urban population.

Funding

Impact on Urban Health, United Kingdom.

[A patient with mesenteric lymphoma who developed amyotrophic lateral sclerosis and sepsis]

We treated a patient with mesenteric lymphoma who concomitantly developed amyotrophic lateral sclerosis (ALS). The patient died of urinary tract infection nine months after the onset of ALS. We herein report the changes in the patient's condition and the sequence of events until death from the viewpoint of a physiotherapist. The patient was a 69-year-old woman who developed mesenteric lymphoma in September of X year and perceived weakness in the toes in November of X year. She showed signs of upper and lower motor neuron disorders, and electrophysiologic testing revealed denervation in three areas of the spinal cord. In March of X+1 year, she was diagnosed with definite ALS based on the Awaji criteria. In April of X+1 year, she began to receive continuous home healthcare, specifically outpatient rehabilitation. No remarkable bulbar palsy was observed soon after the initiation of rehabilitation; however, manual muscle testing revealed strengths in the lower and upper limbs of 1 and 3-5, respectively, indicating muscle weakness and muscle atrophy. She developed exacerbation of neurological symptoms in the upper limbs, bulbar palsy, and respiratory muscle paralysis during rehabilitation. The ALS Functional Rating Scale-Revised indicated a decreased tendency to X [please define X]. In July of X+1 year, the mesenteric lymphoma had enlarged, resulting in the development of ureteric obstruction and ultimately causing hydronephrosis. Urinary tract infection and sepsis were diagnosed, and she was hospitalized. Although her fever temporarily subsided following ceftriaxone administration, she ultimately died due to a systemic inflammatory response syndrome three days after hospitalization. The mean period between the ALS onset and death is reportedly 40.6±33.1 months. The rate of ALS progression differs among individuals. Malignant tumors and paraneoplastic neurological syndrome may be involved in rapidly worsening neurological symptoms. Patients who concomitantly develop motor neuron disorders and malignant tumors are likely to have a higher risk of developing serious conditions associated with the exacerbation of neurological symptoms and complications. Our patient had several diseases that affected her survival prognosis; however, the sharing of information regarding her condition among healthcare professionals may have been insufficient. The primary physician responsible for treating each disease should cooperate with physiotherapists and other paramedical staff who have frequent opportunities to talk to patients in daily clinical practice. In geriatric patients in particular, such an environment is essential.

Multimorbidity patterns in people with HIV

PURPOSE OF REVIEW

With the progressive aging of populations of people with HIV (PWH), multimorbidity is increasing. Multimorbidity patterns, that is groups of comorbidities that are likely to co-occur, may suggest shared causes or common risk factors. We review the literature regarding multimorbidity patterns identified with data-driven approaches and discuss the methodology and potential implications of the findings.

RECENT FINDINGS

Despite the substantial heterogeneity in the methods used to identify multimorbidity patterns, patterns of mental health problems, cardiovascular diseases, metabolic disorders and musculoskeletal problems are consistently reported in the general population, with patterns of mental health problems, cardiovascular diseases or metabolic disorders commonly reported in PWH. In addition to these, patterns of lifestyle-related comorbidities, such as sexually transmitted diseases, substance use (alcohol, recreational drugs and tobacco smoking) or their complications, seem to occur among PWH.

SUMMARY

Multimorbidity patterns could inform the development of appropriate guidelines for the prevention, monitoring and management of multiple comorbidities in PWH. They can also help to generate new hypotheses on the causes underlying previously known and unknown associations between comorbidities and facilitate the identification of risk factors and biomarkers for specific patterns.

Identification of Mortality Risks in the Advancement of Old Age: Application of Proportional Hazard Models Based on the Stepwise Variable Selection and the Bayesian Model Averaging Approach

Identifying factors that affect mortality requires a robust statistical approach. This study’s objective is to assess an optimal set of variables that are independently associated with the mortality risk of 433 older comorbid adults that have been discharged from the geriatric ward. We used both the stepwise backward variable selection and the iterative Bayesian model averaging (BMA) approaches to the Cox proportional hazards models. Potential predictors of the mortality rate were based on a broad range of clinical data; functional and laboratory tests, including geriatric nutritional risk index (GNRI); lymphocyte count; vitamin D, and the age-weighted Charlson comorbidity index. The results of the multivariable analysis identified seven explanatory variables that are independently associated with the length of survival. The mortality rate was higher in males than in females; it increased with the comorbidity level and C-reactive proteins plasma level but was negatively affected by a person’s mobility, GNRI and lymphocyte count, as well as the vitamin D plasma level.

The use of linked routine data to optimise calculation of the Hospital Frailty Risk Score on the basis of previous hospital admissions: a retrospective observational cohort study

BACKGROUND

The Hospital Frailty Risk Score (HFRS) has been widely but inconsistently applied in published studies, particularly in how diagnostic information recorded in previous hospital admissions is used in its construction. We aimed to assess how many previous admissions should be considered when constructing the HFRS and the influence of frailty risk on long length of stay, in-hospital mortality, and 30-day readmission.

METHODS

This is a retrospective observational cohort study of patients aged 75 years or older who had at least one emergency admission to any of 49 hospital sites in the Yorkshire and Humber region of England, UK. We constructed multiple versions of the HFRS for each patient, each form incorporating diagnostic data from progressively more previous admissions in its construction within a 1-year or 2-year window. We assessed the ability of each form of the HFRS to predict long length of stay (>10 days), in-hospital death, and 30-day readmission.

FINDINGS

Between April 1, 2013, and March 31, 2017, 282 091 patients had 675 155 hospital admissions. Regression analyses assessing the different constructions of HFRS showed that the form constructed with diagnostic information recorded in the current and previous two admissions within the preceding 2 years performed best for predicting all three outcomes. Under this construction, 263 432 (39·0%) of 674 615 patient admissions were classified as having low frailty risk, for whom 33 333 (12·7%) had a long length of stay, 10 145 (3·9%) died in hospital, and 45 226 (17·2%) were readmitted within 30 days. By contrast with those patients with low frailty risk, for those with intermediate frailty risk, the probability was 2·5-times higher (95% CI 2·4 to 2·6) for long length of stay, 2·17-times higher (2·1 to 2·2) for in-hospital death, and 0·7% higher (0·5 to 1) for readmission. For patients with high frailty risk, the probability was 4·3-times higher (4·2 to 4·5) for long length of stay, 2·48-times higher (2·4 to 2·6) for in-hospital death, and -1% (-1·2 to -0·5) lower for readmission than those with low frailty risk. The intermediate and high frailty risk categories were more important predictors of long length of stay than any of the other rich set of control variables included in our analysis. These categories also proved to be important predictors of in-hospital mortality, with only the Charlson Comorbidity Index offering greater predictive power.

INTERPRETATION

We recommend constructing the HFRS with diagnostic information from the current admission and from the previous two admissions in the preceding 2 years. This HFRS form was a powerful predictor of long length of stay and in-hospital mortality, but less so of emergency readmissions.

FUNDING

National Institute of Health Research.

Multi-morbidity and frailty at death: A new classification of death records for an ageing world

Mortality statistics based on underlying cause of death are challenged by increased life expectancy and the growing share of population reaching ages associated with frequent multi-morbidity (with death likely resulting from interactions between multiple diseases). We provide a novel way of analysing causes of death: accounting for all causes mentioned on death certificates and summarizing this information along two dimensions emblematic of ageing populations-multi-morbidity and frailty. We implement this classification for all deaths at ages 50+ in Italy in 2014. Multi-morbid processes represent the majority of deaths, rising from 43 per cent at ages 50-54 to 63 per cent at ages 85-89. Multi-morbidity at death is more frequent among males, although age patterns are identical for both sexes. About one in four deaths involves frailty symptoms, rising to 45 per cent at ages 95+. Mortality rates involving frailty are very similar for both sexes. Supplementary material is available for this article at: https://doi.org/10.1080/00324728.2020.1820558.

Care Recipient Multimorbidity and Health Impacts on Informal Caregivers: A Systematic Review

BACKGROUND AND OBJECTIVES

Caregiving outcomes have often been reported in terms of care recipients of single disease, rather than multiple health conditions. A systematic review was conducted to outline caregiving health outcomes and its association with care recipient multimorbidity for informal caregivers of older adults.

RESEARCH DESIGN AND METHODS

A search strategy was applied in six databases and grey literature. Inclusion criteria were primary observational studies on informal caregiving for care recipients aged 60 years and above, in the English language. Informal caregivers were those not formally hired and multimorbidity referred to presence of at least two health conditions. From a total of 2,101 titles, 230 abstracts were screened, and 19 articles were included. Quality assessment was conducted with application of the Newcastle-Ottawa-Scale.

RESULTS

Health-related and caregiving-related outcomes have been assessed for informal caregivers of older adults with multimorbidity. Caregiver subjective burden was most commonly evaluated and often reported to be low to moderate. In association with care recipient multimorbidity, caregiver burden, quality of life, and perceived difficulty in assisting the older adults were examined in 14 of the studies with mixed results. Studies were heterogeneous, with nonuniform definitions of informal caregivers and multimorbidity as well as measurement tools.

DISCUSSION AND IMPLICATIONS

This narrative review found that caring for older adults with multimorbidity impacts caregivers, although overall evidence is not conclusive. Despite caregiving-related outcomes being most commonly assessed among the caregivers, particularly subjective burden, findings suggest that it is worthwhile to examine other outcomes to enrich the evidence base.

Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

OBJECTIVES

Multimorbidity is the coexistence of two or more health conditions in an individual. Multimorbidity in younger adults is increasingly recognised as an important challenge. We assessed the prevalence of secondary care multimorbidity in mid-life and its association with premature mortality over 15 years of follow-up, in the Aberdeen Children of the 1950s (ACONF) cohort.

METHOD

A prospective cohort study using linked electronic health and mortality records. Scottish ACONF participants were linked to their Scottish Morbidity Record hospital episode data and mortality records. Multimorbidity was defined as two or more conditions and was assessed using healthcare records in 2001 when the participants were aged between 45 and 51 years. The association between multimorbidity and mortality over 15 years of follow-up (to ages 60-66 years) was assessed using Cox proportional hazards regression. There was also adjustment for key covariates: age, gender, social class at birth, intelligence at age 7, secondary school type, educational attainment, alcohol, smoking, body mass index and adult social class.

RESULTS

Of 9625 participants (51% males), 3% had multimorbidity. The death rate per 1000 person-years was 28.4 (95% CI 23.2 to 34.8) in those with multimorbidity and 5.7 (95% CI 5.3 to 6.1) in those without. In relation to the reference group of those with no multimorbidity, those with multimorbidity had a mortality HR of 4.5 (95% CI 3.4 to 6.0) over 15 years and this association remained when fully adjusted for the covariates (HR 2.5 (95% CI 1.5 to 4.0)).

CONCLUSION

Multimorbidity prevalence was 3% in mid-life when measured using secondary care administrative data. Multimorbidity in mid-life was associated with premature mortality.

Validating a methodology to measure frailty syndromes at hospital level utilising administrative data

BACKGROUND

Identifying older people with clinical frailty, reliably and at scale, is a research priority. We measured frailty in older people using a novel methodology coding frailty syndromes on routinely collected administrative data, developed on a national English secondary care population, and explored its performance of predicting inpatient mortality and long length of stay at a single acute hospital.

METHODOLOGY

We included patient spells from Secondary User Service (SUS) data for those ≥65 years with attendance to the emergency department or admission to West Middlesex University Hospital between 01 July 2016 to 01 July 2017. We created eight groups of frailty syndromes using diagnostic coding groups. We used descriptive statistics and logistic regression to explore performance of diagnostic coding groups for the above outcomes.

RESULTS

We included 17,199 patient episodes in the analysis. There was at least one frailty syndrome present in 7,004 (40.7%) patient episodes. The resultant model had moderate discrimination for inpatient mortality (area under the receiver operating characteristic curve (AUC) 0.74; 95% confidence interval (CI) 0.72-0.76) and upper quartile length of stay (AUC 0.731; 95% CI 0.722-0.741). There was good negative predictive value for inpatient mortality (98.1%).

CONCLUSIONS

Coded frailty syndromes significantly predict outcomes. Model diagnostics suggest the model could be used for screening of elderly patients to optimise their care.

Urban-rural and socioeconomic status: Impact on multimorbidity prevalence in hospitalized patients

OBJECTIVE

The aim of this study was to describe multimorbidity prevalence in hospitalized adults, by urban-rural area of residence and socioeconomic status (SES).

METHODS

Linked hospital episode data were used. Adults (≥18 years) admitted to hospital as an inpatient during 2014 in Grampian, Scotland, were included. Conditions were identified from admissions during the 5 years prior to the first admission in 2014. Multimorbidity was defined as ≥2 conditions and measured using Tonelli et al. based on International Classification of Diseases-10 coding (preselected list of 30 conditions). We used proportions and 95% confidence intervals (CIs) to summarize the prevalence of multimorbidity by age group, sex, urban-rural category and deprivation. The association between multimorbidity and patient characteristics was assessed using the χ 2 test.

RESULTS

Forty one thousand five hundred and forty-five patients were included (median age 62, 52.6% female). Overall, 27.4% (95% CI 27.0, 27.8) of patients were multimorbid. Multimorbidity prevalence was 28.8% (95% CI 28.1, 29.5) in large urban versus 22.0% (95% CI 20.9, 23.3) in remote rural areas and 28.7% (95% CI 27.2, 30.3) in the most deprived versus 26.0% (95% CI 25.2, 26.9) in the least deprived areas. This effect was consistent in all age groups, but not statistically significant in the age group 18-29 years. Multimorbidity increased with age but was similar for males and females.

CONCLUSION

Given the scarcity of research into the effect of urban-rural area and SES on multimorbidity prevalence among hospitalized patients, these findings should inform future research into new models of care, including the consideration of urban-rural area and SES.

Dr Foster global frailty score: an international retrospective observational study developing and validating a risk prediction model for hospitalised older persons from administrative data sets

OBJECTIVES

This study aimed to examine the prevalence of frailty coding within the Dr Foster Global Comparators (GC) international database. We then aimed to develop and validate a risk prediction model, based on frailty syndromes, for key outcomes using the GC data set.

DESIGN

A retrospective cohort analysis of data from patients over 75 years of age from the GC international administrative data. A risk prediction model was developed from the initial analysis based on seven frailty syndrome groups and their relationship to outcome metrics. A weighting was then created for each syndrome group and summated to create the Dr Foster Global Frailty Score. Performance of the score for predictive capacity was compared with an established prognostic comorbidity model (Elixhauser) and tested on another administrative database Hospital Episode Statistics (2011-2015), for external validation.

SETTING

34 hospitals from nine countries across Europe, Australia, the UK and USA.

RESULTS

Of 6.7 million patient records in the GC database, 1.4 million (20%) were from patients aged 75 years or more. There was marked variation in coding of frailty syndromes between countries and hospitals. Frailty syndromes were coded in 2% to 24% of patient spells. Falls and fractures was the most common syndrome coded (24%). The Dr Foster Global Frailty Score was significantly associated with in-hospital mortality, 30-day non-elective readmission and long length of hospital stay. The score had significant predictive capacity beyond that of other known predictors of poor outcome in older persons, such as comorbidity and chronological age. The score's predictive capacity was higher in the elective group compared with non-elective, and may reflect improved performance in lower acuity states.

CONCLUSIONS

Frailty syndromes can be coded in international secondary care administrative data sets. The Dr Foster Global Frailty Score significantly predicts key outcomes. This methodology may be feasibly utilised for case-mix adjustment for older persons internationally.

Patterns of multimorbid health conditions: a systematic review of analytical methods and comparison analysis

Background

The latest review of studies on multimorbidity patterns showed high heterogeneity in the methodology for identifying groups of multimorbid conditions. However, it is unclear how analytical methods used influence the identified multimorbidity patterns.

Methods

We undertook a systematic review of analytical methods used to identify multimorbidity patterns in PubMed and EMBASE from their inception to January 2017. We conducted a comparison analysis to assess the effect the analytical methods had on the multimorbidity patterns identified, using the Australian National Health Survey (NHS) 2007-08 data.

Results

We identified 13 194 studies and excluded 13 091 based on titles/abstracts. From the full-text reviews of the 103 remaining publications, we identified 41 studies that used five different analytical methods to identify multimorbid conditions in the studies. Thirty-seven studies (90%) adopted either the factor-analysis or hierarchical-clustering methods, but heterogeneity arises for the use of different proximity measures within each method to form clusters. Our comparison analysis showed the variation in identified groups of multimorbid conditions when applying the methods to the same NHS data. We extracted main similarities among the groupings obtained by the five methods: (i) cardiovascular and metabolic diseases, (ii) mental health problems and (iii) allergic diseases.

Conclusion

We showed the extent of effects for heterogeneous analytical methods on identification of multimorbidity patterns. However, more work is needed to guide investigators for choosing the best analytical method to improve the validity and generalizability of findings. Investigators should also attempt to compare results obtained by various methods for a consensus grouping of multimorbid conditions.

The integration of new nurse practitioners into care of older adults: A survey study

AIMS AND OBJECTIVES

To assess Norwegian advanced geriatric nurses' (AGNs) use of their knowledge and skills, and factors that may influence AGNs' opportunities to use their knowledge and skills to reach their full potential.

BACKGROUND

Despite the need for nurses with advanced knowledge and skill in the care of older adults, the introduction of new advanced nursing roles has been challenging. Countries in the process of establishing advanced roles need to monitor and identify possible implementation issues.

DESIGN

A cross-sectional descriptive survey.

METHODS

We invited the total population of AGNs in Norway (n = 26) and some of their colleagues (n = 465) to answer an online questionnaire. Twenty-three (88.5%) of the AGNs and 195 (42.0%) of the invited colleagues completed and submitted the questionnaires. The data were analysed with descriptive statistics. STROBE guidelines were used in reporting this study.

RESULTS

Of the AGNs, 16 (69.6%) used their knowledge and skills to their full potential when providing direct care. However, a minority used their knowledge and skills to their full potential when proving indirect care (n = 11, 47.8%), teaching/supervision (n = 11, 47.8%) and coordination (n = 5, 21.8%). A total of 47 (24.1%) colleagues experienced the AGNs' scope of practice as completely clear, and 52 (26.6%) collaborated with the AGNs several times a week. Of the colleagues, 131 (67.2%) considered the AGNs' role and scope of practice contributed positively to a high degree to health service for older adults.

CONCLUSION

The results indicate the need for greater focus on organisational adjustment for the AGNs to utilise their knowledge and skills to their full potential.

RELEVANCE TO CLINICAL PRACTICE

There is a need for greater focus on organisational adjustment to integrate AGNs at the workplace, as complete integration may improve the AGNs' use of their knowledge and skills.

The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study

BACKGROUND

Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis.

METHODS

From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models.

RESULTS

Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800).

CONCLUSIONS

This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.

The hospital cost of hip replacement for old inpatients in Belgium

INTRODUCTION

The objectives of this research are (i) to describe the medico-administrative characteristics of inpatients aged 65 and more who are hospitalized for hip joint replacement, (ii) to evaluate the complete hospital cost into costs of medical procedures, drugs costs, prostheses costs, and the administrative costs, and (iii) to identify and to evaluate from administrative database predictors influencing the complete hospital costs.

METHODS

The study was based on 961 inpatient stays aged 65 and more, with the APR-DRG 301 "Hip joint replacement". The sample for this study was based on data collected in 2014 among nine Belgian general hospitals. We used the linear regression method for isolating predictors of hospital cost.

RESULTS

The study highlights three different types of patients hospitalized for hip replacement, depending on the primary diagnosis: osteoarthritis problems (57%), femur neck fracture (30%), or other reasons (13%) (complications, infections, or problems with the existing hip prosthesis). The median length of stay (P25-P75) was 9 days (6.29-20.91). The median cost (P25-P75) was 8,023.91 EUR (6678.32-13,670.78). The total cost was composed of the direct hospital cost (30%), the cost of medical procedures (31%), cost of drugs (4%), the cost of hip prosthesis (18%), and other costs (17%). The linear regression reveals that an extreme SOI or risk of mortality, an ICU stay, an in-hospital death, an index of Charlson comorbidities of 4 or 5, to be hospitalized for a hip replacement because of complications, infections, or problems with the existing hip prosthesis, and the length of stay, were predictors of an increase in hospital cost.

CONCLUSION

The cost is not increasing with the age of the patient, but mainly with the length of stay and the comorbidities linked to the age which are considered in the severity of illness and the Charlson comorbidities index. The hospital cost is higher for patients hospitalized for complications linked to an existing hip prosthesis than for a hip replacement linked to osteoarthritis problems.

Measuring multimorbidity in hospitalised patients using linked hospital episode data: comparison of two measures

Introduction

Multimorbidity is a complex and growing health challenge. There is no accepted “gold standard” multimorbidity measure for hospital resource planning, and few studies have compared measures in hospitalised patients.

Aim

To evaluate operationalisation of two multimorbidity measures in routine hospital episode data in NHS Grampian, Scotland.

Methods

Linked hospital episode data (Scottish Morbidity Record (SMR)) for the years 2009-2016 were used. Adults admitted to hospital as a general/acute inpatient during 2014 were included. Conditions (ICD-10) were identified from general/acute (SMR01) and psychiatric (SMR04) admissions during the five years prior to first admission in 2014. Two count-based multimorbidity measures were used (Charlson Comorbidity Index and Tonelli et al.), and multimorbidity was defined as ≥2 conditions. Kappa statistics assessed agreement. The association between multimorbidity and length of stay, readmission and mortality was assessed using logistic and negative binomial regression as appropriate.

Results

In 41,545 adults (median age 62 years, 52.6% female), multimorbidity prevalence was 15.1% (95% CI 14.8%, 15.5%) using Charlson and 27.4% (27.0%, 27.8%) using Tonelli – agreement 85.1% (Kappa 0.57). Multimorbidity prevalence, using both measures, increased with age. Multimorbidity was higher in males (16.5%) than females (13.9%) using the Charlson measure, but similar across genders when measured with Tonelli. After adjusting for covariates, multimorbidity remained associated with longer length of stay (Charlson IRR 1.1 (1.0, 1.2); Tonelli IRR 1.1 (1.0, 1.2)) and readmission (Charlson OR 2.1 (1.9, 2.2); Tonelli OR 2.1 (2.0, 2.2)). Multimorbidity had a stronger association with mortality when measured using Charlson (OR 2.7 (2.5, 2.9)), than using Tonelli (OR 1.8 (1.7, 2.0)).

Conclusions

Multimorbidity measures operationalised in hospital episode data identified those at risk of poor outcomes and such operationalised tools will be useful for future multimorbidity research and use in secondary care data systems. Multimorbidity measures are not interchangeable, and the choice of measure should depend on the purpose.

Highlights

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.

Physical activity interventions are delivered consistently across hospitalized older adults but multimorbidity is associated with poorer rehabilitation outcomes: A population-based cohort study

BACKGROUND

Older adults live with multimorbidity including frailty and cognitive impairment often requiring hospitalization. While physical activity interventions (PAIs) are a normal rehabilitative treatment, their clinical effect in hospitalized older adults is uncertain.

OBJECTIVE

To observe PAI dosing characteristics and determine their impact on clinical performance parameters.

DESIGN

A single-site prospective observational cohort study in an older persons' unit.

SUBJECTS

Seventy-five older persons' unit patients ≥65 years.

INTERVENTION

PAI; therapeutic contact between physiotherapy clinician and patient.

MEASUREMENTS

Parameters included changes in activities-of-daily-living (Barthel Index), handgrip strength, balance confidence, and gait velocity, measured between admission and discharge (episode). Dosing characteristics were PAI temporal initiation, frequency, and duration. Frailty/cognition status was dichotomized independently per participant yielding 4 subgroups: frail/nonfrail and cognitively-impaired/cognitively-unimpaired.

RESULTS

Median (interquartile range) PAI initiation occurred after 2 days (1-4), frequency was 0.4 PAIs per day (0.3-0.5), and PAI duration per episode was 3.75 hours (1.8-7.2). All clinical parameters improved significantly across episodes: grip strength median (interquartile range) change, 2.0 kg (0.0-2.3) (P < .01); Barthel Index, 5 (3-8) (P < .01); gait velocity, 0.06 m.∙s^-1 (0.06-0.16) (P < .01); and balance confidence, -3 (-6 to -1) (P < .01). Physical activity intervention dosing remained consistent within subgroups. While several moderate to large associations between amount of PAIs and change in clinical parameters were observed, most were within unimpaired subgroups.

CONCLUSIONS

PAI dosing is consistent. However, while clinical changes during hospital episodes are positive, more favourable responses to PAIs occur if patients are nonfrail/cognitively-unimpaired. Therefore, to deliver a personalized rehabilitation approach, adaptation of PAI dose based on patient presentation is desirable.

Treatment of Odontoid Fractures in the Aging Population

Odontoid fractures are the most common cervical fracture type among the elderly population. Several treatment options exist for these patients, ranging from immobilization with a semirigid orthosis to surgical arthrodesis. This report reviews the key points in the management of odontoid fractures in the aged patient, including diagnosis, the various forms of conservative therapies, and the options for surgical intervention.