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Jo SJ, Lee SH, Min HJ, Kim HJ, Kong HH. Mortality Outcomes and Contributing Risk Factors in Patients with Hospital-Associated Disability. J Clin Med 2024; 13:4798. [PMID: 39200940 PMCID: PMC11355630 DOI: 10.3390/jcm13164798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/29/2024] [Accepted: 08/12/2024] [Indexed: 09/02/2024] Open
Abstract
Background/Objectives: Hospital-associated disability (HAD), a functional decline following acute hospitalization, is a common complication associated with mortality and unfavorable prognoses in patients admitted to acute care hospitals. However, few studies have investigated mortality and associated factors in patients with HAD and have been limited by inconsistent HAD assessment tools and criteria. This study investigated mortality and risk factors in patients with HAD using specific criteria. Methods: This retrospective study evaluated patients referred to the Department of Rehabilitation Medicine with suspected HAD between June 2022 and March 2023. The collected data included medical histories, diagnostic tests for HAD (including muscle strength, balance, and modified Barthel Index), and bioelectrical impedance analysis (BIA). Multivariate logistic regression analysis was conducted to identify factors associated with mortality. Kaplan-Meier survival curves were constructed for mortality at 3 and 7 months. Results: A total of 455 patients were identified, among which 206 patients diagnosed with HAD (73.1 ± 12.5 years) were included in the analysis. The 3-month mortality rate was 27.2%. In the multivariate analysis, male sex (odds ratio (OR), 3.23; p < 0.01), a history of cancer (OR, 2.18; p < 0.05), and a low phase angle (OR, 0.69; p < 0.05) were significantly associated with mortality. A phase angle < 2.9° on BIA was associated with a significant increase in 3-month (hazard ratio (HR), 1.85; 95% confidence interval (CI), 1.06-3.23) and 7-month (HR, 2.80; 95% CI, 1.75-4.98) mortality. Conclusions: Patients with HAD had a high mortality rate, with several factors, particularly low BIA phase angles, associated with increased mortality.
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Affiliation(s)
- Soo-Jeong Jo
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea; (S.-J.J.); (S.-H.L.)
| | - So-Hee Lee
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea; (S.-J.J.); (S.-H.L.)
| | - Hyo-Jin Min
- Department of Clinical Pharmacology and Therapeutics, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea;
- Department of Medicine, Chungbuk National University Graduate School, Cheongju 28644, Republic of Korea
| | - Hee-Ji Kim
- Department of Nursing, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea;
| | - Hyun-Ho Kong
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea; (S.-J.J.); (S.-H.L.)
- Department of Rehabilitation Medicine, Chungbuk National University College of Medicine, Cheongju 28644, Republic of Korea
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Adsett JA, Mudge AM. Interventions to Promote Physical Activity and Reduce Functional Decline in Medical Inpatients: An Umbrella Review. J Am Med Dir Assoc 2024; 25:105052. [PMID: 38830596 DOI: 10.1016/j.jamda.2024.105052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Physical inactivity in hospitals is common and is associated with poor patient and clinical outcomes. This review was undertaken to identify and describe the effectiveness of interventions implemented at the ward or system level for improving physical activity and reducing functional decline in general medical inpatients. The secondary aim was to describe the effects on length of stay, discharge destination, falls, and hospital costs. DESIGN Umbrella review. SETTING AND PARTICIPANTS Systematic reviews that evaluated ward- or system-level interventions aiming to improve physical activity or reduce functional decline in medical inpatients. METHODS PubMed, EMBASE, Cochrane Database, CINAHL, JBI, and Web of Science databases were searched for English-language reviews published between 2000 and 2023. AMSTAR 2 was used to assess methodologic quality. Two reviewers independently assessed eligibility and methodologic quality and completed data abstraction, with results presented as a narrative synthesis. RESULTS The search yielded 568 systematic reviews of which 12 met criteria, half of which were published since 2020. Reviews included 76 unique primary studies with 72,645 participants. Most reviews were of low quality. Interventions that focused on progressive mobilization likely increased physical activity participation, reduced functional decline, and improved discharge home. Multicomponent interventions that employed multiple strategies targeting a broader range of barriers likely improved functional decline and discharge home and may have been associated with shorter length of stay. No interventions were associated with increased frequency of falls. Few studies reported costs. CONCLUSIONS AND IMPLICATIONS Progressive mobilization interventions and multicomponent interventions appear to be effective for improving physical activity participation and reducing functional decline in medical inpatients. Further high-quality studies may help to determine the most important aspects of multicomponent interventions. Standardized terminology related to inpatient physical activity may help promote a shared understanding and purpose across professions.
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Affiliation(s)
- Julie A Adsett
- Physiotherapy Department, Royal Brisbane and Women's Hospital Brisbane, Brisbane, Queensland, Australia; Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital Brisbane, Brisbane, Queensland, Australia.
| | - Alison M Mudge
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital Brisbane, Brisbane, Queensland, Australia
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Umegaki H. Hospital-associated complications in frail older adults. NAGOYA JOURNAL OF MEDICAL SCIENCE 2024; 86:181-188. [PMID: 38962414 PMCID: PMC11219237 DOI: 10.18999/nagjms.86.2.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/05/2023] [Indexed: 07/05/2024]
Abstract
As the Japanese population continues to age steadily, the number of older adults requiring healthcare has increased. Evidence demonstrates that hospitalization for acute care has a negative impact on the health outcomes of older adults. Frail older adults tend to have multifactorial conditions collectively known as "geriatric syndromes." When those with these premorbid conditions are hospitalized for acute care, they tend to develop new problems such as delirium and new functional impairments. Adverse consequences of hospitalization include the risk of loss of functional independence and chronic disability. In 2019, the new concept of "hospital-associated complications" (HACs) was proposed to describe these new problems. HACs comprise five conditions: hospital-associated falls, delirium, functional decline, incontinence, and pressure injuries. This review discusses the important issues of HACs in relation to their classification, prevalence, risk factors, prevention, and management in older adults hospitalized for acute care. Robust prevention and management are imperative to address the serious consequences and escalating medical costs associated with HACs, and a multidimensional and multidisciplinary approach is key to achieving this goal. Comprehensive geriatric assessment (CGA) is the cornerstone of geriatric medicine and offers a holistic approach involving multidisciplinary and multidimensional assessments. Considerable evidence is accumulating regarding how CGA and coordinated care can improve the prognosis of hospitalized older adults. Further research is needed to understand the occurrence of HACs in this population and to develop effective preventive measures.
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Affiliation(s)
- Hiroyuki Umegaki
- Department of Community Healthcare and Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Ghai S, Chassé K, Renaud MJ, Guicherd-Callin L, Bussières A, Zidarov D. Transition of care from post-acute services for the older adults in Quebec: a pilot impact evaluation. BMC Health Serv Res 2024; 24:421. [PMID: 38570840 PMCID: PMC10993552 DOI: 10.1186/s12913-024-10818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/03/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Early discharge of frail older adults from post-acute care service may result in individuals' reduced functional ability to carry out activities of daily living, and social, emotional, and psychological distress. To address these shortcomings, the Montreal West Island Integrated University Health and Social Services Centre in Quebec, Canada piloted a post-acute home physiotherapy program (PAHP) to facilitate the transition of older adults from the hospital to their home. This study aimed to evaluate: (1) the implementation fidelity of the PAHP program; (2) its impact on the functional independence, physical and mental health outcomes and quality of life of older adults who underwent this program (3) its potential adverse events, and (4) to identify the physical, psychological, and mental health care needs of older adults following their discharge at home. METHODS A quasi-experimental uncontrolled design with repeated measures was conducted between April 1st, 2021 and December 31st, 2021. Implementation fidelity was assessed using three process indicators: delay between referral to and receipt of the PAHP program, frequency of PAHP interventions per week and program duration in weeks. A battery of functional outcome measures, including the Functional Independence Measure (FIM) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 scale, as well as fall incidence, emergency visits, and hospitalizations were used to assess program impact and adverse events. The Patient's Global Impression of Change (PGICS) was used to determine changes in participants' perceptions of their level of improvement/deterioration. In addition, the Camberwell Assessment of Need for the Elderly (CANE) questionnaire was administered to determine the met and unmet needs of older adults. RESULTS Twenty-four individuals (aged 60.8 to 94 years) participated in the PAHP program. Implementation fidelity was low in regards with delay between referral and receipt of the program, intensity of interventions, and total program duration. Repeated measures ANOVA revealed significant improvement in FIM scores between admission and discharge from the PAHP program and between admission and the 3-month follow-up. Participants also reported meaningful improvements in PGICS scores. However, no significant differences were observed on the physical or mental health T-scores of the PROMIS Global-10 scale, in adverse events related to the PAHP program, or in the overall unmet needs. CONCLUSION Findings from an initial sample undergoing a PAHP program suggest that despite a low implementation fidelity of the program, functional independence outcomes and patients' global impression of change have improved. Results will help develop a stakeholder-driven action plan to improve this program. A future study with a larger sample size is currently being planned to evaluate the overall impact of this program. CLINICAL TRIAL REGISTRATION Retrospectively registered NCT05915156 (22/06/2023).
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Affiliation(s)
- Shashank Ghai
- Department of Political, Historical, Religious and Cultural Studies, Karlstad University, Karlstad, Sweden.
- Centre for Societal Risk Research, Karlstad University, Karlstad, Sweden.
| | - Kathleen Chassé
- Montréal West Island Integrated University Health and Social Services Centre, Montreal, Québec, Canada
| | - Marie-Jeanne Renaud
- Montréal West Island Integrated University Health and Social Services Centre, Montreal, Québec, Canada
| | - Lilian Guicherd-Callin
- Montréal West Island Integrated University Health and Social Services Centre, Montreal, Québec, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, McGill University, Montreal, Québec, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain, Montréal, Québec, Canada
- Departement Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Diana Zidarov
- Faculté de Médicine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal (IURDPM), Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal, Montréal, Québec, Canada
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Werner C, Sturm M, Heldmann P, Fleiner T, Bauer JM, Hauer K. Predictors of 2-Year Post-Discharge Mortality in Hospitalized Older Patients. J Clin Med 2024; 13:1352. [PMID: 38592184 PMCID: PMC10931743 DOI: 10.3390/jcm13051352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Understanding prognostic factors for adverse health outcomes is clinically relevant for improving treatment decision-making processes, potentially leading to enhanced patient prognosis. This secondary analysis of a prospective observational study aimed to identify independent factors associated with 2-year post-discharge mortality in acutely hospitalized older patients. METHODS All-cause mortality and date of death of 115 patients (83.3 ± 6.3 years, females: n = 75, 65.2%) admitted to acute geriatric wards were determined two years after hospital discharge through telephone interviews. Potential prognostic factors measured at hospital admission included demographic and clinical characteristics, nutritional, cognitive, and psychological status, Fried frailty phenotype, functioning in activities of daily living, locomotor capacity, and 24 h in-hospital mobility and objectively measured physical activity (PA) behaviors. RESULTS The 2-year mortality rate was 36.7% (n = 41). Univariate and multivariate Cox proportional hazards regression models revealed that mean daily PA level (hazards ratio (HR) = 0.59, 95% confidence interval (CI) 0.90-1.00; p = 0.042), frailty (HR = 3.39, 95% CI 1.20-9.51; p = 0.020), and underweight, in contrast to overweight (HR = 3.10, 95% CI 1.07-9.01; p = 0.038), at hospital admission were independently predictive of post-discharge mortality. CONCLUSION PA, frailty, and underweight at hospital admission should be considered when evaluating long-term survival prognosis, establishing risk profiles, and developing personalized care pathways in acute hospital care of older adults.
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Affiliation(s)
- Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Rohrbacher Str. 149, 69216 Heidelberg, Germany
| | - Melanie Sturm
- Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Patrick Heldmann
- Network Aging Research (NAR), Heidelberg University, Bergheimer Str. 20, 69115 Heidelberg, Germany
- Division of Physiotherapy, Department of Applied Health Sciences, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Tim Fleiner
- Institute for Geriatric Research, Ulm University Medical Centre, Zollernring 26, 89073 Ulm, Germany
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Wilhelm-Griesinger Straße 23, 51109 Cologne, Germany
| | - Jürgen M. Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Rohrbacher Str. 149, 69216 Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Bergheimer Str. 20, 69115 Heidelberg, Germany
| | - Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Rohrbacher Str. 149, 69216 Heidelberg, Germany
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstraße 110, 70376 Stuttgart, Germany
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Rodriguez-Lopez C, Mayordomo-Cava J, Zarralanga-Lasobras T, Romero-Estarlich V, Vidan MT, Ortiz-Alonso J, Valenzuela PL, Rodriguez-Romo G, Lucia A, Serra-Rexach JA. Exercise Intervention and Hospital-Associated Disability: A Nonrandomized Controlled Clinical Trial. JAMA Netw Open 2024; 7:e2355103. [PMID: 38329757 PMCID: PMC10853827 DOI: 10.1001/jamanetworkopen.2023.55103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/28/2023] [Indexed: 02/09/2024] Open
Abstract
Importance Inpatient exercise interventions may prevent, at least partly, hospital-associated disability (HAD) in older adults, but whether they also confer clinical benefits in the months following discharge is unclear. Objective To examine the association of exercise and health education with HAD incidence in hospitalized older adults receiving acute hospital care at discharge and 3 months later. Design, Setting, and Participants This single-center open-label, nonrandomized controlled clinical trial included patients aged 75 years or older seen at an acute care for elders unit at a tertiary public hospital in Madrid, Spain, from May 1, 2018, to June 30, 2022. Interventions Patients were allocated to an intervention or control group. Both groups received usual care, but the intervention group also performed a supervised multicomponent exercise program (daily strength, balance, and walking exercises along with inspiratory muscle training) during hospitalization and received health education on how to exercise at home and telephone counseling during follow-up. Main Outcomes and Measures The primary outcome was HAD incidence (determined by the Katz Index of Independence in Activities of Daily Living [hereafter, Katz Index]) at discharge and after 3 months compared with baseline (ie, 2 weeks before admission). Secondary outcomes included HAD incidence determined by the Barthel Index for Activities of Daily Living, ambulatory capacity decline at discharge and follow-up, changes in physical performance at discharge, and incidence of falls, readmissions, and mortality during the follow-up period. Results The study included 260 patients (134 women [51.5%]; mean [SD] age, 87.4 [4.9] years [range, 75-105 years]; median hospital length of stay, 7 days [IQR, 5-10 days]), of whom 130 received the intervention and 130 were in the control group. Differences in HAD incidence did not reach statistical significance at discharge (odds ratio [OR], 0.62; 95% CI, 0.37-1.05; P = .08) or follow-up (OR, 0.65; 95% CI, 0.36-1.17; P = .15) when using the Katz Index. A lower HAD incidence was observed in the intervention group at discharge (OR, 0.47; 95% CI, 0.27-0.81; P = .01) and at follow-up (OR, 0.36; 95% CI, 0.20-0.66; P = .001) when using the Barthel Index for Activities of Daily Living. The intervention was also associated with a lesser decline in ambulatory capacity (OR, 0.55; 95% CI, 0.32-0.96; P = .03) and improved physical performance at discharge (Cohen d, 0.39; 95% CI, 0.12-0.65; P = .004). No significant associations were observed for readmissions, falls, or mortality. Conclusions and Relevance In this nonrandomized controlled clinical trial, an exercise and health education intervention was not significantly associated with reduced HAD incidence when measured by the Katz Index. However, the benefits found for several secondary outcomes might support the implementation of in-hospital exercise programs for older patients. Trial Registration ClinicalTrials.gov Identifier: NCT03604640.
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Affiliation(s)
- Carlos Rodriguez-Lopez
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
| | - Jennifer Mayordomo-Cava
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
| | - Teresa Zarralanga-Lasobras
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
| | - Vicente Romero-Estarlich
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
| | - Maria Teresa Vidan
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
- School of Medicine, Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Javier Ortiz-Alonso
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
- School of Medicine, Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Pedro L. Valenzuela
- Physical Activity and Health Research Group, Research Institute of Hospital ‘12 de Octubre,’ Madrid, Spain
- Department of Systems Biology, University of Alcalá, Madrid, Spain
| | - Gabriel Rodriguez-Romo
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Physical Activity and Sport Sciences, Universidad Politécnica de Madrid, Madrid, Spain
| | - Alejandro Lucia
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Physical Activity and Health Research Group, Research Institute of Hospital ‘12 de Octubre,’ Madrid, Spain
- Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Jose Antonio Serra-Rexach
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Department of Geriatrics, Hospital General Universitario Gregorio Marañón, Health Research Institute Gregorio Marañón, Madrid, Spain
- School of Medicine, Department of Medicine, Universidad Complutense, Madrid, Spain
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Wu S, Zhao Y, Ning H, Hu H, Feng H. Research progress in the hospitalization-associated disability among elderly patients. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:455-462. [PMID: 37164929 PMCID: PMC10930072 DOI: 10.11817/j.issn.1672-7347.2023.220333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Indexed: 05/12/2023]
Abstract
Hospitalized patients who lose one or more activities of daily living at the time of discharge compared with 2 weeks before admission (before acute onset) are referred to as hospitalization-associated disability (HAD). The incidence of HAD is high among elderly patients, which leads to the increased readmission rates, long-term care rates, and mortality, bringing a huge burden on patients, families, and society. It is vital for doctors and nurses to identify the risk factors of HAD of the elderly patients and take targeted intervention measures to prevent and improve HAD. At present, the research on HAD in foreign countries is relatively perfect, while the research on HAD in China is still in its infancy, and there is still lack of systematic research and reports on the incidence, influencing factors, and intervention measures of HAD. Domestic clinical nursing practice can learn from foreign mature interventions, carry out cultural adjustment, create a friendly environment in the hospital for elderly patients, pay attention to the assessment of the influencing factors of HAD in elderly patients, and provide personalized and patient-centered nursing measures for hospitalized elderly patients according to the assessment results, maintain their function during hospitalization and prevent the occurrence of HAD.
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Affiliation(s)
- Shuang Wu
- Xiangya Nursing School, Central South University, Changsha 410013.
| | - Yinan Zhao
- Xiangya Nursing School, Central South University, Changsha 410013
| | - Hongting Ning
- Xiangya Nursing School, Central South University, Changsha 410013
| | - Hengyu Hu
- Xiangya Nursing School, Central South University, Changsha 410013
| | - Hui Feng
- Xiangya Nursing School, Central South University, Changsha 410013.
- Xiangya-Oceanwide Health Management Research Institute, Central South University, Changsha 410013, China.
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