Melatonin does not reduce delirium severity in hospitalized older adults: Results of a randomized placebo-controlled trial

BACKGROUND

Delirium is common in older inpatients, causing distress, cognitive decline, and death. Current therapies are unsatisfactory, limited by lack of efficacy and adverse effects. There is an urgent need for effective delirium treatment. Sleep wake cycle is disturbed in delirium; endogenous Melatonin is perturbed, and exogenous Melatonin is a safe and effective medication for sleep disorders. This study aims to determine the effect of oral Melatonin 5 mg immediate release (IR) nightly for five nights on the severity of delirium in older (≥65 years) medical inpatients.

METHODS

This was a double-blinded, randomized controlled trial in general internal medicine units of a tertiary teaching hospital. Older inpatients with Confusion Assessment Method positive, hyperactive or mixed delirium within 48 h of admission or onset of in-hospital delirium were included. The primary outcome was change in delirium severity measured with the Memorial Delirium Assessment Scale (MDAS). A previous pilot trial showed 120 participants randomized 1:1 to Melatonin or Placebo would provide 90% power to demonstrate a 3-point reduction in the MDAS.

RESULTS

One hundred and twenty participants were randomized, 61 to Melatonin 5 mg and 59 to Placebo. The medication was well tolerated. The mean MDAS improvement was 4.9 (SD 7.6) in the Melatonin group and 5.4 (SD 7.2) in the Placebo group, p-value 0.42, a non-significant difference. A post-hoc analysis showed length of stay (LOS) was shorter in the intervention group (median 9 days [Interquartile Range (IQR) 4, 12] vs. Placebo group 10 [IQR 6, 16] p-value = 0.033, Wilcoxon Rank Sum test).

CONCLUSIONS

This trial does not support the hypothesis that Melatonin reduces the severity of delirium. This may be due to no effect of Melatonin, a smaller effect than anticipated, an effect not captured on a multidimensional delirium assessment scale, or a type II statistical error. Melatonin may improve LOS; this hypothesis should be studied.

Associations between potentially inappropriate prescribing and increased number of medications with postdischarge health outcomes among geriatric rehabilitation inpatients: RESORT study

AIMS

Older adults are vulnerable to medication-related harm mainly due to high use of medications and inappropriate prescribing. This study aimed to investigate the associations between inappropriate prescribing and number of medications identified at discharge from geriatric rehabilitation with subsequent postdischarge health outcomes.

METHOD

RESORT (REStORing health of acutely unwell adulTs) is an observational, longitudinal cohort study of geriatric rehabilitation inpatients. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation, using Version 2 of the STOPP/START criteria.

RESULTS

In total, 1890 (mean age 82.6 ± 8.1 years, 56.3% female) were included. The use of at least 1 PIM or PPO at geriatric rehabilitation discharge was not associated with 30-day and 90-day readmission and 3-month and 12-month mortality. Central nervous system/psychotropics and fall risk PIMs were significantly associated with 30-day hospital readmission (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.09-2.15), and cardiovascular PPOs with 12-month mortality (AOR 1.34; 95% CI 1.00-1.78). Increased number of discharge medications was significantly associated with 30-day (AOR 1.03; 95% CI 1.00-1.07) and 90-day (AOR 1.06; 95% CI 1.03-1.09) hospital readmissions. The use and number of PPOs (including vaccine omissions) were associated with reduced independence in instrumental activities of daily living scores at 90-days after geriatric rehabilitation discharge.

CONCLUSION

The number of discharge medications, central nervous system/psychotropics and fall risk PIMs were significantly associated with readmission, and cardiovascular PPOs with mortality. Interventions are needed to improve appropriate prescribing in geriatric rehabilitation patients to prevent hospital readmission and mortality.

Communities of practice in residential aged care: A rapid review

BACKGROUND

Communities of practice (CoPs) have the potential to help address the residential aged care system's need for continuing education and quality improvement. CoPs have been used in healthcare to improve clinical practice; however, little is known about their application to the unique residential aged care context.

OBJECTIVES

This rapid review of CoPs for residential aged care was conducted to summarise the features of CoPs, how they are developed and maintained, and assess their effectiveness.

METHODS

MEDLINE and CINAHL databases were searched for studies published from January 1991 to November 2022 about CoPs in residential aged care. Data were extracted regarding the CoPs' three key features of 'domain', 'community' and 'practice' as described by Wenger and colleagues. Kirkpatrick's four levels of evaluation (members' reactions, learning, behaviour and results) was used to examine studies on the effectiveness of CoPs. The Mixed Methods Appraisal Tool was used for quality appraisal.

RESULTS

Nineteen articles reported on 13 residential aged care CoPs. Most CoPs aimed to improve care quality (n = 9, 69%) while others aimed to educate members (n = 3, 23%). Membership was often multidisciplinary (n = 8, 62%), and interactions were in-person (n = 6, 46%), online (n = 3, 23%) or both (n = 4, 31%). Some CoPs were developed with the aid of a planning group (n = 4, 31%) or as part of a larger collaborative (n = 4, 31%), and were maintained using a facilitator (n = 7, 54%) or adapted to member feedback (n = 2, 15%). Thirteen (81%) studies evaluated members' reactions, and three (24%) studies assessed members' behaviour. The heterogeneity of studies and levels of reporting made it difficult to synthesise findings.

CONCLUSIONS

This review revealed the variation in why, and how, CoPs have been used in residential aged care, which is consistent with previous reviews of CoPs in healthcare. While these findings can inform the development of CoPs in this context, further research is needed to understand how CoPs, including the membership makeup, delivery mode, facilitator type and frequency of meetings, impact quality of care.

Patterns of Objectively Measured Sedentary Behavior and Physical Activity and Their Association with Changes in Physical and Functional Performance in Geriatric Rehabilitation Inpatients

OBJECTIVES

To examine whether The Ending PyJama (PJ) Paralysis campaign, focused on increasing in-hospital physical activity, affects objectively measured sedentary behavior and physical activity patterns and if these are associated with changes in physical and functional performance in geriatric rehabilitation inpatients.

DESIGN

Quasi-experimental study.

SETTING AND PARTICIPANTS

Within the REStORing health of acutely unwell adulTs (RESORT) observational, longitudinal cohort of geriatric rehabilitation inpatients, the Ending PJ Paralysis campaign was implemented on 2 out of 4 wards.

METHODS

Objectively measured sedentary behavior and physical activity were measured by an inertial sensor (ActivPAL4) for 1 week, comparing control (non-PJ) and intervention (PJ) groups using linear mixed models. Mean sedentary behavior and physical activity measures and their association with physical and functional performance changes were investigated by linear regression analyses, stratified by low vs high performance at admission using the median as a cut-off.

RESULTS

A total of 145 (n = 68 non-PJ and n = 77 PJ) inpatients with a mean age of 83.0 (7.7) years (55.9% female inpatients) were included. The median nonupright time was 23.1 [22.1-23.6] and 23.0 [21.8-23.6] hours/day for non-PJ and PJ groups, respectively. Objectively measured sedentary behavior and physical activity measures did not significantly change over measurement days and were independent of the Ending PJ Paralysis campaign. For inpatients with low performance at admission, lower sedentary behavior [B(SE) -0.013 (0.005) to -0.157 (0.045), P < .01] and higher physical activity [B(SE) 0.033 (0.007) to 0.814 (0.200), P < .01] measures were associated with improved physical performance. In addition, lower sedentary behaviour [B(SE) = -0.058 (0.024), P < .05 and higher physical activity [B (SE) 0.060 (0.024) to 0.683 (0.182), P < .05] were associated with improved instrumental functional performance.

CONCLUSIONS AND IMPLICATIONS

In geriatric rehabilitation inpatients, the Ending PJ Paralysis campaign did not affect objectively measured sedentary behavior and physical activity patterns. Lower mean sedentary behaviour and higher physical activity measures were associated with improved physical and functional performance in inpatients with low performance.

The Association of Changes in Physical Performance During Geriatric Inpatient Rehabilitation With Short-Term Hospital Readmission, Institutionalization, and Mortality: RESORT

OBJECTIVES

Geriatric inpatient rehabilitation aims to restore function, marked by physical performance, to enable patients to return and remain home after hospitalization. However, after discharge some patients are soon readmitted, institutionalized, or may die. Whether changes in physical performance during geriatric rehabilitation are associated with these short-term adverse outcomes is unknown. This study aimed to determine the association of changes in physical performance during geriatric inpatient rehabilitation with short-term adverse outcomes.

DESIGN

Observational longitudinal study.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients of the REStORing health of acutely unwell adulTs (RESORT) cohort study of the XXXX (Melbourne, Australia) were included.

METHODS

The change from admission to discharge in the Short Physical Performance Battery (SPPB) score, balance, gait speed (GS), chair stand test (CST), and hand grip strength (HGS) were calculated and analyzed using logistic regression analysis with readmission, incidence of institutionalization, and mortality, and ≥1 adverse outcome within 3 months postdischarge.

RESULTS

Of 693 inpatients, 11 died during hospitalization and 572 patients (mean age 82.6 ± 7.6 years, 57.9% female) had available physical performance data. Within 3 months postdischarge, 47.3% of patients had ≥1 adverse outcome: readmission was 20.8%, institutionalization was 26.6%, and mortality was 7.9%. Improved SPPB score, balance, GS, CST, and HGS were associated with lower odds of institutionalization and mortality. Improved GS was additionally associated with lower odds of readmission [odds ratio (OR) 0.35, 95% CI 0.16-0.79]. CST score had the largest effect, with a 1-point increase associating with 40% lower odds of being institutionalized (OR 0.60, 95% CI 0.42-0.86), 52% lower odds of mortality (OR 0.48, 95% CI 0.29-0.81), and a 24% lower odds of ≥1 adverse outcome (OR 0.76, 95% CI 0.59-0.97).

CONCLUSIONS AND IMPLICATIONS

Improvement in physical performance was associated with lower odds of short-term institutionalization and mortality indicating the prognostic value of physical performance improvement during geriatric inpatient rehabilitation.

Predictors for the Transitions of Poor Clinical Outcomes Among Geriatric Rehabilitation Inpatients

OBJECTIVE

To investigate the associations of morbidity burden and frailty with the transitions between functional decline, institutionalization, and mortality.

DESIGN

REStORing health of acutely unwell adulTs (RESORT) is an ongoing observational, longitudinal inception cohort and commenced on October 15, 2017. Consented patients were followed for 3 months postdischarge.

SETTING AND PARTICIPANTS

Consecutive geriatric rehabilitation inpatients admitted to geriatric rehabilitation wards.

METHODS

Patients' morbidity burden was assessed at admission using the Charlson Comorbidity Index (CCI) and Cumulative Illness Rating Scale (CIRS). Frailty was assessed using the Clinical Frailty Scale (CFS) and modified Frailty Index based on laboratory tests (mFI-lab). A multistate model was applied at 4 time points: 2 weeks preadmission, admission, and discharge from geriatric rehabilitation and 3 months postdischarge, with the following outcomes: functional decline, institutionalization, and mortality. Cox proportional hazards regression was applied to investigate the associations of morbidity burden and frailty with the transitions between outcomes.

RESULTS

The 1890 included inpatients had a median age of 83.4 (77.6-88.4) years, and 56.3% were female. A higher CCI score was associated with a greater risk of transitions from preadmission and declined functional performance to mortality [hazard ratio (HR) 1.28, 95% CI 1.03-1.59; HR 1.32, 95% CI 1.04-1.67]. A higher CIRS score was associated with a higher risk of not recovering from functional decline (HR 0.80, 95% CI 0.69-0.93). A higher CFS score was associated with a greater risk of transitions from preadmission and declined functional performance to institutionalization (HR 1.28, 95% CI 1.10-1.49; HR 1.23, 95% CI 1.04-1.44) and mortality (HR 1.12, 95% CI 1.01-1.33; HR 1.11, 95% CI 1.003-1.31). The mFI-lab was not associated with any of the transitions. None of the morbidity measures or frailty assessment tools were associated with the transitions from institutionalization to other outcomes.

CONCLUSIONS AND IMPLICATIONS

This study demonstrates that greater frailty severity, assessed using the CFS, is a significant risk factor for poor clinical outcomes and demonstrates the importance of implementing it in the geriatric rehabilitation setting.

Diagnostic imaging for suspected pulmonary embolism during pregnancy and postpartum: A comparative radiation dose study

INTRODUCTION

To compare the radiation dose exposure and diagnostic efficiency of computed tomographic pulmonary angiography (CTPA) and ventilation/perfusion imaging (V/Q) for clinically suspected pulmonary embolism (PE) in pregnant and postpartum women in a tertiary hospital setting.

METHODS

A retrospective cohort study of 473 pregnant and postpartum women referred for CTPA or V/Q for clinically suspected PE between January 2013 and December 2018 at a tertiary hospital. Maternal effective radiation dose, breast-absorbed radiation dose and fetal-absorbed dose estimates were calculated. Diagnostic yield was evaluated from radiological findings.

RESULTS

Computed tomographic pulmonary angiography (CTPA) was more commonly used for the imaging of suspected PE in pregnant and postpartum populations (51.9% vs. 48.1% and 77.1% vs. 22.9%, respectively). CTPA was associated with higher maternal effective and breast-absorbed doses (maternal effective CTPA 4.7 (±2.9) mSv (millisievert), V/Q 1.7(±0.8) mSv (mean difference 2.93 mSv P < 0.001), and breast-absorbed CTPA 8.0 (±5.2) mGy (milligray), V/Q 0.3 (±0.1) (mean difference 7.67 mGy P < 0.001), respectively). Fetal radiation dose exposure was low. The incidence of positive PE was 5.5%. Indeterminate rates of CTPA and V/Q were 3.0% and 5.5% (P = 0.176), respectively.

CONCLUSIONS

Compared to V/Q, CTPA is associated with higher maternal and breast radiation dose; however, modern CT scanners achieve lower radiation doses than historically described. Fetal radiation dose was comparably low. The diagnostic yield of the imaging modalities in pregnant and postpartum women is similar. Revision of guidelines should occur with the advances in CT technology.

Trajectories of Mini-Mental State Examination Scores over the Lifespan in General Populations: A Systematic Review and Meta-Regression Analysis

Objectives: Over the lifespan cumulative changes to the brain lead to cognitive decline and eventually to dementia in 20-25% of adults 85 years and older. A commonly used screening tool for cognitive function is the Standard 30 point Mini-Mental State Examination (MMSE). Though the MMSE is used to screen for dementia, little is known about the changes in scores over the lifespan in general populations.Method: A systematic search was conducted using Cochrane, EMBASE, MEDLINE and PsycINFO for articles published from January 1, 2007 to May 25, 2017. Articles were included if they had a longitudinal design reporting at least two MMSE scores. A mixed-effect meta-regression analysis was conducted to examine the influence of age on MMSE score followed by a change-point regression analysis determining the age at which MMSE declines.Results: 45 articles including 58,939 individuals (age range 18-108 years, 61.2% female) summarized 222 MMSE point estimates from 35 cohorts. The meta-regression demonstrated a significant decrease in MMSE scores with higher age (regression coefficient of age: -0.10 (Confidence Interval (CI) -0.15, -0.05)). The average annual decline in MMSE scores identified by the change-point analysis at the age of 41 years and 84 years were -0.04 (95% CI: -0.05, -0.03) and -0.53 (95% CI: -0.55, -0.50), respectively.Conclusions: Between the age of 29 and 105 years MMSE scores decline, with the highest decline between age 84 and 105 years.Clinical Implementations: The use of MMSE should be restricted to higher age categories in aging general populations.

Albumin and C-reactive protein relate to functional and body composition parameters in patients admitted to geriatric rehabilitation after acute hospitalization: findings from the RESORT cohort

PURPOSE

Albumin and C-reactive protein (CRP) are non-specific markers of inflammation, which could affect muscle tissue during acute hospitalization. We investigated the association between albumin and CRP during acute hospitalization with functional and body composition parameters in patients admitted to geriatric rehabilitation.

METHODS

The REStORing Health of Acutely Unwell AdulTs (RESORT) cohort includes geriatric rehabilitation patients assessed for change in activities of daily living (ADL, using the Katz index) during acute hospitalization, and subsequently for Katz ADL, gait speed (GS), handgrip strength (HGS) and skeletal muscle mass index (SMI) at geriatric rehabilitation admission. Albumin and CRP average (median), variation (interquartile range), and maximum or minimum were collected from serum samples, and were examined for their association with functional and body composition parameters using multivariable linear regression analysis adjusted for age, sex and length of acute hospital stay.

RESULTS

1769 Inpatients were included for analyses (mean age 82.6 years ± 8.1, 56% female). Median length of acute hospitalization was 7 [IQR 4, 13] days and median number of albumin and CRP measurements was 5 [IQR 3, 12] times. ADL declined in 89% of patients (median - 3 points, IQR - 4, - 2). Lower average albumin, higher albumin variation and lower minimum albumin were associated with larger declines in ADL and with lower ADL, GS, HGS and SMI at geriatric rehabilitation admission. Higher average and maximum CRP were associated with lower GS.

CONCLUSION

Inflammation, especially lower albumin concentrations, during acute hospitalization is associated with lower physical function at geriatric rehabilitation admission.

Effect of a Ward-Based Program on Hospital-Associated Complications and Length of Stay for Older Inpatients: The Cluster Randomized CHERISH Trial

IMPORTANCE

Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging.

OBJECTIVES

To implement and evaluate a ward-based improvement program ("Eat Walk Engage") to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis.

INTERVENTION

A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles.

MAIN OUTCOMES AND MEASURES

Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering.

RESULTS

A total of 265 participants on 4 intervention wards (124 women [46.8%]; mean [SD] age, 75.9 [7.3] years) and 274 participants on 4 control wards (145 women [52.9%]; mean [SD] age, 78.0 [8.2] years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions.

CONCLUSIONS AND RELEVANCE

The Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12615000879561.

Geriatric home-based rehabilitation in Australia: Preliminary data from an inpatient bed-substitution model

Background

The REStORing health of acutely unwell adulTs (RESORT) is an observational longitudinal cohort, including geriatric rehabilitation inpatients aged ≥65 years admitted to a geriatrician‐led rehabilitation service at a tertiary hospital. The aim of this study is to describe a home‐based bed‐substitution rehabilitation model for geriatric inpatients, including patient phenotype, and health outcomes at preadmission, admission, discharge, and three‐month follow‐up.

Methods

A standardized Comprehensive Geriatric Assessment was performed on admission and discharge, including demographics (home situation, cognitive impairment, medical diagnoses, etc.), frailty (Clinical Frailty Scale (CFS)), mobility (patient‐reported and Functional Ambulation Classification), physical performance (Short Physical Performance Battery (SPPB), handgrip strength), and functional independence (Activities of Daily Living (ADL), Instrumental ADL (IADL)). Service provision data (health care staff visits, length of stay (LOS), and negative events (e.g., falls)) were extracted from medical records. Three‐month outcomes included mobility, ADL and IADL scores, institutionalization, and mortality.

Results

Ninety‐two patients were included with a mean age of 81.1 ± 7.8 years, 56.5% female. Twenty‐nine (31.5%) patients lived alone, 39 (42.4%) had cognitive impairment and the commonest geriatric rehabilitation admission reason was falls (n = 30, 32.6%). Patients received care from nurses, physicians, and a median of four (interquartile range (IQR) 3–6) allied health disciplines for a median LOS of 13.0 days (IQR 10.0–15.0). On a population level, patient mobility and functional independence worsened from preadmission to admission. CFS, SPPB, ADL, and IADL scores improved from admission to discharge, and seven (7.6%) patients fell. At three‐month follow‐up, patient‐reported mobility was comparable to preadmission baseline, but functional independence (ADL, IADL) scores worsened for 27/69 (39.1%) and 28/63 (44.4%), respectively.

Conclusions

Hospitalization‐associated decline in mobility and functional independence improved at discharge and three‐months, but was not fully reversed in the multidisciplinary home‐based geriatric rehabilitation bed‐substitution service. Future research should compare outcomes to equivalent hospital‐based geriatric rehabilitation and evaluate patient perspectives.

See related Editorial by William J. Hall in this issue.

Comparison of the modified Frailty-Index based on laboratory tests and the Clinical Frailty Scale in predicting mortality among geriatric rehabilitation inpatients: RESORT

OBJECTIVE

To compare the associations of the FI-lab, modified (m)FI-lab and Clinical Frailty Scale (CFS) with one-year mortality.

STUDY DESIGN

An observational longitudinal inception cohort of inpatients admitted to the geriatric rehabilitation wards in the Royal Melbourne Hospital, Victoria, Australia.

MAIN OUTCOME MEASURES

The measured ratio was defined as the proportion of measured laboratory tests to the total number of tests (n = 77). The FI-lab is the proportion of abnormal results to the total measured laboratory tests. The mFI-lab was calculated by dividing the FI-lab by the measured ratio. The measured ratio of laboratory tests, FI-lab, mFI-lab and CFS were assessed at admission to geriatric rehabilitation. Patients' mortality data were obtained from the Registry of Births, Deaths and Marriages Victoria and medical records.

RESULTS

The total of 1819 inpatients had a median age of 83.3 [77.5-88.3] years and 56.5% were female. The median measured ratio, FI-lab, mFI-lab and CFS scores were 0.58 [0.47-0.70], 0.31 [0.23-0.38], 0.51 [0.38-0.69] and 6 (Abbasi et al., 2018Gill, Gahbauer, Allore & Han, 2006; Howlett et al., 2014;) respectively. The one-year mortality rate was 17.1%. The measured ratio was not associated with one-year mortality. Higher FI-lab (hazard ratio (HR)=1.180, 95%CI: 1.037-1.343), mFI-lab (HR=1.074, 95%CI: 1.030-1.119) and CFS scores (HR=1.350, 95%CI: 1.191-1.530) were associated with higher risk of one-year mortality. The area under the curve (AUC) of FI-lab, mFI-lab and CFS with one-year mortality were 0.581, 0.587 and 0.612 respectively.

CONCLUSION

The FI-lab, mFI-lab and CFS poorly predict mortality in geriatric rehabilitation inpatients despite the statistically significant associations shown.

Feasibility of Diagnosing Initial Orthostatic Hypotension Using a Continuous Blood Pressure Device in Geriatric Rehabilitation Inpatients: RESORT

Background

Initial orthostatic hypotension (IOH) is highly prevalent in older adults and may interfere with the ability to regain function after acute hospitalization. IOH assessment requires a non-invasive, beat-to-beat continuous blood pressure device, which is not widely used in geriatric rehabilitation. Our aim was to test the feasibility of diagnosing IOH using a continuous blood pressure device in geriatric rehabilitation inpatients.

Methods

Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort admitted to a tertiary hospital were randomly selected to undergo continuous blood pressure monitoring (Finapres) for 5 min in the supine position and 3 min of standing or sitting when unable to stand. Interventions to warm hands and adjusting the cuff pressure sizes were attempted if no signal was obtained or an error message occurred.

Results

Of 37 randomly selected inpatients, 29 {55.2% female; mean age 82.8 (standard deviation [SD]) 6.6 years} agreed to the continuous blood pressure measurement. Successful measurements were achieved in 20 out of 29 inpatients, two after hand warming. Patients with unsuccessful measurements were likely to be older (mean age 87.2 [SD] 4.4 years, p = 0.03), have cerebrovascular disease (p = 0.006), lower body mass index (p = 0.012), and a lower short physical performance battery score (p = 0.039). Eight out of 20 patients had IOH.

Conclusion

The number of unsuccessful continuous blood pressure measurements was high in a population with high IOH prevalence despite multiple interventions to establish a signal. Future research should focus on improving the efficiency of continuous blood pressure devices in hospitalized patients with unsuccessful signals.

Unresolved inflammation during hospitalization is associated with post-discharge institutionalization and mortality in geriatric rehabilitation inpatients: The RESORT cohort

BACKGROUND

Inflammation contributes to adverse health outcomes in community-dwelling populations. Little is known about inflammation in hospitalized older adults and its association with adverse outcomes. This study aimed to evaluate the association of the inflammatory markers C-reactive protein (CRP) and albumin measured during acute and geriatric rehabilitation hospitalization with institutionalization and mortality in geriatric rehabilitation inpatients.

METHODS

Within the REStORing health of acutely unwell adulTs (RESORT) cohort, CRP and albumin were measured as part of usual care during acute and geriatric rehabilitation hospitalization. Inflammatory markers are presented as median, peak (CRP: maximum; albumin: minimum), variation (interquartile range) and direction of change (increased CRP or decreased albumin: positive or negative difference between last measurement and median of preceding measurements). Logistic regression was used to determine the associations between inflammatory markers and institutionalization at three-month and all-cause mortality at three- and twelve-month post-discharge.

RESULTS

Geriatric rehabilitation inpatients (n = 1846) with a median age of 83.3 years (interquartile range 77.6-88.3) and 56.6% of female were included. Increased CRP during geriatric rehabilitation was associated with institutionalization. Higher median, peak and increased levels of CRP during geriatric rehabilitation but not during acute hospitalization were associated with higher mortality. Lower CRP variation during acute hospitalization but higher CRP variation during geriatric rehabilitation was associated with higher mortality. Lower median level of albumin during both hospitalizations were associated with higher mortality.

CONCLUSIONS

Inflammation characterized by lower albumin during acute hospitalization and, higher CRP and lower albumin during geriatric rehabilitation was associated with mortality in geriatric rehabilitation inpatients. Increased CRP during geriatric rehabilitation was associated with institutionalization. Unresolved inflammation in geriatric rehabilitation might indicate ongoing disease activity leading to adverse outcomes.

The Association between Sarcopenia as a Comorbid Disease and Incidence of Institutionalisation and Mortality in Geriatric Rehabilitation Inpatients: REStORing health of acutely unwell adulTs (RESORT)

INTRODUCTION

Sarcopenia is associated with poor health outcomes and highly prevalent in individuals with age-related diseases. This study aimed to determine whether sarcopenia as a comorbid disease is associated with the incidence of institutionalisation and mortality in geriatric rehabilitation inpatients.

METHODS

REStORing health of acutely unwell adulTs (RESORT) includes geriatric rehabilitation patients assessed for sarcopenia (the European Working Group on Sarcopenia in Older People [EWGSOP, 2010], EWGSOP2 [2018], and the Asian Working Group for Sarcopenia [AWGS 2019]), multimorbidity, disease severity, and specific diseases (Charlson Comorbidity Index and Cumulative Illness Rating Scale) at admission. The incidence of institutionalisation and mortality was recorded 3 months after discharge. Logistic regressions were adjusted for age and sex with "low morbidity and no sarcopenia" as the reference group.

RESULTS

In 549 included patients (median age was 82.2 [77.4-87.7] years, 58.3% female), sarcopenia prevalence was 37.9, 18.6, and 26.1% according to EWGSOP, EWGSOP2, and AWGS 2019, respectively. Sarcopenia as a comorbid disease with high multimorbidity, dementia, diabetes mellitus, and renal impairment had higher odds of institutionalisation incidence. Sarcopenia as a comorbid disease with high multimorbidity, high disease severity, chronic obstructive pulmonary disease, osteoporosis, and renal impairment had higher odds of mortality.

CONCLUSION

Sarcopenia as a comorbid disease is associated with a higher incidence of institutionalisation and mortality in geriatric rehabilitation inpatients. This highlights the need for in-hospital sarcopenia diagnostics and interventions.

Trajectories of functional performance recovery after inpatient geriatric rehabilitation: an observational study

Objective

To identify functional performance trajectories and the characteristics of people who receive inpatient geriatric rehabilitation after hospital admissions.

Design, setting, participants

REStORing health of acutely unwell adulTs (RESORT) is an observational, prospective, longitudinal inception cohort study of consecutive patients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital. Recruitment commenced on 15 October 2017.

Main outcome measures

Functional performance, assessed with the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales two weeks before acute hospitalisation, on admission to and discharge from geriatric rehabilitation, and three months after discharge from geriatric rehabilitation.

Results

A total of 618 rehabilitation patients were included in our analysis. For each of the two scales, three distinct functional performance trajectories were identified by latent class growth modelling: poor at baseline and 3‐month follow‐up (remained poor: ADL, 6.6% of patients; IADL, 42%), good at baseline but poor recovery (deteriorated: ADL, 33%; IADL, 20%), and good at baseline and good recovery (recovered: ADL, 60%; IADL, 35%). Higher Clinical Frailty Scale (CFS) score (v recovered, per point: odds ratio [OR], 2.51; 95% CI, 1.64–3.84) and cognitive impairment (OR, 6.33; 95% CI, 2.09–19.1) were associated with greater likelihood of remaining poor in ADL, and also with deterioration (CFS score: OR, 1.76; 95% CI, 1.45–2.13; cognitive impairment: OR, 1.87; 95% CI, 1.24–2.82). Higher CFS score (OR, 1.64; 95% CI, 1.37–1.97) and cognitive impairment (OR, 3.60; 95% CI, 2.31–5.61) were associated with remaining poor in IADL, and higher CFS score was also associated with deterioration (OR, 1.63; 95% CI, 1.33–1.99).

Conclusions

Based on ADL assessments, most people who underwent inpatient geriatric rehabilitation regained their baseline functional performance. As higher CFS score and cognitive impairment were associated with poorer functional recovery, assessing frailty and cognition at hospital admission could assist intervention and discharge planning.

SARC-F Is Inaccurate to Identify Geriatric Rehabilitation Inpatients at Risk for Sarcopenia: RESORT

INTRODUCTION

Sarcopenia is highly prevalent in geriatric rehabilitation inpatients; screening using the Strength, Assistance in walking, Rise from a chair, Climb stairs, Falls history questionnaire (SARC-F) has been recommended. This study assessed the diagnostic accuracy of the SARC-F in identifying sarcopenia according to the European Working Group on Sarcopenia in Older People (EWGSOP), EWGSOP2, and Asian Working Group for Sarcopenia (AWGS) definitions in geriatric rehabilitation inpatients.

METHODS

REStOring health of acutely unwell adulTs (RESORT) is an observational, longitudinal cohort of geriatric rehabilitation inpatients. The SARC-F was completed for 2 time-points, status at preadmission (1 month before admission) and at admission; a score ≥4 was considered at risk for sarcopenia. Muscle mass (bioelectrical impedance analysis), handgrip strength (handheld dynamometry), and gait speed (4-m walk test) were measured at admission. Diagnostic accuracy was determined by sensitivity, specificity, and area under the curve (AUC).

RESULTS

The sarcopenia prevalence (n = 290, median age 84.0 years [IQR 79.0-89.0], 56.9% female) was 40.3% (EWGSOP1), 25.4% (EWGSOP2), and 38.8% (AWGS). For preadmission and admission status, respectively, the SARC-F identified 67.9 and 82.1% (EWGSOP), 66.0 and 81.0% (EWGSOP2), and 67.5 and 81.6% (AWGS) inpatients at risk for sarcopenia. The SARC-F showed fair sensitivity (67-74%), poor specificity (32-37%), and poor AUC (0.411-0.474) to identify inpatients at risk for sarcopenia at preadmission status, and fair-good sensitivity (79-84%), poor specificity (17-20%), and poor AUC (0.401-0.432) to identify inpatients at risk for sarcopenia at admission, according to EWGSOP, EWGSOP2, and AWGS definitions.

CONCLUSION

The SARC-F showed poor diagnostic accuracy in identifying sarcopenia in geriatric rehabilitation inpatients. Assessment of sarcopenia is recommended without screening.

Geriatric Rehabilitation Inpatients Roam at Home! A Matched Cohort Study of Objectively Measured Physical Activity and Sedentary Behavior in Home-Based and Hospital-Based Settings

OBJECTIVES

This study aimed to describe objectively measured physical activity and sedentary behavior in geriatric rehabilitation patients receiving care in the home-based compared to the hospital-based setting.

DESIGN

Observational matched cohort study.

SETTING AND PARTICIPANTS

Home-based (patient's home) or hospital-based (ward) geriatric rehabilitation was delivered to inpatients within the REStORing health of acutely unwell adulTs (RESORT) observational, longitudinal cohort of the Royal Melbourne Hospital (Melbourne, Victoria, Australia).

METHODS

Patients were asked to wear ActivPAL4 accelerometers for 1 week and were assessed by a comprehensive geriatric assessment at admission, discharge, and followed up after 3 months. Hospital-based patients were matched to home-based patients for sex and baseline physical function [Short Physical Performance Battery (SPPB), activities (instrumental) of daily living, and Clinical Frailty Scale]. Differences in patient characteristics and physical activity (total, standing and walking durations, number of steps and sit-to stand transitions) and sedentary behavior (total, sitting and lying durations) were assessed.

RESULTS

A total of 159 patients were included: 18 home-based [mean age: 81.9 ± 8.6 years, 38.9% female, median (interquartile range [IQR]) SPPB: 7.0 (5.0-9.0)] and 141 hospital-based [mean age: 82.9 ± 7.8 years, 57.4% female, median (IQR) SPPB: 1.0 (0.0-4.0)] patients, of whom 18 were matched [mean age: 80.1 ± 7.4 years, 38.9% female, median (IQR) SPPB: 6.5 (4.8-10.0)]. Median physical activity measures were consistently higher in home-based patients compared to the total group of hospital-based patients. After matching, physical activity measures remained >2.4 times higher and were significantly different for all measures (total physical activity, standing and walking durations, and steps) except for sit-to-stand transitions. Sedentary behaviors were similar with home-based patients spending non-significantly more time sitting but significantly less time lying than hospital-based patients (matched and total).

CONCLUSIONS AND IMPLICATIONS

Home-based inpatients are more physically active than hospital-based inpatients independent of matching for sex and baseline physical function, which supports home-based geriatric rehabilitation.

Healthcare-providers experiences with Advance Care Planning and Goals of Patient Care medical treatment orders in Residential Aged Care Facilities; an explanatory descriptive study

OBJECTIVES

Advance Care Planning (ACP) is a process by which people communicate their healthcare preferences and values, planning for a time when they are unable to voice them. Within Residential Aged Care Facilities (RACF) both the completion and the clarity of ACP documents is variable and, internationally, medical treatment orders have been used to address these issues. In this study, Goals of Patient Care (GOPC) medical treatment orders were introduced alongside usual ACP in three RACF to improve healthcare decision-making for residents. This study explored the experiences of RACF healthcare-providers with ACP and GOPC medical treatment orders.

METHODS

The study was of Explanatory Descriptive design. Within three RACF where the GOPC medical treatment orders had been introduced, focus groups and interviews with healthcare-providers were performed. The transcribed interviews were analysed thematically.

RESULTS

Healthcare-providers reported support for ACP and GOPC but also discussed many problematic issues. Analysis of the data identified four main themes: Enablers, Barriers, Resident autonomy and Advance documentation (ACP and GOPC).

CONCLUSION

Healthcare-providers identified ACP and GOPC as positive tools for assisting with medical decision-making for residents. Although barriers exist in completion and activation of plans, healthcare-providers described them as progressing resident-centred care. Willingness to follow ACP instructions was reported to be reduced by lack of trust by clinicians. Families were also reported to change their views from those documented in family-completed ACP, attributed to poor understanding of their purpose. Participants reported that GOPC led to clearer documentation of residents' medical treatment-plans than relying on ACP documents alone. This article is protected by copyright. All rights reserved.

Malnutrition is associated with poor trajectories of activities of daily living in geriatric rehabilitation inpatients: RESORT

Malnutrition is associated with poor functional performance in geriatric rehabilitation inpatients. However, it is unclear if malnourished patients have poor functional trajectories over time. This study aimed to determine the association between (the risk of) malnutrition at admission and trajectories of Activities of Daily Living (ADL) and Instrumental ADL (IADL) from pre-admission to post-discharge in geriatric rehabilitation inpatients. An observational, longitudinal study was conducted in the REStORing health of acutely unwell adulTs (RESORT) cohort of geriatric rehabilitation inpatients. A total of 618 patients (mean age 82.1 ± 7.8 years, 57.4 % females) were included. The prevalence of the risk of malnutrition, by Malnutrition Screening Tool (MST) was 41.3 % (n = 255) and malnutrition by the Global Leadership Initiative on Malnutrition (GLIM) and European Society for Clinical Nutrition and Metabolism (ESPEN) criteria were 53.5 % (n = 331) and 13.1 % (n = 81) respectively. Malnutrition by the GLIM criteria but not the ESPEN criteria nor the risk of malnutrition, was associated with ADL trajectories of 'remained poor' (OR: 3.33, 95 %CI: 1.21-9.19) and 'deteriorated' (OR: 1.68, 95 %CI: 1.13-2.52) compared to the 'recovered' trajectory. The risk of malnutrition and malnutrition were not associated with IADL trajectories. Malnutrition at admission was associated with poor ADL trajectories but not IADL trajectories in geriatric rehabilitation inpatients.

Do morbidity measures predict the decline of activities of daily living and instrumental activities of daily living amongst older inpatients? A systematic review

OBJECTIVES

Older adults often suffer from multimorbidity, which results in hospitalisations. These are often associated with poor health outcomes such as functional dependence and mortality. The aim of this review was to summarise the current literature on the capacities of morbidity measures in predicting activities of daily living (ADL) and instrumental activities of daily living (IADL) amongst inpatients.

METHODS

A systematic literature search was performed using four databases: Medline, Cochrane, Embase, and Cinahl Central from inception to 6th March 2019. Keywords included comorbidity, multimorbidity, ADL, and iADL, along with specific morbidity measures. Articles reporting on morbidity measures predicting ADL and IADL decline amongst inpatients aged 65 years or above were included.

RESULTS

Out of 7334 unique articles, 12 articles were included reporting on 7826 inpatients (mean age 77.6 years, 52.7% females). Out of five morbidity measures, the Charlson Comorbidity Index was most often reported. Overall, morbidity measures were poorly associated with ADL and IADL decline amongst older inpatients.

CONCLUSION

Morbidity measures are poor predictors for ADL or IADL decline amongst older inpatients and follow-up duration does not alter the performance of morbidity measures.

Women, clinician and IT staff perspectives on telehealth for enhanced gestational diabetes mellitus management in an Australian rural/regional setting

INTRODUCTION

Women in rural and regional areas encounter challenges when accessing care for gestational diabetes mellitus (GDM). A telehealth initiative for GDM care in an urban setting demonstrated positive effects on achieving glycaemic targets without compromising quality of care, but consumer and health service staff perspectives have not been explored. This research aimed to identify the profiles of women accessing care for GDM in a large regional hospital with a rural catchment in Victoria, Australia as well as gain insight into the views of the women with GDM, clinicians and IT staff on the acceptability and feasibility of a GDM telehealth in this setting.

METHODS

Clinical and demographic characteristics of women accessing the GDM service between October 2016 and October 2017 were audited. Semi-structured interviews were completed with nine patients, three clinical staff and two IT service staff. Quantitative and qualitative data were analysed descriptively and thematically, respectively.

RESULTS

Telehealth was viewed favourably by women and staff, with many perceived benefits identified around mitigating challenges of accessing care, and service capacity and provision. Concerns were raised around potential costs incurred by women and health services in accessing telehealth initiatives. Staff highlighted that moderation of workloads and coordination of telehealth services would be essential to the success of a future telehealth initiative.

CONCLUSION

This article contributes important knowledge around GDM care in rural and regional settings and the perspectives of women with GDM, clinicians and technical support staff. Women and health services staff consider telehealth a feasible and acceptable alternative to current GDM care and address many of the barriers and impacts of attending care in person. Perceived benefits to patients and health services need to be balanced against the concerns around the work and costs to deliver GDM telehealth services.

A study protocol for the development of a multivariable model predicting 6- and 12-month mortality for people with dementia living in residential aged care facilities (RACFs) in Australia

BACKGROUND

For residential aged care facility (RACF) residents with dementia, lack of prognostic guidance presents a significant challenge for end of life care planning. In an attempt to address this issue, models have been developed to assess mortality risk for people with advanced dementia, predominantly using long-term care minimum data set (MDS) information from the USA. A limitation of these models is that the information contained within the MDS used for model development was not collected for the purpose of identifying prognostic factors. The models developed using MDS data have had relatively modest ability to discriminate mortality risk and are difficult to apply outside the MDS setting. This study will aim to develop a model to estimate 6- and 12-month mortality risk for people with dementia from prognostic indicators recorded during usual clinical care provided in RACFs in Australia.

METHODS

A secondary analysis will be conducted for a cohort of people with dementia from RACFs participating in a cluster-randomized trial of a palliative care education intervention (IMPETUS-D). Ten prognostic indicator variables were identified based on a literature review of clinical features associated with increased mortality for people with dementia living in RACFs. Variables will be extracted from RACF files at baseline and mortality measured at 6 and 12 months after baseline data collection. A multivariable logistic regression model will be developed for 6- and 12-month mortality outcome measures using backwards elimination with a fractional polynomial approach for continuous variables. Internal validation will be undertaken using bootstrapping methods. Discrimination of the model for 6- and 12-month mortality will be presented as receiver operating curves with c statistics. Calibration curves will be presented comparing observed and predicted event rates for each decile of risk as well as flexible calibration curves derived using loess-based functions.

DISCUSSION

The model developed in this study aims to improve clinical assessment of mortality risk for people with dementia living in RACFs in Australia. Further external validation in different populations will be required before the model could be developed into a tool to assist with clinical decision-making in the future.

Simulation training in non-cancer palliative care for healthcare workers: a systematic review of controlled studies

Background

The need for healthcare workers (HCWs) to have skills and knowledge in non-cancer palliative care has been recognised. Simulation is increasingly being used for palliative care training, offering participants the opportunity to learn in a realistic environment and fully interactive way.

Objective

The aim of this systematic review was to summarise and critically appraise controlled studies on simulation training in non-cancer palliative care for HCWs.

Selection

Medline, CINAHL, PubMed and Cochrane Library databases were searched using palliative care and simulation terms. Randomised controlled trials (RCTs), non-randomised RCTs and controlled before-and-after (CBA) studies were included. Two reviewers independently screened titles and abstracts and undertook full article review using predefined selection criteria. Studies that met the inclusion criteria had data extracted and risk of bias assessed using the Cochrane Effective Practice and Organisation of Care risk of bias criteria.

Findings

Five articles were included: three RCTs and two CBA studies. All studies assessed learners’ palliative care communication skills, most studies evaluated learners’ perception of change in skills and one study assessed impact on patient outcomes and learners’ change in behaviour when applied in practice. There was variation in intervention content, intensity and duration, outcome measures and study design, making it difficult to compare and synthesise results.

Conclusion

There is a paucity of evidence to support simulation training to improve non-cancer palliative care. This review highlights the need for more robust research, including multicentre studies that use standardised outcome measures to assess clinician skills, changes in clinical practice and patient-related outcomes.

Prevalence of sarcopenia as a comorbid disease: A systematic review and meta-analysis

BACKGROUND

Sarcopenia shares risk factors with various other age-related diseases. This meta-analysis aimed to determine the prevalence of sarcopenia as a comorbid disease.

METHODS

Medline, EMBASE and Cochrane databases were searched for articles from inception to 8th June 2018, reporting the prevalence of sarcopenia in individuals with a diagnosis of cardiovascular disease (CVD), dementia, diabetes mellitus or respiratory disease and, if applicable their controls. No exclusion criteria were applied with regards to definition of sarcopenia, individuals' age, study design and setting. Meta-analyses were stratified by disease, definition of sarcopenia and continent.

RESULTS

The 63 included articles described 17,206 diseased individuals (mean age: 65.3 ± 1.6 years, 49.9% females) and 22,375 non-diseased controls (mean age: 54.6 ± 16.2 years, 53.8% females). The prevalence of sarcopenia in individuals with CVD was 31.4% (95% CI: 22.4-42.1%), no controls were available. The prevalence of sarcopenia was 26.4% (95% CI: 13.6-44.8%) in individuals with dementia compared to 8.3% (95% CI: 2.8-21.9%) in their controls; 31.1% (95% CI: 19.8-45.2%) in individuals with diabetes mellitus compared to 16.2% (95% CI: 9.5-26.2%) in controls; and 26.8% (95% CI: 17.8-38.1%) in individuals with respiratory diseases compared to 13.3% (95% CI: 8.3-20.7%) in controls.

CONCLUSIONS

Sarcopenia is highly prevalent in individuals with CVD, dementia, diabetes mellitus and respiratory disease.

Subacute combined degeneration of the spinal cord masking motor neuron disease: a case report

Background

Subacute combined degeneration of the spinal cord is a potentially reversible myelopathy typically associated with vitamin B12 deficiency. There is predominant involvement of spinal cord posterior and lateral tracts, and manifestations include peripheral paraesthesia, impaired proprioception, gait disturbance, neuropathy and cognitive changes. Motor neuron disease (MND) is an unremittingly progressive neurodegenerative disorder involving upper and lower motor neurons with an average prognosis of 2–3 years. The diagnosis is clinical and may be supported by electromyography. A subset of MND occurs concurrently with frontotemporal dementia (FTD-MND) and may be initially misdiagnosed as a primary psychotic disorder.

Case presentation

We describe a 57-year-old Caucasian woman who presented with confusion and dysarthria. Low vitamin B12 levels and MRI findings led to an initial diagnosis of subacute combined degeneration of the spinal cord. Despite treatment, persistent dysarthria and presence of both upper and lower motor neuron signs on clinical examination prompted further assessment. Electromyography supported the diagnosis of MND. Comorbid chronic paranoid schizophrenia complicated the diagnostic process. We discuss overlapping features between B12 deficiency and MND as well as the neuropsychiatric overlap of B12 deficiency, FTD-MND and chronic schizophrenia.

Conclusions

Firstly, variability in neurocognitive and imaging manifestations of B12 deficiency can limit delineation of other pathologies. Failure to improve following correction of nutritional deficiencies warrants further investigation for an alternate diagnosis. Secondly, re-evaluation of patients with comorbid mental health conditions is important in reaching timely and accurate diagnoses.

A screen-based simulation training program to improve palliative care of people with advanced dementia living in residential aged care facilities and reduce hospital transfers: study protocol for the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) cluster randomised controlled trial

Background

Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners’ knowledge and skills. However, there is little research on simulation training for residential care staff.

This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital.

Methods

A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention.

Discussion

In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector.

Trial registration

ANZCTR, ACTRN12618002012257. Registered 14 December 2018.

Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial

OBJECTIVES

The "Goals of Patient Care" (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF).

DESIGN

The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences.

SETTING AND PARTICIPANTS

The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained.

MEASURES

The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates.

RESULTS

More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016).

CONCLUSIONS AND IMPLICATIONS

In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Obesity in older adults: Effect of degree of weight loss on cardiovascular markers and medications

Obesity worsens the age-related tendency towards cardiovascular disease and diabetes. Older adults are vulnerable to medication adverse effects. Intentional weight loss in older adults with obesity has been shown to improve cardiovascular and glycaemic markers. The effect of rapid weight loss induced by very-low-calorie diets (VLCDs) on these markers has not been evaluated in this group. In this 12-week study, participants were randomized to one of healthy eating, hypocaloric diet or VLCD, all combined with three times weekly exercise (Ex/HE, Ex/Diet, Ex/VLCD, respectively). The effects of these interventions on weight, blood pressure, lipids, glucose and HbA_1c , inflammatory markers and cardiovascular and diabetes medication changes were measured. Weight loss was 3.7%, 5.1% and 11.1% in Ex/HE, Ex/Diet and Ex/VLCD, respectively. There were significant improvements in HbA_1c in all groups, but by the greatest degree in Ex/VLCD (0.18 ± 0.07%, 0.18 ± 0.06% and 0.59 ± 0.13%, respectively). Similar patterns were seen in total cholesterol (0.13 ± 0.15, 0.21 ± 0.11 and 0.53 ± 0.13 mmol/L, respectively, P = .047), triglycerides (0.35 ± 0.13, 0.20 ± 0.10 and 0.51 ± 0.09 mmol/L, respectively, P = .011) and systolic blood pressure (9 ± 2, 2 ± 3 and 14 ± 3 mmHg respectively, P = .025). There were no between-group differences in fasting glucose, high-density lipoprotein (HDL) cholesterol, LDL-C and inflammatory markers. Reductions in anti-hypertensive or diabetes medication were made in 4/29, 7/36 and 16/37 participants in Ex/HE, Ex/Diet and Ex/VLCD, respectively (P = .017). Significant weight loss achieved with a VLCD gave rise to improvements in multiple cardiovascular risk markers, despite reduction in medication. Weight loss is an under-utilized method of cardiovascular risk management in this group.

Sarcopenia and its association with falls and fractures in older adults: A systematic review and meta-analysis

Sarcopenia is a potentially modifiable risk factor for falls and fractures in older adults, but the strength of the association between sarcopenia, falls, and fractures is unclear. This study aims to systematically assess the literature and perform a meta-analysis of the association between sarcopenia with falls and fractures among older adults. A literature search was performed using MEDLINE, EMBASE, Cochrane, and CINAHL from inception to May 2018. Inclusion criteria were the following: published in English, mean/median age ≥ 65 years, sarcopenia diagnosis (based on definitions used by the original studies' authors), falls and/or fractures outcomes, and any study population. Pooled analyses were conducted of the associations of sarcopenia with falls and fractures, expressed in odds ratios (OR) and 95% confidence intervals (CIs). Subgroup analyses were performed by study design, population, sex, sarcopenia definition, continent, and study quality. Heterogeneity was assessed using the I² statistics. The search identified 2771 studies. Thirty-six studies (52 838 individuals, 48.8% females, and mean age of the study populations ranging from 65.0 to 86.7 years) were included in the systematic review. Four studies reported on both falls and fractures. Ten out of 22 studies reported a significantly higher risk of falls in sarcopenic compared with non-sarcopenic individuals; 11 out of 19 studies showed a significant positive association with fractures. Thirty-three studies (45 926 individuals) were included in the meta-analysis. Sarcopenic individuals had a significant higher risk of falls (cross-sectional studies: OR 1.60; 95% CI 1.37-1.86, P < 0.001, I²  = 34%; prospective studies: OR 1.89; 95% CI 1.33-2.68, P < 0.001, I²  = 37%) and fractures (cross-sectional studies: OR 1.84; 95% CI 1.30-2.62, P = 0.001, I²  = 91%; prospective studies: OR 1.71; 95% CI 1.44-2.03, P = 0.011, I²  = 0%) compared with non-sarcopenic individuals. This was independent of study design, population, sex, sarcopenia definition, continent, and study quality. The positive association between sarcopenia with falls and fractures in older adults strengthens the need to invest in sarcopenia prevention and interventions to evaluate its effect on falls and fractures.

Orthostatic hypotension and cognition in older adults: A systematic review and meta-analysis

BACKGROUND

Orthostatic hypotension (OH) is common in older adults with reported prevalence rates of 5-40%. A direct link between OH and cognitive performance has been proposed due to impaired vascular autoregulation.

AIM

To systematically assess the literature of the association between OH and cognitive performance in older adults.

METHODS

Literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from inception to May 2017. Studies were included if OH and cognition were assessed in subjects of mean or median age ≥65 years. Risk of bias was assessed with the Newcastle Ottawa Scale.

RESULTS

Of 3266 studies screened, 32 studies (22 cross-sectional; 10 longitudinal) reporting data of 28,980 individuals were included. OH prevalence ranged from 3.3% to 58%. Of the 32 studies, 18 reported an association between OH and worse cognitive performance and 14 reported no association. Mini Mental State Examination (MMSE) was the most commonly used cognitive assessment tool. Studies using more than one cognitive assessment tool were more likely to find an association between OH and worse cognition. OH was significantly associated with a lower MMSE mean score (mean difference - 0.51 (95% CI: -0.85, -0.17, p = 0.003)) and an increased risk of cognitive impairment (OR 1.19 (95% CI, 1.00-1.42, p = 0.048)).

CONCLUSIONS

OH is common in older populations and is associated with worse cognition expressed as lower MMSE scores. Use of MMSE alone as a cognitive assessment tool may underestimate the association. It is yet unclear whether the association between OH and worse cognitive performance is causative.

Lower Skeletal Muscle Mass at Admission Independently Predicts Falls and Mortality 3 Months Post-discharge in Hospitalized Older Patients

Background

Approximately 10% of older adults are annually admitted to a hospital. Hospitalization is associated with a higher risk of falls and mortality after discharge. This study aimed to identify predictors at admission for falls and mortality 3 months post-discharge in hospitalized older patients.

Methods

The Evaluation of Muscle parameters in a Prospective cohort of Older patients at clinical Wards Exploring Relations with bed rest and malnutrition (EMPOWER) study is an observational, prospective longitudinal inception cohort of 378 patients aged 70 years and older who were subsequently admitted to a tertiary hospital (the Netherlands). Potential predictors for falls and mortality 3 months post-discharge were tested using univariate and multivariate logistic regression analyses and included the following domains: demographic (age, sex, living independently), lifestyle (alcohol, smoking), nutrition (SNAQ score), muscle mass (absolute, relative), physical function (handgrip strength, Katz ADL score), cognition (six-item cognitive impairment test score), and disease (medications, diseases).

Results

The mean age was 79.6 years (standard deviation 6.23) and 50% were male. Within 3 months post-discharge, 19% reported a fall and 13% deceased. Univariate predictors for falls were higher age, lower absolute muscle mass and higher six-item cognitive impairment test score. Lower absolute muscle mass independently predicted falls post-discharge (multivariate). Univariate predictors for mortality were higher age, male sex, no current alcohol use, higher SNAQ score, lower absolute and higher relative muscle mass, higher Katz ADL score and higher number of diseases. Male sex, higher SNAQ score, and lower absolute muscle mass independently predicted mortality post-discharge (multivariate).

Conclusions

In hospitalized older adults, muscle mass should be measured to predict future outcome. Future intervention studies should investigate if increasing muscle mass prevent short-term falls and mortality.

Improving the utility of multisource feedback for medical consultants in a tertiary hospital: a study of the psychometric properties of a survey tool

Objective The aim of this study was to investigate the psychometric properties of a multisource review survey tool for medical consultants in an Australian health care setting. Methods Two sets of survey data from a convenience sample of medical consultants were analysed using SPSS, comprising self-assessment data from 73 consultants and data from 734 peer reviewers. The 20-question survey consisted of three subscales, plus an additional global question for reviewers. Analysis included the reliability coefficient (α) of the scale and the three subscales, inter-rater reliability or agreement and validity of the model, correlation between the single global question, the total performance score and the three survey subfactors (Pearson's), interrater agreement (rWG(J)), the optimal number of peer reviewers required and model-based reliability (ρ). Results The global question, total performance score and the three subfactors were strongly correlated (general scale r=0.81, clinical subscale r=0.78, humanistic subscale r =0.74, management subscale r=0.75; two-tailed P<0.01 for all). The scale showed very good internal consistency, except for the five-question management subscale. Model-based reliability was excellent (ρ=0.93). Confirmatory factor analysis showed the model fit using the 20-item scale was not satisfactory (minimum discrepancy/d.f.=7.70; root mean square error of approximation=0.10; comparative fit index=0.79; Tucker-Lewis index=0.76). A modified 13-item model provided a good fit. Using the 20-item scale, a 99% level of agreement could be achieved with eight to 10 peer reviewers; for the same level of agreement, the number of reviewers increased to >10 using a revised 13-item scale. Conclusions Overall, the 20-item multisource review survey tool showed good internal consistency reliability for both self and peer ratings; however, further investigation using a larger dataset is needed to analyse the robustness of the model and to clarify the role that a single global question may play in future multisource review processes. What is known about the topic? Defining and measuring skills and behaviours that reflect competence in the health setting have proven to be complex, and this has resulted in the development of specific multisource feedback surveys for individual medical specialities. Because little literature exists on multisource reviews in an Australian context, a pilot study of a revised survey tool was undertaken at an Australian tertiary hospital. What does this paper add? The aim of this study was to investigate the psychometric properties of a generic tool (used across specialities) by assessing the validity, reliability and interrater reliability of the scale and to consider the contribution of a single global question to the overall multisource feedback process. This study provides evidence of the validity and reliability of the survey tool under investigation. The strong correlation between the global item, the total performance score and the three subfactors suggests that this is an area requiring further investigation to determine the role that a robust single global question like this may play in future multisource review surveys. Our five-question management skills subscale provides answers to questions relevant to the specific organisation surveyed, and we anticipate that it may serve to stimulate further exploration in this area. What are the implications for practitioners? The survey tool may provide a valid and reliable basis for performance review of medical consultants in an Australian healthcare setting.

Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care

OBJECTIVES

To propose a new multicomponent measure of hospital-associated complications of older people (HAC-OP) and evaluate its validity in a large hospital sample.

DESIGN

Observational study using baseline (pre-intervention) data from the Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital cluster randomized controlled trial.

SETTING

Acute medical and surgical wards in 4 hospitals in Queensland, Australia.

PARTICIPANTS

Individuals aged 65 and older (mean age 76, 48% female) with a hospital stay of 72 hours or longer (N=434).

MEASUREMENTS

We developed a multicomponent measure including 5 well-recognized hospital-associated complications of older people: hospital-associated delirium, functional decline, incontinence, falls, and pressure injuries. To evaluate construct validity, we examined associations with common risk factors (aged ≥75, functional impairment, cognitive impairment, history of falls). To evaluate predictive validity, we examined the association between length of stay, facility discharge, and 6-month mortality and any HAC-OP and total number of HAC-OP.

RESULTS

Overall, 192 (44%) participants had 1 or more HAC-OP during their admission. Any HAC-OP was strongly associated with the proposed shared risk factors, and there was a strong and graded association between HAC-OP and length of stay (9.1±7.4 days for any HAC-OP vs 6.8 ±4.1 days with none, p < .001), facility discharge (59/192 (31%) vs 27/242 (11%), p < .001) and 6-month mortality (26/192 (14%) vs 17/242 (7%), p = .02).

CONCLUSION

This study provides evidence of construct and predictive validity of the proposed measure of HAC-OP as a potential outcome measure for research investigating and improving hospital care of older people. J Am Geriatr Soc 67:352-356, 2019.

Do health assets have a protective effect for hospitalized frail older adults?

BACKGROUND

Although increasing frailty is predictive of increased mortality and length of stay for hospitalized older adults, this approach ignores health assets that individuals can utilize to recover following hospital admission.

AIM

To examine whether health assets mitigate the effect of frailty on outcomes for older adults admitted to hospital.

DESIGN

Patients of 1418 aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care, which surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls and medical diagnosis.

METHODS

The data set was interrogated for potential health assets and a multiple logistic regression adjusted for frailty index, age and gender as covariates was performed for the outcomes mortality, length of stay, re-admission and new need for residential care.

RESULTS

Inpatient mortality was 3% and 4.5% of patients died within 28 days of discharge. Median length of stay was 7 days (IQR 4-11). In multivariate analysis that includes frailty, being able to walk further [OR 0.08 (0.01-0.63)], ability to leave the house [OR 0.35 (0.17-0.74)] and living alone [OR 0.28 (0.10-0.79)] were protective against mortality. The presence of a support person was associated with a decreased length of stay [OR 0.14 (0.08-0.25)].

CONCLUSION

The inclusion of health assets in predictive models can improve prognostication and highlights potential interventions to improve outcomes for hospitalized older adults.

Using technology to support care in gestational diabetes mellitus: Quantitative outcomes of an exploratory randomised control trial of adjunct telemedicine for gestational diabetes mellitus (TeleGDM)

AIMS

The increasing incidence and prevalence of gestational diabetes mellitus (GDM) on a background of limited resources calls for innovative approaches healthcare provision. Our aim was to explore the effects of telemedicine supported GDM care on a range of health service utilisation and maternal and foetal outcomes.

METHODS

An exploratory randomised controlled trial of adjunct telemedicine support in the management of insulin-treated GDM compared to usual care control. Outcomes included health service use, maternal and foetal clinical outcomes as well as costs. Groups were compared on outcomes and Poisson and Cox regression analysis were performed for predictors of health service utilisation, glycaemic control and costs.

RESULTS

95 participants were recruited (intervention n = 61, control n = 34). There were no differences between the groups in number of face-to-face appointments (median (IQR) intervention = 8(7), control = 8(6), p = 0.843), rates of caesareans, macrosomia, large for gestational age, special care nursery admission or newborn birth-weight. The intervention had no impact on total (IRR = 1.04, p = 0.596) or face-to-face (IRR = 1.09, p = 0.257) clinic appointments or service provider costs. Participants receiving the intervention reached optimum glycaemic control quicker: mean (SD) 4.3(4.2) weeks vs. 7.6(4.5) weeks, p = 0.0001). Telemedicine was a significant predictor of better glycaemic control (HR = 1.71(95%CI: 1.11, 2.65, p = 0.015).

CONCLUSIONS

Telemedicine support for GDM care showed no impact on service utilisation and costs. The intervention produced similar GDM clinical outcomes as usual care and posed no added risk to clinical quality of care. The intervention may be associated with fewer insulin dose titrations and participants achieved optimum glycaemic control sooner.

Validation of the health assets index in the Australian inpatient setting: a multicentre prospective cohort protocol study

INTRODUCTION

It is well known that frail older adults are at increased risk for mortality and functional decline on admission to hospital. Systematic review demonstrates that health assets are associated with improved outcomes for hospitalised older adults. The health assets index (HAI) has been developed to measure health assets in the hospital setting. A protocol has been developed to determine the predictive validity of the HAI for frail older adults.

METHODS AND ANALYSIS

The HAI was developed based on a systematic review and secondary analysis of the interRAI-Acute Care (interRAI-AC) dataset. A pilot study was undertaken to refine the tool.The validation study will be a multicentre prospective cohort. Participants will be adults aged 70 years and older with an unplanned admission to hospital. Frailty, illness severity and demographic data will also be recorded. The primary outcomes are mortality at 28 days postdischarge and functional decline at the time of discharge from hospital. The primary hypothesis is that a higher score on the HAI will mitigate the effects of frailty for hospitalised older adults. The secondary outcomes to be recorded are length of stay, readmission at 28 days and functional status at 28 days postdischarge. The correlation between HAI and frailty will be explored. A multivariate analysis will be undertaken to determine the relationship between the HAI and the outcomes of interest.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Austin Health Human High Risk Ethics Committee. The results will be disseminated in peer-reviewed journals and research conferences. This study will determine whether the HAI has predictive validity for mortality and functional decline for hospitalised, frail older adults.

Reliability of an Online Geriatric Assessment Procedure Using the interRAI Acute Care Assessment System

OBJECTIVES

To determine whether geriatric triage decisions made using a comprehensive geriatric assessment (CGA) performed online are less reliable than face-to-face (FTF) decisions.

DESIGN

Multisite noninferiority prospective cohort study. Two specialist geriatricians assessed individuals sequentially referred for an acute care geriatric consultation. Participants were allocated to one FTF assessment and an additional assessment (FTF or online (OL)), creating two groups-two FTF (FTF-FTF, n = 81) or online and FTF (OL-FTF, n = 85).

SETTING

Three acute care public hospitals in two Australian states.

PARTICIPANTS

Admitted individuals referred for CGA.

INTERVENTION

Nurse-administered CGA, based on the interRAI Acute Care assessment system accessed online and other online clinical data such as pathology results and imaging enabling geriatricians to review participants' information and provide input into their care from a distance.

MEASUREMENTS

The primary decision subjected to this analysis was referral for permanent residential care. Geriatricians also recorded recommendations for referrals and variations for medication management and judgment regarding prognosis at discharge and after 3 months.

RESULTS

Overall percentage agreement was 88% (n = 71) for the FTF-FTF group and 91% (n = 77) for the OL-FTF group. The difference in agreement between the FTF-FTF and OL-FTF groups was -3%, indicating that there was no difference between the methods of assessment. Judgements made regarding diagnoses of geriatric syndromes, medication management, and prognosis (with regard to hospital outcome and location at 3 months) were found to be equally reliable in each mode of consultation.

CONCLUSION

Geriatric assessment performed online using a nurse-administered structured CGA system was no less reliable than conventional assessment in making clinical triage decisions.

Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial

INTRODUCTION

Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) 'Goals of Patient Care' (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration.

METHODS AND ANALYSIS

This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration.

DISSEMINATION

The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area.

TRIAL REGISTRATION NUMBER

ACTRN12615000298516, Results.

Medication adherence 1 month after hospital discharge in medical inpatients

BACKGROUND

The rate of medication non-adherence has been consistently reported to be between 20 and 50%. The majority of available data comes from international studies, and we hypothesised that a similar rate of adherence may be observed in Australian patients.

AIMS

To determine the rate of adherence to medications after discharge from acute general hospital admission and identify factors that may be associated with non-adherence.

METHODS

A prospective cohort study of 68 patients, comparing admission and discharge medication regimens to self-reported regimens 30-40 days after discharge from hospital. Patients were followed up via telephone call and univariate and multivariate binary logistic regression used to determine patient factors associated with non-adherence.

RESULTS

In all, 27 of 68 patients (39.7%) were non-adherent to one or more regular medications at follow up. Intentional and unintentional non-adherence contributed equally to non-adherence. Using multivariate analysis, presence of a carer responsible for medications was associated with significantly lower non-adherence (odds ratio (OR) 0.20 (0.05-0.83), P = 0.027) when adjusted for age, co-morbidities, chemist blister pack and total number of discharge medications.

CONCLUSIONS

Non-adherence to prescription medications is suboptimal and consistent with previous overseas studies. Having a carer responsible for medications is associated with significantly lower rates of non-adherence. Understanding patients' preferences and involving them in their healthcare may reduce intentional non-adherence.

Arrythmogenic Right Ventricular Dysplasia

A 10-year-old well and asymptomatic female was referred for screening of acute right ventricular dilatation (ARVD) as she had an elder brother diagnosed with ARVD whom died of sudden cardiac death. Electrocardiography (ECG), transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) were performed. Results of these investigations were suggestive of ARVD. Despite being a rare cardiac disease and largely unrecognised in children and young adult population, ARVD is an important cause of ventricular arrhythmias in this group of patients and is one of the causes of sudden cardiac death (SCD) in this population.

Stenting of vertical vein in an infant with obstructed supracardiac total anomalous pulmonary venous drainage

A 1.7 kg infant with obstructed supracardiac total anomalous pulmonary venous drainage (TAPVD) presented with severe pulmonary hypertension secondary to vertical vein obstruction. The child, in addition, had a large omphalocele that was being managed conservatively. The combination of low weight, unoperated omphalocele, and severe pulmonary hypertension made corrective cardiac surgery very high-risk. Therefore, transcatheter stenting of the stenotic vertical vein, as a bridge to corrective surgery was carried out. The procedure was carried out through the right internal jugular vein (RIJ). The stenotic segment of the vertical vein was stented using a coronary stent. After procedure, the child was discharged well to the referred hospital for weight gain and spontaneous epithelialization of the omphalocele. Stenting of the vertical vein through the internal jugular vein can be considered in very small neonates as a bridge to repair obstructed supracardiac total anomalous venous drainage.