B.M. Buurman

Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients The Transitional Care Bridge Randomized Clinical Trial

IMPORTANCE Older adults acutely hospitalized are at risk of disability. Trials on comprehensive geriatric assessment (CGA) and transitional care present inconsistent results. OBJECTIVE To test whether an intervention of systematic CGA, followed by the transitional care bridge program, improved activities of daily living (ADLs) compared with systematic CGA alone. DESIGN, SETTING, AND PARTICIPANTS This study was a double-blind, multicenter, randomized clinical trial conducted at 3 hospitals with affiliated home care organizations in the Netherlands between September 1, 2010, and March 1, 2014. In total, 1070 consecutive patients were eligible, 674 (63.0%) of whom enrolled. They were 65 years or older, acutely hospitalized to a medical ward for at least 48 hours with an Identification of Seniors at Risk-Hospitalized Patients score of 2 or higher, and randomized using permuted blocks stratified by study site and Mini-Mental State Examination score (<24 vs ≥24). The dates of the analysis were June 1, 2014, to November 15, 2014. INTERVENTIONS The transitional care bridge program intervention was started during hospitalization by a visit from a community care registered nurse (CCRN) and continued after discharge with home visits at 2 days and at 2, 6, 12, and 24 weeks. The CCRNs applied the CGA care and treatment plan. MAIN OUTCOMES AND MEASURES The main outcome was the Katz Index of ADL at 6 months compared with 2 weeks before admission. Secondary outcomes were mortality, cognitive functioning, time to hospital readmission, and the time to discharge from a nursing home. RESULTS The study cohort comprised 674 participants. Their mean age was 80 years, 42.1% (n = 284) were male, and 39.2% (n = 264) were cognitively impaired at admission. Intent-to-treat analysis found no differences in the mean Katz Index of ADL at 6 months between the intervention arm (mean, 2.0; 95% CI, 1.8-2.2) and the CGA-only arm (mean, 1.9; 95% CI, 1.7-2.2). For secondary outcomes, there were 85 deaths (25.2%) in the intervention arm and 104 deaths (30.9%) in the CGA-only arm, resulting in a lower risk on the time to death within 6 months after hospital admission (hazard ratio, 0.75; 95% CI, 0.56-0.99; P = .045; number needed to treat to prevent 1 death, 16). No other secondary outcome was significant. CONCLUSIONS AND RELEVANCE A systematic CGA, followed by the transitional care bridge program, showed no effect on ADL functioning in acutely hospitalized older patients. TRIAL REGISTRATION Netherlands Trial Registry: NTR2384.

Trajectories of Disability Among Older Persons Before and After a Hospitalization Leading to a Skilled Nursing Facility Admission

OBJECTIVES To identify distinct sets of disability trajectories in the year before and after a Medicare qualifying skilled nursing facility (Q-SNF) admission, evaluate the associations between the pre-and post-Q-SNF disability trajectories, and determine short-term outcomes (readmission, mortality). DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study including 754 community-dwelling older persons, 70+ years, and initially nondisabled in their basic activities of daily living. The analytic sample included 394 persons, with a first hospitalization followed by a Q-SNF admission between 1998 and 2012. MAIN OUTCOMES AND MEASURES Disability in the year before and after a Q-SNF admission using 13 basic, instrumental, and mobility activities. Secondary outcomes included 30-day readmission and 12-month mortality. RESULTS The mean (SD) age of the sample was 84.9 (5.5) years. We identified 3 disability trajectories in the year before a Q-SNF admission: minimal disability (37.3% of participants), mild disability (44.6%), and moderate disability (18.2%). In the year after a Q-SNF admission, all participants started with moderate to severe disability scores. Three disability trajectories were identified: substantial improvement (26.0% of participants), minimal improvement (36.5%), and no improvement (37.5%). Among participants with minimal disability pre-Q-SNF, 52% demonstrated substantial improvement; the other 48% demonstrated minimal improvement (32%) or no improvement (16%) and remained moderately to severely disabled in the year post-Q-SNF. Among participants with mild disability pre-Q-SNF, 5% showed substantial improvement, whereas 95% showed little to no improvement. Of participants with moderate disability pre-Q-SNF, 15% remained moderately disabled showing little improvement, whereas 85% showed no improvement. Participants who transitioned from minimal disability pre-Q-SNF to no improvement post-Q-SNF had the highest rates of 30-day readmission and 12-month mortality (rate/100 person-days 1.3 [95% CI 0.6-2.8] and 0.3 [95% CI 0.15-0.45], respectively). CONCLUSIONS Among older persons, distinct disability trajectories were observed in the year before and after a Q-SNF admission. The likelihood of improvement in disability was greatly constrained by the pre-Q-SNF disability trajectory. Most older persons remained moderately to severely disabled in the year following a Q-SNF admission.

Views of Primary Care Physicians and Home Care Nurses on the Causes of Readmission of Older Adults.

in one participant with a cardiovascular explanation for the fall, the history did not provide any clues for an associated cardiovascular condition. Amnesia from loss of consciousness occurs frequently in syncope, and fall events are often not witnessed. Furthermore, cognitive problems can complicate history taking, making history taking for falls due to syncope in older adults more challenging than in younger adults. Therefore, the role of structured “syncope” history taking in this population deserves further study. After a cardiovascular evaluation with structured additional history taking and subsequent intervention, a new or contributing cardiac cause of a fall was identified in nearly half of individuals who attended a falls clinic. This shows that a comprehensive cardiovascular analysis could be of additional value to the current assessment of older fallers, in which standard continuous BP measurement during routine falls examination is an important first step. Effectiveness of treatment of these cardiovascular abnormalities on fall reduction needs to be further studied in randomized clinical trials.

Residential Relocations Among Older People Over the Course of More Than 10 Years

OBJECTIVE The objective of this study was to describe the rates of residential relocations over the course of 10.5 years and evaluate differences in these relocation rates according to gender and decedent status. DESIGN Prospective, longitudinal study with monthly telephone follow-up for up to 126 months. SETTING Greater New Haven, CT. PARTICIPANTS There were 754 participants, aged 70 years or older, who were initially community-living and nondisabled in their basic activities of daily living. MEASUREMENTS Residential location was assessed during monthly interviews and included community, assisted living facility, and nursing home. A residential relocation was defined as a change of residential location for at least 1 week and included relocations within (eg, community-community) or between (community- assisted living) locations. We calculated the rates of relocations per 1000 patient-months and evaluated differences by gender and decedent status. RESULTS Sixty-six percent of participants had at least one residential relocation (range 0-12). Women had lower rates of relocations from nursing home to community (rate ratio [RR] 0.59, P = .02); otherwise, there were no gender differences. Decedents had higher rates of relocation from community to assisted living (RR 1.71, P = .002), from community to nursing home (RR 3.64, P < .001), between assisted living facilities (RR 3.65, P < .001), and from assisted living to nursing home (RR 2.5, P < .001). In decedents, relocations from community to nursing home (RR 3.58, P < .001) and from assisted living to nursing home (RR 3.3, P < .001) were most often observed in the last year of life. CONCLUSIONS Most older people relocated at least once during 10.5 years of follow-up. Women had lower rates of relocation from nursing home to community. Decedents were more likely to relocate to a residential location providing a higher level of assistance, compared with nondecedents. Residential relocations were most common in the last year of life.

A qualitative study of patient-centered goal-setting in geriatric rehabilitation: patient and professional perspectives:

Objective: To characterize how rehabilitation goals of older patients change over time and to explore professionals’ attitudes toward patient-centered goal-setting and their perspectives on rehabilitation goals. Design: Qualitative interview study. Setting: Three geriatric rehabilitation centers. Subjects: Ten patients (aged ⩾ 80), who had recently received inpatient geriatric rehabilitation, and seven professionals were purposively recruited. Methods: Semi-structured interviews. Patients were interviewed in the third or fourth week after discharge from inpatient rehabilitation, to reflect on their inpatient goals and to investigate long-term goals now that they were at home. A thematic analysis was performed. Results: During inpatient rehabilitation, participants’ main goals were regaining independence in self-care activities and going home. Post-discharge, patients were not at their baseline functioning level. Rehabilitation goals appeared to shift over time, and once at home, patients formulated more ambitious rehabilitation goals that were related to regaining full independence and being able to perform activities. Although professionals thought goal-setting together with the patient is important, they also stated that older individuals often are either unable to formulate goals or they set unrealistic ones. In addition, professionals indicated that goals have to be related to discharge criteria, such as performing basic self-care activities, and rehabilitation revolves around getting patients ready for discharge. Conclusion: During inpatient rehabilitation, patient goals are related to going home. After discharge, patients have ambitious goals, related to their premorbid functioning level. Rehabilitation services should distinguish between goals that are important while patients are inpatient and goals that are important after discharge.

TRAJECTORIES OF DEPRESSIVE SYMPTOMS AND APATHY FROM HOSPITALIZATION TO THREE MONTHS POST-DISCHARGE

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