David Basic

Using the Timed Up and Go Test to stratify elderly inpatients at risk of falls

Objective: To determine whether the Timed Up and Go Test is useful at stratifying acutely unwell elderly inpatients according to their risk for subsequent falls. Design: Prospective cohort study. Setting: Multidisciplinary acute care unit for the elderly at Liverpool Hospital, in Sydney, Australia. Participants: A total of 2388 consecutive admissions to the unit of mean age 82 years. Intervention: The Timed Up and Go, administered on admission to the unit, and two modifications (an ordinal scale and a dichotomous scale, both incorporating patients unable to complete the Timed Up and Go) were evaluated. Main outcome measures: Number of falls, and reasons for the inability to complete the Timed Up and Go. Results: During a median length of stay of nine days, 180 patients had at least one fall. The Timed Up and Go was unable to identify those patients who subsequently fell (P=0.78). When the Timed Up and Go was modified to include the majority of patients unable to complete the test, both the ordinal (range of values 1-8, odds ratio (OR) 1.12, 95% confidence interval (95% CI) 1.03-1.21, P=0.01) and dichotomous (OR 1.59, 95% CI 1.09-2.32, P=0.02) modifications significantly predicted falls in multivariate analyses. Patients unable to do the Timed Up and Go due to non-physical disability had the highest fall rate (11%), followed by those with physical disability (9%), while those able to do the Timed Up and Go had the lowest fall rate (6%) (P<0.001). Acutely unwell, immobile patients with dementia and delirium were not at excessive risk of falls. Conclusion: In the acute care setting, the value of the Timed Up and Go lies in the inability to complete the test, and the reasons for this inability, rather than the time recorded.

The Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein MMSE in a multicultural cohort of elderly persons

OBJECTIVE To compare the accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein Mini-mental State Examination (MMSE) for diagnosis of dementia in a multicultural cohort of elderly persons. METHODS A total of 129 community-dwelling persons were selected at random from a database of referrals to an aged-care team. Subjects were stratified according to language background and cognitive diagnosis, and matched for age and gender. The RUDAS and the MMSE were administered to each subject in random order. Within several days, a geriatrician assessed each subject for dementia (DSM-IV criteria) and disease severity (Clinical Dementia Rating Scale). All assessments were carried out independent and blind. The geriatrician also administered the Modified Barthel Index and the Lawton Instrumental Activities of Daily Living Scale, and screened all participants for non-cognitive disorders that might affect instrument scores. RESULTS The area under the receiver operating characteristic curve (AUC) for the RUDAS [0.92, 95% confidence interval (95%CI) 0.85-0.96] was similar to the AUC for the MMSE (0.91, 95%CI 0.84-0.95). At the published cut-points (RUDAS < 23/30, MMSE < 25/30), the positive and negative likelihood ratios for the RUDAS were 19.4 and 0.2, and for the MMSE 2.1 and 0.14, respectively. The MMSE, but not the RUDAS, scores were influenced by preferred language (p = 0.015), total years of education (p = 0.016) and gender (p = 0.044). CONCLUSIONS The RUDAS is at least as accurate as the MMSE, and does not appear to be influenced by language, education or gender. The high positive likelihood ratio for the RUDAS makes it particularly useful for ruling-in disease.

Frailty in an older inpatient population : using the clinical frailty scale to predict patient outcomes

Objective: To evaluate the impact of frailty, measured using the Canadian Study of Health and Aging Clinical Frailty Scale, on outcomes of older people hospitalized with acute illness. Method: Consecutive patients were randomly allocated to a model development sample or a model validation sample. Multivariate analyses were used to model in-hospital mortality, new nursing home placement, and length of stay. Variables selected in the development samples were tested in the validation samples. Results: The mean age of all 2,125 patients was 82.9 years. Most (93.6%) were admitted through the emergency department. Frailty predicted in-hospital mortality (odds ratio [OR] = 2.97 [2.11, 4.17]), new nursing home placement (OR = 1.60 [1.14, 2.24]), and length of hospital stay (hazard ratio = 0.87 [0.81, 0.93]). Discussion: Frailty is a strong predictor of adverse outcomes in older people hospitalized with acute illness. An increased awareness of its impact may alert clinicians to screen for frailty.

Accuracy of the clock drawing test for detecting dementia in a multicultural sample of elderly Australian patients.

OBJECTIVE To assess the accuracy of clock drawing for detecting dementia in a multicultural, non-English-speaking-background population. DESIGN A prospective cohort study. SETTING A general geriatric medical outpatient clinic in southwest Sydney, Australia. PARTICIPANTS Ninety-three consecutive new patients to the clinic who had a non-English-speaking-background country of birth (mean age 78.0 years). MEASUREMENTS The clock drawing test was conducted at the beginning of each clinic visit by a blinded investigator. Each patient was then assessed by a geriatrician who collected demographic data, administered the Modified Barthel Index, the Geriatric Depression Scale, and the Folstein Mini-Mental State Examination, and categorized each patient as normal or demented, according to DSM-IV criteria. Interpreters were used for participants who spoke a language other than English or who requested them. Each clock drawing was scored according to the 4-point CERAD scale and the previously published methods of Mendez, Shulman, Sunderland, Watson, and Wolf-Klein. Scoring was evaluated for reliability and predictive accuracy, using receiver operating characteristic (ROC) curve analysis. Logistic regression analysis was used to assess the potential interaction between level of education and each of the clock scoring methods. RESULTS Using ROC curve analysis, there was no significant difference between the clock scoring methods (area under the curve varied from 0.60 to 0.72). The most sensitive was the Mendez scoring method (98%), with a specificity of 16%. Specificity above 50% was found only for the Wolf-Klein method, with an intermediate sensitivity of 78%. CONCLUSIONS There were no significant differences in the clock scoring methods used to detect dementia. Performance of the clock drawing test was modest at best with low levels of specificity across all methods. Scored according to these methods, clock drawing was not a useful predictor of dementia in our multicultural population.

The Validity of the Rowland Universal Dementia Assessment Scale (RUDAS) in a Multicultural Cohort of Community-dwelling Older Persons With Early Dementia

The 6-item Rowland Universal Dementia Assessment Scale (RUDAS) is a simple, portable multicultural scale for detecting dementia. Items address executive function, praxis, gnosis, recent memory, and category fluency. It can be directly translated to other languages, without the need to change the structure or the format of any item. The RUDAS was administered to 151 consecutive, consenting, culturally diverse community-dwelling subjects of mean age 77 years, 72% of whom had an informant. Subjects were recruited from various clinics and healthcare programs. All were evaluated for cognitive impairment in a blinded manner by experienced clinicians in geriatric medicine. According to Diagnostic and Statistical Manual of Mental Disorder-IV criteria, 40% of the subjects were normal, 22% had cognitive impairment (not otherwise specified), and 38% had dementia; 84% of whom had questionable or mild dementia. In the primary analysis (normal subjects vs. those with definite dementia), the RUDAS accurately identified dementia, with an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.88-0.97); at the published cut point of less than 23/30, the positive likelihood ratio (LR) for dementia diagnosis was 8.77, and the negative likelihood ratio was 0.14. Additional analyses showed that the RUDAS performed less well when subjects with cognitive impairment (not dementia) were included. In all logistic regression models, the RUDAS was an independent predictor of dementia (odds ratio 0.64, 95% confidence interval, 0.52-0.79, primary analysis model), after adjusting for age, sex, years of education, and cultural diversity, none of which were independent predictors. Further studies are needed across the full spectrum of early dementia syndromes, and in additional ethnic minority groups.

The Timed Up and Go Test does not predict length of stay on an acute geriatric ward.

This study aimed to determine whether the admission Timed Up and Go Test (TUG) predicted the length of stay of patients in an acute geriatric ward. Consecutive patients were quasi-randomly allocated to either a model development sample or a model validation sample. Multivariate Cox proportional hazards regression was used to model length of stay. Variables considered for inclusion in the development model were risk factors for length of stay reported in the literature and univariate predictors from our dataset (p < 0.05). Variables selected for use in the development sample were then tested in the validation sample. Of 2463 patients of mean age 82.1 years, 932 (37.8%) were able to complete the TUG. Despite a significant, though weak, relationship between the length of stay and the TUG time (Spearman coefficient 0.18, p < 0.001), no time clearly identified patients with longer length of stay. Patients unable to complete the TUG had a median length of stay of 11 days (IQR 7 to 18), 40% longer than those able to complete the TUG (median 8 days, IQR 8 to 12, p < 0.001). Other significant (p < 0.05) predictors of length of stay in both samples were number of active medical diagnoses, referral from the emergency department, in-patient fall, and diagnosis of ulcer or infection. The admission TUG time should not be used to screen for patients likely to have longer lengths of stay. The value of the TUG lies in determining the patients ability to complete it, rather than the time taken.

Emergency department admissions, older people, functional decline, and length of stay in hospital

Objective:  Early identification of patients at risk of a prolonged admission to the hospital may allow targeted management decisions and discharge planning to begin in the emergency department. The aim of this study was to evaluate the effect of recent decline in function, measured in the emergency department, on length of stay (LOS) in the hospital.

Predictors on admission of functional decline among older patients hospitalised for acute care: A prospective observational study

We sought to investigate the incidence of, and factors associated with, in‐hospital functional decline among older acute hospital patients.

Structured interdisciplinary bedside rounds do not reduce length of hospital stay and 28-day re-admission rate among older people hospitalised with acute illness: an Australian study

Objective Structured interdisciplinary bedside rounds (SIBR) are being implemented across many hospitals in Australia despite limited evidence of their effectiveness. This study evaluated the effect of SIBR on two interconnected outcomes, namely length of stay (LOS) and 28-day re-admission. Methods In the present before-after study of 3644 patients, twice-weekly SIBR were implemented on two aged care wards. Although weekly case conferences were shortened during SIBR, all other practices remained unchanged. Demographic, medical and frailty measures were considered in appropriate analyses. Results There was no significant difference in median (interquartile range) LOS before and during SIBR (8 (5-15) vs 8 (4-15) days respectively; P=0.51). In an adjusted analysis, SIBR had no effect on LOS (hazard ratio 0.97; 95% confidence interval 0.90-1.05). The presence of dementia or delirium, or the ability to speak English, did not modify the effect of SIBR (P>0.05 for all). Similarly, SIBR had no effect on 28-day re-admission rates (20.3% vs 19.0% before and during SIBR respectively; P=0.36). Conclusions Although ineffective interdisciplinary communication is associated with negative outcomes for patients and healthcare services, models of care that aim to improve communication are not necessarily effective in reducing LOS or early re-admission. Clinical services implementing SIBR are encouraged to independently evaluate their effects. What is known about the topic? Ineffective interdisciplinary communication may harm patients and increase LOS. Only two publications have evaluated the implementation of SIBR, a new model of care that aims to improve interdisciplinary communication and collaboration. One paper reported that SIBR reduced unadjusted LOS and in-hospital mortality, whereas the other found that SIBR improved teamwork, communication and staff efficiency. What does this paper add? The effect of SIBR among acutely unwell older people on aged care wards is unknown. The present study is the first to evaluate the effects of SIBR in this population. It shows that the implementation of SIBR did not reduce LOS or early re-admission, and suggests that existing communication strategies may have weakened the effects of SIBR. What are the implications for practitioners? Policies and practice that promote the addition of communication strategies, such as SIBR, may not be effective in all patient populations. More research is needed to determine whether SIBR reduce these and other outcomes, particularly for services with weaker communication frameworks and protocols.

New medical diagnoses and length of stay of acutely unwell older patients: Implications for funding models

To examine the relationship between newly made medical diagnoses and length of stay (LOS) of acutely unwell older patients.