Debra Hain

Cognitive impairment and medication self-management errors in older adults discharged home from a community hospital.

The purpose of this article is to report the results of a pilot study of the relationship between cognitive impairment and medication self-management errors in older adults discharged home from a community hospital. It is hoped that these preliminary data will provide some new ideas for reducing errors in medication self-management posthospitalization.

The Effect of In-Home Cognitive Training on Functional Performance of Individuals with Mild Cognitive Impairment and Early-Stage Alzheimer’s Disease

This intervention study compared an in-home cognitive training program to life story interview in 68 individuals with mild cognitive impairment or early-stage Alzheimers disease. Family caregivers participated in sessions and reinforced learning between sessions. Analyses of covariance controlling for baseline levels were conducted. In comparison with the life story group, participants in the cognitive training group demonstrated significant improvement in all face-name association measures, several of the money-related tasks, and one of two event-related memory tasks. There were no differences in language outcomes or caregiver ratings of functional tasks except shopping. Caregivers in the life story group reported higher perceived satisfaction from being a caregiver. Comparison with earlier studies suggests in-home training is modestly more effective than office-based intervention. Results suggest that improvements are related to specific training and do not generalize to other tasks. Focusing on tasks of critical significance to participant and caregiver is recommended.

Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implications for nursing practice.

Rehospitalization within 30 days consumes a significant portion of health care costs; therefore, interventions aimed at reducing the risk of rehospitalization are needed. A retrospective study was conducted examining rehospitalization rates and diagnoses according to discharge location and comparing characteristics of older adults within 7 and 30 days of discharge from a community hospital. Data on rehospitalization for Medicare fee-for-service patients (75 and older) over a 12-month period were obtained from the information technology department of a not-for-profit community hospital. A total of 6,809 patients were discharged, with 12% rehospitalized within 30 days. Skilled nursing facilities had the highest rehospitalization rates (15%), followed by home with home health care (13%) and then home with self-care (8%). The highest rehospitalization rates were in areas where nursing has a strong presence, suggesting that nurses can play an important role in the development of interventions aimed at reducing rehospitalizations.

Remaining in the Nursing Home Versus Transfer to Acute Care: Resident, Family, and Staff Preferences

Resident and family insistence on transfer is a major factor in the occurrence of potentially avoidable transfers from nursing homes (NHs) to acute care. The purpose of this study was to explore resident, family, and staff preferences regarding transfer to acute care. A sample of 271 NH residents, family members, staff, and medical providers were interviewed. Seventy-seven percent of residents reported that they had not given any thought to the question of whether they would want to be transferred to acute care. Family members wanted more information than residents, but more residents (39%) thought they should be fully involved in the transfer decision than their family members (12%) or staff (12%). Staff preferred keeping residents in the NH. Families were divided between transferring residents and having them remain in the NH. More residents indicated that their desire to transfer would depend on the severity of their condition and their prognosis. Ethnic group differences were noted. Results suggest that discussion of this issue should occur soon after admission and that differences in perspectives may be expected from those involved.

The perfect storm: older adults and acute kidney injury.

Older adults have a high risk for acute kidney injury (AKI), often necessitating critical care admission. The majority of older adults live with 1 or more chronic conditions requiring multiple medications, and when faced with acute illness increased vulnerability can lead to poor health outcomes. When combined with circumstances that exacerbate chronic conditions, clinicians may witness the perfect storm. Some factors that contribute to AKI risk include the aging kidney, sepsis, polypharmacy, and nephrotoxic medications and contrast media. This paper discusses specific risks and approaches to care for older adults with AKI who are in critical care.

Factors Associated With 30-Day Hospital Readmissions Among Participants in a Care Transition Quality Improvement Program

Discharge from hospital to home is a vulnerable period for older adults who have multiple care needs. The Safe Transitions for Elderly People (STEP) program is a care transition program for Medicare fee-for-service patients 75 years and older discharged to home from a community hospital. This quality improvement project (a) compares 30-day hospital readmission rates between 498 STEP participants and 722 patients eligible for STEP but not participating in the program, and (b) determines factors associated with readmissions during STEP. The STEP participants received intervention in 1 of 2 formats: 395 received a telephone-only intervention and 103 received a telephone plus home visit intervention. STEP participants had a lower 30-day hospital readmission rate than nonparticipants (i.e., those who could not be contacted for STEP participation; those who declined to participate). Results of binary logistic regressions showed 2 variables were significant predictors of readmissions: for the group of all STEP participants and the telephone-only intervention group, the (a) hospitalization within the previous year predicted readmission; for the telephone plus home visit group, the (b) degree of assistance needed with ambulation predicted readmission. Given the multifactor nature of readmissions, interdisciplinary teams should develop tailored interventions based on individual’s psychosocial and medical assessments. Reforms to the Medicare fee-for-service system have the potential to change financial incentives that currently favor hospitalization of older patients, the potential to avoid readmissions, and the potential to direct the savings to support interdisciplinary care transition interventions.

Home-based biobehavioural intervention reduces dependence, increases engagement of patients with dementia in the short term and improves care giver well-being and confidence

Commentary on: LN Gitlin, L Winter, MP Dennis, et al.. A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: the COPE randomized trial. JAMA2010;304:983–91.