A prospective, observational study of frailty, quality of life and dialysis in older people with advanced chronic kidney disease.

BACKGROUND: Frailty is prevalent in older people with chronic kidney disease (CKD) and robust evidence supporting the benefit of dialysis in this setting is lacking. We aimed to measure frailty and quality of life (QOL) longitudinally in older people with advanced CKD and assess the impact of dialysis initiation on frailty, QOL and mortality. METHODS: Outpatients aged ≥65 with an eGFR ≤ 20ml/minute/1.73m2 were enrolled in a prospective observational study and followed up four years later. Frailty status was measured using a Frailty Index (FI), and QOL was evaluated using the EuroQol 5D-5L instrument. Mortality and dialysis status were determined through inspection of electronic records. RESULTS: Ninety-eight participants were enrolled. Between enrolment and follow-up, 36% of participants commenced dialysis and 59% died. Frailty prevalence increased from 47% at baseline to 86% at follow-up (change in median FI = 0.22, p < 0.001). Initiating dialysis was not significantly associated with change in FI. QOL declined from baseline to follow-up (mean EQ-5D-5L visual analogue score of 70 vs 63, p = 0.034), though commencing dialysis was associated with less decline in QOL. Each 0.1 increment in baseline FI was associated with 59% increased mortality hazard (HR = 1.59, 95%CI = 1.20 to 2.12, p = 0.001), and commencing dialysis was associated with 59% reduction in mortality hazard (HR = 0.41, 95%CI = 0.20 to 0.87, p = 0.020) irrespective of baseline FI. CONCLUSIONS: Frailty increased substantially over four years, and higher baseline frailty was associated with greater mortality. Commencing dialysis did not affect the trajectory of FI but positively influenced the trajectory of QOL from baseline to follow-up. Within the limitations of small sample size, our data suggests that frail participants received similar survival benefit from dialysis as non-frail participants.

Factors associated with caregiver distress among home care clients in New Zealand: Evidence based on data from interRAI Home Care assessment.

OBJECTIVE: To identify factors associated with caregiver distress among home care clients in New Zealand. METHODS: The cohort consisted of 105,978 community-dwelling people aged 65 years or older requiring home care services in New Zealand who had at least one informal caregiver. Bivariate and multivariable logistic regression analyses were used to identify factors associated with caregiver distress. RESULTS: Variables associated with risk of caregiver distress included Depression Rating Scale score, aggressive behaviour symptoms, primary informal caregiver relationship to patient, Cognitive Performance Scale score, Changes in Health, End-stage disease, and Signs and Symptoms Scale score, informal care time, secondary informal caregiver relationship to care recipient, activities of daily living hierarchy scale score and any hospitalisation. CONCLUSIONS: The study has identified important characteristics that are associated with caregiver stress. These results suggest that caregiver distress can be relieved by promoting protective factors and aiming to reduce risk factors among home care clients in New Zealand.

Prevalence and factors associated with advance health directives in frail older inpatients.

BACKGROUND: Advance health directives (AHD) can be used to explore and document patient preferences for treatment and are therefore an important aspect of care planning. AIMS: To investigate the prevalence and factors associated with AHD among older inpatients. METHODS: This retrospective study included 6449 patients, aged ≥65 years referred for specialist geriatric consultation between 2007 and 2018 in Queensland, Australia. The interRAI-Acute Care Comprehensive Geriatric Assessment tool was used to calculate a frailty index (FI), range 0-1, based on 52 possible deficits, and categorised into intervals of 0.1 for analysis. FI was also grouped according to previously reported cut points: fit (FI ≤0.25), moderately frail (FI >0.25-0.4), frail (FI >0.4-0.6) and severely frail (FI >0.6). RESULTS: An AHD was present in 1032 (16.0%) of 6449 patients. Those with an AHD were significantly frailer than those without an AHD (mean FI 0.52 vs 0.45; P < 0.001). Higher frailty (odds ratio (OR): 1.34 (1.27-1.40)), older age (OR: 1.04 (1.03-1.05)), living in an institution (OR: 1.33 (1.01-1.73)) and recent hospitalisation (OR: 1.42 (1.23-1.62)) were significantly associated with higher prevalence of AHD. Prevalence of AHD increased over time, from 7.6% (n = 66) in 2008 to 35.4% (n = 99) in 2017. CONCLUSIONS: The presence of AHD is associated with sociodemographic factors, as well as higher frailty levels. Prevalence of AHD among inpatients has increased over the past decade but remains modest.

Interventions for frail older inpatients: A systematic review of frailty measures and reported outcomes in randomised controlled trials.

OBJECTIVE: To summarise frailty measures and outcomes reported in trials involving frail older inpatients. METHODS: Databases were searched for randomised controlled trials enrolling frail older inpatients. RESULTS: Twenty-four articles describing twelve trials were included. Seven trials applied six tools to measure frailty, whilst five trials employed ad hoc measures. Eighty outcomes were examined with survival and functional status reported most commonly. Nine studies trialled multidisciplinary, geriatrician-led interventions. Statistically significant between-group differences were detected for at least one outcome in ten trials. All studies represented high risk of bias within at least one domain. CONCLUSIONS: Heterogeneity of interventions, measurement of frailty and outcomes reported limit generalisability of findings. Many articles purport to study frail patients, yet do not enrol patients using any frailty measurement tool. Utilising validated instruments to measure frailty and a standard set of health outcomes relevant to older people would assist consistent reporting and evaluation of future studies.

Implementation and Evaluation of a Standardized Nurse-Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care.

BACKGROUND: Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse-administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care. AIM: This study aimed to implement and evaluate the interRAI AC assessment system using a multi-strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. METHODS: This nurse-led quality improvement study was piloted in a 200-bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance). RESULTS: In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre-implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed. LINKING EVIDENCE TO ACTION: Despite challenges to implementing a system-wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

Medication use and cognitive impairment among residents of aged care facilities.

BACKGROUND: Potentially inappropriate polypharmacy is common in residential aged care facilities (RACF). This is of particular concern among people with cognitive impairment who, compared with cognitively intact residents, are potentially more sensitive to the adverse effects of medications. AIM: To compare the patterns of medication prescribing of RACF residents based on cognitive status. METHODS: De-identified data collected during telehealth-mediated geriatric consultations with 720 permanent RACF residents were analysed. Residents were categorised into cognitively intact, mild to moderate impairment and severe impairment groups using the interRAI Cognitive Performance Scale. The number of all regular and when-required medications used in the past 3 days, the level of exposure to anti-cholinergic/sedative medications and potentially inappropriate medications and the use of preventive and symptom control medications were compared across the groups. RESULTS: The median number of medications was 10 (interquartile range (IQR) 8-14). Cognitively intact residents were receiving significantly more medications (median (IQR) 13 (10-16)) than those with mild to moderate (10 (7-13)) or severe (9 (7-12)) cognitive impairment (P < 0.001). Overall, 82% of residents received at least one anti-cholinergic/sedative medication and 26.9% were exposed to one or more potentially inappropriate medications, although the proportions of those receiving such medications were not significantly different across the groups. Of 7658 medications residents were taking daily, 21.3% and 11.7% were classified as symptom control and preventive medications respectively with no significant difference among the groups in their use. CONCLUSION: Our findings highlight the need for optimising prescribing in RACF residents, with particular attention to medications with anti-cholinergic effects.

Frailty of Maori, Pasifika, and Non-Maori/Non-Pasifika Older People in New Zealand: A National Population Study of Older People Referred for Home Care Services.

BACKGROUND: Little is known about the prevalence of frailty in indigenous populations. We developed a frailty index (FI) for older New Zealand Maori and Pasifika who require publicly funded support services. METHODS: An FI was developed for New Zealand adults aged 65 and older who had an interRAI Home Care assessment between June 1, 2012 and October 30, 2015. A frailty score for each participant was calculated by summing the number of deficits recorded and dividing by the total number of possible deficits. This created a FI with a potential range from 0 to 1. Linear regression models for FIs with ethnicity were adjusted for age and sex. Cox proportional hazards models were used to assess the association between the FI and mortality for Maori, Pasifika, and non-Maori/non-Pasifika. RESULTS: Of 54 345 participants, 3096 (5.7%) identified as Maori, 1846 (3.4%) were Pasifika, and 49 415 (86.7%) identified as neither Maori nor Pasifika. New Zealand Europeans (48 178, 97.5%) constituted most of the latter group. Within each sex, the mean FIs for Maori and Pasifika were greater than the mean FIs for non-Maori and non-Pasifika, with the difference being more pronounced in women. The FI was associated with mortality (Maori subhazard ratio [SHR] 2.53, 95% CI 1.63-3.95; Pasifika SHR 6.03, 95% CI 3.06-11.90; non-Maori and non-Pasifika SHR 2.86, 95% CI 2.53-3.25). CONCLUSIONS: This study demonstrated differences in FI between the ethnicities in this select cohort. After adjustment for age and sex, increases in FI were associated with increased mortality. This suggests that FI is predictive of poor outcomes in these ethnic groups.

Drug related problems in older adults living with dementia.

BACKGROUND: Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population. METHODS: In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses. RESULTS: Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics. CONCLUSIONS: The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.

The Changes in Medication Prescribing Among the Older People with Cognitive Impairment in the Acute Care Setting.

PURPOSE: Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period. PATIENTS AND METHODS: Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses. RESULTS: The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI. CONCLUSION: The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.

The Effect of Age on Gait Speed When Texting.

Texting while walking exerts a high cognitive load, and may be a sensitive test of the integrity of the cognitive-motor interface. We aimed to investigate the association between chronological age and gait speed while texting. A convenience sample of 308 community-dwellers was recruited: n ≥ 50 in each age group (20-29, 30-39, 40-49, 50-59) and n = 100 aged ≥60 years. Gait speed was measured over 10 metres under two experimental conditions: 1) walking at usual pace; 2) walking at usual pace while texting the message "Good morning Harry" on their smartphone. Both median gait speed with and without texting decreased with increasing age (p < 0.001). The differences between single- and dual-task gait speed were substantial for each age group and increased after the age of 50 years (p < 0.001). Median gait speeds while texting in people aged 50-59 (1.07 m/s) and ≥60 years (1.00 m/s) were below the recommended minimum for safely crossing roads (1.20 m/s). Texting while walking currently exposes people aged 50 and over to considerable environmental hazards. The significant slowing of gait speed while texting from middle age may be a marker of neurodegeneration, a cohort effect, or an appropriate compensatory response to reduce the risk of injury.

A scoping review of the use and impact of telehealth medication reviews.

BACKGROUND: Telehealth has been proposed as a mechanism to overcome the practical difficulties associated with conducting timely and efficient medication reviews particularly in rural and remote settings. OBJECTIVE: The aim was to examine the literature on the use and impact of telehealth-facilitated medication reviews. METHODS: A scoping review of the literature was conducted. Articles that reported medication reviews performed by telehealth were identified by searching the Pubmed, Embase, Cochrane Library and CINAHL databases to January 2019 and screened using predefined inclusion criteria. Data were extracted from included articles and synthesised narratively. Findings are reported using the PRISMA-ScR guidelines. RESULTS: Twenty-nine studies, including 15 descriptive and 14 quasi-experimental studies, met the inclusion criteria. Twenty studies were reports of the implementation and/or evaluation of a service and others were proof of concept, feasibility or pilot studies. Telehealth medication reviews, conducted as standalone interventions or as a part of team-based care, included medication order reviews, medication management, antimicrobial stewardship programs and geriatric services and were delivered to patients in outpatient (n = 15) or hospital (n = 12) settings, with one study conducted in residential care and one study across settings. Outcomes reported included process evaluation (n = 23), medication use (n = 8), costs (n = 6), clinical outcomes (n = 5), and healthcare use (n = 1). Positive impact was observed on clinical outcomes (e.g. reduction in haemoglobin A1c), medication use (e.g. reduction in antimicrobial medications) and costs (e.g. savings due to travel avoided). Good overall satisfaction with the interventions was seen in all studies that reported patient satisfaction. CONCLUSIONS: The current evidence suggests that telehealth medication review may be a feasible model for delivering these services and potentially can save costs and improve care. However, the level of evidence may not be sufficient to reliably inform practice and policy on telehealth-facilitated medication-reviews.

Using telehealth to enable collaboration of pharmacists and geriatricians in residential medication management reviews.

Background Practical issues impede optimum collaboration between pharmacists and other clinical specialists in the current Australian residential medication review services which potentially affect efficiency, timeliness and quality of outcomes. Objective This mixed methods study aimed to explore the potential value of an existing telehealth platform to enable collaboration of pharmacists and geriatricians in residential medication reviews. Setting Long term care facilities in Australia. Method Twenty vignettes of aged care residents were prepared and independently reviewed by five pharmacists and five geriatricians using a telehealth platform to record their recommendations for medications. The geriatricians were subsequently asked to re-consider their recommendations after being provided with a pharmacist's report. Main outcome measure The level of agreement between pharmacists and between geriatricians, changes in the mean number of medications after pharmacists' and geriatricians' reviews, number of changes in geriatricians' recommendations after viewing a pharmacist's report, and pharmacists' and geriatricians' feedback. Results Both pharmacists and geriatricians had fair agreement about their recommendations for medications (kappa of 0.30 and 0.31 respectively). The mean number of medications over 20 cases was significantly reduced from a baseline of 14.9 to 13.4 by pharmacists, and to 12.3 by geriatricians after their reviews. There was disagreement between geriatricians and pharmacists on 430/1485 (29%) recommendations on medications; after viewing a pharmacist's report, geriatricians changed their mind in 51 occasions. Geriatricians found the pharmacist report useful in 72% of the cases. The majority of the pharmacists (4/5) were prepared to use the online system routinely. Conclusion The tested telehealth platform has the potential of being used as a part of routine practice to improve accessibility of the service and to enable synchronous collaboration among healthcare professionals.

Prevalence and Impact of Functional and Psychosocial Problems in Hospitalized Adults: A Prospective Cohort Study.

OBJECTIVES: Underpinning standards for delivering comprehensive care in hospital is the need to identify issues contributing to patient complexity and risk of harm. The study aimed to investigate the prevalence of functional and psychosocial problems in hospitalized adults, to compare prevalence rates across age groups, and to assess their impact on discharge outcomes. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted in 4 hospitals in Australia during September 2015 to June 2016, recruiting patients aged 18 and over. MEASURES: Research nurses assessed patients at admission using the interRAI Acute Care instrument, which includes algorithms for diagnostic and risk screening and measuring problem severity. Length of stay and discharge outcome were recorded from medical records. RESULTS: The median age of the study population (n = 910) was 66 (range 18-99 years), and 47.7% were female. Although 64.6% of patients aged ≥70 years had at least 1 classic geriatric syndrome (cognitive impairment, dependency in activities of daily living, history of falls, or incontinence), similar problems were prevalent in younger cohorts (34.6% in those aged <50 and 38.9% in those aged 50-69 years). Of 17 health issues assessed across multiple domains, only 26 patients (2.9%) had no problems. Independent of age, gender, and Comorbidity Index, having a greater number of problems was significantly associated with an adverse discharge outcome, odds ratio 1.19 (95% confidence interval (CI) 1.09-1.29); for each additional problem, the length of stay increased by 6.7% (95% CI 4.3%-9.2%). CONCLUSIONS/IMPLICATIONS: The high prevalence of functional and psychosocial problems across the age range of patients indicates that universal screening and assessment is warranted for all adult patients to aid in care planning to meet patient needs both in acute care and post discharge.

Gait Speed and Frailty Status in Relation to Adverse Outcomes in Geriatric Rehabilitation.

OBJECTIVE: Both slow gait speed (GS) and higher levels of frailty are associated with adverse outcomes in community-dwelling older people. However these measures are not routinely utilized to stratify risk status in the hospital setting. Here we assessed their predictive validity in older inpatients. DESIGN: A prospective cohort study. SETTING: Inpatient rehabilitation wards of a tertiary hospital. PARTICIPANTS: Adults 65 years and older (N=258). INTERVENTIONS: A frailty index (FI) was calculated from routinely collected data and GS was determined from a timed 10-meter walk test. MAIN OUTCOME MEASURES: Adverse outcomes were longer length of stay (≥75th percentile), poor discharge outcome (discharge to a higher level of care or inpatient mortality), and inpatient delirium and falls. RESULTS: Mean age ± SD was 79±8 years and 54% were women. Mean FI ± SD on admission was 0.42±0.13 and an FI could be derived in all participants. Mean GS ± SD was 0.26±0.33 m/sec. Those unable to complete a timed walk on admission (50%) were allocated a GS of 0. There was a weak but significant inverse relationship between FI and GS (correlation coefficient -0.396). Both parameters were significantly associated with longer length of stay (P<.001), poor discharge outcome (P≤.001), and delirium (P<.05).The prevalence of adverse outcomes was highest in the cohort who were more frail and unable to mobilize at admission to rehabilitation. CONCLUSIONS: FI and GS each showed predictive validity for adverse outcomes. In a geriatric rehabilitation setting, they measure different aspects of vulnerability and combining the 2 may add value in identifying patients most at risk.

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.

Interventions to Optimise Prescribing in Older People with Dementia: A Systematic Review.

BACKGROUND: Older adults living with dementia may have a higher risk of medication toxicity than those without dementia. Optimising prescribing in this group of people is a critically important yet challenging process. OBJECTIVE: Our aim was to systematically review the evidence for the effectiveness of interventions for optimising prescribing in older people with dementia. METHODS: This systematic review searched the Pubmed, Embase, CINAHL, PsycINFO and Cochrane Library electronic databases for studies that evaluated relevant interventions. Experimental, quasi-experimental and observational studies published in English prior to August 2018 were included. Data were synthesised at a narrative level. RESULTS: The 18 studies accepted for review included seven randomised, two nonrandomised controlled, five quasi-experimental and four observational studies. Half the studies were conducted in nursing homes and the other half in hospital and community settings. There was great variability in the interventions and outcomes reported and a meta-analysis was not feasible. The three randomised and four nonrandomised studies examining medication appropriateness all reported improvements on at least one measure of the outcome. Six studies reported on interventions that identified and resolved drug-related problems. The results for other outcomes, including the number of medications (10 studies), healthcare utilisation (7 studies), mortality (7 studies), quality of life (3 studies) and falls (3 studies), were mixed and difficult to synthesise because of variability in the study design and measures used. CONCLUSION: Emerging evidence suggests that interventions in older people with dementia may have positive effects on medication appropriateness and resolution of drug-related problems; however, whether optimisation of medication results in clinically meaningful outcomes remains uncertain.

A frailty index derived from a standardized comprehensive geriatric assessment predicts mortality and aged residential care admission.

BACKGROUND: Frailty in older adults is a condition characterised by a loss or reduction in physiological reserve resulting in increased clinical vulnerability. However, evidence suggests that frailty may be modifiable, and identifying frail older people could help better target specific health care interventions and services. METHODS: This was a regional longitudinal study to develop a frailty index for older adults living in Canterbury New Zealand. Participants included 5586 community dwelling older people that had an interRAI Minimum Data Set (MDS-HC) Home Care assessment completed between 2008 and 2012. The outcome measures were mortality and entry into aged residential care (ARC), after five years. RESULTS: Participants were aged between 65 and 101 (mean age was 82 years). The five-year mortality rate, including those who entered ARC, for this cohort was 67.1% (n = 3747). The relationship between the frailty index and both mortality and entry into ARC was significant (P < 0.001). At five years, 25.1% (n = 98) of people with a baseline frailty of < 0.1 had died compared with 28.2% (n = 22) of those with a frailty index of ≥0.5 (FS 5). Furthermore, 43.7% (n = 171) of people with a frailty index of < 0.1 were still living at home compared to 2.6% (n = 2) of those with a frailty index of ≥0.5. CONCLUSION: A frailty index was created that predicts mortality, and admission into ARC. This index could help healthcare professionals and clinicians identify older people at risk of health decline and mortality, so that appropriate services and interventions may be put in place.

Feasibility and validity of frailty measurement in geriatric rehabilitation.

OBJECTIVES: The measurement of frailty using a Frailty Index (FI) has been criticised as too time-consuming for use in hospital settings. We aimed to assess the feasibility and characteristics of an FI derived from routinely collected data. METHODS: A total of 258 participants aged 65 and older were included in a single-centre prospective cohort study conducted in inpatient geriatric rehabilitation wards. The functional independence measure (FIM™), medication count and comorbidities were coded as deficits. RESULTS: An FI could be derived in all participants. It was normally distributed with a mean (SD) of 0.42 (0.13) and reached a submaximal limit of 0.69. Adjusting for age and sex, the odds ratio of a poor outcome (death/discharge to higher care) was 1.38 (confidence interval 1.11-1.70) per unit (0.1) increase in FI. CONCLUSION: Derivation of an FI from routinely collected data is feasible in geriatric rehabilitation settings and is predictive of poor outcomes.

Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care.

BACKGROUND: Underpinning standards for developing comprehensive care in hospital is the need to identify, early in the admission process, functional and psychosocial issues which affect patient outcomes. Despite the value of comprehensive assessment of patients on admission, the process is often sub-optimal due to a lack of standardized assessment practices. This project aimed to develop a concise, integrated assessment for patients admitted to acute care and test its psychometric properties. METHODS: Two international expert panels of clinicians and health scientists collaborated to establish design parameters. Using clinical observations and a variety of derivative applications sourced from the interRAI research collaborative repository, the panels constructed a draft instrument to examine feasibility, resource requirements, and inter-rater reliability. Field testing was conducted in Australia and Canada. Next, the system was revised to its final form, the interRAI Acute Care, after feedback and review from international interRAI members. RESULTS: Constructed using 56 items, the interRAI Acute Care required a median of 15 minutes to complete. Inter-rater reliability tested on 130 paired assessments was substantial to almost perfect for 78% of the clinical items and moderate for the remaining 22% of items. A subset of 30 items from the admission assessment comprised the discharge assessment. DISCUSSION: The interRAI Acute Care has been shown to be an efficient nursing assessment instrument with good psychometric properties. Implementation in a digital environment will enable documentation and care planning to comply with standards for quality of care in the general adult hospital population.