A comparison of changes in drug burden index between older inpatients who fell and people who have not fallen: A case-control study.

OBJECTIVE: Older inpatients who fall are often frail, with multiple co-morbidities and polypharmacy. Although the causes of falls are multifactorial, sedating and delirium-inducing drugs increase that risk. The aims were to determine whether people who fell had a change in their sedative and anticholinergic medication burden during an admission compared to people who did not fall. A secondary aim was to determine the factors associated with change in drug burden. METHODS: A retrospective, observational, case-control study of inpatients who fell. Two hundred consecutive people who fell were compared with 200 randomly selected people who had not fallen. Demographics, functional ability, frailty and cognition were recorded. For each patient, their total medications and anticholinergic and sedative burden were calculated on admission and on discharge, using the drug burden index (DBI). RESULTS: People who fell were more dependent and cognitively impaired than people who did not fallen. People who fell had a higher DBI on admission, than people who had not fall (mean: .69 vs .43, respectively, p < .001) and discharge (.66 vs .38, p < .001). For both cohorts, the DBI decreased between admission and discharge (-.03 and -.05), but neither were clinically significant. Higher total medications and a higher number DBI medications on admission were both associated with greater DBI changes (p = .003 and <.001, respectively). However, the presence (or absence) of cognitive impairment, dependency, frailty and single vs multiple falls were not significantly associated with DBI changes. CONCLUSIONS: In older people, DBI medications and falls are both common and have serious consequences, yet this study was unable to demonstrate any clinically relevant reduction in average DBI either in people who fell or people who had not fallen during a hospital admission.

A broken neck: outcomes from conservative management of C2 fractures in older adults.

AIM: To describe the management, complications and functional outcomes of older patients who sustain fractures of the second cervical vertebra (C2). METHODS: Retrospective review of consecutive patients aged 65 years and older. All patients admitted with the clinical discharge code of S12.1 (fracture of second cervical vertebra) to Christchurch Hospital, New Zealand, over five years were included. Outcomes of mobility, domicile and mortality (inpatient, 30 days, one year and two years) were recorded, as well as all complications from injury and from treatment. RESULTS: Sixty-four patients (26 male, 38 female) with a mean age of 80.6 years were included. On admission, 89% of patients lived at home, 25% used a mobility aid and the median Charlson Comorbidity Index score was 2.0. All patients were managed conservatively (non-surgically) with majority immobilised in a rigid collar (46, 72%). Thirty-seven (58%) received inpatient rehabilitation. Complications were common, with medical (n=39 (61%)) and collar complications (37 (58%), mainly pain and pressure related) the most frequent. Mortality was 9% in hospital and 22% at one year. Of the 57 patients living in their own homes prior to fracture, 43 (75%) were able to return home. More patients required a mobility aid on discharge compared with on admission (25% vs 70%, Chi square=43, p<0.0001). CONCLUSIONS: C2 fractures in older people cause substantial morbidity and loss of function in older patients. Despite the majority needing inpatient rehabilitation and complications related to the collar or immobility being common, three-quarters of patients were still able to return home. Walking ability declined and most needed some walking aid post fracture.

Inpatient healthcare-associated bloodstream infections in older people.

This retrospective study describes inpatient healthcare-associated bloodstream infections (HABSI) in older adults and explores whether urinary catheters (presence/insertion/removal) were related to HABSI events. One hundred and sixty-seven HABSI events were identified, predominantly (124, 74%) with Gram-negative bacteria. HABSI was attributed to a urinary source in 110 patients (66%), with over half (63, 57%) of these associated with urinary catheters. Catheter-associated HABSI may be avoidable and potential preventative strategies are discussed.

Examining the Risks of Major Bleeding Events in Older People Using Antithrombotics.

BACKGROUND: Real-world evidence for the safety of using antithrombotics in older people with multimorbidity is limited. We investigated the risks of gastrointestinal bleeding (GI-bleeding) and intracranial (IC-bleeding) associated with antithrombotics either as monotherapy, dual antiplatelet therapy (DAPT) or as triple therapy (TT) [DAPT plus anticoagulant] in older individuals aged 65 years and above. METHODS: We identified all individuals, 65 years and above, who had a first-time event of either IC- or GI-bleeding event from the hospital discharge data. We employed a case-crossover design and conditional logistic regression analyses to estimate the adjusted relative risks (ARR) of bleeding. RESULTS: We found 66,500 individuals with at least one event of IC- or GI-bleeding between 01/01/2005 and 31/12/2014. DAPT use was associated with an increased risk relative to non-use of any antithrombotics in IC-bleeding (ARR = 3.13, 95% CI = [2.64, 3.72]) and GI-bleeding (ARR = 1.34, 95% CI = [1.14, 1.57]). The increased bleeding risk relative to non-use of any antithrombotics was highest with TT use (IC-bleeding, ARR = 17.28, 95% CI = [6.69, 44.61]; GI-bleeding, ARR = 4.85, 95% CI = [1.51, 15.57]). CONCLUSIONS: Using population-level data, we were able to obtain estimates on the bleeding risks associated with antithrombotic agents in older people often excluded from clinical trials because of either age or comorbidities.

Readmissions to hospital in a frail older cohort receiving a community-based transitional care service.

AIMS: To investigate frequency of and reasons for hospital readmission in a frail older cohort receiving a community-based, multidisciplinary, transitional care service. METHODS: A prospective cohort study with descriptive analysis of reasons for readmission in a cohort of frail older people discharged from hospital with the service. Measures of frailty, comorbidity, cognition, quality of life and function were recorded at discharge. Readmissions were recorded within three months after index discharge. Discharge summaries were reviewed and reasons for readmission categorised. Outcomes following readmission were recorded. RESULTS: Readmission rates were high (42%) in our cohort, despite the intervention. People readmitted had worse functional ability and a greater burden of comorbidities. Half of the readmissions were classified as being new, acute medical problems requiring inpatient treatment, and a quarter as exacerbations of chronic medical problems. Eighty-six percent of those readmitted were able to return home following their readmission. CONCLUSIONS: Our study showed high readmission rates despite the community supports. This high readmission rate does not imply failure of the intervention as the majority of these were with new or acute medical problems requiring inpatient treatment which were not preventable. Most were able to recover and return to their own homes.

Low-Impact Flooring: Does It Reduce Fall-Related Injuries?

OBJECTIVES: To compare fall rates and injuries from falls on low-impact flooring (LIF) compared with a standard vinyl flooring. DESIGN: Prospective, observational, nonrandomized controlled study. SETTING: Subacute Older Persons Health ward (N = 20 beds). PARTICIPANTS: Older inpatients. INTERVENTION: Three different types of LIF. MEASUREMENTS: All falls in the ward were prospectively monitored using incident reporting, noting location and consequences of each fall. Fall rates (per 1000 bed days) and injuries, were compared between bedroom falls on LIF against those occurring on standard vinyl flooring (controls). RESULTS: Over 31 months, there were 278 bedroom falls (from 178 fallers). The bedroom fall rate (falls per 1000 bed days occupied) did not differ between the LIF and control groups (median 15 [IQR 8-18] versus 17 [IQR 9-23], respectively; P = .47). However, fall-related injuries were significantly less frequent when they occurred on LIFs (22% of falls versus 34% of falls on control flooring; P = .02). Fractures occurred in 0.7% of falls in the LIF cohort versus 2.3% in the control cohort. Rolling resistance when moving heavier equipment, such as beds or hoists, was an issue for staff on LIF. CONCLUSIONS: LIF significantly reduced fall-related injuries compared with a standard vinyl flooring, whereas they did not alter the overall risk of falling.

'Real-world' haemorrhagic rates for warfarin and dabigatran using population-level data in New Zealand.

BACKGROUND: Anticoagulants such as warfarin and dabigatran can significantly reduce the risk of stroke in individuals with atrial fibrillation that may lead to increased risk of bleeding, especially in older people. Evidence for bleeding risks with anticoagulants within the context of doses, multimorbidity and impaired renal function in real world setting is lacking. Therefore we aimed to assess and compare real world bleeding risks with warfarin and dabigatran. Secondary analyses involved examining risk of fatal haemorrhages. METHODS AND RESULTS: We formed two inception cohorts of propensity score (PS) matched older patients (≥ 65 years), who initiated dabigatran or warfarin between July 2011 and December 2012. A total of 4835 dabigatran users were matched to 4385 warfarin users in dose independent binary PS matching. A dose dependent PS matching resulted in 2383 warfarin, 2153 dabigatran 150 mg and 3395 dabigatran 110 mg users. In the first cohort, compared to warfarin, the hazard ratios (95% confidence intervals) for dabigatran were 0.45 (0.37-0.55) for any haemorrhage; 1.16 (0.87-1.56) for gastrointestinal haemorrhage; and 0.29 (0.09-0.86) for intracerebral haemorrhage. Similar associations were observed in the first 30 days of treatment. In dose dependent matched cohort, the risk of any haemorrhage was lower in individuals receiving dabigatran 110 mg (HR; 95% CI: 0.40 (0.31-0.52)) and 150 mg (HR; 95% CI: 0.29 (0.19-0.41)) compared to warfarin. CONCLUSIONS: The risk of any haemorrhage and intracerebral haemorrhage was lower in dabigatran users compared to warfarin users. Importantly no increased risk of gastrointestinal haemorrhage was found in dabigatran users. The incidence rates for any haemorrhage were found to be higher in first 30 days of any anticoagulant treatment, but hazard ratios remained similar during the study period.

Introduction of the Pill Pruner to acute medical care: a simple medication guide to control polypharmacy.

AIM: To assess the effect of a simple medication guide (the Pill Pruner) on the number of regular medications taken by older patients following medical admission. METHODS: In July 2009, following introduction of the Pill Pruner, we audited 500 consecutive older patients, recording the number of regular medications being taken on admission and discharge. Safety data included 90-day mortality and readmission rates. Medication numbers were compared to a similar audit undertaken in September 2008 and to a repeat audit in December 2009. RESULTS: The mean number of medications on admission (± SD) was 6.3 ± 3 versus 6.5 ± 3 at discharge (P = 0.13). Number of discharge medications was decreased compared to September 2008 (7.7 ± 4; P = 0.001) but similar to that for the repeat audit. No change in mortality or readmission rate was seen. CONCLUSION: Use of the Pill Pruner reduced the number of regular medications prescribed to older patients without affecting safety.

Perceived factors which shape decision-making around the time of residential care admission in older adults: a qualitative study.

AIM: To understand the perceived factors that shape decision-making around the time of residential care admission in older people. METHOD: Two qualitative methods (telephone interviews at intervals post discharge from geriatric inpatient care and face-to-face interviews with older people and their family carers) were used as part of a multiphase mixed methods study of a cohort of 144 older people discharged from medical wards in a subacute assessment, treatment and rehabilitation facility. RESULTS: Key topics and themes were derived from interviews: the role of the informal carer and other community supports, attitudes to decision-making and loneliness were key aspects of social context. Physical health, the experience of repeated hospital admissions and health professionals' attitudes to repeated admissions were also seen as important. CONCLUSIONS: Social context as an essential component of older people's decisions to enter aged residential care is highlighted in this qualitative study.

Classification of falls in stroke rehabilitation--not all falls are the same.

OBJECTIVE: To develop a practical taxonomy of falls and to determine whether these different fall groups have different outcomes. DESIGN: Descriptive study examining patient characteristics at the time of each fall and iterative development of falls taxonomy. SETTING: An inpatient stroke rehabilitation ward. METHODS: All falls over 21 months were reviewed retrospectively. Case notes were reviewed and each patient's level of functioning at the time of fall, together with admission profile and discharge outcomes, were collected. Outcomes for fallers (as opposed to falls) were compared using the predominant fall type. RESULTS: There were 241 falls in 122 patients and most falls occurred around the bed (196 (81%) falls). Toileting-related falls occurred in 54 patients (22.4%). The taxonomy proposes seven main fall types. One fall type ('I'm giving it a go') appeared quite different and was associated with better functioning at time of fall and better outcomes. Other fall types were related to high dependency needs, visuospatial difficulties or delirium. Medication-related falls were uncommon in this cohort. CONCLUSIONS: The falls taxonomy developed showed four main types of falls with different, but overlapping, patient characteristics at time of fall with different outcomes. Different fall-prevention strategies may be required for each group.

Impacts of the emergency mass evacuation of the elderly from residential care facilities after the 2011 Christchurch earthquake.

OBJECTIVE: The 2011 earthquake that devastated Christchurch, New Zealand, led to the closure and evacuation of 7 residential care facilities and the partial evacuation of 2 more. Altogether, 516 elderly persons were evacuated. The emergent nature of the disaster was unexpected and largely unplanned for. This study explored the evacuees' experiences and identified lessons learned for future disaster planning. METHODS: This qualitative study used a general inductive method. Semistructured interviews with evacuees were held in 4 centers throughout New Zealand. Their informal caregivers were also identified and interviewed. Answers were coded and grouped for key themes to provide lessons learned for future disaster planning. RESULTS: We conducted 50 interviews with older people and 34 with informal caregivers. Key themes that emerged were resilience and factors that promoted resilience, including personal attitudes, life experiences, enhanced family support, and social supports. Areas of concern were (1) the mental health of evacuees: 36% reported some symptoms of anxiety, while 32.4% of caregivers reported some cognitive decline; and (2) communication difficulties during the evacuations. CONCLUSIONS: Older people were remarkably resilient to the difficult events, and resilience was promoted by family and community support. Anxiety was reported by older people, while informal caregivers reported cognitive issues. Communication difficulties were a major concern.

Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial.

BACKGROUND: In New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent. METHODS/DESIGN: This study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study. DISCUSSION: The lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home. TRIAL REGISTRATION: ACTRN12612000464864.

Resource usage and outcomes in a facilitated discharge service in Christchurch, New Zealand.

AIM: To describe the type and level of support provided by a facilitated discharge team to frail older patients discharging from a 113-bed elderly rehabilitation hospital and the outcomes achieved. METHOD: Prospective data detailing reasons for referral, services provided and retrospective data on outcomes, were obtained to 90 days post discharge on visits to new patients during 21/2/08 to 15/7/08. RESULTS: Seventy-four patients (mean age 82, 58% female) were included. The mean duration of intervention was 19 days with the most common reasons for referral being poor mobility/falls risk, poor cognition, hygiene concerns. The average number of contacts was 6.5. Patients with the highest number of contacts were those referred with patient anxiety/low confidence (7.4), and family concern (8.4). The most common interventions were family contact and management of carer stress, liaison with medical staff. Unplanned readmission (within 90 days) occurred in 32% whereas 12% and 8% were in residential care or had died respectively. CONCLUSION: Managing the transition from hospital to home for older people requires a large range of interventions, particularly in this highly selected group. Unplanned readmission occurred in a third of this very frail elderly group, yet only 12% needed residential care, suggesting the reasons for readmission could be resolved. Patient or family anxiety resulted in more follow-up visits to patients, and inpatient teams should be mindful of this when planning discharges.

Acute medical admissions for older people from residential care facilities: are they appropriate?

AIM: Acute medical admissions are increasing and potentially avoidable admissions (PAA) from residential care facilities (RCF) have been blamed. Estimates for the proportion of PAA from RCFs vary enormously in the literature. This study aimed to prospectively determine the level of PAA to a New Zealand hospital. METHODS: Two cohorts of consecutive acute medical admissions of older (65 years and older) people from RCFs were reviewed (one retrospective and one prospective). Discharge domicile and survival at 6 months were determined for all patients. PAAs were determined by the treating general physician/geriatrician in the prospective cohort. RESULTS: Admissions from RCF are a very heterogeneous group with a wide range of diagnoses, levels of dependency and outcomes. Most admissions (88%) from lower level care (LLC) were appropriate and most returned to their usual RCF on discharge. Patients from higher level care (HLC) patients had poorer outcomes (5/8 died in the acute hospital and only 1/8 alive at 6 months). Twenty percent of all RCF admissions were potentially avoidable and could have been managed in a different setting CONCLUSIONS: Most admissions from RCF were appropriate. However for a minority of admissions, other models of care within RCFs and community care are needed to provide alternative options of care. These may reduce some acute hospital admissions.

Frailty: dominos or deliberation?

Frailty is a common, but under-described, condition in older people, that is now better understood thus aiding better identification and treatment. It is characterised by multisystem deterioration and loss of physiological reserve to cope with insults. The traditional physical phenotype of frailty comprises 5 key findings: weakness, sarcopaenia, weight loss, physical inactivity, and slowness (which are also modulated by psychosocial factors). Several inflammatory, endocrine and nutritional markers have been proposed as contributory, although cause-and-effect is not clear. Predisposing factors are early childhood development and lifestyle, followed by physical inactivity, chronic disease, and anorexia/ malnutrition in later adulthood. These may form a cycle of deterioration. Frailty predisposes to marked decline in physical and mental function resulting from even apparently small insults. This commonly manifests as a "domino" effect, with a small initial insult leading to a cascade of adverse events. Several interventions have been shown to be helpful for frail older adults including exercise programs, nutritional support, maximising function prior to a planned interventions such as surgery, and early intervention when an acute insult threatens independence. Specialist geriatric assessment and management identifies and treats unstable medical conditions, reviews polypharmacy, facilitates early mobilisation, offers nutritional support, and assesses social circumstances. Frail older people in whom function has been compromised may be labelled as "unable to cope" but in fact many benefit from early comprehensive geriatric assessment to enable them to regain lost function.

Acute stroke services in New Zealand: changes between 2001 and 2007.

AIM: To determine changes in the organisation of acute stroke management in New Zealand between 2001 and 2007. METHOD: A questionnaire was sent to 58 New Zealand hospitals; it included questions about access to organised stroke care, the presence of designated areas for stroke patient management, guidelines for stroke management, and audit. RESULTS: Responses were received from all hospitals surveyed, with 46 admitting stroke patients either acutely or for stroke rehabilitation. Sixteen District Health Boards (DHBs) covering 88% of the population have a physician who provides overall leadership for stroke services. Seven of 46 hospitals, covering 48% of the population, had areas designated for acute management of stroke patients. Rehabilitation for patients older than 65 years was carried out in designated areas for patients with stroke in seven hospitals, covering 49% of the population. Only 13 hospitals (serving 60% of the population) had audited local inpatient stroke care at the patient level and 10 (45% of the population) at the service level. CONCLUSION: While there have been improvements in the development of an organised approach to acute inpatient acute stroke care in New Zealand there remain major variations between different centres. The training of general physicians, geriatricians, and neurologists in stroke medicine must be seen as a priority.

Rehabilitation after stroke: changes between 2002 and 2007 in services provided by district health boards in New Zealand.

AIM: To determine changes between 2002 and 2007 in stroke rehabilitation services provided by district health boards (DHBs) in New Zealand (NZ). METHOD: A questionnaire about organisation of stroke rehabilitation services and use of recommended guidelines was sent to hospitals in all 21 DHBs. RESULTS: Seven DHBs serving 49% of the NZ population provided a designated inpatient area for stroke rehabilitation in 2007 compared with one DHB serving 10% of the population in 2002 (p<0.001). In six DHBs (37%), this designated area was within a general rehabilitation unit. Only one DHB (12%) had a dedicated stroke rehabilitation unit. DHBs with a designated stroke rehabilitation area (SRA) were more likely to have multidisciplinary teams that spent more than half of the time with stroke patients (94% population with SRA versus 22% without SRA; p<0.001), audit their services (90% vs 39%; p<0.001), and provide education sessions for patients/families (82% vs 55%; p 0.004). However, many DHBs did not have guidelines for the management of common aspects of stroke care. CONCLUSION: Stroke rehabilitation services have improved since 2002 but concerns exist about the variability and quality of services provided. A consistent national approach to implementation of guideline recommendations and audit of services is required.