Nutritional risk screening in a Danish university hospital is insufficient and may underestimate nutritional risk: A cross-sectional study.

BACKGROUND: Disease-related-malnutrition predicts poor clinical outcomes in elderly patients, and screening is pivotal for identifying patients at nutritional risk. The present study aimed to investigate nutrition screening rates in electronic patient records and validate the scores given. A secondary aim was to investigate whether the proportion of patients at risk differed between patients where screening was documented and those where no screening was documented. METHODS: This cross-sectional observational study was conducted in a Danish university hospital during November 2020. Patients aged 65 years or more admitted to a medical department were included. The Nutrition Risk Screening 2002 (NRS-2002) tool was used to identify patients at nutritional risk, both in routine clinical care, where data were collected retrospectively, and during a validation process in a random patient sample, where data were collected prospectively. RESULTS: In total, 817 patients were admitted for more than 24 h. Of these, an NRS-2002 score was documented in 294 (36%), among whom 177 (60%) were at nutritional risk. In 146 patients where no score was documented, 88 (60%) were at risk. Validation was possible in 91 patients where a record-based score and a validated score were documented. The specificity of the record-based score was 100%, whereas the sensitivity was 75%, indicating that routine screening underestimated nutritional risk (p < 0.001, proportion difference 19%; 95% confidence interval = 10%-28%). CONCLUSIONS: Electronic documentation does not solve issues about compliance with nutritional risk screening. In patients where screening was not documented, the occurrence of nutritional risk was similar, indicating that omission of screening is not related to the score.

Faecal microbiota transplantation as a home therapy to frail older people.

BACKGROUND: Clostridioides (Clostridium) difficile infection (CDI) is a leading cause of antibiotics-associated diarrhoea. Faecal microbiota transplantation (FMT) is effective for recurrent CDI and may be provided as a home treatment to frail, older people. METHODS: We present four consecutive patients with recurrent CDI, treated at home using nasojejunal tube-delivered or encapsulated donor faeces. The primary outcome was combined clinical resolution and a negative CD toxin test 8 weeks post-treatment. RESULTS: All four patients had severe CDI and all improved clinically following one FMT. Sustained resolution following one FMT was observed in one patient. Two patients had recurrence and received a second FMT using capsules; both achieved resolution. One patient who had recurrence declined from further FMT due to fear of relapse and was established on long-term vancomycin. No adverse events related to FMT were observed. CONCLUSION: Frail older people may benefit from FMT. Home treatment is a viable option and may be considered both for clinical cure and for palliation.

Mobile X-ray outside the hospital: a scoping review.

BACKGROUND: For several years mobile X-ray equipment has been routinely used for imaging in patients too unwell within the hospital, when transportation to the radiology department was inadvisable. Now, mobile X-ray examinations are also used outside the hospital. The literature describes that fragile patients may benefit from mobile X-ray, but we need to provide insights into the breadth, depth and gaps in a body of literature. METHODS: The scoping review was performed by searching PubMed, Cinahl, Embase, EconLit and Health Technology Assessment. English-, Danish-, Norwegian-, German-, Italian-, French- and Swedish-language studies, published 1.1.2009-1.5.2020 about mobile X-ray outside the hospital were included. Participants were patients examined using mobile X-ray as the intervention. PRISMA was used when eligible to build up the review. To extract data from the selected articles, we used a structured summary table. RESULTS: We included 12 studies in this scoping review. The results were divided into four topics:1. Target population 2. Population health 3. Experience of care and 4. Cost effectiveness. The main findings are that target population could be larger for instance including hospice patients for palliative care, group dwelling for people with intellectual disabilities, or psychiatric patients, population health may be improved, image quality seems to be good and mobile X-ray may be cost effective. Limitations of language, databases and grey literature may have resulted in studies being missed. CONCLUSIONS: Mobile X-ray may be used outside hospital. There seems to be potential benefits to both patients and health care staff. Based on the published studies it is not possible to draw a final conclusion if mobile X-ray examination is a relevant diagnostic offer and for whom. Further studies are needed to assess the feasibility of use in fragile patients, also regarding staff, relatives and societal consequences and therefore the topic mobile X-ray needs more research.

Single-bed rooms in a geriatric ward prevent delirium in older patients.

BACKGROUND: Few studies have investigated treatment environment risk factors for delirium in geriatric patients. In March 2017, a geriatric department was moved from old hospital buildings with multiple-bed rooms (old wards) to a new hospital with single-bed rooms (new wards), with no changes regarding uptake area, staff and admission criteria. AIMS: The aim of this study was to investigate the risk of delirium among patients in single-bed rooms compared with multiple-bed rooms. METHODS: An observational prospective study included patients aged ≥ 75 years admitted between 15 September 2016 and 19 March 2017 to the old wards and between 20 March and 19 December 2017 to the new wards. Exclusion criteria were terminal illness, somnolence at admission and inability to communicate in Danish. Delirium was assessed by trained nurses, nurse assistants, occupational therapists and physiotherapists every morning and evening using the Confusion Assessment Method (CAM). RESULTS: We included 1014 patients. Patients' characteristics were similar between patients admitted to the old wards and to the new wards. Delirium was present at admission in 105 patients, with no significant difference between the old and new wards. Patients in the new wards had a significantly reduced incidence of delirium during hospital stay compared with patients in the old wards; hazard ratio 0.66 (95% CI 0.48-0.93, p < 0.02). No difference between the old and the new wards was observed in the duration of the first delirium episode. CONCLUSION: We found evidence that the risk of delirium is reduced in single-bed rooms compared with multiple-bed rooms in geriatric wards.

Analgesic and psychoactive medications and the risk of falls in relation to delirium in single-bed rooms compared to multiple-bed rooms in geriatric inpatients.

BACKGROUND: Previously, we demonstrated a substantial reduction of delirium incidence among geriatric patients after relocating from old hospital buildings with multiple-bed rooms to a new hospital with single-bed rooms. AIMS: To investigate whether (1) the reduced incidence of delirium in single-bed rooms was associated with a simultaneous change in medication use, (2) the relocation had affected the incidence of falls, (3) the use of analgesics and psychoactive medications was associated with the risk of delirium and falls. METHODS: We included 461 admissions to the old wards and 553 admissions to the new wards. Delirium was assessed by the Confusion Assessment Method. Data on drug use and falls during hospitalization were extracted from medical records. RESULTS: There was no difference in drug use between the wards. In the new wards, patients who had experienced delirium had a much higher risk of falls than patients without delirium, while in the old wards this contrast was small. The risk of delirium was increased among patients who received antipsychotic drugs and anti-dementia drugs, Patients who received these drugs had an insignificantly increased risk of falls. CONCLUSION: Medication of analgesics and psychoactive drugs was similar in the old and new wards. In single-bed rooms, but not in multiple-bed rooms there was a much higher risk of falls among inpatients that developed delirium than among other patients. Patients who had used antipsychotics and anti-dementia drugs during hospitalization had increased risk of developing delirium and an insignificantly higher risk of falls.

Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis.

INTRODUCTION: The management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated. METHODS: Patients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC). RESULTS: 200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders. CONCLUSION: There was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.

Frailty status but not age predicts complications in elderly cancer patients: a follow-up study.

OBJECTIVES: The purposes were to investigate the health status of elderly cancer patients by comprehensive geriatric assessment (CGA) and to compare the complications with respect to baseline CGA and to evaluate the need for geriatric interventions in an elderly cancer patients' population. MATERIAL: Patients aged ≥70 years with lung cancer (LC), cancer of the head and neck (HNC), colorectal cancer (CRC), or upper gastro-intestinal cancer (UGIC) are referred to the Department of Oncology for cancer treatment. METHODS: CGA was performed prior to cancer treatment and addressed the following domains: Activities of daily living (ADL), instrumental ADL (IADL), comorbidity, polypharmacy, nutrition, cognition, and depression. Complications, defined as dose reduction and discontinuation of treatment due to grade 3-4 toxicity, hospital admission, shift to palliative treatment, or death within 90 days, were identified from the medical files. Patients were classified as fit, vulnerable, or frail by CGA. PRINCIPAL RESULTS: Patients (N = 217) with a median age of 75 years (range: 70-93 yeas) were included: 13% were fit, 35% vulnerable, and 52% frail. CGA significantly predicted admittance to hospital in frail and vulnerable patients compared to fit patients: risk ratio (RR) 2.12 (95% CI: 1.01; 4.46). Vulnerable and frail patients had higher absolute risk of death within 90 days compared to fit patients: 7% and 23% versus 0%. HR for death within 90 days in frail patients as compared to vulnerable patients was 3.50 (95% CI: 1.34; 9.15). More frail patients (88%) needed geriatric interventions than the vulnerable (46%) and fit patients (32%). Major conclusion: Few elderly cancer patients seem to be fit. CGA predicts admittance to hospital in a population of elderly patients with mixed cancer diseases. Frail and vulnerable patients have higher risk of death within 90 days as compared to fit patients.

Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial.

OBJECTIVES: To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3 g/dL (7 mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7 g/dL (6 mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90 days after hip surgery. METHODS: This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. RESULTS: The prevalence of delirium was 10 % in patients allocated to a liberal blood transfusion strategy (LB) and 21 % in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95 % CI 0.17-0.96), p = 0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95 % CI 1.72-5.78), p < 0.001. CONCLUSION: In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3 g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.

Computer-assisted training as a complement in rehabilitation of patients with chronic vestibular dizziness--a randomized controlled trial.

OBJECTIVE: To compare a computer-assisted home exercise program with conservative home-training following printed instructions in the rehabilitation of elderly patients with vestibular dysfunction. DESIGN: Single-blind, randomized, controlled trial. SETTING: Geriatric department of a university hospital. PARTICIPANTS: Patients with chronic dizziness due to vestibular dysfunction (N=63) were randomly assigned to either rehabilitation in the clinic followed by computer-assisted home exercises (intervention group: n=32) or rehabilitation in the clinic followed by home exercises according to printed instructions (control group: n=31). INTERVENTIONS: Patients in the intervention group received assisted rehabilitation by a computer program. MAIN OUTCOME MEASURES: Measurements at baseline and at 8 and 16 weeks were compared. These included the One Leg Stand Test, Dynamic Gait Index, Chair Stand Test, Motion Sensitivity Test, Short Form-12, Dizziness Handicap Inventory, and visual analog scale. RESULTS: Both groups improved significantly during 16 weeks of rehabilitation. However, neither t tests nor repeated-measures analysis of variance demonstrated any significant differences between the 2 groups. The overall compliance rate to computer program exercises during 16 weeks was 57%. CONCLUSIONS: A computer-assisted program to support the home training of elderly patients with vestibular dysfunction did not improve rehabilitation more than did printed instructions.

Postoperative blood transfusion strategy in frail, anemic elderly patients with hip fracture: the TRIFE randomized controlled trial.

BACKGROUND AND PURPOSE: Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery. PATIENTS AND METHODS: We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days. RESULTS: No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1-5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1-3.6; p = 0.01). INTERPRETATION: According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.

Blood transfusion and risk of infection in frail elderly after hip fracture surgery: the TRIFE randomized controlled trial.

OBJECTIVES: It is still under debate that red blood cell (RBC) transfusions might increase the risk of healthcare-associated infections after hip fracture surgery. Previously, we found that a liberal RBC transfusion strategy improved survival in nursing home residents. Our aim, therefore, was to investigate whether a more liberal RBC transfusion strategy was associated with a higher infection risk in frail elderly hip fracture patients. DESIGN: Prospective, assessor-blinded, randomized and controlled trial. SETTINGS: Orthopedic ward, Geriatric ward, and Hospital-at-home. PATIENTS: 284 consecutively hospital-admitted elderly with hip fracture from nursing homes or sheltered housing facilities were included. INTERVENTION: A restrictive RBC transfusion strategy (hemoglobin <9.7 g/dL; 6 mmol/L) compared with a liberal strategy (hemoglobin <11.3 g/dL; 7 mmol/L) administered within 30 days after surgery. MAIN OUTCOME MEASUREMENTS: Leukocytes and C-reactive protein (CRP) in repeated blood samples within 30 days, and number of all infections (pneumonia, urinary tract infection, and other infections) within 10 days. RESULTS: 88 % of the patients received a RBC transfusion. A median of 1 RBC unit (interquartile range (IQR): 1-2) was transfused for the restrictive strategy group versus 3 RBC units (IQR: 2-5) for the liberal group. Leukocytes and CRP measurements were similar for both groups. Rates of infection were 72 % for the restrictive group compared to 66 % for the liberal group (risk ratio 1.08; 95 % confidence interval 0.93-1.27, p value 0.29). CONCLUSIONS: A more liberal RBC transfusion strategy was not associated with higher risk of infection among residents from nursing homes or sheltered housing undergoing hip fracture surgery.

Generic substitution does not seem to affect adherence negatively in elderly polypharmacy patients.

PURPOSE: To investigate the association between generic substitutions and medication adherence in elderly patients with prescribed polypharmacy. METHODS: Our study included 672 patients aged 65+ years, living at home in the municipality of Aarhus (Denmark), who at the time of enrolment took at least five prescription drugs daily including both short-term and long-term treatment independently of kind of administration route but without assistance. In this paper, only oral drugs for long-term treatment are included in the analysis resulting in median of three drugs per patient. Adherence was assessed by pill counts. Patients with a mean adherence rate <80% across all oral drugs consumed for long-term treatment were categorised as non-adherent. The number of generic substitutions during 1 year was retrieved from the National Health Insurance prescription database. Each change in either a drug's or a manufacturer's name was regarded as a substitution. The association between generic substitution and the mean adherence rate to all drugs was analysed by contingency table analyses and a trend test. RESULTS: During 1 year, at least one substitution was experienced by 83.6% of patients (n = 562). Patients non-adherent to long-term oral treatment (n = 46) amounted to 8% of all patients who experienced substitutions. Amongst 110 elderly patients (16.4%) who did not experience substitutions, 16% were non-adherent (odds ratio 0.46; 95% confidence interval 0.25-0.82). CONCLUSION: As generic substitution in elderly patients undergoing polypharmacy appears not to affect adherence to long-term drug treatment negatively, there seems to be no obvious reason for avoiding generic substitution in such patients.

Computer habits and digital literacy in geriatric patients: A survey.

Objective: Among hospitalised geriatric patients, only half are computer users. However, many of them refrain from using telehealth solutions. This study aimed to investigate geriatric patients' computer and Internet habits and digital literacy and their associations with stress levels and frequency of Internet use. Methods: Inpatients and outpatients aged 65 years or older, all computer users, were consecutively surveyed. Besides information about computer and Internet habits, computer support, and computer stress, the survey also collected information about digital literacy using the electronic Health Literacy Assessment toolkit. Results: A total of 124 computer users with a mean age of 80.6 ± 7.4 years participated in the study from 1 October to 1 December 2019. Most patients received computer support from their children and grandchildren, whereas 6% did not seek support. They found themselves 'most familiar with using a keyboard' (79%), 59% 'were unfamiliar with the Copy Paste function', and only one-third 'were open to new ways of using computers'. Digital literacy was associated with the frequency of Internet use (P = 0.001), and higher digital literacy was associated with less computer stress (P = 0.01). Conclusions: Geriatric computer users are challenged by their basic computer skills, which may influence their choice of participation in telehealth solutions. If telehealth solutions are to succeed among geriatric patients, individualised computer support based on their basic computer skills and user-friendly computer devices are a prerequisite. For ongoing support, it is also necessary to introduce people close to the patient to telehealth solutions.

Frailty level at discharge predicts mortality in older patients with Clostridioides difficile more accurately than age or disease severity.

PURPOSE: Clostridioides difficile infection (CDI) has a high mortality among older patients. Identification of older patients with CDI in increased mortality risk is important to target treatment and thereby reduce mortality. The aim of this study was to investigate mortality rates and compare frailty levels at discharge, measured by the record-based Multidimensional Prognostic Index (MPI), with age and severity of CDI as mortality predictors in patients with CDI diagnosed during hospitalisation. METHODS: This was a population-based cohort study from Central Denmark Region, Denmark, including all patients ≥ 60 years with a positive CD toxin test without prior infection and diagnosed from 1 January to 31 December 2018. Frailty level, estimated from the electronic medical record, was defined as low, moderate, or severe frailty. CDI severity was graded according to international guidelines. Primary outcome was 90-day mortality. RESULTS: We included 457 patients with median age 77 years (interquartile range 69-84) and females (49%). Overall, 90-day mortality was 28%, and this was associated with age (hazard ratio (HR): 2.71 (95% confidence interval 1.64-4.47)), CDI severity (HR 4.58 (3.04-6.88)) and frailty (HR 10.15 (4.06-25.36)). Frailty was a better predictor of 90-day mortality than both age (p < 0.001) and CDI severity (p = 0.04) with a receiver operating characteristic curve area of 77%. CONCLUSION: The 90-day mortality among older patients with CDI in a Danish region is 28%. Frailty measured by record-based MPI at discharge outperforms age and disease severity markers in predicting mortality in older patients with CDI.

Preoperative dehydration identified by serum calculated osmolarity is associated with severe frailty in patients with hip fracture.

BACKGROUND & AIMS: Preoperative dehydration is a well-known predictor of in-hospital complications and poor functional outcomes in older patients with hip fractures. In an orthopedic and geriatric cooperative setting, we aimed to investigate whether preoperative dehydration was associated with frailty, prolonged hospital stays and short-term mortality in older patients with hip fractures. METHODS: This retrospective cohort study was conducted in a Danish university hospital. The study population consisted of patients 65+ years surgically treated for hip fracture. Dehydration was defined as serum calculated osmolarity above 295 mmol/L. Outcomes were frailty at discharge measured by the Multidimensional Prognostic Index, hospital stay of 7 days or more and 90-day mortality. RESULTS: In total, 214 patients were consecutively included in the study from March 11, 2018, to August 31, 2020. The mean age was 81.2 (SD: 7.6) and 69% of the patients were women. The prevalence of preoperative dehydration was 40%. It was associated with severe frailty (Odds Ratio (OR): 2.08 [95% confidence interval (CI): 1.11-3.90]; p = 0.02) and prolonged hospital stay (OR: 2.28 [95% CI: 1.29-4.04]; p = 0.02). Seven percent died when dehydrated compared to 5% in the non-dehydrated (p = 0.91). CONCLUSION: Prevalence of preoperative dehydration is high among older patients with hip fractures and is associated with severe frailty and length of hospital stay. Systematic screening for dehydration on admission is advisable and may contribute to more adequate fluid management in the perioperative phase.

Prevalence of Computer Use among Geriatric In- and Outpatients.

Objective: Despite its many benefits, tele-rehabilitation is not widely used by the older generations. This study aimed to investigate the opportunity to offer tele-rehabilitation in a geriatric population by determining the prevalence of computer use and to examine whether the patients' characteristics affect computer use. Design: Cross-sectional study. Patients: Cognitive well-functioning in- and outpatients aged 65 years or older. Methods: Patients were consecutively included and surveyed. Results: A total of 249 patients participated in the survey. Among them, 124 were computer users. Four of these never went online. Compared to non-users, computer users were younger OR: 0.91 (95% CI: 0.87; 0.94) p = 0.001, less frail OR: 0.37 (95% CI: 0.25;0.55) p = 0.001, had a higher functional capacity OR: 1.02 (95% CI 1.01; 1.03) p = 0.001 and more often had an education at high school level or higher OR: 1.7 (95% CI: 1.41; 2.40). Conclusion: Only half of the geriatric patients are computer users. If tele-rehabilitation is to be adopted by a wider geriatric population challenged by reduced mobility, long transportation times, or frailty, computer training, user friendly devices and computer support should be considered beforehand.

Faecal microbiota transplantation for first or second Clostridioides difficile infection (EarlyFMT): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Clostridioides difficile infection is an urgent antibiotic-associated health threat with few treatment options. Microbiota restoration with faecal microbiota transplantation is an effective treatment option for patients with multiple recurring episodes of C difficile. We compared the efficacy and safety of faecal microbiota transplantation compared with placebo after vancomycin for first or second C difficile infection. METHODS: We did a randomised, double-blind, placebo-controlled trial (EarlyFMT) at a university hospital in Aarhus, Denmark. Eligible patients were aged 18 years or older with first or second C difficile infection (defined as ≥3 watery stools [Bristol stool chart score 6-7] per day and a positive C difficile PCR test). Patients were randomly assigned (1:1) to faecal microbiota transplantation or placebo administered on day 1 and between day 3 and 7, after they had received 125 mg oral vancomycin four times daily for 10 days. Randomisation was done by investigators using a computer-generated randomisation list provided by independent staff. Patients and investigators were masked to the treatment group. The primary endpoint was resolution of C difficile-associated diarrhoea (CDAD) 8 weeks after treatment. We followed up patients for 8 weeks or until recurrence. We planned to enrol 84 patients with a prespecified interim analysis after 42 patients. The primary outcome and safety outcomes were analysed in the intention-to-treat population, which included all randomly assigned patients. The trial is registered with ClinicalTrials.gov, NCT04885946. FINDINGS: Between June 21, 2021, and April 1, 2022, we consecutively screened 86 patients, of whom 42 were randomly assigned to faecal microbiota transplantation (n=21) or placebo (n=21). The trial was stopped after the interim analysis done on April 7, 2022 for ethical reasons because a significantly lower rate of resolution was identified in the placebo group compared with the faecal microbiota transplantation group (Haybittle-Peto boundary limit p<0·001). 19 (90%; 95% CI 70-99) of 21 patients in the faecal microbiota transplantation group and seven (33%, 95% CI 15-57) of 21 patients in the placebo group had resolution of CDAD at week 8 (p=0·0003). The absolute risk reduction was 57% (95% CI 33-81). Overall, 204 adverse events occurred, with one or more adverse events being reported in 20 of 21 patients in the faecal microbiota transplantation group and all 21 patients in the placebo group. Diarrhoea (n=23 in the faecal microbiota transplantation group; n=14 in the placebo group) and abdominal pain (n=14 in the faecal microbiota transplantation group; n=11 in the placebo group) were the most common adverse events. Three serious adverse events possibly related to study treatment occurred (n=1 in the faecal microbiota transplantation group; n=2 in the placebo group), but no deaths or colectomies during the 8-week follow-up. INTERPRETATION: In patients with first or second C difficile infection, first-line faecal microbiota transplantation is highly effective and superior to the standard of care vancomycin alone in achieving sustained resolution from C difficile. FUNDING: Innovation Fund Denmark.

A group-based real-time videoconferencing telerehabilitation programme in recently discharged geriatric patients: a feasibility study.

PURPOSE: Exercise at home and improvement in the ability to undertake daily tasks are highly valued by older people after hospitalisation. New telerehabilitation (TR) technologies make it possible to supervise and communicate with exercising participants through videoconferencing equipment. This technology has been shown to be both feasible and effective in Danish chronic obstructive pulmonary disease patients in terms of basic mobility, safety, social interactions and patient perception. This study sought to examine whether it was feasible to carry out TR through home exercises in groups. METHODS: Both medical and hip-fracture home-dwelling patients aged 65 years and older admitted to the Emergency Department (ED) and Department of Geriatrics for acute reasons were asked to participate in the study just before their discharge. The inclusion criteria were normal cognitive function, being dependent on a walking aid and computer users before hospitalisation. RESULTS: At discharge, 333 patients were consecutively screened for participation. Of those, 300 patients were excluded. Thirty-three patients met the inclusion criteria. They had a mean age of 82.3 years (± 7.8) and 76% were women. Nine patients agreed to participate, but seven withdrew. The most frequent explanation was exhaustion in the continuation of hospitalisation. CONCLUSION: It was not possible to conduct a videoconference TR study in a geriatric population, as many were excluded and those who were eligible withdrew after inclusion. During the COVID-19 pandemic, TR may be an important tool for isolated older persons to hinder functional decline. Aspects such as recruitment procedures and IT solutions designed for older people must be considered.

Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial.

Purpose Previous studies reported reduced risk of readmission, mortality and shorter length of hospital stay (LOS) among geriatric patients receiving an early (<24h), hospital-based geriatric team intervention after discharge. The objective of this study was to compare a novel, early municipality-based, nurse-led and general practitioner (GP)-supported transitional care intervention (TCI) to an established hospital-based TCI among frail, older, geriatric patients. Material and methods A randomised controlled trial was conducted within a single geriatric department and the adjacent municipality. Inclusion criteria: acutely admitted, frail patients 75+ years old. Eligible patients were randomly allocated (1:1) to the two TCIs. Primary outcome was 30-day unplanned readmission. Secondary outcomes were 90-day all-cause mortality and LOS. Stratified analysis according to type of dwelling was made. Odds ratios (OR) with 95% confidence intervals (CI), and number needed to treat (NNT) were reported. Results 3,103 patients (median age (IQR): 85 (80-90); 57% female) were included. Readmission rates were 22% in the municipality-based intervention (n=332/1,545), and 18% in the hospital-based intervention (n=276/1,558); OR was 1.27, 95% CI (1.06-1.52), p=0.008 and NNT=27. OR for cohabiting patients was 1.47, 95% CI (1.02-2.08); p=0.035. No significant difference was observed in mortality (22% vs. 21%; OR=1.05, 95% CI (0.89-1.25), p=0.577) or LOS (median (IQR): 6 (2-8) vs. 6 (2-8) days, p=0.1787). Conclusions The new municipality-based, nurse-led and GP-supported intervention was inferior to the hospital-based geriatric team intervention in preventing 30-day readmission among frail, geriatric patients. There was no significant difference between the two interventions in regard to 90-day mortality or LOS.

Involving frail older patients in identifying outcome measures for transitional care-a feasibility study.

BACKGROUND: During care transitions, the older (75+) patient's agenda can easily be missed. To counteract this, involving patients in shared clinical decision making has proven to be of great value. Likewise, involving patients and other stakeholders as researchers is gaining ground. Patient and public involvement (PPI) in research entails many benefits, for example, by bringing further insight from those with lived experiences of being ill. There are various challenges associated with involving some older patients, for example frailty, cognitive impairment and other chronic illnesses. To the best of our knowledge, there are only a few examples of initiatives involving older patients beyond research participation. The feasibility of involving frail older patients during an ongoing care transition from hospital to primary health care remains unknown. To investigate the feasibility of including older frail patients, their relatives and health care professionals (HCPs) as co-researchers, we established a study with increasingly demanding levels of patient involvement to identify relevant outcome measures for future transitional care research. METHODS: The study was a pragmatic, qualitative feasibility study. The involved individuals were frail older patients, their relatives and HCPs. Patients and their relatives were interviewed, while the interviewer made reflective notes. A thematic analysis was made. Relatives and HCPs discussed the themes to identify relevant outcome measures and potentially co-create new patient-reported outcome measures (PROMs) for use in future transitional care studies. The feasibility was evaluated according to six involvement steps. The level of involvement was evaluated using the five-levelled Health Canada Public Involvement Continuum (HCPIC). RESULTS: In total, eight patients, five relatives and three HCPs were involved in the study. Patients were involved in discussing care transitions (HCPIC level 3), while some relatives were engaged (HCPIC level 4) in forming PROMs. The partnership level of involvement (HCPIC level 5) was not reached. The thematic analysis and the subsequent theme discussion successfully formed PROMs. The key PROMs were related to care, transparency and the relatives' roles in the transitional care process. CONCLUSIONS: When applying a pragmatic involvement approach, frail older patients can be successfully involved in identifying relevant transitional care outcome measures; however, involving these patients as fellow researchers seems infeasible. To maintain involvement, supportive relatives are essential. Useful experiences for future research involvement of this vulnerable group were reported, arguing that patient participation has the potential to become inherent in future geriatric research.

The purpose of the study was to involve patients in identifying relevant outcome measures for future transitional care research. Involving patients in research is not new. What makes this project special is that it seeks to involve old, frail patients aged 75 plus.The project used open-form interviews that were not constrained in time and were not audio recorded; this was done to obtain confidence from the patients and their relatives. Each patient was interviewed twice: shortly before the patients left the hospital and shortly after discharge. The purpose was to discuss the patient's experiences during the discharge period. The first interview took place in the hospital, whereas the interviewer visited the patients in their residence for the second interview. An expert panel was then formed involving the patients' relatives and the professional health care workers. The expert panel discussed themes based on the data expressed by the patients during the interviews. In addition, an attempt was made to establish long-term cooperation between the patients, their relatives and the researchers. The health condition and vulnerable state of the patients made it difficult to continue their involvement throughout the research process. In fact, only the relatives and professionals were able to take part in the expert panel. Despite these challenges, the outcome of the project was positive. In conclusion, it makes sense to involve frail patients in transitional care research despite the challenges these patients face in their old age. In future research, frail older patients, relatives and other stakeholders can be involved.