Activities of daily living at hospital admission and estimated survival time of older patients.

BACKGROUND: Predicting expected survival time in acutely hospitalised older patients is a clinical challenge. OBJECTIVE: To examine if activities of daily living (ADL) assessed by Barthel-Index-100 (Barthel-Index) at hospital admission adds useful information to clinicians on expected survival time in older patients. METHODS: A nationwide population-based cohort study was used. All patients aged ≥65 years in the National Danish Geriatric Database from 2005 to 2014 were followed up until death, emigration or study termination (31 December 2015). Individual data were linked to national health registers. Barthel-Index was categorised into five-point subcategories with a separate category of Barthel-Index = 0. Kaplan-Meier analysis was used to assess crude survival proportions (95% CI) and Cox regression to examine association of Barthel-Index and mortality adjusting for age, Charlson comorbidity index, medication use, BMI, marital status, prior hospitalisations and admission year. RESULTS: In total, 74,589 patients (63% women) aged (mean (SD)) 82.5(7.5) years with Barthel-Index (median (IQR)) 54(29-77) were included. In patients with Barthel-Index = 100-96 crude survival was 0.96(0.95-0.97) after 90-days, 0.88(0.87-0.89) after 1-year, and 0.79(0.78-0.80) after 2-years. Corresponding survival in patients with Barthel-Index = 0 was 0.49(0.47-0.51), 0.35(0.34-0.37) and 0.26(0.24-0.27). Decreasing Barthel-Index was associated with increasing mortality in the multivariable analysis. In women with Barthel-Index = 0, the mortality risk (HR (95% CI)) was 14.74(11.33-19.18) after 90-days, 8.40(7.13-9.90) after 1-year and 6.22(5.47-7.07) after 2-years using Barthel-Index = 100-96 as reference. In men, the corresponding risks were 11.36(8.81-14.66), 6.22(5.29-7.31) and 5.22(4.56-5.98). CONCLUSIONS: ADL measured by Barthel-Index provides useful, easily accessible and independent information to clinicians on expected survival time in patients admitted to a geriatric department.

Validation of the de Morton mobility index (DEMMI) among acute stroke patients aged ≥65 years: a register study.

PURPOSE: To validate the de Morton Mobility Index (DEMMI) in older (≥65 years) patients with acute stroke in a hospital setting within the first week after stroke onset. MATERIALS AND METHODS: In the Danish National Database of Geriatrics, we identified 4,176 patients with acute stroke (≥65 years). Floor and ceiling effects of DEMMI were investigated. Furthermore, convergent validity was investigated by correlations between DEMMI and the Barthel Index using Spearman's rho. Known-groups validity was tested by comparing DEMMI scores for different groups (with/without dementia, depression, comorbidity, and walking aids), and unidimensionality of DEMMI was evaluated by Mokken scale analysis. RESULTS: A floor effect was identified with 22.1% of the patients scoring 0 on DEMMI on admission. Both convergent and known-groups validity were confirmed for DEMMI. Patients who were bedbound had a lower DEMMI score (median [IQR]: 0 [0;0]) than patients without any walking aid (median [IQR]: 62 [33;74]). Furthermore, Mokken scale analysis identified unidimensionality with overall fit to the model (Loevinger H 0.88 (p < 0.0001)). CONCLUSION: DEMMI is a valid instrument for use in patients with acute stroke (≥65 years) in a hospital setting within the first week after stroke onset.

The de Morton Mobility Index (DEMMI) is a unidimensional measurement instrument of mobility in older (≥65 years) individuals with acute stroke and can be used in acute clinical work to help assess mobility ability and in planning of rehabilitation for the patient groupThe DEMMI has a high convergent validity, with a high correlation with the Barthel Index.The DEMMI has known-groups validity, as DEMMI is significantly different in patients with depression and dementia compared with patients without these conditions, and different in patients using a walking aid on admission compared with non-users and in patients with co-morbidity compared with non-comorbid patients.

Patient-specific versus Organisational Barriers to Program Adherence: A Multivariate Analysis.

INTRODUCTION: This article explores the influence of patient-specific and organisational factors on adherence to program guidelines in an integrated care program targeting older patients. METHODS: The integrated care program aimed to offer post-discharge follow-up visits by a municipality nurse and the general practitioner to frail older patients after discharge from hospital. Adherence was measured as step 1) successful referral from the hospital and step 2) completed post-discharge follow-up visit. We followed a cohort of 1,659 patients who were selected to receive a post-discharge follow-up visit in 2014. We obtained unique data from hospitals, municipalities and from administrative registers. RESULTS: We found substantial lack of adherence in both steps of the program: 69% adherence in step 1 and 54% adherence in step 2. In step 1, adherence was related to hospital, and receiving municipal home care prior to admission. In step 2, level of adherence varied according to municipality, the type of general practitioner and the patient's gender. CONCLUSION: We found that adherence was strongly related to organisational factors. Adherence differed significantly at all organisational levels (hospital, municipality, general practice), thus indicating challenges in the vertical integration of care. Gender influenced adherence as the only patient-related factor.

Development of a prediction model for 30-day acute readmissions among older medical patients: the influence of social factors along with other patient-specific and organisational factors.

Background: Readmission rate is one way to measure quality of care for older patients. Knowledge is sparse on how different social factors can contribute to predict readmission. We aimed to develop and internally validate a comprehensive model for prediction of acute 30-day readmission among older medical patients using various social factors along with demographic, organisational and health-related factors. Methods: We performed an observational prospective study based on a group of 770 medical patients aged 65 years or older, who were consecutively screened for readmission risk factors at an acute care university hospital during the period from February to September 2012. Data on outcome and candidate predictors were obtained from clinical screening and administrative registers. We used multiple logistic regression analyses with backward selection of predictors. Measures of model performance and performed internal validation were calculated. Results: Twenty percent of patients were readmitted within 30 days from index discharge. The final model showed that low educational level, along with male gender, contact with emergency doctor, specific diagnosis, higher Charlson Comorbidity Index score, longer hospital stay, cognitive problems, and medical treatment for thyroid disease, acid-related disorders, and glaucoma, predicted acute 30-day readmission. Area under the receiver operating characteristic curve (0.70) indicated acceptable discriminative ability of the model. Calibration slope was 0.98 and calibration intercept was 0.01. In internal validation analysis, both discrimination and calibration measures were stable. Conclusions: We developed a model for prediction of readmission among older medical patients. The model showed that social factors in the form of educational level along with demographic, organisational and health-related factors contributed to prediction of acute 30-day readmissions among older medical patients.

Barthel Index at hospital admission is associated with mortality in geriatric patients: a Danish nationwide population-based cohort study.

PURPOSE: The Barthel Index (BI)-100 is used to measure geriatric patients' activities of daily living (ADL). The aim of this study was to explore whether BI at hospital admission is associated with mortality. PATIENTS AND METHODS: In a nationwide population-based cohort study, patients aged ≥65 years admitted during 2005-2014 to Danish geriatric departments were assessed with BI at admission. Data were entered into the Danish National Database of Geriatrics and linked at the individual level to the Danish health registers (Civil Registration System, National Patient Register, and National Database of Reimbursed Prescriptions). The BI was categorized into four predefined standard subcategories according to the national Danish version of the statistical classification of diseases (BI =80-100 [independent ADL], BI =50-79 [moderate reduced ADL], BI =25-49 [low ADL], and BI =0-24 [very low ADL]). Patients were followed until death, emigration, or end of the study (December 31, 2015). Associations with mortality adjusted for age, admission year, marital status, body mass index, Charlson comorbidity index, polypharmacy, and hospitalizations during the preceding year were analyzed by multivariable Cox regression analysis. RESULTS: Totally, 74,603 patients were included. Women (63%) were older than men (mean [SD] age; 83 [7] vs 81 [7] years) and had higher BI (median [IQR]; 55 [30-77] vs 52 [26-77]). Median survival (years [95% CI]) was lowest in the subcategory "BI =0-24" in both women (1.3 [1.2-1.4]) and men (0.9 [0.8-0.9]). Adjusted mortalities (HR [95% CI]; reference BI =80-100) in women were 2.41 (2.31-2.51) for BI =0-24, 1.66 (1.60-1.73) for BI =25-49, and 1.34 (1.29-1.39) for BI =50-79 and in men were 2.07 (1.97-2.18) for BI =0-24, 1.58 (1.51-1.66) for BI =25-49, and 1.29 (1.23-1.35) for BI =50-79. CONCLUSION: BI at admission is strongly and independently associated with mortality in geriatric patients. BI has the potential to provide useful supplementary information for the planning of treatment and future care of older patients.