Causes and correlates of 30 day and 180 day readmission following discharge from a Medicine for the Elderly Rehabilitation unit.

BACKGROUND: Recently hospitalized patients experience a period of generalized risk of adverse health events. This study examined reasons for, and predictors of, readmission to acute care facilities within 30 and 180 days of discharge from an inpatient rehabilitation unit for older people. METHODS: Routinely collected, linked clinical data on admissions to a single inpatient rehabilitation facility over a 13-year period were analysed. Data were available regarding demographics, comorbid disease, admission and discharge Barthel scores, length of hospital stay, and number of medications on discharge. Discharge diagnoses for the index admission and readmissions were available from hospital episode statistics. Univariate and multivariate Cox regression analyses were performed to identify baseline factors that predicted 30 and 180-day readmission. RESULTS: A total of 3984 patients were included in the analysis. The cohort had a mean age of 84.1 years (SD 7.4), and 39.7% were male. Overall, 5.6% (n = 222) and 23.2% (n = 926) of the patients were readmitted within 30 days and 180 days of discharge respectively. For patients readmitted to hospital, 26.6% and 21.1% of patients were readmitted with the same condition as their initial admission at 30 days and 180 respectively. For patients readmitted within 30 days, 13.5% (n = 30) were readmitted with the same condition with the most common diagnoses associated with readmission being chest infection, falls/immobility and stroke. For patients readmitted within 180 days, 12.4% (n = 115) of patients were readmitted with the same condition as the index condition with the most common diagnoses associated with readmission being falls/immobility, cancer and chest infections. In multivariable Cox regression analyses, older age, male sex, length of stay and heart failure predicted 30 or 180-day readmission. In addition, discharge from hospital to patients own home predicted 30-day readmission, whereas diagnoses of cancer, previous myocardial infarction or chronic obstructive pulmonary disease predicted 180-day readmission. CONCLUSION: Most readmissions of older people after discharge from inpatient rehabilitation occurred for different reasons to the original hospital admission. Patterns of predictors for early and late readmission differed, suggesting the need for different mitigation strategies.

Psychoactive prescribing for older people--what difference does 15 years make?

OBJECTIVE: The objective of the study was to review prescribing of psychoactive medications for older residents of the Tayside region of Scotland. METHODS: The analysis used community prescribing data in 1995 and 2010 for all older residents in Tayside. For each psychoactive drug class, the name of the most recently prescribed drug and the date prescribed were extracted. The relative risk (RR) and 95% confidence intervals (CI) for patients receiving psychoactive medication in 2010 were compared with those for patients in 1995. Psychoactive prescribing was analyzed by year, age, gender, and deprivation classification. The chi-squared test was used to calculate statistical significance. RESULTS: Total psychoactive prescribing in people over the age of 65 years has increased comparing 1995 with 2010. Antidepressant [RR = 2.5 (95% CI 2.41-2.59) p < 0.001] and opioid analgesia [RR = 1.21 (1.19-1.24) p < 0.001] prescriptions increased between 1995 and 2010. Hypnotics/anxiolytic [RR = 0.69 (0.66-0.71) p < 0.001] and antipsychotic [RR = 0.83 (0.77-0.88) p < 0.001] prescriptions decreased between 1995 and 2010. An increase in psychoactive prescribing is particularly marked in lower socioeconomic groups. Patients in the least affluent fifth of the population had RR = 1.25 (1.20-1.29) [p < 0.001] of being prescribed one to two psychoactive medications and RR = 1.81 (1.56-2.10) [p < 0.001] of being prescribed three or more psychoactive medications in 2010 compared with those in 1995. The RRs for the most affluent fifth were RR = 1.14 (1.1-1.19) [p < 0.001] and RR = 1.2 (1.01-1.42) [p < 0.001] for one to two, and three or more medications, respectively. CONCLUSION: Psychoactive medication prescribing has increased comparing 1995 with 2010, with increases disproportionately affecting patients in lower socioeconomic groups. The availability of new psychoactive drugs, safety concerns, and economic factors may explain these increases.

Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity.

BACKGROUND: currently one of the major challenges facing clinical guidelines is multimorbidity. Current guidelines are not designed to consider the cumulative impact of treatment recommendations on people with several conditions, nor to allow comparison of relative benefits or risks. This is despite the fact that multimorbidity is a common phenomenon. OBJECTIVE: to examine the extent to which National Institute of Health and Clinical Excellence (NICE) guidelines address patient comorbidity, patient centred care and patient compliance to treatment recommendations. METHODS: five NICE clinical guidelines were selected for review (type-2 diabetes mellitus, secondary prevention for people with myocardial infarction, osteoarthritis, chronic obstructive pulmonary disease and depression) as these conditions are common causes of comorbidity and the guidelines had all been produced since 2007. Two authors extracted information from each full guideline and noted the extent to which the guidelines accounted for patient comorbidity, patient centred care and patient compliance. The cumulative recommended treatment, follow-up and self-care regime for two hypothetical patients were then created to illustrate the potential cumulative impact of applying single disease recommendations to people with multimorbidity. RESULTS: comorbidity and patient adherence were inconsistently accounted for in the guidelines, ranging from extensive discussion to none at all. Patient centred care was discussed in generic terms across the guidelines with limited disease-specific recommendations for clinicians. Explicitly following guideline recommendations for our two hypothetical patients would lead to a considerable treatment burden, even when recommendations were followed for mild to moderate conditions. In addition, the follow-up and self-care regime was complex potentially presenting problems for patient compliance. CONCLUSION: clinical guidelines have played an important role in improving healthcare for people with long-term conditions. However, in people with multimorbidity current guideline recommendations rapidly cumulate to drive polypharmacy, without providing guidance on how best to prioritise recommendations for individuals in whom treatment burden will sometimes be overwhelming.

Encouraging healthy ageing: a vital element of NHS reform.

The implications of an ageing population are all around us, with issues such as increasing healthcare and social care costs, and a perceived pensions crisis, for example. However, too often the focus remains on how to manage the challenges of an ageing population rather than investing in research and implementing social reform to promote healthy ageing. This article reviews the major areas of medical, social/political and scientific research that together offer an opportunity to allow people to age in a healthy way.

Clustering long-term health conditions among 67728 people with multimorbidity using electronic health records in Scotland.

There is still limited understanding of how chronic conditions co-occur in patients with multimorbidity and what are the consequences for patients and the health care system. Most reported clusters of conditions have not considered the demographic characteristics of these patients during the clustering process. The study used data for all registered patients that were resident in Fife or Tayside, Scotland and aged 25 years or more on 1st January 2000 and who were followed up until 31st December 2018. We used linked demographic information, and secondary care electronic health records from 1st January 2000. Individuals with at least two of the 31 Elixhauser Comorbidity Index conditions were identified as having multimorbidity. Market basket analysis was used to cluster the conditions for the whole population and then repeatedly stratified by age, sex and deprivation. 318,235 individuals were included in the analysis, with 67,728 (21·3%) having multimorbidity. We identified five distinct clusters of conditions in the population with multimorbidity: alcohol misuse, cancer, obesity, renal failure, and heart failure. Clusters of long-term conditions differed by age, sex and socioeconomic deprivation, with some clusters not present for specific strata and others including additional conditions. These findings highlight the importance of considering demographic factors during both clustering analysis and intervention planning for individuals with multiple long-term conditions. By taking these factors into account, the healthcare system may be better equipped to develop tailored interventions that address the needs of complex patients.

Assessment and management of pain in older patients receiving palliative care.

This article aims to outline the principles that underpin good practice in the assessment and management of pain syndromes in older patients with advanced, life-limiting illnesses. Older patients receiving palliative care can be nursed in a variety of settings, including acute hospitals and in the community either at home, in nursing homes or hospices. An understanding of pain and approaches to treating it will help ensure that nurses in different clinical settings are able to support patients receiving palliative care and their families.

Understanding the processes behind the decisions - GPs and complex multimorbidity decision making.

Complex multimorbidity, defined either as three or more chronic conditions affecting three or more different body systems or by the patients General Practitioner (GPs), is associated with various adverse outcomes. Understanding how GPs reach decisions for this complex group of patients is currently under-researched, with potential implications for health systems and service delivery. Schuttner and colleagues, through a qualitative approach, reported that internal factors of individuals (decisions tailored to patients; Primary Care Physician (PCP) consultation style; care planning towards an agreed goal of care), external factors within the environment or context of encounter (patient access to healthcare; organizational structures acting as barriers), and relationship-based factors (collaborative care planning; decisions within a dynamic patient clinician relationship) all influence care planning decisions. There are other important findings which have broader relevance to the literature such as the ongoing separation of physical and mental health which persist even within integrated care systems, GPs continue to prioritize continuity of care and that organizational barriers are reported as factors in clinician decision-making for patients. More broadly, the work has proved valuable in extending previously reported findings surrounding care coordination, and limitation of current guidelines for patients with complex multimorbidity. Work-load in general practice is increasing due to an ageing population, increasing prevalence of multimorbidity and polypharmacy, and transfer of clinical activities from secondary to primary care. The future for GPs is more complexity in the clinic room, understanding how GPs make decisions and how this can be supported is crucial for the sustainability for general practice.

Changes in clinical manifestation of fibromyalgia syndromes after Alzheimer's disease diagnosis.

Fibromyalgia syndrome (FMS) is defined by chronic widespread pain persisting for more than 3 months without an apparent physical cause. The prevalence of FMS peaks between 50 and 70 years old, and it can be difficult to diagnose and treat due to other comorbid conditions. Recent work has suggested that neurodegenerative conditions can be complicated by chronic pain. This case study presents four patients with FMS residing in nursing homes. In all four cases, with the progression of Alzheimer's disease, patients saw improvements in pain syndromes, albeit to different degrees, and marked improvements in mobility. All four patients also developed challenging behavioral and psychological symptoms of dementia requiring psychotropic prescriptions.

Assessment and treatment of depression associated with dementia.

Depression is a frequent diagnosis for people with dementia, with between 25% and 42% of such patients receiving antidepressants. The diagnosis can be challenging to make, and this patient group is more vulnerable to side effects of commonly used medications. This article outlines the diagnostic considerations and therapeutic approaches for managing depression in people with dementia.

Incidental hip fracture in an outpatient clinic: the importance of patient-centred assessment.

Although many patients presenting with hip fractures have classic symptoms, other patients may present atypically with referred knee pain and reasonably unremarkable clinical examination following initial presentation. Older patients commonly have comorbid conditions such as arthritis, stroke and dementia that can complicate history and examination, making the diagnosis of subtle fractures difficult. Multimorbidity represents an important diagnostic challenge to both primary and secondary care. This case study discusses a 90-year-old lady who was found to have an old right neck of femur fracture after attendance at an geriatric outpatient clinic for a discussion about anticoagulation, after GP referral.

Association between bisphosphonate therapy and outcomes from rehabilitation in older people.

BACKGROUND: Bisphosphonate therapy may have actions beyond bone, including effects on cardiovascular, immune and muscle function. We tested whether bisphosphonate treatment is associated with improved outcomes in older people undergoing inpatient rehabilitation. METHODS: Analysis of prospectively collected, linked routine clinical datasets. Participants were divided into never users of bisphosphonates, use prior to rehabilitation only, use after rehabilitation only, and current users (use before and after rehabilitation). We calculated change in 20-point Barthel scores during rehabilitation, adjusting for comorbid disease and laboratory data using multivariable regression analysis. Cox regression analyses were performed to analyse the association between bisphosphonate use and time to death or hospitalisation. RESULTS: 2797 patients were included in the analysis. Current bisphosphonate users showed greater improvement in Barthel score during rehabilitation than non-users (5.0 points [95%CI 4.3-5.7] vs 3.8 [95%CI 3.6-3.9]), but no difference compared to those receiving bisphosphonates only after discharge (5.1 [95%CI 4.6-5.5]). Previous bisphosphonate use was significantly associated with time to death (adjusted hazard ratio 1.41 [95%CI 1.15-1.73]) but less strongly with time to combined endpoint of hospitalisation or death (adjusted hazard ratio 1.18 [95%CI 0.98-1.48]). Use after discharge from rehabilitation was associated with reduced risk of death (adjusted hazard ratio 0.64 [95%CI 0.55-0.73]; hazard ratio per year of bisphosphonate prescription 0.98 [95%CI 0.97-0.99]). CONCLUSION: Bisphosphonate use is unlikely to be causally associated with improved physical function in older people, but continuing use may be associated with lower risk of death.

Primary care hypnotic and anxiolytic prescription: Reviewing prescribing practice over 8 years.

INTRODUCTION: Over the last few years, hypnotic and anxiolytic medications have had their clinical efficacy questioned in the context of concerns regarding dependence, tolerance alongside other adverse effects. It remains unclear how these concerns have impacted clinical prescribing practice. MATERIALS AND METHODS: This is a study reviewing community-dispensed prescribing data for patients on the East Practice Medical Center list in Arbroath, Scotland, in 2007, 2011 and 2015. Anxiolytic and hypnotic medications were defined in accordance with the British National Formulary chapter 4.1.1 and chapter 4.1.2. All patients receiving a drug within this class in any of the study years were collated and anonymized using primary care prescribing data. The patients' age, gender, name of the prescribed drug(s), and total number of prescriptions in this class over the year were extracted. RESULTS: The proportion of patients prescribed a benzodiazepine medication decreased between 2007 and 2015: 83.8% (n = 109) in 2007, 70.5% (n = 122) in 2011, and 51.7% (n = 138) in 2015 (P = 0.006). The proportion of these patients prescribed a nonbenzodiazepine drug increased between 2007 and 2015: 30% (n = 39) in 2007, 46.2% (n = 80) in 2011, and 52.4% (n = 140) in 2015 (P = 0.001). There was a significant increase in the number of patients prescribed melatonin (P = 0.020). DISCUSSION: This study reports a reduction in benzodiazepine prescriptions in primary care alongside increases in nonbenzodiazepine and melatonin prescribing, with an increase in prescribing rates of this drug class overall. CONCLUSION: Changes in this prescribing practice may reflect the medicalization of insomnia, local changes in prescribing practice and alongside national recommendations.

The transplant patient and transplant medicine in family practice.

Over the last two decades in particular there has been a remarkable increase in the number of solid organ transplants being performed worldwide alongside improvements in long-term survival rates. However, the infrastructure at transplant centres has been unable to keep pace with the current volume of the transplant patient work load. These pressures on transplant specialist centres has led to calls for an increased role of the general practitioner (GP) managing particular aspects of transplant patients' medical care. Indeed, many aspects of follow-up care such as screening for malignancies, preventing infection through immunisation programmes, and managing cardiovascular risk factors are already important aspects of family practice medicine. This paper aims to review some of the aspects of transplant patient care that is important for healthcare workers in family practice to manage.