[Analysis of changes in location before hospital admission, discharge destination and prognostic factors for the survival in hospitals with chronic-phase inpatients].

AIM: To clarify changes in location before hospital admission and discharge destination over the 10-year period of 2010 to 2020 and to identify prognostic factors associated with the survival in hospitals with chronic-phase inpatients. METHODS: The subjects were patients newly admitted to 12 hospitals in 2010 and 2020. The age, sex, location before hospital admission, outcomes at 90 days after admission, discharge destination, and results of 6 biochemical tests at admission were evaluated. A survival analysis was performed for the age, sex, and biochemical tests at admission. RESULTS: We analyzed 8007 newly hospitalized patients. Compared with 2010, there were more hospital admissions from acute-care hospitals and fewer admissions from long-term-care facilities in 2020. In addition, relative to 2010, regarding the outcomes at 90 days after admission, there were more discharges to home and residential facilities in 2020, fewer discharges to long-term-care facilities, and lower mortality rates. In the survival analysis, a multivariate analysis revealed that an elderly age, male sex, low albumin, high total cholesterol, high urea nitrogen, and low serum sodium were poor prognostic factors. These five variables were consistently poor prognostic factors in both 2010 and 2020, and Kaplan-Meier curves showed that the scores were dose-dependent prognostic factors for a poor survival. CONCLUSIONS: The present analysis of pre-admission location and discharge destination in hospitals with chronic-phase patients revealed an elderly age, male sex, high urea nitrogen, low serum sodium, and low albumin at the time of admission to be strong predictors of poor outcomes in these patients.

Submental Muscle Activity and Its Role in Diagnosing Sarcopenic Dysphagia.

PURPOSE: The objectives of this study were two-fold: 1) to investigate differences in activity duration and amplitude of the submental muscles during swallowing measured with surface electromyography (sEMG) in older patients with sarcopenic dysphagia compared to those without dysphagia and 2) to examine the diagnostic accuracy of submental sEMG signals for sarcopenic dysphagia. PATIENTS AND METHODS: Patients (n = 60) aged ≥65 years participated in this cross-sectional study. The submental muscle activity duration parameters were the duration from the onset of swallowing to the maximum amplitude (duration A), duration from the maximum amplitude to the end of the swallowing activity (duration B), and total duration. The amplitude parameters were mean and maximum amplitude. Maximum lingual pressures were also measured for comparison with sEMG parameters. RESULTS: Duration A was not significantly different between the groups (p = 0.15), but duration B (p < 0.001) and total duration (p < 0.001) were significantly different between the non-dysphagic and sarcopenic dysphagic groups. The mean (p = 0.014) and maximum (p < 0.001) amplitudes were significantly different between the groups. The area under the receiver operating characteristic curve (AUC) was 0.94 (95% confidence interval (CI) 0.87-0.98) for duration B, 0.95 (95% CI 0.89-0.99) for total duration, 0.76 (95% CI 0.63-0.87) for maximum amplitude, and 0.61 (95% CI 0.47-0.75) for mean amplitude. The AUC of the total duration was significantly greater than that of lingual pressure (p = 0.02). CONCLUSION: Patients with sarcopenic dysphagia had longer submental muscle activity duration and higher amplitude during swallowing as assessed using sEMG. The findings of this study can be useful in elucidating the underlying pathophysiology of sarcopenic dysphagia and in diagnosing sarcopenic dysphagia.

Is increased "stay away from bed" time associated with improved clinical rehabilitation outcomes in Japanese rehabilitation hospitals? A prospective observational study and clinical practice.

BACKGROUND: A comprehensive team approach for increasing stay away from bed time (SaB-time) called CASaB was conducted at multiple rehabilitation hospitals. AIMS: The aim of the present study was to investigate the association between SaB-time and clinical rehabilitation outcomes (CROs) before introducing CASaB (observational phase), and comparing CROs before and after CASaB (CASaB phase). METHODS: This prospective observational study included patients who were admitted to nine rehabilitation hospitals, with complete data. The final analysis included 197/229 patients in the observation phase, and 229/256 patients in the CASaB phase. We first tested whether SaB-time was positively associated with CROs in an observational study, then compared CROs before and after CASaB. RESULTS: In the observation phase, longer SaB-time was significantly associated with greater rehabilitation efficiency (REy) after adjusting for confounders (standardized ß = 0.20, p = 0.007). In a comparison of CROs before and after CASaB, the length of hospital stay during the CASaB phase was significantly shorter than during the observational phase (61.5, 57.6-65.4 days vs 75.6, 71.4-79.9 days, p < 0.001), and the REy after CASaB was significantly greater than that before the CASaB (0.38, 0.33-0.42/day vs 0.28, 0.25-0.33/day, p = 0.006). DISCUSSION: The current results suggest that increasing SaB-time may help the recovery of functional abilities, particularly for patients in rehabilitation hospitals. CONCLUSIONS: The CASaB provides a method for improving the recovery efficiency of patients in rehabilitation hospitals.

Diagnostic accuracy of lip force and tongue strength for sarcopenic dysphagia in older inpatients: A cross-sectional observational study.

BACKGROUND & AIMS: Dysphagia can be caused by sarcopenia in older adults. Although sarcopenic dysphagia has been reported to be associated with low tongue strength, whether tongue strength can be useful as a diagnostic index for sarcopenic dysphagia remains unclear. In addition, the association between sarcopenic dysphagia and lip force is unknown. The aim of the present study was to clarify the association of lip force and tongue strength with sarcopenic dysphagia, and their diagnostic accuracy for sarcopenic dysphagia. METHODS: A cross-sectional study was conducted in consecutive 245 (166 women) inpatients aged ≥65 years in the post-acute phase of illness. The presence of sarcopenic dysphagia, lip force, and tongue strength were assessed. Additional factors were also assessed: cognitive function, nutritional status, comorbidity, oral intake level, occlusion status, physical function, and inflammatory status. Multivariable logistic regression analysis was conducted with the presence of sarcopenic dysphagia as a dependent variable. Lip force and tongue strength were assessed with the area under the receiver operating characteristic curve (AUC) to clarify diagnostic accuracy for sarcopenic dysphagia. In addition, the cut-off values of lip force and tongue strength for identifying sarcopenic dysphagia were determined according to sex. RESULTS: In total, 86 patients (35.1%) had sarcopenic dysphagia. Both men and women with sarcopenic dysphagia had lower lip force and tongue strength than men and women without dysphagia or sarcopenic dysphagia (p < 0.001 for all). In multivariable logistic regression analysis, sarcopenic dysphagia was significantly associated with lip force (OR = 0.63, 95% CI 0.53-0.74, p < 0.001) and tongue strength (OR = 0.92, 95% CI 0.87-0.98, p = 0.011). The AUCs for lip force in patients with sarcopenic dysphagia were 0.88 (CI 0.81-0.95, p < 0.001) for men and 0.84 (CI 0.77-0.90, p < 0.001) for women. The AUCs for tongue strength were 0.79 (CI 0.69-0.89, p < 0.001) for men and 0.74 (CI 0.65-0.82, p < 0.001) for women. The cut-off values for sarcopenic dysphagia in men were 10.4 N for lip force and 24.3 kPa for tongue strength; the cut-off values in women were 8.5 N for lip force and 23.9 kPa for tongue strength. CONCLUSION: In older inpatients who are suspected as having dysfunction due to sarcopenia, lip force and tongue strength can be independently useful indices for diagnosing sarcopenic dysphagia, and may be factors that prevent and improve sarcopenic dysphagia.

Relationship between tongue strength, lip strength, and nutrition-related sarcopenia in older rehabilitation inpatients: a cross-sectional study.

OBJECTIVE: The objective of this study was to clarify the relationship between tongue strength, lip strength, and nutrition-related sarcopenia (NRS). PATIENTS AND METHODS: A total of 201 older inpatients aged ≥65 years (70 men, median age: 84 years, interquartile range: 79-89 years) consecutively admitted for rehabilitation were included in this cross-sectional study. The main factors evaluated were the presence of NRS diagnosed by malnutrition using the Mini-Nutrition Assessment - Short Form, sarcopenia based on the criteria of the Asian Working Group for Sarcopenia, tongue strength, and lip strength. Other factors such as age, sex, comorbidity, physical function, cognitive function, and oral intake level were also assessed. RESULTS: In all, 78 (38.8%) patients were allocated to the NRS group, and 123 (61.2%) patients were allocated to the non-NRS group. The median tongue strength and lip strength (interquartile range) were significantly lower in the NRS group (tongue: 22.9 kPa [17.7-27.7 kPa] and lip: 7.2 N [5.6-9.8 N]) compared with the non-NRS group (tongue: 29.7 kPa [24.8-35.1 kPa] and lip: 9.9 N [8.4-12.3 N], P<0.001 for both). Multivariable logistic regression analysis showed that NRS was independently associated with tongue strength (odds ratio [OR] =0.93, 95% confidence interval [CI] 0.87-0.98, P=0.012) and lip strength (OR =0.76, 95% CI 0.66-0.88, P<0.001), even after adjusting for age, sex, comorbidity, physical function, cognitive function, and oral intake level. CONCLUSION: The likelihood of occurrence of NRS decreased when tongue strength or lip strength increased. Tongue strength and lip strength may be important factors for preventing and improving NRS, regardless of the presence of low oral intake level in older rehabilitation inpatients.

The association of change in medication regimen and use of inappropriate medication based on beers criteria with adverse outcomes in Japanese long-term care facilities.

AIM: To describe medication use including potentially inappropriate medication (PIM) and examine the association between adverse outcomes and patient factors including PIM use in Japanese elderly patients in long-term care facilities. METHODS: This was a retrospective cohort study of 470 patients in 53 Geriatric Health Service Facilities and 44 Sanatorium Type Medical Care Facilities for the Elderly Requiring Long Term Care. Standardized forms were used to collect information including oral and parenteral medication use on admission, and 1 month and 3 months after admission. PIMs were determined by the 2003 or 2012 Beers criteria. Adverse outcomes were any medical events leading to emergency department transfer, hospitalization to acute care hospitals or death. RESULTS: A total of 2,227 oral medications and 197 parenteral medications were prescribed for 470 patients on admission. PIM exposure based on the 2003 and 2012 Beers criteria was observed in 11.9% and 37.5%, respectively. Adverse outcomes within 3 months after admission were observed in 8.9% of the entire cohort, and were associated with age, sex, facility type and number of parenteral medications on admission. Adverse outcomes between one and three months after admission were associated with age, sex, number of parenteral medications at one month, and a change in the number of oral and parenteral medications within one month after admission. PIM exposure was not associated with adverse outcomes in any models. CONCLUSIONS: Use of PIM was prevalent in long-term care facilities. Our findings support the importance of comprehensive assessment of medication regimens including parenteral medication. Geriatr Gerontol Int 2017; 17: 591-597.

Tongue Strength is Associated with Grip Strength and Nutritional Status in Older Adult Inpatients of a Rehabilitation Hospital.

The aim of this cross-sectional study was to investigate whether tongue strength observed in older adult inpatients of a rehabilitation hospital is associated with muscle function, nutritional status, and dysphagia. A total of 174 older adult inpatients aged 65 years and older in rehabilitation (64 men, 110 women; median age, 84 years; interquartile range, 80-89 years) who were suspected of having reduced tongue strength due to sarcopenia were included in this study. Isometric tongue strength was measured using a device fitted with a disposable oral balloon probe. We evaluated age, muscle function as assessed by the Barthel index and grip strength, nutritional status as measured by the Mini Nutritional Assessment-short form (MNA-SF), body mass index, serum albumin, controlling nutritional status, and calf circumference and arm muscle area to assess muscle mass. In addition, the functional oral intake scale (FOIS) was used as an index of dysphagia. Multivariate linear regression analysis revealed that isometric tongue strength was independently associated with grip strength (coefficient = 0.33, 95 % confidence interval (CI) 0.12-0.54, p = 0.002), MNA-SF (coefficient = 0.74, 95 % CI 0.12-1.35, p = 0.019), and FOIS (coefficient = 0.02, 95 % CI 0.00-0.15, p = 0.047). To maintain and improve tongue strength in association with sarcopenic dysphagia, exercise therapy and nutritional therapy interventions, as well as direct interventions to address tongue strength, may be effective in dysphagia rehabilitation in older adult inpatients.

[Investigation of the effects of intervention by therapists at night on convalescent rehabilitation units].

AIM: This study sought to investigate the influence of intervention by therapists at night on the patient's ADL's, number of falls, etc. On convalescent rehabilitation units in order to examine the efficacy of the intervention. METHODS: The study subjects included patients hospitalized on 11 convalescent rehabilitation units. The period of intervention by the therapists at night and the period of no intervention were each set for three months. The improvements in the ADL scores during each period were compared, and the changes in the number of falls were examined. In addition, a questionnaire survey was conducted among the night shift staff in order to examine the need for intervention. RESULTS: The patients who received intervention by therapists at night showed higher scores for BI, FIM, etc. and fewer falls than those treated without intervention. The results of the questionnaire survey indicated differences between the therapists and other professionals regarding their attitude toward working the night shift. CONCLUSIONS: Our findings suggest that intervention by therapists at night results in favorable outcomes, e.g., improvements in the patient's ADL's and a reduction in the number of falls. Although there are issues to be discussed with respect to raising awareness among therapists and concerns regarding work-related problems, intervention by therapists at night has the possibility to be used as a new treatment strategy on rehabilitation units.

Priorities of health care outcomes for the elderly.

OBJECTIVES: Physicians are uncertain about what medical services should be provided to older and/or disabled patients. Better understanding of health outcome prioritization among health care providers and recipients may help the process of decision- and policy-making. For this purpose, surveys were conducted on priorities of health care outcomes for the elderly. DESIGN: Survey research. SETTING: Four groups of health care providers and four groups of health care recipients. PARTICIPANTS: A total of 2512 health care providers and 4277 recipients. MEASUREMENTS: Questionnaires were sent to more than 8000 health care providers and more than 9000 health care recipients: geriatricians, physicians who commonly see older patients or work in long term care facilities, staff members and participants in adult day care, patients in outpatient geriatric clinics, family members of patients with dementia, and community-dwelling older adults. The questionnaire asked the subjects to rank 12 measures of health care outcomes. RESULTS: The mean response rate was 49%. All health care provider groups considered "improvement of quality of life" the most important. In contrast, in health care recipient groups, "effective treatment of illness," "improvement of physical function," and "reduction of carer burden" were given high priority, whereas "improvement of quality of life" was perceived as less important. All the groups, including health care providers and recipients, ranked "reduction of mortality" the least important, followed by "avoiding institutional care." Stratification analysis showed that the results did not differ by sex, nursing care level, or the existence of relatives who required nursing care, whereas age slightly influenced the order of high-ranked measures. CONCLUSION: Priorities of health care services and their differences between providers and recipients should be taken into account in the health care of older patients and the design of health care policies and research.

[Effect of intermittent rehydration therapy as an oral and enteral rehydration solution, alone or in combination with intravenous administration on intravascular dehydration].

AIM: The purpose of this study was to demonstrate the effectiveness of intermittent fluid infusion (intermittent rehydration therapy) to dehydrated elderly patients and the efficacy of Heisei Solution Water (HSW), an oral and enteral rehydration solution developed by our group. METHODS: We enrolled 375 elderly patients with suspected dehydration from among 1,921 patients of our hospital and 13 affiliated hospitals. A total of 36 of 375 patients received intermittent rehydration therapy. These patients were then divided into 3 groups according to the method of administration: (1) oral and enteral administration (n=16), (2) intravenous administration only (n=10) and (3) combined oral, enteral and intravenous administration (n=10). We then compared blood urea nitrogen/creatinine (BUN/Cr) ratios among the 3 groups. RESULTS: BUN/Cr ratios were improved in all groups, but there was no statistically significant difference in the degree of improvement of BUN/Cr ratios among the 3 groups. CONCLUSION: Intermittent rehydration therapy is a highly effective way to manage dehydration. The intermittent oral and enteral administration of HSW demonstrated the same effectiveness as other forms of administration.

Decline in anthropometric evaluation predicts a poor prognosis in geriatric patients.

OBJECTIVE: Malnutrition is frequent in the geriatric population and is often undetected and untreated. Although we often use serum albumin as a nutritional marker, it has limitations in elderly patients in terms of predicting diseases and infections. Anthropometric measurements are not commonly used, despite their simple, easy, and effective characteristics. We evaluated the associations between anthropometric measurements with other nutritional factors and examined its relationship with mortality, decubitus ulcer, length of hospital stay and antibiotic usage. RESEARCH METHODS AND PROCEDURES: We enrolled 223 patients, performed anthropometric measurements and then followed them for a mean of 24 months. RESULTS: Patients with hypoalbuminemia but with normal body measurements tended to increase serum albumin levels over the next 24 months and had more favorable outcomes including being discharged. Patients with normal albumin but decreased body measurements resulted in a progressive drop in serum albumin and had a higher mortality rate. Additionally, patients with hypoalbuminemia had higher antibiotic usage than patients without hypoalbuminemia. Decreases in anthropometric measurements were related to mortality, length of hospital stay, and decubitus ulcer. CONCLUSIONS: Anthropometric measurements are easily obtained and closely associated with mortality, decubitus ulcer, and length of hospital stay. Anthropometric measurements used in conjunction with serum albumin are more predictive of patient outcome then serum albumin alone.

Effect of saliva collection method on the concentration of protein components in saliva.

In order to clarify how we collect saliva for analyzing salivary protein in aged subjects who can not eat well, we compared the effects of suction, spitting and the swab saliva collection method on the yield of protein components in saliva samples from normal volunteers. The saliva collected by suction, spitting and the swab method were designated as, Saliva I, II and III, respectively. The saliva volume collected by Saliva I was about 2-fold greater than that by of Saliva II and III. This is mainly due to the fact that saliva secretion was stimulated by the suction itself. The content of total protein, S-IgA, trypsin-like activity and human airway trypsin-like protease (HAT) were almost the same in Saliva I and II, and significantly lower in Saliva III than in Saliva I and II. Kallikrein activity was almost the same in Saliva I, II and III. The concentration of each total protein, S-IgA, kallikrein activity, trypsin activity and HAT in Saliva I were significantly positively correlated with that in Saliva II. These results indicate that we can obtain information of change of salivary protein by analyzing saliva collected by suction method, although this method caused the stimulation of saliva to some extent.