Higher levels of multimorbidity are associated with increased risk of readmission for older people during post-acute transitional care.

PURPOSE: Older patients are at high risk for poor outcomes after an acute hospital admission. The Transitional Aged Care Programme (TACP) was established by the Australian government to provide a short-term care service aiming to optimise functional independence following hospital discharge. We aim to investigate the association between multimorbidity and readmission amongst patients on TACP. METHODS: Retrospective cohort study of all TACP patients over 12 months. Multimorbidity was defined using the Charlson Comorbidity Index (CCI), and prolonged TACP (pTACP) as TACP ≥ 8 weeks. RESULTS: Amongst 227 TACP patients, the mean age was 83.3 ± 8.0 years, and 142 (62.6%) were females. The median length-of-stay on TACP was 8 weeks (IQR 5-9.67), and median CCI 7 (IQR 6-8). 21.6% were readmitted to hospital. Amongst the remainder, 26.9% remained at home independently, 49.3% remained home with supports; < 1% were transferred to a residential facility (0.9%) or died (0.9%). Hospital readmission rates increased with multimorbidity (OR 1.37 per unit increase in CCI, 95% CI 1.18-1.60, p < 0.001). On multivariable logistic regression analysis, including polypharmacy, CCI, and living alone, CCI remained independently associated with 30-day readmission (aOR 1.43, 95% CI 1.22-1.68, p < 0.001). CONCLUSIONS: CCI is independently associated with a 30-day hospital readmission in TACP cohort. Identifying vulnerability to readmission, such as multimorbidity, may allow future exploration of targeted interventions.

A Safe Mobilisation Program to Improve Functional Mobility and Reduce Fall Risks in Cognitively Impaired Older Adults with Higher Level Gait Disorders: A Pilot Study.

BACKGROUND: The association between gait and cognition, and their combined impact on postural stability may underlie the increased fall risk in older adults with dementia. However, there are few interventions to improve functional mobility and reduce fall risks in people with cognitive impairment. OBJECTIVES: This study aims to investigate the feasibility and acceptability of a Safe Mobilisation Program for cognitively impaired older adults with higher level gait disorders. It also explores the potential effectiveness of the program on mobility and fall risks. METHODS: Fifteen community-dwelling older adults participated in a 3-week pre-post intervention study. They were trained to take steady steps in transfers and mobilization using errorless learning and spaced retrieval teaching techniques. RESULTS: The intervention program was feasible, all the participants completed the program and were able to mobilize safely. The program was acceptable and participants reported an increase in safety awareness, improvement in confidence while transferring and mobilising, and better quality of life. There was a trend of improvement in Falls Efficacy Scale-international (FES-I), 360° turn and Tinetti Performance Oriented Mobility Assessment (POMA), which may indicate improvement in balance and mobility. CONCLUSION: The Safe Mobilisation Program was feasible and acceptable in older adults with cognitive impairment and gait disorders and warrants further evaluation.

Health-services utilisation amongst older persons during the last year of life: a population-based study.

BACKGROUND: Accurate population-based data regarding hospital-based care utilisation by older persons during their last year of life are important in health services planning. We investigated patterns of acute hospital-based service use at the end of life, amongst older decedents in New South Wales (NSW), Australia. METHODS: Data from all persons aged ≥70 years who died in the state of NSW Australia in 2007 were included. Several measures of hospital-based service utilisation during the last year of life were assessed from retrospectively linked data comprising data for all registered deaths, cause of death, hospital care during the last year of life (NSW Admitted Patient Data Collection [APDC] and Emergency Department [ED] Data Collection [EDDC]), and the NSW Cancer Registry. RESULTS: Amongst 34,556 decedents aged ≥70 years, 82% (n = 28,366) had ≥1 hospitalisation during the last year of life (median 2), and 21% > 3 hospitalisations. Twenty-five percent (n = 5485) of decedents attended ED during the last week of life. Overall, 21% had a hospitalisation > 30 days in the last year of life, and 7% spent > 3 months in hospital; 79% had ≥1 ED attendance, 17% > 3. Nine percent (n = 3239) spent time in an intensive care unit. Fifty-three percent (n = 18,437) died in an inpatient setting. Hospital records had referenced palliative care for a fifth (7169) of decedents. Adjusting for age group, sex, place of residence, area-level socioeconomic status, and cause of death, having > 3 hospitalisations during the last year of life was more likely for persons dying from cancer (35% versus 16% non-cancer deaths, adjusted odds ratio [aOR] 2.33), 'younger' old decedents (29% for age 70-79 and 20% for age 80-89 versus 11% for 90+, aOR 2.42 and 1.77 respectively) and males (25% versus 17% females, aOR 1.38). Patterns observed for other hospital-based service use were similar. CONCLUSIONS: This population-based study reveals high use of hospital care among older persons during their last year of life, although this decreased with increasing older age, providing important data to inform health services planning for this population, and highlighting aspects requiring further study.

Examining barriers to healthcare providers' adoption of a hospital-wide electronic patient journey board.

BACKGROUND: The dynamic environment that characterizes patient care in hospitals requires extensive communication between staff. Electronic status board applications are used to improve the flow of communication in hospitals. To date there has been limited work exploring the adoption of these applications in general acute ward settings. AIM: This study aimed to identify barriers to the adoption of an electronic patient journey board (EPJB)1 application in acute wards of a hospital. METHOD: Data were collected at a large public teaching hospital in Sydney, Australia. The EPJB was implemented across all hospital wards with the aim of improving multidisciplinary communication in wards. Observations (29.5 h) and contextual interviews (n = 33) with hospital staff were conducted in two acute wards of the hospital. RESULTS: Two manual whiteboards were used on wards, in addition to the EPJB, to compensate for information not being available or accessible on the EPJB. Despite the stated purpose of the EPJB, the tool did not appear to support team communication on wards. Barriers to adoption and optimal use of the EPJB included inappropriate location and configuration of the system, limitations in information timeliness, quality and lack of customisation (for different user groups), inconsistent information updates and the absence of a shared understanding of the purpose of the EPJB among the various user groups. CONCLUSION: Multiple socio-technical barriers influenced uptake and optimal use of the EPJB by healthcare providers. Engaging users early in the design and implementation of electronic status board applications is required to ensure effective use of these complex interventions on general wards.

Oral Health Status Is Associated with Common Medical Comorbidities in Older Hospital Inpatients.

OBJECTIVES: To investigate oral health status and abnormalities in older adults admitted acutely to the hospital and explore the association with common medical comorbidities. DESIGN: Cross-sectional study. SETTING: Hospital. PARTICIPANTS: All individuals aged 70 and older (mean age 84.4, 61.4% female) admitted to a geriatric service over 3 months (N = 202). MEASUREMENTS: In-person assessment using the Oral Health Assessment Tool (OHAT) (range 0-2, 2 = poorest) for lips, tongue, gums and soft tissue, saliva, teeth, dentures, oral cleanliness, and dental pain. Comorbidities and medications were also recorded. RESULTS: One hundred twenty-eight (63%) participants had full or partial dentures, and 31 (15%) were edentulous. Median OHAT score was 6 (interquartile range 5-8). Of the eight domains, saliva scored worst, with 53% scoring 2. On univariate analysis, the highest (poorest) tertile of OHAT (score ≥8) was associated with dementia (odds ratio (OR) = 2.41, 95% confidence interval (CI) = 1.13-5.12, P = .02), moderate to severe renal impairment (estimated glomerular filtration rate <30 mL/min per 1.73 m(2) at discharge) (OR = 5.52, 95% CI = 1.54-19.69, P = .009), recent anticholinergic medication burden (P = .02), and low oral pH (P = .05). On multivariate analysis adjusted for oral pH and anticholinergic medication burden, dementia (OR = 2.29, P = .02) and moderate to severe renal impairment (OR = 5.64, P = .01) were independently associated with the highest tertile of OHAT. Charlson Comorbidity Index (includes renal disease, dementia) was associated with OHAT on univariate analysis (Spearman rho = 0.19, P = .01) but not when adjusted for oral pH (P = .10). CONCLUSION: Poorer oral health was not uncommon and was associated with dementia and renal impairment even after adjustment for anticholinergic medication and oral pH. Oral health screening should be considered for vulnerable populations.

Suboptimal bone protection in geriatric inpatients and effect of a simple educational and mnemonic strategy.

AIM: Osteoporosis is underdiagnosed and undertreated in Australia, especially in hospitalised patients. We aimed to improve bone health management in geriatric inpatients by introducing a mnemonic into discharge summaries. METHODS: A retrospective review of patients discharged from our geriatric unit was performed before and after intervention. Outcomes assessed were as follows: vitamin D measurement, bone protection medication and communication to general practitioners. RESULTS: Sixty-one patients were included in the initial audit, and 82 in the reaudit. There was an increase in measurement of vitamin D levels (86.6% vs 57.4%, P < 0.001) and in the communication to the general practitioner (84.7% vs 28.6%, P < 0.001). Patients in the reaudit were more likely to have vitamin D initiated or increased (43.0% vs 7.4%, P = 0.001) and to have antiresorptive therapy commenced (9.8% vs 0%, P = 0.01). CONCLUSION: The introduction of simple education and mnemonic strategy has shown significant improvement in the assessment and management of bone health in at-risk patients.

Potentially inappropriate medications (PIMs) in older hospital in-patients: Prevalence, contribution to hospital admission and documentation of rationale for continuation.

AIM: To establish prevalence, sequelae and documentation of potentially inappropriate medication (PIM) use in older hospital in-patients. METHODS: Notes of all patients ≥65 years old, admitted to our tertiary teaching hospital (January 2013), were retrospectively reviewed, and the Screening Tool of Older Persons' potentially inappropriate Prescriptions applied. RESULTS: Amongst 534 patients, 54.8% (284) were on ≥1 PIM at admission, 26.8% on multiple; 60.8% were discharged on a PIM. Six percent of all admissions were potentially attributable to a PIM; falls associated with risk therapies were commonest (23/30), and often (65.2%) associated with serious injury. Pre-specified subgroup analysis (n = 100) identified 101 PIMs-at-discharge amongst 47 patients. In 82.2%, a clinical rationale for continued prescription was documented, with this communicated to the GP by letter in 71.1%. CONCLUSION: PIMs were common, and contributed to admission and injury. Hospitalisation provides an opportunity for medication rationalisation, and documentation of rationale for any PIM use.

Factors influencing deprescribing habits among geriatricians.

BACKGROUND: deprescribing habits among physicians managing older, frailer, cognitively impaired patients have not been well investigated. METHODS: an anonymised electronic survey was disseminated to all members of an international geriatric society/local advanced trainee network (N = 930). This comprised a Likert-scale analysis of factors influencing desprescribing, and five case vignettes, detailing a patient with progressive cognitive impairment and dependency, on a background of ischaemic heart disease and hypertension. RESULTS: among 134 respondents (response rate 14.4%), 47.4% were female, 48.9% aged 36-50 years and 84.1% specialists (15.9% trainees). Respondents commonly rated limited life expectancy (96.2%) and cognitive impairment (84.1%) as very/extremely important to deprescribing practices. On multivariable analysis, older respondents less commonly rated functional dependency (odds ratio [OR] 0.22 per change in age category; P < 0.001) and limited life expectancy (OR 0.09, P = 0.04) important when deprescribing, while female participants (OR 3.03, P < 0.001) and trainees (versus specialists OR 14.29, P < 0.001) more often rated adherence to evidence-based guidelines important. As vignettes described increasing dependency and cognitive impairment, physicians were more likely to stop donepezil, aspirin, atorvastatin and antihypertensives (all P < 0.001 for trend). Aspirin (93.6%) and ramipril (94.1%) were most commonly deprescribed. Commonest reasons cited for deprescribing medications were 'dementia severity', followed by pill burden. CONCLUSION: in this exploratory analysis, geriatricians rated limited life expectancy and cognitive impairment very important in driving deprescribing practices. Geriatricians more often deprescribed multiple medications in the setting of advancing dependency and cognitive impairment, driven by dementia severity and pill burden concerns. Physician characteristics also influence deprescribing practices. Further exploration of factors influencing deprescribing patterns, and patient outcomes, is needed.

Electroconvulsive therapy use in a 97-year-old woman.

OBJECTIVES: The aim of this paper is to report the use of electroconvulsive therapy (ECT) to successfully treat depression in a 97-year-old woman, and to discuss the safety and efficacy of ECT in the very old. METHODS: A case report and review of the literature on the use of ECT to treat depression in the very old is presented. RESULTS: The subject recovered fully from her depression but suffered a serious adverse event (fractured femur) during the course of ECT. Relatively few publications on the use of ECT in the very old were found. The majority of articles concerned patients aged between 65 and 85, with one study including patients up to age 96. CONCLUSIONS: There appears to be an absence of randomized clinical trial evidence to support the use of ECT as a treatment for depression in the very old. Based on the limited evidence from case reports and case series, the indications appear to be the same as for younger patients. There do not appear to be any absolute contraindications, and ECT appears to be a safe and efficacious treatment for depression in the very old. However, in the light of our subject's serious adverse event, there may be a need to consider additional safety precautions in the very old. Finally, we believe our patient is the oldest person reported to be successfully treated with suprathreshold ECT.