In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system.

BACKGROUND: The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier. METHODS: The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression. RESULTS: A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001). CONCLUSIONS: Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.

Assistance provided in daily tasks and difficulty experienced by caregivers for people living with dementia.

INTRODUCTION: There is a growing body of research that addresses caregivers for people living with dementia. However, there is limited research looking at the perceptions of caregivers in specific daily tasks. To address this gap, this study investigated the assistance caregivers provided and the difficulty they faced when completing daily tasks for people with dementia and, additionally, how these experiences might relate to their perceived burden. METHODS: Sixty-two caregivers for people living with dementia completed the study. Data were collected, through a survey, on the level of assistance caregivers provided, and the difficulties they experienced. The Zarit Burden Scale was used to measure the level of perceived burden. Descriptive statistics and Spearman's correlation coefficient were used to report the results and the relationship between the perceived burden, the level of assistance provided, and the difficulty experienced. RESULTS: The activities of daily living that caregivers provided the most assistance for was dressing and showering. Most instrumental activities of daily living required maximal to total assistance. Overall, the caregivers did not experience a high level of difficulty with assisting with these daily tasks in comparison to the level of assistance provided. The caregiver burden was associated significantly with the difficulties experienced in dressing, toileting, and showering (rho = 0.30-0.75), most instrumental activities of daily living (rho = 0.29-0.47), but not with the level of assistance provided. CONCLUSION: Caregivers are assisting in many daily tasks. Their level of difficulty is relatively low in comparison to the level of assistance they provide. Significant correlations were found between the difficulties experienced and the burden scale. There is a need for occupational therapists to address the specific daily tasks and the concerns experienced by caregivers and to provide them with adequate support to improve the quality of care for people with dementia.

Twice-Weekly Structured Interdisciplinary Bedside Rounds and Falls among Older Adult Inpatients.

BACKGROUND/OBJECTIVE: Ineffective interdisciplinary communication has negative impacts on patient outcomes. The use of regular structured interdisciplinary bedside rounds (SIBR), where each patient interaction lasts 3-5 minutes, is a model of care that improves interdisciplinary communication. We evaluated the impact of SIBR on in-hospital falls. DESIGN: Prospective before-after study of older people hospitalized with acute illness. SETTING: Two side-by-side aged care wards in a university hospital in Sydney, Australia. PARTICIPANTS: A total of 3,673 consecutive inpatients of mean age 83.8 ± 7.7 years, with 1,703 before SIBR compared with 1,970 after SIBR. No patients were excluded from potential participation. INTERVENTION: Twice-weekly SIBR. MEASUREMENTS: Falls data were manually extracted from a mandatory institutional incident reporting database. Medical diagnoses were based on the Australian Refined Diagnosis Related Groups classification system. Injuries due to falls were corroborated using the institutional electronic medical record (Cerner PowerChart). Generalized estimating equations were used to evaluate the incidence rate ratio (IRR) of falls and fall-related injuries. A negative binomial distribution and a logarithmic link function were used to linearize regression equations. RESULTS: After SIBR, there were 7.4 falls per 1,000 occupied bed days (OBD), compared with 10.6 falls per 1,000 OBD before SIBR (P < .001). The implementation of SIBR reduced falls (IRR = 0.67, 95% CI = 0.52-0.85), after adjusting for age, gender, cognitive impairment, behavioral and psychological symptoms of dementia, deconditioning and frailty, but not fall-related injuries (IRR = 0.79, 95% CI = 0.52-1.20). CONCLUSION: This study is the first to investigate the effect of SIBR on in-hospital falls. It provides evidence that a sustainable, twice-weekly intervention is associated with a reduction in falls. It has the potential to be used in other settings where falls are frequent.

Structured interdisciplinary bedside rounds, in-hospital deaths, and new nursing home placements among older inpatients.

PURPOSE: Ineffective interdisciplinary communication is linked to many adverse consequences of hospitalization. This study evaluated the effect of SIBR, a model of care that encourages interdisciplinary communication and patient and family participations, on in-hospital deaths and new nursing home (NH) placements. MATERIALS AND METHODS: This before-after study included 3,673 consecutive inpatients of mean age 83.8 years, of whom 93.2% were admitted through the emergency department. After each twice-weekly SIBR session, an interdisciplinary care plan was implemented and recorded on a datasheet attached to the bedside record. Staff unable to participate in SIBR were asked to view the datasheet and to follow the care plan. Logistic regression models were computed for in-hospital deaths and new NH placements. RESULTS: Although SIBR implementation had no effect on in-hospital deaths (OR, 1.00; 95% CI, 0.77-1.29), SIBR increased NH placements among those who survived the hospitalization (n=3,346) in both unadjusted (14.6% vs 9.1%; P<0.001) and adjusted (OR, 1.75; 95% CI, 1.38-2.23) analyses. CONCLUSION: Although the mechanisms between SIBR implementation and NH placement remain uncertain, SIBR may encourage patients and families to make decisions on placement earlier than they would have otherwise. Models of care aiming to improve communication should be evaluated across diverse services and settings to determine effectiveness and to monitor for adverse findings.

Functional deterioration in the month before hospitalisation is associated with in-hospital functional decline: an observational study.

INTRODUCTION: Functional deterioration preceding acute hospital admission may be associated with poorer in-hospital outcomes. We sought to investigate the association between functional decline in the month preceding admission and in-hospital outcomes. MATERIALS AND METHODS: Consecutive patients admitted under geriatric medicine over 5 years were prospectively included. Pre-hospital decline was defined as decrease in Modified Barthel Index (MBI) between pre-morbid status (1 month prior) and admission. The primary outcome was in-hospital functional decline (decline in MBI and/or new assistance/aid to mobilise). Secondary outcomes included length-of-stay (LOS; highest quartile), in-hospital falls and death. RESULTS: Amongst 1458 patients (mean age 82.0; 60.91% female), 76.89% (1121/1458) experienced pre-hospital MBI decline. On univariate logistic regression, pre-hospital MBI decline was associated with in-hospital functional decline (OR 15.83, p < 0.001). Adjusting for age, nursing home residence, pre-morbid MBI, in-hospital referral source, dementia, adverse drug reaction and number of active diagnoses, pre-hospital decline was independently associated with in-hospital functional decline (OR 15.22, CI 10.89-21.26, p < 0.001). On univariate analysis, those with pre-hospital decline had more in-hospital falls (OR 2. 91, p = 0.02). Adjusting for age, sex, dementia, number of active diagnoses, and ambulation, no strong association was observed between pre-hospital decline and in-hospital falls (OR 1.86, p = 0.08). Prolonged LOS ≥ 20 days was more common amongst patients with pre-hospital decline on univariate (OR 1.95, p < 0.001) but not adjusted analyses (p = 0.14). No association was observed with in-hospital death. CONCLUSION: Pre-hospital functional decline was associated with poorer in-hospital functional outcomes. Exploration of early interventions to optimise function in such patients is needed.

Predictors on admission of functional decline among older patients hospitalised for acute care: A prospective observational study.

OBJECTIVE: We sought to investigate the incidence of, and factors associated with, in-hospital functional decline among older acute hospital patients. METHODS: We conducted a prospective observational study of consecutive patients admitted under geriatric medicine over 5 years. The primary outcome measure was functional decline between admission and discharge, representing deterioration in any of the following: Modified Barthel Index (MBI), independence in Timed Up and Go test or walking, and/or need for walking aid. RESULTS: Overall, 56% (950/1693) patients (mean age 81.9 years) exhibited in-hospital functional decline. Premorbid MBI (odds ratio (OR) 1.05 per unit increase, P < 0.001), adverse drug reaction (OR 1.50, P = 0.001) and in-hospital consultation as the referral source (OR 1.57, P = 0.001) were independently associated with functional decline, adjusting for age, dementia and nursing home residence. CONCLUSION: These factors may aid identification of vulnerable patients who might particularly benefit from targeted multidisciplinary intervention. Further studies validating this, and exploring the impact of focussed management, are needed.

The Impact of Being a Migrant from a Non-English-Speaking Country on Healthcare Outcomes in Frail Older Inpatients: an Australian Study.

The purpose of this prospective study of 2180 consecutive index admissions to an acute geriatric service was to compare in-hospital outcomes of frail older inpatients born in non-English-speaking counties, referred to as culturally and linguistically diverse (CALD) countries in Australia, with those born in English-speaking countries. Multivariate logistic regression was used to model in-hospital mortality and new nursing home placement. Multivariate Cox proportional hazards regression was used to model length of stay. The mean age of all patients was 83 years and 93% were admitted through the emergency department. In multivariate analyses, patients from CALD and non-CALD backgrounds were equally likely to die (CALD odds ratio [OR] 0.69, 95% confidence interval [95% CI] 0.44-1.10) and be newly placed in a nursing home (OR 0.75, 95% CI 0.51-1.12). Patients from CALD backgrounds unable to speak English were more likely to die (11.5% vs. 7.2%, p = 0.02). While patients from CALD backgrounds had significantly shorter lengths of stay in univariate analysis (median 9 days vs. 10 days, p = 0.02), this was not apparent in multivariate analysis (hazard ratio 1.02, 95% CI 0.91-1.14), where the ability to speak English proved to be a strong confounder. While most of the literature shows poorer outcomes of people from minority ethnic groups, our findings indicate that this is not necessarily the case. Developing culturally appropriate services may mitigate some of the adverse outcomes commonly associated with ethnicity. Our findings are particularly relevant to countries populated by multiple ethnic groups.

Structured interdisciplinary bedside rounds do not reduce length of hospital stay and 28-day re-admission rate among older people hospitalised with acute illness: an Australian study.

Objective Structured interdisciplinary bedside rounds (SIBR) are being implemented across many hospitals in Australia despite limited evidence of their effectiveness. This study evaluated the effect of SIBR on two interconnected outcomes, namely length of stay (LOS) and 28-day re-admission. Methods In the present before-after study of 3644 patients, twice-weekly SIBR were implemented on two aged care wards. Although weekly case conferences were shortened during SIBR, all other practices remained unchanged. Demographic, medical and frailty measures were considered in appropriate analyses. Results There was no significant difference in median (interquartile range) LOS before and during SIBR (8 (5-15) vs 8 (4-15) days respectively; P=0.51). In an adjusted analysis, SIBR had no effect on LOS (hazard ratio 0.97; 95% confidence interval 0.90-1.05). The presence of dementia or delirium, or the ability to speak English, did not modify the effect of SIBR (P>0.05 for all). Similarly, SIBR had no effect on 28-day re-admission rates (20.3% vs 19.0% before and during SIBR respectively; P=0.36). Conclusions Although ineffective interdisciplinary communication is associated with negative outcomes for patients and healthcare services, models of care that aim to improve communication are not necessarily effective in reducing LOS or early re-admission. Clinical services implementing SIBR are encouraged to independently evaluate their effects. What is known about the topic? Ineffective interdisciplinary communication may harm patients and increase LOS. Only two publications have evaluated the implementation of SIBR, a new model of care that aims to improve interdisciplinary communication and collaboration. One paper reported that SIBR reduced unadjusted LOS and in-hospital mortality, whereas the other found that SIBR improved teamwork, communication and staff efficiency. What does this paper add? The effect of SIBR among acutely unwell older people on aged care wards is unknown. The present study is the first to evaluate the effects of SIBR in this population. It shows that the implementation of SIBR did not reduce LOS or early re-admission, and suggests that existing communication strategies may have weakened the effects of SIBR. What are the implications for practitioners? Policies and practice that promote the addition of communication strategies, such as SIBR, may not be effective in all patient populations. More research is needed to determine whether SIBR reduce these and other outcomes, particularly for services with weaker communication frameworks and protocols.

Falls in hospital and new placement in a nursing home among older people hospitalized with acute illness.

PURPOSE: To examine the association between falls in hospital and new placement in a nursing home among older people hospitalized with acute illness. MATERIALS AND METHODS: This prospective cohort study of 2,945 consecutive patients discharged alive from an acute geriatric medicine service used multivariate logistic regression to model the association between one or more falls and nursing home placement (primary analysis). Secondary analyses stratified falls by injury and occurrence of multiple falls. Demographic, medical, and frailty measures were considered in adjusted models. RESULTS: The mean age of all patients was 82.8±7.6 years and 94% were admitted through the emergency department. During a median length of stay (LOS) of 11 days, 257 (8.7%) patients had a fall. Of these, 66 (25.7%) sustained an injury and 53 (20.6%) had two or more falls. Compared with nonfallers, fallers were more likely to be placed in a nursing home (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.37-3.00), after adjustment for age, sex, frailty, and selected medical variables (including dementia and delirium). Patients without injury (OR: 1.83, 95% CI: 1.17-2.85) and those with injury (OR: 2.35, 95% CI: 1.15-4.77) were also more likely to be placed. Patients who fell had a longer LOS (median 19 days vs 10 days; P<0.001). CONCLUSION: This study of older people in acute care shows that falls in the hospital are significantly associated with new placement in a nursing home. Given the predominantly negative experiences and the financial costs associated with placement in a nursing home, fall prevention should be a high priority in older people hospitalized with acute illness.

New medical diagnoses and length of stay of acutely unwell older patients: Implications for funding models.

AIM: To examine the relationship between newly made medical diagnoses and length of stay (LOS) of acutely unwell older patients. METHODS: Consecutive patients admitted under the care of four geriatricians were randomly allocated to a model development sample (n = 937) or a model validation sample (n = 855). Cox regression was used to model LOS. Variables considered for inclusion in the development model were established risk factors for LOS and univariate predictors from our dataset. Variables selected in the development sample were tested in the validation sample. RESULTS: A median of five new medical diagnoses were made during a median LOS of 10 days. New diagnoses predicted an increased LOS (hazard ratio 0.90, 95% confidence interval 0.88-0.92). Other significant predictors of increased LOS in both samples were malnutrition and frailty. CONCLUSIONS: Identification of new medical diagnoses may have implications for Diagnosis Related Groups-based funding models and may improve the care of older people.

Frailty in an older inpatient population: using the clinical frailty scale to predict patient outcomes.

OBJECTIVE: To evaluate the impact of frailty, measured using the Canadian Study of Health and Aging Clinical Frailty Scale, on outcomes of older people hospitalized with acute illness. METHOD: Consecutive patients were randomly allocated to a model development sample or a model validation sample. Multivariate analyses were used to model in-hospital mortality, new nursing home placement, and length of stay. Variables selected in the development samples were tested in the validation samples. RESULTS: The mean age of all 2,125 patients was 82.9 years. Most (93.6%) were admitted through the emergency department. Frailty predicted in-hospital mortality (odds ratio [OR] = 2.97 [2.11, 4.17]), new nursing home placement (OR = 1.60 [1.14, 2.24]), and length of hospital stay (hazard ratio = 0.87 [0.81, 0.93]). DISCUSSION: Frailty is a strong predictor of adverse outcomes in older people hospitalized with acute illness. An increased awareness of its impact may alert clinicians to screen for frailty.

Antigen unmasking induced by superheating.

This paper is dedicated to the description of superheating as a method for antigen retrieval. In our investigation, this antigen retrieval method was used on thermal plate, heating tissue sections at temperature 120° C for 90 minutes. In the research we conducted the superheating method was applied to formalin-fixed paraffin-embedded tissue sections of breast tumors. The following monoclonal antibodies were used: estrogen receptor, progesterone receptor, epithelial membrane antigen, CD34, and Ki-67. With these tested antibodies we had good staining and no loss of tissue sections during the staining process.

The validity of the Rowland Universal Dementia Assessment Scale (RUDAS) in a multicultural cohort of community-dwelling older persons with early dementia.

The 6-item Rowland Universal Dementia Assessment Scale (RUDAS) is a simple, portable multicultural scale for detecting dementia. Items address executive function, praxis, gnosis, recent memory, and category fluency. It can be directly translated to other languages, without the need to change the structure or the format of any item. The RUDAS was administered to 151 consecutive, consenting, culturally diverse community-dwelling subjects of mean age 77 years, 72% of whom had an informant. Subjects were recruited from various clinics and healthcare programs. All were evaluated for cognitive impairment in a blinded manner by experienced clinicians in geriatric medicine. According to Diagnostic and Statistical Manual of Mental Disorder-IV criteria, 40% of the subjects were normal, 22% had cognitive impairment (not otherwise specified), and 38% had dementia; 84% of whom had questionable or mild dementia. In the primary analysis (normal subjects vs. those with definite dementia), the RUDAS accurately identified dementia, with an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.88-0.97); at the published cut point of less than 23/30, the positive likelihood ratio (LR) for dementia diagnosis was 8.77, and the negative likelihood ratio was 0.14. Additional analyses showed that the RUDAS performed less well when subjects with cognitive impairment (not dementia) were included. In all logistic regression models, the RUDAS was an independent predictor of dementia (odds ratio 0.64, 95% confidence interval, 0.52-0.79, primary analysis model), after adjusting for age, sex, years of education, and cultural diversity, none of which were independent predictors. Further studies are needed across the full spectrum of early dementia syndromes, and in additional ethnic minority groups.

Admission variables predicting short lengths of stay of acutely unwell older patients: relevance to emergency and medical short-stay units.

OBJECTIVE: To help develop criteria to identify older patients suitable for admission to medical short-stay units, by determining predictors of length of stay (LOS) of 3 days or less. METHODS: The data were prospectively collected from consecutive older patients admitted from the emergency department of a university hospital to an acute geriatric medicine service. Data included active medical diagnoses, the Modified Barthel Index (MBI), the Timed Up and Go (TUG) test, and demographic information. Logistic regression was used to model the probability of LOS of 3 days or less (short LOS). RESULTS: Among 2036 patients discharged alive from hospital (mean age, 82 years; median LOS, 7 days), 398 had a short LOS (median, 2 days), while 1638 had a long LOS (median, 9 days). In logistic regression analysis, the main independent predictors of short LOS were an MBI score > 15/20 (OR, 2.98; 95% CI, 1.97-4.49), ability to perform the TUG test (OR, 2.08; 95% CI, 1.34-3.24) and absence of delirium (OR, 2.66; 95% CI, 1.56-4.54). Patients without infection, anaemia, gastrointestinal disorder and stroke were also more likely to have a short LOS in multivariate analysis (all P < 0.05). CONCLUSION: Preserved function, measured using the MBI and TUG, and the absence of delirium are strong predictors of short LOS. In conjunction with early, skilled clinical evaluation, these criteria could be used to select older patients presenting to the emergency departments for admission to short-stay units.

Using the timed up and go test to stratify elderly inpatients at risk of falls.

OBJECTIVE: To determine whether the Timed Up and Go Test is useful at stratifying acutely unwell elderly inpatients according to their risk for subsequent falls. DESIGN: Prospective cohort study. SETTING: Multidisciplinary acute care unit for the elderly at Liverpool Hospital, in Sydney, Australia. PARTICIPANTS: A total of 2388 consecutive admissions to the unit of mean age 82 years. INTERVENTION: The Timed Up and Go, administered on admission to the unit, and two modifications (an ordinal scale and a dichotomous scale, both incorporating patients unable to complete the Timed Up and Go) were evaluated. MAIN OUTCOME MEASURES: Number of falls, and reasons for the inability to complete the Timed Up and Go. RESULTS: During a median length of stay of nine days, 180 patients had at least one fall. The Timed Up and Go was unable to identify those patients who subsequently fell (P = 0.78). When the Timed Up and Go was modified to include the majority of patients unable to complete the test, both the ordinal (range of values 1-8, odds ratio (OR) 1.12, 95% confidence interval (95% CI) 1.03-1.21, P = 0.01) and dichotomous (OR 1.59, 95% CI 1.09-2.32, P = 0.02) modifications significantly predicted falls in multivariate analyses. Patients unable to do the Timed Up and Go due to non-physical disability had the highest fall rate (11%), followed by those with physical disability (9%), while those able to do the Timed Up and Go had the lowest fall rate (6%) (P< 0.001). Acutely unwell, immobile patients with dementia and delirium were not at excessive risk of falls. CONCLUSION: In the acute care setting, the value of the Timed Up and Go lies in the inability to complete the test, and the reasons for this inability, rather than the time recorded.

The Timed Up and Go Test does not predict length of stay on an acute geriatric ward.

This study aimed to determine whether the admission Timed Up and Go Test (TUG) predicted the length of stay of patients in an acute geriatric ward. Consecutive patients were quasi-randomly allocated to either a model development sample or a model validation sample. Multivariate Cox proportional hazards regression was used to model length of stay. Variables considered for inclusion in the development model were risk factors for length of stay reported in the literature and univariate predictors from our dataset (p < 0.05). Variables selected for use in the development sample were then tested in the validation sample. Of 2463 patients of mean age 82.1 years, 932 (37.8%) were able to complete the TUG. Despite a significant, though weak, relationship between the length of stay and the TUG time (Spearman coefficient 0.18, p < 0.001), no time clearly identified patients with longer length of stay. Patients unable to complete the TUG had a median length of stay of 11 days (IQR 7 to 18), 40% longer than those able to complete the TUG (median 8 days, IQR 8 to 12, p < 0.001). Other significant (p < 0.05) predictors of length of stay in both samples were number of active medical diagnoses, referral from the emergency department, in-patient fall, and diagnosis of ulcer or infection. The admission TUG time should not be used to screen for patients likely to have longer lengths of stay. The value of the TUG lies in determining the patient's ability to complete it, rather than the time taken.

The Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein MMSE in a multicultural cohort of elderly persons.

OBJECTIVE: To compare the accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein Mini-mental State Examination (MMSE) for diagnosis of dementia in a multicultural cohort of elderly persons. METHODS: A total of 129 community-dwelling persons were selected at random from a database of referrals to an aged-care team. Subjects were stratified according to language background and cognitive diagnosis, and matched for age and gender. The RUDAS and the MMSE were administered to each subject in random order. Within several days, a geriatrician assessed each subject for dementia (DSM-IV criteria) and disease severity (Clinical Dementia Rating Scale). All assessments were carried out independent and blind. The geriatrician also administered the Modified Barthel Index and the Lawton Instrumental Activities of Daily Living Scale, and screened all participants for non-cognitive disorders that might affect instrument scores. RESULTS: The area under the receiver operating characteristic curve (AUC) for the RUDAS [0.92, 95% confidence interval (95%CI) 0.85-0.96] was similar to the AUC for the MMSE (0.91, 95%CI 0.84-0.95). At the published cut-points (RUDAS < 23/30, MMSE < 25/30), the positive and negative likelihood ratios for the RUDAS were 19.4 and 0.2, and for the MMSE 2.1 and 0.14, respectively. The MMSE, but not the RUDAS, scores were influenced by preferred language (p = 0.015), total years of education (p = 0.016) and gender (p = 0.044). CONCLUSIONS: The RUDAS is at least as accurate as the MMSE, and does not appear to be influenced by language, education or gender. The high positive likelihood ratio for the RUDAS makes it particularly useful for ruling-in disease.

A prospective, randomised controlled trial of an aged care nurse intervention within the Emergency Department.

The aim of this randomised controlled trial involving 224 elderly patients was to determine whether early geriatric assessment (in the form of an aged care nurse intervention based in the emergency department) reduced admission to the hospital, length of inpatient stay (LOS), or functional decline during the hospitalisation. Baseline geriatric assessments were recorded in the medical files of intervention patients (n = 114). The nurse also liaised with the patients' carers and health care providers, organised referrals for out-of-hospital assessment and support services, and assisted in the care of those admitted as inpatients by documenting suggestions for assessment and referral. Assessment data from control patients (n = 110) were withheld, and the nurse had no further involvement in their inpatient or outpatient care. One hundred and seventy-one patients (76%) were admitted to the hospital, for a median LOS of 10 days. The nurse successfully identified those needing admission (odds ratio [OR], 14.0; 95% confidence interval [CI], 2.6-75.1). Thirty-nine of 160 inpatients with available data (24%) had a functional deterioration during the hospitalisation. The intervention had no significant effect on admission to the hospital (OR, 0.7; CI, 0.3-1.7), LOS (hazard ratio, 1.1; CI, 0.7-1.5) or functional decline during the hospitalisation (OR, 1.3; CI, 0.5-3.3).

The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale.

OBJECTIVE: To develop and validate a simple method for detecting dementia that is valid across cultures, portable and easily administered by primary health care clinicians. DESIGN: Culture and Health Advisory Groups were used in Stage 1 to develop culturally fair cognitive items. In Stage 2, clinical testing of 42 items was conducted in a multicultural sample of consecutive new referrals to the geriatric medicine outpatient clinic at Liverpool Hospital, Sydney, Australia (n = 166). In Stage 3, the predictive accuracy of items was assessed in a random sample of community-dwelling elderly persons stratified by language background and cognitive diagnosis and matched for sex and age (n = 90). MEASUREMENTS: A research psychologist administered all cognitive items, using interpreters when needed. Each patient was comprehensively assessed by one of three geriatricians, who ordered relevant investigations, and implemented a standardized assessment of cognitive domains. The geriatricians also collected demographic information, and administered other functional and cognitive measures. DSM-IV criteria were used to assign cognitive diagnoses. Item validity and weights were assessed using frequency and logistic regression analyses. Receiver-operating characteristic (ROC) curve analysis was used to determine overall predictive accuracy of the RUDAS and the best cut-point for detecting cognitive impairment. RESULTS: The 6-item RUDAS assesses multiple cognitive domains including memory, praxis, language, judgement, drawing and body orientation. It appears not to be affected by gender, years of education, differential performance factors and preferred language. The area under the ROC curve for the RUDAS was 0.94 (95% CI 0.87-0.98). At a cut-point of 23 (maximum score of 30), sensitivity and specificity were 89% and 98%, respectively. Inter-rater (0.99) and test-retest (0.98) reliabilities were very high. CONCLUSIONS: The 6-item RUDAS is portable and tests multiple cognitive domains. It is easily interpreted to other languages, and appears to be culturally fair. However, further validation is needed in other settings, and in longitudinal studies to determine its sensitivity to change in cognitive function over time.