A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study.

BACKGROUND: Older patients experience increased loss of mobility after hospitalization, largely because of physical disabilities and inactivity. There are, however, no current recommendations for prescribing physical activity (PA) at hospital discharge. OBJECTIVES: Develop a decisional tree for the systematic prescription of an individualized, adapted, nonsupervised home-based PA program for older adults after hospital discharge; investigate its feasibility, acceptability, and safety; and estimate its efficacy at improving physical function and mobility. DESIGN: Pragmatic prospective single-arm pilot study. SETTING AND PARTICIPANTS: Geriatric assessment unit (GAU). PARTICIPANTS: Age ≥65 years, Mini-Mental State Examination score ≥18, hospitalization >7 days, discharge to home, no PA contraindications, understand French or English. METHODS: Development of a decisional tree for prescription of home-based exercise programs (Preventing loss of Autonomy by Treatment Post-Hospitalization: PATH tool) through meetings with a group of experts. The PATH tool was implemented in a short-term geriatric hospital. Feasibility, acceptability, and safety outcomes were measured and potential efficacy estimated after a 12-week period. RESULTS: The decisional tree has 3 main components (cognitive, cardio strength, and balance) and comprises 27 different mobility profiles and PA programs. Fifty-six of the first 100 successively admitted GAU patients were found eligible, of whom 29 agreed to participate and 17 completed the protocol. Most were satisfied (14/17) and enjoyed (13/17) the program, and most health professionals found it relevant to patients (7/8) without extra burden (6/8) to patient care. Adherence to the PA program was 5 sessions/wk, and a medium to large effect size on walking speed (P < .01, d = 1.04), chair stand performance (P = .04, d = 0.75), and PA level (P = .07, d = 0.56) was observed after a 12-week period. CONCLUSIONS AND IMPLICATIONS: This study suggests that implementing the PATH tool might be feasible across GAUs, as well as safe and acceptable for patients and health care professionals. If this intervention proves beneficial after conducting a randomized controlled trial, this hospital-initiated care transition strategy should be implemented in short-term geriatric hospitals to prevent long-term mobility disability.

Feasibility of Implementing an Exercise Program in a Geriatric Assessment Unit: the SPRINT Program.

BACKGROUND: An exercise program involving patients, caregivers, and professionals, entitled SPecific Retraining in INTerdisciplinarity (SPRINT), has been developed to prevent functional decline during hospitalization of older patients. GOAL: Assess the feasibility of implementing SPRINT in the context of a Geriatric Assessment Unit (GAU). METHODS: GAU's health-care professionals were instructed with the SPRINT. All new patients were evaluated by a physiotherapist shortly after admission to validate the eligibility criteria and allocation category of exercises. Questionnaires on physical activities were filled out by professionals, patients, and caregivers at baseline and after intervention. Quantitative and qualitative information was collected on adherence to the program. RESULTS: SPRINT was applied to 19 of the 50 patients admitted during the three-month pilot study. A daily average of one exercise session per patient was performed, most frequently with a nurse (37%), physician (20%), care attendant (13%) or by the patient alone (22%). The caregivers participated only 4% of the time. Barriers and facilitators in applying SPRINT have been identified. CONCLUSIONS: SPRINT appears relevant and applicable within GAUs. Future studies should be conducted to assess its safety and effectiveness in preventing hospital-related functional decline.

Interprofessional meetings in geriatric assessment units: a matter of care organization.

Inpatient geriatric assessment units (GAUs) exist in Quebec, Canada, to deliver comprehensive, integrated care to older vulnerable patients. Most cases should be discussed at interprofessional meetings (IMs), but research has shown this not to be so for 39% of GAU patients. Consequently, a study was undertaken to (1) describe GAU team composition and (2) identify GAU and patient characteristics associated with case discussion at IMs at least once during a patient's stay. To this end, 877 hospitalization records from 44 GAUs were reviewed. Results showed most teams were composed of attending physicians, nurses, physical and occupational therapists, dietitians and social workers; 66% included clinical pharmacists and 43% liaison nurses. Multilevel modeling showed longer length of stay to be the strongest predictor of case discussion at an IM. Case discussion was also more likely for patients admitted via in- or inter-hospital transfer rather than via the emergency department, if the GAU included a liaison nurse, and if the GAU was not located in an urban area. In summary, case discussion at an IM depended more on how and where a patient was admitted than on the patient characteristics per se, suggesting that this is a matter of care organization.

Predictors of quality-of-care processes in geriatric assessment units: toward a better organizational framework.

OBJECTIVES: To identify the structural and patient characteristics associated with better care processes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-four Geriatric Assessment Units (GAU). PARTICIPANTS: Patients aged 65 and older who were admitted to a GAU for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, completion of advance health care directives) assessed through chart audit; 14 patient- and 23 GAU-related characteristics obtained from hospitalization records, national databases, and GAU managers. RESULTS: A total of 877 hospitalization records were included. Final models were based on multilevel modeling using stepwise variable selection. Strongest predictors of better comprehensiveness were longer hospital length of stay (LOS), higher clinical complexity (eg, higher mortality risk), and having a geriatrician as attending physician. Comprehensiveness score increased sharply up to 3 weeks LOS and then tended to plateau. Better informational continuity was associated with more comprehensive care, higher risk of mortality, acute rather than rehabilitation care, communication with community health care professionals within 48 hours after admission, and a target LOS of 3 weeks or longer. The completion of advance directives was more likely in the presence of advanced age, higher risk of mortality, cognitive impairment, discharge to another care facility, longer LOS, university-affiliated institution, and nonurban location. CONCLUSION: In GAUs, quality-of-care processes are related to both structural and patient characteristics. Our results pointed toward an organizational framework that may help to streamline the geriatric units and better use resources, notably by narrowing the admission criteria, targeting a proper LOS, improving communication with community organizations, and making systematic completion of advance directives.

Quality-of-care processes in geriatric assessment units: principles, practice, and outcomes.

OBJECTIVES: To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-nine Geriatric Assessment Units. PARTICIPANTS: Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases. RESULTS: A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55-0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82-1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74-0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59-0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes. CONCLUSION: A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.

A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model.

BACKGROUND: Elderly patients admitted to Geriatric Assessment Units (GAU) typically have complex health problems that require multi-professional care. Considering the scope of human and technological resources solicited during hospitalization, as well as the many risks and discomforts incurred by the patient, it is important to ensure the communication of pertinent information for quality follow-up care in the community setting. Conventional discharge summaries do not adequately incorporate the elements specific to an aging clientele. OBJECTIVE: To develop a discharge summary adapted to the frail elderly patient (D-SAFE) in order to communicate relevant information from hospital to community services. METHODS: The items to be included in the D-SAFE have been determined by means of a modified Delphi method through consultation with clinical experts from GAUs (11 physicians and 5 pharmacists) and the community (10 physicians and 5 pharmacists). The consensus analysis and the level of agreement among the experts were reached using a modified version of the RAND®/University of California at Los Angeles appropriateness method. RESULTS: A consensus was reached after two rounds of consultation for all the items evaluated, where none was judged "inappropriate". Among the items proposed, four were judged to be "uncertain" and were eliminated from the final D-SAFE, which was divided into two sections: the medical discharge summary (22 main items) and the discharge prescription (14 main items). CONCLUSIONS: The D-SAFE was developed as a more comprehensive tool specifically designed for GAU inpatients. Additional research to validate its acceptability and practical impact on the continuity of care is needed before it can be recommended for use on a broader scale.

Short-term geriatric assessment units: 30 years later.

BACKGROUND: The increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them. METHODS: In 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their unit's operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile. RESULTS: Overall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAU's operation. CONCLUSIONS: The GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAU's primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition.

BACKGROUND: The number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This study's objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs). METHODS: The methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002-2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis. RESULTS: Three quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability. CONCLUSION: Content validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.

Impact of alcohol intake on measures of lipid metabolism depends on context defined by gender, body mass index, cigarette smoking, and apolipoprotein E genotype.

Hyperlipidemia, smoking, and obesity are well-known risk factors for cardiovascular disease. Conversely, moderate alcohol intake is associated with lower atherosclerosis risk. However, the influence of taking alcohol on the interrelationships of these factors in a particular context has not been thoroughly investigated. In this study, we asked whether the association between plasma measures of lipid metabolism and alcohol intake is dependent on context defined by gender, age, body mass index (BMI), smoking, and apolipoprotein E (APOE) genotype. Data were obtained in a sample of 869 women and 824 men who participated in the Quebec Heart Health Survey. There was no evidence that variation among APOE genotypes influenced the association between LDL cholesterol (LDL-C) or HDL cholesterol (HDL)-C and alcohol, after adjustment for age and BMI. Further, the positive (LDL-C and BMI) and the negative (HDL-C and BMI) associations that were observed in men and women with the epsilon3/2 and epsilon3/3 genotypes were not modified by alcohol intake. However, in women with the epsilon4/3 genotype only, we found a significant influence of an alcohol by BMI interaction on the prediction of total cholesterol, LDL-C, HDL-C, apoA-I, and apoB, and this interaction was influenced by the status of smoking. Whereas the influence of an alcohol by BMI interaction on total cholesterol and LDL-C was significant in smokers, its influence on HDL-C was significant only in non-smokers. This study emphasizes the context dependency of the influence of alcohol on lipid metabolism and demonstrates how biological, environmental, and genetic factors interact to determine cardiovascular disease risk.