Mapping the evidence on dementia care pathways - A scoping review.

BACKGROUND: One way of standardizing practice and improving patient safety is by introducing clinical care pathways; however, such pathways are typically geared towards assisting clinicians and healthcare organizations with evidence-based practice. Many dementia care pathways exist with no agreed-upon version of a care pathway and with little data on experiences about their use or outcomes. The objectives of the review were: (1) to identify the dementia care pathway's purpose, methods used to deploy the pathway, and expected user types; (2) to identify the care pathway's core components, expected outcomes, and implications for persons with dementia and their care partners; and (3) determine the extent of involvement by persons with dementia and/or their care partners in developing, implementing, and evaluating the care pathways. METHODS: We systematically searched six literature databases for published literature in the English language in September 2023 utilizing Arskey and O'Malley's scoping review framework. RESULTS: The findings from the dementia care pathways (n = 13) demonstrated assistance in dementia diagnostic and management practices for clinicians and offered structured care processes in clinical settings. For this reason, these pathways emphasized assessment and interventional post-diagnostic support, with less emphasis on community-based integrated dementia care. CONCLUSION: Future dementia care pathway development can seek the involvement of persons with dementia and care partners in designing, implementing and evaluating such pathways, ensuring that outcome measures properly reflect the impact on persons with lived dementia experience and their care partners.

The association of frailty on cardiac rehabilitation goal achievement.

Introduction: Frailty is common among patients entering cardiac rehabilitation (CR). Frailty is associated with poor health outcomes; however, it is unclear if frailty influences achieving goals in CR. Methods: We report a secondary analysis of participants who were referred to an exercise and education-based CR program from 2005 to 2015. Frailty was measured by a 25-item accumulation of deficits frailty index (FI) ranging from 0 to 1; higher scores indicate higher frailty. Participants were categorized by admission frailty levels (FI scores: < 0.20, 0.20-0.29, 0.30-0.39, > 0.40). CR goals were determined with shared decision-making between CR staff and the patients. We conducted logistic regression analyses to examine the odds of goal attainment by CR completion, adjusting for age, sex, education, marital status, and referring diagnosis. Analyses were performed using baseline frailty as a categorical and continuous outcome, and frailty change as a continuous outcome in separate models. Results: Of 759 eligible participants (age: 59.5 ± 9.8, 24% female), 607 (80%) participants achieved a CR goal at graduation. CR goals were categorized into similar themes: control or lose weight (n = 381, 50%), improve physical activity behaviour and fitness (n = 228, 30%), and improve cardiovascular profile (n = 150, 20%). Compared to the most severe frailty group (FI >0.40), lower levels of frailty at baseline were associated with achieving a goal at CR completion [FI < 0.20: OR = 4.733 (95% CI: 2.197, 10.194), p < .001; FI 0.20-0.29: OR = 2.116 (1.269-3.528), p = .004]. Every 1% increase in the FI was associated with a 3.5% reduction in the odds of achieving a CR goal [OR = 0.965 (0.95, 0.979), p < .001]. Participants who reduced their frailty by a minimally clinically important difference of at least 0.03 (n = 209, 27.5%) were twice as likely to achieve their CR goal [OR = 2.111 (1.262, 3.532), p = .004] than participants who increased their frailty by at least 0.03 (n = 82, 10.8%). Every 1% improvement in the FI from baseline to follow up was associated with a 2.7% increase in the likelihood of CR goal achievement [OR = 1.027 (1.005, 1.048), p = .014]. Conclusion: Lower admission frailty was associated with a greater likelihood of achieving CR goals. Frailty improvements were associated with CR goal achievement, highlighting the influence of frailty on goal attainment.

Cardiac Rehabilitation and Frailty: A systematic review and meta-analysis.

BACKGROUND: Frailty among cardiac rehabilitation (CR) participants is associated with worse health outcomes. However, no literature synthesis has quantified the relationship between frailty and CR outcomes. PURPOSE: Examine frailty prevalence at CR admission, frailty changes during CR, and if frailty is associated with adverse outcomes following CR. METHODS: We searched CINAHL, EMBASE, and MEDLINE for studies published from 2000-2023. Eligible studies included a validated frailty measure, published in English. Two reviewers independently screened articles and abstracted data. Outcome measures included admission frailty prevalence, frailty and physical function changes, and post-CR hospitalization and mortality. RESULTS: Observational and randomized trials were meta-analyzed separately using inverse variance random-effects models. 34 peer reviewed articles (26 observational, 8 randomized trials; 19,360 participants) were included. Admission frailty prevalence was 46% [95% CI 29%, 62%] and 40% [95% CI 28%, 52%] as measured by Frailty Index and Kihon Checklist (14 studies) and Frailty Phenotype (11 studies), respectively. Frailty improved following CR participation (SMD; 0.68, 95% CI 0.37, 0.99; P<.0001; 6 studies). Observational studies meta-analysis revealed higher admission frailty increased participants' risk of all-cause mortality (Hazard ratio: 9.24, 95% CI 2.93, 29.16; P=.0001; 4 studies). Frailer participants at admission had worse physical health outcomes, but improved over the course of CR. CONCLUSIONS: High variability in frailty tools and CR designs was observed, and randomized controlled trials contributions were limited. The prevalence of frailty is high in CR and is associated with greater mortality risk; however, CR improves frailty and physical health outcomes.

Frailty levels are high in cardiac rehabilitation and elevate the risk of adverse health outcomes, however, participating in cardiac rehabilitation may improve prognosis. Key Findings: A large proportion of people in cardiac rehabilitation were frail. Frailty levels were improved by participating in cardiac rehabilitation, especially in those who were frailer at admission.Higher baseline frailty levels were associated with a greater risk of hospitalization and mortality and a reduced likelihood of completing the intervention.

Exploring the Inclusion of Person-Centered Care Domains in Stroke Transitions of Care Interventions: A Scientific Statement From the American Heart Association.

BACKGROUND: Health care teams along the stroke recovery continuum have a responsibility to support care transitions and return to the community. Ideally, individualized care will consider patient and family preferences, best available evidence, and health care professional input. Person-centered care can improve patient-practitioner interactions through shared decision-making in which health professionals and institutions are sensitive to those for whom they provide care. However, it is unclear how the concepts of person-centered care have been described in reports of stroke transitional care interventions. METHODS: A secondary analysis of a systematic review and meta-analysis was undertaken. We retrieved all included articles (n=17) and evaluated the extent to which each intervention explicitly addressed 7 domains of person-centered care: alignment of care with patients' values, preferences, and needs; coordination of care; information and education; physical comfort; emotional support; family and friend involvement; and smooth transition and continuity of care. RESULTS: Most of the articles included some aspects of person-centeredness; we found that certain domains were not addressed in the descriptions of transitional care interventions, and no articles mentioned all 7 domains of person-centered care. We identified 3 implications for practice and research: (1) delineating person-centered care components when reporting interventions, (2) elucidating social and cultural factors relevant to the study sample and intervention, and (3) clearly describing the role of family and nonmedical support in the intervention. CONCLUSIONS: There is still room for greater consistency in the reporting of person-centeredness in stroke transitions of care interventions, despite a long-standing definition and conceptualization of person-centered care in academic and clinically focused literature.

Comparing Virtual and Center-Based Cardiac Rehabilitation on Changes in Frailty.

Many patients with cardiovascular disease (CVD) are frail. Center-based cardiac rehabilitation (CR) can improve frailty; however, whether virtual CR provides similar frailty improvements has not been examined. To answer this question, we (1) compared the effect of virtual and accelerated center-based CR on frailty and (2) determined if admission frailty affected frailty change and CVD biomarkers. The virtual and accelerated center-based CR programs provided exercise and education on nutrition, medication, exercise safety, and CVD. Frailty was measured with a 65-item frailty index. The primary outcome, frailty change, was analyzed with a two-way mixed ANOVA. Simple slopes analysis determined whether admission frailty affected frailty and CVD biomarker change by CR model type. Our results showed that admission frailty was higher in center-based versus virtual participants. However, we observed no main effect of CR model on frailty change. Results also revealed that participants who were frailer at CR admission observed greater frailty improvements and reductions in triglyceride and cholesterol levels when completing virtual versus accelerated center-based CR. Even though both program models did not change frailty, higher admission frailty was associated with greater frailty reductions and change to some CVD biomarkers in virtual CR.

Contribution of individual and cumulative frailty-related health deficits on cardiac rehabilitation completion.

BACKGROUND: Despite the high burden of frailty among cardiac rehabilitation (CR) participants, it is unclear which frailty-related deficits are related to program completion. METHODS: Data from a single-centre exercise- and education-based CR program were included. A frailty index (FI) based on 25 health deficits was constructed. Logistic regression was used to estimate the odds of CR completion based on the presence of individual FI items. The odds of completion for cumulative deficits related to biomarkers, body composition, quality of life, as well as a composite of traditional and non-traditional cardiovascular risk factor domains were examined. RESULTS: A total of 3,756 individuals were included in analyses. Eight of 25 FI variables were positively associated with program completion while 8 others were negatively associated with completion. The variable with the strongest positive association was the food frequency questionnaire score (OR 1.27 (95% CI 1.14, 1.41), whereas the deficit with strongest negative association was a decline in health over the last year (OR 0.74 (95% CI 0.58, 0.93). An increased number of cardiovascular deficits were associated with an increased odds of CR completion (OR per 1 deficit increase 1.16 (95% CI 1.11, 1.22)). A higher number of traditional CR deficits were predictive of CR completion (OR 1.22 (95% CI 1.16, 1.29)), but non-traditional measures predicted non-completion (OR 0.95 (95% CI 0.92, 0.97)). CONCLUSION: A greater number of non-traditional cardiovascular deficits was associated with non-completion. These data should be used to implement intervention to patients who are most vulnerable to drop out to maximize retention.