Changes in the Severity of Frailty Among Older Adults After 12 Months of Supervised Home-Based Physical Exercise: A Randomized Clinical Trial

ObjectiveTo investigate the effects of 12 months of physiotherapist-supervised, home-based physical exercise on the severity of frailty and on the prevalence of the 5 frailty phenotype criteria, using secondary analyses.DesignRandomized clinical trial, with 1:1 allocation into 12-month home-based physical exercise, or usual care. The multicomponent exercise sessions (60 minutes) were supervised by the physiotherapist and included strength, balance, functional, and flexibility exercises twice a week at participants' homes.Setting and ParticipantsHome-dwelling older adults aged ≥65 years who were frail (meeting 3-5 criteria) or prefrail (1-2 criteria) according to frailty phenotype criteria.MethodsThe severity of frailty (nonfrail, prefrail, or frail) was assessed using frailty phenotype criteria, and the prevalence of each frailty criterion (weight loss, low physical activity, exhaustion, weakness, and slowness) were assessed at baseline and at 12 months.ResultsTwo hundred ninety-nine persons were included in the analyses, of whom 184 were prefrail and 115 were frail at baseline. Their mean age was 82.5 (SD 6.3) years, and 75% were women. There was a significant difference between the exercise and usual care groups' transitions to different frailty states from baseline to 12 months among those who at baseline were prefrail (P = .032) and frail (P = .009). At 12 months, the mean number of frailty criteria had decreased in the exercise group (?0.27, 95% CI –0.47, ?0.08) and remained unchanged in the usual care group (0.01, 95% CI –0.16, 0.18; P = .042). The prevalence of the exhaustion (P = .009) and the low physical activity (P < .001) criteria were lower at 12 months in the exercise group than in the usual care group.Conclusions and ImplicationsThe severity of frailty can be reduced through 12-month supervised home-based exercise training. Exercise should be included in the care of older adults with signs of frailty.     

Effect of a Simple Exercise Program on Hospitalization-Associated Disability in Older Patients: A Randomized Controlled Trial

ObjectiveHospitalization-associated disability [HAD, ie, the loss of ability to perform ≥1 basic activities of daily living (ADLs) independently at discharge] is a frequent condition among older patients. The present study assessed whether a simple inpatient exercise program decreases HAD incidence in acutely hospitalized very old patients.DesignIn this randomized controlled trial (Activity in Geriatric Acute Care) participants were assigned to a control or intervention group and were assessed at baseline, admission, discharge, and 3 months thereafter.Setting and ParticipantsIn total, 268 patients (mean age 88 years, range 75–102) admitted to an acute care for older patients unit of a public hospital were randomized to a control (n = 125) or intervention (exercise) group (n = 143).MethodsBoth groups received usual care, and patients in the intervention group also performed simple supervised exercises (walking and rising from a chair, for a total duration of ∼20 minutes/day). We measured ADL function (Katz index) and incident HAD at discharge and after 3 months (primary outcome) and Short Physical Performance Battery, ambulatory capacity, number of falls, rehospitalization, and death during a 3-month follow-up (secondary outcomes).ResultsMedian duration of hospitalization was 7 days (interquartile range 4 days). The intervention group had a lower risk of HAD with reference to both baseline [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17–0.76, P = .007] and admission (OR 0.29; 95% CI 0.10–0.89, P = .030). A trend toward an improved ADL function at discharge vs admission was found in the intervention group compared with controls (OR 0.32; 95% CI ‒0.04 to 0.68; P = .083). No between-group differences were noted for the other endpoints (all P > .05).Conclusion and ImplicationsA simple inpatient exercise program decreases risk of HAD in acutely hospitalized, very old patients.     

Three Nurse-administered Protocols Reduce Nutritional Decline and Frailty in Older Gastrointestinal Surgery Patients: A Cluster Randomized Trial

ObjectiveTo evaluate the effects of the modified Hospital Elder Life Program (mHELP) comprising 3 nurse-administered protocols in older patients undergoing gastrointestinal (GI) surgery.DesignCluster randomized trial.SettingTwo 36-bed GI wards at a university-affiliated medical center in Taiwan.ParticipantsOlder patients (≥65 years, N = 377) were recruited if they were scheduled for elective GI surgery with an expected length of hospital stay >6 days. After transferring to the GI ward after surgery, participants were randomly assigned to the mHELP or control group (1:1) by room rather than individually because most patient units are double- or triple-occupancy rooms.InterventionThe mHELP protocols (early mobilization, oral and nutritional assistance, and orienting communication) were administered daily with usual care by a trained nurse until hospital discharge. The control group received usual care only.MeasuresOutcomes were in-hospital nutritional decline, measured by body weight and Mini-Nutritional Assessment (MNA) scores, and Fried's frailty phenotype. Return of GI motility was examined as a potential mechanism contributing to observed outcomes.ResultsParticipants (mean age = 74.5 years; 56.8% male) primarily underwent colorectal (56.5%), gastric (21.2%), and pancreatobiliary (13.8%) surgery. Participants who received the mHELP [for a median of 7 days (interquartile range = 6–10 days)] had significantly lower in-hospital weight loss and decline in MNA scores (weight −2.1 vs −4.0 lb, P = .002; score −3.2 vs −4.0, P = .03) than the control group. The mHELP group also had significantly lower rates of incident frailty during hospitalization (12.0% vs 21.7%, P = .022), and persistent frailty (50.0% vs 92.9%, P = .03). Participants in the mHELP group had trends toward an accelerated return of GI motility.Conclusion and ImplicationsThe mHELP effectively reduced nutritional decline, prevented new frailty, and promoted recovery of frailty present before admission. These nurse-administered protocols might be useful in other settings, including conditions managed at home or in nursing facilities.     

A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities

ObjectivePatients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.DesignCluster-randomized controlled trial.ParticipantsThe trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).MethodsThe HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.ResultsMean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.Conclusions and ImplicationsThe composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.     

Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions

ObjectivesThe EDIFY program was developed to deliver early geriatric specialist interventions at the emergency department (ED) to reduce the number of acute admissions by identifying patients for safe discharge or transfer to low-acuity care settings. We evaluated the effectiveness of EDIFY in reducing potentially avoidable acute admissions.DesignA quasi-experimental study.SettingED of a 1700-bed tertiary hospital.ParticipantsED patients aged ≥85 years.MeasurementsWe compared EDIFY interventions versus standard care. Patients with plans for acute admission were screened and recruited. Data on demographics, premorbid function, frailty status, comorbidities, and acute illness severity were gathered. We examined the primary outcome of “successful acute admission avoidance” among the intervention group, which was defined as no ED attendance within 72 hours of discharge from ED, no transfer to an acute ward from subacute-care units (SCU) within 72-hours, or no transfer to an acute ward from the short-stay unit (SSU). Secondary outcomes were rehospitalization, ED re-attendance, institutionalization, functional decline, mortality, and frailty transitions at 1, 3, and 6 months.ResultsWe recruited 100 participants (mean age 90.0 ± 4.1 years, 66.0% women). There were no differences in baseline characteristics between intervention (n = 43) and nonintervention (n = 57) groups. Thirty-five (81.4%) participants in the intervention group successfully avoided an acute admission (20.9% home, 23.3% SCU, and 44.2% SSU). All participants in the nonintervention group were hospitalized. There were no differences in rehospitalization, ED re-attendance, institutionalization and mortality over the study period. Additionally, we observed a higher rate of progression to a poorer frailty category at all time points among the nonintervention group (1, 3, and 6 months: all P < .05).Conclusions and ImplicationsResults from our single-center study suggest that early geriatric specialist interventions at the ED can reduce potentially avoidable acute admissions without escalating the risk of rehospitalization, ED re-attendance, or mortality, and with possible benefit in attenuating frailty progression.     

Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure

ObjectiveSkilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP).DesignThis is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate.Setting and ParticipantsPatients with a primary hospital discharge diagnosis of HF discharged to SNF.MethodsComposite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level.ResultsOf 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11).Conclusions and ImplicationsPatients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.     

Prolonged Mechanical Ventilation: A Comparison of Patients Treated at Home Compared With Hospital Long-Term Care

ObjectiveTo compare the characteristics of patients treated with invasive prolonged mechanical ventilation (PMV) at home or in hospital long-term care (HLTC), specifically focusing on medical and functional status, caregiver strain, 6-month outcomes, and health maintenance organization (HMO) costs.DesignObservational study.SettingA single HLTC and home hospital, serving a defined catchment area in the greater Jerusalem area, Israel.ParticipantsA total of 120 PMV patients aged ≥18 years, all insurees of the same HMO. All PMV patients in the local HMO were approached, of whom 46 of 47 home PMV and 74/76 HLTC patients were enrolled.MeasurementsMedical and sociodemographic factors, Barthel Index, Short Geriatric Depression Score, modified Caregiver Strain Index; 6-month follow-up for hospitalization, infections, pressure sores, and mortality; HMO costs.ResultsHome PMV was associated with younger age, improved functional status, financial difficulty, less comorbidity, and longer duration of PMV. Primary reasons for home PMV were degenerative neuromuscular disease and chronic lung disease, compared with acute illnesses with or without resuscitation among HLTC patients. Most home patients were alert and able to communicate (n = 40/46) versus HLTC (n = 22/74), and reported less depression. Caregiver strain was similar for home and HLTC. Among HLTC versus home patients, 6-month mortality (27% vs 7%, P = .012) and frequency of pressure sores (45% vs. 29%, P = .042) were higher in HLTC, with no differences for infection rates or hospitalization. In multivariate analyses, being treated at home with PMV was significantly associated with being able to communicate, lower age, financial difficulties, and improved functional status. HMO costs were one-third for home PMV versus HLTC.Conclusions and ImplicationsDiffering profiles were described for home and HLTC PMV patients, with lower rates of depression, pressure sores, mortality, and one-third the cost to HMO at home. Caregiver strain was similar irrespective of site of care. With appropriate targeting for eligible patients, home PMV is a viable and financially beneficial option.     

Validating the Centre of Excellence on Longevity Self-AdMinistered (CESAM) Questionnaire: An Online Self-Reported Tool for Frailty Assessment of Older Adults

ObjectivesSubjective health measures are often used to assess frailty, but the validity of self-reported online tools to identify frailty remains to be established. We aimed to assess concurrent, known-groups, convergent and predictive validity of the Centre of Excellence on Longevity Self-AdMinistered (CESAM) questionnaire for frailty assessment of older adults in an outpatient setting.DesignCross-sectional analysis of 120 participants.Setting and ParticipantsParticipants of age ≥65 were recruited from an outpatient geriatric clinic. Individuals who had severe neurological, cognitive, or motor deficits were excluded.MethodsWe assessed concurrent validity with area under receiver operating characteristic curve (AUC) against the Frailty Index (FI) and Clinical Frailty Scale (CFS). We analyzed known-groups validity between CESAM scores with frailty status (CFS and FI), Modified Barthel Index (MBI), and modified Chinese Mini-Mental State Examination (mCMMSE) using 1-way analysis of variance. We evaluated convergent validity using correlations with MBI, the Lawton index, mCMMSE, and Geriatric Depression Scale (GDS). Associations between CESAM-identified frailty for clinician-diagnosed geriatric syndromes, and health-related quality of life (HRQoL) was analyzed using regression analysis.ResultsThe CESAM questionnaire demonstrated excellent diagnostic performance for frailty using FI ≥0.25 (AUC = 0.88; 95% CI: 0.82–0.94; P < .001) and CFS ≥4 (AUC = 0.78; 95% CI: 0.68–0.88; P < .001). CESAM scores increased significantly with increasing frailty (both CFS and FI), lower MBI, and lower mCMMSE scores (all P < .001), indicating concurrent validity. The moderate-good correlation of CESAM scores with MBI (r = ?0.61; P < 0.001), Lawton Index (r = ?0.54; P < .001), mCMMSE (r = ?0.53; P < .001) and GDS (r = 0.58; P < .001) supports convergent validity. Using a cutoff of ≥8 for frailty identification, CESAM-identified frailty was associated with cognitive impairment (OR = 3.7; 95% CI: 1.7–8.2; P = .001) depression (OR = 4.0; 95% CI: 1.7–9.6; P = .002), falls (OR = 3.1; 95% CI: 1.2–8.2; P = .021) and poorer HRQoL (β = ?0.1; 95% CI: ?0.2 to ?0.02; P = .017).Conclusion and ImplicationsOur results support the validity of an online self-reported tool to identify frailty and geriatric syndromes in an outpatient setting, an approach that is potentially applicable for remote screening of frailty.     

Outcomes of a Nursing Home-to-Community Care Transition Program

ObjectivesMost transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes.DesignPropensity-matched control-intervention trial.InterventionPatients in the intervention group received care management following nursing stay (a home visit and nursing phone calls).Setting and ParticipantsPatients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF.MethodsProgram enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use.ResultsEach group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001).Conclusions and ImplicationsWe found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.     

Physical Functioning in Older Persons With Somatoform Disorders: A Pilot Study

ObjectivesThe primary objective of this study was to systematically examine the physical functioning of older persons with somatoform disorders, as this has never been carried out before. Second, we wanted to test our hypothesis that higher somatic disease burden in patients with somatoform disorders is associated with a higher level of somatisation.Design and SettingObservational study of patients referred for medically unexplained symptoms (MUS) to our outpatient mental health center for older adults. The patients were offered a standardized, multidisciplinary diagnostic procedure, including a comprehensive geriatric assessment. Inter-rater reliability between two geriatricians assessing the contribution of somatic pathology to the main somatic symptom was assessed.ParticipantsA total of 37 patients referred for MUS (mean age 75 ± 6 years).MeasurementsTimed up and go test (TUG) and hand grip strength were used as measures for frailty; the Cumulative Index Rating Scale for Geriatrics (CIRS-G) sum score and severity index measured the burden of cumulative somatic morbidity. The Groningen Activity Rating Scale (GARS) measured functional status. The Whitely Index was used as measure for somatisation.ResultsPatients’ main symptom could be completely explained by a somatic disease in 3/37 (8%) patients (kappa between geriatricians = 0.72). A total of 32 patients met the criterion for a Somatoform Disorder according to DSM-IV-TR criteria, but somatic comorbidity partially explained the main symptom in 15/32 patients. These patients were older (P = .049), had more somatic comorbidity (P = .049), a slower gait speed (TUG, P = .035), a lower hand grip strength (P = .050), and a lower functional status (P = .30) compared with the 17 patients without any explanation for their main somatic symptom. In contrast to our hypothesis, a higher level of somatisation was associated with less somatic disease burden.ConclusionGeriatric assessment has an important added value in older patients referred with medically unexplained symptoms because in half of these patients, symptoms can be partially or fully explicable following careful assessment of comorbidity and frailty.     

Factors Associated With 30-Day Rehospitalization and Mortality in Older Patients After a Pneumonia Admission

ObjectivesShort-term rehospitalization and mortality are common events in older patients after a pneumonia admission, yet little knowledge exists on how to identify the patients at risk of these events. This knowledge is needed to ensure that health care attention is given to those with the highest needs. We therefore aimed to identify factors of importance for short-term rehospitalization and mortality in older patients after admission for pneumonia.DesignPopulation-based cohort study.SettingThe Danish nationwide registries.ParticipantsIn total, 246,245 individuals aged 65-99 years who experienced 298,564 admissions for pneumonia from 2000 to 2016.MethodsThe explored factors in patients were demographic characteristics, health-seeking behavior, comorbidity, and medication use. A Cox proportional hazards model was used to calculate hazard ratios (HRs) for 30-day rehospitalization and 30-day mortality with 95% confidence intervals (CIs).ResultsOf the 298,564 admissions for pneumonia, 23.0% were rehospitalized and 8.1% died within 30 days of follow-up. Most of the investigated factors were significantly associated with these 2 outcomes. The HRs for rehospitalization ranged from 0.80 (95% CI 0.75-0.85) for old vs young age to 4.29 (95% CI 4.05-4.54) for many vs no prior admissions, whereas the HRs for mortality ranged from 0.87 (95% CI 0.83-0.91) for any vs no practical home care to 5.47 (95% CI 5.08-5.88) for old vs young age. Number of comorbidities, medications, and prior contacts to the health care system were associated with higher risk of both rehospitalization and mortality in a dose-response manner.Conclusions and ImplicationsThis study identified several potential factors of importance for short-term rehospitalization and mortality in older patients discharged after pneumonia. This knowledge can help physicians identify the patients with the highest need of care after admission for pneumonia, thus enabling efficient discharge planning and high-quality provision of care in primary care settings.     

Utility of the Fatigue,Resistance, Ambulation,Illness, and Loss of weight Scale in Older Patients with Cardiovascular Disease

ObjectivesTo compare the Fried criteria for frailty diagnosis with the Frailty Screening Index (FSI) and the fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale in older patients with cardiovascular disease (CVD).DesignWe conducted a retrospective 1-year follow-up cohort study of adult inpatients who participated in a cardiac rehabilitation program between June 2016 and September 2018.Setting and ParticipantsWe included 1472 Japanese patients age 65 years and older with CVD. After excluding 765 patients with incomplete frailty measurements, 707 patients were included in the analysis.MethodsFrailty and physical function were measured before hospital discharge according to each of the 3 definitions. Outcomes were all-cause mortality and physical dysfunction.ResultsThe prevalence of frailty according to the Fried criteria, the FRAIL scale, and the FSI was 213 (30.1%), 181 (25.6%), and 186 (26.3%), respectively. The FSI and the FRAIL scale showed moderate agreement with the Fried criteria [vs FSI: K = 0.52, 95% confidence interval (CI): 0.45–0.59; vs FRAIL scale: K = 0.45, 95% CI: 0.37–0.52; all P < .001]. We found a significant correlation between all-cause mortality and frailty assessed by all of the definitions, even after multivariate adjustment [FSI: hazard ratio (HR): 2.43, 95% CI: 1.30–4.58, P = .006; FRAIL scale: HR: 2.32, 95% CI: 1.21–4.45, P = .011; Fried criteria: HR: 1.99, 95% CI: 1.04–3.82, P = .038). However, the prediction accuracy of the FRAIL scale was higher than that of the FSI and comparable to that of the Fried criteria for physical dysfunction.Conclusions and ImplicationsThe FSI and the FRAIL scale showed moderate agreement with the Fried criteria regarding frailty diagnostic performance and had comparable prognostic value. However, only the FRAIL scale was as accurate as the Fried criteria in screening for physical dysfunction.     

Recovery from Coronavirus Disease 2019 among Older Adults in Post-Acute Skilled Nursing Facilities

ObjectivesTo examine functional outcomes of post-acute care for coronavirus disease 2019 (COVID-19) in skilled nursing facilities (SNFs).DesignRetrospective cohort.Setting and ParticipantsSeventy-three community-dwelling adults ≥65 years of age admitted for post-acute care from 2 SNFs from March 15, 2020, to May 30, 2020.Measure(s)COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index (FI), categorized into nonfrail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT).ResultsAmong 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean [standard deviation (SD)] age was 83.5 (8.8) and 42 (57.5%) were female, with mean FI of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among patients who tested positive for COVID-19. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge [92.0 (6.7) not frail, 81.0 (15.4) mild frailty, 48.6 (20.4) moderate-to-severe frailty; P = .002], lower PT scores on discharge [54.2 (3.9) nonfrail, 51.5 (8.0) mild frailty, 37.1 (9.7) moderate-to-severe frailty; P = .002], and lower OT score on discharge [52.9 (3.2) nonfrail, 45.8 (9.4) mild frailty, 32.4 (7.4) moderate or worse frailty; P = .001].Conclusions and ImplicationsOlder adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge.     

Discharge Coordinator Intervention Prevents Hospitalizations in Patients With COPD: A Randomized Controlled Trial

ObjectivesTo test whether coordination of discharge from hospital reduces hospitalizations in patients with chronic obstructive pulmonary disease (COPD).DesignRandomized controlled clinical trial.SettingSpecialized pulmonary hospital.ParticipantsPatients hospitalized for an acute exacerbation of COPD.InterventionCare as usual included routine patient education, supervised inhaler use, respiratory physiotherapy, and disease-related communication. The discharge coordinator intervention added assessment of patient situation and homecare needs. Patients and caregivers were actively involved and empowered in the discharge planning process, which was communicated with community medical professionals to provide continuity of care at home.MeasurementsThe primary end-point of the study was the number of patients hospitalized because of worsening COPD. Key secondary end-points were time-to-COPD hospitalization, all-cause mortality, all-cause hospitalization, days alive and out of hospital, and health-related quality of life.ResultsOf 253 eligible patients (71 ± 9 years, 72% men, 87% GOLD III/IV), 118 were assigned to intervention and 135 to usual care. During a follow-up of 180 days, fewer patients receiving intervention were hospitalized for COPD (14% versus 31%, P = .002) or for any cause (31% versus 44%, P = .033). In time-to-event analysis, intervention was associated with lower rates of COPD hospitalizations (P = .001). A Cox model of proportional hazards, adjusted for sex, age, GOLD stage, heart failure, malignant disease, and long-term oxygen treatment, demonstrated that intervention reduced the risk of COPD hospitalization (hazard ratio 0.43, 95% confidence interval 0.24–0.77, P = .002).ConclusionAmong patients hospitalized for acute COPD exacerbation, discharge coordinator intervention reduced both COPD hospitalizations and all-cause hospitalizations.     

Inverse Dose-Response Relationship Between Home Health Care Services and Rehospitalization in Older Adults

Objectives(1) To examine the impact of specific services [skilled nursing (SN), physical therapy (PT), occupational therapy (OT), and home health aide (HA)] in Medicare-certified home health care (HHC) on subsequent rehospitalization among older patients during a 60-day HHC episode and (2) to test the moderating effect of functional limitation on these services.DesignSecondary analysis of data from the Outcome and Assessment Information Set (OASIS) and HHC administrative records of a statewide not-for-profit HHC agency from January 1, 2016, to December 31, 2016.Setting and ParticipantsParticipants were ≥65 years old and were admitted to HHC within 48 hours of hospital discharge.MeasuresOutcome was time to rehospitalization during the 60-day HHC episode (ie, number of days). Independent variables were visit intensity (number of visits/week) of SN, PT, OT, and HA, respectively. Functional limitation was measured by a composite score generated from 9 OASIS items on physical function. Multivariate Cox Proportional hazard analyses were conducted. Subgroup analysis (high vs low functional limitation) was conducted to examine the moderating effect of functional limitation on specific HHC services. Ad hoc analysis was conducted to examine potential interaction between specific HHC services that were significantly related to rehospitalization.ResultsThe sample included 1377 participants, among whom 11.5% were rehospitalized during the 60-day HHC episode. At the threshold dose of 1 PT or 2 SN visits/week, higher visit intensity significantly reduced the hazard of rehospitalization in these patients by up to 82% for PT (2.30 visits/week; hazard ratio [HR] = 0.18, P value < .001) and 48% for SN visits (2.51 visits/week; HR = 0.52, P value < .05). The effect of PT on reducing the risk of rehospitalization was more pronounced in patients with low versus high functional limitation (2.30 visits/week, HR = 0.08 vs 0.24, both P < .001). SN was only effective in reducing the hazard of rehospitalization in the low functional limitation group (1.70 visits/week, HR = 0.41, P < .05; 2.51 visits/week, HR = 0.29, P < .05), but not in the high functional limitation group (P > .05 at all intensity levels). Visit intensity of HA or OT was not significantly related to rehospitalization.Conclusions/RelevanceAt a threshold of 1 PT visit or 2 SN visits/week, HHC lowered the risk of rehospitalization in older patients by up to 82% and 48%, respectively. Both PT and SN were more effective in avoiding rehospitalization in patients with low functional limitation than in those with high functional limitation. Older patients should receive enough HHC services (especially PT and SN) to avoid rehospitalizations with consideration of their functional limitation.     

Measurement of Dynamical Resilience Indicators Improves the Prediction of Recovery Following Hospitalization in Older Adults

ObjectivesAcute illnesses and subsequent hospital admissions present large health stressors to older adults, after which their recovery is variable. The concept of physical resilience offers opportunities to develop dynamical tools to predict an individual's recovery potential. This study aimed to investigate if dynamical resilience indicators based on repeated physical and mental measurements in acutely hospitalized geriatric patients have added value over single baseline measurements in predicting favorable recovery.DesignIntensive longitudinal study.Setting and Participants121 patients (aged 84.3 ± 6.2 years, 60% female) admitted to the geriatric ward for acute illness.MeasurementsIn addition to preadmission characteristics (frailty, multimorbidity), in-hospital heart rate and physical activity were continuously monitored with a wearable sensor. Momentary well-being (life satisfaction, anxiety, discomfort) was measured by experience sampling 4 times per day. The added value of dynamical indicators of resilience was investigated for predicting recovery at hospital discharge and 3 months later.Results31% of participants satisfied the criteria of good recovery at hospital discharge and 50% after 3 months. A combination of a frailty index, multimorbidity, Clinical Frailty Scale, and or gait speed predicted good recovery reasonably well on the short term [area under the receiver operating characteristic curve (AUC) = 0.79], but only moderately after 3 months (AUC = 0.70). On addition of dynamical resilience indicators, the AUC for predicting good 3-month recovery increased to 0.79 (P = .03). Variability in life satisfaction and anxiety during the hospital stay were independent predictors of good 3-month recovery [odds ratio (OR) = 0.24, P = .01, and OR = 0.54, P = .04, respectively].Conclusions and ImplicationsThese results highlight that measurements capturing the dynamic functioning of multiple physiological systems have added value in assessing physical resilience in clinical practice, especially those monitoring mental responses. Improved monitoring and prediction of physical resilience could help target intensive treatment options and subsequent geriatric rehabilitation to patients who will most likely benefit from them.     

Impact of Preoperative Social Frailty on Overall Survival and Cancer-Specific Survival among Older Patients with Gastrointestinal Cancer

ObjectivesFrailty is a multidimensional syndrome. However, typical frailty scales used in oncology clinics assess physical impairment and/or malnutrition but do not consider the social domain. Our study aimed to clarify the relationship between preoperative social frailty and overall survival (OS) and cancer-specific survival (CSS) among older patients with gastrointestinal cancer.DesignThis was a prospective cohort study.Setting and ParticipantsThis single-center study recruited 195 patients with gastrointestinal cancer scheduled for curative surgery and aged >60 years.MethodsThe outcomes considered were the OS and CSS of surgery. Primary associated factors included frailty defined as a Geriatric 8 score ≤14; social frailty defined as 2 or more of the following—going out less frequently, rarely visiting friends, feeling unhelpful to friends or family, living alone, and not talking with someone daily, and combinations therein [no frailty without social frailty (−/−), frailty without social frailty (+/−), no frailty with social frailty (−/+), and frailty with social frailty (+/+)]. We used the Cox proportional hazards model and the Fine and Gray proportional subdistribution hazard model adjusting for confounding factors.ResultsOf the 195 patients, 181 (mean age, 72.0 years) were included for analysis. The median follow-up time was 994 days. Social frailty (hazard ratio 3.10) and their combinations [6.35; frailty with social frailty (+/+) vs no frailty without social frailty (−/−)] were significant predictors of OS. Social frailty (subdistribution hazard ratio 3.23) and their combinations (7.57) were significant predictors of CSS.Conclusions and ImplicationsPreoperative social frailty is a predictor of OS and CSS in older patients with gastrointestinal cancer. Screening for social frailty, frailty, and their combinations in older patients with cancer is important.     

Interprofessional Medication Assessment has Effects on the Quality of Medication Among Home Care Patients: Randomized Controlled Intervention Study

ObjectiveMultimorbidity and complex medications increase the risk of medication-related problems, especially in vulnerable home care patients. The objective of this study was to examine whether interprofessional medication assessment has an effect on medication quality among home care patients.DesignThe FIMA (Finnish Interprofessional Medication Assessment) study was a randomized, controlled study comparing physician-led interprofessional medication assessment and usual care.Setting and ParticipantsThe FIMA study was conducted in home care settings in Finland. The participants were ≥65-year-old home care patients with ≥6 drugs daily, dizziness, orthostatic hypotension, or a recent fall.MethodsPrimary outcome measures over the 6-month follow-up were number of drugs, drug-drug-interactions, medication-related risk loads, and use of potentially inappropriate medications (PIMs) examined by SFINX, RENBASE, PHARAO, and Meds75+ databases. The databases classified information as follows: A (no known pharmacologic or clinical basis for an increased risk), B (evidence not available/uncertain), C (moderately increased risk which may have clinical relevance), and D (high risk, best to avoid). Logistic regression adjusted for age, sex, and the baseline level of the outcome measure served as statistical methods.ResultsThe mean number of all drugs for home care patients (n = 512) was 15. The odds of drug-induced impairment of renal function (RENBASE D, P = .020) and medication-related risk loads for bleeding (PHARAO D, P = .001), anticholinergic effects (PHARAO D, P = .009), and constipation (PHARAO D, P = .003) decreased significantly in the intervention group compared with usual care. The intervention also reduced the odds of using PIMs (Meds75+ D, P = .005). There were no significant changes in drug-drug-interactions or number of drugs.Conclusions and ImplicationsFIMA intervention improved the medication quality of home care patients. Risks for renal failure, anticholinergic effects, bleeding, constipation, and the use of PIMs were reduced significantly.     

Predicting Mortality Risk in Older Hospitalized Persons With COVID-19: A Comparison of the COVID-19 Mortality Risk Score with Frailty and Disability

ObjectivesTo assess the association of pre-morbid functional status [Barthel Index (BI)] and frailty [modified Frailty Index (mFI)] with in-hospital mortality and a risk scoring system developed for COVID-19 in patients ≥75 years diagnosed with COVID-19.DesignRetrospective bicentric observational study.Setting and ParticipantsData on consecutive patients aged ≥75 years admitted with COVID-19 at 2 Italian tertiary care centers were collected from February 22 to May 30, 2020.MethodsOverall, 221 consecutive patients with COVID-19 aged ≥75 years were admitted to 2 hospitals in the study period and were included in the analysis. Clinical, functional (BI), frailty (mFI), laboratory, and imaging data were collected. Mortality risk on admission was assessed with the COVID-19 Mortality Risk Score (COVID-19 MRS), a dedicated score developed for hospital triage.ResultsNinety-seven (43.9%) patients died. BI, frailty, age, dementia, respiratory rate, Pao₂/Fio₂ ratio, creatinine, and platelet count were associated with mortality. Analysis of the area under the receiver operating characteristic (AUC) indicated that the predictivity of age was modest and the combination of BI, mFI, and COVID-19 MRS yielded the highest prediction accuracy (AUC_{COVID-19MRS+BI+mFI} vs AUC_Age: 0.87 vs 0.59; difference: +0.28, lower bound–upper bound: 0.17-0.34, P < .001).Conclusions and ImplicationsPremorbid BI and mFI are associated with mortality and improved the accuracy of the COVID-19 MRS. Functional status may prove useful to guide clinical management of older individuals.     

Effectiveness of Comanagement Model: Geriatric Medicine and Vascular Surgery

ObjectivesOlder surgical patients frequently develop postoperative complications due to their frailty and multiple comorbidities. Geriatric medicine consultation helps to optimize risk factors and improve outcomes in patients with hip fracture. This study aimed to evaluate patient outcomes before and after comanagement model implementation between geriatric medicine (Geriatric Surgical Service) and vascular surgery services.DesignThis was a case-control study involving emergency vascular surgical patients who were comanaged by vascular surgery, geriatric medicine, and geriatric nursing services.Settings and ParticipantsThis study was conducted in a tertiary hospital in Singapore from 2015 to 2018 with acute vascular surgical patients aged older than 65 years.MethodsA retrospective cohort of 135 patients from 2013 to 2014 (control group) who fulfilled the criteria for the comanagement model was compared with a prospective cohort of 348 patients who were comanaged by a geriatric surgical service from 2015 to 2018, and a further subgroup analysis of patients between 2015 and 2016 (n = 150) (early intervention group) and between 2017 and 2018 (n = 198) (late intervention group) was performed.ResultsComanaged patients had a significantly shorter length of hospital stay (11.6 vs 20.8 days, P = .001), reduced nosocomial infections (3% vs 12% for urinary tract infection, P = .003) and decreased 30-day readmission rates (22% vs 34%, P = .011). A trend of a decreased incidence of fluid overload was noted in patients comanaged with the geriatric surgical service (3% vs 7%, P = .073). Subgroup analysis showed progressive reductions in the length of stay (15.4 vs 11.6 days, P = .001), 30-day readmission rate (35% vs 22%, P = .01), and nosocomial urinary tract infection (8% vs 3%, P = .003) between the early intervention group and the late intervention group. Although they were not statistically significant, reductions were also observed in the delirium rate (13% vs 11%) and other postoperative medical complications in the early intervention group and the late intervention group.Conclusion and ImplicationsDespite having increasing comorbidities, older vascular surgical inpatients had a significantly shorter length of stay, reduced nosocomial infections, and decreased 30-day readmission rates through a comanagement model with vascular surgery and geriatric medicine services. Improvements in outcomes were observed over time as the model of care evolved. Geriatric medicine intervention in the perioperative period improves the outcomes of older acute vascular surgical patients.