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1.

Background

Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.

Objective

To identify whether early post–SNF discharge care reduces likelihood of 30-day hospital readmissions.

Design

Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.

Participants/setting

Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).

Measurements

The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.

Results

Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).

Conclusion

For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention.  相似文献   

2.

Objectives

Use of exercise technologies has benefits for community-dwelling older adults in terms of improved gait and balance. But research on the feasibility of use of exercise technologies in various geriatric health care settings is lacking. Hence, the current study examined the feasibility of implementing an exercise technology intended to augment rehabilitation in patients receiving post-acute care (PAC) in a skilled nursing facility (SNF). We focused on 3 indicators of feasibility: extent of usage (including predictors of more intense use), patients' acceptability of the technology, and limited efficacy.

Design

Cross-sectional study with data from patients' electronic medical records (EMR), exercise technology portal, and patient interviews.

Setting

SNF.

Participants

A sample of post-acute patients (n = 237).

Measurements

Sociodemographic and health-related variables, time spent using the technology, and 8 items of the Physical Activity Enjoyment Scale (PACES).

Results

Average time spent using the technology varied greatly (range, 1–460 minutes). A regression analysis showed that patients who had a longer length of stay (β = .01, P < .05) and were younger (β = ?0.01, P < .05) spent significantly more time using the technology. Acceptability of technology was high among patients. Finally, patients who used the technology had lower 30-day rehospitalization rates.

Conclusion

Exercise technology is feasible to use in supporting rehabilitation in patients receiving PAC in a SNF and seems to have beneficial effects.  相似文献   

3.

Objectives

To validate the ability of the total Kihon checklist (t-KCL) score to predict the incidence of dependency or death within 3 years in a community-dwelling older population.

Design

Population-based longitudinal observational study.

Setting

Town of Higashi-ura, Japan.

Participants

A total of 5542 independent seniors who were residents in the town of Higashi-ura.

Measurements

The KCL questionnaire was sent to independent older residents. Based on our previous report, those with a t-KCL score of 0-3 were classified as robust, 4-7 as pre-frail, and 8 + as frail. The incidence of dependency or death was observed over 3 years. Dependency was defined as a new certification for long-term care insurance (LTCI) service need. Information regarding LTCI certification or death was obtained from the municipal government.

Results

Of 8091 independent older adults, 5542 seniors completed the KCL questionnaire. Based on the t-KCL score, they were classified into 3 groups: 2962 (53.4%) as robust, 1625 (29.3%) as pre-frail, and 955 (17.2%) as frail. Over the 3 years, 510 seniors (9.2%) had new LTCI certifications and 170 (3.1%) died. Cox regression analysis adjusted for age and sex showed that the classification of frailty status by t-KCL score was significantly associated with the incidence of dependency both in the pre-frail and the frail [hazard ratios (HRs): 2.027 and 4.768; 95% confidence intervals (CIs): 1.575-2.608 and 3.733-6.089, respectively]. On the other hand, the ability to predict death was significant, but only in the frail group (HR: 2.830; 95% CI: 1.952-4.104).

Conclusion

The classification of frailty status by t-KCL score could be a significant tool to predict the incidences of dependency and mortality in older adults.  相似文献   

4.

Background

Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression.

Objectives

To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness.

Design

Randomized controlled trial with waiting list control group.

Setting

Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients’ homes.

Participants

A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness.

Intervention

Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group.

Measurements

HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician.

Results

The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures.

Conclusions

CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis, good access to psychotherapy, and early intervention could improve care for depressive older patients.

Clinical Trial Registration

www.germanctr.de German Trial Register DRKS 00004728  相似文献   

5.

Objective

To analyze the association between dietary patterns and the 12-year risk of frailty and its components in community-dwelling elderly French adults.

Design

A prospective cohort study.

Setting

The Bordeaux sample of the Three-City Study.

Participants

A total of 972 initially nonfrail nondemented participants (336 men and 636 women) aged 73 years on average, re-examined at least once over 12 years.

Measurements

Five sex-specific dietary clusters were previously derived at baseline. Frailty incident to the baseline visit was defined as having at least three out of the following 5 criteria: unintentional weight loss, exhaustion, low energy expenditure, slowness, and muscle weakness. Multivariate Cox proportional hazard models were used to assess the association between dietary clusters and the risk of frailty and its components.

Results

In total, 78 men for 3719 person-years and 221 women for 7027 person-years became frail over the follow-up. In multivariate analyses, men in the “pasta” pattern and women in the “biscuits and snacking” pattern had a significantly higher risk of frailty compared with those in the “healthy” pattern [hazard ratio (HR) 2.2; 95% confidence interval (CI) 1.1–4.4 and HR 1.8; 95% CI 1.2–2.8, respectively; P = .09 and P = .13 for the global test of significance of risk difference across clusters, respectively]. In men, “biscuits and snacking” and “pasta” patterns were significantly associated with higher risk for muscle weakness (HR 3.3; 95% CI 1.6–7.0 and HR 2.1; 95% CI 1.2–3.7, respectively; P = .003 for global test).

Conclusions

This 12-year prospective population-based study suggests that some particular unhealthy dietary patterns may increase the risk of frailty in older adults.  相似文献   

6.

Objectives

To investigate the prevalence and factors associated with the use of medications of questionable benefit throughout the final year of life of older adults who died with dementia.

Design

Register-based, longitudinal cohort study.

Setting

Entire Sweden.

Participants

All older adults (≥75 years) who died with dementia between 2007 and 2013 (n = 120,067).

Measurements

Exposure to medications of questionable benefit was calculated for each of the last 12 months before death, based on longitudinal data from the Swedish Prescribed Drug Register.

Results

The proportion of older adults with dementia who received at least 1 medication of questionable benefit decreased from 38.6% 12 months before death to 34.7% during the final month before death (P < .001 for trend). Among older adults with dementia who used at least 1 medication of questionable benefit 12 months before death, 74.8% remained exposed until their last month of life. Living in an institution was independently associated with a 15% reduction of the likelihood to receive ≥1 medication of questionable benefit during the last month before death (odds ratio 0.85, 95% confidence interval 0.88–0.83). Antidementia drugs accounted for one-fifth of the total number of medications of questionable benefit. Lipid-lowering agents were used by 8.3% of individuals during their final month of life (10.2% of community-dwellers and 6.6% of institutionalized people, P < .001).

Conclusion

Clinicians caring for older adults with advanced dementia should be provided with reliable tools to help them reduce the burden of medications of questionable benefit near the end of life.  相似文献   

7.

Objectives

A simple and inexpensive tool for screening of sarcopenia would be helpful for clinicians. The present study was performed to determine whether the SARC-F questionnaire is useful in screening of patients with cardiovascular disease (CVD) for impaired physical function.

Design

Cross-sectional study.

Setting

Single university hospital.

Participants

A total of 235 Japanese patients ≥65 years old admitted to our hospital for CVD.

Measurements

SARC-F, handgrip strength, leg strength, respiratory muscle strength, standing balance, usual gait speed, Short Physical Performance Battery (SPPB) score, and 6-minute walking distance were measured before discharge from hospital. The patients were divided into 2 groups according to SARC-F score: SARC-F < 4 (nonsarcopenia group) and SARC-F ≥ 4 (sarcopenia group).

Results

The sarcopenia prevalence rate was 25.5% and increased with age (P trend < .001). The sarcopenia group (SARC-F score ≥ 4) had significantly lower handgrip strength, leg strength, and respiratory muscle strength, poorer standing balance, slower usual gait speed, lower SPPB score, and shorter 6-minute walking distance compared to the nonsarcopenia group (SARC-F score < 4). Patients in the sarcopenia group had consistently poorer physical function even after adjusting for covariates.

Conclusion

The SARC-F questionnaire is a useful screening tool for impaired physical function in elderly CVD patients. These findings support the use of the SARC-F for screening in hospital settings.  相似文献   

8.

Objectives

The distinction between dementia and mild cognitive impairment (MCI) relies upon the evaluation of independence in instrumental activities of daily living (IADL). Self- and informant reports are prone to bias. Clinician-based performance tests are limited by long administration times, restricted access, or inadequate validation. To close this gap, we developed and validated a performance-based measure of IADL, the Sydney Test of Activities of Daily Living in Memory Disorders (STAM).

Design

Prospective cohort study (Sydney Memory and Ageing Study).

Setting

Eastern Suburbs, Sydney, Australia.

Participants

554 community-dwelling individuals (54% female) aged 76 and older with normal cognition, MCI, or dementia.

Measurements

Activities of daily living were assessed with the STAM, administered by trained psychologists, and the informant-based Bayer-Activities of Daily Living Scale (B-ADL). Depressive symptoms were measured with the Geriatric Depression Scale (15-item version). Cognitive function was assessed with a comprehensive neuropsychological test battery. Consensus diagnoses of MCI and dementia were made independently of STAM scores.

Results

The STAM showed high interrater reliability (r = 0.854) and test-retest reliability (r = 0.832). It discriminated significantly between the diagnostic groups of normal cognition, MCI, and dementia with areas under the curves ranging from 0.723 to 0.948. A score of 26.5 discriminated between dementia and nondementia with a sensitivity of 0.831 and a specificity of 0.864. Correlations were low with education (r = 0.230) and depressive symptoms (r = ?0.179), moderate with the B-ADL (r = ?0.332), and high with cognition (ranging from r = 0.511 to r = 0.594). The mean time to complete the STAM was 16 minutes.

Conclusions

The STAM has good psychometric properties. It can be used to differentiate between normal cognition, MCI, and dementia and can be a helpful tool for diagnostic classification both in clinical practice and research.  相似文献   

9.

Background

Depression increases disability and health care utilization in older patients with chronic obstructive pulmonary disease (COPD).

Objectives

To determine contribution of depressive symptoms to the incidence of moderate-severe and severe acute exacerbations of COPD (AECOPD) over 3 years.

Design

We analyzed data collected from a prospective cohort of patients with COPD (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints; ECLIPSE).

Setting

Multicentered outpatient.

Participants

A total of 2059 patients with COPD with complete data (63.7% men, mean age 63.4 + 7.1 years).

Measurements

Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). Moderate-severe AECOPDs were collected; a subset of very severe AECOPD was defined as requiring hospital admission.

Results

A total of 540 (26%) patients with COPD reported high depressive symptoms (CES-D ≥16). High depressive symptoms at baseline related to an increased risk of moderate-severe and severe AECOPD during the follow-up (odds ratio [OR] 1.18; 95% confidence interval [CI] 1.07–1.30; for moderate-severe and OR 1.36; 95% CI 1.09–1.69 for severe events risk of hospitalizations) independent of key covariates of an AECOPD history before recruitment in the study, history of gastroesophageal reflux, baseline severity of airflow limitation, and white blood cell count that were also associated with an increased risk of moderate to severe exacerbations (all P < .001).

Conclusion

Presence of high depressive symptoms at baseline were associated with subsequent moderate-severe exacerbations and hospital admissions in patients with COPD over 3 years, independent of a history of exacerbations and other demographic and clinical factors. Targeted personalized medicine that focuses both on AECOPD risk and depression may be a step forward to improving prognosis of patients with COPD.  相似文献   

10.

Background

Homebound status is associated with poor health, comorbidity, and mortality and represents a major challenge for health systems. However, its prevalence among people with disabilities in the basic activities of daily living (ADLs) is unknown.

Objectives

The objectives were to: (1) examine the prevalence of the homebound status among middle-aged and older adults with disabilities in ADLs, and (2) identify its clinical, functional, and environmental determinants.

Methods

This study included 221 community-dwelling subjects, aged ≥50 years, who applied for long-term care services at the Office for Legal Certification of Long-term Care Need of Coruña (Spain). Each subject had a disability in ADLs and was interviewed by a trained examiner in the subject's home. The participants were considered homebound if they remained inside their home during the previous week.

Measures

Demographic, clinical, functional, and environmental factors. Multiple logistic regression was used to determine the factors associated with homebound status.

Results

The prevalence of homebound status was 39.8%. A multivariate analysis revealed that the presence of architectural barriers at the home entrance (stairs [OR: 6.67, p < 0.001] or a heavy door [OR: 2.83, p = 0.023]), walking ability limitations (OR: 3.26, p = 0.006), and higher age (OR: 1.05, p = 0.04) were associated with homebound status.

Conclusions

Homebound status is a highly prevalent problem among middle-aged and older adults with disabilities in ADLs. Architectural factors in the home and walking ability limitations seem to be important predictors, suggesting that health care interventions should target home adaptations and mobility skills as a means to preventing or decreasing homebound status.  相似文献   

11.

Objectives

Initial gait speed is a good predictor of dementia in later life. This prospective study used repeated measures analysis to identify potential gait performance trajectory patterns and to determine whether gait performance trajectory patterns were associated with incident disabling dementia among community-dwelling older Japanese.

Design

A prospective, observational, population-based follow-up study.

Setting

Japan, 2002 to 2014.

Participants

A total of 1686 adults without dementia (mean [SD] age, 71.2 [5.6] years; women, 56.3%) aged 65 to 90 years participated in annual geriatric health assessments during the period from June 2002 through July 2014. The average number of follow-up assessments was 3.9, and the total number of observations was 6509.

Measurements

Gait performance was assessed by measuring gait speed and step length at usual and maximum paces. A review of municipal databases in the Japanese public long-term care insurance system revealed that 196 (11.6%) participants developed disabling dementia through December 2014.

Results

We identified 3 distinct trajectory patterns (high, middle, and low) in gait speed and step length at usual and maximum paces in adults aged 65 to 90 years; these trajectory patterns showed parallel declines among men and women. After adjusting for important confounders, participants in the low trajectory groups for gait speed and step length at usual pace were 3.46 (95% confidence interval 1.88–6.40) and 2.12 (1.29–3.49) times as likely to develop incident disabling dementia, respectively, as those in the high trajectory group. The respective values for low trajectories of gait speed and step length at maximum pace were 2.05 (1.02–4.14) and 2.80 (1.48–5.28), respectively.

Conclusions

Regardless of baseline level, the 3 major trajectory patterns for gait speed and step length tended to show similar age-related changes in men and women in later life. Individuals with low trajectories for gait speed and step length had a higher dementia risk, which highlights the importance of interventions for improvements in gait performance, even among older adults with low gait performance.  相似文献   

12.

Background

Although the older population is increasing worldwide, there is a marked deficit in the number of persons trained in geriatrics. It is now recognized that early detection and treatment of geriatric syndromes (frailty, sarcopenia, anorexia of aging, and cognitive decline) will delay or avert the development of disability.

Objectives

To identify simple screening programs available for primary health professionals to identify geriatric syndromes.

Data sources

PubMed for the last 5 years and study authors.

Results

A number of screening programs for early detection of geriatric syndromes have been developed for use by primary care health providers, for example, EasyCare, Gérontopôle Frailty Screening Tool, the Rapid Geriatric Assessment, the Kihon Checklist, and others.

Limitations

This is an evolving area with limited information on the outcomes of intervention and possible harms.

Conclusion

Validated screening programs exist but more work is required to determine their utility in improving outcomes of older persons.  相似文献   

13.

Objectives

To investigate the association between benzodiazepine and related drug (BZDR) use and hip fracture as well as postfracture mortality and duration of hospital stay in community-dwellers with and without Alzheimer disease (AD).

Design

Retrospective cohort study.

Setting

The register-based Medication Use and Alzheimer's disease (MEDALZ) study, including all community-dwelling persons diagnosed with AD in Finland during 2005–2011 (n = 70,718) and their matched comparison persons without AD.

Participants

Persons without BZDR use during the year preceding the AD diagnosis or the corresponding matching date as well as persons without history of hip fracture were included in this study.

Measurements

We investigated the risk of hip fracture associated with BZDR use compared with nonuse separately in persons with and without AD. Further, we investigated the association between BZDR use during hip fracture and 1-year mortality as well as longer than a 4-month hospital stay after hip fracture. Associations were reported as hazard ratios and odds ratios with 95% confidence intervals (CI).

Results

BZDR use was associated with an increased risk of hip fracture in persons with and without AD (adjusted hazard ratio 1.4 [95% CI 1.2–1.7] and 1.6 [95% CI 1.3–1.9], respectively). BZDR use during hip fracture was associated with longer than 4-month postfracture hospital stay in persons with AD [adjusted odds ratio 1.9 (95% CI 1.3–2.8)] but not in comparison persons. One-year mortality was not associated with BZDR use during hip fracture.

Conclusions

Higher threshold in prescribing BZDRs for neuropsychiatric symptoms might decrease the hip fracture rate and affect the length of hospital stay in persons with AD.  相似文献   

14.

Objectives

A natural decline of muscle strength occurs during the aging process; however, preserving muscle strength may lower the rate of many preventable diseases such as diabetes, especially in higher risk populations. The purpose of this study was to examine the sex-specific association between muscle weakness and incident diabetes in older Mexican Americans.

Design

Observational, longitudinal study.

Setting

Urban and rural households in the Southwestern United States.

Participants

A subsample of 1903 Mexican Americans aged at least 65 years without diabetes at baseline were followed for 19 years.

Measurements

Muscle weakness was assessed with a hand-held dynamometer and was normalized to body weight (normalized grip strength). Male and female participants were categorized as weak if their normalized grip strength was ≤0.46 and ≤0.30, respectively. Sex-stratified Cox proportional hazard regression models were used to determine the association between muscle weakness and incident diabetes (self-reported) when using age as an entry variable and after adjusting for education, employment status, instrumental activities of daily living disability, interview language, marital status, and obesity. A sensitivity analysis was performed to account for influential outliers for the outcome variable (incident diabetes) and the model was re-run.

Results

The hazard ratio for incident diabetes was 1.05 (95% confidence interval: 1.02–1.09; P < .001) in weak vs not-weak male participants and 1.38 (95% confidence interval: 1.35–1.41; P < .001) in weak vs not-weak female participants, after adjusting for relevant covariates.

Conclusions

Muscle weakness was associated with an increased rate of diabetes in older male and female Mexican Americans. Health professionals should encourage activities that preserve muscle strength, thereby preventing the incidence of diabetes in older Mexican Americans.  相似文献   

15.

Importance

Dental neglect and high levels of unmet dental needs are becoming increasingly prevalent among elderly residents of long-term care facilities, although frail, elderly, and dependent populations are the most in need of professional dental care. Little is known about the validity of teledentistry for diagnosing dental pathology in nursing home residents.

Objectives

To evaluate the accuracy of teledentistry for diagnosing dental pathology, assessing the rehabilitation status of dental prostheses, and evaluating the chewing ability of older adults living in nursing homes (using direct examination as a gold standard).

Design

Multicenter diagnostic accuracy study performed in France and Germany.

Setting

Eight nursing homes in France and Germany.

Participants

Nursing home residents with oral or dental complaints, self-reported or reported by caregivers, willing to receive oral or dental preventive care. In total, 235 patients were examined. The mean age was 84.4 ± 8.3 years, and 59.1% of the subjects were female.

Intervention

The patients were examined twice. Each patient was his or her own control. First, the dental surgeon established a diagnosis by reviewing a video recorded in the nursing home and accessed remotely. Second, within a maximum of 7 days, patients were examined conventionally (face-to-face) by the same surgeon who established the initial diagnosis.

Measurements

All residents received a comprehensive clinical examination in their home by a trained geriatrician and underwent a dental hygiene evaluation that used the Silness-Loe and Greene-Vermillion dental hygiene assessment indices. The diagnoses established via the video recording and in the face-to-face setting were compared. The main outcome measure was number of dental pathologies.

Results

In total, 128 (55.4%) patients had a dental pathology. The sensitivity of teledentistry for diagnosing dental pathology was 93.8% (95% confidence interval [CI] 90.7–96.9), and the specificity was 94.2% (95% CI 91.2–97.2). Among the 128 cases of dental pathology identified by teledentistry, 6 (4.8%) were false positives. The teledentistry assessments were quicker than the face-to-to-face examinations (12 and 20 minutes, respectively).

Conclusions

Teledentistry showed excellent accuracy for diagnosing dental pathology in older adults living in nursing homes; its use may allow more regular checkups to be carried out by dental professionals.  相似文献   

16.

Objectives

Studies reporting prompted voiding (PV) interventions were of short duration and were delivered by research personnel rather than nursing home staff. This study examined the effectiveness of the use of PV by nursing home staff in managing urinary incontinence among residents over a 6-month period.

Design

A randomized controlled trial.

Setting

Five nursing homes in Hong Kong.

Participants

Data were collected from 52 nursing home residents who had been admitted to the facility for at least 6 months prior to the initiation of the study and whose incontinence had been stable over the 6-month period.

Intervention

The PV intervention was delivered by the staff for 6 months. All nursing home staff were trained to ensure that they would be able to correctly deliver the intervention before initiating the intervention. The control group received the usual care.

Measurements

Outcomes were defined in terms of wet episodes per day, incontinence rate per day, self-initiated toileting per day, and total continent toileting per day. Data were collected at baseline, 3 months postintervention (T1), and 6 months postintervention (T2).

Results

There were significant differences between the two groups in wet episodes per day, incontinence rate per day, and total continent toileting per day at 6 months post-intervention, with positive results found in the intervention group. A decrease of 9.1% was observed in the incontinence rate of the intervention group.

Conclusions

PV was shown to have positive effects, although the effects in this study were not as powerful as those found in overseas studies. The intervention delivered by staff was sustainable for a 6-month period. Nursing home operators should promote better continence care through PV, as it is a sustainable noninvasive behavioral intervention that can be mastered by staff with training.  相似文献   

17.

Objectives

Examine the effects of postacute discharge setting on unplanned hospital readmissions following total knee arthroplasty (TKA) in older adults.

Design

Secondary analyses of 100% Medicare (inpatient) claims files.

Setting

Acute hospitals across the United States.

Participants

Medicare fee-for-service beneficiaries ≥66 years of age who were discharged from an acute hospital following TKA in 2009-2011 (n = 608,031).

Measurements

The outcome measure was unplanned readmissions at 30, 60, and 90 days. The independent variable of interest was postacute discharge setting: inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), or community. Covariates included demographic, clinical, and facility-level factors. The top 10 reasons for readmission were tabulated for each discharge setting across the 3 consecutive 30-day time periods.

Results

A total of 32,226 patients (5.3%) were re-admitted within 30 days. Compared with community discharge, patients discharged to IRF and SNF had 44% and 40% higher odds of 30-day readmission, respectively. IRF and SNF discharge settings were also associated with 48% and 45% higher odds of 90-day readmission, respectively, compared with community discharge. The largest increase in readmission rates occurred within the first 30 days of hospital discharge for each discharge setting. From 1 to 30 days, postoperative and post-traumatic infections were among the top causes for readmission in all 3 discharge settings. From 31 to 60 days, postoperative or traumatic infections remained in the top 5-7 reasons for readmission in all settings, but they were not in the top 10 at 61 to 90 days.

Conclusions

Patients discharged to either SNF or IRF, in comparison with those discharged to the community, had greater likelihood of readmission within 30 and 90 days. The reasons for readmission were relatively consistent across discharge settings and time periods. These findings provide new information relevant to the delivery of postacute care to older adults following TKA.  相似文献   

18.

Objectives

Persons with osteoporotic fracture history are subject to an increased risk for subsequent fractures and mortality. The aim of this retrospective study was to investigate the impact of a previous osteoporotic low-impact (fragility) index fracture (eg, forearm, lower leg) on mortality of a subsequent femoral fracture.

Design

Retrospective cohort study.

Participants/measurements

Claims data of a German health insurance agency including >1.2 million insurants aged 65 years or older and observed between 2004 and 2009.

Methods

A multistate model was developed handling index fractures and care need as time-dependent exposures, while age was chosen as the underlying time scale. Excess risks were expressed as differences in cause-specific hazards. Nelson-Aalen estimates were used for their nonparametric estimation. Time-simultaneous statistical inference was based on confidence bands provided by wild bootstrap resampling.

Results

Excess femoral fracture risk increased with progressive age and was highest in persons with care need. It was observed starting from an age of 79 years in women and 85 years in men onward. A prior index fracture increased mortality after a femoral fracture by increasing femoral fracture risk, while leaving the hazard of death after a subsequent femoral fracture unchanged.

Conclusions

The results indicated that increased mortality of a subsequent femoral fracture is not triggered by an intrinsically increased mortality hazard but an increased femoral fracture incidence.  相似文献   

19.

Objectives

This study aimed to examine the effects of introducing participatory action research (PAR) within the nursing home (NH) on residents’ quality of life (QoL) and NH experience and participation, and to explore their experiences with PAR.

Design

A mixed methods design was chosen, including a clustered randomized controlled trial (RCT) and qualitative interviews.

Setting

For the RCT, 3 NHs were randomly allocated to 3 conditions: an intervention (weekly PAR activity), an active control (weekly reminiscence-activity), or passive control (care as usual). The qualitative study took place in the intervention NH.

Participants

Within the RCT, about 30 residents were recruited for assessments per NH, including 9 PAR participants and 10 reminiscence participants. Qualitative interviews were held with all PAR participants (residents and internal moderator).

Intervention

PAR is a method to structurally involve residents in the NH operation. Weekly PAR sessions were held with 9 residents and 2 moderators. Here, residents critically analyzed and discussed the NH operation, identified possible problems, suggested improvements, which were further implemented by the NH and monitored by the PAR group.

Measurements

Residents’ NH experience (NH Active Aging Survey), QoL (Anamnestic Comparison Self-Assessment), and experienced participation (Impact on Participation and Autonomy) were measured in the RCT at pre-test, post-test (6 months), and follow-up (12 months). The qualitative study took into account interviews with the PAR stakeholders after 6 months.

Results

The RCT showed residents’ QoL improving more between pre-test and follow-up in the intervention and active control NH compared with the passive control NH. No other effects were observed. The qualitative data revealed a positive PAR experience. Participants enjoyed the activity and indicated various positive influences. Still, there was room for improvement, including communication toward other residents and between staff.

Conclusions

Notwithstanding the modest quantitative effects, PAR led to positive experiences and can have a future in the NH when solving some limitations.  相似文献   

20.

Objectives

The aim of the present study was to (1) evaluate a geriatric outpatient sample with the FRAIL scale; (2) investigate the psychometric properties of the scale; and (3) characterize different associations of the subdimensions of the scale with demographic and clinical data.

Design

Cross-sectional observational study.

Setting

Geriatric outpatient center a university-based hospital in São Paulo, Brazil.

Participants

A total of 811 men and women aged 60 years or older evaluated between March 2015 and September 2015.

Measurements

A translated version of the FRAIL scale was used to evaluate frailty. A review of sociodemographic data, medical records, medication, and laboratory data was conducted. A multivariate ordinal logistic regression model was used to investigate the association between frailty categories and clinical variables. Exploratory factor analysis and 2-parameter logistic item response theory was used to evaluate the psychometric properties of the FRAIL scale.

Results

The sample was distributed as 13.6% robust, 48.7% prefrail, and 37.7% frail older adults. Most participants reported fatigue (72.3%). Frailty was associated with older age (P = .02), depression (P = .02), dementia (P < .001), and number of medications taken (P < .001). A 2-factor model of the FRAIL scale (“ambulation” and “resistance” namely physical performance; “fatigue,” “weight loss,” and “illnesses” namely health status) provided independent classifications of frailty status. Physical performance (ambulation and resistance) was strongly associated with higher age and dementia, whereas health status (fatigue, weight loss, and illnesses) was more associated with female sex and depression.

Conclusions

Our results suggest the existence of 2 subdimensions of the scale, suggesting different pathways to frailty. Frailty was associated with older age, depression, dementia, and number of medications in this outpatient sample.  相似文献   

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