Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study

ObjectiveSensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium.DesignCross-sectional study nested in the 2017 “Delirium Day” project.Setting and ParticipantsPatients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy.MethodsDelirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters).ResultsA total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2–2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1–1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6–1.2, P = .36; OR 1.1; CI 0.8–1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6–1.2, P = .27; OR 1.1, CI 0.8–1.4, P = .63).Conclusions and implicationsOur findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.     

Diagnostic Testing in Long-Term Care and Resident Emergency Department Visits: A Retrospective Cohort Study

ObjectivesTo investigate the association between rapid access to radiographs, blood tests, urine cultures, and intravenous (IV) therapy in a long-term care (LTC) home with resident transfers to the emergency department (ED).DesignRetrospective cohort study.Setting and Participants21,811 residents living in 162 LTC homes in Ontario, Canada.MethodsWe administered a survey to LTC homes to collect wait times for radiographs, basic blood tests, urine culture, and IV therapy. Rapid availability was defined as typically receiving test results within 1 or 2 days, or same-day IV therapy. We linked the survey results to administrative data and defined a cohort of residents living in survey-respondent homes between January and May 2017. We followed residents in the linked administrative databases for 6 months, until discharge, or death. Two physicians identified diagnostic codes for ED visits that were potentially preventable with rapid availability of each of the 4 resources. Multilevel logistic regression models estimated associations between potentially preventable ED visits and rapid diagnostic tests and intravenous access while controlling for demographic characteristics, illness severity, LTC home size, chain status, and physician availability.ResultsRapid blood tests, radiographs, urine culture, and IV therapy were available in 55%, 47%, 34%, and 45% of LTC homes, respectively. LTC homes that were part of multihome chains were less likely to have rapid access to the 4 resources. Of the 4736 residents (27%) who visited an ED during follow-up, individuals from homes with rapid access to radiographs (odds ratio 0.79, 95% confidence interval 0.66-0.97), urine culture (0.88, 0.72-1.08), blood tests (0.83, 0.69-1.00), and IV therapy (0.93, 0.70-1.23) tended to have fewer potentially preventable ED visits.Conclusions and ImplicationsRapid access to diagnostic testing and IV therapy in LTC reduced ED visits. Improving access to these resources may prevent ED visits and allow residents to stay home.     

Decomposing Racial and Ethnic Disparities in Nursing Home Influenza Vaccination

ObjectivesQuantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents.DesignRetrospective cohort.Setting and ParticipantsShort- and long-stay U.S. NH residents aged ≥65 years.MethodsWe linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents.ResultsOur study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity.Conclusions and ImplicationsThe racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination.     

COVID-19 and the Need for Adult Day Services

COVID-19 has shone a harsh light on the inequities of health care in the United States, particularly in how we care for older people. We summarize some of the effects of lockdown orders on clients, family caregivers, and staff of adult day service programs throughout the United States, which may serve as a counterpoint to scientific evidence suggesting a lack of efficacy of these programs. Given the ramifications of state lockdown orders for users and staff of the long-term services and support system, we provide recommendations to better support community-based programs and those they serve. Specifically, (1) adult day programs should be classified as essential, (2) a focus on the value of adult day and similar programs is needed, and (3) an exploration of new ways to finance home and community-based services is warranted. Such advances in policy and science would help to integrate adult day services more effectively into the broader health care landscape.     

Development and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults

PurposeWe developed and validated a measure that assesses the latent construct of sexual and reproductive empowerment among adolescents and young adults. A specific measure for this group is critical because of their unique life stage and circumstances, which often includes frequent changes in sexual partners and involvement from parents in decision-making.MethodsAfter formative qualitative research, a review of the literature, and cognitive interviews, we developed 95 items representing nine dimensions of sexual and reproductive empowerment. Items were then fielded among a national sample of young people aged 15–24 years, and those who identified as sexually active completed a 3-month follow-up survey. We conducted psychometric analysis and scale validation.ResultsExploratory factor analysis on responses from 1,117 participants resulted in the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults, containing 23 items captured by seven subscales: comfort talking with partner; choice of partners, marriage, and children; parental support; sexual safety; self-love; sense of future; and sexual pleasure. Validation using logistic regression demonstrated that the subscales were consistently associated with sexual and reproductive health information and access to sexual and reproductive health services measured at baseline and moderately associated with the use of desired contraceptive methods at 3-month follow-up.ConclusionsThe Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults is a new measure that assesses young people’s empowerment regarding sexual and reproductive health. It can be used by researchers, public health practitioners, and clinicians to measure sexual and reproductive empowerment among young people.     

Comorbidity and Quality of In-Hospital Care for Hip Fracture Patients

ObjectivesWe examined whether the comorbidity burden of patients with hip fracture was associated with quality of in-hospital care reflected by fulfillment of process performance measures.DesignPopulation-based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry (DMHFR).Setting and ParticipantsPatients aged 65 years or older with an incident hip fracture from 2014 to 2018 registered in the DMHFR (n = 31,443).MethodsComorbidity was measured using the Charlson Comorbidity Index based on hospital diagnoses. Quality of in-hospital care was defined as fulfillment of eligible process performance measures, including preoperative optimization, early surgery, early mobilization, pain assessment, basic mobility, nutritional risk, need for anti-osteoporotic medication, fall prevention, and a post-discharge rehabilitation program, reflecting guideline-recommended in-hospital care. The outcomes were (1) an all-or-none composite measure defined as fulfillment of all relevant process performance measures, and (2) fulfillment of the individual process performance measures. Using binary regression, we calculated relative risk (RR) for the association between comorbidity level and outcomes.ResultsThe overall proportion of patients with hip fracture who fulfilled the all-or-none measure was 31%. Among patients with no comorbidity, 34% fulfilled the all-or-none measure versus 29% among patients with high comorbidity (Charlson ≥ 3). This corresponds to a 15% lower chance (RR = 0.85, 95% confidence interval 0.81–0.89). Increasing comorbidity was also associated with lower fulfillment of the individual process performance measures. The largest difference was seen for preoperative optimization, early surgery, and early mobilization, where patients with high comorbidity had 6% to 11% lower chance of fulfillment of these process performance measures compared with patients without comorbidity.Conclusion and ImplicationsIncreasing level of comorbidity was associated with lower quality of in-hospital care among patients with hip fracture. Our results highlight the need for tailored clinical initiatives to ensure that comorbid patients also benefit from the positive progress in hip fracture care in recent years.     

The Prevalence of Frailty Among Older Adults Living With Dementia: A Systematic Review

ObjectivesTo investigate the prevalence of frailty in older adults living with dementia and explore the differences in medication use according to frailty status.DesignSystematic review of published literature from inception to August 20, 2020.Setting and ParticipantsAdults age ≥65 years living with dementia in acute-care, community and residential care settings.MethodsA systematic search was performed in Embase, Medline, International Pharmaceutical Abstracts, APA PscyInfo, CINAHL, Scopus, and Web of Science. Two reviewers independently screened records and conducted quality assessment using the Newcastle-Ottawa Scale.ResultsSixteen articles met the inclusion criteria, with 7 studies conducted in acute care setting and 9 studies in community-dwelling adults. Five studies recruited people with dementia exclusively, and 11 studies were conducted in older populations that included individuals with dementia diagnosis. Among studies conducted in acute care setting, the prevalence of frailty ranged from 50.8% to 91.8% compared with studies in community-dwelling setting, which reported a prevalence of 24.3% to 98.9%. With respect to medication exposure, 3 studies documented medication use according to frailty status but not dementia status. Higher medications use, measured as total number of medications was reported in frail [7.0 ± 4.0 (SD) ?12.0 ± 9.0 (SD)] compared with nonfrail participants [6.1 ± 3.1(SD) ?10.4 ± 3.8 (SD)].Conclusions and ImplicationsCurrent data suggests a wide range of frailty prevalence in individuals with dementia. Future studies should systematically document frailty in adults living with dementia and its impact on medication use.     

High-Intensity Interval and Resistance Training Improve Health Outcomes in Older Adults With Coronary Disease

ObjectiveBoth high-intensity interval training (HIIT) and resistance exercises (R) are used in cardiac rehabilitation in patients with coronary artery disease (CAD). However, the combined effect of an HIIT + R exercise program in older adults with CAD is not well investigated. The study's purpose was to assess the changes in anthropometric parameters, physical activity, functional capacity, physiological parameters, and quality of life (QoL) in this population following a combined HIIT + R program.DesignThe study was a 2-group (n = 45 each) randomized controlled single-blinded trial.Setting and ParticipantsThe study was done at a treatment clinic of a tertiary hospital. The mean age of participants was 69.23 ± 4.9 years. The HIIT + R group performed 8 sessions (1/wk) of HIIT + R training. The 30 minutes of the active exercise phase consisted of ten 3-minute bouts. Each bout comprised of 1 minute of high-intensity treadmill walking at 85% to 90% maximum heart rate (MHR), followed by a low-intensity walking at 60%-70% MHR, followed by low-to moderate-intensity resistance training. The Usual Care group underwent conventional medical treatment.MeasuresAnthropometric measurements [weight, body mass index (BMI), waist circumference, body fat percentage, lean body mass], physical activity (International Physical Activity Questionnaire), functional capacity (Incremental Shuttle Walking Test), physiologic measurements (blood pressure, heart rate), and QoL (36-Item Short Form Health Survey) were measured pre- and postintervention.ResultsSignificant group and time interaction were found for the participants in the HIIT + R Group for BMI (P = .001), body fat percentage (P = .001), waist circumference (P < .001), physical activity (P < .001), functional capacity (P < .001), and QoL (P = .001) compared with the UC Group. Significant improvement in systolic blood pressure (P = .001) was seen in the HIIT + R group.Conclusions and ImplicationsA combined HIIT + R training protocol in older adults with CAD can be useful in producing desired health outcomes. Further evaluation of longer duration exercise programs with more frequent dosing needs to be evaluated for their benefits and sustainability.