Frailty and deconditioning on the acute take

To explore health professionals' perspectives about caring for community-dwelling older patients in the ED. This exploratory qualitative study was undertaken with emergency nursing, medical and allied health staff from the ED of a large metropolitan public hospital in Melbourne. Nine focus groups (n = 54) and seven interviews were conducted between 2013 and 2014. Data were thematically analysed. Health professionals described tailoring their approach when caring for older patients, including adopting a specific communication approach (i.e. increased voice volume, slower rate of speech). Caring for older patients was perceived as challenging given the need to balance the expectations of family members to deal with associated complex needs and limited time for transitional care planning in the ED. The environment and equipment were perceived as unsuitable, alongside a lack of geriatric-specific knowledge; contributing to what health professionals described as a poor fit between the ED system and older patients' needs. The growing number of older patients presents numerous challenges for emergency health professionals and necessitates a tailored approach to care. Understanding health professionals' perspectives about caring for older patients can inform strategies that may improve the quality of care. Creating older person-friendly areas, improving transitional care and providing staff with specific education would foster an environment that promotes person-centred care, safety, independence and functional wellbeing.

Editor, The Editorial from Pinto et al.1 brings to the attention of anaesthesiologists the great amount of clinical, ethical and organisational dilemmas elderly patients pose to anaesthetists when surgical treatment is needed. This is due to a wide range of factors that include, among others, the ageing processes that deteriorate the stress response to surgical aggression and anaesthesia, comorbidities that reduce functional reserves, chronic medication (mostly when presenting with the features of poly-medication or inappropriate drug intake), impaired functional status ranging from minor impairment to total dependency, and frailty. As geriatric medicine is not taught to surgeons and anaesthesiologists in Europe, surgical professionals are often lacking in reference points and are challenged when facing older surgical patients. This has caused the emergence of two opposite trends: an excessive interventional attitude or excessive caution; neither is the right answer to patients’ needs. Whereas the first may be a result of production pressure exerted on professionals, the second is mostly related to both the predominance of ageism and insufficient knowledge. With at least three international guidelines on optimal preoperative evaluation2 and perioperative management3,4 of the elderly surgical patient, and despite the systematic exclusion of older patients from the majority of randomised controlled trials, in light of present knowledge one would expect an Editorial in the European Journal of Anaesthesiology on risk prediction and perioperative care in older patients to report and comment on both the current availability of clinical and methodological tools helpful in investigating surgical risk factors in the elderly and about methods for proactively and effectively managing those risks in clinical practice. We read instead the emphasis on ‘the risk that even minor surgical interventions can be followed by considerable post-interventional complications’ and on the ‘lack of high-quality quantitative risk assessment tools’ or ‘the difficulties in understanding concepts such as validation cohorts, calibration and external validation’ (concepts which often confuse both young and more expert professionals). Such statements lead anaesthetists to deny treatment to older patients, treatment which not only could prolong life (though some would see that as therapeutic overkill), but also would enable a higher quality of life, enhance mobility and/or eliminate pain and discomfort. In the elderly, anaesthetists need to understand that traditional anaesthesia consultations do not capture all those elements that are needed to assess the risk of complications and plan subsequent targeted perioperative strategies. However, interdisciplinary, comprehensive, team-based preoperative evaluation can significantly improve surgical outcome. Instead of excessively caution-inspired considerations, what anaesthesiologists need is a clear, updated, comprehensive and detailed guideline on preoperative risk assessment and perioperative care in older surgical patients: a task that the European Society of Anaesthesiology is still reluctant to perform. Emphasis should be mostly on the concept that age per se should never be considered a reason for denying surgery to older patients. Finally, it should be emphasised that geriatric medicine should be taught to anaesthetists during their postgraduate education and the domain included among the requirements for the European Diploma of Anaesthesia. This would allow today's anaesthesiologists to become what seems to be their prime objective: to be ‘perioperative doctors’ in the full sense of the term. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none.

Review Objective: To identify the best available evidence on age-friendly nursing interventions used in the management of older people (over 65) during their stay in the Emergency Department Review Questions: 1. What is the effectiveness of age-friendly nursing interventions used in the management of older people (over 65) during their stay in the Emergency Department? 2. What are the recommended policies regarding age-friendly nursing interventions for the management of older people (over 65) during their stay in the Emergency Department? Inclusion criteria: Types of participants: This review will consider men and women over the age of 65 presenting to the Emergency Department. Types of intervention(s)/phenomena of interest: The review will consider any age-friendly nursing interventions in the management of older patients during their stay in the Emergency Department. These may include nursing interventions to enhance comfort, nutrition, hydration, pressure area care, pain management and communication. The opinion part of the review will consider the policies and recommendations related to age-friendly nursing interventions. Types of outcomes: Outcomes of interest for the quantitative part of the review are: pressure area status, hydration status, nutritional status and pain status measured during their stay in the emergency department. The text and opinion part of the review will focus on the recommended policies for age-friendly nursing interventions.

Background/Objectives: This study explores the concept of dignity in care for older patients with cancer in Korea using the hybrid model. Methods: A three-phase hybrid model approach was employed for concept analysis. In the theoretical phase, a literature review was conducted to determine the attributes and definition of dignity in care. In the fieldwork phase, the practicability of the defined concept was assessed through practical observations. In the final analysis phase, findings from the theoretical and fieldwork phases were compared and synthesized to validate the attributes and definition of the concept. Results: Four dimensions of dignity in care were found identified: intrinsic, relational, social, and illness-related. Professional dimension was added based on nurses' perspective. Attributes of dignity in care for older cancer patients include eight key elements: personal identity, a deepened sense of value and meaning of life, respect, relationships (with medical staff, family, and fellow patients), support for society's care policies, systemic support from healthcare systems, free will and choice, and proactive coping strategies. For nurses, dignity in care involves seven attributes: understanding and respecting human values, ethical and moral attitudes, interaction-based communication through the cultivation of rapport, systemic support from healthcare systems, protection of dignity, activities promoting dignity, and professional competency. Conclusions: This study provides concept definitions and attributes for dignity in care, equipping clinical nurses with assessment tools to better understand and enhance the dignity of older cancer patients.

BackgroundWith China’s population ageing rapidly, stroke is becoming one of the major public health problems. Nurses are indispensable for caring for older patients with acute and convalescent stroke, and their working experiences are directly linked to the quality of care provided. The study aims to investigate registered nurses’ experiences of caring for older stroke patients.MethodsA qualitative descriptive design was adopted. Data were collected via semi-structured interviews with 26 registered nurses about their lived experiences of caring for older stroke patients. Thematic analysis was used to analyze the data.ResultsTwo main themes were identified. First, the nurses identified an obvious gap between their ideal role in elderly care and their actual practice. The unsatisfactory reality was linked to the practical difficulties they encountered in their working environment. Second, the nurses expressed conflicting feelings about caring for older stroke patients, displaying a sense of accomplishment, indifference, annoyance, and sympathy. Caring for older stroke patients also affects nurses psychologically and physically. The nurses were clear about their own roles and tried their best to meet the elderly people’s needs, yet they lack time and knowledge about caring for older stroke patients. The factors influencing their working experiences extend beyond the personal domain and are linked to the wider working environment.ConclusionsSustaining the nursing workforce and improving their working experiences are essential to meet the care needs of older people. Understanding nurses’ lived working experiences is the first step. At the individual level, nurse mangers should promote empathy, relieve anxiety about aging, and improve the job satisfaction and morale of nurses. At the institutional level, policymakers should make efforts to improve the nursing clinical practice environment, increase the geriatric nursing education and training, achieve a proper skill mix of the health workforce, and overall attract, prepare and sustain nurses regarding caring for older people in a rapidly aging society.

Psychiatric Resident Perceptions of Competency in the Management of Social Isolation and Grief in Geriatric Patients

AGA Clinical Practice Update on Management of Inflammatory Bowel Disease in Elderly Patients: Expert Review

The Identification Of Seniors At Risk (ISAR) Score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Background Frailty predisposes older people to adverse outcomes following hospitalisation. Physiotherapy can reduce the risk of adverse frailty-related outcomes including functional decline. Research examining frailty and physiotherapy referral in Acute Medical Units is limited. The objective of this study was to estimate the prevalence of frailty in older adults admitted to an Acute Medical Admissions Unit (AMAU), and to explore factors associated with early physiotherapy referral in the frail group. Methods A prospective cohort study was conducted in the AMAU of a large acute hospital in Ireland. Participants were those over 65 years who were admitted to the AMAU. All participants underwent frailty screening on admission using both the Clinical Frailty Scale and Program of Research to Integrate Services for the Maintenance of Autonomy-7 questionnaire. They were defined as frail if positive on at least one of the tools. Referral to physiotherapy and time to referral during hospitalisation was recorded. Multivariable logistic regression was used to explore factors associated with early physiotherapy referral (within 24 hours) for frail participants. Results 210 participants (mean age = 78.3 years, 51.9% female) were included. Frailty prevalence was 71% (n = 149) (95% CI = 64.3–77.0%). Within the frail group, 61.1% (n = 91) experienced early referral to physiotherapy, 15.4% (n = 23) were referred after >24 hours and 23.5% (n = 35) were not referred during hospitalisation. Falls history (Odds Ratio [OR]: 4.08; 95% Confidence Interval [CI]: 1.82–1.94), older age (OR: 1.05; 95%CI: 1.00–1.10) and mobilising with an aid or assistance (OR: 2.42; 95% CI: 1.11–5.27) were associated with early physiotherapy referral in the frail group. Sex and living alone were not. Conclusion Frailty screening in AMAU may increase identification of older people at risk of experiencing adverse outcomes. Routine referral to physiotherapy for people who are deemed frail would ensure more equal access to physiotherapy assessment and treatment which could reduce the risk of adverse outcomes including falls, functional decline, and frailty progression.

BackgroundThis programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.MethodsIn the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.ResultsAlthough 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.DiscussionThe interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.Trial registrationCurrent Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.

Early outpatient follow-up within two weeks after hospital discharge is an effective strategy for improving transitions of care in older patients with heart failure (HF). However, implementing timely follow-up care for HF patients has been challenging, especially during the COVID-19 pandemic. This convergent mixed-methods study identified patients’ barriers to accessing care and ascertained their recommendations for addressing these barriers. We enrolled 264 HF patients admitted to the Duke Heart Center between May 2020 and August 2021. A standardized survey and electronic health records (EHR) were used to collect patients’ sociodemographic, psychosocial, behavioral, and clinical data. For patients who reported some difficulty accessing their healthcare (n=30), semi-structured interviews were conducted to understand these barriers. Data were analyzed using rapid analysis techniques. Barriers to accessing care varied across participants, with scheduling an appointment being the most common barrier (12 of the 30 responses). Participants indicated that job-related conflicts, providers’ availability, or COVID-19 contributed most to the difficulty in scheduling an appointment. Some participants experienced more difficulties during the pandemic due to fewer appointments available for non-acute and non-COVID-19 related needs. Transportation was another critical barrier, which was often associated with the participants’ physical functional status. Participants identified the benefits of using telemedicine to address access to care barriers; however, they shared their concerns that telemedicine visits may not be sufficient to assess their HF conditions. Study findings highlight the need for more continual, tailored, and patient-centered interventions to improve access to care in older HF patients.

The aging population in Taiwan increases the demand for care services for older adult patients with cancer, presenting significant challenges to both healthcare and social systems. Family caregivers perceive caregiver burden since they assist patients with daily activities, health management, and medical decision-making face physical, psychological, economic, and social stressors that impact their overall well-being. Taking care of older patients causes more complicated caregiving tasks because of the treatments and care related to cancer and multiple chronic conditions. Caregiver burden is known to be influenced by age, health, education, and disease awareness. Furthermore, in Taiwan, the participation of foreign spouses and migrant workers in family care increases cultural and resource-related challenges and highlights the need for integrated long-term care resources and social support. Using family caregiver assessments testing caregiver burden and quality of life can specify family caregiver needs that assist healthcare teams in developing family care plans. Interventions, including cancer education, psychological support, caregiving training, and collaborative models involving both patients and caregivers, may alleviate caregiver stress, improve quality of life, and enhance coping abilities. Moving forward, nursing professionals should advocate for integrated care models that incorporate comprehensive geriatric assessments and design interventions tailored to the specific needs of diverse family caregivers of older cancer patients. These approaches will help improve the quality of life for both caregivers and older cancer patients and foster a supportive care environment through interdisciplinary collaboration to address the health challenges of an aging society.

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

ALL in Older Adults

One of the distinctive parameters of an aging population is the increasing incidence of urinary incontinence. We analyzed nursing of the enuretic patients of old age. In order to analyze the nursing of the enuretic patients of old age, the qualitative content analysis was used, and the structured interview in the survey was conducted. The study was contingent of 10 nurses who took care of the old age patients who do not hold urine, in internal medicine and rehabilitation departments. The study showed that the old age patients often has urinary incontinence and nurses is the foundation of many environmental changes. Reasons for enuresis of the patients of old age are such as adjacent diseases and physical restriction, by the way, in terms of nurses, the women have urinary incontinence more often than that of men. An enuretic patient of old age nursing is a physical and psychological and physical care is not possible without the support of many tools that facilitate the care of these patients. The nurses tell that they would give the patients of old age the preventive advices improving their quality of life. The results showed that many aspects of urinary incontinence is a definite factor, adversely affect old patients’ health status and problems associated with this specific medicine. It is therefore very important to further explore this issue in order to qualitatively evaluate the effectiveness of care.