Hospital Care For Older People Research Articles

The influence of sociodemographic factors and close relatives at hospital discharge and post hospital care of older people with complex care needs: nurses’ perceptions on health inequity in three Nordic cities

Hospital discharge of older people in need of both medical and social care following their hospital stay requires extensive coordination. This study aims to examine and compare the views of nurses in three Nordic cities on the influence of sociodemographic factors and having close relatives, for the hospital discharge and post hospital care of older people with complex health and social care needs. Thirty-five semi-structured interviews (Copenhagen n = 11, Tampere n = 8, Stockholm n = 16) with nurses were conducted. The nurses were identified through the researchers’ networks, invitation and snowball sampling, and recruited from hospitals, primary care practices, home care units, home nursing units, and geriatric departments. The interviews were transcribed and analysed using thematic analysis. Interpretations were discussed and agreed within the team. Four main themes and 13 sub-themes were identified. Across the cities, informants reported that the patient’s health status, rather than their gender or ethnicity, steered the discharge date and further care. Care costs, commonly reported in Tampere but also in Copenhagen and Stockholm including costs for medications and home help, were considered barriers for disadvantaged older people. Home situation, local arrangements and differences in collaboration between healthcare professionals at different sites also influenced the hospital discharge. Generally, the patient’s health status steered the hospital discharge and post-hospital care. Close relatives were regarded important and a potential advantage. Some informants tried to compensate for the absence of close relatives, highlighting the importance of care systems that can compensate for this to minimise avoidable inequity.

Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study

BackgroundThe aim of this study was to provide high-quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA).Objective(s)(1) To define CGA, its processes, outcomes and costs in the published literature, (2) to identify the processes, outcomes and costs of CGA in existing hospital settings in the UK, (3) to identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK and (4) to develop tools that will assist in the implementation of hospital-wide CGA.DesignMixed-methods study combining a mapping review, national survey, large data analysis and qualitative methods.ParticipantsPeople aged ≥ 65 years in acute hospital settings.Data sourcesLiterature review – Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE and EMBASE. Survey – acute hospital trusts. Large data analyses – (1) people aged ≥ 75 years in 2008 living in Leicester, Nottingham or Southampton (development cohort,n = 22,139); (2) older people admitted for short stay (Nottingham/Leicester,n = 825) to a geriatric ward (Southampton,n = 246) or based in the community (Newcastle,n = 754); (3) people aged ≥ 75 years admitted to acute hospitals in England in 2014–15 (validation study,n = 1,013,590). Toolkit development – multidisciplinary national stakeholder group (co-production); field-testing with cancer/surgical teams in Newcastle/Leicester.ResultsLiterature search – common outcomes included clinical, operational and destinational, but not patient-reported, outcome measures. Survey – highly variable provision of multidisciplinary assessment and care across hospitals. Quantitative analyses – in the development cohort, older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use than older people without a frailty diagnosis. Patients with the highest 20% of hospital frailty risk scores had increased odds of 30-day mortality [odds ratio (OR) 1.7], long length of stay (OR 6.0) and 30-day re-admission (OR 1.5). The score had moderate agreement with the Fried and Rockwood scales. Pilot toolkit evaluation – participants across sites were still at the beginning of their work to identify patients and plan change. In particular, competing definitions of the role of geriatricians were evident.LimitationsThe survey was limited by an incomplete response rate but it still provides the largest description of acute hospital care for older people to date. The risk stratification tool is not contemporaneous, although it remains a powerful predictor of patient harms. The toolkit evaluation is still rather nascent and could have meaningfully continued for another year or more.ConclusionsCGA remains the gold standard approach to improving a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful but require prolonged geriatrician support and implementation phases. Future work could involve comparing the hospital-based frailty index with the electronic Frailty Index and further testing of the clinical toolkits in specialist services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Training interventions to improve general hospital care for older people with cognitive impairment: systematic review.

In response to increasing numbers of older people in general hospitals who have cognitive impairment such as dementia and delirium, many hospitals have developed education and training programmes to prepare staff for this area of clinical practice.AimsTo review the evidence on educational interventions on hospital care for older people with cognitive impairment. A mixed methods systematic review and narrative synthesis was undertaken. The following electronic databases were searched: Medline, Embase, CINAHL, PsycINFO, EBM Reviews, ASSIA and Scopus, as well as Health Management Information Consortium (HMIC), ProQuest, PubMed and SCIE: Social Care Online. Initial searches were run in August 2014 (update search September 2016). Titles and abstracts of studies retrieved were screened independently. The full text of eligible studies were then independently assessed by two review team members. All included studies were assessed using a standard quality appraisal tool. Eight studies relating to delirium, six on dementia and two on delirium and dementia were included, each testing the use of a different educational intervention. Overall, the quality of the studies was low. In relation to delirium, all studies reported a significant increase in participants' knowledge immediately post-intervention. Two of the dementia studies reported an increase in dementia knowledge and dementia confidence immediately post-intervention. The variety of outcomes measured makes it difficult to summarise the findings. Although studies found increases in staff knowledge, there is insufficient evidence to conclude that educational interventions for staff lead to improved patient outcomes.Declaration of interestNone.

Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care.

To propose a new multicomponent measure of hospital-associated complications of older people (HAC-OP) and evaluate its validity in a large hospital sample. Observational study using baseline (pre-intervention) data from the Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital cluster randomized controlled trial. Acute medical and surgical wards in 4 hospitals in Queensland, Australia. Individuals aged 65 and older (mean age 76, 48% female) with a hospital stay of 72 hours or longer (N=434). We developed a multicomponent measure including 5 well-recognized hospital-associated complications of older people: hospital-associated delirium, functional decline, incontinence, falls, and pressure injuries. To evaluate construct validity, we examined associations with common risk factors (aged ≥75, functional impairment, cognitive impairment, history of falls). To evaluate predictive validity, we examined the association between length of stay, facility discharge, and 6-month mortality and any HAC-OP and total number of HAC-OP. Overall, 192 (44%) participants had 1 or more HAC-OP during their admission. Any HAC-OP was strongly associated with the proposed shared risk factors, and there was a strong and graded association between HAC-OP and length of stay (9.1±7.4 days for any HAC-OP vs 6.8 ±4.1 days with none, p < .001), facility discharge (59/192 (31%) vs 27/242 (11%), p < .001) and 6-month mortality (26/192 (14%) vs 17/242 (7%), p = .02). This study provides evidence of construct and predictive validity of the proposed measure of HAC-OP as a potential outcome measure for research investigating and improving hospital care of older people. J Am Geriatr Soc 67:352-356, 2019.

The canary in the coal mine: Continence care for people with dementia in acute hospital wards as a crisis of dehumanization.

Continence is a key moment of care that can tell us about the wider care of people living with dementia within acute hospital wards. The spotlight is currently on the quality of hospital care of older people across the UK, yet concerns persist about their poor treatment, neglect, abuse, and discrimination within this setting. Thus, within hospitals, the care of people living with dementia is both a welfare issue and a human rights issue. The challenge of continence care for people living with dementia can be seen as the ‘canary in the coal mine’ for the unravelling of dignity within the acute setting. This paper draws on an ethnographic study within five hospitals in England and Wales, selected to represent a range of hospital types, geographies and socio‐economic catchments. Observational fieldwork was carried out over 154 days in acute hospitals known to admit large numbers of people living with dementia. This paper starts to fill the gap between theory and data by providing an in‐depth ethnographic analysis examining the ways in which treatment as a person is negotiated, achieved or threatened. We examine how the twin assaults on agency of a diagnosis of dementia and of incontinence threaten personhood. The acute threats to this patient group may then act to magnify perils to treatment as a person. Our findings suggest that personal dignity and the social construction of moral personhood are both threatened and maintained in such a setting. We show how empirical ethnographic data can lend weight to, and add detail to, theoretical accounts of moral personhood and dignity.

Assessing and providing person-centred care of older people with cognitive impairment in acute settings: threats, variability, and challenges

BackgroundPerson-centred care is widely accepted in health policy as a central focus for health services. However, research studies indicate that, for nurses, the person-centred care of older people with cognitive impairment is challenging. AimThis study aimed to compare levels of person-centred care between wards and professional groups (ENs and RNs) providing tertiary hospital care of older people with cognitive impairment. MethodsA descriptive cross-sectional survey design, using the 15-item Person-centredness of Older People with cognitive impairment in Acute Care (POPAC) survey instrument, was undertaken. ResultsNurses working in hospital wards of a tertiary-level health service (n=240; RR=54.3%) responded. Person-centred care was rated lower in wards with higher patient turnover compared to wards with lower patient turnover. Person-centred care was rated higher by enrolled nurses compared to registered nurses. DiscussionHospital context, specifically high turnover wards, present a threat to person-centred care, possibly related to the limited time available to undertake the personal care and associated conversations that can enhance nurses’ knowledge of the person. ENs carry more responsibility for these tasks, possibly explaining the variability in person-centred scores between RNs and ENs. In comparison to other studies, nurses in this study had higher average scores for person-centred care, raising measurement as an important challenge in monitoring the implementation of person-centred care policy. ConclusionThe focus on health service efficiency appears to pose a threat to nurses’ delivery of person-centred care. Further research into the variability between person-centred care of RNs and ENs, and investigation into the practices of other health disciplines would be valuable. Given the importance of person-centred care to the safety and quality of health services, the POPAC addresses the challenge of monitoring person-centred policy initiatives. However, self-report instruments should be balanced with other sources of information about practice.

Person-centred acute hospital care for older people transitioning to residential aged care- whose needs are being met?

ABSTRACTThe acute health care system in Australia, as in the global north, has been increasingly dominated by neoliberal market principles prioritising efficiency and cost reduction. This has occurred in conjunction with a shift towards ‘personalised care’ models in health and social services. Personalised care models are intended to support the provision of holistic health care and consumer choice. Yet, the bureaucratic context of acute health care produces constrained applications of person-centred care that can undermine patient participation. Personalised care models have been criticised for diminishing the choices available to socioeconomically disadvantaged groups. There has been scant attention to these equity issues and ethical implications of the model for older people transferring from acute hospital settings to residential aged care. This is significant, as this major life event is associated with social- and identity-related losses; can produce poor health outcomes; and is affecting an increasing population of older people. The aim of this paper is to address this gap in the debate through a critical literature review applying Tronto’s critical ethics of care. We highlight the current Australian context for this patient group and the transferability of palliative care models as an example for change in practice and resource allocation.

A Scoping Literature Review of Dementia-Friendly Hospital Design.

We report the findings of a knowledge synthesis research project on the topic of dementia-friendly acute care (D-FAC) design. This exploratory project systematically mapped what is known about D-FAC physical design in hospitals. We discuss our challenges in locating reportable evidence and the implications of such design for maximizing independent function while ensuring safety and harm reduction in older people living with dementia. Exploratory iterative design utilizing scoping literature review methodology. A total of 28 primary studies plus expert reviewers' narratives on the impact of design and architectural features on independent function of hospitalized older people with dementia were included and evaluated. Items were mapped to key design elements to describe a D-FAC environment. This scoping review project confirms the limited nature of available acute care design evidence on maximizing function. Physical design influences the usability and activity undertaken in a health care space and ultimately affects patient outcomes. Achieving safe quality hospital care for older people living with dementia is particularly challenging. Evidence of design principle effectiveness is needed that can be applied to general medical and surgical units where the bulk of older persons with and without dementia are treated.

How empowering is hospital care for older people with advanced disease? Barriers and facilitators from a cross-national ethnography in England, Ireland and the USA.

patient empowerment, through which patients become self-determining agents with some control over their health and healthcare, is a common theme across health policies globally. Most care for older people is in the acute setting, but there is little evidence to inform the delivery of empowering hospital care. we aimed to explore challenges to and facilitators of empowerment among older people with advanced disease in hospital, and the impact of palliative care. we conducted an ethnography in six hospitals in England, Ireland and the USA. The ethnography involved: interviews with patients aged ≥65, informal caregivers, specialist palliative care (SPC) staff and other clinicians who cared for older adults with advanced disease, and fieldwork. Data were analysed using directed thematic analysis. analysis of 91 interviews and 340 h of observational data revealed substantial challenges to empowerment: poor communication and information provision, combined with routinised and fragmented inpatient care, restricted patients' self-efficacy, self-management, choice and decision-making. Information and knowledge were often necessary for empowerment, but not sufficient: empowerment depended on patient-centredness being enacted at an organisational and staff level. SPC facilitated empowerment by prioritising patient-centred care, tailored communication and information provision, and the support of other clinicians. empowering older people in the acute setting requires changes throughout the health system. Facilitators of empowerment include excellent staff-patient communication, patient-centred, relational care, an organisational focus on patient experience rather than throughput, and appropriate access to SPC. Findings have relevance for many high- and middle-income countries with a growing population of older patients with advanced disease.

Dementia case-finding in acute hospitals: a qualitative study of perspectives of hospital clinicians and general practitioners

BackgroundConcerns about hospital care of older people with dementia have led to UK Department of Health targets for acute hospitals to identify patients who could have dementia. Although dementia does not fit screening programme criteria, this requirement for dementia case-finding (DCF) reflects policy drives encouraging earlier diagnosis. Hospitals have set up their own processes to conduct assessments on all people aged 75 years and older with unplanned hospital admissions longer than 72 h and inform general practitioners (GPs). The potentially far-reaching effects are unknown. The Cascade study is exploring how hospitals across the East of England are implementing DCF, how results are communicated to GPs, and the impacts on patients and their subsequent care. We aimed to describe current DCF practice and to understand perspectives of both primary and secondary care clinicians on objectives, challenges, barriers, and perceived benefits of DCF. MethodsWe conducted topic-guided telephone interviews and focus groups with relevant health-care professionals contacted through multiple strategies. Direct e-mail invitations to hospital staff including Trust dementia leads and nurse specialists and invitations to GPs circulated through clinical and research networks, primary care services, and local GP forum meetings aimed for a purposive sample representing hospitals across the East of England. Anonymised transcripts were analysed with a framework approach. FindingsWe undertook interviews and focus groups with 23 hospital staff and 36 primary care staff (including 30 GPs). Hospitals differed in their approaches to DCF in terms of how, when, and by whom cognition was assessed and ways in which DCF outcomes were recorded and communicated to GPs. Although hospital IT systems were set up to ensure DCF completion, non-compliance could be a problem, especially within specialties where DCF was not a priority. Overall, staff in secondary care were more positive than were those in primary care about the benefits of DCF, including its awareness-raising, although there were concerns about impacts on resources and workload. GPs raised concerns about duplication of effort, the lack of an evidence-base for DCF, lack of access to information, limited post-diagnostic support services, and the appropriateness of DCF in the hospital setting. InterpretationPreliminary findings re-affirm that policies affecting public health need implementation that allows evaluation to inform the evidence-base. FundingNational Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East of England

Carer engagement in the hospital care of older people: an integrative literature review

There is a lack of definitions, evidence and guidance about carer engagement in hospitals. In this study, researchers carried out an integrative literature review to assess the components of carer engagement for older people’s hospital care.

Carer engagement in the hospital care of older people: an integrative literature review.

The aim of this review was to explore the concept of carer engagement in the hospital care of older people and to build theory to inform future research and practice. Carer engagement can help to improve the delivery and continuity of care provided to older people in hospital. However, definitions, guidance and structures for carer engagement in hospitals are lacking and there can be tensions and conflicts about the role of carers in hospitals. Integrative literature review. Literature searches identified 2745 peer-reviewed articles and studies published between January 1990 and November 2015 in the following databases: PubMed, Cochrane, Medline, EMBASE and CINHAL. After applying inclusion/exclusion criteria, the sample (103 articles) was subject to thematic analysis. Current evidence on carer engagement is dispersed across different research literatures on clinical conditions and contexts. Six distinct components of carer engagement were identified: patient caregiving, information sharing, shared decision-making, carer support and education, carer feedback and patient care transitions. Hospitals can adopt a more consistent and comprehensive approach to carer engagement for older people by developing and supporting the different components of carer engagement identified. The integrated model of carer engagement developed here could help staff and hospitals to develop strategies, staff training and resources that work with rather than against carers. The findings can inform future research on carer engagement interventions and associated outcomes for patients, carers and staff.

Medical day hospital care for older people versus alternative forms of care.

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location. To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status. Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data. Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age). Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care. Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14). There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

Healthcare professionals’ acceptance of BelRAI, a web-based system enabling person-centred recording and data sharing across care settings with interRAI instruments: a UTAUT analysis

BackgroundHealthcare and social care environments are increasingly confronted with older persons with long-term care needs. Consequently, the need for integrated and coordinated assessment systems increases. In Belgium, feasibility studies have been conducted on the implementation and use of interRAI instruments offering opportunities to improve continuity and quality of care. However, the development and implementation of information technology to support a shared dataset is a difficult and gradual process. We explore the applicability of the UTAUT theoretical model in the BelRAI healthcare project to analyse the acceptance of the BelRAI web application by healthcare professionals in home care, nursing home care and acute hospital care for older people with disabilities.MethodsA structured questionnaire containing items based on constructs validated in the original UTAUT study was distributed to 661 Flemish caregivers. We performed a complete case analysis using data from 282 questionnaires to obtain information regarding the effects of performance expectancy (PE), effort expectancy (EE), social influence (SI), facilitating conditions (FC), anxiety (ANX), self-efficacy (SE) and attitude towards using technology (ATUT) on behavioural intention (BI) to use the BelRAI web application.ResultsThe values of the internal consistency evaluation of each construct demonstrated adequate reliability of the survey instrument. Convergent and discriminant validity were established. However, the items of the ATUT construct cross-loaded on PE. FC proved to have the most significant influence on BI to use BelRAI, followed by SE. Other constructs (PE, EE, SI, ANX, ATUT) had no significant influence on BI. The ‘direct effects only’ model explained 30.8% of the variance in BI to use BelRAI.ConclusionsCritical factors in stimulating the behavioural intention to use new technology are good-quality software, interoperability and compatibility with other information systems, easy access to computers, training facilities, built-in and online help and ongoing IT support. These findings can be used by policy makers to maximise the acceptance and the success of new technology. For researchers, the conclusions of the original UTAUT study with regards to the item and scale construction should not be copied blindly across different information systems. A bottom-up approach is preferred when building upon the UTAUT model.

Summit report.

The Royal College of Nursing co-hosted a summit on improving hospital care for older people in London in October with NHS London, Macmillan Cancer Support, Age UK and the NHS Institute for Innovation and Improvement. The event brought together an invited group of nurses and organisations to share good practice and identify priorities for improvement.

The Entrepreneurial Rationalities of Governing and the Construction of the Enterprising Nurse

Drawing from a wider study exploring the role of registered nurses (RNs) in managing hospital care of older people, I present an analysis of some discursive mechanisms through which an enterprising nursing subjectivity was cultivated in RNs working in an Australian hospital. Data comprised information from the hospital Web site, policy documents, job descriptions, and interviews with 26 RNs. The analysis highlighted how texts such as nursing vision statements and job descriptions were not neutral or innocuous, but mechanisms that individually and collectively specified norms of enterprising conduct for RNs working in that hospital. Although the findings detailed how entrepreneurial rationalities and discourses governing health care actively transformed the meaning and practice of nursing, they also illustrated how factors such as role location and ward culture diluted the take up of enterprise discourses, suggesting that it was not possible to guarantee RNs as particular kinds of enterprising subjects.

Dignity on the wards: improving hospital care for older people

Despite improvement in the care and experience of older people being prominent features of NHS health policy over recent years, a number of high level reports show the effectiveness of such policy initiatives has been limited and the provision of dignified care for older people remains difficult to translate into practice.

‘To regulate and confirm inequality’? A regional history of geriatric hospitals under the English National Health Service,c.1948–c.1975

ABSTRACTThe post-war history of hospital care for older people in Britain in the first phase of its National Health Service (NHS) emphasises a detrimental Poor Law legacy. This article presents a regional study, based on the South West of England, of the processes by which Victorian workhouses became the basis of geriatric hospital provision under the NHS. Its premise is that legislative and medical developments provided opportunities for local actors to discard the ‘legacy’, and their limited success in doing so requires explanation. Theoretical perspectives from the literature are introduced including political economy approaches; historical sociology of the medical profession; and path dependence. Analysis of resource allocation decisions shows a persistent tendency to disadvantage these institutions by comparison with acute care hospitals and services for mothers and children, although new ideas about geriatric medicine had some impact locally. Quantitative and qualitative data are used to examine policies towards organisation, staffing and infrastructural improvements, suggesting early momentum was not maintained. Explanations lie partly with national financial constraints and partly with the regional administrative arrangements following the NHS settlement which perpetuated existing divisions between agencies.

Acute care and older people: challenges and ways forward

Objective: This article aims to (a) suggest ways in which acute hospital environments might be modified to better meet the needs of the older person and (b) question whether options other than acute care should be canvassed for older people. Setting: Acute hospital settings. Subjects: Older people and people with cognitive impairment Primary argument: Older people are large consumers of acute hospital care, and acute hospitals are known to pose significant risks for this vulnerable population. Such risks include delirium, falls, restraints, drug side effects, and general de‑conditioning entailing loss of function and independence. Eight dimensions of person‑centred care are presented to promote assessing and meeting the needs of older people in acute care. Alternatives to acute hospital admission are also suggested, such as developing ‘older people centres’ to which older people could be admitted for triage in older‑friendly environments staffed by geriatric experts, places in which their multidimensional care needs could be better met. Conclusions: As an alternative to acute hospital admission, ‘older people centres’ could be developed to which older people could be admitted for triage in older‑friendly environments staffed by experts in care of older people. In the mean time, why not provide a balanced approach that provides some environmental adjustments for older people, core knowledge and skills for all staff, and access to gerontic expertise in the acute hospital care of older people.

Assessing functional decline.

Adequate hospital care for older people with acute medical disorders requires assessment to detect those patients at highest risk of functional decline. Specialist multidisciplinary care and early planning for discharge and follow up are vital to prevent loss of independence and maintain quality of life. Delaying functional loss and increasing the chances of living at home are at least as important as reducing fatality in frail older people.