Hospital Discharge In Elderly Patients Research Articles

Predictors of postoperative physical functional decline at hospital discharge in elderly patients with prolonged intensive care unit stay after cardiac surgery

BackgroundA prolonged stay in the intensive care (ICU) is associated with physical function decline following cardiac surgery. To predict physical function decline after cardiac surgery, it may be important to evaluate physical function in the ICU. ObjectivesThis study aimed to determine that physical function examination at ICU discharge was independently associated with physical functional decline at hospital discharge in elderly patients who had undergone cardiac surgery and prolonged the ICU stay. MethodsWe assessed physical function before and after cardiac surgery in elderly patients who had spent ≥72 h in the ICU in this retrospective cohort study using the short physical performance battery (SPPB). At hospital discharge, a decrease of at least 1 point on the SPPB was considered a postoperative physical functional decline. Postoperative physical functional decline at hospital discharge was predicted using multiple logistic regression. ResultsWe revealed postoperative physical functional deterioration in 28.0% of patients who spent ≥72 h in the ICU following cardiac surgery. The Medical Research Council sum score (MRC-SS) (OR: 0.96, 95% CI: 0.82–0.99) and mechanical ventilation days (OR: 1.27, 95% CI: 1.01–1.64) were independently associated with physical functional decline at hospital discharge. ConclusionsPhysical function at ICU discharge and mechanical ventilation days were predictors of postoperative physical functional decline at hospital discharge in patients. MRC-SS was more accurate in predicting postoperative physical functional decline at hospital discharge when performed at the time of ICU discharge.

Association of long–term exposure to PM2.5 with cause-specific mortality in elderly patients with the previous history of ischemic heart disease

BACKGROUND AND AIM: Numerous studies have reported an association between fine particulate matter (PM2.5) and cardiovascular disease (CVD) morbidity and mortality. However, the association between PM2.5 and mortality among those with a previous history of ischemic heart disease (IHD) is less understood. We aimed to evaluate whether long-term exposure to PM2.5 is related to mortality after hospital discharge in elderly patients with IHD. METHODS: We followed-up 306,418 IHD elderly patients residing in seven major cities between 2008 and 2016 using the Korean National Health Insurance Database and identified cause-specific mortality after the hospital admission. We linked the modelled PM2.5 data corresponding to each patient’s administrative districts. We used time-varying Cox hazard models after adjusting for the individual- and area-level confounders. Subgroup analyses were conducted by age group (65–74 vs ≥ 75), sex, and income- and wealth-based insurance premiums. RESULTS:Of a total of 306,418 IHD elderly patients, 43.1 (%) were male, mean age was 76.8 years, and 105,913 died during a mean follow-up of 21.4 years. The adjusted hazard ratio (HR) of all-cause mortality was 1.10 [95% confidence intervals (CI): 1.07, 1.14] per 10 μg/m3 increase in a 12–month moving average PM2.5. The HRs were greater for cause-specific mortality: 1.17 (95% CI: 1.11, 1.24), 1.17 (95% CI: 1.06, 1.30), and 1.25 (95% CI: 1.15, 1.35) for CVD, stroke, and IHD, respectively. The subgroup analyses showed that for all–cause mortality, 65–74 age group, men, and low wealth-based insurance premiums were more susceptible to PM2.5 exposure. CONCLUSIONS:We found an association between long-term exposure to PM2.5 and mortality among elderly IHD patients, particularly for CVD-related mortality. Our results suggest that those with a previous history of IHD were more susceptible to PM2.5 exposure. KEYWORDS: Cohort Studies, Ischemic heart disease, Mortality,Particulate matter, Republic of Korea

Risk of falls after hospital discharge in elderly patients who underwent lumbar surgery

Risk of falls after hospital discharge in elderly patients who underwent lumbar surgery

Effects of the Cardiac and Comorbid Conditions Heart Failure (3C-HF) Score at Admission on Life Space at Three Months after Hospital Discharge in Elderly Patients with Heart Failure: A Short Report.

We assessed 22 elderly patients with heart failure, 3 months after hospital discharge. We examined and compared factors that predict small life space after discharge with the same factors before discharge. Life-Space Assessment was used to classify the participants as either having “small living spaces” or “large living spaces”. We collected data regarding characteristics, Cardiac and Comorbid Conditions Heart Failure Score (3C-HF score), and evaluated motor function. We also collected data on the patients’ lifestyle habits. We investigated spreading life space at 3 months after discharge by mailing a questionnaire to the subjects. Using multiple logistic regression analysis, we were able to predict the patients having a small life space at 3 months after discharge by the Cardiac and Comorbid Conditions Heart Failure (3C-HF) score (odds ratio, 1.19; 95% confidence interval, 1.01–1.39; p = 0.038) at admission. Overall, the 3C-HF score at admission may be associated with the size of life space at 3 months after hospital discharge in elderly patients with heart failure. Future multicenter studies should be conducted to validate the results of this study by measuring post-discharge activity with a more objective index.

Rising time from bed in acute phase after hospitalization predicts frailty at hospital discharge in patients with acute heart failure

BackgroundThe early prediction of frailty at discharge in elderly patients hospitalized with heart failure (HF) is essential for clinical management and therapeutic decision-making. This study was performed to examine whether the rising time from bed measured immediately after admission can be used as a predictor of frailty in these patients. MethodsA retrospective cohort study was performed in a population of 387 consecutive elderly patients with HF. Rising time from bed was measured within 2 days after admission when cardiac rehabilitation was started. Frailty was assessed at hospital discharge using a composite of four markers as a frailty score (range, 0–12): gait speed, handgrip strength, serum albumin, and activities of daily living status. The patients were divided into two groups based on frailty score <5 (non-frail) or ≥5 (frail). ResultsThe study population had a mean age of 75 years and 63.6 % were men. The median rising time was 6.8s, and 53.5 % were classified as frail. After adjustment for various factors, rising time was independently associated with frailty (odds ratio=1.10; 95 % confidence index=1.04–1.18). The area under the receiver operating characteristics curve of rising time for frailty was 0.71, and the cut-off value for rising time to identify those at high risk of frailty was 7.1s. ConclusionsRising time from bed measured within 2 days after admission was shown to be an independent predictor of frailty at hospital discharge in elderly patients hospitalized for HF.

Safety of robotic-assisted gynecologic surgery and early hospital discharge in elderly patients

A minimally invasive surgical approach has proven to decrease peri- and postoperative complications and shorten duration of hospital stay; however, there are limited data evaluating the safety of robotic-assisted surgery and early hospital discharge in the elderly population. Because age is a well-known, independent risk factor for perioperative morbidity and gynecologists treat many elderly patients, this is an important area of study. The objective of the study was to evaluate discharge timing and surgical outcomes in elderly compared with younger patients undergoing robotic-assisted gynecologic surgery. This was a retrospective cohort study of all patients who underwent robotic-assisted gynecologic surgery at a high-volume, single institution from January 2013 through May 2016. Demographic information, discharge timing, and peri- and postoperative outcomes were compared for patients <65 years with those ≥65 years using univariate and multivariate analyses. There were 2757 patients included, with 2521 <65 years and 236 ≥65 years. Median age of the younger group was 42 years, while the median age of the elderly group was 69 years. Elderly patients had a higher body mass index (kilograms per square meter) (28 vs 26, P < .001) and higher American Society of Anesthesia classification (P < .001). Elderly were more likely to have malignancy as the indication for surgery (68% vs 11%, P < .001) and to undergo hysterectomy (81% vs 38%, P < .001) orsurgery with lymph node dissection (44.5% vs 7.1%, P < .001). Elderlypatients had a higher incidence of intraoperative complications (9%vs 4.6%, P= .002) and longer median hospital stay (17 vs 7 hours, P< .001) compared with younger patients. Same-day discharge was more common in younger patients (76% vs 45%, P < .001), and elderly patients were more likely to have admissions lasting >23 hours (13% vs3%, P < .001) on univariate and multivariate analysis. Analysis of postoperative outcomes included 2023 patients with available postoperative data (80% of total population) (1794 <65 years, 229 ≥ 65 years). There were no differences between elderly and younger patients in overall postoperative complications, reoperations, intensive care unit admissions, emergency room visits, or hospital readmission within 6 weeks of surgery. Despite having more preoperative risk factors and more surgically complex procedures, elderly patients undergoing robotic-assisted gynecologic surgery had similar postoperative complication rates, and almost half of elderly patients were safely discharged the day of surgery. Our data suggest that robotic-assisted gynecologic surgery and early hospital discharge are safe in elderly patients.

Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT

BackgroundInappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients’ priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.MethodsThe study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older.Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward’s discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines.Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients’ quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.DiscussionSo far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.Trial registrationISRCTN, ISRCTN18427377. Registered 11 January 2018

Abstract 17157: Clinical Impact of Digoxin Discontinuation at Hospital Discharge in Patients With Heart Failure With Reduced Ejection Fraction

Introduction: Digoxin use is associated with a lower risk of hospital admission and readmission in patients with heart failure with reduced ejection fraction (HFrEF). Moreover, PROVED and RADIANCE trials have shown that digoxin discontinuation is associated with lower ejection fraction (EF), higher heart rate, and worse heart failure (HF) symptoms in chronic HFrEF patients. Despite these results, digoxin use has declined over recent years. In this study, we examined the clinical impact of digoxin discontinuation at hospital discharge in elderly patients with HFrEF. Hypothesis: Digoxin discontinuation at hospital discharge will increase mortality and heart failure readmission in HFrEF patients. Methods: Of 10,625 patients hospitalized with HFrEF (EF≤40%) in Medicare-linked OPTIMIZE-HF registry, 3,225 were receiving digoxin prior to admission but it was discontinued in 655 of these patients at the time of discharge. Propensity scores for digoxin discontinuation, estimated for each of the 3,225 patients, were used to match 616 pairs of patients (digoxin continued vs. discontinued) balanced on 60 baseline characteristics including age (mean 76 years), EF (mean 26%), gender (31% females) and race (15% African America) among others. Results: Among 1,232 matched patients, digoxin discontinuation was associated with a higher risk of all-cause mortality at 30-days (12% vs. 8%; HR 1.45; 95% CI 1.01-2.07; p=0.044) and 6-months (HR 1.32; p=0.009) but not at 1-year (HR 1.18; p=0.07). Digoxin discontinuation was also associated with increased combined heart failure readmission/all-cause mortality at 4-years of follow up (HR 1.16; 95% CI 1.03-1.30; p=0.017). Conclusions: In patients with HFrEF receiving digoxin prior to admission, digoxin discontinuation at discharge from hospital is associated with increased short-term all-cause mortality and long-term heart failure readmission/all-cause mortality.

Safety of robotic-assisted gynecologic surgery and early hospital discharge in elderly patients

Safety of robotic-assisted gynecologic surgery and early hospital discharge in elderly patients

Hospital discharge of elderly patients to primary health care, with and without an intermediate care hospital - a qualitative study of health professionals' experiences.

Intermediate care is an organisational approach to improve the coordination of health care services between health care levels. In Central Norway an intermediate care hospital was established in a municipality to improve discharge from a general hospital to primary health care. The aim of this study was to investigate how health professionals experienced hospital discharge of elderly patients to primary health care with and without an intermediate care hospital. A qualitative study with data collected through semi-structured focus groups and individual interviews. Discharge via the intermediate care hospital was contrasted favourably compared to discharge directly from hospital to primary health care. Although increased capacity to receive patients from hospital and prepare them for discharge to primary health care was viewed as a benefit, professionals still requested better communication with the preceding care level concerning further treatment and care for the elderly patients. The intermediate care hospital reduced the coordination challenges during discharge of elderly patients from hospital to primary health care. Nevertheless, the intermediate care was experienced more like an extension of hospital than an included part of primary health care and did not meet the need for communication across care levels.

Oropharyngeal dysphagia in elderly inpatients in a unit of convalescence

To describe the prevalence of oropharyngeal dysphagia at hospital discharge in elderly patients admitted to a Subacute Care Unit (SACU) using the Volume-Viscosity Swalow Test (V-VST) and an adapted version for severe dementia (V-VST-G). METHODOLOGY AND DESIGN: Descriptive cross-sectional study; duration; 50 days. Data gathered from the clinical chart at hospital discharge: demographical, clinical, risk factors, and complications of dysphagia, functional course, and V-VCAM and V-VCAM-G outcomes. The results are described comparing the data of the groups with and without dysphagia. 86 Patients (60% women), mean age 83.8 ± 6.7 years. The specific clinical history detected previous oropharyngeal dysphagia in 23 patients (26%). The V-VCAM detected oropharyngeal dysphagia in 46 patients (53.5%). Of them, 30 patients (65.21%) had mixed swallowing disorder, 15 (32.6%) had isolated efficacy disorder, and 1 (2.17%) had isolated safety disorder. Those patients with a positive dysphagia test had a statistically significant higher prevalence of cognitive disorder, higher age, and more positive history of previous dysphagia, worse functional course and mobility impairment, and more complications during their staying at the SACU. Dysphagia is highly prevalent among this group of elderly patients. Only half of the cases are diagnosed through the specific anamnesis. The V-VCAM detected a high prevalence of dysphagia so that its routine use is recommended specially in patients at risk taking into account the peculiarities of using it in the elderly. This at-risk population would be defined by characteristics such as higher age, cognitive and/or functional impairment.

Disfagia orofaríngea en ancianos ingresados en una unidad de convalecencia

Main objective: To describe the prevalence of oropharyngeal dysphagia at hospital discharge in elderly patients admitted to a Subacute Care Unit (SACU) using the Volume-Viscosity Swalow Test (V-VST) and an adapted version for severe dementia (V-VST-G). Methodology and design: Descriptive cross-sectional study; duration; 50 days. Data gathered from the clinical chart at hospital discharge: demographical, clinical, risk factors, and complications of dysphagia, functional course, and V-VCAM and V-VCAM-G outcomes. The results are described comparing the data of the groups with and without dysphagia. Results: 86 patients (60% women), mean age 83.8 ± 6.7 years. The specific clinical history detected previous oropharyngeal dysphagia in 23 patients (26%). The VVCAM detected oropharyngeal dysphagia in 46 patients (53.5%). Of them, 30 patients (65.21%) had mixed swallowing disorder, 15 (32.6%) had isolated efficacy disorder, and 1 (2.17%) had isolated safety disorder. Those patients with a positive dysphagia test had a statistically significant higher prevalence of cognitive disorder, higher age, and more positive history of previous dysphagia, worse functional course and mobility impairment, and more complications during their staying at the SACU. Conclusions: dysphagia is highly prevalent among this group of elderly patients. Only half of the cases are diagnosed through the specific anamnesis. The V-VCAM detected a high prevalence of dysphagia so that its routine use is recommended specially in patients at risk taking into account the peculiarities of using it in the elderly. This at-risk population would be defined by characteristics such as higher age, cognitive and/or functional impairment.

Comparing clinical and administrative data for profiling hospitals on postdischarge medication use by patients with acute myocardial infarction

Postdischarge medication use is frequently used as a measure of hospital performance, with many reports produced using clinical data obtained from chart reviews. The introduction of a drug benefit program administered by the Centers for Medicare and Medicaid Services presents an opportunity to use administrative data for routine reporting on hospital performance. We determined the concordance between hospital-specific prescribing rates of evidence-based medical therapies obtained from clinical and administrative data in Ontario, Canada. This was a retrospective cohort study using data on patients discharged from 102 hospitals in Ontario, Canada with acute myocardial infarction (AMI) between April 1, 1999, and March 31, 2001. We compared hospital-specific rates of discharge prescribing in AMI patients, determined using clinical data obtained using retrospective chart review with hospital-specific rates of prescriptions filled within 30 days of hospital discharge in elderly patients using administrative data. There was a moderate agreement between hospital-specific rates of discharge prescriptions written for AMI patients in clinical data with hospital-specific rates of prescriptions filled using administrative data. Although differences in rates were, on average, small between the 2 data sources, there was moderate variation in the differences between these 2 rates across hospitals. There was very strong agreement between rates of discharge prescribing in all patients and in ideal patients with no contraindications, both determined using clinical data. Post-AMI discharge prescribing in all patients determined using clinical data is an excellent proxy for prescribing in ideal patients using clinical data. However, there is weaker agreement between administrative and clinical data.

Patient empowerment after total hip and knee replacement.

This research was designed to gain an enhanced understanding of empowerment within in-home care relationships after hospital discharge of elderly patients who had undergone total hip or total knee replacement. An interpretive phenomenology method was used. Nine participants were interviewed on audiotape, guided by a semistructured interview guide. Five themes emerged centering on a strong desire to maintain independence. Overall, participants experienced disempowered relationships with professional in-home care providers and a more equitable empowered relationship with nonprofessional care providers. Disempowered relationships with professional personnel were not identified as a dissatisfier to most participants. Rather, patients expressed deference to the traditional expert model of healthcare. Further investigation is needed to understand the effect of empowerment on client satisfaction and clinical outcomes.

Prognostic Impact of Plasma Brain Natriuretic Peptide for Cardiac Events in Elderly Patients with Congestive Heart Failure

Background: Plasma brain natriuretic peptide (BNP) has been reported to be useful in determining the prognosis of patients with ischemic heart disease and cardiomyopathy. However, aging increases the level of plasma BNP; therefore, the prognostic impact of plasma BNP in elderly patients with congestive heart failure has not been fully established. Objective: We sought to determine whether plasma BNP could predict recurrent cardiac events in elderly patients with congestive heart failure. Methods: Forty-eight consecutive elderly patients (>65 years old) were enrolled in the present study. All patients were admitted with their first episode of congestive heart failure. Clinical characteristics, plasma BNP, left ventricular ejection fraction, and left ventricular mass index were compared between patients with and those without recurrent cardiac events. Results: During the follow-up period, twelve cardiac events were observed. The New York Heart Association functional class was signi- ficantly higher in patients with cardiac events than in those without (p < 0.05). The plasma BNP level in pa- tients with cardiac events was significantly higher than in those without (521.0 ± 156.0 vs. 126.8 ± 20.1 pg/ml, p < 0.001), despite more frequent treatment with angiotensin-converting enzyme inhibitors (75 vs. 28%, p < 0.05). The left ventricular ejection fraction was significantly lower and the left ventricular mass index higher in patients with cardiac events as compared with those without (38.1 ± 5.0 vs. 49.2 ± 2.4%, p < 0.05; 193.8 ± 14.3 vs. 132.6 ± 7.8 g/m², p < 0.001, respectively). The plasma BNP was selected as an independent factor associated with cardiac events besides New York Heart Association functional class, left ventricular ejection fraction, and left ventricular mass index using multivariate Cox proportional-hazards regression analysis (hazard ratio = 2.656, p < 0.05). The cardiac event rate was significantly higher in patients with a plasma BNP concentration >132 pg/ml using Kaplan-Meier analysis (p < 0.001). Moreover, the plasma BNP level correlated inversely with the length of time from hospital discharge to a cardiac event (r = –0.575, p < 0.05). Conclusion: Measuring the plasma BNP level before hospital discharge in elderly patients with congestive heart failure was more useful than other conventional examinations for predicting the recurrence of cardiac events.

Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure

The objectives of this investigation were to prospectively assess medication compliance rates in elderly patients with congestive heart failure, to identify factors associated with reduced compliance, and to evaluate the effect of a multidisciplinary treatment approach on medication adherence. A total of 156 patients > or = 70 years of age (mean, 79.4 +/- 6.0; 67% female, 65% nonwhite) hospitalized with congestive heart failure were evaluated prospectively. Prior to discharge, patients were randomized to the study intervention (n = 80) or conventional care (n = 76). The intervention consisted of comprehensive patient education, dietary and social service consultations, medication review, and intensive postdischarge follow-up. Detailed data were collected on all prescribed medications at the time of discharge, and compliance was assessed by pill counts 30 +/- 2 days later. The overall compliance rate during the first 30 days after discharge was 84.6 +/- 15.1% (range, 23.1-100%). Compliance was 87.9 +/- 12.0% in patients randomized to the study intervention, compared with 81.1 +/- 17.2% in the control group (P = 0.003). A compliance rate of > or = 80% was achieved by 85.0% of the treatment group versus 69.7% of the control group (P = 0.036). By multivariate analysis, assignment to the treatment group was the strongest independent predictor of compliance (P = 0.008). Other variables included in the model were Caucasian race (P = 0.044) and not living alone (P = 0.09). A multidisciplinary treatment strategy is associated with improved medication compliance during the first 30 days following hospital discharge in elderly patients with congestive heart failure. Improved compliance may contribute to improved outcomes in these patients.