Older People In Hospital Research Articles

Perspectives about dignity during acute care for older people and their relatives: A qualitative study.

The aim of the study was to enhance understanding about dignified care from older peoples' and their carers' perspectives. The information will contribute to the development of a tool to measure older peoples' dignity during hospitalisation. Older people are a vulnerable cohort at risk of loss of dignity during acute hospitalisation arising from environmental, behavioural and patient factors. It is not clear how older people and their relatives define dignified care in acute care settings. An interpretative descriptive method was used. A purposive sample of older people (at least 65years) who had been hospitalised in acute care and subsequently transferred to sub-acute care, and their relatives, were invited to participate. The study was undertaken in one sub-acute ward in a regional healthcare organisation in Victoria, Australia. Individual interviews were audio-recorded then transcribed. Data were analysed using thematic content analysis. The COREQ checklist was used to document reporting of the study. Individual interviews were conducted: 24 patients and 12 relatives. Three main themes were identified: "Involve me in decisions about my care and treatment," "Keep me safe when I am vulnerable" and "Treat me as an individual and with respect." Older people want to be involved in decisions about their care and treatment and to receive adequate, suitable information. They feel vulnerable during hospitalisation and want to feel safe when speaking up about concerns. Individual acknowledgement is an important aspect of dignity. Older people and their relatives identified specific elements of care that uphold or threaten dignity during acute hospitalisation. Nurses play a major role in upholding dignity for older people in hospital. Clinicians may benefit from systematic dignity-related training. Specific strategies to enhance older persons' dignity, including communication skills training and continence management need to be developed, implemented and evaluated.

Using lived experiences and theoretical insights to gain a better understanding of the adaptation difficulties encountered by elderly patients with chronic heart failure during the hospital-to-home transition

Heart failure is one of the most common reasons for hospitalization in older people, and the hospital-to-home transition can be unsuccessful for these patients. Existing care programs focus primarily on the physiological aspects of the disease and are rarely based on theory. Using Roy's adaptation model (1), the aim of this study was to develop a thorough understanding of the adaptation difficulties and factors that influence how well elderly patients with chronic heart failure cope with the hospital-to-home transition, in order to develop a nursing interventions program. Based on the process proposed by Sidani and Braden (2011), this qualitative descriptive study adopted a deductive approach, with the use of intermediary theories and empirical data, as well as an inductive approach, where older people with chronic heart failure (n=7), caregivers (n=6), and healthcare professionals (n=14) participated in semi-structured individual interviews. The triangulation of data highlights the difficulties and factors influencing adaptation at the physical, psychological, and social levels. Gaining a better understanding of the experience of older people with heart failure when it comes to their transition from hospital to home, and doing so with a holistic vision, provides information for interventions that can contribute to better management of chronic disease and a better quality of life for these elderly patients.

The Contribution of Documentation Systems to How Nurses Understand Older People's Cognitive Function in Hospital.

Nurses are central to the care of older people in hospital. One issue of particular importance to the experience and outcomes of hospitalized older people is their cognitive function. This article reports findings from a focused ethnographic study demonstrating how documentation systems-documents and the social processes surrounding their use-contribute to how nurses come to understand the cognitive function of hospitalized older people. We found that documents contribute to nurses' understanding by serving as a frame of reference, by directing assessments, and by constraining communication. The findings highlight the potential to improve the documents nurses use in hospitals.

The application and tailoring of Colaizzi's phenomenological approach in a hospital setting.

Husserl's descriptive phenomenology is a popular methodology in health research as it provides a way to understand people's experiences. Positioned in Husserl's phenomenology, Colaizzi's approach offers a way to analyse data and develop trustworthy findings. However, it can pose methodological and practical challenges. To present a discussion of the application and tailoring of Colaizzi's phenomenological approach to a study conducted in a hospital. Applying Colaizzi's approach to interview data concerning health professionals' decisions about transferring older people in hospital to residential care provided a decision trail. However, Colaizzi's final step - member-checking - is controversial so was tailored to enhance the development of trustworthy findings. Validating findings is an important part of conducting research. Tailoring the final step of member-checking in Colaizzi's approach supports trustworthy findings while staying connected to phenomenological epistemology. Phenomenology is a popular methodology for nurse researchers. Tailoring Colaizzi's approach provides strategies to augment phenomenological methods, ensuring dependable findings. Nurse researchers conducting phenomenological research can use these strategies.

‘Socialised care futility’ in the care of older people in hospital who call out repetitively: An ethnographic study

BackgroundPeople living with dementia may call out repetitively, sometimes called disruptive vocalisation, or verbal agitation. In literature and policy, patients who call out repetitively are assumed to be expressing an unmet need, which should be met. Yet there has been little systematic study of this patient group in an acute hospital setting. ObjectivesTo better understand patients who call out repetitively and to identify what care looks like in an acute hospital setting. DesignEthnography. SettingsTen acute geriatric medical wards in two hospitals. Participants30 cognitively impaired patients who were calling out repetitively, and 15 members of hospital staff. MethodsSemi-structured interviews with hospital staff, 150 h of ward observations and informal conversations with staff, scrutiny of medical and nursing documentation, and measures of patient health status. ResultsPatients who called out were moderately or severely cognitively impaired, often had delirium, were very physically disabled, and many were approaching the end of life. Most hospital staff were found to hold contradictory views: that calling out represents distress or unmet need, but that nothing can be done to alleviate the calling out. During informal conversations, most staff also tended to say that they intuitively recognised when intervening was likely to alleviate calling out. During observations, many staff appeared to and spoke of the ability to ‘block’ calling out. As a result we argue that social, emotional and physical needs may get overlooked. We argue that some calling out is due to a need that is unmeetable. We also found that while staff would talk about strategies for identifying need, observations and hospital documentation did not support evidence of systematic attempts to identify potential need. ConclusionCalling out repetitively within a hospital setting is difficult for staff to understand and to respond to. This is because many of these patients are severely cognitively impaired, often immobile and dependent on their professional carers. We argue that a form of socialised care futility is communicated between staff and is used to rationalise becoming unresponsive to calling-out. We explain this phenomenon as resulting from two protective mechanisms: defence of staff's professional identity as competent practitioners; and defence of staff as having personal morality. Socialised care futility risks good quality care, therefore systematic strategies to assess and manage possible need should be developed, even if calling out remains irresolvable in some cases.

Sedentary behaviour in hospitalised older people: a scoping review protocol

BackgroundOlder adults spend up to 23 h daily sitting or lying while in hospital. Sedentary behaviour (SB) within a hospital setting is often associated with poor health outcomes including physical and cognitive decline, reduced quality of life and death as well as hospital readmissions. Conversely, replacing SB with mild to moderate levels of physical activity such as walking can significantly reduce hospital readmission risk by 30 days. Given the potentially harmful effects of SB in hospitalised older adults, it is vital to identify current literature by broadly exploring different aspects of SB among older people in hospital. The overall aim of this scoping review is to produce a literature map of current evidence on key domains of sedentary behaviour in hospitalised older people.MethodA search for relevant publications will be undertaken in Pedro, MEDLINE Ovid, Cochrane, Scopus, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, Embase, Ageline, Joanna Briggs Institute (JBI) and clinical trials registries. Publications in English and those where the author can provide the full text in English will be included. Studies conducted in hospitals (including in-patient rehabilitation facilities) or acute and subacute care settings and in people aged ≥ 65 will be included. A three-stage method will be used to identify relevant articles, consisting of database search using keywords, keywords and index words across all databases, and reference searching. Articles will be selected following screening of titles/abstracts succeeded by a full-text appraisal utilising a standardised selection form. Two independent reviewers will extract data using the standardised form that will be tested on two articles. A narrative summary will accompany results presented in tables and figures.

Reliability and validity of the Mandarin version of the Continuity Assessment Record and Evaluation for older people who are transferred between hospitals and nursing homes in China.

To date, assessment tools for older people are different between hospitals and nursing homes in China. The difference between assessment tools can lead to poor communication of information between hospitals and nursing homes, which causes discontinuity of care and adverse outcomes when older people are transferred between these different settings. Continuity Assessment Record and Evaluation (CARE) is a comprehensive geriatric assessment tool developed in the United States of America. This study aimed to evaluate the reliability and validity of the Mandarin Version of CARE for older people who are transferred between hospitals and nursing homes. Using a convenience sampling method, 120 older people in hospitals and 120 older people in nursing homes in Shanghai were selected to test the internal consistency, interrater reliability and criterion-related validity of CARE from May to November 2017. When used among hospital, 70.0% (7/10) of the subscales had a Cronbach's alpha coefficients of greater than 0.7, 94.3% (50/53) of the items had an intraclass correlation coefficient (ICC) of greater than 0.75. When used in nursing homes, 90.0% (9/10) of the subscales had a Cronbach's alpha coefficients of greater than 0.7, 94.3% (50/53) of the items had an ICC of greater than 0.75. For both settings, the correlation coefficients of the subscales with their corresponding instruments for criterion-related validity were all greater than 0.8 (p<.01). The Mandarin version of CARE exhibits good reliability and validity. It can be used as an assessment tool for transition between hospitals and nursing homes.

80 An Exploration of What Stakeholders Reveal About the Behaviours and Personality of Registered Nurses Working in Older People’s Acute Care Settings and the Potential Influence on Nursing Care

Abstract Background Concern around poor standards of nursing care for older people in hospital has been explored in relation to workload and operational pressures. What is less evident from existing literature is an explanation as to why nurses behave differently under the same pressures within the same concrete situations. Notions of personality and associated behaviours as possible influencers on nursing care delivery are variables that required consideration. Aim To critically explore the behaviours of registered nursing staff working in older people's acute care settings from the perspectives gathered from key stakeholders, and to identify whether there are any distinguishing personality traits that influence effective care delivery for older people. Methods A constructivist grounded theory methodology was used. Semi structured interviews were conducted to gather data from 12 stakeholder participants. Results Through the analysis of data gathered from stakeholders a rubric describing specific behaviours with associated traits emerged leading to the identification of two major types of nursing staff. One group of nurses who work with older people are perceived to have no real desire to do so and in turn their care behaviours are perceived as ‘cold’ and task based. The second group of nurses are perceived as having a true commitment to older people’s wellbeing and their behaviours lead to the delivery of care that is perceived as being highly skilled and compassionate. The proposed theoretical framework that was constructed from this data analysis identifies four key personality traits related to nursing behaviours: conscientiousness, sociability, integrity and coping under a core category heading of ‘the authentic self’. Whilst the authentic self is identified as being the direct influencer on how care is delivered which is defined as the consequence, the influence of context is also taken into account. Conclusions This research offers insights into the meaning of four key traits and the behavioral facets comprising them, the associated behaviors that are displayed and what effect these have on nursing care delivery. Implications for healthcare practice include the potential for further research that can inform the development of educational and recruitment strategies for older people’s nurses which will have a positive impact on the care of the older patient in hospital.

Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.

Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.

Managing urinary incontinence in older people in hospital: a best practice implementation project.

This project aimed to improve care in managing urinary incontinence in older patients admitted to a medium-to-long-stay hospital by developing and implementing strategies to improve the compliance with best practice in managing urinary incontinence and decrease its prevalence. Urinary incontinence (UI) is a major problem in hospitalized older people and is of great significance to public health. The application of evidence-based recommendations for this problem could be expected to improve the quality of care. The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in healthcare practice. Participants were evaluated at baseline and at two follow-ups at three and six months after key strategies had been implemented. The location of this implementation project was the functional rehabilitation ward of a medium-to-long-stay Spanish hospital. In baseline audit there were four process criteria with a high level of compliance: two criteria with 35% and 44% respectively and one criterion without compliance. Action was taken to address the four barriers identified, leading to an increase in all cases except one, which was related to the characteristics of the patient. Prevalence of urinary incontinence decreased at follow-up. The development and implementation of strategies improved quality of care. This project obtained positive results in patient health, and the implementation of the strategies used decreased the prevalence of urinary incontinence in patients.

Effectiveness of the Wearable Sensor Based Ambient Intelligent Geriatric Management System (AmbIGeM) in Preventing Falls in Older People in Hospitals

Background: Pressure sensor alarm systems have shown to be ineffective in preventing falls in hospitals. The AmbIGeM system involves a novel wearable sensor (accelerometer and gyroscope) worn by patients where the data captured by the sensor is interpreted by algorithms to trigger alerts on clinician handheld mobile devices when risk movements are detected. Multiple patients in multiple locations undertaking multiple activities are monitored, augmenting best practice and affording the clinicians the opportunity to intervene before a fall. Methods: A 3-cluster stepped wedge pragmatic trial investigating the effect on the primary outcome of falls rate and secondary outcome of injurious fall and proportion of fallers. Two wards in Western Australia (WA) and one ward in South Australia (SA) were included. Patients aged > 65 years were eligible. Patients requiring palliative care were excluded. A waiver (WA) and opt-out (SA) of consent were obtained for this study. Findings: 4924 older patients were admitted to the study wards with 1076 excluded and 3240 (1995 control, 1245 intervention) enrolled. The median proportion of study duration with valid readings per patient was 49% (IQR 25-67%). There was no significant difference between intervention and control relating to the falls rate (ARR=1.41, 95% CI (0.85, 2.34; p=0.192)), proportion of fallers (OR=1.54, 95% CI (0.91, 2.61); P=0.105) and injurious falls rate (ARR=0.90, 95% CI (0.38, 2.14); p=0.807). In a post hoc analysis, falls and injurious falls rate were reduced in the Geriatric Evaluation and Management Unit (GEMU) wards when the intervention period was compared to the control period. Interpretation: The AmbIGeM system did not reduce the rate of falls, rate of injurious falls or proportion of fallers. There remains a case for further exploration and refinement of this technology given the post hoc analysis findings with the GEMU wards. Trial Registration: The trial was registered with the Australia and New Zealand Clinical Trials registry, number (ANZCTR)12617000981325. Funding Statement: Funded by the National Health and Medical Research Council of Australia (APP1082197) Declaration of Interests: Previously, there was a patent filed (mid 2013) by A/Prof Ranasinghe and Professor Visvanathan titled system, method, software application and data signal for determining movement but this has since lapsed. Professor Visvanathan is the Head of Unit of the Aged & Extended Care Services at the Queen Elizabeth Hospital in South Australia within which the GEM Unit is a service for which, Mr Stephen Hoskins is the Nurse Manager. Dr Kate Ingram is the Falls Lead at Sir Charles Gairdner Hospital in Western Australia. All others have nothing to declare. Ethics Approval Statement: Ethics and governance approval were achieved from TQEH/Lyell McEwin Hospital (LMH)/Modbury Hospital (MH) (HREC/15/TQEH/17) and Curtin University (HRE2017- 0449)/SCGH (PRN 2015-110).

What are we asking for when requesting “Specialling” for the confused hospitalised older person? A concept analysis

The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital. This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding. A total of (n=43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities. The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study. Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.

Energy Expenditure in Older People Hospitalized for an Acute Episode.

Weight loss and worsening of nutritional state is a frequent downfall of acute hospitalization in older people. It is usually accepted that acute inflammation is responsible for hypercatabolism. However, several studies suggest, on the contrary, a reduction in resting energy expenditure (REE). This study aimed to obtain a reliable measure of REE and total energy expenditure (TEE) in older patients hospitalized for an acute episode in order to better assess patients’ energy requirements and help understand the mechanisms of weight loss in this situation. Nineteen hospitalized older patients (mean age 83 years) with C-reactive protein (CRP) level >20mg/L were recruited. REE and TEE were measured using gold standard methods of indirect calorimetry and doubly labeled water (DLW), respectively. REE was then compared to data from a previous study on aged volunteers from nursing homes who were free of an acute stressor event. Energy requirements measured by DLW were confirmed at 1.3 × REE. Energy intake covered the needs but did not prevent weight loss in these patients. TEE was not increased in hospitalized patients and was not influenced by inflammation, while the relationship between REE and inflammation was uncertain. Our results suggest that lean mass remains the major determinant of REE in hospitalized older people and that weight loss may not be explained solely by a state of hypercatabolism.

Bed Moves, Ward Environment, Staff Perspectives and Falls for Older People with High Falls Risk in an Acute Hospital: A Mixed Methods Study.

BackgroundFalls remain an important problem for older people in hospital, particularly those with high falls risk. This mixed methods study investigated the association between multiple bed moves and falls during hospitalisation of older patients identified as a fall risk, as well as safety of ward environments, and staff person-centredness and level of inter-professional collaboration.MethodsPatients aged ≥70 years, admitted through the Emergency Department (ED) and identified at high fall risk, who were admitted to four target medical wards, were followed until discharge or transfer to a non-study ward. Hospital administrative data (falls, length of stay [LoS], and bed moves) were collected. Ward environmental safety audits were conducted on the four wards, and staff completed person-centredness of care, and interprofessional collaboration surveys. Staff focus groups and patient interviews provided additional qualitative data about bed moves.ResultsFrom 486 ED tracked admissions, 397 patient records were included in comparisons between those who fell and those who did not [27 fallers/370 non-fallers (mean 84.8 years, SD 7.2; 57.4% female)]. During hospitalisation, patients experienced one to eight bed moves (mean 2.0, SD 1.2). After adjusting for LoS, the number of bed moves after the move to the initial admitting ward was significantly associated with experiencing a fall (OR 1.56, 95% CI 1.11–2.18). Ward environments had relatively few falls hazards identified, and staff surveys indicated components of person-centredness of care and interprofessional collaboration were rated as good overall, and comparable to other reported hospital data. Staff focus groups identified poor communication between discharging and admitting wards, and staff time pressures around bed moves as factors potentially increasing falls risk for involved patients. Patients reported bed moves increased their stress during an already challenging time.ConclusionPatients who are at high risk for falls admitted to hospital have an increased risk of falling associated with every additional bed move. Strategies are needed to minimise bed moves for patients who are at high risk for falls.

Healthcare professionals\u2019 experiences of providing individualized nutritional care for Older People in hospital and home care: a qualitative study

BackgroundRecent studies indicate inadequate nutritional care practices in healthcare institutions and identify several barriers to perform individualized nutritional care to older persons. Organisation of care can become rigid and standardised, thus failing to be respectful of and responsive to each person’s needs and preferences. There is limited research exploring health professionals’ views on how structure of care allows them to individualize nutritional care to older persons. In this study we aim to explore how healthcare professionals’ experience providing individualised nutritional care within the organisational frames of acute geriatric hospital care and home care.MethodsSemi-structured interviews with 23 healthcare professionals from hospital acute geriatric care and home care. Interviews were analyzed using thematic analysis.ResultsTwo main themes and six sub-themes emerged from the material. Theme 1: ‘Meeting patients with complex nutritional problems’ with the sub-themes: ‘It is much more complex than just not eating’ and ‘seeing nutrition as a part of the whole’. Theme 2: ‘The structure of the nutritional care’, with the sub-themes: ‘Nutritional routines: Much ado, but for what?’, ‘lack of time to individualize nutritional care’, ‘lack of interdisciplinary collaboration in nutritional care’ and ‘meeting challenging situations with limited resources in home care’.ConclusionsThe healthcare professionals described having a high focus on and priority of nutritional care when caring for older persons. They did however find it challenging to practice individualized nutritional care due to the complexity of the patients’ nutritional problems and constraints in the way nutritional care was organised. By describing the challenges the healthcare professionals face when trying to individualize the nutritional care, this study may provide important knowledge to health professionals and policy makers on how to decrease the gap between older patients’ preferences for care and nutritional care practice.

Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists.

Backgroundover 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing.Methodsfifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains.Resultsgeriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing.Conclusionthe behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.

A Wireless Sensor System for Identifying Bed Exits for Hospitalized Older People

Falls of older people in hospitals are common, so there should me techniques in order to reduce these falls. Pressure sensor systems were used for the detection of these falls, which resulted in a larger number of false alarms. Wireless sensors became more advanced in current scenario and using these wireless sensors falls can be prevented mostly. Unlike pressure sensors usage which needs a constant maintainance of the system wireless sensor system is more better in many ways. The type of design which can monitor health condition and analyze the movement and give an alert if patient is moving out of his bed going wrong and we can transmit data wirelessly anywhere by using GSM technology.

Using a general theory of implementation to plan the introduction of delirium prevention for older people in hospital.

To develop an implementation plan for delirium prevention. The use of non-pharmacological interventions to prevent hospital-acquired delirium is well established but their implementation has been notoriously difficult to achieve. Systematic analysis of context as part of implementation planning is critical. Ethnographic study was conducted in a 24-bed general medical ward. Eleven patients and family members and 15 health service staff participated through observations, individual interviews and document review. Inductive analysis was used to generate themes that described enablers and barriers. Enablers included a ward culture that embraced safety and placing the person at the centre of care. Barriers were in tension with the enablers and included limited staff knowledge, specialist forms exclusive to the nursing discipline, inflexible ward routines and frequent disruptions. In addition to standard implementation strategies such as individual education and leadership, implementing delirium prevention requires consideration of team practices, review of policy document design and identification of outcomes data than can support collaborative reflexive practice. The use of a theory-informed ethnographic approach exposed tensions that may be otherwise invisible. Understanding the tensions increases the likelihood of implementation success. Using a systematic assessment approach can create a comprehensive implementation plan.

Exercise helps older people in hospital avoid functional decline

Exercise helps older people in hospital avoid functional decline

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

BackgroundThe Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.ObjectivesTo improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.MethodsWe used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.ResultsWe included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.LimitationsThe risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.ConclusionsThe CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.FundingThe National Institute for Health Research Health Services and Delivery Research programme.