Hospitalization In Older Patients Research Articles

Older Adult Inpatient Falls in Acute Care Hospitals: Intrinsic, Extrinsic, and Environmental Factors

The current integrative literature review of 23 studies aimed to identify multidimensional risk factors of falls among older adult patients in acute care hospitals. The incidence rate of fall-related injuries ranged from 6.8% to 72.1%. Advanced age was a major intrinsic risk factor, whereas being a patient in a geriatric unit was a significant extrinsic factor for inpatient falls and fall-related injuries based on statistical significance obtained from quantitative data analyses. Other critical risk factors were: (a) cognitive impairment; (b) impaired mobility; (c) prolonged length of hospital stay; and (d) fall history. Environmental/situational factors, such as patient ambulation and fall locations, also contributed to inpatient falls. In clinical practice, nurses need to know who are the most vulnerable patients in the hospital and develop comprehensive interventions to decrease intrinsic, extrinsic, and environmental risk factors. Prospective mixed-methods studies are needed to examine psychosocial factors and consequences of falls.

Age and sex differences in long-term outcomes following implantable cardioverter-defibrillator placement in contemporary clinical practice: findings from the Cardiovascular Research Network.

BackgroundPatient sex and age may influence rates of death after receiving an implantable cardioverter-defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized.Methods and ResultsWe studied 2954 patients with left ventricular ejection fraction ≤0.35 undergoing first-time implantable cardioverter-defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged >65 years. In a median follow-up of 2.4 years, outcome rates per 1000 patient-years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure-related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged >65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification (P=0.03 for sex–New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure (P=0.05 for age–etiology interaction).ConclusionsThe burden of adverse outcomes after receipt of an implantable cardioverter-defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics.

What do patients wear on their feet? A service evaluation of footwear in elderly patients

Background/Aims: Appropriate footwear is regarded as an important component of falls prevention in older people. Scant data exists regarding the types of footwear older patients wear in hospital, which may hinder the development of future interventions in this high-risk fall group. To address this, we conducted a service evaluation to examine and describe the style and quality of footwear worn by older patients in hospital. Methods: The footwear of older patients admitted to an acute NHS trust in England was assessed using the Footwear Assessment Tool. Patients were interviewed about their footwear choices. Results: A total of 730 pairs of footwear from 675 patients were assessed. The most common types of footwear worn were slippers (46%) and gripper socks (37%). Much of the footwear had a good fit, but over 50% lacked adequate structure, stability and support, more than 60% had no cushioning and 60% had no fixation. Approximately 60% of footwear was more than 12 months old, with signs of moderate to excess wear. Patients valued comfort and the familiarity of their own footwear. Conclusions: This service evaluation provides new information on footwear worn by older inpatients in hospital. Many patients are wearing footwear with insufficient structure to promote optimal stability or gait. Providing safe footwear that is suitable for use in hospital is potentially a low-technology and resource-efficient way to promote safety in older patients.

Older Adults Research in Acute Care – Breaking the Barriers

Population-based growth has familiarized health care providers with the special needs of older patients. We know the elderly, those 65 years or older, represent 13.7% of the U.S. population, with a projected rise to 19% by 2030 (Administration on Aging, 2013). Yet, the Cumulative Index to Nursing and Allied Health indicates that only 3%-6% of clinical trials are specific to the older adult aged population (Orwig, Williams, & Martin, 2011). Older adult patients in acute care hospitals (ACH) are known to have multiple comorbidities that include respiratory ailments, cardiac diseases, falls, cognitive impairments, and depression (Formiga et al., 2012; CDC, 2014). Studies have demonstrated that comorbid conditions increase with age (Formiga et al., 2012; Barnett et al., 2012).

7 * WHAT DO PATIENTS WEAR ON THEIR FEET? A SERVICE EVALUATION OF FOOTWEAR IN ELDERLY PATIENTS (STEP)

Background/Aims: Appropriate footwear is regarded as an important component of falls prevention in older people. Scant data exists regarding the types of footwear older patients wear in hospital, which may hinder the development of future interventions in this high-risk fall group. To address this, we conducted a service evaluation to examine and describe the style and quality of footwear worn by older patients in hospital. Methods: The footwear of older patients admitted to an acute NHS trust in England was assessed using the Footwear Assessment Tool. Patients were interviewed about their footwear choices. Results: A total of 730 pairs of footwear from 675 patients were assessed. The most common types of footwear worn were slippers (46%) and gripper socks (37%). Much of the footwear had a good fit, but over 50% lacked adequate structure, stability and support, more than 60% had no cushioning and 60% had no fixation. Approximately 60% of footwear was more than 12 months old, with signs of moderate to excess wear. Patients valued comfort and the familiarity of their own footwear. Conclusions: This service evaluation provides new information on footwear worn by older inpatients in hospital. Many patients are wearing footwear with insufficient structure to promote optimal stability or gait. Providing safe footwear that is suitable for use in hospital is potentially a low-technology and resource-efficient way to promote safety in older patients.

The relationship of the skeletal muscle index and nutritional status in frail older hospital patients

The relationship of the skeletal muscle index and nutritional status in frail older hospital patients

The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones. We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed. In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode. The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

Why frailty needs vulnerability: A care ethical perspective on hospital care for older patients.

The vulnerability of older hospital patients is increasingly understood in physical terms, often referred to as frailty. This reduces their vulnerability to the functioning body regardless of the psycho-socio-cultural context they are in, and it ignores the role of the hospital environment. This paper starts from a care ethical perspective on care and uses insights from empirical work that shows that hospitalization of older patients is characterized by experiences of uncertainty that give rise to feelings of vulnerability. This paper presents a model that clarifies how vulnerability occurs in the interplay between the embodied subject, others, daily life and the hospital, and shows its dynamic and relational nature. Our complementary perspective of vulnerability is vital for nursing practice in that it starts from the situatedness of the older patient and not only points at what is missing but also at what is of significance to the older patient. Taking into account this perspective helps improving relational care.

Home, please: A conjoint analysis of patient preferences after a bad hip fracture.

An Australian study of older, community-dwelling women found that 80% would rather be dead than experience loss of independence and nursing home admission after a bad hip fracture. We re-examined this issue using a conjoint analysis approach. We asked older hospital patients with a history of falls, fracture or osteoporosis to imagine they had a hip fracture resulting in significant residual disability. Subjects were asked to rank in order of preference an orthogonal array of nine out of 36 potential outcome scenarios reporting risk of falls, life expectancy, discharge home with support or to a nursing home and family agreement or disagreement with discharge location. Of 192 patients satisfying inclusion criteria, 183 agreed to participate and 97 completed the study. Those who failed to complete the study were older and had lower Mini-Mental State Examination scores than those who completed the study. For the group as a whole, averaged importance scores were: discharge residence 31.3%, length of life 27%, fall risk 26.4% and family preference 15.5%. On average, subjects would be willing to sacrifice approximately 9 months of life in order to return home rather than go to a nursing home. In the present study, older people at high risk for fracture judged that after a bad hip fracture their main priority would be to remain at home.

Feeling an outsider left in uncertainty - a phenomenological study on the experiences of older hospital patients.

This paper starts from a care ethical perspective on care and reports on a phenomenological study into older patients' experiences of hospitalisation. Although hospital care for older patients is at the centre of attention, questions what is at stake and what defines quality of care are rarely discussed with a view to the perspective of older patients themselves. The qualitative observational method of shadowing was used. Ten patients of 75 years old or older were shadowed from admission until discharge. The reflective lifeworld approach, based on phenomenological philosophy, was used to analyse the collected data. For the older patients included in the study, the essential meaning of hospitalisation can be described as feeling an outsider left in uncertainty. The word 'left' reveals how hospitalisation is experienced as a solitary struggle with various uncertainties that are related both to the hospital environment and to the patient's personal situation. The essential meaning is composed of the following three constituents: (i) staying in an inhospitable place, (ii) feeling constrained and (iii) experiencing disruption. The busy walking back and forth of care professionals and the functional character of involvement, restrain older patients from participating and make them feel abandoned. Feeling constrained reveals the feelings brought on by the ageing body which are emphasised by hospitalisation but often neglected by hospital staff. The failure of healthcare professionals to recognise and respond to who older patients are aside from their illness exacerbate the experience of disruptions. To improve care, hospital staff must be more sensitive to older patients' uncertainties. Also, hospital staff should provide older patients with understandable information and explanation which besides offering patients the possibility to feel involved, meets their need for recognition.

What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families.

The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families. We used a cross-sectional study design involving patients from 9 Canadian hospitals. We asked older adult patients with serious illness and their family members about the occurrence and importance of 11 guideline-recommended elements of goals-of-care discussions. In addition, we assessed concordance between prescribed goals of care and patient preferences, and we measured patient satisfaction with goals-of-care discussions using the Canadian Health Care Evaluation Project (CANHELP) questionnaire. Our study participants included 233 patients (mean age 81.2 yr) and 205 family members (mean age 60.2 yr). Participants reported that clinical teams had addressed individual elements of goals-of-care discussions infrequently (range 1.4%-31.7%). Patients and family members identified the same 5 elements as being the most important to address: preferences for care in the event of life-threatening illness, values, prognosis, fears or concerns, and questions about goals of care. Addressing more elements was associated with both greater concordance between patients' preferences and prescribed goals of care, and greater patient satisfaction. We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting.

Systematic review of fall risk screening tools for older patients in acute hospitals.

To determine the most accurate fall risk screening tools for predicting falls among patients aged 65years or older admitted to acute care hospitals. Falls represent a serious problem in older inpatients due to the potential physical, social, psychological and economic consequences. Older inpatients present with risk factors associated with age-related physiological and psychological changes as well as multiple morbidities. Thus, fall risk screening tools for older adults should include these specific risk factors. There are no published recommendations addressing what tools are appropriate for older hospitalized adults. Systematic review. MEDLINE, CINAHL and Cochrane electronic databases were searched between January 1981-April 2013. Only prospective validation studies reporting sensitivity and specificity values were included. Recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews have been followed. Three fall risk assessment tools were evaluated in seven articles. Due to the limited number of studies, meta-analysis was carried out only for the STRATIFY and Hendrich Fall Risk Model II. In the combined analysis, the Hendrich Fall Risk Model II demonstrated higher sensitivity than STRATIFY, while the STRATIFY showed higher specificity. In both tools, the Youden index showed low prognostic accuracy. The identified tools do not demonstrate predictive values as high as needed for identifying older inpatients at risk for falls. For this reason, no tool can be recommended for fall detection. More research is needed to evaluate fall risk screening tools for older inpatients.

Medication misadventures in older adults: literature from 2013.

The objective of this paper is to review articles published in 2013 examining drug-related problems in the elderly and comment on their potential impact on clinical practice. To identify articles, we did a systematic search of the English-language literature restricted to those aged 65 + from January 2013 to December 2013 using Medline and Google Scholar and a combination of the following search terms: drug-related problems, medication-related problems, medication errors, suboptimal prescribing, inappropriate prescribing, underutilization, polypharmacy, medication monitoring, medication dispensing, medication administration, medication adherence, adverse drug events, and adverse drug withdrawal events. A manual search of major general medicine and clinical pharmacology journals was also conducted to identify additional articles. A total of 51 articles were identified of which 20 were chosen to highlight. Three were annotated and critiqued and the additional 17 articles were summarized in an appendix. One article reported the results of a randomized controlled trial that showed that a pharmacist intervention successfully reduced suboptimal prescribing in older hospital patients. Another paper from this group previously reported data from the same study showing that the intervention also reduced medication related readmissions to the hospital. An observational study compared the use of two thiazide diuretics in older outpatients. They found that chlorthalidone was more likely to cause hypokalemia than hydrochlorothiazide. Finally, in a randomized controlled trial a pharmacist intervention resulted in the reduction of anticholinergic burden but did result in an improvement in cognition. These studies highlight that medication errors and adverse drug events continue to be important issues for health care professionals caring for older adults.

Depressive symptoms and adverse outcomes from hospitalization in older adults: Secondary outcomes of a trial of falls prevention education

Depression is common in older people and symptoms of depression are known to substantially increase during hospitalization. There is little known about predictors of depressive symptoms in older adults or impact of common interventions during hospitalization. This study aimed to describe the magnitude of depressive symptoms, shift of depressive symptoms and the impact of the symptoms of depression among older hospital patients during hospital admission and identify whether exposure to falls prevention education affected symptoms of depression.Participants (n=1206) were older adults admitted within two Australian hospitals, the majority of participants completed the Geriatric Depression Scale – Short Form (GDS) at admission (n=1168). Participants’ mean age was 74.7 (±SD 11) years and 47% (n=551) were male.At admission 53% (619 out of 1168) of participants had symptoms of clinical depression and symptoms remained at the same level at discharge for 55% (543 out of 987). Those exposed to the low intensity education program had higher GDS scores at discharge than those in the control group (low intensity vs control n=652, adjusted regression coefficient (95% CI)=0.24 (0.02, 0.45), p=0.03). The only factor other than admission level of depression that affected depressive symptoms change was if the participant was worried about falling.Older patients frequently present with symptoms of clinical depression on admission to hospital. Future research should consider these factors, whether these are modifiable and whether treatment may influence outcomes.

Comprehensive geriatric assessment

British Journal of Hospital MedicineVol. 75, No. Sup8 Clinical Skills for Postgraduate ExaminationsComprehensive geriatric assessmentLucille Ramani, Daniel S Furmedge, Swapna PH ReddyLucille RamaniSearch for more papers by this author, Daniel S FurmedgeSearch for more papers by this author, Swapna PH ReddySearch for more papers by this authorLucille Ramani; Daniel S Furmedge; Swapna PH ReddyPublished Online:11 Aug 2014https://doi.org/10.12968/hmed.2014.75.Sup8.C122AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Barton A, Mulley G (2003) History of the development of geriatric medicine in the UK. Postgrad Med J 79(930): 229–34 (doi: https://doi.org/10.1136/pmj.79.930.229) Crossref, Medline, Google ScholarCollerton J, Davies K, Jagger C (2009) Health and disease in 85 year olds: baseline findings from the Newcastle 85+ cohort study. BMJ 339: b4904 (doi: https://doi.org/10.1136/bmj.b4904) Crossref, Medline, Google ScholarDavis DH, Muniz Terrera G, Keage H et al. (2012) Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study. Brain 135(9): 2809–16 (doi: https://doi.org/10.1093/brain/aws190) Crossref, Medline, Google ScholarEllis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P (2011) Comprehensive geriatric assessment for older hospital patients admitted to hospital: meta-analysis of randomised controlled trials. BMJ 343: d6553 (doi: https://doi.org/10.1136/bmj.d6553) Crossref, Medline, Google ScholarFerri CP, Prince M, Brayne C et al. (2005) Global prevalence of dementia: a Delphi consensus study. Lancet 366(9503): 2112–17 (doi: https://doi.org/10.1016/S0140-6736(05)67889-0) Crossref, Medline, Google ScholarFitzgerald R, Pirmohamed M (2007) Polypharmacy and the elderly. Geriatric Medicine 37(7): 41–5 Google ScholarKakuma R, du Fort GG, Arsenault L et al. (2003) Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 51(4): 443–50 (doi: https://doi.org/10.1046/j.1532-5415.2003.51151.x) Crossref, Medline, Google ScholarManthorpe J, Iliffe S (2010) Suicide in later life: public health and practitioner perspectives. Int J Geriatr Psychiatry 25(12): 1230–8 (doi: https://doi.org/10.1002/gps.2473) Crossref, Medline, Google ScholarMatheson J (2009) National statistician's annual article on the population: a demographic review. Population Trends Winter (138): 7–21 Crossref, Medline, Google ScholarNasreddine Z, Phillips N, Bedirian V et al. (2005) The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53(4): 695–9 (doi: https://doi.org/10.1111/j.1532-5415.2005.53221.x) Crossref, Medline, Google ScholarNational Institute for Health and Care Excellence (2006) Dementia: supporting people with dementia and their carers in health and social care. CG42. National Institute for Health and Care Excellence, London Google ScholarNational Institute for Health and Care Excellence (2013) Falls: assessment and prevention of falls in older people. CG161. National Institute for Health and Care Excellence, London Google ScholarOrganisation for Economic Co-operation and Development (2004) Ageing societies and the looming pension crisis. Organisation for Economic Co-operation and Development, Paris, France Google ScholarRoyal College of Physicians, National Council for Palliative Care, British Society of Rehabilitation Medicine, British Geriatrics Society, Alzheimer's Society, Royal College of Nursing, Royal College of Psychiatrists, Help the Aged, Royal College of General Practitioners (2009) Advance care planning: Concise Guidance to Good Practice series, No 12. Royal College of Physicians, London Google Scholar FiguresReferencesRelatedDetailsCited byPerioperative management of elderly and senile patients. RecommendationsAnnals of critical care, No. 3Comprehensive Geriatric Assessment—Resolved and Unresolved Issues (Review)9 December 2021 | Advances in Gerontology, Vol. 11, No. 4Clinical guidelines frailty. Part 226 May 2020 | Russian Journal of Geriatric Medicine, No. 2Meta-analysis: Effectiveness of Comprehensive Geriatric Care for Elderly Following Hip Fracture Surgery17 July 2019 | Western Journal of Nursing Research, Vol. 42, No. 4Clinical guidelines on frailty14 February 2020 | Russian Journal of Geriatric Medicine, No. 1Acute hospital dementia care: results from a national audit31 May 2016 | BMC Geriatrics, Vol. 16, No. 1 1 August 2014Volume 75Issue Sup8ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 11 August 2014 Published in print 1 August 2014 Information© MA Healthcare LimitedPDF download

Amélioration de la couverture vaccinale anti-pneumococcique chez le sujet âgé

PurposeTo study pneumococcal immunization coverage in older patients in hospital, and the impact of two actions aiming at improving this coverage. MethodsWe reported a prospective and descriptive study conducted from November 2009 to August 2010, including all new patients ≥75 years old received in a geriatric short-stay department and residing in Val-de-Marne, France. This study was performed in three successive three-month periods, to assess the vaccination coverage in the months following hospital release. Period I was the reference; Period II included an awareness campaign of general practitioners relying on the hospitalization discharge report, containing an indication for the vaccination; Period III consisted in a systematic proposal of vaccination by the geriatric hospital department. ResultsIndication for pneumococcal vaccination has been given to 139 patients (61.2%) in 227 processed questionnaires. The main indication was heart failure for 105 patients (75.5%). Twenty-four patients were already vaccinated (17.2%). No vaccination was reported in the three months following period I in 33 included patients. The awareness campaign targeting regular doctors resulted in only one vaccination out of 37 patients. Immunization coverage in the department had reached 84.5% of inoculation (38 of 45 patients). ConclusionPneumococcal vaccination is often prescribed in elderly patients but generally not executed. The awareness campaign did not result in a big enough immunization coverage improvement, compared to a codified proposal of vaccination during hospital stay.

Bioelectrical impedance vector analysis, phase-angle assessment and relationship with malnutrition risk in a cohort of frail older hospital patients in the United Kingdom

ObjectiveBioelectrical impedance vector analysis (BIVA) and phase angle (PA) have been shown previously to indicate relative nutritional status in patients. The aim of this study was to investigate the application of BIVA and PA assessments in a cohort of frail older hospital patients and compare these assessments with malnutrition risk screening by MUST (Malnutrition Universal Screening Tool), and the MNA-SF® (Mini-Nutritional Assessment-Short Form). MethodsSixty-nine patients (n = 44 men; n = 25 women; age 82.1 ± 7.6 y [range 62–96 y]; body mass index 25.8 ± 5.4 kg/m2 [range 16.6–45.1 kg/m2]) were recruited from hospital wards specializing in the care of frail older individuals from the United Kingdom. Bioelectrical impedance assessment was performed at 50 khz frequency, BIVA was performed using raw impedance data, PA was calculated, and data were compared against reference population groups. Patients were categorized by malnutrition risk by MUST and MNA-SF. ResultsBIVA indicated that the men and women in the study were significantly different from reference population groups (P < 0.0001), with a noticeable reduced capacitive reactance (xC) component. The group mean PA was 4.6° ± 1.1° (2.4°–9.2°). The mean PA for men was 4.7° ± 1.3° (2.4°–9.2°), and for women it was 4.5° ± 0.7° (2.8–6.0°). Group PA correlated with MNA-SF score (P = 0.05). MUST categorized patients predominantly at low risk for malnutrition (80%); whereas MNA-SF was at risk (46%) and malnourished (45%). ConclusionsThe significant reduction in xC component and PA is consistent with other studies and is indicative of a reduced body cell mass and nutritional status with aging and illness. The general trend in MNA-SF scoring was more consistent with these patterns as a group; but requires clarification in larger cohorts. Future studies are necessary with an aim to improve and optimize care of frail older people.

A comparison of the malnutrition screening tools, MUST, MNA and bioelectrical impedance assessment in frail older hospital patients

This cohort study aimed to investigate and compare the ability to predict malnutrition in a group of frail older hospital patients in the United Kingdom using the nutritional risk screening tools, MUST (malnutrition universal screening tool), MNA-SF(®) (mini nutritional assessment-short form) and bioelectrical impedance assessment (BIA) of body composition. MUST and MNA-SF was performed on 78 patients (49 males and 29 females, age: 82 y ± 7.9, body mass index (BMI): 25.5 kg/m(2) ± 5.4), categorised by nutritional risk, and statistical comparison and test reliability performed. BIA was performed in 66 patients and fat free mass (FFM), fat mass (FM) and body cell mass (BCM) and index values (kg/m(2)) calculated and compared against reference values. MUST scored 77% patients 'low risk', 9% 'medium risk' and 14% 'high risk', compared to MNA-SF categorisation: 9%, 46% and 45%, respectively (P < 0.000001). Reliability assessment found poor reliability between the screening tools (coefficient, r = 0.4). Significant positive correlations were found between most variables (P < 0.05-<0.001); although females exhibited greater variation. FFM index analysis found 40% of males low/depleted, 21% borderline/at risk with 96% categorised by MNA-SF as either malnourished or at risk (MUST-35%). 29% males had low FM index and all appropriately classified by MNA-SF. 30% females had low FFM index or borderline, MNA-SF screening appropriately categorised 86% (compared to MUST-29%). This preliminary data may have significant clinical implications and highlights the potential ability of the MNA-SF and BIA to accurately assess malnutrition risk over MUST in frail older hospital patients.

Serum IL-6 and IGF-1 improve clinical prediction of functional decline after hospitalization in older patients.

Although inflammatory and hormonal markers have been associated with further functional adverse outcomes in community- dwelling seniors, these markers have not been studied from this perspective in acutely ill older patients. This prospective study was designed to determine whether biological markers can improve the predictive value of a clinical screening tool to assess the risk of functional decline in hospitalized older patients. Patients aged 75 years and over admitted for hip fracture, acute heart failure or infection (n=118) were recruited. The clinical screening tool SHERPA was filled in on admission, with concomitant measurement of interleukin-6 (IL-6), insulin-like growth factor 1 (IGF-1), C-reactive protein (CRP), white blood cells, urea, albumin, pre-albumin and total cholesterol. Functional decline was defined as a decrease of one point in the activities of daily living scale between pre-admission and 3-month post-discharge status. We compared the discrimination calibration of SHERPA vs SHERPA+, a logistic regression model including SHERPA and selected biomarkers. Three months after discharge, functional decline had occurred in 46 patients. IL-6 and IGF-1 were selected, since their levels were significantly different between decliners and non-decliners, and were included in the new logistic regression model SHERPA+. Areas under the ROC curve [95% CI] for functional decline prediction were 0.73 [0.63-0.81] for SHERPA vs 0.79 [0.69-0.86] for SHERPA+ (p=0.14). However, SHERPA+ was better calibrated, as the average predicted risk of functional decline within subgroups matched the proportion which actually underwent functional decline (Brier score=0.185). Since functional decline was higher in patients with hip fracture, the SHERPA+ model was challenged by including the diagnosis. Only SHERPA, IGF-1 and diagnosis were significantly associated with functional decline. Selected biological markers may marginally improve the clinical prediction of post-discharge functional decline in hospitalized patients, and may allow to stratify them appropriately. The predictive value of these biomarkers is not fully independent of disease status. Further studies are needed to confirm these results in a cohort representative of older patients admitted through the emergency department.

Barriers to nutritional care for the undernourished hospitalised elderly: perspectives of nurses

Aims and objectivesTo identify what nurses experience as barriers to ensuring adequate nutritional care for the undernourished hospitalized elderly.BackgroundUndernutrition occurs frequently among the hospitalised elderly and can result in a variety of negative consequences if not treated. Nevertheless, undernutrition is often unrecognised and undertreated. Nurses have a great responsibility for nutritional care, as this is part of the patient's basic needs. Exploring nurses' experiences of preventing and treating undernourishment among older patients in hospitals is therefore highly relevant.DesignA focus group study was employed based on a hermeneutic phenomenological methodological approach.MethodsFour focus group interviews with totally 16 nurses working in one large university hospital in Norway were conducted in spring 2012. The nurses were recruited from seven somatic wards, all with a high proportion of older (≥70 years) inpatients. The data were analysed in the three interpretative contexts: self-understanding, a critical common-sense understanding and a theoretical understanding.ResultsWe identified five themes that reflect barriers the nurses experience in relation to ensuring adequate nutritional care for the undernourished elderly: loneliness in nutritional care, a need for competence in nutritional care, low flexibility in food service practices, system failure in nutritional care and nutritional care is being ignored.ConclusionsThe results imply that nutritional care at the university hospital has its limits within the hospital structure and organisation, but also regarding the nurses' competence. Moreover, the barriers revealed that the undernourished elderly are not identified and treated properly as stipulated in the recommendations in the national guidelines on the prevention and treatment of undernutrition.Relevance to clinical practiceThe barriers revealed in this study are valuable when considering improvements to nutritional care practices on hospital wards to enable undernourished older inpatients to be identified and treated properly.