IMPORTANCE Mobility limitations are common in older adults, affecting the physical, psychological, and social aspects of an older adult’s life. OBJECTIVE To identify mobility risk factors, screening ...tools, medical management, need for physical therapy, and efficacy of exercise interventions for older primary care patients with limited mobility. EVIDENCE ACQUISITION Search of PubMed and PEDro from January 1985 to March 31, 2013, using the search terms mobility limitation, walking difficulty, and ambulatory difficulty to identify English-language, peer-reviewed systematic reviews, meta-analyses, and Cochrane reviews assessing mobility limitation and interventions in community-dwelling older adults. Articles not appearing in the search referenced by reviewed articles were also evaluated. FINDINGS The most common risk factors for mobility impairment are older age, low physical activity, obesity, strength or balance impairment, and chronic diseases such as diabetes or arthritis. Several tools are available to assess mobility in the ambulatory setting. Referral to physical therapy is appropriate, because physical therapists can assess mobility limitations and devise curative or function-enhancing interventions. Relatively few studies support therapeutic exercise to improve mobility limitation. Strong evidence supports resistance and balance exercises for improving mobility-limiting physical weakness and balance disorders. Assessing a patient’s physical environment and the patient’s ability to adapt to it using mobility devices is critical. CONCLUSIONS AND RELEVANCE Identification of older adults at risk for mobility limitation can be accomplished through routine screening in the ambulatory setting. Addressing functional deficits and environmental barriers with exercise and mobility devices can lead to improved function, safety, and quality of life for patients with mobility limitations.
OBJECTIVES: To examine the proportion of time spent in three levels of mobility (lying, sitting, and standing or walking) by a cohort of hospitalized older veterans as measured by validated wireless ...accelerometers.
DESIGN: A prospective, observational cohort study.
SETTING: One hundred fifty–bed Department of Veterans Affairs hospital.
PARTICIPANTS: Forty‐five hospitalized medical patients, aged 65 and older who were not delirious, did not have dementia, and were able to walk in the 2 weeks before admission were eligible.
MEASUREMENTS: Wireless accelerometers were attached to the thigh and ankle of patients for the first 7 days after admission or until hospital discharge, whichever came first. The mean proportion of time spent lying, sitting, and standing or walking was determined for each hour after hospital admission using a previously validated algorithm.
RESULTS: Forty‐five male patients (mean age 74.2) with a mean length of stay of 5.1 days generated 2,592 one‐hour periods of data. A baseline functional assessment indicated that 35 (77.8%) study patients were willing and able to walk a short distance independently. No patient remained in bed the entire measured hospital stay, but on average, 83% of the measured hospital stay was spent lying in bed. The average amount of time that any one individual spent standing or walking ranged from a low of 0.2% to a high of 21%, with a median of 3%, or 43 minutes per day.
CONCLUSION: This is the first study to continuously monitor mobility levels early during a hospital stay. On average, older hospitalized patients spent most of their time lying in bed, despite an ability to walk independently.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
IMPORTANCE Providing high-quality care while containing cost is essential for the economic stability of our health care system. The United States is experiencing a rapidly growing elderly population. ...The Acute Care for Elders (ACE) unit interdisciplinary team model of care has been shown to improve outcomes in hospitalized older adults. The University of Alabama at Birmingham ACE unit incorporates evidence-based care processes. We hypothesized that the ACE model would also reduce costs. OBJECTIVE To examine variable direct costs from an interdisciplinary ACE compared with a multidisciplinary usual care (UC) unit. DESIGN Retrospective cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS Hospitalists' patients aged 70 years or older spending the entirety of their hospitalization in either the ACE or UC unit in fiscal year 2010. MAIN OUTCOME MEASURES Using administrative data, we analyzed variable direct costs for ACE and UC patients. We also conducted a subset analysis restricted to the 25 most common diagnosis related groups (DRGs) shared by ACE and UC patients. Generalized linear regression was used to estimate cost ratios and 95% confidence intervals adjusted for age, sex, comorbidity score, and case mix index (CMI). RESULTS A total of 818 hospitalists' patients met inclusion criteria: 428 from the ACE and 390 from the UC unit. For this study group (all DRGs), the mean (SD) variable direct cost per patient was $2109 ($1870) for ACE and $2480 ($2113) for UC (P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) or moderate (0.74; 95% CI, 0.62-0.89) CMI scores; care was cost neutral for patients with high CMI scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients than UC patients were readmitted within 30 days of discharge (7.9% vs 12.8%; P = .02). Subset analysis of the 25 most common DRGs revealed a significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC patients ($1693 $1063 vs $2138 $1431; P < .001); cost ratios for total (0.78; 95% CI, 0.70-0.87) and daily (0.89; 95% CI, 0.85-0.94) variable direct costs remained significant after adjustment. CONCLUSIONS AND RELEVANCE The ACE unit team model reduces costs and 30-day readmissions. In an era when improving care processes while reducing costs is a vital objective for the Medicare program and our nation as a whole, the ACE model meets these goals.
Abstract The purpose of the research was to demonstrate that comorbid health conditions disproportionately affect elderly cancer patients. Descriptive analyses and stacked area charts were used to ...examine the prevalence and severity of comorbid ailments by age of 27,506 newly diagnosed patients treated at one of eight cancer centers between 1998 and 2003. Hypertension was the most common ailment in all patients, diabetes was the second most prevalent ailment in middle-aged patients, and previous solid tumor(s) were the second most prevalent ailment in patients aged 74 and older. Although the prevalence and severity of comorbid ailments including dementia and congestive heart failure increased with age, some comorbidities such as HIV/AIDS and obesity decreased. Advances in cancer interventions have increased survivorship, but the impact of the changing prevalence and severity of comorbidities at different ages has implications for targeted research into targeted clinical and psychosocial interventions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The clinical benefits of Acute Care for Elders (ACE) units have been established for over 25 years. However, how widely disseminated ACE units are in the United States and the degree of fidelity to ...the key elements of this model of care are unknown. Our objective was to identify all existing ACE units in the United States and to obtain detailed information about variations in implementation.
The strategy to identify current ACE units began with online searches and snowball sampling using contacts from professional societies and workgroups. Next, a request for information regarding the existence of ACE units was sent to the remaining US hospitals listed in a national hospital database. An online survey was sent to identified ACE unit contacts to capture information on implementation characteristics and the five key elements of ACE units.
There were 3692 hospitals in the database with responses from 2055 (56%) hospitals reporting the presence or absence of an ACE unit. We identified 68 hospitals (3.3%) with an existing or previous ACE unit. Of these 68 hospitals, 50 (74%) completed the survey and reported that 43 ACE units were currently open and 7 had been closed. Of the 43 currently open ACE units, most are affiliated with an academic hospital and there is variable implementation of each of the five key ACE elements (from 69% to 98%).
Among the 50 hospitals to complete the survey, 43 current ACE units were identified, with variable fidelity to the key elements. Estimates of prevalence of ACE units and fidelity to key elements are limited by nonresponses to the national survey request by nearly half of hospitals.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The ...aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process.
The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed.
Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults.
This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.
Emergency departments (EDs) play a growing role in hospital admissions for older adults, yet nationally representative data on predictors of admission from the EDs are limited.
We examined ...sociodemographic, clinical, and hospital characteristics associated with non-ICU admissions, using National Hospital Ambulatory Medical Care Survey data and multivariate Poisson regression models.
There were an estimated 175 million ED visits by adults older than 65 years from 2001 to 2010. Overall, 32.5% were admitted to non-ICU beds. In multivariate analysis, non-ICU admission was associated with increasing age (16% higher per 10-year increase in age), white versus black race (35% vs 31%), and EDs in the Northeast (40%) or Midwest (38%) versus South (31%) or West (30%).
Non-ICU admission rates for older adults receiving care in U.S. EDs vary by age, race, and region. Understanding the reasons for these disparities in hospitalization rates may guide interventions to reduce hospitalizations in older adults.
OBJECTIVE:The aim of this study was to obtain feedback from key stakeholders and end users to identify program strengths and weaknesses to plan for wider dissemination and implementation of the ...Virtual Acute Care for Elders (Virtual ACE) program, a novel intervention that improves outcomes for older surgical patients.
BACKGROUND:Virtual ACE was developed to deliver evidence-based geriatric care without requiring daily presence of a geriatrician. Previous work demonstrated that Virtual ACE increased mobility and decreased delirium rates for surgical patients.
METHODS:We conducted semi-structured interviews with 30 key stakeholders (physicians, nurses, hospital leadership, nurse managers, information technology staff, and physical/occupational therapists) involved in the implementation and use of the program.
RESULTS:Our stakeholders indicated that Virtual ACE was extremely empowering for bedside nurses. The program helped nurses identify older patients who were at risk for a difficult postoperative recovery. Virtual ACE also gave them skills to manage complex older patients and more effectively communicate their needs to surgeons and other providers. Nurse managers felt that Virtual ACE helped them allocate limited resources and plan their unit staffing assignments to better manage the needs of older patients. The main criticism was that the Virtual ACE Tracker that displayed patient status was difficult to interpret and could be improved by a better design interface. Stakeholders also felt that program training needed to be improved to accommodate staff turnover.
CONCLUSIONS:Although respondents identified areas for improvement, our stakeholders felt that Virtual ACE empowered them and provided effective tools to improve outcomes for older surgical patients.
Delirium is a common complication during acute care hospitalizations in older adults. A substantial percentage of admissions are for ambulatory care-sensitive conditions (ACSCs) or potentially ...avoidable hospitalizations-conditions that might be treated early in the outpatient setting to prevent hospitalization and hospital complications.
This retrospective cross-sectional study examined rates of delirium among older adults hospitalized for ACSCs. Participants were 39 933 older adults ≥65 years of age admitted from January 1, 2015 to December 31, 2019 to general inpatient units and ICUs of a large Southeastern academic medical center. Delirium was defined as a score ≥ 2 on the Nursing Delirium Screening Scale or positive on the Confusion Assessment Method for the Intensive Care Unit during admission, and ACSCs were identified from the primary admission diagnosis using standardized definitions. Generalized linear mixed models were used to examine the association between ACSCs and delirium, compared with admissions for non-ACSC diagnoses, adjusting for covariates and repeated observations for individuals with multiple admissions.
Delirium occurred in 15.6% of admissions for older adults. Rates were lower for ACSC admissions versus admissions for other conditions (13.9% vs 15.8%, p < .001). Older age and higher comorbidity were significant predictors of the development of delirium.
Rates of delirium among older adults hospitalized for ACSCs were lower than rates for non-ACSC hospitalization but still substantial. Optimizing the treatment of ACSCs in the outpatient setting is an important goal not only for reducing hospitalizations but also for reducing risks for hospital-associated complications such as delirium.
To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults.
Retrospective cross-sectional study.
...General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019.
Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD.
One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001).
Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.
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