The objective of this study is to assess the performance of existing wear/nonwear time classification algorithms for accelerometry data collected in the free-living environment using a wrist-worn ...triaxial accelerometer and a waist-worn uniaxial accelerometer in older adults.
Twenty-nine adults age 76 to 96 yr wore wrist accelerometers for approximately 24 h per day and waist accelerometers during waking for approximately 7 d of free living. Wear and nonwear times were classified by existing algorithms (Alg(ActiLife), Alg(Troiano), and Alg(Choi)) and compared with wear and nonwear times identified by data plots and diary records. With the use of bias and probability of correct classification, the performance of the algorithms, two time windows (60 and 90 min), and vector magnitude (VM) versus vertical axis (V) counts from a triaxial accelerometer were compared.
Automated algorithms (Alg(Choi) and Alg(Troiano)) classified wear/nonwear time intervals more accurately from VM than V counts. The use of the 90-min time window improved wear/nonwear classification accuracy when compared with the 60-min window. The Alg(Choi) and Alg(Troiano) performed better than the manufacturer-provided algorithm (Alg(ActiLife)), and the Alg(Choi) performed better than the Alg(Troiano) for wear/nonwear time classification using the data collected by both accelerometers.
Triaxial wrist-worn accelerometer can be used for an accurate wear/nonwear time classification in free-living older adults. The use of the 90-min window and the VM counts improves the performance of commonly used algorithms for wear/nonwear classification for both uniaxial and triaxial accelerometers.
Study objective Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium in ...approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel 2-step approach to delirium surveillance for the ED. Methods This prospective observational study was conducted at an academic ED in patients aged 65 years or older. A research assistant and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were independently conducted within 3 hours of one another. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95% CIs) were calculated. Results Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% sensitive (95% CI 89.5% to 99.5%), with an expected specificity of approximately 55% for both raters. The DTS's negative likelihood ratio was 0.04 (95% CI 0.01 to 0.25) for both raters. As the complement, the bCAM had a specificity of 95.8% (95% CI 93.2% to 97.4%) and 96.9% (95% CI 94.6% to 98.3%) and a sensitivity of 84.0% (95% CI 71.5% to 91.7%) and 78.0% (95% CI 64.8% to 87.2%) when performed by the physician and research assistant, respectively. The positive likelihood ratios for the bCAM were 19.9 (95% CI 12.0 to 33.2) and 25.2 (95% CI 13.9 to 46.0), respectively. If the research assistant DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95% CI 71.5% to 91.7%) and specificity was 95.8% (95% CI 93.2% to 97.4%). If the research assistant performed both the DTS and bCAM, this combination was 78.0% sensitive (95% CI 64.8% to 87.2%) and 97.2% specific (95% CI 94.9% to 98.5%). If the physician performed both the DTS and bCAM, this combination was 82.0% sensitive (95% CI 69.2% to 90.2%) and 95.8% specific (95% CI 93.2% to 97.4%). Conclusion In older ED patients, this 2-step approach (highly sensitive DTS followed by highly specific bCAM) may enable health care professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multicenter trials are needed to confirm these findings and to determine the effect of these assessments on delirium recognition in the ED.
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse ...staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
Objectives
To determine the prevalence, recognition, co‐occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF).
Design
...Quality improvement project.
Setting
Acute care academic medical center and 23 regional partner SNFs.
Participants
Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686).
Measurements
Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital‐implemented screening tools). Estimated prevalence, new‐onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated.
Results
Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most‐prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel.
Conclusion
Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.
This article uses a retrospective approach to critique the research base underlying the nursing home culture-change movement—an effort to radically transform the nation's nursing homes by delivering ...resident-directed care and empowering staff. The article traces the development of the movement from its inception 10 years ago to 2005, when the Centers for Medicare and Medicaid Services implemented its own initiative to support the movement, thus giving it new momentum, to the present day. This historical overview provides context for a proposed research agenda aimed at strengthening the movement's empirical base, thereby facilitating culture-change interventions as well as helping the movement navigate the next step in its evolution.
Background
Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF ...perspectives.
Objectives
To determine the percentage of readmissions from post‐acute care that are considered potentially avoidable from hospital and SNF perspectives.
Design
Prospective cohort study.
Setting
One academic medical center and 23 SNFs.
Participants
We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days.
Measurements
Hospital‐based physicians and SNF‐based staff performed structured root‐cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.
Results
The 30‐day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.
Conclusion
A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse ...staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a ...patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients.
The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status.
The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities.
This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.
Purpose: A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons ...are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model. Design and Methods: The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices. Results: A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature. Implications: NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.
Background
The natural course and clinical significance of delirium in the emergency department (ED) is unclear.
Objectives
We sought to (1) describe the extent to which delirium in the ED persists ...into hospitalization (ED delirium duration) and (2) determine how ED delirium duration is associated with 6‐month functional status and cognition.
Design
Prospective cohort study.
Setting
Tertiary care, academic medical center.
Participants
ED patients ≥65 years old who were admitted to the hospital.
Measurements
The modified Brief Confusion Assessment Method was used to ascertain delirium in the ED and hospital. Premorbid and 6‐month function were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire which ranged from 0 (completely dependent) to 28 (completely dependent). Premorbid and 6‐month cognition were determined using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranged from 1 to 5 (severe dementia). Multiple linear regression was performed to determine if ED delirium duration was associated with 6‐month function and cognition adjusted for baseline OARS ADL and IQCODE, and other confounders.
Results
A total of 228 older ED patients were enrolled. Of the 105 patients who were delirious in the ED, 81 (77.1%) patients’ delirium persisted into hospitalization. For every ED delirium duration day, the 6‐month OARS ADL decreased by 0.63 points (95% CI: −1.01 to −0.24), indicating poorer function. For every ED delirium duration day, the 6‐month IQCODE increased 0.06 points (95% CI: 0.01–0.10) indicating poorer cognition.
Conclusions
Delirium in the ED is not a transient event and frequently persists into hospitalization. Longer ED delirium duration is associated with an incremental worsening of 6‐month functional and cognitive outcomes.
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