frailty is proposed as a summative measure of health status and marker of individual vulnerability. We aimed to investigate the discriminative capacity of a frailty index (FI) derived from interRAI ...Comprehensive Geriatric Assessment for Acute Care (AC) in relation to multiple adverse inpatient outcomes.
in this prospective cohort study, an FI was derived for 1,418 patients ≥70 years across 11 hospitals in Australia. The interRAI-AC was administered at admission and discharge by trained nurses, who also screened patients daily for geriatric syndromes.
in adjusted logistic regression models an increase of 0.1 in FI was significantly associated with increased likelihood of length of stay >28 days (odds ratio OR: 1.29 1.10-1.52), new discharge to residential aged care (OR: 1.31 1.10-1.57), in-hospital falls (OR: 1.29 1.10-1.50), delirium (OR: 2.34 2.08-2.63), pressure ulcer incidence (OR: 1.51 1.23-1.87) and inpatient mortality (OR: 2.01 1.66-2.42). For each of these adverse outcomes, the cut-point at which optimal sensitivity and specificity occurred was for an FI > 0.40. Specificity was higher than sensitivity with positive predictive values of 7-52% and negative predictive values of 88-98%. FI-AC was not significantly associated with readmissions to hospital.
the interRAI-AC can be used to derive a single score that predicts multiple adverse outcomes in older inpatients. A score of ≤0.40 can well discriminate patients who are unlikely to die or experience a geriatric syndrome. Whether the FI-AC can result in management decisions that improve outcomes requires further study.
Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased ...accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.
This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.
A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.
The cost analyses reviewed provided evidence that telehealth reduced costs when health system-funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.
Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.
•We propose a privacy theory for telehealth use in the aged care context.•Our theory explains how improper telehealth practice raises privacy concerns.•Findings highlight the role of context in ...privacy concerns for older users.•Privacy protection practices can facilitate the adoption and use of telehealth in aged care.•This study informs policy makers towards achieving success in telehealth adoption and use.
Effective use of telehealth offers substantial benefits to older persons and aged care providers. However, data privacy concerns challenge the effective use of telehealth and subsequent business value. Through developing a theoretical model, we explain how privacy concerns can influence the adoption ad use of telehealth in this complex context.
An integrative review of empirical investigations was conducted by linking privacy concerns, telehealth use, and aged care. We searched three major databases (PubMed, Web of Science, and Scopus) for articles published until December 2020. Articles were analyzed and presented using an integrative theoretical model that we labeled CPCPO (Context-Privacy Concerns-Practice-Outcomes).
Our review revealed that privacy concerns are a contextual concept, i.e., different contexts (users, telehealth systems, aged care services, data) produce different privacy concerns. We found that privacy concerns were more voiced in home telecare and were associated with the degree of telemonitoring and surveillance. Contextual privacy concerns were related to video recording, behavioral data (e.g., sleep patterns and eating behavior), location data, and future use of data. These concerns can influence the adoption and use of telehealth. However, privacy protection practices (e.g., informed consent) can help in reducing the concerns and improving the acceptance of telehealth for older persons.
CPCPO offers contextual explanations of telehealth privacy concerns and systems use. For improving telehealth acceptance, privacy concerns of data processing (e.g., recording, collection, storage, and secondary use) must be addressed by performing data protection practices. Based on the review results, we suggest avenues for future research.
Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication ...(PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population.
In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses.
Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics.
The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.
Objectives
To assess Australian hospital utilisation, 1993–2020, with a focus on use by people aged 75 years or more.
Design
Review of Australian Institute of Health and Welfare (AIHW) hospital ...utilisation data.
Setting, participants
Tertiary data from all Australian public and private hospitals for the financial years 1993–94 to 2019–20.
Main outcome measures
Numbers and population‐based rates of hospital separations and bed utilisation (bed‐days) (all and multiple day admissions) and mean hospital length of day (multiple day admissions), overall and by age group (under 65 years, 65–74 years, 75 years or more).
Results
Between 1993–94 and 2019–20, the Australian population grew by 44%; the number of people aged 75 years or more increased from 4.6% to 6.9% of the population. The annual number of hospital separations increased from 4.61 million to 11.33 million (146% increase); the annual hospital separation rate increased from 261 to 435 per 1000 people (66% increase), most markedly for people aged 75 years or more (from 745 to 1441 per 1000 people; 94% increase). Total bed utilisation increased from 21.0 million to 29.9 million bed‐days (42% increase), but the bed utilisation rate did not change markedly (1993–94, 1192 bed‐days per 1000 people; 2019–20, 1179 bed‐days per 1000 people), primarily because the mean hospital length of stay for multiple day admissions declined from 6.6 days to 5.4 days; for people aged 75 years or more it declined from 12.2 to 7.1 days. However, declines in stay length have slowed markedly since 2017–18. Total bed utilisation was 16.8% lower than projected from 1993–94 rates, and was 37.3% lower for people aged 75 years or more.
Conclusion
Hospital bed utilisation rates declined although admission rates increased during 1993–94 to 2019–20; the proportion of beds occupied by people aged 75 years or more increased slightly during this period. Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy.
To explore the relationship between polypharmacy and adverse outcomes among older hospital inpatients stratified according to their frailty status.
A prospective study of 1418 patients, aged 70 and ...older, admitted to 11 hospitals across Australia.
The interRAI Acute Care (AC) assessment tool was used for all data collection, including the derivation of a frailty index calculated using the deficit accumulation method. Polypharmacy was categorized into 3 groups based on the number of regular drugs prescribed. Recorded adverse health outcomes were falls, delirium, functional and cognitive decline, discharge to a higher level of care and in-hospital mortality.
Patients had a mean (SD) age of 81 (6.8) years and 55% were women. Polypharmacy (5-9 drugs per day) was observed in 48.2% (n = 684) and hyper-polypharmacy (≥10 drugs) in 35.0% (n = 497). Severe cognitive impairment was significantly associated with nonpolypharmacy compared with polypharmacy and hyper-polypharmacy groups combined (P = .004). In total, 591 (42.5%) patients experienced at least 1 adverse outcome. The only adverse outcome associated with polypharmacy was delirium. Within each polypharmacy category, frailty was associated with adverse outcomes and the lowest overall incidence was among robust patients prescribed 10 or more drugs.
While polypharmacy may be a useful signal for medication review, in this study it was not an independent predictor of adverse outcomes for older inpatients. Assessing the frailty status of patients better appraised risk. Extensive de-prescribing in all older inpatients may not be an intervention that directly improves outcomes.
Objectives
To identify the prevalence of geriatric syndromes in the premorbid for all syndromes except falls (preadmission), admission, and discharge assessment periods and the incidence of new and ...significant worsening of existing syndromes at admission and discharge.
Design
Prospective cohort study.
Setting
Three acute care hospitals in Brisbane, Australia.
Participants
Five hundred seventy‐seven general medical patients aged 70 and older admitted to the hospital.
Measurements
Prevalence of syndromes in the premorbid (or preadmission for falls), admission, and discharge periods; incidence of new syndromes at admission and discharge; and significant worsening of existing syndromes at admission and discharge.
Results
The most frequently reported premorbid syndromes were bladder incontinence (44%), impairment in any activity of daily living (ADL) (42%). A high proportion (42%) experienced at least one fall in the 90 days before admission. Two‐thirds of the participants experienced between one and five syndromes (cognitive impairment, dependence in any ADL item, bladder and bowel incontinence, pressure ulcer) before, at admission, and at discharge. A majority experienced one or two syndromes during the premorbid (49.4%), admission (57.0%), or discharge (49.0%) assessment period.
The syndromes with a higher incidence of significant worsening at discharge (out of the proportion with the syndrome present premorbidly) were ADL limitation (33%), cognitive impairment (9%), and bladder incontinence (8%). Of the syndromes examined at discharge, a higher proportion of patients experienced the following new syndromes at discharge (absent premorbidly): ADL limitation (22%); and bladder incontinence (13%).
Conclusion
Geriatric syndromes were highly prevalent. Many patients did not return to their premorbid function and acquired new syndromes.
Low activity levels in inpatient rehabilitation are associated with adverse outcomes. The study aimed to test whether activity levels can be increased by the provision of monitored activity data to ...patients and clinicians in the context of explicit goal setting.
A randomized controlled trial in three sites in Australia included 255 inpatients aged 60 and older who had a rehabilitation goal to become ambulant. The primary outcome was patients' walking time measured by accelerometers during the rehabilitation admission. Walking times from accelerometry were made available daily to treating therapists and intervention participants to motivate patients to improve incidental activity levels and reach set goals. For the control group, 'usual care' was followed, including the setting of mobility goals; however, for this group, neither staff nor patients received data on walking times to aid the setting of daily walking time targets.
The median daily walking time in the intervention group increased from 10.3 minutes at baseline to 32.1 minutes at day 28, compared with an increase from 9.5 to 26.5 minutes per day in the control group. Subjects in the intervention group had significantly higher non-therapy walking time by about 7 minutes mean (95% CI): 24.6 (21.7, 27.4) compared to those in the control group mean(95% CI): 17.3 (14.4, 20.3) (p = 0.001).
Daily feedback to patients and therapists using an accelerometer increased walking times during rehabilitation admissions. The results of this study suggest objective monitoring of activity levels could provide clinicians with information on clinically important, mobility-related activities to assist goal setting.
Australian New Zealand Clinical Trials Registry ACTRN12611000034932 http://www.ANZCTR.org.au/.
The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of ...cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.
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