Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation.

OBJECTIVES: To evaluate the effect of inpatient geriatric consultation teams (IGCTs), which have been introduced to improve the quality of care of older persons hospitalized on nongeriatric wards, on delirium and overall cognitive functioning in older adults with hip fracture. DESIGN: Controlled trial. SETTING: Two trauma wards in a university hospital setting. PARTICIPANTS: One-hundred seventy-one people with hip fracture aged 65 and older assigned to a multidisciplinary geriatric intervention (n = 94) or usual care (n = 77). MEASUREMENTS: Incidence and duration of delirium were measured using the Confusion Assessment Method, severity of delirium using the Delirium Index, and cognitive status using the 12-item Mini-Mental State Examination. RESULTS: Significantly more controls (53.2%; n = 41) than intervention group participants (37.2%; n = 35; P = .04; odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.04-3.54) were delirious at any point after surgery. No significant difference was found between the groups for duration or severity of delirium episodes. The proportion of participants with cognitive decline at discharge was higher in controls than in those assigned to geriatric intervention (38.7% vs 22.6%; P = .02; OR = 2.16, 95% CI = 1.10-4.24). CONCLUSION: Delirium episodes and cognitive decline during hospitalization were found to be common in older adults with hip fracture, as expected, but an IGCT intervention reduced the incidence of these adverse outcomes. In participants who developed delirium, a geriatric consultation had no effect on severity or duration of the delirium episode.

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial.

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission. DESIGN: Controlled trial based on assignment by convenience. SETTING: Trauma ward in a university hospital. PARTICIPANTS: One hundred seventy-one people with hip fracture aged 65 and older. INTERVENTION: Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture. MEASUREMENTS: End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery. RESULTS: Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between-group differences could be documented for mortality, new nursing home admission, or readmission rate. CONCLUSION: This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more-intensive approach with more-direct control over patient management, more-specific recommendations, and more-intense education would be effective.

Prediction of functional decline in older hospitalized patients: a comparative multicenter study of three screening tools.

BACKGROUND AND AIMS: Older hospitalized patients are at risk of functional decline, which is associated with several negative outcomes. The aim of this study was to compare the predictive accuracy of the Identification of Seniors At Risk (ISAR), Variable Indicative for Placement risk (VIP) and the Flemish version of the Triage Risk Screening Tool (TRST) in predicting functional decline. METHODS: A prospective cohort study with 30 days follow-up in geriatric, medical and surgical wards in 25 hospitals was conducted. 752 participants aged 75 years or older were eligible for inclusion. Baseline data were gathered within 72 hours of admission. Functional decline was defined as an increase of one point or more from the premorbid Katz score to the score 30 days post-discharge. Positive predictive value (PPV) and negative predictive value (NPV) were calculated on 2 x 2 tables as well as by Bayes' theorem. RESULTS: Functional decline at 30 days postdischarge was observed in 279 participants (39%). ISAR and Flemish TRST showed high sensitivity (88% - 78%) and fair NPV (62% - 67%), but low specificity (19% - 30%) and low PPV (47% - 48%) using the original cut-off of ≥ 2. The sensitivity of VIP with cut-off ≥ 2 was too low (62%), but could be optimized with cut-off ≥ 1, showing sensitivity, specificity, PPV and NPV of 88%, 21%, 48% and 68%, respectively. Accuracy varied between 40% and 61% for all instruments on all calculated cut-offs. CONCLUSIONS: All three instruments performed similarly well, showing good sensitivity and fair NPV, the two major characteristics for good screening tools. False positives could be filtered out according to the clinical expert opinion of a care team.

Screening for risk of unplanned readmission in older patients admitted to hospital: predictive accuracy of three instruments.

BACKGROUND AND AIMS: Hospital readmission after discharge is an important clinical and health policy issue. We compared the predictive accuracy of the Identification of Seniors at Risk (ISAR), the Flemish version of the Triage Risk Screening Tool (TRST) and Variable Indicative of Placement risk (VIP) in assessing unplanned readmissions. METHODS: We included 213 patients (≥65 years), hospitalized following admission to the emergency department. The ISAR, TRST and VIP were administered at admission. Unplanned readmissions were registered by telephone follow-up 14, 30 and 90 days post-discharge. RESULTS: Unplanned readmission rates were 6.8%, 14.7% and 23.5% after 14, 30, and 90 days, respectively. The ISAR showed low to moderate sensitivity (54%-69%) and a high negative predictive value (≥78%) at all measurement points. Specificity and positive predictive value were low (≤33% and ≤24%, respectively). The TRST had low to moderate sensitivity (42%-67%) and a high negative predictive value (≥82%). Specificity and positive predictive value were low (≤45% and ≤27%, respectively). The VIP had very low sensitivity (≤26%) and high specificity (≥80%). Its negative predictive value was high (≥79%) and its positive predictive value was low (≤22%). CONCLUSIONS: Due to their moderate to low sensitivity, and low specificity and positive predictive value, none of the instruments was capable of accurately predicting unplanned readmission in older, hospitalized patients. Overall, reducing or increasing the original cut-off value by one point did not result in improved performance. Our findings suggest that these instruments lack the necessary sophistication to capture the complexity of (unplanned) readmissions.

The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis.

OBJECTIVES: To examine how geriatric evaluation and management units (GEMUs) are organized and to examine the effectiveness of admission on a GEMU. DESIGN: Systematic review and meta-analysis based on literature search of multiple databases and the references lists of all identified articles and by contacting authors. SETTING: GEMUs. PARTICIPANTS: Elderly people admitted to a GEMU. MEASUREMENTS: Quality of the studies was assessed on 10 criteria. The outcome parameters were mortality, institutionalization, functional decline, readmission, and length of stay at different follow-up points. A random-effects meta-analysis was performed using Hedges' gu and variance of relative risk (RR). RESULTS: GEMUs are organized in a heterogeneous way and the included studies gave no thorough description of comprehensive geriatric assessment (CGA). Involvement of a multidisciplinary team was a key element in all GEMUs. The individual trials showed that admission to a GEMU has one or more favorable effects on the outcomes of interest, with two significant effects in the meta-analysis: less functional decline at discharge from the GEMU (RR=0.87, 95% confidence interval (CI)=0.77-0.99; P=.04) and a lower rate of institutionalization 1 year after discharge (RR=0.78, CI=0.66-0.92; P=.003). For the other outcomes in the meta-analysis, a GEMU did not induce significantly different outcomes than usual care. CONCLUSION: This meta-analysis shows a significant effect in favor of the GEMU group on functional decline at discharge and on institutionalization after 1 year. There is heterogeneity between the studies, poor quality of some randomized controlled trials, and shortage of information about CGA. Multidisciplinary CGA offered in a GEMU may add value to the care for frail older persons admitted to the hospital, but the limitations confirm the need for well-designed studies using explicit CGA and more-structured and -coherent assessment instruments such as the Minimum Data Set Resident Assessment Instrument.

Geriatrics on the run: rationale, implementation, and preliminary findings of a Belgian internal liaison team.

This article describes the rationale, implementation, interventions and preliminary findings of a Belgian interdisciplinary internal liaison team in a 1470-bed teaching hospital. The motive to start the team was threefold: the ageing of the inhospital population, the conclusion that health care professionals working on non-geriatric wards often lack the necessary skills to deal with older patients' needs and Belgian law, obliging each general hospital to set up an internal liaison team. Our team aims at detecting geriatric patients at risk, assisting health care professionals in caring for older patients and sensitizing them regarding optimal geriatric care. The article explains the underlying philosophy and strategy for implementation, focusing on the concepts of reciprocity, flexibility and cooperation. The preliminary results are based on a process evaluation of 719 consultations carried out from November 2004 to November 2006, a time registration, and a Strengths, Weaknesses, Opportunities, and Threats analysis (SWOT). Although our data are preliminary and the implementation of the team was pragmatic rather than research driven, they provide insight into the development, implementation, functioning and interventions of a Belgian interdisciplinary internal liaison team.

Screening for risk of readmission of patients aged 65 years and above after discharge from the emergency department: predictive value of four instruments.

OBJECTIVES: To compare the abilities of four different screening tools to predict return visits of older persons after they have been discharged from the emergency department (ED). METHODS: We assessed 83 short-term (discharged within 24 h) patients (aged 65 years and above) who visited the ED of the University Hospitals Leuven, Belgium, from 15 October 2005 to 24 December 2005. The Identification of Seniors at Risk (ISAR), the Triage Risk Screening Tool (TRST), the eight-item questionnaire of Runciman, and the seven-item questionnaire of Rowland were administered at admission to screen the patients for risk factors of future ED readmission. By telephone follow-up 14, 30, and 90 days after discharge from the ED, we asked the patients (or their families) whether readmission had occurred since their initial discharge from the ED. RESULTS: Readmission rates were 10%, 15.8%, and 32.5% after 14, 30, and 90 days, respectively. When using three or more positive answers as the cutoff scores, the Rowland questionnaire proved to be the most accurate predictive tool with a sensitivity of 88%, specificity of 72%, and negative predictive value of 98% at 14 days after discharge. Thirty days after discharge, the sensitivity was 73%, specificity was 75%, and negative predictive value was 92%. CONCLUSION: Repeat visits in older persons admitted to an ED seemed to be most accurately predicted by using the Rowland questionnaire, with an acceptable number of false positives. This instrument can be easily integrated into the standard nursing assessment.

Fall prediction in inpatients by bedside nurses using the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument: a multicenter study.

OBJECTIVES: To assess the predictive value of the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument, a simple fall-risk assessment tool, when administered at a patient's hospital bedside by nurses. DESIGN: Prospective multicenter study. SETTING: Six Belgian hospitals. PARTICIPANTS: A total of 2,568 patients (mean age+/-standard deviation 67.2+/-18.4; 55.3% female) on four surgical (n=875, 34.1%), eight geriatric (n=687, 26.8%), and four general medical wards (n=1,006, 39.2%) were included in this study upon hospital admission. All patients were hospitalized for at least 48 hours. MEASUREMENTS: Nurses completed the STRATIFY within 24 hours after admission of the patient. Falls were documented on a standardized incident report form. RESULTS: The number of fallers was 136 (5.3%), accounting for 190 falls and an overall rate of 7.3 falls per 1,000 patient days for all hospitals. The STRATIFY showed good sensitivity (> or = 84%) and high negative predictive value (> or = 99%) for the total sample, for patients admitted to general medical and surgical wards, and for patients younger than 75, although it showed moderate (69%) to low (52%) sensitivity and high false-negative rates (31-48%) for patients admitted to geriatric wards and for patients aged 75 and older. CONCLUSION: Although the STRATIFY satisfactorily predicted the fall risk of patients admitted to general medical and surgical wards and patients younger than 75, it failed to predict the fall risk of patients admitted to geriatric wards and patients aged 75 and older (particularly those aged 75-84).

Detection of delirium by bedside nurses using the confusion assessment method.

A prospective, descriptive study was used to assess the diagnostic validity of the Confusion Assessment Method (CAM) administered at the bedside by nurses in daily practice. Two different scoring methods of the CAM (the specific (SPEC) and sensitive (SENS) methods) were compared with a criterion standard (CAM completed by trained research nurses). During a 5-month period, all patients consecutively admitted to an acute geriatric ward of the University Hospitals of Leuven (Belgium) were enrolled in the study. The 258 elderly inpatients who were included underwent 641 paired but independent ratings of delirium by bedside and trained research nurses. Delirium was identified in 36 of the 258 patients (14%) or in 42 of the 641 paired observations (6.5%). The SENS method of the CAM algorithm as administered by bedside nurses had the greatest diagnostic accuracy, with 66.7% sensitivity and 90.7% specificity; the SPEC method had 23.8% sensitivity and 97.7% specificity. Bedside nurses had difficulties recognizing the features of acute onset, fluctuation, and altered level of consciousness. For both scoring methods, bedside nurses had difficulties with the identification of elderly patients with delirium but succeeded in diagnosing correctly those patients without delirium in more than 90% of observations. Given these results, additional education about delirium with special attention to guided training of bedside nurses in the use of an assessment strategy such as the CAM for the recognition of delirium symptoms is warranted.

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium).

Differentiation between a diminished or altered cognitive functioning asa consequence of aging and one resulting from serious health problems is critical in the elderly. An unrecognized cognitive disorder or the worsening of the impairment may hamper the effectiveness and appropriateness of care and treatment; therefore, standardized assessment procedures and systematic monitoring of cognition and behavior are important aspects of the nursing care. of older adults. In this article, current notions for accurate and comprehensive cognitive assessment in older persons are delineated. Further, an overview of epidemiological screening and diagnostic dilemmas of dementia, depression, and deliriumare provided.

The professional self-image of nurses in Belgian hospitals: a cross-sectional questionnaire survey.

This paper reports data on the professional self-image of 9638 nurses employed in 22 Belgian general hospitals with the goal of identifying problems affecting recruitment and retention. Nurses reported having a positive self-image. Most were proud to be a nurse and considered themselves competent health professionals having great responsibility. Although they reported that an ideal practice requires effective teamwork, supportive management, societal recognition, and sufficient time to perform their duties, they also felt that these essential conditions were absent in daily practice.

Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review.

AIM: The aim of this systematic review was to determine the characteristics and efficacy of various multicomponent intervention strategies for delirium in hospitalized older people. BACKGROUND: Delirium is a common accompaniment to acute illness in hospitalized older people and has greater costs of care concurrent as well as greater morbidity and mortality. METHODS: A comprehensive search was undertaken involving all major databases (including the Cochrane Library, Medline, Cumulative Index for Nursing and Allied Health Literature and Invert) and reference lists of all relevant papers. Selection criteria were: evaluation of a multicomponent intervention for delirium, inclusion of an operational definition for delirium consistent with the Diagnostic and Statistical Manual of Mental Disorders-criteria, randomized controlled trials, studies with a quasi-experimental design and reporting on primary data. To generate a description of the characteristics of these multicomponent strategies, the components of these programmes were identified and categorized. Effects on incidence of delirium, cognitive functioning, duration and severity of delirium, functional status, hospital length of stay, and mortality were analysed. FINDINGS: Three randomized controlled trials, three controlled studies and one before-after study were identified. Intervention strategies to prevent delirium proved to be the most efficacious in reducing its incidence, both with surgical and medical patients. Some additional positive effects of preventive strategies were found on the duration and severity of delirium, and functional status. Conversely, strategies to treat delirium were rather ineffective in older people admitted to medical services. In a population of older people admitted for surgery, however, a shorter duration and a diminished severity of delirium were demonstrated. None of intervention strategies produced beneficial effects on length of stay or mortality. CONCLUSION: Multicomponent interventions to prevent delirium are the most effective and should be implemented through synergistic cooperation between the various healthcare disciplines. Nurses should play a pivotal role in prevention, early recognition and treatment.

[Falls among community-dwelling elderly: a pilot study of prevalence, circumstances and consequences in Flanders]. / Valincidenten bij thuiswonende ouderen: een pilotstudie naar prevalentie, omstandigheden en gevolgen in Vlaanderen.

This pilot study was designed to examine prevalence, circumstances and consequences of falls among 131 community-dwelling elderly (mean age = 76.7 y.; SD = 5.4; response = 29.8%). Based on a retrospective analysis, 39.7% of our study population had experienced one (65.4%) or more (34.6%) falls in the preceding year. Falls appeared to occur predominantly while getting up from the bed, chair or bath (18%), cycling (14%), walking on an uneven surface (14%) and during household work (14%). Fall-related injuries were reported in 67.3% of the fallers, fractures in 17.4%. Additionally, a majority of fallers (63.5%) experienced a mild to serious form of anxiety, 48.1% consulted a general practitioner after the fall and 34.6% was hospitalised. In line with data reported in the literature, falls are a common problem in Flanders and are associated with a negative impact on the physical and psychosocial well being of the elderly population. We conclude that there is an urgent need to develop and implement preventive measures as well as multidisciplinary strategies to identify, assess and target high-risk persons for falling.