Implementation of a model of care for hospitalised older persons with cognitive impairment (the Confused Hospitalised Older Persons program) in six New South Wales hospitals.

OBJECTIVE: To evaluate the implementation of a model of care known as the Confused Hospitalised Older Persons (CHOPs) program to improve recognition, assessment and management of older persons with cognitive impairment (delirium and/or dementia) admitted to acute hospitals. METHODS: The model of care was implemented in six selected hospitals across New South Wales. Pre- and postimplementation medical record audits, environmental audits, and staff knowledge and care confidence surveys were performed. Interviews with clinical leads postimplementation identified enablers and barriers. RESULTS: There were significant increases in cognitive screening within 24 hours (OR = 3.32 [2.50-4.91]), delirium risk identification (OR = 4.04 [2.89-5.64]), assessment of cognitive impairment (OR = 2.55 [1.90-3.43]) and interaction with families (OR = 2.81 [2.09-3.79]). Staff education and care confidence were improved, and positive environmental changes occurred in all hospitals. Barriers and enablers to implementation were identified. CONCLUSION: The CHOPs program improved identification, risk assessment and management of cognitive impairment in older hospitalised patients.

Health service use in the older person with complex health needs.

Objective Effective health care for older people with complex health needs requires a diverse range of healthcare professionals working together. The Building Partnerships Framework of the New South Wales Agency for Clinical Innovation seeks to promote collaboration and integration among service providers. The aim of the present study was to inform implementation and evaluation of the Framework. Methods Data from the 45 and Up Study was linked with deaths and service data from hospitalisations and the Medicare Benefits Schedule (MBS). Participants with a hospitalisation for conditions representing 'geriatric syndrome' were allocated to a complex needs group; the remainder were allocated to a comparison group. Hospital admissions and MBS services use were modelled using log-linear Poisson regression. Results Multivariate analysis showed that the rate of hospitalisation in the 2 years following index admission for the complex needs group was 18% (95% confidence interval (CI) 1.12-1.24) greater than the comparison group and specialist physician attendance was 13% (95% CI 1.06 - 1.21) greater. The rate of general practitioner (GP) attendances was 2% (95% CI 0.97-1.07) greater in the complex needs group, but this was not statistically significant. Discussion The greater rates of hospitalisation and specialist service use, the absence of a similar finding for GP services and the prominence of the role of primary care in service integration literature, policy and strategy underscore the importance of careful planning, consultation and inclusiveness in the development and implementation of integrated care policy. What is known about the topic? Older people with complex health needs are significant consumers of primary and secondary health services and benefit from well-planned and coordinated care. What does this paper add? The findings presented here indicate that although hospitals and specialist physicians provide a significantly greater volume of services to people with complex health needs, GPs do not. Within the limitations of the present study, these findings can contribute to integrated care policy and strategy development and implementation. What are the implications for practitioners? Given the prominence of primary care in service integration literature, policy and strategy and the findings of the present study with regard to the relative level of GP involvement in the management of people with complex needs, careful policy implementation will be required to ensure GPs are able to contribute significantly to coordinated cooperation between health services.

Feasibility of home-based dietetic intervention to improve the nutritional status of older adults post-hospital discharge.

AIM: To determine if a model of home-based dietetic care improves dietary intake and weight status in a specific group of older adults post-hospitalisation. METHODS: The Department of Veterans' Affairs clients aged 65 years and over were recruited from hospitals in a regional area of New South Wales, Australia (n = 32 men, n = 36 women). Nutritional status was assessed at home at baseline (within two weeks post-discharge) and three months post-discharge using a diet history, a food frequency checklist and Mini Nutritional Assessment (MNA). Personalised dietary advice was provided by a single dietitian according to participants' nutritional status. RESULTS: Mean body weight improved significantly (P = 0.048), as well as mean MNA score (21.9 ± 3.5 vs 25.2 ± 3.1) (P < 0.001). Mean energy, protein and micronutrient intakes were adequate at baseline and three months, except for vitamin D. At three months, the underweight group (body mass index (BMI) < 23 kg/m2 ) had significantly higher mean protein intake per body weight (1.7 ± 0.4 g/kg) compared to those who were a desirable weight (BMI 23-27 kg/m2 ) (1.4 ± 0.3 g/kg) or overweight (BMI>27 kg/m2 ) (1.1 ± 0.3 g/kg) peers (P < 0.001). There was significant improvement in energy intake contributed from oral nutrition supplements (+95.5 ± 388.2 kJ/day) and milk (+259.6 ± 659.8 kJ/day). CONCLUSIONS: Dietetic intervention improved nutritional status 3 months after hospital discharge in older adults living in the community.

Development of nutrition standards and therapeutic diet specifications for public hospitals in New South Wales.

In New South Wales (NSW), a new suite of nutrition standards for menus and specifications for therapeutic diets to be used in hospitals has been developed. These standards were required to facilitate centralised menu planning and food production, with the move to management of most hospital food services by HealthShare NSW, a state-wide business unit of NSW Health. The standards also aim to improve communication between health professionals, particularly with the increasing use of computerised meal-ordering systems. Nutrition standards have been developed for adult, paediatric and mental health inpatients, and specifications for 147 different adult and paediatric therapeutic diets. There is still significant variation in the nutrition standards for nutrition and therapeutic diets in hospitals across the Australian states, and a move to a more nationally harmonised approach would be welcome. Further research is required to examine the impact of these standards on operating efficiency and patient care outcomes.

Effect of resistance training during hemodialysis on circulating cytokines: a randomized controlled trial.

The purpose of this study was to evaluate the effect of a 12-week intradialytic progressive resistance training (PRT) regimen on circulating pro- and anti-inflammatory cytokines. Forty-nine patients (62.6 ± 14.2 years) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital, Sydney, Australia. Patients were randomized to: PRT + usual care (n = 24) or usual care control (n = 25). The PRT group performed two sets of 10 exercises at high intensity using free-weights, 3 times per week for 12 weeks during dialysis, while the control group did not exercise. Tumor necrosis factor-alpha, interleukin-1b, interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10, and interleukin-12 were measured in serum before and after the intervention period. Muscle cross-sectional area (CSA), intramuscular lipid, intermuscular adipose tissue, and subcutaneous and total thigh fat, evaluated via computed tomography of the non-dominant mid-thigh, were also collected at both time points. All cytokines were significantly elevated in the total cohort at baseline compared with normative data. There were no cytokine changes over time or between groups (p > 0.05). In secondary analyses pooling the groups, changes in logIL-6 and IL-8 were inversely related to changes subcutaneous thigh fat (p < 0.05) while changes in logIL-6 were also inversely related to changes in thigh muscle CSA, and total thigh fat (p < 0.03). These data suggest that 12 weeks of intradialytic progressive resistance training does not improve circulating pro- and anti-inflammatory markers. Further research is required to elucidate the implications and mechanisms of the relationships between IL-6 and IL-8 and body composition in ESRD.

Investigation of skeletal muscle quantity and quality in end-stage renal disease.

AIM: A more precise understanding of the aetiology and sequelae of muscle wasting in end-stage renal disease (ESRD) is required for the development of effective interventions to target this pathology. METHODS: We investigated 49 patients with ESRD (62.6 +/- 14.2 years, 0.3-16.7 years on haemodialysis). Thigh muscle cross-sectional area (CSA), intramuscular lipid and intermuscular adipose tissue (IMAT) were measured via computed tomography as indices of muscle quantity (i.e. CSA) and quality (i.e. intramuscular lipid and IMAT). Additional health and clinical measures were investigated to determine associations with these variables. RESULTS: Age, energy intake, disease burden, pro-inflammatory cytokines, nutritional status, strength and functioning were related to muscle quantity and quality. Potential aetiological factors entered into forward stepwise regression models indicated that hypoalbuminaemia and lower body mass index accounted significantly and independently for 32% of the variance in muscle CSA (r = 0.56, P < 0.001), while older age and interleukin-8 accounted for 41% of the variance in intramuscular lipid (r = 0.64, P < 0.001) and body mass index accounted for 45% of the variance in IMAT (r = 0.67, P < 0.001). Stepwise regression models revealed that intramuscular lipid was independently predictive of habitual gait velocity and 6 min walk distance, while CSA was independently predictive of maximal isometric strength (P < 0.05). CONCLUSION: Ageing, poor nutritional status and elevated interleukin-8 are factors potentially contributing to the loss of muscle quality and quantity in ESRD. These deficits can predict functional impairments, with intramuscular lipid accumulation most closely related to decline of submaximal musculoskeletal performance (walking), and low muscle CSA most closely related to decline of maximal performance (peak isometric strength).

Randomized controlled trial of intradialytic resistance training to target muscle wasting in ESRD: the Progressive Exercise for Anabolism in Kidney Disease (PEAK) study.

BACKGROUND: To determine whether prolonged (24 weeks) intradialytic progressive resistance training (PRT) could counteract muscle wasting more effectively than short-duration training (12 weeks) in patients with end-stage renal disease. STUDY DESIGN: Randomized controlled trial. SETTING & PARTICIPANTS: 49 patients (age, 62.6 +/- 14.2 years; 0.3 to 16.7 years on hemodialysis therapy) were randomly assigned to PRT plus usual care for 24 weeks (24WK group) or a crossover control group that received usual care for the first 12 weeks, then PRT plus usual care for the latter 12 weeks (12WK group). INTERVENTION: Two sets of 10 free-weight PRT exercises were performed at a high intensity during routine thrice-weekly hemodialysis treatment under direct supervision. OUTCOMES & MEASUREMENTS: Primary outcomes include thigh muscle cross-sectional area by means of computed tomography and intramuscular lipid content estimated through attenuation. Secondary outcomes include muscular strength, exercise capacity, and C-reactive protein level. RESULTS: The 24WK group increased muscle cross-sectional area (+1.82 +/- 3.25 cm(2)) compared with losses in the 12WK group (-1.37 +/- 6.87 cm(2); relative effect size, 0.59; 95% confidence interval [CI], -0.27 to 6.65; P = 0.04). However, this outcome did not achieve the level of statistical significance required (P = 0.025) after Bonferroni correction for multiple primary outcomes. There was no significant change in intramuscular lipid content between groups (+0.19 +/- 1.32 versus +0.16 +/- 1.69 Hounsfield units in the 24WK and 12WK groups, respectively; P = 0.31). Log C-reactive protein level tended to decrease in the 24WK group compared with the 12WK group (relative effect size, -0.63; 95% CI, -0.27 [-0.54 to 0.00]; P = 0.05). The 24WK group improved muscular strength measures and exercise capacity throughout the trial. LIMITATIONS: Single geographic site used; no control group without exercise exposure; unblinded assessment of some secondary outcome measures. CONCLUSIONS: Prolonged intradialytic PRT did not significantly improve muscle cross-sectional area or intramuscular lipid content compared with a shorter duration of exercise. Future trials are required to more thoroughly investigate the clinical importance and magnitude of myogenic adaptations to PRT in this cohort.

Progressive exercise for anabolism in kidney disease (PEAK): a randomized, controlled trial of resistance training during hemodialysis.

Skeletal muscle wasting is common and insidious in patients who receive maintenance hemodialysis treatment for the management of ESRD. The objective of this study was to determine whether 12 wk of high-intensity, progressive resistance training (PRT) administered during routine hemodialysis treatment could improve skeletal muscle quantity and quality versus usual care. Forty-nine patients (62.6 +/- 14.2 yr; 0.3 to 16.7 yr on dialysis) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital (Sydney, Australia). Patients were randomized to PRT + usual care (n = 24) or usual care control only (n = 25). The PRT group performed two sets of 10 exercises at a high intensity (15 to 17/20 on the Borg Scale) using free weights, three times per week for 12 wk during routine hemodialysis treatment. Primary outcomes included thigh muscle quantity (cross-sectional area [CSA]) and quality (intramuscular lipid content via attenuation) evaluated by computed tomography scan. Secondary outcomes included muscle strength, exercise capacity, body circumference measures, proinflammatory cytokine C-reactive protein, and quality of life. There was no statistically significant difference in muscle CSA change between groups. However, there were statistically significant improvements in muscle attenuation, muscle strength, mid-thigh and mid-arm circumference, body weight, and C-reactive protein in the PRT group relative to the nonexercising control group. These findings suggest that patients with ESRD can improve skeletal muscle quality and derive other health-related adaptations solely by engaging in a 12-wk high-intensity PRT regimen during routine hemodialysis treatment sessions. Longer training durations or more sensitive analysis techniques may be required to document alterations in muscle CSA.