More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study.

BACKGROUND: To improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway. METHODS: We conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands. RESULTS: The palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84-5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49-6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation. CONCLUSIONS: The pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.

Global Prevalence of Young-Onset Dementia: A Systematic Review and Meta-analysis.

Importance: Reliable prevalence estimates are lacking for young-onset dementia (YOD), in which symptoms of dementia start before the age of 65 years. Such estimates are needed for policy makers to organize appropriate health care. Objective: To determine the global prevalence of YOD. Data Sources: The PubMed, Embase, CINAHL, and PsycInfo databases were systematically searched for population-based studies on the prevalence of YOD published between January 1, 1990, and March 31, 2020. Study Selection: Studies containing data on the prevalence of dementia in individuals younger than 65 years were screened by 2 researchers for inclusion in a systematic review and meta-analysis. Data Extraction and Synthesis: Prevalence estimates on 5-year age bands, from 30 to 34 years to 60 to 64 years, were extracted. Random-effects meta-analyses were conducted to pool prevalence estimates. Results were age standardized for the World Standard Population. Heterogeneity was assessed by subgroup analyses for sex, dementia subtype, study design, and economic status based on the World Bank classification and by meta-regression. Main Outcomes and Measures: Prevalence estimates of YOD for 5-year age bands. Results: A total of 95 unique studies were included in this systematic review, of which 74 with 2 760 379 unique patients were also included in 5-year age band meta-analyses. Studies were mostly conducted in Europe and in older groups in Asia, North America, and Oceania. Age-standardized prevalence estimates increased from 1.1 per 100 000 population in the group aged 30 to 34 years to 77.4 per 100 000 population in the group aged 60 to 64 years. This gives an overall global age-standardized prevalence of 119.0 per 100 000 population in the age range of 30 to 64 years, corresponding to 3.9 million people aged 30 to 64 years living with YOD in the world. Subgroup analyses showed prevalence between men and women to be similar (crude estimates for men, 216.5 per 100 000 population; for women, 293.1 per 100 000 population), whereas prevalence was lower in high-income countries (crude estimate, 663.9 per 100 000 population) compared with upper-middle-income (crude estimate, 1873.6 per 100 000 population) and lower-middle-income (crude estimate, 764.2 per 100 000 population) countries. Meta-regression showed that age range (P < .001), sample size (P < .001), and study methodology (P = .02) significantly influenced heterogeneity between studies. Conclusions and Relevance: This systematic review and meta-analysis found an age-standardized prevalence of YOD of 119.0 per 100 000 population, although estimates of the prevalence in low-income countries and younger age ranges remain scarce. These results should help policy makers organize sufficient health care for this subgroup of individuals with dementia. Study Registration: PROSPERO CRD42019119288.

An email-based intervention to improve the number and timeliness of letters sent from the hospital outpatient clinic to the general practitioner: A pair-randomized controlled trial.

OBJECTIVE: Letters from the hospital to the general practitioner are important for maintaining continuity of care. Although doctors feel letters are important, they are often not written on time. To improve the number and timeliness of letters sent from the hospital outpatient department to the general practitioner using an email-based intervention evaluated in a randomized controlled trial. MATERIALS AND METHODS: Users were interviewed to determine the requirements for the intervention. Due to high between-doctor variation at baseline, doctors were matched for baseline performance and pair-randomized. The effectiveness of the intervention was assessed using meta-analytic methods. The primary outcome was the number of patient visits which should have generated a letter that had a letter by 90 days after the visit. Satisfaction was assessed with an anonymous survey. RESULTS: The intervention consisted of a monthly email reminder for each doctor containing a list of his or her patients who were (over)due for a letter. Doctors in the intervention group had 21% fewer patient visits which did not have a letter by 90 days (OR = 5.7, p = 0.0020). Satisfaction with the system was very high. DISCUSSION: This study examines the effect of a simple reminder in absence of other interventions, and provides an example of an effective non-interruptive decision support intervention. CONCLUSION: A simple email reminder improved the number and timeliness of letters from the outpatient department to the general practitioner, and was viewed as a useful service by its users.

The Cross-Cultural Dementia Screening (CCD): A new neuropsychological screening instrument for dementia in elderly immigrants.

OBJECTIVE: Currently, approximately 3.9% of the European population are non-EU citizens, and a large part of these people are from "non-Western" societies, such as Turkey and Morocco. For various reasons, the incidence of dementia in this group is expected to increase. However, cognitive testing is challenging due to language barriers and low education and/or illiteracy. The newly developed Cross-Cultural Dementia Screening (CCD) can be administered without an interpreter. It contains three subtests that assess memory, mental speed, and executive function. We hypothesized the CCD to be a culture-fair test that could discriminate between demented patients and cognitively healthy controls. METHOD: To test this hypothesis, 54 patients who had probable dementia were recruited via memory clinics. Controls (N = 1625) were recruited via their general practitioners. All patients and controls were aged 55 years and older and of six different self-defined ethnicities (Dutch, Turkish, Moroccan-Arabic, Moroccan-Berber, Surinamese-Creole, and Surinamese-Hindustani). Exclusion criteria included current or previous conditions that affect cognitive functioning. RESULTS: There were performance differences between the ethnic groups, but these disappeared after correcting for age and education differences between the groups, which supports our central hypothesis that the CCD is a culture-fair test. Receiver-operating characteristic (ROC) and logistic regression analyses showed that the CCD has high predictive validity for dementia (sensitivity: 85%; specificity: 89%). DISCUSSION: The CCD is a sensitive and culture-fair neuropsychological instrument for dementia screening in low-educated immigrant populations.

Health-Related Quality of Life at Admission Is Associated with Postdischarge Mortality, Functional Decline, and Institutionalization in Acutely Hospitalized Older Medical Patients.

OBJECTIVES: To assess the independent association between health-related quality of life (HRQOL) at admission and mortality, functional decline, and institutionalization 3 and 12 months after admission in acutely hospitalized older adults. DESIGN: Post hoc analysis of data from prospective cohort study, 2006 to 2009, 12-month follow-up. SETTING: Eleven medical wards in three hospitals in the Netherlands. PARTICIPANTS: Medical patients aged 65 and older acutely hospitalized for 48 hours or longer (N = 473). OUTCOMES: mortality, functional decline, and institutionalization, 3 and 12 months after admission. Main determinant was HRQOL (utility based on the EuroQol-5D at admission, reflecting the relative desirability of a particular health state and is measured on a scale from 0 (death) to 1 (full health). Some health states are regarded as being worse than death, resulting in negative utilities, with a minimum of -0.330). Participants were split into two groups based on median utility at admission. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using Cox and logistic regression analyses, adjusted for sociodemographic and health variables. RESULTS: Median utility was 0.775 (interquartile range 0.399-0.861). Utility greater than 0.775, indicating high HRQOL, was associated with lower risk of mortality (hazard ratio = 0.38, 95% CI = 0.18-0.83) and functional decline (OR = 0.47, 95% CI = 0.28-0.79) at 3 months in the adjusted models. At 12 months, these associations were statistically significant in the crude models but not in the adjusted models. Utility was not associated with risk of institutionalization at 3 or 12 months. CONCLUSION: Higher HRQOL at admission was associated with lower risk of mortality and functional decline 3 months after admission. In older, acutely hospitalized individuals, the EQ-5D may provide a means of risk stratification and may ultimately guide individuals, their families, and professionals in treatment decisions during hospitalization.

Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial.

IMPORTANCE: Older adults acutely hospitalized are at risk of disability. Trials on comprehensive geriatric assessment (CGA) and transitional care present inconsistent results. OBJECTIVE: To test whether an intervention of systematic CGA, followed by the transitional care bridge program, improved activities of daily living (ADLs) compared with systematic CGA alone. DESIGN, SETTING, AND PARTICIPANTS: This study was a double-blind, multicenter, randomized clinical trial conducted at 3 hospitals with affiliated home care organizations in the Netherlands between September 1, 2010, and March 1, 2014. In total, 1070 consecutive patients were eligible, 674 (63.0%) of whom enrolled. They were 65 years or older, acutely hospitalized to a medical ward for at least 48 hours with an Identification of Seniors at Risk-Hospitalized Patients score of 2 or higher, and randomized using permuted blocks stratified by study site and Mini-Mental State Examination score (<24 vs ≥24). The dates of the analysis were June 1, 2014, to November 15, 2014. INTERVENTIONS: The transitional care bridge program intervention was started during hospitalization by a visit from a community care registered nurse (CCRN) and continued after discharge with home visits at 2 days and at 2, 6, 12, and 24 weeks. The CCRNs applied the CGA care and treatment plan. MAIN OUTCOMES AND MEASURES: The main outcome was the Katz Index of ADL at 6 months compared with 2 weeks before admission. Secondary outcomes were mortality, cognitive functioning, time to hospital readmission, and the time to discharge from a nursing home. RESULTS: The study cohort comprised 674 participants. Their mean age was 80 years, 42.1% (n = 284) were male, and 39.2% (n = 264) were cognitively impaired at admission. Intent-to-treat analysis found no differences in the mean Katz Index of ADL at 6 months between the intervention arm (mean, 2.0; 95% CI, 1.8-2.2) and the CGA-only arm (mean, 1.9; 95% CI, 1.7-2.2). For secondary outcomes, there were 85 deaths (25.2%) in the intervention arm and 104 deaths (30.9%) in the CGA-only arm, resulting in a lower risk on the time to death within 6 months after hospital admission (hazard ratio, 0.75; 95% CI, 0.56-0.99; P = .045; number needed to treat to prevent 1 death, 16). No other secondary outcome was significant. CONCLUSIONS AND RELEVANCE: A systematic CGA, followed by the transitional care bridge program, showed no effect on ADL functioning in acutely hospitalized older patients. TRIAL REGISTRATION: Netherlands Trial Registry: NTR2384.

Acute and chronic diseases as part of multimorbidity in acutely hospitalized older patients.

BACKGROUND: To describe the prevalence of multimorbidity and to study the association between acute and chronic diseases in acutely hospitalized older patients METHODS: Prospective cohort study conducted between 2006 and 2008 in three teaching hospitals in the Netherlands. 639 patients aged 65 years and older, hospitalized for >48 h were included. Two physicians scored diseases, using ICD-9 codes. Chronic multimorbidity was defined as the presence of ≥2 chronic diseases, and acute multimorbidity as ≥1 acute diseases upon pre-existent chronic diseases. Logistic regression analyses were conducted to analyse cluster associations between a chronic index disease and the concurrent chronic or acute disease, corrected for age and sex. RESULTS: The mean age of patients was 78 years, over 50% had ADL impairments. Prevalence of chronic multimorbidity was 69%, and acute multimorbidity was present in 88%. Hypertension (OR 1.16; 95% CI 1.08-1.24), diabetes (type I or type 2) (OR 1.12; 95% CI 1.04-1.21), heart failure (OR 1.25; 95% CI 1.14-1.38) and COPD (OR 1.19; 95% CI 1.05-1.34) were associated with acute renal failure. Hypertension (OR 1.10; 95% CI 1.04-1.17) and atrial fibrillation (OR 1.17; 95% CI 1.08-1.27) were associated with an adverse drug event. Gastro-intestinal bleeding was clustered with atrial fibrillation (OR 1.11; 95% CI 1.04-1.19) and gastric ulcer (OR 1.16; 95% CI 1.07-1.25). CONCLUSION: Both acute and chronic multimorbidity was frequently present in hospitalized older patients. We identified specific associations between acute and chronic diseases. There is a need for strategies addressing multimorbidity during the exacerbation of chronic diseases.

Insufficient cross-cultural adaptations and psychometric properties for many translated health assessment scales: a systematic review.

OBJECTIVES: If researchers want to assess reliably different aspects of general health in the migrant populations, they need translations of internationally used health assessment scales with appropriate cross-cultural adaptations and satisfactory psychometric properties. A systematic review was performed to assess the quality of the cross-cultural adaptations and the psychometric properties of health assessment scales measuring cognition, mood, activities of daily living, health-related quality of life, and loneliness. We focused on the scales that were adapted for use with Turkish, Arab, and Surinamese (Creole and Hindi) individuals aged 65 years and older. STUDY DESIGN AND SETTING: PubMed, PsycINFO, and EMBASE databases were systematically searched, and selected articles were cross-checked for other relevant publications. RESULTS: In total, 68 relevant studies of the Turkish, Arab, and Surinamese populations were identified. To arrive at an appropriate cross-culturally adapted scale, five steps are required. Six studies followed this complete process. Only a few studies assessed all the psychometric properties of the cross-culturally adapted scales. The studies in which these were best assessed primarily involved cognitive and functional scales. CONCLUSION: Cross-cultural adaptations are insufficient, and psychometric properties are unknown for many translated health assessment scales.

Association between acute geriatric syndromes and medication-related hospital admissions.

BACKGROUND: Elderly patients are at a 4-fold higher risk of adverse drug events (ADEs) and drug-related hospitalization. Hospitalization of an elderly patient is often preceded by geriatric syndromes, like falls or delirium. OBJECTIVES: The primary aim of this study was to investigate whether geriatric syndromes were associated with ADEs in acutely admitted elderly patients. METHODS: Consecutive medical patients, aged 65 years or more, who were acutely admitted, were enrolled. An initial multidisciplinary evaluation was completed and baseline characteristics were collected. A fall before admission was retrieved from medical charts. Delirium was determined by the Confusion Assessment Method. RESULTS: A total of 641 patients were included. Over 25% had an ADE present at admission, 26% presented with delirium and 12% with a fall. Delirium was associated with the use of antidepressants, antipsychotics and antiepileptics. In all ADEs (n = 167), ADEs were associated with a fall, with non-steroidal anti-inflammatory drugs or diuretics, but not with pre-existing functioning, delirium or older age. For ADEs involving psychoactive medication (n = 35), an association was found between delirium, falls, opioids and antipsychotics in bivariate analyses. A fall just before hospitalization (odds ratio [OR] 3.69 [95% CI 1.41, 9.67]), antipsychotics (OR 3.70 [95% CI 1.19, 11.60]) and opioids (OR 14.57 [95% CI 2.02, 105.30]) remained independently associated with an ADE involving psychoactive medication. CONCLUSION: This prospective study demonstrated that, in a cohort of elderly hospital patients, a fall before admission and prevalent delirium are associated with several pharmacological groups and/or with ADE-related hospital admission.

Systematic comprehensive geriatric assessment in elderly patients on chronic dialysis: a cross-sectional comparative and feasibility study.

BACKGROUND: Elderly dialysis patients are prone to disabilities and functional decline. This aggravates their last period of life. It would be valuable to be able to preserve daily function and quality of life. Identification of domains requiring additional attention is not common practice in standard care. Therefore, we performed a systematic Comprehensive Geriatric Assessment (CGA) to assess physical and psychosocial function and tested its feasibility in daily practice. The CGA is used more frequently in the assessment of elderly cancer patients, and we therefore compared the outcomes to this group. METHODS: A cross-sectional, multicenter study, between June 1st and September 31st, 2009, in four Dutch outpatient dialysis units. Fifty patients aged 65 years or above who received dialysis because of end-stage renal disease (ESRD) were randomly included. We assessed the CGA during a systematic interview with patients and their caregivers. The cancer patients had had a similar CGA in an earlier study. We compared prevalences between groups. RESULTS: In the dialysis population (68.0% 75 years or above, 76.6% on haemodialysis) caregivers often observed behavioral changes, such as deviant eating habits (34.0%) and irritability (27.7%). In 84.4%, caregivers felt overburdened by the situation of their family member. Somatic and psychosocial conditions were frequently found (polypharmacy (94.6%), depression (24.5%)) and prevalence of most geriatric conditions was comparable to those in elderly cancer patients. CONCLUSIONS: Geriatric conditions were highly prevalent among elderly dialysis patients and prevalences were comparable in both populations. The CGA proved feasible for recognition of these conditions and of overburdened caregivers. This could prevent further functional decline and preserve quality of life.

A randomised clinical trial on a comprehensive geriatric assessment and intensive home follow-up after hospital discharge: the Transitional Care Bridge.

BACKGROUND: Older patients are at high risk for poor outcomes after acute hospital admission. The mortality rate in these patients is approximately 20%, whereas 30% of the survivors decline in their level of activities of daily living (ADL) functioning three months after hospital discharge. Most diseases and geriatric conditions that contribute to poor outcomes could be subject to pro-active intervention; not only during hospitalization, but also after discharge. This paper presents the design of a randomised controlled clinical trial concerning the effect of a pro-active, multi-component, nurse-led transitional care program following patients for six months after hospital admission. METHODS/DESIGN: Three hospitals in the Netherlands will participate in the multi-centre, double-blind, randomised clinical trial comparing a pro-active multi-component nurse-led transitional care program to usual care after discharge. All patients acutely admitted to the Department of Internal Medicine who are 65 years and older, hospitalised for at least 48 hours and are at risk for functional decline are invited to participate in the study. All patients will receive integrated geriatric care by a geriatric consultation team during hospital admission. Randomization, which will be stratified by study site and cognitive impairment, will be conducted during admission. The intervention group will receive the transitional care bridge program, consisting of a handover moment with a community care Care Nurse (CN) during hospital admission and five home visits after discharge. The control group will receive 'care as usual' after discharge. The main outcome is the level of ADL functioning six months after discharge compared to premorbid functioning measured with the Katz ADL index. Secondary outcomes include; survival, cognitive functioning, quality of life, and health care utilization, satisfaction of the patient and primary care giver with the transitional care bridge program. All outcomes will be measured at three, six and twelve months after discharge. Approximately 674 patients will be enrolled to either the intervention or control group. DISCUSSION: The study will provide new knowledge on a combined intervention of integrated care during hospital admission, a proactive handover moment before discharge and intensive home visits after discharge. TRIAL REGISTRATION NUMBER: NTR 2384.