Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study.

BACKGROUND: Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. METHODS: We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. RESULTS: Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. CONCLUSIONS: Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly. STUDY REGISTRATION: ISRCTN65924234.

Scaling properties of the subjective index of physical and social outcome after stroke in a study population unselected by age.

OBJECTIVE: To investigate the scaling properties of the Subjective Index of Physical and Social Outcome (SIPSO) after stroke in survivors to hospital discharge, unselected by age. DESIGN: Factor, Mokken, and Rasch analyses of the SIPSO using data from a prospective observational cohort study. SETTING: Three acute care hospitals. PARTICIPANTS: Consecutive admissions (N=312) with acute stroke, unselected by age. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient- or proxy-reported SIPSO, collected by postal survey 6 months after stroke. RESULTS: Complete SIPSO questionnaires were returned by 166 of 268 survivors (median age, 72y; interquartile range, 66-81y). Factor and Mokken analyses supported both 1- and 2-factor solutions. Fit to the Rasch model for the 10-item scale was poor (χ(2) test for item-trait interaction, χ(2)=69.6; P<.001). Differential item functioning by sex and age was demonstrated for the physical subscore and was dealt with through the creation of 2 super items, resulting in a good fit to the Rasch model (χ(2)=2.35; P=.67), ordered thresholds, good targeting to the latent trait, and reasonable separation reliability (Person-Separation Index, 0.8). For the social subscore, no differential item functioning was demonstrated by age or sex. Local dependence was dealt with through the creation of 2 super items. Thereafter, fit to the Rasch model (χ(2)=5.21; P=.27) and targeting to the latent trait were good, and thresholds ordered. Separation reliability was poor (Person-Separation Index, .67). CONCLUSIONS: The 10-item SIPSO is a valid ordinal scale in a population including older stroke survivors. A physical and social subscale structure is also supported. Subscales can be manipulated to fit the Rasch model, and a conversion table for conversion to an interval scale is provided. The social subscore has poor separation reliability, limiting its use in older stroke survivors.

A systematic review of case-mix adjustment models for stroke.

OBJECTIVE: To identify any externally validated prognostic model for predicting outcome in unselected populations following acute stroke comprising variables feasible for collection in routine care. DATA SOURCES: Searches were run in MEDLINE, EMBASE, CINAHL, PsycInfo, AMED and ISI Web of Science with no limits on publication date or language. REVIEW METHODS: Any study describing the development or external validation of a discernible prognostic model to predict any valid outcome following acute stroke was included. Papers were retained if they met pre-specified inclusion criteria identified from previous reviews and pertinent discussion papers. Data extraction focused on methodological quality of model development, generalizability and feasibility of variable collection. Model performance was examined through consideration of external validation studies. RESULTS: Seventeen externally validated models were identified from 43 papers fulfilling inclusion criteria. Quality of studies describing model development was variable and model performance in external validation studies was generally poor. Models were generally constructed through secondary use of randomized trial or stroke database data. Prognostic variables broadly encompassed markers of stroke severity, pre-stroke function and comorbidities. One model that fulfilled the review criteria and had extensive external validation in a range of post-stroke populations was identified (the Six Simple Variables model). CONCLUSION: The Six Simple Variables model performed well in six external validation studies, although prediction of outcome in patients with milder strokes was less reliable. Other models identified in this review have been developed using robust methodology but comprise more complex clinical variables which may limit their utility in routine stroke care.

Is there a role for physical activity in preventing cognitive decline in people with mild cognitive impairment?

Mild cognitive impairment (MCI) is a common clinical syndrome that identifies people at high risk of developing dementia. Although treatments for MCI are currently unavailable, preliminary evidence has identified potential neuro-protective effects of physical activity, which may lead to improved outcomes. However, there is uncertainty regarding the effectiveness, feasibility and acceptability of this treatment strategy. These uncertainties require further investigation before physical activity interventions can be recommended for routine care.

Do home-based exercise interventions improve outcomes for frail older people? Findings from a systematic review.

BACKGROUND: Frailty is common in older age, and is associated with important adverse health outcomes including increased risk of disability and long-term care admission. OBJECTIVES: To evaluate whether home-based exercise interventions improve outcomes for frail older people. DATA SOURCES: We searched systematically for randomised controlled trials (RCTs) and cluster RCTs, with literature searching to February 2010. STUDY SELECTION: All trials that evaluated home-based exercise interventions for frail older people were eligible. Primary outcomes were mobility, quality of life and daily living activities. Secondary outcomes included long-term care admission and hospitalisation. RESULTS: Six RCTs involving 987 participants met the inclusion criteria. Four trials were considered of high quality. One high quality trial reported improved disability in those with moderate but not severe frailty. Meta-analysis of long-term care admission rates identified a trend towards reduced risk. Inconsistent effects on other primary and secondary outcomes were reported in the other studies. CONCLUSIONS: There is preliminary evidence that home-based exercise interventions may improve disability in older people with moderate, but not severe, frailty. There is considerable uncertainty regarding effects on important outcomes including quality of life and long-term care admission. Home-based exercises are a potentially simple, safe and widely applicable intervention to prevent dependency decline for frail older people.

Which medications to avoid in people at risk of delirium: a systematic review.

BACKGROUND: delirium is a common clinical problem and is associated with adverse health outcomes. Many medications have been associated with the development of delirium, but the strength of the associations is uncertain and it is unclear which medications should be avoided in people at risk of delirium. METHODS: we conducted a systematic review to identify prospective studies that investigated the association between medications and risk of delirium. A sensitivity analysis was performed to construct an evidence hierarchy for the risk of delirium with individual agents. RESULTS: a total of 18,767 studies were identified by the search strategy. Fourteen studies met the inclusion criteria. Delirium risk appears to be increased with opioids (odds ratio [OR] 2.5, 95% CI 1.2-5.2), benzodiazepines (3.0, 1.3-6.8), dihydropyridines (2.4, 1.0-5.8) and possibly antihistamines (1.8, 0.7-4.5). There appears to be no increased risk with neuroleptics (0.9, 0.6-1.3) or digoxin (0.5, 0.3-0.9). There is uncertainty regarding H(2) antagonists, tricyclic antidepressants, antiparkinson medications, steroids, non-steroidal anti-inflammatory drugs and antimuscarinics. CONCLUSION: for people at risk of delirium, avoid new prescriptions of benzodiazepines or consider reducing or stopping these medications where possible. Opioids should be prescribed with caution in people at risk of delirium, but this should be tempered by the observation that untreated severe pain can itself trigger delirium. Caution is also required when prescribing dihydropyridines and antihistamine H1 antagonists for people at risk of delirium and considered individual patient assessment is advocated.

Is physical rehabilitation for older people in long-term care effective? Findings from a systematic review.

OBJECTIVE: to determine the effects of physical rehabilitation for older people resident in long-term care. DESIGN: systematic review of randomised controlled trials. DATA SOURCES: The Cochrane Central Register of Controlled Trials, Medline, EMBASE, AMED, CINAHL, PEDro, British Nursing Index, ASSIA, IBSS, PsychINFO, DARE, HMIC, NHS EED, HTA, Web of Science, AsLib Index to UK Theses and Dissertation Abstracts, the National Research Register, Medical Research Council Register, CRIB, Current Controlled Trials and HSRPRoj. TRIALS: all randomised trials investigating physical rehabilitation for people permanently resident in long-term care aged > or = 60 years. The primary outcome was measures of activity restriction. RESULTS: 49 trials were identified involving 3,611 subjects with an average age of 82 years. Intervention duration was typically 12 weeks with a treatment intensity of three 30-min sessions per week. Exercise was the main component of the interventions. The mean attendance rate for 17 studies was 84% (range 71-97%). Thirty-three trials, including the nine trials recruiting over 100 subjects, reported positive findings, mostly improvement in mobility but also strength, flexibility and balance. CONCLUSION: physical rehabilitation for older people in long-term care is acceptable and potentially effective. Larger scale studies are needed to confirm the findings and should include longer term follow-up and assessment for possible harms.

Post-acute care for older people in community hospitals--a cost-effectiveness analysis within a multi-centre randomised controlled trial.

OBJECTIVES: to compare the cost effectiveness of post-acute care for older people provided in community hospitals with general hospital care. DESIGN: cost-effectiveness study embedded within a randomised controlled trial. SETTING: seven community hospitals and five general hospitals at five centres in the midlands and north of England. PARTICIPANTS: 490 patients needing rehabilitation following hospital admission with an acute illness. INTERVENTION: multidisciplinary team care for older people in community hospitals. MEASUREMENTS: EuroQol EQ-5D scores transformed into quality-adjusted life years; health and social service costs during the 6-month period following randomisation. RESULTS: there was a non-significant difference between the community hospital and general hospital groups for changes in quality-adjusted life-year values from baseline to 6 months (mean difference 0.048; 95% confidence interval -0.028 to 0.123; P = 0.214). Resource use was similar for both groups. The mean (standard deviation) costs per patient for health and social services resources used were comparable for both groups: community hospital group 8,946 pounds ( 6,514 pounds); general hospital group 8,226 pounds ( 7,453 pounds). These findings were robust to sensitivity analyses. The incremental cost-effectiveness ratio estimate was 16,324 pounds per quality-adjusted life year. A cost effectiveness acceptability curve suggests that if decision makers' willingness to pay per quality-adjusted life year was 10,000 pounds, then community hospital care was effective in 47% of cases, and this increased to only 50% if the threshold willingness to pay was raised to 30,000 pounds. CONCLUSIONS: the cost effectiveness of post-acute rehabilitation for older people was similar in community hospitals and general hospitals.

The feasibility of care mapping to improve care for physically ill older people in hospital.

BACKGROUND: providing dignity in health care for older people is an important policy and clinical objective but requires implementation using reliable methods. Our objective was to investigate the feasibility of a person-centred observational practice development method known as dementia care mapping (DCM) in hospital wards for physically ill older people, including those who do not have dementia. METHODS: DCM (version 8) was conducted in three elderly care general hospital wards and in two community hospitals. Summary statistics were calculated from the DCM data to assess feasibility and adequacy of the DCM coding system. RESULTS: fifty-eight participants were mapped for 84 observation hours/414 patient hours (4,968 5-min time frames). There was a relatively high proportion (942/2,376; 40% time frames) of missing data in the community hospitals due to time patients spent away from the area under observation. All 3,624 of the time frames with patient-observed data could be coded utilising the existing Behaviour Category and Mood/Engagement Value coding frameworks. DISCUSSION: the results from this preliminary study are promising and indicate that DCM is potentially feasible in elderly care general hospital wards, without the need for major modification.

A whole system study of intermediate care services for older people.

BACKGROUND: Intermediate care (IC) services have been widely introduced in England and have the strategic objectives of reducing hospital and long-term care use. There is uncertainty about the clinical outcomes of these services and whether their strategic aims will be realised. SETTING: A metropolitan city in northern England. DESIGN: A quasi-experimental study comparing a group of older people before and after the introduction of an IC service. A quota sampling method was used to match the groups. SUBJECTS: Patients presenting as emergency admissions to two elderly care departments with falls, confusion, incontinence or immobility. INTERVENTION: a city-wide service in which a joint care management team (multi-agency, multi-disciplinary) assessed patient need and purchased support and rehabilitation from sector-based IC teams. OUTCOMES: Nottingham Extended Activities of Daily Living score, Barthel Index, Hospital Anxiety and Depression score, mortality, readmission to hospital, and new institutional care placement at 3, 6 and 12 months post-recruitment. RESULTS: There were 800 and 848 patients, respectively, in the control and intervention groups. Clinical outcomes, hospital and long-term care use were similar between the groups. Uptake of IC was lower than anticipated at 29%. An embedded case-control study comparing the 246 patients who received IC with a matched sample from the control group demonstrated similar clinical outcomes but increased hospital bed days used over 12 months (mean +8 days; 95% CI 3.1-13.0). CONCLUSION: This city-wide IC service was associated with similar clinical outcomes but did not achieve its strategic objectives of reducing long-term care and hospital use.

Reliability of the Barthel Index when used with older people.

OBJECTIVE: the Barthel Index (BI) has been recommended for the functional assessment of older people but the reliability of the measure for this patient group is uncertain. To investigate this issue we undertook a systematic review to identify relevant studies from which an overview is presented. METHOD: studies investigating the reliability of the BI were obtained by searching Medline, Cinahl and Embase to January 2003. Screening for potentially relevant papers and data extraction of the studies meeting the inclusion criteria were carried out independently by two researchers. RESULTS: the scope of the 12 studies identified included all the common clinical settings relevant to older people. No study investigated test-retest reliability. Inter-rater reliability was reported as 'fair' to 'moderate' agreement for individual BI items, and a high percentage agreement for the total BI score. However, these findings were difficult to interpret as few studies reported the prevalence of the disability categories for the study populations. There may be considerable inter-observer disagreement (95% CI of +/-4 points). There was evidence that the BI might be less reliable in patients with cognitive impairment and when scores obtained by patient interview are compared with patient testing. The role of assessor training and/or guidelines on the reliability of the BI has not been investigated. CONCLUSIONS: although the BI is highly recommended, there remain important uncertainties concerning its reliability when used with older people. Further studies are justified to investigate this issue.