The Role of Subjective Age in Predicting Post-Hospitalization Outcomes of Older Adults.

INTRODUCTION: Studies of community-dwelling older adults find subjective age affects health and functional outcomes. This study explored whether younger subjective age serves as a protective factor against hospital-associated physical, cognitive, and emotional decline, well-known consequences of hospitalization among the elderly. METHODS: This study is a secondary data analysis of a subsample (N = 262; age: 77.5 ± 6.6 years) from the Hospitalization Process Effects on Mobility Outcomes and Recovery (HoPE-MOR) study. Psychological and physical subjective age, measured as participants' reports on the degree to which they felt older or younger than their chronological age, was assessed at the time of hospital admission. Independence in activities of daily living, life-space mobility, cognitive function, and depressive symptoms were assessed at hospital admission and 1 month post-discharge. RESULTS: The odds of decline in cognitive status, functional status, and community mobility and the exacerbation of depressive symptoms were significantly lower in those reporting younger vs. older psychological subjective age (odds ratio [OR] = 0.68, 95% CI = 0.46-0.98; OR = 0.59, 95% CI = 0.36-0.98; OR = 0.64, 95% CI = 0.44-0.93; OR = 0.64, 95% CI = 0.43-0.96, respectively). Findings were significant after controlling for demographic, functional, cognitive, emotional, chronic, and acute health predictors. Physical subjective age was not significantly related to post-hospitalization outcomes. CONCLUSION: Psychological subjective age can identify older adults at risk for poor hospitalization outcomes and should be considered for preventive interventions.

Family Support During Hospitalization Buffers Depressive Symptoms Among Independent Older Adults.

OBJECTIVES: Hospitalization is a stressful event that may lead to deterioration in older adults' mental health. Drawing on the stress-buffering hypothesis, we examined whether family support during hospitalization would moderate the relations between level of independence and in-hospital depressive symptoms. METHOD: This research was a secondary analysis of a cohort study conducted with a sample of 370 hospitalized older adults. Acutely ill older adults reported their level of independence at time of hospitalization and their level of depressive symptoms three days into the hospital stay. Family support was estimated by a daily report of hours family members stayed with the hospitalized older adult. RESULTS: Independent older adults whose family members stayed longer hours in the hospital had fewer depressive symptoms than independent older adults with shorter family visits. Relations between depressive symptoms and family support were not apparent for dependent older adults, even though their family members stayed more hours. CONCLUSIONS: This study partially supports the stress-buffering hypothesis, in that social support ameliorated depressive symptoms among hospitalized independent older adults. CLINICAL IMPLICATIONS: Assessing depressive symptoms and functional ability and creating an environment conducive to family support for older adults may be beneficial to hospitalized older adults' mental health.

Still WALKing-FOR: 2-year sustainability of the 'WALK FOR' intervention.

BACKGROUND: low mobility of hospitalised older adults is associated with adverse outcomes and imposes a significant burden on healthcare and welfare systems. Various interventions have been developed to reduce this problem; at present, however, their methodologies and outcomes vary and information is lacking about their long-term sustainability. This study aimed to evaluate the 2-year sustainability of the WALK-FOR (walking for better outcomes and recovery) intervention implemented by teams in acute care medical units. METHODS: a quasi-experimental three-group comparative design (N = 366): pre-implementation, i.e. control group (n = 150), immediate post-implementation (n = 144) and 2-year post-implementation (n = 72). RESULTS: mean participant age was 77.6 years (± 6 standard deviation [SD]) and 45.3% were females. We conducted an analysis of variance test to evaluate the differences in primary outcomes: number of daily steps and self-reported mobility. Levels of mobility improved significantly from the pre-implementation (control) group to the immediate and 2-year post-implementation groups. Daily step count: pre-implementation (median: 1,081, mean: 1,530 SD = 1,506), immediate post-implementation (median: 2,225, mean: 2,724. SD = 1,827) and 2-year post-implementation (median: 1,439, mean: 2,582, SD = 2,390) F = 15.778 P < 0.01. Self-reported mobility: pre-implementation (mean:10.9, SD = 3.5), immediate post-implementation (mean: 12.4, SD = 2.2), 2-year post-implementation (mean: 12.7, SD = 2.2), F = 16.250, P < 0.01. CONCLUSIONS: the WALK-FOR intervention demonstrates 2-year sustainability. The theory-driven adaptation and reliance on local personnel produce an effective infrastructure for long-lasting intervention. Future studies should evaluate sustainability from a wider perspective to inform further in-hospital intervention development and implementation.

Shared and distinct factors underlying in-hospital mobility of older adults in Israel and Denmark (97/100).

BACKGROUND: Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested. METHODS: The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days. RESULTS: Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample. CONCLUSIONS: Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches.

Identifying patients in need of palliative care: Adaptation of the Necesidades Paliativas CCOMS-ICO© (NECPAL) screening tool for use in Israel.

OBJECTIVES: The Necesidades Paliativas CCOMS-ICO© (NECPAL) screening tool was developed to identify patients in need of palliative care and has been used in Israel without formal translation, reliability testing, or validation. Because cultural norms significantly affect subscales such as social vulnerability and health-care delivery, research is needed to comprehensively assess the NECPAL's components, adapt it, and validate it for an Israeli health-care setting. This study linguistically and culturally translated the NECPAL into Hebrew to examine cultural and contextual acceptability for use in the Israeli geriatric health sector. The newly adapted tool was measured for itemized and scale-level content validity, inter-rater reliability (IRR), and construct validity. METHODS: The NECPAL was back-translated and its content validated by a 5-member expert panel for clarity and relevance, forming the Israeli-NECPAL (I-NECPAL). Six health-care professionals used the I-NECPAL with 25 post-acute geriatric patients to measure IRR. For construct validity, the known-groups method was used, as there is no "gold standard" method for identifying palliative needs for comparison with the NECPAL. The known groups were 2 fictitious cases, predetermined of palliative need. Thirty health-care professionals, blinded to the predetermined palliative status, used the I-NECPAL to determine whether a patient needs a palliative-centered plan of care. RESULTS: The findings point to acceptable content and construct validity as well as IRR of the I-NECPAL for potential inclusion as a tool for identifying geriatric patients in need of palliative care. Content-validity assessment brought linguistic changes and the exclusion of the frailty parameter from the annex of chronic diseases. The kappa-adjusted scale-level content-validity index indicated a high level of content validity (0.96). IRR indicated a high level of agreement (all parameters with an "excellent-good" agreement level). The sensitivity (0.93), specificity (0.17), positive predictive value (0.53), and negative predictive value (0.71) revealed how heavily the scale weighed upon the surprise question. These metrics are improved when removing the surprise question from the instrument. SIGNIFICANCE OF RESULTS: Similar to other countries, the Israeli health-care system is regulated by policies that portray the local beliefs and culture as well as evidence-based practice. The decision about when to switch a patient to a palliative-centered plan of care is one such example. It is thus of utmost importance that only locally adapted and vigorously tested screening tools be offered to health-care providers to assist in this decision. The I-NECPAL is the first psychometrically tested palliative needs identification tool for use in the geriatric population in Israel, on both a scale and an itemized level. The results indicate that it can immediately replace the current unvalidated version in use. Further research is needed to determine whether all parts of the scale are relevant for this patient population.

Adapting the Geriatric Institutional Assessment Profile for different countries and languages: A multi-language translation and content validation study.

BACKGROUND: Hospitalization can be hazardous for older people, but most hospitals in Europe are not prepared to meet the unique needs of older adult inpatients. Adaptations of the physical environment, care processes, and staff knowledge and skills in geriatric care are essential to improve the quality of care for older people. An assessment of baseline organizational approaches to older adult care is an important first step toward recognizing the challenges organizations face when delivering acute care services to older adults and attempting to improve them. The Geriatric Institutional Assessment Profile could be a promising tool for this endeavor. OBJECTIVES: To describe a systematic process implemented across seven countries and languages that sought to develop valid and culturally-appropriate translations of the Geriatric Institutional Assessment Profile. DESIGN: Cross-cultural instrument translation and content validation study. SETTING AND PARTICIPANTS: Expert review panels comprised of 68 practicing nurses from seven European or EU associated countries (Austria (German), Belgium (Dutch), Denmark (Danish), Israel (Hebrew), Poland (Polish), Switzerland (German, French), and Turkey (Turkish)) evaluated cross-cultural relevance, including translation, of the Geriatric Institutional Assessment Profile. METHOD: A systematic approach to translating and validating a cross-cultural survey instrument, including back-to-back translation, adaptation, and evaluation of content validity using content validity indexing (CVI) techniques for each country and language, assessing translation and relevance content validity separately. The item, subscale and domain content validity index scores were calculated and adjusted for chance agreement among raters for all parts of the Geriatric Institutional Assessment Profile: the four subscales of geriatric care environment, the general knowledge about older adults subscale, and the clinical geriatric knowledge subscale. Consensus discussions among the raters then finalized translations. RESULTS: CVI scores for relevance and translation were all in the "good" to "excellent" range. The geriatric care environment scale's CVI scores were 0.84 to 0.94 for relevance and 0.82 to 0.98 for translation. The clinical geriatric knowledge subscale's CVI scores were 0.83 to 0.97 for relevance and 0.94 to 0.98 for translation. The general knowledge about older adults subscale received high translation agreement (0.93 to 0.99) but slightly lower scores for relevance, ranging from 0.46 to 0.94. CONCLUSION: Study results provided preliminary evidence of the applicability and validity of a multi-factor measure of age-friendly care in diverse health care systems, in German, Dutch, Danish, Hebrew, Polish, French, and Turkish languages.

Assessment of Sleep Duration and Number of Awakenings Based on Ankle and Wrist Actigraphy in Medical Hospitalized Older Patients.

BACKGROUND: Most studies performed in the hospital assess sleep using self-reports; few rely on actigraphy. Although wrist actigraphy is commonly used for sleep assessment in field studies, in-hospital assessment may be challenging and cumbersome because other more necessary monitoring devices are often attached to patients' upper limbs; these may affect interpretation of wrist activity data. Placement on the ankle may be a viable solution. OBJECTIVE: To compare total sleep time (TST) and number of awakenings (NOA) using concomitant wrist and ankle actigraphy, as well as self-reports in a sample of older adult patients hospitalized in medical units. METHODS: This was a prospective observational study. Objective sleep data were collected using ankle and wrist actigraphy, and subjective data using sleep diary. Repeated measures mixed model analysis was performed, adjusting for age, gender, sleep medications, symptoms severity, interaction between types of measure, and night number. RESULTS: Twenty-one older adults (65+) wore ankle and wrist actigraphy devices and subjectively estimated sleep parameters for an average of (2.15 ± 1.01) nights, with 40 nights available for analysis. TST was lower for wrist than ankle actigraphy (F(2,87) = 7.92, p = .0007). Neither differed from self-reports. NOA differed between all types of measure (ankle, 8.58 ± 6.66; wrist, 15.49 ± 7.47; self-report, 1.81 ± 1.83; F(2,85) = 47.66, p < .001). No significant within-subject variations and no interaction between devices and repeated measures were found. CONCLUSIONS: Despite differences between ankle and wrist assessments, all three methods provided consistent TST estimation within participants. Findings provide preliminary support for the use of ankle actigraphy for sleep assessment in hospital settings.

"Behind the Scenes" of Accelerometer Use to Quantify In-Hospital Mobility of Older Adults.

Measuring in-hospital mobility of older adults with accelerometers is becoming more common practice. However, neither the unique challenges surrounding accelerometer use within acute hospital settings nor the potential solutions to these challenges have been well documented. The aim of this article is to present and discuss what occurs "behind the scenes" when using accelerometers to quantify in-hospital mobility among older adults in acute hospital wards. The article identifies the challenges related to accelerometer use that emerged over the course of daily data collection for 2 large-scale studies, including matters of recruitment, daily use, technical and methodological issues, loss of devices, missing data, and troubleshooting. The article details the tasks and the strategies we developed for overcoming these challenges and how we implemented them within the acute wards. Finally, the article provides recommendations for researchers and clinicians on how to improve future use of accelerometers or other devices aimed to enhance in- hospital mobility of older adults.

Days of worry: Emotional intelligence and social support mediate worry in the COVID-19 pandemic.

This study tested a model accounting for worries among 275 adults during the height of the COVID-19 pandemic in Israel. The main hypothesis posited that psychological and instrumental social support will mediate the association between emotional intelligence and worry, controlling for the level of exposure to the virus risk and demographics. The results showed that social support mediated the above association: social support showed a negative association with worries while instrumental support showed a positive one. The results are discussed in light of existing findings and theories.

A conceptual model for achieving well-being in adults with mild cognitive impairment.

OBJECTIVE: Low well-being is common among people with Mild Cognitive Impairment (MCI). We propose a model to examine how different types of resources work together to maintain well-being in people with MCI. METHODS: Participants included 121 community dwelling adults over the age of 60 who were diagnosed with MCI. Structural equation modeling assessed suggested relationships between resources and well-being. RESULTS: Emotional intelligence, general mental ability, morbidity, economic status, basic activities of daily living, and age were correlated to well-being in a triple mediation process through cognitive function, instrumental activities of daily living, and social support. Model fit was excellent (RMSEA-0.04; IFI-.96; CFI-.96; CMIN/DF-1.23), CONCLUSION: Achieving well-being when coping with MCI requires a combination of objective resources and subjective evaluation of the situation. Ultimately, social support determines an individual's level of well-being. Findings suggest the need to understand what kind of social support is required by those coping with MCI.

The role of nurse staffing in the performance of function-preserving processes during acute hospitalization: A cross-sectional study.

BACKGROUND: Performance of function-preserving hospitalization processes related to patient mobility, use of continence aids and food intake is significantly associated with outcomes in older adults. Nurses are the front-line personnel responsible for promoting performance of such processes. The degree to which nurse staffing is related to this performance is unclear. OBJECTIVE: To identify nurse-staffing characteristics and nursing-related care needs associated with older patients' mobility, continence care and food intake during acute hospitalization. DESIGN: Cross-sectional study using survey data from the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) cohort study combined with day-level administrative nurse staffing data and clinical day-level aggregated data for all patients hospitalized during the HoPE-FOR study period. SETTING: Internal medicine units in two medical centers in Israel. PARTICIPANTS: Eight hundred seventy-three older adults. METHODS: Mobility, continence care and food intake were assessed within 2 days of admission using validated questionnaires. Nurse-to-patient ratios and nursing-skill mix (i.e. registered nurses (RNs), nurse aides, nurses with advanced clinical training and RNs with an academic degree) were assessed using administrative data. Decision trees were developed for mobility, continence care and food intake, applying classification and regression-tree analysis. RESULTS: The mobility decision tree identified three characteristics subdividing patients into six nodes: pre-admission functioning, pre-admission activity level and percentage of nurses with advanced training. The percentage of nurses with advanced training classified low-functioning patients into those walking in corridors versus walking or sitting only inside the room. The continence-care classification decision tree identified two characteristics that subdivided the patients into four nodes: pre-admission functioning and bladder control. Nurse-to-patient-ratio variables and patients' nursing-related care needs did not contribute to this classification. The food-intake decision tree identified four characteristics-pre-admission functioning, gender, percentage of nurses with advanced training and percentage of nurse aides-subdividing patients into eight nodes. Low-functioning patients exposed to a higher percentage of nurses with advanced training had food-intake scores 14% higher than patients exposed to a lower percentage of nurses with advanced training. Independent men exposed to a higher percentage of nurse aides had a 14% higher habitual daily in-hospital food-intake score than independent men exposed to a lower percentage of nurse aides. CONCLUSIONS: A higher percentage of nurses with post-graduate education is associated with better performance of mobility and food intake of hospitalized older adults. To maintain the potential benefits of highly trained staff, education levels should be considered in scheduling and assignment decision-making processes in internal medicine units. Tweetable abstract: A higher percentage of nurses with post-graduate education is associated with better mobility and food intake of hospitalized older adults.

Assessing attitudes and intention to work with older adults by American and Israeli nursing students: Adapting and testing a measure.

BACKGROUND: Finding workers to care for older adults in healthcare settings has become a priority, and research identifying factors influencing a nursing student's intention to make geriatrics a career choice is needed. This calls for the development of a reliable measure of students' perceptions and attitudes. OBJECTIVES: To determine the adaptability of Carolina Opinions on Care of Older Adults (COCOA) to assess nursing students' attitudes to older adults and their intentions to work with them in two countries. DESIGN: Cross-sectional survey. SETTINGS: Nursing students enrolled in an introduction to gerontological nursing course in the United States and Israel. PARTICIPANTS: A convenience sample of 231 undergraduates pursuing a Bachelor of Science in nursing in the United States (N=122) and Israel (N=109). METHODS: Students completed the COCOA instrument and basic demographics using an electronic platform. RESULTS: Exploratory Factor Analysis (EFA) produced five factors explaining 59% of the variation, with the majority of the items (17, 71%) loading above 0.40 on subscales from the instrument's original structure. EFA led to the elimination of one subscale (Value of Older Adults) and the creation of a new subscale (Older versus Younger Adults) with three items. The reliability scores were good to acceptable for all subscales in both Israeli and American samples (α-Cronbach 0.80 to 0.60). Confirmatory FA supported the data's fit to the 21 items of the modified COCOA instrument (CMIN/DF=1.55, CFI=0.93, IFI=0.93, RMSEA=0.05). The analysis of model equivalence for American and Israeli samples revealed significant differences only on the Experience in Caring for Older Adults subscale. CONCLUSIONS: The modified COCOA demonstrated good construct validity and reliability and can serve as estimation of nursing students' attitudes to older adults and their intention to make geriatrics a career choice. Future studies should further evaluate its predictive validity.

Moderating Role of Attachment Orientation in the Association between the Level of Depressive Symptoms and Informal Support among Hospitalized Older Adults.

Objectives: Close family members or friends support hospitalized older adults in many countries. This support might act as a protective factor against the adverse consequences of hospitalization. However, individual differences might interfere with the ability to gain from this kind of support, especially if the patient in question is suffering from a high level of depression. This study explores how attachment predispositions shape the relationship between depression and informal support in the hospital setting. Methods: A short version of the attachment orientation questionnaire and the level of depression questionnaire were completed by 387, age M(SD) = 75.4(7.1) hospitalized older adults at admission. The number of hours informal caregivers stayed in the hospital and support received were collected for up to three consecutive hospitalization days. Results: Both attachment anxiety (t = -2.47, p = .01) and avoidance (t = -2.17, p = .03) moderated the relationship between depression and hours of support. Post hoc analysis revealed that older adults with high levels of attachment anxiety and avoidance received fewer hours of support under conditions of high depression (t = -3.04, p = .003; t = -2.92, p = .004, respectively). There were no significant results for received support. Conclusions: The study results emphasize the relevance of attachment orientation to caregiving relations in health-related contexts and call for awareness of the effect that level of depression combined with attachment orientation can have during hospitalization. Clinical implications: Assessing attachment orientation and depression in hospitalized elders might be useful for identifying older adults at risk for insufficient informal support during hospitalization.

Symptom clusters in hospitalized older adults: Characteristics and outcomes.

Hospital care in medical patients relies mostly on objective measures with limited assessment of subjective symptoms. We subgrouped 331 hospitalized older adults with medical diagnosis (age 75.5 ± 7.1) according to the severity of multiple symptoms to explore if these subgroups differed in health-related characteristics on admission and functional outcomes one month post-discharge. Cluster analysis identified three subgroups based on experiences with five highly distressing symptoms (fatigue, dyspnea, dizziness, sleep disturbance, pain): low levels of all symptoms, high levels of all symptoms; moderate levels of four symptoms with high dyspnea. Belonging in different subgroups was accompanied by different levels of cognitive and mental, but not physical or health status. Patients in the subgroup "Moderate Levels with High Dyspnea" had significantly lower risk of decline in post-discharge instrumental activities of daily living than other subgroups. Better understanding of older hospitalized adults' symptom profiles may yield important information on health condition and recovery.

Patterns of informal family care during acute hospitalization of older adults from different ethno-cultural groups in Israel.

INTRODUCTION: Informal caregiving during hospitalization of older adults is significantly related to hospital processes and patient outcomes. Studies in home settings demonstrate that ethno-cultural background is related to various aspects of informal caregiving; however, this association in the hospital setting is insufficiently researched. OBJECTIVES: Our study explore potential differences between ethno-cultural groups in the amount and kind of informal support they provide for older adults during hospitalization. METHODS: This research is a secondary data analysis of two cohort studies conducted in Israeli hospitals. Hospitalized older adults are divided into three groups: Israeli-born and veteran immigrant Jews, Arabs, and Jewish immigrants from the Former Soviet Union (FSU). Duration of caregiver visit, presence in hospital during night hours, type of support (using the Informal Caregiving for Hospitalized Older Adults scale) are assessed during hospitalization. Results are controlled by background parameters including functional Modified Barthel Index (MBI) and cognitive Short Portable Mental Status Questionnaire (SPMSQ) status, chronic morbidity (Charlson), and demographic characteristics. RESULTS: Informal caregivers of "FSU immigrants" stay fewer hours during the day in both cohorts, and provide less supervision of medical care in Study 2, than caregivers in the two other groups. Findings from Study 1 also suggest that informal caregivers of "Arab" older adults are more likely to stay during the night than caregivers in the two other groups. CONCLUSIONS: Ethno-cultural groups differ in their patterns of caregiving of older adults during hospitalization. Health care professionals should be aware of these patterns and the cultural norms that are related to caregiving practices for better cooperation between informal and formal caregivers of older adults.

Association between continuity of nursing care and older adults' hospitalization outcomes: A retrospective observational study.

AIM: To assess the relationship between continuity in nursing assignment in older adults' acute hospitalization and patient experience and functional decline. BACKGROUND: In-hospital functional decline affects up to 40% of hospitalized older adults. Nurses are responsible for performing functioning-preserving interventions. Whether continuity of nursing care contributes to patients' functional outcomes is unclear. METHOD: A retrospective observational study of 609 patients aged ≥70 admitted to internal medicine units. Patients were surveyed on their functional (cognitive and physical) status and satisfaction with the hospital care experience. Dispersion and sequence of nursing assignment were measured by the Continuity of Care Index and Sequential Continuity Index. Multivariate logistic regressions were modelled for each continuity score and outcome. RESULTS: Achieving 25% of the maximum Continuity of Care Index was associated with lower odds of cognitive decline (OR = 0.64, 95% CI = 0.43-0.94) and higher odds of satisfaction (OR = 1.52, 95% CI = 1.06-2.17). Achieving 25% of the maximum Sequential Continuity Index was associated only with higher odds of satisfaction (OR = 1.43, 95% CI = 1.01-2.02). Continuity scores were not associated with physical functioning decline. CONCLUSION: Continuity in nursing assignment is related to a positive patient experience and cognitive functioning of hospitalized older adults. IMPLICATIONS FOR NURSING MANAGEMENT: Continuity should be prioritized in scheduling and assignment algorithms.

Relationship Between Changes in Sedative-Hypnotic Medications Burden and Cognitive Outcomes in Hospitalized Older Adults.

BACKGROUND: Sedative-hypnotic medications (SHMs) are frequently used in hospitalized older patients, despite undesirable effects on cognitive status. Although previous studies found a significant number of patients experience changes in SHM use during hospitalization, it is unclear which pattern of change leads to hospital-associated cognitive decline (HACD). This study tested the association between patterns of SHM change and HACD. METHODS: This secondary analysis study included 550 patients age 70+ who were cognitively intact at admission (Short Portable Mental Status Questionnaire [SPMSQ] ≥8). HACD was defined as at least 1-point decline in SPMSQ between admission and discharge. Changes in sedative burden (SB) before and during hospitalization (average SB of all hospitalization days) were coded using the Drug Burden Index sorting study participants into four groups: without SB (n = 254), without SB changes (n = 132), increased SB (n = 82), and decreased SB (n = 82). RESULTS: Incidence of HACD was 233/550 (42.4%). In multivariate logistic analysis controlling for demographic characteristics, length of stay, severity of acute illness, comorbidity, SB score at home, pain on admission and depression, the odds of HACD were 2.45 (95% CI: 1.16 to 5.13) among participants with increased SB, 2.10 (95% CI: 1.13 to 3.91) among participants without SB changes, compared with participants with decreased SB. CONCLUSION: Older patients whose SB is increased or does not change are at higher risk for acquired cognitive decline than are those whose SB is reduced. Identifying patients with a potential increase in SB and intervening to reduce it may help to fight HACD.