Home-based Rehabilitation After Inpatient Rehabilitation: Utilization Rate and Characteristics of Referred Patients.

OBJECTIVE: To determine the utilization rate of a home-based rehabilitation program after an inpatient rehabilitation stay, and to investigate the profile of users. DESIGN: Observational study. SETTING: Inpatient rehabilitation facility in a tertiary hospital. PARTICIPANTS: Older patients (N=1913) discharged home between June 2018 and May 2021, after an inpatient rehabilitation stay. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge to home-based rehabilitation. RESULTS: Over the study period, 296 (15.5%) patients were discharged to home-based rehabilitation. Compared with the others, home-based rehabilitation patients were more frequently women (69.6% vs 61.5%; P=.008), and admitted after orthopedic surgery (elective or for fracture) (30.1% vs 16.1%; P<.001). They had worse functional performance at admission (mean Functional Independence Measure self-care score: 27.8±7.3 vs 30.8±6.7; P<.001), but greater gain in self-care during their inpatient stay (5.0±4.8 vs 4.4±4.7; P=.038). In multivariable analysis, being a woman (adjusted odds ratio [adjOR], 1.36; 95% confidence interval [CI], 1.01-1.82; P=.040), being admitted after orthopedic surgery (adjOR, 2.32; 95% CI, 1.64-3.27; P<.001), being admitted for gait disorders or falls (adjOR, 1.38; 95% CI, 1.01-1.88; P=.039), and showing greater gain in mobility during the inpatient stay (adjOR, 1.12; 95% CI, 1.07-1.17; P<.001) remained associated with discharge to home-based rehabilitation. In contrast, higher mobility at discharge decreased the odds of discharge to home-based rehabilitation (adjOR, 0.87; 95% CI, 0.83-0.91; P<.001). CONCLUSIONS: One in 6 patients benefited from home-based rehabilitation after their inpatient stay. Although these patients had poorer functional performance at admission and discharge, they showed greater mobility improvement during their inpatient stay, suggesting that their good recovery potential was a key determinant of their orientation toward home-based rehabilitation.

Unplanned transfer to acute care during inpatient geriatric rehabilitation: incidence, risk factors, and associated short-term outcomes.

BACKGROUND: Information is scarce on unplanned transfers from geriatric rehabilitation back to acute care despite their potential impact on patients' functional recovery. This study aimed 1) to determine the incidence rate and causes of unplanned transfers; 2) to compare the characteristics and outcomes of patients with and without unplanned transfer. METHODS: Consecutive stays (n = 2375) in a tertiary geriatric rehabilitation unit were included. Unplanned transfers to acute care and their causes were analyzed from discharge summaries. Data on patients' socio-demographics, health, functional, and mental status; length of stay; discharge destination; and death, were extracted from the hospital database. Bi- and multi-variable analyses investigated the association between patients' characteristics and unplanned transfers. RESULTS: One in six (16.7%) rehabilitation stays was interrupted by a transfer, most often secondary to infections (19.3%), cardiac (16.8%), abdominal (12.7%), trauma (12.2%), and neurological problems (9.4%). Older patients (AdjORage≥85: 0.70; 95%CI: 0. 53-0.94, P = .016), and those admitted for gait disorders (AdjOR: 0.73; 95%CI: 0.53-0.99, P = .046) had lower odds of transfer to acute care. In contrast, men (AdjOR: 1.71; 95%CI: 1.29-2.26, P < .001), patients with more severe disease (AdjORCIRS: 1.05; 95%CI: 1.02-1.07, P < .001), functional impairment before (AdjOR: 1.69; 95%CI: 1.05-2.70, P = .029) and at rehabilitation admission (AdjOR: 2.07; 95%CI: 1.56- 2.76, P < .001) had higher odds of transfer. Transferred patients were significantly more likely to die than those without transfer (AdjOR 13.78; 95%CI: 6.46-29.42, P < .001) during their stay, but those surviving had similar functional performance and rate of home discharge at the end of the stay. CONCLUSION: A significant minority of patients experienced an unplanned transfer that potentially interfered with their rehabilitation and was associated with poorer outcomes. Men, patients with more severe disease and functional impairment appear at increased risk. Further studies should investigate whether interventions targeting these patients may prevent unplanned transfers and modify associated adverse outcomes.

Diabetes mellitus in older persons with neurocognitive disorder: overtreatment prevalence and associated structural brain MRI findings.

BACKGROUND: Tight diabetes control is often applied in older persons with neurocognitive disorder resulting in increased hypoglycemic episodes but little is known about the pattern of brain injury in these overtreated patients. This study aims to: (a) quantify the prevalence of diabetes overtreatment in cognitively impaired older adults in a clinical population followed in an academic memory clinic (b) identify risk factors contributing to overtreatment; and (c) explore the association between diabetes overtreatment and specific brain region volume changes. METHODS: Retrospective study of older patients with type 2 diabetes and cognitive impairment who were diagnosed in a memory clinic from 2013 to 2020. Patients were classified into vulnerable and dependent according to their health profile. Overtreatment was defined when glycated hemoglobin was under 7% for vulnerable and 7.6% for dependent patients. Characteristics associated to overtreatment were examined in multivariable analysis. Grey matter volume in defined brain regions was measured from MRI using voxel-based morphometry and compared in patients over- vs. adequately treated. RESULTS: Among 161 patients included (median age 76.8 years, range 60.8-93.3 years, 32.9% women), 29.8% were considered as adequately treated, 54.0% as overtreated, and 16.2% as undertreated. In multivariable analyses, no association was observed between diabetes overtreatment and age or the severity of cognitive impairment. Among patients with neuroimaging data (N = 71), associations between overtreatment and grey matter loss were observed in several brain regions. Specifically, significant reductions in grey matter were found in the caudate (adj ß coeff: -0.217, 95%CI: [-0.416 to -0.018], p = .033), the precentral gyri (adj ßcoeff:-0.277, 95%CI: [-0.482 to -0.073], p = .009), the superior frontal gyri (adj ßcoeff: -0.244, 95%CI: [-0.458 to -0.030], p = .026), the calcarine cortex (adj ßcoeff:-0.193, 95%CI: [-0.386 to -0.001], p = .049), the superior occipital gyri (adj ßcoeff: -0.291, 95%CI: [-0.521 to -0.061], p = .014) and the inferior occipital gyri (adj ßcoeff: -0.236, 95%CI: [-0.456 to - 0.015], p = .036). CONCLUSION: A significant proportion of older patients with diabetes and neurocognitive disorder were subjected to excessively intensive treatment. The association identified with volume loss in several specific brain regions highlights the need to further investigate the potential cerebral damages associated with overtreatment and related hypoglycemia in larger sample.

Impact of an early geriatric rehabilitation program in acutely hospitalised vulnerable patients: a real-life study in an ACE unit in Switzerland.

INTRODUCTION: Early geriatric rehabilitation programs are potential means to prevent acute hospitalisation-associated functional decline. METHODS: The objectives were to measure the impact of an interdisciplinary rehabilitation program on patients' administrative in hospital data and on functional trajectories. With a before-and-after design, we compared all patients admitted from January to August 2018 into the Acute Care for Elders (ACE) unit of an Academic hospital in Switzerland who received this type of program to those admitted during the same period in 2016 and 2017. We considered vulnerable patients aged 75 or older. Functional independency level was assessed at baseline, admission, and discharge according to Katz's basic activities daily living (BADL). RESULTS: In total, 378/1,073 patients (mean age 86.6 ± 6.4; 74.6% women; 84% admitted from the emergency department) were prospectively admitted into the ACE unit in 2018. With an adherence rate of 74.0% to functional therapies and compared to the prior years, the program reduced transfers to rehabilitation settings (28.5 vs. 24.3%, p=0.04) and increased direct discharges to home (46.8 vs. 42.4%, p=0.04). Rates of early-unplanned readmission were similar. Between admission to discharge, 89.9% of the patients engaged in the program remained functionally stable or enhanced. Whatever the BADL score at the admission, 46.5% improved their status for at least one BADL. Even though no clinical determinant was identified, patients who engaged ≥ 5 sessions of functional therapy per week were more likely to improve their functional level (OR = 3.05; 95% CI 1.76-5.27). CONCLUSION: This real-life study demonstrates arguments to implement early interdisciplinary rehabilitation program in ACE units in particular to prevent functional decline in vulnerable patients. These findings support consideration regarding the interest of switching from the traditional disease-centred approach in acute care for older patients to a modern one, that also put the emphasis on maintaining functional capacities.

Mortality in COVID-19 older patients hospitalized in a geriatric ward: Is obesity protective?

BACKGROUNDS: To investigate the relationship between obesity and 30-day mortality in a cohort of older hospitalized COVID-19 inpatients. METHODS: Included patients were aged 70 years or more; hospitalized in acute geriatric wards between March and December 2020; with a positive PCR for COVID-19; not candidate to intensive care unit admission. Clinical data were collected from patients electronic medical records. Data on 30-day mortality were retrieved from the hospital administrative database. RESULTS: Patients included (N = 294) were on average 83.4 ± 6.7 years old, 50.7% were women, and 21.7% were obese (BMI > 30 kg/m2). At 30-day, 85 (28.9%) patients were deceased. Compared to survivors in bivariable analysis, deceased patients were older (84.6 ± 7.6 vs 83.0 ± 6.3 years), more frequently with very complex health status (63.5% vs 39.7%, P < .001), but less frequently obese (13.4% vs 24.9%, P = .033) at admission. Over their stay, deceased patients more frequently (all P < .001) developed radiologic signs of COVID-19 (84.7% vs 58.9%), anorexia (84.7% vs 59.8%), hypernatremia (40.0% vs 10.5%), delirium (74.1% vs 30.1%), and need for oxygen (87.1% vs 46.4%) compared to survivors. In multivariable analysis that controlled for all markers of poor prognosis identified in bivariable analysis, obese patients remain with 64% (adjOR 0.36, 95%CI 0.14-0.95, P = .038) lower odds to be deceased at 30-day than non-obese patients. CONCLUSIONS: In this population of older COVID-19 inpatients, an inverse association between obesity and 30-day mortality was observed even after adjusting for all already-known markers of poor prognosis. This result challenges previous observations in younger cohorts and would need to be replicated.

Executive function and prospective falls: a 6-year longitudinal study in community-dwelling older adults.

BACKGROUND: Older people with impaired executive function (EF) might have an increased fall risk, but prospective studies with prolonged follow-up are scarce. This study aimed to investigate the association between a) EF at baseline; b) 6-year decline in EF performance; and fall status 6 years later. METHODS: Participants were 906 community-dwelling adults aged 65-69 years, enrolled in the Lausanne 65 + cohort. EF was measured at baseline and at 6 years using clock drawing test (CDT), verbal fluency (VF), Trail Making Test (TMT) A and B, and TMT ratio (TMT-B - TMT-A/TMT-A). EF decline was defined as clinically meaningful poorer performance at 6 years. Falls data were collected at 6 years using monthly calendars over 12 months. RESULTS: Over 12-month follow-up, 13.0% of participants reported a single benign fall, and 20.2% serious (i.e., multiple and/or injurious) falls. In multivariable analysis, participants with worse TMT-B performance (adjusted Relative Risk Ratio, adjRRRTMT-B worst quintile = 0.38, 95%CI:0.19-0.75, p = .006) and worse TMT ratio (adjRRRTMT ratio worst quintile = 0.31, 95%CI:0.15-0.64, p = .001) were less likely to report a benign fall, whereas no significant association was observed with serious falls. In a subgroup analysis among fallers, participants with worse TMT-B (OR:1.86, 95%CI = 0.98-3.53, p = .059) and worse TMT ratio (OR:1.84,95%CI = 0.98-3.43,p = .057) tended to have higher odds of serious falls. EF decline was not associated to higher odds of falls. CONCLUSIONS: Participants with worse EF were less likely to report a single benign fall at follow-up, while fallers with worse EF tended to report multiple and/or injurious falls more frequently. Future studies should investigate the role of slight EF impairment in provoking serious falls in active young-old adults.

Effectiveness of Information Sessions About COVID-19 Vaccines in Healthcare Professionals Working in Geriatrics.

Objectives: To determine change in (a) perceived knowledge about COVID-19 vaccines; (b) level of confidence in transmitting information about vaccines; and (c) intention to get vaccinated; among healthcare professionals (HCP) working in a Swiss academic geriatric department who attended a 30-minute information session about COVID-19 vaccines. Measurements: At the session's end, a self-administered questionnaire collected information about socio-demographics, personnel, and/or relatives' experience with COVID-19. In addition, participants were asked to rate their: (a) perceived knowledge about COVID-19 vaccines; (b) level of confidence in transmitting information about COVID-19 vaccines to patients and relatives; and (c) intention to get vaccinated; before and after the session. Results: Overall, 97 (42.2% of all HCPs) participated to 14 sessions and completed the questionnaire. Improvements were observed in knowledge, confidence in providing information, and intention to be vaccinated after the session (all p < .001). Similar improvements were observed in subgroup analyses by gender, age groups, profession (involved in direct care or not), and previous experience with COVID-19 (all p < .010). However, HCP aged 20 to 29 years were less likely to feel completely confident in providing information than those aged 30 to 49 and 50+ years (17.1% vs. 43.2% vs. 44.0%, respectively, p = .031) and to report being very likely to be vaccinated (31.4% vs. 56.8% vs. 56.0%, respectively, p = .060). Conclusions: These information sessions positively influenced HCP knowledge, confidence in providing information, and, to a lesser extent, intention to be vaccinated. Younger HCP reported similar improvements but remained less likely to consider vaccination. Additional efforts are needed to convince these undecided HCP and enhance COVID-19 vaccines uptake.

Instrumented 5-Time Sit-To-Stand Test: Parameters Predicting Serious Falls beyond the Duration of the Test.

BACKGROUND: Falls are a major cause of injuries in older adults. To evaluate the risk of falls in older adults, clinical assessments such as the 5-time sit-to-stand (5xSTS) test can be performed. The development of inertial measurement units (IMUs) has provided the possibility of a more in-depth analysis of the movements' biomechanical characteristics during this test. The goal of the present study was to investigate whether an instrumented 5xSTS test provides additional information to predict multiple or serious falls compared to the conventional stopwatch-based method. METHODS: Data from 458 community-dwelling older adults were analyzed. The participants were equipped with an IMU on the trunk to extract temporal, kinematic, kinetic, and smoothness movement parameters in addition to the total duration of the test by the stopwatch. RESULTS: The total duration of the test obtained by the IMU and the stopwatch was in excellent agreement (Pearson's correlation coefficient: 0.99), while the total duration obtained by the IMU was systematically 0.52 s longer than the stopwatch. In multivariable analyses that adjusted for potential confounders, fallers had slower vertical velocity, reduced vertical acceleration, lower vertical power, and lower vertical jerk than nonfallers. In contrast, the total duration of the test measured by either the IMU or the stopwatch did not differ between the 2 groups. CONCLUSIONS: An instrumented 5xSTS test provides additional information that better discriminates among older adults those at risk of multiple or serious falls than the conventional stopwatch-based assessment.

Delirium in older patients undergoing aortic valve replacement: incidence, predictors, and cognitive prognosis.

BACKGROUND: Transcatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR). METHODS: Patients (N = 93) aged 70 years and older, undergoing transcatheter (TAVR, N = 66) or surgical (SAVR, N = 27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients' socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR. RESULTS: Delirium occurred in 21 (23%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66 = 20%) than SAVR (8/27 = 30%) patients, but this difference was not statistically significant (p = .298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0 ± 3.0 vs 28.0 ± 3.0, p = .029), lower performance in IADL (7.0 vs 8.0, p = .038), and higher STS risk scores (4.7 ± 2.7 vs 2.9 ± 2.3, p = .020). In multivariate analyses, patients with intermediate (score > 3 to ≤8) and high (score > 8) STS risk scores had 4.3 (95%CI 1.2-15.1, p = .025) and 16.5 (95%CI 2.0-138.2, p = .010), respectively, higher odds of incident delirium compared to patients with low (score ≤ 3) STS risk scores. At 3-month follow-up (N = 77), patients with delirium still had lower MMSE score (27.0 ± 8.0 vs 28.0 ± 2.0, p = .007) but this difference did not remain significant once adjusting for baseline MMSE (ß-coefficient 1.11, 95%CI [- 3.03-0.80], p = .248). CONCLUSIONS: Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions.

Falls Efficacy Is Associated With Better Gait and Functional Outcomes After Rehabilitation in Older Patients.

OBJECTIVE: To examine the relationship between falls efficacy and the change in gait speed and functional status in older patients undergoing postacute rehabilitation. DESIGN: Prospective cohort study. SETTING: Postacute rehabilitation facility. PARTICIPANTS: Patients (N=180) aged 65 years and older (mean age ± SD, 81.3±7.1y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Data on demographics; functional, cognitive, and affective status; and falls efficacy using a 10-item version of the Falls Efficacy Scale (FES; range, 0-100) were collected upon admission. Data about gait speed and functional status (Barthel Index and Basic Activities of Daily Living [BADL]) were measured at admission and discharge. In addition, BADL performance was self-reported 1 month after discharge. RESULTS: Compared with admission, all rehabilitation outcomes improved at discharge: gait speed (0.41±0.15 m/s vs 0.50±0.16 m/s; P<.001), Barthel Index score (68.4±16.3 vs 82.5±13.6; P<.001), and BADL (3.5±1.6 vs 4.7±1.3; P<.001). Adjusting for baseline status and other potential confounders, baseline FES independently predicted gait speed (adjusted coefficient: 0.002; 95% confidence interval [CI], 0.000-0.004; P=.025) and Barthel index (adjusted coefficient: 0.225; 95% CI, 0.014-0.435; P=.037) at discharge, with higher confidence at baseline predicting greater improvement. Baseline FES was also independently associated with self-reported BADL performance at the 1-month follow-up (adjusted coefficient: 0.020; 95% CI, 0.010-0.031; P<.001). CONCLUSIONS: In older patients, higher falls efficacy predicted better gait and functional rehabilitation outcomes, independently of baseline performance. These results suggest that interventions aiming at falls efficacy improvement during rehabilitation might also contribute to enhancing gait speed and functional status in patients admitted to this setting.