Delirium Due to Potentially Avoidable Hospitalizations Among Older Adults.

BACKGROUND: Delirium is a common complication during acute care hospitalizations in older adults. A substantial percentage of admissions are for ambulatory care-sensitive conditions (ACSCs) or potentially avoidable hospitalizations-conditions that might be treated early in the outpatient setting to prevent hospitalization and hospital complications. METHODS: This retrospective cross-sectional study examined rates of delirium among older adults hospitalized for ACSCs. Participants were 39 933 older adults ≥65 years of age admitted from January 1, 2015 to December 31, 2019 to general inpatient units and ICUs of a large Southeastern academic medical center. Delirium was defined as a score ≥ 2 on the Nursing Delirium Screening Scale or positive on the Confusion Assessment Method for the Intensive Care Unit during admission, and ACSCs were identified from the primary admission diagnosis using standardized definitions. Generalized linear mixed models were used to examine the association between ACSCs and delirium, compared with admissions for non-ACSC diagnoses, adjusting for covariates and repeated observations for individuals with multiple admissions. RESULTS: Delirium occurred in 15.6% of admissions for older adults. Rates were lower for ACSC admissions versus admissions for other conditions (13.9% vs 15.8%, p < .001). Older age and higher comorbidity were significant predictors of the development of delirium. CONCLUSIONS: Rates of delirium among older adults hospitalized for ACSCs were lower than rates for non-ACSC hospitalization but still substantial. Optimizing the treatment of ACSCs in the outpatient setting is an important goal not only for reducing hospitalizations but also for reducing risks for hospital-associated complications such as delirium.

Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative.

BACKGROUND: The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN: The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS: Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS: This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.

Delirium Mediates Incidence of Hospital-Associated Disability Among Older Adults.

OBJECTIVE: To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults. DESIGN: Retrospective cross-sectional study. SETTING AND PARTICIPANTS: General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019. METHODS: Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD. RESULTS: One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001). CONCLUSIONS AND IMPLICATIONS: Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.

The current landscape of Acute Care for Elders units in the United States.

BACKGROUND: The clinical benefits of Acute Care for Elders (ACE) units have been established for over 25 years. However, how widely disseminated ACE units are in the United States and the degree of fidelity to the key elements of this model of care are unknown. Our objective was to identify all existing ACE units in the United States and to obtain detailed information about variations in implementation. METHODS: The strategy to identify current ACE units began with online searches and snowball sampling using contacts from professional societies and workgroups. Next, a request for information regarding the existence of ACE units was sent to the remaining US hospitals listed in a national hospital database. An online survey was sent to identified ACE unit contacts to capture information on implementation characteristics and the five key elements of ACE units. RESULTS: There were 3692 hospitals in the database with responses from 2055 (56%) hospitals reporting the presence or absence of an ACE unit. We identified 68 hospitals (3.3%) with an existing or previous ACE unit. Of these 68 hospitals, 50 (74%) completed the survey and reported that 43 ACE units were currently open and 7 had been closed. Of the 43 currently open ACE units, most are affiliated with an academic hospital and there is variable implementation of each of the five key ACE elements (from 69% to 98%). CONCLUSIONS: Among the 50 hospitals to complete the survey, 43 current ACE units were identified, with variable fidelity to the key elements. Estimates of prevalence of ACE units and fidelity to key elements are limited by nonresponses to the national survey request by nearly half of hospitals.

An Implementation Assessment of the Virtual Acute Care for Elders Program From the Perspective of Key Stakeholders.

OBJECTIVE: The aim of this study was to obtain feedback from key stakeholders and end users to identify program strengths and weaknesses to plan for wider dissemination and implementation of the Virtual Acute Care for Elders (Virtual ACE) program, a novel intervention that improves outcomes for older surgical patients. BACKGROUND: Virtual ACE was developed to deliver evidence-based geriatric care without requiring daily presence of a geriatrician. Previous work demonstrated that Virtual ACE increased mobility and decreased delirium rates for surgical patients. METHODS: We conducted semi-structured interviews with 30 key stakeholders (physicians, nurses, hospital leadership, nurse managers, information technology staff, and physical/occupational therapists) involved in the implementation and use of the program. RESULTS: Our stakeholders indicated that Virtual ACE was extremely empowering for bedside nurses. The program helped nurses identify older patients who were at risk for a difficult postoperative recovery. Virtual ACE also gave them skills to manage complex older patients and more effectively communicate their needs to surgeons and other providers. Nurse managers felt that Virtual ACE helped them allocate limited resources and plan their unit staffing assignments to better manage the needs of older patients. The main criticism was that the Virtual ACE Tracker that displayed patient status was difficult to interpret and could be improved by a better design interface. Stakeholders also felt that program training needed to be improved to accommodate staff turnover. CONCLUSIONS: Although respondents identified areas for improvement, our stakeholders felt that Virtual ACE empowered them and provided effective tools to improve outcomes for older surgical patients.

Improving Geriatric Care Processes on Two Medical-Surgical Acute Care Units: A Pilot Study.

The Acute Care for Elders (ACE) Unit model improves cognitive and functional outcomes for hospitalized elders but reaches a small proportion of patients. To disseminate ACE Unit principles, we piloted the "Virtual ACE Intervention" that standardizes care processes for cognition and function without daily geriatrician oversight on two non-ACE units. The Virtual ACE Intervention includes staff training on geriatric assessments for cognition and function and on nurse-driven care algorithms. Completion of the geriatric assessments by nursing staff in patients aged 65 years and older and measures of patient mobility and prevalence of an abnormal delirium screening score were compared preintervention and postintervention. Postintervention, the completion of the assessments for current functional status and delirium improved (62.5% vs. 88.5%, p < .001) and (4.2% vs. 96.5%, p < .001). In a subsample analysis, in the postintervention period, more patients were up to the chair in the past day (36.4% vs. 63.5%, p = .04) and the prevalence of an abnormal delirium screening score was lower (13.6% vs. 4.8%, p = .16). The Virtual ACE Intervention is a feasible model for disseminating ACE Unit principles to non-ACE Units and may lead to increased adherence to care processes and improved clinical outcomes.

A Performing Arts Intervention Improves Cognitive Dysfunction in 50 Hospitalized Older Adults.

BACKGROUND AND OBJECTIVES: Arts in medicine programs have emerged as a patient-centered approach that aims to improve health-related quality of life for patients in U.S. hospitals. Storytelling and poetry/monologue recitation are forms of arts-based experiences designed to enhance healing and are delivered by an artist-in-residence. We evaluated the effect of a storytelling/poetry experience on delirium screening scores and patient satisfaction in hospitalized older adults. RESEARCH DESIGN AND METHODS: We conducted an observational pre-post study with a control group in the Acute Care for the Elders (ACE) unit at an academic medical center. A convenience sample of 50 participants was recruited to participate and complete two questionnaires measuring pain, anxiety, general well-being, and distress at hospital admission and at hospital discharge. Multivariable regression models were used to compare delirium screening score (primary outcome) between the control and intervention groups and to adjust for the differences in baseline characteristics between groups. RESULTS: At baseline participants in the intervention group were younger and had significantly lower cognitive impairment compared with those in the control group. Participants exposed to the storytelling/poetry intervention had a lower delirium screening score at hospital discharge compared with those in the control group. The result remained significant after adjusting for age, baseline cognitive impairment, and general well-being. Participants in the intervention group reported a high level of satisfaction with the interaction with the artist delivering the intervention. DISCUSSION AND IMPLICATIONS: An artist in residence-delivered storytelling/poetry experience was associated with a lower delirium score at discharge in this pilot study. Further larger studies in diverse inpatient settings are needed to examine whether storytelling/poetry interventions or other types of arts in medicine programs can prevent or reduce delirium in hospitalized older adults.

Acute Care for Elders (ACE) Team Model of Care: A Clinical Overview.

The Institute of Medicine (IOM) Reports of To Err is Human and Crossing the Quality Chasm have called for more interprofessional and coordinated hospital care. For over 20 years, Acute Care for Elders (ACE) Units and models of care that disseminate ACE principles have demonstrated outcomes in-line with the IOM goals. The objective of this overview is to provide a concise summary of studies that describe outcomes of ACE models of care published in 1995 or later. Twenty-two studies met the inclusion. Of these, 19 studies were from ACE Units and three were evaluations of ACE Services, or teams that cared for patients on more than one hospital unit. Outcomes from these studies included increased adherence to evidence-based geriatric care processes, improved patient functional status at time of hospital discharge, and reductions in length of stay and costs in patients admitted to ACE models compared to usual care. These outcomes represent value-based care. As interprofessional team models are adopted, training in successful team functioning will also be needed.

Factors Associated With Hospital Admission for Older Adults Receiving Care in U.S. Emergency Departments.

BACKGROUND: Emergency departments (EDs) play a growing role in hospital admissions for older adults, yet nationally representative data on predictors of admission from the EDs are limited. METHODS: We examined sociodemographic, clinical, and hospital characteristics associated with non-ICU admissions, using National Hospital Ambulatory Medical Care Survey data and multivariate Poisson regression models. RESULTS: There were an estimated 175 million ED visits by adults older than 65 years from 2001 to 2010. Overall, 32.5% were admitted to non-ICU beds. In multivariate analysis, non-ICU admission was associated with increasing age (16% higher per 10-year increase in age), white versus black race (35% vs 31%), and EDs in the Northeast (40%) or Midwest (38%) versus South (31%) or West (30%). CONCLUSION: Non-ICU admission rates for older adults receiving care in U.S. EDs vary by age, race, and region. Understanding the reasons for these disparities in hospitalization rates may guide interventions to reduce hospitalizations in older adults.

Meals Enhancing Nutrition After Discharge: Findings from a Pilot Randomized Controlled Trial.

BACKGROUND: After older adults experience episodes of poor health or are hospitalized, they may not return to premorbid or prehospitalization eating behaviors. Furthermore, poor nutrition increases hospital readmission risk, but evidence-based interventions addressing these risks are limited. OBJECTIVE: This pilot study's objective was to evaluate the feasibility of conducting a randomized controlled trial assessing a post-discharge home-delivered meal program's impact on older adults' nutritional intake and hospital readmissions and to assess patient acceptability and satisfaction with the program. The aims of the study were to evaluate successful recruitment, randomization, and retention of at least 80% of the 24 participants sought; to compare the outcomes of hospital readmission and total daily caloric intake between participants in the intervention and control groups; and to assess patient acceptability and satisfaction with the program. DESIGN: This study used a two-arm randomized controlled trial design, and baseline data were collected at enrollment; three 24-hour food recalls were collected during the intervention period; and health services utilization and intervention satisfaction was evaluated 45 days post-discharge. PARTICIPANTS/SETTING: Twenty-four patients from the University of Alabama at Birmingham Hospital's Acute Care for Elders (ACE) Unit were enrolled from May 2014 to June 2015. They were 65 years or older; at risk for malnutrition; cognitively intact; able to communicate; discharged to a place where the patient or family was responsible for preparing meals; and diagnosed with congestive heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia. Final analysis included 21 participants. INTERVENTION: The intervention group received 10 days of home-delivered meals and nutrition education; the control group received usual care and nutrition education. MAIN OUTCOME MEASURES: The main outcome was intervention feasibility, measured by recruitment and retention goals. Hospital readmissions, caloric intake, and satisfaction with the intervention were also evaluated. STATISTICAL ANALYSES PERFORMED: Univariate and bivariate parametric statistics were used to evaluate differences between groups. Goals for success were identified to assess feasibility of conducting a full-scale study and outcomes were measured against the goals. RESULTS: Of the randomized participants, 87.5% were retained for final data collection, indicating that this intervention study is feasible. There were no significant differences between groups for hospital readmissions; however, caloric intake during the intervention period was greater for intervention vs control participants (1,595 vs 1,235; P=0.03). Participants were overwhelmingly satisfied (82% to 100% satisfied or very satisfied) with staff performance, meal quality, and delivery processes. CONCLUSIONS: Conducting a randomized controlled trial to assess outcomes of providing home-delivered meals to older adults after hospital discharge in partnership with a small nonprofit organization is feasible and warrants future research.

Geriatric assessment factors are associated with mortality after hospitalization in older adults with cancer.

PURPOSE: Survival in older adults with cancer varies given differences in functional status, comorbidities, and nutrition. Prediction of factors associated with mortality, especially in hospitalized patients, allows physicians to better inform their patients about prognosis during treatment decisions. Our objective was to analyze factors associated with survival in older adults with cancer following hospitalization. METHODS: Through a retrospective cohort study, we reviewed 803 patients who were admitted to Barnes-Jewish Hospital's Oncology Acute Care of Elders (OACE) unit from 2000 to 2008. Data collected included geriatric assessments from OACE screening questionnaires as well as demographic and medical history data from chart review. The primary end point was time from index admission to death. The Cox proportional hazard modeling was performed. RESULTS: The median age was 72.5 years old. Geriatric syndromes and functional impairment were common. Half of the patients (50.4 %) were dependent in one or more activities of daily living (ADLs), and 74 % were dependent in at least one instrumental activity of daily living (IADLs). On multivariate analysis, the following factors were significantly associated with worse overall survival: male gender; a total score <20 on Lawton's IADL assessment; reason for admission being cardiac, pulmonary, neurologic, inadequate pain control, or failure to thrive; cancer type being thoracic, hepatobiliary, or genitourinary; readmission within 30 days; receiving cancer treatment with palliative rather than curative intent; cognitive impairment; and discharge with hospice services. CONCLUSIONS: In older adults with cancer, certain geriatric parameters are associated with shorter survival after hospitalization. Assessment of functional status, necessity for readmission, and cognitive impairment may provide prognostic information so that oncologists and their patients make more informed, individualized decisions.

The Association Between Life-Space and Health Care Utilization in Older Adults with Heart Failure.

BACKGROUND: Life-space is associated with adverse health outcomes in older adults, but its role in health care utilization among individuals with heart failure is not well understood. We examined the relationship between life-space and both emergency department (ED) utilization and hospitalization. METHODS: Participants were community-dwelling older adults with a verified diagnosis of heart failure who completed a baseline in-home assessment and at least one follow-up telephone interview. Life-space was measured at baseline and at follow-up every 6 months for 8.5 years. Poisson models were used to determine the association between life-space, measured at the beginning of each 6-month interval, and health care utilization, defined as ED utilization or hospitalization in the immediate ensuing 6 months, adjusting for sociodemographic and clinical confounders. RESULTS: A total of 147 participants contributed 259 total health care utilization events involving an ED visit or a hospital admission. Multivariate analysis demonstrated an inverse association between life-space and health care utilization, where a clinically significant 10-point difference in life-space was independently associated with a 14% higher rate of ED utilization or hospitalization (incidence rate ratio 1.14, 95% CI 1.04-1.26, p = .004). CONCLUSIONS: Life-space may be a useful identifier of community-dwelling older adults with heart failure at increased risk of ED visits or hospital admissions in the ensuing 6 months. Life-space may therefore be a potentially important component of intervention programs to reduce health care utilization.

Geriatric assessment as predictors of hospital readmission in older adults with cancer.

BACKGROUND: Hospital readmission is a common, costly problem. Little is known regarding risk factors for readmission in older adults with cancer. This study aims to identify factors associated with 30-day readmission in a cohort of older medical oncology patients. SETTING/PARTICIPANTS: Adults age 65 and over hospitalized to an Oncology Acute Care for Elders Unit at Barnes-Jewish Hospital. MEASUREMENTS: Standard geriatric screening tests were administered in routine clinical care. Clinical data and 30-day readmission status were obtained through medical record review. RESULTS: 677 patients met the inclusion criteria. 77% were white and 53% were male. Thoracic (32%), hematologic (20%), and gastrointestinal (18%) malignancies were most common. The 30-day unplanned readmission rate was 35.2%. Multivariable analyses identified complete dependence in feeding (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.29-10.65), and some dependence (1.58, 1.04-2.41) and complete dependence (2.64, 1.70-4.12) in housekeeping, prior to admission, as associated with higher odds of readmission. Age<75 (1.49, 1.04-2.14), African-American race (1.59, 1.06-2.39), potentially inappropriate medications (1.36, 0.94-1.99), and higher-risk reasons for index admission (1.93, 1.34-2.78) also increased odds of readmission. These factors were organized into a prognostic index. CONCLUSION: Hospital readmission was common and higher than previously reported rates in general medical populations. We identified several previously unrecognized factors associated with increased risk for readmission, including some geriatric assessment parameters, and developed a practical tool that can be used by clinicians to assess risk of 30-day readmission.

Mobility limitation in the older patient: a clinical review.

IMPORTANCE: Mobility limitations are common in older adults, affecting the physical, psychological, and social aspects of an older adult's life. OBJECTIVE: To identify mobility risk factors, screening tools, medical management, need for physical therapy, and efficacy of exercise interventions for older primary care patients with limited mobility. EVIDENCE ACQUISITION: Search of PubMed and PEDro from January 1985 to March 31, 2013, using the search terms mobility limitation, walking difficulty, and ambulatory difficulty to identify English-language, peer-reviewed systematic reviews, meta-analyses, and Cochrane reviews assessing mobility limitation and interventions in community-dwelling older adults. Articles not appearing in the search referenced by reviewed articles were also evaluated. FINDINGS: The most common risk factors for mobility impairment are older age, low physical activity, obesity, strength or balance impairment, and chronic diseases such as diabetes or arthritis. Several tools are available to assess mobility in the ambulatory setting. Referral to physical therapy is appropriate, because physical therapists can assess mobility limitations and devise curative or function-enhancing interventions. Relatively few studies support therapeutic exercise to improve mobility limitation. Strong evidence supports resistance and balance exercises for improving mobility-limiting physical weakness and balance disorders. Assessing a patient's physical environment and the patient's ability to adapt to it using mobility devices is critical. CONCLUSIONS AND RELEVANCE: Identification of older adults at risk for mobility limitation can be accomplished through routine screening in the ambulatory setting. Addressing functional deficits and environmental barriers with exercise and mobility devices can lead to improved function, safety, and quality of life for patients with mobility limitations.

Mealtime assistance for hospitalized older adults: a report on the SPOONS volunteer program.

Mealtime assistance may be necessary to prevent declines in hospitalized older adults' nutritional well-being. This article reports the implementation of the Support for and Promotion Of Optimal Nutritional Status (SPOONS) volunteer assistance program. Patients were 65 and older, admitted to the Acute Care for Elders Unit at the University of Alabama at Birmingham Hospital, and in need of mealtime assistance. There were 236 documented patient-volunteer encounters at which social interaction (n = 217; 92%), assistance with tray set-up (n = 162; 69%), and prompting to eat (n = 161; 68%), among other activities, were performed. Mean time of interaction was 47.8 minutes, with an average estimated cost savings of $11.94 per encounter had the service been provided by a patient care technician and $26 per encounter had it been provided by an RN. This demonstration of the SPOONS program should be followed up with an evaluation of its effectiveness.

Effects of an acute care for elders unit on costs and 30-day readmissions.

IMPORTANCE: Providing high-quality care while containing cost is essential for the economic stability of our health care system. The United States is experiencing a rapidly growing elderly population. The Acute Care for Elders (ACE) unit interdisciplinary team model of care has been shown to improve outcomes in hospitalized older adults. The University of Alabama at Birmingham ACE unit incorporates evidence-based care processes. We hypothesized that the ACE model would also reduce costs. OBJECTIVE: To examine variable direct costs from an interdisciplinary ACE compared with a multidisciplinary usual care (UC) unit. DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center. PARTICIPANTS: Hospitalists' patients aged 70 years or older spending the entirety of their hospitalization in either the ACE or UC unit in fiscal year 2010. MAIN OUTCOME MEASURES: Using administrative data, we analyzed variable direct costs for ACE and UC patients. We also conducted a subset analysis restricted to the 25 most common diagnosis related groups (DRGs) shared by ACE and UC patients. Generalized linear regression was used to estimate cost ratios and 95% confidence intervals adjusted for age, sex, comorbidity score, and case mix index (CMI). RESULTS: A total of 818 hospitalists' patients met inclusion criteria: 428 from the ACE and 390 from the UC unit. For this study group (all DRGs), the mean (SD) variable direct cost per patient was $2109 ($1870) for ACE and $2480 ($2113) for UC (P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) or moderate (0.74; 95% CI, 0.62-0.89) CMI scores; care was cost neutral for patients with high CMI scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients than UC patients were readmitted within 30 days of discharge (7.9% vs 12.8%; P = .02). Subset analysis of the 25 most common DRGs revealed a significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC patients ($1693 [$1063] vs $2138 [$1431]; P < .001); cost ratios for total (0.78; 95% CI, 0.70-0.87) and daily (0.89; 95% CI, 0.85-0.94) variable direct costs remained significant after adjustment. CONCLUSIONS AND RELEVANCE: The ACE unit team model reduces costs and 30-day readmissions. In an era when improving care processes while reducing costs is a vital objective for the Medicare program and our nation as a whole, the ACE model meets these goals.

Nutritional processes of care for older adults admitted to an oncology-acute care for elders unit.

BACKGROUND: Acute care for elders (ACE) units have been established in the United States to prevent functional decline in older hospitalized patients. PURPOSE: We sought to examine whether an ace unit that focused specifically on care of older oncology patients (OACE) compared with a usual care cancer ward (UCCW) demonstrated improved nutritional processes of care in patients who had documentation of nutritional deficits. METHODS: We conducted a retrospective chart review to examine whether orders had been placed for a nutritional consult or use of nutritional supplements. Logistic regression analyses, controlling for confounding variables, were conducted to evaluate differences between the wards. RESULTS: OACE unit patients were 2.1 times more likely than UCCW patients to have a nutrition consult placed and 2.5 times more likely to have nutritional supplements ordered. CONCLUSIONS: An OACE unit model of care resulted in increased nutritional interventions. Future work is warranted to evaluate outcomes of care.

The underrecognized epidemic of low mobility during hospitalization of older adults.

OBJECTIVES: To examine the proportion of time spent in three levels of mobility (lying, sitting, and standing or walking) by a cohort of hospitalized older veterans as measured by validated wireless accelerometers. DESIGN: A prospective, observational cohort study. SETTING: One hundred fifty-bed Department of Veterans Affairs hospital. PARTICIPANTS: Forty-five hospitalized medical patients, aged 65 and older who were not delirious, did not have dementia, and were able to walk in the 2 weeks before admission were eligible. MEASUREMENTS: Wireless accelerometers were attached to the thigh and ankle of patients for the first 7 days after admission or until hospital discharge, whichever came first. The mean proportion of time spent lying, sitting, and standing or walking was determined for each hour after hospital admission using a previously validated algorithm. RESULTS: Forty-five male patients (mean age 74.2) with a mean length of stay of 5.1 days generated 2,592 one-hour periods of data. A baseline functional assessment indicated that 35 (77.8%) study patients were willing and able to walk a short distance independently. No patient remained in bed the entire measured hospital stay, but on average, 83% of the measured hospital stay was spent lying in bed. The average amount of time that any one individual spent standing or walking ranged from a low of 0.2% to a high of 21%, with a median of 3%, or 43 minutes per day. CONCLUSION: This is the first study to continuously monitor mobility levels early during a hospital stay. On average, older hospitalized patients spent most of their time lying in bed, despite an ability to walk independently.

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.

BACKGROUND: A novel Oncology-Acute Care for Elders (OACE) unit that uses an interdisciplinary team to enhance recognition and management of geriatric syndromes in hospitalized older adult cancer patients has been established at Barnes-Jewish Hospital (St. Louis, Missouri). The OACE team includes a clinical pharmacist whose primary role is to improve the appropriateness of prescribing. OBJECTIVE: Using polypharmacy as the prototypical geriatric syndrome addressed by the OACE team, the objective of this study was to document the processes of communication of an interdisciplinary team and the impact on polypharmacy when the treating physician did not participate in the daily interdisciplinary team rounds. METHODS: This was a prospective, observational study of older cancer patients admitted to the OACE unit. We tracked processes and outcomes of interdisciplinary communication regarding medications by prospectively recording OACE team recommendations and evaluating the frequency of implementation of these recommendations through a chart review. Treating physicians, who did not attend team rounds, received these recommendations on a communication form placed in the patient's chart. RESULTS: Forty-seven patients were included in the study. The mean (SD) age was 73.5 (7.5) years. Twenty-one percent (10/47) of patients were prescribed > or =1 Beers medication as part of their home-care regimen before admission to the OACE unit. The OACE team made 51 medication recommendations, and 42 of those recommendations (82%) were implemented. Twenty-five patients (53%) had an alteration in their medication regimen; 13 (28%) had a potentially inappropriate medication discontinued. A medication error was corrected in ~1 of every 8 patients (6/47 [13%]). CONCLUSIONS: We found that polypharmacy was common in older cancer patients and increased during hospitali-zation. We also found that most OACE team recommendations communicated to physicians were implemented even though the primary physicians were not members of the OACE team. Future randomized trials are needed to assess the impact of the OACE team model of care on adverse events, survival, and cost in hospitalized older adult cancer patients.