A frailty index derived from a standardized comprehensive geriatric assessment predicts mortality and aged residential care admission

Frailty in older adults is a condition characterised by a loss or reduction in physiological reserve resulting in increased clinical vulnerability. However, evidence suggests that frailty may be modifiable, and identifying frail older people could help better target specific health care interventions and services.

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El indice fragilidad desarrollado a partir del instrumento interRAI Atención Domiciliaria predice mortalidad e institucionalización permitiendo identificar grupos de riesgo y procurar intervenciones específicas en estos grupos. 

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Appropriateness of transferring nursing home residents to emergency departments: a systematic review | BMC Geriatrics | Full Text

Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable. Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract. Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital. The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

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The quest for semantic interoperability

2018 Apr;9(2):348-365. doi: 10.1055/s-0038-1649488. Epub 2018 May 23.

Documenting Routinely What Matters to People: Standardized Headings for Health Records of Patients with Chronic Health Conditions.

Abstract

OBJECTIVE:

Specifying the content in electronic health records (EHRs) through standardized headings based on international reference classifications will facilitate their semantic interoperability. The objective of this study was to specify potential chapter headings for EHRs aligned with the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF) based on the perspectives of people living with chronic health conditions, carers, and professionals.

METHODS:

A multistage process was established including (1) a patient workshop, (2) an online survey of both patients and carers, and (3) an online consultation with patient and professional bodies. The ICF served as a starting point. Based on the first stage, a first draft of the headings was developed and further refined based on the feedback at each stage. We examined in a fourth step whether items from existing assessment tools support the operationalization of the identified headings. Therefore, we used the WHO Disability Assessment Schedule 2.0 (WHODAS2.0), a patient-reported instrument, and interRAI, a clinician-administered instrument.

RESULTS:

The first workshop was attended by eight people, the survey was completed by 250 persons, and the online consultation received detailed feedback by 18 professional bodies. This study resulted in 16 potential chapter headings for EHRs which capture aspects related to the body, such as emotions, motivation, sleep, and memory or thoughts, to being involved in social life, such as mobility, social activities, and finances, as well as to the care process, such as understanding of health issues and treatment or care priorities and goals. When using the WHODAS2.0 and interRAI together, they capture all except one of the proposed headings.

CONCLUSION:

The identified headings provide a high level structure for the standardized recording, use, and sharing of information. Once implemented, these headings have the potential to facilitate the delivery of personalized care planning for patients with long-term health problems.

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Clinical characteristics associated with the onset of delirium among long-term nursing home residents

Evelyn Ning Man Cheung, Sophia Benjamin, George HeckmanJoanne Man-Wai HoLinda LeeSamir K. Sinha and Andrew P. Costa

Abstract

Background

Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay.

Methods

This is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium.

Results

The incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay.

Conclusions

Dementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.

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Identificación del anciano frágil en ucias

Identification of older adults with frailty in the Emergency Department using a frailty index: results from a multinational study.

Brousseau et al Age and Aging (pub ahead of print)

Este trabajo sitúa la fragilidad como signo vital pronóstico en el anciano atendido en el servicio de Urgencias.

La identificación de la fragilidad se realiza a través de 24 ítems incluidos en un proceso de valoración geriátrica integral y se basa en la teoría de acúmulo de déficits de Rockwood .

Esta valoración estandarizada se realiza con el instrumento de valoración de contacto interRAI Contact Assessment de Urgencias. Una valoración geriátrica administrada en unos 15 minutos, mayoritariamente por enfermería, contemplando los diferentes dominios geriátricos y habiendo demostrado su valor predictivo.

El presente trabajo estudia la relación de este índice de fragilidad con resultados adversos (muerte a 28 día, estancia media hospitalaria, institucionalización) y demuestra la factibilidad de aplicar el índice de fragilidad en los servicios de urgencias y su asociación con resultados asistenciales.

Los autores demuestran en este estudio la validez del índice de Fragilidad en Urgencias en una cohorte internacional procedente de 7 países. La identificación de los ancianos más vulnerables en urgencias brinda la oportunidad de considerar la fragilidad en la orientación diagnostica, en la intervención y en la planificación de cuidados. Permitiendo así disponer de una herramienta que nos ayude a asignar y ajustar mejor los recursos sociosanitarios.

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Validation of a Falls Risk Screening Tool Derived From InterRAI Acute Care Assessment.

Journal of Patient Safety, 2018 Jan 22

Peel NM, Jones LV, Berg K, Gray LC.

OBJECTIVES:

This study aimed to develop and validate a falls risk screening tool derived from interRAI Acute Care (AC) Assessment.

METHODS:

For derivation and validation, two prospective cohorts were recruited from AC hospitals in Australia. The derivation cohort comprised 1418 patients from 11 hospitals. In the validation cohort, 393 patients were recruited from four hospitals. The interRAI AC tool was used to collect comprehensive geriatric assessment data at admission. In-hospital falls were documented from medical records. A falls risk score was calculated using logistic regression. Predictive ability was compared with St. Thomas Risk Assessment Tool In Falling elderlY (STRATIFY), using area under curve (AUC). The validation cohort provided external validity.

RESULTS:

Complete data in the derivation cohort were available for 1288 patients (91%), with 75 (5.8%) having an in-hospital fall. The derived interRAI AC falls risk score (range = 0-6) had significantly better predictive ability (AUC = 0.70, 95% confidence interval [CI] = 0.63-0.76) compared with St. Thomas Risk Assessment Tool In Falling elderlY (AUC = 0.64, 95% CI = 0.58-0.70) (P = 0.033). At a cut point of three, 54 of 75 falls were correctly predicted by the falls risk score derived from interRAI AC (sensitivity = 0.72 [95% CI = 0.60-0.82] and specificity = 0.60 [95% CI = 0.57-0.62]). The falls risk score performed similarly in the validation cohort.

CONCLUSIONS:

The falls risk tool developed from interRAI AC is a valid measure to screen for in-hospital falls. Reduction in assessment burden without loss of fidelity can be achieved through integrating the risk screener within the interRAI hospital system, which automatically triggers protocols for falls prevention based on identified risk.

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Un nuevo instrumento de Calidad de Vida autopercibida (interRAI SQOL) para el medio residencial. Morris et al, JAMDA 2017

Este instrumento el SQOL-LTCF pertenece a la familia de herramientas de valoración interRAI usadas en dispositivos de atención domiciliaria, salud mental y residencias de válidos. Como ocurre con los instrumentos interRAI utiliza un core de variables comunes y otras específicas, en este caso con el dispositivo de cuidados de larga duración (Long Term Care Facilities, LTCF).

Los resultados presentados en el artículo pertenecen a un grupo de  8 «early adopters countries» con una muestra de 16.017 residentes, procedentes de 355 unidades de cuidados de larga duración. La herramienta identificó 5 escalas: vida social, Control personal, Alimentación, Staff cuidador y Respuesta del Staff.

Las escalas incorporadas en la herramienta relacionan significativamente la percepción, en las residencias, de un entorno hogareño «como en casa» (home like). Esta herramienta podrá  ayudar en la monitorización y benchmarking de la mejora de la calidad de vida en el sector residencial

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Indice de Fragilidad de…Morris’s interRAI Home Care Frailty Scale

La aportación de John Morris al concepto de fragilidad

Morris JN, Howard EP, Steel KR. Development of the interRAI home care frailty scale. BMC geriatrics. 2016;16(1):188.

Conocidos los dos paradigmas de Fried vs Rockwood y el consabido recelo de muchos investigadores en penetrar en la caverna platoniana de la fragilidad. John Morris se adentra por fin en este difícil terreno y nos aporta una valiente e interesante visión. Esta contrasta con la recomendación de muchos, de realizar una valoración geriatrica integral cuando se detecta fragilidad; anteponiendo por lo tanto la valoración sistemática al diagnostico específico.

La escala de fragilidad surge de la VGI realizada a través del instrumento de valoración interRAI de Atención Domiciliaria. El abordaje que propone Morris también pivota en la teoría del acumulo de déficits y en la valoración multidimensional incorporando componentes físicos, cognitivos, clínicos y psiocoosiclaes.

La escala de fragilidad estudió 70 variables procedentes de 967,865 valoraciones basales y 464,788 valoraciones de seguimiento semestral. La escala final consiste en 29 ítems que se correlacionan con una selección de medidas de deterioro y complicaciones clínicas. Estos ítems contemplan función, movimiento, cognición y comunicación, vida social, nutrición y síntomas clínicos. La escala resultante es consistente con estudios previos que demuestran la fragilidad como un estado relativo de debilidad con expectativa de perdida progresiva.

Esta escala puede servir en la planificación y toma de decisiones sobre los pacientes y sus cuidadores (formales e informales) de atención domiciliaria  a nivel mundial.

 

 

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FORUM MUNDIAL SOBRE EXCELENCIA EN ATENCIÓN SANITARIA DE AGUDOS

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Para más información sobre la conferencia clickar aquí

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Mixed methods for telehealth research.

«La alternativa»

Evaluation in “real world settings”…the success of complex health interventions like telehealth is dependent on human behaviour, program adoption, level of participant activation or engagement, and other contextual factor present where intervention is implemented. Randomized controlled trials are the gold standard method for conducting rigorous evaluation. However, this is not always the rule in telehealth evaluation; introducing again the debate on the positivist versus naturalist approach. Mixed methods, an emerging and evolving research methodology  combining quantitative plus qualitative approaches could be the answer as pointed out by Martin-Khan and cols. in her paper  «Mixed methods for telehealth research». J Telemed Telecare. 2016.

telehealth-heart-graphic-update

 

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