Impaired Arousal in Older Adults Is Associated With Prolonged Hospital Stay and Discharge to Skilled Nursing Facility

Abstract Background Despite their elevated risk for morbidity and mortality from infections, the microbiota of older adults remain understudied. While colonization resistance from resident microflora is a promising means to prevent infections, little is known about pathogenicity reservoirs and colonization resistance in this vulnerable population. Here we study the skin, oral, and gut microbiome dynamics of older adults in both community and Skilled Nursing Facility (SNF) settings, investigating relationships between age, frailty, environment, microbiota, and pathogenicity reservoirs. Methods We conducted a longitudinal metagenome survey of 47 adults age 65+ years of age; 22 residents of 3 different SNFs and 25 community dwelling individuals. We performed metagenomic whole genome shotgun sequencing on stool, oral, and skin samples from 8 sites, 1421 total. To correlate clinical and behavioral variables, we measured frailty, collected medical records, and interviewed participants on diet and lifestyle. We also draw comparisons with previous younger cohorts. Results • Compared to younger adults, the skin microbiota of older adults was characterized by ◦ High heterogeneity ◦ Decreased stability over time, suggesting increased susceptibility to colonization and pathogenicity ◦ Compositional differences including significantly lower levels of Cutibacterium acnes, with reciprocal increases in Staphylococci, Corynebacteria, and Malassezia • In older adults, Frailty (Rockwood) was found to have linear correlation with relative abundance of species relevant to infection risk including acnes, staphylococci, streptococci, E. coli, Akkermansia mucinophila, and Enterococcus faecalis. • The skin, oral, and gut microbiota of SNF residents had substantially elevated virulence factor and antibiotic resistance genes. Conclusion To the best of our knowledge, this is largest report to date of the skin metagenome in older adults. We demonstrate distinct and significant differences between cohorts with clinically relevant implications. We believe these results may inform infection control and prevention by increasing our understanding of colonization resistance and pathogenicity reservoirs, as well as advance our knowledge of the relationship between aging, the microbiome, and infections. Disclosures All Authors: No reported disclosures

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Clinical Courses and Characteristics of Residents During a SARS-CoV-2 Outbreak at a Central Indiana Skilled Nursing Facility

Proceedings of IMPRS ◽

10.18060/24501 ◽

2020 ◽

Vol 3 ◽

Author(s):

Lauren Albert ◽

Kristi Lieb ◽

Laramie Mack ◽

Kathleen Unroe

Keyword(s):

Older Adults ◽

Case Reports ◽

Skilled Nursing Facility ◽

Nursing Facilities ◽

Retrospective Case ◽

Nursing Facility ◽

Skilled Nursing ◽

Increased Risk ◽

Symptom Load ◽

Retrospective Case Study

Background/Objective: Older adults such as skilled nursing facility residents have increased risk of serious SARS-CoV-2 infection and comprise a large proportion of the COVID-19 pandemic’s deceased—the US Centers for Medicare & Medicaid Services report 232,831 cases and 38,518 resident deaths to date. Recent case reports reveal, as in other diseases, older adults may experience atypical symptomology, complicating identification of ill residents and efforts to slow transmission. While a few facility outbreaks have been characterized epidemiologically, little research exists regarding clinical timelines and trajectories which residents experience during COVID-19 illness. Methods: From May 9, 2020-June 1, 2020, daily notes on each COVID-19 positive resident’s status (n = 69) were taken by the medical director of a central Indiana nursing facility. Combined with a retrospective resident chart review of this same period, these notes were examined for COVID-19 infection symptoms and illness timelines to descriptively categorize a number of common illness trajectories and symptoms seen in residents with SARS-CoV-2 infection. Results: Residents fit four descriptive clinical timelines: concurrent symptom load with quick death (Avg 5.6 days) (n = 5), accumulating symptom load with gradual decline (Avg. 13.9 days) (n = 9), prolonged active symptom load with periods of stabilization and symptom reoccurrence (n = 42), and asymptomatic or atypical symptom load (n = 12). Most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. Of the 14 residents who died (20.3% of infected), 8 died in the facility and 6 died in the hospital. Conclusion and Implications: This retrospective case study adds to literature describing the presentation and symptomology of SARS-CoV-2 infection in residents of skilled nursing facilities and aids efforts to evaluate resident presentation, prognosis, and disease course. Robust descriptions of expected clinical courses may support realistic expectations of disease progression for residents and their family members experiencing future outbreaks.

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Cognitive Status of Older Adults on Admission to a Skilled Nursing Facility According to a Hospital Discharge Diagnosis of Dementia

Journal of the American Medical Directors Association ◽

10.1016/j.jamda.2017.04.021 ◽

2017 ◽

Vol 18 (8) ◽

pp. 726-728 ◽

Cited By ~ 1

Author(s):

Brian Downer ◽

Kali S. Thomas ◽

Vincent Mor ◽

James S. Goodwin ◽

Kenneth J. Ottenbacher

Keyword(s):

Older Adults ◽

Hospital Discharge ◽

Skilled Nursing Facility ◽

Cognitive Status ◽

Discharge Diagnosis ◽

Nursing Facility ◽

Skilled Nursing ◽

Hospital Discharge Diagnosis ◽

Diagnosis Of Dementia

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Trends in inpatient discharges with drug or alcohol admission diagnoses to a skilled nursing facility among older adults, New York City 2008–2014

Harm Reduction Journal ◽

10.1186/s12954-020-00450-8 ◽

2020 ◽

Vol 17 (1) ◽

Author(s):

Benjamin H. Han ◽

Ellenie Tuazon ◽

Hillary V. Kunins ◽

Denise Paone

Keyword(s):

Older Adults ◽

New York ◽

New York City ◽

York City ◽

Functional Limitations ◽

Skilled Nursing Facility ◽

Age Groups ◽

Nursing Facility ◽

Term Care ◽

Skilled Nursing

Abstract Background Recent research shows an increase in drug and alcohol-related hospitalizations in the USA, especially among older adults. However, no study examines trends in discharges to a skilled nursing facility (SNF) after a drug or alcohol-related hospitalization. Older adults are more likely to need post-hospital care in a SNF after a hospitalization due to an increased presence of chronic diseases and functional limitations. Therefore, the objective of this study was to estimate trends in drug or alcohol-related hospitalizations with discharge to a SNF among adults age 55 and older. Methods We analyzed data from New York State’s Statewide Planning and Research Cooperative System to calculate the number of cannabis, cocaine, opioid, and alcohol-related hospitalizations in New York City that resulted in discharge to a SNF from 2008 to 2014 among adults age 55 and older. Using New York City population estimates modified from US Census Bureau, we calculated age-specific rates per 100,000 adults. Trend tests were estimated using joinpoint regressions to calculate annual percentage change (APC) with 95% confidence intervals (CI) and stratified by adults age 55–64 and adults age 65 and older. Results During the study period, among adults age 55–64, there were significant increases in cocaine, cannabis, and opioid-related hospitalizations that resulted in discharge to a SNF. For adults ≥ 65 years, there were sharp increases across all substances with larger increases in opioids (APC of 10.66%) compared to adults 55–64 (APC of 6.49%). For both age groups and among the four substances, alcohol-related hospitalizations were the leading cause of discharge to a SNF. Conclusions We found an increase in hospital discharges to SNFs for patients age 55 and older admitted with alcohol or drug-related diagnoses. Post-acute and long-term care settings should prepare to care for an increase in older patients with substance use disorders by integrating a range of harm reduction interventions into their care settings.

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Disparate perspectives: Exploring healthcare professionals' misaligned mental models of older adults’ transitions of care between the emergency department and skilled nursing facility

Applied Ergonomics ◽

10.1016/j.apergo.2021.103509 ◽

2021 ◽

Vol 96 ◽

pp. 103509

Author(s):

Nicole E. Werner ◽

Rachel A. Rutkowski ◽

Sheryl Krause ◽

Hanna J. Barton ◽

Kathryn Wust ◽

...

Keyword(s):

Older Adults ◽

Emergency Department ◽

Mental Models ◽

Healthcare Professionals ◽

Skilled Nursing Facility ◽

Transitions Of Care ◽

Nursing Facility ◽

Skilled Nursing

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Care Management and the Transition of Older Adults From a Skilled Nursing Facility Back Into the Community

Care Management Journals ◽

10.1891/1521-0987.12.2.54 ◽

2011 ◽

Vol 12 (2) ◽

pp. 54-59 ◽

Cited By ~ 9

Author(s):

Adam G. Golden ◽

Shanique Martin ◽

Melanie da Silva ◽

Bernard A. Roos

Keyword(s):

Older Adults ◽

Health Care ◽

Nursing Care ◽

Care Management ◽

Skilled Nursing Facility ◽

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Nursing Facility ◽

Skilled Nursing ◽

Management Interventions

After hospitalization, many older adults require skilled nursing care. Although some patients receive services at home, others are admitted to a skilled nursing facility. In the current fragmented health care system, hospitals are financially incentivized to discharge frail older adults to a facility for postacute care as soon as possible. Similarly, many skilled nursing facilities are incentivized to extend the posthospitalization period of care and to transition the patient to custodial nursing home care. The resulting overuse of institution-based skilled nursing care may be associated with various adverse medical, social, and financial consequences. Care management interventions for more efficient and effective skilled nursing facility use must consider the determinants involved in the decisions to admit and maintain patients in skilled nursing facilities. As we await health care reform efforts that will address these barriers, opportunities already exist for care managers to improve the current postacute transition processes.

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Clostridioides difficile Enteritis Induced Anastomotic Rupture: A Case Report and Literature Review

Case Reports in Surgery ◽

10.1155/2020/9794823 ◽

2020 ◽

Vol 2020 ◽

pp. 1-3

Author(s):

David R. Velez ◽

Mentor Ahmeti

Keyword(s):

Small Bowel ◽

Primary Anastomosis ◽

Skilled Nursing Facility ◽

Anastomotic Dehiscence ◽

Hemodynamic Instability ◽

Small Bowel Resection ◽

Nursing Facility ◽

Skilled Nursing ◽

Clostridioides Difficile ◽

Prolonged Hospital

Background. A 76-year-old male patient who suffered small bowel anastomotic dehiscence believed to be a complication provoked by Clostridioides difficile enteritis. Case Presentation. The patient was a 76-year-old male who underwent small bowel resection with primary anastomosis for a small bowel obstruction. On postoperative day #7, he rapidly decompensated and upon return to the operating room was found to have complete anastomotic dehiscence with copious enteric spillage. The presentation appeared as if the staple line had burst open. Enteric contents confirmed the diagnosis of Clostridioides difficile enteritis. Subsequent hospital course was complicated by ventilatory-dependent respiratory failure, hemodynamic instability, and persistent anemia secondary to gastric ulcer requiring endoscopic cauterization. After a prolonged hospital course, he eventually progressed and was transferred to a skilled nursing facility on hospital day #42. Discussion. Clostridioides difficile causes inflammation and copious large volume secretions that would theoretically increase intraluminal pressures creating an internal tension. This tension along with other factors from the infection itself would likely be inhibitory of anastomotic healing. Although it is rare, Clostridioides difficile enteritis is being reported with increasing frequency, and in the setting of recent small bowel anastomosis, it should be considered a possible risk factor for anastomotic leak.

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Trends in isolated lumbar spinal stenosis surgery among working US adults aged 40–64 years, 2010–2014

Journal of Neurosurgery Spine ◽

10.3171/2018.1.spine17964 ◽

2018 ◽

Vol 29 (2) ◽

pp. 169-175 ◽

Cited By ~ 11

Author(s):

Micheal Raad ◽

Callum J. Donaldson ◽

Mostafa H. El Dafrawy ◽

Daniel M. Sciubba ◽

Lee H. Riley ◽

...

Keyword(s):

Surgical Treatment ◽

Hospital Stay ◽

Spinal Stenosis ◽

Lumbar Spinal Stenosis ◽

Skilled Nursing Facility ◽

Length Of Hospital Stay ◽

Nursing Facility ◽

Skilled Nursing ◽

The Us ◽

Lumbar Spinal

OBJECTIVERecommendations for the surgical treatment of isolated lumbar spinal stenosis (LSS) (i.e., in the absence of concomitant scoliosis or spondylolisthesis) are unclear. The aims of this study were to investigate trends in the surgical treatment of isolated LSS in US adults and determine implications for outcomes.METHODSThe authors analyzed inpatient and outpatient claims from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database for 20,279 patients aged 40–64 years who underwent surgery for LSS between 2010 and 2014. Only patients with continuous 12-month insurance coverage after surgery were included. The rates of decompression with arthrodesis versus decompression only and of simple (1- or 2-level, single-approach) versus complex (> 2-level or combined-approach) arthrodesis were analyzed by year and geographic region. These trends were further analyzed with respect to complications, length of hospital stay, payments made to the hospital, and patient discharge status. Statistical significance was set at p < 0.05.RESULTSThe proportion of patients who underwent decompression with arthrodesis compared with decompression only increased significantly and linearly from 2010 to 2014 (OR 1.08; 95% CI 1.06–1.10). Arthrodesis was more likely to be complex rather than simple with each subsequent year (OR 1.4; 95% CI 1.33–1.49). This trend was accompanied by an increased likelihood of postoperative complications (OR 1.11; 95% CI 1.02–1.21), higher costs (payments increased by a mean of US$1633 per year; 95% CI 1327–1939), and greater likelihood of being discharged to a skilled nursing facility as opposed to home (OR 1.11; 95% CI 1.03–1.20). The South and Midwest regions of the US had the highest proportions of patients undergoing arthrodesis (48% and 42%, respectively). The mean length of hospital stay did not change significantly (p = 0.324).CONCLUSIONSFrom 2010 to 2014, the proportion of adults undergoing decompression with arthrodesis versus decompression only for the treatment of LSS increased, especially in the South and Midwest regions of the US. A greater proportion of these fusions were complex and were associated with more complications, higher costs, and a greater likelihood of being discharged to a skilled nursing facility.

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