Longitudinal course of GDF15 levels before acute hospitalization and death in the general population

Growth differentiation 15 (GDF15) is a potential novel biomarker of biological aging. To separate the effects of chronological age and birth cohort from biological age, longitudinal studies investigating associations of GDF15 levels with adverse health outcomes are needed. We investigated changes in GDF15 levels over 10 years in an age-stratified sample of the general population and their relation to the risk of acute hospitalization and death. Serum levels of GDF15 were measured three times in 5-year intervals in 2176 participants aged 30, 40, 50, or 60 years from the Danish population-based DAN-MONICA cohort. We assessed the association of single and repeated GDF15 measurements with the risk of non-traumatic acute hospitalizations. We tested whether changes in GDF15 levels over 10 years differed according to the frequency of hospitalizations within 2 years, or survival within 20 years, after the last GDF15 measurement. The change in GDF15 levels over time was dependent on age and sex. Higher GDF15 levels and a greater increase in GDF15 levels were associated with an increased risk of acute hospitalization in adjusted Cox regression analyses. Participants with more frequent admissions within 2 years, and those who died within 20 years, after the last GDF15 measurement already had elevated GDF15 levels at baseline and experienced greater increases in GDF15 levels during the study. The change in GDF15 levels was associated with changes in C-reactive protein and biomarkers of kidney, liver, and cardiac function. Monitoring of GDF15 starting in middle-age could be valuable for the prediction of adverse health outcomes.

Older Adults and Family Perspective on Interaction with Nurses in Hospital: the Role of Mutual Understanding

Optimal nurse-patient-family interaction is required to provide effective family-centered care for hospitalized older adults and their families. This qualitative descriptive study explored nurses’ interactions with older adult patients and their family members during acute hospitalization. We used semi-structured interviews to collect data from a convenience sample of nine dyads of older adults (aged 62-85) and family members (7 children and 2 spouses) who accompanied them during an acute hospitalization in medical or surgical units. Interviews were performed via Zoom beginning in December 2020 until August 2021, 1-12 months after the hospitalization. Thematic analysis was used to inductively capture key patterns in data. Both patients and family members revealed three factors contributing to the way nurses interact with patients and families: (1) nurses’ recognition and understanding of patients’ needs for family members’ presence and participation in care; (2) nurses recognition that family members expect dedication of attention, beyond nurses’ focus on patient’s care (3) patient and family members’ recognition of the extreme workload of nursing staff. Participants described a range of informal approaches used by both nurses and families to address each other’s needs. Both patients and families emphasize the benefits and costs of nurses engaging in “exceptional” interactions with patients and families considering structural characteristics such as establishing a personal relationship or accepting family visits beyond the rules. The findings provide direction for further exploration of hospitalization structures and processes needed to support optimal nurses’ interactions with families accompanying older adults and family-centered approach training in acute care context.

Paretic upper extremity strength at acute rehabilitation evaluation predicts motor function outcome after stroke

Objective: The primary objective of this study was to retrospectively assess current care practices to determine the routinely collected measures that are most predictive of paretic upper extremity (PUE) functional outcome post-stroke in patients undergoing acute inpatient rehabilitation (AR). Methods: We conducted a longitudinal chart review of patients post-stroke who received care in the Emory University Hospital system for acute hospitalization, AR, and outpatient therapy in fiscal years 2016-2018. We identified eligible patients using previously established inclusion and exclusion criteria. We extracted demographics, stroke characteristics, and longitudinal documentation of post-stroke motor function from institutional electronic medical records. Serial assessments of PUE strength were estimated using available shoulder abduction and finger extension manual muscle test documentation (E-SAFE). Estimated Action Research Arm Test (E-ARAT) was used to quantify 3-month PUE functional outcome. Metric associations were explored through correlation and cluster analyses, Kruskal-Wallis tests, classification and regression tree (CART) analysis. Results: Thirty-four patients met study eligibility criteria. E-SAFE assessments performed closest to acute hospitalization day-3 (Acute E-SAFE) and upon AR admission (AR E-SAFE) were correlated with E-ARAT. Cluster analysis produced three distinct outcome groups and aligned closely to previous outcome categories. Outcome groups significantly differed in Acute E-SAFE and AR E-SAFE. Exploratory CART analysis selected AR E-SAFE to classify patient outcome with 70.6% accuracy. Conclusions: Current study findings reveal that: PUE E-SAFE, measured both acutely and at AR admission, is associated with PUE motor recovery outcome; categorizations of outcome are consistent with previous studies; and predictive models can identify recovery outcome category in patients undergoing AR. Impact Statement: Our findings highlight the clinical utility of SAFE as an easy-to-acquire, readily implementable screening metric. Early, intentional use of SAFE in AR settings may improve clinical decision-making, enabling therapists to deliver precision-based interventions that serve to speed or enhance recovery outcome for patients post-stroke.

Continuity in general practice as a predictor of mortality, acute hospitalization, and use of out-of-hours services: registry-based observational study in Norway

Background: Continuity, usually considered a quality aspect of primary care, is under pressure. Aim: To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospitalization, and mortality. Design and setting: Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs. Method: Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospitalization, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorized as 1, 2–3, 4–5, 6–10, 11–15, and > 15 years. Results are given as adjusted odds ratio (OR) with 95 % confidence interval resulting from multilevel logistic regression analyses. Results: Compared with a one-year RGP-patient relationship the OR for use of OOH services decreased gradually from 0.87 (0.86 – 0.88) after 2 – 3 years duration to 0.70 (0.69 – 0.71) after more than 15 years. OR for acute hospitalization decreased gradually from 0.88 (0.86 – 0.90) after 2 – 3 years duration to 0.72 (0.70 – 0.73) after more than 15 years. OR for dying decreased gradually from 0.92 (0.86 – 0.98) after 2 – 3 years duration to 0.75 (0.70 – 0.80) after an RGP-patient relationship of more than 15 years. Conclusion: Length of RGP-patient relationship is significantly associated with lower use of out-of-hours services, fewer acute hospitalizations, and lower mortality. The associations are dose-dependent and probably causative.

Dietary Intake Patterns of Community-Dwelling Older Adults after Acute Hospitalization

Background Malnutrition and sarcopenia are a growing concern in community-dwelling older adults. Hospitalization increases the risk of malnutrition and leads to a decline in functional and nutritional status at discharge. Persistent malnutrition after hospital discharge may worsen post-hospital outcomes, including readmissions. The aim of this study was to determine dietary intakes and nutrient distribution patterns of community-dwelling older adults after acute hospitalization. Methods Participants (≥65 yrs old, n=85) were enrolled during acute hospitalization and dietary 24-hour recalls were collected weekly for one month post-discharge. Analysis included: change in dietary intake over recovery timeframe; daily intake of energy, protein, fruit, vegetables, and fluids; comparison of intake to recommendations; distribution of energy and protein across mealtimes; and analysis of most common food choices. Results Most participants did not meet current recommendations for energy, fruit, vegetables, or fluids. Average protein consumption was significantly higher than the current recommendation of 0.8g/kg/day; however only 55% of participants met this goal and less than 18% met the 1.2 g/kg/day proposed optimal protein intake for older adults. The protein distribution throughout the day was skewed and no one met the 0.4 g/meal protein recommendation at all meals. Conclusions Our findings indicate that community-dwelling older adults did not meet their nutritional needs during recovery after hospitalization. These data highlight the need for better nutritional evaluation and support of geriatric patients recovering from hospitalization.

In the Aftermath of Acute Hospitalization for Traumatic Brain Injury: Factors Associated with the Direct Pathway into Specialized Rehabilitation

Previous research has demonstrated that early initiation of rehabilitation and direct care pathways improve outcomes for patients with severe traumatic brain injury (TBI). Despite this knowledge, there is a concern that a number of patients are still not included in the direct care pathway. The study aim was to provide an updated overview of discharge to rehabilitation following acute care and identify factors associated with the direct pathway. We analyzed data from the Oslo TBI Registry—Neurosurgery over a five-year period (2015–2019) and included 1724 adults with intracranial injuries. We described the patient population and applied multivariable logistic regression to investigate factors associated with the probability of entering the direct pathway. In total, 289 patients followed the direct pathway. For patients with moderate–severe TBI, the proportion increased from 22% to 35% during the study period. Significant predictors were younger age, low preinjury comorbidities, moderate–severe TBI and disability due to TBI at the time of discharge. In patients aged 18–29 years, 53% followed the direct pathway, in contrast to 10% of patients aged 65–79 years (moderate–severe TBI). This study highlights the need for further emphasis on entering the direct pathway to rehabilitation, particularly for patients aged >64 years.

Irreversible effects of anticholinergic withdrawal in the elderly: a case report

Anticholinergics, such as benztropine and trihexyphenidyl, are a class of medications that have been used to treat several different conditions including antipsychotic-induced extrapyramidal side effects (EPS) that are most often associated with first-generation antipsychotics (FGAs), such as haloperidol and fluphenazine. Many other medications, including antimuscarinics, antipsychotics, and antidepressants, also have anticholinergic effects. In this report, we review the case of an 80-year-old male who experiences irreversible anticholinergic withdrawal effects following the discontinuation of trihexyphenidyl and trospium secondary to side effects. Discontinuation of anticholinergics must be approached with care as abrupt withdrawal can lead to cholinergic rebound and muscular rigidity, and in some cases can lead to acute hospitalization and an inability to return to baseline functioning, as seen in our elderly patient. Keywords: Anticholinergic withdrawal, trihexyphenidyl, trihexyphenidyl withdrawal, trospium, anticholinergic drugs, cholinergic rebound