Depressive Symptoms and Malnutrition are Associated with Other Geriatric Syndromes and Increase Risk for 30-Day Readmission in Hospitalized Older Adults: A Prospective Cohort Study

Background: Readmission in older adults is typically complex with multiple contributing factors. We aim to examine how two prevalent and potentially modifiable geriatric conditions – depressive symptoms and malnutrition – relate to other geriatric syndromes and 30-day readmission in hospitalized older adults. Methods: Consecutive admissions of patients >65 years to a general medical department were recruited over 15 months. Patients were screened for depression, malnutrition, delirium, cognitive impairment, and frailty at admission. Medical records were reviewed for intermediary events including poor oral intake and functional decline during hospitalization. Unplanned readmission within 30-days of discharge was tracked through the hospital’s electronic health records and follow-up telephone interviews. We use directed acyclic graphs (DAGs) to depict the relationship of depressive symptoms and malnutrition with geriatric syndromes that constitute covariates of interest and 30-day readmission outcome. Multiple logistic regression was performed for the independent associations of depressive symptoms and malnutrition with 30-day readmission, adjusting for variables based on DAG-identified minimal adjustment set. Results: We recruited 1619 consecutive admissions, with mean age 76.4 (7.9) years and 51.3% females. 30-day readmission occurred in 331 (22.0%) patients. Depressive symptoms (OR 1.55, 95% CI 1.15-2.07), malnutrition (OR 1.59, 95% CI 1.14-2.23), higher comorbidity burden, hospitalization in the one-year preceding index admission, frailty, delirium, as well as functional decline and poor oral intake during the index admission, were more commonly observed among patients who were readmitted within 30 days of discharge (P<0.05). Patients with active depressive symptoms were significantly more likely to be frail (OR=1.62, 95% CI 1.22-2.16), had poor oral intake (OR=1.35, 95% CI 1.02-1.79) and functional decline during admission (OR=1.58, 95% CI 1.11-2.23). Malnutrition at admission was significantly associated with frailty, delirium, cognitive impairment and poor oral intake during hospitalization (P<0.05). In minimal adjustment set identified by DAG, depressive symptoms (OR=1.38, 95% CI 1.02-1.86) remained significantly associated with 30-day readmission. The association of malnutrition with 30-day readmission was attenuated after adjusting for age, ethnicity and depressive symptoms in the minimal adjustment set (OR=1.40, 95% CI 0.99-1.98, P=0.06). Conclusion: The observed causal associations support screening and targeted interventions for depressive symptoms and malnutrition during admission and in the post-acute period.

Serum Leptin Levels, Nutritional Status, and the Risk of Healthcare-Associated Infections in Hospitalized Older Adults

We aimed to determine whether serum leptin levels are predictive of the occurrence of healthcare-associated infections (HAIs) in hospitalized older patients. In a prospective cohort, 232 patients had available data for leptin and were monitored for HAIs for 3 months. Admission data included comorbidities, invasive procedures, the Mini Nutritional Assessment (MNA), BMI, leptin, albumin and C-reactive protein levels, and CD4 and CD8 T-cell counts. Multivariate logistic regression modelling was used to identify predictors of HAIs. Of the 232 patients (median age: 84.8; females: 72.4%), 89 (38.4%) experienced HAIs. The leptin level was associated with the BMI (p < 0.0001) and MNA (p < 0.0001) categories. Women who experienced HAIs had significantly lower leptin levels than those who did not (5.9 μg/L (2.6–17.7) and 11.8 (4.6–26.3), respectively; p = 0.01; odds ratio (OR) (95% confidence interval): 0.67 (0.49–0.90)); no such association was observed for men. In a multivariate analysis of the women, a lower leptin level was significantly associated with HAIs (OR = 0.70 (0.49–0.97)), independently of comorbidities, invasive medical procedures, and immune status. However, leptin was not significantly associated with HAIs after adjustments for malnutrition (p = 0.26) or albuminemia (p = 0.15)—suggesting that in older women, the association between serum leptin levels and subsequent HAIs is mediated by nutritional status.

Effects of Resistance Training Intervention along with Leucine-Enriched Whey Protein Supplementation on Sarcopenia and Frailty in Post-Hospitalized Older Adults: Preliminary Findings of a Randomized Controlled Trial

Resistance training and protein supplementation are expected to exert the greatest effect in counteracting muscle-wasting conditions. Myokines might play a key role, but this remains to be elucidated. The aim of this study (NCT03815201) was to examine the effects of a resistance training program with post-exercise leucine-enriched protein supplementation on sarcopenia and frailty status and on the plasma myokine concentrations of post-hospitalized older adults. A total of 41 participants were included in this 12-week resistance training intervention and randomized either to the placebo group or the protein group. Sarcopenia, frailty, body composition and blood-based myokines were measured at baseline and after 12 weeks. Both groups improved in terms of physical performance (p < 0.005) and frailty (p < 0.07) following the resistance training intervention, but without any difference between groups. Myokine concentrations did not change after the intervention in either group. Changes in myostatin concentrations were associated with greater improvements in appendicular skeletal muscle mass at the end of the intervention (p < 0.05). In conclusion, the implementation of resistance training programs after hospitalization in older adults should be prioritized to combat sarcopenia and frailty immediately. The results regarding myostatin should be taken as preliminary findings.

The impact of including a medication review in an integrated care pathway: a pilot study

Objective: Our hypothesis was that the intervention would decrease (or at least not increase) the number of potentially inappropriate medications (PIMs) and the number of hospital readmissions within 30 days of discharge per hospital stay. Methods: A cohort of hospitalized older adults enrolled in the PAERPA integrated care pathway (the exposed cohort) was matched retrospectively with hospitalized older adults not enrolled in the pathway (unexposed cohort) between January 1st, 2015, and December 31st, 2018. It was an analysis of French health administrative database. The inclusion criteria for exposed patients were admission to an acute care department in general hospital, age 75 or over, at least three comorbidities or the prescription of diuretics or oral anticoagulants, discharge alive, and performance of a medication review. Results: For the study population (n=582), the mean ± standard deviation age was 82.9 ± 4.9, and 190 (65.3%) were women. Depending on the definition used, the overall median number of PIMs ranged from 2 [0;3] upon admission to 3 [0;3] at discharge. The intervention was not associated with a significant difference in the mean number of PIMs. Patients in the exposed cohort were half as likely to be readmitted to hospital within 30 days of discharge, relative to patients in the unexposed cohort. Conclusion: Our results show that a medication review was not associated with a decrease in the mean number of PIMs. However, the integrated care intervention including the medication review was associated with a reduction in the number of hospital readmissions at 30 days.

Evaluating the Appropriateness and Feasibility of the Care Partner Hospital Assessment Tool (CHAT)

Hospital practitioners rely on care partners of older adults to provide complex care without identifying and addressing their needs. The Care Partner Hospital Assessment Tool (CHAT) was developed to identify the education skill training needs of care partners of hospitalized older adults. This two-phased mixed-method study evaluated the appropriateness and feasibility of the CHAT. The phase 1 quantitative survey with caregiving experts indicated 70–100% agreement for the length and helpfulness of the CHAT (n = 23). These results were supported by phase 2 qualitative interviews with hospital administrators and practitioners, which revealed the following themes: (1) intuitive and clear design worth sustaining and (2) concerns and proposed solutions for implementation. Findings suggest the CHAT is an appropriate and feasible tool for hospital practitioners to tailor their education and skills training to address care partners’ needs. Identifying care partners’ needs is an important step in ensuring they are prepared to complete their caregiving responsibilities.

Hospital-Associated Disability Associated With Delirium Among Older Adults

Hospital-associated disability (HAD), defined as a loss of activities of daily living (ADLs) occurring during hospitalization, is a common complication among older adults. Delirium is also a common complication during hospitalization and is associated with multiple long-term sequelae. We sought to determine the effect of delirium and known covariates on the risk of incident HAD in hospitalized older adults. We examined electronic health record (EHR) data for 35,201 older adults ≥ 65 years of age admitted to the general inpatient (non-ICU) units of UAB Hospital from January 1, 2015 to December 31, 2019. Delirium was defined as a score ≥ 2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission, and HAD defined as a decline on the Katz 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 for individuals with multiple admissions. We found that 21.2% of older adults developed HAD during their hospitalization and experienced higher delirium rates as compared to those not developing HAD (25.2% vs. 16.3%). Presence of delirium, medical comorbidity score, baseline cognitive status, and baseline ADL function were associated (all p &lt;0.001) with incident HAD. Mediation analyses also showed that 8% of the effect of comorbidity on incident HAD was due to delirium (p &lt; 0.001). Reducing rates of delirium can be one component of a comprehensive approach to reduce rates of HAD in older adults.

A Delirium Risk Stratification Tool and Interdisciplinary Rounds to Prevent Delirium in Hospitalized Older Adults

Delirium is a disturbance of attention accompanied by a change in baseline cognition that is commonly seen in acute care settings, and effects up to 80% of ICU patients. The development of delirium has adverse effects on patient outcomes and high health care costs. Of patients aged 65+ admitted to our hospital in 2019, non-delirious patients had a five-day length of stay (LOS) compared to a 10-14 days LOS in delirious patients. A five days LOS increase adds an additional $ 8,325 per patient for an extra annual cost of 15 million dollars. Additionally, delirium is often not recognized. A prior retrospective study showed that 31% of older adults seen by a Geriatrics provider were diagnosed with delirium, while only 11% were detected by nurse’s CAM screen. Given the need to improve delirium detection and management, a QI project was undertaken with a goal to recruit an interdisciplinary team, create a risk stratification tool to identify patients at substantial risk for developing delirium, and develop a delirium prevention protocol. Patients with a score of ≥ 4 were initiated on a nurse driven delirium protocol that included a delirium precaution sign and caregiver education. 6 months data has shown increased delirium detection of 33%, a reduction in 7.7 days LOS, reduced SNF discharge by 27%, and a significant LOS saving of 231 days. The results were statistically significant, p &lt; 0.04 for LOS reduction. The cost avoidance in LOS alone were $384,615 for delirium patients.

Trends in Delirium Rate Across 14 Hospitals During the COVID-19 Pandemic: A Comparative Study

During the COVID-19 pandemic, strategies to prevent delirium in the hospital were limited due to restrictions in staff and visitor policies. Thus, we suspected the delirium rate may increase during the pandemic. This study aimed to investigate the trends in delirium rate over past 2-years and compare this trend prior-to-and-during the COVID-19 pandemic in hospitalized older adults. Data was retrospectively obtained from the Acute-Care-for-Elders Tracker snapshot, an electronic health record tool to identify the presence of delirium within 48hrs of hospitalization for patients ≥65 years. Periods of interests were 3/2019-6/2019 (pre-COVID) and 3/2020-6/2020 (during-COVID). A weighted rate was calculated for each month by combining data from all hospitals for the total number of inpatients ≥65 years. The overall trend in the delirium rate was assessed with simple linear regression models and an ANCOVA. A χ2 and a Wilcoxon-Signed-Rank-Test were utilized to test for differences in the overall delirium rate between two time periods. Overall median delirium rate was 6.8% in 70,562 encounters of 42,878 patients (mean age= 78 years; mean length-of-stay= 6.5 days). The median delirium rate increased by 2.1% (6.6%to8.6%), for pre-COVID vs. during-COVID, respectively (Z=-3.044,p&lt;0.001). There were no significant differences between actual and projected weighted delirium rates (p=0.18). However, the weighted delirium rate—for both the actual and projected trend lines—demonstrated significant changes over time (p&lt;0.001).The trend in delirium rate increased over the study time period regardless of the pandemic. Further analyses with longer time-frame are crucial to understand the consequences of the pandemic on delirium rate.