Content uploaded by Laurence Z Rubenstein
Author content
All content in this area was uploaded by Laurence Z Rubenstein on Feb 07, 2018
Content may be subject to copyright.
Hospital-Associated Deconditioning and Dysfunction
... According to Pisot et al. [23], it takes four months to recover from the negative systemic effects of just ten days of bed rest. Hospitalization can result in an irreversible decline in functional capability and quality of life in elderly patients [24]. Therefore, when considering the detrimental effects of bed rest, the ABR period should arguably be further reduced if the patient can bear the pain and wear a brace immediately. ...
Study design:
Retrospective case-control study.
Purpose:
To reduce unnecessary absolute bed rest (ABR), this study sought to determine the optimal aimed length of ABR in older patients getting conservative treatment for osteoporotic vertebral fractures (OVFs).
Overview of literature:
OVFs are quite common in elderly patients. ABR is a vital part of conservative treatment for OVFs, although the length of ABR may increase patient. No recommendations regarding how long ABR should last.
Methods:
This study was conducted in 134 patients with OVFs initially treated conservatively. The patients were split into two groups: 3-day and 7-day ABR. From the time of injury to 1, 4, and 12 weeks after injury, compression rate (CR) and local kyphotic angle (LKA) were assessed and compared between the two groups. Any complications such as pneumonia, deep vein thrombosis, delirium, and urinary tract infection known to be related to ABR were examined based on the electronic medical record.
Results:
Forty-four patients underwent ABR for 3 days and 90 underwent ABR for 7 days. There was no significant difference in CR and LKA between the two groups at the time of injury versus 1, 4, and 12 weeks after injury. The patients were divided into two groups: those who received a 3-day ABR and those who received a 7-day ABR. CR and LKA were measured and compared between the two groups from the time of damage to 1, 4, and 12 weeks after injury. The ABR-related complication rate was 43.4% in the 7-day ABR group and 22.7% in 3-day ABR group (p=0.02). The duration of hospital stay was significantly shorter in the 3-day ABR group (12.8 days) than in the 7-day group (16 days) (p=0.01).
Conclusions:
Considering radiological outcomes, prognosis, complications, patient convenience, and economic impact, a 3-day ABR period is appropriate for the conservative treatment of OVFs.
... Similarly, prolonged hospitalization is associated with an increased risk of hospital-acquired infections and deconditioning. (38)(39)(40)(41)(42) Efforts should be sought to prevent delays in surgical intervention for acute hip fracture patients. Academic centres may benefit from quality improvement initiatives to optimize the process and flow of patients presenting with proximal femoral fractures. ...
Background:
Surgical intervention within 48 hours is recommended for hip fractures in the elderly in order to reduce post-operative complications and lower mortality rates. The purpose of this retrospective study is to explore the causes of surgical delays for acute geriatric hip fractures.
Methods:
This is a retrospective cohort study involving a total of 109 consecutive geriatric patients who sustained proximal femur fractures ("hip fractures"), who subsequently underwent definitive fixation. Clinical, demographic, and direct costing data were extracted via a modern system and electronic medical records on a centralized data warehouse. Surgical delays and length of stay were analyzed according to clinical variables.
Results:
The established benchmark of a time-to-surgery of less than 48 hours was respected for 63 (57.8%) patients. Patients on oral anticoagulant (ACO) waited significantly longer, on average 58 hours compared to 44 for non-anticoagulated patients (p = .007). Patients with higher ASA scores waited significantly longer (p = .0018). More importantly, patients treated within 48 hours were discharged significantly earlier, on average after 10 days compared to 16 days for patients who waited more than 48 hours before receiving surgical treatment (p = .003), regardless of the pre-operative waiting time.
Conclusion:
Fewer than 60% of patients received surgery within the 48-hour benchmark after being admitted for an acute hip fracture in a Level-1 trauma centre. Patients with more comorbidities waited longer and stayed longer in the hospital after surgery. Implementing strategic, evidence-based changes should be done using this data to improve care of this vulnerable population.
... For the young adults tested, orthostatic intolerance, decreased plasma volume of 5 to 10 percent, and average loss of muscle mass between 1 and 5 percent per day began within 24 hours of assuming the supine position [29]. The impact of low mobility on older patients is unknown; however, the adverse consequences of bed rest and low mobility are presumably amplified given this population's lower physiological reserves [30][31][32]. For example, sarcopenia, or muscle atrophy, is a known consequence of normal aging [33]. ...
Methods to measure physical activity and sedentary behaviors typically quantify the amount of time devoted to these activities. Among patients with chronic diseases, these methods can provide interesting behavioral information, but generally do not capture detailed body motion and fine movement behaviors. Fine detection of motion may provide additional information about functional decline that is of clinical interest in chronic diseases. This perspective paper highlights the need for more developed and sophisticated tools to better identify and track the decomposition, structuration, and sequencing of the daily movements of humans. The primary goal is to provide a reliable and useful clinical diagnostic and predictive indicator of the stage and evolution of chronic diseases, in order to prevent related comorbidities and complications among patients.
Background
The Emergency unit of the hospital (Department) (ED) is the fastest and most common way for most French general practitioners (GPs) to respond to the complexity of managing older adults patients with multiple chronic diseases. In 2013, French regional health authorities proposed to set up telephone hotlines to promote interactions between GP clinics and hospitals. The main objective of our study was to analyze whether the hotlines and solutions proposed by the responding geriatrician reduced the number of hospital admissions, and more specifically the number of emergency room admissions
Methods
We conducted a multicenter observational study from April 2018 to April 2020 at seven French investigative sites. A questionnaire was completed by all hotline physicians after each call.
Results
The study population consisted of 4,137 individuals who met the inclusion and exclusion criteria. Of the 4,137 phone calls received by the participants, 64.2% (n = 2 657) were requests for advice, and 35.8% (n = 1,480) were requests for emergency hospitalization. Of the 1,480 phone calls for emergency hospitalization, 285 calls resulted in hospital admission in the emergency room (19.3%), and 658 calls in the geriatric short stay (44.5%). Of the 2,657 calls for advice/consultation/delayed hospitalization, 9.7% were also duplicated by emergency hospital admission.
Conclusion
This study revealed the value of hotlines in guiding the care of older adults. The results showed the potential effectiveness of hotlines in preventing unnecessary hospital admissions or in identifying cases requiring hospital admission in the emergency room. Hotlines can help improve the care pathway for older adults and pave the way for future progress.
Trial registration
Registered under Clinical Trial Number NCT03959475. This study was approved and peer-reviewed by the Ethics Committee for the Protection of Persons of Sud Est V of Grenoble University Hospital Center (registered under 18-CETA-01 No.ID RCB 2018-A00609-46).
Older adults continue to spend little time engaged in physical activity when hospitalized. The purpose of this study was to (a) describe activity among hospitalized older adults with dementia and (b) identify the association between specific factors (gender, ambulation independence, comorbidities, race, and hospital setting) and their physical activity. This descriptive study utilized baseline data on the first 79 participants from the Function Focused Care for Acute Care using the Evidence Integration Triangle. Multiple linear regression models were run using accelerometry data from the first full day of hospitalization. The participants spent an average of 83.7% of their time being sedentary. Male gender, ambulation independence, and hospital setting (the hospital in which the patient was admitted) were associated with greater activity. This study reports on the limited time spent in activity for older adults with dementia when hospitalized and highlights patient profiles that are particularly vulnerable to sedentary behavior in the hospital setting.
Initieel werd sarcopenie gedefinieerd als leeftijdsgebonden afname in spiermassa. Operationele definities voor sarcopenie omvatten functieverlies in aanwezigheid van spierzwakte en/of spieratrofie. De pathofysiologie is multifactorieel en een nauwe samenhang met inflammatoire processen werd aangetoond. Sarcopenie verergert door een complexe interactie tussen veroudering, ondergebruik, immobilisatie, ziekte en ondervoeding. Aan de hand van een uitgebreid geriatrisch assessment kan de relatieve bijdrage van deze factoren worden bepaald en een adequate behandelstrategie worden ontwikkeld. Intensieve krachttraining is thans de meest efficiënte behandeling voor sarcopenie, zelfs bij zeer oude geriatrische patiënten. Significante verbeteringen (tot > 50 % krachtswinst) kunnen verwacht worden na zes weken training aan 2–3 sessies per week. Vanuit een preventief oogpunt zou alle oudere patiënten geadviseerd moeten worden om een dergelijk oefenprogramma op te starten en vol te houden. Naast effecten ter hoogte van de spier zelf, worden ook systemische reacties uitgelokt door spierkrachttraining, waaronder een betere cellulaire bescherming en een verlaging van het inflammatoir profiel.
Background
There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients.
Methods
A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05.
Results
A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05).
Conclusions
Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.
Objective: This study was conducted to evaluate whether the patient's nutritional status on admission may influence a successful return to their pre-hospitalization medical environment.
Method: This is a single-center cohort study. We enrolled patients aged 65 years or older, hospitalized between September 2014 and October 2015 in one community hospital in Oita. Among 307 patients, 28 were excluded because of death, terminal conditions, lack of essential data on admission, and prolonged hospitalization beyond the study period, thus finally 279 patients were analyzed. Nutritional status on admission was compared between two study groups, i.e. a return group who could return to their home or pre-hospitalization care facility, and a non-return group who could not return to their home or pre-hospitalization medical environment.
Results: The return group comprises 192 patients and 87 patients in the non-return groups, respectively. Compared with the return group, participants in the non-return group revealed to be older, and had lower MNA-SF (Mini Nutritional Assessment Short-Form), Barthel Index, body mass index, calf circumference, and serum albumin levels. They also had more comorbidities, and the mean hospital stay was longer in the non-return group. Cox proportional hazard analysis was performed to disclose the factors which may influence patient's non-return, however, none of nine nutrition-related factors contributed to non-return to the pre-hospitalization medical environment.
Conclusion: In this study, there was no significant difference in the nutritional status of individuals who failed to discharge to their pre-hospitalization medical environment.
Space analogues, such as bed rest, are used to reproduce microgravity-induced morphological and physiological changes and can be used as clinical models of prolonged inactivity. Nevertheless, non-uniform decreases in muscle mass and function have been frequently reported, and peripheral nerve adaptations have been poorly studied, although some of these mechanisms may be explained. Ten young healthy males (18-33 y) underwent 10 days of horizontal bed rest. Peripheral neurophysiological assessments were performed bilaterally for the dominant (DL) and non-dominant upper and lower limbs (N-DL) on the 1 st and 10 th day of bed rest, including ultrasound of the median, deep peroneal (DPN) and common fibular (CFN) nerves, as well as a complete nerve conduction study (NCS) of the upper and lower limbs. Consistently reduced F-waves, suggesting peripheral nerve dysfunction, of both the peroneal (DL: p= 0.005, N-DL p= 0.013) and tibial nerves (DL: p= 0.037, N-DL p= 0.005) were found bilaterally, while no changes were observed in nerve ultrasound or other parameters of the NCS of both the upper and lower limbs were observed. In these young healthy males, only the F-waves, known to respond to postural changes, were significantly affected by short-term bed rest. These preliminary results suggest that during simulated microgravity, most changes occur at the muscle or central nervous system level. Since the assessment of F-waves is common in clinical neurophysiological examinations, caution should be used when testing individuals after prolonged immobility.
This article presents results of a prospective multivariate study of hospitalized elderly patients at an acute-care Veterans Administration (VA) hospital to identify factors on hospital admission predictive of several short- and long-term outcomes: in-hospital and 6-month mortality, immediate and delayed nursing home admission, length of hospital stay, and 6-month rehospitalization. All patients aged 70 years and over admitted to acute-care beds on the medical service wards during a 1-year period were included in the study (N = 396). Factors most predictive of 6-month mortality (using logistic regression) were decreased functional status, admitting diagnosis, and decreased mental status. Factors most predictive of nursing home admission were decreased functional status, living location, and decreased mental status. Functional status was a stronger predictor of length of stay, mortality, and nursing home placement than was principal admitting diagnosis--of relevance to the current emphasis on diagnosis-related groups (DRGs). These data may be helpful in improving discharge planning, in resource allocation, and in targeting patients for different specialized geriatric programs
1. Seven patients who had suffered unilateral leg fracture were studied after removal of immobilizing plaster casts.
2. Leg volume measured anthropometrically was reduced by 12% in the injured leg (5·68 ± 1·05 litres) compared with the uninjured (6·43 ± 0·87 litres). Associated with this loss was a similar reduction in the net maximum oxygen uptake achieved in one-leg cycling, from 1·89 ± 0·21 l/min in the uninjured leg to 1·57±0·18 l/min in the injured.
3. Measured by a percutaneous needle biopsy technique, a reduction of 42% was found in the cross-sectional area of the muscle fibres sampled from the vastus lateralis of the injured compared with the uninjured leg.
4. Staining for myosin adenosine triphosphatase activity showed that both type I and II fibres were affected, being reduced respectively from 3410 to 1840 μm2 and from 3810 to 2390 μm2 cross-sectional area.
5. Possible reasons and implications are discussed for the discrepancy between the magnitude of the difference observed in the gross measurement of leg function (maximum oxygen uptake) and structure (leg volume) as compared with the cellular level (cross-sectional fibre area).
Nursing homes and hospitals are dynamically inter-related. Most nursing home patients came from hospitals and many of them will return to hospitals at some time during their nursing home stay. This relationship has evolved over the years, with more hospital-nursing home interaction and faster patient movement. Recent changes in Medicare hospital payment and other policies have accelerated this evolution. These changes have clear implications for patient care, and there is much the nursing home clinician can do to optimize patient transitions between nursing home and hospital. This article approaches these issues in three sections. First is a discussion of the epidemiology of movement between hospitals and nursing homes. Why does such movement occur, what benefits and disadvantages are associated with such movement, and what patient factors are predictive of transfers in both directions? Second is a discussion of the impact of recent policy changes and financial incentives on the interface. Have such changes been helpful or detrimental to individuals already receiving or likely to require nursing home care? Third is a more clinically based discussion of strategies to optimize management of nursing home patients in order to avoid unnecessary hospitalizations and to quickly identify patients in need of acute hospital care.
The size and the distribution of type I and type II fibres was determined in the gluteus maximus (21 cases), gluteus medius (56 cases) and tensor fasciae latae (27 cases) muscles of patients with osteoarthritis of the hip. The patients were of both sexes, aged between 37 and 64 years (younger group) and between 65 and 78 years (older group). Autopsy material of the two comparable age groups and of a group of “normal” adults (aged 22–44 years) served as controls. It was shown statistically that the diameter of both types of fibres and the relative number of type II fibres diminished with progressing age. In patients with osteoarthritis the degree of the selective atrophy of type II fibres was significantly higher than in the control groups.
Nine healthy subjects were studied under control conditions and following 5 mo of heavy resistance training and 5 wk of immobilization in elbow casts. Needle biopsies were taken from triceps brachii and analyzed for adenosine triphosphate (ATP), adenosine diphosphate (ADP), creatine (C), creatine phosphate (CP, and glycogen concentrations. Training resulted in an 11% increase in arm circumference and a 28% increase in maximal elbow extension strength. Immobilization resulted in decreases in arm circumference and elbow extension strength of 5% and 35%, respectively. Training also resulted in significant increases in resting concentrations of muscle creatine (by 39%), CP (by 22%), ATP (by 18%), and glycogen (by 66%). Conversely, immobilization significantly reduced CP concentration by 25% and glycogen concentration by 40%. It was concluded that heavy-resistance training results in increases in muscle energy reserves which may be reversed by a period of immobilization-induced disuse.
Bed rest deconditioning was assessed in seven healthy men (19-22 yr) following three 14-day periods of controlled activity during recumbency by measuring submaximal and maximal oxygen uptake (VO2), ventilation (VE), heart rate, and plasma volume. Exercise regimens were performed in the supine position and included a) two 30-min periods daily of intermittent static exercise at 21% of maximal leg extension force, and b) two 30-min periods of dynamic bicycle ergometer exercise daily at 68% of VO2max. No prescribed exercise was performed during the third bed rest period. Compared with their respective pre-bed rest control values, VO2max decreased (P less than 0.05) under all exercise conditions; -12.3% with no exercise, -9.2% with dynamic exercise, but only -4.8% with static exercise. Maximal heart rate was increased by 3.3% to 4.9% (P less than 0.05) under the three exercise conditions, while plasma volume decreased (P less than 0.05) -15.1% with no exercise and -10.1% with static, but only -7.8% (NS) with dynamic exercise. Since neither the static nor dynamic exercise training regimes minimized the changes in all the variables studied, some combination of these two types of exercise may be necessary for maximum protection from the effects of the bed deconditioning.
This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy-one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patient's caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patient's nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67% showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.