Abstracts from the Journal of the American Geriatrics Society

Effect of an In-Home Occupational and Physical Therapy Intervention on Reducing Mortality in Functionally Vulnerable Older People: Preliminary Findings
Laura N. Gitlin, PhD, Walter W. Hauck, PhD, Laraine Winter, PhD, Marie P. Dennis, PhD, EdM, and Richard Schulz, PhD

Objectives: To evaluate the effect of a multicomponent intervention on mortality and the role of control-oriented strategy use as the change mechanism.

Design: Two-group randomized design with survivorship followed for 14 months. Participants were randomized to intervention or a no-treatment control group.

Setting: Urban, community-living older people.

Participants: Three hundred nineteen people aged 70 and older with functional difficulties.

Intervention: Occupational therapy and physical therapy sessions involving home modifications, problem solving, and training in energy conservation, safe performance, balance, muscle strength, and fall recovery techniques.

Measurements: Survival time was number of days between baseline interview and date of death or final interview if date unknown. Control-oriented strategy use was measured using eight items.

Results: Intervention participants exhibited a 1% rate of mortality, compared with a 10% rate for no-treatment control participants (P=.003, 95% confidence interval=2.4–15.04%). At baseline, those who subsequently died had more days hospitalized and lower control-oriented strategy use 6 months before study enrollment than survivors. No intervention participants with previous days hospitalized (n=31) died, whereas 21% of control group counterparts did (n=35; P=.001). Although intervention participants with low and high baseline control strategy use had lower mortality risk than control participants, mortality risk was lower for intervention participants with low strategy use at baseline (P=.007).

Conclusion: An occupational and physical therapy intervention to ameliorate functional difficulties may reduce mortality risk in community-dwelling older people overall and benefit those most compromised. Instruction in control-oriented strategies may account for the intervention's protective effects on survivorship. J Am Geriatr Soc 2006;54(6):950-955.

NURSING
Detection of Delirium by Bedside Nurses Using the Confusion Assessment Method
Joke Lemiengre, RN, MSN, Tine Nelis, RN, MSN, Etienne Joosten, MD, PhD, Tom Braes, RN, MSN, Marquis Foreman, RN, PhD, FAAN, Chris Gastmans, PhD, and Koen Milisen, RN, PhD

A prospective, descriptive study was used to assess the diagnostic validity of the Confusion Assessment Method (CAM) administered at the bedside by nurses in daily practice. Two different scoring methods of the CAM (the specific (SPEC) and sensitive (SENS) methods) were compared with a criterion standard (CAM completed by trained research nurses). During a 5-month period, all patients consecutively admitted to an acute geriatric ward of the University Hospitals of Leuven (Belgium) were enrolled in the study. The 258 elderly inpatients who were included underwent 641 paired but independent ratings of delirium by bedside and trained research nurses.

Delirium was identified in 36 of the 258 patients (14%) or in 42 of the 641 paired observations (6.5%). The SENS method of the CAM algorithm as administered by bedside nurses had the greatest diagnostic accuracy, with 66.7% sensitivity and 90.7% specificity; the SPEC method had 23.8% sensitivity and 97.7% specificity. Bedside nurses had difficulties recognizing the features of acute onset, fluctuation, and altered level of consciousness.

For both scoring methods, bedside nurses had difficulties with the identification of elderly patients with delirium but succeeded in diagnosing correctly those patients without delirium in more than 90% of observations. Given these results, additional education about delirium with special attention to guided training of bedside nurses in the use of an assessment strategy such as the CAM for the recognition of delirium symptoms is warranted. J Am Geriatr Soc 2006; 54(4):685-689.

BRIEF REPORTS
Feeding Assistance Needs of Long-Stay Nursing Home Residents and Staff Time to Provide Care
Sandra F. Simmons, PhD, and John F. Schnelle, PhD

Objectives: To describe the staff time requirements to provide feeding assistance to nursing home residents who require three different types of assistance to improve oral food and fluid intake (social stimulation, verbal cuing, or both; physical guidance; or full physical assistance) and to determine whether physically dependent residents require more staff time, as defined in the national Resource Utilization Group System (RUGS) used for reimbursement.

Design: Descriptive.

Setting: Six skilled nursing homes. Participants: Ninety-one long-stay residents with low oral intake who responded to improved feeding assistance.

Measurements: Research staff conducted direct observations of usual nursing home care for 2 consecutive days (total of six meals) to measure oral food and fluid consumption (total percentage eaten) and staff time spent providing assistance (minutes and seconds). Research staff then implemented a standardized graduated-assistance protocol on 2 separate days (total of six meals) that enhanced residents' oral food and fluid intake.

Results: Staff time to provide feeding assistance that improved food and fluid consumption was comparable across different levels of eating dependency. Across all levels, residents required an average of 35 to 40 minutes of staff time per meal; thus, residents who needed only supervision and verbal cuing required just as much time as those who were physically dependent on staff for eating.

Conclusion: The current RUGS system used for reimbursement likely underestimates the staff time required to provide feeding assistance care that improves oral intake. J Am Geriatr Soc 2006;54(6):919-924.

Anemia and Recovery from Disability in Activities of Daily Living in Hospitalized Older Persons
Cinzia Maraldi, MD, Stefano Volpato, MD, MPH, Matteo Cesari, MD, PhD, Margherita Cavalieri, MD, Graziano Onder, MD, PhD, Irene Mangani, MD, Richard C. Woodman, MD, Renato Fellin, MD, and Marco Pahor, MD

Objectives: To evaluate the predictive value of hemoglobin levels upon hospital admission on recovery from activity of daily living (ADL) disability during hospital stay in older patients.

Design: Longitudinal observational study.

Setting: Geriatric and internal medicine acute care units.

Participants: Data are from 5,675 patients aged 65 and older enrolled in the Italian Group of Pharmacoepidemiology in the Elderly Study with ADL disability upon hospital admission.

Measurements: ADL disability was defined as inability to perform or need for assistance in performing one or more ADLs. Recovery from ADL disability was defined as independence in ADLs upon hospital discharge. Anemia was defined according to the World Health Organization criteria. Sociodemographic and clinical characteristics were considered as potential confounders.

Results: Mean age was 80.5 years; 57.7% of subjects were female. Prevalence of anemia was 46.8%. A total of 536 (9.4%) participants regained independence in all six ADLs at hospital discharge. Patients with anemia had a lower rate of recovery from ADL disability than those with normal hemoglobin levels (7.0% vs 11.6%; P<.001). Adjusted analyses confirmed that anemia was inversely associated with the likelihood of ADL recovery (odds ratio=0.71, 95% confidence interval=0.57–0.88). The probability of ADL recovery in anemic patients was higher at higher hemoglobin concentrations.

Conclusion: In older hospitalized patients, anemia is inversely associated with the likelihood of regaining ADL independence during a hospital stay. J Am Geriatr Soc 2006;54(4):632-636.

Clinical Yield of Computed Tomography Brain Scans in Older General Medical Patients
Lianne A. Hirano, MD, Sidney T. Bogardus, Jr., MD, Sanjay Saluja, MD, Linda Leo-Summers, MPH, and Sharon K. Inouye, MD, MPH

Objectives: To evaluate the clinical yield of computed tomography (CT) brain scans in a prospective cohort of older patients admitted to the general medicine service.

Design: Nested cohort study of 117 subjects enrolled in previous prospective cohort study of 919 subjects.

Setting: University-affiliated teaching hospital. Participants: Hospitalized general medical patients aged 70 and older who received one or more brain CT scans during their hospital stay.

Measurements: Review of medical records and interpretation of the first brain CT scan in these 117 patients for indications for ordering scans and clinically significant brain abnormalities. Medical records of patients with brain CT scans with abnormalities were reviewed for 2 weeks after the scan for changes in medical management resulting from scan findings. Three independent reviewers adjudicated the presence of abnormalities and resulting treatment changes.

Results: Of the 117 brain CT scans, 32 (27%) were ordered to exclude intracranial hemorrhage, 30 (26%) to exclude cerebrovascular accident (CVA), 16 (14%) for falls, 15 (13%) for syncope, seven (6%) to exclude subdural hemorrhage, five (4%) for mental status change, and 12 (10%) for other reasons. Of the 117 brain CT scans, 29 (25%) had abnormalities, including acute CVA or hemorrhage, old CVA, meningioma, and other abnormalities. Only 10 (9% of all scans, 34% of abnormal scans) resulted in treatment changes (including consultations, further imaging, stroke evaluation, and drug changes). The presence of focal neurological deficits was significantly associated with treatment changes after CT scans (odds ratio=13.2, 95% confidence interval=1.7–161.5).

Conclusion: These results suggest that the overall clinical yield of brain CT scans in unselected older hospitalized patients is low. Targeting scans toward patients with new focal neurological deficits will help to improve clinical yield. J Am Geriatr Soc 2006;54(4):587-592.