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FRAILTY IS ASSOCIATED WITH INCREASED MORTALITY IN OLDER ADULTS 12 MONTHS AFTER DISCHARGE FROM POST-ACUTE CARE IN SWISS NURSING HOMES

 

C. Fompeyrine1,2, L.A. Abderhalden2, N. Mantegazza2, N. Hofstetter2, G. Bieri-Brüning3, H.A. Bischoff-Ferrari1,2,4, M. Gagesch1,2

 

1. Department of Geriatrics and Aging Research, University Hospital Zurich, Zurich, Switzerland; 2. Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
3. Zurich Geriatric Services and Nursing Homes, Zurich, Switzerland; 4. University Clinic for Acute Geriatric Care, City Hospital Waid and Triemli, Zurich, Switzerland.
Corresponding author: Michael Gagesch, MD, Dept. of Geriatrics and Aging Research, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland, michael.gagesch@usz.ch

J Frailty Aging 2020;in press
Published online October 20, 2020, http://dx.doi.org/10.14283/jfa.2020.58

 


Abstract

Frail older adults with ongoing care needs often require post-acute care (PAC) following acute hospitalization when not eligible for specific rehabilitation. Long-term outcomes of PAC in this patient group have not been reported for Switzerland so far. In the present report, we investigated 12-month mortality in regard to frailty status upon admission to PAC in a nursing home setting. In our sample of 140 patients (mean age 84 [±8.6] years) 4.3% were robust, 37.1% were pre-frail, 54.3% were frail and 4.3% were missing frailty status. Mortality at 12-months follow-up stratified by baseline frailty was 0% (robust), 11.5% (pre-frail) and 31.6% (frail). Kaplan-Meier analysis stratified by frailty status showed a decreased probability of 12-months survival for frail individuals compared to their pre-frail and robust counterparts (P = 0.0096). Being frail was associated with more than 4-fold increased odds of death at follow-up (OR 4.19; 95% CI 1.53-11.47).

Key words: Frailty, long-term mortality, post-acute care, nursing homes.


Introduction

Health in older age comprises a broad spectrum from robustness to vulnerability and frailty (1). The latter is associated with multiple negative outcomes in various care settings, from general practice to acute hospital care (2). With their often complex health status, older adult patients frequently require longer lengths of stay in the hospital and often remain at an increased level of care, impeding a prompt discharge home after an acute illness (3). At the same time, standard rehabilitation programs do not always appear suitable for many frail older patients (4).
Post-acute care (PAC) programs aim to bridge the gap between acute care and returning home for older adults, not otherwise eligible for rehabilitation. While earlier studies from different countries and specific settings (i.e. heart-failure patients) have demonstrated positive effects of PAC, such as reduced readmissions and decreased mortality rates (5, 6), its potential benefits and outcomes, particularly in frail older adults are still understudied (7). In addition, healthcare systems and PAC programs appear to have major differences between countries, hampering direct comparisons (8).
In a prior analysis, clinically significant improvements of physical function and ADL were reported in robust and frail Swiss older adults after a PAC program in nursing homes with a mean duration of 31 days (9). However, no research on the long-term outcomes of PAC in Swiss nursing homes exists so far (4). Therefore, the aim of our study was to investigate the association of frailty status upon admission to PAC with 12-month mortality in a real-world sample of Swiss older adults.

 

Methods

Study Design

We conducted a one-year follow-up study at designated PAC units of three municipal nursing homes within the City of Zurich, Switzerland. Written informed consent was obtained before study enrolment. The competent ethics committee of the Canton of Zurich approved our study (BASEC 2016-01069).

PAC Setting and Patients

Our study recruited consecutive patients 60 years and older referred to a PAC unit after acute care hospitalization between August and September 2016. An interdisciplinary team under the supervision of a board-certified geriatrician completed a comprehensive geriatric assessment (CGA) for each patient within one week upon admission, performed the PAC program and held bi-weekly team meetings. PAC consisted of activating nursing care (i.e. goal-directed instruction and training of ADL), five sessions of individual physical therapy per week and additional occupational therapy as needed, based upon the initial CGA. The maximum length of stay at PAC units was usually limited to 10 weeks duration and the effective date of discharge was based on the accomplishment of specific goals, derived from the individual care plan (9).
For our follow-up investigation, we matched the initial list of PAC patients with the death registry of the City of Zurich at one year after discharge. Living status and mortality date (if applicable) was recorded. We utilized frailty status from CGA at admission to a PAC unit according to the Fried frailty phenotype (items: unintentional weight loss, fatigue, slowness, weakness, low activity level) (10). Among numerous proposed frailty definitions, the Fried frailty phenotype is one of the most recognized and highly cited concepts and has been validated in various healthcare settings (2, 11). Patients with zero positive criteria were classified as robust, patients with 1-2 positive criteria as pre-frail and patients with ≥3 positive criteria were considered frail (10). In addition, we utilized further patient characteristics recorded at admission (Barthel-Index, Short physical performance battery (SPPB), Mini-Mental State Examination (MMSE) score, number of drugs and number of diagnoses) to describe the functional status and comorbidity burden.

Statistical Analysis

Three months and one year mortality rate after PAC discharge as well as further patient characteristics recorded at admission were calculated and stratified by level of frailty (robust, pre-frail, frail). Kaplan-Meier curves for visual representation were constructed for the overall sample to compare frail vs. robust and pre-frail at admission to PAC. Fisher’s exact test was used to evaluate whether mortality rate one year after discharge from PAC was independent of frailty status at admission. ANOVA and Chi-square test were used to evaluate whether there was a difference in mortality rate between frailty levels, as well as age and gender. Furthermore, a logistic regression model predicting mortality was evaluated to determine a possible association between frailty status upon admission to PAC and mortality rate on follow-up. The model was adjusted for age and gender. Statistical significance was determined as P<0.05 using 2-sided tests. All statistical analyses were performed using R v3.5.0 (The R Foundation for Statistical Computing, Vienna, Austria) and SAS v9.4 (SAS Institute, Inc. Cary, USA).

 

Results

Baseline Population

Our baseline sample consisted of n=140 patients, including 62.9% (n=88) women. Mean age at admission to PAC was 84 years (± 8.57). Mean length of stay at PAC was 31 days (± 16.5). In all, the most frequent diagnoses on admission to PAC were fractures (n=29), infections except pulmonary manifestations (n=18), mobility disorders (n=17), cognitive impairment (n=15), and heart disease (n=11), as reported earlier (12).

Mortality and Frailty Status

For n=139 patients, mortality status and mortality date at 3 and 12 months after discharge from PAC were applicable. At admission to PAC, 4.3% (n=6) of patients were robust, 37.1% (n=52) were pre-frail, 54.3% (n=76) were frail and 4.3% (n=6) were missing information on frailty status. The one-year mortality rate for the overall sample was 22.9% (32/140). One-year mortality rate stratified according to the different levels of frailty was 0% (robust, 0/6), 11.5% (pre-frail, 6/52) and 31.6% (frail, 24/76). Frailty status in relation to mortality, functional status and comorbidity burden is summarized in Table 1.

Table 1 Baseline characteristics and mortality after PAC stratified by frailty status

a. n=6 missing frailty status at admission; b. testing the difference between frailty levels; c. n=5 missing patients; d. SPPB, Short physical performance battery, n=10 missing patients; e. n=3 missing patients; f. n=1 missing patients; g. MMSE, Mini-Mental State Examination, n=7 missing patients; h. n=1 missing patient; i. n=2 deceased patients were missing frailty status at admission

 

For further analysis, we combined the group of robust and pre-frail patients, as none of the robust group deceased in the year following discharge from PAC. Our logistic regression model showed significantly increased odds of death for being frail (OR 4.19; 95% CI 1.53-11.47), and male gender (OR 3.19; 95% CI 1.28-8.0), but not for older age (OR 1.06, 95% CI 1.00-1.13 for each additional year).
Estimating survival with a Kaplan Meier analysis stratified by frailty status at admission to PAC showed a decreased probability of one-year survival for frail individuals, compared to patients classified as pre-frail or robust (P = 0.0096), Figure 1. In addition, each point increment on the frailty score at admission to PAC was associated with a decreasing one-year survival (P = 0.014).

Figure 1 Kaplan Meier estimates stratified for frailty status

 

Discussion

With more than one in two patients being frail and more than one in three being at risk for the condition (i.e. pre-frail) in our sample, frailty appears to be highly prevalent in Swiss older adults undergoing PAC in a nursing home setting. In comparison, the estimated prevalence of frailty in community-dwelling older adults in Switzerland is 5.8% (13). In our analysis, male gender and prevalent frailty were significantly associated with decreased survival at 12 months follow-up. In particular, frail patients had a greater than 4-fold increased odds for long-term mortality compared to their robust and pre-frail counterparts.
Our findings are in line with results from a prior study in older adults from Spain, where age, male gender and worse functional status were associated with higher 12-month mortality after acute illness (14). Our overall mortality rate of 22.9% is comparable to reports from earlier studies in former hospitalized geriatric patients from Germany and Italy (20.3% in Ritt et al. (15); 24.9% in Pilotto et al. (16)). However, those studies investigated one-year mortality after acute hospitalization without reporting on the utilization of PAC. Notably, patients in one of the aforementioned studies had a lower frailty prevalence at admission to acute care than our patient group (e.g. 43.3% vs. 54.3% in this study) (15).
When comparing the 12-month mortality rate of 31.6% in our frail patients with the aforementioned studies from acute care settings in Germany and Italy, it appears consistent with those reported by Ritt et al. (36.1%) and Pilotto et al. (24.9%) (15, 16). Of note, the higher mean age of patients in our study was more comparable to the first study (mean age >80 years), while Pilotto and colleagues investigated a sample with a mean age <80 years. Therefore, this difference is probably due to the influence of age in relation to the difference in mortality and warrants further investigation.
As a strength, our study is the first to report on the long-term outcomes of PAC in Swiss nursing homes and its association with frailty status. Further, we used a standardized operationalization of the Fried frailty phenotype, a derivation of the original version by Fried et al. (10). Our study also has its limitations. First, our sample size and short duration of patient recruitment limit the generalizability of our results. We also lack information on causes of death during follow-up. Furthermore, we had to cluster robust and pre-frail patients for our analysis, which might hinder comparisons to other studies. In addition, the frailty phenotype may not be the best frailty instrument to predict 12-month mortality in this patient group (15). Finally, our study did not include a control group of “standard” nursing home care residents to compare with our results regarding potential recovery time in the absence of specific interventions.

 

Conclusion

Our study in 140 former geriatric inpatients 12 months after discharge from PAC suggests that male gender and frailty status upon admission to PAC are significantly associated with increased long-term mortality in this group of Swiss older adults. While in line with prior studies from other populations, our study adds important knowledge on the specific situation in Switzerland. More studies are needed to further investigate the impact of PAC programs on short and long-term outcomes in Switzerland, including older adults affected by frailty.

 

Acknowledgments: We like to thank Marion Thalmann and Thomas Tröster for performing the initial data collection. In addition we thank Dr. Wei Lang for his statistical advice. Furthermore, we would like to thank all involved staff members at the participating municipal nursing homes in the City of Zurich.
Conflicts of Interest: The authors declare no conflict of interest.
Ethical Standards: The authors declare that the study porcedures comply with current ethical standards for research involving human participants in Switzerland. The study protocol has been approved by the Cantonal Ethics Committee of the Canton of Zurich, Switzerland (BASEC 2016-01069);
Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.
Funding section: Open Access funding provided by University Hospital Zurich.

 

References

1. Buchner DM, Wagner EH. Preventing frail health. Clin Geriatr Med. 1992;8(1):1-17.
2. Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: A review. Eur J Intern Med. 2016;31:3-10.
3. Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51(4):451-8.
4. Kone I, Zimmermann B, Wangmo T, Richner S, Weber M, Elger B. Hospital discharge of patients with ongoing care needs: a cross-sectional study using data from a city hospital under SwissDRG. Swiss medical weekly. 2018;148:w14575.
5. Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJ, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774-84.
6. Prvu Bettger J, Alexander KP, Dolor RJ, Olson DM, Kendrick AS, Wing L, et al. Transitional care after hospitalization for acute stroke or myocardial infarction: a systematic review. Ann Intern Med. 2012;157(6):407-16.
7. Roberts PS, Goud M, Aronow HU, Riggs RV. Frailty in a Post-Acute Care Population: A Scoping Review. PM & R : the journal of injury, function, and rehabilitation. 2018.
8. Abrahamsen J, Rozzini R, Boffelli S, Cassinadri A, Ranhoff A, Trabucchi M. Comparison of Italian and Norwegian postacute care settings for older patients in need of further treatment and rehabilitation after hospitalization. The Journal of Aging Research and Clinical Practice (JARCP). 2015.
9. Thalmann M, Troster T, Fischer K, Bieri-Bruning G, Patrick B, Bischoff-Ferrari HA, et al. Do older adults benefit from post-acute care following hospitalisation? A prospective cohort study at three Swiss nursing homes. Swiss medical weekly. 2020;150:w20198.
10. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.
11. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet. 2019;394(10206):1365-75.
12. Tröster T, Thalmann M, Fischer K, Bieri-Brüning G, Beeler PE, Bischoff-Ferrari HA, et al. Frailty, underweight and impaired mobility are associated with institutionalisation after post-acute care. Swiss medical weekly. 2020;150:w20276.
13. Santos-Eggimann B, Cuenoud P, Spagnoli J, Junod J. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol A Biol Sci Med Sci. 2009;64(6):675-81.
14. Baztan JJ, Galvez CP, Socorro A. Recovery of functional impairment after acute illness and mortality: one-year follow-up study. Gerontology. 2009;55(3):269-74.
15. Ritt M, Bollheimer LC, Sieber CC, Gaßmann KG. Prediction of one-year mortality by five different frailty instruments: A comparative study in hospitalized geriatric patients. Arch Gerontol Geriatr. 2016;66:66-72.
16. Pilotto A, Rengo F, Marchionni N, Sancarlo D, Fontana A, Panza F, et al. Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients. PLoS One. 2012;7(1):e29090.

IMPACT OF POST-ACUTE TRANSITION CARE FOR FRAIL OLDER PEOPLE: A PROSPECTIVE STUDY

 

N.M. PEEL1, R.E. HUBBARD1, L.C. GRAY1

 

1.  Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland 4102, Australia

Corresponding Author: Dr Nancye Peel, Research Fellow, Centre for Research in Geriatric Medicine, Level 2 Building 33, Princess Alexandra Hospital, Ipswich Road, Brisbane, Queensland 4102, Australia, Ph:  +61 7 3176 7402, Fax: +61 7 3176 6945, Email: n.peel@uq.edu.au

J Frailty Aging 2013;2(3):165-171
Published online February 12, 2016, http://dx.doi.org/10.14283/jfa.2013.24


Abstract

Objectives: To describe the characteristics and outcomes of frail older people in a post-acute transitional care program and to compare the recovery trajectories of patients with high and low care needs to determine who benefits from transition care. Design: Prospective observational cohort. Participants and Setting: 351 patients admitted to community-based transition care in two Australian states during an 11 month recruitment period. Intervention: Transition care provides a package of services including personal care, physiotherapy and occupational therapy, nursing care and case management post discharge from hospital. It is targeted at frail older people who, in the absence of an alternative, would otherwise be eligible for admission to residential aged care. Measurements: A comprehensive geriatric assessment using the interRAI Home Care instrument was conducted at transition care admission and discharge. Primary outcomes included changes in functional ability during transition care, living status at discharge and six months follow-up, and hospital re-admissions over the follow-up period. For comparison of outcomes, the cohort was divided into two groups based on risk factors for admission to high or low-level residential aged care. Results: There were no significant differences between groups on outcomes, with over 85% of the cohort living in the community at follow-up. More than 80% of the cohort showed functional improvement or maintenance of independence during transition care, with no significant differences between the groups. Conclusions: Post-acute programs should not be targeted solely at fitter older people: those who are frail also have the potential to gain from community-based rehabilitation.

Key words: Post-acute care, frail aged, community-based rehabilitation.


 

Introduction

Older people hospitalised with acute illness are at increased risk of acquired disability and cognitive decline (1). Post discharge, physical weakness following illness and the need for adjustments to formal and informal care arrangements can result in further decline in function, with consequent risk of re-admission to hospital or residential aged care (2). Internationally, a high demand for post-acute programs has led to new models of care (variously described as transitional care, intermediate care, subacute care, early supported discharge and rehabilitation) to facilitate transitions from hospital to home for older people (3).

One such model of care is the Australian Transition Care Program (TCP), a national program specifically designed to offer post-acute care to older patients at the conclusion of a hospital episode.  The program provides a package of services which includes home help and personal care, physiotherapy and occupational therapy, nursing care and case management over a maximum period of 12 weeks (average seven weeks) post discharge from hospital (4). Access to TCP is based on approval by an Aged Care Assessment Team and is targeted at older people who, in the absence of an alternative, would otherwise be eligible for admission to at least low-level residential aged care (RAC) (5). In Australia, government subsidised residential aged care provides a permanent live-in setting for older Australians whose care needs are such that they can no longer remain in their own homes. There are two levels of care available, high-care and low-care. High-care offers nursing care along with the assistance received for low-care, which includes meals, laundry and personal care (5).

For older people, the risk of admission to residential care on discharge from hospital has been shown to increase proportionately with the number of risk factors (6). These risk factors include cognitive impairment, dementia and behavioural problems (6, 7), incontinence (6), high dependency in Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) (8, 9), mobility impairment (6) and falls risk (6, 8).  Living alone (having no co-resident carer) is also associated with discharge from hospital to RAC (7, 8).

In common with other post-acute models of care (10, 11), the TCP has a planned objective of maximising functional recovery and independence, thereby enabling a significant proportion of care recipients to resume living at home rather than remain in hospital for extended lengths of stay or prematurely enter long-term residential aged care (5). However, the evidence regarding the efficacy of post-acute programs is mixed, and it remains unclear whether such approaches achieve their objectives and positively influence clinical or other outcomes (4, 12). There is also controversy about those most likely to gain from these interventions and whether frail older people who are at increased risk for adverse outcomes such as onset of disability, morbidity, institutionalisation or mortality can benefit from post-acute care programs (13, 14).

The aims of this study, therefore, are to describe the characteristics and outcomes of TCP recipients and to compare the recovery trajectories of high and low care needs patients to determine who benefits from transition care.

 

Methods

Study Design, Setting and Participants

In this prospective cohort observational study, the setting was community-based transition care offered in the home. Consenting patients entering community-based TCP at six sites in two states in Australia (Queensland and South Australia) during an eleven month recruitment period from November 2009 to September 2010 were eligible to participate in the study.  Ethics approval was given by the University Human Research Ethics Committee (HREC) as well as HRECs responsible for governance at each of the TCP sites.

Data Collection and Measurement Procedures

A comprehensive geriatric assessment was conducted at TCP admission and discharge using the interRAI-Home Care (HC), one of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings (15). Overall performance of the instruments shows that the interRAI suite has substantial reliability on core items in common (16). Data items in the instrument include socio-demographic information, cognition, communication, mood and behaviour, Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), continence, falls, nutrition, medications, medical diagnoses, and discharge destination. A number of scales embedded in the interRAI instruments combine single items belonging to a domain, such as cognition, that be used to describe the presence and extent of deficits in that domain (1). Scales for measuring the assessment of the problem are calculated for each time period of the interRAI HC assessment. Premorbid observations, collected at admission to TCP, pertain to the status 3 days prior to the time at which the acute illness (or the reason for admission to hospital) appeared to commence. Other observations pertain to admission and discharge status. At TCP admission  frailty status was measured by an index of accumulated deficits (22), based on core items in the InterRAI HC.  Table 1 defines the measurement of variables examined in this study.

Participants were followed-up by telephone at six months post TCP admission to determine current living status. Re-admissions to hospital over the follow-up period were also ascertained at follow-up, as well as through supplementary administrative data on hospital separations from state health departments.

The data collection instruments were administered by trained assessors to collect research data and were not part of usual clinical assessment.

Outcome Variables

Primary outcomes included TCP discharge destination coded as remaining in the community, in institutional care (readmitted to hospital or to RAC), or death; and improvement/ maintenance of independent functioning between TCP admission and discharge (defined in Table 1). Outcomes at six months post TCP admission included living status (living in the community, in RAC, or died) and whether re-admitted to hospital in the six months follow-up period.

Data Analysis

The cohort was divided into two groups (“high needs” and “low needs”) based on risk profile for admission to either high-level or low-level RAC. The high needs group was characterised as having two or more geriatric syndromes such as moderate to severe cognitive impairment, high dependency in personal ADL or IADL, daily incontinence or mobility impairment (defined in Table 1) that are risk factors for admission to high-level RAC. The groups were compared on characteristics and outcomes.

Table 1 Measurement of geriatric syndromes and frailty

 

For continuous normally distributed data, t-tests for independent samples were used to compare means.  If the data were not normally distributed, Mann Whitney U-Test was utilised to analyse the difference between mean ranks for independent samples and Wilcoxon Signed Rank Test utilised for repeated measures.  For the categorical variables, a Chi-Square Test was performed. All proportions were calculated as percentages of patients with available data. Significance levels were set at p<0.05. Patients with missing data were excluded from the relevant analyses. The findings are reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guideline for cohort studies (24). Analyses were performed using IBM SPSS Statistics 20.

Results

Of 590 consecutive TCP admissions to six sites over the recruitment period, 381 (64.6% of those eligible) consented to participate. After withdrawals (21) and missing case files (9), 351 participants were included in the analysis. A schematic of recruitment is shown in Figure 1. A comparison of mean ages of participants and non-participants (those who refused consent) showed that non-participants were older (mean age 80.8) compared with participants (mean age 79.0) (p<0.05). However there was no significant difference in gender distribution.

Figure 1 Recruitment Flowchart

Of the 351 participants, 175 (49.9%) were classified as having low needs and 176 (50.1%) were in the high needs group. Participants were community-dwelling at the time of admission to TCP and were classified as ‘frail’, having a mean Frailty Index (FI) of 0.31. Over 70% of the group had an FI above the threshold of 0.25 which has been proposed as the demarcation between ‘fitness’ and ‘frailty’ in community-dwelling older people (23). The most common diagnosis which resulted in admission to TCP was for orthopaedic conditions (including fractures, joint replacement surgery, limb amputation and arthritis) (50.4%). Other reasons included post hospital deconditioning following medical illness (24.2%), stroke and neurological disorders (15.1%) and cardiac conditions (5.4%). Characteristics and outcomes for all participants and by group (low or high needs) are shown in Tables 2 and 3 respectively. Unless otherwise specified, missing data on any variable was less than five percent.

Table 2 shows significant differences in risk profile between the low and high needs groups at admission to TCP. A comparison of outcomes (Table 3) showed that there were no significant differences between the groups on discharge destination from TCP, living status at six months follow-up, nor rehospitalisation over the follow-up period. In addition, the proportion of patients showing ADL, IADL and cognitive functional improvement or maintenance of independence over the TCP episode did not differ significantly between the groups. The high needs group, however, had a lower proportion who improved mobility independence (p<0.01) and also recorded a higher proportion of fallers (p<0.01) during their TCP episode of care.

Table 2 Characteristics of participants at admission to TCP

Moderate to severe cognitive impairment: CPS score ≥3. High dependency in personal ADL: requiring extensive assistance (scores ≥4) on any personal ADL item (bathing, personal hygiene, dressing upper body and lower body, toilet transfers, toilet use, bed mobility or eating). High dependency in IADL: requiring extensive assistance (scores ≥4) on any IADL item. Mobility impairment: requiring physical assistance (score of ≥3) on ADL walking independence item. Unless otherwise specified columns represent number (%). All proportions were calculated as percentages of patients with available data. Abbreviations: SD: standard deviation; LOS: length of stay; IQR: interquartile range

Table 3 Outcomes of participants

Unless otherwise specified columns represent number (%). All proportions were calculated as percentages of patients with available data; * Missing data >6%  and <10%. Abbreviations: RAC: Residential aged care; FU: Follow-up

Figure 2 (A) to (C) shows the differences between the low and high needs groups at premorbid, admission and discharge for (a) ADL, (b) IADL, and (c) Cognitive Performance Scale (CPS). Higher scores on each scale are indicative of more impaired status. Non-parametric comparison of means between the two groups on each of the measures at the three time points (premorbid, admission and discharge) indicated that the high needs group was significantly more impaired (p<0.001) than the low needs group (except for premorbid ADL and IADL scale scores). For each group, premorbid and admission means were compared with subsequent discharge measures using Wilcoxon Signed Ranks Test for repeated measures. For the high needs group their values were significantly different at the different time points (p< 0.001) and followed the pattern, as illustrated in Figure 2 (A) to (C), that the dependency level increased between premorbid and admission and improved by discharge, but not to premorbid levels. The pattern was similar for the low needs group except there was a non-significant change between admission and discharge CPS scale scores.

Figure 2 Premorbid, admission and discharge functional profile. Error bars are Standard Error of Mean. Higher scores on ADL Scale, IADL Scale and Cognitive Performance Scale (defined in Table 1) indicate greater dependency/impairment

Discussion

This study describes the recovery trajectories of frail older people with multiple geriatric syndromes in receipt of TCP.  Half of the study population were characterised as having high care needs placing them at risk of admission to residential aged care. The high needs group were significantly less likely to live alone and more likely to have a co-resident carer, which would be an enabling factor in allowing them to remain living in the community, rather than enter residential aged care (7). Consistent with the literature also was that the high needs group was at greater risk of falls (6, 8).

While there is debate about the subgroup of patients who will benefit most from rehabilitation (13), this study showed that both the low and high needs groups improved functionally over the TCP episode of care. The gains were both significant and clinically meaningful (25).  In agreement with a previous study of geriatric rehabilitation (14), even in a group with a high prevalence of moderate to severe cognitive impairment (33.7% in the high needs group), significant functional gain was achieved. It might even be argued, as demonstrated in Figure 2, that starting from a baseline of high dependency/impairment at admission, the high needs group had the greater potential to improve and, therefore, benefit from the TCP intervention.

For other outcomes such as TCP discharge destination, living status at six months follow-up and re-hospitalisations over the follow-up period, there were no significant differences between the groups.  Even in the high needs group over 85% were still living in the community at six months post TCP admission, while 6.8% had entered permanent long term care. The high rate of hospital readmissions in the 6 months of follow-up (40%) is consistent with previous studies (26, 27).

Further comparison of outcomes in this TCP cohort with studies included in systematic reviews of post-discharge support programs is made difficult because of the heterogeneity of interventions, wide range of care settings, composition of the post-discharge team and focus on specific patient groups such as those with hip fractures, stroke or heart failure (28). Because of lack of a comparison group, it is difficult to determine whether the TCP results in functional capacity gains over that of the normal recovery trajectory (29).  A properly controlled trial with an economic analysis is needed to confirm the results of this study as well as determine its cost effectiveness.

Even though specific to an Australia program, the results of this study are thought to be generalizable to similar post-acute care programs in other health care systems. The cohort is characteristic of older people eligible for post discharge home-based care and representative of TCP recipients in particular, having been recruited across multiple sites in both rural and metropolitan communities.

Conclusions

The high needs group in this study are frail, with physical and cognitive impairment and dependence on others for activities of daily living. Since frailty arises from a critical mass of abnormalities across different systems (22), optimisation of any single domain is unlikely to be effective in its management (30). The TCP, embracing physical therapy, environmental optimisation, re-enablement and social support, can be considered a multifactorial intervention. Our findings that frail older people potentially benefit from such programs, with improved physical function and avoidance of institutional care, have implications for clinical practice. Post-acute programs should not be targeted solely at fitter older people: those who are frail also have the potential to gain from community-based rehabilitation.

Conflicts of Interest: The authors certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organisation with which we are associated.

Declaration of Sources of Funding: This work was supported by the Australian National Health and Medical Research Council Health Services Research Program Grant (ID 402791) on Transition Care: Innovation and Evidence. The funding sources had no involvement in the design, execution, analysis and interpretation of data, nor writing of the paper.

 

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