ObjectivesTo compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care.DesignSystematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources.SettingAcute care geriatric and nongeriatric hospital units.ParticipantsAcutely ill or injured adults (N = 6,839) with an average age of 81.InterventionsAcute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment.MeasurementsFalls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions.ResultsAcute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29–0.88), less delirium (RR = 0.73, 95% CI = 0.61–0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78–0.97), shorter length of hospital stay (weighted mean difference (WMD) = −0.61, 95% CI = −1.16 to −0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68–0.99), lower costs (WMD = −$245.80, 95% CI = −$446.23 to −$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01–1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions.ConclusionAcute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults' illness or injury, improves patient- and system-level outcomes.

BackgroundOlder age and higher acuity are associated with prolonged hospital stays and hospital readmissions. Early discharge planning may reduce lengths of hospital stay and hospital readmissions; however, its effectiveness with acutely admitted older adults is unclear.MethodsIn this systematic review, we compared the effectiveness of early discharge planning to usual care in reducing index length of hospital stay, hospital readmissions, readmission length of hospital stay, and mortality; and increasing satisfaction with discharge planning and quality of life for older adults admitted to hospital with an acute illness or injury.We searched the Cochrane Library, DARE, HTA, NHSEED, ACP, MEDLINE, EMBASE, CINAHL, Proquest Dissertations and Theses, PubMed, Web of Science, SciSearch, PEDro, Sigma Theta Tau International’s registry of nursing research, Joanna Briggs Institute, CRISP, OT Seeker, and several internet search engines. Hand-searching was conducted in four gerontological journals and references of all included studies and previous systematic reviews. Two reviewers independently extracted data and assessed risk of bias. Data were pooled using a random-effects meta-analysis. Where meta-analysis was not possible, narrative analysis was performed.ResultsNine trials with a total of 1736 participants were included. Compared to usual care, early discharge planning was associated with fewer hospital readmissions within one to twelve months of index hospital discharge [risk ratio (RR) = 0.78, 95% CI = 0.69 − 0.90]; and lower readmission lengths of hospital stay within three to twelve months of index hospital discharge [weighted mean difference (WMD) = −2.47, 95% confidence intervals (CI) = −4.13 − −0.81)]. No differences were found in index length of hospital stay, mortality or satisfaction with discharge planning. Narrative analysis of four studies indicated that early discharge planning was associated with greater overall quality of life and the general health domain of quality of life two weeks after index hospital discharge.ConclusionsEarly discharge planning with acutely admitted older adults improves system level outcomes after index hospital discharge. Service providers can use these findings to design and implement early discharge planning for older adults admitted to hospital with an acute illness or injury.

1 Structured Abstract OBJECTIVES. To describe the Acute Care for Elders (ACE) model components implemented as part of acute geriatric unit care and explore the association of each ACE component with outcomes of reduced iatrogenic complications, functional decline, length of hospital stay, nursing home discharges, and costs and increased discharges home. DESIGN.Systematic descriptive review of 32 articles, including 14 trials reporting on the implementation of ACE components or the effectiveness of their implementation in improving outcomes. Mean effect sizes (ESs) were calculated using trial outcome data. Information describing implementation of the ACE components in the trials was analyzed using content analysis.SETTING. Acute care geriatric units. (N= 6,839) with an average age of 81 years. PARTICIPANTS. Acutely ill or injured adults INTERVENTIONS.Acute geriatric unit care was characterized by the implementation of one or more ACE components: medical review, early rehabilitation, early discharge planning, prepared environment, patient-centered care.MEASUREMENTS. Falls, pressure ulcers, delirium, functional decline, length of hospital stay, discharge destination (home or nursing home), and costs. RESULTS.Medical review, early rehabilitation, and patient-centered care, characterized by the implementation of standardized and individualized function-focused interventions, had larger standardized mean ESs (all ES = .20) averaged across all outcomes, than did early discharge planning (ES = .17) or prepared environment (ES = .11).CONCLUSION. Specific ACE component interventions of medical review, early rehabilitation, and patient-centered care, appear to be optimal for overall positive outcomes. These findings can 2 help service-providers design and evaluate the most effective ACE model within the contexts of their respective institutions to improve outcomes for acutely ill or injured older adults. The aims in this systematic descriptive review were to describe ACE components implemented as part of acute geriatric unit care in terms of objectives, ACE interventions, dose, and approach, and to explore the association of each ACE component with the outcomes of reduced iatrogenic complications, functional decline, length of hospital stay, nursing home discharges, and costs and increased discharge home. 4 METHODSThis was a systematic descriptive review of the trials reported in a recent meta-analysis. 7 For the first aim, conceptual, clinical, and empirical articles that provided accounts of how the ACE components were designed or implemented in these trials were reviewed. For the second aim, trial outcome data were used to calculate the mean effect size (ES) associated with each ACE component. Components associated with larger ESs were interpreted as having larger contributions to the outcomes. Selection CriteriaSelection criteria for trials included in this descriptive review have been previously reported. 7Conceptual, clinical, and empirical articles that contained supplemental information about one or more ACE comp...

Increasing evidence suggests that early diagnosis and management of dementia-related symptoms may improve the quality of life for patients and their families. However, individuals may wait from 1-3 years from the onset of symptoms before receiving a diagnosis. The objective of this qualitative study was to explore the perceptions and experiences of problem recognition, and the process of obtaining a diagnosis among individuals with early-stage dementia and their primary carers. From 2006-2009, six Anglo-Canadians with dementia and seven of their carers were recruited from the Alzheimer's Society of Calgary to participate in semi-structured interviews. Using an inductive, thematic approach to the analysis, five major themes were identified: becoming aware of memory problems, attributing meanings to symptoms, initiating help-seeking, acknowledging the severity of cognitive changes and finally obtaining a definitive diagnosis. Individuals with dementia reported noticing memory difficulties earlier than their carers. However, initial symptoms were perceived as ambiguous, and were normalised and attributed to concurrent health problems. The diagnostic process was typically characterised by multiple visits and interactions with health professionals, and a diagnosis was obtained as more severe cognitive deficits emerged. Throughout the diagnostic pathway, carers played dynamic roles. Carers initially served as a source of encouragement to seek help, but they eventually became actively involved over concerns about alternative diagnoses and illness management. A better understanding of the pre-diagnosis period, and the complex interactions between people's beliefs and attributions about symptoms, may elucidate some of the barriers as well as strategies to promote a timelier dementia diagnosis.

BackgroundThe assessment and ongoing management of dementia falls largely on family physicians. This pilot study explored perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists.MethodsSemi-structured, one-to-one interviews were conducted with six family physicians and six specialists (three geriatric psychiatrists, two geriatricians, and one neurologist) from University of Toronto-affiliated hospitals. Transcripts were subjected to thematic content analysis.ResultsPhysicians’ clinical experience averaged 16 years. Both physician groups acknowledged that family physicians are more confident in diagnosing/treating uncomplicated dementia than a decade ago. They agreed on care management issues that warranted specialist involvement. Driving competency was contentious, and specialists willingly played the “bad cop” to resolve disputes and preserve long-standing therapeutic relationships. While patient/caregiver education and support were deemed essential, most physicians commented that community resources were fragmented and difficult to access. Improving collaboration and communication between physician groups, and clarifying the roles of other multi-disciplinary team members in dementia care were also discussed.ConclusionsFuture research could further explore physicians’ and other multi-disciplinary members’ perceived roles and responsibilities in dementia care, given that different health-care system-wide dementia care strategies and initiatives are being developed and implemented across Ontario.