Delirium: a barometer for quality of hospital care.
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Biomedical subjects
S K Inouye
Publications and source records attributed to S K Inouye.
Goals for the care of frail older adults: do caregivers and clinicians agree?
PURPOSE: Establishing shared treatment goals for patients may improve the quality of care by facilitating achievement of appropriate and desired outcomes. The purpose of this study was to describe types of family caregiver and physician treatment goals for frail elderly patients who had a high prevalence of cognitive impairment, and to ascertain the level of agreement between family caregivers and physicians on principal treatment goals. SUBJECTS AND METHODS: We surveyed family caregivers and physicians for 200 consecutive older adults who were initially evaluated at the outpatient geriatric assessment center of a major teaching hospital. Treatment goals for patients were measured after a comprehensive geriatric assessment. RESULTS: Goals commonly chosen as most important by family caregivers and physicians pertained to day-to-day functioning (61 [31%] family caregivers, 81 [41%] physicians), behavior and emotional health (56 [28%] family caregivers, 50 [25%] physicians), and safety (40 [20%] family caregivers, 29 [15%] physicians). Although a substantial proportion of family caregiver and physician pairs shared at least one goal (157 [79%] of 200), agreement on presence or absence of individual categories of goals was poor (kappas from -0.19 to 0.28), and agreement on the most important goal was also poor (kappa 0.20). CONCLUSIONS: Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that encounters between family caregiver and physician may need improvement. Further research is needed to assess whether lack of agreement is found in other settings, persists over time, and affects achievement of goals and optimal health outcomes.
Activities of Daily Living↗
Methodologic issues in conducting research on hospitalized older people.
OBJECTIVE: To describe challenges in conducting research with hospitalized geriatric patients. DESIGN: Quasi-experimental longitudinal study with inperson interviews at baseline and discharge and a three-month postdischarge telephone interview. Study protocol required baseline interviews within 48 hours of admission for patients or 72 hours for proxies. SETTING: 813-bed urban teaching hospital. PARTICIPANTS: 240 patients, mean age 83.8 years, at moderate to high risk for functional decline during hospitalization, admitted from the emergency room to a general medical unit. MEASUREMENTS: Delays starting or interruptions continuing interviews; patient and environmental conditions potentially affecting data quality; and information on proxy use. RESULTS: Timely access to patients or proxies was a major difficulty, resulting in the screening of only 53.1% of 867 potentially eligible patients. Multiple patient contacts and visits were required to complete interviews. Only 61.3% of baseline and 28.1% of follow-up interviews were completed on the initial day of contact. Despite having on-site interviewers 7 days a week, 29% of discharge interviews were conducted by telephone. Interviews were >90% complete in 487 of 503 of encounters (97%). Baseline delays and interruptions were usually due to the presence of medical staff, off-unit tests, patient illness, nurse unavailability for interview, and need for a proxy. Most in-hospital interviews were conducted with others present. Proxies were required for approximately one-third of patients at all three interviews. CONCLUSION: Conducting clinical research with older adults in the current inpatient setting, where patients are more severely ill yet have shorter lengths of stay now than in the past, proves a challenging yet achievable goal. Effective procedures for negotiating the acute care environment are critical to successful studies.
Acute Disease↗
Goals in geriatric assessment: are we measuring the right outcomes?
Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.
Activities of Daily Living↗
The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program.
OBJECTIVES: To describe the Hospital Elder Life Program, a new model of care designed to prevent functional and cognitive decline of older persons during hospitalization. PROGRAM STRUCTURE AND PROCESS: All patients aged > or =70 years on specified units are screened on admission for six risk factors (cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment). Targeted interventions for these risk factors are implemented by an interdisciplinary team-including a geriatric nurse specialist, Elder Life Specialists, trained volunteers, and geriatricians--who work closely with primary nurses. Other experts provide consultation at twice-weekly interdisciplinary rounds. INTERVENTION: Adherence is carefully tracked. Quality assurance procedures and performance reviews are an integral part of the program. PROGRAM OUTCOMES: To date, 1,507 patients have been enrolled during 1,716 hospital admissions. The overall intervention adherence rate was 89% for at least partial adherence with all interventions during 37,131 patient-days. Our results indicate that only 8% of admissions involved patients who declined by 2 or more points on MMSE and only 14% involved patients who declined by 2 or more points on ADL score. Comparative results for the control group from the clinical trial were 26% and 33%, and from previous studies 14 to 56% and 34 to 50% for cognitive and functional decline, respectively. Effectiveness of the program for delirium prevention and of the program's nonpharmacologic sleep protocol have been demonstrated previously. CONCLUSIONS: These results suggest that the Hospital Elder Life Program successfully prevents cognitive and functional decline in at-risk older patients. The program is unique in its hospital-wide focus; in providing skilled staff and volunteers to implement interventions; and in targeting practical interventions toward evidence-based risk factors. Future studies are needed to evaluate cost-effectiveness and longterm outcomes of the program as well as its effectiveness in non-hospital settings.
Activities of Daily Living↗
Prevention of delirium in hospitalized older patients: risk factors and targeted intervention strategies.
Delirium is a common, costly, and potentially devastating condition for hospitalized older patients. Delirium is a multifactorial syndrome, involving the inter-relationship between patient vulnerability, or predisposing factors at admission, and noxious insults or precipitating factors during hospitalization. Through a series of studies, we first identified significant predisposing factors for delirium, including vision impairment, severe illness, cognitive impairment, and dehydration. Subsequently, significant precipitating factors were identified, including physical restraint use, malnutrition, adding more than three drugs, bladder catheter use, and any iatrogenic event. Through targeting preventive strategies towards six identified risk factors in a controlled clinical trial, we were successful in the primary prevention of delirium. In 852 subjects, the incidence of delirium was significantly reduced in the intervention group compared with usual care (9.9% vs 15.0%, matched odds ratio: 0.60; 95% confidence interval: 0.39-0.92). The total number of days and episodes of delirium were also significantly reduced in the intervention group. Based on this work, evidence-based recommendations for delirium prevention are proposed. While not all cases of delirium will be preventable with this approach, unifying medical and epidemiological approaches to delirium represents a key advance essential to reducing the high morbidity and mortality associated with delirium in the older population.
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A multicomponent intervention to prevent delirium in hospitalized older patients.
BACKGROUND: Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. METHODS: We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge. RESULTS: Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment. CONCLUSIONS: The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.
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Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care.
Delirium, or acute confusional state, which often results from hospital-related complications or inadequate hospital care for older patients, can serve as a marker of the quality of hospital care. By reviewing five pathways that can lead to a greater incidence of delirium--iatrogenesis, failure to recognize delirium in its early stages, attitudes toward the care of the elderly, the rapid pace and technological focus of health care, and the reduction in skilled nursing staff--we identify how future trends and cost-containment practices may exacerbate the problem. Examining delirium also provides an opportunity to improve the quality of hospital care for older persons. Interventions to reduce delirium would need to occur at the local and national levels. Local strategies would include routine cognitive assessment and the creation of systems to enhance geriatric care, such as incentives to change practice patterns, geriatric expertise, case management, and clinical pathways. National strategies might include providing education for physicians and nurses to improve the recognition of delirium and the awareness of its clinical implications, improving quality monitoring systems for delirium, and creating environments to facilitate the provision of high-quality geriatric care.
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Goal-setting in clinical medicine.
The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.
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Prospective individual matching: covariate balance and power in a comparative study.
In phase II to phase IV studies, randomization has gained widespread acceptance as a methodologic tool for the allocation of patients to treatment. However, randomization is not always feasible. At times, the treatment intervention occurs universally throughout one or more units (for example, a hospital unit), while the control therapy is the only intervention provided in other units. Patients may arrive randomly at a unit, based solely on availability of the unit to accept new subjects. Thus, the treatment assignment process is out of the investigator's control and not subject to selection bias. We describe a prospective individual matching procedure through which one can achieve balanced allocation of subjects to treatment groups in this comparative study setting. In this paper, we compare balance of baseline covariates and power for this design, in which the subject is selected at random and assigned to a treatment group, and the traditional randomized block design, in which the treatment is chosen at random and assigned to a subject. We show that the prospective individual matching procedure compares favourably to the traditional randomized blocked design with respect to both baseline covariate comparability and statistical power.
Analysis of Variance↗
Importance of functional measures in predicting mortality among older hospitalized patients.
CONTEXT: Measures of physical and cognitive function are strong prognostic predictors of hospital outcomes for older persons, but current risk adjustment and burden of illness assessment indices do not include these measures. OBJECTIVE: To evaluate and validate the contribution of functional measures to the ability of 5 standard burden of illness indices (Charlson, Acute Physiology and Chronic Health Evaluation [APACHE] II, Disease Staging, All Patient Refined Diagnosis Related Groups, and a clinician's subjective rating) in predicting 90-day and 2-year mortality among older hospitalized patients. DESIGN: Two prospective cohort studies. SETTING: General medicine service, university teaching hospital. PATIENTS: For the development cohort, 207 consecutive patients aged 70 years or older, and for the validation cohort, 318 comparable patients. MAIN OUTCOME MEASURE: Death within 90 days and 2 years from the index admission. RESULTS: In the development cohort, 29 patients (14%) and 81 patients (39%) died within 90 days and 2 years, respectively. A functional axis was developed using 3 independent risk factors: impairment in instrumental activities of daily living, Mini-Mental State Examination score of less than 20, and shortened Geriatric Depression Scale score of 7 or higher, creating low-, intermediate-, and high-risk groups with associated mortality rates of 20%, 32%, and 60%, respectively (P<.001); the C statistic for the final model was 0.69. The corresponding mortality rates in the validation cohort, in which 59 (19%) and 138 (43%) died within 90 days and 2 years, respectively, were 24%, 45%, and 60% (P<.001); the C statistic for the final model was 0.66. For each burden of illness index, the functional axis contributed significantly to the predictive ability of the model for both 90 days and 2 years. When the functional axis and each burden of illness measure were analyzed in cross-stratified format, mortality rates increased progressively from low-risk to high-risk functional groups within strata of burden of illness indices (double-gradient phenomenon). The contributions of functional and burden of illness measures were substantive and interrelated. CONCLUSIONS: Functional measures are strong predictors of 90-day and 2-year mortality after hospitalization. Furthermore, these measures contribute substantially to the prognostic ability of 5 burden of illness indices. Optimal risk adjustment for older hospitalized patients should incorporate functional status variables.
Activities of Daily Living↗
Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.
OBJECTIVE: To determine the independent contribution of admission delirium to hospital outcomes including mortality, institutionalization, and functional decline. DESIGN: Three prospective cohort studies. SETTING: Three university-affiliated teaching hospitals. PATIENTS: Consecutive samples of 727 patients, aged 65 years and older. MEASUREMENTS AND MAIN RESULTS: Delirium was present at admission in 88 (12%) of 727 patients. The main outcome measures at hospital discharge and 3-month follow-up were death, new nursing home placement, death or new nursing home placement, and functional decline. At hospital discharge, new nursing home placement occurred in 60 (9%) of 692 patients, and the adjusted odds ratio (OR) for delirium, controlling for baseline covariates of age, gender, dementia, APACHE II score, and functional measures, was 3.0, (95% confidence interval [CI] 1.4, 6.2). Death or new nursing home placement occurred in 95 (13%) of 727 patients (adjusted OR for delirium 2.1, 95% CI 1.1, 4.0). The findings were replicated across all sites. The associations between delirium and death alone (in 35 [5%] of 727 patients) and between delirium and length of stay were not statistically significant. At 3-month follow-up, new nursing home placement occurred in 77 (13%) of 600 patients (adjusted OR for delirium 3.0; 95% CI 1.5, 6.0). Death or new nursing home placement occurred in 165 (25%) of 663 patients (adjusted OR for delirium 2.6; 95% CI 1.4, 4.5). The findings were replicated across all sites. For death alone (in 98 [14%] of 680 patients), the adjusted OR for delirium was 1.6 (95% CI 0.8, 3.2). Delirium was a significant predictor of functional decline at both hospital discharge (adjusted OR 3.0; 95% CI 1.6, 5.8) and follow-up (adjusted OR 2.7; 95% CI 1.4, 5.2). CONCLUSIONS: Delirium is an important independent prognostic determinant of hospital outcomes including new nursing home placement, death or new nursing home placement, and functional decline-even after controlling for age, gender, dementia, illness severity, and functional status. Thus, delirium should be considered as a prognostic variable in case-mix adjustment systems and in studies examining hospital outcomes in older persons.
Activities of Daily Living↗
Screening for dementia in the outpatient setting: the time and change test.
OBJECTIVE: To develop and validate the Time and Change (T&C) test, a simple, standardized method for detecting dementia in a diverse older outpatient population with varying levels of education. DESIGN: A prospective cohort validation study. SETTING: Two outpatient clinics at an urban teaching hospital. PARTICIPANTS: The concurrent validation sample consisted of 100 consecutive outpatients 70 years of age or older who were 58% non-white and had a 16% dementia prevalence rate and educational levels ranging from 0 to 17+ years. Reliability was tested in a sample of 42 consecutive outpatients 75 years of age or older with a 36% dementia prevalence rate. MEASUREMENTS: T&C ratings were validated against a reference standard based on the Blessed Dementia Rating Scale and the Mini-Mental State Examination. Reliability, contribution to physician recognition of dementia, and ease of use were assessed. RESULTS: In the outpatient setting, the T&C had a sensitivity of 63%, specificity of 96%, a negative predictive value of 93%, a positive predictive value of 77%, and test-retest and inter-observer reliability agreement rates of 95% and 100%, respectively. When T&C results were added to the physician's documentation of dementia, the number of missed cases decreased from 44% to 19%, and the number of overcalled cases decreased by 100%. When timed cut points were added, the T&C test had a sensitivity of 94 to 100%, specificity of 37 to 46%, negative predictive value of 98 to 100%, positive predictive value of 23 to 25%, and test-retest and inter-observer agreement rates of 82% and 70 to 75%, respectively. CONCLUSION: The T&C test is a simple, accurate, reliable, performance-based tool that can improve physician ability to recognize dementia in diverse outpatient populations.
Activities of Daily Living↗
A nonpharmacologic sleep protocol for hospitalized older patients.
OBJECTIVES: To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative-hypnotic drug (SHD) use. DESIGN: Prospective cohort study. SETTING: A 34-bed general medical unit in a university-affiliated teaching hospital. PARTICIPANTS: A total of 175 consecutive admissions aged 70 years or older. INTERVENTION: A nonpharmacologic sleep protocol consisting of a back rub, warm drink, and relaxation tapes was administered by nursing personnel to patients who complained of difficulty initiating sleep or who requested a SHD. After 1 hour, if the patient still requested it, the nurse administered the SHD. MEASUREMENTS: The main outcomes of sleep quality and SHD use were measured by patient interview and chart abstraction. Feasibility and adherence to the protocol were tracked daily by patient and nurse interviews and chart abstraction. RESULTS: A cohort of 111 patients, mean age 79.3 (+/- 6.4), 68% women, received the sleep protocol. Patients required the protocol for a mean of 4.9 days per patient, totalling 539 patients-days. The overall adherence rate was 400/539 (74%) patient-days. The rate of complete nonadherence was 139/539 (26%), with reasons for nonadherence including nurse nonadherence in 30 (6%), patient refusal in 104 (19%), and medical contraindications in five (1%). The quality of sleep correlated strongly with the number of parts of the protocol received, suggesting a dose-response relationship, with the highest correlation for receiving two to three parts (p = .64, P < 0.001). The sleep protocol was successful in reducing SHD use from the baseline preintervention rate of 51/94 (54%) to 34/111 (31%) (P < .002). The sleep protocol had a stronger association with quality of sleep (p = .75, P = .001) than did SHDs (p = .07, P = .45). However, chronic SHD users were more likely to refuse the protocol than nonusers (64% vs 41%, P < .03) and received SHDs 4.5 times more often than nonusers (67% vs 15%, P = .001). CONCLUSION: The nonpharmacologic sleep protocol provides a feasible, effective, and nontoxic alternative to SHDs to promote sleep in older hospitalized patients. Use of the protocol can substantially decrease use of SHDs.
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Delirium in hospitalized older patients: recognition and risk factors.
Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.
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Delirium in hospitalized older patients.
Delirium is a common, serious problem for hospitalized older patients. Recognition of delirium poses challenges requiring cognitive assessment and knowledge of the clinical course. Delirium often is of multiple causes and is associated with a poor long-term prognosis. Nonpharmacologic approaches for delirium management are recommended; pharmacologic management should be reserved for patients who pose a danger to themselves or others. Importantly, delirium and its complications may be preventable through a targeted risk factor approach.
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The informed consent process in older patients who developed delirium: a clinical epidemiologic study.
PURPOSE: Delirium, defined as an acute, fluctuating disorder of attention and cognition, is a serious and increasingly common problem for hospitalized older persons. Delirium poses unique ethical challenges for the informed consent process, notably the preservation of patient autonomy in the face of potentially fluctuating decision-making capacity. To clarify these issues, we examined the informed consent process in a group of hospitalized older patients who developed delirium. PATIENTS: Eighty-four hospitalized patients aged >70 years who developed delirium during hospitalization at a large urban teaching hospital. METHODS: We conducted a clinical epidemiologic investigation of informed consent in 173 medical and surgical procedures performed in 84 patients. Clinical researchers carried out detailed cognitive evaluation of patients on or near the consent date. A separate blinded researcher extracted medical record information on the procedures and informed consent process variables. RESULTS: Of 173 procedures, 33 (19%) had no documentation of any consent, and 34 (20%) used surrogate consent. There were no documented assessments of competency/ decisional capacity; cognitive assessments were done in 7 (4%) cases, and legal consults in 2 (1%) cases. Discussion of potential risks of the procedure with patient or surrogate were documented in 61 (35%) cases. In multivariable analysis, independent predictors for failure to obtain consent were presence of delirium (adjusted odds ratio [OR] = 2.7, 95% confidence interval [CI] 1.3, 5.3) and less invasive procedure (OR = 5.0, CI 2.0, 12.8). Although cognitive impairment predicted surrogate use, we found that 47% of cases with substantial impairment did not involve use of a surrogate, whereas surrogates signed for 4% of cases with normal mental status near the time of consent. CONCLUSIONS: Our results highlight the ethical challenges that delirium poses for the informed consent process, including the high rate of no consent, lack of cognitive and decisional capacity assessment, and inconsistent surrogate use.
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Functional outcomes of acute medical illness and hospitalization in older persons.
BACKGROUND: Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. METHODS: A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. RESULTS: At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. CONCLUSION: This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.
Activities of Daily Living↗