Improving older patients’ journey to recovery in the community by tackling depressive symptoms and malnutrition

RESEARCH HIGHLIGHT

A GERI study finds that older adults can have a better chance at recovery at home after hospitalisation if these dietary and psychosocial needs are identified and addressed early on.

A first-of-its-kind study by researchers from the Geriatric Education and Research Institute (GERI) and Sengkang General Hospital (SKH) found that depressive symptoms and malnutrition – which are prevalent but modifiable health conditions amongst the elderly – were associated with an increased risk of 30-day hospital readmission amongst older patients.

Published in BMC Geriatrics, the findings from the GERI-funded study underscore the need to identify and address these dietary and psychosocial needs early on, so as to boost older adults’ chances of recovering well in their homes and communities after hospitalisation.

“Frail older patients often have multiple health conditions. As a result, models for predicting the risk of hospital readmission amongst this already high-risk group of older adults may not always perform well. We may then miss out on directing resources to patients who need them the most,” said Associate Professor Laura Tay, Joint Faculty, GERI and Head and Senior Consultant, Geriatric Medicine, SKH. Associate Professor Tay is the study’s Principal Investigator and lead author.

“Hence, it is important to drill down to specific conditions, such as depressive symptoms and malnutrition, and examine how they relate to readmission. In doing so, our study seeks to support broader efforts to improve screening programmes and devise more targeted interventions for vulnerable older patients,” Associate Professor Tay added.

Researchers recruited 1619 consecutive admissions of older adults aged 65 years and above who were admitted to SKH between October 2018 to January 2020. Patients were screened for depression, malnutrition and other geriatric syndromes such as delirium, cognitive impairment and frailty at admission. Patients were tracked for unplanned readmission within 30-days of discharge.

To depict the relationships between depressive symptoms, malnutrition, other geriatric syndromes and readmission, directed acyclic graphs (DAGs) were constructed. These graphs can be used to represent likely causal effects beyond mere associations. Using the DAGs, researchers adjusted for confounding variables to identify potentially modifiable causal effects when performing statistical analysis on the hospitalisation data.

“Hospital readmission amongst older adults often involves multiple contributing factors. For such complex situations, DAGs are useful visual aids that can illustrate pathways that incorporate specific risk factors. This is the first study to employ DAGs on this subject, as indicated by our review of the field,” said Associate Professor Ding Yew Yoong, Executive Director, GERI. Associate Professor Ding is a Co-Investigator of the study.

Researchers found that 22% of the older patients studied were readmitted within 30 days of discharge. Of this group, 26.1% were more likely to report depressive symptoms compared with 20.4% amongst those who were not readmitted. Malnutrition at admission was more prevalent among those readmitted, with 17.4% identified with this condition compared to 11.6% amongst those who were not readmitted.

“After further statistical analysis, we found that patients reporting depressive symptoms continued to have significantly increased risk for readmission compared to patients with neither depressive symptoms nor history of depression. This supports vigilance for active depressive symptoms beyond reliance on established historical diagnosis,” shared Associate Professor Tay. Malnutrition also continued to be associated with readmission, albeit not as significantly as depressive symptoms.

Patients with active depressive symptoms and malnutrition were also more likely to be frail, experience functional decline during their hospital stay and have cognitive impairment, amongst other geriatric syndromes.

“The findings remind us that diet and mental health have a considerable influence over older adults’ overall health outcomes after hospitalisation. To give our seniors a smoother journey to recovery at home, early intervention is key—starting from the hospital bed, ” said Associate Professor Ding.

"For example, hospitalised older patients identified to be malnourished could receive targeted dietary intervention. Timely mental health support and treatment could also be rendered to those who exhibit features of depression,” Associate Professor Ding elaborated.

In the long run, Associate Professor Tay pointed towards community care as a sustainable path forward to support older adults in recovery after hospitalisation.

“After discharge, partnerships amongst older patients, their caregivers, and community care and health providers come to the fore. Their proactive involvement is critical for the success of any care management plan,” shared Associate Professor Tay. “In this phase, community partners could provide valuable support by working closely with older adults and their caregivers, to address older adults’ health and social needs and follow up on care management.”

Building on GERI’s study, Associate Professor Ding suggested for future research to uncover additional causal factors beyond depressive symptoms and malnutrition, with the intention of incorporating them in future readmission risk prediction models to improve their performance and impact.

“Ultimately, we hope that GERI’s study galvanises further research and translation efforts, to address more comprehensively the issue of hospital readmission amongst older adults, to help them age healthily in the community,” said Associate Professor Ding.

The full study can be accessed here. 

Reference: Tay L., Chua M., Ding YY. "Depressive symptoms and malnutrition are associated with other geriatric syndromes and increase risk for 30-Day readmission in hospitalized older adults: a prospective cohort study." BMC Geriatrics 22, 634 (2022).