J Gerontol Nurs. 2024 Apr;50(4):34-41. doi: 10.3928/00989134-20240312-03. Epub 2024 Apr 1.
Older adults with Alzheimer's disease and related dementias (ADRD) are at high risk for acute medical problems and their health trajectories frequently include hospital admission and care in a skilled nursing facility (SNF). Their health trajectories after SNF discharge are poorly understood. Therefore, in the current study, we sought to describe health trajectories and factors associated with hospital read-missions for older adults with ADRD during the 30 days following SNF discharge.
We conducted a secondary analysis of data from a clinical trial of transitional care of older adults with transitions from SNF to home and assisted living. A multiple case study design was used in the analysis of the health trajectories of 49 SNF patients with ADRD, 51% discharged from SNF to their own home, 34% discharged to a family member's home, and 15% transferred to assisted living.
Within 30 days of discharge, 20% of patients with ADRD experienced new or recurrent acute needs and hospital readmission.
Our findings suggest the need for nursing interventions to support patients with ADRD during care transitions, such as focusing care on the patient-caregiver dyad, providing transitional care, referring patients for palliative care consultation, and conducting nurse-led research to improve care transitions of these patients and their caregivers. [(4), 34-41.].
患有阿尔茨海默病和相关痴呆症（ADRD）的老年人存在发生急性医疗问题的高风险，他们的健康轨迹通常包括住院和在熟练护理机构（SNF）接受护理。他们在离开 SNF 后的健康轨迹了解甚少。因此，在当前的研究中，我们旨在描述患有 ADRD 的老年人在离开 SNF 后的 30 天内的健康轨迹和与医院再入院相关的因素。
我们对一项针对从 SNF 过渡到家庭和辅助生活的老年人过渡的过渡护理的临床试验数据进行了二次分析。在对 49 名患有 ADRD 的 SNF 患者的健康轨迹进行分析时采用了多案例研究设计，其中 51%从 SNF 出院到自己的家中，34%出院到家庭成员的家中，15%转移到辅助生活。
在出院后的 30 天内，20%的 ADRD 患者出现新的或复发的急性需求和医院再入院。
我们的研究结果表明，需要对患有 ADRD 的患者进行护理干预，以支持他们在护理过渡期间的需求，例如关注患者-照顾者的双重关系，提供过渡护理，为姑息治疗咨询转介患者，并进行护士主导的研究，以改善这些患者及其照顾者的护理过渡。[（4），34-41]。
