Association of clinical indicators of acute deterioration and morbidity and mortality in the residential aged care population: a retrospective cohort study of routinely collected health data (interRAI-LTCF New Zealand)

Association of clinical indicators of acute deterioration and morbidity and mortality in the residential aged care population: a retrospective cohort study of routinely collected health data (interRAI-LTCF New Zealand) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of clinical indicators of acute deterioration and morbidity and mortality in the residential aged care population: a retrospective cohort study of routinely collected health data (interRAI-LTCF New Zealand) Julie Daltrey, Michal Boyd, Vanessa Burholt, Heather McLeod, Zhenqiang Wu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3819019/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The timely identification of acute deterioration in people living in residential aged care is critical to avoiding or reducing rates of adverse events such as Emergency Department (ED) presentation or hospitalisation or death. This task is difficult as advanced age, multiple morbidity and frailty cause atypical or non-specific presentations of ill health. This study aimed to quantify the association between clinical indicators of acute deterioration reported in the literature and adverse events in his population. Method: A retrospective cohort study using routinely collected health data. The cohort (n=5238) were aged 65 years or older in their last year of life and had an interRAI-LTCF assessment completed (I January to 31 December 2015). InterRAI-LTCF variables were matched with clinical indicators of acute deterioration reported in the literature. Univariate and multivariate logistic regression tested the association between those variables and ED presentation, hospitalisation or death 7 days or less from last completed interRAI-LTCF assessment. Results: Nine clinical indicators, from four health domains were independently associated with acute deterioration. Cognitive indicators were being ‘largely asleep or unresponsive’odds ratio (OR) 7.95 95% CI 4.72-13.39, p<.001 and being ‘easily distracted; different to usual’ (OR 1.78 95% CI 1.28-2.49, p<.001). In the behavioural domain, eating ‘one or fewer meals a day’ (OR 2.13 95% CI 1.67-2.73, p<.001) and functional domain, a decline in activities of daily living status (OR 2.06 95% CI 1.11-3.82, p = .02) and not transferring to the toilet in the last three days (OR 1.95 95% CI 1.24-3.03, p = .004) were significant. Physical domain indicators were ‘dyspnoea; at rest’ (OR 1.81 5% CI 1.32-2.49, p<.001), ‘two or more falls in last 30 days’ (OR 1.53 95% CI 1.15-2.03, p = .003), daily peripheral oedema (OR 1.37 95 CI 1.07-1.77, p = .014) and daily pain (OR 1.37 95% CI 1.05-1.77, p = .019). Conclusion and implication: Clinical indicators of acute deterioration reported in the literature are significantly associated with adverse events. This evidence is a first step towards the future development of tools to support residential aged care staff with the identification of acute deterioration. Geriatrics & Gerontology clinical indicators acute deterioration residential aged care mortality and morbidity Figures Figure 1 BACKGROUND The accurate and timely identification of acute deterioration in people living in residential aged care (RAC) is critical to avoiding or reducing rates of adverse health events such as Emergency Department (ED) presentation or hospitalisation or death ( 1 – 4 ). Also, timely identification of anticipated dying allows for the establishment of appropriate end of life care ( 5 ). This task, however, is complex in people living with advanced age, multiple morbidity and frailty. RAC provide services for people assessed as having long-term high and complex health needs ( 6 ) related to advanced age physiological, psychosocial, cognitive and functional limitations ( 7 – 10 ). Furthermore, frailty affects a high proportion people living in RAC. A 2015 meta-analysis ( 7 ) reported a 52% pooled prevalence of frailty in RAC populations. While a 2021 systematic review ( 11 ) reported prevalence rates ranging from 15 to 80%, across 20 countries, measured with the frail-nursing home tool. Longitudinal studies ( 12 , 13 ) confirm that the rate of frailty in RAC populations has been steadily increasing over time. Frailty increases the vulnerability of older people to even relatively minor stressors ( 14 ). Their likelihood of experiencing disability or death is increased compared to those of the same age without frailty ( 6 , 15 , 16 ). Advanced age and frailty together mean that not only do this population have a higher risk of death than those without frailty but they are also more likely to have nonspecific clinical indicators (symptoms) of illness when they are acutely unwell ( 17 – 19 ). Nonspecific indicators of acute deterioration are those not easily attributable to a particular underlying condition. They are also known as ‘non-specific complaints’ ‘atypical’ symptoms, ‘general decline’ and ‘home care impossible’ in the literature ( 20 – 22 ). Older people with nonspecific indicators are some of the most vulnerable ED patients ( 23 ). They are triaged as less urgent than people with specific complaints, yet they have higher mortality rates, spend more time in ED and have more frequent hospital admissions with longer lengths of stay than their similarly aged counterparts ( 23 – 26 ). There is a growing sense of clinical concern about this group of older people. So much so, that there are calls for these presentations to be considered major emergencies ( 24 ) or red flag issues ( 27 ). Collectively, the indicators of acute deterioration described in ED-based research, closely resemble the definition of an acute deterioration in the RAC population namely; “a sudden, clinically important deviation from the persons baseline cognitive, behavioural, functional or physical domains ... that without intervention, may result in complications or death.”( 28 ) Specifically ED research names these indicators as, loss of consciousness, altered mental status, speech disorders, dizziness (cognitive domain), not eating and drinking (behavioural domain), functional decline, mobility changes and falls (functional domain) new urinary incontinence, weakness, fatigue, dyspnoea (physical domain) ( 17 , 20 , 26 , 29 ) These are consistent with RAC reports that clinical indicators of acute deterioration are unresponsiveness, altered mental status, behavior change, reduced food or fluid intake, functional decline, falls, continence changes, fatigue, dyspnoea, uncontrolled pain, nausea and vomiting and vital sign abnormalities ( 9 , 18 , 19 , 30 ). There is a body of evidence naming the clinical indicators of acute deterioration in older people and in RAC populations. However, there is less recent evidence describing the strength of the relationship between the indicators and the event of ED presentation, hospitalisation or death in older people living in RAC. Three RAC studies ( 31 – 33 ) conducted more than two decades ago reported mental status change, lethargy, change in mood and behavior, reduced food intake, functional loss, mobility dependence, falls, faecal incontinence, skin ulcers, weakness, dizziness and weight loss positively predicted hospitalisation. One recent study ( 34 ) reported a change in mental status, consciousness, behavior, function, dyspnoea, fever, pain, were associated with hospital transfer. Other recent RAC hospital transfer studies have split their analysis into subgroups of ‘potentially preventable’ versus ‘non preventable’ transfers, hospital admission versus ED only ( 34 – 38 ) or transfers categorised by diagnostic group ( 39 ). Due to the subgroup analysis, it is not possible to draw conclusions about the strength of the relationship between indicators and combined acute deterioration events (ED presentation, hospitalisation & death) from these studies. There is a need to understand the strength of the relationship between reported clinical indictors of acute deterioration and acute deterioration events in older people living in RAC. Quantifying this relationship is a first step towards developing tools to support RAC staff with the timely and accurate identification of acute deterioration in residents in these facilities. In this article we aim to confirm whether indicators of acute deterioration described in the literature are a) correlated with the event of ED presentation or hospitalisation or death in the Aotearoa New Zealand (NZ) RAC population and b) calculate the strength of that relationship using national routinely collected health data. METHODS Study design and data sources We used a retrospective cohort study design, analysing routinely collected health data from RAC facilities across all regions in Aotearoa NZ. This was secondary analysis of an existing database ( 40 ) that linked sixteen administrative health data sets for all deaths in the period of 1 January to 31 December 2015. The subset for this research used data from five sets: the National Minimum Dataset (hospital admissions), National Non-Admitted Patients Collection (ED admissions), Mortality Collection (deaths) and the International Resident Assessment Instrument-Long Term Care Facility (interRAI-LTCF) assessment. Variables for this study were drawn from interRAI-LTCF assessments. Informed consent for research use of interRAI-LTCF data is provided at first patient assessment. All data used in this study was de-identified at source and trace back to individuals was not possible. Ethical approval was provided by The University of Auckland Human Ethics Committee (024202). The interRAI-LTCF assessment contains complete data of routine standardised clinical assessment of people living in long term care settings ( 41 ). In Aotearoa NZ interRAI-LTCF assessments became mandated in 2015, they are required to be completed within 21 days of admission to RAC, routinely at 6-monthly intervals and in the event of a change in the need for a long-term level of care ( 42 ). InterRAI-LTCF assessments are conducted exclusively by trained health professionals who complete annual competency review to maintain interrater reliability ( 43 ). The REporting of studies Conducted using Observation Routinely-collected health Data (RECORD) statement was followed for this study ( 44 ). Study participants Our cohort included all people who died and had death registered in Aotearoa NZ from 1 January to 31 December 2015 (inclusive), who used RAC, were aged 65 years or older, and who had a completed interRAI-LTCF assessment in the last 12 months of life. Those making use of RAC without an interRAI-LTCF assessment, with an incomplete interRAI-LTCF assessment or younger than 65 years of age were excluded. Outcome To confirm from our data set whether clinical indicators of acute deterioration described in the literature were correlated with all available adverse event, we created a single variable; ED presentation or hospital admission or death occurring seven day or less from the date of the last completed interRAI-LTCF assessment. Based on the mandated RAC interRAI-LTCF (re)assessment schedule we reasoned that ED presentation or hospitalisation or death occurring within seven days of a completed interRAI-LTCF were acute or unanticipated deterioration events. Event dates were determined from the linked data. Independent variable selection interRAI-LTCF Independent variables for analysis (clinical indicators of acute deterioration) were selected by determining the closest match between the clinical indicator of acute deterioration reported in the literature ( 18 , 19 ) and the available interRAI-LTCF variable (Table 1 ). Two categories of literature were used for variable matching, reports of clinical indicators observed in RAC populations (Table 1 column 1) and components of deterioration detection tools used in RAC (Table 1 column 2) ( 18 , 19 ). Forty-six interRAI-LTCF variables (Table 1 column 3) were matched with clinical indicators reported in the literature. We were unable to find an exact interRAI-LTCF variable match for clinical indicator ‘change in level of consciousness.’ We selected variable ‘time asleep during the day’ because it has one outcome level ‘largely asleep or unresponsive’ that is indicative of a changed level of consciousness. As this study focuses on acute deterioration, we were interested in the most severe outcome level for each interRAI-LTCF variable. For example, ‘dyspnoea’ has four outcome levels ranging from ‘absent’ to the most severe ‘present at rest,’ in this example ‘present at rest’ was the outcome level of interest. There were no interRAI-LTCF variables that could be reasonably matched to the following clinical indicators of acute deterioration reported in the literature: seems different to usual, talks or communicates less, weakness, slowed movement and cough. Table 1 Matching clinical indicators of acute deterioration (literature) with interRAI-LTCF variables Observed indicators (literature)(18,19) Acute deterioration detection tool indicators (literature)(18,19) interRAI-LCTF variable: outcome level Cognitive Domain Unresponsive Drowsy or tired, Altered LOC Time asleep during the day: largely asleep or unresponsive Altered mental status Inattention Easily distracted: different to usual Confusion Disorientation Acute change in mental status: yes Change in decision making: declined Disorganised thinking Disorganised speech: different to usual Fluctuation Mental function varies over day: different to usual Difficulty following instruction Ability to understand others: rarely Depressed Mood Sad depressed or hopeless: daily Little interest or pleasure in things normally enjoyed: daily Behavioural Domain Decreased food / fluid Decreased appetite Ate less One or fewer meals a day: yes Decrease in food or fluid: yes Drank less, hydration Dehydrated: yes Fluid intake: reduced Aggression Aggression Resists care: daily Persistent anger with self / others: daily Physical abuse: daily Participated less in activity Withdrawal from activities of interest: daily Reduced social interaction: daily Restless Anxious Repetitive anxious complaints: daily Anxious restless or uneasy: daily Self-reported complaint Self-rated health: poor Seems different to usual No match available Agitated / nervous No match available Talks / communicates less No match available Functional Domain Functional decline More help dress / toilet / transfer Dressing upper body: dependent Personal hygiene: dependent Toilet transfer: did not occur Overall needs more help Change in ADL status: declined Reduced mobility Walking: did not occur Difficulty standing: daily Movement slowed No match available Physical Domain Constipation Diarrhoea Toilet / bowel habit Bowel not opened for 3 days or diarrhoea Constipation: daily Bowel continence: no bowel movement in 3 days Problem frequency: diarrhoea daily Fever Pyrexia Rigour Fever: daily Lethargy Tired Fatigue: cannot complete day-to-day activity Skin or wound changes Skin Change skin colour / condition Wound infection Pressure ulcer: not codeable Skin tear: yes Breathing difficulty Breathing Respiratory infection Dyspnoea: at rest Pain (uncontrolled) Pain (new or increased) Pain frequency: daily Pain: intensity: excruciating Pain: constant Break through pain: yes Dizziness Dizziness: daily Falls Falls Falls: 2 or more in 30 days Difficulty standing: daily Weight loss Weight change Weight loss: yes Leg pain/swelling Swollen leg / feet Peripheral oedema: daily New UI or symptoms Urinary symptoms Bladder continence: incontinent Urinary tract infection: active treatment Cough No match available Weak Weak, feeble No match available Abnormal vital signs No match available Abbreviations: UI: urinary incontinence BOLD : health domains Statistical Analysis Initial exploration of interRAI-LTCF variables was conducted using STATA SE version 13.1, from StataCorp and a summarised extract was provided for further analysis using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp. Armonk, NY, USA). Statistical analysis was used to describe the association between the independent variables (clinical indicators of acute deterioration from interRAI-LTCF) and acute deterioration events. Demographic information was assessed using descriptive statistics (Chi-Squared). Univariate logistic regression assessed the association between the adverse events and each interRAI-LTCF variable. A p value ≤ .05 was considered to indicate statistical significance and unadjusted odds ratios (OR) and their 95% confidence intervals (CI) identified the strength of that association. All interRAI-LTCF variables with a p value ≤ .05 and a 95% confidence interval for an OR that did not include one were entered into a multivariable forward stepwise logistic regression. The variables included in the regression model were assessed for multicollinearity using variance inflation factor. A two-sided p value ≤ .05 was considered statistically significant. Adjusted OR and their 95% CI were reported to consider the strength of association. RESULTS A total of 5,372 individuals were identified for this study, 134 were excluded from analysis because 107 were aged under 65 years and 27 had incomplete data. Final study cohort included 5,238 individuals aged 65 to 107 years (Fig. 1 ) of whom 62% (n = 3238) were female, mean (SD) age was 86.6 (7.4) years, and ages ranged from 65 to 107 years (Table 2 ). Most people (n = 4906, 94%) identified as NZ European and 4% (n = 185) identified as Māori. These proportions of gender, age, and ethnicity are consistent with current reported population distributions in RAC in Aotearoa NZ ( 45 ). Overall, 531 people (10% of the cohort) experienced an acute deterioration event (ED presentation or hospitalisation or death ≤ seven days from the completion of the last interRAI-LTCF assessment). There were no significant demographic differences between groups. Table 2 Cohort characteristics Rest of cohort n = 4707 (%) Acute deterioration* n = 531 (%) Female 2911 (61.8) 327 (61.6) Male 1796 (38.2) 204 (38.4) Age 65–69 106 (2.3) 18 (3.4) 70–74 233 (5) 33 (6.2) 75–79 440 (9) 51 (9.6) 80–84 832 (17.7) 98 (18.5) 85–89 1307 (27.8) 142 (26.7) 90–94 1179 (25) 137 (25.8) 95–104 604 (12.8) 52 (9.8) ≥ 105 6 (0.1) 0 (0) Ethnicity NZ European 4413 (93.8) 493 (92.8) Maori 160 (3.4) 25 (4.7) Asian 74 (1.6) 5 (0.9) Pacific 60 (1.3) 8 (1.5) *Emergency Department presentation or hospitalisation or death ≤ 7 days from last completed interRAI-LTCF assessment Univariate analysis Of the 46 interRAI-LTCF variables that were matched to the clinical indicators of acute deterioration reported in the literature, 40 had a statistically significant association with acute deterioration at the outcome level of interest. Table 3 presents these variables in cognitive, behavioural, functional and physical health domains that are consistent with the definition of acute deterioration in older people living in RAC. Odd ratios compare the 531 people who experienced acute deterioration with the rest of the cohort. Table 3 Univariate analysis: interRAI-LTCF variable association with ED presentation, hospitalisation or death ≤ 7 days from last completed interRAI-LTCF assessment (acute deterioration) InterRAI-LTCF variable: outcome level Acute deterioration n = 531 (%) Odds Ratio (95% CI), p Cognitive Domain Time asleep during the day: largely asleep/unresponsive 73 (13.7) 28.91 (18.34, 43.63), < 0.001 Easily distracted: different to usual 94 (17.7) 3.45 (2.65, 4.50), < 0.001 Acute mental status change: yes 171 (32.2) 3.30 (2.69, 4.03), < 0.001 Disorganised speech: different 86 (16.2) 3.04 (2.32, 3.97), < 0.001 Change in decision making: declined 294 (55.4) 2.79 (2.31, 3.36), < 0.001 Mental fluctuation: different to usual 98 (18.5) 2.36 (1.83, 3.05), < 0.001 Sad/depressed/hopeless: daily 52 (9.8) 1.76 (1.44, 2.14), < 0.001 Little interest/pleasure things usually enjoyed: daily 57 (10.7) 1.73 (1.42, 2.10), < 0.001 Understands others: rarely 58 (10.9) 1.72 (1.25, 2.38), 0.001 Behavioural Domain One or fewer meals per day: yes 183 (34.5) 4.53 (3.70, 5.59), < 0.001 Dehydrated: yes 62 (11.7) 4.48 (3.27, 6.14), < 0.001 Fluid Intake: reduced 158 (29.8) 3.35 (2.73, 4.12), < 0.001 Decrease in food/fluid: yes 244 (46) 3.15 (2.63, 3.79), < 0.001 Reduced social interaction: daily 152 (28.6) 2.16 (1.78, 2.66), < 0.001 Withdrawal from activity: daily 117 (22) 2.11 (1.68, 2.64), < 0.001 Resists care: daily 69 (13) 1.92 (1.45, 2.55), < 0.001 Anxious/restless/uneasy: daily 64 (12.1) 1.78 (1.45, 2.17), < 0.001 Functional Domain Transfer toilet: did not occur 95 (17.9) 5.09 (3.64, 7.11), < 0.001 Change ADL status: declined 393 (74) 4.17 (2.32, 7.50), < 0.001 Personal Hygiene: dependant 199 (37.5) 2.77 (1.88, 4.21), < 0.001 Walking: did not occur 221 (41.6) 2.57 (1.87, 3.53), < 0.001 Dress upper body: dependant 190 (35.8) 2.33 (1.55, 3.50), < 0.001 Difficulty standing: daily 314 (59.1) 1.51 (1.29, 1.85), < 0.001 Physical Domain Bowel: not open last 3 days 19 (3.6) 8.07 (4.34, 15.01), < 0.001 Fever: daily 4 (0.8) 6.19 (1.74, 22.00), 0.005 Fatigue: daily impact 137 (25.8) 4.74 (3.60, 6.23), < 0.001 Pressure ulcer: not codeable 10 (1.7) 3.16 (1.48, 6.77), 0.003 Dyspnoea: present at rest 87 (16.4) 2.84 (2.18, 3.70), < 0.001 Pain consistency: constant 52 (9.8) 2.77 (1.99, 3.86), < 0.001 Pain intensity: horrible 18 (3.4) 2.58 (1.52, 4.38), < 0.001 Constipation: daily 39 (7.3) 2.41 (1.66, 3.51), < 0.001 Pain frequency: daily 168 (31.6) 2.23 (1.78, 2.80), < 0.001 Dizzy: daily 35 (6.6) 2.13 (1.46, 3.12), < 0.001 Falls: ≥2 in last 30 days 108 (20.3) 2.05 (1.61, 2.62), < 0.001 Pain: breakthrough 110 (20.7) 1.88 (1.50, 2.36), < 0.001 Peripheral oedema: daily 126 (23.7) 1.81 (1.45, 2.25), < 0.001 Weight loss: yes 152 (28.6) 1.80 (1.47, 2.20), < 0.001 Bladder: incontinent 185 (34.8) 1.72 (1.29, 2.29), < 0.001 Urinary tract infection: active 43 (8.1) 1.67 (1.19, 2.35), 0.002 Skin tear: yes 90 (16.9) 1.32 (1.32, 1.68), 0.026 In the cognitive domain, level of consciousness and mental status variables had the greatest odds ratios. Indicator, ‘time asleep during the day: largely asleep or unresponsive’ (proxy for level of consciousness) had an OR of 28.91 ( 95% CI 18.34–43.63, p < .001). This was followed by being, ‘easily distracted: different to usual’ (OR 3.45, 95% CI 2.56–4.50, p < .001) having an ‘acute change in mental status’ (OR 3.30, 95% CI 2.69–4.03, p < .001) and a ‘mental fluctuation: different to usual’ (OR 2.36, 95% CI 1.83–3.05 p < .001). Eating and drinking variables predominated in the behavioural domain. Eating ‘one or fewer meals a day’ (OR 4.53, 95% CI 3.70–5.59, p < .001) having a ‘decrease in food or fluid intake’ (OR 3.15, 95% CI 2.63–3.79, p < .001) and being ‘dehydrated’ (OR 4.44, 95% CI 3.27–6.14, p < .001) were most highly correlated with acute deterioration. Functionally having a ‘decline in activities of daily living status (ADL)’ and ‘toilet transfer that did not occur’ in the three days preceding the assessment were the most notable, (OR 4.17, 95% CI 2.32–7.50, p < .001; OR 5.09, 95% CI 3.64–7.11, p < .001). Physically, having ‘fatigue: daily impact’ on routine activities (OR 4.74, 95% CI 3.60–6.23, p < .001 ) and experiencing ‘dyspnoea: at rest’ (OR 2.84, 95% CI 2.18–3.70, p < .001) were highly correlated with acute deterioration. Acute deterioration multivariable analysis The multivariable analysis (Table 4 ) produced a list of nine clinical indicators that had a statistically significant relationship with the acute deterioration variable. Multivariable regression assumptions were met and the maximum variance inflation factor was 1.32 (between change in ADL status & daily pain) suggesting overall multicollinearity was unlikely to be a confounding factor. There was at least one variable from each heath domain supporting the definition of acute deterioration. The consciousness variable ‘time asleep during the day: largely asleep or unresponsive’ conferred an eight-fold increase in odds of acute deterioration (OR 7.95 95% CI 4.72–13.39, p < .001) and ‘easily distracted: different to usual’ (OR 1.78 95% CI 1.28–2.49, p < .001) continued to feature. The behavioural domain included only eating ‘one or fewer meals a day’ (OR 2.13 95% CI 1.67–2.73, p < .001). Functionally a ‘change in ADL status: declined’ (OR 2.06 95% CI 1.11–3.82, p = .02) and a ‘toilet transfer that did not occur’ in the three days preceding the interRAI-LTCF assessment (OR 1.95 95% CI 1.24–3.03, p = .004) doubled the odds of acute deterioration. While all the physical variables had lower ORs, that is ‘dyspnoea: at rest’ (OR 1.81 5% CI 1.32–2.49, p < .001) having ‘falls: two or more in the last 30 days’ (OR 1.53 95% CI 1.15–2.03, p = .003) or ‘peripheral oedema: daily’ (OR 1.37 95 CI 1.07–1.77, p = .014) and ‘pain frequency: daily’ (OR 1.37 95% CI 1.05–1.77, p = .019). Table 4 Multivariable analysis; clinical indicators independently associated with ED presentation or hospitalisation or death ≤ 7 days from last completed interRAI-LTCF assessment (acute deterioration) Variable (outcome level) Acute Deterioration cohort n = 531 (%) Odds Ratio (95% CI), p Cognitive domain Time asleep during the day: largely asleep/unresponsive 73 (13.7) 7.95 (4.72, 13.39), < 0.001 Easily distracted: different to usual 94 (17.7) 1.78 (1.28, 2.49), < 0.001 Behavioural domain One or fewer meals per day: yes 183 (34.5) 2.13 (1.67, 2.73), < 0.001 Functional domain Transfer toilet: did not occur 95 (17.9) 1.95 (1.24, 3.03), 0.004 Change ADL status: declined 393 (74) 2.06 (1.11, 3.82), 0.02 Physical domain Dyspnoea: present at rest 87 (16.4) 1.81 (1.32, 2.49), < 0.001 Falls: ≥2 last 30 days 108 (20.3) 1.53 (1.15, 2.03), 0.003 Peripheral oedema: daily 126 (23.7) 1.37 (1.07, 1.77), 0.014 Pain frequency: daily 168 (31.6) 1.37 (1.05, 1.77), 0.019 ED: Emergency Department Sensitivity analysis The odds ratio for ‘time asleep during the day: largely asleep or unresponsive’ was considerably higher than the other variables in both univariate and multivariate analysis. Removing this variable from the analysis and repeating analysis with those who died within 7 days of interRAI-LTCF assessment only did not substantially change our results. As a change in level of consciousness is a key clinical indicator reported in the literature and our interest was all acute deterioration this variable was retained in the final model. DISCUSSION Using routinely collected health data, this study confirmed that the clinical indicators of acute deterioration described in the literature were correlated with ED presentation or hospitalisation or death within seven days of the last completed interRAI-LTCF assessment, in the RAC population in Aotearoa NZ. We were also able to develop a short list of nine clinical indicators that were independently correlated with acute deterioration and estimate the strength of that relationship. The indicators included at least one from each of the health domains, aligning with the definition of acute deterioration in RAC populations ( 28 ). To the best of our knowledge this is the first study of its kind to draw on interRAI-LTCF data in this way. This novel use of the data has provided first step evidence for the future development of tools to support RAC staff with the identification of acute deterioration. Currently there are no validated acute deterioration detection tools in RAC ( 19 ) with which to compare our results. Using routinely collected health data from an internationally available data set (interRAI-LCFT) means our research could be replicated in other localities and validate our findings. This study confirmed the clinical importance of non-specific indicators of acute deterioration as described in both ED ( 17 , 20 , 26 , 29 ) and RAC ( 31 – 33 ) studies. The doubling of ORs for ED admission, hospitalisation or dying found in this study adds weight to the argument that non-specific indicators if acute deterioration on older people ( 17 , 20 , 26 , 29 ) should be considered red-flag presentations ( 24 , 27 ). Our study differed from ED based studies in the clinical indictors of weakness and fatigue. Our interRAI-LTCF database did not include weakness so no data was available and fatigue was eliminated by the multivariable analysis. Multivariable analysis eliminates variables with multicollinearity and it is possible that in a RAC cohort that a decline in ADL status is a consequence of fatigue. The acute deterioration variable in this study included death was well as hospital transfers and this likely explains why our ORs are higher than the ORs reported in the RAC studies ( 34 ). Including death in this study has added some information to the evidence describing the presentation of end-of-life in the population living with frailty ( 46 ). However, further study focusing exclusively on clinical indicators associated with dying for people living with frailty would be needed to draw robust conclusions. One advantage of the final model including only nine clinical indicators is that in time pressured health care environments, quick to assess shortlists are more likely to be translated into in day-to-day practice ( 47 ). That no special equipment is required to observe these clinical indicators makes them ideal for health care assistants (HCA) to assess during routine care ( 18 ). As HCA has the most clinical contact time this has the potential to maximize the use of the healthcare workforce and opportunities for detecting acute deterioration. Furthermore indicators of acute deterioration that can be ‘measured’ unobtrusively have the potential to be incorporated into clinical practice without disturbing the home-like ideology of RAC ( 48 ). limitations We used routinely collected health data (interRAI-LTCF) for this study a purpose for which it was not intended. Consequently, clinical indicators may be have been useful for the identification of acute deterioration such as vital signs and ‘weakness’ could not be assessed. This was a retrospective cross-sectional study, other than ‘decline in ADL status’ and ‘easily distracted; different to usual’ it is unknown whether these indicators represent a change in the person’s baseline heath status. The variables were drawn from interRAI-LTCF assessments completed in the last year of life for people who died during 2015. Mandated use of RAI-LTCF occurred in July 2015 and although a rolling implementation had been occurring in NZ, some data is missing. Further, not everyone in RAC is in their last year of life and the prevalence of frailty in this population has increased over time this limits generalisability. CONCLUSION With the exception of vital signs, we confirmed that the majority of clinical indicators of acute deterioration reported in the literature are correlated with ED presentation, hospitalisation, and death in the Aotearoa NZ RAC population. Furthermore, we found a short list of nine clinical indicators that were independently associated with those outcomes and increased the odds of occurrence by between 1.4 and 8 times. The observable nature of those clinical indicators means there is potential to use them in practice without disturbing the home-like experience of people living in RAC. This evidence is a first step towards the future development of tools to support residential aged care staff with the identification of acute deterioration. Abbreviations RAC residential aged care ED Emergency Department NZ New Zealand interRAI-LTCF International Resident Assessment Instrument; Long Term Care Facility RECORD The REporting of studies Conducted using Observation Routinely-collected health Data OR odds ratio CI confidence interval Declarations Ethics approval: Ethical approval was provided by The University of Auckland Human Ethics Committee (024202). This is a cohort study using national routinely collected health data. Individual informed consent from the competent individual or their Enduring Power of Attorney for personal care and welfare (legal representative) for the use of this de-identified health data in research is collected at the point of data collection in New Zealand. The de-identification of data used in this study was undertaken at source (before it was received by researchers) and trace back to individuals via the data was not possible. Consent for publication: not applicable Availability of data and materials: Data may be obtained from a third party and are not publicly available. Any data made available to other parties upon reasonable request would need ethics approval from the New Zealand Health and Disability Ethics Committees (https://ethics.health.govt.nz) and the prior consent of all the primary data sources, which for this project would include Te Whatu Ora (Ministry of Health) ( [email protected] ) and interRAI ( [email protected] ). Contact corresponding author for data requests related to this study. Competing interests: The authors declare that they have no competing interests. Funding sources: This research was funded by Ageing Well National Science Challenge, Ministry of Business, Innovation and Employment, New Zealand (project 3720418). The funder made no contribution to the study design, methodology, data collection, analysis or preparation of this article. Authors contributions: All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Authors specific contributions were, study concept and design. JD, MB. Acquisition of data and preliminary analysis, HM c L. Analysis and interpretation of data: ZW, HM c L, JD, MB, VB, KB. Drafting of the manuscript, JD and critical revision of the manuscript for important intellectual content and approval of final manuscript JD, MB, VB, ZW, HM c L, JR, KB. Acknowledgements: In addition to the above authors would like to acknowledge JA for assistance in the preparation and extraction of the data set References Andersson Å, Frank C, Willman AM, Sandman P-O, Hansebo G. Factors contributing to serious adverse events in nursing homes. J Clin Nurs. 2018 Jan;27(1–2):e354–62. Mowat R, Dewar J, Ram F. Learning from complaints to the Health and Disability Commission Office: A case study into indicators of deterioration in aged residential care organisations in New Zealand. Australas J Ageing. 2022 Oct 7; Wall R. Complaints to the Health and Disability Commissioner about Residential Aged Care Facilities: Analysis and Report 2010 - 2014 [Internet]. HDC; 2016 [cited 2020 Sep 10]. Available from: https://www.hdc.org.nz/news-resources/search-resources/articles/complaints-to-hdc-about-residential-aged-care-facilities-analysis-and-report-2010-2014/ Cain P, Alan J, Porock D. Emergency department transfers from residential aged care: what can we learn from secondary qualitative analysis of Australian Royal Commission data? BMJ Open. 2022 Sep 20;12(9):e063790. Allers K, Hoffmann F. Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia. Soc Psychiatry Psychiatr Epidemiol. 2018 Aug;53(8):833–9. Khadka J, Visvanathan R, Theou O, Moldovan M, Amare AT, Lang C, et al. Development and validation of a frailty index based on Australian Aged Care Assessment Program data. Med J Aust. 2020 Oct;213(7):321–6. Kojima G. Prevalence of Frailty in Nursing Homes: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2015 Nov 1;16(11):940–5. Matthews FE, Bennett H, Wittenberg R, Jagger C, Dening T, Brayne C, et al. Who Lives Where and Does It Matter? Changes in the Health Profiles of Older People Living in Long Term Care and the Community over Two Decades in a High Income Country. PLoS ONE. 2016 Sep 2;11(9):e0161705. Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing. 2014 Nov;43(6):759–66. Lang L, Clifford A, Wei L, Zhang D, Leung D, Augustine G, et al. Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. BMJ Open. 2017 Feb 3;7(2):e011146. Liau SJ, Lalic S, Visvanathan R, Dowd LA, Bell JS. The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes. J Nutr Health Aging. 2021;25(10):1205–16. Theou O, Sluggett JK, Bell JS, Lalic S, Cooper T, Robson L, et al. Frailty, hospitalization, and mortality in residential aged care. J Gerontol A Biol Sci Med Sci. 2018 Jul 9;73(8):1090–6. Boyd M, Broad JB, Kerse N, Foster S, von Randow M, Lay-Yee R, et al. Twenty-year trends in dependency in residential aged care in Auckland, New Zealand: a descriptive study. J Am Med Dir Assoc. 2011 Sep;12(7):535–40. Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013 Jun;14(6):392–7. Romero-Ortuno R, Wallis S, Biram R, Keevil V. Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study. Eur J Intern Med. 2016 Nov;35:24–34. Amblàs-Novellas J, Murray SA, Oller R, Torné A, Martori JC, Moine S, et al. Frailty degree and illness trajectories in older people towards the end-of-life: a prospective observational study. BMJ Open. 2021 Apr 21;11(4):e042645. Simon NR, Jauslin AS, Bingisser R, Nickel CH. Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients. Am J Emerg Med. 2022 Sep;59:111–7. Chambers S, Spooner A, Parker C, Jack L, Schnitker L, Beattie E, et al. Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review. J Nurs Scholarsh. 2022 Oct 20; Daltrey JF, Boyd ML, Burholt V, Robinson JA. Detecting acute deterioration in older adults living in residential aged care: A scoping review. J Am Med Dir Assoc. 2022 Jun 21; Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010 Sep;56(3):261–9. Limpawattana P, Phungoen P, Mitsungnern T, Laosuangkoon W, Tansangworn N. Atypical presentations of older adults at the emergency department and associated factors. Arch Gerontol Geriatr. 2016 Feb;62:97–102. Hofman MR, van den Hanenberg F, Sierevelt IN, Tulner CR. Elderly patients with an atypical presentation of illness in the emergency department. Neth J Med. 2017 Jul;75(6):241–6. Bingisser R, Nickel CH. The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition. Swiss Med Wkly. 2019 Oct 7;149:w20141. Kemp K, Mertanen R, Lääperi M, Niemi-Murola L, Lehtonen L, Castren M. Nonspecific complaints in the emergency department - a systematic review. Scand J Trauma Resusc Emerg Med. 2020 Jan 28;28(1):6. Karakoumis J, Nickel CH, Kirsch M, Rohacek M, Geigy N, Müller B, et al. Emergency Presentations With Nonspecific Complaints-the Burden of Morbidity and the Spectrum of Underlying Disease: Nonspecific Complaints and Underlying Disease. Medicine (Baltimore). 2015 Jul;94(26):e840. Wachelder JJH, Stassen PM, Hubens LPAM, Brouns SHA, Lambooij SLE, Dieleman JP, et al. Elderly emergency patients presenting with non-specific complaints: Characteristics and outcomes. PLoS ONE. 2017 Nov 30;12(11):e0188954. van Dam CS, Peters MJL, Hoogendijk EO, Nanayakkara PWB, Muller M, Trappenburg MC. Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes. Eur J Intern Med. 2023 Jun;112:86–92. American Medical Directors Association. Acute Change of Condition in the Long Term Care Setting; clinical practice guideline. 1st ed. America; 2003. Salvi F, Morichi V, Grilli A, Giorgi R, De Tommaso G, Dessì-Fulgheri P. The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med. 2007 Dec;2(4):292–301. Dwyer RA, Gabbe BJ, Tran T, Smith K, Lowthian JA. Predictors of transport to hospital after emergency ambulance call-out for older people living in residential aged care. Australas J Ageing. 2020 Dec;39(4):350–8. Boockvar KS, Lachs MS. Predictive value of nonspecific symptoms for acute illness in nursing home residents. J Am Geriatr Soc. 2003 Aug;51(8):1111–5. Boockvar K, Brodie HD, Lachs M. Nursing assistants detect behavior changes in nursing home residents that precede acute illness: development and validation of an illness warning instrument. J Am Geriatr Soc. 2000 Sep;48(9):1086–91. Alessi CA, Harker JO. A prospective study of acute illness in the nursing home. Aging (Milano). 1998 Dec;10(6):479–89. Ouslander JG, Engstrom G, Reyes B, Tappen R, Rojido C, Gray-Miceli D. Management of acute changes in condition in skilled nursing facilities. J Am Geriatr Soc. 2018 Nov 19;66(12):2259–66. Ouslander JG, Naharci I, Engstrom G, Shutes J, Wolf DG, Rojido M, et al. Hospital transfers of skilled nursing facility (SNF) patients within 48 hours and 30 days after SNF admission. J Am Med Dir Assoc. 2016 Sep 1;17(9):839–45. Aryal K, Mowbray F, Gruneir A, Griffith LE, Howard M, Jabbar A, et al. Nursing home resident admission characteristics and potentially preventable emergency department transfers. J Am Med Dir Assoc. 2022 Aug;23(8):1291–6. Aryal K, Mowbray FI, Strum RP, Dash D, Tanuseputro P, Heckman G, et al. Examining the “potentially preventable emergency department transfer” indicator among nursing home residents. J Am Med Dir Assoc. 2023 Jan;24(1):100-104.e2. Unroe KT, Caterino JM, Stump TE, Tu W, Carnahan JL, Vest JR, et al. Long-Stay Nursing Facility Resident Transfers: Who Gets Admitted to the Hospital? J Am Geriatr Soc. 2020 Sep;68(9):2082–9. Tu W, Li R, Stump TE, Fowler NR, Carnahan JL, Blackburn J, et al. Age-specific rates of hospital transfers in long-stay nursing home residents. Age Ageing. 2022 Jan 6;51(1). McLeod HD, Atkinson J. Technical Note on Trajectories of Care at the End of Life Research. Unpublished. 2019; Hirdes JP, Ljunggren G, Morris JN, Frijters DHM, Finne Soveri H, Gray L, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res. 2008 Dec 30;8:277. TAS Kahui tuitui tangata. Age-Related Residential Care Services Agreement. [cited 2020 Sep 9]; Available from: https://tas.health.nz/dhb-programmes-and-contracts/health-of-older-people-programme/aged-residential-care/ Vuorinen M. Registered Nurses’ experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for Long-Term Care Facilities in New Zealand in 2017. Journal of Research in Nursing. 2020 Mar;25(2):141–55. Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015 Oct 6;12(10):e1001885. InterRAI NZ. Annual Report 2018/19 [Internet]. TAS Kahui tuitui tangata; 2020 [cited 2020 Aug 8]. Available from: https://www.interrai.co.nz/search/?search=gender people in aged care Hall A, Boulton E, Kunonga P, Spiers G, Beyer F, Bower P, et al. Identifying older adults with frailty approaching end-of-life: A systematic review. Palliat Med. 2021 Dec;35(10):1832–43. Kabell Nissen S, Rueegg M, Carpenter CR, Kaeppeli T, Busch J-M, Fournaise A, et al. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc. 2022 Dec 13; Fleming A, Kydd A, Stewart S. Care homes: The developing ideology of a homelike place to live. Maturitas. 2017 May;99:92–7. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3819019","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264180491,"identity":"bffe82a6-a3ad-4cfe-b916-070242025833","order_by":0,"name":"Julie Daltrey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIie3RsWrDMBCA4TMCZzGdLwTiPoJMwE0gIa9yJpCpm6F0i8HQLnqBvoVCpm4GQ734ARRSSkohs6ci6FIJQuiiNGOh+gdxgz5O2AA+3x8sKIDD3k69whzV2Bx0ASF7Kaoswd+J6UiQLiSsYOsu029Dvv04oG4xvulR0Gl4nbsfFuZIlI/4bpn2hcLkWexZX8CBuUnEDaFM7igdQIeBVAQDgDo8Q0bakJXcNp+WzA1hX4ZEZ0hqtxBXkdmiMDMktFvQScrwbkxLSp7a23wiWlzI9v1hInjNXSR5LDeqm1J81TRrpV+mM9ksaqXva+cXS8rjcF39eKz9Wc7i01C4L/l8Pt8/7xsH8lqVHUfrxQAAAABJRU5ErkJggg==","orcid":"","institution":"The University of Auckland","correspondingAuthor":true,"prefix":"","firstName":"Julie","middleName":"","lastName":"Daltrey","suffix":""},{"id":264180511,"identity":"9a6bcb5b-219c-475c-9471-e2b28a2646a1","order_by":1,"name":"Michal Boyd","email":"","orcid":"https://orcid.org/0000-0002-8895-1251","institution":"The University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Michal","middleName":"","lastName":"Boyd","suffix":""},{"id":264180538,"identity":"aeff33f9-bf56-4a65-9fd2-4e0b97bdf8b9","order_by":2,"name":"Vanessa Burholt","email":"","orcid":"","institution":"The University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"","lastName":"Burholt","suffix":""},{"id":264180556,"identity":"2de2c5d7-858a-456b-a5da-0c3e05ca13f5","order_by":3,"name":"Heather McLeod","email":"","orcid":"https://orcid.org/0000-0002-6833-0079","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"McLeod","suffix":""},{"id":264180567,"identity":"50508da3-c604-4db3-9e41-4100f97cbc58","order_by":4,"name":"Zhenqiang Wu","email":"","orcid":"https://orcid.org/0000-0002-6712-8602","institution":"The University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Zhenqiang","middleName":"","lastName":"Wu","suffix":""},{"id":264180607,"identity":"301d16c0-3a56-442b-97f5-d5dc1e22e0b2","order_by":5,"name":"Katherine Bloomfield","email":"","orcid":"https://orcid.org/0000-0001-6679-1763","institution":"The University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Bloomfield","suffix":""},{"id":264180637,"identity":"0301ac32-0827-4149-b039-8702bffa200a","order_by":6,"name":"Jacqualine Robinson","email":"","orcid":"https://orcid.org/0000-0002-9678-2005","institution":"The University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Jacqualine","middleName":"","lastName":"Robinson","suffix":""}],"badges":[],"createdAt":"2023-12-29 01:42:18","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3819019/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3819019/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49060763,"identity":"efb745d5-0a55-4205-bc8f-a4ce82522679","added_by":"auto","created_at":"2024-01-02 14:08:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34916,"visible":true,"origin":"","legend":"\u003cp\u003eStudy participant flow chart. Selection of study cohort from existing data set\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3819019/v1/b0de31ffd96d30cb7100cb9f.png"},{"id":49061548,"identity":"cb736b51-c8bb-42da-8d4d-942f69210cfd","added_by":"auto","created_at":"2024-01-02 14:16:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":616445,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3819019/v1/4e7abd29-a46b-4b42-b2f1-0ad962aa8665.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAssociation of clinical indicators of acute deterioration and morbidity and mortality in the residential aged care population: a retrospective cohort study of routinely collected health data (interRAI-LTCF New Zealand)\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe accurate and timely identification of acute deterioration in people living in residential aged care (RAC) is critical to avoiding or reducing rates of adverse health events such as Emergency Department (ED) presentation or hospitalisation or death (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Also, timely identification of anticipated dying allows for the establishment of appropriate end of life care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This task, however, is complex in people living with advanced age, multiple morbidity and frailty.\u003c/p\u003e \u003cp\u003eRAC provide services for people assessed as having long-term high and complex health needs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) related to advanced age physiological, psychosocial, cognitive and functional limitations (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Furthermore, frailty affects a high proportion people living in RAC. A 2015 meta-analysis (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) reported a 52% pooled prevalence of frailty in RAC populations. While a 2021 systematic review (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) reported prevalence rates ranging from 15 to 80%, across 20 countries, measured with the frail-nursing home tool. Longitudinal studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) confirm that the rate of frailty in RAC populations has been steadily increasing over time.\u003c/p\u003e \u003cp\u003eFrailty increases the vulnerability of older people to even relatively minor stressors (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Their likelihood of experiencing disability or death is increased compared to those of the same age without frailty (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Advanced age and frailty together mean that not only do this population have a higher risk of death than those without frailty but they are also more likely to have nonspecific clinical indicators (symptoms) of illness when they are acutely unwell (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Nonspecific indicators of acute deterioration are those not easily attributable to a particular underlying condition. They are also known as \u0026lsquo;non-specific complaints\u0026rsquo; \u0026lsquo;atypical\u0026rsquo; symptoms, \u0026lsquo;general decline\u0026rsquo; and \u0026lsquo;home care impossible\u0026rsquo; in the literature (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Older people with nonspecific indicators are some of the most vulnerable ED patients (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). They are triaged as less urgent than people with specific complaints, yet they have higher mortality rates, spend more time in ED and have more frequent hospital admissions with longer lengths of stay than their similarly aged counterparts (\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). There is a growing sense of clinical concern about this group of older people. So much so, that there are calls for these presentations to be considered major emergencies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) or red flag issues (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCollectively, the indicators of acute deterioration described in ED-based research, closely resemble the definition of an acute deterioration in the RAC population namely; \u0026ldquo;a sudden, clinically important deviation from the persons baseline cognitive, behavioural, functional or physical domains ... that without intervention, may result in complications or death.\u0026rdquo;(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Specifically ED research names these indicators as, loss of consciousness, altered mental status, speech disorders, dizziness (cognitive domain), not eating and drinking (behavioural domain), functional decline, mobility changes and falls (functional domain) new urinary incontinence, weakness, fatigue, dyspnoea (physical domain) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) These are consistent with RAC reports that clinical indicators of acute deterioration are unresponsiveness, altered mental status, behavior change, reduced food or fluid intake, functional decline, falls, continence changes, fatigue, dyspnoea, uncontrolled pain, nausea and vomiting and vital sign abnormalities (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere is a body of evidence naming the clinical indicators of acute deterioration in older people and in RAC populations. However, there is less recent evidence describing the strength of the relationship between the indicators and the event of ED presentation, hospitalisation or death in older people living in RAC. Three RAC studies (\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) conducted more than two decades ago reported mental status change, lethargy, change in mood and behavior, reduced food intake, functional loss, mobility dependence, falls, faecal incontinence, skin ulcers, weakness, dizziness and weight loss positively predicted hospitalisation. One recent study (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) reported a change in mental status, consciousness, behavior, function, dyspnoea, fever, pain, were associated with hospital transfer. Other recent RAC hospital transfer studies have split their analysis into subgroups of \u0026lsquo;potentially preventable\u0026rsquo; versus \u0026lsquo;non preventable\u0026rsquo; transfers, hospital admission versus ED only (\u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) or transfers categorised by diagnostic group (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Due to the subgroup analysis, it is not possible to draw conclusions about the strength of the relationship between indicators and combined acute deterioration events (ED presentation, hospitalisation \u0026amp; death) from these studies.\u003c/p\u003e \u003cp\u003eThere is a need to understand the strength of the relationship between reported clinical indictors of acute deterioration and acute deterioration events in older people living in RAC. Quantifying this relationship is a first step towards developing tools to support RAC staff with the timely and accurate identification of acute deterioration in residents in these facilities.\u003c/p\u003e \u003cp\u003eIn this article we aim to confirm whether indicators of acute deterioration described in the literature are a) correlated with the event of ED presentation or hospitalisation or death in the Aotearoa New Zealand (NZ) RAC population and b) calculate the strength of that relationship using national routinely collected health data.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data sources\u003c/h2\u003e \u003cp\u003eWe used a retrospective cohort study design, analysing routinely collected health data from RAC facilities across all regions in Aotearoa NZ. This was secondary analysis of an existing database (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) that linked sixteen administrative health data sets for all deaths in the period of 1 January to 31 December 2015. The subset for this research used data from five sets: the National Minimum Dataset (hospital admissions), National Non-Admitted Patients Collection (ED admissions), Mortality Collection (deaths) and the International Resident Assessment Instrument-Long Term Care Facility (interRAI-LTCF) assessment. Variables for this study were drawn from interRAI-LTCF assessments. Informed consent for research use of interRAI-LTCF data is provided at first patient assessment. All data used in this study was de-identified at source and trace back to individuals was not possible. Ethical approval was provided by The University of Auckland Human Ethics Committee (024202).\u003c/p\u003e \u003cp\u003eThe interRAI-LTCF assessment contains complete data of routine standardised clinical assessment of people living in long term care settings (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). In Aotearoa NZ interRAI-LTCF assessments became mandated in 2015, they are required to be completed within 21 days of admission to RAC, routinely at 6-monthly intervals and in the event of a change in the need for a long-term level of care (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). InterRAI-LTCF assessments are conducted exclusively by trained health professionals who complete annual competency review to maintain interrater reliability (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The REporting of studies Conducted using Observation Routinely-collected health Data (RECORD) statement was followed for this study (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy participants\u003c/h2\u003e \u003cp\u003eOur cohort included all people who died and had death registered in Aotearoa NZ from 1 January to 31 December 2015 (inclusive), who used RAC, were aged 65 years or older, and who had a completed interRAI-LTCF assessment in the last 12 months of life. Those making use of RAC without an interRAI-LTCF assessment, with an incomplete interRAI-LTCF assessment or younger than 65 years of age were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcome\u003c/h2\u003e \u003cp\u003eTo confirm from our data set whether clinical indicators of acute deterioration described in the literature were correlated with all available adverse event, we created a single variable; ED presentation or hospital admission or death occurring seven day or less from the date of the last completed interRAI-LTCF assessment. Based on the mandated RAC interRAI-LTCF (re)assessment schedule we reasoned that ED presentation or hospitalisation or death occurring within seven days of a completed interRAI-LTCF were acute or unanticipated deterioration events. Event dates were determined from the linked data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIndependent variable selection interRAI-LTCF\u003c/h2\u003e \u003cp\u003eIndependent variables for analysis (clinical indicators of acute deterioration) were selected by determining the closest match between the clinical indicator of acute deterioration reported in the literature (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and the available interRAI-LTCF variable (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Two categories of literature were used for variable matching, reports of clinical indicators observed in RAC populations (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e column 1) and components of deterioration detection tools used in RAC (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e column 2) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Forty-six interRAI-LTCF variables (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e column 3) were matched with clinical indicators reported in the literature. We were unable to find an exact interRAI-LTCF variable match for clinical indicator \u0026lsquo;change in level of consciousness.\u0026rsquo; We selected variable \u0026lsquo;time asleep during the day\u0026rsquo; because it has one outcome level \u0026lsquo;largely asleep or unresponsive\u0026rsquo; that is indicative of a changed level of consciousness. As this study focuses on acute deterioration, we were interested in the most severe outcome level for each interRAI-LTCF variable. For example, \u0026lsquo;dyspnoea\u0026rsquo; has four outcome levels ranging from \u0026lsquo;absent\u0026rsquo; to the most severe \u0026lsquo;present at rest,\u0026rsquo; in this example \u0026lsquo;present at rest\u0026rsquo; was the outcome level of interest. There were no interRAI-LTCF variables that could be reasonably matched to the following clinical indicators of acute deterioration reported in the literature: seems different to usual, talks or communicates less, weakness, slowed movement and cough.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMatching clinical indicators of acute deterioration (literature) with interRAI-LTCF variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObserved indicators (literature)(18,19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcute deterioration detection tool indicators (literature)(18,19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003einterRAI-LCTF variable: outcome level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCognitive Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnresponsive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrowsy or tired, Altered LOC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime asleep during the day: largely asleep or unresponsive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAltered mental status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInattention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEasily distracted: different to usual\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eConfusion\u003c/p\u003e \u003cp\u003eDisorientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcute change in mental status: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChange in decision making: declined\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisorganised thinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisorganised speech: different to usual\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFluctuation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMental function varies over day: different to usual\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifficulty following instruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbility to understand others: rarely\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDepressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSad depressed or hopeless: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLittle interest or pleasure in things normally enjoyed: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBehavioural Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDecreased food / fluid Decreased appetite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAte less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOne or fewer meals a day: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDecrease in food or fluid: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDrank less, hydration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDehydrated: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFluid intake: reduced\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAggression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAggression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResists care: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePersistent anger with self / others: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysical abuse: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParticipated less in activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithdrawal from activities of interest: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReduced social interaction: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRestless Anxious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRepetitive anxious complaints: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxious restless or uneasy: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-reported complaint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-rated health: poor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeems different to usual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgitated / nervous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTalks / communicates less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFunctional Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eFunctional decline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMore help dress / toilet / transfer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDressing upper body: dependent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePersonal hygiene: dependent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eToilet transfer: did not occur\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall needs more help\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChange in ADL status: declined\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReduced mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWalking: did not occur\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDifficulty standing: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMovement slowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eConstipation Diarrhoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eToilet / bowel habit Bowel not opened for 3 days or diarrhoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConstipation: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBowel continence: no bowel movement in 3 days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProblem frequency: diarrhoea daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePyrexia Rigour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFever: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLethargy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFatigue: cannot complete day-to-day activity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSkin or wound changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSkin Change skin colour / condition Wound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePressure ulcer: not codeable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSkin tear: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreathing difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreathing Respiratory infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDyspnoea: at rest\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePain (uncontrolled)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePain (new or increased)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain frequency: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain: intensity: excruciating\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain: constant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBreak through pain: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDizziness: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFalls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFalls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFalls: 2 or more in 30 days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDifficulty standing: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeight loss: yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg pain/swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwollen leg / feet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeripheral oedema: daily\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNew UI or symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUrinary symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBladder continence: incontinent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrinary tract infection: active treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeak, feeble\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal vital signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo match available\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAbbreviations: UI: urinary incontinence \u003cb\u003eBOLD\u003c/b\u003e: health domains\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003e Initial exploration of interRAI-LTCF variables was conducted using STATA SE version 13.1, from StataCorp and a summarised extract was provided for further analysis using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp. Armonk, NY, USA). Statistical analysis was used to describe the association between the independent variables (clinical indicators of acute deterioration from interRAI-LTCF) and acute deterioration events. Demographic information was assessed using descriptive statistics (Chi-Squared). Univariate logistic regression assessed the association between the adverse events and each interRAI-LTCF variable. A p value\u0026thinsp;\u0026le;\u0026thinsp;.05 was considered to indicate statistical significance and unadjusted odds ratios (OR) and their 95% confidence intervals (CI) identified the strength of that association. All interRAI-LTCF variables with a p value\u0026thinsp;\u0026le;\u0026thinsp;.05 and a 95% confidence interval for an OR that did not include one were entered into a multivariable forward stepwise logistic regression. The variables included in the regression model were assessed for multicollinearity using variance inflation factor. A two-sided p value\u0026thinsp;\u0026le;\u0026thinsp;.05 was considered statistically significant. Adjusted OR and their 95% CI were reported to consider the strength of association.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 5,372 individuals were identified for this study, 134 were excluded from analysis because 107 were aged under 65 years and 27 had incomplete data. Final study cohort included 5,238 individuals aged 65 to 107 years (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) of whom 62% (n\u0026thinsp;=\u0026thinsp;3238) were female, mean (SD) age was 86.6 (7.4) years, and ages ranged from 65 to 107 years (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Most people (n\u0026thinsp;=\u0026thinsp;4906, 94%) identified as NZ European and 4% (n\u0026thinsp;=\u0026thinsp;185) identified as Māori. These proportions of gender, age, and ethnicity are consistent with current reported population distributions in RAC in Aotearoa NZ (\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e). Overall, 531 people (10% of the cohort) experienced an acute deterioration event (ED presentation or hospitalisation or death\u0026thinsp;\u0026le;\u0026thinsp;seven days from the completion of the last interRAI-LTCF assessment). There were no significant demographic differences between groups.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCohort characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRest of cohort n\u0026thinsp;=\u0026thinsp;4707 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAcute deterioration* n\u0026thinsp;=\u0026thinsp;531 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2911\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(61.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u0026ndash;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70\u0026ndash;74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75\u0026ndash;79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80\u0026ndash;84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85\u0026ndash;89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90\u0026ndash;94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95\u0026ndash;104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNZ European\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4413\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e493\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaori\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePacific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*Emergency Department presentation or hospitalisation or death\u0026thinsp;\u0026le;\u0026thinsp;7 days from last completed interRAI-LTCF assessment\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eUnivariate analysis\u003c/h2\u003e\n \u003cp\u003eOf the 46 interRAI-LTCF variables that were matched to the clinical indicators of acute deterioration reported in the literature, 40 had a statistically significant association with acute deterioration at the outcome level of interest. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents these variables in cognitive, behavioural, functional and physical health domains that are consistent with the definition of acute deterioration in older people living in RAC. Odd ratios compare the 531 people who experienced acute deterioration with the rest of the cohort.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate analysis: interRAI-LTCF variable association with ED presentation, hospitalisation or death\u0026thinsp;\u0026le;\u0026thinsp;7 days from last completed interRAI-LTCF assessment (acute deterioration)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInterRAI-LTCF variable: outcome level\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAcute deterioration n\u0026thinsp;=\u0026thinsp;531 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds Ratio (95% CI), p\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime asleep during the day: largely asleep/unresponsive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.91 (18.34, 43.63), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEasily distracted: different to usual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.45 (2.65, 4.50), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute mental status change: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e171 (32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.30 (2.69, 4.03), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDisorganised speech: different\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.04 (2.32, 3.97), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChange in decision making: declined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e294 (55.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.79 (2.31, 3.36), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMental fluctuation: different to usual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.36 (1.83, 3.05), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSad/depressed/hopeless: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.76 (1.44, 2.14), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLittle interest/pleasure things usually enjoyed: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.73 (1.42, 2.10), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderstands others: rarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.72 (1.25, 2.38), 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioural Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne or fewer meals per day: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.53 (3.70, 5.59), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDehydrated: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.48 (3.27, 6.14), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFluid Intake: reduced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.35 (2.73, 4.12), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecrease in food/fluid: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e244 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.15 (2.63, 3.79), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced social interaction: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.16 (1.78, 2.66), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWithdrawal from activity: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.11 (1.68, 2.64), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResists care: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.92 (1.45, 2.55), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxious/restless/uneasy: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.78 (1.45, 2.17), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransfer toilet: did not occur\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.09 (3.64, 7.11), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChange ADL status: declined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e393 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.17 (2.32, 7.50), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersonal Hygiene: dependant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e199 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.77 (1.88, 4.21), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWalking: did not occur\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e221 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.57 (1.87, 3.53), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDress upper body: dependant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e190 (35.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.33 (1.55, 3.50), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifficulty standing: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e314 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.51 (1.29, 1.85), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBowel: not open last 3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.07 (4.34, 15.01), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFever: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.19 (1.74, 22.00), 0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue: daily impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e137 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.74 (3.60, 6.23), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePressure ulcer: not codeable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.16 (1.48, 6.77), 0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDyspnoea: present at rest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.84 (2.18, 3.70), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain consistency: constant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.77 (1.99, 3.86), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain intensity: horrible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.58 (1.52, 4.38), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConstipation: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.41 (1.66, 3.51), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain frequency: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e168 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.23 (1.78, 2.80), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDizzy: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.13 (1.46, 3.12), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalls: \u0026ge;2 in last 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.05 (1.61, 2.62), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain: breakthrough\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110 (20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.88 (1.50, 2.36), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeripheral oedema: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e126 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.81 (1.45, 2.25), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight loss: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.80 (1.47, 2.20), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBladder: incontinent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e185 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.72 (1.29, 2.29), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary tract infection: active\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.67 (1.19, 2.35), 0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin tear: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32 (1.32, 1.68), 0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eIn the cognitive domain, level of consciousness and mental status variables had the greatest odds ratios. Indicator, \u0026lsquo;time asleep during the day: largely asleep or unresponsive\u0026rsquo; (proxy for level of consciousness) had an OR of 28.91 ( 95% CI 18.34\u0026ndash;43.63, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). This was followed by being, \u0026lsquo;easily distracted: different to usual\u0026rsquo; (OR 3.45, 95% CI 2.56\u0026ndash;4.50, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) having an \u0026lsquo;acute change in mental status\u0026rsquo; (OR 3.30, 95% CI 2.69\u0026ndash;4.03, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and a \u0026lsquo;mental fluctuation: different to usual\u0026rsquo; (OR 2.36, 95% CI 1.83\u0026ndash;3.05 p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003cp\u003eEating and drinking variables predominated in the behavioural domain. Eating \u0026lsquo;one or fewer meals a day\u0026rsquo; (OR 4.53, 95% CI 3.70\u0026ndash;5.59, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) having a \u0026lsquo;decrease in food or fluid intake\u0026rsquo; (OR 3.15, 95% CI 2.63\u0026ndash;3.79, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and being \u0026lsquo;dehydrated\u0026rsquo; (OR 4.44, 95% CI 3.27\u0026ndash;6.14, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) were most highly correlated with acute deterioration.\u003c/p\u003e\n \u003cp\u003eFunctionally having a \u0026lsquo;decline in activities of daily living status (ADL)\u0026rsquo; and \u0026lsquo;toilet transfer that did not occur\u0026rsquo; in the three days preceding the assessment were the most notable, (OR 4.17, 95% CI 2.32\u0026ndash;7.50, p\u0026thinsp;\u0026lt;\u0026thinsp;.001; OR 5.09, 95% CI 3.64\u0026ndash;7.11, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Physically, having \u0026lsquo;fatigue: daily impact\u0026rsquo; on routine activities (OR 4.74, 95% CI 3.60\u0026ndash;6.23, p\u0026thinsp;\u0026lt;\u0026thinsp;.001 ) and experiencing \u0026lsquo;dyspnoea: at rest\u0026rsquo; (OR 2.84, 95% CI 2.18\u0026ndash;3.70, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) were highly correlated with acute deterioration.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eAcute deterioration multivariable analysis\u003c/h2\u003e\n \u003cp\u003eThe multivariable analysis (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) produced a list of nine clinical indicators that had a statistically significant relationship with the acute deterioration variable. Multivariable regression assumptions were met and the maximum variance inflation factor was 1.32 (between change in ADL status \u0026amp; daily pain) suggesting overall multicollinearity was unlikely to be a confounding factor. There was at least one variable from each heath domain supporting the definition of acute deterioration. The consciousness variable \u0026lsquo;time asleep during the day: largely asleep or unresponsive\u0026rsquo; conferred an eight-fold increase in odds of acute deterioration (OR 7.95 95% CI 4.72\u0026ndash;13.39, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and \u0026lsquo;easily distracted: different to usual\u0026rsquo; (OR 1.78 95% CI 1.28\u0026ndash;2.49, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) continued to feature. The behavioural domain included only eating \u0026lsquo;one or fewer meals a day\u0026rsquo; (OR 2.13 95% CI 1.67\u0026ndash;2.73, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Functionally a \u0026lsquo;change in ADL status: declined\u0026rsquo; (OR 2.06 95% CI 1.11\u0026ndash;3.82, p\u0026thinsp;=\u0026thinsp;.02) and a \u0026lsquo;toilet transfer that did not occur\u0026rsquo; in the three days preceding the interRAI-LTCF assessment (OR 1.95 95% CI 1.24\u0026ndash;3.03, p\u0026thinsp;=\u0026thinsp;.004) doubled the odds of acute deterioration. While all the physical variables had lower ORs, that is \u0026lsquo;dyspnoea: at rest\u0026rsquo; (OR 1.81 5% CI 1.32\u0026ndash;2.49, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) having \u0026lsquo;falls: two or more in the last 30 days\u0026rsquo; (OR 1.53 95% CI 1.15\u0026ndash;2.03, p\u0026thinsp;=\u0026thinsp;.003) or \u0026lsquo;peripheral oedema: daily\u0026rsquo; (OR 1.37 95 CI 1.07\u0026ndash;1.77, p\u0026thinsp;=\u0026thinsp;.014) and \u0026lsquo;pain frequency: daily\u0026rsquo; (OR 1.37 95% CI 1.05\u0026ndash;1.77, p\u0026thinsp;=\u0026thinsp;.019).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultivariable analysis; clinical indicators independently associated with ED presentation or hospitalisation or death\u0026thinsp;\u0026le;\u0026thinsp;7 days from last completed interRAI-LTCF assessment (acute deterioration)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable (outcome level)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAcute Deterioration cohort n\u0026thinsp;=\u0026thinsp;531 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds Ratio (95% CI), p\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime asleep during the day: largely asleep/unresponsive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.95 (4.72, 13.39), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEasily distracted: different to usual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.78 (1.28, 2.49), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioural domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne or fewer meals per day: yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.13 (1.67, 2.73), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransfer toilet: did not occur\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.95 (1.24, 3.03), 0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChange ADL status: declined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e393 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.06 (1.11, 3.82), 0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDyspnoea: present at rest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.81 (1.32, 2.49), \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalls: \u0026ge;2 last 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.53 (1.15, 2.03), 0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeripheral oedema: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e126 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.37 (1.07, 1.77), 0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain frequency: daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e168 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.37 (1.05, 1.77), 0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eED: Emergency Department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSensitivity analysis\u003c/h2\u003e\n \u003cp\u003eThe odds ratio for \u0026lsquo;time asleep during the day: largely asleep or unresponsive\u0026rsquo; was considerably higher than the other variables in both univariate and multivariate analysis. Removing this variable from the analysis and repeating analysis with those who died within 7 days of interRAI-LTCF assessment only did not substantially change our results. As a change in level of consciousness is a key clinical indicator reported in the literature and our interest was all acute deterioration this variable was retained in the final model.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eUsing routinely collected health data, this study confirmed that the clinical indicators of acute deterioration described in the literature were correlated with ED presentation or hospitalisation or death within seven days of the last completed interRAI-LTCF assessment, in the RAC population in Aotearoa NZ. We were also able to develop a short list of nine clinical indicators that were independently correlated with acute deterioration and estimate the strength of that relationship. The indicators included at least one from each of the health domains, aligning with the definition of acute deterioration in RAC populations (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). To the best of our knowledge this is the first study of its kind to draw on interRAI-LTCF data in this way. This novel use of the data has provided first step evidence for the future development of tools to support RAC staff with the identification of acute deterioration. Currently there are no validated acute deterioration detection tools in RAC (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) with which to compare our results. Using routinely collected health data from an internationally available data set (interRAI-LCFT) means our research could be replicated in other localities and validate our findings.\u003c/p\u003e \u003cp\u003eThis study confirmed the clinical importance of non-specific indicators of acute deterioration as described in both ED (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and RAC (\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) studies. The doubling of ORs for ED admission, hospitalisation or dying found in this study adds weight to the argument that non-specific indicators if acute deterioration on older people (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) should be considered red-flag presentations (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Our study differed from ED based studies in the clinical indictors of weakness and fatigue. Our interRAI-LTCF database did not include weakness so no data was available and fatigue was eliminated by the multivariable analysis. Multivariable analysis eliminates variables with multicollinearity and it is possible that in a RAC cohort that a decline in ADL status is a consequence of fatigue. The acute deterioration variable in this study included death was well as hospital transfers and this likely explains why our ORs are higher than the ORs reported in the RAC studies (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Including death in this study has added some information to the evidence describing the presentation of end-of-life in the population living with frailty (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). However, further study focusing exclusively on clinical indicators associated with dying for people living with frailty would be needed to draw robust conclusions.\u003c/p\u003e \u003cp\u003eOne advantage of the final model including only nine clinical indicators is that in time pressured health care environments, quick to assess shortlists are more likely to be translated into in day-to-day practice (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). That no special equipment is required to observe these clinical indicators makes them ideal for health care assistants (HCA) to assess during routine care (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). As HCA has the most clinical contact time this has the potential to maximize the use of the healthcare workforce and opportunities for detecting acute deterioration. Furthermore indicators of acute deterioration that can be \u0026lsquo;measured\u0026rsquo; unobtrusively have the potential to be incorporated into clinical practice without disturbing the home-like ideology of RAC (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003elimitations\u003c/h2\u003e \u003cp\u003eWe used routinely collected health data (interRAI-LTCF) for this study a purpose for which it was not intended. Consequently, clinical indicators may be have been useful for the identification of acute deterioration such as vital signs and \u0026lsquo;weakness\u0026rsquo; could not be assessed. This was a retrospective cross-sectional study, other than \u0026lsquo;decline in ADL status\u0026rsquo; and \u0026lsquo;easily distracted; different to usual\u0026rsquo; it is unknown whether these indicators represent a change in the person\u0026rsquo;s baseline heath status. The variables were drawn from interRAI-LTCF assessments completed in the last year of life for people who died during 2015. Mandated use of RAI-LTCF occurred in July 2015 and although a rolling implementation had been occurring in NZ, some data is missing. Further, not everyone in RAC is in their last year of life and the prevalence of frailty in this population has increased over time this limits generalisability.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWith the exception of vital signs, we confirmed that the majority of clinical indicators of acute deterioration reported in the literature are correlated with ED presentation, hospitalisation, and death in the Aotearoa NZ RAC population. Furthermore, we found a short list of nine clinical indicators that were independently associated with those outcomes and increased the odds of occurrence by between 1.4 and 8 times. The observable nature of those clinical indicators means there is potential to use them in practice without disturbing the home-like experience of people living in RAC. This evidence is a first step towards the future development of tools to support residential aged care staff with the identification of acute deterioration.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eresidential aged care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNZ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNew Zealand\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003einterRAI-LTCF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Resident Assessment Instrument; Long Term Care Facility\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRECORD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe REporting of studies Conducted using Observation Routinely-collected health Data\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eodds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval: \u003c/strong\u003eEthical approval was provided by The University of Auckland Human Ethics Committee (024202). This is a cohort study using national routinely collected health data. Individual informed consent from the competent individual or their Enduring Power of Attorney for personal care and welfare (legal representative) for the use of this de-identified health data in research is collected at the point of data collection in New Zealand. The de-identification of data used in this study was undertaken at source (before it was received by researchers) and trace back to individuals via the data was not possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials: \u003c/strong\u003e\u003cstrong\u003eData may be obtained from a third party and are not publicly available. \u003c/strong\u003eAny data made available to other parties upon reasonable request would need ethics approval from the New Zealand Health and Disability Ethics Committees (https://ethics.health.govt.nz) and the prior consent of all the primary data sources, which for this project would include Te Whatu Ora (Ministry of Health) ([email protected]) and interRAI ([email protected]). Contact corresponding author for data requests related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources: \u003c/strong\u003eThis research was funded by Ageing Well National Science Challenge, Ministry of Business, Innovation and Employment, New Zealand (project 3720418). The funder made no contribution to the study design, methodology, data collection, analysis or preparation of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions:\u003c/strong\u003e All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Authors specific contributions were, study concept and design. JD, MB. Acquisition of data and preliminary analysis, HM\u003csup\u003ec\u003c/sup\u003eL. Analysis and interpretation of data: ZW, HM\u003csup\u003ec\u003c/sup\u003eL, JD, MB, VB, KB. Drafting of the manuscript, JD and critical revision of the manuscript for important intellectual content and approval of final manuscript JD, MB, VB, ZW, HM\u003csup\u003ec\u003c/sup\u003eL, JR, KB. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e In addition to the above authors would like to acknowledge JA for assistance in the preparation and extraction of the data set\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndersson \u0026Aring;, Frank C, Willman AM, Sandman P-O, Hansebo G. Factors contributing to serious adverse events in nursing homes. J Clin Nurs. 2018 Jan;27(1\u0026ndash;2):e354\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eMowat R, Dewar J, Ram F. Learning from complaints to the Health and Disability Commission Office: A case study into indicators of deterioration in aged residential care organisations in New Zealand. Australas J Ageing. 2022 Oct 7;\u003c/li\u003e\n\u003cli\u003eWall R. Complaints to the Health and Disability Commissioner about Residential Aged Care Facilities: Analysis and Report 2010 - 2014 [Internet]. HDC; 2016 [cited 2020 Sep 10]. Available from: https://www.hdc.org.nz/news-resources/search-resources/articles/complaints-to-hdc-about-residential-aged-care-facilities-analysis-and-report-2010-2014/\u003c/li\u003e\n\u003cli\u003eCain P, Alan J, Porock D. Emergency department transfers from residential aged care: what can we learn from secondary qualitative analysis of Australian Royal Commission data? BMJ Open. 2022 Sep 20;12(9):e063790.\u003c/li\u003e\n\u003cli\u003eAllers K, Hoffmann F. Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia. Soc Psychiatry Psychiatr Epidemiol. 2018 Aug;53(8):833\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKhadka J, Visvanathan R, Theou O, Moldovan M, Amare AT, Lang C, et al. Development and validation of a frailty index based on Australian Aged Care Assessment Program data. Med J Aust. 2020 Oct;213(7):321\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eKojima G. Prevalence of Frailty in Nursing Homes: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2015 Nov 1;16(11):940\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eMatthews FE, Bennett H, Wittenberg R, Jagger C, Dening T, Brayne C, et al. Who Lives Where and Does It Matter? Changes in the Health Profiles of Older People Living in Long Term Care and the Community over Two Decades in a High Income Country. PLoS ONE. 2016 Sep 2;11(9):e0161705.\u003c/li\u003e\n\u003cli\u003eDwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing. 2014 Nov;43(6):759\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eLang L, Clifford A, Wei L, Zhang D, Leung D, Augustine G, et al. Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. BMJ Open. 2017 Feb 3;7(2):e011146.\u003c/li\u003e\n\u003cli\u003eLiau SJ, Lalic S, Visvanathan R, Dowd LA, Bell JS. The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes. J Nutr Health Aging. 2021;25(10):1205\u0026ndash;16.\u003c/li\u003e\n\u003cli\u003eTheou O, Sluggett JK, Bell JS, Lalic S, Cooper T, Robson L, et al. Frailty, hospitalization, and mortality in residential aged care. J Gerontol A Biol Sci Med Sci. 2018 Jul 9;73(8):1090\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBoyd M, Broad JB, Kerse N, Foster S, von Randow M, Lay-Yee R, et al. Twenty-year trends in dependency in residential aged care in Auckland, New Zealand: a descriptive study. J Am Med Dir Assoc. 2011 Sep;12(7):535\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eMorley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013 Jun;14(6):392\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eRomero-Ortuno R, Wallis S, Biram R, Keevil V. Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study. Eur J Intern Med. 2016 Nov;35:24\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eAmbl\u0026agrave;s-Novellas J, Murray SA, Oller R, Torn\u0026eacute; A, Martori JC, Moine S, et al. Frailty degree and illness trajectories in older people towards the end-of-life: a prospective observational study. BMJ Open. 2021 Apr 21;11(4):e042645.\u003c/li\u003e\n\u003cli\u003eSimon NR, Jauslin AS, Bingisser R, Nickel CH. Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients. Am J Emerg Med. 2022 Sep;59:111\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eChambers S, Spooner A, Parker C, Jack L, Schnitker L, Beattie E, et al. Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review. J Nurs Scholarsh. 2022 Oct 20;\u003c/li\u003e\n\u003cli\u003eDaltrey JF, Boyd ML, Burholt V, Robinson JA. Detecting acute deterioration in older adults living in residential aged care: A scoping review. J Am Med Dir Assoc. 2022 Jun 21;\u003c/li\u003e\n\u003cli\u003eSamaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010 Sep;56(3):261\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLimpawattana P, Phungoen P, Mitsungnern T, Laosuangkoon W, Tansangworn N. Atypical presentations of older adults at the emergency department and associated factors. Arch Gerontol Geriatr. 2016 Feb;62:97\u0026ndash;102.\u003c/li\u003e\n\u003cli\u003eHofman MR, van den Hanenberg F, Sierevelt IN, Tulner CR. Elderly patients with an atypical presentation of illness in the emergency department. Neth J Med. 2017 Jul;75(6):241\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBingisser R, Nickel CH. The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition. Swiss Med Wkly. 2019 Oct 7;149:w20141.\u003c/li\u003e\n\u003cli\u003eKemp K, Mertanen R, L\u0026auml;\u0026auml;peri M, Niemi-Murola L, Lehtonen L, Castren M. Nonspecific complaints in the emergency department - a systematic review. Scand J Trauma Resusc Emerg Med. 2020 Jan 28;28(1):6.\u003c/li\u003e\n\u003cli\u003eKarakoumis J, Nickel CH, Kirsch M, Rohacek M, Geigy N, M\u0026uuml;ller B, et al. Emergency Presentations With Nonspecific Complaints-the Burden of Morbidity and the Spectrum of Underlying Disease: Nonspecific Complaints and Underlying Disease. Medicine (Baltimore). 2015 Jul;94(26):e840.\u003c/li\u003e\n\u003cli\u003eWachelder JJH, Stassen PM, Hubens LPAM, Brouns SHA, Lambooij SLE, Dieleman JP, et al. Elderly emergency patients presenting with non-specific complaints: Characteristics and outcomes. PLoS ONE. 2017 Nov 30;12(11):e0188954.\u003c/li\u003e\n\u003cli\u003evan Dam CS, Peters MJL, Hoogendijk EO, Nanayakkara PWB, Muller M, Trappenburg MC. Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes. Eur J Intern Med. 2023 Jun;112:86\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eAmerican Medical Directors Association. Acute Change of Condition in the Long Term Care Setting; clinical practice guideline. 1st ed. America; 2003.\u003c/li\u003e\n\u003cli\u003eSalvi F, Morichi V, Grilli A, Giorgi R, De Tommaso G, Dess\u0026igrave;-Fulgheri P. The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med. 2007 Dec;2(4):292\u0026ndash;301.\u003c/li\u003e\n\u003cli\u003eDwyer RA, Gabbe BJ, Tran T, Smith K, Lowthian JA. Predictors of transport to hospital after emergency ambulance call-out for older people living in residential aged care. Australas J Ageing. 2020 Dec;39(4):350\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eBoockvar KS, Lachs MS. Predictive value of nonspecific symptoms for acute illness in nursing home residents. J Am Geriatr Soc. 2003 Aug;51(8):1111\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBoockvar K, Brodie HD, Lachs M. Nursing assistants detect behavior changes in nursing home residents that precede acute illness: development and validation of an illness warning instrument. J Am Geriatr Soc. 2000 Sep;48(9):1086\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eAlessi CA, Harker JO. A prospective study of acute illness in the nursing home. Aging (Milano). 1998 Dec;10(6):479\u0026ndash;89.\u003c/li\u003e\n\u003cli\u003eOuslander JG, Engstrom G, Reyes B, Tappen R, Rojido C, Gray-Miceli D. Management of acute changes in condition in skilled nursing facilities. J Am Geriatr Soc. 2018 Nov 19;66(12):2259\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eOuslander JG, Naharci I, Engstrom G, Shutes J, Wolf DG, Rojido M, et al. Hospital transfers of skilled nursing facility (SNF) patients within 48 hours and 30 days after SNF admission. J Am Med Dir Assoc. 2016 Sep 1;17(9):839\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eAryal K, Mowbray F, Gruneir A, Griffith LE, Howard M, Jabbar A, et al. Nursing home resident admission characteristics and potentially preventable emergency department transfers. J Am Med Dir Assoc. 2022 Aug;23(8):1291\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eAryal K, Mowbray FI, Strum RP, Dash D, Tanuseputro P, Heckman G, et al. Examining the \u0026ldquo;potentially preventable emergency department transfer\u0026rdquo; indicator among nursing home residents. J Am Med Dir Assoc. 2023 Jan;24(1):100-104.e2.\u003c/li\u003e\n\u003cli\u003eUnroe KT, Caterino JM, Stump TE, Tu W, Carnahan JL, Vest JR, et al. Long-Stay Nursing Facility Resident Transfers: Who Gets Admitted to the Hospital? J Am Geriatr Soc. 2020 Sep;68(9):2082\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eTu W, Li R, Stump TE, Fowler NR, Carnahan JL, Blackburn J, et al. Age-specific rates of hospital transfers in long-stay nursing home residents. Age Ageing. 2022 Jan 6;51(1).\u003c/li\u003e\n\u003cli\u003eMcLeod HD, Atkinson J. Technical Note on Trajectories of Care at the End of Life Research. Unpublished. 2019;\u003c/li\u003e\n\u003cli\u003eHirdes JP, Ljunggren G, Morris JN, Frijters DHM, Finne Soveri H, Gray L, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res. 2008 Dec 30;8:277.\u003c/li\u003e\n\u003cli\u003eTAS Kahui tuitui tangata. Age-Related Residential Care Services Agreement. [cited 2020 Sep 9]; Available from: https://tas.health.nz/dhb-programmes-and-contracts/health-of-older-people-programme/aged-residential-care/\u003c/li\u003e\n\u003cli\u003eVuorinen M. Registered Nurses\u0026rsquo; experiences with, and feelings and attitudes towards, the International Resident Assessment Instrument for Long-Term Care Facilities in New Zealand in 2017. Journal of Research in Nursing. 2020 Mar;25(2):141\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eBenchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015 Oct 6;12(10):e1001885.\u003c/li\u003e\n\u003cli\u003eInterRAI NZ. Annual Report 2018/19 [Internet]. TAS Kahui tuitui tangata; 2020 [cited 2020 Aug 8]. Available from: https://www.interrai.co.nz/search/?search=gender people in aged care\u003c/li\u003e\n\u003cli\u003eHall A, Boulton E, Kunonga P, Spiers G, Beyer F, Bower P, et al. Identifying older adults with frailty approaching end-of-life: A systematic review. Palliat Med. 2021 Dec;35(10):1832\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eKabell Nissen S, Rueegg M, Carpenter CR, Kaeppeli T, Busch J-M, Fournaise A, et al. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc. 2022 Dec 13;\u003c/li\u003e\n\u003cli\u003eFleming A, Kydd A, Stewart S. Care homes: The developing ideology of a homelike place to live. Maturitas. 2017 May;99:92\u0026ndash;7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"The University of Auckland","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"clinical indicators, acute deterioration, residential aged care, mortality and morbidity","lastPublishedDoi":"10.21203/rs.3.rs-3819019/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3819019/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe timely identification of acute deterioration in people living in residential aged care is critical to avoiding or reducing rates of adverse events such as Emergency Department (ED) presentation or hospitalisation or death. This task is difficult as advanced age, multiple morbidity and frailty cause atypical or non-specific presentations of ill health. This study aimed to quantify the association between clinical indicators of acute deterioration reported in the literature and adverse events in his population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eA retrospective cohort study using routinely collected health data. The cohort (n=5238) were aged 65 years or older in their last year of life and had an interRAI-LTCF assessment completed (I January to 31 December 2015). \u0026nbsp;InterRAI-LTCF variables were matched with clinical indicators of acute deterioration reported in the literature. Univariate and multivariate logistic regression tested the association between those variables and ED presentation, hospitalisation or death 7 days or less from last completed interRAI-LTCF assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNine clinical indicators, from four health domains were independently associated with acute deterioration. Cognitive indicators were being ‘largely asleep or unresponsive’odds ratio (OR) 7.95 95% CI 4.72-13.39, p\u0026lt;.001 and being ‘easily distracted; different to usual’ (OR 1.78 95% CI 1.28-2.49, p\u0026lt;.001). In the behavioural domain, eating ‘one or fewer meals a day’ (OR 2.13 95% CI 1.67-2.73, p\u0026lt;.001) and functional domain, a decline in activities of daily living status (OR 2.06 95% CI 1.11-3.82, p = .02) and not transferring to the toilet in the last three days (OR 1.95 95% CI 1.24-3.03, p = .004) were significant. Physical domain indicators were ‘dyspnoea; at rest’ (OR 1.81 5% CI 1.32-2.49, p\u0026lt;.001), ‘two or more falls in last 30 days’ (OR 1.53 95% CI 1.15-2.03, p = .003), daily peripheral oedema (OR 1.37 95 CI 1.07-1.77, p = .014) and daily pain (OR 1.37 95% CI 1.05-1.77, p = .019).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion and implication:\u003c/strong\u003e Clinical indicators of acute deterioration reported in the literature are significantly associated with adverse events. This evidence is a first step towards the future development of tools to support residential aged care staff with the identification of acute deterioration.\u003c/p\u003e","manuscriptTitle":"Association of clinical indicators of acute deterioration and morbidity and mortality in the residential aged care population: a retrospective cohort study of routinely collected health data (interRAI-LTCF New Zealand)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-02 14:07:56","doi":"10.21203/rs.3.rs-3819019/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc196762-2647-459f-b896-8de6f8aef952","owner":[],"postedDate":"January 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":27852830,"name":"Geriatrics \u0026 Gerontology"}],"tags":[],"updatedAt":"2024-01-02T14:07:56+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-02 14:07:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3819019","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3819019","identity":"rs-3819019","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}