Geriatric Day Research Articles

Geriatrie in Bayern-Datenbank (GiB-DAT)

In the year 2000, a database was implemented in Bavaria, covering the majority of geriatric clinics. Benchmarking statistics are generated in quarterly periods and scientifically analyzed. Actually, 41 of the 57 geriatric clinics in Bavaria participate in the project 'Geriatrics in Bavaria-Database' (GiB-DAT). For geriatric rehabilitation, the coverage is 82.4%. In addition, all 7 geriatric day clinics participate; thus, a total of 24,000 cases are documented each year. Therefore, GiB-DAT is the largest database for geriatric rehabilitation in Germany and Europe. To make documentation more effective and easy, new software (GERIDOCTM) has been generated which is integrated in the process of daily treatment. GiB-DAT offers good data quality, especially concerning completeness of items. This manuscript describes conception and construction of GiB-DAT and identifies differences compared to the Geriatric Minimum-Dataset (GEMIDAS), a nationwide geriatric database in Germany.

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556

Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care.The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottingham's Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting.SitesGeneral practices across Nottinghamshire and Derbyshire.Day hospitals:Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service (Nottingham City Hospital Trust)Leengate Day Hospital (Queen's Medical Centre Nottingham University Hospital NHS Trust)

Evaluation of Pharmacotherapy in Geriatric Patients after Performing Complete Geriatric Assessment at a??Diagnostic Day Clinic

Elderly patients often take multiple drugs. It is known that polypharmacy, i.e. use of five or more drugs, may lead to drug interactions and adverse events. However, undertreatment of conditions or illnesses is also a concern in geriatric patients. A centralised review of both diagnoses and medication may play a key role in optimising pharmacotherapy in geriatric patients. The aims of this study were to evaluate the quality and appropriateness of medication after performing a complete geriatric assessment (CGA) and medication review at a diagnostic geriatric day clinic, to investigate reasons for drug changes, and to determine whether medication review leads to a reduction in the number of drugs used. A chart review was performed in 702 patients (mean age 82.0 years, range 57.1-104.1 years) who underwent a CGA at a diagnostic geriatric day clinic. Medication at admission, changes in medication and reasons for changes were noted. Vitamins, for example folic acid and vitamin B(12) (cyanocobalamin), and trimethoprim for urinary tract infections were the most frequently started medications after CGA and medication review. The number of drugs used was reduced in only a minority of patients (11.7%); reasons for discontinuation were a diagnosis that was no longer relevant (38.8%), adverse events (33.2%) and identification of better pharmacotherapeutic options (22.0%). In 69.2% of the cases a new diagnosis was the reason for starting a new medication, followed by osteoporosis prophylaxis (15.0%) and improvement in pharmacotherapy (10.6%). At admission, patients were taking a mean number of 4.6 drugs (range 0-17). A mean of 0.8 drugs (range from reduction of 5 to addition of 7) had been added per patient, resulting in a mean number of 5.4 (range 0-18) prescribed drugs at discharge. Evaluation of medication in patients after performing CGA at the geriatric day clinic investigated resulted in relevant medication changes. The main reason for prescribing new drugs was a new diagnosis. Absence of a relevant medical indication was the main reason for stopping drugs. CGA and medication review resulted in a mean net addition of 0.8 drugs per patient.

Unmeasured aspects of the geriatric day hospital!

Unmeasured aspects of the geriatric day hospital!

Assessing the potential for functional improvement of stroke patients attending a geriatric day hospital

In the present study the potential for functional improvement in 103 stroke patients attending a geriatric day hospital was evaluated using the Orpington Prognostic Scale (OPS). This information may assist in coordinating the patients’ and caregivers’ expectations, allocating resources efficiently, and advance care planning. The Spearman correlation was used to calculate the association between OPS score and Functional Independent Measure (FIM), the Nottingham Extended ADL Index (NEAI), and the timed Get Up and Go test (TUG). The studied population was divided into two groups: patients with mild neurological impairment (OPS score < 3.2) and those with moderate to severe neurological impairment (OPS score ≥ 3.2) and their performance on the above outcome measure were compared. The OPS score significantly correlated ( p < 0.001) with discharge scores of FIM ( r = −0.730), NEAI ( r = −0.675), and TUG ( r = 0.448). Patients with OPS score <3.2 achieved significantly higher discharge scores ( p < 0.001) in all three measures (FIM, TUG, and NEAI) compared to patients with OPS score ≥3.2. Nevertheless, patients with moderate to severe neurological impairment achieved greater score changes in FIM and TUG than patients with mild neurological impairment, although their discharge scores were less favorable. These results indicate that stroke patients even the more impaired, may continually recover and should be exposed to a prolonged rehabilitation program.

B‐Type Natriuretic Peptide Is Associated with Mortality in Older Functionally Impaired Patients

To determine the predictive power of B-type natriuretic peptide (BNP) regarding death in older, functionally impaired patients with multiple comorbidity. Prospective cohort study. Specialist geriatric assessment clinic and day hospital. Two hundred ninety-nine older, functionally impaired patients, mean age 79 at enrollment. Full clinical history and examination, baseline BNP, and echocardiography. Date and cause of death were ascertained from Scottish death records. Kaplan-Meier survival curves were constructed for quartiles of log (BNP), and the contribution of BNP to prediction of death was investigated. The follow-up period ranged from 3.9 to 5.2 years (mean 4.4 years). BNP was a powerful independent predictor of all-cause and cardiovascular mortality. BNP was a more powerful predictor than blood pressure, diabetes mellitus, smoking, echocardiographic left ventricular hypertrophy, left ventricular systolic dysfunction, or age. BNP predicted death in those with and without a previous cardiovascular event at baseline. BNP has significant predictive power for death in older, functionally impaired patients.

The geriatric day hospital

The geriatric day hospital

Validation of a New Lower-Extremity Motor Coordination Test

Desrosiers J, Rochette A, Corriveau H. Validation of a new lower-extremity motor coordination test. Objective To determine the test-retest reliability and construct validity of a new lower-extremity motor coordination test, the Lower Extremity MOtor COordination Test (LEMOCOT). Design To test reliability, subjects with impairments in at least 1 lower extremity were evaluated twice by the same evaluator. To test construct validity, the LEMOCOT scores obtained from subjects who had had a stroke were correlated with physical, functional, cognitive, and perceptual tests. Setting Geriatric day hospital and functional intensive rehabilitation unit. Participants In the reliability test, 29 people (mean age, 69.6y; range, 28–87y); in the construct validity, 144 people who recently had had a stroke. Intervention Not applicable. Main outcome measures In addition to the LEMOCOT, the following measures were used for construct validity: the Fugl-Meyer Assessment (motor function), Berg Balance Scale, 5-m walking test, 2-minute walking test, Functional Autonomy Measurement System, Modified Mini-Mental State Examination, and Motor-Free Visual Perceptual Test. Results Intraclass correlation coefficients (ICCs) indicated that test-retest reliability is good (right-side ICC=.88; left-side ICC=.83). The construct validity of the LEMOCOT was demonstrated by obtaining high correlations with physical and functional tests ( r range, .62–.79; P<.001) and no correlations with cognitive ( r=.11, P=.20) or visual perceptual tests ( r=.15, P=.08) and by discriminating between subjects discharged to long-term care versus other living environments ( P<.001). Conclusions The LEMOCOT is a simple lower-extremity motor coordination test that showed good test-retest reliability and construct validity. It can be used in clinical and research settings, specifically with people who have had a stroke. Other studies should be carried out to confirm its psychometric properties.

Patient Outcomes after Discharge from a Geriatric Day Hospital

Evidence suggests that frailer older patients benefit from a continuum of care rather than the admit/discharge model of our health system. This study examined patient outcomes after discharge from a geriatric day hospital (GDH) to determine what proportion continues to do well, what proportion declines, how the two groups differ, and if factors predictive of deterioration can be identified. Using telephone survey and Goal Attainment Scaling methodologies, the goals of 151 patients discharged from a GDH between 6 and 18 months previously were examined to determine whether GDH achievements were maintained or lost. All but 5 patients improved between GDH admission and discharge; after discharge, 39 per cent deteriorated. The need for more support in the community was predictive of deterioration, probably reflecting patient frailty. Number of medical diagnoses or medications were not predictive. Frailer older patients tend not to maintain goals achieved in a GDH after discharge and may benefit from ongoing maintenance.

A retrospective analysis of the sentence writing component of Folstein's MMSE.

Agraphia is the loss or impairment of the ability to produce written language as a consequence of brain damage and is a well recognised feature of dementia. However there is no generally accepted classification of agraphic disorders. Our aim was to determine the influence of writing style, lettercase and sentence polarity of the writing component of Folstein's MMSE on the overall test score. We retrospectively reviewed the 'write a sentence' request of Folstein's MMSE of 280 randomly selected patients attending a geriatric day hospital. We analysed four sentence characteristics: 1 Number of words, 2 Writing legibility, 3 Sentence polarity, 4 Letter case. 280 MMSE forms were examined, 165 were from female patients. Mean age was 81.7(± 6.6) years. Mean MMSE score was 21.6 (males: 21.9, females: 21.4). Significant correlation was detected between the overall MMSE score and both legibility and number of words. Legibility scores were significantly higher for females than for males (7.2 vs. 6.6, p < 0.03). The mean MMSE of females writing in lowercase was significantly higher than for those writing in uppercase (21.5 vs. 18.6, p < 0.05). The mean MMSE score of subjects writing sentences with a positive tone was significantly higher than that of those writing a neutral or negative sentence (22.6 vs. 21.0 p < 0.03). We have demonstrated a relationship between the content and structure of the writing assessment aspect of the MMSE and the overall test score.

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

Objective To evaluate an occupational therapy intervention to improve outdoor mobility after stroke.Design Randomised controlled trial.Setting General practice registers, social services departments, a primary care rehabilitation service, and a geriatric...

Characteristics of patients who made gains at a geriatric day hospital

The charts of patients who attended a geriatric day hospital (DH) over a 16-month period were reviewed retrospectively ( n = 112). Home visits were conducted on consenting patients who made gains (either functional, psychosocial or medical) according to the chart review; they (and/or their caregivers) were questioned about what gains were made at the DH and whether these gains were still present. Initial gains ( n = 77, or 69%) were gains identified by chart review, and confirmed by patients at the home visit (when a home visit was possible). Patients who had home visits performed ( n = 58) were further classified as to if they had persistent gains or not. Measurements of mood, function, cognition, mobility, balance, and medications were also collected. Patients were defined as having had persistent gains if they relayed gains were still present and, when a gain was measurable (e.g., mobility), there had to be objective evidence of persistent improvement. Backwards elimination modeling using logistic regression analyses was conducted to look for characteristics of patients who made initial gains and had persistent gains. In gender-adjusted analyses, people with cardiac conditions ( p = 0.006) or depression ( p = 0.047) were most likely to make initial gains whereas those with dementia were less likely to make initial gains ( p = 0.005). There were no statistically significant associations ( p < 0.05) found between any of the variables examined and the likelihood of having persistent gains. This study suggests that certain types of patients may be more likely to benefit, at least initially, from a DH program.

Outcome predictors of pneumonia in elderly patients: importance of functional assessment.

To evaluate the outcome of elderly patients with community-acquired pneumonia (CAP) seen at an acute-care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty. Prospective observational study. Emergency department and geriatric medical day hospital of a university teaching hospital. Ninety-nine patients aged 65 and older seen for CAP over a 6-month recruitment period. Clinical data were used to calculate Pneumonia Severity Index (PSI), Barthel Index (BI), Charlson Comorbidity Index, and Hospital Admission Risk Profile (HARP). Patients were then assessed 15 days later to determine functional decline and 30 days and 18 months later for mortality and readmission. Multiple logistic regression was used to analyze outcomes. Functional decline was observed in 23% of the 93 survivors. Within the 30-day period, case-fatality rate was 6% and readmission rate 11%; 18-month rates were 24% and 59%, respectively. Higher BI was a protective factor for 30-day and 18-month mortality (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.94-0.98 and OR=0.97, 95% CI=0.95-0.99, respectively; P<.01), and PSI was the only predictor for functional decline (OR=1.03, 95% CI=1.01-1.05; P=.01). Indices did not predict readmission. Analyses were repeated for the 74 inpatients and indicated similar results except for 18-month mortality, which HARP predicted (OR=1.73; 95% CI=1.16-2.57; P<.01). Functional status was an independent predictor for short- and long-term mortality in hospitalized patients whereas CAP severity predicted functional decline. Severity indices for CAP should possibly thus be adjusted in the elderly population, taking functional status assessment into account.

Exploring the links between depression, integrity, and hope in the elderly.

To explore the links between depression, integrity, and hope in the elderly. For this pilot study, we recruited a voluntary sample of cognitively intact elderly patients receiving psychiatric care (n = 35). Recruitment sources included an inpatient geriatric psychiatry unit (n = 14), a geriatric psychiatry day program (n = 6), and an outpatient geriatric psychiatry service (n = 15). Participants completed a questionnaire designed to measure depression, acording to the Geriatric Depression Scale Short Form (GDSSF); integrity, according to the Sense of Coherence Scale-Short Form (SOC-13); and hope, according to the Hope Differential-Short (HDS) and the Hope Numerical Rating Scale (Hope-NRS). The HDS consists of 3 separate subscales: Personal Spirit, Risk, and Authentic Caring. We analyzed the data, using descriptive statistics, t tests, and Pearson correlations. Patients with no depression (n = 17) showed a greater sense of coherence (SOC) (P < 0.01), higher levels of hope (Hope-NRS, P < 0.05), enhanced Personal Spirit (HDS subscale, P < 0.05), and greater risk taking (HDS subscale, P < 0.01) than did patients with depression (n = 18). The 2 variables that correlated most highly with depression were SOC (r = -0.65, P < 0.01) and Risk (HDS subscale, r = -0.62, P < 0.01). These findings suggest that depression, integrity, and hope are highly interrelated in the elderly population and may influence mastery of the developmental tasks of aging. Further research is warranted to better understand these complex experiences in late life.

Is a day hospital rehabilitation programme associated with reduction of handicap in stroke patients?

(1) To assess whether a rehabilitation day hospital programme is associated with a reduced handicap level of stroke patients. (2) To estimate the relationship between the London Handicap Scale (LHS) and other outcome measures. (3) To examine the effect of demographic parameters (age, gender, family status, education) on LHS scores. A prospective longitudinal survey. An urban geriatric rehabilitation day hospital. Two hundred and seven elderly stroke patients admitted between December 1999 and February 2001. London Handicap Scale (LHS), Functional Independent Measure (FIM), Nottingham Extended ADL Index, timed get up and go test. LHS scores at discharge changed significantly (p < 0.008) for mobility, physical independence and occupation. The overall change in LHS score was 2.3 points (20%); effect size 0.43. A significant relationship was found between discharge score of LHS and admission score of FIM, Nottingham Index, timed get up and go and age. Multiple linear regressions did not identify a good predictor for the discharge score of LHS. Higher education was associated with higher LHS scores on admission (p = 0.016) but with less success in correcting handicap (p = 0.046). A day hospital programme is associated with reduced level of handicap in stroke patients. The LHS is a useful and simple scale for measuring change in these patients. LHS in stroke patients correlates with other outcome measures, yet they cannot be used interchangeably. A significant relationship between education and level of handicap exists.

Holocaust Experience and Suicidal Ideation in High-Risk Older Adults

Objective Depression is an identified risk factor for suicidal ideation, a precursor for more serious suicidal behaviors. This risk might be further compounded in individuals who experience negative life events, including traumatic experiences, and those who might have comorbid illnesses. The authors examined the impact of past exposure to the Nazi Holocaust on the development of suicidal ideation in a sample of depressed older adults. Methods Authors conducted a retrospective cross-sectional study. The study sample comprised data on 530 consecutive eligible first admissions of Jewish patients who were referred and admitted to a geriatric psychiatry day hospital program between September 1986 and December 2000. Results Multiple logistic-regression analyses, controlling for social support, history of suicide attempts, and other negative life events, showed that severity of depression and exposure to the Holocaust were independently associated with suicidal ideation. Those not showing suicidal ideation were slightly more likely to have reported having a confidant. Conclusions This is the first empirical study to demonstrate an increased likelihood for suicidal ideation in survivors of the Nazi Holocaust. The chronic stress produced by these traumatic events may have predisposed survivors to cope ineffectively as they age, thus resulting in suicidal ideation. Authors highlight the importance of a multifaceted approach when assessing suicidal behaviors in high-risk groups. Depression is an identified risk factor for suicidal ideation, a precursor for more serious suicidal behaviors. This risk might be further compounded in individuals who experience negative life events, including traumatic experiences, and those who might have comorbid illnesses. The authors examined the impact of past exposure to the Nazi Holocaust on the development of suicidal ideation in a sample of depressed older adults. Authors conducted a retrospective cross-sectional study. The study sample comprised data on 530 consecutive eligible first admissions of Jewish patients who were referred and admitted to a geriatric psychiatry day hospital program between September 1986 and December 2000. Multiple logistic-regression analyses, controlling for social support, history of suicide attempts, and other negative life events, showed that severity of depression and exposure to the Holocaust were independently associated with suicidal ideation. Those not showing suicidal ideation were slightly more likely to have reported having a confidant. This is the first empirical study to demonstrate an increased likelihood for suicidal ideation in survivors of the Nazi Holocaust. The chronic stress produced by these traumatic events may have predisposed survivors to cope ineffectively as they age, thus resulting in suicidal ideation. Authors highlight the importance of a multifaceted approach when assessing suicidal behaviors in high-risk groups.

Can functional status, after rehabilitation, independently predict long-term mortality of hip-fractured elderly patients?

Hip fractures are one of the most serious causes of functional impairment and death in the elderly. The aim of this study was to evaluate prospectively the predictive value of functional performance, after rehabilitation, of hip fracture on long-term mortality in community-dwelling patients. One hundred and seventy-one patients aged 60 years and over, admitted to a geriatric rehabilitation day unit after inpatient rehabilitation, were followed for up to 4 years. Main outcome measures were Functional Independent Measure (FIM), Timed Get Up and Go test (GUAG), cognitive status using the Mini-Mental State Examination on admission, and mortality during the follow-up period. Kaplan-Meier analysis was carried out on survival curves. All 24 deceased patients performed the GUAG test in > 20 seconds. Although approaching significance, the survival curves were not statistically different between patients performing the test in < or = 20 and those performing it in > 20 seconds (p = 0.08). Survival curves were significantly higher in patients with a FIM score of > or = 90 (p = 0.004), no cardio-cerebrovascular (CCV) diseases (p = 0.001) and no diabetes mellitus (p = 0.01). There were no differences in survival according to age, gender, educational level, marital status, surgical vs conservative treatment, and cognition. A multivariate analysis including FIM score, CCV diseases and diabetes mellitus, demonstrated that only CCV disease was an independent variable for survival (p = 0.02). Performance, as evidenced by FIM scores after rehabilitation for hip fracture, may provide additional useful information on long-term survival. However, since functional status after rehabilitation is not an independent risk factor for long-term mortality, its predictive value must be interpreted in view of the comorbidities, mainly CCV diseases, which are more important to the risk of mortality than the event of hip fracture itself.

A Geriatric Day Hospital: Who Improves the Most?

This study compared the changes in some bio-psychosocial variables (functional independence, nutritional risk, pain, balance and walking, grip strength, general well-being, psychiatric profile, perception of social support, leisure satisfaction, and caregivers' feeling of burden) in four categories of clients during their program at a geriatric day hospital (GDH). The study also evaluated whether or not improvements, if any, were maintained 3 months after discharge. One-hundred-and-fifty-one people, categorized by primary reason for admission, were assessed at the GDH with reliable and valid tools, at admission and at discharge. Three months after discharge, they were reassessed with the same tools. Overall, two categories of clients, stroke / neurological diseases and musculoskeletal disorders / amputations, improved the most. For the gait disorders and falls group, only the functional independence score improved, but not at a clinically significant level. Finally, clients in the cognitive function disorders / psychopathologies group improved the most on their well-being scores and caregivers' burden decreased the most. All gains were maintained up to 3 months after discharge, except for leisure satisfaction. With the exception of clients who attended the GDH because of gait disorders and falls, the improvements and maintenance achieved in each category occurred in the domains where improvement had been hoped for, because of the particular disabilities in question and because of the nature of the GDH services offered.

Holocaust Experience and Suicidal Ideation in High-Risk Older Adults

Depression is an identified risk factor for suicidal ideation, a precursor for more serious suicidal behaviors. This risk might be further compounded in individuals who experience negative life events, including traumatic experiences, and those who might have comorbid illnesses. The authors examined the impact of past exposure to the Nazi Holocaust on the development of suicidal ideation in a sample of depressed older adults. Authors conducted a retrospective cross-sectional study. The study sample comprised data on 530 consecutive eligible first admissions of Jewish patients who were referred and admitted to a geriatric psychiatry day hospital program between September 1986 and December 2000. Multiple logistic-regression analyses, controlling for social support, history of suicide attempts, and other negative life events, showed that severity of depression and exposure to the Holocaust were independently associated with suicidal ideation. Those not showing suicidal ideation were slightly more likely to have reported having a confidant. This is the first empirical study to demonstrate an increased likelihood for suicidal ideation in survivors of the Nazi Holocaust. The chronic stress produced by these traumatic events may have predisposed survivors to cope ineffectively as they age, thus resulting in suicidal ideation. Authors highlight the importance of a multifaceted approach when assessing suicidal behaviors in high-risk groups.

Improvement of functional deficits, physical mobility and cognitive function by treatment in a geriatric day hospital

Several studies showed the efficacy of inpatient geriatric treatment. Different outcomes were reported for geriatric patients treated in outpatient facilities. To analyze the course of rehabilitation, 312 patients (62.2% female) with a mean age of 77.2 years (SD = 7.4) in a geriatric day hospital were evaluated regarding a) changes of functional deficits and mobility, b) cognitive function and c) depression. Patients were examined with a geriatric assessment including activities of daily living, Tinetti, Timed-up and go, Mini Mental State Examination (MMSE), Clock Completion Test, Handgrip Strength-Test, Money-Counting Test and Geriatric Depression Scale (GDS) at admission and discharge. All examined parameters had changed significantly after treatment. A clear decrease in the portion of patients with disability-related outcomes in the examined parameters (Barthel Index, Tinetti, Timed-up and go, MMSE, GDS) was demonstrated: a) the proportion of patients with a Barthel Index under 75 had decreased by 26.5%, the proportion of patients with an increased risk of falls was reduced by 27%, b) the proportion of patients with a MMSE Score less than 24 was decreased by 14.8% and c) mild effects were achieved in depression. Day hospital geriatric treatment leads to an improvement of functional deficits, mobility and mental health of patients. The results contrast to other studies in day hospital treatment.