Geriatric Rehabilitation Care Research Articles

Effects of the FIT-HIP Intervention for Fear of Falling After Hip Fracture: A Cluster-Randomized Controlled Trial in Geriatric Rehabilitation

ObjectivesFear of falling (FoF) is common after hip fracture and can impede functional recovery because of activity restriction. The Fear of falling InTervention in HIP fracture geriatric rehabilitation (FIT-HIP intervention) was designed to target FoF and consequently to improve mobility. The aim of this study was to evaluate the effect of the FIT-HIP intervention in patients with FoF in geriatric rehabilitation (GR) after hip fracture. Design, setting, and participantsThis cluster-randomized controlled trial was performed in 11 post-acute GR units in the Netherlands (2016-2017). Six clusters were assigned to the intervention group, 5 to the usual care group. We included 78 patients with hip fracture and FoF (aged ≥65 years; 39 per group). Intervention(s)The FIT-HIP intervention is a multicomponent cognitive behavioral intervention conducted by physiotherapists, embedded in usual care in GR. The FIT-HIP intervention was compared to usual care in GR. MeasurementsFoF was assessed with the Falls Efficacy Scale–International (FES-I) and mobility, with the Performance Oriented Mobility Assessment (POMA). Data were collected at baseline, discharge, and 3 and 6 months postdischarge from GR. Primary endpoints were change scores at discharge. Linear mixed models were used to evaluate the treatment effect. ResultsNo significant between-group differences were observed for primary outcome measures. With the usual care group as reference, the FES-I estimated difference between mean change scores was 3.3 [95% confidence interval (CI) −1.0, 7.5, P = .13] at discharge from GR; −4.1 (95% CI –11.8, 3.6, P = .29) after 3 months; and −2.8 (95% CI –10.0, 4.4, P = .44) after 6 months. POMA estimated difference was −0.3 (95% CI –6.5, 5.8, P = .90). Conclusion/ImplicationsThe FIT-HIP intervention was not effective in reducing FoF. Possibly FoF (shortly) after hip fracture can to some extent be appropriate. This may imply the study was not able to accurately identify and accordingly treat FoF that is maladaptive (reflective of disproportionate anxiety).

The effectiveness of an integrated care pathway in geriatric rehabilitation among older patients with complex health problems and their informal caregivers: a prospective cohort study

BackgroundTo improve continuity and coordination of care in geriatric rehabilitation, an integrated care pathway was developed and implemented in The Netherlands. The purpose of this study was to assess the effects of this pathway on patients and informal caregivers.MethodsTwo cohorts of patients and their informal caregivers were prospectively recruited before implementation of the pathway (2011–2012) and after implementation of the pathway (2013–2014). Primary outcome measures were dependence in activities of daily living in patients (KATZ-15) and self-rated burden among informal caregivers (SRB-VAS). Secondary outcome measures were the frequency of performing extended daily activities, social participation, psychological well-being, quality of life and discharge location (patients) and quality of life and objective care burden (informal caregivers). Outcomes were measured at baseline, after three and after nine months.ResultsNo effect was shown on the KATZ-15 after three and nine months. However, a larger percentage of patients were discharged home in the care pathway cohort (83% vs 58.1% after three months and 88.6% vs 67.4% after nine months; p = 0.004). Furthermore, after three months, patients from the care pathway cohort performed more extended daily activities (p = 0.014) and informal caregivers experienced a lower self-rated burden (p = 0.05). After nine months, these effects disappeared. No differences were found for the other outcome measures.ConclusionsDue to the positive effects of the integrated care pathway, we are inclined to recommend implementing the care pathway in regular care. To have longer lasting effects among patients and informal caregivers, we suggest actively disseminating information about the pathway to primary care providers who are currently still unaware of its content.Trial registrationISRCTN90000867 (date of registration: 07-04-2016).

Rehospitalization following a stay in geriatric rehabilitation wards: rates and predictive factors.

The study was retrospective, case-control, including all the patients hospitalized in the 4 geriatric post-acute and rehabilitation care wards of a hospital in Paris (France) and returned at home. Data collection was carried out on the basis of the hospitalization report and the information system of the hospital. Rehospitalizations were documented by the information system as well as by telephone interview. We compared patients according to whether they had been rehospitalized or not within 60 days after discharge. Out of a total of 1,063 stays during a 12 months period, 435 (41%) were discharged at home. Re-admission rate was 10.1% at 30 days and 18.4% at 90 days. Mean age of rehospitaliszed patients was 87.2 years ± 5.3 vs 87.9 years ± 5.8 for non-rehospitalized patients. Patients rehospitalized had more often a delirium during the prior hospitalization. Unplanned rehospitalisation is a major public health issue and should be prevented particularly after a stay in a geriatric post-acute and rehabilitation care wards.

Building Consensus on an Integrated Care Pathway in Geriatric Rehabilitation: A Modified Delphi Study Among Professional Experts.

To improve continuity and coordination of care in geriatric rehabilitation, an integrated care pathway was developed in the south of the Netherlands. This study aims to reach nationwide consensus on the content and structure of this locally developed pathway using a two-round Delphi study with specialized elderly care physicians (n = 37) as experts. In the first round, experts indicated their level of agreement on 65 statements representing the pathway on a 5-point Likert-type scale. Statements that did not gain consensus (interquartile range > 1) were redistributed to participants in Round 2. Consensus was reached on 56 statements (86%) after Round 1 and on 60 statements (92%) after Round 2. In total, 53 statements were assessed as relevant, seven statements were considered irrelevant, and five statements did not reach consensus. We conclude that there is broad nationwide consensus on the pathway, which therefore has the potential to be disseminated and implemented on a wider scale.

Pilot study: effectiveness of a training program about autonomy in elderly patients hospitalized after an acute episode.

Patients hospitalized in rehabilitation after an acute episode is at high risk of functional impairment and require active measures to prevent loss of autonomy. Resistance training has been proved beneficial to improve physical performances of aged subjects in the community. However, the feasibility and effects of training programs has never been assessed among hospitalized patients after an acute medical episode. In this pilot study, we aimed to evaluate a personalized training program of adapted physical education teacher combining muscular reinforcement and endurance training among patients over 65 year-old hospitalized in a geriatric rehabilitation care setting. The principal outcome considered was the evolution of the SPPB (short physical performance battery) score from baseline, after the 3-week period of training. Thirty-eight patients (mean age> 80 years) participated to the program. The mean SPPB score at baseline was 6.37 points (standard deviation: 2.17). After the intervention, the SPPB showed a significant improvement of 2.50 points, to reach 8.87 points (standard deviation: ±1.60; p=0.001). These results confirm the feasibility of resistance-training programs among hospitalized elderly. The observed improvements in terms of physic al performances also appear promising with regard to the prevention of loss of autonomy during rehabilitation after acute medical episodes.

Successful Geriatric Rehabilitation: Effects on Patients’ Outcome of a National Program to Improve Quality of Care, the SINGER Study

ObjectiveTo determine whether the implementation of a national program to improve quality of care in geriatric rehabilitation (GR) in the Netherlands improves successful GR in terms of independence in activities of daily living (ADL), discharge destination, and length of stay. DesignProspective longitudinal study, comparing 2 consecutive cohorts: at the start of implementation (n = 386) and at 1 year after implementation (n = 357) of this program. Setting/ParticipantsIncluded were 16 skilled nursing facilities, 743 patients (median age 80 years, interquartile range 72–85; 64.5% females) indicated for GR and their health care professionals (elderly care physicians, physiotherapists, and nursing staff). InterventionNational program to stimulate self-organizing capacity to develop integrated care to improve GR service delivery in 4 domains: alignment with patients’ (care) needs, care coordination, team cooperation, and quality of care. MeasurementsData on patients’ characteristics, functional outcomes at admission and discharge, length of stay, and discharge destination were collected via an online questionnaire sent to health care professionals. The primary outcome measure was successful rehabilitation defined as independence in ADL (Barthel Index ≥15), discharge home, and a short length of stay (lowest 25% per diagnostic group). Generalized estimating equation analysis was used to adjust for age, gender, and clustering effects in the total population and for the 2 largest diagnostic subgroups, traumatic injuries and stroke. ResultsIn the total population, at 1 year postimplementation there was 12% more ADL independence [odds ratio (OR) 1.59, 95% confidence interval (CI) 1.00–2.54]. Although successful rehabilitation (independence in ADL, discharge home, short length of stay) was similar in the 2 cohorts, patients with traumatic injuries were more successful 1 year postimplementation (OR 1.61, 95% CI 1.01–2.54). In stroke patients, successful rehabilitation was similar between the cohorts, but with more independence in ADL in the follow-up cohort (OR 1.99, 95% CI 1.09–3.63). ConclusionsThis study shows that 1-year after the implementation of the Dutch national program to improve quality of care there was more independence in ADL at discharge, but the combined outcome of successful GR (independence in ADL, discharge home, short length of stay) was only significantly improved in patients with traumatic injuries.

Geriatric medicine and geriatricians in the UK. How they relate to acute and general internal medicine and what the future might hold?

The Royal College of Physicians and its Future Hospitals Commission has a renewed focus on general internal medicine. But in 2015, most is in effect either acute medicine or geriatric medicine. Acute physicians and 'organ specialists' looking after inpatients on specialty wards or at the acute hospital 'front door' will need sufficient skills in geriatric medicine, rehabilitation, discharge planning and palliative care, as frailty, dementia and complex comorbidities may complicate the care of older patients with predominant speciality-defining complaints. In an era where we are urged to focus on patient-centred care, patients' preference for continuity and 'whole-stay', consultants must be recognised and respected. Ideally, this will require increasing numbers of geriatricians and acute physicians, more age attuned training for all; a shift in values and status. This should be backed by adequate capacity and rapid access to social and intermediate care services outside hospital, as well as adequate multidisciplinary staff and skills within the acute hospital to ensure that older patients' needs beyond the immediate complaints are not neglected. Meanwhile, geriatric medicine itself has diversified into specialised, community and interface roles, aligned with the integration agenda, and continues to contribute substantially to acute, general and stroke medicine. These developments are described here.

La filière orthogériatrique : une prise en charge d’avenir

The frequency and seriousness of fractures in frail elderly people has led to the creation of an orthogeriatric service in Paris, between Ambroise-Paré and Sainte-Périne hospitals. This care model, focused on early postoperative geriatric follow-up and rehabilitation care, has resulted in an increase in the flow of trauma patients admitted to Sainte-Périne, reduced mortality and higher home-discharge rate.

Change in cognitive performance is associated with functional recovery during post-acute stroke rehabilitation: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia.

Recovery after a stroke is determined by a broad range of neurological, functional and psychosocial factors. Evidence regarding these factors is not well established, in particular influence of cognition changes during rehabilitation. We aimed to investigate whether selective characteristics, including cognitive performance and its change over time, modulate functional recovery with home discharge in stroke survivors admitted to post-acute rehabilitation units. We undertook a multicenter cohort study, including all patients discharged from acute wards to any geriatric rehabilitation unit in Catalonia-Spain during 2008. Patients were assessed for demographics, clinical and functional variables using Conjunt Mínim Bàsic de Dades dels Recursos Sociosanitaris (CMBD-RSS), which adapts the Minimum Data Set tool used in America's nursing homes. Baseline-to-discharge change in cognition was calculated on repeated assessments using the Cognitive Performance Scale (CPS, range 0-6, best-worst cognition). The multivariable effect of these factors was analyzed in relation to the outcome. 879 post-stroke patients were included (mean age 77.48 ± 10.18 years, 52.6% women). A worse initial CPS [OR (95% CI) = 0.851 (0.774-0.935)] and prevalent fecal incontinence [OR (95% CI) = 0.560 (0.454-0.691)] reduced the likelihood of returning home with functional improvement; whereas improvement of CPS, baseline to discharge, [OR (95% CI) = 1.348 (1.144-1.588)], more rehabilitation days within the first 2 weeks [OR (95% CI) = 1.011 (1.006-1.015)] and a longer hospital stay [OR (95% CI) = 1.011 (1.006-1.015)] were associated with the outcome. In our sample, different clinical characteristics, including cognitive function and its improvement over time, are associated with functional improvement in stroke patients undergoing rehabilitation. Our results might provide information to further studies aimed at exploring the influence of cognition changes during rehabilitation.

Challenges in geriatric rehabilitation: the development of an integrated care pathway

Coordination and continuity of care within geriatric rehabilitation is challenging. To tackle these challenges, an integrated care pathway within geriatric rehabilitation care (hospital, geriatric rehabilitation and follow-up care in the home situation) has been developed. The aim of this article is to expound the process of developing the integrated care pathway, and to describe and discuss the results of this process (which is the integrated care pathway). Developing the integrated care pathway was done by the guidance of the first four steps of the theoretical framework for implementation of change from Grol and Wensing: (1) development of a specific proposal for change in practice; (2) analysis of current care practice; (3) analysis of the target group and setting; and (4) development and selection of interventions/strategies for change. The organizations involved in geriatric rehabilitation argued that the integrated care pathway should focus on improving the process of care, including transfer of patients, handovers and communication between care organizations. Current practice, barriers and incentives for change were analyzed through literature research, expert consultation, and interviews with the involved caregivers and by establishing working groups of health care professionals, patients and informal caregivers. This resulted in valuable proposals for improvement of the care process, which were gathered and combined in the integrated care pathway. The integrated care pathway entails agreements on (a) the triage process in the hospital; (b) active engagement of patients and informal caregivers in the care process; (c) timely and high quality handovers; and (d) improved communication between caregivers.

Nursing competencies in geriatric rehabilitation and palliative care team

Rehabilitation is a process which enables persons with physiological or anatomical abnormalities to achieve their optimal physical, psychological, social, vocational and avocational status. It means more than simple physical restoration, compensation of the loss of a function or adapting to the physical loss - appearance. Persons with limited mobility have lost their limb function or mobility of a body part. Depending on the kind of functional loss, these people may have a problem in handling objects or they may need assistance for some other functions. When curative medicine is not helping any more, patients are included into palliative care. Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening disease, through the prevention and relief of suffering, by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Nurses play a very important role in an interdisciplinary team since they provide help, support and encouragement for patients in direct contact with them and their family; moreover, they make a valuable contribution to the rest of the team since they are present 24 hours a day. Due to the difficult and complex situation, they are required to comply with all ethical principles, especially principles of confidence, doing good and avoiding evil. They foster a professional relationship with seriously ill patients, showing understanding for their needs. At the same time, they help the rest of the team to offer better and more efficient health services by keeping medical records. They do their best to relieve total pain and total suffering.

O4.06: Prediction of functional improvement and rehabilitation efficiency after stroke: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia

O4.06: Prediction of functional improvement and rehabilitation efficiency after stroke: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia

Determinants for the Use of Ambulation Aids in a Geriatric Rehabilitation Care Unit: A Retrospective Study

This study aimed at assessing the profile of ambulation aid users among patients admitted for geriatric rehabilitation care. Retrospective chart review. Geriatric Rehabilitation Department of the Hôpital Albert Chenevier, Créteil, France. The sample comprised 206 records of patients aged 65 or older with no previous use of assistive device before admission and length of stay longer than 7 days. Ambulation levels were classified as independent ambulators (IA, reference category), ambulation aid users (AA), or nonambulatory patients (NA). we explored age, gender, purpose of initial admission, comorbidities, and past medical history as factors potentially associated with ambulation levels, using multinomial logistic regression. The study population (mean age 84 years [6.1 standard deviation], 68.5 % women) comprised 110 IA (53.4% of the overall population), 72 AA (34.9%), and 24 NA (11.6%). Factors independently associated with AA use were the following: older age (odds ratio= 1.17; [95% confidence interval 1.09-1.25]), previous history of lower limb surgery (2.15; [1.0-4.73]), and admission for hip surgery (8.14; [2.60-25.53]). Factors independently associated with NA were the following: older age (1.12 [1.02-1.23]) and low Mini-Mental State Exam score (0.77 [0.70-0.85]). A borderline association was observed for visual impairment (3.36 [0.93-12.95]). Cardiac disease, respiratory disease, falls, and dementia were not associated with ambulation aid use. History of lower-limb surgery, particularly recent hip surgery, and old age are the primary predictive factors of ambulation aid use in a geriatric rehabilitation hospital.

Geriatric Rehabilitation and Palliative Care

Geriatric Rehabilitation and Palliative Care

Are Elderly Hospitalized Patients Getting Enough Protein?

To determine the protein requirements of elderly hospitalized patients. Cross-sectional evaluation of nitrogen balance. Short-stay geriatric ward or rehabilitation care unit. Thirty-six elderly hospitalized patients (aged 65-99) admitted to short-stay and rehabilitation care units. Resting energy expenditure and nitrogen balance were determined under usual and spontaneous energy and protein intake after subjects were clinically stable (3-5 days after admission). All items consumed over a 3-day period were weighed to determine energy and protein intake. Energy (23.5+/-6.3 kcal/kg per day) and protein (0.99+/-0.24 g/kg per day) intake were similar in men and women, and nitrogen balance was neutral (0.37+/-2.6 g/day; P=.41 vs a neutral nitrogen balance, i.e., 0 g/d). Half of the patients had a positive nitrogen balance. Plasma C-reactive protein, renal function, nutritional status, and initial diagnosis had no influence on nitrogen balance. In contrast, energy and protein intakes correlated positively with nitrogen balance. Linear regression analysis suggested that an elderly hospitalized patient with an energy intake of 1.31 times resting energy expenditure or greater appears to require a minimum protein intake of 1.06+/-0.28 g/kg per day. Mean protein intake to reach a neutral nitrogen balance in elderly hospitalized patients is 1.06+/-0.28 g/kg per day, which is higher than current recommendations for healthy elderly people. Safe protein intake (that would be adequate to ensure that 95% of patients remain in positive nitrogen balance) is difficult to establish.

Trajectories of cognitive decline and functional status in the frail older adults

This study investigates the implications of different levels of cognitive decline on functional status in frail older adults. Four cognitive trajectories, including two with catastrophic cognitive decline, were defined in a 3-year study. Participants with complete cognitive and functional status data at baseline, 12 and 36 months of follow-up were included in the study ( n = 456). Data were analysed with repeated measures statistics. Substantial functional deterioration over time was observed for the participants with catastrophic cognitive decline. Catastrophic cognitive decline influenced performance in instrumental activities of daily living (IADL) and activities of daily living (ADL) at 12 months, whereas basic physical and mental actions were affected at 36 months. IADL were found to deteriorate more than ADL. The results have implications on planning appropriate geriatric rehabilitation and long-term care program.

Attitudes of nursing staff working with older people towards nutritional nursing care

The aim of this study was to examine attitudes of the nursing staff in geriatric care towards factors of importance for nutritional nursing care. Studies show that nutritional risk assessment is seldom performed on older patients as routine and very few patients have a nutritional care plan. Patients in long-term care who are easy to feed are also found to be looked upon more positively than those with high feeding needs. A total of 252 registered nurses and nurse aids working at geriatric rehabilitation and medical care clinics and resident homes participated in the study. Attitudes were examined using the Staff Attitudes to Nutritional Nursing Care Geriatric scale. The scale includes 18 items and was designed as a one to five-point Lickert-type scale. It gives a total score and five subscales representing the dimensions 'Norms', 'Habits', 'Assessment', 'Intervention' and 'Individualization'. A higher score indicates a more positive attitude. Of all nursing staff, 53% displayed a positive attitude towards factors of importance for nutritional nursing care and the rest displayed a neutral or negative attitude. The 'Intervention' dimension, dealing with nutritional problems and how to manage them, reflected the highest level of positive attitudes, which represents 71% of the nursing staff. The 'Norms' dimension had the lowest relative frequency of positive attitudes, 27%. The registered nurses held significantly more positive attitudes than the nurse aids did. Nutritional issues comprise an important and time-consuming responsibility in geriatric care; however, nursing staff do not show an unequivocal positive attitude regarding this responsibility. The consequences this entails for the older patient need to be examined further. Relevance to clinical practice. Nursing staff play an important role in caring for patients who are malnourished or at risk for malnutrition. Positive attitudes might hinder the development of undernourishment or the further worsening of an already undernourished patient's condition.

Geriatric Nutritional Risk Index: a new index for evaluating at-risk elderly medical patients

Patients at risk of malnutrition and related morbidity and mortality can be identified with the Nutritional Risk Index (NRI). However, this index remains limited for elderly patients because of difficulties in establishing their normal weight. Therefore, we replaced the usual weight in this formula by ideal weight according to the Lorentz formula (WLo), creating a new index called the Geriatric Nutritional Risk Index (GNRI). First, a prospective study enrolled 181 hospitalized elderly patients. Nutritional status [albumin, prealbumin, and body mass index (BMI)] and GNRI were assessed. GNRI correlated with a severity score taking into account complications (bedsores or infections) and 6-mo mortality. Second, the GNRI was measured prospectively in 2474 patients admitted to a geriatric rehabilitation care unit over a 3-y period. The severity score correlated with albumin and GNRI but not with BMI or weight:WLo. Risk of mortality (odds ratio) and risk of complications were, respectively, 29 (95% CI: 5.2, 161.4) and 4.4 (95% CI: 1.3, 14.9) for major nutrition-related risk (GNRI: <82), 6.6 (95% CI: 1.3, 33.0), 4.9 (95% CI: 1.9, 12.5) for moderate nutrition-related risk (GNRI: 82 to <92), and 5.6 (95% CI: 1.2, 26.6) and 3.3 (95% CI: 1.4, 8.0) for a low nutrition-related risk (GNRI: 92 to < or =98). Accordingly, 12.2%, 31.4%, 29.4%, and 27.0% of the 2474 patients had major, moderate, low, and no nutrition-related risk, respectively. GNRI is a simple and accurate tool for predicting the risk of morbidity and mortality in hospitalized elderly patients and should be recorded systematically on admission.

Quality of Care in Geriatric Rehabilitation: Clients' Perceptions, ADL Dependence, and Subjective Well-being in a One-year Perspective

World-wide, the development of community-based geriatric rehabilitation has received increased attention. In Sweden, national reforms during the 1990s aimed at improved quality of geriatric rehabilitation. This paper focuses clients' perceptions of the rehabilitation process, dependence in activities of daily living (ADL), and subjective well-being in a one-year perspective. A study-specific questionnaire, a revised version of the ADL Staircase, and the Göteborg Quality of Life Instrument were administered, in 1996 (N = 278) and 1997 (N = 233). Even if 77% of the clients were content as regards rehabilitation quality, in 1997 contentment diminished among clients in sheltered housing facilities. Most clients also reported a diminished contentment with the training provided during the period investigated. Most clients were dependent in ADL, but in sub-groups independence in some activities diminished over the study period. In contrast, in some aspects sub-groups scored their subjective well-being lower on the second measurement than on the first. The investigation of clients' perceptions of quality of care is a multifaceted matter, and the results of this study were partly ambiguous. Still, since valid descriptions of variables at target for rehabilitation is one important key to the continuous process of quality development, this study produced information valuable for further studies following geriatric rehabilitation processes over time. The implementation of this study could be applicable in similar settings.

The problem-oriented multidisciplinary approach in Dutch nursing home care

In The Netherlands, nursing home medicine is an important branch of geriatric medicine. Therapeutic emphasis in this field is placed on function rather than disease. Multidisciplinary geriatric rehabilitation and long-term care are provided on an inpatient as well as on a semi-outpatient (day hospital) and outpatient ('substitution care') basis. This article discusses the reasons for the adoption of a problem-oriented approach in this field of geriatric medicine. It also outlines the modifications that were necessary to make the method suitable for application in the care of chronically ill elderly patients and describes how it can be used. The teaching of the problem-oriented approach is a cornerstone of the postacademic training programme for nursing home physicians and this method is currently being implemented in university- affiliated nursing homes.