Geriatric Rehabilitation Ward Research Articles

Involving Nurses in Participatory Action Research: Facilitators and Barriers

Involving nurses in research and quality improvement is desirable because nurses are often aware of weaknesses in care or organizational processes. In participatory action research (PAR), practitioners are encouraged to identify problems they encounter and, together with the researcher, develop strategies to solve these problems. This study aimed to evaluate the process of involving nurses in PAR, as well as learn what hampers and facilitates collaboration between the nursing team and the researcher and facilitator. Data collected during a 2.5-year PAR process with a nursing team (15–18 participants) on a geriatric rehabilitation ward was deductively analyzed using seven quality criteria (collaboration, prudent handling of assumptions, accountability, participation, reflection, knowledge sources, and transparency). This study describes how reflection and collective learning as core processes of PAR were facilitated using complementary knowledge sources (theoretical models, knowledge based on practical experiences, and results of empirical research collected during the PAR). The study uncovered that providing the time and setting for reflection and collective learning enables a nursing team to be actively involved in PAR: it helps them diagnose their current practice, plan ahead, and critically experiment with actions. Additionally, a positive learning climate is a prerequisite for this process. However, without a strong link between quality policy and consequent facilitation of participation through earmarked time, these efforts might not lead to sustainable changes. A more permanent link between PAR initiatives and organizational ambitions regarding quality of care is recommended.

Under Pressure: An Audit of Pressure Injury Documentation in Hospitalised Older Adults

Abstract Background Pressure injuries are common in hospitalised older adults. They are associated with adverse outcomes including reduced quality of life, pain, insomnia, mood disturbance and secondary infection. They can negatively affect mobility and prolong hospital stay with financial cost to the health service. Pressure injuries represent a geriatric syndrome with multifactorial risk factors, requiring multidisciplinary communication to optimise management. Methods Retrospective audit over three months in adults over 65 years, admitted to a geriatric rehabilitation ward. Audit aims were (1) Review medical staff pressure injury written documentation and (2) Review medical staff written communication and handover regarding pressure injuries. Data were gathered from medical records including written notes and discharge letters. Results Twenty-six patients had thirty-six individual pressure injuries. The mean age was 83 years, 53% female and 47% male. Total length of stay mean was 50 days (range 16 – 147 days). Thirty-nine percent of pressure injuries were stage 1, 42% stage 2, 3% stage 3, 6% suspected deep and 11% unstageable. Documentation in the medical admission occurred in 21% and medical notes in 33%. Documentation in multidisciplinary team (MDT) meetings occurred in 17% and discharge letters in 22%. The mean time between nursing pressure injury identification, and medical and MDT documentation was 17 and 16 days respectively. Conclusion Medical team written documentation of pressure injuries was low. Only one-fifth to one-third of pressure injuries were recorded. Although pressure injuries benefit from multidisciplinary management, they were documented in MDT meetings in under one-fifth of cases. Delays of more than two weeks between nursing and medical documentation occurs. Improving documentation and communication between the MDT can optimise pressure injury management, highlighting the need for ongoing medical education and more effective documentation processes.

Body Weight and Composition Changes in Geriatric Rehabilitation Are Dependent on Sarcopenia and Malnutrition: RESORT

ObjectivesBody weight and muscle mass loss following an acute hospitalization in older patients may be influenced by malnutrition and sarcopenia among other factors. This study aimed to assess the changes in body weight and composition from admission to discharge and the geriatric variables associated with the changes in geriatric rehabilitation inpatients. DesignRESORT is an observational, longitudinal cohort. Setting and ParticipantsGeriatric rehabilitation inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital, Melbourne, Australia (N = 1006). MethodsChanges in body weight and body composition [fat mass (FM), appendicular lean mass (ALM)] from admission to discharge were analyzed using linear mixed models. Body mass index (BMI) categories, (risk of) malnutrition (Global Leadership Initiative on Malnutrition), sarcopenia (European Working Group on Sarcopenia in Older People), dependence in activities of daily living (ADL), multimorbidity, and cognitive impairment were tested as geriatric variables by which the changes in body weight and composition may differ. ResultsA total of 1006 patients [median age: 83.2 (77.7–88.8) years, 58.5% female] were included. Body weight, FM (kg), and FM% decreased (0.30 kg, 0.43 kg, and 0.46%, respectively) and ALM (kg) and ALM% increased (0.17 kg and 0.33%, respectively) during geriatric rehabilitation. Body weight increased in patients with underweight; decreased in patients with normal/overweight, obesity, ADL dependence and in those without malnutrition and sarcopenia. ALM% and FM% decreased in patients with normal/overweight. ALM increased in patients without multimorbidity and in those with malnutrition and sarcopenia; ALM% increased in patients without multimorbidity and with sarcopenia. Conclusions and ImplicationsIn geriatric rehabilitation, body weight increased in patients with underweight but decreased in patients with normal/overweight and obesity. ALM increased in patients with malnutrition and sarcopenia but not in patients without. This suggests the need for improved standard of care independent of patients’ nutritional risk.

The association between blood biological age at rehabilitation admission and physical activity during rehabilitation in geriatric inpatients: RESORT

Geriatric rehabilitation inpatients have high levels of sedentary behaviour (SB) and low levels of physical activity (PA). Biological age predicted by blood biomarkers is indicative of adverse outcomes. The objective was to determine the association between blood biological age at rehabilitation admission and levels of SB and PA during rehabilitation in geriatric inpatients. Inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital (Melbourne, Australia) from October 22, 2019, to March 29, 2020, in the REStORing health of acute unwell adulTs (RESORT) observational cohort were included. Blood biological age was predicted using SenoClock-BloodAge, a hematological ageing clock. Patients wore an inertial sensor to measure SB and PA. Logistic regression analyses were conducted. A total of 111 patients (57.7% female) with mean age 83.3 ± 7.5 years were included in the analysis. The mean blood biological age was 82.7 ± 8.4 years. Patients with 1-year higher blood biological age had higher odds of having high SB measured as non-upright time greater than 23 h/day (odds ratio (OR): 1.050, 95% confidence interval (CI): 1.000–1.102). Individuals having 1-year higher age deviation trended towards lower odds of having high levels of PA measured as stepping time greater than 7.4 min/day (OR: 0.916, CI: 0.836–1.005) and as greater than 19.5 sit-to-stand transitions/day (OR: 0.915, CI: 0.836–1.002). In conclusion, higher biological age was associated with higher levels of SB and trended towards lower PA. Incorporating blood biological age could facilitate resource allocation and the development of more tailored rehabilitation plans.

Barriers and facilitators for physical fitness training in orthopedic geriatric rehabilitation. A qualitative study

Purpose The aim of this explorative, qualitative study is to identify factors that potentially influence the execution of physical fitness training in inpatient orthopedic geriatric rehabilitation (GR), from the perspectives of patients, their relatives and professionals. Materials and methods In GR wards of skilled nursing facilities in the Netherlands, semi-structured interviews were held with triads of patients, their relatives and responsible nurses, and focus groups with members of the multidisciplinary teams. Verbatim reports were analyzed according to the framework method. Results We found twelve categories of barriers and facilitators related to characteristics of the patients, their family, staff, training program and organization. Conclusions The barriers and facilitators found largely correspond with those found for participation in exercise in related settings, but also show important differences. This overview of barriers and facilitators enables multidisciplinary teams to design improvements at the level of the organization and interventions, as well as at the level of the individual training program, tailoring it to the patient’s circumstances and needs. Further research should focus on weighing these barriers and facilitators to develop a feasible guidance for daily practice, as well as testing their effect on the adherence to existing physical fitness training guidelines.

Development and feasibility of the Geriatric Activity Program Pellenberg with the Caregiver as an exercise partner (GAPP+Care).

The Geriatric Activation Program Pellenberg (GAPP), among other programs for geriatric rehabilitation, improves patient functioning. However, hospitalized patients rarely move enough to meet the WHO recommendation of 300 minutes of moderate-intensity exercise per week.
 Increasing exercise time by physiotherapy is hindered by staffing and financial restrictions both being dependent on health care and hospital financing. Integrating unpaid caregivers in an geriatric rehabilitation program could close this gap.
 Along with the physiotherapist, we wish to make the patient's informal caregiver an exercise partner. We want to teach the caregiver how to literally support their family member in hands-on sessions and to enable them to take part in the pluridisciplinary geriatric rehabilitation team.
 The development of the Geriatric Activity Program Pellenberg with the Caregiver as an exercise partner (GAPP+Care) was founded on three aspects: 1) the WHO daily activity guideline; 2) the current program GAPP; and 3) a systematic review on the effect of informal caregiver involvement on self-efficacy of hospitalized older adults.
 We conducted semi-structured interviews to determine the overall perception of patients and caregivers toward the GAPP+Care concept. Based on the findings, GAPP+Care was finalized. The questions were divided into 3 domains: 1) reasons to participate, 2) exercise moments (number, duration and time), and 3) the exercise booklet. The interview started with explaining GAPP+Care and a prototype of the exercise booklet was given. Sixteen patients from UZ Leuven's geriatric rehabilitation ward, as well as 15 informal caregivers, took part in the study. 75% of patients and 80% of family caregivers stated that they would participate in the GAPP+Care exercise program. The main motivations for participating were activation of the patient, to follow their progress, as well as to learn more about their abilities. The main reasons for refusal were a lack of time, greater care load for the caregiver, and the patient's lack of motivation. Although 52% of participants agreed to four additional exercise moments per week, 45% prefers less moments. All participants reported that the instruction booklet was clear, easy to read, and simple to use. With some adjustment GAPP+Care appears to be acceptable for implementation on a geriatric rehabilitation ward.
 The GAPP+Care program consists of GAPP plus three additional 30-minute exercise sessions each week led by an informal caregiver (+Care). One of these three exercise sessions is always carried out in partnership with a physiotherapist, while the other two can be independently given by the caregiver at any time, such as in the evening or on the weekend. These +Care practice sessions, in addition to the individual physiotherapy treatment, continue in the patient's home for the first six weeks following discharge.
 GAPP+Care requires an integrated approach towards patients and their family caregivers. We initiated a feasibility study of GAPP+Care (March 2022 - March 2023). In this study we are investigating: 1) the feasibility, appropriateness, barriers and facilitators of GAPP+Care, 2) the fidelity to GAPP+Care, and 3) the percentage (proportion) of eligible individuals and their willingness to participate in GAPP+Care.

Improving goal setting and achieving in geriatric rehabilitation through participatory action research

Introduction/background summary: In geriatric rehabilitation a means to achieve client centered care is to work collaboratively on setting and achieving goals. This might enhance self-efficacy, motivation, adherence to rehabilitation and goal-specific performance. In this participatory action research (PAR) project, a nursing team investigated for itself how to improve goal setting and achieving.
 Who is it for? The actions the nursing team chose and implemented contribute to improved goal setting and achieving and subsequently enhances client centered care.
 Who did you involve and engage with? This research project took place in a Learning and Innovation Network (LIN) on a geriatric rehabilitation ward, in which students and nurses work together on quality improvement projects. The team consisted of fifteen vocational trained nurses and healthcare assistants and eight nursing students, a nurse team leader and a lecturer practitioner spending a day per week on educational activities.
 What did you do? Facilitated by the lecturer practitioner, the nursing team (both staff and students) conducted a participatory action research project: they reflected on the steps they could take to work collaboratively on improving their practice, constantly evaluating their experiences. Data collected during the participatory action research consisted of, amongst others: student’s notes on patient interviews and interviews with nurses of the team, fieldnotes made by the facilitator during the PAR process. During PAR there is a constant need to feedback information and clarify issues. Therefor data analysis in PAR is partly performed concurrently. Data which had been collected by the facilitator or the nurses or students were used as a basis for planning and reflecting in the project group.
 
 Results: The team identified two themes influencing their goal setting and goal achieving with patients. Firstly, continuity of care is sub-optimal; in their opinion all should work on the same goals. Secondly, patients could be better informed about their rehabilitation path. The team chose to work on better preparation of the multidisciplinary care plan meeting with the patient and at the same time updating the patient record to advance continuity of care. A sound evaluation of the rehabilitation process and preparing the multidisciplinary care plan meeting to attain this, is now part of a shared team practice. During their process the team discovered certain barriers to optimally prepare the multidisciplinary care plan meeting, e.g. to optimally evaluate progress on rehabilitation goals the initial plan needs to be complete; certain barriers hamper preparation with the patient, like cognitive abilities or language problems. New actions have been chosen and are being worked on.
 Learning for the international audience: PAR which involves nurses can be seen as advantageous for facilitating change and improving services. Time and setting for reflection and collective learning supports the nursing team to diagnose their current practice and to improve their practice.
 Next steps: The Learning and Innovation Network was a temporary agreement between the nursing home and the nursing college based on research funding. Because of the positive results on team culture of improvement the Learning and Innovation Network might become a permanent facility.

Associations of 25-Hydroxyvitamin D Status and Supplementation with Adverse Outcomes in Geriatric Rehabilitation Inpatients: RESORT

ObjectivesGeriatric rehabilitation inpatients are at a higher risk of 25-hydroxyvitamin D (25(OH)D) deficiency due to poor nutrition and low sunlight exposure. This study aimed to evaluate the prevalence of 25-hydroxyvitamin (25(OH)D) deficiency and supplementation and to investigate their association with adverse health outcomes in geriatric rehabilitation inpatients. DesignProspective, observational and longitudinal study. Setting and ParticipantsGeriatric rehabilitation inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital (Melbourne, Australia) from 16th, October 2017 and discharged until 18th, March 2020 in the REStORing health of acutely unwell adulTs (RESORT) study were included. Methods25(OH)D levels measured close to rehabilitation admission were classified as sufficiency (>54 nmol/L), insufficiency (26–54 nmol/L), or deficiency (<26 nmol/L). The usage of vitamin D supplementation was extracted from medication records. Outcomes included incidence of institutionalization at three-month post-discharge, in-hospital mortality and post-discharge mortality. ResultsThe median age of 1328 geriatric rehabilitation inpatients was 83.9 years (IQR: 78.1–88.7, 58.6% female). 25(OH)D deficiency and insufficiency were present in 8.1% and 26.4% of inpatients, respectively; 74.2% used vitamin D supplementation. 25(OH)D deficiency was associated with higher odds of institutionalization (odds ratio (OR): 1.88, 95% confidence interval (CI): 1.14–3.11), in-hospital mortality (OR: 3.30, 95% CI: 1.54–7.07) and higher risks of one-year mortality (hazard ratio (HR): 1.77, 95% CI: 1.17–2.69) compared to 25(OH)D sufficiency but not with three-month mortality. 25(OH)D insufficiency was not associated with outcomes. Patients who did not use supplementation and had 25(OH)D insufficiency or deficiency had significantly higher in-hospital mortality compared to those who used supplementation. ConclusionsAmong geriatric rehabilitation inpatients, 25(OH) D deficiency was associated with institutionalization, in-hospital mortality and one-year mortality. Attention to monitor the vitamin D status is of upmost importance during hospitalization.

Is there a relationship between ‘getting up and dressed’ and functional and physical outcomes in geriatric rehabilitation inpatients? A quasi-experimental study

Objectives To evaluate the physical and functional outcomes of the ‘Ending Pyjama Paralysis’ intervention in an inpatient geriatric rehabilitation unit. Design Quasi-experimental mixed-methods design nested within the ‘REStORing health of acutely unwell adulTs’ (RESORT) prospective, observational, longitudinal cohort of geriatric rehabilitation inpatients study. Setting Geriatric rehabilitation wards in a major metropolitan public hospital between June 2019 and March 2020. Intervention The ‘Ending Pyjama Paralysis’ movement originated in the UK. Its aim was to encourage patients to ‘Get up, Get dressed and Get moving’ to reduce hospital-associated functional decline. However, the physical and functional benefits of this campaign have not yet been evaluated. The ‘Ending Pyjama Paralysis’ was adopted as an integrated intervention on two out of four geriatric rehabilitation wards. The two control wards received usual care. Main Measures Physical measures included the Short Physical Performance Battery, and functional measures included the Katz Index of Independence in Activities of Daily Living and Lawton and Brody’s Instrumental Activities of Daily Living, which were completed on admission and discharge. A linear mixed-effects model was used to analyse the results. Results A total of 833 admissions were included in this study. Of these, 512 patients were in the control group, and 321 were in the intervention group. There were no significant differences in both physical and functional measures between the intervention and control groups. Conclusion The ‘Ending Pyjama Paralysis’ campaign did not result in enhanced functional or physical benefits in geriatric rehabilitation inpatients in this setting when applied in addition to usual care.

Hypnosis to reduce fear of falling in hospitalized older adults: a feasibility randomized controlled trial

BackgroundFear of falling is associated with numerous negative health outcomes in older adults and can limit the rehabilitation process. Hypnosis is now recognized as an effective treatment for a variety of conditions, especially anxiety and pain, which can be integrated safely with conventional medicine. The objective of this study was to assess the feasibility and acceptability of a hypnosis intervention in hospitalized older adults to reduce fear of falling.MethodsIn this feasibility randomized controlled trial, 32 older patients, hospitalized in geriatric rehabilitation wards, were randomly allocated (1:1 ratio) to either an intervention group (hypnosis, 2 sessions, one per week, plus usual rehabilitation program) or a control group (usual rehabilitation program only). Clinical assessors and statistician were blinded to group allocation. Primary outcomes were recruitment rate, retention rate, and adherence to the intervention. Exploratory outcomes, analyzed according to the intention-to-treat principle, included impact of hypnosis on fear of falling (assessed by a new scale perform-FES), functional status, in-hospital falls, and length of hospital stay.ResultsRecruitment rate was 1.3 patients per week. The recruitment of the population sample was achieved in 5.5 months. The retention rate did not differ significantly between groups and a good adherence to the hypnosis intervention was achieved (77% of patients received the full intervention). No adverse event related to the hypnosis intervention was observed. Regarding exploratory clinical outcomes, no differences were found between groups on any outcome.ConclusionHypnosis is feasible and well accepted in a geriatric hospitalized population undergoing rehabilitation. Further pilot work should be conducted, with an increased number of hypnosis sessions, before conducting a full-scale trial to conclude whether, or not, hypnosis is effective to reduce fear of falling.Trial registrationNCT04726774.

Association of Different Restriction Levels With COVID-19-Related Distress and Mental Health in Somatic Inpatients: A Secondary Analysis of Swiss General Hospital Data.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic and related countermeasures hinder health care access and affect mental wellbeing of non-COVID-19 patients. There is lack of evidence on distress and mental health of patients hospitalized due to other reasons than COVID-19—a vulnerable population group in two ways: First, given their risk for physical diseases, they are at increased risk for severe courses and death related to COVID-19. Second, they may struggle particularly with COVID-19 restrictions due to their dependence on social support. Therefore, we investigated the association of intensity of COVID-19 restrictions with levels of COVID-19-related distress, mental health (depression, anxiety, somatic symptom disorder, and mental quality of life), and perceived social support among Swiss general hospital non-COVID-19 inpatients.MethodsWe analyzed distress of 873 hospital inpatients not admitted for COVID-19, recruited from internal medicine, gynecology, rheumatology, rehabilitation, acute geriatrics, and geriatric rehabilitation wards of three hospitals. We assessed distress due to the COVID-19 pandemic, and four indicators of mental health: depressive and anxiety symptom severity, psychological distress associated with somatic symptoms, and the mental component of health-related quality of life; additionally, we assessed social support. The data collection period was divided into modest (June 9 to October 18, 2020) and strong (October 19, 2020, to April 17, 2021) COVID-19 restrictions, based on the Oxford Stringency Index for Switzerland.ResultsAn additional 13% (95%-Confidence Interval 4–21%) and 9% (1–16%) of hospital inpatients reported distress related to leisure time and loneliness, respectively, during strong COVID-19 restrictions compared to times of modest restrictions. There was no evidence for changes in mental health or social support.ConclusionsFocusing on the vulnerable population of general hospital inpatients not admitted for COVID-19, our results suggest that tightening of COVID-19 restrictions in October 2020 was associated with increased COVID-19-related distress regarding leisure time and loneliness, with no evidence for a related decrease in mental health. If this association was causal, safe measures to increase social interaction (e.g., virtual encounters and outdoor activities) are highly warranted.Trial registrationwww.ClinicalTrials.gov, identifier: NCT04269005.

Comparison of the modified Frailty-Index based on laboratory tests and the Clinical Frailty Scale in predicting mortality among geriatric rehabilitation inpatients: RESORT

ObjectiveTo compare the associations of the FI-lab, modified (m)FI-lab and Clinical Frailty Scale (CFS) with one-year mortality. Study designAn observational longitudinal inception cohort of inpatients admitted to the geriatric rehabilitation wards in the Royal Melbourne Hospital, Victoria, Australia. Main outcome measuresThe measured ratio was defined as the proportion of measured laboratory tests to the total number of tests (n = 77). The FI-lab is the proportion of abnormal results to the total measured laboratory tests. The mFI-lab was calculated by dividing the FI-lab by the measured ratio. The measured ratio of laboratory tests, FI-lab, mFI-lab and CFS were assessed at admission to geriatric rehabilitation. Patients’ mortality data were obtained from the Registry of Births, Deaths and Marriages Victoria and medical records. ResultsThe total of 1819 inpatients had a median age of 83.3 [77.5–88.3] years and 56.5% were female. The median measured ratio, FI-lab, mFI-lab and CFS scores were 0.58 [0.47–0.70], 0.31 [0.23–0.38], 0.51 [0.38–0.69] and 6 (Abbasi et al., 2018Gill, Gahbauer, Allore & Han, 2006; Howlett et al., 2014;) respectively. The one-year mortality rate was 17.1%. The measured ratio was not associated with one-year mortality. Higher FI-lab (hazard ratio (HR)=1.180, 95%CI: 1.037–1.343), mFI-lab (HR=1.074, 95%CI: 1.030–1.119) and CFS scores (HR=1.350, 95%CI: 1.191–1.530) were associated with higher risk of one-year mortality. The area under the curve (AUC) of FI-lab, mFI-lab and CFS with one-year mortality were 0.581, 0.587 and 0.612 respectively. ConclusionThe FI-lab, mFI-lab and CFS poorly predict mortality in geriatric rehabilitation inpatients despite the statistically significant associations shown.

Association of anemia with rehabilitation outcome for subacute geriatric rehabilitation patients in a secondary hospital in malaysia

Background: To evaluate the effects of anemia on rehabilitation outcomes for geriatric subjects in the Taiping Hospital subacute geriatric rehabilitation ward. Methods: This was a retrospective study with 126 subjects that compared the change in the modified Barthel Index score of anemic and non-anemic subjects. Results: In the study, 43.7% of subjects were anemic. Among anemic subjects, 45.5% were Malay, 38.2% were Chinese, 14.5% were Indian, and 1% were others. The median (Interquartile (IQR)) modified Barthel Index (MBI) on admission for anemic and non-anemic subjects was insignificantly different, at 47 (29, 63) and 36 (21, 59), respectively (P = 0.059). The median (IQR) of MBI improvement for non-anemic subjects was found to be significantly higher than for anemic subjects, which were 14 (5, 26) and 8 (1, 18; P = 0.021). Subjects with hemoglobin (hb) ≥ 9 g/dL were significantly associated with MBI improvement of more than 20, P = 0.009. Simple linear regression found that the P-values were not significant for albumin, creatinine, the Charlson comorbidity index, or the clinical frailty scale; hence, they were not significantly associated with rehabilitation outcome. Conclusions: The study suggested that non-anemic subjects showed significant MBI improvement. Our study also suggested that judicious practices to target a hb threshold of 9 g/dL might be able to improve a subject’s functional outcome. These results should encourage further research with a larger elderly population to provide insights and awareness for the need to treat anemia in rehabilitation subjects. Keywords: Geriatric, anemia, rehabilitation, modified barthel index

155 CHARACTERISTICS AND PREDICTORS OF INPATIENT FALLS IN A GERIATRIC REHABILITATION UNIT

Abstract Background Falls are one of the most frequent complications on geriatric rehabilitation wards. In addition to having adverse consequences for patients, falls also result in prolonged hospitalisation and increased healthcare costs. Therefore, identification of risk factors and development of successful falls prevention strategies targeted at this population are essential. The aim of this study is to identify predisposing or situational risk factors contributing to falls in older adults completing post-acute inpatient rehabilitation. Methods Retrospective review of all inpatient falls on two geriatric rehabilitation units over a one year period identified from incident forms. Chi-squared test was used to calculate differences between fallers and non-fallers. Results One in five patients admitted to the unit suffered a fall (average age 81, 52% male) with a total of 95 falls involving 56 patients. Of these, only 77% (n = 43) were identified as high risk on falls screening. 61% (n = 34) had one fall and 39% (n = 22) had two or more falls. Nearly one in three (n = 15) falls resulted in injury. More falls occurred in the single bedded unit (14.8 per 1,000 bed-days) as compared to the multi-bedded unit (6.8 per 1,000 bed days). Use of a Zimmer frame or rollator was associated with more falls than use of other mobility aids. Fallers tended to have a previous history of falls (75%, n = 42) and polypharmacy (average 10 medications). Delirium and dementia were present in one third of fallers. Falls were associated with a higher risk of discharge to long-term care, with 70% of fallers discharged home compared to 89% of non-fallers (p = 0.0006). Conclusion Previous falls, single room occupancy, polypharmacy and a medium level of dependency when mobilizing were identified as predictors of falls in our review. Nearly a quarter of fallers were not identified as high falls risk on screening further questioning the utility of falls risk screening assessments.

Trajectories of functional performance recovery after inpatient geriatric rehabilitation: an observational study.

ObjectiveTo identify functional performance trajectories and the characteristics of people who receive inpatient geriatric rehabilitation after hospital admissions.Design, setting, participantsREStORing health of acutely unwell adulTs (RESORT) is an observational, prospective, longitudinal inception cohort study of consecutive patients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital. Recruitment commenced on 15 October 2017.Main outcome measuresFunctional performance, assessed with the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales two weeks before acute hospitalisation, on admission to and discharge from geriatric rehabilitation, and three months after discharge from geriatric rehabilitation.ResultsA total of 618 rehabilitation patients were included in our analysis. For each of the two scales, three distinct functional performance trajectories were identified by latent class growth modelling: poor at baseline and 3‐month follow‐up (remained poor: ADL, 6.6% of patients; IADL, 42%), good at baseline but poor recovery (deteriorated: ADL, 33%; IADL, 20%), and good at baseline and good recovery (recovered: ADL, 60%; IADL, 35%). Higher Clinical Frailty Scale (CFS) score (v recovered, per point: odds ratio [OR], 2.51; 95% CI, 1.64–3.84) and cognitive impairment (OR, 6.33; 95% CI, 2.09–19.1) were associated with greater likelihood of remaining poor in ADL, and also with deterioration (CFS score: OR, 1.76; 95% CI, 1.45–2.13; cognitive impairment: OR, 1.87; 95% CI, 1.24–2.82). Higher CFS score (OR, 1.64; 95% CI, 1.37–1.97) and cognitive impairment (OR, 3.60; 95% CI, 2.31–5.61) were associated with remaining poor in IADL, and higher CFS score was also associated with deterioration (OR, 1.63; 95% CI, 1.33–1.99).ConclusionsBased on ADL assessments, most people who underwent inpatient geriatric rehabilitation regained their baseline functional performance. As higher CFS score and cognitive impairment were associated with poorer functional recovery, assessing frailty and cognition at hospital admission could assist intervention and discharge planning.

Persisterende zwelling na enkelartroscopie: pseudoaneurysma van de arteria tibialis anterior als zeldzame complicatie

Persistent swelling after ankle arthroscopy: pseudoaneurysm of the anterior tibial artery as a rare complication A patient was admitted to a geriatric rehabilitation ward following a septic arthritis for which she received an antibiotic treatment and arthroscopic irrigation. She had a normal kidney function and received a prophylactic dose of enoxaparin for the prevention of a deep venous thrombosis (DVT). During the hospitalization, a progressive, painless swelling of the ankle was seen. The ultrasonography showed a pseudoaneurysm of the anterior tibial artery measuring 4.2 cm by 4 cm by 1.7 cm. Following the surgical consultation, compression therapy was started. The follow-up ultrasonography after 4 weeks showed absence of flow in the pseudoaneurysm. A pseudoaneurysm is a rare complication (0.008%) of foot and ankle surgery. Risk factors are malnutrition, immunosuppression, diabetes mellitus and trauma or infection. Abnormal coagulation may contribute to the development of a pseudoaneurysm. The diagnosis is mostly based on clinical clues, confirmed by means of color-flow Doppler imaging. The treatment options include non-surgical methods (external compression, ultrasound-guided compression and ultrasound-guided thrombin injections), percutaneous endovascular therapy (coil, stenting) or surgical ligation with an aneurysmectomy and an arterial reconstruction. Although pseudoaneurysms are a rare complication, their possibility should be considered in the period following the commencement of mobilization and weight-bearing after ankle surgery, especially if risk factors are present.

Incorporating foot assessment in the comprehensive geriatric assessment

BackgroundFoot problems are common in older adults and associated with poorer physical function, falls, frailty and reduced quality of life. Comprehensive Geriatric Assessment (CGA), a multidisciplinary process that is considered the gold standard of care for older adults, does not routinely include podiatry assessment and intervention in hospitalized older adults.AimsTo introduce foot assessment to inpatient CGA to determine prevalence of foot disease, foot disease risk factors and inappropriate footwear use, assess inter-rater reliability of foot assessments, determine current podiatry input and examine associations between patient characteristics and foot disease risks.MethodsProspective, observational cohort study of older adults on geriatric rehabilitation wards. Foot assessment completed using the Queensland Foot Disease Form (QFDF) in addition to routine CGA.ResultsFifty-two patients (median age [inter-quartile range] 86.4 [79.2–90.3] years, 54% female) were included. Six patients (12%) had foot disease and 13 (25%) had a ‘high risk’ or ‘at risk’ foot. Foot disease risk factor prevalence was peripheral arterial disease 9 (17%); neuropathy 10 (19%) and foot deformity 11 (22%). Forty-one patients (85%) wore inappropriate footwear. Inter-rater agreement was substantial on presence of foot disease and arterial disease, fair to moderate on foot deformity and fair on neuropathy and inappropriate footwear. Eight patients (15%) saw a podiatrist during admission: 5 with foot disease, 1 ‘at risk’ and 2 ‘low risk’ for foot disease. Patients with an at risk foot or foot disease had significantly longer median length of hospital stay (25 [13.7–32.1] vs 15.2 [8–22.1] days, p = 0.01) and higher median Malnutrition Screening Test scores (2 [0–3] vs 0 [0–2], p = 0.03) than the low-risk group. Patients with foot disease were most likely to see a podiatrist (p < 0.001).ConclusionFoot disease, foot disease risk factors and inappropriate footwear are common in hospitalized older adults, however podiatry assessment and intervention is mostly limited to patients with foot disease. Addition of routine podiatry assessment to the multidisciplinary CGA team should be considered. Examination for arterial disease and risk of malnutrition may be useful to identify at risk patients for podiatry review.

Geriatric Activation Program Pellenberg, a novel physiotherapy program for hospitalized patients on a geriatric rehabilitation ward

Regaining functional independence and independent living is challenging in hospitalized geriatric patients. Different from community dwelling and institutionalized older people, geriatric patients on rehabilitation wards generally receive more frequent and structured physiotherapy with the primary aim to discharge them to their home or place of residence. There is a paucity of evidence concerning the structure and components of physiotherapy programs to improve functional performance in this particular group. In this paper, we describe how we developed the Geriatric Activation Program Pellenberg (GAPP) based on patients' needs and available literature. We searched the literature on physiotherapy interventions focusing on the core components for improvement of functional performance: strength, balance, function, (gait)speed, coordination, and endurance training. Based on physiotherapist staffing and physiotherapy time allocated to each patient, we organized the practical, daily delivery of the program. GAPP is a 5-day program, repeated weekly, delivered by physiotherapists and physiotherapy students. Each day, one or a combination of two to three different core components of functional performance is trained intensively in 45-min sessions. A set of standard exercises is constantly adjusted to each patients' capacity. On day 5, there is a mix of these core elements in a group session (e.g., chair-dance, table tennis, karate) and the Berg Balance Scale is completed to evaluate progress. GAPP is a multicomponent physiotherapy program for hospitalized patients on a geriatric rehabilitation ward, aimed at improving functional performance.

Factors associated with improved walking in older people during hospital rehabilitation: secondary analysis of a randomized controlled trial

BackgroundOlder people are often admitted for rehabilitation to improve walking, yet not everyone improves. The aim of this study was to determine key factors associated with a positive response to hospital-based rehabilitation in older people.MethodsThis was a secondary data analysis from a multisite randomized controlled trial. Older people (n= 198, median age 80.9 years, IQR 76.6- 87.2) who were admitted to geriatric rehabilitation wards with a goal to improve walking were recruited. Participants were randomized to receive additional daily physical therapy focused on mobility (n = 99), or additional social activities (n = 99). Self-selected gait speed was measured on admission and discharge. Four participants withdrew. People who changed gait speed ≥0.1 m/s were classified as ‘responders’ (n = 130); those that changed <0.1m/s were classified as ‘non-responders’ (n = 64). Multivariable logistic regression explored the association of six pre-selected participant factors (age, baseline ambulation status, frailty, co-morbidities, cognition, depression) and two therapy factors (daily supervised upright activity time, rehabilitation days) and response.ResultsResponding to rehabilitation was associated with the number of days in rehabilitation (OR 1.04; 95% CI 1.00 to 1.08; p = .039) and higher Mini Mental State Examination scores (OR 1.07, 95% CI 1.00 – 1.14; p = .048). No other factors were found to have association with responding to rehabilitation.ConclusionIn older people with complex health problems or multi-morbidities, better cognition and a longer stay in rehabilitation were associated with a positive improvement in walking speed. Further research to explore who best responds to hospital-based rehabilitation and what interventions improve rehabilitation outcomes is warranted.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12613000884707; ClinicalTrials.gov Identifier NCT01910740.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BackgroundIn some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.MethodsWe used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.ResultsAmong the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80–88] had available ADL scores at baseline (median score 7 [IQR 4–10]) and at discharge (median 9 [6–12]). Median CIRS-G score was 11 [8–13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27–7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17–8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4–37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83–6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.ConclusionBaseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.