How can we improve targeting of frail elderly patients to a geriatric day-hospital rehabilitation program?

Reimagining Day Rehabilitation For Frailty and Neurodegenerative Conditions through the integrated Rehabilitation and EnAblement Program (iREAP)

Background

integrated Rehabilitation and EnAblement Program (iREAP) is an innovative redesign of the traditional day rehabilitation model, providing an anticipatory, early assessment and intervention program that manages care of community-dwelling older people with complex needs. It coordinates access to disciplines across medical, allied health and nursing, with a self-management focus, partnering with primary health in an integrated approach.

Objective

This observational study reviews the effectiveness of iREAP on frailty, patient activation, quality of life and physical outcome measures on older people at risk of, or experiencing falls and frailty, or with neurodegenerative conditions, including Parkinson's Disease.

Methods

99 participants completed the eight-week multidisciplinary program. Patient outcome measures included Rockwood Clinical Frailty Scale, quality of life measures, Patient Activation Measure, Timed Up and Go, 6 Minute Walk Test and Berg Balance Scale.

Results

On completion of iREAP, participants displayed improvements in their Rockwood Clinical Frailty Scores (mildly frail to vulnerable), 'patient activation' (55.08 to 60.61), quality of life (Parkinson's Disease Questionnaire-39, 49.93 to 47.16; WHO Quality of Life - Bref physical domain, 21 to 22.7) and physical measures including balance (44 to 49/56 Berg Balance scale) and mobility (294 m to 336 m, 6-minute walk test). Falls were not reduced at twelve months post-program (3.40 to 2.01).

Conclusion

iREAP is an interdisciplinary, early assessment and intervention program with the potential to reverse frailty and improve quality of life for complex older patients. This paper offers a platform for future research, given the paucity of evidence reviewing the efficacy of integrated anticipatory models of care in older adults with complex needs.

Assessment Tools for the Admission of Older Adults to Inpatient Rehabilitation: A Scoping Review

(1) Objective: To identify the assessment tools and outcome measures used to assess older adults for inpatient rehabilitation. (2) Design: Scoping review. (3) Data sources: ProQuest, PEDro, PubMed, CINAHL Plus with full text (EBSCO), Cochrane Library and reference lists from included studies. (4) Review method: The inclusion of studies covering patients aged >60, focusing on rehabilitation assessments delivered in hospitals in community settings. Studies reporting on rehabilitation specifically designed for older adults-testing for at least one domain that affects rehabilitation or assessments for admission to inpatient rehabilitation-were also included. Results were described both quantitatively and narratively. (5) Results: 1404 articles were identified through selected databases and registers, and these articles underwent a filtering process intended to identify and remove any duplicates. This process reduced the number to 1186 articles. These, in turn, were screened for inclusion criteria, as a result of which 37 articles were included in the final review. The majority of assessments for geriatric rehabilitation were carried out by a multidisciplinary team. Multiple studies considered more than one domain during assessment, with a high percentage evaluating a specific outcome measure used in geriatric rehabilitation. The most common domains assessed were function, cognition and medical status-with communication, vision and pain being the least common. A total of 172 outcome measures were identified in this review, with MMSE, BI, FIM and CCI being the most frequent. (6) Conclusions: This review highlights the lack of standardised approaches in existing assessment processes. Generally, older-adult-rehabilitation assessments struggle to capture rehabilitation potential in a holistic manner. Hence, a predictive model of rehabilitation for assessing patients at the initial stages would be useful in planning a patient-specific programme aimed at maximising functional independence and, thus, quality of life.

Frailty as a Predictor of Poor Rehabilitation Outcomes among Older Patients Attending a Geriatric Day Hospital Program: An Observational Study

Background: The Geriatric Day Hospital (GDH) is an important outpatient geriatric service, but there are few data on the role of frailty as a potential predictor of poor outcomes in this setting. Methods: Data were analyzed from 499 patients aged ≥ 60 years attending a 12-week GDH program between 2018 and 2021. Frailty status was defined as non-frail (68, 13.6%), mild/moderate frailty (351, 70.3%), and severe frailty (80, 16.0%) based on the Clinical Frailty Scale (CFS). Outcomes were defined as (1) poor outcome (hospital readmission, death, or medical deterioration) during the program and (2) admission to permanent nursing home care upon completion of the program. Multivariate logistic models were used for predictive analyses. Results: The mean age was 80.3 (standard deviation 7.0); 58.3% were women. Overall, 77 patients (15.4%) had a poor outcome, and 48 (9.6%) were admitted to permanent nursing home care. Poor outcome was experienced by none of the non-frail patients (0%), by 49 (14.0%) patients with mild/moderate frailty, and 22 (27.5%) patients with severe frailty (adjusted OR, 2.0; 95% CI 1.3, 3.2; p < 0.01). Admission to a permanent nursing home care was experienced by none of the non-frail patients (0%), 20 (5.7%) of those with mild/moderate frailty, and 28 (35.0%) with severe frailty (adjusted OR, 2.9; 95% CI 1.3, 6.3; p < 0.01). Conclusions: The CFS is a promising risk predictor of poor outcome and admission to permanent nursing home discharge among older patients attending a GDH program.

Reliability, validity and minimal detectable change of 2-min walk test and 10-m walk test in frail older adults receiving day care and residential care

BACKGROUND

The psychometric properties of the 2-min walk test (2MWT) and 10-m walk test (10MeWT) for frail older adults are unclear.

AIMS

To determine the test-retest and inter-rater reliability, construct and known-group validity, and minimal detectable change at 95% level of confidence (MDC₉₅) of these walk tests in frail older adults receiving day care and residential care services.

METHODS

A cross-sectional study with repeated measures was conducted on frail older adults who could walk independently for at least 15 m. The participants completed the 2MWT and 10MeWT on three separate occasions over a 2-week period under two independent assessors.

RESULTS

Forty-four frail older adults were examined. Excellent test-rest (ICC = 0.95-0.99) and inter-rater reliability (ICC = 0.95-0.97) were shown in both walk tests. Good to strong correlations were found between the walk tests and 6-min walk test (r = 0.89-0.92), Elderly Mobility Scale (r = 0.56-0.57), Berg Balance Scale (r = 0.66-0.66) and Modified Barthel Index (r = 0.55-0.59). The MDC₉₅ were 7.7 m in the 2MWT and 0.13 m/s in the 10MeWT.

DISCUSSION

Although the walking performances of the day care and residential care participants were similar, the validity of the walk tests was different between these two subgroups.

CONCLUSIONS

The 2MWT and 10MeWT are reliable and valid measures in evaluating the walking performances of frail older adults. The MDC₉₅ of the walk tests has been recommended.

Treatment in a Geriatric Day Hospital improve individualized outcome measures using Goal Attainment Scaling

Background

Evidence regarding outcomes in the Geriatric Day Hospital (GDH) model of care has been largely inconclusive, possibly due to measurement issues. This prospective cohort study aims to determine whether treatment in a GDH could improve individualized outcome measures using goal attainment scaling (GAS) and whether improvements are maintained 6-months post-discharge.

Methods

A total of 469 outpatients admitted to a Canadian Geriatric Day Hospital, between December 2008 and June 2011, were included in the analysis (81.1 ± 6.7 years, 66.3% females); a smaller cohort of 121 patients received a follow-up phone call 6 months following discharge. Baseline, discharge and 6 month post-discharge observer-rated measures of mobility, cognition, and function were completed using GAS. Traditional psychometric measures were also captured.

Results

The mean number of goals set was 1.6 (SD 0.8) and patients set goals in the following domains: 88% mobility or falls reduction; 18% optimization of home supports; 17% medication optimization;12% cognition; 8% increasing social engagement; and 5% optimization of function. Total GAS was the most responsive measure to change with 86% of patients improving at discharge; mobility goals were the most likely to be achieved. Six-month GAS scores remained significantly higher than GAS scores on admission. Those who had more goals were more likely to improve during GDH admission (OR 1.49, CI 1.02-2.19) but this association was not seen 6 months after discharge.

Conclusions

This study demonstrated short- and long-term effectiveness of GDH in helping patients achieve individualized outcome measures using GAS.

Nutritional and Functional Status in Geriatric Day Hospital Patients - MNA Short Form Versus Full MNA

OBJECTIVES

The aims of this study were to determine the prevalence of malnutrition in patients of a geriatric day hospital using the Mini Nutritional Assessment short form (MNA-SF) and the full MNA, to compare both tools, and to examine the relationship between nutritional and functional status.

DESIGN

Cross-sectional study.

SETTING

Geriatric day hospital.

PARTICIPANTS

190 patients (72.1% female, median 80 years) aged 65 years or older.

MEASUREMENTS

In consecutively admitted geriatric day hospital patients nutritional status was assessed by MNA-SF and full MNA, and agreement between both tools calculated by Cohen´s kappa. Basic activities of daily living (ADL), instrumental activities of daily living (IADL) and short physical performance battery (SPPB) were determined and related to MNA categories (Chi2-test, Mann-Whitney-U-test).

RESULTS

36.3 % and 44.7% of the patients were at risk of malnutrition, 8.9 % and 5.8 % were malnourished according to MNA-SF and full MNA, respectively. Agreement between both MNA forms was moderate (κ=0.531). No significant associations between MNA-SF and ADL, IADL and SPPB, and between full MNA and SPPB were observed. According to full MNA, the proportion of patients with limitations in ADL and IADL significantly increased with declining nutritional status (ADL: 2.1 vs. 8.2 vs. 18.2 %, p=0.044; IADL: 25.5 vs. 47.1 vs. 54.5 %, p=0.005) with a simultaneous decrease of the proportion of patients without limitations. Well-nourished patients reached significantly higher ADL scores than patients at risk of malnutrition (95 (90-100) vs. 95 (85-100), p=0.005) and significantly higher IADL scores than patients at risk or malnourished (8 (6-8) vs. 7 (5-8) vs. 6 (4-8), p=0.004).

CONCLUSION

The high prevalence of risk of malnutrition and the observed association between functional status and nutritional status according to full MNA call for routine nutritional screening using this tool in geriatric day hospital patients.

Factors associating with shuttle walking test results in community-dwelling elderly people

BACKGROUND

The shuttle walking test (SWT) is a simple, widely used method for assessing endurance performance in the elderly. Despite widespread community use, its associated factors are unclear.

AIMS

We aim to identify previously undefined SWT association factors in community-dwelling elderly people.

METHODS

Herein, 149 healthy elderly Japanese subjects performed the SWT, and were assessed for height, weight, smoking history, 10-m walk time, Timed Up and Go (TUG) scores, handgrip strength, skeletal mass index (SMI), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), cardio-ankle vascular index, and ankle brachial index. We divided men and women into higher and lower SWT score groups, compared between-group parameters, and performed stepwise multivariate logistic regression analysis to identify factors independently associated with SWT scores.

RESULTS

Age, BMI, 10-m walk time, TUG score, SMI, FVC (L; %-predicted), and FEV1 (L; %-predicted) were significantly different between SWT score groups for men, while in women, significant differences were observed in age, TUG score, handgrip strength, FVC (L; %-predicted), and FEV1 (L; %-predicted) (p < 0.05). In the multivariate logistic regression model, 10-m walk time, and FEV1 showed significant associations with SWT results in men; among women, age was the only significantly associated factor (p < 0.05).

CONCLUSIONS

Results indicate that better lung function and shorter walk time independently associate with SWT results in community-dwelling men; in women, age is the only association. Our findings may offer insight when considering the focus of community exercise programs among the elderly.

Medical day hospital care for older people versus alternative forms of care

BACKGROUND

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location.

OBJECTIVES

To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status.

SEARCH METHODS

Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care.

MAIN RESULTS

Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14).

AUTHORS' CONCLUSIONS

There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource

Background and design

This research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.

Research objectives

(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.

Setting

Community-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).

Participants

The combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.

Interventions

The interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.

Outcome measures

(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.

Results

(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.

Conclusions

This study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.

Funding

The NIHR Health Services and Delivery Research programme.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.