Programme evaluation of a geriatric rehabilitation day hospital

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

Objective: (1) To assess whether a rehabilitation day hospital programme is associated with a reduced handicap level of stroke patients. (2) To estimate the relationship between the London Handicap Scale (LHS) and other outcome measures. (3) To examine the effect of demographic parameters (age, gender, family status, education) on LHS scores.

Design: A prospective longitudinal survey.

Setting: An urban geriatric rehabilitation day hospital.

Subjects: Two hundred and seven elderly stroke patients admitted between December 1999 and February 2001. Main outcome measures: London Handicap Scale (LHS), Functional Independent Measure (FIM), Nottingham Extended ADL Index, timed get up and go test.

Results: LHS scores at discharge changed significantly (p < 0.008) for mobility, physical independence and occupation. The overall change in LHS score was 2.3 points (20%); effect size 0.43. A significant relationship was found between discharge score of LHS and admission score of FIM, Nottingham Index, timed get up and go and age. Multiple linear regressions did not identify a good predictor for the discharge score of LHS. Higher education was associated with higher LHS scores on admission (p= 0.016) but with less success in correcting handicap (p= 0.046).

Conclusions: A day hospital programme is associated with reduced level of handicap in stroke patients. The LHS is a useful and simple scale for measuring change in these patients. LHS in stroke patients correlates with other outcome measures, yet they cannot be used interchangeably. A significant relationship between education and level of handicap exists.

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.

The efficacy of counseling and progressive resistance home-exercises on adherence, health-related quality of life and function after discharge from a geriatric day-hospital

Loss of function and low exercise adherence is common among older people after hospitalization. The aim of this randomized-controlled trial was to evaluate the effects of a combined counseling- and exercise program on changes in health-related quality of life (HRQL) and physical function in patients attending a day hospital and continuing exercise at home. The exercise program consisted of counseling, balance- and progressive resistance training and support from the physical therapist at Geriatric Day-Hospital (GDH) and home for the Intervention-group. The Control-group received counseling, balance-training and support from the physical therapist. The sample was recruited from a GDH in Norway. 108 participants were randomized into the Intervention group (IT) (n=53) or the Control group (CT) (n=55). After 3 months 77 participants were tested. The intention to treat analysis showed that the program had significant benefits in terms of Health Related Quality of Life, measured by SF-36, on the domains vitality and bodily pain, in favor of the IT-group who performed the combined resistance exercises and balance program. All participants increased their scores on physical function, measured by Berg Balance Scale, Timed Up and Go, 5 times Sit-to-Stand, 6 Min Walk Test and Activities Balance Confidence Scale, no group differences. Both groups were adherent to the home exercise program The results show that it is possible to facilitate older people to increase their HRQL, physical function and level of physical activity through counseling, exercise and support from physical therapists.

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

Background

The optimal patient selection of frail elderly persons undergoing rehabilitation in Geriatric Day Hospital (GDH) programs remains uncertain. This study was done to identify potential predictors of rehabilitation outcomes for these patients.

Methods

This study is a retrospective cohort analysis of patients admitted to the rehabilitation program of our GDH, in Montreal, Canada, over a five year period. The measures considered were: Barthel Index, Older Americans Resources and Services, Folstein Mini Mental Status Exam, Timed Up & Go (TUG), 6-minute walk test (6 MWT), Gait speed, Berg Balance, grip strength and the European Quality of life - 5 Dimensions. Successful improvement with rehabilitation was defined as improvement in three or more tests of physical function. Logistic regression analysis using the Bayesian Information Criterion (BIC) was employed to select the optimal model for making predictions of rehabilitation success.

Results

A total of 335 patients were studied, but only 233 patients had a complete data set suitable for the predictive model. Average age was 81 years and patients attended the GDH an average of 24 visits. Significant changes were found in several measures of physical performance for many patients ranging from improved gait speed in 21.3% to improved TUG in 62.7% of the cohort. Fifty-eight percent of patients attained successful improvement with rehabilitation by our criteria. This group was characterized by lower test scores on admission. Using BIC, the best predictor model was the 6 MWT [OR: 0.994 per meter walked (95% CI: 0.990-0.997)].

Conclusions

The GDH rehabilitation program is effective in improving patients' physical performance. Although no single measure was found to be sufficiently predictive to help target candidates appropriately, the 6 MWT showed a trend to significance. Further research will be done to elucidate the utility of a composite 'rehab appropriateness index' and the role of International Classification of Function concepts for targeting frail elderly to GDH rehabilitation services.

The association between patients' cognitive status and rehabilitation outcome in a geriatric day hospital

PURPOSE

To assess whether and to what extent cognitive status affects functional gain in mobility and extended activities of daily living (ADL) in patients admitted to a geriatric day hospital.

METHODS

During 2003, 135 older patients admitted to a rehabilitation day hospital were evaluated by the Mini Mental State Examination (MMSE) and the Cognitive Functional Independence Measure (FIM). On admission and at discharge, they were assessed by the Nottingham Extended ADL Index (NEAI) and the Timed Get Up and Go test (TUG).

RESULTS

Orthopedic and stroke patients achieved significant functional gain in mobility regardless of their cognitive status. Nevertheless, cognitively intact stroke patients achieved higher admission and discharge NEAI scores, manifesting greater absolute functional gain than cognitively impaired patients. The patients' ability to extract their rehabilitation potential was significantly better.

CONCLUSIONS

Cognitively impaired patients can improve in mobility and performance of extended ADL during day hospital rehabilitation. Evaluation of the patients' cognitive status may enable the multidisciplinary team to develop suitable individual programs and better allocate resources. Cognitively intact stroke patients may benefit from extended rehabilitation treatment compared to impaired stroke patients as they are more capable of utilizing their potential to achieve independence in daily tasks.

Evaluation of a geriatric day rehabilitation centre: subjective and objective outcomes in community-dwelling older adults

Pre and post testing were conducted on community-dwelling older adults referred to a geriatric day rehabilitation centre (DRC). Consecutive DRC clients were screened for inclusion over a 16-month period and were eligible if: aged 60+ years; cognitively intact; and reason for referral involved spinal or lower limb musculoskeletal impairment, disability or surgery, and/or reduced functional mobility or falls. Clients were excluded if they had a neurological disorder, or did not complete the program. Outcome measures included: lower limb strength; balance; mobility; self-reported pain; activities of daily living; and quality of life. Data were summarised using descriptive statistics and analysed using paired t-tests. Of the 137 participants recruited, 110 were female and the mean age was 79.5 ± 7.3 years. In total, 106 participants completed the DRC program and were assessed at baseline and re-assessed at discharge. The mean length of stay was 12.4 ± 2.9 weeks, with 21.4 ± 5.4 attendances. From baseline to discharge, statistically significant differences were found for all objective measures of physical functioning, balance, and for all lower limb strength tests (P < 0.0001). Glasgow Pain Questionnaire scores demonstrated statistically significant improvements in all five domains of the scale (P < 0.0001). The Barthel Index and Multi-dimensional Functional Assessment Questionnaire both showed a statistically significant improvement in the level of independence in activities of daily living (ADL) (P < 0.05). The Assessment of Quality of Life Questionnaire showed a statistically significant improvement (P = 0.027). The Exercise Benefits/Barriers Scale also showed a statistically significant improvement over DRC attendance (P = 0.005). The Falls Efficacy Scale showed a positive change, but the improvement was not statistically significant (P = 0.80). The study’s results indicate that community-dwelling older adults with physical disabilities and multiple comorbidities who attended the interdisciplinary geriatric DRC, significantly improved their lower limb strength, balance and physical function, and also showed significant decreases in self-reported pain, and improvements in independence in ADL and quality of life. Given the limitations of the current study, further research, in the form of high quality studies with larger sample sizes that involve direct comparisons with other forms of care or against a control group, is needed to determine whether day rehabilitation centre programs provide the optimum mode of rehabilitation for this population in the most cost effective manner.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

The proportion of the world's population aged 60 or over is increasing. This review sets out to examine the effectiveness and resource implications of geriatric medical day hospital attendance for elderly people. This is an update of a Cochrane review first published in 1999.

OBJECTIVES

To examine the effectiveness of attendance at a medical day hospital for elderly people in preventing death, disability, and institutionalisation and improving subjective health status.

SEARCH STRATEGY

We searched the EPOC group specialist register (March 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2008), MEDLINE (1996 to January 2008), EMBASE (1996 to 2008 week 5), and other databases.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing attendance at a geriatric medical day hospital with alternative forms of care for elderly medical patients (usually > 60 years).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed research reports to determine eligibility, categorise trial type and extract data.

MAIN RESULTS

Thirteen trials involving 3007 participants were included. These compared day hospital with a) comprehensive elderly care (five trials), b) domiciliary care (five trials), or c) no comprehensive elderly care (three trials).There were no significant differences between day hospital attendance and the sub-categories of comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio (OR) 0.73; 95% confidence interval (CI) 0.53 to 1.00; P < 0.05).Dependency was measured in 12 trials using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remaining trials there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed a reduced odds of deterioration when compared with those receiving no comprehensive elderly care (OR 0.60; 95% CI 0.38 to 0.97; P < 0.05).When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care.

AUTHORS' CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

Reliability and validity of the Turkish version of the Nottingham Extended Activities of Daily Living Scale

BACKGROUND AND AIMS

The aim of this study was to develop a Turkish version of the Nottingham Extended Activities of Daily Living Scale (NEADLS) and to assess its reliability and validity.

METHODS

Sixty healthy volunteers over 67 years old were included in the study. After translation, the Turkish version of the scale was filled in by each participant over a period of 2 weeks. Reliability was assessed by internal consistency, test-retest intraclass correlation coefficient (ICC) and Spearman's correlation. Converging validity was determined correlating the scale with the Modified Barthel Index (MBI).

RESULTS

The mean age of participants was 77+/-5.67 years. In the reliability studies, internal consistency within the subsections and items of the NEADLS was good and very good, with Cronbach's alpha values ranging between 0.84-0.93 and 0.74-0.97 respectively. The Cronbach's alpha for the total NEADLS score was also determined as 0.97. Test-retest intraclass correlation coefficients, determined as 0.97 in total score, ranged from 0.84-0.97 between items. The converging validity study for the NEADLS total score was correlated with the MBI and the r value was found statistically significant (r=0.84, p<0.0001).

CONCLUSIONS

The Turkish version of the NEADLS is a reliable and valid scale and can be used in activities of daily living assessment of Turkish elderly persons.

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

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

Get up and go--home

BACKGROUND AND AIMS

One of the most important objectives of a rehabilitation program is to improve patients' mobility. Mobility measures are necessary in evaluating treatment effectiveness. The aims of the present study were to assess the usefulness of the "Timed Get Up and Go" (TUG) test as a mobility measure for patients attending a day hospital, and as an additional tool in assisting a multidisciplinary team in clinical decision-making regarding length of stay in a day hospital.

METHODS

Two hundred and thirty elderly patients, admitted during 2000, were assessed by the TUG test and Functional Independence Measure (FIM) on admission and at discharge. The patients were divided into four performance categories (TUG score <20; 20.01-40; 40.01-60 and >60 seconds). The sensitivity of the test to changes in patients' mobility level and the relationship between it and other measures were assessed.

RESULTS

Mean TUG score on admission was 32.6+/-24.2 seconds, and upon discharge 21.8+/-18.3 seconds. The difference in score changes between orthopedic patients (14.2 sec), patients with chronic disabling diseases (10.3 sec) and stroke patients (10.1) was statistically significant (p=0.013). On admission, 35.7% performed the TUG test in <20 seconds and upon discharge in 60.9%. A significant negative correlation was found between TUG scores and FIM and motor FIM scores on admission and at discharge.

CONCLUSIONS

The TUG test is a sensitive test for measuring changes in the mobility level of patients attending a day hospital. Easy to carry out, the test furnishes additional information that may assist medical personnel in deciding criteria for discharge readiness.