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Presents information on a study which examined the effectiveness of geriatric evaluation and home intervention in the care of hospitalized aged patients in improving medical outcomes. Methodology; Results of the study; Discussion.

Background: Geriatric patients requiring rehabilitation and admitted to short-term care after an acute inpatient hospital stay seldom receive rehabilitative services later. Rehabilitative short-term care (REKUP) supplements short-term care with rehabilitative measures, aiming to prevent functional restrictions and long-term care., Study Objective: To conduct a cost and cost-effectiveness analyses of REKUP and provide data for a nationwide rollout., Material and Methods: A non-randomized controlled prospective study was carried out. The intervention group (IG) was paired 1:2 with a control group (KG), resulting in the formation of three collectives with follow-up periods of either 30, 90 or 180 days (each with IG and KG). Using administrative claims data from the AOK Baden-Württemberg, the mean total costs from the perspective of the health insurance were calculated. A potential impact of the intervention on costs was analyzed using the difference in differences approach., Results: The analysis comprised 129 patients (IG 43; KG 86). During the follow-up periods, the IG presented higher rates of rehabilitation and lower rates of long-term care and mortality. Regarding costs, no statistically significant differences were found between the IG and KG in any of the three collectives. For nursing care and medication costs, costs were significantly higher in the follow-up period for the KG, whereas costs for rehabilitation were significantly higher for the IG (p < 0.001)., Discussion: Patients receiving REKUP utilize rehabilitation services more often and have a lower likelihood of requiring nursing care or dying with no statistically significant differences in costs. There are potential advantages of REKUP in the target population, which warrant further investigation due to methodological limitations., (© 2024. The Author(s).)

Background: Geriatric patients in subacute inpatient care (SC) with rehabilitation needs after hospitalization seldom utilize rehabilitative services and are often transitioned to long-term care (LTC), suggesting that their care in SC can be optimized., Objective: To evaluate the effectiveness of rehabilitative subacute inpatient care (REKUP) in improving the care of geriatric patients in SC with rehabilitation needs after hospitalization., Methods: The study was conducted as a nonrandomized intervention trial with an historical control group (CG). The intervention group (IG: n = 49) received REKUP (activating therapeutic care, functional rehabilitative therapy, psychosocial services, medical care), while the CG (n = 57) received usual care during SC. Primary outcomes were transition to inpatient rehabilitation, home, and LTC, deteriorated care setting, care level, and mortality within 3 months after SC. Secondary outcomes were functional, motor and psychological variables., Results: The transition rate to inpatient rehabilitation (82% vs. 37%) and home (86% vs. 65%) was higher (p < 0.05) in the IG than in the CG. The proportion of persons utilizing LTC (12% vs. 35%) and with deteriorated care setting (35% vs. 60%) was lower (p < 0.01) in the IG than in the CG. The Barthel Index, visual analogue scale of the EQ-5D, and numerical pain scale improved (p < 0.05) during the SC stay in the IG but not in the CG., Discussion: REKUP as a new care model for SC promotes the transition to inpatient rehabilitation, reduces the utilization of LTC and improves the chances of returning home and achieving greater independence in geriatric patients with rehabilitation needs after hospitalization., (© 2024. The Author(s).)

Background: Failures of communication between professional caregivers and physicians affect the quality of supply of nursing home residents., Aim: As part of a model project it was aimed to develop a training for caregivers to improve communication and promote cooperation with physicians., Methods: For the needs assessment as a basis to develop the training 56 professional caregivers and 40 physicians engaged in nursing home care answered questionnaires regarding their cooperation. Based on these results a module for communication between professional caregivers and physicians was developed and adapted the TANDEM communication training for caregivers by Haberstroh and Pantel (2011). 25 professional caregivers in leading positions have been trained as multipliers in order to provide their colleagues the communication training with the additional element (TANDEMplus). TANDEMplus was evaluated in forms of reflection rounds and feedback questionnaires., Results: 254 professional caregivers, housekeeping staff and daytime companions participated in a complete TANDEMplus training by the multipliers until July 2014. The implementation of their developed communication strategies into practice was experienced positively by the participants., Conclusions: The module “communication with physicians” is relevant for professional caregivers to raise awareness of their own competence and facilitate a structured information exchange at eye level. The training of multipliers was executed in order to ensure transfer effects and sustainability.

Aim: The goal of this study was to perform a structured analysis of the treatment quality and acute complications of geriatric patients with diabetes mellitus (DM) cared for by nursing services and nursing home facilities. Secondly, structural problems and potentials for improvement in the care of multimorbid older people with DM treated by nursing homes and nursing services were analysed from the viewpoint of geriatric nurses, managers of nursing homes and general practitioners., Methods: In all, 77 older persons with DM from 13 nursing homes and 3 nursing services were included in the analysis (76.6% female, HbA1c 6.9 ± 1.4%, age 81.6 ± 9.9 years). Structural problems and potentials for improvement were collected from 95 geriatric nurses, 9 managers of nursing homes and 6 general practitioners using semistandardized questionnaires., Results: Metabolic control was too strict in care-dependent older people with DM (mean HbA1c value: 6.9 ± 1.4 %; recommended by guidelines: 7-8%). The measurement of HbA1c was performed in 16 of 77 people (20.8%) within the last year despite a high visitation frequency of the general practitioners (12.7 ± 7.7 within the last 6 months). The incidence of severe hypoglycemia was 7.8%/patient/year. Regarding the management in case of diabetes-related acute complications 33 geriatric nurses (34.7%) stated not having any written standard (nursing home 39%, geriatric services 16.7%)., Conclusion: Complex insulin therapies are still used in older people with DM with the consequence of a high incidence of severe hypoglycemia. Concrete management standards in the case of diabetes-related acute complications for geriatric nurses are lacking for more than one third of the nursing services.

Objective: The goal of the present study was to systematically assess treatment quality, perceptions, and cognitive function of elderly patients with diabetes admitted to an acute geriatric hospital from different home environments (nursing home residents, home care, assisted living, family caregivers, self-sufficient)., Methods: Quality of diabetes treatment, metabolic control (HbA(1c)), nutrition, treatment satisfaction, cognition, disability, and level of dependency were assessed in 128 patients with diabetes., Results: Out of 128 patients, 87 patients (68%) showed an HbA1c≤8% according to the guidelines for aging people with diabetes of the German Diabetes Association (DDG). Compared to patients living independently at home, the metabolic control in nursing home residents and their treatment satisfaction were as good. They had a higher degree of dependency though (Barthel, p<0.001), more strongly impaired mobility (Tinetti, p<0.01), less diabetes knowledge (p<0.001), inferior cognitive performance (MMSE, SPMSQ, p<0.01), and a higher prevalence of depression (GDS) (p<0.01). Better cognitive function correlated with better diabetes knowledge (r=0.49; p<0.001), but not with better metabolic control., Conclusion: The treatment of geriatric patients with diabetes mellitus requires individual considerations and interdisciplinary care. Particularly the continuing education of geriatric nurses could contribute to improved diabetes treatment quality in nursing home residents.

Background: Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes., Methods: The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design)., Results: 332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 +/- 8.3 vs. 15.0 +/- 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001)., Conclusions: The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

This paper describes the development and management of a new model of care for hospitalized patients with challenging behaviour evoked by dementia and/or delirium. To ameliorate care for patients with dementia in a geriatric acute care hospital a segregated Special Care Unit for patients with challenging behaviour was created. Environmental features allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Day-time activities structure the day and assure additional professional presence in the unit. An intensive training program for the staff was provided. The SCU has been well accepted by the staff and is considered to be an improvement in care. Psychological burden of the nurses did not increase over a time period of one year in caring for these difficult patients.

Background: To describe hospitalisations of nursing home (NH) residents in Germany during their last months of life., Methods: Retrospective cohort study on 792 NH residents in the Rhine-Neckar region in South-West Germany, newly institutionalized in the year 2000, who died until the study end (December 2001). Baseline variables were derived from a standardized medical examination routinely conducted by the medical service of the health care insurance plans in Germany. Information on hospitalisations and deaths was extracted form records of the pertinent health insurance plans., Results: NH residents who died after NH stay of more than 1 year spent 5.8% of their last year of life in hospitals. Relative time spent in hospitals increased from 5.2% twelve months before death (N = 139 persons) to 24.1% in their last week of life (N = 769 persons). No major differences could be observed concerning age, gender or duration of stay in NH. Overall, 229 persons (28.9%) died in hospital. Among these, the last hospital stay lasted less than 3 days for 76 persons (31.9%). Another 25 persons (3.2%) died within three days after hospital discharge., Conclusion: Our study indicates that proximity of death is the most important driver of health care utilization among NH residents. The relation of age or gender to health care expenditures seem to be weak once time to death is controlled for. Duration of NH stay does not markedly change rates of hospitalisation during the last months of life.

For the prevention and rehabilitation of fall-related fractures, not only functional status is important. It is necessary to describe the level of help and care needed at the time the fracture happened and its changes after a certain period. Investigations of the changes in the need of help and care after a fall-related fracture hardly exist for the Federal Republic of Germany. The first step in the present investigation was to analyze the changes in the need of help and care. In a second step, different developments of changes in the need of help and care after a fall-related hip fracture should be identified. Data for the present analysis were taken from a prospective 12-month observational survey (Fractures in late life). A total of 332 people aged 65 and over were assessed at two timepoints (T1-within the first 4 days post-fracture and T2-six months later by phone call). The assessed aspects were formal and informal support, financial support, ability to walk, cognition (only at T1) and form of housing. After the fall-related fracture the strain of formal and informal support increases. The strain of financial support and institutional care also increases. 20% of the patients achieved for the first time the criteria for the lowest level in the legal care system of Germany which indicates a higher level of need of care. 5% of the patients achieved post-fracture a higher level in the legal care system. Six different groups of patients could be identified by cluster analyses. They show differences in the changes in the ability to walk, form of housing, mortality and level of care and help. The different health status before and after the fall-related fracture leads to different developments post-fracture. In prevention and rehabilitation of patients with fall-related fractures, the individual needs of the subgroups should be taken into consideration.

The high rates of hospitalization in nursing home residents are as well known as the hazards of in-hospital treatment especially in this group of frail older people. Moreover, hospital admissions cause considerable costs. The objective of the study was to analyze why nursing home residents are admitted for in-hospital geriatric care, and to form hypotheses of how to prevent these admissions without loss of quality of care. Reason of admission, comorbidity, competence and length of in-hospital stay were assessed in all nursing home residents referred to the Geriatric Centre at the University Hospital of Heidelberg over 12 months. There were 245 admissions of 231 nursing home residents (83.1% female; age 84.2 +/- 7.10 years). Comorbidity was substantial (77% urinary incontinence, 69% dementia, 40% stool incontinence, 22% pressure ulcers), and 56% of residents needed assistance in using the toilet before admission. Mean length of in-hospital stay was 32.6 days (median 29 days). Out of a total amount of 7983 days of in-hospital care, 3627 (45%) were caused by falls and fractures, 2039 (26%) by cardiovascular events (mainly ischemic stroke), 835 (11%) by infections and 495 (6%) by problems concerning nutrition. Most of the leading causes of admission of nursing home residents to in-hospital geriatric care might be affected by improvements in nursing home care. Thus, data suggest that hospitalization rates might be substantially reduced by targeted prevention and therapy as well as by structural measures to improve case management in the nursing homes. Such interventions should be developed and proved in controlled studies.

The purpose of the study was to identify associations between drug prescriptions and the risk of falls in community-dwelling frail elderly people. 360 frail elderly patients underwent a comprehensive geriatric assessment during hospital stay. After discharge, the home falls were recorded by a questionnaire during the follow-up year and a home visit was carried out at the end of the year. Of 279 final patients with complete data, 141 subjects (50.5%) fell once; 62 subjects (22.2%) had a history of two or more falls during the follow-up period. Compared with subjects who did not fall or fell at the most once, those subjects with two or more falls showed a significantly higher prescription of tranquillizers/hypnotics, neuroleptics, diuretics, nitrates, and five or more different drugs. In multivariate analysis the prescription of tranquillizers/hypnotics with an adjusted odds ratio of 2.02 (95 percent confidence interval, 1.14 to 3.68) and the prescription of five or more different drugs with an adjusted odds ratio of 2.25 (95 percent confidence interval, 1.03 to 4.49) were found to be independent risk factors for multiple falls. In this prospective study in community-dwelling frail, elderly people the prescription of tranquillizers/hypnotics and five or more different medications could be identified as independent risk factors for multiple falls.

The competent handling of money is an essential basis for living independently. Seventy-eight consecutively admitted patients to a geriatric hospital underwent the Timed Test of Money Counting (TTMC) which measures patients' ability to open a purse, take out all the money and count it. Further assessment included Mini-Mental State Examination (MMSE), Barthel Index of ADL, Self-maintaining and Instrumental Activities of Daily Living (IADL), grip strength and Williams' Board Test. The TTMC was reliable (inter-rater and intra-rater) and showed construct and concurrent validity with other measures of physical function. Unlike many other physical performance tests the TTMC is quickly performed and requires no special equipment or training.

In this ongoing randomized controlled trial the effectiveness of an interdisciplinary team implementing hospital-based comprehensive geriatric assessment (CGA) and home intervention is being studied. All patients admitted from home showing functional decline with impairment of any basic activity of daily living are randomly assigned to one of the following courses of treatment: CGA with in-hospital and post discharge management by a home intervention team (HIT), where necessary (group 1): CGA with recommendations and usual care at home (group 2); or usual hospital and home care (group 3). The HIT consists of 3 nurses, 1 geriatrician, 1 physiotherapist, 1 occupational therapist, and 1 social worker. 540 patients will be recruited for the trial, which will assess the effects of GEM-HIT on the following outcomes: health status, functional status, survival, hospital readmission, nursing home placement and costs. The purpose of the GEM-HIT trial is to answer many of the current questions concerning treatment and health care delivery for frail older persons under the specific conditions found in Germany. The large sample size and the broad range of diagnoses included in the study will allow the evaluation of effects of GEM-HIT for subgroups and may help to identify the most effective assessment tools for use within our particular context.

To evaluate social aspects of elderly patients which are important for diagnosis and therapy within geriatric assessment, a questionnaire was developed and validated. Raters showed a high degree of agreement on the scale, which contains social contacts and support, activities, economic situation, and housing conditions (0.92-0.97; p < 0.05). Compared to the interrater reliability the test-retest reliability was somewhat lower (0.75), but also significant at the 5% level. The internal consistency showed high values between 0.72-0.89. In order to evaluate the validity of the screening test the answers of the patients were compared with the assessment of the therapeutic team. The team had information from a home visit, patients spouse, relatives, neighbors, community nurses and/or general practitioners. There was a significant relationship (p < 0.01) between therapeutic assessment and the scale (r = 0.51). Sensitivity, specificity, and total efficiency also attained sufficiently high values at a cut-off of 16/17 for the complete scale (max. 25 points). The test is easily and quickly performed; its acceptance is high. Social data relevant for treatment and discharge planning can thus be obtained and patients can be identified, for whom a home visit seems to be useful.

The causes of early rehospitalization (within 3 weeks) of very elderly patients, its possible avoidance and appropriate preventive measures were analysed retrospectively in patients of a geriatric hospital. Included were all those patients who had been admitted to the hospital from their home several (mean: five) times between 1987 and 1990 (48 women, 19 men; mean age 81.3 +/- 7.2 years--a total of 331 re-admissions). The most frequent diagnoses were heart failure (38.8%), acute cerebrovascular accident or its sequelae (31.3%), dementia (23.9%), fall or its sequelae (22.3%) and diabetes (20.9%). Of the 331 re-admissions 87 (26.3%) occurred during the first 3 weeks after discharge. The most important reasons of this early re-admissions were inadequate home care (41.4%), undesirable drug effects and non-compliance (25.3%), as well as rapid progression of the basic disease (14.9%). In the judgement of the hospital team more than 40% of the early re-admissions were avoidable, among those re-admitted because of inadequate home care and those in connection with drug intake even more than half. Early hospitalization is frequently avoidable, if individual geriatric assessment is undertaken and discharge carefully planned.