Rehabilitative treatment of cerebral apoplectic insults in advanced age and evaluating its effectiveness--results of a model project

This report is of a two year study of stroke rehabilitation. Given certain conditions with specialized personnel and equipment the rehabilitation of elderly stroke patients can be managed co-operatively in hospitals and old age care centres. The rehabilitation of stroke affected is based on the support of multidisciplinary diagnosis and interdisciplinary teamwork between physicians, physiotherapists, occupational therapists, speech therapists, psychologists and social workers. Each patient requires an individual treatment program. In this study were 72 patients ranging in age from 42-87 years, average age 73 years. They had been judged as progressively degenerative and helpless following their stroke and consequently regarded as patients for a nursing home. Following special rehabilitation treatment 75% (54 patients) had improved enough that it was possible for them to return to their homes. Only 12.5% (9 patients) had to remain in a nursing home. 6.6% (4 patients) transferred to an old people's home. 6.9% (9 patients) were readmitted to hospital because of additional serious complications. The average duration of rehabilitative treatment was 72.3 days. The degree of hemiplegia and the patients ability to lead their own active daily independent life was reviewed before and after rehabilitation and used as control. 76.6% showed an improvement in their motor function. 61.1% returned to their own independent daily life as measured by ADL-Indices. (a. Barthel Index, b. ADL-Index-Katz-, c. Patient Classification for Long Term Care-Jones-, d. Crichton Royal Behavioural Rating Scale-Robinson-.).(ABSTRACT TRUNCATED AT 250 WORDS)     

The attitude of stationary hospital patients towards the old people home and the nursing home (author's transl)

Changes in our health and hospital policy towards shorter stays in hospital as well as changes in our social and family structures have led to a lot of problems in geriatrics. It is complicated to insure a necessary continuing home-treatment or a supply of daily necessities which are often necessary with advancing age after acute sicknesses. This has resulted in that many of the old peoples' or nursing home places are filled directly from the hospital. During investigations of 496 patients of an internal clinic we found that a rather high number of geriatric patients accepted a change into an old peoples or nursing home in contrast to investigations conducted outside the clinic. But the hospital patients complained about the same points in these institutions as the non-hospitalized. Therefore hospital personnel (doctors, sisters, nurses, therapeuts and social workers) ought to try all possibilities for rehabilitation inside and outside the usual stationary institutions (Reha-clinic, day-clinic) to insure the reintegration of old people in familiar or neighbourly surroundings. If this is not possible, the patients should be given enough time and opportunity to adjust themselves to the new life situation and to make independent decisions.     

Begutachtung von Pflegebedürftigkeit nach SGBXI Weichenstellung für Interventionsprogramme der geriatrischen Rehabilitation

Zusammenfassung Eine der Zielvorgaben des SGB XI ist der “Vorrang von Prävention und Rehabilitation” vor Pflege. Die GutachterInnen der Medizinischen Dienste führen pro Jahr ca. 1,2Mio. Begutachtungen durch. Nur bei ca. 12% der Betroffenen werden dabei gezielt Rehabilitationsmaßnahmen für notwendig erachtet. Es ist auf den ersten Blick kaum vorstellbar, dass nur so wenige Patienten eine solche Maßnahme benötigen sollen.¶ Es ist zu diskutieren, ob der Anspruch des Gesetzgebers, der Vorrang von Prävention und Rehabilitation vor Pflege, nicht sachgerecht ist, oder die derzeitigen sozialpolitischen und medizinischen Umstände eine höhere Empfehlungsrate nicht zulassen.¶ Es werden Problemfelder dargestellt, die bei der Begutachtung von Pflegebedürftigkeit nach SGB XI offensichtlich werden und die direkt oder indirekt Auswirkungen auf die Empfehlung von Maßnahmen der geriatrischen Rehabilitation für die Betroffenen haben.¶ Als Ergebnis der Problemdiskussion ergeben sich folgende Konsequenzen: Die Betroffenen und ihre Angehörigen, aber auch die behandelnden Ärzte, müssen über die diagnostischen und therapeutischen Möglichkeiten mehr und bedarfsgerechtere Informationen erhalten. Alle Beteiligten müssen schnellstmöglich konsensfähige Konzepte, Modellprojekte und Lösungsmöglichkeiten gemeinsam erarbeiten und umsetzen.¶ Die Überalterung der Bevölkerung in der Bundesrepublik muss als gesamtgesellschaftliches Problem erkannt und die Bewältigung ihrer Folgen als prioritäre Aufgabe des Gemeinwesens verstanden werden. Die Geriatrie, als eine der zukunftsträchtigsten Bereiche der Medizin, muss deshalb endlich die notwendige Aufmerksamkeit in der (politischen) Öffentlichkeit erlangen. Summary "Rehabilitation instead of nursing care" is one of the most important entitlements of the social welfare legislation to long-term care. In Germany 1.2 million evaluations per year are done by the experts of the medical review boards of the health insurance funds. As a part of those evaluations the experts also have to discuss the necessity of any kind of rehabilitation procedures. In 1999 according to the experts' opinion only about 12% of the patients need such special support. At first this number seems much too low.¶ We discuss the problems in that social field: Does the demand of the social welfare legislation "prevention and rehabilitation instead of nursing care" not correspond to the real needs or are the circumstances of social policy and medical supply responsible for that low recommendation of rehabilitation programs.¶ This discussion leads to the following consequences: The patients, the members of their family but also the treating physicians must be informed much better than today about diagnostic and therapeutic possibilities for the special diseases of elderly people.¶ All in the game have to prepare concepts, pilot projects and then common solutions for geriatric rehabilitation programs as soon as possible. Politicians, physicians, nursing staff, rehabilitation staff, patients, family members and any other caregivers all have to take responsibility, maybe the liability.¶ Not only German people will be growing older than ever before, which everyone has to recognize as one of the most important facts of our welfare state. To handle this development will be the most serious duty of our community in the future. Therefore, geriatrics has to receive high public attention.     

The nursing home resident with dementia. Clinical care, ethics, and policy implications

How much treatment should be given elderly patients with dementing illness is controversial. Nursing home care should be based on palliation, rehabilitation, and the control of coexisting illness. Ethical standards are advanced from the principle that the life and well-being of the demented nursing home resident should be protected. The decision to forego medical treatment is justified only when the life of an affected person is burdened by severe, unrelieved suffering or by the absence of self-awareness and relational potential. Introducing this philosophy of care to institutions requires a greater societal commitment to nursing home care.     

Social sequelae and problems following apoplexy

162 patients with stroke (cerebrovascular accident) were investigated of some social problems. The patients were treated in two internal clinics or in a rehabilitation center for stroke-patients. The assessments were accomplished in 30 months after clinical treatment. The average of age was 69 years. The percentage of women was 61%. The majority of patients lives in own flats, 12% in a nursing home. The furniture of flats, was often not approximated for disabled persons. The care almost was undertaken through relatives. More institutional support could be helpful in few cases. Help was wished in according to conditions of flats, meals on wheels, programs for self-activities, references to nursing, technical helpings and transportation services. These investigations suggest that the families are an important factor in rehabilitation of stroke. They need social and psychological support. The attitude of family determinated essential the prognosis of rehabilitation.     

Kardiologische Rehabilitation

The goal of cardiac rehabilitation is to support heart patients using a multidisciplinary team in order to obtain the best possible physical and mental health and achieve long-term social reintegration. In addition to improving physical fitness, cardiac rehabilitation restores self-confidence, thus better equipping patients to deal with mental illness and improving their social reintegration ("participation"). Once the causes of disease have been identified and treated as effectively as possible, drug and lifestyle changes form the focus of cardiac rehabilitation measures. In particular diseases, rehabilitation offers the opportunity for targeted educational courses for diabetics or drug dose escalation, as well as special training for heart failure patients. A nationwide network of outpatient heart groups is available for targeted follow-up. Cardiac patients predominantly rehabilitated in follow-up rehabilitation are older and have greater morbidity than in the past; moreover, they generally come out of acute clinical care earlier and are discharged from hospital more quickly. The proportion of severely ill and multimorbid patients presents a diagnostic and therapeutic challenge in cardiac rehabilitation, although cardiac rehabilitation was not initially conceived for this patient group. The benefit of cardiac rehabilitation has been a well documented reduction in morbidity and mortality. However, hurdles remain, partly due to the patients themselves, partly due to the health insurers. Some insurance providers still refuse rehabilitation for non-ST-segment elevation infarction. In principle rehabilitation can be carried out in an inpatient or an outpatient setting. Specific allocation criteria have not yet been established, but the structure and process quality of outpatient rehabilitation should correspond to that of the inpatient setting. The choice between the two settings should be based on pragmatic criteria. Both settings should be possible for an individual patient. Cardiac rehabilitation is already focusing on older, sicker and polymorbid patients; this will become ever more the case in the future. There is still a need for future clinical research for these patients.     

心理干预对抑郁症患者康复效果的影响

目的探讨心理干预对抑郁症患者康复效果的影响。方法将60例抑郁症患者随机分为干预组和对照组,每组30例,对照组进行常规治疗与护理,干预组在此基础上进行心理干预治疗。6周后应用汉密顿抑郁量表(HAMD)及护士观察量表(NOSIE)进行评定。结果治疗6周后,干预组中社会能力、社会兴趣、个人清洁度等分值明显高于对照组(P0.05),差异有统计学意义。结论心理干预可以促进抑郁症患者的治愈及社会功能的恢复,对抑郁症患者的治愈有积极的临床意义。     

早期康复护理在张力带治疗鹰嘴骨折患者中的应用

目的观察早期康复护理在张力带治疗鹰嘴骨折患者中的应用效果。方法分析2006年我科对张力带治疗鹰嘴骨折患者中进行早期康复护理进行总结。结果本组38例,均采用克氏针加钢丝张力带固定,除伴骨化性肌炎1例为良外,其余均为优。结论术后早期康复护理有利于骨折愈合及进行早期功能锻炼并能防止术后并发症。     

Geriatrie in der ambulanten Versorgung durch haus?rztlich t?tige Internisten

Internal medicine specialists involved in primary care will have a leading part in the treatment of geriatric patients with complex healthcare needs in the future. Approved models like specialized geriatric practices, ambulant or mobile geriatric rehabilitation and special geriatric services for nursing homes are available. Essential is a geriatric qualification that fits with the tasks of an internist in primary care. An incentive payment system has to be created for this purpose to improve the treatment of elderly patients.     

Cardiac rehabilitation in Germany.

The purpose of this review is to give an overview of the rehabilitation measures provided for cardiac patients in Germany and to outline its legal basis and outcomes. In Germany the cardiac rehabilitation system is different from rehabilitation measures in other European countries. Cardiac rehabilitation in Germany since 1885 is based on specific laws and the regulations of insurance providers. Cardiac rehabilitation has predominantly been offered as an inpatient service, but has recently been complemented by outpatient services. A general agreement on the different indications for offering these two services has yet to be reached. Cardiac rehabilitation is mainly offered after an acute cardiac event and bypass surgery. It is also indicated in severe heart failure and special cases of percutaneous coronary intervention. Most patients are men (>65%) and the age at which events occur is increasing. The benefits obtained during the 3-4 weeks after an acute event, and confirmed in numerous studies, are often later lost under 'usual care' conditions. Many attempts have been made by rehabilitation institutions to improve this deficit by providing intensive aftercare. One instrument set up to achieve this is the nationwide institution currently comprising more than 6000 heart groups with approximately 120000 outpatients. After coronary artery bypass grafting or acute coronary syndrome cardiac rehabilitation can usually be started within 10 days. The multidisciplinary rehabilitation team consists of cardiologists, psychologists, exercise therapists, social workers, nutritionists and nurses. The positive effects of cardiac rehabilitation are also important economically, for example, for the improvement of secondary prevention and vocational integration.     

星状神经节阻滞对心率变异性影响的实验研究

目的：探讨在家兔清醒状态下,以第7颈椎横突为标志,经皮行星状神经节阻滞的可行性和有效性．及其对心率变异性的影响。方法：健康新西兰大耳白兔16只被随机均分为左侧星状神经节阻滞组（LSGB组）、右侧星状神经节阻滞组（RSGB组）。白兔均在清醒状态下四肢固定,仰卧于动物手术台,胸前及四肢连接十二导动态心电图分析系统,稳定30min后,以第七颈椎横突为骨性标志,垂直进针,给予0．5％布比卡因1ml,行星状神经节阻滞。观察眼睑下垂程度、耳廓温度、心率变异性指标[24h正常RR间期标准差（SDNN）、低频功能（LF）、高频功能（HF）、LF／HF]。另取9只家兔同法向星状神经节处推注亚甲蓝溶液后暴露星状神经节,以其是否蓝染判断注射阻滞部位的精确程度。结果：两组动物均完成星状神经节阻滞操作,术后即刻及饲养1周均未发现并发症。阻滞10min后两组动物阻滞侧均出现上睑下垂和眼裂变小。与对侧及阻滞前相比．阻滞侧耳廓温度明显升高（P〈0．05）。两组动物阻滞前后心率无明显差异,LSGB组,阻滞前、后SDNN、LF、HF、LF/HF无显著差异。RSGB组．LF和HF值在阻滞后较阻滞前显著减小（P〈0．05）．但LF／HF、SDNN无明显改变。9只家兔行亚甲蓝注射后．解剖发现8只星状神经节被染色,精确程度为88．9％（8／9）。结论：以第7颈椎横突为标志,经皮行星状神经节阻滞建立动物模型的方法切实可行,眼睑、眼裂及耳廓温度是较好的阻滞成功判断指标。星状神经节阻滞对自主神经功能有调节作用,可能就是其阻滞治疗各种疾病的作用机制之一。     

社区家庭康复护理干预对脑卒中患者康复的影响

目的评价社区家庭康复护理干预对脑卒中患者日常生活活动能力、心理的影响。方法将我社区内脑卒中患者60例随机分为干预组和对照组各30例,干预组做好出院指导后并执行一套为期3个月的社区家庭康复护理综合干预,对照组仅在患者出院时进行出院指导。分别于干预前及干预后3个月对两组患者采用Barthel指数评分量表和汉密尔顿抑郁量表（HAMD）进行评价。结果社区家庭康复护理干预3个月后,干预组Barthel指数评分及HAMD评分均优于对照组（P〈0.05）。结论系统的社区家庭康复护理干预能有效提高脑卒中患者的日常生活活动能力,减轻抑郁程度。     

Growth of the teaching nursing home. The Veterans Administration experience

Nursing homes are becoming increasingly involved with medical education, and the Veterans Administration (VA) has been particularly active in this movement. We conducted a system-wide survey of VA nursing home facilities to determine the degree to which they participate in medical and other professional training and the features associated with such training. Of the 116 VA nursing homes in 1987, 113 (97.4%) returned completed questionnaires. Compared to "standard" VA facilities (n = 85), "teaching" nursing homes (n = 28)--those in which physicians received at least 20 hours of training per capita annually--were significantly larger, admitted and discharged significantly more patients per occupied bed, and placed a significantly larger proportion of discharged patients in noninstitutional community settings. Care costs in the teaching nursing homes were slightly but not significantly higher, despite significant increases in levels of professional staffing and amounts of training activities in all disciplines. During the survey year, teaching nursing homes provided training experiences for 440 students, residents, and fellows in internal and rehabilitation medicine, as well as for 2,700 other health professionals. The growth of teaching nursing homes in the VA system appears to be associated with positive changes in the pattern of health-care delivery, and it is increasing the number of health-care professionals trained in long-term care.     

Medical rehabilitation. Basic function of the German pension insurance

Medical rehabilitation is an important part of the German health care system in addition to medical and nursing care. For people with impairments, especially with chronic diseases, rehabilitation aims at emancipated participation in social life. The German pension insurance carries out rehabilitation mainly for gainfully employed people. To be entitled to these benefits legal and personal (medical) requirements must be fulfilled. The rehabilitation concepts of the German pension insurance are interdisciplinary, following the bio-psycho-social model of health and illness. Concepts of rehabilitation are presented exemplarily for musculoskeletal, oncologic, heart/circulation, metabolic/gastrointestinal, and neurological diseases as well as mental disorders. Elements of structure, process, and outcome quality are illustrated. Research topics in rehabilitation are presented.     

儿童急性淋巴细胞白血病的运动康复研究进展

急性淋巴细胞白血病(ALL)患儿受疾病和肿瘤治疗的影响导致身体素质下降.过去多建议卧床休息,尽可能地放松.最近研究表明过于少动反而会导致身体功能的进一步下降.运动康复已在治疗期和治疗后的ALL患儿中应用并发现对患儿骨骼、骨骼肌、神经肌肉、心肺和心血系统损伤,以及对疲劳、身体平衡障碍和代谢改变的治疗效果显著.该文就当前A...     

Kardiologische Rehabilitation in Deutschland

Over the past 20 years the German Pension Insurance has rehabilitated nearly 800,000 patients with coronary heart disease. In particular, phase-II rehabilitation has been established as an integral part of cardiac patient care. However, the decreasing number of participants in phase-III must be seen critically. Today's cardiac rehabilitation is characterised by evidence-based treatment modules and a sophisticated quality assurance system that ensures quality orientation in all aspects, from access to rehabilitation through to aftercare. Future developments such as vocationally-oriented medical rehabilitation and the use of new technologies will further improve cardiac rehabilitation. Positive patient feedback and scientific evidence of the effectiveness of cardiac rehabilitation are further incentives to maintain this forward-looking approach.     

Reduction of urinary incontinence in nursing homes: does it reduce or increase costs?

Labor and supply costs associated with the care of urinary incontinent patients in three nursing homes were measured. First, normal nursing home changing patterns and their associated costs were measured. Second, the costs were documented when patients were checked by research staff and changed on an hourly basis as needed. Nursing home staff changed patients significantly less frequently than patient voiding as detected by the hourly checking system. Thus, cost of incontinence during the hourly checking condition ($3.35) per 12-hour patient-day was significantly higher than the cost normally incurred in nursing homes ($1.52) per 12-hour patient-day. The cost of an incontinence rehabilitation program, which significantly reduced incontinence episodes, was contrasted to the cost of incontinence as measured under both of the previous conditions. The rehabilitation program produced significant labor and supply savings only when compared with the hourly checking and changing system. Maintaining patients in a more continent condition costs significantly more than the direct incontinence cost normally incurred by the nursing home. Quality of life and other second-order benefits must be considered if continence rehabilitation is to be judged cost-effective.     

Quality assurance in hospitals following the Health Reform Law of the Federal Republic of Germany

Since January 1, 1989, hospitals licensed in accordance with section 108 of the Social Legal Code, Statute Book V (SGB V) as well as the prevention or rehabilitation facilities under contract in accordance with section 111 SGB V are obliged to participate in quality assurance measures. According to the statement of reasons in the government draft of the Health Reform Law, "quality management in the hospital as well as in the prevention or rehabilitation facilities must ensure high-quality and economic provision of medical services". Quality assurance of medical services in the hospital is intended to disclose professional, structural, and organizational deficits, and thus to create the prerequisites for their elimination. It is not primarily intended to serve as a basis for questions of economy in the hospital. Nonetheless, demands for quality management (above all on the part of the health insurance funds) will also increase continuously for this reason under the pressure of the constantly increasing costs of hospital care. Medical associations and the specialist scientific societies are therefore called on to ensure that not only economic and technical quality are primarily considered, but that the quality of professionally and technically qualified medical action is secured by qualified and convincing contributions to quality assurance.