Factors affecting activity of daily living (ADL) in stroke patients at home

To examine the effects of housing conditions, health care, age, functional status and other demographic factors on the Activity of Daily Living (ADL), an interview survey of the caregivers of 68 cerebral stroke patients was performed. All patients received care at home for 6-128 (mean 40) months after discharge from hospitals and were 56-91 (mean 79) years old at the time of the survey. During the home care, ADL improved in 28 patients (improved ADL group), and did not change or deteriorated in 26 patients (unchanged/deteriorated ADL group). Three variables, i.e. reconstruction of bathroom (bathing facility and not toilet) in the patient's house after starting the home care, the patient whose main caregiver was his or her spouse, and consultation with a physician at a hospital (not a clinic), were significantly more frequent in the improved ADL group than in the unchanged/deteriorated ADL group. Similarly, the ADL level at the start of home care and age at the time of survey were significantly lower in the improved ADL group. The results of multiple logistic regression analysis indicates that the level of ADL when home care was started (p less than 0.01) and reconstruction of the bathroom (p less than 0.05) were major factors affecting the improvement in ADL.     

Costs of health care and social services during the first year after ischemic stroke

OBJECTIVES: Knowledge of resource use and costs can be useful when evaluating existing services or planning new services. This study investigates the use of health care and social services during the first year after a stroke. Total costs are calculated, costs are compared across subgroups of patients, and resource items of major importance for the total costs are identified. METHODS: The study is based on a database comprising data on all stroke patients admitted to a university hospital in Copenhagen, Denmark, over a 1-year period, 1994-95. Patients were followed for 1 year after the stroke, and data on resource use during and after hospitalization were collected prospectively at interviews. This paper focuses on a subset of 385 patients who were admitted because of cerebral infarct or unspecified stroke. RESULTS: The mean cost, based on all patients, of health care and social services during the first year was 142,900 DKK (US $25,500). The hospital care until the first discharge, including acute care and rehabilitation, cost 101,600 Danish krones (DKK) (US $18,100), i.e., 71% of the total cost. Major resource items after discharge were nursing homes, readmissions, outpatient rehabilitation, and home help. The cost during the first year varied with a number of factors, with the most important being survival and degree of disability. Patients who survived the acute phase and who had severe disability (Barthel Activities of Daily Living [ADL] Index: 0-9) 7-10 days after admission had a total cost during the first year that was five times as high as patients with no disability (Barthel ADL Index: 20). CONCLUSION: Costs of health care and social services during the first year after a stroke vary considerably. Disability as measured with the Barthel ADL Index is a stronger predictor of costs than Scandinavian Stroke Scale scores and other clinical and demographic variables.     

护理干预对脑卒中病人生存质量的影响

目的探讨护理干预对脑卒中病人生存质量的影响。方法选取2012年1月—2013年10月入住我科的脑卒中病人128例为研究对象,随机分为对照组64例和干预组64例。对照组给予常规护理,干预组在常规护理基础上进行康复训练和康复指导。比较2组入院时和出院时Barthel评分。结果入院时2组病人Barthel评分差异无统计学意义（P〉0.05）,出院时Barthel评分试验组明显优于对照组（P〈0.01）。结论护理干预能提高脑卒中病人生存质量。     

Efficacy of agreements within the Enchede Stroke Service to refer patients with a stroke from the stroke unit in the hospital to a nursing home for short-term rehabilitation

OBJECTIVE: To assess the efficacy of agreements within the Enschede Stroke Service to refer patients with a stroke from the stroke unit in the hospital to a nursing home for short-term rehabilitation. DESIGN: Prospective, partly retrospective. METHOD: All patients who were referred from the stroke unit at Medisch Spectrum Twente to the CVA Rehabilitation Unit (CRU) in the period 1 July 1999-31 July 2003 were included. Referral took place via an active multidisciplinary approach and specific referral agreements. The primary outcome was the number of patients that could be discharged home after rehabilitation. In addition, we assessed the influence on final discharge destination of age, the Barthel and Rankin scores at the time of admission to the CRU and the medical complications during the period of rehabilitation. RESULTS: 232 patients were included (133 women and 99 men, mean age 76.4 years). Within 3 months, 63% of the patients were discharged home. After 6 months, 82% had returned home. 8% of the patients died within 6 months and 9% had to stay in a nursing home permanently. Of the patient aged 80 years or older, 75% could return home within 6 months. Patients with poor Barthel and Rankin scores and medical complications had a smaller chance of being discharged home. CONCLUSION: Effective referral of patients from the stroke unit to a nursing home for short-term rehabilitation is possible. With adequate patient selection, the use of good referral agreements and multidisciplinary consultations, most patients could finally return home.     

Use of health care services after stroke.

OBJECTIVES--To describe the use of care before and after stroke and to evaluate equity in access to health care services after stroke. DESIGN--Cross sectional study. SETTING--The Netherlands. PATIENTS--382 patients living in the community who had been admitted to hospital with a stroke six months before. MAIN MEASURES--Sociodemographic status and functional health status according to The Barthel index, Rankin scale, and sickness impact profile, assessed during interview, and general practitioner (GP) characteristics obtained by postal questionnaire. Univariate and multivariate analyses of the relation between patient and GP related factors and use of care. RESULTS--Compared with the period before stroke the use of care six months after stroke increased significantly, especially use of physical therapy, home help, and aids. Multivariate analyses showed that impaired functional health increased the use of care (range in odds ratios 1.6 to 6.7). Compared with younger patients, elderly patients were more likely to have home help (odds ratio 2.9) and aids (2.4) but less likely to receive therapy (0.4), psychosocial support (0.5), and an appreciable amount of care (0.5). Being female (1.7), living alone (4.0), and whether the GP was informed about patients' discharge (2.2) increased the use of home help. Higher financial income (2.8) and having a male GP (3.2) contributed to use of therapy. Emotional distress (1.6), living protected (3.2), and living alone (1.7) accounted for psychosocial support. CONCLUSIONS--Although older age, lower income, and poor discharge information to the GP decreased the use of some types of care, there is equity in access to care after stroke, primarily determined by needs in terms of functional health status and predisposing factors such as living arrangement and social circumstances. IMPLICATIONS--Patient oriented studies focusing on care processes and care outcomes in terms of subjective needs, perceived care deficits, and satisfaction with care are still required.     

Development and results of a questionnaire to measure carer satisfaction after stroke.

STUDY OBJECTIVE--To develop a carer satisfaction questionnaire for use as an outcome measure in stroke, to test the measure for reliability and validity, and to survey levels of carer satisfaction with services for stroke patients. DESIGN--Postal survey of carer satisfaction with stroke services was carried out using the questionnaire we developed and tested. Internal consistency was tested and construct validation was explored by examining correlations with other outcome measures (the Faces Scale, the Nottingham Health Profile, the short form of the Geriatric Depression Scale, and the patient's Barthel Index score). SETTING--Two adjacent districts in North East Thames Regional Health Authority. PARTICIPANTS--A total of 103 carers were identified from 219 people who had survived a stroke to six months. During the pilot stage, six of seven carers who were invited to participate in in depth interviews and 15 of 23 carers (65%) who were invited to completed the first draft of the questionnaire. MAIN RESULTS--The questionnaire was divided into two sections, one on inpatient services (Carer Hospsat) and one on services after discharge (Carer Homesat). The questionnaire had construct validity, providing significant correlations with the Faces Scale (Carer Hospsat r = 0.59, p < 0.00001 and Carer Homesat r = 0.68, p < 0.00001), the patients' Barthel score (Carer Hospsat r = 0.25, p = 0.01), and the patients' Nottingham extended Activities of Daily Living (ADL) scale (Carer Hospsat r = 0.31, p = 0.002). Internal consistency was high for both sections (Cronbach's alpha: Carer Hospsat 0.87, Carer Homesat 0.79). Most carers (77%) were satisfied with the care their relative or friend received while in hospital, but only 39% were satisfied with services after discharge. CONCLUSIONS--Carer satisfaction is an important outcome measure in stroke research. This study has shown that carers are dissatisfied with services after hospital discharge. Our questionnaire is valid, reliable, and sensitive and could be used to test interventions aimed at improving services.     

Resource Utilization and Costs of Stroke Unit Care in Germany

OBJECTIVES: Stroke imposes a considerable economic burden on the individual and society. Recently, the concept of an integrated stroke unit has been established in several countries to improve the outcome of patients. This study evaluates the costs of acute care of the different cerebrovascular insults in a stroke unit. METHODS: The study population included 340 patients who were consecutively admitted to the Department of Neurology, Philipps University Marburg, with the diagnosis of stroke or transient ischemic attack (TIA) between January 1 and June 30, 2000. Clinical status and course were evaluated by using the Barthel index and the modified Rankin scale. Employing a "bottom-up" approach, we calculated the costs from the perspective of the hospital and the third-party payer using data from provider departments and other published sources. RESULTS: Inpatient costs were 3020 euros (3290 US dollars) for TIA, 3480 euros (3790 US dollars) for ischemic stroke (IS), and 5080 euros (5540 US dollars) for intracerebral hemorrhage (ICH) and differed significantly among these subgroups (P < .05). Patient subgroups ranked in the same order for average length of stay at 9.4 days for TIA, 10.2 days for IS, and 11.9 days for ICH (P > .05). Approximately 30% of the hospital costs are due to physician charges and care. Imaging amounted to 10% and lab investigations to 14% of total costs, independent of the diagnosis. Postacute treatment, including inpatient rehabilitation, cost 9880 euros per patient. Across all diagnostic groups, a mean clinical improvement was observed at time of discharge. CONCLUSIONS: Care of patients with cerebrovascular events in a stroke unit causes a high demand of resources and has a considerable impact on health-care expenditure. Therefore, investigations comparing the stroke unit concept with other strategies in stroke care are necessary to evaluate the stroke unit concept for a rational use of available resources in patients with cerebrovascular events.     

A survey of survivors of acute stroke discharged from hospital to private nursing homes in Nottingham

Increasing numbers of disabled elderly stroke survivors are being discharged from hospital to Private Nursing Homes. However, there is little data available on which specific guidelines for the care of stroke patients in these homes can be based. A survey was undertaken therefore, to review patients on their discharge from hospital to Private Nursing Homes, and to assess the severity of their disability and handicap before and after entering the home. Nearly all patients were severely disabled on discharge from hospital, and the Barthel Activities of Daily Living scores of the survivors showed no significant change after four months. High levels of emotional distress and loneliness were identified by the Nottingham Health Profile, with little change after four months of nursing home care. The National Health Service has a continuing responsibility for the welfare of such vulnerable elderly people. The findings of this survey indicate that the emphasis of their care should be on the management of severe physical disability, exploitation of opportunities for further rehabilitation, alleviation of emotional distress and loneliness and, where appropriate, the provision of humane terminal care.     

脑卒中患者实施医养结合长期照护模式的实践与效果

目的 探索对脑卒中后患者实施医养结合长期照护模式的可行性及其效果。 方法 2013年6月-2014年12月期间,选择在湘南学院附属医院住院的脑卒中后患者195例,将出院后收住医院养老区的62例作为研究组,医院对其实施医养结合长期照护。将出院后居家养护的68例作为对照1组,出院后入住老年公寓的65例作为对照2组,于出院时、出院后3个月、6个月评价各组患者的 Barthel 指数、孤独感及出院后6个月患者的生存质量(GQOLI-74评分)。 结果 出院后3个月、6个月后,研究组Barthel指数评分(31.96±8.18、37.85±7.18)均明显高于对照1组(24.23±6.26、28.41±8.47)和对照2组(26.19±7.42、30.56±7.59),研究组UCLA 孤独感评分(32.08±9.42、33.93±9.12)均明显低于对照1组(39.52±11.68、48.52±13.54)和对照2组(33.41±10.31、38.52±10.19),差异均有统计学意义(均 P＜0.01);出院6个月后,研究组患者GQOLI-74评分除物质生活维度外,其余三个维度(躯体功能、心理功能、社会功能)得分和总分均优于对照1组和对照2组(均P＜0.01)。 结论 实施医养结合长期照护模式可明显提高脑卒中后患者的日常生活能力、生存质量、降低患者的孤独感。     

Excellence in regional stroke care: An evaluation of the implementation of a stroke care unit in regional Australia

Objective: To assess the effectiveness of a formalised stroke service in a regional hospital. Design: A pretest post‐test design. Setting: An acute stroke unit in a regional health service. Participants: Overall sample comprised 80 patients with 36 (45.0%) men. Forty patients (19 men, 21 women) comprised pre‐intervention group and 40 (17 men, 23 women) post‐intervention group. Interventions: Establishment of an acute stroke unit. Main outcome measure(s): Increased frequency in meeting key performance indicators for acute stroke care as recommended by National Stroke Foundation. Results: On discharge, fewer survivors in the pre‐intervention group were independent (n = 5) and returned home (n = 9) than the post‐intervention group (n = 13) for both independent and returned home. More survivors in the pre‐intervention group were discharged to aged care or inpatient rehab (n = 22) than the post‐intervention group (n = 12). Within required time frames, the frequency of CT scans (χ² (1, 80) = 4.1, P < 0.05), swallow assessments (χ² (1, 80) = 9.0, P < 0.01), occupational therapy assessments (χ² (1, 80) = 14.5, P < 0.0001), multidisciplinary meetings involving patient and family (χ² (1, 80) = 19.9, P < 0.0001) and self‐management plans (χ² (1, 80) = 10.9, P < 0.05) all increased significantly. Conclusions: Our evaluation demonstrated that introduction of formalised stroke care to a regional hospital resulted in improved compliance with key performance indicators and better patient outcomes. Thus evidence‐based specialised stroke care can be offered with confidence in regional populations.     

'Neurodevelopmental treatment' following stroke: no beneficial effect shown in measurements taken after 1 year; comparative study

OBJECTIVE: To determine whether neurodevelopmental treatment (NDT) in the care of stroke patients is effective with respect to the functional status and quality of life (QoL) during one year after stroke onset. DESIGN: Prospective, non-randomised, comparative parallel group design. METHODS: 324 consecutive stroke patients from 12 Dutch hospitals were divided into 2 groups: an experimental group (n=223), in which nurses and physiotherapists used the NDT approach, and a control group who received conventional therapy (n=101). Functional status was assessed with the Barthel Index. Primary outcome was considered poor when the Barthel Index <12 after 1 year or when the patient had died. QoL was assessed with the 'Stroke adapted sickness impact profile'-30 and on a visual analogue scale. RESULTS: At 12 months, 59 patients in the NDT group (26%) and 24 patients in the control group (24%) had a poor outcome (corresponding adjusted odds ratio: 1.7; 95% CI: 0.8-3.5). At point of discharge and after 6 months, the adjusted odds ratio was 0.8 (95% CI: 0.4-1-5) and 1.6 (95% CI: 0.8-3.2) respectively. The adjusted mean differences of the QoL measurements did not show statistically significant differences between the 2 study groups at 6 and 12 months after stroke onset. CONCLUSION: The NDT approach was not an effective method in the care of stroke patients. Health care professionals need to reconsider the use of the NDT approach.     

Abstract

Aims: The overall aims of this thesis were: a) to compare stroke unit (SU) care and its continuum with care on general wards (GW) for elderly patients concerning resource use and costs for care and rehabilitation focusing on assistive technology in a one-year follow-up and, b) to explore the use and cost of assistive devices (ADs), ability in daily activities and self-rated health-related quality of life (HRQL) longitudinally. Methods: Two hundred and forty-nine persons ≥70 years were followed in a randomized, prospective study evaluating stroke unit care after acute stroke. The patients were interviewed and observed four times during the first year by two registered occupational therapists. In two of the studies the patients were followed longitudinally. Results: There were no statistically significant differences in total resource use and costs for care and rehabilitation between the SUs and the GWs during the first year after stroke. Costs in relation to the severity at stroke onset showed statistically significant differences, indicating that patients with severe stroke were treated at a higher cost. Informal care widely exceeded the care provided by the community. The total cost of ADs was 2% of the total costs of care and rehabilitation during the first year. One third of the patients had ADs before stroke. One year after stroke the majority of the patients used ADs. There was a statistically significant difference between the SU group and the GW group in the proportion of patients who had supplementary ADs prescribed between 0-3 months after stroke; the patients at the SU had a higher number of uncomplicated and cheap ADs prescribed. The ADs had a large impact and were prescribed at low cost. Different types of ADs were needed at different stages in the rehabilitation process. Constant routine evaluation of elderly patients with stroke is recommended during the first year after acute stroke. High concordance was found between the assessments in the Functional Independence Measure (FIM?) and the Barthel Index (BI). The assessments in the 7-level FIM? polarize, and the intermediary levels are rarely used, suggesting that a 5-level FIM is sufficient. There were no statistically significant differences between the SU group and the GW group regarding dependence or HRQL as assessed longitudinally. There were statistically significant differences in daily activities and HRQL as assessed with the 5-level FIM and the Nottingham Health Profile (NHP) in patients who used at least one AD and those who did not. Conclusions: Since the majority of the patients with stroke used ADs one year after acute stroke but at relatively low cost, assistive technology must be considered to be one of the best tools for maintaining the highest possible level of daily activity in this patient group. Regular routine evaluations are required both for best use of resources and adaptation to individual needs. The 5-level FIM proved to be useful, but further research into its clinical utility is required. More attention should be paid to the role of spouses as caregivers in stroke survivors, since informal care carries a far greater burden than the care provided by the community. Support schemes of all types are required to relieve the spouses.     

Nutritional support in acute stroke: the impact of evidence-based guidelines

BACKGROUND AND AIMS: Stroke patients experience multiple impairments which impair ability to eat and render them vulnerable to the deleterious sequelae of malnutrition. This study aimed to develop, implement and evaluate evidence-based guidelines for nutrition support following acute stroke using a multifaceted change management strategy. METHODS: Prospective quasi-experimental design. Documentation of two groups of 200 acute stroke patients admitted to medical and care of the elderly wards of an acute NHS Trust in South London was surveyed using a checklist before and after implementation of 24 guidelines for nutritional screening, assessment and support. Guidelines were based on systematic literature review and developed by consensus in a nurse-led multiprofessional group; implemented via a context-specific, multifaceted strategy including opinion leaders and educational programmes linked to audit and feedback. STAFF OUTCOMES: Compliance with guidelines by doctors, nurses, therapists. PATIENT OUTCOMES: Changes in Barthel Index scores and Body Mass Index in hospital, infective complications, length of stay, discharge destination. RESULTS: Statistically significant improvements in compliance with 15 guidelines occurred in the post-test group. Infective episodes showed a significant reduction in the post-test group but other patient outcomes were unaffected. CONCLUSIONS: Implementation of evidence-based guidelines for nutritional support following acute stroke using a multifaceted strategy was associated with improvements in documented practice and selected patient outcomes.     

Long-term care provision,hospital bed blocking,and discharge destination for hip fracture and stroke patients

We examine the relationship between long-term care supply (care home beds and prices) and (i) the probability of being discharged to a care home and (ii) length of stay in hospital for patients admitted to hospital for hip fracture or stroke. Using patient level data from all English hospitals and allowing for a rich set of demographic and clinical factors, we find no association between discharge destination and long-term care beds supply or prices. We do, however, find evidence of bed blocking: hospital length of stay for hip fracture patients discharged to a care home is shorter in areas with more long-term care beds and lower prices. Length of stay is over 30% shorter in areas in the highest quintile of care home beds supply compared to those in the lowest quintile.     

Clostridium difficile colitis in older adults in long-term facilities and the community: do their outcomes differ?

OBJECTIVE: To determine if older adults from long-term care facilities (LTCF) have a greater risk of death than older people in the community after the development of Clostridium difficile (CD) colitis during hospitalization. DESIGN: A retrospective review of medical records from all older hospitalized patients with a confirmed diagnosis of CD colitis from February 1995 to February 1997 at Our Lady of Mercy Medical Center, Bronx, NY, a University hospital of the New York Medical College. METHODS: A total of 108 patients (aged 60-97 yrs.) with a positive diagnosis of CD colitis (EIA of CD cytotoxin A and B) were identified. Residence (nursing home vs. community), sex and age, length of hospital stay, laboratory values, the number, dose, and duration of all antibiotics used, and co-morbid medical conditions were examined as potential risk factors for adverse outcome (mortality). RESULTS: Fifty-two nursing home and 56 older patients living in the community were compared. Outcome (survival vs. death) was equivalent between nursing home (13 of 52 died, 25% death rate) and community elderly (13 of 56 died, 23% death rate). The patients in the nursing home were, on average, 3 years older than community those in the community, but age was not related to outcome in either group. Death occurred significantly more often in LTCF and community patients who received prolonged antibiotic therapy (P = 0.0056) or were prescribed four or more antibiotics (P = 0.036) during hospitalization. Low serum albumin level was found to be a strong predictor of death (P = 0.002). However, nursing home and community elderly had similar mean serum albumin levels (P = 0.2797). Death was also predicted by the use of clindamycin alone (P = 0.046) or penicillin-like antibiotics (excluding cephalosporins) and clindamycin (P = 0.021), or a history of cardiac disease (coronary artery disease or congestive heart failure) (P = 0.022). CONCLUSIONS: Patients from LTCF do not have an increased risk of mortality compared with older people in the community after developing CD colitis during hospitalization. Factors such as low serum albumin, prolonged antibiotic therapy, the number of antibiotics used, use of specific antibiotics, and cardiac disease were significantly related to an increased risk of death in both LTCF and community older adults. Age did not influence outcome in either group of older adults.     

The effect on the use of hospital resources in a geriatric domiciliary care program among the elderly patients with advanced cardiorespiratory diseases

BACKGROUND: One of the objectives of the geriatric home care teams is that of the follow-up of elderly patients having a high risk of hospital readmission. Although they have been operating in our country for years, no data shows the impact on the use of hospital resources in accordance with this follow-up. The objective of this study is that of analyzing the effect which the monitoring, by geriatric home care unit, involves on patients having very advanced chronic cardiorespiratory disease. METHODS: The patients with chronic cardiorespiratory disease followed up by the unit during the January 1995-January 1999 period were included, excluding those on follow-up for less than 3 months. A comparison is drawn among the number of hospital emergency room visits, hospital admissions and days of hospitalization for the year prior to the care provided by the unit and throughout the follow-up time thereof are compared. RESULTS: Eighty-one (81) patients, mean age 80.57 years (DE 7.39) and a median length of care per unit of nine (9) months (5-13.5), were included in the study. The uses per patient and month of follow-up decreased by 0.07 Emergency Room visits (0.02-0.11) (p = 0.04), 0.10 hospital admissions (0.07-0.14) (p < 0.001) and 2.01 days of hospitalization (1.87-2.15) (p < 0.001). CONCLUSIONS: A specialized geriatric home care unit reduces the use of hospital resources on elderly people diagnosed as severe chronic cardiorespiratory disease.     

康复联动型卒中单元在地市级医院急性脑梗死治疗中的应用

目的 评价康复联动型卒中单元在地市级医院急性脑梗死治疗中的疗效.方法 急性脑梗死患者随机进入康复联动型卒中小组病房(77例)和普通病房(73例),比较治疗前后两组患者神经功能(NIHSS评分)、日常生活能力(ADL Barthel指数)及住院时间.结果 两组患者治疗前平均NIHSS评分分别为9.26与9.12(P＞0.05),治疗后分别为2.62与7.64(P＜0.01),治疗前平均ADLBarthel指数分别为52.04与53.16(P＞0.05),治疗后分别为87.26与64.20(P＜0.01),两组平均住院日分别为22.25 d及26.67 d(P＜0.05).结论 康复联动型卒中单元模式应用于脑梗死急性期治疗,可改善患者的神经功能及日常生活能力,缩短住院时间,在地市级医院优于普通卒中病房.     

Factors Associated With Hospital Presentation of Self-Harm Among Older Canadians in Long-Term Care: A 12-Year Cohort Study

ObjectivesThis study aimed to examine the incidence of, and factors associated with, hospital presentation for self-harm among older Canadians in long-term care (LTC).DesignRetrospective cohort study.Setting and ParticipantsThe LTC data were collected using Resident Assessment Instrument–Minimum Data Set (RAI-MDS) and Resident Assessment Instrument–Home Care (RAI-HC), and linked to the Discharge Abstract Database (DAD) with hospital records of self-harm diagnosis. Adults aged 60+ at first assessment between April 1, 2003, and March 31, 2015, were included.MethodsAdjusted hazard ratios (HRs) of self-harm for potentially relevant factors, including demographic, clinical, and psychosocial characteristics, were calculated using Fine & Gray competing risk models.ResultsRecords were collated of 465,870 people in long-term care facilities (LTCF), and 773,855 people receiving home care (HC). Self-harm incidence per 100,000 person-years was 20.76 [95% confidence interval (CI) 20.31–25.40] for LTCF and 46.64 (44.24–49.12) for HC. In LTCF, the strongest risks were younger age (60–74 years vs 90+: HR, 6.00; 95% CI, 3.24–11.12), psychiatric disorders (bipolar disorder: 3.46; 2.32–5.16; schizophrenia: 2.31; 1.47–3.62; depression: 2.29; 1.80–2.92), daily severe pain (2.01; 1.30–3.11), and daily tobacco consumption (1.78; 1.29–2.45). For those receiving HC, the strongest risk factors were younger age (60–74 years vs 90+: 2.54; 1.97–3.28), psychiatric disorders (2.20; 1.93–2.50), daily tobacco consumption (2.08; 1.81–2.39), and frequent falls (1.98; 1.46–2.68). All model interactions between setting and factors were significant.Conclusions and ImplicationsThere was lower incidence of hospital presentation for self-harm for LTCF residents than HC recipients. We found sizable risks of self-harm associated with several modifiable risk factors, some of which can be directly addressed by better treatment and care (psychiatric disorders and pain), whereas others require through more complex interventions that target underlying factors and causes (tobacco and falls). The findings highlight a need for setting- and risk-specific prevention strategies to address self-harm in the older populations.     

Association of total serum cholesterol with functional outcome following home care rehabilitation in Italian patients with stroke

BackgroundStroke is a disabling disease. In elderly populations, stroke is the third leading cause of death and the primary cause of reduction in or loss of functional ability and personal autonomy. Possible associations between levels of total serum cholesterol (TC) and both incidence of stroke and functional outcomes after rehabilitation are still under study.ObjectiveTo detect positive and negative prognostic factors associated with functional outcomes in first-time stroke patients admitted to an integrated home care rehabilitative program.MethodsThis study enrolled 141 patients with a first-time stroke who were admitted to a home care rehabilitation program. Primary outcome measures were the Barthel activities of daily living (ADL) and mobility indices at the beginning and end of the rehabilitative treatment. The impact of TC and other demographic and clinical variables was analyzed using bivariate and multivariate logistic regression analyses.ResultsAge and Short Portable Mental Status Questionnaire (SPMSQ) score were negatively associated with functional outcome. In contrast, elevated TC was positively associated with a better home rehabilitative treatment outcome. Barthel index score at admission was negatively associated with outcomes assessed by the Barthel ADL index and age with outcomes assessed by the Barthel mobility index. In a multivariate logistic regression analysis, SPMSQ score and elevated TC were significantly associated with outcome. Specifically, higher SPMSQ scores were negatively associated with better rehabilitative treatment outcomes, whereas elevated TC was positively associated.ConclusionsElevated TC seems to be associated with better functional outcomes in patients with first-time stroke.     

Living arrangements decisions at discharge and later: differences in criteria and outcomes

This study examined the pattern of post rehabilitation living arrangements over 18 months of 172 adults discharged from a geriatric rehabilitation unit at a large urban medical center, all of whom were living alone prior to admission. Results showed the diminishing importance of physical function and cognition as factors in decisions to return home as the length of time after hospital discharge increased. Patients who returned home to live alone after a period of time living in more supported environments had significantly lower assessment scores on physical function (p < 0.001) and cognition (p < 0.001) compared to patients who went home to live alone immediately upon discharge. As well, patients who returned home to live alone later than three months post discharge were significantly more likely to move to more supported environments by 18 months after discharge (p = 0.043) and to experience re-hospitalizations (p = 0.008), which raises questions about the appropriateness of these later decisions.