Dementia care in European countries, from the perspective of people with dementia and their caregivers.

AIM: To investigate persons with dementia and their informal caregivers' views of inter-sectoral information, communication and collaboration throughout the trajectory of dementia care, in eight European countries. BACKGROUND: Living with dementia and being next of kin to a person with dementia means having to live through stages that have different characteristics, needs, challenges and requirements. DESIGN: Qualitative research. Focus groups were conducted in England, Estonia, Finland, France, Germany, The Netherlands, Spain and Sweden. METHODS: Persons with dementia and their informal caregivers (N = 137) participated in focus group interviews during 2011. Content analysis generated a tentative model of information, communication and collaboration for people with dementia and their caregivers, which was then tested. RESULTS: The core finding was that information, communication and collaboration were to be focused on the persons with dementia and the informal caregivers. Entering into the trajectory of the disease and its consequences was addressed as an important point of departure. The relation to professional care required establishing a trusting relationship, tailor-made intervention and a single person or organization to contact. Professional knowledge and commitment, variation in service and care adapted to needs were important. CONCLUSION: As focus of care is on the person with dementia and their informal caregivers, a dyadic approach seems most suitable for dementia care. A trusting relationship and a specific person or organization to contact seem to be indicators of best practice, as does adaptation to the needs of the person with dementia and their informal caregiver.

Dementia care in eight European countries: developing a mapping system to explore systems.

PURPOSE: There is a knowledge gap with regard to the structure of the care and service system available to persons with dementia. This is very much a concern for nurses who are the main providers in the care of dementia. The study, a part of the "RightTimePlaceCare" project, describes the development and content of a mapping system aimed at exploring the content of care and service for persons with dementia and their informal caregiver throughout the disease trajectory. The usefulness of the mapping system is illustrated in describing the availability of care and service at the diagnostic stage, and at the institutional and palliative stages. DESIGN: A descriptive cross-country design concerning eight European countries differing in demographic composition and terms of long-term care provided is employed. METHODS: A modified consensus strategy was used to develop the mapping system and define the terminology. Thereafter, each country's mapping system was completed by its research group collecting country-specific information and using expert groups either as consultants or for completing the system. FINDINGS: The consensus procedure worked satisfactorily with regard to content and definitions, whereas assessing the availability and utilization of care and service was problematic. Some 50 types care and service activities were identified and defined and were categorized as follows: (a) screening, diagnostic procedures, and treatment of dementia; (b) outpatient care facilities; (c) care at home; (d) institutional care; (e) palliative care; (f) informal caregiving and supportive actions; and (g) civic activities. Care at home included the broadest range of activities; palliative care, informal caregiving, and supportive actions were the smallest range. CONCLUSIONS: The dementia care systems were found to be comprehensive and to emphasize home care. Activities aimed at transferring knowledge to informal caregivers, though highly important for home care, seemed less extensive. The mapping system appears useful from a nurse manager's standpoint for exploring the dementia care pathway. Comparisons between countries appear useful for developing the care system and for sharing information of how to perfect it. Further testing and development are needed regarding information on the availability and utilization of care and service activities. CLINICAL RELEVANCE: The mapping system can be useful in clarifying the dementia care system for those concerned, in helping nurse researchers and managers review and initiate evaluation and communicate with policy makers, as well as to ensure that providers use appropriate parts of the system. It can also be useful in national and international comparative studies.

Care satisfaction among older people receiving public care and service at home or in special accommodation.

AIMS AND OBJECTIVES: To explore care satisfaction in relation to place of living, health-related quality of life, functional dependency and health complaints among people 65 years or older, receiving public care and service. The concept public care and service concerns formal care from the municipality, including home help, home nursing care, rehabilitation and a special accommodation. BACKGROUND: To be able to provide care and service of high quality to older people, knowledge about factors influencing their experience of satisfaction with the care is essential. DESIGN: Cross-sectional, including comparison and correlation. METHODS: One-hundred sixty-six people receiving public care and service from the municipality were interviewed regarding demography, functional ability, perceived health complaints and care. Health-related quality of life was measured with SF-12, and self-rated care satisfaction was measured with a questionnaire. RESULTS: Low self-rated care satisfaction was associated with dependency in Instrumental Activities of Daily Living, blindness, faeces incontinence and anxiety, while high self-rated care satisfaction was associated with dependency in Personal Activities of Daily Living. Those at home rated an overall higher care satisfaction and were more satisfied with care continuity and personal relations; they thought that the staff had more time and were more respectful and quiet, than the ratings by those in a special accommodation (equivalent to a nursing home). CONCLUSIONS: Care satisfaction and health-related quality of life among older people was more associated with functional impairment and health complaints than to whether care and service was received at home or in a special accommodation. RELEVANCE TO CLINICAL PRACTICE: An approach using intervention focused on functional ability and health complaints is important for development of improved care satisfaction for older people receiving public care and service.

Psychometric properties of the Chinese version of the Functional Assessment of Cancer Therapy-Cervix (FACT-Cx) measuring health-related quality of life.

BACKGROUND: The Functional Assessment of Cancer Therapy (FACT) is one of the most commonly used self-report instruments for evaluation of health-related quality of life in oncology patients. However, cultural considerations necessitate testing of the subscales in different populations. We sought to qualitatively and quantitatively investigate the applicability and psychometric properties of the Chinese version of the FACT-Cervix (FACT-Cx) in Chinese women with cervical cancer. METHODS: Ten personal interviews were conducted in order to explore patients' opinions about the scale and its items in depth. In addition the questionnaire was administered to 400 women with cervical cancer to test its psychometric properties. Reliability was assessed using Cronbach's alpha coefficient and item-subscale correlation while validity was evaluated using factor analysis and known-group validity. RESULTS: Some items related to sex and the ability to give birth were questioned in the personal interviews, mostly regarding their significance and acceptance in the Chinese cultural context. The Cronbach's alphas of FACT-Cx and the subscales were greater than 0.7, except for the cervical-cancer-specific subscale which was 0.57. Factor analysis demonstrated that the FACT-G construct generally paralleled the original. There were significant differences in the FACT-Cx and some subscales between those receiving and not receiving treatment and among the patients with different performance status. CONCLUSIONS: In general, psychometric properties of the Chinese version supported its use with cervical cancer patients in Mainland China. Further work is needed to improve the psychometric adequacy of the cervical-cancer-specific subscale and adjust it to cultural considerations.

Hospital and outpatient clinic utilization among older people in the 3-5 years following the initiation of continuing care: a longitudinal cohort study.

BACKGROUND: Few studies have investigated the subsequent rate of hospital and outpatient clinic utilization in those who receive continuing care and have documented frequent usage over one year. Such knowledge may be helpful in identifying those who would benefit from preventive interventions. The aim of this study was to investigate and compare the subsequent rate of hospital and outpatient clinic utilization among older people with 0, 1, 2, 3 or more hospital stays in the first year following the initiation of continuing care. A further aim was to compare these groups regarding demographic data, health complaints, functional and cognitive ability, informal care and mortality. METHODS: A total of 1079 people, aged 65 years or older, who received a decision regarding the initiation of continuing care during the years 2001, 2002 or 2003 were investigated. Four groups were created based on whether they had 0, 1, 2 or ≥ 3 hospital stays in the first year following the initiation of continuing care and were investigated regarding the rate of hospital and outpatient clinic utilization in the subsequent 3-5 years. RESULTS: Fifty seven percent of the sample had no hospital stay during the first year following the initiation of continuing care, 20% had 1 stay, 10% had 2 stays and 13% had three or more hospital stays (range: 3-13). Those with ≥ 3 hospital stays in the first year continued to have the significantly highest rate of hospital and outpatient care utilization in the subsequent years. This group accounted for 57% of hospital stays in the first year, 27% in the second year and 18% in the third year. In this group the risk of having ≥ 3 hospital stays in the second year was 27% and 12% in the third year. CONCLUSIONS: There is a clear need for interventions targeted on prevention of frequent hospital and outpatient clinic utilization among those who are high users of hospital care in the first year after the initiation of continuing care. Perhaps an increased availability of medically skilled staff in the day to day care of these people in the municipalities could prevent frequent hospital and outpatient clinic utilization, especially hospital readmissions.

Effects on blood pressure in patients with refractory angina pectoris after enhanced external counterpulsation.

OBJECTIVE: Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to reduce the frequency and severity of angina pectoris. Little is known how EECP affects the blood pressure. METHODS: 153 patients with refractory angina were treated with either EECP or retained on their pharmacological treatment (reference group). Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP) and heart rate were measured pre- and post-treatment and at 12 months follow-up. RESULTS: EECP treatment altered the blood pressure in patients with refractory angina pectoris. A decrease in the blood pressure was more common in the EECP group compared with the reference group. In the reference group, an increase in the blood pressure was more common. A correlation between a decrease in blood pressure after EECP treatment and a higher baseline MAP, SBP and DBP was seen. No such correlation was seen in the reference group. The blood pressure response did not persist at 12 months follow-up. CONCLUSION: EECP treatment affects the blood pressure in patients with refractory angina pectoris. The decreased blood pressure may be a result of an improved exercise capacity, an improved endothelial function and vasoreactivity in general.

Case managers for frail older people: a randomised controlled pilot study.

AIM: The aim was to test sampling and explore sample characteristics in a pilot study using a case management intervention for older people with functional dependency and repeated contact with the healthcare services as well as to investigate the effects of the intervention on perceived health and depressed mood after 3 months. The aim was also to explore internal consistency in the life satisfaction index Z, activities of daily living-staircase and Geriatric Depression Scale-20. METHOD: This pilot study was carried out in a randomised controlled design with repeated follow-ups. In all, 46 people were consecutively and randomly assigned to either an intervention (n = 23) or a control (n = 23) group. Two nurses worked as case managers and carried out the intervention, which consisted of four parts. RESULT: No differences were found between the groups at baseline. The results showed the participants had low life satisfaction (median 14 vs. 12), several health complaints (median 11) and a high score on the Geriatric Depression Scale (median 6) at baseline, indicating the risk of depression. No significant effects were observed regarding depressed mood or perceived health between or within groups at follow-up after 3 months. Cronbach's alpha showed satisfactory internal consistency for group comparisons. CONCLUSIONS: The sampling procedure led to similar groups. The life satisfaction, functional dependency and symptoms of depression measures were reliable to use. No changes in perceived health and symptoms of depression were found after 3 months, indicating that it may be too early to expect effects. The low depression score is noteworthy and requires further research.

The experience of being next of kin to an older person in the last phase of life.

OBJECTIVE: The aim of the study was to investigate the experience of being next of kin to an older person in the last phase of life as narrated after the older person's death. METHOD: Qualitative interviews were performed with the next of kin (n = 17) to people aged 75 years and older who had recently died and had received help and/or care from the municipality in the last phase of life. Eleven women and six men participated, of whom seven were spouses, nine were children, and one was a grandchild. The interviews were analysed using qualitative content analysis. RESULTS: The experience of the next of kin could be understood as being a devoted companion during the transition toward the inevitable end, embracing the categories of living in the shadow of death; focusing on the needs of the dying person, making adjustments to everyday life; feeling the major responsibility; struggling with the health and social care system; and gaining strength from support. SIGNIFICANCE OF RESULTS: Being next of kin to an old person at the end of life means being a devoted companion during the transition toward the inevitable end, including the feeling of bearing the major responsibility and the need to be acknowledged by professionals. This study points to the importance of having access to professional care when it is needed, to complement and support the next of kin when his or her own resources and strength falter. This also includes support to enable the next of kin to remain involved in the care of his or her loved ones, thereby fulfilling their own wishes.

Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care.

This study aimed at examine the number of planned and acute hospital admissions during 1 year among people 65+ and its relation to municipal care, outpatient care, multimorbidity, age and sex. Four thousand nine hundred and seven individuals having one or more admissions during 2001 were studied. Data were collected from two registers and comparisons were made between those having one, two and three or more hospital stays and between those with and without municipal care and services. Linear regression was used to examine factors predicting number of acute and planned admissions. Fifteen percent of the sample had three or more hospital stays (range 3-15) accounting for 35% of all admissions. This group had significantly more contacts in outpatient care with physician (median number of contacts (md)=15), compared to those with one (md: 8), or two admissions (md: 11). Main predictors for number of admissions were number of diagnosis groups and number of contacts with physician in outpatient care. Those who are frequently admitted to hospital constitute a small group that consume a great deal of inpatient care and also tend to have frequent contacts in outpatient care. Thus interventions focusing on frequent admissions are needed, and this requires collaboration between outpatient and hospital care.

Determinants of feeling hindered by health problems in daily living at 60 years and above.

Although the ability to perform activities of daily living (ADL) is frequently used to identify the impact on daily living caused by health problems such as diseases, impaired eyesight or hearing, it is still not well known what makes people feel hindered in daily living with more or less inability to perform ADL. The aim of this study was to investigate feeling hindered by health problems in daily living among people (n = 958, 60-96 years) in relation to ADL capacity, health problems as well as social and financial resources, sense of coherence and life satisfaction. The data are taken from a baseline survey in one of the four included centres (Blekinge) of the longitudinal multicentre cohort study, The Swedish National Study on Aging and Care. The result showed that people felt hindered by their health problems despite no impairment in ADL capacity. Feeling greatly hindered by health problems was associated with factors linked to mobility but also to fatigue, no help when needed, and avoiding being outdoors due to fear of falling. Factors associated with feeling greatly hindered differed depending on whether people were impaired in ADL capacity or not. In people with excellent ADL capacity feeling hindered was associated with picking up things from the floor and rising from a chair and fatigue, whereas avoiding being outdoors, no help when needed and rising from a chair were found to be associated with feeling hindered by health problems among people with impaired ADL capacity. Combining people's ADL capacity with questions about feeling hindered may provide knowledge of determinant factors of feeling hindered in relation to ADL capacity, impaired or not, to identify people in need of rehabilitation or other interventions.

Old people receiving municipal care, their experiences of what constitutes a good life in the last phase of life: a qualitative study.

BACKGROUND: Old people's life situation when receiving municipal help and care in their last period of life is sparsely investigated from their own perspective. OBJECTIVE: The aim of this study was to investigate the experiences of aspects that bring about a good life in the last phase of life among people (75+ years) receiving municipal care. PARTICIPANTS: Older people living in a municipality in Southern Sweden being 75 years or older, receiving help and/or care from the municipality, and having a life-threatening disease and/or receiving palliative care were asked to participate. In all 17 people, 10 women and 7 men, aged 78-100 years were included. METHODS: Qualitative interviews, with the emphasis on their present life situation especially what brought about a good life, were performed. The interviews were analysed using qualitative content analysis. RESULTS: The experience was interpreted to be Turning inwards to come to peace with the past, the present and approaching death while being trapped by health complaints. Six categories embraced the experience of aspects that constitute a good life in the last phase of life: Maintaining dignity, Enjoying small things, Feelings of "being at home", Being in the hands of others, trying to adjust, Still being important for other people and Completing life while facing death. CONCLUSION: This study confirm theories suggesting that the last phase of life in old age meant focusing inwards, reflecting on the entire life as a way of completing it as well as enjoying small things and also viewing oneself in the perspective of contributing to the future. It also indicated that this phase of life meant being trapped by health complaints and functional limitations. The struggle to maintaining dignity as opposed to being in the hands of others implies that the concept of palliative care may be useful as a framework for providing nursing care to very old people, especially at the end of life.

Costs of Care of Agitation Associated With Dementia in 8 European Countries: Results From the RightTimePlaceCare Study.

OBJECTIVE: To estimate the additional societal costs for people living with dementia (PwD) with agitation in home care (HC) and institutional long-term care (ILTC) settings in 8 European countries. DESIGN: Cross-sectional data from the RightTimePlaceCare cohort. SETTING: HC and ILTC settings from 8 European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, and England). PARTICIPANTS: A total of 1997 PwD (1217 in HC group and 780 lived in an ILTC) and their caregivers. MAIN OUTCOME MEASURES: Medical care, community care, and informal care were recorded using the Resource Utilization in Dementia (RUD) questionnaire. Agitation was assessed based on the agitation symptoms cluster defined by the presence of agitation and/or irritability and/or disinhibition and/or aberrant motor behavior items of the Neuropsychiatric Inventory Questionnaire (NPI-Q). RESULTS: Total monthly mean cost differences due to agitation were 445€ in the HC setting and 561€ in the ILTC setting (P = .01 and .02, respectively). Informal care costs were the main driver in the HC group (73% of total costs) and institutional care costs were the main driver in the ILTC group (53% of total costs). After adjustments, the log link generalized linear mixed model showed an association between agitation symptoms and an increase of informal care costs by 17% per month in HC setting (P < .05). CONCLUSION: This study found that agitation symptoms have a substantial impact on informal care costs in the community care setting. Future research is needed to evaluate which strategies may be efficient by improving the cost-effectiveness ratio and reducing the burden associated with informal care in the management of agitation in PwD.

Feeling hindered by health problems and functional capacity at 60 years and above.

It is common to use activities of daily living (ADL) rating scales to identify the impact of health problems such as diseases, impaired eyesight or hearing on daily life. However, for various reasons people with health problems might feel hindered in daily life before limitations in ability to perform ADL have occurred. In addition, there is sparse knowledge of what makes people feel hindered by health problems in relation to their ADL capacity. The aim was to investigate feeling hindered by health problems among 1297 people aged 60-89 living at home in relation to ADL capacity, health problems, life satisfaction, self-esteem, and social and financial resources, using a self-reported questionnaire, including questions from Older Americans' Resources and Services schedule (OARS), Rosenberg's self-esteem and Life Satisfaction Index Z (LSIZ). People feeling greatly hindered by health problems rarely had anyone who could help when they needed support, had lower life satisfaction and self-esteem than those not feeling hindered. Feeling hindered by health problems appeared to take on a different meaning depending on ADL capacity, knowledge that seems essential to include when accomplishing health promotion and rehabilitation interventions, especially at the early stages of reduced ADL capacity.

The final period of life in elderly people in Sweden: factors associated with QOL.

Whether elderly people in the final period of life have a high quality of life (QOL) and what factors relate QOL in this context, is not well known. The aim of this study was to examine the final period in life in elderly people (75 years or older) in need of help with instrumental activities of daily living (ADL), with the focus on quality of life, sense of coherence (SOC), health complaints and self-reported diseases. Also to investigate factors associated with QOL and factors predicting mortality. The sample consisted of 411 people, fifty of the respondents (the study group) had died within 1 year of data collection. The results showed that the study group had lower QOL than the comparison group. More admissions to hospital as well as the number of health complaints present negatively affected QOL for all respondents. Factors that predicted mortality included older age and higher number of health complaints.

Exploring the meaning of everyday life, for those suffering from dementia.

Living with dementia means struggling to preserve a sense of self, to retain (and reevaluate) one's values in a new situation, and to search for a new way of life. This study explored the meaning of everyday life as expressed by 11 people suffering from dementia. Data were collected through interviews with people in the early stage of a diagnosed dementia disease. The findings indicate that many people with dementia feel shame, sorrow, and sadness when their life with the disease begins but also indicate prospects of a more manageable life. Since the reaction and adjustment to dementia differs from person to person, professional caregivers need to use a case-specific approach in the provision of care.

Quality of life among older people in Sweden receiving help from informal and/or formal helpers at home or in special accommodation.

The present study describes and compares quality of life (QoL) and factors which predict QoL among people aged 75 years and over who receive help with activities of daily living (ADLs) from formal and/or informal helpers. The subjects were living at home or in special accommodation in Sweden. A postal questionnaire was sent to a randomly selected and age-stratified sample of 8500 people. The response rate was 52.8% (n = 4337), and 1247 people [mean age (+/- SD) = 86.4 +/- 5.9 years] received help and indicated who helped them with ADLs. The findings suggest that a greater age, being a woman, being a widow/widower, a higher number of health-related complaints, needing more help with ADLs and a lower QoL were found among those receiving help in special accommodation in comparison with those receiving help at home. The extent of help was highest among those receiving help in special accommodation. Having help with ADLs every day at home indicated having help from both informal and formal helpers, while respondents receiving help from only informal or only formal helpers received the smallest amount of help with ADLs. A need for greater help with ADLs, and a higher number of self-reported diseases and complaints determined low QoL, whilst a social network (contact with more than three people) and a greater age determined high QoL. However, who the helpers were did not have a significant influence on QoL; it was the extent of help with ADLs that influenced QoL negatively and the density of the social network that influenced QoL positively.

Acute confusional episodes in elderly orthopaedic patients: the patients' actions and speech.

The aim of this study was to illuminate the pattern of confusional episodes with regard to the content of elderly patients' actions and speech. Fifty-one (11.2%) out of 457 people admitted to an orthopaedic clinic developed acute confusional state. Non-participant direct observations and daily clinical bedside follow-up observations were made during the confusional episodes, focusing on the patients' speech, actions and reactions with reference to situation, the surroundings, and the nurses' actions, including their verbal communication with the patient. The texts were analysed using manifest and latent content analysis and revealed disturbances in motor activity, speech and mood. 'Struggling to understand and to gain control when in a state of confusion and viewing oneself as being confused' was the main theme illuminated in the texts. In the struggle to achieve understanding and take control over themselves and what was currently taking place, the patients used a variety of strategies. They attempted to find clarity, to make a sensible story out of the present and to impute meaning to the present by using their life story. The findings indicated that the patients had a drive to achieve control when they were confused and that they were both aware and unaware of their state and tended to oscillate between being in a confused state and viewing their confusion from an outside perspective. The findings indicated that possibly the best approach is to support their inner drive to gain control. This means moving between confirmation of their emotional state and their perceptions and trying to introduce 'reality' when they realize their state of confusion. Thus the nurse--patient relationship perhaps needs to hold a balance between confirmation and introducing in reality.

Nurses' experiences of the encounter with elderly patients in acute confusional state in orthopaedic care.

The aim of this study was to illuminate nurses' experiences of the encounter with elderly patients who developed acute confusional state (ACS) in orthopaedic care. Forty-eight nurses with professional background as registered (n=26) or licensed practical nurses (n=22) who took part in the nursing care of acute confused patients were involved. Open-ended unstructured interviews were conducted with regard to the course of events, experiences and interpretation of what had happened during the ACS as well as the nurses' actions and encounter with the confused patient. The texts were analysed using manifest and latent content analysis, revealing that the nurses had difficulties in reaching the patients and their reality, and thus in understanding their experiences. Interpretation of the nurses' experiences showed that the nurses found it difficult to reach the patients' reality because the patients were in a divided and/or different world. They interpreted the patients as seeking solitude or company, keeping a distance or being suspicious of the nurses. The findings indicated that the interaction in the encounter between the acutely confused patients and the nurses indicated insufficient and/or broken reciprocity. The nurses used various strategies to meet the patients, being a companion and/or being a surrogate. They acted in the encounter based on their view of the patient and their ability to enter into and understand the patients' situation. The strategies were more or less successful, sometimes resulting in contact and calming the patients and in other cases increasing the patients' irritation and anger. The results were more successful when the strategies were derived from the nurses' interpretation of the patients' situation and the nurses paid attention to the patients and confirmed them.

Eating difficulties, assisted eating and nutritional status in elderly (> or = 65 years) patients in hospital rehabilitation.

This study describes frequencies and associations between eating difficulties, assisted eating and nutritional status in 520 elderly patients in hospital rehabilitation. Eating difficulties were observed during a meal and nutritional status was assessed with Subjective Global Assessment form. Eighty-two percent of patients had one or more eating difficulties, 36% had assisted eating and 46% malnutrition. Three components of eating were focused upon ingestion, deglutition, and energy (eating and intake). Deglutition and ingestion difficulties and low energy were associated with assisted eating, and low energy associated with malnutrition. Underestimation of low energy puts patients at risk of having or developing malnutrition.

Comparison of oral health status on admission and at discharge in a group of geriatric rehabilitation patients.

PURPOSE: The aim of this study was to compare oral health status on a geriatric rehabilitation ward among patients who were assessed using the Revised Oral Assessment Guide (ROAG) on admission and at discharge; and to investigate in what respect the oral health procedures (OHP) suggested in ROAG were applied when oral health problems were detected. MATERIALS AND METHODS: Registered nurses on the ward performed oral health assessments using ROAG with 107 patients on admission and at discharge. When oral health problems were detected measures to be taken were suggested using ROAG. RESULTS: Oral health problems were common among the patients on admission (86%), as well as at discharge (51%). The frequency of the problems was significantly lower at discharge compared to admission. The OHP that were recommended in ROAG were completely followed when saliva flow-related problems were detected. Regarding other oral health problems, measures other than the recommended ones were often performed. CONCLUSION: This study demonstrated that the oral health was better at the end of the hospital stay compared to admission.