[Legally improved access to geriatric rehabilitation - prerequisites and weaknesses]. / Der gesetzlich verbesserte Zugang zur geriatrischen Rehabilitation ­ Voraussetzungen und Schwächen.

Geriatric rehabilitation is a cornerstone of the German healthcare system to maintain the functional capacity of older patients and prevent the need for long-term care. Until recently, access to geriatric rehabilitation was largely limited to post-acute care. With the introduction of new legislation, patients aged 70 and over can be referred to geriatric rehabilitation by practitioners. However, in order to prescribe geriatric rehabilitation, physicians must document relevant diagnoses supported by the results of a series of functional or cognitive assessments. Alongside this information, the SINGER profile has been introduced. It is mandatory, although there is currently no manual to guide assessment with this tool. Diagnoses and test results must be consistent in documenting the need for geriatric rehabilitation. However, individual assessment of resources and motivation are prerequisites that need to be assessed by prescribing practitioners prior to prescription, considering the structure of the available formats. First analyses document improvement in access to geriatric rehabilitation but point to limited availability.

[Assessment of mobility-Geriatric assessment instruments for mobility impairments and perspectives of instrumentation]. / Assessment von Mobilität ­ geriatrisches Assessment zur Erfassung lokomotorischer Mobilitätseinschränkungen und Perspektiven der Instrumentierung.

Mobility and its limitations play an important role in the quality of life of geriatric patients and influence activity and participation. The assessment of mobility is therefore of particular importance for treatment and treatment planning in geriatric patients. There is a variety of assessment tools that cannot be used in every patient group, e.g. due to floor effects. This article provides an overview of common assessment tools and facilitates the evaluation and use of these tools. Special consideration is given to performance-oriented aspects and current technical developments such as wearables.

[Validation of the geriatrie-check for identification of geriatric patients in emergency departments]. / Validierung des Geriatrie-Checks zur Identifikation geriatrischer Patienten in der Notaufnahme.

BACKGROUND: The geriatric check was developed for identification of geriatric patients in emergency departments (ED) as part of the concept for geriatric care in Baden-Württemberg. AIM: Determination of convergent and predictive validity of the geriatric check with respect to identification and outcome prediction of geriatric patients in the ED. MATERIAL AND METHODS: A prospective cohort study between November 2015 and April 2016 including 146 patients older than 70 years in the internal medicine ED of Ulm University Hospital. Separate assessment by physicians and nursing staff of the following: identification of seniors at risk (ISAR), geriatric check, additional cognitive and functional assessments and for outcome: change in care index, Barthel index, living arrangements. RESULTS: The ISAR classified 117 patients as geriatric patients and the geriatric check 107. The correlation was 78.1%. With ISAR as the gold standard the geriatric check showed a sensitivity of 82.0% and a specificity of 62.1%. The positive and negative predictive values were 89.7% and 46.1%, respectively. The identification by simple estimation was better for nurses than for doctors (sensitivity 70.5% vs. 58%, specificity 88.9% vs. 83.3%). The predictive validity 5 months after admission with respect to the abovementioned outcome parameters was best for nurses and doctors (especially regarding specificity). Both tests were very sensitive but not very specific. DISCUSSION: The geriatric check is comparable to the ISAR. The convergent validity showed little difference. Both the ISAR and geriatric check were slightly more sensitive than doctors and nurses. Regarding predictive validity, doctors and nurses were superior to both scores. An algorithm starting with ISAR or geriatric check and followed by an estimation by doctors or nurses could be most suitable for optimal resource allocation.

[Validation of the Geriatric Check in a cohort of hospitalized neurological patients]. / Validierung des Geriatrie-Checks in einer Kohorte von stationären neurologischen Patienten.

BACKGROUND: The Geriatrie-Check was developed as a screening tool for the identification of older patients with geriatric treatment requirements in hospitals. It was recommended by the Baden-Wuerttemberg Hospitals Association for routine use in hospitals in 2014 although no published validation studies are available. The test takes 3-5 min. AIM: Validation of the Geriatrie-Check in a prospective cohort of hospitalized neurological patients with and without geriatric characteristics. METHODS: In this prospective cross-sectional observational study at the University Hospital Tübingen, Germany the Geriatrie-Check was compared with a comprehensive geriatric assessment in 107 neurological inpatients aged 70 years and older (41% women, mean age 76.7 years). RESULTS: The Geriatrie-Check classified 61 patients (57%) as geriatric patients. These patients with a positive result in the Geriatrie-Check had a higher percentage of frailty (according to Fried et al.), higher values in the Gérontopôle frailty screening tool, higher values in the geriatric screening according to Lachs et el., slower gait speed, lower grip force, needed longer for the timed up-and-go test, had a greater fear of falling in the Falls Efficacy Scale - International, lower scores in the Mini Mental State Examination, needed more time to perform the Trail Making Test A and B, had higher values in the Beck's Depressions Inventar II and lower values in the visual analogue scale of the EQ-5D. A higher percentage of patients took more than five different drugs. INTERPRETATION AND CONCLUSION: The Geriatrie-Check has been shown to be a useful and valid tool for the identification of geriatric inpatients in neurological wards due to the good agreement with the results of the geriatric assessment.

Assessing Physical Activity in Inpatient Rehabilitation: validity, practicality, and sensitivity to change in the physical activity in inpatient rehabilitation assessment.

OBJECTIVE: To validate a novel assessment of inpatient physical activity. DESIGN: Prospective cohort study for the evaluation of a novel questionnaire for physical activity in geriatric inpatients. SETTING: German geriatric inpatient rehabilitation unit. PARTICIPANTS: Patients (N=96; 67 [72%] women; median age, 81y) with a variety of main underlying diagnoses, including musculoskeletal diseases, hip fracture, cardiovascular diseases, stroke, and others. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ceiling and floor effects and administration time were measured. For criterion-related concurrent validity (convergent and discriminative), the Physical Activity in Inpatient Rehabilitation Assessment (PAIR) was administered in parallel to self-rated, proxy-rated, and performance-based measures of physical function at admission. Measurements were repeated at discharge and 4-month follow-up in the home environment, including a standard physical activity questionnaire to determine predictive validity. Spearman correlation coefficients were calculated to describe associations between parameters. Sensitivity to change was estimated using standardized response means (SRMs). RESULTS: Administration time of the PAIR ranged from less than 1 to 4 minutes. Ceiling effects occurred mainly at discharge (5%-14%), and floor effects (5%-11%), at admission. There were no missing values. Associations between convergent and predictive validity measures and functional measures (r=.43-.53, r=.49-.54, respectively) were clearly better when cognition was intact. Discriminative validity expressed as effect sizes ranged from .27 to 1.44. The SRM to describe sensitivity to change was .65 for the total score. CONCLUSIONS: The PAIR is the first validated questionnaire to assess physical activity in geriatric inpatients. It is practical and its validity and sensitivity to change are similar to existing physical activity questionnaires for community-dwelling older persons.

Depressive symptoms and fear of falling in previously community-dwelling older persons recovering from proximal femoral fracture.

BACKGROUND AND AIMS: Depression and fear of falling are common problems following proximal femoral fracture. The role of fear of falling in depressive symptoms after such a fracture has not yet been investigated. The aim of this study was to establish possible changes during recovery in fear of falling and depressive symptoms following rehabilitation in this population and to explore their association. METHODS: Observational study with pre-post design at a single geriatric rehabilitation hospital in Germany. Data were collected during in-hospital rehabilitation and four months later at participants' home. The data of 51 participants living in the community at the time of fracture could be analysed. MAIN MEASURES: Fear of falling, depressive symptoms, cognition, pain, ADL functioning, and physical performance. RESULTS: Although physical and ADL performance improved between admission to rehabilitation and follow-up four months later, the prevalence of depressive symptoms increased, and levels of fear of falling remained at the same level. There was a significant correlation between fear of falling and depressive symptoms at follow-up, but the two were not significantly correlated at baseline. Fear of falling and depressive symptoms were not significantly associated in a path analysis model. CONCLUSIONS: Fear of falling and depressive symptoms are highly prevalent after proximal femoral fracture. Yet there seems to be no simple association between either psychological parameter in older persons recovering from fall-related fractures. Further research is warranted, in order to develop interventions targeting these psychological outcomes.

Does functional change predict the course of improvement in geriatric inpatient rehabilitation?

OBJECTIVE: The evaluation of rehabilitation success as measured by different tools is becoming increasingly important in terms of time and money allocation. We wanted to know whether functional change in the first week predicts subsequent improvement in a geriatric inpatient rehabilitation clinic. DESIGN: Observational longitudinal study. SETTING: Geriatric inpatient rehabilitation clinic in Germany. SUBJECTS: One hundred and sixty-one inpatients (117 women) with a median age of 82 years, capable of walking at baseline. MAIN MEASURES: Weekly assessments of physical function were performed from admission until three weeks later. We used a self-rated tool (the function component of the Short Form - Late Life Function and Disability Index), a proxy-rated tool (the Barthel Index) and a performance-based tool (gait speed). We set up linear regression models to estimate the predictive capacity of change in physical function within the first week on change in physical function within the following two weeks. RESULTS: Positive correlations were found between functional change within the first week and total change within three weeks. However, correlations of the same periods of change with subsequent change were negative. Correlations were highly significant for both analysis with P-values <0.0001 when the same measures for prediction and outcome were used. Correlations were inconsistent when prediction and outcome were different. CONCLUSIONS: Improvement within the first week of inpatient rehabilitation is negatively correlated with subsequent functional change.

Relationship between fear of falling and outcomes of an inpatient geriatric rehabilitation population--fear of the fear of falling.

OBJECTIVES: To examine the effects of various risk factors on three functional outcomes during rehabilitation. SETTING: Geriatric inpatient rehabilitation unit. DESIGN: Observational longitudinal study. PARTICIPANTS: One hundred sixty-one geriatric rehabilitation inpatients (men, women), mean age 82, who were capable of walking at baseline. MEASUREMENTS: Functional status was assessed weekly between admission and discharge and at a follow-up 4 months later at home using the function component of the Short Form-Late Life Function and Disability Instrument, the Barthel Index, and Habitual Gait Speed. Various risk factors, such as falls-related self-efficacy (Falls Efficacy Scale-International), were measured. Associations between predictors and functional status at discharge and follow-up were analyzed using linear regression models and bivariate plots. RESULTS: Fear of falling predicted functioning across all outcomes except for habitual gait speed at discharge and follow-up. Visual comparison of functional trajectories between subgroups confirmed these findings, with different levels of fear of falling across time in linear plots. Thus, superior ability of this measure to discriminate between functional status at baseline across all outcomes and to discriminate between functional change especially with regard to the performance-based outcome was demonstrated. CONCLUSION: Falls-related self-efficacy is the only parameter that significantly predicts rehabilitation outcome at discharge and follow-up across all outcomes. Therefore, it should be routinely assessed in future studies in (geriatric) rehabilitation and considered to be an important treatment goal.

Evaluation of the short form of the late-life function and disability instrument in geriatric inpatients-validity, responsiveness, and sensitivity to change.

OBJECTIVES: To evaluate the function component of the Short Form of the Late-Life Function and Disability Instrument (SF-LLFDI, German version) in geriatric inpatients and compare it with established performance-based and self-rated assessment tools. SETTING: Geriatric inpatient rehabilitation unit. PARTICIPANTS: One hundred fifty-six geriatric rehabilitation inpatients (44 men, 112 women) with a mean age of 81.7 who were capable of walking at baseline. MEASUREMENTS: Weekly assessments were performed from admission until discharge (3 weeks later) using the function component of the SF-LLFDI, the Barthel Index (BI), the Falls Efficacy Scale International (FES-I), gait characteristics, the Timed Up and Go Test, and the Short Physical Performance Battery. Baseline characteristics were measured at admission. Construct validity was evaluated using Spearman correlation coefficients, internal consistency was measured using Cronbach alpha, and sensitivity to change was estimated using standardized response means. RESULTS: The SF-LLFDI did not show significant floor or ceiling effects. Internal consistency was good, with alpha (function component sub-scores) equal to 0.80 to 0.86. Convergent validity measures concerning performance-based scores were moderate to good, and correlations increased over time (correlation coefficient (r)=0.35-0.64). There was a high correlation with the FES-I (admission: r=0.61, discharge: r=0.76). Sensitivity to change was significant for all examined scores, with the BI outperforming all other instruments, although the SF-LLFDI showed better responsiveness than the BI regarding change characteristics over time. CONCLUSION: The SF-LLFDI is a reliable and valid self-report instrument to measure functional status in geriatric rehabilitation inpatients. It improves the assessment of clinically relevant responsiveness. Further research is warranted to improve its sensitivity to change.