Assessing health status and outcomes in a geriatric day hospital

The study objective was to assess the feasibility and usefulness of recommended outcome measures in older people attending a geriatric day hospital for multidisciplinary assessment and rehabilitation. We used the 'Short Form 36' (SF36) questionnaire which had been proposed as a suitable outcome tool for the elderly, as well as standard assessment scales (eg Barthel index). These were administered by interviewers at the start of day hospital attendance and repeated by postal survey three and six months later. Change in overall health status was rated by the clinical team. The study took place in a geriatric day unit based in a support hospital, specialising in assessment and rehabilitation of older people. Participants were older people referred directly from the community, or following an inpatient day, whose assessment indicated a need for multidisciplinary rehabilitation. Stroke and musculo-skeletal disorders were the commonest underlying conditions. There was a high incidence of non-completion on SF36 questions relating to physical and mental function. Subsequent interviews showed that patients found some questions irrelevant. Floor effects were common. In contrast, the standard scales were invariably fully completed. Compared with local population survey data, respondents had low baseline scores on all SF36 dimensions. Differences over time were probably explained by varying methods of administration. In spite of a clinical perception of improved health status during day hospital attendance, both standard and SF36 scores showed overall deterioration. Two conclusions could be drawn from this study. 1. Measures of physical and mental disability and quality of life gave lower results than expected and continued declining over a six month period, even when the clinical team felt that the patient had improved. 2. Administration of SF36 by an interviewer is essential to obtain meaningful results in older people with poor physical health, which should be interpreted with caution. Goal-specific measures may be more useful in this group of patients.

Casemix for inpatient care of elderly people: rehabilitation and post-acute care. Casemix for the Elderly Inpatient Working Group

BACKGROUND

defining contracts for the care of elderly people on the basis of the number of episodes is inappropriate as it fails to take account of the wide variation in their physical disability and rehabilitation needs. Resource use on a day-to-day basis can be estimated for patients using the Resource Utilization Groups version III (RUG-III) casemix system. For practical use, RUG-III assessments cannot be made daily and so assessments at different time intervals were evaluated in order to give an indication of resource use for an inpatient stay. This study describes how RUG-III assessments can be used to give an indication of resource use for an inpatient episode.

METHOD AND RESULTS

RUG-III assessments were completed for all admissions to elderly care rehabilitation wards in two Health Districts over a 10 week period. There were 336 patients and 965 RUG-III assessments. The average time required to make RUG-III assessments fell from 10 to 4 min by the end of the study period. Fortnightly assessment intervals including a discharge assessment correlated well with the average of weekly assessments (R2 = 0.88-0.91, P < 0.0001).

CONCLUSION

using the results from these assessments we propose a model for use of the RUG-III system in contracts for rehabilitation and post-acute care of elderly people which addresses the difficulty of combining clinical characteristics, rehabilitation, resource use and length of stay into a single useful meaningful casemix system.

Maximal expiratory flow-volume curves in Londoners aged 60 years and over

To obtain more accurate information about respiratory function in the elderly, we carried out spirometry and constructed maximum expiratory flow-volume curves in 136 volunteers over the age of 60 years (90 women, 46 men). Significant age related differences were found. Although vital capacity appeared well preserved in all groups, mid expiratory flow rates were low, even in lifelong non-smokers. On the basis of previous work, many of the subjects in this study would have been assessed as having small airways obstruction. The number of subjects is larger than in previous studies of airflow in this age group. Old people have often smoked, and many have a history of cardiovascular disease. Such individuals were included provided that they were fit and active for their age, and had no overt respiratory disease. It is argued that our findings will be of more clinical relevance to the elderly population than values derived either from population studies or studies that have used rigorous selection criteria to exclude subjects who smoked or had a history of non-respiratory disease.

Ageing and lung function

Studies of lung function have largely ignored the elderly. This paper reviews what is known of the decline in measurements of lung function, and focuses on reduced elastic recoil as a key to these changes. Independent anthropometric changes which may affect lung function with advancing years are also discussed.