Health
 Vol.5 No.6A2(2013), Article ID:33714,5 pages DOI:10.4236/health.2013.56A2014

Modification in self-rated health in patients discharged by a geriatric rehabilitation ward

Eleonora Marelli1, Giuseppe Procino1, Maria Cottino1, Giorgio Previderè1, Silvio Giorgi1, Davide Dell’Acqua1, Santina Bruno1, Marco Cairati1, Danila Ferrari1, Rosella Capuano1, Mauro Colombo1,2*

1Geriatric Institute “Camillo Golgi”, Milan, Italy; *Corresponding Author: m.colombo@golgiredaelli.it

2“Golgi-Cenci” Foundation, Milan, Italy

Copyright © 2013 Eleonora Marelli et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received 1 April 2013; revised 1 May 2013; accepted 1 June 2013

Keywords: Cognition; Functional Gains; Geriatric Rehabilitation; Mood; Pain; Self-Rated Health

ABSTRACT

Self-rated health is a valuable outcome in geriatric rehabilitation besides objective results. The present work aims at measuring and analyzing overall health as it is perceived at admission into and at discharge from a geriatric rehabilitation ward. Overall health was self-appraised through a visual-analogue scale (VAS), spanning from 0 (worst) to 10 (best). We studied 1997 patients (70% females), aged 79 (standard deviation, s.d. 8.7) years; most were frail, either functionally, clinically and cognitively. 80% of patients were discharged to home after a length of stay lasting 47.5 (s.d. 22.7) days. At admission, 3/5 patients appraised favorably their overall health (VAS ≥ 6/10): at discharge, the proportion rose to 3/4, with a mean (s.d.) gain = 2 (2) points. The improvement in self-perceived health score positively correlates with the grade expressing clients’ overall satisfaction for the stay (p 0.001), and with discharge versus admission differences in: Barthel Index (BI) total score (p < 0.001), Tinetti total score, Mini Mental State Examination (MMSE), Geriatric Depression Scale (5 items GDS), pain (VAS 0 to 10). A Linear regression model predicting the changes in self-perceived health included changes in BI, MMSE, GDS, pain, dropping Tinetti test. Changes in selfrated health were positively correlated to functional gain adjusted for pre-morbid level, and to relative functional gain. By analysis of variance, health self-appraisal changed more favorably in patients discharged to home than for other social outcomes (all p < 0.001). As expected, trends in self-perceived health parallel improvements in objective functional gauges and subjective indicators.

1. INTRODUCTION

Geriatric rehabilitation wards face the complexity of different clinically important goals. A wide array of health outcomes and situations must be addressed, that range from overcoming adverse clinical [1] or unexpected events [2] to managing comorbidity and frailty [3,4]. Moreover, we must prioritize subjective feelings besides, objective targets. Health-related quality of life is quoted as a reference outcome measure in clinical trials. Furthermore, it is best used in older persons to capture the global burden of multiple, simultaneous and interactive chronic conditions on physical, psychological and social function. Moreover, in diseases like stroke, Parkinson’s disease or chronic coronary artery disease, the relationship between clinical measures of disease severity and health-related quality of life is nonlinear [5]. Also, in five common chronic diseases (arthritis, ischemic heart disease, chronic pulmonary disease, diabetes mellitus and cancer), physicians’ ratings are generally worse and only weakly associated with the patients’ ratings of quality of life. Patients’ own perception of their health, as well as social and other factors adds to the multidimensional construct of quality of life in elderly outpatients [6]. Core issues of geriatric rehabilitation like ambulation difficulties and depression heavily impinge on perceived health and functioning in community living older bearing “geriatric syndromes” like sleep disturbances, falls and urinary incontinence [7]. Rehabilitation interventions which focused on restoring independence in basic activities of daily living most related to self-rated health (like taking stairs, ambulation and chair/bed transfer) could theoretically improve self-rated health [8]. Disease, observed function and self-perceived health status are separate but interrelated entities, wherein disease shows a stronger relationship to observed function than self-perceived health. Comprehensive assessment of frail elderly may have to take into account all these three areas, especially in very frail elders [9]. Hence, an individualized approach to outcome measurement is warranted in geriatric rehabilitation [10].

The present work aims at measuring and analyzing overall health as it is perceived at admission into and at discharge from a geriatric rehabilitation ward.

2. MATERIALS AND METHODS

2.1. Outcome and Explanatory Measures

Overall health was self-appraised through a visualanalogue scale (VAS), spanning from 0 (worst) to 10 (best). Both close to admission and to discharge, patients were asked to rate their overall health prompted by images like “☹” or “☺”, at respective ends of a line (Figure 1). The same kind of appraisal applied to pain: score 0 meaning no pain, whilst score 10 pointing at top level pain. Functional state was assessed through the Barthel Index (BI) [11], balance and gait performances by Tinetti test [12-14], general cognition by the Mini Mental State Examination (MMSE) [15,16], mood (depressive symptoms) by 5 items Geriatric Depression Scale (GDS) [17, 18].

2.2. Setting

1997 patients (70% females) were studied, aging 20 to 100 years (age: mean = 79, standard deviation, s.d. = 8.7, median = 80, mode = 82). Our sample mostly includes typically frail elders, as shown by the prevalence at admission of a set of indicators: pressure ulcers (European Pressure Ulcer Advisory Panel stage ≥ 2nd) almost 2 out of 5, potential risk of malnutrition almost 4 out 5, food texture modification more than 1 out of 7, communication difficulties 2 out of 5, MMSE < 24/30 one half, depressive symptoms in almost 3 out of 5—with severe depressive symptoms (GDS ≥ 4/5) in 1 out 12, clinically relevant pain (VAS ≥ 6/10) about 2 out of 5. Patients were also functionally impaired at entry: BI (total score/ 100) = 55.4 (s.d. = 24.4), high falling risk (Tinetti test total score ≤ 18/24) in 9 out of 10 people.

2.3. Statistical Analysis

Descriptive and inferential analysis was carried out through the SPSS software. Either parametric or nonparametric tests were performed, as appropriate. Relative

Figure 1. Prompted visual analogue scale.

functional gain was calculated according to the Montebello Rehabilitation Factor Score [19].

3. RESULTS

After a length of stay lasting 47.5 (s.d. 22.7) days, 80% of patients were discharged to home, 8.5% to nursing homes, 4% to hospital, 7% to other rehabilitative settings (including day hospital); 0.5% of patients died. At admission, 3 out of 5 patients appraised favorably their overall health (VAS ≥ 6/10): at discharge, the proportion rose to 3 out of 4, with a mean (s.d.) gain = 2 (2) points. Mean (s.d.) self-rated was 5.7 (2.1) at admission, and 7.7 (1.8) at discharge (p < 0.001) (Table 1). The improvement in self-perceived health score positively correlates with the grade expressing clients’ overall satisfaction for the stay (Spearman’s rho = 0.11; p 0.001), and with discharge versus admission differences in: BI total score (Spearman’s rho = 0.16; p < 0.001), Tinetti total score (Spearman’s rho = 0.12; p < 0.001), MMSE (Spearman’s rho = 0.24; p < 0.001), GDS (Spearman’s rho = 0.14; p < 0.001), pain (Spearman’s rho = 0.12; p < 0.001). A model was found that predicted the changes in self-perceived health (R = 0.28; p < 0.001). Linear regression selected as independent variables the discharge versus admission differences in the following variables: BI, MMSE, GDS, pain; differences for Tinetti test were dropped out. Discharge versus admission differences in pain score and GDS kept their statistically significant correlations with trends in self-appraised health after respective adjustment while performing partial correlations. No relationship was found between changes in self-appraised health and length of stay.

Changes in self-rated health was positively correlated to functional gain adjusted for pre-morbid level (Spearman’s rho = 0.12; p < 0.001), and to relative functional gain (functional gain as a % of rehabilitative potential) (Spearman’s rho = 0.14; p < 0.001). By analysis of variance, health self-appraisal changed more favorably in patients discharged to home than in those going across different social outcomes (nursing home, hospital, other rehabilitation settings) (p < 0.001) (Table 2).

4. DISCUSSION

The American Geriatrics Society and the American Academy of Physical Medicine and Rehabilitation joint-

Table 1. Self-rated health at admission and at discharge.

Table 2. Difference in self-appraised health (discharge minus admission) according to social outcome.

ly addressed in a statement of principles what matters while measuring key rehabilitation outcomes. Common principles and complementary approaches by geriatrics and physical medicine and rehabilitation concur to face 21st century demography caring older patients in surgical and medical specialties [20-23]. Significant differences in physical function and dependency in activities of daily living (ADL) were seen in relation also to wellbeing, in Nordic nursing home residents [24]. It is greatly challenging to find out whether individually tailored and enhanced activities can lead to decreased dependence and increased wellbeing, in nursing home settings [25]. As we expected, trends in self-perceived health parallel improvements in either cognitive performances, objective functional gauges or other subjective indicators (like pain or mood) [26-31]. More, statistical modeling supports the plausibility of our results. Subacute rehabilitation patients feel accurate expectations of their health-related quality of life at discharge [32].

Further, we previously showed that customer satisfaction is realistically related to reasonably attainable functional as well as clinical outcomes [33], consistently with the majority of the literature [34-37]. Other Authors stressed subjective evaluation of therapy over objective success on health-related quality of life after rehabilitation. Congruent positive (subjective and objective) and “satisfaction paradox” (incongruent positive subjective and negative objective ratings) hip fracture patients got the highest subjective gains in health-related quality of life. Unfortunate patients and “dissatisfaction dilemma” patients (incongruent subjective negative with objective positive ratings) estimated their gains as similarly low [38]. Another study reported the impact of the treatment and rehabilitation in hip-fracture patients by using structured self-assessment instruments of perceived health and related them to objective outcome assessments. The objective outcome seemed as informative as the subjective evaluations of patients’ self-assessment [39].

We are aware of limitations in the present study. First, 13% of patients were unable to reliably self-rate their overall health. Second, the strength of correlations between modification in self-appraised health and other variables is low, albeit statistically significant. Third, the same limitation applies to the amount of variance accounted for by our model.

5. CONCLUSIONS

Traditional outcomes of geriatric rehabilitation include: 1) functional improvement, 2) clinical stabilization, 3) getting back home. Such aims can be pursued to somewhat different extents and at varying degrees of combinations [26]. Our data show we substantially achieved all these goals. Besides these objective results, subjective aspects are getting increasing relevance. Hence, we point, to a relevant issue, the patients’ subjective improvement in self-appraisal of overall health. Our results in terms of objective and subjective rehabilitative outcomes are consistent with the literature supporting inpatient rehabilitation specifically designed for geriatric patients [40], as well as the role of context to influence health outcomes [41].

Then, whilst evaluating the treatment outcomes, “shouldn’t we be asking patients if they are better?” [42].

6. ACKNOWLEDGEMENTS

The authors thank the whole staff of “Golgi” Institute rehabilitative wards.

REFERENCES

  1. Bellelli, G., Bernardini, B., Pievani, M., Frisoni, G.B., Guaita, A. and Trabucchi, M. (2012) A score to predict the development of adverse clinical events after transition from acute hospital wards to post-acute care settings. Rejuvenation Research, 15, 553-563. doi:10.1089/rej.2012.1332
  2. Gurwitz, J.H., Sanchez-Cross, M,T., Eckler, M.A. and Matulis, J. (1994) The epidemiology of adverse and unexpected events in the long-term care setting. Journal of the American Geriatrics Society, 42, 33-38
  3. Bellelli, G., Guerini, F., Bianchetti, A., De Palma, D., Ther, P. and Trabucchi, M. (2002) Medical comorbity and complexity of the rehabilitative procedures for older patients with functional impairments. Journal of the American Geriatrics Society, 50, 2095-2096. doi:10.1046/j.1532-5415.2002.50628.x
  4. Yancic, R., Ershler, W., Satariano, W., Hazzard, W., Cohen, H.J. and Ferrucci L. (2007) Report of the National Institute on aging task force on comorbidity. Journal of Gerontology Medical Sciences, 62A, 275-280. doi:10.1093/gerona/62.3.275
  5. Ferrucci, L., Baldasseroni, S., Bandinelli, S., de Alfieri, W., Cartei, A., Calvani, D., Baldini, A., Masotti, G. and Marchionni, N. (2000) Disease severity and health-related quality of life across different chronic conditions. Journal of the American Geriatrics Society, 48, 1490-1495.
  6. Pearlman, R.A. and Uhlmann, R.F. (1988) Quality of life in chronic diseases: Perceptions of elderly patients. Journal of Gerontology, 43, M25-M30. doi:10.1093/geronj/43.2.M25
  7. Kutner, N.G., Schechtman, K.B., Ory, M.G. and Baker, D.I. (1994) Older adults’ perceptions of their health and functioning in relation to sleep disturbance, falling, and urinary incontinence. FICSIT Group. Journal of the American Geriatrics Society, 42, 757-762.
  8. Gama, E.V., Damián, J.E., Pérez de Molino, J., López, M.R., López Pérez, M. and Gavira Iglesias, F.J. (2000) Association of individual activities of daily living with self-rated health in older people. Age and Ageing, 29, 267-270. doi:10.1093/ageing/29.3.267
  9. Mulrow, C.D., Gerety, M.B., Cornell, J.E., Lawrence, V.A. and Kanten, D.N. (1994) The relationship between disease and function and perceived health in very frail elders. Journal of the American Geriatrics Society, 42, 374-380.
  10. Stolee, P., Stadnyk, K., Myers, A.M. and Rockwood, K. (1999) An individualized approach to outcome measurement in geriatric rehabilitation. Journal of Gerontology A Biological Sciences Medical Sciences, 54, M641-M647. doi:10.1093/gerona/54.12.M641
  11. Shah, S., Vanclay, F. and Cooper, B. (1989) Improving the sensitivity of the Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology, 42, 703-709. doi:10.1016/0895-4356(89)90065-6
  12. Tinetti, M.E. (1986) Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34, 119-126.
  13. Cipriani-Dacko, L.M., Innerst, D., Johannsen, J. and Rude, V. (1997) Interater reliability of the Tinetti Balance Score in novice and experienced physical therapy clinicians. Archives of Physical Medicine and Rehabilitation, 78, 1160-1164. doi:10.1016/S0003-9993(97)90145-3
  14. Kegelmeyer, D.A., Kloos, A.D., Thomas, K.M. and Kostyk, S.K. (2007) Reliability and validity of the Tinetti Mobility Test for individuals with Parkinson Disease. Physical Therapy, 87, 1369-1378. doi:10.2522/ptj.20070007
  15. Folstein, M.F., Folstein, S.E. and McHugh, P.R. (1975) Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. doi:10.1016/0022-3956(75)90026-6
  16. Tombaugh, T.N. and McIntyre, N.J. (1992) The MiniMental State Examination: A comprehensive review. Journal of the American Geriatrics Society, 40, 922-935.
  17. Mecocci, P., Cherubini, A., Mariani, E., Ruggiero, C. and Senin, U. (2004) Depression in the elderly: New concepts and therapeutic approaches. Aging Clinical Experimental Research, 16, 176-189.
  18. Rinaldi, P., Mecocci, P., Benedetti, C., Ercolani, S., Bregnocchi, M., Menculini, G., Catani, M., Senin, U. and Cherubini, M. (2003) Validation of the five-item Geriatric Depression Scale in elderly subjects in three different settings. Journal of the American Geriatrics Society, 51, 694-698. doi:10.1034/j.1600-0579.2003.00216.x
  19. Heruti, R.J., Lusky, A., Dankner, R., Ring, H., Dolgopiat, M., Barell, V., Levenkrohn, S. and Adunsky, A. (2002) Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome. Archives of Physical Medicine and Rehabilitation, 83, 742-749. doi:10.1053/apmr.2002.32739
  20. Whiteneck, G.G. (1994) Measuring what matters: Key rehabilitation outcomes. Archives of Physical Medicine and Rehabilitation, 75, 1073-1076. doi:10.1016/0003-9993(94)90080-9
  21. Reinstein, L. (1994) Physical medicine and rehabilitation in the 21st century. Archives of Physical Medicine and Rehabilitation, 75, 1-2.
  22. American Geriatrics Society, John A. Hartford Foundation (2002) A statement of principles towards improved care of older patients in surgical and medical specialties. Archives of Physical Medicine and Rehabilitation, 83, 1317-1319. doi:10.1053/apmr.2002.34803
  23. Strasser, D,C,, Solomon, D.H. and Burton, J.R. (2002) Geriatrics and physical medicine and rehabilitation: Common principles, complementary approaches, and 21st century demographics. Archives of Physical Medicine and Rehabilitation, 83, 1323-1324. doi:10.1053/apmr.2002.34804
  24. Grönstedt, H., Hellström, K., Bergland, A., Helbostad, J.L., Puggaard, L., Andresen, M., Granbo, R. and Frändin, K. (2011) Functional level, physical activity and wellbeing in nursing home residents in three Nordic countries. Aging Clinical Experimental Research, 23, 413-420.
  25. Frändin, K., Borell, L., Grönstedt, H., Bergland, A., Helbostad, J.L., Puggaard, L., Andresen, M., Granbo, R. and Hellström, K. (2009) A Nordic multi-center study on physical and daily activities for residents in nursing home settings: Design of a randomized, controlled trial. Aging Clinical Experimental Research, 21, 314-322.
  26. Colombo, M., Guaita, A., Cottino, M., Previderè, G., Ferrari, D. and Vitali, S. (2004) The impact of cognitive impairment on the rehabilitation process in geriatrics. Archives of Gerontology and Geriatrics Supplement, 9, 85- 92. doi:10.1016/j.archger.2004.04.014
  27. Masiero, S., Avesani, R., Pegoraro, S., Frigo, A.C. and Bonaldo, L. (2011) Predictive factors for functional recovery in patients admitted to subacute care nursing home in Italy. Aging Clinical Experimental Research, 23, 74- 77.
  28. Ostir, G.V., Smith, P.M., Smith, D., Berges, I.M. and Ottenbacher, K.J. (2005) The influence of perceived pain on satisfaction with community participation after hospital discharge. Archives of Physical Medicine and Rehabilitation, 86, 2095-2100. doi:10.1016/j.apmr.2005.05.011
  29. Bergés, I.M., Ottenbacher, K.J., Smith, P.M., Smith, D. and Ostir, G.V. (2006) Perceived pain and satisfaction with medical rehabilitation after hospital discharge. Clinical Rehabilitation, 20, 724-730. doi:10.1191/0269215506cre1006oa
  30. Barbisoni, P., Bertozzi, B., Franzoni, S., Rozzini, R., Frisoni, G.B. and Trabucchi, M. (1996) Mood improvement in elderly women after in-hospital physical rehabilitation. Archives of Physical Medicine and Rehabilitation, 77, 346-349. doi:10.1016/S0003-9993(96)90082-9
  31. Blumenthal, J.A., Babyak, M.A., O’Connor, C., Keteyian, S., Landzberg, J., Howlett, J., Kraus, W., Gottlieb, S., Blackburn, G., Swank, A. and Whellan, D.J. (2012) Effects of exercise training on depressive symptoms in patients with chronic heart failure: the HF-ACTION randomized trial. The journal of the American Medical Association, 308, 465-474. doi:10.1001/jama.2012.8720
  32. McPhail, S. and Haines, T. (2012) Patients undergoing sub acute rehabilitation have accurate expectations of their health-related quality of life at discharge. Health and Quality of Life Outcomes, 10, 94. http://www.hqlo.com/content/10/1/94 doi:10.1186/1477-7525-10-94
  33. Colombo, M., Guaita, A., Cottino, M., Cairati, M., Previderè, G., Procino, G., Gandolfi, M.C., Tararà, R. and Mercanti, A. (2009) Customer satisfaction as a quality factor in geriatric rehabilitation. The Open Geriatric Medicine Journal, 2, 1-4. doi:10.2174/1874827900902010001
  34. Studenski, S. and Duncan, P.M. (1993) Measuring rehabilitation outcomes. Clinics in Geriatric Medicine, 9, 823-830.
  35. Ostir, G.V., Smith, P.M., Smith, D., Rice, J.L. and Ottenbacher, J. (2005) Orthopedic impairment after medical rehabilitation: functional performance and satisfaction with community participation. American Journal of Physical Medicine and Rehabilitation, 84, 763-769. doi:10.1097/01.phm.0000179440.91045.f9
  36. Mancuso, M., Smith, P., Illig, S., Granger, C.V., Gonzales V.A., Linn, R.T. and Ottenbacher, K.J. (2003) Satisfaction with medical rehabilitation in patients with orthopedic impairment. Archives of Physical Medicine and Rehabilitation, 84, 1343-1349. doi:10.1016/S0003-9993(03)00144-8
  37. Tooth, L.R., Ottenbacher, K.J., Smith, P.M., Illig, S., Linn, R.T., Gonzales V.A. and Granger, C.V. (2003) Effect of functional gain on satisfaction with medical rehabilitation after stroke. American Journal of Physical Medicine and Rehabilitation, 82, 692-699. doi:10.1097/01.PHM.0000083672.01300.47
  38. Papadopoulos, C., Jagsch, R., Griesser, B., Magenheim, E., Mozelt, C., Chhatwal, C., Kryspin-Exner, I. and Pils, K. (2007) Health-related quality of life of patients with hip fracture before and after rehabilitation therapy: Discrepancies between physicians’ findings and patients’ ratings. Aging Clinical Experimental Research, 19, 125-131.
  39. Borgquist, L., Nilsson, L.T., Lindelöw, G., Wiklund, I., Thorngren, K.G. (1992) Perceived health in hip-fracture patients: a prospective follow-up of 100 patients. Age and Ageing, 21, 109-116. doi:10.1093/ageing/21.2.109
  40. Bachmann, S., Finger, C., Huss, A., Egger, M., Stuck, A.E. and Clough-Gorr, K.M. (2010) Inpatient rehabilitation specifically designed for geriatric patients: Systematic review and meta-analysis of randomised controlled trials. BMJ, 340, c1718. doi:10.1136/bmj.c1718
  41. Di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A. and Kleijnen, J. (2001) Influence of context effects on health outcomes: A systematic review. Lancet, 357, 757-762. doi:10.1016/S0140-6736(00)04169-6
  42. Wright, J.G. (2000) Evaluating the outcome of treatment: Shouldn’t we ask the patients if they are better? Journal of Clinical Epidemiology, 53, 549-553.

Journal Menu >>