Background
Methods
Study design
Sample
Procedures and instruments
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Sociodemographic variables included age, sex, family status (single, married, divorced, widowed), living situation (alone/ not alone), and having children (yes/ no).
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Cognitive status was assessed using the German version of the Mini Mental State Exam (MMSE) [27, 28]. The MMSE provides a categorization differentiating “no indication” (score 27–30) “mild” (score 20–26), “moderate” (score 10–19) and “severe cognitive impairment” (score 0–9) as well as a total score which consists of items covering orientation, memory, attention, arithmetic, and language [29]..
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The functional status was assessed using the Barthel Index of Activities of Daily Living [30]. We utilized eight of the ten variables addressed in the Barthel Index, which were the items of help needed with feeding, grooming, bathing, dressing, toilet use and climbing stairs and the presence of stool and urinary incontinence. This yields a mean score of 0 to 70, where 0 indicates the highest possible impairment and 70 indicates the lowest possible impairment.
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The status of balance and mobility was assessed using the Hierarchical Assessment of Balance And Mobility (HABAM) [31] with the three domains balance, transfer and mobility. The assessment assigns a score to each domain and a total score, which indicates the highest level of performance in the three domains. For balance the score has a range from 0 to 21, thereby the value 0 marks no performance and 21 the highest level in balance. For transfer the range spans from 0 to 18 and for mobility from 0 to 26.
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Frailty was assessed using the Edmonton Frail Scale (EFS) [32]. This is a multidimensional measurement with nine dimensions. Each dimension is measured and scored separately and the sum score of all quantifies frailty. The frailty score ranges between 0 and 17 meaning the higher the score the frailer the participant. Due to the special situation of recruiting in a hospital setting, changes were needed with some dimensions. Furthermore to lessen the burden with a time consuming interview some items were replaced with items that were already part of the questionnaire, while staying as close to the EFS as possible. Cognition for example was measured using the MMSE instead of the clock-drawing test. Functional performance was replaced with the HABAM.
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For all patients who had provided the respective informed consent all formal medical diagnoses were retrieved from medical records. The presence of formal geriatric diagnosis, for example dizziness and giddiness or repeated falls, and formal diagnosis of dementia were analyzed for this paper.
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Level of impairment was defined according to the “care level (Pflegegrad)” used by the German care insurance for long-term care [33]. Each person is assigned to either none or one of five specific grades of care need. If a care level is assigned, each patient is categorized into one of five levels ranging from 1 to 5, with people in five needing the highest and in one the lowest level of care.
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Depressive symptoms were screened with the Patient Health Questionnaire (PHQ-2) [34]. The patients were asked how often they had been bothered by a) loss of interest or pleasure in activities and b) sadness during the last 2 weeks. These two variables represent the main indicators for a positive screening of depression according to DSM-V. The options to answer were 0 = never, 1 = single days, 2 = more than half of the days and 3 = nearly daily. If one of the items had a value of 3, the patient had a positive screening of depression.
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A possible delirium was assessed using the 4AT [35], which is a 4 question tool feasible for all patients, including those unable to speak, so that no patient is ‘unable to assess’. It consists of an item assessing level of alertness, a test of orientation, a test of attention, and an item discriminating acute change from a fluctuating course [36].
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For all patients pharmacological treatment information was retrieved from the medical records in the hospital. We summarized the total number of regularly taken drugs, prescription only, non-prescription and over-the-counter.
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Utilization of health care services was assessed by whether the person had used one or more of a list of services during the preceding 12 months (yes/no). Services asked for were hospital stays, rehabilitation, ambulatory care, all day and night care, short-term care, care counselling and additional care services.
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Health care needs were assessed using the Camberwell Assessment for Needs in the elderly (CANE) as validated questionnaire with sufficient psychometric properties [37, 38]. The CANE has been used extensively in various countries and has been validated for a German population of older people [39, 40]. The CANE assessment covers 25 dimensions, such as self-care or daytime activities, which can be adapted to fit the requirements of the study. 5 dimensions were not assessed: safety (deliberate self-harm, accidental self-harm, abuse/neglect), psychotic symptoms and physical health.
Statistical analysis
Results
Total sample (n = 401) | Control group (n = 192) | Intervention group (n = 209) | p-value* | ||||
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Age, mean (years) (SD) | 82.4 | (6.1) | 82.4 | (6.1) | 82.5 | (6.0) | .764 |
Sex (female), n (%) | 254 | 63.3% | 121 | 63.0% | 133 | 63.6% | .490 |
Family status | n = 391 | n = 185 | n = 206 | ||||
Single | 17 | 4.3% | 8 | 4.3% | 9 | 4.4% | .460 |
Married | 142 | 36.3% | 70 | 37.8% | 72 | 35.0% | |
Divorced | 23 | 5.9% | 14 | 7.6% | 9 | 4.4% | |
Widowed | 209 | 53.5% | 93 | 50.3% | 116 | 56.3% | |
Living alone | n = 394 | n = 188 | n = 206 | ||||
(yes), n (%) | 244 | 61.9% | 113 | 60.1% | 131 | 63.6% | .272 |
Having children | n = 391 | n = 185 | n = 206 | ||||
(yes), n (%) | 350 | 90.0% | 170 | 92.9% | 180 | 87.4% | .050 |
Medical specialties, n (%) | Total sample (n = 401) | Control group (n = 192) | Intervention group (n = 209) | |||
---|---|---|---|---|---|---|
Internal medicine | 59 | 14.7% | 29 | 15.1% | 30 | 14.4% |
Neurology | 30 | 7.5% | 12 | 6.3% | 18 | 8.6% |
Geriatrics | 106 | 26.4% | 50 | 26.0% | 56 | 26.8% |
Trauma surgery | 40 | 10.0% | 17 | 8.9% | 23 | 11.0% |
Nephrology | 81 | 20.2% | 46 | 24.0% | 35 | 16.7% |
Gastroenterology | 85 | 21.2% | 38 | 19.8% | 47 | 22.5% |
Hospital, n (%) | Total sample (n = 401) | Control group (n = 192) | Intervention group (n = 209) | |||
---|---|---|---|---|---|---|
1 | 200 | 49.9% | 100 | 52.1% | 100 | 47.8% |
2 | 62 | 15.5% | 24 | 12.5% | 38 | 18.2% |
3 | 139 | 34.7% | 68 | 35.4% | 71 | 34.0% |
Total sample (n = 401) | Control group (n = 192) | Intervention group (n = 209) | p-value | ||||
---|---|---|---|---|---|---|---|
Cognitive status (MMSE) | n = 401 | n = 192 | n = 209 | ||||
Score, (10–26), mean (SD) | 22.2 | (3.6) | 22.0 | (3.6) | 22.3 | (3.7) | .374 |
Mild cognitive impairment (score 20–26), n (%) | 323 | 80.5% | 154 | 80.2% | 169 | 80.9% | .484 |
Moderate cognitive impairment (score 10–19), n (%) | 78 | 19.5% | 38 | 19.8% | 40 | 19.1% | |
Functional Status (Barthel) | n = 400 | n = 191 | n = 209 | ||||
Score, (5–70), mean (SD) | 50.4 | (15.4) | 49.9 | (15.6) | 50.8 | (15.2) | .541 |
HABAM | n = 401 | n = 192 | n = 209 | ||||
Score (0–26), mean (SD) | 19.1 | (5.9) | 19.0 | (5.7) | 19.3 | (6.1) | .556 |
Balancea (0–21), mean (SD) | 12.7 | (7.0) | 12.7 | (6.9) | 12.7 | (7.1) | .994 |
Transferb (0–18), mean (SD) | 14.5 | (5.0) | 14.5 | (4.9) | 14.5 | (5.1) | .959 |
Mobilityc (0–26),mean (SD) | 16.0 | (7.8) | 16.0 | (7.5) | 16.0 | (8.1) | .978 |
Edmonton Frailty Index | n = 397 | n = 188 | n = 209 | ||||
Score, (2–15), mean (SD) | 7.4 | (2.5) | 7.4 | (2.5) | 7.3 | (2.6) | .675 |
Level of impairment | n = 396 | n = 188 | n = 208 | ||||
Yes, n (%) | 197 | 50.3% | 106 | 56.4% | 91 | 43.8% | .008* |
Care level | |||||||
None, n (%) | 199 | 51.0% | 82 | 44.8% | 117 | 56.5% | .084 |
1, n (%) | 29 | 7.4% | 15 | 8.2% | 14 | 6.8% | |
2, n (%) | 88 | 22.6% | 41 | 22.4% | 47 | 22.7% | |
3, n (%) | 63 | 16.2% | 38 | 20.8% | 25 | 12.1% | |
4, n (%) | 10 | 2.6% | 6 | 3.3% | 4 | 1.9% | |
5, n (%) | 1 | 0.3% | 1 | 0.5% | 0 | 0.0% | |
Diagnosis of dementia (ICD-10) | n = 401 | n = 192 | n = 209 | ||||
Yes, n (%) | 12 | 3.0% | 8 | 4.2% | 4 | 1.9% | .152 |
Geriatric Diagnosis (ICD-10) | n = 401 | n = 192 | n = 209 | ||||
Yes, n (%) | 188 | 46.9% | 89 | 46.4% | 99 | 47.4% | .459 |
Delirium possible | n = 387 | n = 185 | n = 202 | ||||
Yes, n (%) | 31 | 8.0% | 16 | 8.6% | 15 | 7.4% | .399 |
Depression | n = 401 | n = 192 | n = 209 | ||||
At least one main symptom of depression according to DSM-V, n (%) | 77 | 19.2% | 38 | 19.8% | 39 | 18.7% | .436 |
Pharmacological treatment | n = 398 | n = 191 | n = 207 | ||||
Total number of regularly taken drugs, mean (SD) | 8.2 | (3.8) | 8.6 | (4.0) | 7.9 | (3.7) | .078 |
Utilization of health care services (preceding year) | |||||||
Hospital stayd | |||||||
One or two hospital staysd, n (%) | 293 | 74.9% | 144 | 77.0% | 149 | 73.0% | .216 |
More than two hospital staysd, n (%) | 98 | 25.1% | 43 | 23.0% | 55 | 27.0% | |
Rehabilitatione, n (%) | 46 | 11.8% | 23 | 12.6% | 23 | 11.1% | .372 |
Ambulatory caref, n (%) | 152 | 38.8% | 85 | 45.9% | 67 | 32.4% | .004* |
Total formal care (all day & night care)g, n (%) | 13 | 3.3% | 10 | 5.5% | 3 | 1.5% | .027* |
Short term careh, n (%) | 28 | 7.3% | 20 | 10.9% | 8 | 4.0% | .007* |
Care counsellingi, n (%) | 75 | 21.2% | 45 | 27.4% | 30 | 15.8% | .005* |
Additional care servicesj, n (%) | 79 | 21.6% | 46 | 26.0% | 33 | 17.5% | .032* |
CANE | n = 396 | n = 188 | n = 208 | ||||
Sum needs overall (0–15), mean (SD) | 4.38 | (0.14) | 4.65 | (0.22) | 4.13 | (0.19) | .074 |
Sum unaddressed needs (0–8), mean (SD) | 0.60 | (0.05) | 0.60 | (0.08) | 0.59 | (0.07) | .927 |
Hospital 1 (n = 200) | Hospital 2 (n = 62) | Hospital 3 (n = 139) | p-value | ||||
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Cognitive status (MMSE) | n = 200 | n = 62 | n = 139 | ||||
Score, (10–26), mean (SD) | 22.9 | (3.1) | 21.6 | (3.9) | 21.4 | (4.1) | <.001* |
Mild cognitive impairment (score 20–26), n (%) | 169 | 84.5% | 50 | 80.6% | 104 | 74.8% | .086 |
Moderate cognitive impairment (score 10–19), n (%) | 31 | 15.5% | 12 | 19.4% | 35 | 25.2% | |
Functional Status (Barthel) | n = 200 | n = 62 | n = 138 | ||||
Score, mean (SD) | 52.6 | (15.3) | 55.7 | (11.8) | 44.9 | (15.4) | <.001* |
HABAM | n = 200 | n = 62 | n = 139 | ||||
Score (0–26), mean (SD) | 20.0 | (5.7) | 21.8 | (4.8) | 16.7 | (5.8) | <.001* |
Balancea (0–21), mean (SD) | 16.4 | (5.7) | 8.1 | (7.1) | 9.4 | (5.8) | <.001* |
Transferb (0–18), mean (SD) | 15.9 | (4.3) | 14.2 | (5.4) | 12.7 | (5.3) | <.001* |
Mobilityc (0–26), mean (SD) | 18.9 | (6.3) | 14.2 | (9.3) | 12.6 | (7.4) | <.001* |
Edmonton Frailty Index | n = 198 | n = 60 | n = 121 | ||||
Score, (2–15), mean (SD) | 6.6 | (2.3) | 6.2 | (1.8) | 9.0 | (2.2) | <.001* |
Level of impairment | n = 196 | n = 62 | n = 138 | ||||
Yes, n (%) | 100 | 51.0% | 23 | 37.1% | 74 | 53.6% | .085 |
Care Level | |||||||
None, n (%) | 96 | 50.3% | 39 | 63.9% | 64 | 46.4% | .020* |
1, n (%) | 12 | 6.3% | 8 | 13.1% | 9 | 6.5% | |
2, n (%) | 43 | 22.5% | 9 | 14.8% | 36 | 26.1% | |
3, n (%) | 32 | 16.8% | 4 | 6.6% | 27 | 19.6% | |
4, n (%) | 8 | 4.2% | 0 | 0.0% | 2 | 1.4% | |
5, n (%) | 0 | 0.0% | 1 | 1.6% | 0 | 0.0% | |
Diagnosis of dementia (ICD-10) | n = 200 | n = 62 | n = 139 | ||||
Yes, n (%) | 4 | 2.0% | 1 | 1.6% | 7 | 5.0% | .214 |
Geriatric Diagnosis (ICD-10) | n = 200 | n = 62 | n = 139 | ||||
Yes, n (%) | 76 | 38.0% | 8 | 12.9% | 104 | 74.8% | <.001* |
Delirium possible | n = 200 | n = 50 | n = 137 | ||||
Yes, n (%) | 9 | 4.5% | 2 | 4.0% | 20 | 14.6% | .002* |
Depression | n = 200 | n = 62 | n = 139 | ||||
At least one main symptom of depression according to DSM-V, n (%) | 17 | 8.5% | 11 | 17.7% | 49 | 35.3% | <.001* |
Pharmacological treatment | n = 197 | n = 62 | n = 139 | ||||
Total number of regularly taken drugs, mean (SD) | 7.5 | (3.8) | 7.2 | (4.4) | 9.8 | (3.2) | <.001* |
Utilization of health care services (preceding year) | |||||||
Hospital stayd | |||||||
One or two hospital staysd, n (%) | 158 | 79.8% | 48 | 80.0% | 87 | 65.4% | .008* |
More than two hospital staysd, n (%) | 40 | 20.2% | 12 | 20.0% | 46 | 34.6% | |
Rehabilitatione, n (%) | 28 | 14.4% | 1 | 1.6% | 17 | 12.6% | .024* |
Ambulatory caref, n (%) | 67 | 34.2% | 18 | 29.5% | 67 | 49.6% | .005* |
Total formal care (all day & night care) g, n (%) | 5 | 2.6% | 1 | 1.6% | 7 | 5.3% | .287 |
Short term careh, n (%) | 22 | 11.3% | 0 | 0.0% | 6 | 4.6% | .004* |
Care counsellingi, n (%) | 53 | 28.8% | 9 | 15.8% | 13 | 11.5% | .001* |
Additional care servicesj, n (%) | 23 | 12.2% | 1 | 1.7% | 55 | 47.0% | <.001* |
CANE | n = 196 | n = 62 | n = 138 | ||||
Sum needs overall (0–15), mean (SD) | 3.60 | (0.17) | 5.19 | (0.47) | 5.13 | (0.25) | <.001* |
Sum unaddressed needs (0–8), mean (SD) | 0.21 | (0.05) | 1.29 | (0.20) | 0.83 | (0.08) | <.001* |
Total sample (n = 401) | Male (n = 147) | Female (n = 254) | p-value | ||||
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Age, mean [years] (SD) | 82.4 | (6.1) | 81.5 | (5.9) | 83.0 | (6.1) | .013* |
Family status | n = 391 | n = 142 | n = 249 | ||||
Single | 17 | 4.3% | 8 | 5.6% | 9 | 3.6% | <.001* |
Married | 142 | 36.3% | 88 | 62.0% | 54 | 21.7% | |
Divorced | 23 | 5.9% | 5 | 3.5% | 18 | 7.2% | |
Widowed | 209 | 53.5% | 41 | 28.9% | 168 | 67.5% | |
Living alone | n = 391 | n = 142 | n = 249 | ||||
(yes), n (%) | 244 | 61.9% | 50 | 34.7% | 131 | 63.6% | <.001* |
Having children | n = 391 | n = 140 | n = 251 | ||||
(yes), n (%) | 351 | 89.8% | 129 | 92.1% | 222 | 88.4% | .163 |
Total sample (n = 401) | Male (n = 147) | Female (n = 254) | p-value | ||||
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Cognitive status (MMSE) | n = 401 | n = 147 | n = 254 | ||||
Score, (10–26), mean (SD) | 22.2 | (3.6) | 21.9 | (4.0) | 22.3 | (3.5) | .273 |
Mild cognitive impairment (score 20–26), n (%) | 323 | 80.5% | 116 | 78.9% | 207 | 81.5% | .307 |
Moderate cognitive impairment (score 10–19), n (%) | 78 | 19.5% | 31 | 21.1% | 47 | 18.5% | |
Functional Status (Barthel) | n = 400 | n = 146 | n = 254 | ||||
Score, mean (SD) | 50.4 | (15.4) | 49.1 | (16.1) | 51.1 | (14.9) | .196 |
HABAM | n = 401 | n = 147 | n = 254 | ||||
Score (0–26), mean (SD) | 19.1 | (5.9) | 19.3 | (6.3) | 19.1 | (5.7) | .762 |
Balancea (0–21), mean (SD) | 12.7 | (7.0) | 12.3 | (7.3) | 13.0 | (6.9) | .300 |
Transferb (0–18), mean (SD) | 14.5 | (5.0) | 14.6 | (5.0) | 14.5 | (5.1) | .812 |
Mobilityc (0–26),mean (SD) | 16.0 | (7.8) | 15.9 | (8.2) | 16.1 | (7.6) | .850 |
Edmonton Frailty Index | n = 397 | n = 145 | n = 252 | ||||
Score, (2–15), mean (SD) | 7.4 | (2.5) | 7.6 | (2.4) | 7.2 | (2.5) | .136 |
Level of impairment | n = 396 | n = 144 | n = 252 | ||||
Yes, n (%) | 197 | 50.3% | 64 | 44.4% | 133 | 52.8% | .068 |
Care level | |||||||
None, n (%) | 199 | 51.0% | 80 | 56.3% | 119 | 48.0% | .338 |
1, n (%) | 29 | 7.4% | 9 | 6.3% | 20 | 8.1% | |
2, n (%) | 88 | 22.6% | 24 | 16.9% | 64 | 25.8% | |
3, n (%) | 63 | 16.2% | 26 | 18.3% | 37 | 14.9% | |
4, n (%) | 10 | 2.6% | 3 | 2.1% | 7 | 2.8% | |
5, n (%) | 1 | 0.3% | 0 | 0.0% | 1 | 0.4% | |
Diagnosis of dementia (ICD-10) | n = 401 | n = 147 | n = 254 | ||||
Yes, n (%) | 12 | 3.0% | 2 | 1.4% | 10 | 3.9% | .122 |
Geriatric Diagnosis (ICD-10) | n = 401 | n = 147 | n = 254 | ||||
Yes, n (%) | 188 | 46.9% | 76 | 51.7% | 112 | 44.1% | .086 |
Delirium possible | n = 387 | n = 140 | n = 247 | ||||
Yes, n (%) | 31 | 8.0% | 19 | 13.6% | 12 | 4.9% | .003* |
Depression | n = 401 | n = 147 | n = 254 | ||||
At least one main symptom of depression according to DSM-V, n (%) | 77 | 19.2% | 27 | 18.4% | 50 | 19.7% | .427 |
Pharmacological treatment | n = 398 | n = 145 | n = 253 | ||||
Total number of regularly taken drugs, mean (SD) | 8.2 | (3.8) | 8.7 | (3.6) | 8.0 | (4.0) | .064 |
Utilization of health care services (preceding year) | |||||||
Hospital stayd | |||||||
One or two hospital staysd, n (%) | 293 | 74.9% | 103 | 72.0% | 190 | 76.6% | .187 |
More than two hospital staysd, n (%) | 98 | 25.1% | 40 | 28.0% | 58 | 23.4% | |
Rehabilitatione, n (%) | 46 | 11.8% | 13 | 9.2% | 33 | 13.3% | .153 |
Ambulatory caref, n (%) | 152 | 38.8% | 45 | 31.9% | 107 | 42.6% | .023* |
Total formal care (all day & night care)g, n (%) | 13 | 3.3% | 2 | 1.4% | 11 | 4.4% | .093 |
Short term careh, n (%) | 28 | 7.3% | 5 | 3.6% | 23 | 9.3% | .025* |
Care counsellingi, n (%) | 75 | 21.2% | 28 | 20.9% | 47 | 21.4% | .514 |
Additional care servicesj, n (%) | 79 | 21.6% | 27 | 20.1% | 52 | 22.4% | .356 |
CANE | n = 396 | n = 147 | n = 254 | ||||
Sum needs overall (0–15), mean (SD) | 4.38 | (0.14) | 4.17 | (0.25) | 4.50 | (0.17) | .269 |
Sum unaddressed needs (0–8), mean (SD) | 0.60 | (0.05) | 0.76 | (0.11) | 0.50 | (0.05) | .033* |