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1.  Effects of a home visiting nurse intervention versus care as usual on individual activities of daily living: a secondary analysis of a randomized controlled trial 
BMC Geriatrics  2014;14:24.
Home visiting nurses (HVNs) have long been part of home and community-based care interventions designed to meet the needs of functionally declining older adults. However, only one of the studies including HVNs that have demonstrated successful impacts on Activities of Daily Living (ADL) has reported how those interventions affected individual ADLs such as bathing, instead reporting the effect on means of various ADL indices and scales. Reporting impacts on means is insufficient since the same mean can consist of many different combinations of individual ADL impairments. The purpose of our study was to identify which individual ADLs were affected by a specific HVN intervention.
This is a secondary analysis comparing two arms of a randomized controlled study that enrolled Medicare patients (mean age = 76.8 years; 70% female) with considerable ADL impairment. At baseline difficulty with individual ADLs ranged from a low of 16.0% with eating to a high of 78.0% with walking. Through monthly home visits, the HVN focused on empowering patients and using behavior change approaches to facilitate chronic disease self-management. Three categories of analyses were used to compare difficulty with and dependence in 6 individual ADLs between the HVN (n = 237) and care as usual (n = 262) groups (total N = 499) at 22 months after study entry: (1) unadjusted analyses that strictly depend on random assignment, (2) multinomial logistic regression analyses adjusting for baseline risk factors, and (3) multinomial regression analyses that include variables reporting post-randomization healthcare use as well as the baseline risk factors.
Compared to care as usual, patients receiving the HVN intervention had less difficulty performing bathing at 22 months. However, there were no effects for difficulty performing the other 5 ADLs. While no effects were found for lower levels of dependence for any ADLs, impacts were detected for the most dependent levels of 4 ADLs: patients experienced less dependence in walking and transferring, a substitution effect for toileting, and more dependence in eating.
Future research is needed to confirm these findings and determine how HVN interventions affect individual ADLs of older adults with multiple ADLs.
PMCID: PMC3933382  PMID: 24555502
Activities of daily living; Disability; Home care; Visiting nurses; Medicare
2.  A Clinical Index to Stratify Hospitalized Older Adults According to Risk for New-Onset Disability 
Journal of the American Geriatrics Society  2011;59(7):10.1111/j.1532-5415.2011.03409.x.
Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study’s objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge.
Data analyses derived from two prospective studies.
Two teaching hospitals in Ohio.
Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission.
New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission.
Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80–89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2–3 ADLs, 1 point; 4–5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC) =0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC =0.784). The risk score also predicted (P<.001) disability severity, nursing home placement, and long-term survival.
This clinical index determines risk for new-onset disability in hospitalized older adults and may inform clinical care.
PMCID: PMC3839864  PMID: 21649616
hospitalization; prognosis; disability; activities of daily living
3.  The Effects of Resident and Nursing Home Characteristics on Activities of Daily Living 
Existing studies on the relationships between impairments and activities of daily living (ADLs) in nursing home residents have serious limitations. This study examines the relationships among admission impairments, including pain, depression, incontinence, balance, and falls, and follow-up ADLs, as well as the effect of the nursing home on follow-up ADLs of extended-stay nursing home residents.
This longitudinal cohort study consisted of 4,942 extended-stay residents who were admitted into 377 Minnesota nursing homes during 2004. General linear mixed models were used for all analyses, with 14 resident-level and 8 facility-level control variables.
Incontinence and balance function at admission were significantly associated with increases in ADL dependence at follow-up. Individual nursing homes had independent effects on all three ADL models. Similar findings were found after facility-level control variables were added.
Incontinence predicts subsequent ADL functional levels. The relationship between balance dysfunction and subsequent ADL dependence could be causal. Future studies of the causal relationships between impairments and ADL should examine the effectiveness of impairment interventions on ADL as well as these relationships in different subgroups of nursing home residents.
PMCID: PMC2657168  PMID: 19201787
Nursing homes; Activities of daily living; Impairments; Incontinence; Falls
4.  Measuring Prognosis and Case Mix in Hospitalized Elders 
Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients’ activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses.
The general medical service of a teaching hospital.
Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women).
Independence in ADL function on admission was assessed by interviewing each patient’s primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent.
ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS, Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1–58.8), 1-year mortality (OR 4.4; 2.7–7.4), and 90-day nursing home use (OR 14.9; 6.0–37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both.
ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case–mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.
PMCID: PMC1497092  PMID: 9127223
prognosis; case mix; activities of daily living; severity; functional status
5.  Case mix of home health patients under capitated and fee-for-service payment. 
Health Services Research  1995;30(1 Pt 1):79-113.
OBJECTIVE. We compare case mix of Medicare home health patients under HMO and FFS payment. STUDY DESIGN. A pseudo-experimental design was employed to study case mix using three types of Medicare-certified home health agencies (HHAs): HMO-owned agencies, pure FFS agencies that admit few Medicare HMO patients (less than 5 percent of admissions are Medicare HMO patients), and mixed (or contractual) agencies that admit at least 15 Medicare FFS patients and 15 Medicare HMO patients per month. SAMPLES OF PROVIDERS AND PATIENTS. Random samples of Medicare-aged patients (> or = 65 years) were selected at admission between June 1989 and November 1991 from the 38 study HHAs. Sample sizes by agency type were: 308 patients from 9 HMO-owned agencies; 529 patients from 15 pure FFS agencies; and 381 HMO patients and 414 FFS patients from 14 contractual agencies. DATA. Primary longitudinal data were prospectively collected at admission for all patients on health status indicators, demographics, admission source, and home environment. MEASURES. The most important case-mix measures were functional and physiologic indicators of health status, including (instrumental) activities of daily living ([I]ADLs). Selected indicators of demographic variables, prior location, living situation, characteristics of informal caregivers, mental/behavioral factors, and resource needs were also used. PRINCIPAL FINDINGS. (a) The case mix of Medicare FFS patients compared with Medicare HMO patients was more intense in terms of impairments in ADLs, IADLs, and various physiologic conditions. Pressure ulcers as well as neurological and orthopedic impairments requiring rehabilitation care were also more prevalent among FFS patients. (b) Relative to HMO patients admitted to contractual agencies, HMO patients admitted to HMO-owned agencies were moderately more dependent in ADLs and IADLs. However, only 62 percent of HMO patients admitted to HMO-owned agencies, in contrast to 77 percent of HMO patients admitted to contractual agencies, had been hospitalized during the 30 days prior to home health admission. (c) In all, the case mix of patients receiving care from HMO-owned agencies is more heterogeneous than the case mix of HMO patients receiving care from contractual agencies. CONCLUSIONS. The case-mix (and selected utilization) findings indicate that HMOs use home health care differently than does the FFS sector. The greater diversity of case mix for HMO-owned agencies and the narrower or less diverse case mix that characterizes HMO patients receiving home care on a contractual basis point to the likelihood of cost differences among the two types of HMO patients and FFS patients, and raise the question of possible outcome differences.
PMCID: PMC1070352  PMID: 7721587
6.  Urinary incontinence and risk of functional decline in older women: data from the Norwegian HUNT-study 
BMC Geriatrics  2013;13:47.
The main objective of the present study was to determine whether UI is an independent predictor of ADL decline and IADL decline in elderly women. We also aimed to find out whether incontinent subjects were at higher risk of needing help from formal home care or home nursing care during 11 year follow-up.
A prospective cohort study conducted as part of the North-Trøndelag Health Study 2 and 3. Women aged 70–80 years when participating in the HUNT 2 study, who also participated in the HUNT 3 study, were included in this study. Analyses on self-reported urinary incontinence at baseline and functional decline during a11-year period were performed for incontinent and continent subjects.
Baseline prevalence of urinary incontinence was 24%. At on average eleven year follow up, logistic regression analysis showed a significant association between incontinence and decline in activities of daily living (ADL) (OR =2.37, 95% CI =1.01-5.58) (P=0.04). No association between urinary incontinence and instrumental activities of daily living (IADL) in incontinent women compared with continent women was found (OR=1.18, CI=.75-1.86) (P=.46). Data were adjusted for ADL, IADL and co morbid conditions at baseline. No significant differences in need of more help from formal home care and home nursing care between continent and incontinent women were found after 11 years of follow-up.
Urinary incontinence is an important factor associated with functional decline in women aged 70–80 years living in their own homes. At eleven years of follow up, no significant differences in need of more help from formal home care and home nursing care between continent and incontinent women were found.
PMCID: PMC3660293  PMID: 23678851
7.  A 52 month follow-up of functional decline in nursing home residents – degree of dementia contributes 
BMC Geriatrics  2014;14:45.
Few have studied how personal activities of daily living (P-ADL) develop over time in nursing home residents with dementia. Thus, the aim was to study variables associated with the development of P-ADL functioning over a 52-month follow-up period, with a particular focus on the importance of the degree of dementia.
In all, 932 nursing home residents with dementia (Clinical Dementia Rating–CDR- Scale ≥1) were included in a longitudinal study with four assessments of P-ADL functioning during 52 months. P-ADL was measured using the Lawton and Brody’s Physical Self-Maintenance Scale. Degree of dementia (CDR), neuropsychiatric symptoms and use of psychotropic medication were assessed at the same four time points. Demographic information and information about physical health was included at baseline. Linear regression models for longitudinal data were estimated.
Follow-up time was positively associated with a decline in P-ADL functioning. Degree of dementia at baseline was associated with a decline in P-ADL functioning over time. The association between degree of dementia and P-ADL functioning was strongest at baseline, and then flattened over time. A higher level of neuropsychiatric symptoms such as agitation and apathy and no use of anxiolytics and antidementia medication were associated with a decline in P-ADL functioning at four time points. Higher physical co-morbidity at baseline was associated with a decline in P-ADL functioning.
P-ADL functioning in nursing home patients with dementia worsened over time. The worsening was associated with more severe dementia, higher physical comorbidity, agitation, apathy and no use of anxiolytics and antidementia medication. Clinicians should pay attention to these variables (associates) in order to help the nursing home residents with dementia to maintain their level of functioning for as long as possible.
PMCID: PMC3985541  PMID: 24720782
8.  Patient and Caregiver Characteristics Associated with Depression in Caregivers of Patients with Dementia 
Journal of General Internal Medicine  2003;18(12):1006-1014.
Many patients with dementia who live at home would require nursing home care if they did not have the assistance of family caregivers. However, caregiving sometimes has adverse health consequences for caregivers, including very high rates of depression. The goal of this study was to determine the patient and caregiver characteristics associated with depression among caregivers of patients with dementia.
Cross-sectional study.
Five thousand six hundred and twenty-seven patients with moderate to advanced dementia and their primary caregivers upon enrollment in the Medicare Alzheimer's Disease Demonstration (MADDE) at 8 locations in the United States.
Caregiver depression was defined as 6 or more symptoms on the 15-item Geriatric Depression Scale. Patient characteristics measured included ethnicity and other demographic characteristics, income, activities of daily living (ADL) function, Mini-Mental Status Exam (MMSE) score, and behavioral problems. Caregiver characteristics measured included demographic characteristics, relationship to the patient, hours spent caregiving, and ADL and Instrumental Activities of Daily Living (IADL) function. We used χ2 and t tests to measure the bivariate relationships between patient and caregiver predictors and caregiver depression. We used logistic regression to determine the independent predictors of caregiver depression.
Thirty-two percent of caregivers reported 6 or more symptoms of depression and were classified as depressed. Independent patient predictors of caregiver depression included younger age (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.33 to 2.76 in patients less than 65 years compared to patients over 85 years), white (OR, 1.53; 95% CI, 1.18 to 1.99) and Hispanic ethnicity (OR, 2.50; 95% CI, 1.69 to 3.70) compared to black ethnicity, education (OR, 1.16; 95% CI, 1.01 to 1.33 for those with less than a high school education), ADL dependence (OR, 1.55; 95% CI, 1.26 to 1.90 for patients dependent in 2 or more ADL compared to patients dependent in no ADL), and behavioral disturbance, particularly angry or aggressive behavior (OR, 1.47; 95% CI, 1.27 to 1.69 for patients with angry or aggressive behavior). Independent caregiver predictors of depression included low income (OR, 1.45; 95% CI, 1.18 to 1.77 for less than $10,000/per year, compared to >$20,000 per year), the relationship to the patient (OR, 2.73; 95% CI, 1.31 to 5.72 for wife, compared to son of male patient), hours spent caregiving (OR, 1.89; 95% CI, 1.51 to 2.38 for 40 to 79 hours/week compared to less than 40 hours/week), and functional dependence (OR, 2.53; 95% CI, 2.13 to 3.01 for ADL dependent compared to IADL independent).
Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.
PMCID: PMC1494966  PMID: 14687259
caregivers; depression; Alzheimer's disease; dementia; race/ethnicity
9.  Problems of Older Adults Living Alone After Hospitalization 
To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization.
Secondary analysis of a prospective cohort study.
Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed.
One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization.
One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P=.0001). Patients who were ADL–dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7.6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11.9) times more likely to be admitted to a nursing home in the month after hospitalization.
Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence.
PMCID: PMC1495595  PMID: 11029674
hospitalization; risk factors; activities of daily living; socioeconomic factors; support; aged
10.  Predictors of Recovery in Activities of Daily Living Among Disabled Older Persons Living in the Community 
To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community.
Prospective cohort study with 2-year follow-up.
General community.
213 men and women 72 years or older, who reported dependence in one or more ADLs.
All participants underwent a comprehensive home assessment and were followed for recovery of ADL function, defined as requiring no personal assistance in any of the ADLs within 2 years. Fifty-nine participants (28%) recovered independent ADL function. Compared with those older than 85 years, participants aged 85 years or younger were more than 8 times as likely to recover their ADL function (relative risk [RR] 8.4; 95% confidence interval [CI] 2.7, 26). Several factors besides age were associated with ADL recovery in bivariate analysis, including disability in only one ADL, self-efficacy score greater than 75, Folstein Mini-Mental State Examination (MMSE) score of 28 or better, high mobility, score in the best third of timed physical performance, fewer than five medications, and good nutritional status. In multivariable analysis, four factors were independently associated with ADL recovery—age 85 years or younger (adjusted RR 4.1; 95% CI 1.3, 13), MMSE score of 28 or better (RR 1.7; 95% CI 1.2, 2.3), high mobility (RR 1.7; 95% CI 1.0, 2.9), and good nutritional status (RR 1.6; 95% CI 1.0, 2.5).
Once disabled, few persons older than 85 years recover independent ADL function. Intact cognitive function, high mobility, and good nutritional status each improve the likelihood of ADL recovery and may serve as markers of resiliency in this population.
PMCID: PMC1497202  PMID: 9436895
activities of daily living (ADLs); recovery; elderly; prospective cohort study; prognosis
11.  Predictors of Nursing Home Admission among Alzheimer's Disease Patients with Psychosis and/or Agitation 
The purpose of this study is to identify factors that predict nursing home placement among community-dwelling Alzheimer's Disease (AD) patients with psychosis or agitation in a randomized clinical trial.
418 participants with AD enrolled in the CATIE-AD trial of anti-psychotic medications and having no evidence of nursing home use at baseline were followed 9 months post-random assignment using data provided by caregiver proxy. χ2 tests, t-tests and Cox proportional hazard modeling were used to examine the baseline correlates of nursing home use.
Of outpatients with no prior nursing home use, 15.0% were placed in a nursing home in the 9 months following baseline, with the average time to placement being 122 days. Bivariate analyses indicate that those with prior outpatient mental health use at study entry were more likely to be admitted; so too were those with worse physical functioning—lower scores on the AD Cooperative Study Activities of Daily Living Scale (ADCS-ADL), lower utility scores on the Health Utility Index (HUI)-III, and worse cognition on the Mini-Mental State Examination. Controlling for other factors, non-Hispanic white race (hazard ratio [HR]=2.16) and prior mental health use (HR=1.87) increased the likelihood of admission. Those with higher ADCS-ADL scores were less likely to be placed (HR=0.97).
Factors leading to nursing home entry among psychotic/agitated AD patients are similar to the general population, though high incidence of nursing home entry highlights the importance of accounting for such utilization in health economic studies of AD outcomes. It also highlights the importance of using information on ADLs and other characteristics to develop profiles identifying those at greater or lesser risk of nursing home entry and, in so doing inform population planning associated with AD and identification of those patients and caregivers who might benefit most from interventions to prevent eventual placement. ( number, NCT00015548.)
PMCID: PMC3951873  PMID: 20214847
Institutionalization; Elderly; Clinical Trial; Dementia; Risk Factors; Survival Analysis; Mental Health; Psychiatry
12.  Validity and reliability of the Arabic version of Activities of Daily Living (ADL) 
BMC Geriatrics  2009;9:11.
The Activity of Daily Living (ADL) is an instrument that screens elderly respondents for physical functioning and assesses whether they are dependent or independent in their daily activities. This study demonstrates a translation procedure and obtains the reliability and validity of a translated, Arabic ADL.
The ADL was translated to Arabic through a forward translation method followed by a committee-consensual approach. The ADL and the Arabic Mini-Mental State Examination (AMMSE) were administered to an opportunistic sample of 354 Lebanese elderly living in nursing homes who did not have dementia.
Reliability split half measures, sensitivity, and negative predictive values were high across all dimensions of the ADL with the exception of feeding. There were non-significant differences on the scored ADL between the three age groups: young age, middle age and older old. In addition, a non-significant difference was found on the scored ADL between the high and low AMMSE scores.
Overall, the translated ADL was consistent and valid measure for assessing daily activities in elderly nursing home residents. As it is quick and easy to use, the ADL in Arabic could help caregivers and doctors to prescribe appropriate physical exercise for elderly Arabic speaking patients.
PMCID: PMC2670307  PMID: 19327172
13.  Scaling functional status within the interRAI suite of assessment instruments 
BMC Geriatrics  2013;13:128.
As one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies.
A secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments.
Using items from interRAI’s suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community.
An integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.
PMCID: PMC3840685  PMID: 24261417
14.  Willingness to use and pay for options of care for community-dwelling older people in rural Vietnam 
The proportion of people in Vietnam who are 60 years and over has increased rapidly. The emigration of young people and impact of other socioeconomic changes leave more elderly on their own and with less family support. This study assesses the willingness to use and pay for different models of care for community-dwelling elderly in rural Vietnam.
In 2007, people aged 60 and older and their family representatives, living in 2,240 households, were randomly selected from the FilaBavi Demographic Surveillance Site. They were interviewed using structured questionnaires to assess dependence in activities of daily living (ADLs), willingness to use and to pay for day care centres, mobile care teams, and nursing centres. Respondent socioeconomic characteristics were extracted from the FilaBavi repeated census. Percentages of those willing to use models and the average amount (with 95% confidence intervals) they are willing to pay were estimated. Multivariate analyses were performed to measure the relationship of willingness to use services with ADL index and socioeconomic factors. Four focus group discussions were conducted to explore people's perspectives on the use of services. The first discussion group was with the elderly. The second discussion group was with their household members. Two other discussion groups included community association representatives, one at the communal level and another at the village level.
Use of mobile team care is the most requested service. The fewest respondents intend to use a nursing centre. Households expect to use services for their elderly to a greater extent than do the elderly themselves. Willingness to use services decreases when potential fees increase. The proportion of respondents who require that services be free-of-charge is two to three times higher than the proportion willing to pay full cost. Households are willing to pay more than the elderly for day care and nursing centres. The elderly are more willing to pay for mobile teams than are their households. Age group, sex, literacy, marital status, living arrangement, living area, working status, poverty, household wealth and dependence in ADLs are factors related to willingness to use services.
Community-centric elderly care will be used and partly paid for by individuals if it is provided by the government or associations. Capacity building for health professional networks and informal caregivers is essential for developing formal care models. Additional support is needed for the most vulnerable elderly to access services.
PMCID: PMC3305522  PMID: 22333517
15.  Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site,, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
To assess the effectiveness of behavioural interventions for the treatment and management of urinary incontinence (UI) in community-dwelling seniors.
Clinical Need: Target Population and Condition
Urinary incontinence defined as “the complaint of any involuntary leakage of urine” was identified as 1 of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home. Urinary incontinence is a health problem that affects a substantial proportion of Ontario’s community-dwelling seniors (and indirectly affects caregivers), impacting their health, functioning, well-being and quality of life. Based on Canadian studies, prevalence estimates range from 9% to 30% for senior men and nearly double from 19% to 55% for senior women. The direct and indirect costs associated with UI are substantial. It is estimated that the total annual costs in Canada are $1.5 billion (Cdn), and that each year a senior living at home will spend $1,000 to $1,500 on incontinence supplies.
Interventions to treat and manage UI can be classified into broad categories which include lifestyle modification, behavioural techniques, medications, devices (e.g., continence pessaries), surgical interventions and adjunctive measures (e.g., absorbent products).
The focus of this review is behavioural interventions, since they are commonly the first line of treatment considered in seniors given that they are the least invasive options with no reported side effects, do not limit future treatment options, and can be applied in combination with other therapies. In addition, many seniors would not be ideal candidates for other types of interventions involving more risk, such as surgical measures.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Description of Technology/Therapy
Behavioural interventions can be divided into 2 categories according to the target population: caregiver-dependent techniques and patient-directed techniques. Caregiver-dependent techniques (also known as toileting assistance) are targeted at medically complex, frail individuals living at home with the assistance of a caregiver, who tends to be a family member. These seniors may also have cognitive deficits and/or motor deficits. A health care professional trains the senior’s caregiver to deliver an intervention such as prompted voiding, habit retraining, or timed voiding. The health care professional who trains the caregiver is commonly a nurse or a nurse with advanced training in the management of UI, such as a nurse continence advisor (NCA) or a clinical nurse specialist (CNS).
The second category of behavioural interventions consists of patient-directed techniques targeted towards mobile, motivated seniors. Seniors in this population are cognitively able, free from any major physical deficits, and motivated to regain and/or improve their continence. A nurse or a nurse with advanced training in UI management, such as an NCA or CNS, delivers the patient-directed techniques. These are often provided as multicomponent interventions including a combination of bladder training techniques, pelvic floor muscle training (PFMT), education on bladder control strategies, and self-monitoring. Pelvic floor muscle training, defined as a program of repeated pelvic floor muscle contractions taught and supervised by a health care professional, may be employed as part of a multicomponent intervention or in isolation.
Education is a large component of both caregiver-dependent and patient-directed behavioural interventions, and patient and/or caregiver involvement as well as continued practice strongly affect the success of treatment. Incontinence products, which include a large variety of pads and devices for effective containment of urine, may be used in conjunction with behavioural techniques at any point in the patient’s management.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials that examined the effectiveness, safety, and cost-effectiveness of caregiver-dependent and patient-directed behavioural interventions for the treatment of UI in community-dwelling seniors (see Appendix 1).
Research Questions
Are caregiver-dependent behavioural interventions effective in improving UI in medically complex, frail community-dwelling seniors with/without cognitive deficits and/or motor deficits?
Are patient-directed behavioural interventions effective in improving UI in mobile, motivated community-dwelling seniors?
Are behavioural interventions delivered by NCAs or CNSs in a clinic setting effective in improving incontinence outcomes in community-dwelling seniors?
Assessment of Quality of Evidence
The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Executive Summary Table 1 summarizes the results of the analysis.
The available evidence was limited by considerable variation in study populations and in the type and severity of UI for studies examining both caregiver-directed and patient-directed interventions. The UI literature frequently is limited to reporting subjective outcome measures such as patient observations and symptoms. The primary outcome of interest, admission to a LTC home, was not reported in the UI literature. The number of eligible studies was low, and there were limited data on long-term follow-up.
Summary of Evidence on Behavioural Interventions for the Treatment of Urinary Incontinence in Community-Dwelling Seniors
Prompted voiding
Habit retraining
Timed voiding
Bladder training
PFMT (with or without biofeedback)
Bladder control strategies
CI refers to confidence interval; CNS, clinical nurse specialist; NCA, nurse continence advisor; PFMT, pelvic floor muscle training; RCT, randomized controlled trial; WMD, weighted mean difference; UI, urinary incontinence.
Economic Analysis
A budget impact analysis was conducted to forecast costs for caregiver-dependent and patient-directed multicomponent behavioural techniques delivered by NCAs, and PFMT alone delivered by physiotherapists. All costs are reported in 2008 Canadian dollars. Based on epidemiological data, published medical literature and clinical expert opinion, the annual cost of caregiver-dependent behavioural techniques was estimated to be $9.2 M, while the annual costs of patient-directed behavioural techniques delivered by either an NCA or physiotherapist were estimated to be $25.5 M and $36.1 M, respectively. Estimates will vary if the underlying assumptions are changed.
Currently, the province of Ontario absorbs the cost of NCAs (available through the 42 Community Care Access Centres across the province) in the home setting. The 2007 Incontinence Care in the Community Report estimated that the total cost being absorbed by the public system of providing continence care in the home is $19.5 M in Ontario. This cost estimate included resources such as personnel, communication with physicians, record keeping and product costs. Clinic costs were not included in this estimation because currently these come out of the global budget of the respective hospital and very few continence clinics actually exist in the province. The budget impact analysis factored in a cost for the clinic setting, assuming that the public system would absorb the cost with this new model of community care.
Considerations for Ontario Health System
An expert panel on aging in the community met on 3 occasions from January to May 2008, and in part, discussed treatment of UI in seniors in Ontario with a focus on caregiver-dependent and patient-directed behavioural interventions. In particular, the panel discussed how treatment for UI is made available to seniors in Ontario and who provides the service. Some of the major themes arising from the discussions included:
Services/interventions that currently exist in Ontario offering behavioural interventions to treat UI are not consistent. There is a lack of consistency in how seniors access services for treatment of UI, who manages patients and what treatment patients receive.
Help-seeking behaviours are important to consider when designing optimal service delivery methods.
There is considerable social stigma associated with UI and therefore there is a need for public education and an awareness campaign.
The cost of incontinent supplies and the availability of NCAs were highlighted.
There is moderate-quality evidence that the following interventions are effective in improving UI in mobile motivated seniors:
Multicomponent behavioural interventions including a combination of bladder training techniques, PFMT (with or without biofeedback), education on bladder control strategies and self-monitoring techniques.
Pelvic floor muscle training alone.
There is moderate quality evidence that when behavioural interventions are led by NCAs or CNSs in a clinic setting, they are effective in improving UI in seniors.
There is limited low-quality evidence that prompted voiding may be effective in medically complex, frail seniors with motivated caregivers.
There is insufficient evidence for the following interventions in medically complex, frail seniors with motivated caregivers:
habit retraining, and
timed voiding.
PMCID: PMC3377527  PMID: 23074508
16.  Small-scale, homelike facilities versus regular psychogeriatric nursing home wards: a cross-sectional study into residents' characteristics 
Nursing home care for people with dementia is increasingly organized in small-scale and homelike care settings, in which normal daily life is emphasized. Despite this increase, relatively little is known about residents' characteristics and whether these differ from residents in traditional nursing homes. This study explored and compared characteristics of residents with dementia living in small-scale, homelike facilities and regular psychogeriatric wards in nursing homes, focusing on functional status and cognition.
A cross-sectional study was conducted, including 769 residents with dementia requiring an intensive level of nursing home care: 586 from regular psychogeriatric wards and 183 residents from small-scale living facilities. Functional status and cognition were assessed using two subscales from the Resident Assessment Instrument Minimum Data Set (RAI-MDS): the Activities of Daily Living-Hierarchy scale (ADL-H) and the Cognitive Performance Scale (CPS). In addition, care dependency was measured using Dutch Care Severity Packages (DCSP). Finally, gender, age, living condition prior to admission and length of stay were recorded. Descriptive analyses, including independent samples t- tests and chi-square tests, were used. To analyze data in more detail, multivariate logistic regression analyses were performed.
Residents living in small-scale, homelike facilities had a significantly higher functional status and cognitive performance compared with residents in regular psychogeriatric wards. In addition, they had a shorter length of stay, were less frequently admitted from home and were more often female than residents in regular wards. No differences were found in age and care dependency. While controlling for demographic variables, the association between dementia care setting and functional status and cognition remained.
Although residents require a similar intensive level of nursing home care, their characteristics differ among small-scale living facilities and regular psychogeriatric wards. These differences may limit research into effects and feasibility of various types of dementia care settings. Therefore, these studies should take resident characteristics into account in their design, for example by using a matching procedure.
PMCID: PMC2827474  PMID: 20113496
17.  Caregiver Confidence: Does It Predict Changes in Disability Among Elderly Home Care Recipients? 
The Gerontologist  2011;52(1):79-88.
Purpose of the study:
The primary aim of this investigation was to determine whether caregiver confidence in their care recipients’ functional capabilities predicts changes in the performance of activities of daily living (ADL) among elderly home care recipients. A secondary aim was to explore how caregiver confidence and care recipient functional self-efficacy jointly influence changes in ADL performance over time.
Design and Methods:
The sample included 5,138 elderly recipients of home and community-based long-term care in Michigan. ADL performance was assessed multiple times over a 2-year period. Caregiver confidence was measured at baseline with a single item. Multilevel modeling was used to estimate the effect of caregiver confidence on changes in ADL performance over time, controlling for baseline self-efficacy, ADL performance, and other factors that might confound the relationship. Based on caregiver confidence and elder self-efficacy, we created 4 groups of elder caregiver dyads to explore the combined effect of caregiver and elder confidence on change in ADL performance.
Elders whose caregivers were confident in their capacity for greater functional independence experienced greater improvement in ADL performance than those whose caregivers were not confident. Elders in dyads in which both members expressed confidence experienced more improvement in ADL performance than those in dyads in which either one or both members lacked confidence.
Interventions to strengthen caregivers’ confidence in their care recipients’ functional capabilities may slow functional losses among home care elders. Additional research is needed to confirm these findings and identify the factors that influence caregiver confidence.
PMCID: PMC3297017  PMID: 21856746
Self-efficacy; Caregiving; Frail elders; Long-term care; Disability trajectory; Multilevel analysis
18.  Predicting nursing home admission in the U.S: a meta-analysis 
BMC Geriatrics  2007;7:13.
While existing reviews have identified significant predictors of nursing home admission, this meta-analysis attempted to provide more integrated empirical findings to identify predictors. The present study aimed to generate pooled empirical associations for sociodemographic, functional, cognitive, service use, and informal support indicators that predict nursing home admission among older adults in the U.S.
Studies published in English were retrieved by searching the MEDLINE, PSYCINFO, CINAHL, and Digital Dissertations databases using the keywords: "nursing home placement," "nursing home entry," "nursing home admission," and "predictors/institutionalization." Any reports including these key words were retrieved. Bibliographies of retrieved articles were also searched. Selected studies included sampling frames that were nationally- or regionally-representative of the U.S. older population.
Of 736 relevant reports identified, 77 reports across 12 data sources were included that used longitudinal designs and community-based samples. Information on number of nursing home admissions, length of follow-up, sample characteristics, analysis type, statistical adjustment, and potential risk factors were extracted with standardized protocols. Random effects models were used to separately pool the logistic and Cox regression model results from the individual data sources. Among the strongest predictors of nursing home admission were 3 or more activities of daily living dependencies (summary odds ratio [OR] = 3.25; 95% confidence interval [CI], 2.56–4.09), cognitive impairment (OR = 2.54; CI, 1.44–4.51), and prior nursing home use (OR = 3.47; CI, 1.89–6.37).
The pooled associations provided detailed empirical information as to which variables emerged as the strongest predictors of NH admission (e.g., 3 or more ADL dependencies, cognitive impairment, prior NH use). These results could be utilized as weights in the construction and validation of prognostic tools to estimate risk for NH entry over a multi-year period.
PMCID: PMC1914346  PMID: 17578574
19.  Cost-effectiveness implications based on a comparison of nursing home and home health case mix. 
Health Services Research  1985;20(4):387-405.
Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states in 1982 and 1983. Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients. Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients. From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.
PMCID: PMC1068890  PMID: 3932258
20.  Association Between Activities of Daily Living and Mortality Among Institutionalized Elderly Adults in Japan 
Journal of Epidemiology  2012;22(6):501-507.
We assessed the association between activities of daily living (ADL) and mortality among nursing home residents in Japan.
This 1-year prospective cohort study investigated 8902 elderly adults in 140 nursing homes. Baseline measurements included age, sex, height, weight, body mass index (BMI), ADL, and dementia level. ADL levels were obtained by caregivers, using the Barthel Index (BI), after which total BI scores were calculated (higher scores indicate less dependence). Information on dates of discharge and mortality was also obtained to calculate person-years. The Cox proportional hazards model was used to estimate hazard ratios (HRs).
Mean age was 84.3 years, and mean total BI score was 38.5. The HRs of mortality adjusted for sex, age, BMI, and type of nursing home were 7.6 (95% CI: 3.3–17.8) for those with a BI score of 0 (totally dependent), 3.9 (1.7–9.0) for those with a score of 1 to 10, 3.5 (1.4–8.7) for those with a score of 11 to 40, 2.7 (1.4–5.1) for those with a score of 41 to 70, and 1.3 (0.7–2.4) for those with a score of 71 to 99 (P for trend <0.001), as compared with those with a score of 100. Multivariate analysis revealed that BI, sex, age, and BMI were significantly associated with mortality rate.
There was a clear inverse association between ADL level and mortality. In conjunction with other risk factors, ADL level might effectively predict short-term mortality in institutionalized elderly adults.
PMCID: PMC3798561  PMID: 22850544
activities of daily living; frail elderly; nursing homes; mortality
21.  Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at:
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at:
For more information on the economic analysis, please visit the PATH website:
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website:
The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED).
Clinical Need: Condition and Target Population
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations.
Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year.
Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter.
Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling.
There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home.
In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only.
Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home.
The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population.
Ontario Context
No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals.
Research Question
What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search.
Inclusion Criteria
English language full-text reports;
health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs);
studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately;
studies performed in patients with acute exacerbations of COPD who present to the ED;
studies published between January 1, 1990, and August 5, 2010;
studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD;
studies that include at least 1 of the outcomes of interest (listed below).
Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment.
Exclusion Criteria
< 18 years of age
animal studies
duplicate publications
grey literature
Outcomes of Interest
Patient/clinical outcomes
lung function (forced expiratory volume in 1 second)
health-related quality of life
patient or caregiver preference
patient or caregiver satisfaction with care
Health system outcomes
hospital readmissions
length of stay in hospital and hospital-at-home
ED visits
transfer to long-term care
days to readmission
eligibility for hospital-at-home
Statistical Methods
When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1.
Quality of Evidence
The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs.
The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution.
Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care.
Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care.
Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home.
Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up.
Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days).
There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function.
The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life.
A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence.
Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.
PMCID: PMC3384361  PMID: 23074420
22.  Effect of physical training on urinary incontinence: a randomized parallel group trial in nursing homes 
Residents in nursing homes (NHs) are often frail older persons who have impaired physical activity. Urinary incontinence (UI) is a common complaint for residents in NHs. Reduced functional ability and residence in NHs are documented to be risk factors for UI.
To investigate if an individualized training program designed to improve activity of daily living (ADL) and physical capacity among residents in nursing homes has any impact on UI.
Materials and methods
This randomized controlled trial was a substudy of a Nordic multicenter study. Participants had to be >65 years, have stayed in the NH for more than 3 months and in need of assistance in at least one ADL. A total of 98 residents were randomly allocated to either a training group (n = 48) or a control group (n = 50) after baseline registrations. The training program lasted for 3 months and included accommodated physical activity and ADL training. Personal treatment goals were elicited for each subject. The control group received their usual care. The main outcome measure was UI as measured by a 24-hour pad-weighing test. There was no statistically significant difference between the groups on this measure at baseline (P = 0.15). Changes were calculated from baseline to 3 months after the end of the intervention.
Altogether, 68 participants were included in the analysis, 35 in the intervention group and 33 in the control group. The average age was 84.3 years. The 3 months’ postintervention adjusted mean difference between groups according to amount of leakage was 191 g (P = 0.03). This result was statistically significant after adjusting for baseline level, age, sex, and functional status. The leakage increased in residents not receiving the experimental intervention, while UI in the training group showed improvement.
The intervention group had significant better results compared with the control group after an individualized training program designed to improve ADL and physical capacity. Further studies are needed to evaluate the effect of a goal-oriented physical training program toward NH residents UI complaints.
PMCID: PMC3278198  PMID: 22334767
effect study; nursing homes; residents; physical training program; urinary incontinence
23.  Lack of nutritional and functional effects of nutritional supervision by nurses: a quasi-experimental study in geriatric patients 
Undernutrition affects recovery from disease and regaining functional abilities; however, it frequently occurs in elderly hospitalized patients.
To study whether identification of geriatric patients at nutritional risk followed by individualized nursing care could improve their nutritional and activities of daily living (ADL) status.
The design was quasi-experimental. In total, 345 rehabilitation patients (aged 84±7 years, 72% women) were allocated, according to bed availability, to either an intervention or a control ward. Nurses on the intervention ward attended a short class on nutrition and were supervised in nutritional care by trained nurses. In the intervention unit, the nursing staff identified patients at risk of undernutrition through systematic assessment of risk factors, e.g. body mass index (BMI) <24 kgm−2, and treated them according to individual care plans. On the control ward routine nutritional care was offered. Functional status was assessed by the Barthel ADL index.
Mean BMI was 24±5 on both wards. Fifty-five per cent of the patients had BMI <24. On average, patients were weight stable from admission to discharge, irrespective of allocation. No difference was found in ADL status as a result of the intervention. However, patients who gained weight improved more in ADL status than patients who remained stable or lost weight.
In this geriatric setting standard care and care by trained and supervised nurses were equally effective in maintaining weight stability and functionality in rehabilitation patients with a mean BMI of 24. Weight increase was associated with improved functionality.
PMCID: PMC2606983
ADL; elderly; hospitalized; undernutrition; weight gain
24.  One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial; “Continuum of care for frail older people” 
BMC Geriatrics  2013;13:76.
The intervention; “Continuum of Care for Frail Older People”, was designed to create an integrated continuum of care from the hospital emergency department through the hospital and back to the older person’s own home. The aim of this study is to evaluate the effects of the intervention on functional ability in terms of activities of daily living (ADL).
The study is a non-blinded controlled trial with participants randomised to either the intervention group or a control group with follow-ups at three-, six- and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of the older people in the municipality with a case manager as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the municipality of Mölndal, Sweden were asked to participate. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one ADL. Analyses were made on the basis of the intention-to-treat principle. Outcome measures were ADL independence and eight frailty indicators. These were analysed, using Chi-square and odds ratio (OR).
A total of 161 participated in the study, 76 persons allocated to the control group and 85 to the intervention group were analysed throughout the study. There were no significant differences between the groups with regards to change in frailty compared to baseline at any follow-up. At both the three- and twelve-month follow-ups the intervention group had doubled their odds for improved ADL independence compared to the control (OR 2.37, 95% CI; 1.20 – 4.68) and (2.04, 95% CI; 1.03 – 4.06) respectively. At six months the intervention group had halved their odds for decreased ADL independence (OR 0.52, 95% CI; 0.27 – 0.98) compared to the control group.
The intervention has the potential to reduce dependency in ADLs, a valuable benefit both for the individual and for society.
Trial registration NCT01260493
PMCID: PMC3750658  PMID: 23875866
Integrated care; Health care chain; Rehabilitation; Independence; Aging in place; Frail older people
25.  Weight Change and Lower Body Disability in Older Mexican Americans 
To examine the association between 2-year weight change and onset of lower body disability over time in older Mexican Americans.
Data were from the Hispanic Established Population for the Epidemiological Study of the Elderly (1993–2001). Weight change was examined by comparing baseline weight to weight at 2-year follow-up. Incidence of lower body disability was studied from the end of this period through an additional 5 years.
Five southwestern states: Texas, New Mexico, Colorado, Arizona, and California.
One thousand seven hundred thirty-seven noninstitutionalized Mexican-American men and women aged 65 and older who reported no limitation in activities of daily living (ADLs) and were able to perform the walk test at 2-year follow-up.
In-home interviews assessed sociodemographic factors, self-reported physician diagnoses of medical conditions (arthritis, diabetes mellitus, heart attack, stroke, hip fracture, and cancer), self-reported ADLs, depressive symptoms, and number of hospitalizations. Cognitive function, handgrip muscle strength, and body mass index (BMI) were obtained. The outcomes were any limitation of lower body ADL (walking across a small room, bathing, transferring from a bed to a chair, and using the toilet) and limitation on the walk test over subsequent 5-year follow-up period. General Estimation Equation (GEE) was used to estimate lower body disability over time.
Weight change of 5% or more occurred in 42.3% of the participants; 21.7% lost weight, 20.6% gained weight, and 57.7% had stable weight. Using GEE analysis, with stable weight as the reference, weight loss of 5% or more was associated with greater risk of any lower body ADL limitation (odds ratio (OR) = 1.43, 95% confidence interval (CI) = 1.06–1.95) and walking limitation (OR = 1.35, 95% CI = 1.03–1.76) after controlling for sociodemographic variables and BMI at baseline. Weight gain of 5% or more was associated with greater risk of any lower body ADL limitation (OR = 1.39, 95% CI = 1.02–1.89), after controlling for sociodemographic variables and BMI at baseline. When medical conditions, handgrip muscle strength, high depressive symptomatology, cognitive function, and hospitalization were added to the equation, the relationship between 2-year weight change (>5% loss or >5% gain) and lower body disability decreased.
Health conditions and muscle strength partially mediate the association between weight loss or gain and future loss of ability to walk and independently perform ADLs.
PMCID: PMC1941701  PMID: 16181172
weight change; ADL disability; walking; Mexican Americans

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