Geriatric Rehabilitation as an Integral Part of Geriatric Medicine in the Nordic Countries

Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/OpenObjective: Firstly to outline the theoretical and practical framework for geriatric rehabilitation in Iceland and other Nordic countries and secondly to survey the scientific medical publications for evidence based geriatric rehabilitation. Methods: Brain storming on geriatric rehabilitation in a working group of Nordic teachers in geriatric medicine. Papers on scientific programs for geriatric rehabilitation from Internet sources were collected and analyzed. All articles describing randomized studies in geriatric rehabilitation were selected for overview. The papers were divided into four groups according to diseases, infirmity and resource settings; 1) stroke, 2) hip-fractures, 3) acute admissions and 4) programs conducted in nursing homes, day hospitals and home services. Results: A spectrum of biological and social events creates the conditions underlying most causes for illness and disability in old people. The process of established geriatric services promotes the efficiency of geriatric rehabilitation. The literature survey included 27 scientific studies (8586 patients) on randomized studies with valid endpoints. Geriatric rehabilitation programs for stroke patients in geriatric settings, six studies (1138 patients), reduced mortality and the need for nursing home placement but the outcome for ADL. Function and length of stay was more variable between the studies. The outcome of geriatric rehabilitation was even more decisive in the randomized hip-fracture studies, six studies (2171 patients). Eight studies were found comparing the outcome between acute admission of frail elderly to either geriatric (GEMU, GRU) or general medical wards. The outcome as regards to mortality rate at one year, placement to a nursing home, physical function, contentment with services, readmission rate and cost was all significantly better in the geriatric settings. Internal comparisons of geriatric programs in nursing homes, day hospitals and in home service, seven studies (1261 patient), revealed some differences in outcomes in function, contentment and costs. Conclusions: Specialized geriatric rehabilitation is complicated but effective when properly performed. Interdisciplinary teamwork, targeting of patients, comprehensive assessment and intensive and patient-targeted rehabilitation seem to characterize the most effective programs. Rehabilitation of frail elderly people poses a major challenge for the future and has to be developed further for the sake of quality of life of elderly people as well as for economic reasons.Markmið: Að gera úttekt á öldrunarendurhæfingu á Íslandi og öðrum Norðurlöndum, marka hinn hugmyndafræðilega grunn, tengja hann norrænum veruleika og taka saman vísindalegar niðurstöður um árangur öldrunarendurhæfingar. Aðferð: Hugarflugsfundir vinnuhóps kennara í öldrunarlækningum um öldrunarendurhæfingu. Sértæk leit í helstu læknatímarita á Medline í greinum sem fjalla um aðferðir og meðferðarleiðir endurhæfingar fyrir aldraða á vísindalegan hátt. Um er að ræða samantekt á rannsóknum sem notast við slembiúrtök og taka til elstu aldurshópa. Greinunum var skipt niður í fjóra flokka eftir sjúkdómum, færni og staðsetningu; 1) heilablóðfall, 2) mjaðmarbrot, 3) bráðveikir og hrumir, 4) prógrömm á hjúkrunarheimilum, dagspítölum og í heimaþjónustu. Niðurstöður: Lífeðlisfræðilegir og félagslegir þættir marka veikindaferli og fötlun aldraðra. Verklag öldrunarþjónustunnar skiptir miklu um árangur öldrunarendurhæfingar. Leit í 27 tímaritsgreinum náði til 8586 sjúklinga en þær báru saman slembiúrtök og höfðu haldbærar viðmiðanir. Endurhæfing aldraðra heilablóðfallssjúklinga á öldrunarlækningadeild, sex rannsóknir (1138 sjúklingar), dró úr dánarlíkum og minnkaði þörf fyrir stofnanavist en breyting á mælanlegri færni og legudagafjöldi varð ekki afgerandi hjá öllum. Enn betri árangur náðist við endurhæfingu eftir mjaðmarbrot, sex rannsóknir (2171 sjúklingur). Átta rannsóknir (4016 sjúklingar) báru saman árangur öldrunarlækningadeilda borið saman við almennar lyflæknisdeildir í meðhöndlun bráðveikra og hrumra sjúklinga. Niðurstöður voru flestar afgerandi betri á öldrunarlækningadeildum hvað varðar dánartíðni að ári, vistun á hjúkrunarheimili, líkamlega færni, ánægju, endurinnlagnir og kostnað. Innbyrðis samanburður á endurhæfingaraðferðum fyrir aldraða á hjúkrunarheimilum, dagspítölum og í heimaþjónustu, sjö rannsóknir (1261 sjúklingur), sýndu mun á nokkrum viðmiðunum í færniþáttum, ánægju og kostnaði. Ályktanir: Sérhæfð endurhæfing aldraðra er flókin en skilar árangri þegar rétt er á haldið. Bestur árangur næst með fjölfaglegri teymisvinnu, val á þeim sjúklingum sem mestu áhættuna hafa, alhliða öldrunarmati og virkri og einstaklingsmiðaðri endurhæfingu. Endurhæfing á hrumu gömlu fólki er og verður vaxandi viðfangsefni fyrir heilbrigðisþjónustuna og mikilvægt að hún nái því markmiði að auka lífsgæði aldraðs fólks. Benda rannsóknir einnig til að við það skapist einnig efnahagslegur ávinningur fyrir land og þjóð

The role of geriatric syndromes in predicting unplanned hospitalizations : a population-based study using Minimum Data Set for Home Care

Background: The predictive accuracies of screening instruments for identifying home-dwelling old people at risk of hospitalization have ranged from poor to moderate, particularly among the oldest persons. This study aimed to identify variables that could improve the accuracy of a Minimum Data Set for Home Care (MDS-HC) based algorithm, the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale, in classifying home care clients’ risk for unplanned hospitalization. Methods: In this register-based retrospective study, factors associated with hospitalization among home care clients aged ≥ 80 years in the City of Tampere, Finland, were analyzed by linking MDS-HC assessments with hospital discharge records. MDS-HC determinants associated with hospitalization within 180 days after the assessment were analyzed for clients at low (DIVERT 1), moderate (DIVERT 2–3) and high (DIVERT 4–6) risk of hospitalization. Then, two new variables were selected to supplement the DIVERT algorithm. Finally, area under curve (AUC) values of the original and modified DIVERT scales were determined using the data of MDS-HC assessments of all home care clients in the City of Tampere to examine if addition of the variables related to the oldest age groups improved the accuracy of DIVERT. Results: Of home care clients aged ≥ 80 years, 1,291 (65.4%) were hospitalized at least once during the two-year study period. Unplanned hospitalization occurred following 15.9%, 22.8%, and 33.9% MDS-HC assessments with DIVERT group 1, 2–3 and 4–6, respectively. Infectious diseases were the most common diagnosis within each DIVERT groups. Many MDS-HC variables not included in the DIVERT algorithm were associated with hospitalization, including e.g. poor self-rated health and old fracture (other than hip fracture) (p 0.001) in DIVERT 1; impaired cognition and decision-making, urinary incontinence, unstable walking and fear of falling (p < 0.001) in DIVERT 2–3; and urinary incontinence, poor self-rated health (p < 0.001), and decreased social interaction (p 0.001) in DIVERT 4–6. Adding impaired cognition and urinary incontinence to the DIVERT algorithm improved sensitivity but not accuracy (AUC 0.64 (95% CI 0.62–0.65) vs. 0.62 (0.60–0.64) of the original DIVERT). More admissions occurred among the clients with higher scores in the modified than in the original DIVERT scale. Conclusions: Certain geriatric syndromes and diagnosis groups were associated with unplanned hospitalization among home care clients at low or moderate risk level of hospitalization. However, the predictive accuracy of the DIVERT could not be improved. In a complex clinical context of home care clients, more important than existence of a set of risk factors related to an algorithm may be the various individual combinations of risk factors.Peer reviewe

Selittääkö fyysinen toimintakyky asiakkaan saamaa hoitoaikaa vanhusten laitoshoidossa? RAVA-indeksin ja RAI-järjestelmän hierarkkisen toimintakykymittarin vertailu

Tutkimuksessa verrattiin kahden vanhusten laitoshoidossa käytettävän fyysisen toimintakykymittarin luokituksen yhteyttä asiakkaiden saamaan hoitoaikaan. Hoitoaika mitattiin aikamittaustutkimuksen avulla. Tutkimuksen toisena tavoitteena oli arvioida sitä, kuinka yhteneväisesti fyysisen toimintakyvyn mittarit luokittelevat asiakkaat fyysisen toimintakyvyn suhteen eri luokkiin. RAI-järjestelmän hierarkkinen toimintakykymittari ja RAVA-indeksi korreloivat samalla tavalla potilaskohtaisen hoitoajan (min/vrk) kanssa. Kummankaan mittarin osalta yhteys asiakkaiden hoitoaikaan ei kuitenkaan ollut täysin lineaarinen tai voimakas. Mittarit antavat kohtuullisen yhdenmukaisen kuvan asiakkaiden fyysisestä toimintakyvystä ja henkilökunnan ajankäytöstä. Asiakkaan palveluntarpeen arviointiin, hoitopaikan valintaan ja henkilöstövoimavarojen jakamiseen tarvitaan kuitenkin myös muita mittareita, koska fyysinen toimintakyky ei selitä tarpeeksi hoitoaikojen vaihtelua eikä avun tarvetta

Astmapotilaan ohjauksen prosessikuvaus

Opinnäytetyö toteutettiin Kolmiosairaala-hankkeessa. Kolmiosairaala on Meilahden tornisairaalan ‎viereen marraskuussa 2010 valmistunut uusi sisätautien sairaala. Kolmiosairaala-hanke on ‎yhteistyöprojekti Helsingin ja Uudenmaan sairaanhoitopiirin / HYKSin Medisiinisen tulosyksikön ja ‎Laurea-ammattikorkeakoulun Otaniemen paikallisyksikön välillä. Varsinaisena yhteis-‎työkumppanina toimi Keuhkosairauksien ja allergologian poliklinikka, joka muutti marraskuussa ‎‎2010 Kolmiosairaalaan. ‎ Opinnäytetyön tarkoituksena oli tuottaa astmapotilaan ohjauksen prosessikuvaus Meilahden ‎sairaalan Keuhkosairauksien ja allergologian poliklinikalle. Työn toteuttamisessa käytettiin ‎kvalitatiivista tutkimusmenetelmää. Aineisto kerättiin teemahaastattelulla, joka toteutettiin ‎haastattelemalla Keuhkosairauksien ja allergologian poliklinikan kolmea sairaanhoitajaa ryh-‎mänä. Käytetyt teema-alueet olivat: astmapotilaan ohjauksen eri vaiheet, astmapotilasta ohjaavat ‎ammattihenkilöt, ohjauksen sisällöt, ohjausmenetelmät sekä ohjauksen arviointi. Haastattelusta ‎saatu tieto litteroitiin ja analysoitiin sisällönanalyysillä. Sisällönanalyysin pohjalta astmapotilaiden ‎ohjauksesta tuotettiin QPR ProcessGuide -ohjelmalla prosessikuvaus. ‎ Opinnäytetyön tulosten mukaan astmapotilaiden ohjaus jakautuu kolmeen vaiheeseen: ohjauksen ‎määrittelyyn ja valmisteluun, ohjauksen toteutukseen sekä ohjauksen arviointiin ja jatkuvuuteen. ‎Ohjauksen sisältöjä ovat sairauden hallinta, lääkehoito, sairauden huomioiminen ja vaikutus ‎arkielämään sekä tukipalvelut. Potilasta ohjaavat lääkäri ja sairaanhoitaja sekä tarvittaessa ‎fysioterapeutti, kuntoutusohjaaja, sosiaalityöntekijä ja ravitsemusterapeutti. Astmapotilaat käyvät ‎Keuhkosairauksien ja allergologian poliklinikalla keskimäärin kolme kertaa puolen vuoden sisällä, ‎minkä jälkeen heidän hoitonsa siirtyy perusterveydenhuoltoon. Astmapotilaiden hoito perustuu ‎hyvin toteutettuun omahoitoon ja ohjauksen tavoitteena on, että potilaat voivat saamiensa tietojen ‎ja taitojen avulla toteuttaa omahoitoa kotona. Astmapotilaita ohjataan yksilöllisesti, jokaisen ‎potilaan tarpeet huomioon ottaen.‎ Opinnäytetyön tuloksia ja prosessikuvausta voidaan hyödyntää toiminnan tarkastelussa ja ‎kehittämisessä Keuhkosairauksien ja allergologian poliklinikalla. Prosessikuvausta voidaan käyttää ‎myös ohjauksen runkona sekä tukena uusien työntekijöiden perehdytyksessä. ‎ Asiasanat: astmapotilas, potilasohjaus, prosessikuvausA process description of an asthma patient’s guidance The thesis was carried out in the Triangle Hospital project. Triangle Hospital is a new hospital for ‎internal medicine located next to Meilahti Tower Hospital and has been completed in November ‎‎2010. The Triangle Hospital project is a collaboration project between the hospital district of ‎Helsinki and Uusimaa, medical unit at HUCH (Helsinki University Central Hospital) and Laurea ‎University of Applied Sciences. ‎ The purpose of this thesis was to create a process description of an asthma patient's guidance for ‎the Clinic for Pulmonary Diseases and Allergology in Meilahti hospital. Qualitative method was ‎used in implementing this thesis. The material was gathered by interviewing three nurses as a ‎group from the Clinic for Pulmonary Diseases and Allergology using a theme interview. The ‎themes were: the different stages of asthma patient's guidance, the professionals guiding an ‎asthma patient, the contents of the guidance, the guidance methods and the evaluation of the ‎guidance. The material gathered from the interview was transcribed and analyzed by using ‎material-based content analysis. Based on the analysis the process description was created with the ‎QPR-Process Guide programme. ‎ Based on the analysis of the thesis, an asthma patient's guidance can be divided into three stages: ‎determining and preparing the guidance, implementing the guidance and evaluating and securing ‎the continuity of the guidance. The content of the guidance consists of controlling the illness, ‎medical care, acknowledging the illness and its influence to everyday life and support services. ‎The patient is guided by a doctor and a nurse, and then, if needed, by a physiotherapist, a ‎rehabilitation instructor, a social worker and a dietician. Asthma patients visit the clinic on an ‎average three times in six months. After that their care is transferred to primary health care. ‎Asthma patients' treatment is based on well implemented self-care. The objective of the guidance ‎is that patients can practice their self-care at home with the help of the information and skills that ‎they have gained from the guidance. Every patient is guided considering their individual needs.‎ The findings and process description of this thesis can be used to review and develop the work in ‎the Clinic for Pulmonary Diseases and Allergology. The process description can also be used as a ‎framework for guidance and in instructing new employees. ‎ Key words: asthma patient, patient guidance, process descriptio

Ad-Hoc-verkot : Projektit, protokollat ja reititys

Tämän insinöörityön aiheena on tutustua langattomissa verkoissa vähemmän tunnettuihin Ad-Hoc– ja mesh-topologiaratkaisuihin. Insinöörityössä käydään aluksi läpi pintaraapaisu 802.11-lähiverkkostandardin peruskäsitteistä. Tämän jälkeen käsitellään syvemmin ns. Ad-hoc– sekä mesh-tyyppisiä verkkoja, tutustutaan muutamaan näitä hyödyntäviin sekä kehittäviin projekteihin sekä mahdollisiin käyttökohteisiin. Suuri osa työstä käsittelee Mesh-verkkoja, eli sellaista langattoman Ad­-Hoc-verkon muotoa, joissa tukiasemaa ei tarvita, sillä jokainen solmu voi toi­mia viestien välittäjänä. Esittelen erään harrastelijavoimin toteutetun mesh-verkkoja käyttävän projek­tin verkkorakennetta, sekä käyn läpi useita nimenomaan Ad-Hoc-verkkoon to­teutettuja ja suunniteltuja reititysprotokollia. Lopussa kerrotaan hieman yleisiä tietoturva-asioita, jotka koskevat avoimia verkkoja yleisellä tasolla. Kerron mm. PGP-salausohjelman periaatteesta. Tarkoitus on kertoa mahdollisimman selkeästi, mitä tukiasematon (Ad-Hoc) verkko tarkoittaa, missä tällaisia verkkoja käytetään ja voitaisiin käyttää sekä antaa lukijalle perustason ymmärrystä reitityksestä langattomissa verkoissa. Työtä tehdessä opittiin, että avoimesti ja harrastelijavoimin toteutetuilla projek­teilla voi olla suuri merkitys kaupungin tai kylän asukkaille sekä taloudelliselle tilanteelle. Työ osoitti myös, että projektit ovat hajanaisia, heikosti dokumentoi­tuja ja usein vielä heikommin tunnettuja.The subject of this thesis is to take a look on the less well known Ad-Hoc and mesh-network topologies used in Wireless networks. At first, this thesis will cover very basic understanding of the concepts of the 802.11 wireless network standard. After that, the document will dive a little deeper into the Ad-Hoc and mesh network models. We will also take a look at a few projects which develop and target areas, which take advantage of these sort of networks. A large portion of this thesis cover mesh-networks, which are the kind of net­works without bases tations, in which every node can participate in forwarding the routing messages. I present the contruction of a particular network, which was put together by hobbyists - based on meshes, I also cover several routing protocols specificly aimed and designed for Ad-Hoc networks. Lastly, a few general security issues are discussed shortly f.ex. The very basics of the PGP-encryption software is provided. The purpose is to as simply as possible put, to tell what does it mean to have a network without a base station, where these kind of networks are and could be used, and to give rough understanding about routing in wireless networks. Writing this thesis taught me, that openly developed, hobbyist-driven projects can have a significant impact on people and the economics of a city or village. It was also discovered, that the projects are highly diverse, not well documented and even less known by general public