Trends in function and postdischarge mortality in a medicine for the elderly rehabilitation center over a 10-year period.

OBJECTIVES: To ascertain trends in function and mortality after admission to a medicine for the elderly rehabilitation unit, and to analyze factors associated with these outcomes. DESIGN: Retrospective cohort analysis of routinely collected clinical data during the period from January 1, 1999, to December 31, 2008. SETTING: Hospital-based medicine for the elderly rehabilitation unit. PARTICIPANTS: Patients (N=4449) admitted for rehabilitation after medical and surgical illness, stroke, and fractured neck of the femur. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Analysis of routinely collected clinical data: admission and discharge Barthel scores; indices of cognitive impairment, mental illness, swallowing and feeding difficulties. Discharge diagnoses, place of discharge, date of death, and discharge medications were analyzed, along with length of stay. Regression analysis of factors associated with improvement in Barthel score, place of discharge, and postdischarge mortality. RESULTS: Length of stay and admission Barthel scores were unchanged over the study period, but discharge Barthel scores improved from 13.5 (maximum score, 20) in 2002 to 14.8 in 2008 (P=.002 for trend). Discharge to home increased from 290 (61%) of 472 patients in 2001 to 290 (76%) of 382 patients in 2007 (P<.001 for trend). Age, admission Barthel score, cognitive impairment, problems with understanding, and problems with expression were independent predictors of the change in Barthel score between admission and discharge. The adjusted hazard ratio for postdischarge mortality in 2007 to 2008 compared with 1999 to 2000 was .76 (95% confidence interval, .63-.93). CONCLUSIONS: Functional and mortality outcomes improved over a 10-year period in this rehabilitation unit, despite similar Barthel scores on admission and equivalent lengths of stay.

Older people and ill fitting shoes.

BACKGROUND: Foot health is an important issue in older people. Inappropriate shoes increase the risk of callous and ulcer formation, as well as increasing the risk of falls. There are no data defining the size of this problem. OBJECTIVE: The aim of the study was to investigate the proportion of elderly people on a general rehabilitation ward wearing incorrectly sized shoes and to look for the presence of complications. METHODS: Sixty five consecutive patients (mental state questionnaire score >6) admitted to a rehabilitation ward had their foot length and width measured, and the size of their current footwear recorded. Sensation was tested with a standard 10 g monofilament. The presence of ulceration was noted. Foot pain was recorded by the patient on a visual analogue scale. Any history of diabetes mellitus, peripheral vascular disease, or peripheral neuropathy was noted. RESULTS: The median age of the subjects was 82 (range 64-93). Six (9%) had a history of diabetes, seven (11%) had symptomatic peripheral vascular disease, and 17 (26%) had sensory impairment. Ten patients (15%) had foot ulceration present, and 47 patients (72%) had ill fitting shoes (a discrepancy in length of more than half a British shoe size fitting or more than one British width fitting, 7 mm). Incorrect shoe length was significantly associated with the presence of ulceration (odds ratio (OR) = 10.04, p = 0.016). Presence of ulceration was significantly associated with a history of peripheral vascular disease (OR = 11.56, p = 0.008). Pain was significantly associated with incorrect shoe length (p = 0.0238) and with sensory impairment (p = 0.0314). CONCLUSION: Most older people on a rehabilitation ward wore ill fitting shoes. An association was found between ill fitting shoes and self reported pain, and between ill fitting shoes and ulcer formation. A straightforward assessment of footwear in older people could improve comfort and avoid preventable foot disorders.