We conducted a randomized trial in a community rehabilitation hospital to determine the effect of treatment in a geriatric assessment unit on the physical function, institutionalization rate, and mortality of elderly patients. Functionally impaired elderly patients (mean age, 78.8 years) who were recovering from acute medical or surgical illnesses and were considered at risk for nursing home placement were randomly assigned either to the geriatric assessment unit (n = 78) or to a control group that received usual care (n = 77). The two groups were similar at entry and were stratified according to the perceived risk of an immediate nursing home placement. After six months, the patients treated in the geriatric assessment unit had significantly more functional improvement in three of eight basic self-care activities (P less than 0.05). Those in the lower-risk stratum had significantly more improvement in seven of eight self-care activities. Both six weeks and six months after randomization, significantly more patients treated in the geriatric assessment unit than controls (79 vs. 61 percent after six months) were residing in the community. During the year of follow-up, the control patients had more nursing home stays of six months or longer (10 vs. 3; P less than 0.05). However, there was no difference between the groups in the mean number of days spent in health care facilities (acute care hospital, nursing home, or rehabilitation hospital). Survival analysis showed a trend toward fewer deaths among the patients treated in the geriatric assessment unit, and mortality was significantly reduced in the patients considered to be at lower risk of immediate nursing home placement (P less than 0.05). We conclude that the treatment of selected elderly patients in a specialized geriatric rehabilitation unit improves function, decreases the risk of nursing home placement, and may reduce mortality. The beneficial effects on mortality and function appear greatest for patients at a moderate rather than high risk of nursing home placement.
This clinical translation achieved outcomes similar to the REACH II randomized controlled trial, providing clinically significant benefits for caregivers of a veteran with a progressive dementing disease. This model of caregiver support can inform public policy in providing assistance to caregivers.
Our data suggest that brief primary care interventions may be effective in reducing caregiver distress and burden in the long-term management of the dementia patient. They further suggest that interventions that focus only on care recipient behavior, without addressing caregiving issues, may not be as adequate for reducing caregiver distress.
Objectives-To examine the cost-effectiveness of a randomized, clinical trial of a home-based intervention for caregivers of people with dementia. Setting-Community-dwelling dementia caregiving dyads from the Memphis REACH II site. Design-This Participants-OfMemphis' random sample of 55 intervention and 57 control black and white dyads, 46 in each arm completed without death or discontinuation. Family caregivers were aged 21 and older, lived with the care recipient, and had provided 4 or more hours of care per day for 6 months or longer. Care recipients were cognitively and functionally impaired.Address correspondence to Linda O. Nichols, PhD, VAMC (11-H), 1030 Jefferson Avenue, Memphis, TN 38104. E-mail: linda.nichols@va.gov. Author Contributions: Dr. Nichols had full access to all the data in the study and takes responsibility for the integrity for the data and the accuracy of the data analysis. All contributors are included as authors. Study concept and design: Burns, Chang, Czaja, Nichols. Acquisition of data: Coon, Lummus, Martindale, Nichols. Analysis and interpretation of data: Burns, Chang, Czaja, Graney, Lummus, Nichols. Drafting of the manuscript: Chang, Lummus, Nichols. Critical Revision of the manuscript for important intellectual content: Burns, Chang, Coon, Czaja, Graney, Martindale, Nichols. Statistical analysis: Graney, Lummus. Obtaining funding: Burns, Coon, Martindale, Nichols. Administrative, technical, or material support: Burns, Coon, Czaja, Graney, Lummus, Martindale, Nichols. Supervision: Martindale, Nichols. Sponsor's Role:No sponsors were involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation or review of the manuscript. The Department of Veterans Affairs approved the manuscript. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptIntervention(s)-Twelve individual sessions (9 home sessions and 3 telephone sessions) supplemented by five telephone support-group sessions. Control caregivers received two "check in" phone calls.Measurements-Incremental cost-effectiveness ratio (ICER), the additional cost to bring about one additional unit of benefit (hours per day of providing care).Results-At 6 months, there was a significant difference between intervention caregivers and control caregivers in hours providing care (P =.01). The ICER showed that intervention caregivers had 1 extra hour per day not spent in caregiving, at a cost of $5 per day. Conclusion-The intervention provided that most scarce of caregiver commodities-time. The emotional and physical costs of dementia caregiving are enormous, and this intervention was able to alleviate some of that cost. The 6-month intervention included modules focusing on information, safety, caregiver health and well-being, and behavior management for the care recipient. Twelve individual sessions were delivered in the caregivers' home (9 sessions) and through telephone (3 sessions), supplemented by five telephone-administered support...
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