jarlife journal
Sample text

AND option

OR option



E. Lindhorst, M. Ramel, P. Kelly, L. Jones


Department of Nutrition and Dietetics, Saint Louis University, Saint Louis, Missouri. 

Corresponding Author: Erin Lindhorst, Department of Nutrition and Dietetics, Saint Louis University, Allied Health Professions Building, 3437 Caroline Street St. Louis, MO 63104, Tel. 816-210-2394, erinlindhorst@gmail.com


 Objective:  The aim of this study was to determine which nutritional support setting fostered the best nutritional status in elderly patients using the Mini Nutritional Assessment survey. Design and Participants: The analytical sample included a total of 75 adults aged 60-89 years. Setting: There were three nutrition support settings: a nursing home, an assisted living facility, and independent living with congregate feeding.  Measurements: The Mini Nutritional Assessment was used to examine nutritional status in patients living in one of the three nutritional support settings. Results: Individuals living independently individuals and attending congregate feedings resulted in the most people in the “normal nutritional status” category when compared with nursing home and assisted living residents.  Conclusion: Individuals living independently in their homes who use congregate feeding have reduced risk of malnutrition.


Key words: Mini Nutritional Assessment, nursing home, assisted living, independent living, congregate feeding. 



According to the U.S. Department of Health and Human Services, the elderly population is expected to increase about 19% by the year 2030. Compared to 12.4% increase in the elderly population in 2000, the United States is on a steady climb to having one of the largest elderly populations it has ever encountered (1). As individuals age, cognitive function gradually declines. This cognitive impairment may result in decreased nutrient intake, leading to poor nutritional status and possibly malnutrition. Cognitive decline, commonly known as dementia, can also result in a decrease in daily activities as well as behavioral and physiological changes. (2) It is estimated that by the year 2040, 81 million people will be affected by dementia (2).

As documented in previous studies, weight loss has been shown to increase the rate of functional decline and increase the risk of morbidity and mortality in the elderly (3). The presence of weight loss and physical decline is heavily correlated with increasing age (3). Therefore, malnutrition is prevalent in about 5-15% of the general elderly population.  Studies suggest that institutionalized elderly have even greater rates of malnutrition, where 52-82% of the population may suffer from malnourishment (4). Additionally, malnutrition often goes undetected in elderly living independently at home, with the prevalence of malnutrition ranging from 13-30% (5). Malnutrition is also seen more in adults with co-morbidities and on multiple prescription medications (4).

Increased mortality rates are correlated with malnutrition but can be prevented by nutritional screening and simple nutritional interventions (4). In order to assess malnutrition in elderly patients a multidimensional approach is needed (4). The Mini Nutritional Assessment (MNA) survey includes factors such as anthropometric measures, weight changes, dietary problems, motility issues, and neuropsychological status (4). The MNA survey consists of six questions that cover decline in food intake, weight loss during the last 3 months, mobility, psychological stress or acute disease, neuropsychological problems, and body mass index (BMI). The results of the assessment categorized individuals as “at normal nutritional status,” “at risk of malnutrition,” or “malnourished.” Early detection of elderly individuals at nutritional risk, followed by nutritional intervention, can help to conserve muscle function as well as muscle strength, improve quality of life, and potentially prolong length of survival (6). Using the MNA survey can provide that early detection. 

Nutrition status can vary between elderly patients living in different settings. There are three main settings where elderly tend to reside in as they age. These include: within a nursing home, in an assisted living facility, or within their home. Each of these living settings provides different nutrition support models. Within a nursing home, patients are provided care 24 hours a day. Skilled nurses or nursing aides can assist these patients with feeding, bathing and dressing if needed. These patients typically gather in a central dining area with other residents for meal times, but they are able to eat in their room if they so desire (7). An assisted living facility is for individuals who require minimal assistance and/or care with every day activities such as bathing, dressing and feeding. These individuals have access to a central dining area where they are provided meals, but they also have the option to prepare meals in their own kitchen (8). Elderly individuals who live independently but attend a congregate feeding site are usually able to perform activities of daily living without any assistance. They generally cook for themselves and potentially for other loved ones. Congregate feeding sites provide elderly individuals 60 years or above access to a meal 5 days a week. Along with a meal, these individuals also get social interaction and support from others attending the congregate feeding site. A review of current literature indicated that there was limited research on malnutrition prevalence in elderly living in these 3 nutrition support settings. 




The principal investigator (PI) found voluntary participants in a nursing home and recruited them during a gathering time where most residents were present. Persons in assisted living were recruited while they were gathered in the communal dining area of the residency. The participants living independently were recruited while they were at their congregate feeding site. Voluntary participants from each site were given a description of the research being conducted. The PI assessed them using the Mini Nutritional Assessment survey and 2 additional nutrition support questions. Surveys and additional questions were anonymous and all information collected throughout this study was kept confidential. The Saint Louis University Institutional Review Board approved the study. 


Study participants were recruited from each of the following nutrition support settings: nursing home care, assisted living, or congregate feeding. Participants ranged in age from 60-89 years and had good cognitive status. The goal was to recruit 25 seniors from each nutrition support setting, for a total of 75 participants. 


The short form of the Mini Nutritional Assessment (MNA) and 2 additional questions were used to gather information during this research study. The MNA is a validated survey and detects whether or not an individual is malnourished or at risk of being malnourished. The survey consists of six questions that look at decline in food intake, weight loss during the past 3 months, mobility, psychological stress or acute disease, neuropsychological problems, and body mass index. The 2 additional questions that were asked depended on the nutrition support setting. The questions for the nursing home and assisted living participants were how long have you been living at this facility? Do you eat in your room or in the communal dining setting? The questions for the congregate feeding participants were how long have you been receiving nutrition support from the congregate feeding site? How many times a week do you receive meals at the facility? These questions were asked to determine if there was an association between nutritional status and length of residency, place where meals were eaten, and frequency of meals received under a nutrition support setting. 

Anthropometrics were also required to complete this assessment. The most recent weight and height for the assisted living and nursing home residents were obtained from the facilities medical records. For congregate feeding participants, calf circumference (CC) was obtained using a standard measuring tape. According to the MNA survey, CC can be used in place of BMI if weight and height are unavailable.

Data Analysis

For the statistical analysis, Statistical Package for the Social Sciences (SPSS, 22.0, 2013) was used. The data were compared using descriptive statistics and analyzed using Chi-square tests of association. These tests were used to determine if there was an association between a participant’s living facility and nutritional status.



Demographic Characteristics


Table 1 Demographic Characteristics of Population Study


Comparison of Results between the Nutrition Support Settings 

This study compared the nutritional status of individuals living in a nursing home, an assisted living facility, and living independently at home but attending a congregate feeding site. The data analysis determined that individuals living independently but attending a congregate feeding site had the best nutritional status of the 3 groups.  The individuals living independently while attending a congregate feeding site had the most participants in the “normal nutritional status” category. There were 20 individuals with “normal nutritional status” and 5 individuals “at risk or malnourished” (Table 2). The nursing home and assisted living participants had the same results. There were 12 individuals in the “normal nutritional status” category and 13 individuals in the “at risk or malnourished” category (Table 2). Using a Chi-square test to compare living facility and nutritional status showed a significant association between individual’s living facility and their nutritional status (chi-square=7.038 (2), p<0.05) (Table 2). 


Table 2 Nutritional Context: Nutritional Status by Type of Living Facility



The purpose of this study was to compare nutritional status between elderly in 3 different nutritional support settings: a nursing home, an assisted living facility, and congregate feeding site. This study was conducted to determine which environment supported the best nutritional status as well as overall health status. 

This study showed the independent living setting with access to congregate feeding resulted in lower risk of malnutrition in the elderly than the other two settings.  The results of this study line up with previous studies that determined malnutrition rates increase in elderly that are institutionalized. Previous studies have also concluded that social support settings such as congregate feeding sites provide the greatest nutritional status outcome (9). Congregate feeding sites have been shown to provide the elderly with affordable, healthy food options, resulting in improved nutritional status (9). From these results we can determine that there is an association between independent living while attending a congregate feeding site and good nutritional status. 

Further research is needed to discover what specifically supports good nutritional status in independent living individuals and to pinpoint why institutionalized elderly have higher rates of malnutrition. Individuals in nursing homes and assisted living require a higher level of care than individuals living independently and they typically have more medical concerns that can affect nutritional status. Since institutionalized elderly are cared for daily by a medical team and skilled staff, the results of higher rates of malnutrition were unexpected. 

There were some weaknesses and limitations in this study. One weakness was the limited relevance of the MNA survey. The 3 different nutritional support settings had very different participant characteristics and therefore not all of the survey questions were relevant. In future research, the use of a different malnutrition survey instrument should be considered.  Another potential weakness of this study was its reliance on self-reported information from the participant. Individuals may not tell the truth about their current status when conversing with a medical professional. Using nursing staff and medical chart records could decrease inaccurate self-reporting when collecting data for two of the nutritional settings, but would still prove difficult for individuals living independently with limited medical oversight. Another weakness that could have skewed the results of this study is that the BMI was not used consistently for all participants to determine their final nutritional status score. The independent living group of participants who attended a congregate feeding site had no recorded weight and height on file, resulting in the use of calf circumference in place of BMI. Although this is an acceptable measurement to use according to the MNA, future researchers should standardize the BMI component and directly measure height and weight of all participants for more accurate and consistent results. A limitation of this study was the lack of diversity within the participant group (Table 1). Most of the participants were Caucasian. To ensure that the results are generalizable to the elderly population, future research should incorporate greater diversity in study participants.



From the results of this study, it was determined that individuals living in a nursing home or assisted living facility could actually be “at risk for malnutrition” or “malnourished” based on the MNA survey. The nursing home residents and assisted living residents showed the highest prevalence of “at risk for malnutrition” or “malnourished” individuals when compared with individuals who live independently, but use congregate feeding. The results of this study help identify the importance of regular nutrition assessments and follow-ups within living institutions to improve the nutritional status among the elderly. This research also sets the framework for future studies to use more variables and compare results at a nominal level. 

Future research can go in-depth and look at variables such as caloric intake, number of meals eaten per day, amount of weight lost over a specific period of time, and number of nutrition supplements consumed per day. Variables such as these will help in understanding why institutionalized elderly have the highest rate of malnourishment. This can also help to determine the main contributors of malnutrition in the growing elderly population. 


1. Administration on Aging (AoA). (n.d.). Retrieved November 16,2014, from http://www.Aoa.acl.gov/Aging_Statistics/index.aspx

2. Meijers, J. Malnutrition in Care Home Residents. The Journal of Nutrition, Health & Aging, 18, 2013.

3. Bagshaw, S. M., & McDermid, R. C. The role of frailty in outcomes from critical illness. Curr Opin Crit Care, 2013;19(5), 496-503. doi: 10.1097/MCC.0b013e328364d57

4. Chavarro-Carvajal, D., Reyes-Ortiz, C., Samper-Ternent, R., Arciniegas, A. J., & Gutierrez, C. C. Nutritional Assessment and Factors Associated to Malnutrition in Older Adults: A Cross-Sectional Study in Bogota, Colombia. J Aging Health, 2014. doi: 10.1177/0898264314549661

5. Kozáková, R., & Zeleníková, R. Assessing the nutritional status of the elderly living at home. European Geriatric Medicine, 2014;5(6), 377-381. doi: 10.1016/j.eurger.2014.07.003

6. van Bokhorst-de van der Schueren, M. A., Guaitoli, P. R., Jansma, E. P., & de Vet, H. C. A systematic review of malnutrition screening tools for the nursing home setting. J Am Med Dir Assoc, 2014;15(3), 171-184. doi: 10.1016/j.jamda.2013.10.006

7. Help Guide. A Guide to Nursing Homes, Skilled Nursing Facilities and Convalescent Homes. http://www.helpguide.org/articles/senior-housing/guide-to-nursing-homes.htm. December 2014. Accessed February 2014;17, 2015. 

8. The Assisted Living Federation of America. Assisted Living. http://www.alfa.org/alfa/Assisted_Living_Information.asp. 2013. Accessed February 17, 2015. 

9. Sylvie, A. K., Jiang, Q., & Cohen, N. Identification of environmental supports for healthy eating in older adults. J Nutr Gerontol Geriatr, 2013;32(2), 161-174. doi: 10.1080/21551197.2013.779621



J.F. Abrahamsen1, R. Rozzini2, S. Boffelli2, A. Cassinadri2, A.H. Ranhoff3, M. Trabucchi4

1. Departement of Nursing Home Medicine, Municipality of Bergen and Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Bergen, Norway; 2. Fondazione Ospedale Poliambulanza, Brescia and Geriatric Research Group, Brescia, Italy; 3. Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Bergen, and Departement of Clinical Science, University of Bergen, Norway; 4. Professor of Neuropsycopharmacology,  University of Rome II, and Geriatric Research Group, Brescia, Italy

Corresponding Author: Jenny Foss Abrahamsen, Departement of Nursing Home Medicine, Municipality of Bergen and Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, Ulriksdal 8, 5009, Bergen, Norway. jennyfossabrahamsen@gmail.com Telephone: 004799514977




Background/Objectives: Little is known regarding the influence of sociodemographic and clinical factors, on the short term outcomes of different postacute care (PAC) models in different countries. Design and setting: Prospective cohort study of a 19- bed Italian hospital subacute care (SAC) unit and a 19-bed  Norwegian nursing home (NH) intermediate care (IC) unit, both based on Comprehensive Geriatric Assessment and similar multidisciplinary staffing. Participants: A total of 664 Italian and 961 Norwegian community-dwelling patients  ≥70 years of age, in need of postacute geriatric based treatment, rehabilitation and care. The patients were admitted from acute medical, surgical and orthopaedic hospital units. Measurements: Demographic data, clinical information, comprehensive geriatric assessment (CGA), discharge destination and length of stay were recorded in an Italian and a Norwegian database and compared. Results: The Italian patients receiving hospital SAC, were more seriously affected by the acute disease and trauma, median Barthel index (BI) at admission/discharge was 40/60, compared to 75/85 in the Norwegian patients, and fewer of them were able to return to own home as compared to the Norwegian patients ( 64% vs. 82%). Although the Italian patients had a lower BI at discharge, fewer of them were transferred to nursing homes (9%), as compared to the Norwegian patients (14%), while more of them were discharged to further rehabilitation, acute hospitalization, hospice or died (27%), as compared to the Norwegian patients (4%). Of the patients discharged to own home, only 8% of the Italian compared to 71% of the Norwegian patients received nurse assisted home care. Admission BI and improvement in BI, were highly significant predictors for the ability to return home in multivariate logistic regression analysis both in the Italian and the Norwegian patients. Conclusions: Both clinical and sociodemographic factors influenced the clinical outcome of older patients receiving PAC in Italy and Norway. Such differences should be taken into account when results from different PAC models in different countries are compared.  Both the Italian hospital SAC model and the Norwegian NH IC model are feasible and good alternatives, but more firm inclusion criteria may further optimize the selection of patients suitable for different PAC options.  

Key words: Postacute care, subacute care, intermediate care, nursing home, older patients. 



Hospitalization for acute disease or injury may, in older home- dwelling patients, be associated with functional decline and increasing dependency (1-3). Some patients are not able to return to their own home after acute hospitalization and need further multidimensional geriatric based care to regain their functional capacity. 

There are numerous facilities that offer this kind of care, different terms are used, different patients are selected and different kind of care is offered. 

In the present article we define Post-Acute Care (PAC) as different treatment modalities available after an acute hospital stay to further the goals of acute care (4, 5). PAC facilities may be located in hospitals, rehabilitation centers or nursing homes. Older adults who have overcome the acute phase of their hospitalization but are not able to carry out functional tasks with the level of independence required to return to their previous accommodation, may be considered candidates for PAC.

In England and other European countries, the term Intermediate care (IC) has been used as synonymous/overlapping with PAC (6-8). In the present study we define IC as one type of PAC offered to older patients after acute hospitalization with the main intention to provide active treatment and rehabilitation in the community after hospital discharge.  IC services are generally, but not always, based on community-based interdisciplinary teams.

Another form of PAC is SubAcute Care (SAC), which focuses on inpatient multidisciplinary geriatric treatment and rehabilitation (9, 10). This care model is a complement to acute and curative medicine and share the aims of other PAC models.

While earlier studies have demonstrated beneficial effects of both community based IC (11) and hospital based SAC (12), there is an ongoing discussion regarding the content of, and which patients are best suited for different models (8, 13, 14). Furthermore, there is a lack of evidence comparing different PAC models and rehabilitation results between healthcare settings from different Europeans countries. 

Since geriatric research collaboration earlier had been taken place between Italy and Norway and both countries recently had established new PAC treatments modalities, a new study was set up with the goal to describe and compare these two different PAC models. The Italian model was an inpatient hospital SAC model, while the Norwegian model was a skilled nursing home (NH) IC model.  However both models were based on Comprehensive Geriatric Assessment (CGA) and had comparable multidisciplinary staffing.

The overall aim of the present study was to describe and assess the feasibility and benefits the two different PAC models, and to investigate how sociodemographic, clinical and health care features affected the short term treatment results.



Overall aim of the two postacute care models

The overall aim of both models was to relieve pressure on the acute hospital beds and to deliver CGA based treatment and rehabilitation for older patients that did not need to stay in an acute hospital unit, but still had more complex medical and functional needs than could be managed at home. The final goal was that the patients should be able to return to their own home. 

The 19-bed Italian SAC unit was established in 2011 as part of the geriatric department at the Fondazione Ospedale Poliambulanza in Brescia, Italy (15).  In addition to treating and rehabilitate patients after an acute hospital admission, this treatment option was also available for home dwelling elderly patients with chronic disease to avoid early flare-up, relapse and acute hospitalization.

The 19-bed Norwegian IC unit was established in 2005 as a collaboration between the municipality of Bergen, and the two hospitals serving the town (16-18). Emphasis was put on selecting patients from the acute medical and orthopaedic hospital departments that had a treatment and rehabilitation potential, and that the treatment period should be rather short, preferably ≤14 days, to allow a rather high turnover of patients that were able to receive CGA based treatment and care. 

Patient selection 

The inclusion criteria for the Italian and Norwegian units are shown in Table 1.


Table 1 Inclusion criteria and treatment options for older patients receiving hospital subacute care (SAC) in Italy and nursing home intermediate care (IC) in Norway

Abbreviations: IADL-instrumental activities of daily life, CIRS, Cumulative Illness Rating Scale comorbidity and severity, CDR Clinical Dementia Rating, MNA-SF, TUG- Timed up and go, Mini Nutritional Assessment-Short Form; *As long as the patient has medical needs and the cognitive decay was not the reason for the admittance. †Nursing home doctor only present at ordinary daily working hours and not in weekends. Nursing home doctor on call for all the nursing homes in Bergen could be contacted and visit the patient. Otherwise, at nights, if needed, the nursing home nurse could call the hospital directly for advise or readmittance of the patients


In the Italian SAC unit, the doctor in the acute hospital ward or less frequently, the patient`s family physician (if the patient were not yet admitted to hospital) would call the geriatrician in the SAC unit that would decide whether the patient was suitable for admittance.  From 2014 and onwards, major cognitive impairment was no exclusion criteria, as long as the patient had medical needs and the cognitive decline was not the reason for the admittance. The Italian SAC unit also admitted patients with acute delirium. Patients in immediate needs of nursing home were excluded.

In the Norwegian IC unit the selection process was as follows: 1)The hospital doctor selected patients that needed further medical treatment and rehabilitation, according to the inclusion criteria. 2) The hospital doctor or nurse phoned the NH giving a short report on the patient including, diagnosis, social status, physical ability and purpose of admission to intermediate care. 3) The NH doctor decided, based on the information given from the hospital, whether the patient was suitable for IC. Approximately 80 % of the referred patients were considered suitable for transferral from the hospital to the IC unit.

Design, setting and treatment options

The treatment options given by the Italian SAC unit and the Norwegian IC unit are shown in Table 1. In both units, in addition to continuation of the medical treatment started in the acute hospital, multidisciplinary CGA-based treatment was given according to the patient`s needs, e.g. physiotherapy, nursing care and social and nutritional intervention. Treatment plans and decisions about discharge and making arrangements for further treatment and care after discharge, were conducted after discussion in the multidisciplinary team. 

Both treatment modalities were based on care in an environment adjusted to elderly patients, with main emphasis on multidisciplinary staffing, ADL training, nutrition and social wellbeing. Furthermore, communication with the family, community nurse- and physiotherapy service, to improve the patients home condition was essential to enable a safe return to their own home and avoid further NH transferral.

The patients in the Italian SAC unit had all the acute hospital facilities available, including the possibility of 24-hour doctor visits, blood samples, radiological investigations and rapid transfer to the acute departments. However, main emphasis was put on avoiding unnecessary further investigations and rather offering multidisciplinary treatment to achieve maximum independence.  Extensive geriatric assessment was performed with Barthel index (BI)(19),  Mini Mental Status Examination (MMSE) (20), 15 item Geriatric Depression scale (GDS) (21) and Tinetti scale (22)  by the doctor when admitting the patients and the day before discharge, Cumulative Illness Rating Scale (CIRS) severity and comorbidity (23),  Blaylock scale (24),  and  Instrumental ADL (I-ADL) (25) at admission. In addition, the patient or their relatives were asked for information on the status of the patient 14 days before the hospital admission concerning BI, I-ADL and Clinical Dementia Rating (CDR) (26).  

Information of the patients’ home situation and caregivers were obtained at admission. In Italy, the family usually makes high effort to take care of the patients after return to own home. Otherwise the patient or his/her family may hire a personal assistant living with the patient, or the hospital would ask the municipality for nurse assisted home care for personal needs. If the patient needed further rehabilitation, they were discharge to a geriatric rehabilitation centre. Patients who lacked a rehabilitation potential, but were unable to return home were transferred to a skilled nursing facility or hospice. Patients that deteriorated and became medically unstable with potential ability to reverse were readmitted to acute hospital units.

The Norwegian IC NH patients were after a short stay in the hospital for establishing the diagnosis and start of therapy, transported to the NH that was located 3 km away. Main emphasis was made on mobilizing the patients out of bed and out of the room, and that the patient should transfer (possible with aid) to the dining room for all meals. All patients were assessed by a physiotherapist and sometimes an occupational therapist, offered individual physiotherapy and group-based exercise. CGA was performed on all of the patients during the first week.  Activities of daily living (ADL) were assessed by nurses observing the patients with the BI at the day of admission and at the day before discharge. Within the first week, the Norwegian version of the MMSE (20, 27), 30-item GDS (21), and Mini Nutritional Assessment- Short Form (MNA-SF) (28) was performed. The IC unit was supplied with equipment for intravenous treatment, blood transfusions, nebulizer for inhalation, bladder scan, 24-hour blood pressure recording, pulse oximetry and oxygen supply. Some blood tests could be analysed on the spot (haemoglobin, C-reactive protein and glucose), other blood samples were sent to the hospital laboratory for analysis within a few hours, when needed. NH doctors were only present at ordinary daily working hours and not in weekends.  At other times a NH doctor on call for all the nursing homes in Bergen could be contacted and visit the patient or the NH nurse could, at night time, when needed, call the hospital directly for advice or readmission of the patients.

Nurse assisted home care and follow up by the physiotherapist in the community was offered to all patients that were in need of this, when they were discharged to their own home.  If the patient could not return home within 14 days, transfer to an ordinary, lower-cost, skilled nursing facility should occur, however in a few instances exceptions were made.  If the patients had a further rehabilitation potential they were further transferred to a  NH with more physiotherapy resources. If the patients were not adequately medically diagnosed or stabilised, they were readmitted to hospital (acute hospitalization).  

Data collection and Statistical analysis

The data on the patient`s demographic, baseline clinical characteristics and discharge destination, were obtained from hospital or IC nursing home records  and included prospectively in an Italian and a Norwegian database, respectively. The data were analysed with standard descriptive statistics using the Statistical Package for Social Science IBM SPSS 20 for Windows. Continuous variables that had a normal distribution (age and days in PAC) was described as mean and SD otherwise the variables were described as median and min-max values.  

For identifying characteristics that were independently associated with return to own home, odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using logistic regression models.  Variables that were available in both the Italian and Norwegian patients were included in univariate analysis (age, sex, BI admission, BI improvement (BI discharge – BI admission), MMSE and GDS). The variables associated with p < 0.25 in univariate analysis were noted as likely predictors and included in multivariate, adjusted logistic regression models. In this analysis, p ≤ 0.01 was considered to be statistically significant to account for multiple testing.


The study was performed in appliance with the Helsinki Declaration(29), and no experimental interventions were performed.

In Italy, the study was approved by hospital Ethical board. Patients were informed about the study at admission. If the relative was absent, information was given at the first meeting with the family. Information was given mainly orally, while written consent was obtained for the treatment of personal data, and collected in the clinical charts. Consent for patients with severe cognitive impairment was obtained by the legal tutor. For other patients, consent was written, in presence of a relative. All of the consecutively admitted patients agreed to sign the informed consent.

In Norway the study was approved by the Regional Committee for Medical and Health Research Ethics.  Information of the study was given by the doctor when admitting the patients, along with the written informed consent, that the patients would sign during the stay, possibly after consulting his/her family. No patients with major cognitive impairment or delirium was included.



Patients` characteristics

During 2011-2014, 798 consecutive Italian patients were admitted to the SAC unit, 134 patients had age <70 years, thus altogether 664 Italian patients with age≥ 70 years were included in the present study. Of 1085 consecutive Norwegian patients with age ≥70 years and  admitted to the IC unit, 112 were not asked to participate in the study at times when the geriatrician in charge was absent, 5 refused to participate, 4 had acute delirium and 2 had language problems. Thus 961 Norwegian patients were included.  

As shown in Table 2, a majority of the Italian and Norwegian patients were admitted from the departments of internal medicine, cardiology, pulmonology, and in Italy, an acute geriatric department.  Most of the medical patients had cardiovascular diseases or infections; many had started intravenous antibiotic therapy in the hospital. The Norwegian IC unit included more patients from the orthopaedic departments. Most of these patients had suffered a fall, including 76 hip fracture patients.  None were admitted after elective surgery. 


Table 2 Characteristics of Italian patients treated in a hospital subacute care unit and Norwegian patients treated in a nursing home intermediate care unit

Abbreviations: CIRS, Cumulative Illness Rating Scale, MMSE, Mini-Mental-Status Examination, I-ADL, Instrumental Activities of Daily Life, MNA-SF, Mini Nutritional Assessment- Short Form, CDR, Clinical Dementia Rating. Categorical variables are described as numbers and % of patients. Numerical variables, except age, are described as median and min-max.; *Italian patients assessed with 15 item scale, Norwegian population with 30 item scale


As shown in Table 2, fewer Italian patients were living alone, as compared to the Norwegian patients. Functional status 2 weeks before hospital admission indicated that the Italian patients, in general, were rather independent in ADL (BI= 85) and did not have major cognitive impairment (CDR=0), before the acute hospital admission. However more of them had >5 diagnoses and were using > 5 drugs, a higher percentage than the Norwegian patients.  Furthermore, CGA indicated that the Italian patients in general were more severely affected by the acute disease, they had worse scores on all physical function and ADL assessment tests, and 19% of them had delirium on admission.

Outcome at discharge

The Italian patients experienced a substantial improvement in functional status, as shown in Table 3. However, as their admission ADL was low, their BI at discharge was still lower than that of the Norwegian patients, 60 versus 85, respectively (Table 2). 

Despite that the Italian patients in general had a lower discharge BI, fewer of them were transferred to NH (9%), as compared to the Norwegian patients (14%). The Ital patients that were discharged to NH had lower median scores both on ADL assessment, BI 40(0-80) vs 60 (15-100) and MMSE 18 (0-30) vs 23 (8-30), as compared to the Norwegian patients. 

Although the Norwegian patients that were discharge home had higher median BI score at discharge, 85 (35-100), compared to the Italian patients, 75 (5-100), more of them received nurse assisted home care after arriving home (Table 3). However, twice as many of the Norwegian patients were living alone (67% vs 33% (Table 3). As the majority of the Norwegian patients had a higher functional status and were able to return to their own home, fewer of them were transferred to further rehabilitation, acute hospitalization, hospice, or died during post-acute care, as compared to the Italian patients. 


Table 3 Outcome at discharge in Italian patients treated in a hospital subacute care unit and Norwegian patients treated in a nursing home intermediate care unit

Abbreviations: CIRS, Cumulative Illness Rating Scale, MMSE, Mini-Mental-Status Examination; I-ADL, Instrumental Activities of Daily Life, MNA-SF, Mini Nutritional Assessment- Short Form, CDR, Clinical Dementia Rating. Categorical variables are described as numbers and % of patients


The Italian patients had a slightly longer stay, and fewer patients were discharged to own home. Possible predictors for the ability to return home was assessed by logistic regression analyses. Table 4 shows that in multivariate analysis, the admission BI and improvement in BI remained significant predictors for both the Italian and Norwegian patients. 


Table 4 Simple and multiple logistic regression for predictors of return to own home in Italian patients treated in a hospitalsubacute care unit and Norwegian patients treated in a nursing home intermediate care unit

SAC= Sub Acute Care, IC= Intermediate Care, OR= odds ratio, CI=confidence interval, BI, Barthel index,  MMSE, Mini Mental State Examination, GDS, Geriatric; Depression Scale.  OR were estimated using logistic regression models and adjusted for the covariates as described in the Methods section; *Variables are per unit increase,  †Experienced any BI improvement during postacute care


Geriatric resources in Brescia, Italy and Bergen, Norway

Table 5 show the comparison of geriatric hospital care and nursing home care in the Municipalities of Brescia, Italy and Bergen, Norway.


Table 5 Comparison of geriatric hospital care and nursing home care in the Municipalities of Brescia, Italy and Bergen, Norway



The present study shows the influence of clinical and sociodemographic factors, regarding the short-term treatment and rehabilitation outcome of older patients cared for in an Italian hospital SAC unit and a Norwegian NH IC unit, both based on CGA and with comparable multidisciplinary staffing. 

To our knowledge, no similar cross- national comparison has been done on different PAC settings, although a study comparing two hospital geriatric rehabilitation departments in Italy and Israel has previously been published (10). This study concluded that differences in sociodemographic and clinical factors could not account for all differences in ADL improvement that was observed between the two patients groups, and that the organization of care and constraints of the health system also influence functional outcome.  

Regarding the rehabilitation outcomes after different PAC models, a Cochrane database review has concluded that there were insufficient evidence to compare the effects of NH, hospital and own home environments on older patients` rehabilitation outcomes (30), while  a systematic review and meta-analysis of randomized controlled trials concludes that different hospital SAC models had the potential to improve outcomes relative to function, admission to NH and mortality (9).  Intermediate care models are more heterogeneous (8, 31), but somewhat comparable facilities to the Norwegian NH IC unit have reported improved short-term functional recovery, improved long-term functional recovery and decreased mortality (5, 11).

In the present study, fewer Italian patients were discharged to NH and received home assisted nurse care, although their clinical condition was worse than that of the Norwegian patients. We believe that this probably is due to the influence of different sociodemographic and health care system factors: in Italy, more family care as compared to community based home nurse care, and a higher personal patient charge combined with less availability of nursing homes, as compared to Norway.

As indicated  in Table 5, Italian geriatric hospital medicine is better developed with more hospital geriatric beds and more geriatricians, as compared to Norway, where a major political aim over the last years has been to treat elderly patients outside the hospital, in their local community, where the family physician is the primary health service provider. These differences may contribute to the set-up of an in-hospital SAC unit in Italy and a NH IC unit in Norway. 

Although the aim, the set up, and the inclusion criteria of the two models had several similarities, a higher threshold for transferral of patients with a bad functional status to the Norwegian NH IC (with doctors present only at daytime) was probably applied, as compared to the Italian patients referred for hospital SAC. The Italian patients in general were more clinically instable, had higher medical needs, and the majority of them would probably be unable to be treated in a different settings other than a hospital. However, some of them, either with the best or the worst functional status might also have benefitted from treatment in different care facilities outside the hospital, as for example a NH IC ward (best status) or a NH palliative ward (worst status). Altogether this suggests that different postacute alternatives are needed for patients with different functional status and different medical needs, but more firm inclusion criteria’s might be considered to optimize the selection of patients.

ADL function, assessed by BI was the most important clinical factor predicting the ability to return to own home, both for the Italian and the Norwegian patients, and this is partly in accordance with other studies (32, 33). In the Italian patients, higher scores on GDS, implying depression, were also significantly negatively associated with the ability to return home, while this was not so for the Norwegian patients. The present study could not explain this difference, but other studies have demonstrated that older hospitalized patients with depressive symptoms are at higher risk of unfavorable outcome and mortality (34, 35).

A limitation of the present study is that we have only reported short term results while only follow up over time concerning mortality and autonomy can tell to what extent the patients are suited for and have benefit from the two different treatment modalities. We are planning to do such a study when the patients have been followed for 12 months. Secondly, two different PAC settings – in hospital and in NH were compared, thus the generalizability of the study may be limited. The strength of the study is that, as far as we know, no other study has earlier compared different PAC models in different countries. 

We conclude that some caution should be taken when clinical outcomes from different countries and societies are compared, because end-points, like the ability to return to home and the use of NH, is influenced by health care and sociodemographic differences. Both the Italian hospital SAC model and the Norwegian NH IC model presented in this article are feasible and good alternatives, but more firm inclusion criteria based on knowledge about the long term clinical outcome of both patient groups may further optimize the selection of patients suitable for these different PAC options. 


Funding: This work was funded by Western Norway Regional Health Authority. No commercial role was played in the design, execution, analyses, interpretation of data or writing of the study.

Conflict of interest: JFA, RR, SB, AC, AHR and MT have no conflicts of interests to declare.



1. Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 2008;56(12):2171-9.

2. Wong RY, Miller WC. Adverse outcomes following hospitalization in acutely ill older patients. BMC geriatr 2008;8:10.

3. Gill TM, Gahbauer EA, Han L, Allore HG. Factors associated with recovery of prehospital function among older persons admitted to a nursing home with disability after an acute hospitalization. J Gerontol A Biol Sci Med Sci 2009;64(12):1296-303.

4. Young J, Green J, Forster A, Small N, Lowson K, Bogle S, et al. Postacute care for older people in community hospitals: a multicenter randomized, controlled trial. J Am Geriatr Soc 2007;55(12):1995-2002.

5. Lee WJ, Peng LN, Cheng YY, Liu CY, Chen LK, Yu HC. Effectiveness of short-term interdisciplinary intervention on postacute patients in Taiwan. J Am Med Dir Assoc 2011;12(1):29-32.

6. Martin GP, Hewitt GJ, Faulkner TA, Parker H. The organisation, form and function of intermediate care services and systems in England: results from a national survey. Health Soc Care Community  2007;15(2):146-54.

7. Garasen H, Windspoll R, Johnsen R. Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial. BMC Public Health. 2007;7:68.

8. Ariss SM, Enderby PM, Smith T, Nancarrow SA, Bradburn MJ, Harrop D, et al. Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource. Health Serv and Deliv Res 2015; No 3. 1. Southampton (UK)

9. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;340:c1718.

10. Gindin J, Walter-Ginzburg A, Geitzen M, Epstein S, Levi S, Landi F, et al. Predictors of rehabilitation outcomes: a comparison of Israeli and Italian geriatric post-acute care (PAC) facilities using the minimum data set (MDS). J Am Med Dir Assoc  2007;8(4):233-42.

11. Garasen H, Windspoll R, Johnsen R. Long-term patients’ outcomes after intermediate care at a community hospital for elderly patients: 12-month follow-up of a randomized controlled trial. Scand J Public Health 2008;36(2):197-204.

12. Chen LK, Chen YM, Hwang SJ, Peng LN, Lin MH, Lee WJ, et al. Effectiveness of community hospital-based post-acute care on functional recovery and 12-month mortality in older patients: a prospective cohort study. Ann Med 2010;42(8):630-6.

13. Kilgore C. Why intermediate care services need to be refreshed. Nurs Older People 2014;26(3):16-20.

14. Plochg T, Delnoij DM, van der Kruk TF, Janmaat TA, Klazinga NS. Intermediate care: for better or worse? Process evaluation of an intermediate care model between a university hospital and a residential home. BMC Health Services Res 2005;5:38.

15. Boffelli S, Cassinadri A, Mercurio F, Rozzini R, Trabucchi M. Le cure sub acuta fra ospedal e territorio: una nuova opportunita di cura geriatrica. J Gerontol. 2014;62:21-8.

16. Herfjord JK, Heggestad T, Ersland H, Ranhoff AH. Intermediate care in nursing home after hospital admission: a randomized controlled trial with one year follow-up. BMC Res Notes 2014;7(1):889.

17. Abrahamsen J, Haugland C, Nilsen R, Ranhoff AH. Predictors for return to own home and being alive at 6 months after nursing home intermediate care following acute hospitalization. Eur Geriatr Medi 2014;5:108-12.

18. Abrahamsen J, Haugland C, Nilsen R, Ranhoff AH. Three different outcomes in older community-dwelling patients receiving intermediate care in nursing home after acute hospitalization. J Nutr Health Aging. 2015;In press.

19. Mahoney FI. Functional Evaluation: the Barthel Index. Md State Med J. 1965;14:108-12.

20. Folstein MF, Folstein SE, McHugh PR. «Mini-mental state». A practical method for grading the cognitive state of patients for clinicians. J Psychiatr Res 1975;12:189-98.

21. Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull 1988;24(4):709-11.

22. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34(2):119-26.

23. Parmelee PA, Thuras PD, Katz IR, Lawton MP. Validation of the Cumulative Illness Rating Scale in a geriatric residential population.  J Am Geriatr Soc 1995;43(2):130-7.

24. Blaylock A, Cason CL. Discharge planning predicting patients’ needs. J Gerontolo Nurs 1992;18(7):5-10.

25. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist. 1969;9(3):179-86.

26. Lanctot KL, Hsiung GY, Feldman HH, Masoud ST, Sham L, Herrmann N. Assessing the validity of deriving clinical dementia rating (CDR) global scores from independently-obtained functional rating scale (FRS) scores in vascular dementia with and without Alzheimer’s disease. Int J Geriatr Psychiatry. 2009;24(10):1174-6.

27. Strobel CEK, Engedal K. MMSE-NR. Norwegian Revised Mini Mental Status Evaluation. Revised and Expanded Manual.  Norwegian Centre for Ageing and Health, Oslo, Norway, 2008.

28. Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clin Geriatr Med 2002;18(4):737-57.

29. Wilson CB. An updated Declaration of Helsinki will provide more protection. Nature Med 2013;19(6):664.

30. Ward D, Drahota A, Gal D, Severs M, Dean TP. Care home versus hospital and own home environments for rehabilitation of older people. The Cochrane database of systematic reviews. 2008(4):CD003164.

31. Young J. The development of intermediate care services in England. Arch Gerontol Geriatr 2009;49 Suppl 2:S21-5.

32. Bellelli G, Magnifico F, Trabucchi M. Outcomes at 12 months in a population of elderly patients discharged from a rehabilitation unit. J Am Med Dir Assoc 2008;9(1):55-64.

33. Sleiman I, Rozzini R, Barbisoni P, Morandi A, Ricci A, Giordano A, et al. Functional trajectories during hospitalization: a prognostic sign for elderly patients. J Gerontol A Biol Sci Med Sci 2009;64(6):659-63.

34. Covinsky KE, Kahana E, Chin MH, Palmer RM, Fortinsky RH, Landefeld CS. Depressive symptoms and 3-year mortality in older hospitalized medical patients. Ann Intern Med 1999;130(7):563-9.

35. Cullum S, Metcalfe C, Todd C, Brayne C. Does depression predict adverse outcomes for older medical inpatients? A prospective cohort study of individuals screened for a trial. Age Ageing. 2008;37(6):690-5.




A. Malara, G. Sgrò, F. Ceravolo, G. Curinga, G.F. Renda, F. Spadea, V. Rispoli


Scientific Commettee of National Association of Nursing Home for Third Age (ANASTE) Calabria, Lamezia Terme (CZ), Italy

Corresponding Author: Alba Malara, Scientific Commettee of National Association of Nursing Home for Third Age (ANASTE) Calabria, Lamezia Terme (CZ), Italy E-mail: alba.doc@tiscali.it, mobile phone: +39.340.6621250, fax: +39.0968.400478



Backgrounds: The International Classification of Functioning, Disability and Health (ICF) is a suitable tool to standardize the status of health and disability. A previous study, carried out on 546 subjects included in the database ANASTE (National Association of Nursing Home for Third Age) Calabria, showed that 78.43% of the patients suffered from cognitive impairment whereas 52% had a severe degree of dementia. 65% of them was suffering from Alzheimer’s Disease (AD), whereas 23% from vascular dementia (VD). Objectives: Aim of this study was to analyse the prevalence of functional impairments, activity limitations and participation restrictions of patients affected by AD and VD. Design: Observational descriptive study. Setting: Nursing Homes ANASTE Calabria. Participants: 10 patients with probable AD (ADPr) and 10 patients affected Citalopram by probable VD (VDPr). Measurements: All patients were underwent multidimensional geriatric assessment. The profiles of disability ICF, were expressed in terms of Capacity and Performance, and coded according to mild, medium, severe and complete disability. Environmental factors were skilled in facilitator or no facilitator. Results: The patients with ADPr displayed a severe impairment of functional status, and advanced clinical stage requiring higher care burden compared with VDPr patients. The ICF assessment showed that the global and specific Mental Functions, Communication and Interpersonal Relationships were more reduced in patients with ADPr respect those with VDPr. Conclusions: The identification of a ICF checklist of various forms of dementia, might provides a more detailed description of the profiles of disability and improving therapeutic, rehabilitative interventions and psico-social care.

Key words: ICF, dementia, nursing home.


The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization (WHO) in 2001 to standardize descriptions of health and disability (1). ICF organizes information in three components:

– The Body construct, which comprises two classifications, one for body functions, and another for body structure. Body functions and body structures refer to the human organism as a whole, it includes the brain and its functions, (i.e. the mind).

– The Activities and Participation constructs denote the aspects of functioning from both an individual and social perspective. The domains of activity and participation are listed in a single list that includes the large range of areas of life, by learning basic to social tasks.

i taking zoloft

– The Environmental factors make up the physical environment, social environment in which people live and conduct their lives. The factors are external to individuals and can have a positive or negative effect on participation, activities or on the individual’s body function or structure. The Personal factors are the individual background of an individual’s life, regardless of their health condition. These may include age, race, sex, education, experience, personality and character style, aptitudes, fitness, lifestyle, education, coping styles, social background, profession (2).

Each of the components can be expressed in terms of both positive and negative influence. The negative aspects are defined as «impairment» (dysfunction or loss of BF), «limitation of Activity» (individual difficulty in performing a particular activity) or «restriction of Participation» (individual problems in involvement in life http://abilifygeneric-online.com/catalog/Depression/Paxil.htm situations) (3). Impairments of structure can involve an anomaly, defect, loss or other significant deviation in body structures. Impairments can be temporary or permanent; progressive, regressive or static; intermittent or continuous. Difficulties or problems of these domains can arise when there is a qualitative or quantitative alteration in the way in which the functions of these domains are carried out. These characteristics are captured in further descriptions, mainly in the codes, by means of qualifiers. The positive aspects are expressed as AP codes, that identify profiles of mild, serious and complete disability, expressed in terms of «Capacity» and «Performance». The Capacity qualifier describes the highest level of functioning of a person to perform a task; the Performance describes what a person does, in actual conditions, considering all available environmental factors (instrumental and personal). Differences between Capacity and Performance qualifiers indicate the presence of environmental factors that facilitate or hinder the operating profile (1). ICF is a multi-purpose classification designed to serve various disciplines and different sectors. Its specific aim is to provide a scientific basis for understanding and studying health states and health-related outcomes, and their determinants; and to establish a common language for describing health states that will permit comparison of data across countries, health care disciplines and services. Several efforts have been implemented to develop the use of ICF codes in geriatric care settings, improving appropriate qualifications for each code according to user interest (4). ICF has an important role in the clinical setting to identify the patient who requires multiple complex performance, and to evaluate the results of medical treatments, surgical, rehabilitative, palliative, undertaken in connection with such problem. At the same time, ICF takes an important role in the organizational-management, since based on the problems and strengths of the individual, being able to indicate the range of services appropriate to the care, treatment and rehabilitation (5).

In 2011 we processed and analysed, by the database of ANASTE (National Association of Nursing Home for Third Age) Calabria, data coming from 546 subjects resident in ANASTE’s Nursing Homes. This study showed that 78.43% of the patients suffered from cognitive impairment whereas 52% had a severe degree of dementia. Was estimated, according to the ICD9 codes, that 65% of patients with dementia was suffering from Alzheimer’s Disease (AD), whereas 23% had vascular dementia (VD). The assessment of disability, by the ICF model for patients with dementia, allows us to formulate a dynamic functional-profile and identify the associations among health conditions, environmental and personal factors with disability levels.


A network of Long Term Care (LTC) Facilities, consisting of Nursing Homes and structures organization for Extensive Rehabilitation, is operating in the care of the frail elderly in Calabria. The access of these facilities is regulated according to the guidelines provided by the Calabria Region (DGR 685/2002, DGR 695/2003, LR 29/2008, DGR 3137/1999). This is an observational descriptive study carried out on a sample of residents, accross in two nursing homes associated to ANASTE Calabria at June 2011. The present study was conducted by carrying out the customary practice of care, provided to all patients who belong to the LTC ANASTE Calabria, and nursing care didn’t involve any different procedures. At the moment of admission in LTC the informed consent of the patients and/or their reference was acquired for daily care practice and use of their personal data. In brief, we used the National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer’s Disease and Related Disorders Association (NINCDS/ADRA) (6) criteria for diagnosis of Alzheimer’s disease (AD), and moreover the criteria of National Institute for Neurological Disorders and Stroke- Association Internationale puor la Recherche et Enseignement en Neusoscience (NINCDS-AIREN) (7) was used to diagnose vascular dementia. We enrolled 10 patients (7 F and 3M, mean age 69 ± 17 years) with probable AD (ADPr), according to the NINCDS-ADRDA criteria, and 10 patients (4 Fe and 6 M, mean age 88 ± 4.8 years) affected by VD Probability (VDPr), according to NINDS-AIREN criteria.

All patients underwent multidimensional geriatric assessment. The clinical diagnosis of dementia was firstly investigated by an interview through a detailed personal as well as family history and, subsequently, confirmed by the administration of psychometric tests. All patients fulfilled the criteria for dementia as described in the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM IV) (8). The diagnosis of chronic pain was made according to ICD9-CM Official (9).The cognitive evaluation, was conducted by Folstein’s Mini-Mental State Examination (MMSE) (10). According to MMSE, the patients were affected by severe, moderate or slight cognitive impairment, if MMSE score ranging 0-10, 11-20 or 21-23 respectively. The Clinical Dementia Rating (CDR) (11) was used for the staging of disease. The functional state was evaluated by the use of the Activity Daily Living scale (ADL) (12) and Barthel Index (BI) (13), in both scale a lower score indicate a worse of functional state. The burden of care was calculated in minutes assistance/day according to the Resource Utilization Group (RUG) III (14). The profiles of disability, by ICF, has been expressed in terms of Capacity and Performance. The Performance qualifier indicates the degree of Participation and/or Restriction in describing the current performance of the people in a task or action in their real environment. This context includes the environmental factors (physical, social and attitudinal) that can be coded using the Environmental Factors. Performance can be understood as «involvement in a life situation» or «lived experience» of people in the actual context in which they live. The Capacity qualifier indicates the degree of limitation by describing the person’s ability to perform a task or an action. The Capacity qualifier focuses on limitations that are inherent or intrinsic features of the people themselves, due to the state of health of the person, without assistance of environmental factors (15). The components of the ICF classification are indicated with the letters b (body functions), s (body structures), d (dimension Activity/Partecipation) and e (environmental factors) and are followed by a four-digit numeric code. The ICF also provides a scale of qualification for generic categories, where 0 stands for «no problem» (0-4% limitation/impairment), 1 for «sensitive issue» (5-24% limitation/impairment), 2 for «moderate problem» (25-49% limitation/impairment), 3 for «serious problem» (50-95% limitation / impairment), and 4 for «complete problem» (96-100% limitation/impairment) (1). According to th ICF guidellnes, only the explicit and specific information were coded, such as those observed by the operator, through the patient’s behavior, and codified in the categories closest to the operation observed, regardless of the patient’s health. For the «Functions of the body» of the ICF components and «Activities and Participation», were calculated the prevalence of impairments and limitations in both the AD group and VD group. The disability were coded according to the following scale: mild (5-24%), medium (25-49%), severe (50-95%), complete (96 to 100%). The environmental factors (personal and instrumental) were listed as able in Barrier or No barrier, facilitator or No Facilitator (15).


Patients with ADPr exhibited a severe impairment of functional status (ADL: 0.9 ± 1.5 and BI: 19 ± 24.8 IB), and an advanced clinical stage of dementia (CDR: 3.8 ± 0.6). Instead of patients with VDPr showed less impairment of functional status (ADL: 1.1 ± 0,87 and BI; 31.6 ± 24.9), but an advanced clinical stage of dementia too (CDR of3.4 ± 0.69). The care burden calculated according RUG III indicated an increased need of care in minutes of care for patients with AD Pr (327,2 min/day/one) compared with patients with VD Pr (213 min/day/one) (Tab1). In patients with dementia, relevant information, those related to Mental Functions (b1.) and those related to restrictions in performance associated with Mental Functions, were found; in particular, the items relating to Communication (d3), Interaction and Relationships (d7), mobility (d4) and self-care (d5), civil and social life of the community (d9), while learning and applying knowledge (d1), home life (d6) and Area of life Main (d8) were not applicable in this patient population. The global and specific Mental Functions, Communication and Interpersonal Relationships were more reduced in patients with ADPr compared with VDPr (Fig.1, 2 and 3), whereas in this group there were no significant differences about mobility and personal care. The assessment of the ICF AP, according to the qualifier “Capacity”, showed that 60% of ADPr patients and 40% of VDPr patients had a complete disability, while 40% of ADPr patients and 60% of VDPr patients showed a severe disability. Instead of observation according to the ICF qualifier “Performance”, which takes into account environmental factors, showed a improvement of disability in both groups (Fig.4). The following environmental factors have been encoded Facilitator: as E355 (health professionals, nurses, rehabilitation therapists), E360 (educators, social workers.) E110 (drugs) and E115 (devices).

Table 1 Population and measurement characteristics

Notes: Alzheimer Disease Probable (ADPr); Vascular Dementia Probable (VDPr); Mini Mental State Examination (MMSE); Clinical Dementia Rating (CDR); Activities of Daily Living (ADL); Barthel Index (BI) Care Need by Resource Utilization Groups-III.

Figure 1 Impairments in ADPr and VDPr patients relating to the chapters: Mental Functions in the ICF component of Body Fuctions




The aim of this study is to describe the profiles of disability ICF across Activity and Partecipations domains in a cohort of residents suffering from ADPr and VDPr, to verify the effect of the environmental factors such as barrier or no barrier, facilitator or no facilitator and, finally, to sketch a checklist for the two forms of dementia. The ICF is based on a universal model that theoretically can be applied regardless of culture, age or care settings. The diagnosis alone does not explain what patients can do, what they need, and what can be the impairment of their functional status. The ICF allows us to obtain information on the operation of individuals and therefore plays an important role in the clinical setting to identify complicated patients, to evaluate the results of the medical treatment, rehabilitation and care. The ICF takes on an important role in the organizational-management, indicating the range of services that are appropriate for each treatment (16). In Italian Nursing homes, all clinical activity and care given to patients with dementia, is planned by the multi-professional equipe, with a bio-psycho-social approach, through an operational tool called Personalized Care Plan (PCP). PCP is the main tool in the clinical-organizational pathways of care particularly for patients with dementia. The PCP developed through the use of ICF, can define goals, interventions, and related health professionals, for each detected need. The ICF, compared with other rating scales of disability and the burden of care, ADL, Barthel Index or RUGIII, has allowed to include the assessment of the environmental context of dementia patients: environmental factors such as nurses, rehabilitation therapists, educators, social workers, drugs, and devices in generally, that have proven to be important facilitators. Moreover, the use of the ICF has also permitted to plan the interventions of care for patients with dementia, and taking into account important aspects of daily life, usually less considered, such as communication, social relationships, recreation and free time. The ICF is a tool that allows to go beyond the negative focus of the impairment of functions and structures of the body, to assess the complexity of living with dementia. In the field of clinical management and about the quality of life for these patients, the latter task is of great importance.The present study, despite the small sample number, shows that the goals of care processed according to the indicators of Capacity and Performance, allow an improvement of disability in ADPr and VDPr patients. This study also allows us to identify one preliminary spectrum of problems, limitations and restrictions of the most common functioning and disability in these two patients groups. The identification of a specific checklist of disease, provides a more detailed description of the profiles of disability in the various forms of dementia and helps caregivers to deduce what interventions have to be made. There are different protocols for evaluation and classification systems of disability based on ICF for other chronic diseases, such as chronic widespread pain, osteoporosis, chronic ischemic heart disease, diabetes mellitus, obstructive pulmonary diseases, breast cancer, depression, and stroke (17). The ICF core-sets contains the full spectrum of the problems of patients with a specific health condition and / or in a given clinical environment (18). It would be useful to also individuate a core-sets for the various forms of dementia, to improve the interventions and to have the possibility to verify the efficiency over a time period. The results of our study may be an initial contribution to this, but more researchs is needed on the development of the relevant ICF domains of this disease, http://cymbaltaonline-pharmacy.com/ especially taking into account other comorbidities such as metabolic and cardiovascular problems. The interventions, based on the ICF model, are able to orient the assistance and rehabilitation programs, improving the activities and participation in dementia patients, this may also induce a positive effect on their cognitive impairment and their quality of life.

Figure 2 Limitation or restriction in ADPr and VDPr patients, relating to the chapters: Comunications in the ICF component ‘Activities and Participation’

Figure 3 Limitation or restriction in ADPr and VDPr patients, relating to the chapters: Interpersonal Interactions and Relationship in the ICF component ‘Activities and Participation’

Figure 4 Prevalance of ICF disability in ADPr e VDPr patients according to the qualifier Capacity and Performance


Acknowledgments: We thank the following Nursing Homes, for the recruitment of patients: RSA “San Domenico”, Lamezia Terme (CZ) Italy, RSA “Villa Elisabetta” Cortale, (CZ) Italy, RSA “Ippolito Dodaro”, Falerna (CZ) Italy.

Funding: This study did not receive any funding for its implementation.

Disclosure: The authors report no conflicts of interest in this work.

Ethics Standards: The experiments described in this manuscript comply with the current Italian laws.


1. World Health Organization.: International Classification of Functioning, Disability and Health : ICF. Geneva, World Health Organization; 2001.

2. Ustun B: The international classification of functioning, disa- bility and health-a common framework for describing health states. 2002. http://whqlibdoc.who.int/publications/2002/9241545518_Chap7.3.pdf.

3. Mueller M, Lohmann S, Strobl R, Boldt C, Grill E. Patients’ functioning as predictor of nursing workload in acute hospital units providing rehabilitation care: a multi-centre cohort study. BMC Health Services Research 2010; 10:295-307

4. Okochi J, Utsunomiya S, Takahashi T. Health measurement using the ICF: Test-retest reliability study of ICF codes and qualifiers in geriatric care. Health and Quality of Life Outcomes 2005; 3:46-59

5. Mueller M, Boldt C, Grill E, Strobl R, Stucki G: Identification of ICF categories relevant for nursing in the situation of acute and early post- acute rehabilitation. BMC Nurs 2008; 7:3.

6. McKhann G, Drachman D, Folstein M, Katzman R, Price Amitriptyline D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ARDRA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology. 1984;34:934–994.

7. Roman GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JH, et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN Inter- national Workshop. Neurology. 1993; 43(2):250-60.

8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). 2000. Washington, DC.

9. ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2011

10. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.

11. Morris, J.C. The Clinical Dementia Rating (CDR): Current vision and scoring rules Neurology, 1993; 43:2412-2414

12. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31: 721–727.

13. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61–65.

14. Carpenter I, Perry M, Challis D, Hope K. Identification of registered nurs- ing care of residents in English nursing homes using the Minimum Data Set Resident Assessment Instrument (MDS/RAI) and Resource Utilisa- tion Groups version III (RUG-III). Age Ageing. 2002;32: 279–285.

15. World Health Organization. ICF Checklist Version 2.1a, Clinician Form for International Classification of Functioning, Disability and Health. September 2003. Available from: http://www.who.int/entity/classifications/icf/training/icfchecklist.pdf.

16. Stier-Jarmer M, Grill E, Muller M, Strobl R, Quittan M, Stucki G. Validation of the comprehensive ICF Core Set for patients in geriatric post-acute rehabilitation facilities. Journal of rehabilitation medicine : official journal of the UEMS European Board of Physical and Rehabilitation Medicine. 2011;43(2):102-12.

17. Jelsma J. Use of the International Classification of Functioning, Disability and Health: a literature survey. Rehabil Med 2009; 41: 1–12

18. Cieza A, Ewert T, T. Berdirhan Ustun TB, Chatterji S, Kostanjsek N, Stucki G. Development of ICF core sets for patients with chronic condition. J Rehabil Med 2004; Suppl. 44: 9–11