The number of nursing home residents being admitted to hospital has been increasing. Residents in nursing homes (NH) are an increasingly vulnerable group with complex medical and care needs. Access to acute care will always be an important component of quality care for nursing homes residents. Nevertheless, reducing preventable hospitalization is fundamental in terms of better quality of care, improved health and cost savings. Evidence indicates that many hospitalizations of NH residents could be avoided, but it is not so clear what specific interventions or combination of interventions effectively decrease potentially avoidable hospital admissions. The objective of this work is a revision of more recent literature on problems and possibile solutions to manage the difficult reationship between hospital and nursing homes.

Introduction. This study was performed to evaluate if an early discharge to a Hospital at Home Service (HHS) produced differences in all cause mortality (combined endpoint) and hospital readmissions in elderly patients affected by severe heart failure.Methods. From September 1st 2008 to May 31st 2010, patients 65 years or older admitted to the Emergency Department of the San Giovanni Battista Hospital of Turin for acute decompensated CHF were selected. Patients were randomly assigned to two groups: 26 hospitalized in general wards where they received routine hospital care (group 1), 26 hospitalized and early discharged to the Hospital at Home Service- HHS (within 120 hours) (group 2).Results. Patients were very old (mean age 81 years), comorbid, 73% had severe symptoms of heart failure (NYHA IV), without differences between the two groups. No differences in mortality and hospital readmission rates were found. Mood level improved in HHS patients only.Discussion. This is a pilot study on early discharge for elderly patients with advanced heart failure. Home care should be considered as an important element toward adjusting the transition in frail hospitalized patients effectively.

Introduction. The aim of the study was to evaluate the main features of patients 65 years of age or older admitted to the Emergency Department (ED) for a fall and analyze consequences of falls, new falling events and related predicting factors, hospital recovery rate and institutionalization at 1 month follow-up.Methods. From February 1st to April 30th 2011, 100 patients 65 years of age or older admitted to the ED of the San Giovanni Battista Hospital of Turin for a fall were selected. In the ED a baseline multidimensional assessment was performed. On discharge, we evaluated: allocation, complications, length of hospital stay and diagnosis. At one-month follow-up new falling events, mortality, hospital readmission rate and institutionalization were evaluated.Results. The enrolled patients were very old (mean age 82.5 years), comorbid and in polipharmacy. Twenty four percent of the falls produced traumas, 51% required hospitalization. At 1-month follow-up, 85 patients lived at home, 13 were institutionalized and 2 died. Recurrent falls occurred in 12% of the subjects.Discussion. Patients who access the ED for a fall are often very old and frail. Falls are frequently responsible for traumas and fractures which can determine longer hospitalization or institutionalization. There is need to introduce prevention strategies in order to reduce the incidence of the events and improve quality of life in the elderly with previous falls.

Introduction. The objective of the study was to evaluate the epidemiology of pressure ulcers and the characteristics of an elderly population with pressure sores admitted to the Hospital at Home Service (HHS) of the San Giovanni Battista Hospital (Torino, Italy). Methods. A descriptive study was conducted on patients admitted to the HHS from January 1st to June 30th 2010, referred from the Emergency Department or other hospital wards. Results. Data of 36 patients with pressure sores were analyzed: 34 patients presented an ulcer upon admission and 2 patients developed pressure ulcers during hospitalization. Patients were very old (mean age 85 years), comorbid, functionally impaired. 50% of patients had stage I ulcers, 28% stage II, 22% stage III-IV; 50% of patients had more than one pressure sore. Most patients were discharged to their home (61%), with programmed health care services in about 17% of cases; mortality rate was 30.5%. Discussion. In our study prevalence rates (about 13%) agree with international data; incidence (0.6%) was lower than data from hospital wards. A possible explanation could be that patients who are at home continue to be followed not only by a multidisciplinary team, but can also rely on the presence of a costant caregiver, who if appropriately educated by the geriatric team, can provide specific and ongoing care.

Demographic, epidemiological, social, and cultural trends in European countries are changing the traditional patterns of care.The next decades will see increasing rates of caredependent older people and non communicable diseases as the leading cause of chronic illness and disability.The break-up of the traditional large family group and urbanization will also lead to gaps in the care of older or disabled family members.These changes in needs and social structure require a different approach to health and social sector policy and services since a disease-oriented approach, alone, is no longer appropriate.An answer to these issues could be home care, a sustainable approach to prevent the need for unnecessary acute or long-term institutionalization and maintain individuals in their home and community as long as possible providing diagnostic, therapeutic and social support (Tarricone & Tsouros, 2008).Home is a place of emotional and physical associations, memories and comfort.Although many people can be happy in assisted-living facilities, retirement communities or nursing homes -and for many people these are better options -leaving home can be disruptive and depressing for some people.Recent trends in health care favour alternatives to traditional hospital care for patients with acute or chronic diseases.Home care used appropriately decreases hospitalization and nursing home use without compromising medical outcomes.Moreover, patients generally prefer to remain in familiar surroundings.Physician support of home care services honors that preference (Levine et al., 2003).Chronic Obstructive Pulmonary Disease (COPD) has been the focus of several hospital at home studies, however, most models studied have been early-discharge schemes that employed nursing care, without physician care in the home.There have been fewer studies of substitutive physician-led clinical unit model of hospital at home. www.intechopen.comChronic Obstructive Pulmonary Disease -Current Concepts and Practice 376 Ageing population: Demographics trendsPopulation ageing is progressing rapidly in many industrialized countries.For the world as a whole, the elderly will grow from 6.9% of the population in 2000 to a projected 19.3% in 2050 (Gavrilov & Heuveline, 2003).Population ageing is a great challenge for the health care systems.As nations age, the prevalence of disability, frailty, and chronic diseases (Alzheimer's disease, cancer, cardiovascular and cerebrovascular diseases, COPD, etc.) is expected to increase dramatically.Frailty is gaining attention in many fields because it increases the risk of hospitalization, falls, mortality and institutionalization. Geriatricians, gerontologists, and social scientists study frailty to better understand its impacts on health, individuals, and society.Frailty has been considered synonymous of disability or co-morbidity, but it is recognized that it is a biological syndrome identified by decreased reserves in multiple organ systems.The incidence of frailty increases with age, reaching more than 32% in those older than 90 years (Fried et al., 2001).Frailty can be a primary diagnosis, when the state is not associated directly with a specific disease, or a secondary diagnosis when the syndrome occur as a result of an acute event or the end stage of many chronic conditions, including severe congestive heart failure, stroke, chronic inflammatory diseases and dementia.The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal environment for frail elderly patients.A new functional impairment and iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common during hospital stay.Chronic obstructive pulmonary disease is a major cause of chronic morbidity and mortality.Patients with COPD usually have progressive airflow obstruction that is not fully reversible, which leads to a history of progressive, worsening breathlessness that can impact on daily activities and health-related quality of life.Winter outbreaks of COPD exacerbations, mostly occurring in elderly people with concurrent chronic co-morbidities, often generate dramatic increases in hospital emergency room admission.Such admissions have increased substantially over the past decade, comprising a significant proportion of all hospital admissions, and are associated with a high rate of readmission contributing to the high costs of care for COPD. Chronic obstructive pulmonary disease: Epidemiological dataChronic obstructive pulmonary disease is a leading cause of mortality and morbidity worldwide, affecting approximately 210 million people and leading to 3 million deaths annually (WHO, 2011).The prevalence and morbidity data greatly understimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced.Furthermore, population-based estimates of COPD prevalence by region are problematic since the disease is progressive, measurement tools and definitions still vary among studies, and implementation of spirometry is often not feasible in developing regions (Lopez et al., 2006a).A recent systematic review and meta-analysis on global burden of COPD reported a prevalence of physiologically defined COPD of 9-10% in adults (Halbert et al., 2006).These www.intechopen.com

Introduction. The aim of this study was to evaluate the feasibility of the Step Training System (STS, an exergame appropriate for training) in old frail patients undergoing rehabilitation. In particular, we focused our attention on factors, such as physical and cognitive functions, which could interfere with an appropriate use of this technology; moreover, we assessed the degree of enjoyment and satisfaction experienced by patients during the training period.Methods. From 1st October 2009 through 31st January 2010, we enrolled 44 elderly patients admitted to the Geriatric Rehabilitation ward of the Prince of Wales Hospital of Sydney. All patients have practiced the STS daily with different speed levels, based on patient's capabilities. At the end of the study period, patients were divided into two groups: poor performers, which have been unable to improve speed velocity over basal speed at the STS, and good performers, including those patients that improved their performances over time.Results. The mean age of the patients was 82.8 years, the mean number of comorbidities was 6.3 per patient, and all patients showed mild cognitive and functional impairment. Fifty two percent of patients reported at least one fall in the previous year. By comparing the 2 groups, good performer patients were more likely to live alone (p = 0.046) and to have an higher score at the cognitive tests. Patients' satisfaction was very high (97% of the patients reported a good-great experience).Discussion. Taking together the results of the present pilot-study demonstrate the utility of the STS in old patients undergoing rehabilitation.

Introduction. Malnutrition is a frequent condition among the elderly. The present study aims to evaluate the risk of malnutrition in a sample of elderly patients affected by cognitive impairment but still living at home. Methods. From April to September 2005, all patients affected by cognitive disorders and consecutively admitted to the Memory Clinic of the Geriatric Section of the San Giovanni Battista Hospital of Torino, were asked to participate to the present observational study. At baseline, demographic data, past and recent clinical data and socio-economic status were collected. Cognitive, behaviour, and nutritional status were evaluated using the Mini Mental State Examination (MMSE), the Neuropsychiatric Inventory (NPI) and the Mini Nutritional Assessment (MNA). Results. The MNA total score was significantly related with age (p = 0.01), mean duration of dementia (p = 0.001), severity of cognitive (p = 0.001) and behaviour (p = 0.001) status. In particular, risk of malnutrition was related with delusions (p = 0.001), depression/dysphoria (p = 0.001), appetite/eating (p = 0.001), wandering (p = 0.001), agitation/aggression (p = 0.01). Discussion. The present study confirms that elderly patients with dementia present a risk of malnutrition that seems to be strictly related with patients' age and duration of disease. Moreover, malnutrition is related with severity of cognitive impairment and behavioural problems. The evaluation of nutritional status in elderly demented subjects could prevent and diagnose nutrition related problems.

Objectives. Several challenges are posed to the healthcare sector in terms of using innovative tools and technologies. They include a growing ageing population, an epidemic of citizens in chronic conditions, and further development in medical progress which offers new and better treatments. The main goal of this study is to evaluate how telemedicine could be helpful for the home treatment of acutely decompensated chronic heart failure patients or for patients affected by chronic obstructive pulmonary disease (COPD). Methods. Telemonitoring devices have been tested on an elderly population affected by acute heart failure or chronic obstructive pulmonary disease. Results. Eighteen patients have been involved in the study, with a mean age of 86,07 years. They were functional and cognitively impaired. We have collected 772 tele-relevations with only 3 technical problems. Conclusions. Tele-homecare and telemedicine could be useful in different settings and situations: in rural context and in big cities. Our preliminary results demonstrate that telemonitoring elderly patients is feasible. Randomized controlled trials (RCT) are required to evaluate the impact of these new technologies.

OBJECTIVES: To evaluate whether home treatment of elderly patients with acute uncomplicated first ischemic stroke is associated with different mortality rates and clinical outcomes from those of patients treated on a general medical ward (GMW).DESIGN: Randomized, controlled, single-blind trial.SETTING: S. Giovanni Battista Hospital of Turin.PARTICIPANTS: One hundred twenty elderly patients admitted to the emergency department of the hospital with first acute ischemic stroke were randomized to home treatment from a geriatric home hospitalization service (GHHS) or to GMW treatment.MEASUREMENT: Main outcome was cumulative survival at 6 months in the two groups. Residual functional impairment, neurological deficit, depression, morbidity, and admission to rehabilitation and long-term care facilities were considered as secondary outcomes in survivors.RESULTS: One hundred twenty patients (mean age 82; 54 men and 66 women) were enrolled (60 in each study arm). The cumulative proportion of cases surviving at 6 months was 0.65 in the GHHS group and 0.60 in GMW group (log-rank test P=.53). Functional and neurological parameters were significantly improved in both GHHS and GMW patients, without significant differences between the two groups. Depression score was significantly better in home-treated patients (P<.001), who were more likely to remain at home at 6 months than hospital-treated patients and had a lower rate of select medical complications.CONCLUSION: Home-treated elderly patients with ischemic stroke have better depressive scores and lower rates of admission to nursing homes. These results should prompt further studies to evaluate home hospitalization for elderly stroke patients.

Since 1985, a home hospitalization service (HHS) has been operating in Turin. HHS allows to perform diagnostic and therapeutic interventions which are usually made in hospital, also at home. HHS has started a stroke care project since the beginning. This study was designed to assess the feasibility of home care for elderly patients, aged over 65 years, after an acute stroke and to identify the benefits of this care setting. The study was conducted on 40 randomized patients with ischemic stroke, admitted to the emergency department of our hospital; 20 of them were managed at home by HHS, and 20 in a general medical ward (GMW). Both groups were examined using the same protocol and received the same medical and rehabilitation therapy. Mortality and length of stay was not significantly different in either of the two care settings. Compared with the GMW patients, HHS patients presented a significant improvement of functional status assessed by functional independence measure (FIM).

The experience of the home hospitalization service (HHS) started with a decision of the Turin Health Authority having charged the Department of Gerontology of the University with the HHS experimental project. The nursing staff works on a day and evening shift system providing regular and emergency interventions. Medical care is provided by seven geriatricians of the Department who perform this activity as a part of their duties. In four years, 519 patients were treated at home. The service has proved to be effective and of benefit for the patients. From the phsychological point of view, the results were considered excellent both by the patients and the relatives. In terms of cost, as compared to a stay in a medical hospital ward, the HHS is less expensive.