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Original Research
Background
Geriatric day hospital programs that address the needs of
older adults are especially important as, globally, we are
experiencing an aging population, with the number of peo-
ple who are 65 years of age or older surpassing those who
are 14 years and younger; with this trend expected to con-
tinue for the foreseeable future.1 This is significant for the
health care system as more resources will be required to
address the unique health needs of older adults.
Though aging itself does not necessarily result in disease
or disability, the risks of developing them often rise with
age. As a result, “the demand for health services is expected
to increase as the population ages.”2(p2) However, having
chronic illnesses or disabilities does not automatically
imply poor quality of life. With appropriate care and man-
agement, older adults can learn to cope with their illness or
disability and still live independently.3
Geriatric day hospitals programs were primarily devel-
oped to focus on physical rehabilitation, but some programs
also include mental or psychological interventions and social
related activities. Research results on the effects of geriatric
day hospital care report mix results. Some studies found that
day hospital care greatly improved functional ability.4-10
Whereas, other studies found that day hospital care did
not improve functional status or prevent deterioration.11,12
This dichotomy is likely due to the fact that each day
hospital program is unique in its structure, in its care deliv-
ery, and in its patient population; and as a result, the effects
of one program may not be identical to—or cannot be
applied to—another program.
940504JPCXXX10.1177/2150132720940504Journal of Primary Care & Community HealthChung et al
research-article2020
1University of Ottawa, Ottawa, Ontario, Canada
2Bruyère Research Institute, Ottawa, Ontario, Canada
3Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
Corresponding Author:
Chantal Backman, School of Nursing, Faculty of Health Sciences,
University of Ottawa, 451, Smyth Road, RGN 3239, Ottawa, Ontario,
K1H 8M5, Canada.
Email: chantal.backman@uottawa.ca
Impact of a Geriatric Day Hospital
Program on Older Adults’ Functional
Independence and Caregiver Stress:
A Non-Experimental, Single Group
Pre-/Posttest Study
Yung-En Chung1, Douglas E. Angus1, and Chantal Backman1,2,3
Abstract
Objective: To evaluate the impact of a geriatric day hospital program on older adults’ functional independence and on
caregiver stress. Methods: We used a single group pre- and posttest design. The data were collected through chart reviews
and follow-up phone calls. Outcomes included fear of falling, balance, functional exercise capacity (walking distance), and
caregiver stress. Descriptive statistics were used for sociodemographic data, dependent t test for paired samples of normally
distributed data, and the Wilcoxon signed-rank test for determining differences between nonnormally distributed data sets.
Results: We found a statistically significant difference in pre (33.54) and post (27.47) mean rank scores for fear of falling (Z =
−3.895, P < .001), pre (49.5) and post (59.42) scores for balance (Z = −8.725, P < .001), and pre (250.07 m) and post (291.20
m) for functional exercise capacity (P < .001). No statistically significant difference was found with respect to caregiver stress
pre (22.05) and post (19.90) scores (Z = −0.422, P = .673). Discussion: Future research may consider approaching evaluative
studies of a similar type using not only quantitative but also qualitative methods to obtain a more comprehensive understanding
of older adults’ functional ability and caregiver stress before and after participating in a geriatric day hospital program.
Keywords
geriatric day hospitals, functional status, program evaluation
Dates received 4 May 2020; revised 29 May 2020; accepted 10 June 2020.
2 Journal of Primary Care & Community Health
The Bruyère Geriatric Day Hospital (GDH) program is
a bilingual (English and French) interprofessional outpa-
tient program located in Ottawa, Ontario, Canada. The aim
of the GDH program is to assist frail older adults with tran-
sitions that come with aging, and the multimorbidity and
decline in functional capabilities which are often associ-
ated with aging. It also aims to help patients improve their
functional status, maintain their independence, and prevent
hospitalization or being prematurely admitted to long-term
care homes. The purpose of this study was to evaluate the
impact of the Bruyère GDH program on older adults’ func-
tional independence and on caregiver stress.
Methods
Study Design
We used a non-experimental, single group pretest-posttest
design. The data were collected through retrospective chart
reviews and follow-up phone calls. We chose a single group
as it was not possible to recruit a comparable control group.
Ethics approval was obtained by the local Research Ethics
Board.
Study Population and Setting
The majority of the patients admitted to the GDH present
with mobility or balance issues and at least one other prob-
lem. To be admitted, patients (1) must be at least 65 years
old, (2) must be referred by a physician, and (3) must have
2 or more concerns related to mobility/falls, activities of
daily living, cognitive issues, symptoms that are affecting
function, medication concerns, and/or caregiver stress. The
program consists of 3-hour therapy sessions 2 days per
week for approximately 10 weeks. Patients attend activities
in large groups and individual sessions with clinicians (ie,
physiotherapy, occupational therapy, social work, nursing,
pharmacy, recreational therapy, neuropsychology) based on
their individual needs. Patients who are severely cogni-
tively impaired are not usually admitted to the program and
are referred to other more appropriate types of care, as this
population requires interventions different from what the
GDH offers.
Sample Size
Since there are no known pre and post studies examining
functional independence of older adults following a geriat-
ric day hospital program, the effect size required to yield a
statistically significant difference in scores was unknown.
Therefore, according to sample size requirements for para-
metric and nonparametric tests, a minimum of 30 data
points was needed.13 Although missing data must also be
taken into account for each of the outcomes, we recruited a
total of 128 participants for this study.
Study Eligibility
All patients admitted to the program were eligible for the
study. English assessment tools and self-administered ques-
tionnaires were used with patients who spoke and under-
stood English. Patients who had moderate to severe cognitive
impairment were excluded from the self-administered ques-
tionnaires. Patients who did not complete the 10-week pro-
gram because they were unexpectedly discharged early or
were admitted to another unit or facility due to worsening of
their condition were also excluded. Caregivers, 18 years of
age or older, were invited to complete the caregiver stress-
related questionnaire. Patients and caregivers with at least
one complete set of data collected for at least one indicator
were included.
Data Collection
A pretest and a posttest were administered at the first visit
and the last (week 10) visit, respectively. The clinical
staff conducted the assessments and provided the self-
administered questionnaires to both the patients and the
caregivers during the visits. For any missing self-admin-
istered questionnaires that were not completed during the
visit, the clinical staff obtained permission from the
patients and the caregivers to participate in a follow-up
call. A research team member (YEC) conducted the fol-
low-up calls with patients and caregivers (n = 128) to
complete the questionnaires postdischarge.
The sociodemographic information collected included
age, sex, language(s) spoken, marital status, source of refer-
ral, living environment, living arrangement, relationship
with primary caregiver, significant medical conditions, and
frailty status.
Outcome Measures
The selected indicators of functional independence in this
study included (1) fear of falling, (2) balance, (3) functional
exercise capacity, (4) caregiver stress, and (5) overall frailty.
Fear of Falling. A population-based longitudinal study found
that falls and fear of falling are risk factors for each other.14
Falls are a significant concern in older adults because
they: are “the cause of 85% of seniors’ injury-related
hospitalizations”15(p1); may affect the ability of a person to
live on their own, and; can put restrictions on a person’s
mobility as a result of injuries.16 If seniors are afraid of fall-
ing, they may be less likely to perform daily tasks on their
own. Fear of falling thus perpetuates, or can be part of the
cause of, impaired functional independence in older adults.
In this study, we used the Falls Efficacy Scale–International
(FES-I) for assessing fear of falling and activities of daily
living functional ability.17-23 The 16-item FES-I is a 4-point
Chung et al 3
scale (1-4) that has a total possible score of 64, with higher
total scores indicating a greater fear of falling.19,20 One
study found the minimal detectable change (MDC) for this
tool to be 17.7 points,22 while its minimal clinically impor-
tant difference (MCID) has not been established.
Balance. Balance is essential to assess when evaluating
functional independence. If older adults are physically
weakened or injured, their level of independence may be
impaired as a result because they may find it more challeng-
ing to ambulate for a prolonged time, to dress and feed
themselves, or to maintain good hygiene. The Berg Balance
Scale (BBS) was used for assessing balance.24-30 The BBS
is a test with very few equipment needed: a ruler, 2 standard
chairs, a footstool, a stopwatch, and a 15-feet pathway. It is
a 5-point scale (0-4) that has 14 items and a possible total
score of 56,31 with higher total scores indicating a lower
falls risk. A study on balance in patients with chronic
obstructive pulmonary disease found that the MCID of the
BBS is 5 to 7 points.28
Functional Exercise Capacity. It is important to assess func-
tional exercise capacity, as this metric relates to how long
patients can endure ambulating around their residence or
neighborhood. If they can only walk a short distance before
feeling fatigue or exhaustion and need to rest, it tends to
limit the activities they could perform at home and in the
community, including performing activities of daily living
such as buying groceries, walking pets, or going to appoint-
ments. The 6-minute walk test (6MWT) was chosen for
assessing functional exercise capacity.32-37 The 6MWT
“measures the distance an individual is able to walk over a
total of six minutes on a hard, flat surface.”38 The person
administering the test would ask the patient to walk as far as
they can in 6 minutes down a straight pathway 100 feet
long, and to instruct the patient to slow down, stop, or rest
if needed.39
Caregiver Stress. The level of caregiver stress might indicate
how functionally independent a geriatric patient is. Gratão
and colleagues noted that “Caregiving, when associated
with a senior’s lack of ability to perform the basic activities
of daily living, results in caregiver burden. The level of
dependence of the senior was an important predictor of ele-
vated burden levels.”40(p140) The Zarit Caregiver Burden
Index (ZBI), a measure of caregiver stress and burden was
used in this study.41,42 The ZBI is a 22-item questionnaire,
5-point (0-4) scale, with a total possible score of 88.42
Higher total scores indicate higher levels of burden. Inter-
pretation of scores is as the following: “little or no burden”
(0-20), “mild to moderate burden” (21-40), “moderate to
severe burden” (41-60), and “severe burden” (61-88). To
the best of our knowledge, the MCID of this tool has not
been established yet.
Overall Frailty. Overall frailty is important to consider when
assessing functional independence since frailty is identi-
fied as a predictor for falls, hospitalizations, disability, and
mortality.43 We used the Clinical Frailty Scale (CFS) for
measuring overall frailty.44-46 The CFS is a 9-point ordinal
scale with classifications ranging from “very fit” to “termi-
nally ill”.47 For the CFS, it was agreed that only the assess-
ment scores for frailty at admission would be included in
the analysis as no posttest frailty data were available.
Data Analysis
Sociodemographic data were reported using descriptive
statistics. For normally distributed data and where the
dependent variable was either at the interval or ratio levels
of measurement, the dependent t test for paired samples
was used.48 For the outcomes that are not normally distrib-
uted, nonparametric tests were used. The related-samples
Wilcoxon signed-rank test in SPSS were used for statistical
analysis where the data were not normally distributed and
the dependent variable was at least of the ordinal level of
measurement.49 The Wilcoxon test is the nonparametric
equivalence of the dependent t test and is used to compare
data from 2 related groups, with the same individuals in
each group, between 2 time points.49 Data missing for either
the pre or post outcome were excluded from the analysis.
The software package IBM SPSS Statistics version 25 was
used to support the data analysis.
Results
A total of 86.5% (n = 128) of patients were included in the
study. Participants were older adults ranging from age 65 to
95 years (mean = 79.92 years). Of these, 26.6% were aged
65 to 74 years; 43.6% were aged 75 to 84 years; and 29.8%
were aged 85 to 95 years. With regards to sex, 48.4% were
male and 51.6% were female. A total of 68.0% of partici-
pants lived in their own home; 17.2% lived in a shared
home with people other than their spouse; and 14.8% lived
in a retirement residence or assisted living facility. The most
prevalent medical conditions were hypertension (n = 75,
58.6%), arthritis (n = 48, 37.5%), diabetes, type 2 (n = 47,
36.7%), stroke (n = 33, 25.8%), mood disorder (n = 33,
25.8%), and chronic obstructive pulmonary disease (n = 16,
12.5%). Of the 61 patients who had a CFS assessment com-
pleted, 5 (8.2%) were severely frail, 29 (47.5%) were mod-
erately frail, 19 (31.1%) were mildly frail, and 6 (9.8%)
were vulnerable, and 2 (3.3%) were managing well. The
sociodemographic information can be found in Table 1.
Fear of Falling
For fear of falling, the Wilcoxon signed-rank test showed
that there was a statistically significant change in FES-I
4 Journal of Primary Care & Community Health
Table 1. Participants’ Sociodemographic Information (n = 128).
Variables n %
Age, years mean (range): 79.92 (65-95)
65-74 34 26.56
75-84 56 43.75
85-95 38 29.69
Sex
Male 62 48.4
Female 66 51.6
Languages spoken
English only 70 54.7
French only 11 8.6
English and French 19 14.8
English and/or French and other language(s) 23 18.0
Other language(s) only 5 3.9
Marital status
Single 9 7.0
Married/common-law 63 49.2
Widowed 40 31.3
Divorced/separated 16 12.5
Source of referral
Family physician 34 26.6
Geriatric Rehabilitation Program (GRP) 31 24.2
Geriatric Emergency Management Clinic (GEM) 17 12.9
Geriatric Assessment Outreach Team (GAOT) 29 22.6
GEM to GAOT 3 2.4
Other sources 14 11.3
Living environment
Private dwelling
Own home 87 68.0
Sharing a home with people other than their spouse 22 17.2
Collective dwelling (retirement resident, assisted living facility, etc) 19 14.8
Living arrangement
Alone 52 41.4
With primary caregiver 67 52.3
With someone NOT their primary caregiver, or are caregivers themselves 8 6.3
Relationship with their primary caregiver
Spouse/partner 49 38.3
Children 47 36.7
Other family members/friends 6 4.7
Professional services (retirement home, personal support worker, home help etc) 19 14.8
No caregivers 7 5.5
scores (n = 67) between admission and discharge. FES-I
pretest scores (mean rank = 33.54) were higher than FES-I
posttest scores (mean rank = 27.47), Z = −3.895, P < .001;
indicating a decrease in fear of falling. The range of pretest
scores was 18 to 62 with a mean of 35.78, while the range of
posttest scores was 16 to 55 with a mean of 31.01 (Table 2).
Balance
For balance, the Wilcoxon signed-rank test showed that
there was a statistically significant change in the BBS scores
(n = 125) between admission and discharge. BBS posttest
scores (mean rank = 59.42) were higher than BBS pretest
scores (mean rank = 49.50), Z = −8.725, P < .001; indicat-
ing an improvement in balance. The range of pretest scores
was 8 to 56 with a mean of 39.05, while the range of post-
test scores was 8 to 56 with a mean of 44.34 (Table 2).
Functional Exercise Capacity
For functional exercise capacity, the dependent t test for
paired samples showed that there was a statistically significant
Chung et al 5
improvement in walking distance as measured during
the 6MWT from 250.07 ± 95.24 to 291.20 ± 95.26 m
between admission and discharge (n = 82); an increase of
41.12 ± 54.08 m (P < .001), indicating an improvement in
functional exercise capacity (Table 2).
Caregiver Stress
For caregiver stress, the Wilcoxon signed-rank test showed
that scores for the ZBI did not change significantly between
admission and discharge (n = 46). ZBI pretest scores (mean
rank = 22.05) were higher than ZBI posttest scores (mean
rank = 19.90), Z = −0.422, P = .673. The range of pretest
scores was 5 to 65 with a mean of 29.48, while the range of
posttest scores was 1 to 72 with a mean of 28.96. Therefore,
the decrease in caregiver stress levels was not statistically
significant (Table 2).
Discussion
Overall, our study findings have demonstrated the impact of
the GDH program on select older adults’ functional inde-
pendence outcomes and on caregiver stress.
Improvement in Fear of Falling
We found a statistically significant decrease in fear of fall-
ing pre and post (Z = −3.895, P < .001). Delbaere and
colleagues19,20 differentiated between low and high fear of
falling, with scores between 23 and 64 indicating a greater
fear of falling. Thus, in our study, the decrease in fear of
falling between the pre (M = 35.78, range = 18-62), and
the post (M = 31.01, range = 16-55) scores is not clinically
significant as both these mean scores are considered high
for fear of falling.19,20
Improvement in Balance
A statistically significant improvement was found in BBS
scores pre (49.5) and post (59.42) (Z = −8.725, P < .001).
The fall risk decreased between the pre (M = 39.05,
range = 8-56) and post (M = 44.34, range = 8-56) scores.
This was considered clinically significant as the risk
decreased from a medium fall risk (21-40) to a low fall risk
(41-56).31
Improvement in Functional Exercise Capacity
Similarly, functional exercise capacity also improved sig-
nificantly between pre (250.07 m) and post (291.20 m)
tests (P < .001). However, a difference of 41.12 m is not
considered clinically significant.50 Perera and colleagues50
reported a meaningful clinical change of 50 m based on
analyses from a sample of 692 community-living post-
stroke older adults.
No Change in Caregiver Stress
We did not find a significant decrease in caregiver stress
levels between the pre (22.05) and the post (19.90) scores
(Z = −0.422, P = .673). Although, the results show a mild
to moderate burden in caregiver stress,42 the difference pre
(M = 29.48, range = 5-65) and post (M = 28.96, range =
1-72) was not clinically significant. Warren and colleagues51
found in their study of the effect of adult day programs on
family caregivers of older adults that caregiver burden
remained stable over time; there was no significant differ-
ences in burden scores across the points of measurement.
They did find that there was a trend of slight decrease in
total burden scores, but not significant. Similarly, we found
that although there was no statistically significant change in
ZBI scores, the posttest score mean was slightly lower than
the pretest score mean.
It is possible that caregiver stress is not entirely based on
how well an older adult who receives care functions physi-
cally. Gratão and colleagues noted that “Caregiving, when
associated with a senior’s lack of ability to perform the
basic activities of daily living, results in caregiver burden.
The level of dependence of the senior was an important pre-
dictor of elevated burden levels.”40(p140) It can be speculated
that since (1) the level of dependence was only a predictor
and not the cause of stress levels and (2) having good bal-
ance and exercise capacity and/or a low level of fear of fall-
ing may not necessarily reflect ability to perform activities
of daily living—which might be more closely associated
with caregiver stress levels yet was not measured in this
study, it is reasonable that ZBI scores did not improve sig-
nificantly even though the other indicators did.
There is also the possibility that before they came to the
GDH, patients had attended other rehabilitative or day
programs—which we do not know about—that would
Table 2. Pre- and Poststudy Scores for Each Outcome.
Outcomes (n) Pre, mean (range) Post, mean (range) Mean difference (SD)
Fear of falling (n = 67) 35.78 (18-62) 31.01 (16-55) −4.76a (9.203)
Balance (n = 125) 39.05 (8-56) 44.34 (8-56) 5.3a (4.786)
Functional exercise capacity (n = 82) 250.07 ± 95.24 (SD) 291.20 ± 95.26 (SD) 41.12a (54.075)
Caregiver stress (n = 46) 29.48 (5-65) 28.96 (1-72) −0.52 (9.399)
aDifference was statistically significant between pre and post (P < .001).
6 Journal of Primary Care & Community Health
similarly allow caregivers to rest and alleviate their stress
and/or responsibilities temporarily. As a result, the level of
stress that caregivers experience may be comparable before
and after the GDH program, since the length of time of
respite or the amount of support or resources that caregivers
receive due to having their loved ones attend another pro-
gram might be the same as that experienced as a result of
the GDH.
In addition, it could be considered that the fact that care-
giver stress levels did not decrease significantly does not
indicate failure of interventions to make a difference in this
area. Zarit and colleagues studied the effects of adult day
services on care-related stressors in family caregivers and
found that they experienced “lower exposure to care-related
stressors . . ., more positive experiences, and more noncare
stressors”52(p570) on the days that their family member
attended adult day services, with noncare stressors being
work-related. This supports the suggestion that caregivers
of GDH participants do experience less stress associated
with relief of caregiving responsibilities on GDH days, but
that temporary relief may not be enough to decrease their
overall level of stress.
It is quite possible as well that caregiver stress levels
would have not only stagnated in improvement but even
increase more, had their loved ones not attended the GDH.
That is to say, perhaps the GDH’s actual role was not neces-
sarily to improve caregiver stress level, but rather to prevent
it from worsening any further or at a faster rate, which can
be argued that it is just as valuable an outcome as improve-
ment in relation to this aging population.
Most people who directly provide care as part of a pro-
gram, or are involved in managing a program, are interested
in knowing whether or not the interventions provided are
working as well as they intend it to. This study has helped
the GDH staff to gain a better understanding of their pro-
gram compared to before the indicators were implemented,
as they lacked systematic and concrete evidence due to the
absence of an evaluation process previously.
The results of this study can also help administrators
make a more informed decision regarding changes (if any)
to the program. It allows for the administration level to
review the study results and subsequently decide whether
certain interventions need to be adjusted accordingly. For
instance, if no significant difference can be observed
between the scores before and after the GDH intervention in
a particular functional area, adjustments to the usual care
plan which may improve the scores in that area at a more
significant degree may be considered.
Furthermore, it will add to how we understand how the
team structure, length of program, and the therapy regimen
at this particular day hospital affect its patients, with the
GDH as a variation of the general day hospital care model.
This study is an important first step in helping to establish
the most appropriate indicators or outcome measures that
can be used to monitor and evaluate this specific type of day
hospital. It can help to inform the future research of other
GDHs that have a similar program structure.
Limitations
The limitations of this study are as follows. One source lies
in the sampling method. Patients from the GDH who were
available and fit the set of criteria over the data collection
period indicated in our study design were used as our sam-
ple. Those who had language and/or cognitive barriers were
excluded. More specifically, only patients who were able to
understand English well enough were given the question-
naires to complete, since the questionnaires were in English
only. In addition, patients who were discharged early unex-
pectedly or admitted to other units or facilities due to wors-
ening condition were excluded as they would not be able to
complete the discharge assessment (ie, the posttest). The
potential impact of excluding the aforementioned patients is
that our sample may not represent the overall GDH patient
population as well as it could otherwise have, if those
excluded were also part of this study.
As with other studies that involve only one group of par-
ticipants and no control or comparison group, there are
single group threats that may arise from the design used in
this study. A testing threat is a “threat to internal validity
that occurs when taking the pretest affects how participants
do on the post-test.”53 Testing threat may be present in our
study as we used a prepost design. There is a possibility that
taking the pretest subconsciously influenced participants to
answer differently or made them more aware of how they
might want to give their responses, on the post-test. For
instance, although FES-I scores statistically improved as a
whole, some individuals experienced an increase in fear of
falling. This could be attributed to increased awareness of
their own internal thoughts about their functional ability,
and not necessarily because they had worsened fear after
participating in the program.
Conclusion
Our study of the influence of the GDH program on the func-
tional independence outcomes of its patients show that the
indicators of fear of falling, balance, and the walking dis-
tance aspect of functional exercise capacity improved sig-
nificantly, and that caregiver stress did not. Future research
may consider approaching evaluative studies of a similar
type using both quantitative and qualitative methods to
obtain a more comprehensive understanding of patients’
functional ability and caregiver stress.
Author Contributions
CB was a major contributor in writing the manuscript. All co-
authors were involved in the design of the project and critically
Chung et al 7
appraised and edited the manuscript. All authors read and approved
the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Chantal Backman https://orcid.org/0000-0001-7431-8159
References
1. Statistics Canada. Canada’s population estimates: age and
sex, July 1, 2015. Accessed June 22, 2020. http://www.stat-
can.gc.ca/daily-quotidien/150929/dq150929b-eng.htm
2. Canadian Medical Association. Health and health care for an
aging population. Accessed June 22, 2020. https://www.cma.
ca/sites/default/files/2018-11/CMA_Policy_Health_and_
Health_Care_for_an_Aging-Population_PD14-03-e_0.pdf
3. Economist Intelligence Unit. Healthcare strategies for an age-
ing society. Accessed June 22, 2020. http://graphics.eiu.com/
upload/eb/Philips_Healthcare_ageing_3011WEB.pdf
4. Brown L, Forster A, Young J, et al; Day Hospital Group. Medical
day hospital care for older people versus alternative forms of
care. Cochrane Database Syst Rev. 2015;2015:CD001730.
doi:10.1002/14651858.CD001730.pub3
5. Hershkovitz A, Gottlieb D, Beloosesky Y, Brill S. Assessing
the potential for functional improvement of stroke patients
attending a geriatric day hospital. Arch Gerontol Geriatr.
2006;43:243-248. doi:10.1016/j.archger.2005.10.012
6. Hershkovitz A, Brill S. The association between patients’
cognitive status and rehabilitation outcome in a geriatric day
hospital. Disabil Rehabil. 2007;29:333-337. doi:10.1080
/09638280600787096
7. Luk JKH, Chan CF. Rehabilitation outcomes of older patients
at 6 months follow-up after discharged from a geriatric day
hospital (GDH). Arch Gerontol Geriatr. 2011;52:327-330.
doi:10.1016/j.archger.2010.05.006
8. Desrosiers J, Hébert R, Payette H, Roy P, Tousignant M,
Côté S, Trottier L. A geriatric day hospital: who improves
the most? Can J Aging. 2004;23:217-228. doi:https://doi.
org/10.1353/cja.2004.0031
9. Manckoundia P, Gerbault N, Mourey F, ‘et al. Multidisciplinary
management in geriatric day-hospital is beneficial for elderly
fallers: a prospective study of 28 cases. Arch Gerontol Geriatr.
2007;44:61-70. doi:10.1016/j.archger.2006.02.004
10. Moorhouse P, Theou O, Fay S, McMillan M, Moffatt H,
Rockwood K. Treatment in a geriatric day hospital improve
individualized outcome measures using Goal Attainment
Scaling. BMC Geriatr. 2017;17:9. doi:10.1186/s12877-016-
0397-9
11. Chew J, Chong M, Fong Y, Tay L. Outcomes of a multimodal
cognitive and physical rehabilitation program for persons with
mild dementia and their caregivers: a goal-oriented approach.
Clin Interv Aging. 2015;10:1687-1694. doi:10.2147/CIA.
S93914
12. Fowler RW, Congdon P, Hamilton S. Assessing health sta-
tus and outcomes in a geriatric day hospital. Public Health.
2000;114:440-445. doi:10.1038/sj.ph.1900700
13. Hulley SB, Cummings SR, Browner WS, Grady DG, Newman
TB. Designing Clinical Research. Lippincott Williams &
Wilkins; 2013.
14. Friedman SM, Munoz B, West SK, Rubin GS, Fried LP.
Falls and fear of falling: which comes first? A longitudinal
prediction model suggests strategies for primary and sec-
ondary prevention. J Am Geriatr Soc. 2002;50:1329-1335.
doi:10.1046/j.1532-5415.2002.50352.x
15. Public Health Agency of Canada. You CAN prevent falls!
Accessed June 22, 2020. http://www.phac-aspc.gc.ca/seniors-
aines/alt-formats/pdf/publications/public/injury-blessure/
prevent-eviter/prevent-eviter-e.pdf
16. National Institute on Aging. Balance exercises. Accessed
June 30, 2020. https://www.nia.nih.gov/health/four-types-
exercise-can-improve-your-health-and-physical-ability#
balance
17. Marques-Vieira CM, Sousa LM, Severino S, Sousa L,
Caldeira S. Cross-cultural validation of the Falls Efficacy
Scale International in elderly: systematic literature review.
J Clin Gerontol Geriatr. 2016;7:72-76. doi:10.1016/j.jcgg
.2015.12.002
18. Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd
C. Development and initial validation of the Falls Efficacy
Scale–International (FES-I). Age Ageing. 2005;34:614-619.
doi:10.1093/ageing/afi196
19. Delbaere K, Close JCT, Mikolaizak AS, Sachdev PS, Brodaty
H, Lord SR. The Falls Efficacy Scale International (FES-I).
A comprehensive longitudinal validation study. Age Ageing.
2010;39:210-216. doi:10.1093/ageing/afp225
20. Dewan N, MacDermid JC. Fall Efficacy Scale–International
(FES-I). J Physiother. 2014;60:60. doi:10.1016/j.jphys
.2013.12.014
21. Greenberg SA. Assessment of fear of falling in older adults:
The Falls Efficacy Scale–International (FES-I). Accessed
June 22, 2020. https://medicine.osu.edu/-/media/files/medicine/
departments/orthopaedics/research/clinical-trials/ffp-fes-i.
pdf?la=en&hash=17E635EACC101A11BB68537E5DD2A0
B9CC014C98
22. Visschedijk JH, Terwee CB, Caljouw MA, Spruit-van Eijk M,
van Balen R, Achterberg WP. Reliability and validity of the
Falls Efficacy Scale–International after hip fracture in patients
aged ≥65 years. Disabil Rehabil. 2015;37:2225-2232. doi:10.
3109/09638288.2014.1002573
23. Morgan MT, Friscia LA, Whitney SL, Furman JM, Sparto
PJ. Reliability and validity of the Falls Efficacy Scale–Inter-
national (FES-I) in individuals with dizziness and imbalance.
Otol Neurotol. 2013;34:1104-1108. doi:10.1097/MAO.0b013
e318281df5d
24. Berg K, Wood-Dauphine S, Williams JI, Gayton D.
Measuring balance in the elderly: preliminary develop-
ment of an instrument. Physiother Can. 1989;41:304-311.
doi:10.3138/ptc.41.6.304
8 Journal of Primary Care & Community Health
25. Downs S. The Berg Balance Scale. J Physiother. 2015;61:46.
doi:10.1016/j.jphys.2014.10.002
26. Pickenbrock HM, Diel A, Zapf A. A comparison between
the Static Balance Test and the Berg Balance Scale: valid-
ity, reliability, and comparative resource use. Clin Rehabil.
2016;30:288-293. doi:10.1177/0269215515578297
27. Suzuki M, Fujisawa H, Machida Y, Minakata S. Relationship
between the Berg Balance Scale and Static Balance Test in
hemiplegic patients with stroke. J Phys Ther Sci. 2013;25:
1043-1049. doi:10.1589/jpts.25.1043
28. Beauchamp MK, Harrison SL, Goldstein RS, Brooks D.
Interpretability of change scores in measures of balance in
people with COPD. Chest. 2016;149:696-703. doi:10.1378/
chest.15-0717
29. Hiengkaew V, Jitaree K, Chaiyawat P. Minimal detectable
changes of the Berg Balance Scale, Fugl-Meyer Assessment
Scale, Timed “Up & Go” Test, gait speeds, and 2-Minute
Walk Test in individuals with chronic stroke with different
degrees of ankle plantar flexor tone. Arch Phys Med Rehabil.
2012;93:1201-1208. doi:10.1016/j.apmr.2012.01.014
30. Romero S, Bishop MD, Velozo CA, Light K. Minimum
detectable change of the Berg Balance Scale and Dynamic
Gait Index in older persons at risk for falling. J Geriatr Phys
Ther. 2011;34:131-137. doi:10.1519/JPT.0b013e3182048006
31. American Academy of Health and Fitness. Berg Balance
Scale. Accessed June 22, 2020. http://www.aahf.info/pdf/
Berg_Balance_Scale.pdf
32. ATS Committee on Proficiency Standards for Clinical
Pulmonary Function Laboratories. ATS statement: guidelines
for the six-minute walk test. Am J Respir Crit Care Med.
2002;166:111-117. doi:10.1164/rccm.166/1/111
33. Eichinger K, Heatwole C, Heininger S, et al. Validity of the 6
minute walk test in facioscapulohumeral muscular dystrophy.
Muscle Nerve. 2017;55:333-337. doi:10.1002/mus.25251
34. Hamilton DM, Haennel RG. Validity and reliability of
the 6-minute walk test in a cardiac rehabilitation popula-
tion. J Cardiopulm Rehabil. 2000;20:156-164. doi:10.1097
/00008483-200005000-00003
35. Larsen CM, Overgaard J, Kristensen MT. Inter-rater reliabil-
ity and agreement of the 6-minute walk test in women with
hip fracture. Accessed June 22, 2020. http://findresearcher.
sdu.dk/portal/en/publications/interrater-reliability-and-
agreement-of-the-6minute-walk-test-in-women-with-hip-
fracture(eaab921e-65a4-4e56-965a-74c3a26abf35).html
36. Overgaard JA, Larsen CM, Holtze S, Ockholm K, Kristensen
MT. Interrater reliability of the 6-minute walk test in women
with hip fracture. J Geriatr Phys Ther. 2017;40:158-166.
doi:10.1519/JPT.0000000000000088
37. Rikli RE, Jones CJ. The reliability and validity of a 6-minute
walk test as a measure of physical endurance in older adults. J
Aging Phys Activity. 1998;6:363-375. doi:10.1123/japa.6.4.363
38. American College of Rheumatology. Six minute walk test
(6MWT). Accessed June 22, 2020. https://www.rheuma-
tology.org/I-Am-A/Rheumatologist/Research/Clinician-
Researchers/Six-Minute-Walk-Test-SMWT
39. Heart Foundation. Six minute walk test (6MWT) instruc-
tions. Accessed June 22, 2020. http://www.heartonline.org.
au/media/DRL/6MWT_standardised_instructions.pdf
40. Gratão ACM, Talmelli LF, Figueiredo LC, Rosset I, Freitas CP,
Rodrigues RAP. Functional dependency of older individuals
and caregiver burden [in Portuguese]. Rev Esc Enferm USP.
2013;47:137-144. doi:10.1590/S0080-62342013000100017
41. American Psychological Association. Zarit Burden Interview.
Accessed June 22, 2020. http://www.apa.org/pi/about/publi-
cations/caregivers/practice-settings/assessment/tools/zarit.
aspx
42. Seng BK, Luo N, Ng WY, et al. Validity and reliability of the
Zarit Burden Interview in assessing caregiving burden. Ann
Acad Med Singapore. 2010;39:758-763.
43. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults:
evidence for a phenotype. J Gerontol A Biol Sci Med Sci.
2001;56:M146-M156.
44. Rockwood K, Song X, MacKnight C, et al. A global clini-
cal measure of fitness and frailty in elderly people. CMAJ.
2005;173:489-495. doi:10.1503/cmaj.05005
45. Ekerstad N, Swahn E, Janzon M, et al. Frailty is indepen-
dently associated with short-term outcomes for elderly
patients with non-ST-segment elevation myocardial infarc-
tion. Circulation. 2011;124:2397-2404. doi:10.1161/
CIRCULATIONAHA.111.025452
46. Grossman D, Rootenberg M, Perri GA, et al. Enhancing
communication in end-of-life care: a clinical tool translat-
ing between the Clinical Frailty Scale and the Palliative
Performance Scale. J Am Geriatr Soc. 2014;62:1562-1567.
doi:10.1111/jgs.12926
47. Moorhouse P, Rockwood K. Frailty and its quantitative clini-
cal evaluation. J R Coll Physicians Edinb. 2012;42:333-340.
doi:10.4997/JRCPE.2012.412
48. Laerd Statistics. Dependent t test using SPSS statistics using
SPSS statistics. Accessed June 22, 2020. https://statistics.
laerd.com/spss-tutorials/dependent-t-test-using-spss-statistics.
php
49. Laerd Statistics. Wilcoxon signed-rank test using SPSS sta-
tistics. Accessed June 22, 2020. https://statistics.laerd.com/
spss-tutorials/wilcoxon-signed-rank-test-using-spss-statis-
tics.php
50. Perera S, Mody S, Woodman R, Studenski S. Meaningful
change and responsiveness in common physical performance
measures in older adults. J Am Geriatr Soc. 2006;54:743-749.
51. Warren S, Kerr JR, Smith D, Schalm C. The impact of adult
day programs on family caregivers of elderly relatives. J
Community Health Nurs. 2003;20:209-221. doi:10.1207/
S15327655JCHN2004_02
52. Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The
effects of adult day services on family caregivers’ daily stress,
affect, and health: outcomes from the Daily Stress and Health
(DaSH) Study. Gerontologist. 2014;54:570-579. doi:10.1093/
geront/gnt045
53. Trochim W, Donnelly JP, Arora K. Research Methods: The
Essential Knowledge Base. 2nd ed. Cengage Learning; 2016.
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