Archives of Gerontology and Geriatrics 53 (2011) e144–e148

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Archives of Gerontology and Geriatrics

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Rehabilitation outcomes of older Chinese patients with different cognitive

function in a geriatric day hospital
James Ka Hay Luk a,*, Charles Fei Chan a, Felix Hon Wai Chan b, Leung Wing Chu a
a
The University of Hong Kong Division of Geriatrics, Department of Medicine, Queen Mary Hospital, Room 801 Administrative Block, Pokfulam Road, Hong Kong, SAR, China
b
Department of Medicine and Geriatrics, Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong, SAR, China

A R T I C L E I N F O A B S T R A C T

Article history: The relationship between cognitive function and geriatric day hospital (GDH) rehabilitation has not been
Received 7 July 2010 explored. This study investigated this association in 547 older Chinese patients attended GDH. Cognitive
Received in revised form 26 July 2010 status was assessed by Cantonese version of mini-mental state examination (C-MMSE). Functional
Accepted 28 July 2010
independence measure (FIM) upon GDH admission and discharge were measured, with FIM gain = FIM
Available online 21 August 2010
discharge  FIM admission while FIM efficiency = FIM gain/by number of GDH visits. FIM discharge 90
was defined as satisfactory outcome of rehabilitation. Positive correlation was observed between C-
Keywords:
MMSE admission and FIM discharge (p < 0.001). There were significant differences in the FIM admission
Geriatric day hospital
and FIM discharge among the three C-MMSE groups, with lower discharge scores in low C-MMSE groups
Cognitive function in elderly
Rehabilitation outcomes (p < 0.001). The FIM gain and FIM efficiency during GDH rehabilitation were not different among
different C-MMSE groups. C-MMSE admission (p = 0.03) and FIM admission (p < 0.001) were both
positive independent predictors for a satisfactory rehabilitation outcomes (FIM discharge 90).
Cognitive function was not associated with FIM gain and efficiency. This suggested that selected patients
with impaired cognition could still benefit from GDH rehabilitation.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
After the first geriatric day hospital (GDH) opening in UK in
1952, it has become an indispensable part of geriatric service in UK
(Brocklehurst, 1973; Black, 2005). Since then, the model has been
applied in Australia, New Zealand, Canada, USA, Israel and several
European countries (Lee and Pasupati, 1994; Siu et al., 1994; Crotty
et al., 2008). In Hong Kong, the first GDH was opened in 1975
(Kong, 1991; Lum et al., 1995). At present, there are 14 GDHs
serving different parts of Hong Kong. Although GDH can play a
number of different roles in provision of geriatric services, the most
important task of GDH traditionally associates with geriatric
rehabilitation (Hui et al., 1995; Roderick et al., 2001; Lee et al.,
2002; Hershkovitz et al., 2004). While on one hand GDH is effective
in rehabilitation, on the other it has been pointed out that GDH is in
fact quite expensive (Tousignant et al., 2003). Hence, selecting the
appropriate candidates to attend the GDH for rehabilitation is
important to avoid wasting of valuable resources.
Dementia is not uncommon in Hong Kong and we are facing a
significant proportion of older patients referred to GDH who are
cognitively impaired (Yu et al., 1989; Woo et al., 1994). Patients
* Corresponding author. Tel.: +852 2855 6182; fax: +852 2817 6181.
E-mail address: lukkh@ha.org.hk (J.K.H. Luk).
may need a certain level of cognitive function before they can
follow the instructions of the therapists to do training. Therefore,
one important question concerning GDH is whether it is suitable
for patients of poor cognitive function. To date, the effect of
cognition on inpatient rehabilitation has led to many controver-
sies. On one hand, cognitive impairment has been regarded as an
obstacle and a negative factor for rehabilitation success (Schuman
et al., 1981; Cummings et al., 1988; Gruber-Baldini et al., 2003). On
the other hand, there have been reports showing that cognitive
impairment does not affect rehabilitation success in older patients
(Luxenberg and Feigebbaum, 1986; Jette et al., 1987; Lenze et al.,
2007). One recent publication in Chinese inpatients showed
cognitive function was not associated with absolute motor and
functional gain, but was an independent predictor for satisfactory
motor outcome (Luk et al., 2008). After thorough literature review,
we cannot find any study looking at the relationship between
cognitive function and GDH rehabilitation. The patient character-
istics in GDH are different from inpatients. Patients referred to
GDH are usually more medically stable. They are now living in the
community, either at their own homes or nursing homes. They are
a selected group of patients fit enough to travel to the GDH several
times a week. They have to be fairly cooperative and at least
moderately motivated before they can benefit from the rehabili-
tation training in GDH. Hence, the finding of previous inpatient
studies may not be generalizable to GDH setting.

0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.archger.2010.07.012
 J.K.H. Luk et al. / Archives of Gerontology and Geriatrics 53 (2011) e144–e148
The objective of the present study is to examine the effect of
cognition on gain in functional and motor performance in older
patients undergoing geriatric rehabilitation in GDH. Both absolute
gain and efficiency in the rehabilitation outcomes will be analyzed.
In addition, we look at the independent predictors for satisfactory
rehabilitation outcomes of these patients. We hypothesize that
older patients with poorer cognitive function have poorer outcome
in GDH rehabilitation as compare with the cognitively intact group.
However, cognitively impaired patients can still benefit from GDH
rehabilitation. To our knowledge, it is the first study that has
examined this important issue in GDH. It is also the first study
looking at a large group of Chinese patients in a GDH setting.
2. Subjects and methods
2.1. Subjects and setting
This was a retrospective study carried out in the GDH of Fung
Yiu King Hospital, Hong Kong Special Administrative Region,
China. We recruited older patients (age 65) attended between
January 2005 and December 2007. The GDH has a daily capacity of
22. The subjects of this study were all the older patients attended
the GDH. Patients in GDH were from multiple sources. These
included patients discharged from acute or convalescence
hospitals, or from different outpatient departments. In addition,
a proportion of patients were recruited from nursing homes
directly by the Community Geriatric Assessment Teams (CGATs)
(Luk et al., 2002). We did not have a formal referral criteria for GDH
patients, but all referrals were screened by the geriatricians to
ensure they were suitable candidates for GDH. If in doubt, the GDH
nurses would contact the patients or carers for further assessment
prior to starting GDH services. Patients who were confused,
uncooperative, poorly motivated, medically unstable and unfit for
travelling would not be recruited for GDH training.
Patients usually attend the GDH 2 times a week from 9:30 am to
4:30 pm, Monday to Friday. Non-emergency ambulance transport
services are provided by GDH for patients who could not arrange
their own transport. Comprehensive geriatric assessment is
performed on all newly attended patients (Luk et al., 2000). After
assessment, an individualized care plan will be formulated and all
patients will routinely receive physiotherapy and occupational
therapy, unless they are considered to be unsuitable. The duration
of physiotherapy and occupational therapy varies from patient to
patient, but usually between 1 to 2 h per session depending on
individual need. Between 12:00 and 2:00 pm, there is a lunch break
and all patients will sit together for lunch. Health education will be
provided by GDH nurses or allied health members during the lunch
period. If needed, dietitians, speech therapists and medical social
workers will be referred for assessment and treatment. Patient
progress is discussed in a monthly multidisciplinary case confer-
ence where the rehabilitation goals are reviewed. Patients are
discharged from the GDH if the multidisciplinary team agrees the
patient’s progress has reached a plateau at the case conference. All
patients discharged from GDH are scheduled to come back for a
post-6 month assessment. If indicated, patients who have
deterioration in functional or mobility states in the post-6 month
assessment will be called back to GDH for another course of
rehabilitation.
This study protocol was approved by the Institutional Review
Board of the University of Hong Kong/Hospital Authority Hong
Kong West Cluster.
2.2. Data collection
Collected data included demography, length of training in GDH,
number of visits, urinary incontinence, number of diagnoses and
e145
chief diagnoses leading to referral to GDH. Body mass index (BMI)
was measured by the nurses. The C-MMSE was performed by the
occupational therapists on GDH admission (C-MMSE admission)
and discharge (C-MMSE discharge) of GDH. C-MMSE is a Cantonese
translation of the original MMSE (Chiu et al., 1994). A local study
showed that using DSM III R criteria for diagnosis of dementia, a
cut-off score of 19/20 yielded a high sensitivity rate of 97.5% and
specificity of 97.3% (Chiu et al., 1994). If patients were unable to
perform C-MMSE due to various reasons such as inability to
respond to questions, severe deafness, dysphasia, language barrier
or refused cooperation, they were recorded as ‘‘FAILED’’, a C-MMSE
score was not given and they were excluded from the final analysis.
The FIM on GDH admission (FIM admission) and discharge
(FIM discharge) were studied (Hamilton et al., 1991). We analyzed
the FIM gain and FIM efficiency in this study to judge rehabilita-
tion outcome. FIM gain = (FIM discharge  FIM admission) while
FIM efficiency = (FIM gain/number of GDH visits). The FIM
efficiency reflects the absolute functional gain per GDH visit. In
addition, FIM discharge 90 was used to indicate a satisfactory
rehabilitation outcome. FIM 90 represents a mildly impaired
functional state, requiring only minor assistance and FIM 90 was
used in previous studies to indicate a favorable rehabilitation
outcome (Luk et al., 2006).
We stratified the patients according to their C-MMSE admission
into three groups: (<10), (10–19) and (20). The 20 cut-off
point was chosen because the usual cut-off point for C-MMSE
defining impaired cognitive function was <20. This was based on
the original local validation study showing that a cut-off score of
19/20 yielded a high sensitivity and specificity (Chiu et al., 1994).
Demographic and clinical characteristics of the patients were
examined in these three stratified age groups. In addition, we
analyzed the FIM admission and FIM discharge as well as the FIM
gain and efficiency across the three C-MMSE groups.
2.3. Statistical analyses
The statistical package for social science (Windows version 16;
SPSS Inc, Chicago, United States) was used in statistical analysis.
Continuous valuables were expressed as mean  S.D. We used the
paired t-test to compare the change of continuous variables within
group. The x2-test for proportions and Fisher’s exact test were
employed to compare categorical variables. Simple correlation was
performed by Pearson correlation test. We used the one-way ANOVA
test to compare continuous variables among three different age
groups. Bonferroni correction was used for multiple comparisons.
Statistical significance was inferred by a two-tailed p  0.05.
Multivariate analysis was performed using stepwise logistic
regression to delineate the independent predictive factors for
satisfactory rehabilitation outcomes. Variables that had a signifi-
cant association with FIM discharge 90 to a value of p < 0.05 on
univariate analyses were entered into the final multivariate
analysis. Odd ratios (OR) and 95% confidence intervals (CI) were
used to estimate the association between the independent factors
of satisfactory functional gain. Statistical significance was inferred
by a two-tailed p  0.05.
3. Results
Between January 2005 and December 2007, 689 elderly
patients attended the GDH; 40 cases defaulted GDH training
and were not included in the study. In addition, 102 cases were
excluded in the final review because of failure to perform C-MMSE
or incomplete data entry. Finally, 547 (79.4%) patients were
included in this study. There were 232 (42.4%) men and 315
(57.6%) women. Their mean age was 80.1  7.0 (range 65–100
years). Table 1 shows the demographic and clinical characteristics of
e146 J.K.H. Luk et al. / Archives of Gerontology and Geriatrics 53 (2011) e144–e148

Table 1
Demographic and clinical characteristics of the GDH patients, n, n(%), mean  S.D.

All patients C-MMSE p=

<10 10–<20 20

Number 547 75 234 238

Males 232(42.4) 24(32.0) 84(35.9) 124(52.1) <0.001*
Age 80.1  7.0 83.8  6.1 81.1  6.7 78.0  7.0 <0.001*

Single/divorced/widow 292(53.4) 52(69.3) 132(56.4) 108(45.4) 0.001*

Live at home 335(61.2) 24(32.0) 133(56.8) 178(74.8) <0.001*
Illiterate 295(53.9) 56(74.7) 153(65.4) 86(36.1) <0.001*
Smoker/ex-smoker 182(33.3) 25(33.3) 67(28.6) 90(37.8) 0.15
Drinker/ex-drinker 122(22.3) 17(22.7) 43(17.4) 62(26.1) 0.17

Duration of stay in GDH (days) 71.0  39.8 62.9  36.4 69.9  44.6 74.7  35.3 0.07
Number of visits 17.2  8.8 15.2  6.8 16.6  8.6 18.4  9.4 0.01*
N of diagnosis 3.95  1.87 3.92  1.7 3.85  1.7 4.0  2.0 0.7
Urinary incont. 128(23.4) 41(54.7) 60(25.6) 27(11.3) <0.001*
BMI admission 21.5  5.0 20.9  4.7 21  5.5 22.4  4.4 0.005*
C-MMSE admission 17.9  6.8 6.8  2.1 14.8  2.97 24.4  2.8 <0.001*
C-MMSE discharge 18.4  6.7y 8.1  3.8y 15.7  3.7y 24.3  3.3 <0.001*

Chief problems of GDH referral

Deconditioning 115(21.0) 24(32.0) 59(25.2) 32(13.4) 0.001*
Stroke 104(19.0) 13(17.3) 42(17.9) 49(20.5) 0.7
Fall 100(18.3) 18(24.0) 43(18.3) 39(16.4) 0.33

Musculoskeletal diseases 89(16.3) 8(10.7) 32(13.7) 49(20.5) 0.046

Fracture of hip 76(13.9) 5(6.7) 30(12.8) 41(17.2) 0.058
Parkinsonism 31(5.7) 2(2.7) 12(5.1) 17(7.1) 0.31

Notes: x2-test for proportions, one-way ANOVA for continuous variables.

*
Denotes significant difference at p < 0.05.
y
Significant difference comparing C-MMSE discharge and C-MMSE admission within each C-MMSE group by using paired t-test (p = 0.0001).

the patients. As shown in the table, a small but significant
improvement was observed in the C-MMSE admission compared
with C-MMSE discharge in all the patients (p = 0.0001). This was also
noted in the C-MMSE <10 group (p = 0.0001) and the C-MMSE  10–
<20 group (p = 0.0001), but not in the C-MMSE  20 group.
A significant positive correlation was observed between C-
MMSE admission and FIM discharge (Pearson correlation = 0.59,
p < 0.001). No significant correlation was found between C-MMSE
admission and FIM gain (Pearson correlation = 0.042, p = 0.33) as
well as FIM efficiency (Pearson correlation = 0.002, p = 0.97). Table
2 shows the FIM admission and FIM discharge as well as the change
during rehabilitation. There were significant differences between
the FIM admission and FIM discharge within patients of different
C-MMSE groups by paired t-test (p < 0.001). Significant differences
were observed in FIM admission (p < 0.001) and FIM discharge
(p < 0.001) across the three cognitive function groups by one-way
ANOVA, with the groups with better cognitive function having
better results. The difference in the FIM gain during rehabilitation
by one-way ANOVA test was not significant among the three C-
MMSE groups (p = 0.44). Similarly, we could not notice any
difference in FIM efficiency in the three cognitive function groups
(p = 0.87).
Of the patients, 345 (63.1%) achieved a FIM discharge 90.
Multivariate analysis of variables associated with a satisfactory
FIM outcome after GDH rehabilitation included significant
variables obtained from univariate analysis: age, education,
accommodation, urinary incontinence, C-MMSE admission, ad-
mission BMI, FIM admission, hip fracture and deconditioning. We
found that C-MMSE admission (OR = 1.08, 95%CI = 1.0–1.15,
p = 0.03) and FIM admission (OR = 1.33, 95%CI = 1.25–1.41,
p < 0.001) were both positive independent predictors for a
satisfactory rehabilitation outcomes (FIM discharge 90).
4. Discussion
This study is one of the few studies looking at the relationship
between cognitive function and rehabilitation in a heterogeneous
group of geriatric patients. It is also the only study trying to
delineate the association between cognitive function and rehabili-
tation outcome in terms of functional gain and efficiency in a GDH
setting. We also involve a large group of Chinese patients and we
believe the result of this study is particularly relevant for
geriatricians or rehabilitation specialists looking after Chinese
patients in an outpatient rehabilitation setting.
This study was not designed to look at the controversial subject
concerning the effectiveness of GDH as compared with other forms
of care (Forster et al., 1999, 2008). However, the significant
improvement in FIM amongst our patients at the end of GDH
training seemed to serve for another evidence of GDH effectiveness
in fostering functional and motor status. We also noticed a

Table 2
Total FIM admission and discharge as well as change of FIM during GDH rehabilitation in different C-MMSE groups, n, mean  S.D.

All patients C-MMSE p=

<10 10–<20 20

Number 547 75 234 238

FIM admission 86.0  17.5 69.7  16.4 81.9  15.2 95.2  14.3 <0.001y
FIM discharge 92.3  17.6* 74.8  17.5* 88.3  15.7* 101.9  13.0* <0.001y
FIM gain 5.63  18.0 5.2  5.3 4.7  26.3 6.74  7.6 0.44
FIM efficiency 0.39  0.93 0.38  0.41 0.37  1.35 0.42  0.39 0.87
*
Significant difference comparing FIM discharge and FIM admission within each C-MMSE group by using paired t-test.
y
Significant difference using one-way ANOVA.
 J.K.H. Luk et al. / Archives of Gerontology and Geriatrics 53 (2011) e144–e148
significant small improvement in cognitive function in our patients
at the last attendance. This improvement of C-MMSE was seen in
the C-MMSE < 10 group as well as C-MMSE  10–<20 group, but
not in the high C-MMSE patients. It suggested that GDH could have
benefit in the patients with dementia. We believe the failing of
high C-MMSE group to show benefit after GDH training might be
partly due to ceiling effect of the C-MMSE assessment tool.
Patients may need a certain level of cognitive function before
they can follow the instructions of the therapists to do training.
Therefore, one important question concerning GDH is whether it is
suitable for patients of poor cognitive function. We found no
difference in the FIM gain and efficiency across the three C-MMSE
groups. C-MMSE admission was also not correlated with either FIM
efficiency or gain. However, cognitive function did associate with
final FIM outcomes in two ways. First, C-MMSE admission
positively correlated with the FIM discharge. Second, multivariate
analysis also shows that C-MMSE admission was an independent
predictor for satisfactory FIM discharge score. The above finding
suggested that patients with poor cognition could still benefit from
rehabilitation in a GDH. Nevertheless, we would expect older
patients with cognitive impairment to have less favorable final
rehabilitation outcomes as compared with those with better
cognitive state. One should be aware that patients referred for GDH
were a selected group of patients. They had been screened by
health care team to be suitable for GDH rehabilitation setting.
Patients with poor cognitive function selected for GDH training
were usually those who were more cooperative and motivated
with less behavioral problems. Therefore, the finding of the present
study could not be generalized to all demented patients. Judicious
assessment and selection of patients, especially those with
cognitive impairment, are still needed by the health care team
to choose the right patients to GDH training. We were not
surprised to find that FIM admission was also a significant
independent predictor for satisfactory rehabilitation outcome in
our study. This observation had been repeatedly shown in previous
inpatient studies (Dimitrios et al., 2002).
In this study, we defined FIM efficiency as FIM gain divided by
number of GDH visits. The reason was that the most of the patients
came to GDH at a frequency of two visits per week for training and
there were visits that they could not attend due to various reasons,
such as the need to attend other medical clinic follow-up, public
holidays, bad weather such as typhoon, or patients absence due to
sickness. Hence, we believe that using number of sessions attended
as denominator is better than the duration of GDH training. There are
certain limitations in our study. Being a retrospective study, data
accuracy is reliant on the quality of documentation in the case notes.
Nevertheless, we believe that the large sample size in this study can
to a certain extent minimizes this potential flaw. One important
question is whether the results are generalizable. This study looks at
Chinese patients and the finding may be applicable to some cultures
and not others due to different support systems, expectations and
patient beliefs. We did not record the proportion of visits that the
patients were absent for scheduled GDH training and the reasons
behind these absence. This could be significant in influencing the
final outcome of the rehabilitation. We also had not looked at the
motivation of the patients. Patients with better motivation could be
an important factor leading to better outcome. Finally, whether the
rehabilitation benefits could be maintained after discharge from
GDH was not investigated in the present report. One study reported
in Canada could not find sustained improvements in mobility or
functional status at 3 months following discharge from a geriatric
day hospital (Malone et al., 2002). Further study is needed to look
whether there are any prolonged effects of GDH training after
discharged from GDH in our patients.
In conclusion, we found that there were important differences
in characteristics in patients with different cognitive functions.
e147
There was strong association between C-MMSE admission and FIM
discharge. Cognitive function was also an independent predictor
for satisfactory FIM discharge. However, cognitive function was
not associated with FIM gain and efficiency suggesting that
selected patients with impaired cognitive function could still
benefit from GDH rehabilitation. This study supports the provision
of GDH services to selected older patients of different cognitive
function, as even the severely demented patients could demon-
strate significant improvement in FIM, with gain and efficiency
comparable to those with higher cognitive function. This study also
advocates for more research in future and to develop strategies to
improve the GDH outcome in older patients with cognitive
impairment. Our findings are very useful for planning of GDH
services and geriatricians to predict the functional and motor
status of older patients in GDH more accurately.
Conflict of interest statement
None.
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