Evidence-based Risk Factors for Adverse Health Outcomes in Older Patients after Discharge Home and Assessment Tools: A Systematic Review

REFERENCES

• Alibhai , S. , Greenwood , C. and Payette , H. 2005 . An approach to the management of unintentional weight loss in elderly people . Canadian Medical Association Journal , 172 : 773 – 779 .
   PubMed Web of Science ®Google Scholar
• Almagro , P. , Barreiro , B. , Ochoa de Echaguen , A. , Quintana , S. , Rodriguez Carballeira , M. , Heredia , J. L. and Garau , J. 2005 . Risk factors for hospital readmission in patients with chronic obstructive pulmonary disease . Respiration: International Review of Thoracic Diseases , 73 : 311 – 317 .
   PubMedGoogle Scholar
• Andrews , K. 1986 . Relevance of readmission of elderly patients discharged from a geriatric unit . Journal of the American Geriatrics Society , 34 : 5 – 11 .
   PubMedGoogle Scholar
• Aronovitch , S. A. 2006 . Falls and patient safety for older adults . Ostomy Wound Management , 52 : 22 – 43 .
   PubMedGoogle Scholar
• Bates , D. , Pruess , K. , Souney , P. and Platt , R. 1995 . Serious falls in hospitalised patients; Correlates and resource utilization . American Journal of Medicine , 99 : 137 – 143 .
   PubMed Web of Science ®Google Scholar
• Berkman , B. and Abrams , R. D. 1986 . Factors related to readmission of elderly cardiac patients . Social Work , 31 : 99 – 103 .
   PubMed Web of Science ®Google Scholar
• Berkman , B. , Chauncey , S. , Holmes , W. , Daniels , A. , Bonander , E. , Sampson , S. and Robinson , M. 1999 . Standardized screening of elderly patients' needs for social work assessment in primary care: Use of the SF-36 . Health & Social Work , 24 : 9 – 16 .
   PubMed Web of Science ®Google Scholar
• Berkman , B. , Walter , S. , Bonander , E. and Holmes , W. 1992 . Early unplanned readmissions to social work of elderly patients—Factors predicting who needs follow up services . Social Work in Health Care , 17 : 103 – 119 .
   PubMed Web of Science ®Google Scholar
• Blaylock , A. and Cason , C. 1992 . Discharge planning: Predicting patients' needs . Journal of Gerontological Nursing , 18 : 5 – 10 .
   PubMedGoogle Scholar
• Bond , S. , Neelson , V. and Belyea , M. J. 2006 . Delirium in hospitalized older patients with cancer . Oncology Nursing Forum , 33 : 1075 – 1083 .
   PubMedGoogle Scholar
• Boone , C. , Coulton , C. and Keller , S. 1981 . The impact of early and comprehensive social work services on length of stay . Social Work in Health , 7 : 1 – 9 .
   PubMed Web of Science ®Google Scholar
• Boutin Foster , C. , Euster , S. , Rolon , Y. and Motal , A. 2005 . Social work admission assessment tool for identifying patients in need of comprehensive social work evaluation . Health & Social Work , 30 : 117 – 125 .
   PubMedGoogle Scholar
• Brantervik , A. M. , Jacobsson , I. E. , Grimby , A. , Wallen , T. C. E. and Bosaeus , I. G. 2005 . Older hospitalized patients at risk of malnutrition: Correlation with quality of life, aid from the social welfare system and length of stay? . Age and Aging , 34 : 444 – 449 .
   PubMed Web of Science ®Google Scholar
• Bull , M. J. 2000 . Discharge planning for older people: A review of the current research . British Journal of Community Nursing , 5 : 70 – 74 .
   PubMedGoogle Scholar
• Callen , B. L. , Mahoney , J. E. , Wells , T. J. , Enlow , M. and Hughes , S. 2004 . Admission and discharge mobility of frail hospitalized older adults . Medsurg Nursing , 13 : 156 – 164 .
   PubMedGoogle Scholar
• Callen , B. L. and Wells , T. J. 2005 . Screening for nutritional risk in community-dwelling old-old . Public Health Nursing , 22 : 138 – 146 .
   PubMed Web of Science ®Google Scholar
• Celkan , M. A. , Ustunsory , H. , Daglar , B. , Kazaz , H. and Kocoglu , H. 2005 . Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol . Heart and Vessels , 20 : 251 – 255 .
   PubMedGoogle Scholar
• Charles , C. , Gauld , M. , Chambers , L. , O'Brien , B. , Haynes , R. B. and Labelle , R. 1994 . How was your hospital stay? Patients' reports about their care in Canadian hospitals . Canadian Medical Association Journal , 159 : 1813 – 1822 .
   Google Scholar
• Chen , Y. and Narasavage , G. L. 2006 . Factors related to chronic obstructive pulmonary disease readmission in Taiwan . Western Journal of Nursing Research , 28 : 105 – 124 .
   PubMed Web of Science ®Google Scholar
• Chiovenda , P. , Vincentelli , G. M. and Alegiani , F. 2002 . Cognitive impairment in elderly ED patients: Need for multidimensional assessment for better management after discharge . The American Journal of Emergency Medicine , 20 : 332 – 335 .
   PubMedGoogle Scholar
• Chu , C. M. , Chan , V. L. , Lin , A. W. N. , Wong , I. W. Y. , Leung , W. S. and Lai , C. K. W. 2004 . Readmission rates and life threatening events in COPD survivors treated with non-invasive ventilation for acute hypercapnic respiratory failure . Thorax , 59 : 1020 – 1025 .
   PubMed Web of Science ®Google Scholar
• Connerney , I. , Shapiro , P. A. , McLaughlin , J. S. , Bagiella , E. and Sloan , R. P. 2001 . Relation between depression after coronary artery bypass surgery and 12-month outcome: A prospective study . Lancet , 358 : 1766 – 1771 .
   PubMed Web of Science ®Google Scholar
• Cornette , P. , D'Hoore , W. , Malhomme , B. , Van Pee , D. , Meert , P. and Swine , C. 2005a . Differential risk factors for early and later hospital readmission of older patients . Aging clinical and experimental research , 17 : 322 – 328 .
   PubMedGoogle Scholar
• Cornette , P. , Swine , C. , Malhomme , B. , Gillet , J. , Meert , P. and D'Hoore , W. 2005b . Early evaluation of the risk of functional decline following hospitalization of older patients: Development of a predictive tool . European Journal of Public Health , 16 : 203 – 208 .
   PubMed Web of Science ®Google Scholar
• Covinsky , K. E. , Forinsky , R. H , Palmer , R. M. , Kresevic , D. M. and Landefeld , C. S. 1997 . Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons . Annals of Internal Medicine , 126 : 417 – 425 .
   PubMed Web of Science ®Google Scholar
• Cummings , S. M. 1999 . Adequacy of discharge plans and rehospitalization among hospitalized dementia . Health and Social Work , 24 : 249 – 259 .
   PubMed Web of Science ®Google Scholar
• De Rooij , S. E. , Govers , A. , Korevaar , J. C. , Abu–Hanna , A. , Levi , M. and De Jonge , E. 2006 . Short-term and long-term mortality in very elderly patients admitted to an intensive care unit . Intensive Care Medicine , 32 : 1039 – 1044 .
   PubMedGoogle Scholar
• Dorland's Pocket Medical Dictionary, , 23rd ed. Philadelphia, PA : W. B. Saunders Company. .
   Google Scholar
• Douglas , S. L. , Daly , B. J. , Brennan , P. F. , Gordon , N. H. and Uthis , P. 2001 . Hospital readmission among long-term ventilator patients . Chest , 120 : 1278 – 1286 .
   PubMedGoogle Scholar
• Dubois , M. and Herbert , R. 2006 . Cognitive-impairment-free life expectancy for Canadian seniors . Dementia and Geriatric Cognitive Disorders , 22 : 327 – 333 .
   PubMedGoogle Scholar
• Esche , C. and Tanner , E. 2005 . Resiliency: A factor to consider when facilitating the transtition from hospital to home in older adults . Geriatric Nursing , 26 : 218 – 222 .
   PubMedGoogle Scholar
• Fan , J. , Worster , A. and Fernandes , C. M. B. 2006 . Predictive validity of the triage screening tool for elderly patients in a Canadian emergency department . American Journal of Emergency Medicine , 24 : 540 – 544 .
   PubMedGoogle Scholar
• Fasken , L. L. , Wipke–Tevis , D. D. and Sagehorn , K. K. 2001 . Factors associated with unplanned readmissions following cardiac surgery . Progress in Cardiovascular Nursing , 16 : 107 – 115 .
   PubMedGoogle Scholar
• Firestone , P. and Marshall , W. L. 2003 . Abnormal Psychology: Perspectives, , 2nd. ed. Toronto, ON : Pearson Education Canada Inc. .
   Google Scholar
• Forster , A. J. , Murff , H. J. , Peterson , J. F. , Gandhi , T. K. and Bates , D. W. 2005 . Adverse drug events occurring following hospital discharge . Journal of General Internal Medicine: Official Journal of the Society For Research and Education in Primary Care Internal Medicine , 20 : 317 – 323 .
   PubMed Web of Science ®Google Scholar
• Fortinsky , R. H , Madigan , E. A. , Sheehan , T. J. , Tullai–McGuinness , S. and Fenster , J. R. 2006 . Risk factors for hospitalization among Medicare home care patients . Western Journal of Nursing Research , 28 : 902 – 917 .
   PubMed Web of Science ®Google Scholar
• Foust , J. B. , Naylor , M. D. , Boling , P. A. and Cappuzzo , K. A. 2005 . Opportunities for improving post-hospital home medication management among older adults . Home Health Care Services Quarterly , 24 : 101 – 122 .
   PubMedGoogle Scholar
• Fox , G. N. 1993 . Resource use by younger and older patients . Family Practice Research Journal , 13 : 283 – 290 .
   PubMedGoogle Scholar
• Franka , B. , Schlote , A. , Hasenbeina , U. and Wallesch , C. W. 2006 . Prognosis and prognostic factors in ADL-dependent stroke patients during their first in-patient rehabilitation—a prospective multicentre study . Disability and Rehabilitation , 28 : 1311 – 1318 .
   PubMedGoogle Scholar
• Frondini , C. , Lanfranchi , G. , Minardi , M. and Cucinotta , D. 2007 . Affective, behavior and cognitive disorders in the elderely with chronic musculoskeletal pain: The impact on an aging population . Archives of Gerontology and Geriatrics , 44 : 167 – 171 .
   PubMed Web of Science ®Google Scholar
• Glanz , K. 1985 . Nutrition education for risk factor reduction and patient education: A review . Preventive Medicine , 14 : 721 – 752 .
   PubMedGoogle Scholar
• Gray , S. L. , Mahoney , J. E. and Blough , D. K. 1999 . Adverse drug events patients receiving home health services following hospital discharge . The Annals of Pharmacotherapy , 33 : 1147 – 1153 .
   PubMed Web of Science ®Google Scholar
• Gray , S. L. , Mahoney , J. E. and Blough , D. K. 2001 . Medication adherence in elderly patients receiving home health services following hospital discharge . The Annals of Pharmacotherapy , 35 : 539 – 545 .
   PubMed Web of Science ®Google Scholar
• Gray , S. L. , Sager , M. , Lestico , M. R. and Jalaluddin , M. 1998 . Adverse drug events in hospitalized elderly . The Journals of Gerontology , 53 : M59 – M63 .
   Google Scholar
• Grimmer , K. , Moss , J. and Falco , J. 2004 . Experiences of elderly patients regarding independent community living after discharge from hospital: A longitudinal study . International Journal for Quality in Health Care , 16 : 465 – 472 .
   PubMed Web of Science ®Google Scholar
• Guigoz , Y. , Lauque , S. and Vellas , B. J. 2002 . Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment . Clinical Geriatric Medicine , 18 : 737 – 757 .
   PubMed Web of Science ®Google Scholar
• Hanlon , J. T. , Pieper , C. F. , Carl , F. , Hajjar , E. R. , Sloane , R. J. , Richard , J. and Schmader , K. E. 2006 . Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital . The Journals of Gerontology , 61 : 511 – 515 .
   Google Scholar
• Hebert , R. , Bravo , G. , Korner–Bitensky , N. and Voyer , L. 1996 . Predictive validity of a postal questionnaire for screening community-dwelling elderly individuals at risk of functional decline . Age & Aging , 25 : 159 – 167 .
   PubMed Web of Science ®Google Scholar
• Hewitt , G. , Ismail , S. , Patterson , P. and Draper , A. 2006 . The nutritional vulnerability of older Guyanese in residential homes . West Indian Medical Journal , 55 : 334 – 339 .
   PubMedGoogle Scholar
• Hustey , F. M. and Smith , M. D. 2007 . A depression screen and intervention for older ED patients . The American Journal of Energy Medicine , 25 : 133 – 137 .
   Google Scholar
• Izawa , I. S. , Kuzuya , M. , Okada , K. , Enoki , H. , Koike , T. , Kanda , S. and Iguchi , A. 2006 . The nutritional status of frail elderly with care needs according to the mini-nutritional assessment . Clinical Nutrition , 25 : 962 – 967 .
   PubMed Web of Science ®Google Scholar
• Islamoglu , F. , Apaydin , A. Z. , Ozbaran , M. , Yuksel , M. , Telli , A. and Durmaz , I. 2002 . Predictors of outcome after coronary bypass surgery in patients with left ventricular dysfunction . Anadolu Kardiyoloji Dergisis , 2 : 26 – 34 .
   PubMedGoogle Scholar
• Kadushin , G. and Kulys , R. 1993 . Discharge planning revisited: What do social workers actually do in discharge planning? . Social Work , 38 : 713 – 726 .
   PubMed Web of Science ®Google Scholar
• Kanjanarat , P. , Winterstein , A. G. , Johns , T. , Hatton , R. , Gonzales–Rothi , R. and Segal , R. 2003 . Nature of preventable adverse drug events in hospitals: A literature review . American Journal of Health Systems Pharmacy , 60 : 1750 – 1759 .
   PubMed Web of Science ®Google Scholar
• Keller , H. H. and Hedley , M. R. 2000 . Development of SCREEN—seniors in the community: Risk evaluation for eating and nutrition . Canadian Journal of Dietetic Practice Research , 61 : 67 – 72 .
   PubMed Web of Science ®Google Scholar
• Kimura , K. , Minematsu , K. , Kazui , S. and Yamaguchi , T. 2005 . Mortality and cause of death after hospital discharge in 10,981 patients with ischemic stroke and transient ischemic attack . Cerebrovascualr Diseases , 19 : 171 – 178 .
   PubMed Web of Science ®Google Scholar
• Kronish , I. M. , Rieckman , N. , Halm , E. A. , Shimbo , D. , Vorchheimer , D. , Haas , D. and Karina , W. 2006 . Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes . Official Journal of the Society for Research and Education in Primary Care Internal Medicine , 21 : 1178 – 1183 .
   PubMedGoogle Scholar
• Lee , J. 2006 . An imperative to improve discharge planning predictors of physical function among residents of a Medicare skilled nursing facility . Nursing Administration Quarterly , 30 : 38 – 47 .
   PubMedGoogle Scholar
• Leeper , B. 1996 . AACN nursing scan in critical care . Journal of Cardiovascular Nursing , 10 : 30 – 50 .
   Google Scholar
• Lehtola , S. , Koistenen , P. and Luukinen , H. 2006 . Falls and injurious falls late in home-dwelling life . Archives of Gerontology and Geriatrics , 42 : 217 – 224 .
   PubMed Web of Science ®Google Scholar
• Lockery , S. A. , Dunkle , R. E. , Kart , C. S. and Coulton , C. J. 1994 . Factors contributing to the early rehospitalization of elderly people . Health & Social Work , 19 : 182
   PubMed Web of Science ®Google Scholar
• Lui–Ambrose , T. , Pang , M. Y. C. and Eng , J. J. 2007 . Executive function is independently associated with performances of balance and mobility in community-dwelling older adults after mild stroke: Implications for falls prevention . Cerebrovascular Diseases , 23 : 203 – 210 .
   PubMedGoogle Scholar
• Macmillian , M. S. 1994 . Hospital staff's perceptions of risk associated with the discharge of elderly people from acute hospital care . Journal of Advanced Nursing , 19 : 249 – 256 .
   PubMedGoogle Scholar
• Marcantonio , E. R. , McKean , S. , Goldfinger , M. , Kleefield , S. , Yurkofsky , M. and Brennan , T. A. 1999 . Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan . The American Journal of Medicine , 107 : 13 – 17 .
   PubMed Web of Science ®Google Scholar
• McCusker , J. , Bellavance , F. , Cardin , S. , Trepanier , S. , Verdon , J. and Ardman , O. 1999 . Detection of older people at increased risk of adverse outcomes after an emergency visit: The ISAR screening tool . Journal of the American Geriatric Society , 47 : 1229 – 1237 .
   PubMed Web of Science ®Google Scholar
• McCusker , J. , Cole , M. G. , Dendukuri , N. and Belzile , E. 2004 . The delirium index, a measure of the severity of delirium: New findings on reliability, validity and responsiveness . Journal of the American Geriatrics Society , 52 : 1744 – 1749 .
   PubMed Web of Science ®Google Scholar
• McWilliam , C. L. and Sangster , J. R. 1994 . Managing patients' discharge to home: The challenges of achieving quality of care . International Journal for Quality in Health Care , 6 : 147 – 161 .
   PubMedGoogle Scholar
• Miller , E. F. R. , McElnay , J. C. , Watt , N. T. , Scott , M. G. and McConnell , B. J. 2001 . Factors affecting the unplanned hospital readmission of elderly patients with cardiovascular disease—A predictive model . Clinical Drug Investigation , 21 : 705 – 714 .
   Google Scholar
• Mistiaen , P. , Duijnhouwer , E. , Wijkel , D. , deBont , M. and Veeger , A. 1997 . The problems of elderly people at home one week after discharge from an acute care setting . Journal of Advanced Nursing , 25 : 1233 – 1240 .
   PubMed Web of Science ®Google Scholar
• Morrow–Howell , N. , Proctor , E. K. and Mui , A. C. 1991 . Adequacy of discharge plans for elderly patients . Social Work Research & Abstracts , 27 : 6 – 13 .
   PubMedGoogle Scholar
• Moser , D. K. , Doering , L. V. and Chung , M. L. 2005 . Vulnerabilities of patients recovering from an exacerbation of chronic heart failure . American Heart Journal , 150 : 984 e.7 – 984 e.13 .
   Google Scholar
• Oktay , J. S. , Steinwachs , J. M. , Bone , L. R. and Fahey , M. 1992 . Evaluating social work discharge planning for elderly people: Access, complexity, and outcome . Health & Social Work , 17 : 290 – 298 .
   PubMedGoogle Scholar
• Oliver , D. , Daly , F. , Martine , F. C. and McMurdo , M. E. T. 2004 . Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review . Age and Ageing , 33 : 122 – 130 .
   PubMed Web of Science ®Google Scholar
• Paratz , J. , Thomas , P. and Adsett , J. 2005 . Re-admission to intensive care: Identification of risk factors . Physiotherapy Research International , 10 : 154 – 163 .
   PubMedGoogle Scholar
• Pedone , C. , Ercolani , S. , Catani , M. , Maggio , D. , Ruggiero , C. and Quartesan R., … GIFA Study Group . 2005 . Elderly patients with cognitive impairment have a high risk for functional decline during hospitalization: The GIFA Study . The Journals of Gerontology , 60 : 1576 – 1580 .
   Google Scholar
• Peterson , K. J. 1987 . Changing needs of patients and families in the acute care hospital: Implications for social work practice . Social Work in Health Care , 13 : 1 – 14 .
   PubMedGoogle Scholar
• Pettersen , R. , Dahl , T. and Wyller , T. B. 2002 . Prediction of long-term functional outcome after stroke rehabilitation . Clinical Rehabilitation , 16 : 149 – 159 .
   PubMed Web of Science ®Google Scholar
• Pioli , G. , Barone , A. , Giusti , A. , Oliveri , M. , Pizzzonia , M. , Razzano , M. and Palummeri , E. 2006 . Predictors of mortality after hip fracture: Results from 1-year follow-up . Aging Clinical and Experimental Research , 18 : 381 – 387 .
   PubMed Web of Science ®Google Scholar
• Preyde , M. and Chapman , T. 2007 . Psychosocial profile of elderly patients discharged from a community hospital . Social Work in Health Care , 45 : 77 – 95 .
   PubMed Web of Science ®Google Scholar
• Preyde , M. , MacAulay , C. and Dingwall , T. Discharge planning from hospital to home for elderly patients: A meta-analysis . Journal of Evidence-based Social Work , (In press)
   Google Scholar
• Rea , T. D. , Heckbert , S. R. , Kaplan , R. C. , Pstay , B. M. , Smith , N. L. , Lemaitre , R. N. and Lin , D. 2001 . Body mass index and the risk of recurrent coronary events following acute myocardial infarction . Amercian Journal of Cardiology , 88 : 467 – 472 .
   PubMedGoogle Scholar
• Rockx , M. A. J. , Fox , S. A. , Stitt , L. W. , Lehnhardt , K. R. , McKenzie , F. N. , Quantz , M. and Novick , R. J. 2004 . Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? . Canadian Journal of Surgery , 47 : 34 – 38 .
   PubMed Web of Science ®Google Scholar
• Romanelli , J. , Fauerbach , J. A. , Bush , D. E. and Ziegelstein , R. C. 2002 . The significance of depression in older patients after myocardial infarction . Journal of the American Geriatrics Society , 50 : 817 – 822 .
   PubMed Web of Science ®Google Scholar
• Rosenburg , A. L. and Watts , C. 2000 . Patients readmitted to ICUs: A systematic review of risk factors and outcomes . Chest , 118 : 492 – 502 .
   PubMedGoogle Scholar
• Rothman , K. J. and Greenland , S. 1998 . Modern Epidemiology, , 2nd ed. Philadelphia, PA : Lippincott, Williams & Wilkins. .
   Google Scholar
• Scanaill , C. N. , Carew , S. , Barralon , P. , Noury , N. , Lyons , D. and Lyons , G. M. 2006 . A review of approaches to mobility telemonitoring of the elderly in their environment . Annals of Biomedical Engineering , 34 : 547 – 563 .
   PubMed Web of Science ®Google Scholar
• Schwarz , K. A. and Elman , C. S. 2003 . Identification of factors predictive of hospital readmissions for patients with heart failure . Heart & Lung , 32 : 88 – 99 .
   PubMed Web of Science ®Google Scholar
• Shipton , S. 1996 . Risk factors associated with multiple hospital readmissions . Home Care Provider , 1 : 83 – 85 .
   PubMedGoogle Scholar
• Smith , J. , Forster , A. and Young , J. 2006 . Use of the STRATIFY falls risk assessment in patients recovering from acute stroke . Age and Ageing , 35 : 138 – 143 .
   PubMed Web of Science ®Google Scholar
• Soffer , D. , Klausner , J. , Szold , O. , Schulman , C. , Halpern , P. , Savitsky , B. and Peleg , K. 2006 . Non-hip fracture-associated trauma in the elderly population . Israel Medical Association Journal , 8 : 635 – 640 .
   PubMedGoogle Scholar
• Sorensen , C. , Brandes , A. , Hendricks , O. , Thrane , J. , Friis–Hasche , E. , Haghfelt , T. and Bech , P. 2005 . Psychosocial predictors of depression in patients with acute coronary syndrome . Acta Psychiatrica Scandinavica , 111 : 116 – 124 .
   PubMed Web of Science ®Google Scholar
• Testa , J. A. , Malec , J. F. , Moessner , A. M. and Browt , A. W. 2006 . Predicting family functioning after TBI—Impact of neurobehavioral factors . Journal of Head Trauma Rehabilitation , 21 : 236 – 247 .
   PubMed Web of Science ®Google Scholar
• Thomas , J. W. and Holloway , J. J. 1991 . Investigating early readmission as an indicator for quality of care . Medical Care , 29 : 377 – 394 .
   PubMed Web of Science ®Google Scholar
• Tinneti , M. F. 1986 . Performance-oriented assessment of mobility problems in elderly people . Journal of the American Geriatric Society , 34 : 119 – 126 .
   PubMedGoogle Scholar
• Tseng , M. , Shyu , Y. L. , See , L. and Chen , S. 2001 . Changes in discharge needs and satisfaction of family caregivers of frail elders during the discharge transition . Journal of Nursing Research , 9 : 311 – 321 .
   Google Scholar
• Tyden , P. , Hansen , O. , Engstrom , G. , Hedblad , B. and Janzon , L. 2002 . Myocardial infarction in an urban population: Worse long term prognosis for patients from less affluent residential areas . Journal of Epidemiology and Community Health , 56 : 785 – 790 .
   PubMedGoogle Scholar
• Valach , L. , Signer , S. , Hartmeier , A. , Hofer , K. and Steck , G. C. 2003 . Chedoke–McMaster stroke assessment and modified Barthel Index self-assessment in patients with vascular brain damage . International Journal of Rehabilitation Research , 26 : 93 – 99 .
   PubMed Web of Science ®Google Scholar
• Van Hook , M. P. , Berkman , B. and Dunkle , R. 1996 . Assessment tools for general health care settings: PRIME-MD, OARS, and SF-36 . Health & Social Work , 21 : 230 – 235 .
   PubMed Web of Science ®Google Scholar
• Van Wijk , I. , Algra , A. , Van de Port , I. G. , Bevaart , B. and Lindeman , E. 2006 . Change in mobility activity in the second year after stroke in a rehabilitation population: Who is at risk for decline? . Archives of Physical Medicine and Rehabilitation , 87 : 45 – 50 .
   PubMed Web of Science ®Google Scholar
• Vetter , N. and Ford , D. 1989 . Anxiety and depression scores in elderly fallers . International Journal of Geriatric Psychology , 4 : 168 – 173 .
   Google Scholar
• von Laue , N. C. , Schwappach , D. L. B. and Koeck , C. M. 2003 . The epidemiology of preventable adverse drug events: A review of the literature . Wiener Klinische Wochenschrift , 115 : 407 – 415 .
   PubMed Web of Science ®Google Scholar
• Weaver , C. , Schiech , L. , Held–Warmkessel , J. , Kedziera , P. , Haney , E. , DiLullo , G. and Dell , D. 2006 . Risk for unplanned hospital readmission of patients with cancer: Results of a retrospective medical record review . Oncology Nursing Forum , 33 : E44 – E52 .
   Google Scholar
• Westra , B. L. , Holland , D. E. , Aufenthie , J. , Cullen , L. , Finley , J. , Griebenow , L. and Wollan , P. 1998 . Testing the Uniform Needs Assessment Instrument for hospital discharge planning with older adults . Journal of Gerontological Nursing , 24 : 42 – 46 .
   PubMedGoogle Scholar
• Wu , H. Y. , Sahadevan , S. and Ding , Y. Y. 2006 . Factors associated with functional decline of hospitalized older persons following discharge form an acute geriatric unit . Annals Academy of Medicine Singapore , 35 : 17 – 23 .
   PubMed Web of Science ®Google Scholar
• Yeaw , E. M. J. and Burlingame , P. A. 2003 . Identifying high-risk patients from the emergency department to the home . Home Healthcare Nurse , 21 : 473 – 480 .
   PubMedGoogle Scholar
• Zuccala , G. , Onder , G. , Pedone , C. , Cocchi , A. , Carosella , L. , Cattel , C. and Bernabei , R. 2001 . Cognitive dysfunction as a major determinant of disability in patients with heart failure: Results from a multicentre survey . Journal of Neurology, Neurosurgery and Psychiatry , 70 : 109 – 112 .
   PubMed Web of Science ®Google Scholar