In Taiwan, according to LTC version 2, senior citizens 65 years of age or older who are mildly to moderately disabled and adults 55 years of age or older with dementia diagnosis can apply for DCS as long as it can be shown that they are not capable of managing their daily routine to some extent. The severity of disability was evaluated using the clinical frailty scale (CFS), which classifies patients into nine categories based on their dependence on others . The diagnosis of dementia was based on previous medical records, and disease severity was determined by the clinical dementia rating (CDR) . According to the regulations of the Ministry of Health and Welfare, Taiwan, the maximum number of participants who can receive DCS at any given time is decided by area and the number of staff number at each day care center. Therefore, the maximum number allowed is 20 in our day care service. This study retrospectively reviewed the serial follow-up data of physical and mental function status in participants who received DCS in a hospital-affiliated day care center in central Taiwan between February 2018 and November 2019. During the study period, a total of 26 participants, who were enrolled consecutively, received DCS at our day care center. Among them, 18 had the follow-up time more than 6 months (5 more than 18 months, 3 between 15 to 18 months, 4 between 12 to 15 months, 3 between 9 to 12 months, and 3 between 6 to 9 months), and 8 less than 6 months. Finally, we analyzed the data in 18 participants with at least 3 serial CGAs (e.g. one baseline and two follow-up). This study was approved by the Institution Review Board of the hospital (Reference Number: CE20010B).
The day care center staff comprised five formal care givers and a leading registered nurse who had received dementia-specific training. Their duties mainly involved general daily services, health programs, and related activities. At admission, general demographic data, including lifestyle habits, age, gender, body mass index, social, and family histories and medical histories, including diagnosed diseases and medications, were recorded. Moreover, at baseline, and every three months thereafter, a CGA was conducted for each participant to evaluate underlying geriatric problems and changes after DCS. If the participants had medical, functional, and/or social difficulties, they were referred to geriatricians, dietitians, rehabilitation therapists, psychiatrists, or social workers, as appropriate. In brief, the components of the CGA, as previously described , includes basic personal information (age, gender, history of chronic illness, education, source of referral) and various assessment tools, including the Activities of Daily Living (ADL) scale was evaluated using the Barthel Index, the Lawton Instrumental Activities of Daily Living (IADL) scale, and Mini-Mental State Examination (MMSE). Additionally, a five-item Geriatric Depression Scale (GDS-5) was used to screen for depressive symptoms in the elderly patients with a cut-off score of ≥ 2points for the presence of depressive symptoms. The Mini -Nutritional Assessment-Short Form (MNA-SF) was used to identify older adults who have or are at risk for developing malnutrition with a total score ranging from 0 to 14 . A cut-off of ≥ 12 points is regarded as an indication of being well-nourished, from 8 to 11 points indicates a risk of malnutrition, and < 7 points indicates the person is malnourished. Frailty was defined according to the criteria of the Cardiovascular Health Study Group . Handgrip strength was measured by a dynameter (Smedley's Dynamometer, TTM, Tokyo, Japan), and slowness was measured by a 6-meter walking test. Comorbid conditions were measured using the age-adjusted Charlson Comorbidity Index (ACCI), which was a combination of the age equivalence index and the Charlson Comorbidity Index originally included 19 chronic diseases that were weighted based on their association with mortality . The attendance rate was measured by the completion percentage of attending various DCS programs by the participants.
Every activity was provided for the participants together twice per week, and spent approximately 1 hour per section. The various programs were run by the designers with assistance from formal care giver in the day care center.
The group leader presented some pictures that would stimulate the elders’ memories, and then listened as the participants talked about them.
Patients performed resistance and stretching movements for 15–50 min five times per week.
-Cognitive occupational therapy
Patients were asked to name various different objects, and were taught the appropriate use of different tools.
To encourage the use of the fine muscles of the hand, participants were invited to draw.
Horticultural therapy consisted of planting plants and creating flower-based decorations.
Participants were encouraged to express themselves musically by singing folk songs or other popular songs.
Measurements Of Life Quality And Caregiver Burden
Life quality was measured by the 3-level version of European Quality of life-5 dimensions (EQ-5D) questionnaire, which consists of two elements designed for self-completion: the EQ-5D descriptive system and the EQ visual analogue scale (EQ-VAS) . The descriptive system comprises measures of mobility, ability to perform activities of self-care (e.g., washing and dressing), ‘usual’ activities (e.g., work, study, housework, family and leisure activities), and levels of pain/discomfort and anxiety/depression. Each of these dimensions is divided into three levels of perceived problems: Level 1 indicating no problems, Level 2 indicating some problems, and Level 3 indicating extreme problems. The 3-level version of EQ-5D score is mathematically converted to an EQ-5D utility index for analysis, and a higher EQ-5D utility index score indicates a better quality of life. The Chinese version of this questionnaire has been validated in a Taiwanese population . The EQ-VAS is a single index value for health status which records the participants’ self-rated health using a 100-point vertical visual scale ranging from “worst imaginable health state” (0) to “best imaginable health state” (100) . The caregiving burden is self-assessed based on the clinical caregiver’s recollection of stress, and the test includes a total of 14 questions . For each item, the family caregiver is asked to respond with one of four selections, which are as follows: never, with a score of zero; rarely, with a score of 1; sometimes, with a score of 2; and quite frequently, with a score of 3. The level of caregiving burden was obtained by aggregating the total scores from these 14 questions. The caregiving burden of each family caregiver based on the total score was classified into three levels, i.e., 0–13 (little or no burden), 14–15 (moderate burden), and 26–42 (severe burden).
Continuous variables were expressed as median and interquartile range (IQR: 25%-75%). Categorical data were expressed as number and percentages of the total due to the small sample size. Paired comparisons were made using the Wilcoxon signed rank test or Friedman test for continuous variates, and McNemar’s or Cochran’s Q tests for categorical variates during follow-up. Spearman's correlation analysis was used to measure the relationships between various baseline parameters and physical and cognitive function after the 6-month DCS. Statistical analyses were performed using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA). A p value of less than 0.05 was considered to be significant.