Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures
Abstract
:1. Introduction
2. Methods
2.1. Patients and Measures
2.2. Comprehensive Geriatric Care (CGC)
- Age ≥ 65 years;
- Multimorbidity (two or more chronic diseases);
- Disabling deficits expected to improve after completing CGC.
2.3. Assessment of Balance and Gait (Tinetti Balance and Gait Test, TBGT)
2.4. Assessment of Basic Activities of Daily Living (Barthel Index, BI)
2.5. Statistical Analyses
2.6. Ethical Approval
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Fuhrmann, R. Übersicht Über die Versorgungsstrukturen der klinischen und rehabilitativen Geriatrie und ihre Entwicklung in der Bundesrepublik Deutschland. Zeitschrift für Gerontologie und Geriatrie 2001, 34, I016–I020. [Google Scholar] [CrossRef]
- Landefeld, C.S.; Palmer, R.M.; Kresevic, D.M.; Fortinsky, R.H.; Kowal, J. A Randomized Trial of Care in a Hospital Medical Unit Especially Designed to Improve the Functional Outcomes of Acutely Ill Older Patients. N. Engl. J. Med. 1995, 332, 1338–1344. [Google Scholar] [CrossRef] [PubMed]
- Parker, S.G.; McCue, P.; Phelps, K.; McCleod, A.; Arora, S.; Nockels, K.; Kennedy, S.; Roberts, H.; Conroy, S. What is Comprehensive Geriatric Assessment (CGA)? An umbrella review. Age Ageing 2018, 47, 149–155. [Google Scholar] [CrossRef] [Green Version]
- Pilotto, A.; Cella, A.; Pilotto, A.; Daragjati, J.; Veronese, N.; Musacchio, C.; Mello, A.M.; Logroscino, G.; Padovani, A.; Prete, C.; et al. Three Decades of Comprehensive Geriatric Assessment: Evidence Coming from Different Healthcare Settings and Specific Clinical Conditions. J. Am. Med. Dir. Assoc. 2017, 18, 192.e1–192.e11. [Google Scholar] [CrossRef]
- Rubenstein, L.Z.; Stuck, A.E.; Siu, A.L.; Wieland, D. Impacts of Geriatric Evaluation and Management Programs on Defined Outcomes: Overview of the Evidence. J. Am. Geriatr. Soc. 1991, 39, 8S–16S. [Google Scholar] [CrossRef]
- Aziz, N.A.S.A.; Teng, N.I.M.F.; Hamid, M.R.A.; Ismail, N.H. Assessing the nutritional status of hospitalized elderly. Clin. Interv. Aging 2017, 12, 1615–1625. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Brown, P.J.; Sneed, J.R.; Rutherford, B.R.; Devanand, D.P.; Roose, S.P. The nuances of cognition and depression in older adults: The need for a comprehensive assessment. Int. J. Geriatr. Psychiatry 2014, 29, 506–514. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- De Coninck, L.; Bekkering, G.E.; Bouckaert, L.; Declercq, A.; Graff, M.J.L.; Aertgeerts, B. Home- and Community-Based Occupational Therapy Improves Functioning in Frail Older People: A Systematic Review. J. Am. Geriatr. Soc. 2017, 65, 1863–1869. [Google Scholar] [CrossRef]
- Lancaster, J. Dysphagia: Its nature, assessment and management. Br. J. Community Nurs. 2015, 20, S28–S32. [Google Scholar] [CrossRef]
- Sherrington, C.; Tiedemann, A. Physiotherapy in the prevention of falls in older people. J. Physiother. 2015, 61, 54–60. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Steultjens, E.M.J.; Dekker, J.; Bouter, L.M.; Jellema, S.; Bakker, E.B.; Ende, C.H.M.V.D. Occupational therapy for community dwelling elderly people: A systematic review. Age Ageing 2004, 33, 453–460. [Google Scholar] [CrossRef] [Green Version]
- Åhlund, K.; Bäck, M.; Öberg, B.; Ekerstad, N. Effects of comprehensive geriatric assessment on physical fitness in an acute medical setting for frail elderly patients. Clin. Interv. Aging 2017, 12, 1929–1939. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Baztán, J.J.; Suárez-García, F.M.; López-Arrieta, J.; Rodríguez-Mañas, L.; Rodríguez-Artalejo, F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: Meta-analysis. BMJ 2009, 338, b50. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hickman, L.D.; Phillips, J.L.; Newton, P.J.; Halcomb, E.J.; Al Abed, N.; Davidson, P.M. Multidisciplinary team interventions to optimise health outcomes for older people in acute care settings: A systematic review. Arch. Gerontol. Geriatr. 2015, 61, 322–329. [Google Scholar] [CrossRef]
- Thingstad, P.; Taraldsen, K.; Saltvedt, I.; Sletvold, O.; Vereijken, B.; Lamb, S.E.; Helbostad, J.L. The long-term effect of comprehensive geriatric care on gait after hip fracture: The Trondheim Hip Fracture Trial—A randomised controlled trial. Osteoporos. Int. 2015, 27, 933–942. [Google Scholar] [CrossRef] [PubMed]
- Dodson, J.A.; Matlock, D.D.; Forman, D.E. Geriatric Cardiology: An Emerging Discipline. Can. J. Cardiol. 2016, 32, 1056–1064. [Google Scholar] [CrossRef] [Green Version]
- Fischer, K.; Trombik, M.; Freystätter, G.; Egli, A.; Theiler, R.; Bischoff-Ferrari, H. Timeline of functional recovery after hip fracture in seniors aged 65 and older: A prospective observational analysis. Osteoporos. Int. 2019, 30, 1371–1381. [Google Scholar] [CrossRef]
- Namioka, N.; Hanyu, H.; Hatanaka, H.; Fukasawa, R.; Sakurai, H.; Iwamoto, T. Comprehensive geriatric assessment in elderly patients with dementia. Geriatr. Gerontol. Int. 2014, 15, 27–33. [Google Scholar] [CrossRef]
- Lin, S.-N.; Su, S.-F.; Yeh, W.-T. Meta-analysis: Effectiveness of Comprehensive Geriatric Care for Elderly Following Hip Fracture Surgery. West. J. Nurs. Res. 2019, 42, 293–305. [Google Scholar] [CrossRef] [PubMed]
- Wang, H.; Li, C.; Zhang, Y.; Jia, Y.; Zhu, Y.; Sun, R.; Li, W.; Liu, Y. The influence of inpatient comprehensive geriatric care on elderly patients with hip fractures: A meta-analysis of randomized controlled trials. Int. J. Clin. Exp. Med. 2015, 8, 19815–19830. [Google Scholar]
- Wang, Y.; Tang, J.; Zhou, F.; Yang, L.; Wu, J. Comprehensive geriatric care reduces acute perioperative delirium in elderly patients with hip fractures. Medicine 2017, 96, e7361. [Google Scholar] [CrossRef]
- Ambrose, A.F.; Cruz, L.; Paul, G. Falls and Fractures: A systematic approach to screening and prevention. Maturitas 2015, 82, 85–93. [Google Scholar] [CrossRef] [PubMed]
- Folstein, M.F.; Folstein, S.E.; McHugh, P.R. “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 1975, 12, 189–198. [Google Scholar] [CrossRef]
- Mahoney, F.I.; Barthel, D.W. Functional Evaluation: The Barthel Index. Md. State Med. J. 1965, 14, 61–65. [Google Scholar] [PubMed]
- Podsiadlo, D.; Richardson, S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. J. Am. Geriatr. Soc. 1991, 39, 142–148. [Google Scholar] [CrossRef] [PubMed]
- Tinetti, M.E. Performance-Oriented Assessment of Mobility Problems in Elderly Patients. J. Am. Geriatr. Soc. 1986, 34, 119–126. [Google Scholar] [CrossRef] [PubMed]
- Yesavage, J.A.; Brink, T.; Rose, T.L.; Lum, O.; Huang, V.; Adey, M.; Leirer, V.O. Development and validation of a geriatric depression screening scale: A preliminary report. J. Psychiatr. Res. 1982, 17, 37–49. [Google Scholar] [CrossRef]
- Lübke, M.N.; Meinck, P.M.; Von Renteln–Kruse, M.W. Der Barthel–Index in der Geriatrie. Eine Kontextanalyse zum Hamburger Einstufungsmanual. Zeitschrift für Gerontologie und Geriatrie 2004, 37, 316–326. [Google Scholar] [CrossRef]
- Lieberman, D.; Lieberman, D. Rehabilitation following hip fracture surgery: A comparative study of females and males. Disabil. Rehabilit. 2004, 26, 85–90. [Google Scholar] [CrossRef]
- Arinzon, Z.; Shabat, S.; Peisakh, A.; Gepstein, R.; Berner, Y.N. Gender differences influence the outcome of geriatric rehabilitation following hip fracture. Arch. Gerontol. Geriatr. 2010, 50, 86–91. [Google Scholar] [CrossRef]
- Prestmo, A.; Saltvedt, I.; Helbostad, J.L.; Taraldsen, K.; Thingstad, P.; Lydersen, S.; Sletvold, O. Who benefits from orthogeriatric treatment? Results from the Trondheim hip-fracture trial. BMC Geriatr. 2016, 16, 49. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Loomer, L.; Downer, B.; Thomas, K.S. Relationship between Functional Improvement and Cognition in Short-Stay Nursing Home Residents. J. Am. Geriatr. Soc. 2018, 67, 553–557. [Google Scholar] [CrossRef] [PubMed]
- Tröster, T.; Thalmann, M.; Fischer, K.; Bieri-Brüning, G.; Beeler, P.E.; Bischoff-Ferrari, H.A.; Gagesch, M. Frailty, underweight and impaired mobility are associated with institutionalisation after post-acute care. Swiss Med. Wkly. 2020, 150, w20276. [Google Scholar] [CrossRef] [PubMed]
- Araki, A.; Ito, H. Diabetes mellitus and geriatric syndromes. Geriatr. Gerontol. Int. 2009, 9, 105–114. [Google Scholar] [CrossRef]
- Meneilly, G.S.; Tessier, D. Diabetes in Elderly Adults. J. Gerontol. A Boil. Sci. Med. Sci. 2001, 56, M5–M13. [Google Scholar] [CrossRef] [PubMed]
Treatment Method | Measures/Target Deficits/Symptoms |
---|---|
Physiotherapy |
|
Occupational therapy |
|
Speech therapy/orofacial therapy |
|
Psychological support |
|
Total Group (n = 1099) | Fractures (n = 300) | No Fractures (n = 799) | p * | |
---|---|---|---|---|
Age (median, IQR *, years) | 83.1 (79.0–87.8) | 85.6 (81.1–89.6) | 82.4 (78.3–86.9) | 0.001 |
Age ≥ 80 years | 754 (68.6%) | 239 (79.7%) | 515 (64.5%) | 0.001 |
Sex | ||||
female | 704 (64.1%) | 219 (73.0%) | 314 (60.7%) | 0.001 |
male | 395 (35.9%) | 81 (27.0%) | 314 (39.3%) | |
Co-morbidities | ||||
Hypertension | 853 (77.6%) | 246 (82.0%) | 607 (76.0%) | 0.035 |
Diabetes mellitus | 337 (30.7%) | 69 (23.0%) | 268 (33.5%) | 0.001 |
Heart failure | 258 (23.5%) | 66 (22.0%) | 192 (24.0%) | 0.523 |
Coronary heart disease | 281 (25.6%) | 61 (20.3%) | 220 (27.5%) | 0.016 |
Peripheral artery disease | 59 (5.4%) | 9 (3.0%) | 50 (6.3%) | 0.035 |
Atrial fibrillation | 388 (35.3%) | 93 (31.0%) | 295 (36.9%) | 0.076 |
Functional assessment on admission | ||||
Barthel index (median, IQR) | 45 (30–60) | 40 (30–50) | 45 (30–60) | 0.001 |
Tinetti geriatric assessment (median, IQR) | 11 (12–16) | 8 (1–14) | 12 (4–17) | 0.001 |
Geriatric depression scale (median, IQR) | 3 (1–6) | 3 (1–6) | 3 (1–6) | 0.844 |
Geriatric depression scale > 5 | 302 (27.7%) | 83 (27.8%) | 219 (27.6%) | 0.999 |
Timed up and go (median, IQR) | 4 (3–5) | 5 (3–5) | 4 (3–5) | 0.001 |
MMSE (median, IQR) (n = 812) | 26 (21–28) | 25 (19–28) | 26 (21–28) | 0.282 |
Prior to CGC * | After CGC * | p * | |
---|---|---|---|
Patients with fracture | |||
Tinetti score (median, IQR) | 8 (1–14) | 14 (8–19) | <0.001 |
Barthel index (median, IQR) | 40 (30–50) | 55 (40–75) | <0.001 |
Patients without fracture | |||
Tinetti score (median, IQR) | 12 (4–17) | 16 (9–21) | <0.001 |
Barthel index (median, IQR) | 45 (30–60) | 60 (45–80) | <0.001 |
Total Group (n = 258) | Improvement in Tinetti Score > 5 (n = 122) | No Improvement in Tinetti Score > 5 (n = 136) | p * | |
---|---|---|---|---|
Age (median, IQR, years) | 85.5 (81.1–89.9) | 85.7 (81.6–89.9) | 84.7 (80.9–88.9) | 0.368 |
Age ≥ 80 years | 208 (80.6%) | 102 (83.6%) | 106 (77.9%) | 0.273 |
Sex | ||||
female | 193 (74.8%) | 100 (82.2%) | 93 (68.4%) | 0.015 |
male | 65 (25.2%) | 22 (18.0%) | 43 (31.6%) | |
Co-morbidities | ||||
Hypertension | 209 (81.0%) | 103 (84.4%) | 206 (77.9%) | 0.206 |
Diabetes mellitus | 56 (21.7%) | 35 (28.7%) | 21 (15.4%) | 0.011 |
Heart failure | 53 (20.5%) | 20 (16.4%) | 33 (24.3%) | 0.126 |
Renal insufficiency | 73 (28.3%) | 34 (27.9%) | 39 (28.7%) | 0.891 |
Coronary heart disease | 49 (19.0%) | 22 (18.0%) | 27 (19.9%) | 0.752 |
Peripheral artery disease | 8 (3.1%) | 3 (2.5%) | 5 (3.7%) | 0.726 |
Atrial fibrillation | 78 (30.2%) | 35 (28.7%) | 43 (31.6%) | 0.684 |
Chronic pulmonary artery disease | 13 (5.0%) | 5 (4.1%) | 8 (5.9%) | 0.579 |
Dementia | 61 (23.6%) | 32 (26.2%) | 29 (21.3%) | 0.381 |
Morbus Parkinson | 14 (5.4%) | 4 (3.3%) | 10 (7.4%) | 0.177 |
Previous stroke | 24 (9.3%) | 13 (10.7%) | 11 (8.1%) | 0.524 |
Osteoporosis | 51 (19.8%) | 29 (23.8%) | 22 (16.2%) | 0.159 |
Vitamin B deficiency | 133 (51.6%) | 60 (49.2%) | 73 (53.7%) | 0.533 |
Location of fractures | ||||
Lower extremities | 143 (55.4%) | 73 (59.8%) | 70 (51.5%) | 0.236 |
Pelvic region | 38 (14.7%) | 21 (17.2%) | 17 (12.5%) | |
Spinal column | 36 (14.0%) | 13 (10.7%) | 23 (16.9%) | |
Thorax | 7 (2.7%) | 2 (1.6%) | 5 (3.7%) | |
Upper extremities | 24 (9.3%) | 8 (6.6%) | 16 (11.8%) | |
Different locations | 10 (3.9%) | 5 (4.1%) | 5 (3.7%) | |
Short term adverse events while hospitalization | ||||
Diffuse pain | 84 (32.6%) | 45 (36.9%) | 39 (28.7%) | 0.184 |
Delirium | 9 (3.5%) | 5 (4.1%) | 4 (2.9%) | 0.739 |
Pneumonia | 15 (5.8%) | 7 (5.7%) | 8 (5.9%) | 0.999 |
Urinary tract infection | 40 (15.5%) | 24 (19.7%) | 16 (11.8%) | 0.087 |
Dizziness | 13 (5.0%) | 7 (5.7%) | 6 (4.4%) | 0.777 |
Deep vein thrombosis | 1 (0.4%) | 0 (0%) | 1 (0.7%) | 0.999 |
Pulmonary emboli | 1 (0.4%) | 0 (0%) | 1 (0.7%) | 0.999 |
Electrolyte imbalance | 75 (29.1%) | 33 (27.0%) | 42 (30.9%) | 0.583 |
Hypokalemia | 61 (23.6%) | 26 (21.3%) | 35 (25.7%) | 0.464 |
Hyponatremia | 20 (7.8%) | 10 (8.2%) | 10 (7.4%) | 0.820 |
Functional assessment on admission | ||||
Barthel index (median, IQR) | 40 (30–50) | 40 (30–50) | 45 (30–55) | 0.010 |
Tinetti on admission (median, IQR) | 8 (1–14) | 5 (0–11.25) | 12 (7.25–18) | 0.001 |
Geriatric depression scale (median, IQR) | 3 (1–6) | 4 (1–6) | 3 (1–5) | 0.195 |
Geriatric depression scale >5 | 67 (26.0%) | 37 (30.3%) | 30 (22.1%) | 0.155 |
Timed up and go (median, IQR) | 5 (3–5) | 5 (4–5) | 4 (3–5) | 0.001 |
MMSE (median, IQR) | 24 (10–27) | 24 (17.75–27) | 25 (13.3–28) | 0.599 |
Discharging mode | ||||
Home care | 255 (98.8%) | 120 (98.4%) | 135 (99.3%) | 0.604 |
Referral to other department | 3 (1.2%) | 1 (1.6%) | 2 (0.7%) |
Total Group (n = 284) | Improvement in Barthel Index ≥ 15 (n = 179) | No Improvement in Barthel Index ≥ 15 (n = 105) | p * | |
---|---|---|---|---|
Age (median, IQR, years) | 85.6 (81.1–89.9) | 84.5 (81.6–89.8) | 86.4 (81.2–90.7) | 0.332 |
Age ≥ 80 years | 226 (79.6%) | 139 (77.7%) | 87 (82.9%) | 0.361 |
Sex | ||||
female | 210 (73.9%) | 137 (76.5%) | 73 (69.5%) | 0.209 |
male | 74 (26.1%) | 42 (23.5%) | 32 (30.5%) | |
Co-morbidities | ||||
Hypertension | 231 (81.3%) | 149 (83.2%) | 82 (78.1%) | 0.344 |
Diabetes mellitus | 67 (23.6%) | 33 (18.4%) | 34 (32.4%) | 0.009 |
Heart failure | 61 (21.5%) | 38 (21.2%) | 23 (21.9%) | 0.882 |
Renal insufficiency | 82 (28.9%) | 46 (25.7%) | 36 (34.3%) | 0.137 |
Coronary heart disease | 56 (19.7%) | 39 (21.8%) | 17 (16.2%) | 0.282 |
Peripheral artery disease | 9 (3.2%) | 6 (3.4%) | 3 (2.9%) | 0.999 |
Atrial fibrillation | 88 (31.0%) | 52 (29.1%) | 36 (34.3%) | 0.356 |
Chronic pulmonary artery disease | 16 (5.6%) | 7 (3.9%) | 9 (8.6%) | 0.114 |
Dementia | 75 (26.4%) | 45 (25.1%) | 30 (38.6%) | 0.578 |
Morbus Parkinson | 18 (6.3%) | 9 (5.0%) | 9 (8.6%) | 0.313 |
Previous stroke | 27 (9.5%) | 12 (6.7%) | 15 (14.3%) | 0.035 |
Osteoporosis | 53 (18.7%) | 41 (22.9%) | 12 (11.4%) | 0.018 |
Vitamin B deficiency | 145 (51.1%) | 91 (50.8%) | 54 (51.4%) | 0.999 |
Location of fractures | ||||
Lower extremities | 159 (50.0%) | 97 (54.2%) | 62 (59.0%) | 0.606 |
Pelvic region | 44 (15.5%) | 32 (17.9%) | 12 (11.4%) | |
Spinal column | 40 (14.1%) | 24 (13.4%) | 16 (15.2%) | |
Thorax | 6 (2.1%) | 3 (1.7%) | 3 (2.9%) | |
Upper extremities | 24 (8.5%) | 17 (9.5%) | 7 (6.7%) | |
Different locations | 11 (3.9%) | 6 (3.4%) | 5 (4.8%) | |
Short term adverse events while hospitalization | ||||
Diffuse pain | 91 (32.0%) | 63 (35.2%) | 28 (26.6%) | 0.149 |
Delirium | 12 (4.2%) | 7 (3.9%) | 5 (4.8%) | 0.765 |
Pneumonia | 21 (7.4%) | 11 (6.1%) | 10 (9.5%) | 0.349 |
Urinary tract infection | 46 (16.2%) | 30 (16.8%) | 16 (15.2%) | 0.868 |
Dizziness | 15 (5.3%) | 11 (6.1%) | 4 (3.8%) | 0.584 |
Deep vein thrombosis | 1 (0.4%) | 0 (0%) | 1 (1.0%) | 0.370 |
Pulmonary emboli | 1 (0.4%) | 1 (0.6%) | 0 (0%) | 0.999 |
Electrolyte imbalance | 89 (31.3%) | 53 (29.6%) | 36 (34.3%) | 0.429 |
Hypokalemia | 75 (26.4%) | 44 (24.6%) | 31 (29.5%) | 0.404 |
Hyponatremia | 23 (8.1%) | 14 (7.8%) | 9 (8.6%) | 0.825 |
Functional assessment on admission | ||||
Barthel index (median, IQR) | 40 (30–50) | 40 (30–55) | 35 (20–50) | 0.289 |
Tinetti on admission (median, IQR) | 8 (1–14) | 10 (4–15) | 4 (0–11) | 0.001 |
Geriatric depression scale (median, IQR) | 3 (1–6) | 4 (1–6) | 3 (0–6) | 0.180 |
Geriatric depression scale >5 | 77 (27.1%) | 52 (29.1%) | 25 (23.8%) | 0.407 |
Timed up and go (median, IQR) | 5 (3–5) | 4 (3–5) | 5 (4–5) | 0.001 |
MMSE (median, IQR) | 24 (10–27) | 25 (18–28) | 18 (0–27) | 0.001 |
Discharging mode | ||||
Home care | 282 (99.3%) | 177 (98.9%) | 105 (100%) | 0.532 |
Referral to other department | 2 (0.7%) | 2 (1.1%) | 0 (0%) |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Meyer, M.; Schmetsdorf, S.; Stein, T.; Niemoeller, U.; Arnold, A.; Reuter, I.; Kostev, K.; Grünther, R.-A.; Tanislav, C. Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures. Healthcare 2021, 9, 560. https://doi.org/10.3390/healthcare9050560
Meyer M, Schmetsdorf S, Stein T, Niemoeller U, Arnold A, Reuter I, Kostev K, Grünther R-A, Tanislav C. Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures. Healthcare. 2021; 9(5):560. https://doi.org/10.3390/healthcare9050560
Chicago/Turabian StyleMeyer, Marco, Stefanie Schmetsdorf, Thomas Stein, Ulrich Niemoeller, Andreas Arnold, Iris Reuter, Karel Kostev, Ralf-Achim Grünther, and Christian Tanislav. 2021. "Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures" Healthcare 9, no. 5: 560. https://doi.org/10.3390/healthcare9050560