Change in cognitive performance is associated with functional recovery during post-acute stroke rehabilitation: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia

Using Machine Learning to Study Factors Affecting Discharge Destination in Recovery Units

BACKGROUND

In recent years, machine learning has been developed in the medical community to construct multidimensional datasets consisting of many variables and perform simultaneous factor analysis.

OBJECTIVE

This study aimed to construct a multidimensional dataset of 50 items by incorporating supervised machine learning in a random forest algorithm to predict whether patients will be discharged home or to a facility after a stroke.

METHODS

Thirty patients hospitalized with cerebrovascular diseases who were subsequently discharged were considered as the study subjects. The dataset used for analysis consisted of attributes such as characteristics (three items), physical and cognitive functions (seven items), functional independence measure (FIM) (18 items), blood data (16 items), and social characteristics (six items). The discharge destination variable was either a home or a facility. Machine learning was used to extract factors important for this classification. The accuracy of the random forest was calculated by five-fold cross-validation. The mean decrease Gini, a measure of importance in classification, was calculated for each fold.

RESULTS

The results indicated that FIM, a measure of activities of daily living (ADL), and cognitive function, including memory, which strongly influenced the prediction equation, were important factors in the proposed algorithm. The results of the analysis revealed that the algorithm predicted home discharge or institutionalization with 87.1% accuracy.

CONCLUSION

Through this study, ADL and cognitive function were identified as important factors in predicting home discharge for patients with cerebrovascular disease.

Evaluation of the functional outcome and mobility of patients after stroke depending on their cognitive state

The study aimed to analyze the functional outcome and mobility in stroke patients depending on their cognitive state. 180 patients after first stroke were divided into four groups: 48 patients without symptoms of cognitive impairment (G1); 38 with mild cognitive impairment without dementia (G2); 47 with mild dementia (G3); 47 with moderate dementia (G4). The Mini Mental State Examination (MMSE), Barthel Index (BI), Sitting Assessment Scale (SAS), Berg Balance Scale, Trunk Control Test and Test Up & Go were used. The tests were carried out at the time of admission to the ward (T1) and at the time of discharge (T2). A statistically significant improvement was demonstrated in all parameters in almost all groups. No significant difference was observed only in groups G1 and G4 in SAS head. Statistically significant differences in BI results in T2 between groups G1 and G4 were noted. The lowest change in BI was observed in the G4. Regression analysis showed that MMSE and BI at T1 and MMSE score at T2 explained the functional status at T2. Cognitive dysfunction at the time of admission to the ward and discharge may determining the patient's functional status at the time of discharge from the ward.

Current Incidence and Risk Factors of Fecal Incontinence After Acute Stroke Affecting Functionally Independent People

Background: Previously published retrospective series show a high prevalence of fecal incontinence (FI) in stroke patients. We aimed to analyze in a prospective series the current incidence of FI in acute stroke in functionally independent patients and its evolution over time and the patient characteristics associated with the appearance of FI in acute stroke. Methods: We included consecutive patients with acute stroke admitted in our stroke unit who fulfilled the following inclusion criteria: a first episode of stroke, aged >18 years, with no previous functional dependency [modified Rankin Scale (mRS) ≤ 2] and without previous known FI. FI was assessed by a multidisciplinary trained team using dedicated questionnaires at 72 ± 24 h (acute phase) and at 90 ± 15 days (chronic phase). Demographic, medical history, clinical and stroke features, mortality, and mRS at 7 days were collected. Results: Three hundred fifty-nine (48.3%) of 749 patients (mean age 65.9 ± 10, 64% male, 84.1% ischemic) fulfilled the inclusion criteria and were prospectively included during a 20-month period. FI was identified in 23 patients (6.4%) at 72 ± 24 h and in 7 (1.9%) at 90 days ± 15 days after stroke onset. FI was more frequent in hemorrhagic strokes (18 vs. 5%, p 0.007) and in more severe strokes [median National Institute of Health Stroke Scale (NIHSS) 18 (14-22) vs. 5 (3-13), p < 0.0001]. No differences were found regarding age, sex, vascular risk factors, or other comorbidities, or affected hemisphere. Patients with NIHSS ≥12 (AUC 0.81, 95% CI 0.71 to 0.89) had a 17-fold increase for the risk of FI (OR 16.9, IC 95% 4.7-60.1) adjusted for covariates. Conclusions: At present, the incidence of FI in acute stroke patients without previous functional dependency is lower than expected, with an association of a more severe and hemorrhagic stroke. Due to its impact on the quality of life, it is necessary to deepen the knowledge of the underlying mechanisms to address therapeutic strategies.

CCL23: a new CC chemokine involved in human brain damage

BACKGROUND

CCL23 role in the inflammatory response after acute brain injuries remains elusive. Here, we evaluated whether CCL23 blood levels associate with acquired cerebral lesions and determined CCL23 predictive capacity for assessing stroke prognosis. We used preclinical models to study the CCL23 homologous chemokines in rodents, CCL9 and CCL6.

METHODS

Baseline CCL23 blood levels were determined on 245 individuals, including ischaemic strokes (IS), stroke mimics and controls. Temporal profile of circulating CCL23 was explored from baseline to 24 h in 20 of the IS. In an independent cohort of 120 IS with a 3-month follow-up, CCL23 blood levels were included in logistic regression models to predict IS outcome. CCL9/CCL6 cerebral expression was evaluated in rodent models of brain damage. Both chemokines were also profiled in circulation and histologically located on brain following ischaemia.

RESULTS

Baseline CCL23 blood levels did not discriminate IS, but permitted an accurate discrimination of patients presenting acute brain lesions (P = 0.003). IS exhibited a continuous increase from baseline to 24 h in circulating CCL23 (P < 0.001). Baseline CCL23 blood levels resulted an independent predictor of IS outcome at hospital discharge (OR_adj : 19.702 [1.815-213.918], P = 0.014) and mortality after 3 months (OR_adj : 21.47 [3.434-134.221], P = 0.001). In preclinics, expression of rodent chemokines in neurons following cerebral lesions was elevated. CCL9 circulating levels decreased early after ischaemia (P < 0.001), whereas CCL6 did not alter within the first 24 h after ischaemia.

CONCLUSIONS

Although preclinical models do not seem suitable to characterize CCL23, it might be a novel promising biomarker for the early diagnosis of cerebral lesions and might facilitate the prediction of stroke patient outcome.

Frailty Related Factors as Predictors of Functional Recovery in Geriatric Rehabilitation: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) Multi-Centric study

BACKGROUND

Frailty-related characteristics, such as sarcopenia, malnutrition and cognitive impairment, are often overlooked, both in clinical practice and research, as potential contributors to functional recovery during geriatric rehabilitation.

OBJECTIVE

The aim of the study was to identify frailty-related characteristics associated with functional recovery in a cohort of post-orthopedic surgery and post-stroke older adults.

DESIGN

Multi-centric cohort study. Participanst and Settings: Patients over 65 years, admitted to three geriatric rehabilitation units, in Spain and Italy, after an orthopedic event or a stroke, from December 2014 to May 2016.

MEASUREMENTS

The Absolute Functional Gain (AFG) defined as the difference between Barthel Index score at discharge and at admission, and the Relative Functional Gain (RFG) that represents the percentage of recovery of the function lost due to the event, were selected as outcomes. Both outcomes were analyzed as continuous and dichotomous variables. Analyses were also stratified as diagnostic at admission.

RESULTS

We enrolled 459 patients (mean age±SD=80.75±8.21 years), 66.2% women, 69.5% with orthopedic conditions and with a length of stay of 28.8±9.1 days. Admission after a stroke (Odds Ratio=0.36, 95% Confidence Interval=0.22-0.59]) and a better functional status at admission (OR=0.96, 95% CI=0.94-0.97), were associated with a lower likelihood of AFG, while a better pre-event Barthel index (OR=1.03 for each point in score, 95% CI=1.01-1.04), being able to walk (OR=2.07, 95% CI=1.16-3.70), and a better cognitive status at admission (OR=1.05, 95% CI=1.01-1.09), were associated with a higher chance of AFG. Post-stroke patients with delirium at admission had a re-duced chance of AFG (OR=0.25, 95% CI=0.07-0.91]). Patients admitted after an ortho-pedic event with better pre-event functional status (OR=1.04, 95% CI=1.02-1.06) and able to walk at admission (OR=2.79, 95% CI=1.29-6.03]) had an increased chance of AFG. Additionally, in both diagnostics groups, a better handgrip strength increased the chance of RFG.

CONCLUSIONS

Among frailty-related variables, physical, cognitive and muscular function at admission could be relevant for functional improvement during geriatric reha-bilitation. If confirmed, this data might orient targeted interventions.

Rehabilitation Profiles of Older Adult Stroke Survivors Admitted to Intermediate Care Units: A Multi-Centre Study

BACKGROUND

Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units.

METHODS

We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes).

RESULTS

Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles.

CONCLUSION

Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.