Defining Rehabilitation Success in Older Adults with Dementia--Results from an Inpatient Geriatric Rehabilitation Unit

Rehabilitation success and related costs following stroke in a regional hospital: a retrospective analysis based on the Australian National Subacute and Non-Acute Patient (AN-SNAP) classification

BACKGROUND

Evidence is limited on the factors influencing successful stroke rehabilitation in regional contexts. Additionally, the relationship between rehabilitation costs following acute stroke, based on Australian National Subacute and Non-Acute Patient (AN-SNAP) casemix classification, and rehabilitation success remains unclear.

OBJECTIVE

This retrospective cohort study investigated the factors contributing to improved functional outcomes following stroke rehabilitation in an Australian regional hospital, also evaluating the respective average daily and total payments.

METHODS

Stroke patients' admission records, during 2010-2020, were linked with rehabilitation registry data. Rehabilitation success was defined as relative functional gain (RFG) ≥ 0.5 and Functional Independence Measure (FIM) efficiency ≥ 1. Multivariate mixed effects logistical regressions modelled the sociodemographic and medical (i.e., comorbidities and stroke type) predictors of rehabilitation success, while logarithms of average daily and total rehabilitation payments were modelled using robust regressions.

RESULTS

Of 582 included patients, 315 (54.1%) achieved RFG ≥ 0.5 and 258 (52.2%) achieved FIM efficiency ≥ 1. A longer delay in starting rehabilitation was associated with a lower likelihood of achieving RFG success [Odds Ratio (OR): 0.85, 95% confidence interval (CI): 0.78-0.93, P < 0.001] and FIM efficiency success (OR: 0.89, 95% CI: 0.82-0.97, P = 0.010). A higher FIM score at admission was associated with decreased odds of FIM efficiency success (OR: 0.35, 95% CI: 0.20-0.60, P < 0.001). The average daily and total rehabilitation payments for inpatients were $AU1,255 (median) [interquartile range (IQR): 1,040, 1,771] and $AU28,363 (median) (IQR: 18,822, 41,815), respectively. FIM efficiency success was positively associated with the average daily payment (Beta: 0.25, 95% CI: 0.20-0.30, P < 0.001), but negatively correlated with the total payment (Beta: -0.18, 95% CI: -0.24-0.13, P < 0.001). No significant associations were found between RFG success and these payments.

CONCLUSION

This study identifies key factors affecting stroke rehabilitation outcomes in a regional Australian setting. Delays in starting rehabilitation were linked to lower success rates, underscoring the importance of timely intervention. While higher average daily costs were associated with better FIM efficiency, total costs did not correlate with relative functional gains. These findings may inform rehabilitation practices and may influence future funding strategies for rehabilitation services.

Predictive value of a self-administered frailty screening questionnaire for the effectiveness of functional rehabilitation evaluated with the locomotor functional independence measure in a geriatric rehabilitation unit: a multicentre cohort study

BACKGROUND

Patient Reported Outcome Measures (PROMs) are questionnaires that collect health data directly from the patient, without any intervention from a third party. The aim of rehabilitation units is to restore function. Functional gain can be evaluated with classic scales, such as the locomotor subscale of the Functional Independence Measure. This study aimed to assess the accuracy of a new self-assessment questionnaire pertaining to physical, sensory and cognitive ability (abbreviated SEPCO) for the prediction of functional prognosis in older patients admitted to a rehabilitation unit.

METHODS

In this multicentre observational study including patients admitted to 12 rehabilitation centres in France, all included patients completed the SEPCO on admission. Poor response to rehabilitation was defined as relative effectiveness < 40% on the evolution of the locomotor FIM subscale. Components of the questionnaire potentially associated with the outcome of rehabilitation were confirmed for inclusion upon expert review and summed to form an overall score. The final score had five components: the depression score of the HADS, the SOFRESC vision score, the SOFRESC balance score, the stress urinary incontinence subscale of the USP, and the EPICES socio-economic deprivation score. A logistic regression model adjusted for baseline characteristics assessed the performance of the SEPCO score to predict change in functional status, defined by the relative functional gain for the locomotion subscale of the Functional Independence Measure (FIM).

RESULTS

A total of 153 patients (mean age 79.2 ± 8.1 years, 72.5% women) were included. By multivariate analysis, a 5-scale SEPCO score ≥ 1.1 predicted worse functional improvement with an odds ratio (OR) of 2.575, 95% Confidence Interval (CI) 1.081 to 6.133, p = 0.03. Sensitivity for this threshold was 67.4% (95% CI 52.0-80.5%), with a specificity of 58.8% (95% CI 46.2-70.6%). Having a SEPCO ≥ 1.1 almost doubled the probability of poor response to rehabilitation (from 27.3 to 52.5%).

CONCLUSION

The SEPCO score can predict poor functional gain from rehabilitation. Future studies should validate this score on an external cohort. The SEPCO could serve as a complement to the initial clinical evaluation performed by physicians, and assist physicians in setting each patient's rehabilitation goals.

Interventions focusing on learning pre-transfer wheelchair manipulation in a patient with severe Alzheimer's disease: a case report

BACKGROUND

Independence of transfer is important for the daily activities of wheelchair users. A critical step in performing this transfer includes a pre-transfer wheelchair manipulation, and patients with Alzheimer's disease (AD) experience difficulties in learning these tasks. In this report, we present the results of a treatment focused on learning pre-transfer wheelchair manipulation and its learning course in a patient with severe AD.

CASE DESCRIPTION

The patient was a 92-year-old woman with severe AD during hospitalization in a long-term care ward. Since her cognitive function was highly compromised, she required assistance for pre-transfer wheelchair manipulation. Physiotherapists implemented a treatment plan that incorporated post-behavioral praise into a practice combining errorless learning and spaced retrieval training for pre-transfer wheelchair manipulation.

OUTCOMES

The patient was able to accurately perform pre-transfer wheelchair manipulation in the seventh treatment session and achieved transfer independence after 12 physiotherapy sessions.

CONCLUSION

This case report suggests that practicing combined errorless learning, spaced retrieval training, and post-behavioral praise was helpful as a treatment modality for an individual with severe AD for wheelchair manipulation learning before transfer.

Characteristic of process analysis on instrumental activities of daily living according to the severity of cognitive impairment in community-dwelling older adults with Alzheimer's disease

OBJECTIVES

To clarify the characteristic of impaired and unimpaired Instrumental Activities of daily living (IADL) processes with the severity of cognitive impairment in community-dwelling older adults with Alzheimer's disease (AD) using the Process Analysis of Daily Activity for Dementia (PADA-D).

DESIGN

Cross-sectional study.

SETTING

13 medical and care centers in Japan.

PARTICIPANTS

115 community-dwelling older adults with AD.

METHODS

The severity of cognitive impairment was classified by Mini-Mental State Examination (20 ≥ mild group, 20 < moderate group ≥ 10, 10 < severe group), and IADL scores and eight IADL items in PADA-D were compared among three groups after adjusting for covariates. Rate of five feasible processes included in each IADL of PADA-D was compared.

RESULTS

IADL score showed a decrease in independence with the severity of AD except for Use modes of transportation and Managing finances, which was especially pronounced in Shopping (F = 25.58), Ability to use the telephone (F = 16.75), and Managing medication (F = 13.1). However, when the PADA-D was examined by process, some processes that were impaired and unimpaired with the severity of cognitive impairment were clear. For example, Plan a meal was impaired (ES = 0.29) with the severity, but Prepare the food was not in Cooking performance.

CONCLUSIONS

We suggested that detailed process analysis in IADLs can clarify the characteristic of processes that are impaired and unimpaired with the severity of cognitive impairment in older adults with AD living in the community. Our findings may be useful for rehabilitation and care in IADL to continue living at home.

Associations Between Patient Characteristics and Unplanned or Delayed Discharges From Geriatric Rehabilitation: A Retrospective Chart Review

ABSTRACT

Returning home is considered an indicator of successful rehabilitation for community-dwelling older adults. However, the factors associated with unplanned discharge remain uncertain. This retrospective chart review included patients 65 yrs and older admitted to a geriatric rehabilitation unit from medical and surgical wards in an academic hospital. Patient characteristics and outcomes were abstracted from the electronic medical record. The primary outcome was unplanned discharge destination defined as anything other than return to patients' preexisting residence. The associations between patient variables and unplanned discharge destination were analyzed using Pearson χ 2 and univariate logistic regression. Of the 251 charts screened, 25 patients (10.0%) had an unplanned discharge destination, and 74 of the remaining 226 (32.7%) experienced a delayed discharge (beyond 20 days). Requiring assistance for activities of daily living (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.17-7.47), a diagnosis of chronic obstructive pulmonary disease (OR, 4.04; 95% CI, 1.63-9.71), and lower serum albumin level (OR, 1.67; 95% CI, 1.06-2.72) were associated with unplanned discharge. Variables commonly associated with worse outcomes such as age, cognitive scores, delirium, and number of comorbidities were not barriers to returning home and should therefore not be used on their own to limit access to geriatric rehabilitation.

Factors associated with improved walking in older people during hospital rehabilitation: secondary analysis of a randomized controlled trial

Background

Older people are often admitted for rehabilitation to improve walking, yet not everyone improves. The aim of this study was to determine key factors associated with a positive response to hospital-based rehabilitation in older people.

Methods

This was a secondary data analysis from a multisite randomized controlled trial. Older people (n= 198, median age 80.9 years, IQR 76.6- 87.2) who were admitted to geriatric rehabilitation wards with a goal to improve walking were recruited. Participants were randomized to receive additional daily physical therapy focused on mobility (n = 99), or additional social activities (n = 99). Self-selected gait speed was measured on admission and discharge. Four participants withdrew. People who changed gait speed ≥0.1 m/s were classified as ‘responders’ (n = 130); those that changed <0.1m/s were classified as ‘non-responders’ (n = 64). Multivariable logistic regression explored the association of six pre-selected participant factors (age, baseline ambulation status, frailty, co-morbidities, cognition, depression) and two therapy factors (daily supervised upright activity time, rehabilitation days) and response.

Results

Responding to rehabilitation was associated with the number of days in rehabilitation (OR 1.04; 95% CI 1.00 to 1.08; p = .039) and higher Mini Mental State Examination scores (OR 1.07, 95% CI 1.00 – 1.14; p = .048). No other factors were found to have association with responding to rehabilitation.

Conclusion

In older people with complex health problems or multi-morbidities, better cognition and a longer stay in rehabilitation were associated with a positive improvement in walking speed. Further research to explore who best responds to hospital-based rehabilitation and what interventions improve rehabilitation outcomes is warranted.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000884707; ClinicalTrials.gov Identifier NCT01910740.

Understanding the factors influencing physiotherapists' attitudes towards working with people living with dementia

Background: Research suggests healthcare professionals feel uncomfortable or inadequately prepared to provide care to people living with dementia. Importantly, research on the attitudes of physiotherapists toward people with dementia is limited. The objective was to assess personal, educational, and clinical experiences on physiotherapists' attitudes toward working with people with dementia.Methods: An online survey was completed by registered physiotherapists. Data were collected on their dementia knowledge, confidence, and attitudes. Structural equation modeling (SEM) evaluated the factors associated with attitudes of physiotherapists.Results: A total of 231 physiotherapists completed the survey. Participants' scores on knowledge of dementia were excellent. Interactions with people with dementia were positive (67.4%) and access to rehabilitation was important (70.4%). However, most respondents reported a lack of confidence and strategies to successfully deal with cognitive (42.5%) or behavioral (58.3%) symptoms. In the SEM, only education (p = .048) was significantly related to attitude. Specifically, more education was related to more positive attitudes.Conclusions: Scores on knowledge of dementia were high. Yet, most respondents reported reduced confidence from a lack of skills to manage behavioral or cognitive symptoms associated with dementia. More education related to working with people with dementia was significantly related to positive attitudes among physiotherapists.

Equipping staff with the skills to maximise recovery of people with dementia after an injurious fall

Objectives: People with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explores the importance of compensating for cognitive impairment when working with people with dementia. Methods: Qualitative methods - interviews, focus groups and observation - were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. A thematic, iterative analysis was undertaken in which emerging themes were identified from each individual dataset, prior to an integrative analysis. Results: A key theme across all datasets was the need to deliver services in ways that compensate for cognitive impairment, such as negotiating meaningful activities that can be embedded into the routines of people with dementia. Professionals varied in their ability to adapt their practice to meet the needs of people with dementia. Negative attitudes towards dementia, a lack of knowledge and understanding of dementia limited the ability of some professionals to work in person-centred ways. Conclusion: Improving outcomes for people with dementia following a fall requires the principles of person-centred care to be enacted by professionals with a generic role, as well as specialist staff. This requires additional training and support by specialist staff to address the wide variability in current practice.

Is it feasible to deliver a complex intervention to improve the outcome of falls in people with dementia? A protocol for the DIFRID feasibility study

Background

People with dementia (PWD) experience ten times as many incident falls as people without dementia. Little is known about how best to deliver services to people with dementia following a fall. We used an integrated, mixed-methods approach to develop a new intervention which combines theory generated via a realist synthesis and data on current provision and pathways, gathered through a prospective observational study as well as qualitative interviews, focus groups and ethnographic observation. This intervention is to be tested in a feasibility study in the UK National Health Service.

Methods

People living with dementia in one of three geographical areas will be eligible for the study if they experience a fall requiring healthcare attention and have an informal carer. Potential participants will be identified by community services (primary care, paramedics, telecare), secondary care (ED, facilitated discharge services, rehabilitation outreach teams) and research case registers. Participants will receive a complex multidisciplinary intervention focused on their goals and interests for up to 12 weeks. The intervention will be delivered by occupational therapists, physiotherapists and rehabilitation support workers. Feasibility outcomes will include recruitment and retention, suitability and acceptability of outcome measures and acceptability, feasibility and fidelity of intervention components. PWD outcome measures will include number of falls, Montreal Cognitive Assessment (MOCA), European Quality of Life Instrument (EQ-5D-5L), Quality of Life–Alzheimer’s Disease Scale (QOL-AD), Modified Falls Efficacy Scale (MFES) and Goal Attainment Scaling (GAS). PWD outcome measures completed by an informal carer will include Disability Assessment for Dementia (DAD), EQ-5D-5L Proxy, QoL-AD Proxy and a Health Utilisation Questionnaire (HUQ). The carer outcome measure will be the Zarit Burden Interview (ZBI). An embedded process evaluation will explore barriers and facilitators to recruitment and intervention delivery.

Discussion

The study results will inform whether and how a larger multicentre RCT should be undertaken. A full RCT would have the potential to show how outcomes can be improved for people with dementia who have fallen.

Ethics and dissemination

The National Research Ethics Service Committee Newcastle and North Tyneside 2 approved the feasibility study.

Trial registration

International Standard Randomised Controlled Trial Registry. Registration number: ISRCTN41760734. Date of registration: 16/11/2015.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0364-7) contains supplementary material, which is available to authorized users.

Involvement of insulin resistance in D-galactose-induced age-related dementia in rats: Protective role of metformin and saxagliptin

Age-related dementia is one of the most devastating disorders affecting the elderly. Recently, emerging data suggest that impaired insulin signaling is the major contributor in the development of Alzheimer's dementia (AD), which is the most common type of senile dementia. In the present study, we investigated the potential therapeutic effects of metformin (Met) and saxagliptin (Saxa), as insulin sensitizing agents, in a rat model of brain aging and AD using D-galactose (D-gal, 150 mg/kg/day, s.c. for 90 successive days). Six groups of adult male Wistar rats were used: normal, D-gal, Met (500 mg/kg/day, p.o), and Saxa (1 mg/kg/day, p.o) control groups, as well as D-gal/Met and D-gal/Sax treated groups. Impaired learning and memory function was observed in rats treated with D-gal using Morris water maze test. Biochemical and histopathological findings also revealed some characteristic changes of AD in the brain that include the increased content of acetylcholine, glutamate, and phosphorelated tau, as well as deposition of amyloid plaques and neurofibrillary tangles. Induction of insulin resistance in experimentally aged rats was evidenced by increased blood glycated hemoglobin, brain contents of insulin and receptors for advanced glycated end-products, as well as decreased brain insulin receptor level. Elevation of oxidative stress markers and TNF-α brain content was also demonstrated. Met and Saxa, with a preference to Met, restored the normal memory and learning functions in rats, improved D-gal-induced state of insulin resistance, oxidative stress and inflammation, and ameliorated the AD biochemical and histopathological alterations in brain tissues. Our findings suggest that D-gal model of aging results in a diminishing of learning and memory function by producing a state of impaired insulin signaling that causes a cascade of deleterious events like oxidative stress, inflammation, and tau hyper-phosphorylation. Reversing of these harmful effects by the use of insulin-sensitizing drugs like Met and Saxa suggests their involvement in alleviation insulin resistance as the underlying pathology of AD and hence their potential use as anti-dementia drugs.

A comprehensive approach to reablement in dementia

As society grapples with an aging population and increasing prevalence of disability, “reablement” as a means of maximizing functional ability in older people is emerging as a potential strategy to help promote independence. Reablement offers an approach to mitigate the impact of dementia on function and independence. This article presents a comprehensive reablement approach across seven domains for the person living with mild-to-moderate dementia. Domains include assessment and medical management, cognitive disability, physical function, acute injury or illness, assistive technology, supportive care, and caregiver support. In the absence of a cure or ability to significantly modify the course of the disease, the message for policy makers, practitioners, families, and persons with dementia needs to be “living well with dementia”, with a focus on maintaining function for as long as possible, regaining lost function when there is the potential to do so, and adapting to lost function that cannot be regained. Service delivery and care of persons with dementia must be reoriented such that evidence-based reablement approaches are integrated into routine care across all sectors.

•

We present a comprehensive reablement approach in dementia.

•

The reablement approach is described across seven domains.

•

Reablement aims to maintain or regain function, or adapt to lost function.

•

Evidence-based reablement should be integrated into routine care across all sectors.