Predictors of rehabilitation outcome among frail elderly patients living in the community

The association between receipt of home care rehabilitation services and acute care hospital utilization in clients with multimorbidity following an acute care unit discharge: a retrospective cohort study

BACKGROUND

Individuals experiencing multimorbidity have more complex healthcare needs, use more healthcare services, and access multiple service providers across the healthcare continuum. They also experience higher rates of functional decline. Rehabilitation therapists are well positioned to address these functional needs; however, little is known about the influence of rehabilitation therapy on patient outcomes, and subsequent unplanned healthcare utilization for people with multimorbidity. The aims of this study were to: 1) describe and compare the characteristics of people with multimorbidity receiving: home care rehabilitation therapy alone, other home care services without rehabilitation therapy, and the combination of home care rehabilitation therapy and other home care services, and 2) determine the association between home care rehabilitation therapy and subsequent healthcare utilization among those recently discharged from an acute care unit.

METHODS

This retrospective cohort study used linked health administrative data housed within ICES, Ontario, Canada. The cohort included long-stay home care clients experiencing multimorbidity who were discharged from acute care settings between 2007-2015 (N = 43,145). Descriptive statistics, ANOVA's, t-tests, and chi-square analyses were used to describe and compare cohort characteristics. Multivariable logistic regression was used to understand the association between receipt of rehabilitation therapy and healthcare utilization.

RESULTS

Of those with multimorbidity receiving long-stay home care services, 45.5% had five or more chronic conditions and 46.3% required some assistance with ADLs. Compared to people receiving other home care services, those receiving home care rehabilitation therapy only were less likely to be readmitted to the hospital (OR = 0.78; 95% CI: 0.73-0.83) and use emergency department services (OR = 0.73; 95% CI: 0.69-0.78) within the first 3-months following hospital discharge.

CONCLUSIONS

Receipt of rehabilitation therapy was associated with less unplanned healthcare service use when transitioning from hospital to home among persons with multimorbidity. These findings suggest rehabilitation therapy may help to reduce the healthcare burden for individuals and health systems. Future research should evaluate the potential cost savings and health outcomes associated with providing rehabilitation therapy services for people with multimorbidity.

Prediction tool for disability progression and mortality in older adults eligible for Japanese long-term care insurance: Koriyama study

This study aims to create a simple model for predicting disability progression and death among older adults with Japanese long-term care insurance certification. This retrospective study analyzed the anonymized data provided by Koriyama City. The participants were 7706 older adults who were initially certified to be support levels 1 and 2 or care levels 1 and 2 for the purpose of obtaining Japanese long-term care insurance. The results of the certification questionnaire at the initial survey stage were used to create decision tree models intended to predict whether disability progression and death would occur within 1 year. In support levels 1 and 2, among those who scored both "daily decision making" item as other than "possible" and the "taking drugs" item as other than "independent," 64.7% had an adverse outcome. In care levels 1 and 2, among those who scored both the "shopping" item as "totally dependent" and the "defecation" item as other than "independent," 58.6% had an adverse outcome. The accuracy of classification of the decision trees were 61.1% in support levels 1and 2, and 61.7% in care levels 1 and 2. The overall accuracy of the decision tree is low, making it impractical to use it for all subjects. Nevertheless, based on the results of the 2 assessments in this study, the process of identifying a particular group of older adults at a high risk of an increased need for long-term care or possible death within a year is very simple and useful.

Rehabilitation potential in older people living with frailty: a systematic mapping review

Background

Following periods of acute ill-health and injury, older people are frequently assessed and provided with rehabilitation services. Healthcare practitioners are required to make nuanced decisions about which patients are likely to benefit from and respond to rehabilitation. The clinical currency in which these decisions are transacted is through the term “rehabilitation potential”. The aim of this study was to explore information about rehabilitation potential in older people to inform the development of an evidence-based assessment tool.

Methods

A systematic mapping review was completed to describe the extent of research and the concepts underpinning rehabilitation potential. We searched Medline, CINHAL, EMBASE, AMED, PsycINFO, PEDro, Cochrane Library, Web of Science, ProQuest, Trip and EThOS from inception to December 2020. We included studies which focused on rehabilitation potential and/or assessing for rehabilitation interventions for older people with comorbidities in the hospital and community setting. Reviewer pairs independently screened articles and extracted data against the inclusion criteria. A descriptive narrative approach to analysis was taken.

Results

13,484 papers were identified and 49 included in the review. Rehabilitation potential was found to encompass two different but interrelated concepts of prognostication and outcome measurement. 1. Rehabilitation potential for prognostication involved the prediction of what could be achieved in programmes of rehabilitation. 2. Rehabilitation potential as an outcome measure retrospectively considered what had been achieved as a result of rehabilitation interventions. Assessments of rehabilitation potential included key domains which were largely assessed by members of the multi-disciplinary team at single time points. Limited evidence was identified which specifically considered rehabilitation potential amongst older people living with frailty.

Conclusions

Current approaches to rehabilitation potential provide a snapshot of an individual’s abilities and conditions which fail to capture the dynamic nature and fluctuations associated with frailty and rehabilitation. New approaches to measures and abilities over time are required which allow for the prognostication of outcomes and potential benefits of rehabilitation interventions for older people living with frailty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02498-y.

Home care rehabilitation therapy services for individuals with multimorbidity: A rapid review

Multimorbidity refers to the co-occurrence of two or more chronic conditions, where no one disease is considered the central disease. Individuals with multimorbidity experience increased patient health complexity, increased disability and functional decline, and increased health care utilization. Rehabilitation therapists are well positioned to address the complex functional needs that can contribute to disability for people living with multimorbidity; however, it is not well understood how they address these needs within the home care setting. A rapid review was conducted to identify and synthesize the existing literature on home care rehabilitation services for clients with multimorbidity and the effect of those services. Two electronic databases (Medline and CINAHL) were searched. The Journal of Comorbidity was hand-searched for thoroughness because this journal focuses on populations with multiple chronic conditions. This rapid review included observational and experimental studies that focused on rehabilitation therapy interventions embedded within existing home care systems for adults with multimorbidity. Four studies were included in the final review. The results revealed that therapists delivered interventions aimed towards improving functional outcomes related to activities of daily living and instrumental activities of daily living. Physical therapy interventions were the only therapy delivered in three of the four studies included. Furthermore, 50% of these studies explicitly included people with chronic conditions impacting the musculoskeletal system only. This review offers an important perspective on how home care rehabilitation therapy interventions and outcomes are operationalized for individuals with multimorbidity. Despite the varying definitions of multimorbidity, therapeutic intervention supported functional improvements.

Impact of long term care and mortality risk in community care and nursing homes populations

OBJECTIVES

To identify the survival time, the mortality risk factors and the individuals' characteristics associated with cognitive and physical status at discharge, among the Portuguese long-term care (LTC) populations.

SETTINGS

Home-and-Community-Based Services (HCBS) and three types of Nursing Homes (NH).

PARTICIPANTS

20,984 individuals admitted and discharged in 2015.

MEASUREMENTS

The Kaplan-Meier survival analysis and the Cox Proportional Hazards Models were used to study the mortality risk; the Wilcoxon signed-rank test to identify the number of individuals with cognitive and physical changes between admission and discharge; two cumulative odds ordinal logistic regressions to predict the cognitive and physical dependence levels at discharge RESULTS: The mortality rate at HCBS was 30%, and 17% at the NH, with a median survival time of 173 and 200 days, respectively. The main factors associated with higher mortality were older age, male gender, family/neighbour support, neoplasms and cognitive/physical dependence at admission. In NH/HCBS, 26%/18% of individuals improve their cognitive status, while in physical status the proportion was 38%/27%, respectively. Finally, older age, being illiterate and being classified at the lowest cognitive and physical status at admission decrease the likelihood of achieving a higher level of cognitive and physical independence at discharge.

CONCLUSIONS

The adoption of a robust and complete assessment tool, the definition of guidelines to enable a periodical assessment of individuals' autonomy and the adoption of benchmark metrics allowing the comparison of results between similar units are some of the main goals to be taken into account for future developments of this care in Portugal.

The association between patient participation and functional gain following inpatient rehabilitation

OBJECTIVES

To evaluate patients' participation during physical therapy sessions as assessed with the Pittsburgh rehabilitation participation scale (PRPS) as a possible predictor of functional gain after rehabilitation training.

METHODS

All patients aged 65 years or older consecutively admitted to a Department of Rehabilitation and Aged Care (DRAC) were evaluated on admission regarding their health, nutritional, functional and cognitive status. Functional status was assessed with the functional independence measure (FIM) on admission and at discharge. Participation during rehabilitation sessions was measured with the PRPS. Functional gain was evaluated using the Montebello rehabilitation factor score (MRFS efficacy), and patients stratified in two groups according to their level of functional gain and their sociodemographic, clinical and functional characteristics were compared. Predictors of poor functional gain were evaluated using a multivariable logistic regression model adjusted for confounding factors.

RESULT

A total of 556 subjects were included in this study. Patients with poor functional gain at discharge demonstrated lower participation during physical therapy sessions were significantly older, more cognitively and functionally impaired on admission, more depressed, more comorbid, and more frequently admitted for cardiac disease or immobility syndrome than their counterparts. There was a significant linear association between PRPS scores and MRFS efficacy. In a multivariable logistic regression model, participation was independently associated with functional gain at discharge (odds ratio 1.51, 95 % confidence interval 1.19-1.91).

CONCLUSION

This study showed that participation during physical therapy affects the extent of functional gain at discharge in a large population of older patients with multiple diseases receiving in-hospital rehabilitation.

Depression and frailty in later life: a systematic review

Frailty and depression are important issues affecting older adults. Depressive syndrome may be difficult to clinically disambiguate from frailty in advanced old age. Current reviews on the topic include studies with wide methodological variation. This review examined the published literature on cross-sectional and longitudinal associations between frailty and depressive symptomatology with either syndrome as the outcome, moderators of this relationship, construct overlap, and related medical and behavioral interventions. Prevalence of both was reported. A systematic review of studies published from 2000 to 2015 was conducted in PubMed, the Cochrane Database of Systematic Reviews, and PsychInfo. Key search terms were "frailty", "frail", "frail elderly", "depressive", "depressive disorder", and "depression". Participants of included studies were ≥ 55 years old and community dwelling. Included studies used an explicit biological definition of frailty based on Fried et al's criteria and a screening measure to identify depressive symptomatology. Fourteen studies met the inclusion/exclusion criteria. The prevalence of depressive symptomatology, frailty, or their co-occurrence was greater than 10% in older adults ≥ 55 years old, and these rates varied widely, but less in large epidemiological studies of incident frailty. The prospective relationship between depressive symptomatology and increased risk of incident frailty was robust, while the opposite relationship was less conclusive. The presence of comorbidities that interact with depressive symptomatology increased incident frailty risk. Measurement variability of depressive symptomatology and inclusion of older adults who are severely depressed, have cognitive impairment or dementia, or stroke may confound the frailty syndrome with single disease outcomes, accounting for a substantial proportion of shared variance in the syndromes. Further study is needed to identify medical and behavioral interventions for frailty and depressive symptomatology that prevent adverse sequelae such as falls, disability, and premature mortality.

Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource

Background and design

This research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.

Research objectives

(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.

Setting

Community-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).

Participants

The combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.

Interventions

The interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.

Outcome measures

(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.

Results

(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.

Conclusions

This study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.

Funding

The NIHR Health Services and Delivery Research programme.

[Determinants of changes in physical fitness after a square-stepping exercise program in community-dwelling older Japanese females]

AIM

The purpose of this study was to investigate determinants of changes in physical fitness after a fall-prevention exercise program in older females.

METHODS

The study subjects included 83 community-dwelling females 65 years of age or older (mean age: 70.4±4.0 years) living in Kasama City, rural Japan. All subjects participated in a fall-prevention exercise program called square-stepping exercise (SSE) conducted once a week for 11 weeks. In order to assess the physical fitness benefits of by the exercise program, we measured the results of five physical performance tests: grip strength, one leg stand, sit and reach, timed up and go and the choice-stepping reaction time. In addition, we evaluated comprehensive physical fitness scores based on the standardized total score of the five physical performance tests. The changes in the comprehensive physical fitness score between baseline and after the program was used as the dependent variable, while the baseline values of age, education, clinical history, physical activity, Lubben social network scale, geriatric depression scale, five cognitive function test result, comprehensive physical fitness score and percentage of attendance were treated as independent variables.

RESULTS

A stepwise multiple regression analysis revealed that the change in comprehensive physical fitness score correlated significantly with the baseline values of age (β=-0.273), the five cognitive function test result (β=0.293) and comprehensive physical fitness score (β=-0.607).

CONCLUSIONS

These results suggest that older females with a low level of physical fitness at baseline are more likely to improve their physical fitness with a period of exercise training. However, the improvements in physical fitness are lower in older females with a low level of cognitive function than in those with a high level of cognitive function.

Predictors of functional and gait outcomes for persons poststroke undergoing home-based rehabilitation

BACKGROUND

The literature on the impact of home-based rehabilitation on functional outcomes for patients after stroke is limited. The purpose of this study was to describe the outcomes of home-based rehabilitation (HBR) on functional and gait performance for patients after stroke and associated factors that contribute to better outcomes after an episode of care.

METHODS

The nature of the study design was retrospective and the settings used were home care services. The total number of subjects receiving home care services after stroke was 213 (mean age 76.5 ± 9 years, 51% female). Treatment records for patients receiving HBR in 2010 were reviewed at the start of care and discharge. The primary outcome measure was a change in a gait speed and activities of daily living (ADL) performance between admission and discharge from home health care services. The composite score to calculate overall functional status (Outcome Information and Assessment Set-version C [OASIS-C]) was used. Mean change in ADL and gait scores and factors predictive of improvement were identified using an analysis of covariance and multivariate linear models. The main outcome measures were change in the OASIS-C composite scores and gait speed.

RESULTS

After adjustment for age and ADL score at the start of care, discharge from skilled nursing or long-term facilities, presence of confusion most of the times, cognitive impairment, and memory deficits were negatively associated with an improvement in functional scores (ADL). Living in congregate facilities was also negatively associated with an improvement in gait speed. The best multivariate model included age, baseline ADL composite scores, confusion status, and gait speed at the start of care, which predicted 41% of the variance in ADL score changes over the course of intervention.

CONCLUSIONS

Gait speed and ADL scores at the start of care had largest influence on functional and gait improvement. Type of discharge facility, confusion status, and living arrangement had effects on HBR outcomes for stroke survivors.

Improving the health care of geriatric patients: management of urinary incontinence: a position paper

A multidisciplinary German expert group met in 2012 to discuss the current status and prospects of health care of geriatric patients with urinary incontinence in Germany. The purpose of this position paper is to raise awareness among health care providers for the challenges associated with adequate management of urinary incontinence in frail elderly. The experts agree that a multidisciplinary collaboration is essential for the successful treatment of urinary incontinence symptoms which are often associated with loss of autonomy and social isolation. For most geriatric patients, usually the general practitioner is the first contact when seeking help. Hence, the general practitioner plays a crucial role in the coordination of diagnosis and treatment. The involved health care providers should have adequate education and training in their respective disciplines and should be networked allowing quick turnaround times. Non-pharmacological treatments (e.g. behavioural interventions) should have been tried before any pharmacotherapy is initiated. If pharmacological treatment of urinary incontinence involves the use of anticholinergic agents, cognitive performance should be monitored regularly. If indicated, anticholinergic agents with a documented efficacy and safety profile, explicitly assessed in the elderly population, should be preferred.

Predictors of functional recovery in patients admitted to geriatric postacute rehabilitation

OBJECTIVE

To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation.

DESIGN

Observational study.

SETTING

Postacute rehabilitation facility.

PARTICIPANTS

Patients (N=2754) aged ≥65 years admitted over a 4-year period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement.

RESULTS

Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16-1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01-1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31-1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15-1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19-23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13-2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67-2.93; P<.001, respectively).

CONCLUSIONS

Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.

Testing the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0

OBJECTIVES

To test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations.

METHODS

The PHQ-9 was tested as part of the national Minimum Data Set 3.0 (MDS 3.0) evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents from 71 community nursing homes (NHs) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS ≥30) agreement between PHQ-9 and the modified Schedule for Affective Disorders and Schizophrenia (m-SADS) was measured with weighted kappas (κ). For residents with severe cognitive impairment (3MS <30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for Depression in Dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MDS assessors.

RESULTS

The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SADS was very good (weighted κ = 0.69, 95% CI = 0.61-0.76), whereas agreement between MDS 2.0 and m-SADS was poor (weighted κ = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MDS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minutes.

DISCUSSION

Compared with the MDS 2.0 observational items, the PHQ-9 interview had greater agreement with criterion standard diagnostic assessments. For residents who could not complete the interview, the PHQ-9 OV also had greater agreement with a criterion measure for depression than did the MDS 2.0 observational items. Moreover, the majority of NH residents were able to complete the PHQ-9, and most surveyed staff reported improved assessments with the new approach.

[Outcome and predictors of early geriatric rehabilitation in an acute care setting]

BACKGROUND

Geriatric assessment and treatment including an interdisciplinary team is a well accepted method to improve functionality and mortality in the elderly. Nevertheless, only little evidence and limited data are available concerning the outcome of this approach in an acute care setting and early rehabilitation.

PATIENTS AND METHODS

All patients included in a comprehensive geriatric program within 1 year were eligible for inclusion in a retrospective chart analysis. Admission to the program was allowed after counseling by an experienced geriatrician applying pre-defined criteria including significant deconditioning, preserved rehabilitation prognosis and/or ongoing instable medical condition requiring an acute care setting. Patients who refused therapy or died within the first week of treatment were excluded. A telephone interview was performed 6 months after patient discharge and data concerning mortality, functional course and quality of life (activities of daily life ADL) were retrieved. All patients were treated in an acute care setting in two geriatric and general internal medicine wards.

RESULTS

A total of 138 patients were included in the program. In 128 cases data concerning the 6 month mortality could be retrieved and 92 patients agreed to participate in a complete telephone interview. Mortality within the early rehabilitation course was 4%, the 6 month mortality however was 28%. Functionality improved during early rehabilitation and a median increment of 10 points in the Barthel index was found (range 0-100). Analysis of individual increments showed high interindividual variability throughout the whole range of the ADL score at the beginning of the treatment. Concerning the 6 month course after hospital discharge functionality remained at a steady median value but showed a large range of both increasing and decreasing ADL values. Analysis of predictors by logistic regression revealed the ADL score on admission to the early rehabilitation program as the predominant predictor overriding other factors such as depression or cognitive impairment. An ADL value ≤15 on admission was a strong predictor for an unfavorable outcome in early rehabilitation defined as death or an ADL increment ≤10. An ADL value ≤15 on admission was also a strong predictor for overall mortality within 6 months. On the other hand an ADL value ≤15 on admission was a strong predictor for a steady or increasing functionality among the survivors of the 6 month postdischarge interval.

CONCLUSIONS

The mortality rate in the early rehabilitation course in this preliminary and observational study was relatively low and may be explained by both the exclusion of patients not surviving the first week of treatment and an effective inclusion algorithm. The high overall 6 month mortality rate may also be explained by the selection of patients focusing on those severely functionally impaired. This subpopulation of elderly inpatients in acute care units reveals a high vulnerability to critical incidents. Besides scale effects there is also a remarkable variability in the 6 month postdischarge course pointing to heterogeneity and different patterns concerning the time course of functionality.

Moderate to severe depressive symptoms and rehabilitation outcome in older adults with hip fracture

OBJECTIVE

To evaluate if depressive symptoms affect recovery of walking ability and 1-year institutionalization or mortality in older adults who underwent post-hip fracture (HF) surgery rehabilitation.

METHODS

Depressive symptoms were assessed on admission using the 15-item Geriatric Depression Scale (GDS), with scores ≥10/15 indicating moderate to severe depressive symptoms. Multidimensional assessment included Mini Mental State Examination, Charlson Comorbidity Index, Body Mass Index, albumin serum levels, number of drugs, antidepressants and Barthel Index (BI) on admission and at discharge. Walking ability was evaluated using the BI walking sub-item referred to 1 month before HF, on admission, and at discharge. Patients scoring ≤3/15 BI walking sub-item on admission (i.e. those fully dependent or requiring major supervision in walking) were included. Walking independence at discharge was defined as a score ≥12/15 at the BI walking sub-item.

RESULTS

In multivariate analyses, after adjustment for covariates and potential confounders, patients with moderate to severe depressive symptoms were more likely to fail walking independence at discharge (odds ratio, OR = 3.2; 95% CI = 1.3 to 7.8; p = 0.010) and to be institutionalized or died at 1 year (OR = 3.6, 95% CI = 1.4 to 9.1, p = 0.007). In further analyses, the failure to recover walking independence at discharge partly mediates the relationship between moderate to severe depressive symptoms and 1-year adverse events.

CONCLUSIONS

Moderate to severe depressive symptoms affect the recovery of walking independence after HF rehabilitation and are associated with severe adverse outcomes at 1 year.

Predictors of functional capacity changes in a US population of Medicare home health care (HHC) patients with heart failure (HF)

PURPOSE

Functional capacity is widely recognized as a key factor in maintaining the ability of older people to live independently and safely at home. Promoting functional capacity is an important priority particularly in HHC. The purpose of the study was to examine predictors of functional capacity change among HHC patients with HF.

MATERIALS AND METHODS

Clinical and administrative data from 2005 from the Medicare Chronic Conditions Warehouse were linked at the population level for HHC patients with a primary diagnosis of HF. The primary outcome was change in functional capacity score from HHC admission to HHC discharge.

RESULTS

Over the course of the episode (M=44 days), most (70%) patients improved, 15.6% stayed the same, and 14.4% declined in activities of daily living (ADL) scores. The mean change score was modest (mean=-0.74, SD=1.11) with a median change of -0.58. Multivariate analyses (R(2)=0.23) showed that the largest influence was the admission ADL score followed by receiving any physical therapy (PT), admission ability to manage oral medications, cognitive functioning, rehabilitation prognosis, and urinary incontinence.

DISCUSSION

There is a modest rate of improvement from admission to discharge that likely represents the progressive nature of HF and/or the short time frames over which HHC is provided. Providers may want to use the predictive factors to identify patients most at risk for functional decline.

Hearing loss: a potential deterrent to successful rehabilitative therapy

If untreated, hearing loss can greatly impact on patients' ability to understand speech and their overall quality of life and sense of wellbeing. Any or all of these factors may affect a patient's willingness and ability to carry out clinic or home-based therapeutic activities.