Postacute rehabilitation in cognitively impaired patients: comprehensive assessment and tailored interventions

A screening test is not enough to define the prognostic role of cognitive impairment after hip fracture: a short-term prospective study

BACKGROUND

Cognitive impairment assessed by easy-to-administer tests successfully predicts function after hip fracture, whereas the prognostic role of additional cognitive evaluations is largely unknown.

AIMS

To investigate the capability of further assessments to discriminate cognitive impairment with prognostic relevance in hip-fracture women defined cognitively intact or mildly impaired on the Short Portable Mental Status Questionnaire (SPMSQ).

METHODS

We prospectively investigated women with subacute hip fracture admitted to our rehabilitation facility. The women who made ≤4 errors on the SPMSQ were further assessed by 4 tests: Montreal Cognitive Assessment, Rey Auditory Verbal Learning Test (immediate and delayed recall) and Frontal Assessment Battery. Activities of daily living (ADL) were measured by the Barthel index. Successful rehabilitation was defined with a Barthel index score ≥85.

RESULTS

Data from 127 women were available. Each of the 4 cognitive tests assessed at admission significantly predicted the Barthel index scores measured at discharge. The predictive role persisted after multiple adjustments. For a change in cognitive scores corresponding to the difference between 25° and 75° percentiles in their distribution in the sample, the adjusted odds ratio to achieve successful rehabilitation roughly ranged from 2 to 4, depending on which cognitive test was adopted.

DISCUSSION

The women with subacute hip fracture defined cognitively intact or mildly impaired on the SPMSQ could have cognitive impairment revealed by further examination, with prognostic disadvantages in ADL.

CONCLUSIONS

Assessing cognition by the SPMSQ seems not enough to exclude the presence of cognitive impairment with relevant prognostic disadvantage in hip-fracture women.

Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients

Objective

Delirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation.

Design

Prospective cohort study.

Setting

Hospital rehabilitation unit.

Participants

A total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006.

Measurements

Dementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations.

Results

The median age was 77 years (interquartile range: 71–83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6–42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8–8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1–2.8; P = .01).

Conclusions

DSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.

Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial

OBJECTIVES

For millions of disabled older adults each year, postacute care in skilled nursing facilities is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly because of therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in postacute-care rehabilitation.

DESIGN

Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation.

SETTING

Postacute care unit of a skilled nursing facility in St Louis, MO.

PARTICIPANTS

Twenty-six older adults admitted from a hospital for postacute rehabilitation.

INTERVENTION

Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists that increase patient engagement and intensity, with the goal of improving functional outcome, through (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress.

MEASUREMENTS

Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and 6-minute walk.

RESULTS

Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 m/s versus 0.08 to 0.22 in standard of care, P = .003) and 6-minute walk (from 73 to 266 feet versus 40 to 94 feet in standard of care, P = .026), with a trend for better improvement of Barthel Index (+43 points versus 26 points in standard of care, P = .087), compared with participants randomized to standard-of-care rehabilitation.

CONCLUSION

Higher intensity and patient engagement in the postacute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.