The older adult with a spinal cord injury

Trends in the characteristics and outcomes of older patients with non-traumatic spinal cord injury treated in inpatient rehabilitation facilities: 2013-2018

OBJECTIVE

To describe the characteristics and outcomes of older (≥ 65 years of age) patients with a non-traumatic spinal cord injury (NTSCI) treated in inpatient rehabilitation facilities (IRFs) between 2013 and 2018.

DESIGN

Observational study.

SETTING

IRFs in the United States.

PARTICIPANTS

93,631 IRF Medicare stays for patients with NTSCI.

INTERVENTIONS

Not Applicable.

MAIN OUTCOME MEASURES

Length of stay, self-care and mobility function, discharge destination.

RESULTS

Between 2013 and 2018, the number of older (≥ 65 years of age) Medicare patients with a NTSCI treated in IRFs increased about 22.1 percent, from 14,149 to 17,275. In addition to the increase, patients' sociodemographic characteristics shifted to have a slightly higher percentage of patients aged 65-74 years, a slightly higher percentage of males, and slightly fewer patients who identified as Hispanic. There was also a trend of more patients in the higher acuity case-mix groups and comorbidities tiers, but the median length of stay remained 12 days across all years. The percent of patients discharged home or to a community-based setting varied from 73.7 to 75.2 without a trend, although discharge self-care and mobility function increased slightly across the years.

CONCLUSIONS

Between 2013 and 2018, the number of Medicare patients with NTSCI treated in IRFs increased by more than 22 percent. While patient complexity increased, the median length of stay remained 12 days across the years. Discharge self-care and mobility function increased slightly, and the percent of patients discharged home ranged from 73.7 to 75.2 across the years.

Long-term body-weight-supported treadmill training for incomplete cervical spinal cord injury: a case report

[Purpose] To investigate the effects of long-term body-weight-supported treadmill training on walking ability and physical function in an elderly individual with incomplete cervical spinal cord injury. [Participant and Methods] The patient was a 68 year-old male with an incomplete spinal cord injury at the C3/C4 level, incurred when he was 56 years old. He initiated home-based body-weight-supported treadmill training using a body-weight-supported treadmill installed at his home. His walking ability was measured as the percentage of body weight load reduction, and his physical function was evaluated using manual muscle testing and measuement of the range of motion of his lower limbs. [Results] The physical function of the lower limbs was improved, maintained, or showed delayed decline until 9.5 years post-injury. [Conclusion] Long-term body-weight-supported treadmill training may improve, maintain, or at least delay the decline of the physical function of participants for several years, without causing any remarkable complications.

Interorganizational Linkages and Service and Personnel Shortages in Rural Nursing Homes

Increased demands on nursing homes for more diversified and technically complex services pose particular challenges for rural facilities. Because coordinating mechanisms have been proposed as a management strategy to deal with these issues, we studied the relationship between interorganizational linkages and shortages of personnel and services in a sample of 152 rural Pennsylvania nursing homes. Significant shortages of health care personnel that are central to long-term care were reported, as were shortages of services, especially for ventilator-dependent and demented residents. Although no evidence exists that coordination efforts were effective remedies to these problems in early 1992, it is apparent that managing patient/resident flows between hospitals and nursing homes through contractual agreements and other forms of "coordination" was identified as a strategy. Further research is required to assess the effectiveness of these types of agreements in terms of ensuring the continuity and quality of long-term care services in rural areas.

[Traumatic spinal cord injury in people over 65 in Asturias]

AIMS

to assess incidence, causes and socio-demographicaspects of traumatic spinal cord injury among patients over 65 in Asturias (Spain).

PATIENTS AND METHODS

A census was performed between 1951 and 2013 of patients in Asturias, over 65 years-old coded as «traumatic spinal cord injury with or without vertebral fracture». Socio-demographic, hospital and clinical variables were recorded.

RESULTS

In total 180 patients were registered, most of them males (60%), with a mean age of 73 years (maximum 91). The estimated incidence in 2010 was found to be 24.9, in 2011, 28.9 and in 2012, 32.9 cases/million/year. The distribution in the type of injury was homogeneous and location in the cervical spine (40%) was found to be more common. There was bone injury in 71.4%, with multilevel injury in more than half of the cases. The main cause was accidental fall (52.1%), mainly at own height (68.6%), and most of them located in the cervical spine (38.5%), followed by traffic accidents with 57.6% located in the cervical spine.

CONCLUSIONS

A change was observed in the epidemiological profile of the patients over 65 years old with spinal cord injury. There were more cases associated with accidental fall. It is necessary to create specific preventive and therapeutic strategies for this group.

Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury

BACKGROUND

Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (≥ 70 yr) on treatment decisions and outcomes.

METHODS

We identified patients with traumatic spinal cord injury for whom consent and detailed data were available from among patients recruited (2004-2013) at any of the 31 acute care and rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry. Patients were assessed by age group (< 70 v. ≥ 70 yr). The primary outcome was the rate of acute surgical treatment. We used bivariate and multivariate regression models to assess patient and injury-related factors associated with receiving surgical treatment and with the timing of surgery after arrival to a participating centre.

RESULTS

Of the 1440 patients included in our study cohort, 167 (11.6%) were 70 years or older at the time of injury. Older patients were more likely than younger patients to be injured by falling (83.1% v. 37.4%; p < 0.001), to have a cervical injury (78.0% v. 61.6%; p = 0.001), to have less severe injuries on admission (American Spinal Injury Association Impairment Scale grade C or D: 70.5% v. 46.9%; p < 0.001), to have a longer stay in an acute care hospital (median 35 v. 28 d; p < 0.005) and to have a higher in-hospital mortality (4.2% v. 0.6%; p < 0.001). Multivariate analysis did not show that age of 70 years or more at injury was associated with a decreased likelihood of surgical treatment (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.22-1.07). An unplanned sensitivity analysis with different age thresholds showed that a threshold of 65 years was associated with a decreased chance of surgical treatment (OR 0.39, 95% CI 0.19-0.80). Older patients who underwent surgical treatment had a significantly longer wait time from admission to surgery than younger patients (37 v. 19 h; p < 0.001).

INTERPRETATION

We found chronological age to be a factor influencing treatment decisions but not at the 70-year age threshold that we had hypothesized. Older patients waited longer for surgery and had a substantially higher in-hospital mortality despite having less severe injuries than younger patients. Further research into the link between treatment delays and outcomes among older patients could inform surgical guideline development.

The burden of acute traumatic spinal cord injury among adults in the united states: an update

The current incidence estimate of 40 traumatic spinal cord injuries (TSCI) per million population/year in the United States (U.S.) is based on data from the 1990s. We sought to update the incidence and epidemiology of TSCI in U.S adults by using the Nationwide Emergency Department Sample (NEDS), the largest all-payer emergency department (ED) database in the United States. Adult ED visits between 2007 and 2009 with a principal diagnosis of TSCI were identified using International Classification of Diseases (ICD)-9 codes (806.0-806.9 and 952.0-952.9). We describe TSCI cumulative incidence, mortality, discharge disposition, and hospital charges weighted to the U.S. population. The estimated 3-year cumulative incidence of TSCI was 56.4 per million adults. Cumulative incidence of TSCI in older adults increased from 79.4 per million older adults in 2007 to 87.7 by the end of 2009, but remained steady among younger adults. Overall, falls were the leading cause of TSCI (41.5%). ED charges rose by 20% over the study period, and death occurred in 5.7% of patients. Compared with younger adults, older adults demonstrated higher adjusted odds of mortality in the ED (adjusted odds ratio [AOR]=4.4; 95% confidence interval [CI]: 1.1-16.6), mortality during hospitalization (AOR=5.9; 95% CI: 4.7-7.4), and being discharged to chronic care (AOR=3.7; 95% CI: 3.0-4.5). The incidence of TSCI is higher than previously reported with a progressive increase among older adults who also experience worse outcomes compared with younger adults. ED-related TSCI charges are also increasing. These updated national estimates support the development of customized prevention strategies based on age-specific risk factors.

Concepts of aging with paralysis: implications for recovery and treatment

This chapter deals with the impact of age on the occurrence, clinical presentation, outcome, and course of a spinal cord injury (SCI). This is of importance in a society where the population of elderly people continuously increases. The chapter is focused first, on the actual problems of a SCI in elderly subjects and second, on age-specific sequelae after a SCI. The etiology and clinical presentation of a SCI differs in elderly subjects compared to young subjects. With advanced age, incomplete cervical lesions following falls or due to spondylotic degeneration of the cervical spine and non-traumatic SCI occur more frequently. Research pertaining to the comparison of different age groups is prone to bias due to survival and treatment cohort effects. There is an increased risk of complications and mortality after a complete SCI in elderly people. Surprisingly, the recovery of the neurological deficit does not depend on age. However, elderly subjects with SCI have more problems in transferring an improvement in motor score into a functional improvement in their ability to carry out the activities of daily living. With increasing age after a SCI the completeness and level of injury determine the occurrence of complications and outcome restrictions. In addition, problems in general health (e.g., in circulation, kidney function, diabetes mellitus) may affect the functional independence of elderly subjects with SCI.

Predictors for mortality in elderly patients with cervical spine injury: a systematic methodological review

STUDY DESIGN

Systematic methodological review.

OBJECTIVE

Identify predictors for cervical spine injury (CSI) mortality in elderly patients by reviewing the available literature.

SUMMARY OF BACKGROUND DATA

The proportion of active elderly individuals in society is increasing. This population is at high risk for CSI mortality. The results of studies identifying predictors for CSI mortality in the elderly population are often inconclusive or even conflicting. Currently, there is no set of predictors that can adequately identify and describe CSI mortality risk for the elderly. Thus, we performed a systematic review to identify the predictors for mortality in elderly patients with CSI.

METHODS

We performed searches in the MEDLINE, EMBASE, ScienceDirect, and OVID databases (articles published prior to May 2012) for noninterventional studies that evaluated predictors for CSI mortality in the elderly. Only those observational studies with eligible data were included. Study quality was assessed using a modified quality assessment tool that was designed previously for an observational study. Study outcomes were combined with study quality scores using a best-evidence synthesis model.

RESULTS

Twenty-three observational studies involving 2325 patients were included. These studies were published between 1993 and 2011. According to the quality assessment criteria, 8 studies were of high quality, 11 studies were of moderate quality, and 4 studies were of low quality. We identified 3 strong evidence predictors for CSI mortality, including pre-existing comorbidities, spinal cord injury, and age. We also identified 3 moderate evidence predictors, 7 limited evidence predictors and 1 conflicting evidence predictor.

CONCLUSION

Although there is no conclusive evidence regarding the mortality of elderly patients with CSI, these data provide information that can help us to make recommendations and to counsel patients and their families. Special attention should be paid to the 3 strong predictors. Further studies will be required to validate these predictors.

Spinal cord injuries sustained in road crashes are not on the decrease in france: a study based on epidemiological trends

Traumatic spinal cord injuries (SCI) are rare but extremely costly. In order to improve the modelling of inclusion criteria for studies of SCI it is necessary to determine what epidemiological trends affect SCI. Using the Rhone Registry, which contains all the casualties resulting from road crashes in the Rhône département of France and codes their injuries using the Abbreviated Injury Scale (AIS), we describe the epidemiological trends that affect spinal cord injury (SCI), major spinal trauma (MST) and severe injuries (AIS4+) to other body regions between two periods 1996-2001 and 2003-2008. Although there has been a marked decrease (35%) in the incidence of casualties after a road traffic crash, and reductions of 22% in the incidence of MST and 33% in that of severe injuries (AIS4+) (p<0.001), for SCI the incidence rate and number of casualties have remained surprisingly stable. In the second period, there was no change in the incidence of SCI resulting from road traffic crashes, nor in the associated fatality, mortality and survival rates. The incidence for car users was significantly lower in the second period. This contrasts with the incidences for motorcyclists and for the group including pedestrians and cyclists which were respectively 47% and 77% higher in the second period. The median age of the casualties, the age-adjusted incidence of SCI and the number of associated injuries were also higher in the second period. We have observed a marked reduction in the incidence of road trauma including the most severe injuries, but not SCI. The higher proportion of motorcyclists, the increase in the age of casualties and the greater presence of multiple injuries are new factors in the epidemiology of SCI after a road crash.

Age influences rehabilitative outcomes in patients with spinal cord injury (SCI)

BACKGROUND AND AIMS

To define differences in rehabilitative outcome after Spinal Cord Injury (SCI), according to age at injury.

METHODS

This is a prospective, observational, follow-up study. Completion of a questionnaire administered by a psychologist through a telephone interview to subjects discharged about 4 years previously from 22 SCI centers in Italy, who had already participated in a prospective multicenter study. A total of 403 out of 511 patients with SCI (79%), discharged between 1997 and 1999 after comprehensive rehabilitation in SCI centers, who gave their consent to a telephone interview. Main outcome measures are: number of re-admissions and medical consultations for clinical problems during follow-up (FU) period, clinical outcome related to bowel/ bladder function, family, sentimental and personal satisfaction, mobility, three-day autonomy, subjective feelings of dependency, subjective perception of quality of life.

RESULTS

The sample population was categorized into two subgroups according to severity on the Asia Spinal Injury Association (ASIA) scale by the ROC method: 276 subjects, the younger group were aged between 0 and 49 years, mean age 32 (±8 yrs), and 127 subjects in over 50 group, mean age 63 (±8 yrs). Differences in sample characteristics were found as regards cervical/dorsal lesion distribution and incompleteness of damage, more frequent in the older group. Incidence of hospital re-admissions and medical consultations, bladder autonomy, bowel autonomy and bowel continence were similar in both groups. Variables related to personal and social life, as well as life satisfaction, showed significant differences, with worse outcomes in the older group.

CONCLUSIONS

Age at injury deserves major attention, as persons not yet in geriatric age may show greater vulnerability after SCI.

Risk factors predicting mortality after blunt traumatic cervical fracture

OBJECTIVE

Risk factors for mortality after blunt cervical trauma have received little attention within the literature. Therefore, we performed a study, to determine which factors are associated with mortality in patients with blunt cervical trauma.

STUDY DESIGN

A retrospective study of 88 trauma patients, with cervical fractures, who were admitted to the emergency department of the St. Elisabeth hospital, Tilburg, The Netherlands.

SUMMARY OF BACKGROUND DATA

A retrospective cohort study was performed within the trauma department of the St. Elisabeth Hospital, in Tilburg, The Netherlands. From January 2000 to December 2005, all patients with cervical fractures after blunt trauma were included (N=88). All patient records were reviewed. Patient and trauma characteristics were registered within a standardised electronic database. Our follow-up period was 1 year.

RESULTS

In total, 12 (13.6%) patients died after a traumatic cervical fracture. Age (p=0.005), gender (p=0.005), involvement of the third cervical vertebrae (p=0.003), involvement of three cervical vertebrae (p=0.010) and involvement of the spinous process (p=0.032) were associated with mortality. The multivariate analysis showed that age and the involvement of the third cervical vertebrae (both p=0.016) are both independently associated with mortality.

CONCLUSION

Age and involvement of the third cervical vertebrae were both independent predictors of mortality. Age has been previously described as a risk factor for adverse prognosis in different diseases and trauma's. However, involvement of the third cervical vertebrae has not yet been described as a significant risk factor. Before implementation within trauma support further research is needed to evaluate the role of the third cervical vertebra regarding adverse prognosis and mortality in trauma patients.

Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury

OBJECTIVE

To investigate how injury level and American Spinal Injury Association Impairment Scale (AIS) grade at rehabilitation admission are related to walking at discharge after traumatic spinal cord injury (SCI).

DESIGN

Retrospective study.

SETTING

Comprehensive rehabilitation hospital.

PARTICIPANTS

A total of 343 adult inpatients with traumatic SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

FIM instrument walking rating of 3 (moderate assistance) or higher at discharge.

RESULTS

Significantly more subjects admitted with AIS grade C (28.3%) than AIS grade A or B injuries (0.9%) walked at discharge. Significantly more subjects admitted with AIS grade D (67.2%) than AIS grade C (28.3%) injuries walked at discharge. Level of injury did not significantly affect walking after AIS grade C or D injuries. Being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries.

CONCLUSIONS

Admission AIS grades give information about walking for treatment and discharge planning during acute inpatient rehabilitation, including the following: (1) patients admitted with AIS grade C injuries should not be considered functionally complete when predicting walking (FIM score > or = 3; no more than moderate assistance) at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older has a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries.

A comparative study of outcomes and expenses following tetraplegia and paraplegia

OBJECTIVE

A study was designed to directly compare individuals with tetraplegia and paraplegia to further explore neurological and functional outcomes and their impact on the expense of rehabilitation when controlling for level of completeness, age at the time of injury, and length of stay.

METHODS

A sample was drawn from the National Spinal Cord Injury Database consisting of 2069 individuals, 1005 with paraplegia and 1064 with tetraplegia.

RESULTS

Significant demographic differences were found between the 2 groups with regard to age, ethnicity, marital status, and employment status. Significant differences were found between the groups with regard to all individual outcome variables (p < .001) and expenses (p < .05). On average, patients with paraplegic injuries evidenced greater change and efficiency on a functional independence measure than patients with tetraplegia. In contrast, patients with tetraplegia showed greater changes and efficiency with regard to ASIA Motor Index scores. Higher rehabilitation expenses were found for patients with tetraplegia.

Influence of age and gender on rehabilitation outcomes in nontraumatic spinal cord injury

STUDY DESIGN

Retrospective, 3-year case series.

OBJECTIVE

To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI).

SETTING

Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI.

METHOD

Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores.

RESULTS

Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P = 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P = 0.04) subscores. There were no significant relationships between gender and FIM subscale scores.

CONCLUSIONS

Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.

Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation

OBJECTIVE

To compare outcomes, complications, and therapy intensity of inpatient rehabilitation in patients with paraplegia caused by spinal cord injury associated with aortic aneurysm repair (SCI-AA) versus patients with traumatic spinal cord injury (SCI).

DESIGN

Case-controlled study.

SETTING

SCI unit in a rehabilitation center.

PARTICIPANTS

Seventeen patients with SCI-AA and 17 patients with traumatic SCI.

INTERVENTION

Standard rehabilitation therapy for SCI.

MAIN OUTCOME MEASURES

Length of stay (LOS) in acute and rehabilitation hospitals; FIM instrument scores; FIM change; FIM efficiency; complications; therapy intensity; and ambulatory state and return to community at discharge.

RESULTS

No significant differences were noted in acute and rehabilitation LOS and admission FIM scores. Discharge FIM scores, FIM change, and FIM efficiencies were significantly lower in the SCI-AA group, which had many complications related to AA and SCI. Intensity of rehabilitation sports therapy in the SCI-AA group was significantly lower than that of the traumatic SCI group, but total therapy intensity did not differ significantly. Both had similar rates of return to ambulatory state and discharge to the community.

CONCLUSIONS

SCI-AA patients had many complications that interfered with rehabilitation therapy, and could not achieve functional gains comparable to those with traumatic SCI. However, both groups achieved comparable success with return to ambulatory state and discharge to the community.

The clinical significance of spinal cord injuries in patients older than 60 years of age

OBJECTIVES

To study the causes and the rehabilitation outcome of traumatic spinal cord injury (SCI) in patients older than 60 years at the time of injury.

MATERIAL

Forty-four patients were included.

METHODS

The American Spinal Injury Association Motor Impairment Scale on admission and at discharge and the Functional Independence Measure Motor subscale at discharge were calculated retrospectively according to the patient records. The causes of injury and treatment were obtained. The MRI-scans in patients with cervical injuries during the last 5 years were evaluated.

RESULTS

Thirty-four patients (77%) were injured after falling from a height, 24 with cervical lesions. Thirty-five patients (80%) had incomplete lesions and they had the best outcome with regard to functional level. MR images of 15 patients with cervical lesions revealed preexisting cervical stenosis in 80%.

CONCLUSIONS

A high proportion of the patients had a cervical spinal stenosis and incomplete SCI; most of them regained good function.

The effects of gender on clinical and neurological outcomes after acute cervical spinal cord injury

The potential clinical relevance of gender on clinical and neurological outcome after spinal cord injury (SCI) has received little attention. In order to address this issue, we examined all consecutive cases of acute traumatic cervical SCI admitted to our institution from 1998 to 2000. There were 38 males (ages 17-89 years, mean of 51.6) and 17 females (ages 18-84 years, mean of 63.2). Both groups were comparable regarding level (C1 to C7) and severity of SCI (ASIA A to D) at admission. Age differences between the groups approached significance (p = 0.057), and thus this factor was treated as a covariate in the analysis. Co-morbidities were as frequent in men (86.8%) as in women (76.5%). The therapeutic approaches, length-of-stay in the acute care unit, mortality, and discharge disposition were similar in men and women. During hospitalization, 44.7% of men and 52.9% of women developed post-SCI secondary complications without any significant gender-related differences. Both groups showed a similar incidence of infections, cardiovascular complications, thromboembolism, and pressure sores. Univariate analysis revealed a trend for higher incidence of psychiatric complications (p = 0.054) and deep venous thrombosis (p = 0.092) in women, which was confirmed by multivariate analysis. Neurological outcome was not correlated with gender. A similar number of males and females (42.1%, 47.1%) showed evidence of neurological recovery as revealed by an improvement in ASIA scores. Moreover, 18.4% of males and 29.4% of females recovered to ASIA E status. Our data suggest a shift in the demographics of acute SCI with an increasing incidence in elderly women. Although neurological outcomes were not significantly related to gender, we observed a trend for higher rates of reactive depression and deep venous thrombosis in women. These issues may be of key clinical importance in developing improved management protocols for SCI so as to maximize functional recovery and quality-of-life.

Medical co-morbidities, secondary complications, and mortality in elderly with acute spinal cord injury

Despite an increasing incidence of spinal cord injury (SCI) in the elderly and evidence that age appears to influence outcome after neurotrauma, surprisingly little is known regarding clinical outcomes and secondary complications in elderly with an acute SCI. This study was undertaken to evaluate the effect of age on clinical outcomes after acute traumatic SCI managed in an acute care unit by a multidisciplinary team. A retrospective chart review of all patients with acute SCI admitted to an acute care unit at a university hospital between 1998 and 2000 was performed. Data on clinical outcomes and secondary complications in younger individuals (group 1: age < 60 years) were compared to elderly subjects (group 2: age > or = 60 years). There were 28 elderly (age 60-89 years) and 30 younger (age 17-56 years) individuals. The severity and level of SCI were similar in both groups (p = 0.11; p = 0.93). Co-morbidities were more frequent in the elderly (p < 0.01). There was a trend, which did not achieve significance, for an increased incidence of secondary complications in the elderly (57.1% versus 33.3%; p = 0.11). The most common secondary complications in both groups were infections, psychiatric disorders, pressure sores, and cardiovascular complications. Mortality rates in elderly and younger individuals with acute SCI (p = 0.41) were not significantly different. Our data suggest that rigorous attention to principles of acute SCI care can minimize previously reported higher susceptibility for secondary complications in the elderly. A multidisciplinary team approach to the management of the elderly with acute SCI is essential to minimize or prevent secondary complications.

Outcomes of nurse caring as perceived by individuals with spinal cord injury during rehabilitation

A study was undertaken to describe the meaning, process, and consequences of nurse caring from the perspective of persons with spinal cord injuries (SCI) during rehabilitation. The constant comparative method, or grounded theory, was used in this prospective, exploratory project. In-depth tape-recorded interviews were conducted with 22 participants throughout their initial rehabilitation stay. A process of knowledge acquisition and decision making, facilitated by nurses and therapists in special caring relationships with the persons with SCI, resulted in outcomes of well-being, self-care, autonomy in decision making, independence, and hope, all of which contributed to the persons with SCI's reintegration of self before their discharge from inpatient rehabilitation.

Age, outcome, and rehabilitation costs after paraplegia caused by traumatic injury of the thoracic spinal cord, conus medullaris, and cauda equina

The object of this study was to investigate the relationships of age on neurologic and functional outcome, hospitalization length of stay (LOS), and hospital charges after spinal cord injury (SCI). At 20 medical centers, 2,169 consecutive adult patients with paraplegia SCI were assessed in acute care and inpatient rehabilitation. Outcome and treatment measures included the ASIA motor index score, functional independence measure, discharge to community ratio, LOS, and hospital charges. Age differences were examined by separating the sample into 11 age categories and conducting one-way analyses of variance on treatment, medical expense, and outcome measures that included the Functional Independence Measure (FIM) and ASIA motor index scores. Cramer's statistic was used to derive a chi-square value that indicated whether variables differed significantly in terms of age. Post-hoc Tukey tests were also performed. Age-related differences were found with multiple demographic variables. Significant differences between age categories were found with regard to the following treatment measures: ASIA motor index scores at acute-care admission and at discharge, rehabilitation LOS, inpatient rehabilitation hospitalization charges, total LOS, total hospitalization charges, FIM scores at inpatient rehabilitation admission and discharge, FIM change, and FIM efficiency. In conclusion, in patients with paraplegia, age appears to adversely affect functional outcome, rehabilitation LOS, and hospital costs. However, neurologic recovery as defined by the ASIA motor scores does not appear to be related to age.

Discharge disposition from model spinal cord injury care system rehabilitation programs

OBJECTIVE

To identify and quantify factors associated with discharge to a nursing home for people with spinal cord injuries.

DESIGN

Case control within a cohort of spinal cord injured persons.

SETTING

Model spinal cord injury care systems throughout the United States.

PATIENTS

A total 16,633 patients consecutively discharged alive between 1973 and 1996 who were admitted to the model system within 1 year of injury, who were both injured in and resided in the catchment area of the model system, and who were discharged to either a nursing home or a community residence.

MAIN OUTCOME MEASURE

Discharge disposition.

RESULTS

Overall, 4.3% of patients were discharged to a nursing home. Factors that were significantly associated (p < .0001) with place of discharge were age, race, employment status at injury, bladder management method at discharge, education level, marital status, Frankel grade, functional independence in performing activities of daily living, independent ambulation, geographic region, neurologic level of injury, ventilator dependency, and third-party sponsor of rehabilitation. A multivariate predictive model was developed from these factors and was both 78% sensitive and specific in identifying patients who were discharged to a nursing home.

CONCLUSIONS

Knowing the probability of nursing home placement can assist in evaluating the success of a rehabilitation program by allowing adjustment for case-mix differences across facilities.

A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample

OBJECTIVE

To examine the effects of age at injury on lengths of stay, treatment costs, and outcomes using a matched sample of tetraplegic spinal cord injury (SCI) patients.

DESIGN

Differences were examined by separating the sample into three age categories (18 to 34, 35 to 64, and 65+ years old) matched for American Spinal Injury Association (ASIA) Motor Impairment Classification and level of neurologic preservation bilaterally. Analysis of variance was used to examine age group differences for lengths of stay, medical expenses, and functional outcome.

SETTING

Sixteen medical centers in the federally sponsored Spinal Cord Injury Model Systems Project.

PARTICIPANTS

Three hundred seventy-five adult patients with tetraplegic SCI admitted between 1988 and 1996 were assessed at acute care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge.

MAIN OUTCOME MEASURES

ASIA Motor Index and Functional Independence Measure (FIM) admission, discharge, and efficiency scores; acute care and rehabilitation lengths of stay and medical care charges; and discharge disposition.

RESULTS

Analyses revealed equivalent lengths of stay and charges for all age groups. There were no age-related differences in ASIA and FIM Motor scores at acute care and inpatient rehabilitation admission. Younger patients' scores on the FIM Motor subscale improved significantly more than did middle and older patients'. The two younger groups of patients had a more significant improvement than did older patients, as indicated by ASIA Motor Index scores. When taking lengths of stay into account, the FIM motor scores of the youngest group of patients improved more quickly than those of the two older groups. Furthermore, the younger and middle age groups demonstrated greater treatment efficiency than the older patient group based on ASIA Motor Index score ratios. Younger patients were least likely to be discharged to institutional settings.

CONCLUSIONS

Along with neurologic and functional status, age should be considered when formulating treatment plans and prognostic statements. For older patients, alternative rehabilitation settings with lower-intensity treatment and lower charges may prove to be a more efficacious use of resources.

Recovery of ambulation in motor-incomplete tetraplegia

OBJECTIVE

To determine the effect of age and initial neurologic status on recovery of ambulation in patients with motor-incomplete tetraplegia.

STUDY DESIGN

Inception cohort study.

SETTING

Urban, tertiary care hospital with Regional Spinal Cord Injury Center.

PATIENTS

One hundred five patients with American Spinal Injury Association (ASIA) C or D tetraplegia at admission or within 72 hours of injury.

MAIN OUTCOME MEASURE

Ambulatory status at time of discharge from inpatient rehabilitation.

RESULTS

Ninety-one percent (30/33) of ASIA C patients younger than 50 years of age became ambulatory by discharge, versus 42% (13/31) ASIA C patients age 50 or older (p < .0001). All (41/41) patients initially classified as ASIA D became ambulatory by discharge.

CONCLUSION

For patients with ASIA D tetraplegia, prognosis for recovery of independent ambulation is excellent. For patients with ASIA C tetraplegia, recovery of ambulation is significantly less likely if age is 50 years or older.

Early predictors of functional independence 2 years after spinal cord injury

OBJECTIVE

To determine: (1) how well factors measured at admission to an acute care facility predict functional independence measure (FIM) scores, use of personal care assistance, and wheelchair ownership 2 years after traumatic spinal cord injury (SCI); (2) the extent that factors measured during inpatient stay add to these predictions; and (3) if FIM scores differ through use of assistance and wheelchair ownership 2 years after SCI.

DESIGN

Prospective, longitudinal.

SETTING

Tertiary care acute, rehabilitation hospitals and home settings.

PATIENTS

One hundred sixty SCI admissions.

MAIN OUTCOME MEASURES

FIM, use of personal care assistance (yes/no), and wheelchair ownership (manual/electric/none) 2 years after SCI.

RESULTS

Year 2 FIM scores were highly correlated (> or = .68) to the ASIA admission and discharge light touch, pin prick, and motor scores. Admission neurological status and age accounted for 65% of year 2 FIM score variance. Adding hospital events and the discharge ASIA motor score increased prediction to 76% of the variance. A separate regression model using only year 2 neurological scores and age accounted for 73% of the total FIM variance. Discriminant function analysis indicated 86% correct classification regarding use of personal care assistance and 88% correct classification of wheelchair ownership. Using a separate cross-validation sample, overall classification accuracy for assistance was 80% and wheelchair ownership 67%. FIM scores were significantly lower in assistance users (78 +/- 24) than nonusers (120 +/- 8) and were significantly different between wheelchair ownership groups: manual (103 +/- 21), electric (61 +/- 15), and none (125 +/- 2).

CONCLUSIONS

Late disability can be predicted using early impairment measures. The FIM prediction from variables measured during the early treatment phase was as good as prediction based on concurrent measures.

Intermediate-term outcome of cervical spinal cord-injured patients older than 50 years of age

STUDY DESIGN

This study retrospectively reviewed the intermediate-term clinical outcome of patients who were 50 years of age or older at the time they experienced their cervical spinal cord injury.

OBJECTIVES

To establish reasonable expectations for the functional outcome in the older patient with cervical spinal cord injury.

BACKGROUND DATA

The long-term morbidity and mortality of large groups of patients with spinal cord injury have been reported. The specific functional ability, disposition, morbidity, and mortality of this group of older patients injured after 50 years of age, however, have been less well defined.

METHODS

Forty-one consecutive patients older than 50 years of age at the time of cervical cord injury were studied, and functional abilities, independence, need for assistance in activities of daily living, disposition, morbidity, and mortality were assessed. All patients had more than 2 years of follow-up examinations (mean, 5.5 years) by the same spine injury service.

RESULTS

There were 13 complete and 28 incomplete cervical cord lesions. The mean age of the patients at follow-up examination was 67.5 years. The average follow-up period was 5.5 years after injury. None of the patients with complete cord injury improved, and all required extensive care. Twenty-one (80%) of 26 of the patients with incomplete cord injury were able to ambulate with some assistance. Nineteen of 26 patients had independent or near-independent abilities with activities of daily living. Twenty (77%) of 26 were able to return home. All patients with complete cord injury (13 of 13) had died by the time of the follow-up visit. Seventy-seven percent (10 of 13) of this patient group had died within the first year. Those surviving lived an average of 3.5 years after their injury. Fourteen of 28 patients with incomplete cord injury (50%) had died by the time of the follow-up visit. Six (43%) of the 14 deaths were attributed to complications of their spinal cord injury.

CONCLUSION

The functional outcome of the person older than 50 years with a complete cervical cord injury is poor. Of the 14% who survived the first year, all required extensive attendant care, and no neurologic improvement was seen. The patient with an incomplete cord injury has an overall good outcome regarding ambulation and returning to home.

Interpreting the effect of common medical conditions on voiding dysfunction in the elderly

Medical conditions often have an important causal role in urinary incontinence in the elderly. Aside from causing functional impairments, such diseases directly may involve the genitourinary system--particularly its neurologic control--resulting in specific lower urinary tract pathophysiology. Knowledge of the specific effects that medical conditions may have on the genitourinary system and continence can assist the urologic specialist in determining the often complex cause(s) of UI in older persons.