Rehabilitation of amputees with end-stage renal disease. Functional outcome and cost

REHABILITATION OUTCOMES IN PATIENTS WITH LOWER LIMB AMPUTATION RECEIVING HAEMODIALYSIS: A RETROSPECTIVE COHORT STUDY

OBJECTIVE

To compare the functional outcomes of patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis.

DESIGN

A retrospective cohort study.

PATIENTS

Patients with lower limb amputation who were admitted to a convalescent rehabilitation ward between January 2018 and December 2021.

METHODS

The primary outcome was the effectiveness of the Functional Independence Measure (FIM) during hospitalisation in the ward. Secondary outcomes included the total and subtotal (motor/cognitive) FIM scores at discharge, gain in the total and subtotal (motor/cognitive) FIM scores, K-level at discharge, length of hospital stay in the ward, rehabilitation time, and discharge destination. Outcomes were compared between the non-haemodialysis and haemodialysis groups.

RESULTS

A total of 28 patients (mean [standard deviation] age, 67.0 [11.9] years; men, 20) were enrolled in this study. Among them, 11 patients underwent haemodialysis. The FIM effectiveness was significantly higher in the non-haemodialysis group than in the haemodialysis group (median [interquartile range], 0.78 [0.72 - 0.81] vs 0.65 [0.28 - 0.75], p = 0.038). The amount of rehabilitation and all secondary outcomes were not significantly different between the groups (p > 0.05).

CONCLUSION

Patients with lower limb amputation who were receiving haemodialysis had poorer FIM effectiveness than those not receiving haemodialysis.

Importance of Early Inpatient Geriatric Rehabilitation on Outcomes in Individuals on Dialysis

OBJECTIVE

To report short-term functional outcomes of patients incident to dialysis undergoing inpatient rehabilitation within 3 months of dialysis initiation.

DESIGN

Retrospective observation study using prospectively collected data.

SETTING

Single-center, hospital-based geriatric dialysis rehabilitation unit. All patients incident to hemodialysis admitted to the geriatric dialysis rehabilitation unit between May 2002 and April 2016 were identified using a retrospective observational design. Clinical and demographic data were collected prospectively and linked, using the unique hospital number and dates of admission and discharge, to FIM scores (used to assess functional recovery) at admission and discharge.

PARTICIPANTS

Patients (N=449; mean age ± SD, 74±9y) newly started on hemodialysis (within 3mo).

INTERVENTIONS

Inpatient rehabilitation care, short daily dialysis therapy with nephrologist support, and geriatrician assessment.

MAIN OUTCOMES

Change in FIM score; discharge location.

RESULTS

Patients were admitted within 3 months of hemodialysis initiation. The median length of stay in the rehabilitation program was 43 days (25th and 75th quartile, 33-55 days). Of those with complete data (n=370), 95% had improvement in FIM scores (median changes in total FIM score 25 [quartiles, 16, 33]; in motor FIM 23 [quartiles, 15, 32]; and in cognitive FIM 1 [quartiles, 0, 3], respectively). Most improvement was seen in transfer abilities, grooming, and mobility. A total of 324 patients (72%; 95% CI, 68%-76%) were discharged to a private home. An additional 11 were discharged to a seniors' residence.

CONCLUSION

The data suggest that older patients incident to dialysis with functional decline respond well to specialized rehabilitation care and suggest this may be a novel approach to dialysis initiation.

Geriatric Assessment, Falls and Rehabilitation in Patients Starting or Established on Peritoneal Dialysis

Individuals aged over 70 years at the time of starting dialysis have a varied and often challenging existence on dialysis. Canadian data suggest those starting dialysis between the ages of 75 and 79 years will have an average life expectancy of 3.2 years, while based on US data, patients can expect an average life expectancy of 25 months. A substantial proportion of these patients will, however, experience transient or permanent loss of personal independence within the first few months to years on dialysis. Preliminary data from patients recently started on peritoneal dialysis (PD) suggest patients and families adapt, but that the adaptation often involves limiting activities and altering the social role the patient has within the family. As data emerge, it will be possible to hypothesize whether this adaptation is beneficial in the long term, or whether these adaptations are permissive, allowing the patient to play a sick role leading to an accelerated transition to frailty and possibly death. Future research will hopefully inform us whether the functional dependency can be identified early and whether it is preventable. In the interim, repair rather than prevention is possible through rehabilitation. We therefore advocate that programs providing PD care consider the integration of protocols whereby patients may undergo formal evaluation to identify those who would benefit from walking or personal care aids, rehabilitation interventions, and, when needed, personal support.

Functional outcomes of patients with amputation receiving chronic dialysis for end-stage renal disease

OBJECTIVE

The aim of this study was to compare the rehabilitation length of stay and functional outcome of patients with amputation on chronic dialysis with a similar group of patients not on dialysis.

DESIGN

This was a retrospective cohort study. Twenty-five patients with amputations on chronic dialysis and 25 nonrenal controls with amputation were included in the two groups. Primary outcome measures were Functional Independence Measure scores through discharge and follow-up, the percentage of patients fitted with a prosthesis, the number of patients able to ambulate independently indoors or outdoors or operate a wheelchair, and acute and rehabilitation length of stay for inpatients. Comorbidities and complications in end-stage renal disease (ESRD) patients with amputation on chronic dialysis vs. those without renal disease were also evaluated.

RESULTS

Eleven women and 14 men were included in each group. The study group patients were younger than non-ESRD controls (54 ± 12 and 61 ± 11 yrs, respectively; P = 0.05). No significant differences were found between the groups in sex, race, amputation etiology, or comorbidities, except minor amputations of toes and fingers, which were performed more often in the ESRD group compared with the non-ESRD group (14 and 2, respectively; P = 0.0003). Functional Independence Measure score was higher in the non-ESRD group on discharge (112.1 ± 7.6 vs. 107.5 ± 7.7; P = 0.04) and follow-up (111.3 ± 10.7 vs. 104.4 ± 8.7; P = 0.02). The number of patients able to ambulate indoors and outdoors or operate wheelchair independently on discharge was not statistically different between the groups. Length of stay was higher in the ESRD group (153 ± 67 vs. 105 ± 42 days; P = 0.04).

CONCLUSIONS

Patients with limb amputations on chronic dialysis had significantly longer length of stay and lower Functional Independence Measure scores compared with the non-ESRD group. It is suggested that current practices may need to be adjusted to accommodate the complex rehabilitation needs of the ESRD patient population.

Geriatric hemodialysis rehabilitation care

The 2 objectives of this review are to provide background information about functional status in older dialysis patients and to discuss the utility of geriatric dialysis rehabilitation. We performed a literature search using PubMed and MedLine. All relevant texts were reviewed for information on functional status and disability in the renal population and in the general population. Data pertaining to geriatric rehabilitation and geriatric dialysis rehabilitation were also reviewed. We show how disability and functional limitations are more prevalent in populations with advanced stages of chronic kidney disease (CKD) compared with those with only mild stages of CKD. We describe data showing that dedicated geriatric dialysis rehabilitation units, using interdisciplinary care models, result in more than 70% of patients meeting their rehabilitation goals and being successfully discharged home. Nephrologists increasingly will be faced with problems arising from functional decline. We conclude by offering suggestions for future changes that may help to stem the rising tide of dialysis disability.

Quality improvement through the introduction of interdisciplinary geriatric hemodialysis rehabilitation care

Background

Provision of rehabilitation with the aim of restoring personal independence in elderly hemodialysis patients faces several challenges.

Design

Quality improvement report.

Setting & Participants

First 3 years of experience of an inpatient geriatric hemodialysis rehabilitation program in Toronto. Patients with new-onset disability from prolonged illness or an acute event rendering them incapable of living independently.

Quality Improvement Plan

Provision of in-patient rehabilitation with on-site dialysis; a simplified referral system; preferential admission of elderly dialysis patients; short daily dialysis sessions; integrated multidisciplinary care by experts in rehabilitation, geriatric medicine, and nephrology; and reciprocal continued medical education among staff.

Measures

Outcome measures were percentage of patients discharged home, score on the Functional Independence Measure, and attainment of rehabilitation goals.

Results

In the first 36 months, 164 dialysis patients aged 74.5 ± 7.8 years were admitted. On admission, patients had a mean Charlson comorbidity score of 7.8 ± 2.5, 98% had difficulty walking, and 84% required help with bed-to-chair transfers. After a median of 48.5 days, 111 patients (69%) were discharged home; 15 patients (9%), to an assisted-living setting; 20 patients (12%), to a long-term care facility; and 18 patients (11%), to other facilities for acute or palliative care. Of those completing therapy, 82% met some or all of their rehabilitation goals.

Limitations

The program relied on the leadership and drive of key personnel. Discharge disposition as an outcome can be affected by many factors, and definition of attainment of rehabilitation goals is arbitrary.

Conclusion

The introduction of an integrated dialysis rehabilitation service can help older dialysis patients with new-onset functional decline return to their home. Am J Kidney Dis 00:00-00

Quality of life and rehabilitation of elderly dialysis patients

Chronologic age per se does not measure the ability of an individual to benefit from dialysis. Elderly patients gain added lifetime on dialysis that is satisfying, and elderly patients as a group often show better psychosocial adjustment to dialysis than do younger patients. However, the limitations in physical functioning that characterize chronic dialysis patients increase with patient age. The clinical challenge is to identify factors that contribute to patients' compromised functioning and to arrange targeted supportive services. An integrated comprehensive program can address elderly dialysis patients' multiple care needs. Strategies that improve outcomes by reducing the risks of elderly persons for increased disability, assisting them to function in their usual environment whenever possible, can also have benefits.

A bibliography of cost-effectiveness practices in physical medicine and rehabilitation: AAPM&R white paper

Cost-effectiveness studies attempt to determine the ratio of costs to outcomes of a particular intervention or treatment and to compare a standard intervention with an alternative intervention to determine if the alternative is more cost effective. The goal is to establish priorities for the resources allocation and to decide among alternative interventions for the same medical condition. The global process of rehabilitation does not usually lend itself to cost-effective analysis (due to the complex set of treatments provided) but rather to specific interventions and specific aspects of outcome. The American Academy of Physical Medicine and Rehabilitation has published a cost effectiveness annotated bibliography on the Internet (http://www.aapmr.org/memphys/cebfinala.htm) that identifies 132 studies in the literature that meet specified criteria and are related to the field of rehabilitation. This White Paper attempts to interpret and synthesize the studies in that bibliography that relate to stroke, spinal cord injury (SCI), orthopedic conditions, pain syndromes, amputations, and traumatic brain injury (TBI). Most studies support the cost effectiveness of care for stroke and SCI in dedicated units or centers rather than in a general medical unit. Studies also support back programs and revascularization procedures in limb ischemia. Studies in TBI underscore the significant financial resources for the care of these patients as well as the potential benefit from rehabilitation services even in the most severely injured. Further high quality research in this area is needed.

Limb amputation on renal replacement therapy

Ten (10) diabetic and 7 non-diabetic patients on renal replacement therapy have undergone limb amputation in the authors' unit in the 1988 to 1996 period. The article examines the course of illness and survival patterns in this distinct and increasing sub-set in the amputee population. Rehabilitation and survival were significantly better in the diabetic group and it is recommended that it would be helpful for both prognosis and analysis if the sub-set of amputees on treatment for chronic renal failure is further divided into diabetic and non-diabetic sub-sets.

Functional outcome of quadruple amputees with end-stage renal disease

A rare but catastrophic complication in end-stage renal disease (ESRD) patients with peripheral vascular disease is amputation of all four limbs secondary to gangrene. We present three patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputees. Our large, tertiary acute care hospital admitted 1,469 patients with ESRD during a continuous 63-month period. There were 72 amputation procedures: 57 involving lower limbs, and 15 involving upper limbs. Three patients had all four limbs amputated; these three were subsequently admitted to our acute inpatient rehabilitation center. Their median Functional Independence Measurement (FIM) score on admission was 52 and on discharge was 75. Their median length of stay was 24.5 days, which may be attributed to early postoperative therapy and de-emphasis on prosthetic replacement. At discharge, all three patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis three times per week. Two patients were independent with feeding using adaptive equipment, and one required verbal cues. Two patients were able to write using dorsal wrist splints and pencil holders. One patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook-type prosthesis. Our review of these three cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size to demonstrate statistical significance.

Rehabilitation of the older lower limb amputee: a brief review

OBJECTIVE

To review outcomes, over the last 25 to 30 years, of prosthetic rehabilitation in the older patient with a major lower limb amputation.

DESIGN

Literature review of articles and reports about lower limb amputation, using key words elderly amputee rehabilitation, and lower limb amputation, through a computerized Medline Search.

CONCLUSIONS

Age alone should not determine prosthetic rehabilitation. Comorbidities and general health are important determinants. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait. Changes in surgical technique and revascularization procedures have allowed preservation of the knee, which decreases energy demands and allows more older patients a chance to undergo rehabilitation for ambulation. Although the ratio of below knee (transtibial) amputations to above knee (transfemoral) amputations has increased, overall postsurgical mortality (10-30%), long term survival (40-50%@2 years, 30-40%@5 years), and risk of loss of the contralateral leg (15-20%@2 years) has not changed significantly since the 1960s. Despite the lack of improvement in survival as a result of the systemic vascular disease, the older patient can benefit from rehabilitation efforts with goals of prosthetic ambulation or simply cosmesis. The shortened longevity emphasizes the need for timely rehabilitation to enhance the quality of the remaining years. The geriatrician can add to the presurgical care and preprosthetic phase of rehabilitation by attention to the problems common to the older patient, i.e., multiple comorbidities, polypharmacy, immobility, and depression. Postoperatively, early mobilization is crucial to avoid the deleterious effects of immobility in the older person. Further investigations into the psychosocial issues and cost benefits of limb loss and prosthetic rehabilitation are needed. In addition, comparison of the various rehabilitation protocols and the impact of cardiac resting before rehabilitation are needed.

Functional outcome and comorbidity indexes in the rehabilitation of the traumatic versus the vascular unilateral lower limb amputee

This study compared the Functional Independence Measure (FIM) scores of traumatic (n=12) and vascular (n=12) unilateral lower limb amputees at admission and discharge from a rehabilitation facility. FIM scores that were measured were amputation FIM subscores and total FIM scores. Comorbidity indexes were developed to weight the stump condition and comorbidities seen in both groups. The vascular group was significantly (P<0.01) greater stump comorbidity, but there was no significant difference with respect to length of stay, medical comorbidity score, and amputation and total FIM scores both at admission and discharge between the two groups. Medical comorbidity was significantly (P<0.05) correlated with amputation and total FIM scores at discharge for traumatic amputees with r = -0.64 and r = -0.66, respectively. Stump comorbidity was significantly (P<0.05) correlated with total FIM at discharge with r = -0.64 for vascular amputees. Medical comorbidity was a good predictor of discharge FIM scores for traumatic amputees, whereas stump comorbidity predicted discharge FIM scores for vascular amputees, although not as well. In conclusion, inpatient traumatic amputees may be younger than vascular amputees, but traumatic amputees may not necessarily be healthier or do better functionally at discharge than vascular amputees.