Predictors of reintegration to normal living in older adults discharged from an intensive rehabilitation program

Long-term trajectories of community integration: identification, characterization, and prediction using inpatient rehabilitation variables

BACKGROUND

Community integration (CI) is often regarded as the foundation of rehabilitation endeavors after stroke; nevertheless, few studies have investigated the relationship between inpatient rehabilitation (clinical and demographic) variables and long-term CI.

OBJECTIVES

To identify novel classes of patients having similar temporal patterns in CI and relate them to baseline features.

METHODS

Retrospective observational cohort study analyzing (n = 287) adult patients with stroke admitted to rehabilitation between 2003 and 2018, including baseline Functional Independence Measure (FIM) at discharge, follow-ups (m = 1264) of Community Integration Questionnaire (CIQ) between 2006 and 2022. Growth mixture models (GMMs) were fitted to identify CI trajectories, and baseline predictors were identified using multivariate logistic regression (reporting AUC) with 10-fold cross validation.

RESULTS

Each patient was assessed at 2.7 (2.2-3.7), 4.4 (3.7-5.6), and 6.2 (5.4-7.4) years after injury, 66% had a fourth assessment at 7.9 (6.8-8.9) years. GMM identified three classes of trajectories.

Lowest CI (n=105, 36.6%): The lowest mean total CIQ; highest proportion of dysphagia (47.6%) and aphasia (46.7%), oldest at injury, largest length of stay (LOS), largest time to admission, and lowest FIM.

Highest CI (n=63, 21.9%): The highest mean total CIQ, youngest, shortest LOS, highest education (27% university) highest FIM, and Intermediate CI (n=119, 41.5%): Intermediate mean total CIQ and FIM scores. Age at injury OR: 0.89 (0.85-0.93), FIM OR: 1.04 (1.02-1.07), hypertension OR: 2.86 (1.25-6.87), LOS OR: 0.98 (0.97-0.99), and high education OR: 3.05 (1.22-7.65) predicted highest CI, and AUC was 0.84 (0.76-0.93).

CONCLUSION

Novel clinical (e.g. hypertension) and demographic (e.g. education) variables characterized and predicted long-term CI trajectories.

The Contribution of Frailty to Participation of Older Adults

Background: Participation, which is involvement in life situations, is an important indicator of human health and well-being of older adults. Frailty is known to be related to difficulties in activities of daily living (ADL) but the association with participation restriction has not been sufficiently researched. Therefore, we aimed to (1) to assess the correlations between frailty, ADL, and participation; and (2) to identify the contribution of frailty to explaining the participation restriction of older adults. Methods: A cross-sectional study included home visits to community-dwelling older adults aged 75 and older. The Reintegration to Normal Living Index (RNL-I) assessed participation, PRISMA-7 assessed frailty, and the Functional Independence Measure and IADL questionnaire assessed the basic and instrumental ADL. Cognition, which may explain participation, was also assessed (The Montreal Cognitive Assessment) and demographic information was collected. Results: Older adults (N = 121, 60 women), aged 75 to 91 years (mean (SD)—79.6 (3.1)), were included. Older adults demonstrated full to restricted participation (RNL-I-mean (SD)—78.2 (18.0)/100). Frailty was identified in 39 (32%) older adults (mean (SD) PRISMA-7—2.9 (1.4)/7points). A negative moderate significant correlation was found between participation and frailty (r = −0.634, p < 0.001). The variance of participation was significantly explained by frailty, 31.5%, and basic ADL, 5.6% (after controlling for age and cognition); the total model explained 44.6% (F = 23.29, p < 0.001). Conclusions: Frailty is significantly associated with participation restriction. Since participation has many health benefits, understanding which factors are associated to participation is central to developing interventions for older adults. These findings may help health professionals in the future develop interventions for maintaining and promoting the participation of older adults.

Factors That Influence the Reintegration to Normal Living for Older Adults 2 Years Post Hip Fracture

Objectives: This study aims to identify factors that influence older adults' reintegration to normal living 2 years following a hip fracture and the association between caregiver burden and reintegration over time. Methods: This longitudinal cohort study followed 76 community-dwelling older adults and their caregivers for 2 years post-hip fracture. The primary outcome was Reintegration to Normal Living Index (RNLI), and the secondary outcome was caregiver burden. Results: Older adults scored significantly lower on RNLI at 18 to 24 months if they had few social interactions, cognitive impairment, or lower pre-fracture functional status. During follow-up, greater independence in activities of daily living and greater mobility were each positively associated with RNLI. Caregiver burden reduced if reintegration improved. Implications: Results suggest a need for targeted interventions for older adults' post-hip fracture to improve their function to enhance their reintegration to normal living and to support caregivers in decreasing their burden of care.

Role of rehabilitation in the elderly after an acute event: insights from a real-life prospective study in the subacute care setting

BACKGROUND

Any acute event, either primary or secondary to a chronic disease, is generally followed by some degree of physical impairment. Subacute care (SAC) represents one of the inpatient intermediate care settings aimed at completing recovery and restoring functional capacity. Debate exists on the role of the rehabilitation treatment in the SAC setting.

AIM

The aim of this study was to compare the outcomes of patients managed in two different SAC Units where A) patients undergo an individualized rehabilitation program on top of optimal medical therapy (OMT) B) patients receive OMT only.

DESIGN

Real-life prospective study.

SETTING

SAC units.

POPULATION

Seventy-five chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) patients transferred after an acute hospitalization.

METHODS

Upon SAC admission, the following scales were obtained: cumulative illness rating scale comorbidity and severity (CIRSC and CIRSS), mini mental state examination (MMSE), Performance-Oriented Mobility Assessment (POMA), Barthel Index (BI), the 10-meter walking test (10MWT). Pre-admission BI was also collected based on history. Upon SAC discharge, BI, POMA, and 10MWT were repeated.

RESULTS

Patients (44 in Group A, 31 in Group B) were similar with regard to age, gender, MMSE, clinical complexity, pre-admission BI, admission 10MWT, POMA, and bedrest conditions. Admission BI was lower in Group A. In both groups BI was lower when compared to the respective pre-admission score. Upon discharge, Group A patients were characterized by a higher BI and POMA compared to Group B. Indeed, BI and POMA improved at discharge only in Group A patients. Only this latter group reached the pre-morbid BI. Upon discharge the number of bedrest patients decreased only in Group A. The percentage of patients discharged home was also much higher in Group A, while a greater number of Group B patients were transferred to a rehabilitation ward or were enrolled in an integrated home care assistance program.

CONCLUSIONS

In a real-life prospective experience, a better outcome is demonstrated in elderly CHF and COPD patients undergoing a rehabilitative approach during their in-hospital SAC stay.

CLINICAL REHABILITATION IMPACT

An individualized rehabilitation program should integrate medical treatment of CHF and BPCO patients in the SAC setting. This approach demonstrates a better cost-effectiveness management of these patients.

How to Find Lessons from the Public Health Literature: Example of a Scoping Study Protocol on the Neighborhood Environment

Background:

As key determinants of many favorable health and quality of life outcomes, it is important to identify factors associated with mobility and social participation. Although several investigations have been carried out on mobility, social participation and neighborhood environment, there is no clear integration of these results. This paper presents a scoping study protocol that aims to provide a comprehensive understanding of how the physical and social neighborhood environment is associated with or influences mobility and social participation in older adults.

Methods:

The rigorous methodological framework for scoping studies is used to synthesize and disseminate current knowledge on the associations or influence of the neighborhood environment on mobility and social participation in aging. Nine databases from public health and other fields are searched with 51 predetermined keywords. Using content analysis, all data are exhaustively analyzed, organized, and synthesized independently by two research assistants.

Discussion:

A comprehensive synthesis of empirical studies provides decision-makers, clinicians and researchers with current knowledge and best practices regarding neighborhood environments with a view to enhancing mobility and social participation. Such a synthesis represents an original contribution and can ultimately support decisions and development of innovative interventions and clear guidelines for the creation of age-supportive environments. Improvements in public health and clinical interventions might be the new innovation needed to foster health and quality of life for aging population. Finally, the aspects of the associations or influence of the neighborhood environment on mobility and social participation not covered by previous research are identified.

Conclusions:

Among factors that impact mobility and social participation, the neighborhood environment is important since interventions targeting it may have a greater impact on an individual's mobility and social participation than those targeting individual factors. Although investigations from various domains have been carried out on this topic, no clear integration of these results is available yet.

Importance of proximity to resources, social support, transportation and neighborhood security for mobility and social participation in older adults: results from a scoping study

BACKGROUND

Since mobility and social participation are key determinants of health and quality of life, it is important to identify factors associated with them. Although several investigations have been conducted on the neighborhood environment, mobility and social participation, there is no clear integration of the results. This study aimed to provide a comprehensive understanding regarding how the neighborhood environment is associated with mobility and social participation in older adults.

METHODS

A rigorous methodological scoping study framework was used to search nine databases from different fields with fifty-one keywords. Data were exhaustively analyzed, organized and synthesized according to the International Classification of Functioning, Disability and Health (ICF) by two research assistants following PRISMA guidelines, and results were validated with knowledge users.

RESULTS

The majority of the 50 selected articles report results of cross-sectional studies (29; 58%), mainly conducted in the US (24; 48%) or Canada (15; 30%). Studies mostly focused on neighborhood environment associations with mobility (39; 78%), social participation (19; 38%), and occasionally both (11; 22%). Neighborhood attributes considered were mainly 'Pro ducts and technology' (43; 86) and 'Services, systems and policies' (37; 74%), but also 'Natural and human-made changes' (27; 54%) and 'Support and relationships' (21; 42%). Mobility and social participation were both positively associated with Proximity to resources and recreational facilities, Social support, Having a car or driver's license, Public transportation and Neighborhood security, and negatively associated with Poor user-friendliness of the walking environment and Neighborhood insecurity. Attributes of the neighborhood environment not covered by previous research on mobility and social participation mainly concerned 'Attitudes', and 'Services, systems and policies'.

CONCLUSION

Results from this comprehensive synthesis of empirical studies on associations of the neighborhood environment with mobility and social participation will ultimately support best practices, decisions and the development of innovative inclusive public health interventions including clear guidelines for the creation of age-supportive environments. To foster mobility and social participation, these interventions must consider Proximity to resources and to recreational facilities, Social support, Transportation, Neighborhood security and User-friendliness of the walking environment. Future studies should include both mobility and social participation, and investigate how they are associated with 'Attitudes', and 'Services, systems and policies' in older adults, including disadvantaged older adults.

Community reintegration following a total joint replacement: a pilot study

PURPOSE

To examine community reintegration following a hip or knee total joint replacement (TJR) from the perspective of rehabilitation clients.

METHODS

A phenomenological frame of reference guided the present study. Ten participants who received inpatient rehabilitation completed semi-structured qualitative interviews to explore their experiences with reintegrating back into their chosen communities and the meanings that they ascribed to their reintegration. Interview data were analysed using thematic analysis. Demographic data, and information regarding participants' living situation and supports were extracted from existing databases and used to characterize the sample.

RESULTS

Participants revealed that reintegration after a TJR encompassed two key elements of meaning: i) engagement in meaningful activities; and ii) satisfaction levels. Additionally, the following five factors were identified as facilitators or barriers to community reintegration following a TJR: i) ongoing preparation and education; ii) confounding health issues; iii) driving and transportation; iv) personal facilitators; v) access to supports from professionals, family and friends, and community programmes.

CONCLUSIONS

The present study highlights the significance of engaging in meaningful activities and being satisfied in one's level of engagement to achieving a sense of community reintegration following a TJR. This suggests that reintegration post-TJR has broader meanings than just improvements in functional abilities. Practitioners are encouraged to inquire about patients' meaningful activities, support their preparedness throughout the rehabilitation process, to identify confounding health issues that may limit reintegration, consider patients' fears and anxieties and establish supports to enhance their feelings of self-efficacy and abilities to cope following a TJR.

Community integration outcomes after traumatic brain injury due to physical assault

BACKGROUND

Community integration is considered an ultimate goal for rehabilitation after traumatic brain injury (TBI).

PURPOSE

To determine (a) whether differences exist in rehabilitation outcomes between intentional and unintentional TBI populations and (b) whether TBI from assault is a predictor of community integration following inpatient rehabilitation.

METHOD

Retrospective cohort study using population-based data from Canadian hospital administration records, 2001 to 2006. Outcome measure was the Reintegration to Normal Living Index (RNLI).

FINDINGS

From a sample of 243 persons, 24 (9.9%) had sustained TBI from physical assault. Persons with TBI from physical assault reported significantly lower scores on two items on the RNLI's Daily Functioning subscale: "recreation" and "family role."

IMPLICATIONS

These findings suggest that targeted intervention in these specific areas could be beneficial, which are often primarily addressed by occupational therapists in both inpatient rehabilitation and community settings.

Patients undergoing subacute rehabilitation have accurate expectations of their health-related quality of life at discharge

Background

Expectations held by patients and health professionals may affect treatment choices and participation (by both patients and health professionals) in therapeutic interventions in contemporary patient-centered healthcare environments. If patients in rehabilitation settings overestimate their discharge health-related quality of life, they may become despondent as their progress falls short of their expectations. On the other hand, underestimating their discharge health-related quality of life may lead to a lack of motivation to participate in therapies if they do not perceive likely benefit. There is a scarcity of empirical evidence evaluating whether patients’ expectations of future health states are accurate. The purpose of this study is to evaluate the accuracy with which older patients admitted for subacute in-hospital rehabilitation can anticipate their discharge health-related quality of life.

Methods

A prospective longitudinal cohort investigation of agreement between patients’ anticipated discharge health-related quality of life (as reported on the EQ-5D instrument at admission to a rehabilitation unit) and their actual self-reported health-related quality of life at the time of discharge from this unit was undertaken. The mini-mental state examination was used as an indicator of patients’ cognitive ability.

Results

Overall, 232(85%) patients had all assessment data completed and were included in analysis. Kappa scores ranged from 0.42-0.68 across the five EQ-5D domains and two patient cognition groups. The percentage of exact correct matches within each domain ranged from 69% to 85% across domains and cognition groups. Overall 40% of participants in each cognition group correctly anticipated all of their self-reported discharge EQ-5D domain responses.

Conclusions

Patients admitted for subacute in-hospital rehabilitation were able to anticipate their discharge health-related quality of life on the EQ-5D instrument with a moderate level of accuracy. This finding adds to the foundational empirical work supporting joint treatment decision making and patient-centered models of care during rehabilitation following acute illness or injury. Accurate patient expectations of the impact of treatment (or disease progression) on future health-related related quality of life is likely to allow patients and health professionals to successfully target interventions to priority areas where meaningful gains can be achieved.

Aerobic exercise versus combined exercise therapy in women with fibromyalgia syndrome: a randomized controlled trial

OBJECTIVE

To investigate the effects of supervised aerobic exercise (AE) and a combined program of supervised aerobic, muscle strengthening, and flexibility exercises (combined exercise [CE]) on important health outcomes in women with fibromyalgia syndrome (FMS).

DESIGN

Randomized controlled trial.

SETTING

Community-based supervised intervention.

PARTICIPANTS

Women (N=64) with a diagnosis of FMS according to the American College of Rheumatology criteria.

INTERVENTION

Participants were randomly allocated to 1 of 3 groups: supervised AE, supervised CE, or usual-care control. Exercise sessions were performed twice weekly (45-60min/session) for 24 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure was the Fibromyalgia Impact Questionnaire (FIQ). Exploratory outcome measures were the 36-Item Short-Form Health Survey, Beck Depression Inventory (BDI), aerobic capacity (6-minute walk test), hand-grip strength, and range of motion in the shoulders and hips.

RESULTS

Compliance with both interventions was excellent, with women in the exercise groups attending more than 85% of sessions. A 14% to 15% improvement from baseline in total FIQ score was observed in the exercise groups (P≤.02) and was accompanied by decreases in BDI scores of 8.5 (P<.001) and 6.4 (P<.001) points in the AE and CE groups, respectively. Relative to nonexercising controls, CE evoked improvements in the SF-36 Physical Functioning (P=.003) and Bodily Pain (P=.003) domains and was more effective than AE for evoking improvements in the Vitality (P=.002) and Mental Health (P=.04) domains. Greater improvements also were observed in shoulder/hip range of motion and handgrip strength in the CE group.

CONCLUSION

Given the equivalent time commitment required for AE and CE, our results suggest that women with FMS can gain additional health benefits by engaging in a similar volume of CE.

Evidence of disagreement between patient-perceived change and conventional longitudinal evaluation of change in health-related quality of life among older adults

Objective: To identify agreement levels between conventional longitudinal evaluation of change (post—pre) and patient-perceived change (post—then test) in health-related quality of life.

Design: A prospective cohort investigation with two assessment points (baseline and six-month follow-up) was implemented.

Setting: Community rehabilitation setting.

Subjects: Frail older adults accessing community-based rehabilitation services.

Intervention: Nil as part of this investigation.

Main measures: Conventional longitudinal change in health-related quality of life was considered the difference between standard EQ-5D assessments completed at baseline and follow-up. To evaluate patient-perceived change a ‘then test’ was also completed at the follow-up assessment. This required participants to report (from their current perspective) how they believe their health-related quality of life was at baseline (using the EQ-5D). Patient-perceived change was considered the difference between ‘then test’ and standard follow-up EQ-5D assessments.

Results: The mean (SD) age of participants was 78.8 (7.3). Of the 70 participants 62 (89%) of data sets were complete and included in analysis. Agreement between conventional (post—pre) and patient-perceived (post—then test) change was low to moderate (EQ-5D utility intraclass correlation coefficient (ICC) = 0.41, EQ-5D visual analogue scale (VAS) ICC = 0.21). Neither approach inferred greater change than the other (utility P =0.925, VAS P =0.506). Mean (95% confidence interval (CI)) conventional change in EQ-5D utility and VAS were 0.140 (0.045,0.236) and 8.8 (3.3,14.3) respectively, while patient-perceived change was 0.147 (0.055,0.238) and 6.4 (1.7,11.1) respectively.

Conclusions: Substantial disagreement exists between conventional longitudinal evaluation of change in health-related quality of life and patient-perceived change in health-related quality of life (as measured using a then test) within individuals.

Accomplishment level and satisfaction with social participation of older adults: association with quality of life and best correlates

PURPOSE

This study aimed to (1) explore whether quality of life (QOL) is more associated with satisfaction with social participation (SP) than with level of accomplishment in SP and (2) examine respective correlates of accomplishment level and satisfaction with SP.

METHODS

A cross-sectional design was used with a convenience sample of 155 older adults (mean age=73.7; 60% women) having various levels of activity limitations. Accomplishment level and satisfaction with SP (dependent variables) were estimated with the social roles items of the assessment of life habits. Potential correlates were human functioning components.

RESULTS

Correlations between QOL and accomplishment level and satisfaction with SP did not differ (P=0.71). However, best correlates of accomplishment level and satisfaction with SP were different. Higher accomplishment level of SP was best explained by younger age, activity level perceived as stable, no recent stressing event, better well-being, higher activity level, and fewer obstacles in "Physical environment and accessibility" (R2=0.79). Greater satisfaction with SP was best explained by activity level perceived as stable, better self-perceived health, better well-being, higher activity level, and more facilitators in "Social support and attitudes" (R2=0.51).

CONCLUSION

With some exceptions, these best correlates may be positively modified and thus warrant special attention in rehabilitation interventions.