Functional status of geriatric rehabilitation patients: a one-year follow-up study

Is occupational therapy practice for older adults with lower limb amputations evidence-based? A systematic review

BACKGROUND

Although occupational therapists are integral to the rehabilitation process of people with amputations, the effectiveness of the occupational therapy intervention for older adults with lower limb amputations has not been investigated.

OBJECTIVES

To identify the effectiveness of the occupational therapy interventions with older adults aged 65 years and older with lower limb amputations.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was conducted in CINAHL, PUBMED, OTSEEKER and OTDBASE from January 1985 to January 2011. The eligible papers were critiqued using a typology, which involved designation of levels of evidence and quality markers.

RESULTS

The databases yielded 2,664 potential publications. Of these, only two were included in the final review. These studies suggested that the frequency of the occupational therapy sessions was found to be statistically significantly related to prosthesis use and that service users perceived positive benefits about the provision of stump boards. Both studies had limitations resulting in a need for further investigation in these areas.

CONCLUSION

Research evidence on the occupational therapy interventions with this population is limited and scarce. Occupational therapists need to take urgent action to address the identified evidence-based gaps in order to devise informed targeted rehabilitation programmes for this client group.

Mental Status and Self-Medication Ability in the Hospitalized Elderly

This study investigated the relationships among several aspects of cognitive functioning and the outcome of self-medication training in hospitalized elderly patients. Data from 53 geriatric patients who received rehabilitation treatment at the SCO Hospital in Ottawa, Canada between 1992 and 1997 were collected, on an archival basis. Patients began a graduated self-medication program after undergoing a neuropsychological evaluation. Performance scores from five different aspects of cognition were regressed on the self-medication training outcome measures. Findings revealed that aspects of cognitive functioning were significantly related to the outcome of self-medication training. Thus, psychometric measures of cognition can be useful in predicting which patients are most likely to benefit from a self-medication program, or alternatively, those who would require a modified program to be able to learn. The clinical implications of these results are discussed.

Rehabilitation service utilization and determinants among people with an intellectual disability: Preliminary findings in Taiwan

Improving rehabilitation services for people with intellectual disabilities (ID) remains an ongoing challenge in the public health system. The purpose of this article was to investigate the types of rehabilitation services used by people with ID and determine what factors predict resource utilization in Taiwan. Samples of 957 people with ID were recruited from the Taiwan National Disability Register in a cross-sectional study in 2001. The findings indicated that 24.5% of individuals with ID had received rehabilitation services in the past 7 months. The main types of services used were speech and communication therapy (50%), psychotherapy (32.1%), occupational therapy (30.3%) and physiotherapy (25.2%). Stepwise logistic regression was carried out for the utilization of rehabilitation services (yes/no). The model revealed that the following factors: (i) Major Illness Card holder, (ii) time spent in medical care, (iii) having a family physician, (iv) having illnesses, (v) age of ID individual, and (vi) gender of the main carer, were all significantly associated with the utilization of rehabilitation services. We should reorient the healthcare system to respond adequately to the health needs of rehabilitation service users and its determinants, and further research should focus on the effectiveness and efficiency of rehabilitation for people with ID in Taiwan.

A randomized controlled trial on early physiotherapy intervention versus usual care in acute care unit for elderly: potential benefits in light of dietary intakes

OBJECTIVE

To evaluate effects of early intensive physiotherapy during acute illness on post hospitalization activity daily living autonomy (ADL).

DESIGN

Prospective randomized controlled trial of intensive physiotherapy rehabilitation on day 1 to 2 after admission until clinical stability or usual care.

SETTING

acute care geriatric medicine ward.

PATIENTS

A total of 76 acutely ill patients, acutely bedridden or with reduced mobility but who were autonomous for mobility within the previous 3 months. Patients in palliative care or with limiting mobility pathology were excluded. Mean age was 85.4 (SD 6.6) years.

MEASUREMENTS

At admission, at clinical stability and one month later: anthropometry, energy and protein intakes, hand grip strength, ADL scores, and baseline inflammatory parameters. An exploratory principal axis analysis was performed on the baseline characteristics and general linear models were used to explore the course of ADL and nutritional variables.

RESULTS

A 4-factor solution was found explaining 71.7% of variance with a factor "nutrition", a factor "function" (18.8% of variance) for ADL, handgrip strength, bedridden state, energy and protein intakes, serum albumin and C-reactive protein concentrations; a factor "strength" and a fourth factor . During follow-up, dietary intakes, handgrip strength, and ADL scores improved but no changes occurred for anthropometric variables. Intervention was associated only with an increase in protein intake. Better improvement in ADL was found in intervention group when model was adjusted on "function" factor items.

CONCLUSION

Physical intervention programs should be proposed according to nutritional intakes with the aim of preventing illness induced disability.

Life satisfaction and leisure activities during men's retirement: a Turkish sample

This study was planned and carried out as a pilot study to determine the life satisfaction of men from the Official Social Security Institutions in Turkey (n = 231). The Life Satisfaction Index was used as the measure. Among this group of retired men, the most popular leisure activities were audio-visual and reading. The strongest predictor of life satisfaction was the frequency of participation in leisure activities, followed by the level of satisfaction with health, income, and planning of leisure activities.

Factors affecting outpatient rehabilitation outcomes in elders

PURPOSE

To identify factors affecting outpatient rehabilitation outcomes in elders.

DESIGN

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

METHODS

Analyses of health records from a nurse-managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini-Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

FINDINGS

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age > or = 80 years, admission function, and the interaction of age > or = 80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

CONCLUSIONS

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age > or = 80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.

The impact of reducing in-patient stay on long-term geriatric rehabilitation outcome

Clinicians at the SCO Health Service were concerned that frail elderly patients who had shorter lengths of stay in rehabilitation would not be able to maintain their gains following discharge. A follow-up telephone survey was administered 300 days after discharge to 197 patients. This study found that the functional status of the group was maintained as measured by Barthel, type of mobility aid, and type of discharge location.

Evaluation of life satisfaction index of the elderly people living in nursing homes

The aim of our study was to evaluate the quality of life of the elderly living in nursing homes. A pool of 183 elderly people living in nursing homes were involved in the study. Data regarding the socio-demographic characteristics and life satisfaction index-A (LSI-A) of the participants were collected by means of a questionnaire during face-to-face interviews. The average LSI-A score of the whole group of participants was 25.26+/-5.51. When the mean LSI-A score of participants in relation to their independent variables was analyzed, no statistically significant differences were found for gender, socio-economic status or body mass indexes (BMI). However, the mean LSI-A score of those elderly people who spent some time in leisure activities was significantly higher than those who did not (p=0.03). In the stepwise linear regression analysis, the education level and place of residence were found to be the statistically significant independent predictors of LSI-A scores in the study group (p=0.05, p=0.001).

Development of a conceptual framework for the assessment of geriatric rehabilitation outcomes

The objective of the study was to develop a conceptual framework of key assessment areas for the evaluation of rehabilitation outcomes in older persons. The study was designed in four stages. First, a review of the literature generated a list of 84 potential outcome variables. Second, semi-structured interviews were conducted with older adults informants (n = 19) to record their thoughts about important rehabilitation outcomes. From the analyses of the transcripts, 20 recurrent themes became apparent. Third, relevant assessment areas were determined based on the merged data from the literature and the interviews. Fourth, a focus group was held with a panel of eight interdisciplinary experts with strong involvement in geriatric rehabilitation to evaluate, improve, and validate the preliminary work. As a result of the study, the conceptual framework for the assessment of geriatric rehabilitation outcomes (FAGRO) is composed of four primary outcome domains related to important activities for community-living older persons: mobility activities, basic activities of daily living, activities of independent living, and leisure activities. The models also allows for four brief evaluations of underlying functioning components, including: physical functioning, psychological functioning, social functioning, and factors related to the caregiver status and available resources. The model has the potential to become a valuable additional tool for outcome assessment, researched and developed specifically for geriatric rehabilitation.

State of the art in geriatric rehabilitation. Part I: review of frailty and comprehensive geriatric assessment

OBJECTIVES

To increase recognition of geriatric rehabilitation and to provide recommendations for practice and future research.

DATA SOURCES

A CINAHL and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search used the Cochrane database.

STUDY SELECTION

One author reviewed the reference for relevance and another for quality. A total of 336 articles were selected. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports.

DATA EXTRACTION

The following major geriatric rehabilitation subtopics were identified: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. Part I describes the first 5 subtopics on concepts and processes in geriatric rehabilitation. Part II focuses on the latter 5 subtopics of common clinical problems in frail older persons. A level-of-evidence framework was used to review the literature. Level 1 evidence was a randomized controlled trial (RCT) or a meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts or descriptive studies.

DATA SYNTHESIS

Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic. In cases in which several articles were written on the same topic and drew similar conclusions, the authors chose those articles with the strongest level of evidence, reducing the total number of references.

CONCLUSIONS

Frail elderly patients should be screened for rehabilitation potential. Standardized tools are recommended to aid diagnosis, assessment, and outcome measurement. The team approach to geriatric rehabilitation should be interdisciplinary and use a comprehensive geriatric assessment. Medication reviews and self-medication programs may be beneficial. Future research should address cost effectiveness, consensus on outcome measures, which components of geriatric rehabilitation are most effective, screening, and what outcomes are sustainable.

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.

Medical comorbidity and rehabilitation efficiency in geriatric inpatients

OBJECTIVES

To measure and describe medical comorbidity in geriatric rehabilitation patients and investigate its relationship to rehabilitation efficiency.

DESIGN

Prospective, multivariate, within-subject design.

SETTING

The Geriatric Rehabilitation inpatient unit of the SCO Health Service in Ottawa, Canada.

PARTICIPANTS

One hundred ten patients, with a mean age of 82 years.

MEASUREMENTS

The rehabilitation efficiency ratio, based on gains in functional status achieved with rehabilitation treatment, and the length of stay were computed for all patients. Values were regressed on the scores of the Cumulative Illness Rating Scale (CIRS), the Mini-Mental State Examination, and the Geriatric Depression Scale to establish predictive power.

RESULTS

The findings suggest that geriatric rehabilitation patients experience considerable medical comorbidity. Sixty percent of patients had impairments across six of the 13 dimensions of the CIRS, whereas 36% of patients had impairments across 11 of the 13 dimensions. In addition, medical comorbidity was negatively related to rehabilitation efficiency. This relationship was significant even after controlling for age, cognitive status, depressive symptoms, and functional independence status at admission.

CONCLUSION

Medical comorbidity was a significant predictor of rehabilitation efficiency in geriatric patients. Comorbidity scores >5 were prognostic of poorer rehabilitation outcomes and can serve as an empirical guide in estimating a patient's suitability for rehabilitation. Medical comorbidity predicted both the overall functional change achieved with retabilitation (Functional Independence Measure gains) and the rate at with which those gains were reached (rehabilitation efficiency ratio).

Selecting patients for falls-prevention protocols: an evidence-based approach on a geriatric rehabilitation unit

Geriatric rehabilitation treatment focuses on maximizing functional independence in older adults to facilitate a return to independent living following hospitalization. Rehabilitation professionals must therefore balance the need to foster increasing activity levels among patients while, at the same time, preventing falls and potential injuries. This study investigated measures of patient cognition and aspects of health as predictors of the risk for falls among geriatric rehabilitation patients. Fall rates and patient data were collected over an 18-month period. Data from 98 patients were included in the data set. The number of falls was regressed on the patient data to investigate their predictive power. Analyses were also conducted comparing fallers and nonfallers across the independent variables. Results revealed that the primary diagnosis was the only factor evidencing sufficient power for empirical identification of patients at the greatest risk for falls. The clinical implications of findings, in terms of an evidence-based approach to managing falls risk in this population, are discussed in this article.

Progressive resistance muscle strength training of hospitalized frail elderly

OBJECTIVE

To determine whether frail elderly patients recuperating from acute illnesses could safely participate in and gain appreciable improvement in muscle strength from progressive resistance muscle strength training.

DESIGN

Muscle strength (one repetition maximum), functional abilities (sit-to-stand maneuver and 20-sec maximal safe gait speed), and body composition were measured before and at the conclusion of a 10-wk program of lower limb progressive resistance muscle strength training. The nonrandomized study was conducted in a 30-bed geriatric rehabilitation unit of a university-affiliated Veterans Affairs hospital and a 28-bed transitional care unit of a community nursing home. Participants included 19 recuperating elderly subjects (14 male, 5 female; 13 ambulatory, 6 nonambulatory) >64 yr (mean age, 82.8+/-7.9 yr).

RESULTS

The one repetition maximum increased an average of 74%+/-49% (median, 70%; interquartile range, 38%-95%, and an average of 20+/-13 kg (P = 0.0001). Sit-to-stand maneuver times improved in 15 of 19 cases (79%). Maximum safe gait speeds improved in 10 of 19 cases (53%). Four of the six nonambulatory subjects progressed to ambulatory status. No subject experienced a complication.

CONCLUSIONS

A carefully monitored program of progressive resistance muscle strength training to regain muscle strength is a safe and possibly effective method for frail elderly recuperating from acute illnesses. A randomized control study is needed to examine the degree to which progressive resistance muscle strength training offers advantages, if any, over routine posthospital care that includes traditional low-intensity physical therapy.

Functional performance and exercise of older adults in long-term care settings

Performing functional activities and exercising are important for older adults living in long-term care settings. Participation in these activities not only improves and maintains function in older adults but also can improve physical and emotional health and quality of life. The purpose of this study was to explore the variables that influence functional performance and exercise activity in a group of nursing home residents. Participants included 59 residents in a long-term care facility. The mean age of participants was 88 +/- 6.9, and the majority were women (76%), White (97%), and unmarried (76%). Residents participated in a single face-to-face interview. Chart reviews for demographic and health information also were performed. Based on stepwise multiple regression analyses, upper and lower extremity contractures and cognitive status were the only variables that significantly influenced functional performance and accounted for 49% of the variance in function. Self-efficacy and outcome expectations were the only variables to significantly influence exercise behavior and accounted for 57% of the variance in this behavior. These findings can be used to help develop and implement effective restorative nursing care programs in long-term care settings.

Motivation to perform activities of daily living in the institutionalized older adult: can a leopard change its spots?

The concept of motivation has great relevance for the older adult because of the multiple problems that can result in functional limitations. The ability to overcome and transcend these problems is related to the individuals' motivation to maintain and/or improve function. The purpose of this study, which used a naturalistic or constructivist inquiry, was to explore what motivates the institutionalized older adult to perform functional activities. Primary selection was used to obtain the sample which included 44 older adults, 37 (84%) females, and 7(16%) males. The average of participants was 88 +/- 6.4, and they were institutionalized for 2.8 +/- 2.8 years. Semi-structured interviews were done in the participants room. Data analysis involved content analysis. A total of 27 codes were initially identified, and these were categorized and developed into five major themes: Personality, Goals, Beliefs, Fear and Physical factors. The participants indicated that basic personality had a major on motivation, i.e. 'a leopard can't change his spots'. Further findings suggested that although personality may be central to the individuals' motivation to perform, goals, fear, beliefs and physiological sensations also influenced motivation and behavior. Appropriate interventions can be used to foster motivation to perform functional activities for institutionalized older adults.

A standardized assessment and intervention protocol for managing risk for falls on a geriatric rehabilitation unit

This article describes the intervention protocols implemented at the Sisters of Charity Hospital of Ottawa, Canada on a 36-bed geriatric rehabilitation unit for managing the risk for falls in patients assessed to be at high, moderate, or low risk. The implementation of tailored protocols is of particular importance on rehabilitation units because staff must balance the treatment goal to increase patient mobility, activity level, and independence with the need to prevent falls. Thus, this article also describes the related standardized criteria and decisional guidelines used in determining patients' level of independence on the unit for each fall-risk category. This article concludes with an outline of practices designed to facilitate safe transfers and completion of activities of daily living among geriatric patients with functional impairments by teaching and promoting the use of behavioral compensatory strategies for disability-related deficits.

Functional performance of older adults in a long-term care setting

Motivation has been identified as an important factor in the older adult's ability to perform functional activities. The purpose of this study was to explore functional performance and factors that have an impact on functional performance in nursing home residents. Participants included 44 White older adults from two nursing homes. The majority of the participants were female (84%). The mean age of the participants was 88 +/- 6.4 years and, on the average, they had been institutionalized for 2.85 +/- 2.8 years. Following data reduction of the predictors, two factors--motivation (efficacy beliefs and intrinsic motivation) and lower extremity function (contractures and standing balance)--were identified. In a stepwise multiple regression analysis, these two factors were the only variables that significantly predicted functional performance and accounted for 81% of the variance in function.

Efficacy beliefs in geriatric rehabilitation

Motivation is an important variable in older adults' ability to recover from any disabling event. The theory of self-efficacy states that efficacy beliefs affect behavior, motivational level, thought patterns, and emotional reactions in response to any situation. This study explored the impact of efficacy beliefs on older adults in a rehabilitation program and tested interventions to strengthen efficacy beliefs related to participation in rehabilitation and functional performance. An experimental pretest-posttest design was used. Participants were randomly assigned to: the usual care control group or the treatment group. The study was completed on an inpatient geriatric rehabilitation unit. The sample consisted of 77 participants, 55 women and 22 men with a mean age of 78 +/- 7.2. Individuals in the treatment group received three efficacy enhancing interventions: role modeling, verbal persuasion, and physiological feedback. Baseline data were collected within 48 hours of admission and included four investigator-developed efficacy measures: Functional Inventory Measure, Participation Index, Numeric Rating Scale for pain, amount of analgesic used for pain, and Health Status. With the exception of Health Status, these measures were again completed within 48 hours of discharge. Admission performance was the only statistically significant predictor of efficacy beliefs. All efficacy beliefs increased over time and were significantly correlated with performance behaviors and length of stay. The treatment group had stronger efficacy beliefs regarding participation, higher participation at discharge, and less pain than the control group. Efficacy beliefs, both self-efficacy and outcome expectations, are related to participation, functional performance, and length of stay. Interventions to strengthen these beliefs improved participation in rehabilitation and decreased pain. Consideration of motivation can facilitate rehabilitation and help older adults obtain and maintain their highest functional level.

Use of the Apathy Evaluation Scale as a measure of motivation in elderly people

Motivation plays an important part in an elderly individual's ability to recover from a disabling event. On the other hand, apathy is a lack of motivation. The Apathy Evaluation Scale (AES) is an 18-item instrument that rates a person's thoughts, actions, and emotions over the previous 4 weeks. The purpose of this study was to use the AES with 102 patients in a geriatric rehabilitation program to determine if it predicted improved function after rehabilitation. In addition, a short 7-item version of the AES was tested. A strong correlation was demonstrated between the 18-item AES and the 7-item AES, the Mini-Mental State Examination, and the Geriatric Depression Scale. In separate regression analyses, we found that admission function and both the 18-item and 7-item AES were significant predictors of discharge function, and that functional level at admission to rehabilitation accounted for 31% of the variance in function after rehabilitation. The findings suggest that the AES might be an appropriate measure of motivation in older adults and might predict success in rehabilitation. Moreover, the ability to identify patients with low motivation can alert healthcare providers to develop interventions to improve older adults' motivation and help them attain and maintain their highest functional level.

Predictors of functional ability in geriatric rehabilitation patients

This study explored the impact that motivation, cognitive status, depression, age, and physical status have on the functional ability of older adults in a rehabilitation program. The study was based on a hypothesized model and was conducted with 200 patients on a geriatric rehabilitation unit. Structural equation modeling was done to test the hypothesized model. The average age of participants was 78 years, and the majority were female, Caucasian, unmarried, and had been admitted for rehabilitation after an orthopedic event. The data fit the hypothesized model; however, only five paths were significant. Mental status was a significant predictor of function on admission and a direct and indirect predictor of function at discharge, and diagnosis and age directly predicted function at discharge.

Aspects of cognitive status as predictors of mobility following geriatric rehabilitation

This study aimed to determine the specific aspects of cognitive functioning which are related to geriatric rehabilitation treatment-outcome, and was based on a within-subject repeated measures design. In the setting of the inpatient Geriatric Rehabilitation Program (GRP) of the SCO Hospital in Ottawa, Canada 40 patients underwent six weeks of physiotherapy treatment for mobility training, on a twice daily schedule. Measurements were performed by the Clinical Outcome Variables Scale (COVS) and a mental status battery composed of five neuropsychological tests. Patients with a poorer mobility status at admission were significantly more depressed, more apraxic, less educated and had greater memory problems than their counterparts. The extent of treatment gains achieved by discharge was significantly related to a single aspect of cognition, namely procedural memory. Longer-term maintenance of treatment gains, however, was predicted by cognitive functioning more globally, including measures of praxis, declarative memory and reasoning. Together, the measures of cognition explained 52% of the variance in functional mobility outcome. In conclusion, patients with mild-to-moderate difficulties of cortically-based higher-order cognitive functions may still achieve significant gains in mobility function following geriatric rehabilitation. However, these patients may not be able to maintain their gains over time to the same extent as their cognitively healthier counterparts. Thus, from an empirical viewpoint, the decision to include or exclude cognitively impaired patients in GRPs varies with the definition of "treatment success" selected (i.e., short-term vs long-term gains). Alternatively, cognitively impaired patients may require more frequent follow-up rehabilitation services in order to maintain their gains.