Geriatric rehabilitation: state of the art

Multiparametric Evaluation of Geriatric Patients Admitted to Intermediate Care: Impact on Geriatric Rehabilitation

Optimizing the functional status of patients of any age is a major global public health goal. Rehabilitation is a process in which a person with disabilities is accompanied to achieve the best possible physical, functional, social, intellectual, and relational outcomes. The Intermediate Care Unit within the O.U. of Geriatrics and Gerontology of the San Martino Hospital in Genoa is focused on the treatment and motor reactivation of patients with geriatric pathologies. The objective of this study was to identify which factor, among the characteristics related to the patient and those identified by the geriatric evaluation, had the greatest impact on rehabilitation outcomes. Our findings revealed significant correlations between the Barthel Index delta, the 4AT Screening Test, and the number of drugs taken. This association highlights the potential benefits of medication management in enhancing the overall well-being and functional abilities of frail older adults, despite the literature suggesting that polypharmacotherapy is associated with a reduction in functional status and an increase in mortality. These findings underscore the significance of a multidimensional geriatric assessment. Refining and optimising these multidisciplinary approaches is the objective of a more effective geriatric rehabilitation strategy.

Cardiovascular disease patients and predictors of length of stay of residential of cardiac rehabilitation. A specific rehabilitation is mandatory in very old patients?

As more adults are living into old age, they are predisposed to cardiovascular disease (CVD) and the demand for cardiac rehabilitation is increasing. We aimed to verify predictors of length of stay (LOS) in young (Y) vs older (O) vs very old (VO) CVD patients, admitted to residential cardiac rehabilitation. Patients' demographic and clinical characteristics at admission, as well as Barthel index (BI), Cumulative Illness Rating Scale (CIRS), comorbidity severity/complexity, NYHA classification, left ventricular ejection fraction (LVEF), physical activity level were compared in Y (≤65 years) vs O (between >65 and <76 years) vs VO patients (with an age of ≥76 years) against LOS. In 5,070 consecutively CVD patients were included; they were 1392 Y (38%) 1944 O (35%) 1334 VO patients (27%) and LOS duration was 16±7, 19±9 and 22±10 days, respectively (p<0.0001). In Y, LOS was linked to BI (p=0.000) and to LVEF (p=0.000) at multivariable analysis with area under ROC curve of 0.82, whereas in O, LOS was associated to gender (p=0.013) CIRS severity (p=0.000), BI (p=0.000), LVEF (p=0.000), and in those VO to gender (p=0.004), BI (p=0.000) and medical infusion (p=0.000) at multivariable with ROC curve of 0.83 and 0.74, respectively. In very old patients, a prolonged LOS is related to extra-cardiac conditions. Therefore, we promote a specific cardiac rehabilitation for these patients.

Referral to geriatric rehabilitation: a scoping review of triage factors in acutely hospitalised older patients

OBJECTIVE

Old or frail acutely hospitalised patients can benefit from geriatric rehabilitation but criteria concerning referral decisions are unclear. This review presents an overview of clinical factors associated with referral to geriatric rehabilitation that may further consensus between hospital and rehabilitation professionals on triage.

DESIGN

Scoping review.

METHODS

A review was conducted following Arksey and O'Malley's framework. The search included literature concerning a broad spectrum of acutely hospitalised patients and factors associated with their referral to geriatric rehabilitation.

RESULTS

Selected abstracts were categorised into distinct geriatric rehabilitation care pathways such as stroke, hip fracture, amputation of lower limb, cardiac and oncologic rehabilitation. Abstracts on internal medical patients were further reviewed and 29 studies were included. A total of 13 studies focused on factors identifying rehabilitation needs and 16 on factors associated with outcome of geriatric rehabilitation. Triage factors were diverse and included frailty status, functional decline, cognitive symptoms and multimorbidity. Mood symptoms and living situation further specified post-acute care needs. In overview, triage factors could be characterised as demographic (n = 4), diagnosis-related (n = 8), mental (n = 6), functional (n = 10) or multi-domain (n = 12) and mapped in a transitional care pathway.

CONCLUSIONS AND IMPLICATIONS

Frailty and functional decline are characteristics frequently associated with referral to geriatric rehabilitation of acutely hospitalised internal medical patients. A comprehensive geriatric assessment or a simpler multi-domain set of tests reveals rehabilitation needs and approximates a functional prognosis. Professional consensus on factors and timing of triage in hospital is within reach.

Functional Effects of Intervening Illnesses and Injuries After Hospitalization for Major Surgery in Community-living Older Persons

OBJECTIVE

To evaluate the functional effects of intervening illnesses and injuries, that is, events, in the year after major surgery.

BACKGROUND

Intervening events have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after major surgery.

METHODS

From a cohort of 754 community-living persons, aged 70+ years, 317 admissions for major surgery were identified from 244 participants who were discharged from the hospital. Functional status (13 activities) and exposure to intervening hospitalizations, emergency department (ED) visits, and restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months.

RESULTS

In the year after major surgery, exposure rates (95% CI) per 100-person months to hospitalizations, ED visits, and restricted activity were 10.0 (8.0-12.5), 3.9 (2.8-5.4), and 12.3 (10.2-14.8) for functional recovery and 7.2 (6.1-8.5), 2.5 (1.9-3.2), 11.2 (9.8-12.9) for functional decline. Each of the 3 intervening events were independently associated with reduced recovery, with adjusted hazard ratios (95% CI) of 0.20 (0.09-0.47), 0.35 (0.15-0.81), and 0.57 (0.36-0.90) for hospitalizations, ED visits, and restricted activity. For functional decline, the corresponding odds ratios (95% CI) were 5.68 (3.87-8.33), 1.90 (1.13-3.20), and 1.30 (0.96-1.75). The effect sizes for hospitalizations and ED visits were larger than those for the covariates.

CONCLUSIONS

Intervening illnesses/injuries are common in the year after major surgery, and those leading to hospitalization and ED visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors.

Functional Effects of Intervening Illnesses and Injuries After Critical Illness in Older Persons

OBJECTIVES

Intervening illnesses and injuries have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after critical illness. We set out to evaluate the functional effects of intervening illnesses and injuries in the year after critical illness.

DESIGN

Prospective longitudinal study of 754 nondisabled community-living persons, 70 years old or older.

SETTING

Greater New Haven, CT, from March 1998 to December 2018.

PATIENTS

The analytic sample included 250 ICU admissions from 209 community-living participants who were discharged from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional status (13 activities) and exposure to intervening illnesses and injuries leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. In the year after critical illness, recovery of premorbid function was observed for 169 of the ICU admissions (67.6%), and the mean (sd) number of episodes of functional decline (from 1 mo to the next) was 2.2 (1.6). The adjusted hazard ratios (95% CI) for recovery were 0.18 (0.09-0.39), 0.46 (0.17-1.26), and 0.75 (0.48-1.18) for intervening hospitalizations, emergency department visits, and restricted activity, respectively. For functional decline, the corresponding odds ratios (95% CI) were 2.06 (1.56-2.73), 1.78 (1.12-2.83), and 1.25 (0.92-1.69). The effect sizes for hospitalization and emergency department visit were larger than those for any of the covariates.

CONCLUSIONS

In the year after critical illness, intervening illnesses and injuries leading to hospitalization and emergency department visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors. To improve functional outcomes, more aggressive efforts will be needed to prevent and manage intervening illnesses and injuries after critical illness.

Can in-hospital or post discharge caregiver involvement increase functional performance of older patients? A systematic review

BACKGROUND

Regaining pre-hospitalization activity levels is only achieved in 30-50% of older patients. Extra physiotherapy time has been proven to improve functional outcome and shorten length of stay, but is costly. Considering their key role in caring for older people, involving informal caregivers in rehabilitation might further improve functional performance.

AIM

To determine if in-hospital or post discharge caregiver involvement can increase functional performance in older adults. The secondary aim was to determine if caregiver involvement can influence, quality of life of patient and caregiver, medical costs, readmission rate, discharge location, and mortality.

DESIGN

Systematic review with narrative synthesis.

METHODS

The electronic bibliographic databases MEDLINE, Embase, CINAHL, Cochrane and Web of Science were searched for (quasi) experimental and observational studies, with the following inclusion criteria; caregiver involvement regarding functional performance, mean age over 65 years, admitted to a hospital unit and subsequently discharged to their home setting. Risk of bias was assessed with the Rob 2 (randomized trials) and the ROBINS-1 tool (non-randomized studies).

RESULTS

Eight studies of an initial 4683 were included: four randomized controlled trials, one prospective cohort study, one non-randomized controlled trial, one subgroup analysis of an RCT and one prospective pre-post study. All but one study included patients with stroke. Three types of caregiver interventions could be distinguished: a care pathway (inclusion of caregivers in the process of care), education on stroke and teaching of bed-side handling-skills, and caregiver-mediated exercises. The one study evaluating the care pathway reported 24.9% more returns home in the intervention group. Studies evaluating the effect of education and bed-side handling-skills reported higher effect sizes for several outcomes with increasing session frequency. All studies with caregiver-mediated exercises showed beneficial effects on functional performance, immediately after the intervention and within 3 months follow-up.

CONCLUSION

The findings of this review suggest that involvement of caregivers in the rehabilitation of older adults leads to better functional performance up to 3 months after initiation. However, evidence is low and mainly focusing on stroke.

Risk Factors and Precipitants of Severe Disability Among Community-Living Older Persons

IMPORTANCE

Severe disability greatly diminishes quality of life and often leads to a protracted period of long-term care or death, yet the processes underlying severe disability have not been fully evaluated.

OBJECTIVE

To evaluate potential risk factors and precipitants associated with severe disability that develops progressively (during ≥2 months) vs catastrophically (from 1 month to the next).

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2016, with 754 nondisabled community-living persons aged 70 years or older. Data analysis was conducted from November 2018 to May 2019.

MAIN OUTCOMES AND MEASURES

Candidate risk factors were assessed every 18 months. Functional status and potential precipitants, including illnesses or injuries leading to hospitalization, emergency department visit, or restricted activity, were assessed each month. Severe disability was defined as the need for personal assistance with at least 3 of 4 essential activities of daily living. The analysis was based on person-months within 18-month intervals.

RESULTS

The mean (SD) age for the 754 participants was 78.4 (5.3) years, 487 (64.6%) were women, and 683 (90.5%) were non-Hispanic white participants. The incidence of progressive and catastrophic severe disability was 3.5% and 9.7%, respectively, based on 3550 intervals. In multivariable analysis, 6 risk factors were independently associated with progressive disability (≥85 years: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; hearing impairment: HR, 1.7; 95% CI, 1.0-2.8; frailty: HR, 2.4; 95% CI, 1.6-3.7; cognitive impairment: HR, 2.0; 95% CI, 1.3-3.1; low functional self-efficacy: HR, 1.8; 95% CI, 1.2-2.8; low peak flow: HR, 1.7; 95% CI, 1.2-2.4), and 4 were independently associated with catastrophic disability (visual impairment: HR, 1.4; 95% CI, 1.1-1.8; hearing impairment: HR, 1.3; 95% CI, 1.0-1.7; poor physical performance: HR, 1.8; 95% CI, 1.3-2.5; low peak flow: HR, 1.3; 95% CI, 1.0-1.7). The associations of the precipitants were much more pronounced than those of the risk factors, with HRs as high as 321.4 (95% CI, 194.5-531.0) for hospitalization and catastrophic disability and 48.3 (95% CI, 31.0%-75.4%) for hospitalization and progressive disability. Elimination of an intervening hospitalization was associated with a decrease in the risk of progressive and catastrophic severe disability of 3.0% (95% CI, 3.0%-3.1%) and 12.3% (95% CI, 12.1%-12.5%), respectively. Risk differences were 0.6% (95% CI, 0.6%-0.6%) and 1.3% (95% CI, 1.3%-1.4%) for emergency department visit and 0.1% (95% CI, 0.1%-0.2%) and 0.4% (95% CI, 0.4%-0.4%) for restricted activity, and ranged from 0.1% (95% CI, 0.1%-0.1%) to 0.3% (95% CI, 0.3%-0.3%) for the independent risk factors, for progressive and catastrophic disability, respectively.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that whether it develops progressively or catastrophically, severe disability among older community-living adults arises most commonly in the setting of an intervening illness or injury. To reduce the burden of severe disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.

Goal-setting in geriatric rehabilitation: a systematic review and meta-analysis

Objective:

To explore the effect of goal-setting on physical functioning, quality of life and duration of rehabilitation in geriatric rehabilitation compared to care as usual.

Data sources:

Medline, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from initiation to October 2018.

Methods:

We included randomized controlled trials (RCTs), controlled before–after studies and studies using historic controls of older patients (mean age ⩾55 years) receiving rehabilitation for acquired disabilities. Our primary outcome was physical functioning; secondary outcomes were quality of life and rehabilitation duration. Cochrane guidelines were used to assess the risk of bias of the studies and extract data. Only RCT data were pooled using standardized mean difference (SMD).

Results:

We included 14 studies consisting of a total of 1915 participants with a mean age ranging from 55 to 83 years. Ten out of the 14 studies had a randomized controlled design, 7 of which could be pooled for the primary outcome. The risk of bias was judged high in several domains in all included studies. The meta-analysis showed no statistically significant differences between goal-setting and care as usual for physical functioning (SMD −0.11 (−0.32 to 0.10)), quality of life (SMD 0.09 (−0.56 to 0.75)) and rehabilitation duration (MD 13.46 days (−2.46 to 29.38)).

Conclusion:

We found low-quality evidence that goal-setting does not result in better physical functioning compared to care as usual in geriatric rehabilitation. For quality of life and duration of rehabilitation, we could not exclude a clinically relevant effect.

Burden of Restricted Activity and Associated Symptoms and Problems in Late Life and at the End of Life

OBJECTIVES

To compare rates of restricted activity and associated symptoms and problems in the last 6 months of life with those in the period before the last 6 months of life.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Community-living persons aged 70 and older (N=754).

MEASUREMENTS

The occurrence of restricted activity (staying in bed for at least half the day or cutting down on usual activities) and 24 prespecified symptoms and problems leading to restricted activity was ascertained monthly for nearly 19 years.

RESULTS

Rates of restricted activity per 100 person-months were 36.5 in the last 6 months of life versus 16.1 in the period before the last 6 months of life (P<.001). Of 737 participants with 1 month or more of restricted activity, rates of restricting symptoms per 100 person-months of restricted activity ranged from 8.0 for frequent or painful urination to 65.6 for been fatigued, and rates of restricting problems ranged from 0.1 for problem with alcohol to 23.4 for been afraid of falling. Rates were significantly higher in the last 6 months of life than in the prior period for 13 of the 24 restricting symptoms and problems (P<.05), most notably for shortness of breath (38.6 vs 21.8), weakness (37.3 vs 18.9), and confusion (31.2 vs 9.8). Mean (standard error) number of restricting symptoms and problems was significantly higher in the last 6 months of life (6.1 (0.1)) than in the prior period (4.7 (0.03)) (P<.001).

CONCLUSION

Rates of restricted activity and associated symptoms and problems are substantially greater in the last 6 months of life than in the period before the last 6 months of life. Enhanced palliative care strategies may be needed to diminish the burden of distressing symptoms and problems at the end of life. J Am Geriatr Soc 66:2282-2288, 2018.

Is an in-home telerehabilitation program for people with proximal humerus fracture as effective as a conventional face-to face rehabilitation program? A study protocol for a noninferiority randomized clinical trial

Background

Proximal humerus fractures can be treated surgically (eg: pinning, plate and screws) or conservatively by wearing a splint or a cast. Following both of these approaches, rehabilitation has proven effective to prevent functional limitations and to re-establish normal shoulder function. However, access to these rehabilitation services and compliance tends to be limited in elderly patients due to travelling difficulties caused by their precarious health status and, in some cases, social and marital status. Since the majority of patients with a proximal humerus fracture are elderly, it becomes relevant to find a new way to offer quick, simple and suitable rehabilitation service. Thus, the use of promising alternative approaches, as in-home telerehabilitation, can enhance access to rehabilitation services for such population. The main objective of the study is to compare the clinical effects of the innovative telerehabilitation approach (TELE group) compared to face-to-face visits to a clinic (CLINIC group) for patients treated for a proximal humerus fracture.

Methods/Design

In this randomized controlled trial, individuals who have had a proximal humerus fracture treated conservatively at the Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l’Estrie CHUS), and who are returning home will be included. Participants will be recruited during their visit to the emergency ward or outpatient clinic by the medical or research team and will then sign the informed consent form if they are interested to participate in the study. We expect to recruit 52 participants (26 per group). Randomization will be done by a random number generator with sealed envelopes. Each patient will be evaluated before the beginning of the rehabilitation (T1), and immediately after the 2-month intervention (T2). The following outcomes will be measured: 1) upper extremity function (Constant Shoulder Score and Disability of the Arm, Shoulder and Hand questionnaire [DASH]); 2) range of motion (conventional goniometer); 3) user satisfaction (Health Care Satisfaction questionnaire); and 4) cost of services to the public healthcare system.

The difference between the two groups will be compared using a t-test or a chi-squared test, and through a cost-effectiveness economic analysis.

Discussion

We hypothesize that in-home telerehabilitation will provide a good alternative to conventional rehabilitation, in terms of its efficacy, simplicity, patient satisfaction, and low associated costs.

Trial registration

ClinicalTrials.gov: NCT02425267. April 22^nd, 2015.

Article Predictors of Wellbeing and Autonomy Before and After Geriatric Rehabilitation

The aim of this study was to explore changes in the correlational association between predictors (i.e. sociodemographics, subjective health, social support, anxiety and coping) and outcome measures (i.e. subjective wellbeing and autonomy) before and after rehabilitation treatment. The data came from a sample of 90 patients (mean age 78.8 years; 84 percent female; 37 percent stroke, 44 percent fracture, 19 percent other diagnoses), who were assessed before and after rehabilitative treatment. Results revealed that although changes between predictors and outcomes were not prevalent with respect to subjective wellbeing, they were clearly evident with respect to autonomy. Whereas psychological variables, such as state anxiety and behavioural coping, played no predictive role at entry, they became the strongest predictors of autonomy at discharge.

The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older people

OBJECTIVE

To evaluate the role of intervening hospital admissions on trajectories of disability in the last year of life.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut, United States, from March 1998 to June 2013.

PARTICIPANTS

552 decedents from a cohort of 754 community living people, aged 70 years or older, who were initially non-disabled in four essential activities of daily living: bathing, dressing, walking, and transferring.

MAIN OUTCOME MEASURE

Occurrence of admissions to hospital and severity of disability (range 0-4), ascertained during monthly interviews for more than 15 years.

RESULTS

In the last year of life, six distinct trajectories of disability were identified, from least disabled to most disabled: 95 participants (17.2%) had no disability, 61 (11.1%) had catastrophic disability, 53 (9.6%) had accelerated disability, 61 (11.1%) had progressively mild disability, 127 (23.0%) had progressively severe disability, and 155 (28.1%) had persistently severe disability. 392 (71.0%) participants had at least one hospital admission and 248 (44.9%) had multiple hospital admissions. For each trajectory the course of disability closely tracked the monthly prevalence of hospital admission. In a set of multivariable models that included several potential confounders, hospital admission in a given month had a strong independent effect on the severity of disability, in both relative and absolute terms. The largest absolute effect was observed for catastrophic disability, with a mean increase in disability score of 1.9 (95% confidence interval 1.5 to 2.4) in the setting of a hospital admission, corresponding to a rate ratio (or relative effect) of 2.0 (95% confidence interval 1.5 to 2.7).

CONCLUSIONS

In the last year of life, acute hospital admissions play an important role in the disabling process. Knowledge about the course of disability before these intervening events may facilitate clinical decision making at the end of life. For older patients admitted to hospital with progressive or persistent levels of severe disability, representing more than half of the decedents, clinicians might consider a palliative care approach to facilitate discussions about advance care planning and to better deal with personal care needs.

The role of intervening illnesses and injuries in prolonging the disabling process

OBJECTIVES

To evaluate the relationship between intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, and prolongation of disability in four essential activities of daily living in newly disabled older persons.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Community-living persons aged 70 and older who had at least one episode of disability from March 1998 to June 2013 (N=632).

MEASUREMENTS

Disability and exposure to intervening illesses and injuries leading to hospitalization and restricted activity, respectively, were assessed every month. Prolongation of disability was operationalized in two complementary ways: as a dichotomous outcome, based on the persistence of any disability, and as a count of the number of disabled activities.

RESULTS

During a median follow-up of 114 months, the 632 participants experienced 2,764 disability episodes. The mean exposure rates for hospitalization and restricted activity were 80.7 (95% confidence interval (CI)=73.7-88.4) and 173.6 (95% CI=162.5-185.5), respectively, per 1,000 person-months. After adjustment for multiple disability risk factors, the likelihood of disability prolongation was 2.5 times as great (odds ratio (OR) 2.54, 95% CI=2.05-3.15) for hospitalization and 1.2 times as great (1.21, 95% CI=1.06-1.40) for restricted activity as for no hospitalization or restricted activity, and the mean number of disabilities was 35% (risk ratio (RR)=1.35, 95% CI=1.30-1.39) greater in the setting of hospitalization and 7% (1.07, 95% CI=1.05-1.09) greater in the setting of restricted activity.

CONCLUSION

Intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, are strongly associated with prolongation of disability in newly disabled older adults. Efforts to prevent and more-aggressively manage these intervening events have the potential to break the cycle of disability in older persons.

In-home telerehabilitation for proximal humerus fractures: a pilot study

The objective of this study was to investigate the feasibility of an in-home telerehabilitation program for proximal humerus fractures. Seventeen patients with proximal humerus fractures were recruited by an orthopedic specialist during emergency room visits. Telerehabilitation treatments were given at the patient’s home over an 8-week period using a videoconferencing system. Pain (Short-Form McGill Pain Questionnaire [SF-MPQ]), disabilities including shoulder range of motion (flexion, extension, internal rotation, external rotation, abduction), and upper limb function (Disability of the Arm, Shoulder and Hand questionnaire [DASH]) were measured in face-to-face evaluations before (T1) and immediately after (T2) the program. Participant satisfaction with the health care received was also evaluated at T2 with the Health care satisfaction questionnaire. All the clinical outcomes improved post-intervention (p < 0.05). Also, patient satisfaction was high (overall score of 82 ± 7%). Therefore, in-home teletreatment seems to be a promising way to dispense rehabilitation services for this population.

Disentangling the disabling process: insights from the precipitating events project

Among older persons, disability in activities of daily living is common and highly morbid. The Precipitating Events Project (PEP Study), an ongoing longitudinal study of 754 initially nondisabled, community-living persons, aged 70 or older, was designed to further elucidate the epidemiology of disability, with the goal of informing the development of effective interventions to maintain and restore independent function. Over the past 16 years, participants have completed comprehensive, home-based assessments at 18-month intervals and have been interviewed monthly to reassess their functional status and ascertain intervening events, other health care utilization, and deaths. Findings from the PEP Study have demonstrated that the disabling process for many older persons is characterized by multiple and possibly interrelated disability episodes, even over relatively short periods of time, and that disability often results when an intervening event is superimposed upon a vulnerable host. Given the frequency of assessments, long duration of follow-up, and recent linkage to Medicare data, the PEP Study will continue to be an outstanding platform for disability research in older persons. In addition, as the number of decedents accrues, the PEP Study will increasingly become a valuable resource for investigating symptoms, function, and health care utilization at the end of life.

An economic evaluation of resistance training and aerobic training versus balance and toning exercises in older adults with mild cognitive impairment

Background

Mild cognitive impairment (MCI) represents a critical window to intervene against dementia. Exercise training is a promising intervention strategy, but the efficiency (i.e., relationship of costs and consequences) of such types of training remains unknown. Thus, we estimated the incremental cost-effectiveness of resistance training or aerobic training compared with balance and tone exercises in terms of changes in executive cognitive function among senior women with probable MCI.

Methods

Economic evaluation conducted concurrently with a six-month three arm randomized controlled trial including eighty-six community dwelling women aged 70 to 80 years living in Vancouver, Canada. Participants received twice-weekly resistance training (n = 28), twice weekly aerobic training (n = 30) or twice-weekly balance and tone (control group) classes (n = 28) for 6 months. The primary outcome measure of the Exercise for Cognition and Everyday Living (EXCEL) study assessed executive cognitive function, a test of selective attention and conflict resolution (i.e., Stroop Test). We collected healthcare resource utilization costs over six months.

Results

Based on the bootstrapped estimates from our base case analysis, we found that both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes. Compared with the balance and tone group, the resistance-training group had significantly improved performance on the Stroop Test (p = 0.04).

Conclusions

Resistance training and aerobic training result in health care cost saving and are more effective than balance and tone classes after only 6 months of intervention. Resistance training is a promising strategy to alter the trajectory of cognitive decline in seniors with MCI.

Trial Registration

ClinicalTrials.gov NCT00958867.

Long-term functional outcomes in the elderly after burn injury

Although the elderly represent a substantial proportion of the population, limited information exists on postdischarge long-term outcomes of elderly burn survivors. The purpose of this study was to assess elderly burn patient outcomes 2 to 10 years after discharge. This study was a prospective cross-sectional survey assessment of quality of life and retrospective trauma registry for the American College of Surgeons review of patients ≥ 60 years of age discharged alive after acute burn from 1997 to 2007. In-hospital treatment and burn demographic information were obtained from database and chart review. Surviving patients or their families were contacted, and the Short-Form-12 and Functional Independence Measure (FIM) administered. Of the 344 patients discharged, 232 participated. Mean age was 72.3 (60-85.8) years, TBSA burn was 7.8% (1-79), and length of stay was 11.2 ± 0.9 days (1-51). Most patients were discharged home (71%) or to a skilled nursing facility (SNF; 20%). Mean interval between discharge and survey administration was 46.1 months. In all, 24% of patients sent home died after discharge and prior to interview compared with 58% of patients sent to an SNF. On multivariate analysis, mortality increased with age (confidence interval [CI] 1.04-1.09), and government insurance (CI 0.34-0.94), but decreased with discharge to home (CI 1.68-4.47). There were no differences in FIM or Short-Form-12 scores between groups. Long-term mortality after discharge in elderly burn survivors is substantial. Patients sent to an SNF or with government insurance had increased mortality postdischarge. These data suggest that issues that may influence disposition status of elderly burn patients should be optimized prior to discharge to mitigate adverse outcomes associated with SNF placement.

The impact of mild stroke on participation in physical fitness activities

Objective. To compare participation in moderate to high intensity physical activities in persons before and after a mild stroke. Methods. We used data from the Cognitive Rehabilitation and Research Group to examine changes in moderate to high intensity physical activity participation in persons who had a mild stroke as defined by an NIH Stroke Scale score of less than 6 (N = 127). Using the Activity Card Sort, we compared the participants' high-demand leisure activity (leisure activities that are moderate to high intensity physical activities) participation at 6-months after stroke with their prestroke level. Results. We found a significant decrease in numbers of high-demand leisure activities in all participants and in each demographic group after mild stroke. Conclusion. These results suggest that persons after mild stroke are not retaining the high-demand leisure activities they were doing prior to their stroke. Health professionals must promote participation in high-demand leisure activities in patients with mild stroke as a tool to enhance health and fitness.

Patients' satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists' satisfaction toward technology for post-knee arthroplasty: an embedded study in a randomized trial

OBJECTIVE

We measured the satisfaction of both patients and healthcare professionals with the technologies and services provided during in-home telerehabilitation as an alternative to conventional rehabilitation after discharge from total knee arthroplasty surgery.

METHODS

This study was embedded in a larger controlled trial where 48 community-living older adults who received total knee arthroplasty were recruited prior to discharge from acute care following surgery and randomly assigned to treatment arms (Tele and Comparison). The participants' satisfaction with the services was assessed at the end of the intervention for both groups using the Healthcare Satisfaction Questionnaire. For the Tele group, the patients' perception of in-home telehealth was assessed before treatment and after completion of teletreatments. The satisfaction of the healthcare professionals with the technology during the telerehabilitation services was noted at the end of each treatment session using a technical quality subjective appreciation questionnaire.

RESULTS

Both groups of patients (Tele and Comparison) were satisfied with the services received and no significant difference was observed between them. Moreover, the physiotherapists' satisfaction with regard to goal achievement, patient-therapist relationship, overall session satisfaction, and quality and performance of the technological platform was high.

CONCLUSIONS

As patient satisfaction is important in maintaining motivation and treatment compliance and the satisfaction of healthcare professionals must be high in order for new treatments to become mainstream in clinics, the results show that in-home telerehabilitation seems to be a promising alternative to traditional face-to-face treatments.

Using intervention mapping to develop and adapt a secondary stroke prevention program in Veterans Health Administration medical centers

Secondary stroke prevention is championed by the stroke guidelines; however, it is rarely systematically delivered. We sought to develop a locally tailored, evidence-based secondary stroke prevention program. The purpose of this paper was to apply intervention mapping (IM) to develop our locally tailored stroke prevention program and implementation plan. We completed a needs assessment and the five Steps of IM. The needs assessment included semi-structured interviews of 45 providers; 26 in Indianapolis and 19 in Houston. We queried frontline clinical providers of stroke care using structured interviews on the following topics: current provider practices in secondary stroke risk factor management; barriers and needs to support risk factor management; and suggestions on how to enhance secondary stroke risk factor management throughout the continuum of care. We then describe how we incorporated each of the five Steps of IM to develop locally tailored programs at two sites that will be evaluated through surveys for patient outcomes, and medical records chart abstraction for processes of care.

Change in disability after hospitalization or restricted activity in older persons

CONTEXT

Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of disability. The role of intervening illnesses and injuries (ie, events) on these transitions is uncertain.

OBJECTIVES

To evaluate the relationship between intervening events and transitions among states of no disability, mild disability, severe disability, and death and to determine the association of physical frailty with these transitions.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months.

MAIN OUTCOME MEASURE

Transitions between no disability, mild disability, and severe disability and 3 transitions from each of these states to death, evaluated each month.

RESULTS

Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval [CI], 118-239) for the transition from no disability to severe disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild disability to no disability. Restricted activity also increased the likelihood of transitioning from no disability to both mild and severe disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild disability to severe disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or severe disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no disability to mild disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening disability.

CONCLUSIONS

Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from disability.

Current blood pressure self-management: a qualitative study

Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors. Each participant completed a questionnaire regarding current BP management. We analyzed and coded qualitative transcripts from the focus groups and found four emergent themes that were supported by questionnaire results. The four self-management themes include: (1) external support for BP self-management is helpful; (2) BP self-management strategies include medication adherence, routine development, and BP monitoring; (3) BP risk factor management involves diet, exercise, and stress reduction; and (4) taking advantage of the"teachable moment" may be advantageous for behavior change to self-manage BP. This research provides key elements for the development of a successful BP self-management program.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 1)

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the issues and identify their diverse causes. Together, the two segments of this fourth and final article (divided between this month's issue and the next one) in the series identify strategies that should tie reform efforts together. This Segment 1 of Article 4 discusses the need to judge initiatives and proposals by how well they support and/or promote critical elements such as the care delivery process and clinical problem solving and decision making activities. It also covers the need to critically scrutinize and modify the conventional wisdom and to suppress "political correctness" thatcontinues to inhibit vital critical inquiry and dialogue that are needed to define issues correctly and make further progress. Ultimately, relatively uncomplicated and inexpensive strategies have the potential to bring dramatic progress. But there needs to be more willingness to rethink the issues and reconsider current approaches.

Facilitating aerobic exercise training in older adults with Alzheimer's disease

Emerging science suggests that aerobic exercise might modify the pathophysiology of Alzheimer's disease (AD) and improve cognition. However, there are no clinical practice guidelines for aerobic exercise prescription and training in older adults with AD. A few existing studies showed that older adults with AD can participate in aerobic exercise and improve dementia symptoms, but lack adequate descriptions of their aerobic exercise training programs and their clinical applicability. In this paper, we summarize current knowledge about the potential benefits of aerobic exercise in older adults with AD. We then describe the development of a moderate-intensity aerobic exercise program for this population and report results from its initial testing in a feasibility trial completed by two persons with AD. Two older adults with AD completed the aerobic exercise program. Barriers to the program's implementation are described, and methods to improve more wide-spread adoption of such programs and the design of future studies that test them are suggested.

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.

Subtypes of disability in older persons over the course of nearly 8 years

OBJECTIVES

To characterize distinct and clinically meaningful subtypes of disability, defined based on the number and duration of disability episodes, and to determine whether the incidence of these disability subtypes differ according to age, sex, or physical frailty.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Seven hundred fifty-four community-living residents aged 70 and older and initially nondisabled in four essential activities of daily living.

MEASUREMENTS

Disability was assessed during monthly telephone interviews for nearly 8 years; physical frailty was assessed during comprehensive home-based assessments at 18-month intervals. The incidence of five disability subtypes was determined within the context of the 18-month intervals in participants who were nondisabled at the start of the interval: transient, short-term, long-term, recurrent, and unstable.

RESULTS

Incident disability was observed in 29.8% of the 18-month intervals. The most common subtypes were transient disability (9.7% of all intervals), defined as a single disability episode lasting only 1 month, and long-term disability (6.9%), defined as one or more disability episodes, with at least one lasting 6 or more months. Approximately one-quarter (24.7%) of all participants had two or more intervals with an incident disability subtype. Although there were no sex differences in the incidence rates for any of the subtypes, differences in rates were observed for each subtype according to age and physical frailty, with only one exception, and were especially large for long-term disability.

CONCLUSION

The mechanisms underlying the different disability subtypes may differ. Additional research is warranted to evaluate the natural history, risk factors, and prognosis of the five disability subtypes.

Evidence rocks in long-term care, but does it roll?

This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.

Applicability of a toolkit for geriatric rehabilitation outcomes

PURPOSE

To field test the applicability of a multidimensional toolkit for geriatric rehabilitation outcomes which includes nine standardized tools. Applicability is defined as context- and population-specific pragmatic qualities of an assessment tool such as respondent and examiner burden, score distribution and format compatibility.

METHOD

A sample of 48 older adults representing four diagnostic groups, as well as 26 caregivers, were assessed at home in the first month after discharge from intensive rehabilitation (T1) and 2 months later (T2). Pre-determined qualitative and quantitative applicability criteria were coded and compared at T1 and T2, as well as responsiveness.

RESULTS

A higher respondent burden was found for three self-report tools, as well as a ceiling effect on social functioning tools. Respondent burden, examiner burden and score distribution remained stable or diminished at T2. Format compatibility deteriorated only for the mobility test due to a higher proportion of non ambulatory participants (17%). Low to moderate associations between the tools corroborated that they were not redundant (rPearson <or= 0.77). Responsiveness estimates confirmed that mean scores were stable between T1 and T2.

CONCLUSION

Overall, the toolkit was found to be applicable at home after geriatric rehabilitation. Modifications are proposed to further improve its applicability. This study highlighted practical aspects that could alleviate the burden on research participants and facilitate the use of those tools for community follow-up for clinical and research purposes.

Improving knowledge and skills for use of medication by patients after stroke: evaluation of a nursing intervention

OBJECTIVE

The objective of this study was to determine if a tailored nursing intervention, as opposed to usual rehabilitation care, can improve knowledge and behavioral skills for correct use of medication use in aged stroke patients.

DESIGN

Stratified random sampling created two homogenous groups: 73 intervention patients, who were provided with the nursing intervention program along with usual rehabilitation care, and 82 controls, who underwent usual rehabilitation care alone. Participants were assessed within the first week of admission to the rehabilitation ward, 3 mos after stroke (at the end of the intervention), and 6 mos after stroke. An assessment instrument measuring correct knowledge and skills concerning medications was used.

RESULTS

After 3 and 6 mos, intervention subjects were significantly better than controls in knowledge of shape and dosage of their medications, in knowledge of side effects and correct response to side effects, and in adherence to their dietary regimen. However, for knowledge of color and daily schedule of medications, there were differences at 3 mos, but differences were diminished after 6 mos.

CONCLUSIONS

This nursing intervention, tailored to the specific needs of the aged stroke patient, increased the patients' knowledge and skills concerning medication therapy, but to a limited extent and for a limited time.

Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: the Women's Health and Aging Study I

BACKGROUND

Changes in self-reported function in older adults are known to occur in the 2 weeks prior to, during, and in the first few months after hospitalization. The long-term outcome of hospitalization on functional status in disabled older adults is not known. The objective of this study was to determine whether hospitalization predicts long-term Activities of Daily Living (ADL) dependence in previously ADL independent, although disabled, older women.

METHODS

The Women's Health and Aging Study I is a population-based, prospective cohort study of disabled, community-dwelling women > or =65 years old. We evaluated participants who were independent in ADLs at baseline and excluded women with incident stroke, lower extremity joint surgery, amputation, or hip fracture. We examined the association between self-reported incident hospitalization at three consecutive 6-month intervals and incident dependence in at least one ADL at 18 months (n = 595).

RESULTS

Of 595 women evaluated, 32% had at least one hospitalization. Women who were hospitalized were more likely to become dependent in ADLs than were women who were not hospitalized (17% vs 8%, p =.001). In a multivariate model, hospitalization was independently predictive of development of ADL dependence that persisted at 18 months after baseline (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7-5.8), adjusting for age, race, education, baseline walking speed, difficulty with ADLs, self-reported health status, depressive symptoms, cognitive status, and presence of congestive heart failure, diabetes, or pulmonary disease. Increasing numbers of 6-month intervals with hospitalizations were independently predictive of higher risk in an adjusted model: one (OR, 2.3; 95% CI, 1.1-4.6), two (OR, 5.8; 95% CI, 2.4-14.4), and three (OR, 12.5; 95% CI, 2.7-57.6).

CONCLUSIONS

These results suggest that hospitalization has an independent and dose-response effect on loss of ADL independence in disabled older women over an 18-month period.

Functional Outcomes for Older Adults with Cognitive Impairment in a Comprehensive Outpatient Rehabilitation Facility

The purpose of the study was to examine functional outcomes of a nurse-managed, community-based Comprehensive Outpatient Rehabilitation Facility (CORF) for frail older adults and to compare the outcomes between two groups: older adults with cognitive impairment and those with intact cognition. A retrospective cohort design using healthcare record abstraction was used for the study. Two hundred and one older adults who were admitted to the CORF from the end of 1997 to early 1999 were included in the study. Data were abstracted from healthcare records, including clinician-generated Mini-Mental State Examination, Geriatric Depression Scale, and Functional Independence Measure scores from the healthcare records and investigator-constructed measures of functional gain, rehabilitation efficiency, days of service, and discharge location. Multivariate regression analyses were performed to compare rehabilitation outcomes between the two groups. Regardless of cognitive status, all subjects improved significantly in their levels of functional dependence through participating in this outpatient rehabilitation program (P<.001). Subjects with cognitive impairment exhibited more functional dependence at baseline and discharge than did their cognitively intact counterparts. Nevertheless, there was no difference between the two groups in functional gain (P=.63), rehabilitation efficiency (P=.66), days of service (P=.83), or discharge location (P=.69). Therefore, despite their greater degree of functional dependence on admission, older adults with cognitive impairment benefited from this CORF without requiring more days of service and should thus be referred for rehabilitation services.

A Pilot Study: Post-Acute Geriatric Rehabilitation Versus Usual Care in Skilled Nursing Facilities

OBJECTIVES

To compare discharge outcomes, postdischarge health care use, and death rates among patients treated in a postacute geriatric rehabilitation unit (GRU) housed within a skilled nursing facility (SNF) with those treated in a traditional SNF.

DESIGN

Retrospective observational pilot study.

SETTING

Two similar SNFs were compared.

PARTICIPANTS

All patients were admitted from the acute hospital to either the GRU (n = 95) or to the usual care (UC) SNF (n = 55).

INTERVENTION

The GRU intervention consisted of comprehensive geriatric assessment and weekly interdisciplinary team rounds with a geriatrician and a geriatric nurse practitioner (GNP). The geriatrician visited the GRU twice a week and the GNP was present 4 to 5 times per week. On discharge, GRU patients were followed up with telephonic case management for 1 year.

MEASUREMENTS

Demographic data collected included age, gender, and race. Information collected from each facility's patient records included admitting diagnosis, length of stay, discharge disposition, and functional outcomes. Emergency department (ED) visits and hospital readmissions for 1 year after discharge from the nursing facility were obtained from our institutional database. The Rehabilitation Outcome Measure (ROM) was used by each facility to measure functional status on admission and at the time of discharge.

RESULTS

Baseline patient characteristics were comparable between the 2 facilities. At discharge from the nursing facility, GRU patients showed greater improvement in ADLs and mobility, had a significantly shorter length of stay, and were discharged to home more often. At 1 year, GRU patients had significantly fewer hospital readmissions. GRU patients also had fewer ED visits and days in the hospital at 1 year, however these results were not significant.

CONCLUSION

These pilot results suggest that GRU may be an effective means to improve patient outcomes and reduce undesirable health care use after an acute illness. Further studies using a randomized design are needed.

The geriatric amputee

There are special aspects of aging with an amputation and with being elderly at the time of an amputation. Older adults who have undergone amputation have many issues to contend with, including comorbidities that affect postoperative care and rehabilitation, general deconditioning and loss of mobility (especially if the onset of rehabilitation is delayed), and lack of social support upon returning to the community. These problems are compounded by a lack of knowledge about caring for the residual limb and prosthesis, maintenance of general health, and management of comorbid conditions. People who have sustained an amputation at an early age and who are ambulatory may find increasing difficulties as they age. Acquired chronic disease occurs more frequently as people age. These conditions can adversely affect function after amputation. Prosthetic designs may need modification because certain components may become more difficult to use. The prevention of a (second) amputation results in saving a limb and preserving self-image and independent function. Considering the emotional and economic cost of amputation and lifelong management of a prosthesis, it is worth the time and effort to practice preventive measures. Should amputation become necessary, careful patient assessment, compassionate management, and communication among the team members results in a more favorable outcome. Including the physiatrist early in the clinical course makes this process easier.

Research Agenda for Geriatric Rehabilitation

The Research Agenda Setting Process is a joint endeavor by the American Geriatrics Society and the Hartford Foundation to increase geriatric expertise in the surgical and related specialties. This article provides the results of the Research Agenda Setting Process project on research needs in geriatric rehabilitation, which included a systematic review of the literature and a group consensus process. Explicit research questions and methodologies were developed for three cross-cutting research needs in geriatric rehabilitation and for the rehabilitation of eight specific conditions affecting older individuals.

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.

Does Payment Structure Influence Change in Physical Functioning After Rehabilitation Therapy?

PURPOSE

To determine if there are differences by payment structure (Medicare managed care versus fee-for-service) in the duration and intensity of geriatric rehabilitation therapy treatments and measure their effect on change in physical functioning at discharge.

METHODS

Sixty-eight Medicare managed care (MCO) and 32 fee-for-service (FFS) subjects from 3 skilled nursing facilities (SNFs) in Southern California answered the physical functioning dimension of the Sickness Impact Profile (SIP-PFD) before and after rehabilitation therapy. Patient characteristics at admission, therapy treatments, and discharge physical functioning were compared by payment structure using chi-square and t-tests; logistic and ordinary least squares (OLS) regressions were employed to determine significant predictors of enrollment in managed care and change in physical functioning at discharge.

RESULTS

Payment structure yielded no significant differences in patient characteristics (physical functioning, socio-demographics, and clinical characteristics) at admission to rehabilitation. Compared to MCO subjects, FFS subjects received significantly more minutes per day (intensity) of rehabilitation therapy (Mean difference = - 16.90; t-test = - 4.504; p =.000). On average, all subjects reported significant, positive change in physical functioning from admission to discharge after rehabilitation (Mean change = 7.98, SD = 12.96; t-test = 6.157; p =.000); but change in physical functioning between MCO and FFS subjects was not significant.

CONCLUSIONS

Payment structure did not significantly influence change in physical functioning at discharge. Future studies, using a larger sample- size, should consider the effects of structural elements, process, and patient behavior on therapy treatments and physical functioning outcomes.

Functional and self-efficacy changes of patients admitted to a Geriatric Rehabilitation Unit

BACKGROUND

Geriatric Rehabilitation Units (GRUs) have been established to restore functional abilities of older hospitalized patients. Although considerable health care resources have been allocated to these units, few outcome-based research studies have been reported on Canadian GRUs.

AIM

The aim of this paper is to report a study examining the effect of admission to a GRU on changes in patients' functional ability and self-efficacy in performing everyday activities at home.

METHODS

Following Institutional Review Board approval, data were collected from 40 patients age 65-101 years (mean 83.8, sd 6.57) admitted to a 21-bed interdisciplinary GRUs over a 7-month period. All were living independently prior to hospital admission. Data were collected on admission to the unit and on discharge using two instruments: the Functional Independence Measure and Falls Efficacy Scale.

RESULTS

Statistically significant improvements were found in functional ability and self-efficacy following admission to the GRUs.

CONCLUSIONS

Although functional level and feelings of self-efficacy on admission to the unit were at levels which may have prevented participants from returning home, the majority were discharged to the community. Results suggest that admission to a GRU helps prepare patients to return to community living.

Attitudes towards rehabilitation needs and support from assistive technology and the social environment among elderly people with disability

This study aimed to survey the attitudes of elderly people with disabilities who were living at home regarding their support from assistive technology and the social environment. These attitudes were compared with their identified needs by an occupational therapist and in relation to perception of social engagement, loneliness and overall contentment with life. From a sample of 102 participants who were interviewed using a standardized procedure, 53 persons were included in the study. The results indicated that attitudes among elderly people towards social and occupational engagement and change have a greater influence on their rehabilitation status than their disability as indicated by their health condition and limitations in activities of daily living and instrumental activities of daily living. The elderly people who accepted rehabilitation were more able, and were better equipped and better supported with assistive technology, than those who declined rehabilitation. Rehabilitation needs that the occupational therapists recognized were not always shared by the disabled elderly people, for several reasons; one reason of particular importance was the elderly person's attitude towards change and social engagement. However, the small sample size limits the generalization of the findings to the population of elderly people with disabilities. An ethnographic research design that allows for repeated interviews and observations of elderly people with disabilities for a prolonged period of time in their ordinary everyday lives may present an avenue for future research and lead to a deeper understanding of the issues.

Rehabilitation and the older cancer patient

Older persons with cancer can often benefit from rehabilitative care. Rehabilitation may be of benefit to the patient whether or not their malignancy is curable. Rehabilitative programs must be tailored to the patient's abilities, endurance, prognosis, and individual goals.