Predicting discharge destination for patients with severe motor stroke: important functional tasks

Predictive Validity of Motor Assessment Scale on Poststroke Discharge Destination

Background: Stroke frequently leads to hospital admission and subsequent rehabilitation in order to overcome poststroke sequelae, such as motor impairments. Efficient planning of the steps following hospital admission includes early prediction of whether the patient can be discharged home or not. Early assessment of motor performance in patients with stroke-induced motor deficits may be able to function as a predictor of discharge destination but is less explored. Objective: The primary objective was to assess the predictive validity of the Motor Assessment Scale (MAS) on discharge destination both regarding total score and regarding subscores (transfer-mobility items and upper extremity items). Design: The study was designed as a prospective cohort study. Subjects: Thirty-seven consecutively recruited patients with stroke are the subjects of the study. Methods: Logistic regression model was used to calculate the odds of being discharged to own home upon hospital admittance. The predictive ability was examined with a receiving operator characteristic (ROC) curve, and cut-points from the curve were employed in Cox regression. Results: A one-unit higher score on the total MAS significantly increased the odds of being discharged home upon hospital admittance (odds ratio (OR) 1.14, 95% CI 1.04-1.25). The same pattern was observed with the summed items of 1-5 and 6-8. The total MAS showed sensitivity of 91.7% and specificity of 68.0%. Patients having a total MAS score ≥ 24 were 17 times more likely to be discharged home (HR 17.64, 95% CI 2.23-139.57) compared to patients with a lower score. Conclusion: Motor function measured by the MAS can be applied as a predictor of discharge destination upon hospital admission after stroke in Danish setting.

Physical functioning factors predicting a return home after stroke rehabilitation: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis sought to identify the physical functioning factors associated with home discharge after inpatient stroke rehabilitation.

DATA SOURCES

A search of PubMed, Embase, CINHAL, The Cochrane Library (Trials), Web of Science, and PEDro were conducted up until May 2023.

METHODS

Two independent reviewers selected studies for population (patients with stroke), predictive factors (physical functioning), outcome (discharge destination), setting (inpatient rehabilitation), and study designs (observational and experimental studies). Predictive factors were identified among assessments of the "body function" and "activity" components of the International Classification of Functioning. Methodological quality was assessed with the Newcastle-Ottawa Scale. The findings used quantitative and narrative syntheses. Meta-analyses were performed with the inverse variance method and the random-effects model using included studies with sufficient data.

RESULTS

Forty-five studies were included with 204,787 participants. Included studies assessed the association of independence in activities of daily living, walking, rolling, transferring, and balance on admission with a probability of returning home. Motor (odds ratio = 1.23, 95% confidence interval: 1.12-1.35, p < .001) and total (odds ratio = 1.34, 95% confidence interval: 1.14-1.57, p < .001) Functional Independence Measure scores on admission were significantly associated with home discharge in meta-analyses. Additionally, included studies showed that independence in motor activities, such as sitting, transferring, and walking, and scores above thresholds for the Functional Independence Measure and Berg Balance Scale on admission were associated with discharge destination.

CONCLUSION

This review showed that higher independence in activities of daily living on admission is associated with home discharge after inpatient stroke rehabilitation.

Change in care hours, cost, and functional independence following continence and assistive technology intervention in an acquired brain injury population

PURPOSE

After acquired brain injury (ABI) dependence on intervention for continence management is common. This preliminary investigation aimed to (i) quantify toileting care hours and costs in a community-based ABI rehabilitation and disability setting, and (ii) measure change in care needs, costs, and functional independence after intervention with assistive technologies (ATs).

METHOD

Pragmatic pre-post intervention pilot study of 14 adults with ABI and toileting disability accessing community-based neurorehabilitation or disability support in Western Australia. Toileting and functional independence were assessed monthly from baseline (T₀) to 3-month follow-up (T₃). Basic and nursing care hours (Northwick Park Dependency Score), cost of care estimates (Northwick Park Care Needs Assessment), functional independence (Functional Independence and Assessment Measure), and cost of consumables were examined pre- and post-intervention with ATs. Multilevel mixed-effects models with bootstrap estimation were conducted.

RESULTS

Cost of consumables significantly declined (AU$69/week), and functional independence significantly improved following intervention (+23.5 points). There was a non-significant reduction in care needs for toileting (4 h/week) and in the cost of toileting care (AU$633/week).

CONCLUSION

Toileting disability substantially impacts care hours and costs. This study provides preliminary evidence that comprehensive continence management is beneficial in reducing costs and supporting people with an ABI to increase their independence.IMPLICATIONS FOR REHABILITATIONA comprehensive continence assessment and management plan reduces the number of care hours, cost of care, and cost of continence products in a neurorehabilitation and disability support sample for people with acquired brain injury (ABI).Assistive technologies for continence management are beneficial in supporting people with ABI to increase independence, and reduce costs.Providing comprehensive continence assessment and management plan reduces reliance on staff for continence care, and improves functional independence.

Association between the Cognitive-Related Behavioral Assessment Severity Stage and Activities of Daily Living Required for Discharge to Home in Patients with Stroke: A Cross-Sectional Study

This study aimed to characterize cognitive function examined using Cognitive-related Behavioral Assessment (CBA) in activities of daily living (ADLs). According to CBA severity at discharge, 791 patients were assigned to five groups (most severe, severe, moderate, mild, and normal). The total scores for Functional Independence Measure (FIM) motor items were compared for each group. Multiple logistic regression analysis was performed to clarify the association between CBA severity and independence in ADL items. Independence in each ADL according to CBA severity was 0-4.8%, 26.8-45.0%, 84.3-91.0%, and 97.2-100% for all ADLs in the most severe to severe, moderate, mild, and normal groups, respectively. Significant differences were found in the FIM motor score according to CBA severity between the groups (p < 0.01). A mild or normal CBA was associated with a higher odds ratio (OR) for dressing the upper body (OR = 21.90; 95% confidence interval (CI), 13.50-35.70), bladder management (OR = 11.60; 95% CI, 7.21-18.60), transfers to the bed/chair/wheelchair (OR = 18.30; 95% CI, 11.40-29.40), transfers to the toilet (OR = 18.30; 95% CI, 11.40-29.30), and walking (OR = 6.60; 95% CI, 10.60-26.10). A CBA severity greater than mild (23 points) was associated with independence in ADLs that are important for discharge to home.

Inpatient Rehabilitation After Acute Severe Stroke: Predictive Value of the National Institutes of Health Stroke Scale Among Other Potential Predictors for Discharge Destination

Background

Research focusing on predictors for discharge destination after rehabilitation of inpatients recovering from severe stroke is scarce. The predictive value of rehabilitation admission NIHSS score among other potential predictors available on admission to rehabilitation has not been studied.

Aim

The aim of this retrospective interventional study was to determine the predictive accuracy of 24 hours and rehabilitation admission NIHSS scores among other potential socio-demographic, clinical and functional predictors for discharge destination routinely collected on admission to rehabilitation.

Material and Methods

On a university hospital specialized inpatient rehabilitation ward 156 consecutive rehabilitants with 24 hours NIHSS score ⩾15 were recruited. On admission to rehabilitation, routinely collected variables potentially associated with discharge destination (community vs institution) were analyzed using logistic regression.

Results

70 (44.9%) of rehabilitants were discharged to community, and 86 (55.1%) were discharged to institutional care. Those discharged home were younger and more often still working, had less often dysphagia/tube feeding or DNR decision in the acute phase, shorter time from stroke onset to rehabilitation admission, less severe impairment (NIHSS score, paresis, neglect) and disability (FIM score, ambulatory ability) on admission, and faster and more significant functional improvement during the in-stay than those institutionalized.

Conclusion

The most influential independent predictors for community discharge on admission to rehabilitation were lower admission NIHSS score, ambulatory ability and younger age, NIHSS being the most powerful. The odds of being discharged to community decreased with 16.1% for every 1 point increase in NIHSS. The 3-factor model explained 65.7% of community discharge and 81.9% of institutional discharge, the overall predictive accuracy being 74.7%. The corresponding figures for admission NIHSS alone were 58.6%, 70.9% and 65.4%.

Clinical Items for Geriatric Patients with Post-Stroke at Discharge or Transfer after Rehabilitation Therapy in a Chronic-Phase Hospital: A Retrospective Pilot Study

Clinical factors related to destination after rehabilitation therapy for geriatric patients with post-stroke in chronic-phase hospitals have not been elucidated. This study analyzed the clinical characteristics of geriatric patients with post-stroke at discharge/transfer after rehabilitation therapy in a chronic-phase hospital. Fifty-three patients (20 men, 33 women; mean age 81.36 ± 8.14 years) were recruited (the period analyzed: October 2013−March 2020). Clinical data were statistically analyzed among patients discharged to homes or facilities for older adults or transferred to another hospital. In addition, we analyzed the clinical items at discharge and transfer after rehabilitation therapy using a decision tree analysis. Twelve patients were discharged, eighteen were discharged to facilities for older adults, and twenty-three were transferred to another hospital. There were significant differences in the modified Rankin Scale, admission dates, functional independence measure (FIM) score, and Barthel Index score in the three groups (p < 0.05). Patients with motor subtotal functional independence scores of ≥14 (chronologically improved ≥5) after rehabilitation therapy for <291 days were more likely to be discharged home. Patients in a chronic-phase hospital who improved within a limited period were discharged to their homes, whereas those who were bedridden tended to be transferred to another hospital.

Effect of residual lower-extremity function on strategies and execution time for raising and lowering trousers in patients with hemiparetic stroke: a cross-sectional study

Background/aims

There are no established methods for patients with hemiparetic stroke to practice the raising and lowering of trousers. The aim of this study was to investigate the use of different strategies by patients with hemiparetic stroke for lowering and raising trousers by using the non-paretic upper limb in the standing position, based on residual motor function in the paretic lower limb.

Methods

A total of 28 patients with hemiparetic stroke were included in the study (n=10, 12, and 6 with lower-limb Brunnstrom stages III, IV and V respectively). Endpoints were execution time and frequency of changing the manipulation region.

Results

Lower-limb Brunnstrom stages III, IV and V were associated with execution times of 24.1 ± 11.1, 18.1 ± 6.5 and 16.9 ± 9.6 seconds respectively, and the mean frequency of manipulation of trousers on the posterior paretic side was significantly lower than those of the anterior paretic, anterior non-paretic, and posterior non-paretic sides in all patients (P<0.05).

Conclusions

Motor function of the paretic lower limb did not affect the strategies used for lowering and raising trousers with the non-paretic upper limb. Manipulation of trousers on the posterior paretic side was especially difficult.

Post-acute care referral in United States of America: a multiregional study of factors associated with referral destination in a cohort of patients with coronary artery bypass graft or valve replacement

Background

The use of post-acute care (PAC) for cardiovascular conditions is highly variable across geographical regions. Although PAC benefits include lower readmission rates, better clinical outcomes, and lower mortality, referral patterns vary widely, raising concerns about substandard care and inflated costs. The objective of this study is to identify factors associated with PAC referral decisions at acute care discharge.

Methods

This study is a retrospective Electronic Health Records (EHR) based review of a cohort of patients with coronary artery bypass graft (CABG) and valve replacement (VR). EHR records were extracted from the Cerner Health-Facts Data warehouse and covered 49 hospitals in the United States of America (U.S.) from January 2010 to December 2015. Multinomial logistic regression was used to identify associations of 29 variables comprising patient characteristics, hospital profiles, and patient conditions at discharge.

Results

The cohort had 14,224 patients with mean age 63.5 years, with 10,234 (71.9%) male and 11,946 (84%) Caucasian, with 5827 (40.96%) being discharged to home without additional care (Home), 5226 (36.74%) to home health care (HHC), 1721 (12.10%) to skilled nursing facilities (SNF), 1168 (8.22%) to inpatient rehabilitation facilities (IRF), 164 (1.15%) to long term care hospitals (LTCH), and 118 (0.83%) to other locations. Census division, hospital size, teaching hospital status, gender, age, marital status, length of stay, and Charlson comorbidity index were identified as highly significant variables (p- values < 0.001) that influence the PAC referral decision. Overall model accuracy was 62.6%, and multiclass Area Under the Curve (AUC) values were for Home: 0.72; HHC: 0.72; SNF: 0.58; IRF: 0.53; LTCH: 0.52, and others: 0.46.

Conclusions

Census location of the acute care hospital was highly associated with PAC referral practices, as was hospital capacity, with larger hospitals referring patients to PAC at a greater rate than smaller hospitals. Race and gender were also statistically significant, with Asians, Hispanics, and Native Americans being less likely to be referred to PAC compared to Caucasians, and female patients being more likely to be referred than males. Additional analysis indicated that PAC referral practices are also influenced by the mix of PAC services offered in each region.

Impairment in toileting behavior after a stroke

AIM

Dependence for toileting is the most problematic aspect for patients after a stroke. However, the relative difficulty of each component of toileting and the predictors for independent performance of these activities are unknown. We investigated these issues in stroke patients using Boltzmann sigmoid and generalized linear modeling.

METHODS

We carried out a cross-sectional correlation study, including 107 adult inpatients, hospitalized for a stroke. We assessed the activity components of toileting, as well as evaluated physical impairment using the Fugl-Meyer Assessment, impairments in balance using the Berg Balance Scale, cognitive impairments using the Mini-Mental State Examination and the presence or absence of unilateral spatial neglect or aphasia.

RESULTS

Boltzmann sigmoid modeling showed that the total scores required to obtain a response at 50% of the maximal value for the required components of toileting ranged between 2.691 and 34.962 points, for the components of "wearing pants" and "cutting the toilet paper," respectively. A generalized linear model showed that the Berg Balance Scale score was a significant predictor for independent performance on most component activities of toileting.

CONCLUSIONS

The component of toileting that was easiest to carry out was cutting the toilet paper, and the most difficult was wearing pants. Balance impairment was an independent predictor of independent toileting after stroke. This detailed toileting assessment enabled us to document the most difficult components of toileting, and to assess the motor and process skills required for independent toileting. Geriatr Gerontol Int 2018; 18: 1166-1172.

Functional outcomes by age after inpatient stroke rehabilitation in Saudi Arabia

Background

Among various risk factors, age has been identified as a nonmodifiable risk factor for stroke that influences functional outcomes after inpatient stroke rehabilitation in the developed world as well as in Saudi Arabia (SA). The demand for inpatient stroke rehabilitation services increases with population aging and stroke incidence; however, these services are limited in SA.

Objective

To examine functional outcomes by age after inpatient stroke rehabilitation in SA.

Patients and methods

Data from 418 patients with stroke who underwent inpatient stroke rehabilitation at the King Fahad Medical City-Rehabilitation Hospital, Riyadh, SA, between November 2008 and December 2014 were collected from electronic medical records. According to the patients’ age, we classified participants into two groups: adults, aged <65 years (n=255), and older adults, aged ≥65 years (n=163). All patients’ functional statuses at admission and discharge from inpatient stroke rehabilitation were assessed using the functional independence measure (FIM) scale.

Results

The mean age was 59.9 years (SD =9.4). Older adults had significantly smaller changes in functional outcome from admission to discharge on both the total FIM (23 [SD =15.9]) and the motor FIM (21 [SD =15.4]), and they were significantly less independent (36%) compared to adults. In the adjusted models, older adults had significantly lower scores than adults, by 11 points (p<0.0001) for the total FIM score and by 10 points (p<0.0001) for the motor FIM subscale score. There was no significant change with age in the cognitive FIM subscale score.

Conclusion

After inpatient stroke rehabilitation, older adults had limited functional outcomes or were less independent than adults. However, the clinical relevance of this finding is questionable, so there is currently no justification to deny patients access to intensive stroke rehabilitation solely because of advanced age. Future large-scale research is needed to confirm rehabilitation outcomes by including confounders such as social support, socioeconomics, comorbidities, and the patient’s opinion after rehabilitation.

Does vibration training reduce the fall risk profile of frail older people admitted to a rehabilitation facility? A randomised controlled trial

PURPOSE

To determine the effect of Vibration Training (VT) on functional ability and falls risk among a group of frail older people admitted to an inpatient rehabilitation unit in a regional hospital in New Zealand.

METHOD

A randomized controlled trial of 56 participants (mean 82.01 years in the intervention group and 81.76 years in the control group). VT targeting lower limb muscles with a frequency 30-50 Hz occurred three times per week until discharge. Amplitude progressively increased from 2 to 5 mm to allow the programme to be individually tailored to the participant. The control group received usual care physiotherapy sessions. Outcome measures were: Physiological profile assessment (PPA); and Functional Independence measure (FIM) and Modified Falls Efficacy Scale (MFES).

RESULTS

There was a statistically significant difference observed between the two groups in terms of FIM score (F = 5.09, p = 0.03) and MFES (F = 3.52, p = 0.007) but no difference was observed in terms of PPA scores (F = 0.96, p = 0.36).

CONCLUSIONS

Among older people admitted to an inpatient rehabilitation facility there may be some beneficial effect to the use of VT in conjunction with usual care physiotherapy in terms of improved functional ability. The study design and the small dosage of VT provided may have precluded any change in falls risk among participants.

IMPLICATIONS FOR REHABILITATION

Vibration training (VT) may assist in reducing the risk of falling among at risk older people. Current pressures on health systems (ageing population, reduced hospital length of stay) necessitate the development of innovative strategies to maximise the rehabilitation potential of older people. Among older people admitted to an inpatient rehabilitation facility there may be some beneficial effect to the use of vibration training in conjunction with usual care physiotherapy in terms of improved functional ability.

A comprehensive assessment of family caregivers of stroke survivors during inpatient rehabilitation

PURPOSE

Stroke caregivers have been identified as a group at high risk for poor outcomes as a result of the suddenness of stroke and a potentially high level of care needed due to significant functional limitations of the patient. However, there is little research on the assessment of family members who will assume the caregiving role prior to patient discharge from rehabilitation. The purpose of this article is to delineate critical assessment domains identified by a subset of spousal stroke caregivers.

METHODS

Semi-structured interviews were conducted pre- and post-discharge from rehabilitation as part of a larger study that focused on identifying caregiver and stroke survivor needs as they transitioned home from inpatient rehabilitation. For this study, two semi-structured interviews with 14 spousal caregivers were analyzed using grounded theory methods.

RESULTS

Long-term stroke survivor outcomes were dependent upon the commitment, capacity and preparedness of the family caregiver. Twelve domains of assessment were identified and presented.

CONCLUSIONS

A comprehensive, systematic caregiver assessment to understand the caregiver's concerns about stroke should be conducted during rehabilitation to help the team to develop a plan to address unmet needs and better prepare family caregivers to take on the caregiving role.

IMPLICATIONS FOR REHABILITATION

Stroke is a sudden event that often leaves stroke survivors and their families in crisis. The needs of stroke family caregivers are not often systematically assessed as part of inpatient rehabilitation. Long-term stroke survivor outcomes are dependent upon the commitment, capacity and preparedness of the family caregiver. Stroke caregiver assessment should include the commitment, capacity and preparedness to provide care, and the overall impact of stroke in order to develop discharge plans that will adequately address the needs of the stroke survivor/caregiver dyad.

Determinants of Discharge Destination for Stroke Patients

Discharge to community is an important outcome measure for rehabilitation facilities. Studies consistently find that stroke patients with higher scores on the Functional Independence Measure (FIM) are more likely to be discharged to the community. Other variables, including age, gender, and living status, also have shown a relationship to discharge destination for stroke patients. This study explored the differences between stroke patients who were discharged to the community and those who were discharged to a nursing home after a stay on an acute inpatient rehabilitation unit. Results indicated that older patients and those with lower admission FIM scores are more likely to be discharged to nursing homes, but many patients who fit this profile are discharged to the community. The main destination determinant was how well a patient's need for care matched informal caregiving resources. These findings indicate a need for additional focused assessment of available care giving resources.

Recovery of the Sit-to-Stand Movement After Stroke: A Longitudinal Cohort Study

Background and Objective . To present quantitative data on sit-to-stand (STS)-related functioning and recovery during the first year after stroke. STS-related functioning was used to evaluate independent STS movement, rising speed, and actual STS performance during normal daily life. Methods. This was a prospective cohort study of 50 patients poststroke. Assessments were made at 0, 3, 6, 9, 12, 24, and 48 weeks poststroke. Actual STS performance was assessed at 0, 12, and 48 weeks. The main outcome measures were the following: ability to rise independently, rising speed (power chair stand up), number of STS movements, percentage of time walking and standing during daily life (using an activity monitor), and clinical outcomes, measured among others by the Barthel index (BI). Results. During year 1, the percentage of patients able to rise increased from 54% to 83%. Most improvements occurred during weeks 0 to 12, whereas no significant changes were observed during weeks 12 to 24. Rising speed similarly increased from 0.15 to 0.26 s− 1 during weeks 0 to 12 and to 0.30 s−1 at week 48. Gait speed and BI also significantly increased. The number of STS movements increased significantly during weeks 0 to 12 (from 10.6 to 17.7) but not during weeks 12 to 48. Conclusions. STS-related functioning improved significantly in the first year after stroke, with the most improvement occurring during the first 12 weeks. After 12 weeks, rising speed, gait speed, and BI continue to improve.

'Show me, don't tell me'; is this a good approach for rehabilitation?

Objective: To assess the possible memory advantages of the subject-performed task (SPT) and experimenter-performed task (EPT) encoding method in rehabilitation settings.

Design: Controlled quasi-experimental trial.

Setting: University research laboratory and community setting.

Subjects: Eighteen stroke survivors and 18 age-, education- and gender-matched controls.

Intervention: Participants were instructed to study three lists of 20 action phrases (such as 'ring the bell') by either reading, performing or observing others perform the tasks for later memory assessment.

Main measure: After the phrases had been studied, verbal and written memory tests were implemented and responses were recorded.

Results: The memory performance of stroke survivors and control groups was significantly better under the SPT method (mean (SD) 7.95 (2.7)) and EPT method (mean (SD) 7.95 (2.5)) relative to the baseline verbal task method (mean (SD) 4.2 (1.9)), (P<0.001 ANOVA). Participants also remembered functional tasks better than clinical tasks (P<0.001 ANOVA).

Conclusion: Encoding by the SPT and EPT methods are significantly more effective than receiving verbal instructions. The SPT and EPT encoding methods show promise and therapists may be able to use them in the clinic to facilitate the memory performance of stroke survivors.

Social determinants of discharge destination for patients after stroke with low admission FIM instrument scores

OBJECTIVE

To investigate the effects of immigrant status (via country of birth), marital status, and area-based socioeconomic status (SES) on discharge destination after stroke for those with low admission scores on the FIM instrument.

DESIGN

Cross-sectional study.

SETTING

Inpatient rehabilitation ward at an urban community hospital in Australia.

PARTICIPANTS

A total of 326 inpatients admitted for rehabilitation poststroke.

INTERVENTION

Multidisciplinary rehabilitation.

MAIN OUTCOME MEASURE

Discharge home versus nursing home.

RESULTS

A total admission FIM score of 75 or lower was associated with a higher probability of nursing home discharge. Married patients with a total FIM admission score of 75 or lower were significantly more likely to be discharged home, after adjusting for immigrant status, type and side of stroke, sex, and age (odds ratio, 6.07; 95% confidence interval, 1.65-22.40; P<.01). This effect was also observed for low motor and cognition components of FIM admission score. The effect of immigrant status did not remain significant after adjusting for marital status. Area-based SES and stroke characteristics did not substantially attenuate the relationship between immigrant status, marital status, and discharge location.

CONCLUSIONS

Marital status is a significant determinant of discharge destination. Immigrant status and area-based SES were not significant predictors of discharge disposition.

The utility of the functional independence measure (FIM) in discharge planning for burn patients

Determining burn patients' need for inpatient rehabilitation at discharge is difficult and an objective clinical indicator might aid in this decision. The functional independence measure (FIM) is a validated outcome measure that predicts the need for rehabilitation services. This study evaluated the utility of the FIM score for discharge planning in burn patients. A retrospective chart review and FIM score determination was performed on all major burn patients discharged from a regional adult burn centre between July 1, 1999 and June 30, 2000. From 164 adult burn patients discharged, 37 met the American Burn Association criteria for major burns. One patient had insufficient data. Therefore, 36 patients were studied (mean age 47.3 +/- 17.4 years, and mean body area burned 27.4 +/- 12.9%). All 17 patients with FIM scores greater than 110 were discharged home, and patients with FIM score of 110 or lower were discharged to another institution (rehabilitation hospital n = 14, other acute care hospital n = 4, or a nursing home n = 1) p < 0.0001. A discharge FIM score of 110 or lower was strongly associated with the need for inpatient rehabilitation, while a FIM score greater than 110 indicates the patient is independent enough to manage at home. Further prospective studies will be necessary to validate these findings.

Memory Impairment Following Right Hemisphere Stroke: A Comparative Meta-Analytic and Narrative Review

We examined the evidence for widely held clinical beliefs about memory impairment following right hemisphere stroke (RHS), conducting both narrative and meta-analytic reviews of the literature [MEDLINE (1966-January 2003), PsycINFO (1974-January 2003), and CINAHL (1982-December 2002)]. We sought to determine whether RHS patients experience more problems with non-verbal memory than non-stroke controls (NSCs) and left hemisphere stroke (LHS) patients. Secondarily, we sought to determine whether RHS patients experience more problems with verbal memory than NSCs and fewer verbal memory problems than LHS patients. We also examined the effect of type of memory assessment (recall versus recognition) on reported findings. As regards non-verbal memory, narrative and meta-analytic reviews found that RHS patients had deficits relative to NSCs, on tests of both recall and recognition. The evidence for RHS non-verbal memory deficits relative to LHS was mixed in the narrative review, whereas the meta-analysis found RHS deficits on non-verbal recognition tests, but no difference between RHS and LHS patients on non-verbal recall tests. Deficits on recognition tests imply problems with early encoding of material or possibly its storage. Regarding verbal memory, the narrative review found that RHS patients performed more poorly than NSCs in about half of all studies. The meta-analytic review confirmed poorer RHS performance on tests of verbal recall, but none of the studies that compared RHS and NSCs on verbal recognition could be included in this type of review. The narrative review found mixed evidence as regards the performance of RHS and LHS patients on verbal memory tests, but the meta-analysis pointed to RHS superiority for both verbal recall and recognition. The relative strengths of both types of review are discussed.

Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community

OBJECTIVE

To examine the outcomes of patients with varying levels of cognitive impairment who received rehabilitation in skilled nursing facilities (SNFs).

DESIGN

A retrospective analysis of the records of people admitted to SNFs for rehabilitation.

SETTING

Seven SNFs in Colorado.

PARTICIPANTS

Community-dwelling persons (N=7159), 65 years of age and older, admitted for rehabilitation after a hospitalization or decline in function between May 1998 and May 2002. Interventions Not applicable.

MAIN OUTCOME MEASURES

Cognitive impairment was assessed using a 4-level categorization of the FIM instrument cognitive score at admission. Functional gain was measured using the FIM. Community discharge was measured as the proportion of patients discharged to home, board and care, or assisted living facility. Rehabilitation progress was measured as the number of FIM points gained per day.

RESULTS

Significant functional gains were made during rehabilitation in motor and cognitive FIM scores, regardless of cognitive impairment. The most cognitively impaired patients required more rehabilitation intervention, achieved less FIM gain, and were less likely to be discharged to the community. The strongest predictors of FIM gain were the amount of therapy hours and admission cognitive FIM score. The strongest predictors of discharge to the community were the discharge total FIM score and age. The strongest predictors of adequate rehabilitation progress were medical complexity and admission cognitive FIM score.

CONCLUSIONS

Patients with cognitive impairment were able to recover function with rehabilitation intervention. Patients with a more serious cognitive impairment received more rehabilitation intervention than patients with less impairment. Outcomes were predicted by admission and rehabilitation measures that were qualitatively different from other discharge outcomes. Health care professionals need to consider these factors as they create a rehabilitation plan of care for patients with cognitive impairment.