Three measures of physical rehabilitation effectiveness in elderly patients: a prospective, longitudinal, comparative analysis

Impact of the Comorbidity Polypharmacy Score on Clinical Outcome in Patients with Hip Fracture undergoing surgery Using Real-World Data

BACKGROUND

The Comorbidity Polypharmacy Score (CPS) is calculated by the number of drugs carried plus the number of comorbidities on admission and divided into three categories (minor, 0-7; moderate, 8-14; and severe, 15+). This study investigates whether CPS can predict the clinical outcomes in older patients with hip fractures undergoing surgery.

METHODS

This retrospective longitudinal study used a multicenter hospital-based database containing the Diagnosis Procedure Combination. Consecutive patients with hip fractures (ICD-10 codes S720 and S721) who were aged ≥65 years between April 2014 and August 2020 were included. We evaluated the predictive association between the CPS and Barthel Index (BI) efficiency. The primary outcome was defined as the BI efficiency, and the secondary outcome was the length of hospital stay.

RESULTS

We enrolled 11,564 patients, and 80.5% of them were female. The mean age was 83.9 ± 6.5 years. The BI efficiency was the lowest in the CPS severe group with a median [interquartile range] of 0.67 [0.10, 1.43]. The length of hospital stay was the highest in the CPS severe group, with a median of 35 [21, 58]. Additionally, multiple linear regression analysis revealed that the CPS was independently associated with the BI efficiency (β = -0.100, 95% CI: -0.040, -0.029; P < 0.001) and the length of hospital stay (β = 0.047, 95% CI: 0.199, 0.366; P < 0.001).

CONCLUSIONS

An increased CPS score is associated with low BI efficiency and longer length of hospital stay in patients with hip fractures.

Evaluation of improvement of functional independence in a multicentre cohort of rehabilitation outpatients with neurological conditions

PURPOSE

The objectives were to examine: (1) the changes in independence in basic activities of daily living (ADL) following an outpatient occupational therapy (OT) intervention in people with neurological conditions; (2) the factors associated with good relative functional gain (RFG) and with good OT efficiency; (3) and the effects on instrumental activities of daily living (IADL) and caregiver assistance.

MATERIALS AND METHODS

A prospective observational study examining changes in a multicentre cohort (three urban hospitals). Ninety-eight adults were assessed on admission and after intervention. Barthel Index was the primary outcome (ADL).

RESULTS

Acquired brain damage (ABI) was the most frequent diagnosis (84.7%). There was an improvement in ADL (p < 0.001); the effect size (r) was large (r = 0.59). RFG was good for 88.8% of participants. A good RFG was significantly associated with ABI, a lower number of hours of caregiver assistance, and a greater intensity of OT. The OT efficiency was good for 43.9% of participants. Factors significantly associated with good efficiency were being young and male patients, and receiving fewer hours of caregiver assistance. Secondary measures were improved: IADL (p < 0.001) and hours of caregiver assistance (p < 0.001).

CONCLUSIONS

This study suggests that the intervention is an effective approach to improve functional independence.Implications for rehabilitationLittle is known about the outcomes of outpatient occupational therapy intervention in neurorehabilitation services for the adult population with neurological diseases.In a multicentre cohort of neurorehabilitation outpatients, the occupational therapy intervention can lead to improvements in the level of independence in basic and instrumental daily activities, as well as reducing the hours of caregiver assistance.A good relative functional gain is associated with acquired brain injury, a lower number of hours of assistance, and a greater intensity of occupational therapy.The factors associated with good efficiency are being younger, male patients, and receiving fewer hours of assistance.

Biofeedback Applied to Interactive Serious Games to Monitor Frailty in an Elderly Population

This article proposes an example of a multiplatform interactive serious game, which is an additional tool and assistant used in the rehabilitation of patients with musculoskeletal system problems. In medicine, any actions and procedures aimed at helping the rehabilitation of patients should entail the most comfortable, but at the same time, effective approach. Regardless of how these actions are orientated, whether for rehabilitation following surgery, fractures, any problems with the musculoskeletal system, or just support for the elderly, rehabilitation methods undoubtedly have good goals, although often the process itself can cause all kinds of discomfort and aversion among patients. This paper presents an interactive platform which enables a slightly different approach to be applied in terms of routine rehabilitation activities and this will help make the process more exciting. The main feature of the system is that it works in several ways: for normal everyday use at home, or for more in-depth observation of various biological parameters, such as heart rate, temperature, and so on. The basic component of the system is the real-time tracking system of the body position, which constitutes both a way to control the game (controller) and a means to analyze the player’s activity. As for the closer control of rehabilitation, the platform also provides the opportunity for medical personnel to monitor the player in real time, with all the data obtained from the game being used for subsequent analysis and comparison. Following several laboratory tests and feedback analysis, the progress indicators are quite encouraging in terms of greater patient interest in this kind of interaction, and effectiveness of the developed platform is also on average about 30–50% compared to conventional exercises, which makes it more attractive in terms of patient support.

Effect of rehabilitation on biologic and transcriptomic responses after hospital-acquired deconditioning: a prospective longitudinal feasibility study

PURPOSE

The objective of this study is to explore the transcriptomic and biologic variables characterizing the longitudinal rehabilitation intervention of patients with hospital-acquired deconditioning (HAD).

METHODS

This prospective clinical trial recruited HAD patients (n = 10) who spent ≥3 weeks hospitalized and then received inpatient rehabilitation. Functional improvement was measured using the Functional Independence Measure (FIM). Transcriptomic and biological variables were recorded at rehabilitation admission and 1, 2, 4, and 6 weeks post-admission. RNA sequencing studied the temporal changes of gene expression in leukocytes. Between-subject transcriptome comparisons were performed using principle component analysis. Within-subject changes in gene expression were analyzed using a gene ontology hierarchical clustering to identify common biological terms. Heart rate, weight, albumin, creatinine, and complete blood counts were analyzed.

RESULTS

Patients average age was 50.6 ± 7.2, FIM increased during inpatient rehabilitation (p = 0.01), weight increased (p = 0.01), lymphocytes decreased (p = 0.05), neutrophil increased (0.03) and red cell distribution width decreased (p = 0.05). The temporal profiles of gene expression revealed within-patient homogeneity and between-patients heterogeneity. The biological terms "bone morphogenesis" and "muscle cell development" were the most significantly enriched differentially expressed genes.

CONCLUSION

Transcriptomic and biologic markers paralleled the functional improvements of HAD patients during inpatient rehabilitation. Transcriptomic analyses were consistent with the cohort heterogeneity. Enrichment of the biological pathways bone morphogenesis and muscle cell development constituted evidence at the gene expression level of the effect of rehabilitation. Larger studies of various rehabilitation patient groups may increase gene expression profile homogeneity. Objective transcriptomic and biologic markers have the potential to improve the rehabilitation of HAD patients.IMPLICATIONS FOR REHABILITATIONNovel gene expression methods are increasingly being integrated into clinical practice and may apply to rehabilitation.Patients with hospital-acquired deconditioning (HAD) enriched gene expression of pathways targeted by inpatient rehabilitation such as bone morphogenesis and muscle cell development.The gene expression paralleled functional improvement of HAD patients.These data demonstrated the feasibility of molecular methods to identify markers of rehabilitation success in HAD patients.

Impact of Number of Drugs on Rehabilitation Outcomes in Patients after Traumatic Brain Injury: A Retrospective Cohort Study

OBJECTIVE

To investigate the impact of the number of drugs on rehabilitation outcomes for patients with acute traumatic brain injury.

DESIGN

Retrospective cohort study.

SETTING

Hospital-based database created by the Japan Medical Data Center.

PARTICIPANTS

Patients with acute traumatic brain injury admitted between April 2014 and November 2017.

METHODS

Analysis of relationships among 1-5 and ≥ 6 drugs as well as clinical outcomes in 2603 patients.

MAIN OUTCOME MEASUREMENTS

The primary outcome was defined as the Barthel index efficiency, and the secondary outcome was Barthel index gain and length of hospital stay.

RESULTS

Median Barthel index score on admission was 40. Barthel index efficiency and Barthel index gain were significantly higher in the group that had taken 1-5 drugs than in the group that had taken ≥6 drugs on admission (median: 1.19 vs 0.50, 20.0 vs 10.0). Also, the group that had taken 1-5 drugs had a significantly shorter length of hospital stay than in the group that had taken ≥6 drugs on admission (median 11.0 vs 14.0). Moreover, multiple linear regression analysis showed that having taken ≥6 drugs on admission was independently associated with Barthel index efficiency, Barthel index gain, and length of stay.

CONCLUSIONS

Taking≥6 drugs for acute traumatic brain injury was associated with lower Barthel index efficiency, lower Barthel index gain, and longer length of stay than taking 1-5 drugs.

Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways

AIM

The aim of this study was to compare the clinical impact of two intermediate care pathways.

METHODS

A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge.

RESULTS

Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain.

CONCLUSIONS

The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.

Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions

OBJECTIVES

To compare clinical outcomes in older patients with acute medical crises attended by a geriatrician-led home hospitalization unit (HHU) vs an inpatient intermediate-care geriatric unit (ICGU) in a post-acute care setting.

DESIGN

Quasi-experimental longitudinal study, with 30-day follow-up.

PARTICIPANTS

Older patients with chronic conditions attended at the emergency department or day hospital for an acute medical crisis.

INTERVENTIONS

Patients were referred to geriatrician-led HHU or ICGU wards.

SETTING

An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe.

MEASUREMENTS

We compared health crisis outcomes (recovery from the acute health crisis, referral to an acute hospital, or death), length of stay, relative functional gain (RFG) at discharge, readmission to an acute care unit within 30 days of discharge, and mortality within 30 days of discharge.

RESULTS

We included 171 older adults (57 in the HHU and 114 in the ICGU) with complex conditions at risk of negative outcomes. At baseline, HHU patients were significantly younger and less likely to be cognitively impaired and referred from an emergency department. Most patients in both groups recovered from their health crises (91.2% in the HHU group vs 88.6% in the ICGU group, P = .79). No differences were found between the 2 groups in 30-day mortality (8.6% vs 9.6%, P = >.99). There was a trend toward lower 30-day readmission to an acute care unit in the HHU group (10.5% vs 19.3% in the ICGU group, P = .19). HHU patients had higher RFG (mean 0.75 days vs 0.51 in the ICGU group, P = .01), and a longer stay in the unit (9.7 vs 8.2 days in the ICGU group, P < .01).

CONCLUSIONS

These preliminary results suggest that the geriatrician-led HHU seems effective in resolving acute medical crises in older patients with chronic disease. Patients attended by the HHU obtained better functional outcomes compared to those from the ICGU, although the groups did have some baseline differences.

[Impact of a centralised hospital admission system on the efficacy and efficiency of a geriatric functional recovery unit]

OBJECTIVE

To evaluate the influence of a change in the management of admissions on the activity and care outcomes of a Geriatric Functional Recovery Unit (GFRU).

MATERIAL AND METHODS

A retrospective observational study was conducted. Since 2000, the Hospital Central Cruz Roja GFRU has been collecting data grouped into periods of 4 years, except for the centralised admissions (September 2016-December 2018). The data collected on admission included the Red Cross Functional and Mental scales, the Barthel index, the main diagnosis of the functional decline (grouped into stroke, orthopaedic problem, and multifactorial immobility episodes), and comorbidity evaluated by the Charlson index. The following outcome variables were analysed: the overall and relative functional gain at discharge; length of hospital stay; the functional efficiency, discharges to nursing homes, and transfers to acute care units. An analysis was made of the relationship between the admissions from the centralised unit and the previous period (directly admission managed by GFRU), using multivariate analysis (linear regression for continuous outcome variables and logistic regression for the dichotomous ones), adjusted for admission variables.

RESULTS

Patients admitted from the centralised unit showed a greater overall and relative functional gain (difference between both means: 3.49 points, 95% CI; 1.65-5.33, and 12.41%, 95% CI; 0.74-24.08, respectively), longer stay (12.92 days, 95% CI; 11.54-14.30) and lower efficiency (-0.36, 95% CI; -0.16 to -0.57), higher risk of institutionalisation (OR 1.61, 95% CI; 1.19-2.16), and transfers to acute care units (OR 3.16, 95% CI; 2.24-4.47).

CONCLUSIONS

A centralised admissions system had an influence on the improvement of functional parameters in the patients, but with a longer length of hospital stay, and lower efficiency. Increases in institutionalisation at discharge and transfers to acute care units were also observed.

Impact of heart failure on functional recovery after hip fracture

[Purpose] Heart failure has been identified as a risk factor for reduced physical function and falls; however, the impact of heart failure on functional recovery after a hip fracture is unclear. This study aimed to examine how heart failure and pre-fracture physical function affect recovery after a hip fracture. [Participants and Methods] The study population consisted of 122 patients with sub-acute hip fracture (mean age 81.7 ± 9.7 years, 18.9% male) who were divided into two groups: heart failure and non-heart failure. The outcome measurement was the functional independence measure effectiveness. A two-way analysis of variance was performed to investigate how heart failure and ambulatory ability prior to hip fracture were related to the functional independence measure effectiveness. [Results] Seventeen patients (13.9%) had a history of heart failure. The two-way analysis of variance showed the two independent variables (heart failure and ambulatory ability before fracture) had significant main effects; however, their interaction effect was not significant. [Conclusion] Heart failure affects functional recovery after hip fracture independent of the pre-fracture physical function, and vice versa. Further research on rehabilitation in hip fracture patients with heart failure is required to develop strategies to overcome poor functional recovery in such patients.

[Complexity and prevalence of geriatric syndromes in patients treated in intermediate care units in Catalonia: A multicentre study of XARESS project]

BACKGROUND

Descriptive study is presented on the complexity and prevalence of geriatric syndromes (GS) in Intermediate Care Units in Catalonia.

METHODS

A retrospective study was conducted on 6471 stays completed during the year 2014 in the participating centres of the XARESS network. Data was obtained by extracting the information routinely collected on the CMBD-RSS registry (Minimum Basic Dataset for the Intermediate Care Resources). The prevalence and associations between geriatric síndromes (resource group) RG category, length of stay, and destination at discharge is described. Results were stratified by type of unit (convalescence or long stay).

RESULTS

Participants presented a median of 3 GS at admission in long stay units, and 2 GS at admission in convalescence units. The number of GS varied with RG category, although in all RG categories, there were patients without complexity (no SG), and patients with extreme complexity (up to 9 GS). Patients with geriatric syndromes had a longer mean length of stay and greater dependence than patients without syndromes, although with great variability across GS. However, the presence of geriatric syndromes had no impact on the destination at discharge.

CONCLUSIONS

The population cared for in intermediate care units have high complexity and a high prevalence of geriatric syndromes at admission. The CMBD-RSS registry allows the characterisation of complexity of the population admitted to the Catalan convalescence and long term intermediate care units.

[Hospital-at-home Integrated Care Programme tailored to older patients with disabling acute processes: identification of prognostic factors]

INTRODUCTION

Several authors have demonstrated the efficacy of different hospital-at-home strategies in older patients. The identification of prognostic factors is key for improving the targeting process of candidates.

METHODS

We performed an analysis of a cohort of older patients attended due to disabling health crises (medical, orthopaedics, or stroke) by a hospital-at-home scheme developed in an integrated care institution over a 5-year period. Main outcomes were: health crisis resolution (discharge to Primary Care); functional resolution (relative functional gain ≥35%), and their combined variable. A logistic regression analysis was performed, including clinical variables from Comprehensive Geriatric Assessment at admission to detect factors related to favourable outcomes.

RESULTS

A total of 484 patients were included. The main characteristics were: age 84.4 (6.7), female gender 69%, baseline Barthel score 74.2 (22.6), family-private caregiver/nursing home 82%/18%, referral from hospital wards/emergency department-community in 55%/45%. The main results (for selected processes medical/orthopaedics/stroke) were: health crisis resolution 71.7/87.5/77.6%; functional resolution 72.1/84.9/73.5%; favourable crisis resolution (health crisis resolution with functional resolution) 67.1/81.6/67.3%. Favourable crisis resolution was associated with [OR (95%CI)]: orthopaedic as main diagnosis [2.00 (1.22-3.29)], Barthel score at admission higher than 40 points [2.00 (1.18-3.38)], and the absence of pressure ulcers at admission [2.80 (1.68-4.65)].

CONCLUSIONS

Patients presenting with an orthopaedic diagnosis, not having severe disability at admission, and not having pressure ulcers at admission could obtain better results on favourable crisis resolution. Suffering cognitive impairment or delirium, or being institutionalised, was not found related with less favourable results.

Impact of Number of Drug Types on Clinical Outcome in Patients with Acute Hip Fracture

OBJECTIVES

This study aims to investigate the impact of the number of drug types on clinical outcomes for patients with acute hip fracture.

DESIGNS

This is a retrospective cross-sectional study.

SETTING

A hospital-based database constructed by the Japan Medical Data Center.

PARTICIPANTS

Consecutive patients exhibiting acute hip fractures on admission between April 2014 and November 2017 were included.

MEASUREMENTS

Relationships among the numbers of varying drug types of ≥6 and ≤5 as well as clinical outcomes were analyzed in 11,073 patients aged ≥65 years. The primary outcome was defined as the Barthel Index efficiency, with the secondary outcome being the length of hospital stay.

RESULTS

Median Barthel Index scores at admission and discharge were 5 (interquartile range: 5-20) and 50 (interquartile range: 20-85). The Barthel Index efficiency was significantly higher in the group having received 5 or fewer drug variations taken (1.45 ± 1.77) than in the group receiving 6 or more drug types taken (0.94 ± 1.18) during hospital stays (p < 0.001). The length of hospital stay was significantly shorter in the group receiving 5 or fewer drug types taken (29.9 ± 23.8) than in the group having 6 or more drug types taken (44.3 ± 30.3) during hospital stays (p < 0.001), with the latter number being independently associated with the Barthel Index efficiency and length of hospital stay.

CONCLUSIONS

Number of drug types of 6 or more were associated with lower Barthel Index efficiency and longer lengths of hospital stays.

Predicting Motor and Cognitive Improvement Through Machine Learning Algorithm in Human Subject that Underwent a Rehabilitation Treatment in the Early Stage of Stroke

BACKGROUND

The objective of this study was to investigate, in subject with stroke, the exact role as prognostic factor of common inflammatory biomarkers and other markers in predicting motor and/or cognitive improvement after rehabilitation treatment from early stage of stroke.

METHODS

In this longitudinal cohort study on stroke patients undergoing inpatient rehabilitation, data from 55 participants were analyzed. Functional and clinical data were collected after admission to the rehabilitation unit. Biochemical and hematological parameters were obtained from peripheral venous blood samples on all individuals who participated in the study within 24hours from the admission at the rehabilitative treatment. Data regarding the health status were collected at the end of rehabilitative treatment. First, a feature selection has been performed to estimate the mutual dependence between input and output variables. More specifically, the so called Mutual Information criterion has been exploited. In the second stage of the analysis, the Support Vector Machines (SVMs), a non-probabilistic binary machine learning algorithm widely used for classification and regression, has been used to predict the output of the rehabilitation process. Performances of the linear SVM regression algorithm have been evaluated considering a different number of input features (ranging from 4 to 14). The performance evaluation of the model proposed has been investigated in terms of correlation, Root Mean Square Error (RMSE) and Mean Absolute Deviation Percentage (MADP).

RESULTS

Results on the test samples show a good correlation between all the predicted and measured outputs (i.e. T1 Barthel Index (BI), T1 Motor Functional Independence Measure (FIM), T1 Cognitive FIM and T1 Total FIM) ranging from 0.75 to 0.81. While the MADP is high (i.e., 83.96%) for T1 BI, the other predicted responses (i.e., T1 Motor FIM, T1 Cognitive FIM, T1 Total FIM) disclose a smaller MADP of 30%. Accordingly, the RMSE ranges from 4.28 for T1 Cognitive FIM to 22.6 for T1 BI.

CONCLUSIONS

In conclusion, the authors developed a new predictive model using SVM regression starting from common inflammatory biomarkers and other ratio markers. The main efforts of our model have been accomplished in regard to the evidence that the type of stroke has not shown itself to be a critical input variable to predict the discharge data, furthermore, among the four selected indicators, Barthel at T1 is the less predictable (MADP > 80%), while it is possible to predict T1 Cognitive FIM with an MADP less than 18%.

Patient-Reported Outcomes in Functioning Following Nursing Home or Inpatient Rehabilitation

OBJECTIVES

Our study examines factors associated with patient-reported outcomes in functioning among Medicare beneficiaries who reported receiving rehabilitation services in a nursing home or inpatient (ie, hospital or rehabilitation facility) setting in the prior year.

DESIGN

Data are from the 2015 and 2016 rounds of the National Health and Aging Trends Study (NHATS), a longitudinal study of a nationally representative sample of Medicare beneficiaries aged 65 years and older.

SETTING AND PARTICIPANTS

A total of 479 participants in the 2016 sample who reported receiving rehabilitation services in a nursing home or inpatient setting in the past year.

MEASURES

Bivariate and logistic regression analyses examined the association of demographic, socioeconomic status, and health variables (from the 2015 interview) and rehabilitation characteristics (from the 2016 interview) with patient-reported improvement in "functioning and ability to do activities" while receiving rehabilitation services in the past year.

RESULTS

Among Medicare beneficiaries who received rehabilitation services in nursing home or inpatient settings, 33.4% (weighted percent) reported no improvement in functioning while they were receiving rehabilitation. In a regression analysis that accounted for demographics, those with a high school education or less (compared with those with a college degree), instrumental activities of daily living impairments, certain primary conditions for rehabilitation, less than 1-month total duration of rehabilitation services, and no outpatient rehabilitation services had greater odds of reporting no improvement.

CONCLUSIONS/IMPLICATIONS

Our weighted sample represents approximately 2.3 million Medicare beneficiaries who received rehabilitation services in nursing home or inpatient settings. In this sample, 1 in 3 reported no improvement in functioning, with differences in patient-reported outcomes across socioeconomic status, health status, and rehabilitation characteristics domains. Consideration of characteristics across these domains may be clinically pertinent, but investigation as to why these differences are present and whether services can be optimized to further improve patient-reported outcomes is warranted.

Developing quality indicators for in-patient post-acute care

BACKGROUND

This paper describes an integrated series of functional, clinical, and discharge post-acute care (PAC) quality indicators (QIs) and an examination of the distribution of the QIs in skilled nursing facilities (SNF) across the US. The indicators use items available in interRAI based assessments including the MDS 3.0 and are designed for use in in-patient post-acute environments that use the assessments.

METHODS

Data Source: MDS 3.0 computerized assessments mandated for all patients admitted to US skilled nursing facilities (SNF) in 2012. In total, 2,380,213 patients were admitted to SNFs for post-acute care. Definition of the QI numerator, denominator and covariate structures were based on MDS assessment items. A regression strategy modeling the "discharge to the community" PAC QI as the dependent variable was used to identify how to bring together a subset of seven candidate PAC QIs for inclusion in a summary scale. Finally, the distributional property of the summary scale (the PAC QI Summary Scale) across all facilities was explored.

RESULTS

The risk-adjusted PAC QIs include indicators of improved status, including measures of early, middle, and late-loss functional performance, as well as measures of walking and changed clinical status and an overall summary functional scale. Many but not all patients demonstrated improvement from baseline to follow-up. However, there was substantial inter-state variation in the summary QI scores across the SNFs.

CONCLUSIONS

The set of PAC QIs consist of five functional, two discharge and eight clinical measures, and one summary scale. All QIs can be derived from multiple interRAI assessment tools, including the MDS 2.0, interRAI-LTCF, MDS 3.0, and the interRAI-PAC-Rehab. These measures are appropriate for wide distribution in and out of the United States, allowing comparison and discussion of practices associated with better outcomes.

Comorbidity and intercurrent diseases in geriatric stroke rehabilitation: a multicentre observational study in skilled nursing facilities

Background

Older patients often have multiple comorbidities and are susceptible to develop intercurrent diseases during rehabilitation. This study investigates intercurrent diseases and associated factors in patients undergoing geriatric stroke rehabilitation, focussing on pre-existing comorbid conditions, overall comorbidity and baseline functional status.

Materials and methods

This multicentre prospective cohort study included 15 skilled nursing facilities. Data were collected at baseline and at discharge. The primary outcome measures were presence and number of intercurrent diseases. Furthermore, their impact on change in rehabilitation goals or length of stay was examined. Comorbidity was assessed with the Charlson index, and functional status with the Barthel index (BI).

Results

Of the 175 included patients, 51% developed an intercurrent disease. A lower baseline BI, a higher Charlson index, presence of diabetes mellitus (DM) and kidney disease were related to the occurrence of an intercurrent disease (p < 0.05). Moreover, a lower BI, a higher Charlson index, and particularly the presence of DM were independently associated. If both comorbidity and a lower baseline functional status were present, the odds ratio (95% CI) of developing intercurrent diseases was 6.70 [2.33-19.2], compared to 1.73 [0.52-5.72] (comorbidity only) and 1.62 [0.53-4.94] (only BI ≤ 14).

Conclusions

On admission, functional impairments and comorbidity, particularly diabetes, independently contribute to developing intercurrent diseases during geriatric stroke rehabilitation. Therefore, routine evaluation of comorbidity integrated with functional status at the start of rehabilitation is essential to identify patients at risk. Finally, particular attention should be paid to patients with DM to prevent intercurrent diseases and support optimal functional recovery .

Frailty Related Factors as Predictors of Functional Recovery in Geriatric Rehabilitation: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) Multi-Centric study

BACKGROUND

Frailty-related characteristics, such as sarcopenia, malnutrition and cognitive impairment, are often overlooked, both in clinical practice and research, as potential contributors to functional recovery during geriatric rehabilitation.

OBJECTIVE

The aim of the study was to identify frailty-related characteristics associated with functional recovery in a cohort of post-orthopedic surgery and post-stroke older adults.

DESIGN

Multi-centric cohort study. Participanst and Settings: Patients over 65 years, admitted to three geriatric rehabilitation units, in Spain and Italy, after an orthopedic event or a stroke, from December 2014 to May 2016.

MEASUREMENTS

The Absolute Functional Gain (AFG) defined as the difference between Barthel Index score at discharge and at admission, and the Relative Functional Gain (RFG) that represents the percentage of recovery of the function lost due to the event, were selected as outcomes. Both outcomes were analyzed as continuous and dichotomous variables. Analyses were also stratified as diagnostic at admission.

RESULTS

We enrolled 459 patients (mean age±SD=80.75±8.21 years), 66.2% women, 69.5% with orthopedic conditions and with a length of stay of 28.8±9.1 days. Admission after a stroke (Odds Ratio=0.36, 95% Confidence Interval=0.22-0.59]) and a better functional status at admission (OR=0.96, 95% CI=0.94-0.97), were associated with a lower likelihood of AFG, while a better pre-event Barthel index (OR=1.03 for each point in score, 95% CI=1.01-1.04), being able to walk (OR=2.07, 95% CI=1.16-3.70), and a better cognitive status at admission (OR=1.05, 95% CI=1.01-1.09), were associated with a higher chance of AFG. Post-stroke patients with delirium at admission had a re-duced chance of AFG (OR=0.25, 95% CI=0.07-0.91]). Patients admitted after an ortho-pedic event with better pre-event functional status (OR=1.04, 95% CI=1.02-1.06) and able to walk at admission (OR=2.79, 95% CI=1.29-6.03]) had an increased chance of AFG. Additionally, in both diagnostics groups, a better handgrip strength increased the chance of RFG.

CONCLUSIONS

Among frailty-related variables, physical, cognitive and muscular function at admission could be relevant for functional improvement during geriatric reha-bilitation. If confirmed, this data might orient targeted interventions.

Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: comparison with bed-based Intermediate Care

Objective

to analyse the clinical impact of a home-based Intermediate Care model in the Catalan health system, comparing it with usual bed-based care.

Design

quasi-experimental longitudinal study.

Setting

hospital Municipal de Badalona and El Carme Intermediate Care Hospital, Badalona, Catalonia, Spain.

Participants

we included older patients with medical and orthopaedic disabling health crises in need of Comprehensive Geriatric Assessment (CGA) and rehabilitation.

Methods

a CGA-based hospital-at-home Integrated Care Programme (acute care and rehabilitation) was compared with a propensity score matched cohort of contemporary patients attended by usual inpatient hospital care (acute care plus intermediate care hospitalisation), for the management of medical and orthopaedics processes. Main outcomes measures were: (a) Health crisis resolution (referral to primary care at the end of the intervention); (b) functional resolution: relative functional gain (functional gain/functional loss) ≥ 0.35; and (c) favourable crisis resolution (health + functional) = a + b. We compared between-groups outcomes using uni/multivariable logistic regression models.

Results

clinical characteristics were similar between home-based and bed-based groups. Acute stay was shorter in home group: 6.1 (5.3-6.9) versus 11.2 (10.5-11.9) days, P < 0.001. The home-based scheme showed better results on functional resolution 79.1% (versus 75.2%), OR 1.62 (1.09-2.41) and on favourable crisis resolution 73.8% (versus 69.6%), OR 1.54 (1.06-2.22), with shorter length of intervention, with a reduction of -5.72 (-9.75 and -1.69) days.

Conclusions

in our study, the extended CGA-based hospital-at-home programme was associated with shorter stay and favourable clinical outcomes. Future studies might test this intervention to the whole Catalan integrated care system.

[New integrated care model for older people admitted to Intermediate Care Units in Catalonia: A quasi-experimental study protocol]

OBJECTIVE

To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia.

PATIENTS AND METHODS

The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources.

DISCUSSION

This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies.

Prevalence of malnutrition and sarcopenia in a post-acute care geriatric unit: Applying the new ESPEN definition and EWGSOP criteria

BACKGROUNDS & AIMS

The European Society of Clinical Nutrition and Metabolism (ESPEN) consensus definition of malnutrition has been applied in hospitalized older diabetics and middle-aged patients, geriatric outpatients, and healthy elderly and young individuals. In a post-acute care setting, our aim was to assess malnutrition (ESPEN definition) and determine its relationship with sarcopenia in older in-patients deconditioned due to an acute process.

METHODS

Eighty-eight in-patients aged ≥70 years with body mass index (BMI) <30 kg/m² were included (84.1 years old; 62% women) and screened for malnutrition risk using biochemical markers and Mini-Nutritional Assessment-Short Form (MNA-SF). The ESPEN definition was applied: 1) BMI <18.5 kg/m² or 2) unintentional weight loss plus a) low BMI or b) low fat-free mass index (FFMI). European Working Group on Sarcopenia in Older People (EWGSOP) criteria were also applied.

RESULTS

Unintentional weight loss occurred in 27 (30.7%) of 88 in-patients considered "at risk" by MNA-SF. Malnutrition prevalence was 4.5%, 7.9%, and 17% using ESPEN definitions 1, 2a, and 2b, respectively; 19.3% were malnourished. Prevalence of sarcopenia was 37.5%, of which 90.9% fulfilled ESPEN malnutrition criteria, a significant association (p = 0.02). No differences in biochemical markers were observed between patients with or without malnutrition or sarcopenia.

CONCLUSIONS

ESPEN criteria constitute an appropriate tool to establish a malnutrition diagnosis in post-acute care. Sarcopenia, as defined by EWGSOP, was present in 37.5% of patients, of which 90.9% fulfilled ESPEN criteria; therefore, malnutrition was significantly related to sarcopenia. Additional work is needed to determine further implications of the ESPEN consensus definition.