Measuring mobility in older hospital patients with cognitive impairment using the de Morton Mobility Index

Validation of the de Morton mobility index (DEMMI) among acute stroke patients aged ≥65 years: a register study

PURPOSE

To validate the de Morton Mobility Index (DEMMI) in older (≥65 years) patients with acute stroke in a hospital setting within the first week after stroke onset.

MATERIALS AND METHODS

In the Danish National Database of Geriatrics, we identified 4,176 patients with acute stroke (≥65 years). Floor and ceiling effects of DEMMI were investigated. Furthermore, convergent validity was investigated by correlations between DEMMI and the Barthel Index using Spearman's rho. Known-groups validity was tested by comparing DEMMI scores for different groups (with/without dementia, depression, comorbidity, and walking aids), and unidimensionality of DEMMI was evaluated by Mokken scale analysis.

RESULTS

A floor effect was identified with 22.1% of the patients scoring 0 on DEMMI on admission. Both convergent and known-groups validity were confirmed for DEMMI. Patients who were bedbound had a lower DEMMI score (median [IQR]: 0 [0;0]) than patients without any walking aid (median [IQR]: 62 [33;74]). Furthermore, Mokken scale analysis identified unidimensionality with overall fit to the model (Loevinger H 0.88 (p < 0.0001)).

CONCLUSION

DEMMI is a valid instrument for use in patients with acute stroke (≥65 years) in a hospital setting within the first week after stroke onset.

A generic outcome assessment of mobility capacity in neurorehabilitation: measurement properties of the de Morton Mobility Index

Background

Mobility capacity is a key outcome domain in neurorehabilitation. The de Morton Mobility Index (DEMMI), an established and generic outcome assessment of mobility capacity in older patients, is promising for use in neurorehabilitation. The aim of this study was to examine the measurement properties of the DEMMI in rehabilitation inpatients with neurological conditions.

Methods

Cross-sectional study including a mixed sample of adult inpatients in a neurorehabilitation hospital. Structural validity, unidimensionality and measurement invariance (Rasch analysis), construct validity, internal consistency reliability, and inter-rater reliability of the DEMMI (scale range: 0–100 points) were established. The minimal detectable change, the 95% limits of agreement, and possible floor and ceiling effects were calculated to indicate interpretability.

Results

We analyzed validity (n = 348) and reliability (n = 133) in two samples. In both samples, the majority of participants had a sub-acute stroke or Parkinson’s disease.

Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 59.4, P = 0.074). There was no relevant measurement invariance by disease group. Hypotheses-based correlation analyses (DEMMI and other functional outcome assessments) showed sufficient construct validity. Internal consistency reliability (Cronbach’s alpha = 0.94) and inter-rater reliability (intraclass correlation coefficient = 0.94; 95% confidence interval: 0.91–0.95) were sufficient. The minimal detectable change with 90% confidence was 15.0 points and the limits of agreement were 39%. No floor or ceiling effects were observed.

Conclusions

Results indicate sufficient measurement properties of the DEMMI in rehabilitation inpatients with neurological conditions. The DEMMI can be used as a generic outcome assessment of mobility capacity in neurorehabilitation.

Trial registration

German Clinical Trials Register (DRKS00004681). Registered May 6, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02327-0.

Construct Validity, Test-Retest Reliability, Sensitivity to Change, and Feasibility of the Patient-Specific Functional Scale in Acutely Hospitalized Older Patients With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

The Patient-Specific Functional Scale (PSFS) as an individualized patient-reported outcome measure may allow to assess limitations and changes in self-determined functional activities most important to an older patient in the acute care setting. However, its clinimetric properties have not yet been evaluated in these patients. The study aimed to investigate the construct validity, test-retest reliability, sensitivity to change, and feasibility of the PSFS in acutely hospitalized older patients with and without cognitive impairment (CI).

METHODS

The clinimetric properties of the PSFS were investigated by secondary data analysis from a prospective observational cohort study examining physical activity and mobility in acutely hospitalized older patients. In this analysis, 120 older patients-83.0 (6.4) years-with (Mini-Mental State Examination [MMSE] 18-23, n = 52) and without CI (MMSE ≥24, n = 68) receiving early multidisciplinary geriatric rehabilitation in acute care were included. Construct validity was assessed by Spearman correlations (rs) with the Activity-specific Balance Confidence Scale (ABC-6), Short Falls Efficacy Scale-International (Short FES-I), EuroQoL-5 Dimensions (EQ-5D), Short Physical Performance Battery (SPPB), de Morton Mobility Index (DEMMI), and Barthel Index (BI); test-retest reliability within 24 hours by intraclass correlation coefficients (ICCs); sensitivity to change by standardized response means (SRMs) calculated for treatment effects, and feasibility by completion rates/times and floor/ceiling effects.

RESULTS

The PSFS showed fair to moderate correlations with all construct variables in patients with CI (rs = 0.31 to 0.53). In patients without CI, correlations were fair for the ABC-6, FES-I, EQ-5D, and BI (rs = |0.27 to 0.36|), but low for the SPPB and DEMMI (rs = -0.04 to 0.14). Test-retest reliability (both: ICC = 0.76) and sensitivity to change (CI: SRM = 1.10, non-CI: SRM = 0.89) were excellent in both subgroups. Excellent feasibility was documented by high completion rates (>94%), brief completion times (<8 min), and no floor/ceiling effects in both subgroups.

CONCLUSIONS

The PSFS has adequate clinimetric properties for assessing patient-specific functional limitations and changes in acutely hospitalized older patients with and without CI. It might be an appropriate complement to traditional functional scales to enhance patient-centeredness in clinical geriatric assessment.

Responsiveness and interpretability of commonly used outcome assessments of mobility capacity in older hospital patients with cognitive spectrum disorders

Background

In older hospital patients with cognitive spectrum disorders (CSD), mobility should be monitored frequently with standardised and psychometrically sound measurement instruments. This study aimed to examine the responsiveness, minimal important change (MIC), floor effects and ceiling effects of commonly used outcome assessments of mobility capacity in older patients with dementia, delirium or other cognitive impairment.

Methods

In a cross-sectional study that included acute older hospital patients with CSD (study period: 02/2015–12/2015), the following mobility assessments were applied: de Morton Mobility Index (DEMMI), Hierarchical Assessment of Balance and Mobility (HABAM), Performance Oriented Mobility Assessment, Short Physical Performance Battery, 4-m gait speed test, 5-times chair rise test, 2-min walk test, Timed Up and Go test, Barthel Index mobility subscale, and Functional Ambulation Categories. These assessments were administered shorty after hospital admission (baseline) and repeated prior to discharge (follow-up). Global rating of mobility change scales and a clinical anchor of functional ambulation were used as external criteria to determine the area under the curve (AUC). Construct- and anchor-based approaches determined responsiveness. MIC values for each instrument were established from different anchor- and distribution-based approaches.

Results

Of the 63 participants (age range: 69–94 years) completing follow-up assessments with mild (Mini Mental State Examination: 19–24 points; 67%) and moderate (10–18 points; 33%) cognitive impairment, 25% were diagnosed with dementia alone, 13% with delirium alone, 11% with delirium superimposed on dementia and 51% with another cognitive impairment. The follow-up assessment was performed 10.8 ± 2.5 (range: 7–17) days on average after the baseline assessment. The DEMMI was the most responsive mobility assessment (all AUC > 0.7). For the other instruments, the data provided conflicting evidence of responsiveness, or evidence of no responsiveness. MIC values for each instrument varied depending on the method used for calculation. The DEMMI and HABAM were the only instruments without floor or ceiling effects.

Conclusions

Most outcome assessments of mobility capacity seem insufficiently responsive to change in older hospital patients with CSD. The significant floor effects of most instruments further limit the monitoring of mobility alterations over time in this population. The DEMMI was the only instrument that was able to distinguish clinically important changes from measurement error.

Trial registration

German Clinical Trials Register (DRKS00005591). Registered February 2, 2015.

An investigation of the measurement properties of the de Morton Mobility Index for measuring mobility capacity in hospital patients with Parkinson's disease

OBJECTIVE

To examine the measurement properties of the de Morton Mobility Index (DEMMI), a performance-based clinical outcome assessment of mobility capacity, in hospital patients with Parkinson's disease.

DESIGN

Cross-sectional study.

PARTICIPANTS

Hospital patients with Parkinson's disease.

MAIN OUTCOME MEASURE(S)

Structural validity and unidimensionality (Rasch analysis), construct validity, internal consistency reliability, and inter-rater reliability of the de Morton Mobility Index (scale range: 0-100 points) were established. The minimal detectable change, the 95% limits of agreement and possible floor and ceiling effects were calculated to indicate interpretability.

RESULTS

We analysed validity (n = 100; mean age: 70 years; 71% male) and reliability (n = 47; mean age: 71 years; 68% male) in two samples. The mean Hoehn and Yahr stage was 3.2 and the mean disease duration was 12 years in both samples. Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 21.49, P = 0.122). Seventy-three percent of hypotheses on construct validity were confirmed. Internal consistency reliability (Cronbach's alpha = 0.91) and inter-rater reliability (intraclass correlation coefficient = 0.88; 95% confidence interval: 0.80 to 0.93) were sufficient. The minimal detectable change with 90% confidence was 17.5 points and the limits of agreement were 31%. No floor or ceiling effects were observed. The mean administration time was 6.6 minutes.

CONCLUSION

This study provides evidence of unidimensionality, sufficient internal consistency reliability, inter-rater reliability, construct validity, and feasibility of the de Morton Mobility Index in hospital patients with Parkinson's disease.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00004681). Registered May 6, 2013.

The Effect of Pre-Operative Medical Co-Morbidities on Rehabilitation Outcomes Following Surgery for Hip Fracture Management in Geriatric Populations

Introduction:

As a result of increasing longevity, we are seeing more elderly patients with complex medical co-morbidities who sustain hip fractures requiring surgical management. The aim of this study is to understand and analyze the effect of preoperative medical comorbidities and associated low physiological reserve status on functional rehabilitation outcomes following surgical management of hip fractures.

Materials and methods:

This study conducted a retrospective analysis of 73 patients who fulfilled the inclusion criteria .We utilized the de Morton Mobility Index (DEMMI) scores pre surgery and at the time of discharge from hospital following a period of rehabilitation as a measure of their pre and post-surgery functional status. The Physiological and Operative Score (POSSUM) was used as our tool to objectively quantify medical co-morbidities including but not limited to cardiovascular and pulmonary conditions.

Results:

The median age of our study population was 83 years of which 55(75%) were female. Time to surgery was a median of 21.0 hours, IQR (15.0-29.0), with a median physiological score of 21.0, IQR (19.0-26.0), the median pre surgery DEMMI was 85.0, IQR (55.5- 100.0) and the median DEMMI at discharge was 33.0, IQR (30.0-41.0).There is a moderate correlation between DEMMI pre and DEMMI at 3 months, 0.38 that is statistically significant, p = 0.001.

Discussion:

The effect of medical co- morbidities which causes the patient to have a poor physiological reserve even when coupled with the effect of the operative stress have no significant negative impact on the 90-day functional outcome of these patients.

Conclusion:

This study demonstrated that the presence of medical comorbidities in patients who require surgical management of hip fractures would not adversely affect their rehabilitation outcomes. The preinjury functional status of a patient is a significant factor in predicting functional rehabilitation outcomes.

A novel early mobility bundle improves length of stay and rates of readmission among hospitalized general medicine patients

Inpatient early mobility initiatives are effective therapeutic interventions for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients. To establish and demonstrate guidelines for early patient ambulation, we developed and implemented a novel multidisciplinary mobility bundle utilizing the JH-HLM (Johns Hopkins Highest Level of Mobility) scale for mobility classification, on a single adult general medicine unit of a community hospital. Our results show that patients admitted to the unit after implementation of the mobility bundle had improved mobility scores, reduced rates of 30-day hospital readmission, and a shortened length of hospital stay. This study emphasizes the importance of measuring mobility using a systematic method, easing workflow among unit practitioners, and allowing mobility initiatives to be jointly driven by nursing, physical therapy, and physicians.

An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT)

BACKGROUND

Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome.

MAIN BODY

The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT).

SHORT CONCLUSION

In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.

An augmented prescribed exercise program (APEP) to improve mobility of older acute medical patients - a randomized, controlled pilot and feasibility trial

BACKGROUND

There is inconclusive evidence for the effectiveness of additional exercise in older hospital patients. The aims of this study were (1) to assess the feasibility of an augmented prescribed exercise program (APEP) in older acute medical patients and (2) to measure the potential effects of APEP on mobility capacity in order to assess the feasibility of a large full-scale study.

METHODS

We conducted a single-center, prospective, parallel-group, single-blinded, randomized (1:1) controlled pilot and feasibility trial. Participants were recruited from acute geriatric wards of a general hospital. Key inclusion criteria were: age ≥ 65 years and walking ability. Key exclusion criteria were severe cognitive impairment and medical restriction for physical exercise interventions. Both groups received usual care, including physiotherapy. Intervention group participants were scheduled for additional exercise sessions (20-30 min, 4-5x/week). Feasibility of the trial design was assessed along pre-defined criteria for process, resources and management. Feasibility of the APEP intervention was analyzed by means of adherence, compliance and safety. Outcomes were measured at baseline and prior to hospital discharge. The primary outcome was mobility capacity (de Morton Mobility Index; DEMMI). Secondary outcomes were walking ability, physical endurance, fear of falling, frailty and length of stay.

RESULTS

Thirty-five participants were recruited (recruitment rate 20.3%). We lost 7 participants to follow-up (retention rate: 80%). Intervention group participants (n = 17) each participated in 5.3 ± 2.2 additional exercise sessions (mean duration: 23.2 ± 4.0 min; mean adherence rate 78% ± 26%). No severe adverse events occurred during study assessments or APEP sessions. There were no statistically significant differences in mean change scores in any outcome measure. A sample of 124 participants would be required to detect a difference of 4 DEMMI points (ES = 0.45) with a power of 80%.

CONCLUSIONS

This small feasibility RCT indicates that an APEP intervention may be safe and feasible in older acute medical patients. APEP may possibly induce small to moderate effects on mobility, but the clinical relevance of these effects may be limited. These results inform the planning of a larger-scale phase III study.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00011262 ). Registered 27 October 2016.

Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment

Background

Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate.

Methods

Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d’Aubigne and the EQ. 5D-3 L scores.

Results

Over an 11-year period (2004–14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d’Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts.

Conclusion

Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients.

Trial registration

DRKS, no. 00000488. Registered 14th July 2010 - Retrospectively registered

Reliability of mobility measures in older medical patients with cognitive impairment

Background

Mobility is a key indicator of physical functioning in older people, but there is limited evidence of the reliability of mobility measures in older people with cognitive impairment. This study aimed to examine the test-retest reliability and measurement error of common measurement instruments of mobility and physical functioning in older patients with dementia, delirium or other cognitive impairment.

Methods

A cross-sectional study was performed in a geriatric hospital. Older acute medical patients with cognitive impairment, indicated by a Mini-Mental State Examination (MMSE) score of ≤24 points, were assessed twice within 1 day by a trained physiotherapist.

The following instruments were applied: de Morton Mobility Index, Hierarchical Assessment of Balance and Mobility, Performance-Oriented Mobility Assessment, Short Physical Performance Battery, 4-m gait speed, 5-times chair rise test, 2-min walk test, timed up and go test, Barthel Index mobility subscale and Functional Ambulation Categories.

As appropriate, the intraclass correlation coefficient (ICC), Cohen’s kappa, standard error of measurement, limits of agreement and minimal detectable change (MDC) values were estimated.

Results

Sixty-five older acute medical patients with cognitive impairment participated in the study (mean age: 82 ± 7 years; mean MMSE: 20 ± 4, range: 10 to 24 points). Some participants were physically or cognitively unable to perform the gait speed (46%), 2-min walk (46%), timed up and go (51%) and chair rise (75%) tests.

ICC and kappa values were above 0.9 in all instruments except for the gait speed (ICC = 0.86) and chair rise (ICC = 0.72) measures. Measurement error is reported for each instrument. The absolute limits of agreement ranged from 11% (de Morton Mobility Index and Hierarchical Assessment of Balance and Mobility) to 35% (chair rise test).

Conclusions

The test-retest reliability is sufficient (> 0.7) for group-comparisons in all examined instruments. Most mobility measurements have limited use for individual monitoring of mobility over time in older hospital patients with cognitive impairment because of the large measurement error (> 20% of scale width), even though relative reliability estimations seem sufficient (> 0.9) for this purpose.

Trial registration

German Clinical Trials Register (DRKS00005591). Registered 2 February 2015.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1036-z) contains supplementary material, which is available to authorized users.