Frailty recommendations and guidelines: an evaluation of the implementability and a critical appraisal of clinical applicability by the ISPRM Frailty Focus Group

INTRODUCTION

Aging is associated with an increased burden of multi-morbidity and disease related functional loss and disability, widely impacting patients and health care systems. Frailty is a major actor in age-related disability and is an important target for rehabilitation interventions, considering that is a reversible condition.

EVIDENCE ACQUISITION

A working group of members of the ISPRM, responding to WHO 2030 call for action to strengthen rehabilitation, was established to assess the quality and implementability of the existing guidelines for the rehabilitation of frailty. Guidelines were retrieved using a systematic search on Pubmed, Scopus and Web of Science and from the reference lists of screened articles. The included guidelines were evaluated using the AGREE II to assess their quality and using the AGREE-REX to assess their clinical credibility and implementability. Guidelines with a score >4 in the AGREE II item evaluating the overall quality of the guideline were considered for endorsement. Finally, nine external reviewers evaluated the applicability of each recommendation from the endorsed guidelines, providing comments about the barriers and facilitators for their implementation in their country.

EVIDENCE SYNTHESIS

Ten guidelines were retrieved and evaluated by the working group, of which four guidelines, i.e. the WHO Guidelines on Integrated Care for Older People, the FOCUS guidelines, the Asia-Pacific Clinical Practice Guidelines for the Management of Frailty and the ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty, were considered for endorsement. All these guidelines were rated as of adequate quality and implementability.

CONCLUSIONS

The WHO Guidelines on Integrated Care for Older people (24) the ICFSR International Clinical Practice Guidelines for Identification and management of Frailty (15), the FOCUS guidelines (25) and the Asia Pacific Clinical Practice Guidelines (14) for the Management of Frailty have the best quality and applicability of the existing guidelines on the management of frailty, we suggest that should be employed to define the standards of care for patients with frailty. There are barriers for their implementation, as stated by our experts, to take into account, and some of them are country- or region-specific. Screening for frailty, exercise, nutrition, pharmacological management, social and psychological support, management of incontinence, and an overall comprehensive clinical management are the best tools to face upon frailty.

Association of delirium and spatial neglect in patients with right-hemisphere stroke

BACKGROUND

Delirium, an acute and fluctuating decline in cognitive functioning, increases mortality and length of hospital stays (LOS) and adversely affects functional outcomes. Previous studies suggested that the incidence of delirium may be increased in right-hemisphere strokes. Similarly, spatial neglect, a disabling deficit in unilateral spatial processing, is more common and more severe following a right-sided stroke. Spatial neglect has been established as a risk factor for delirium.

OBJECTIVE

It was hypothesized that functionally relevant spatial neglect and delirium are associated in patients with right-hemisphere stroke during acute inpatient rehabilitation. Data were examined from consecutive unilateral stroke patients evaluated with the 3-minute diagnostic interview for confusion assessment method (3D-CAM) and the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP).

DESIGN

A retrospective, cohort study.

SETTING

Data collected in an acute inpatient rehabilitation facility.

PARTICIPANTS

Six hundred twenty six patients with stroke were included.

MAIN OUTCOME MEASURES

The measures were the relative risk of patients with right-hemisphere stroke having delirium when also positive for spatial neglect compared to patients with right-hemisphere stroke without spatial neglect, the incidence of 3D-CAM positive results by stroke hemisphere, and the effect of spatial neglect and delirium on functional outcomes for patients with right-brain stroke patients.

RESULTS

There was a significantly higher risk of delirium in patients with right-hemisphere stroke with spatial neglect compared to patients with right-hemisphere stroke without spatial neglect. The rates of 3D-CAM positive results were not statistically different for left- compared to right-hemisphere strokes. Both delirium and spatial neglect had significant adverse effects on right-hemisphere stroke patients' functional independence.

CONCLUSIONS

The results demonstrate an association between spatial neglect and delirium in patients with right hemisphere stroke in the acute inpatient rehabilitation setting. Because of the negative effect of these impairments on functional outcomes after stroke, prevention, early detection, and targeted treatments should be prioritized for these patients.

Clinical Characteristics and Outcomes of Inpatient Falls During Inpatient Rehabilitation: A Case-Control Study

ABSTRACT

Inpatient falls have a significant impact on the outcomes of older patients during inpatient rehabilitation. A retrospective case-control study was conducted using data of 7066 adults aged 55 yrs or older to evaluate significant predictors of inpatient falls during inpatient rehabilitation and the association of inpatient falls with discharge destination and length of stay. A stepwise logistic regression was used to model odds of inpatient falls and home discharge with demographic and clinical characteristic variables and a multivariate linear regression to evaluate the association between inpatient falls and length of stay.Nine hundred thirty-one of 7066 patients (13.18%) had inpatient falls during inpatient rehabilitation. The group with inpatient falls had longer length of stay (14.22 ± 7.82 vs. 11.85 ± 5.33 days, P < 0.0001) and a decreased proportion of home discharges when compared with the group without inpatient falls. There were increased odds of inpatient falls among patients with diagnoses of head injury, other injuries, a history of falls, dementia, a divorced marital status, and a use of laxatives or anticonvulsants. Inpatient falls were associated with an increased length of stay (coefficient = 1.62, confidence interval = 1.19-2.06) and decreased odds of home discharge (odds ratio = 0.79, confidence interval = 0.65-0.96) after inpatient rehabilitation. This knowledge may be incorporated into strategies for reducing inpatient falls during inpatient rehabilitation.

Influence of preparedness on caregiver burden, depression, and quality of life in caregivers of people with disabilities

Introduction

Caregiver preparedness is defined as the perceived preparation of caregivers to care for the physical and emotional needs of the patient.

Purpose

This study investigated caregiver preparedness and its influences on caregiver burden, depression, and quality of life (QoL) in caregivers of individuals with disabilities.

Methods

We conducted a multicenter cross-sectional survey study on caregivers caring for patients with disabilities. Sociodemographic characteristics were collected via questionnaires. The Preparedness for Caregiving Scale (PCS), Burden Interview (BI), Center for Epidemiologic Studies Depression Scale (CES-D), and EuroQol-Visual Analogue Scale (EQ-VAS) were administered.

Results

A total of 151 caregivers were enrolled. The mean age of caregivers was 53.7 ± 12.4 years, and 80.8% were female. The majority of participants were the main caregivers of patients with stroke, spinal cord injury, or traumatic brain injury. The mean PCS score was 2.1 ± 0.9, demonstrating significant relationships with BI (r = -0.512, p < 0.001), CES-D (r = -0.622, p < 0.001), and EQ-VAS (r = 0.441, p < 0.001). The CES-D was significantly associated with the PCS after controlling other variables. However, PCS did not show any correlation with the duration of caregiving or amount of time spent per day on caregiving.

Discussion

The clinical implications of this study are that higher caregiver preparedness is a predictor of less caregiver burden and depression, and better QoL. However, preparedness did not increase as the duration or time spent on caregiving was extended. Therefore, efforts to enhance the caregivers' preparedness are required to reduce caregiver burden and improve health outcomes for both caregivers and patients.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions

OBJECTIVE

A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported.

DESIGN

This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs.

RESULTS

A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion.

CONCLUSION

Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization

OBJECTIVE

The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions.

DESIGN

For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned.

RESULTS

The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data.

CONCLUSIONS

The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

Abnormal synergistic gait mitigation in acute stroke using an innovative ankle-knee-hip interlimb humanoid robot: a preliminary randomized controlled trial

Abnormal spasticity and associated synergistic patterns are the most common neuromuscular impairments affecting ankle–knee–hip interlimb coordinated gait kinematics and kinetics in patients with hemiparetic stroke. Although patients with hemiparetic stroke undergo various treatments to improve gait and movement, it remains unknown how spasticity and associated synergistic patterns change after robot-assisted and conventional treatment. We developed an innovative ankle–knee–hip interlimb coordinated humanoid robot (ICT) to mitigate abnormal spasticity and synergistic patterns. The objective of the preliminary clinical trial was to compare the effects of ICT combined with conventional physical therapy (ICT-C) and conventional physical therapy and gait training (CPT-G) on abnormal spasticity and synergistic gait patterns in 20 patients with acute hemiparesis. We performed secondary analyses aimed at elucidating the biomechanical effects of Walkbot ICT on kinematic (spatiotemporal parameters and angles) and kinetic (active force, resistive force, and stiffness) gait parameters before and after ICT in the ICT-C group. The intervention for this group comprised 60-min conventional physical therapy plus 30-min robot-assisted training, 7 days/week, for 2 weeks. Significant biomechanical effects in knee joint kinematics; hip, knee, and ankle active forces; hip, knee, and ankle resistive forces; and hip, knee, and ankle stiffness were associated with ICT-C. Our novel findings provide promising evidence for conventional therapy supplemented by robot-assisted therapy for abnormal spasticity, synergistic, and altered biomechanical gait impairments in patients in the acute post-stroke recovery phase.

Trial Registration: Clinical Trials.gov identifier NCT03554642 (14/01/2020).

Association of Academic Physiatrists Women's Task Force Follow-up Report

ABSTRACT

The Association of Academic Physiatrists convened a Women's Task Force in 2016, under the leadership of then Association of Academic Physiatrists President Gerard Francisco, MD, to evaluate data and metrics pertaining to the representation and inclusion of female physiatrists in the society. An initial published report focused on a retrospective analysis of data in categories such as leadership, conference presentations, and recognition awards. The findings, which highlighted areas in which the Association of Academic Physiatrists had been successful in supporting gender equity as well as areas in which female physiatrists were underrepresented, provided a base from which to strategically focus on closing gaps in representation. The task force developed an action plan that was approved by the Board of Trustees and included strategies aimed at closing gaps and collecting data to determine corresponding effectiveness. Because most of the categories fell under the supervision of various Association of Academic Physiatrists committees, an appointee from each committee ("diversity steward") liaised with the Women's Task Force. The diversity stewards reviewed the plan with their respective committees and collected data within their committee's purview. This task force follow-up report documents recent progress, consistent with the Association of Academic Physiatrists Board of Trustees commitment to transparency and gender equity.

Telerehabilitation for Geriatrics

Advancements in medical science and technology, along with global increases in life expectancy, are changing the way health care services are delivered to the aging society. Telerehabilitation refers to rehabilitation services involving evaluation and treatment. It is an attractive option for older adults who may have multiple comorbidities. Limited access to in-person services and the concern about potential exposure to severe acute respiratory syndrome coronavirus-2 during this pandemic accelerated the implementation of telerehabilitation. This article review the scope, need, and implementation of telehealth and telerehabilitation in the aging population from the perspective of clinicians, patients, and caregivers.

Technology Utilization in Fall Prevention

ABSTRACT

Falls, defined as unplanned descents to the floor with or without injury to an individual, remain to be one of the most challenging health conditions. Fall rate is a key quality metric of acute care hospitals, rehabilitation settings, and long-term care facilities. Fall prevention policies with proper implementation have been the focus of surveys by regulatory bodies, including The Joint Commission and the Centers for Medicare and Medicaid Services, for all healthcare settings. Since October 2008, the Centers for Medicare and Medicaid Services has stopped reimbursing hospitals for the costs related to patient falls, shifting the accountability for fall prevention to the healthcare providers. Research shows that almost one-third of falls can be prevented and extensive fall prevention interventions exist. Recently, technology-based applications have been introduced in healthcare to obtain superior patient care outcomes and experience via efficiency, access, and reliability. Several areas in fall prevention deploy technology, including predictive and prescriptive analytics using big data, video monitoring and alarm technology, wearable sensors, exergame and virtual reality, robotics in home environment assessment, and personal coaching. This review discusses an overview of these technology-based applications in various settings, focusing on the outcomes of fall reductions, cost, and other benefits.

Robotic Exoskeleton Gait Training During Acute Stroke Inpatient Rehabilitation

Stroke is the leading cause of severe disability in adults resulting in mobility, balance, and coordination deficits. Robotic exoskeletons (REs) for stroke rehabilitation can provide the user with consistent, high dose repetition of movement, as well as balance and stability. The goal of this intervention study is to evaluate the ability of a RE to provide high dose gait therapy and the resulting effect on functional recovery for individuals with acute stroke. The investigation included a total of 44 participants. Twenty-two participants received RE gait training during inpatient rehabilitation (RE+SOC Group), and a matched sample of 22 individuals admitted to the same inpatient rehabilitation facility-receiving conventional standard of care treatment (SOC group). The effect of RE training was quantified using total distance walked during inpatient rehabilitation and functional independence measure (FIM). The total distance walked during inpatient rehabilitation showed a significant difference between the SOC and RE+SOC groups. RE+SOC walked twice the distance as SOC during the same duration (time spent in inpatient rehabilitation) of training. In addition, the average change in motor FIM showed a significant difference between the SOC and RE+SOC groups, where the average difference in motor FIM was higher in RE+SOC compared to the SOC group. The results suggest that RE provided increased dosing of gait training without increasing the duration of training during acute stroke rehabilitation. The RE+SOC group increased their motor FIM score (change from admission to discharge) compared to SOC group, both groups were matched for admission motor FIM scores suggesting that increased dosing may have improved motor function.

Feasibility of integrative games and novel therapeutic game controller for telerehabilitation of individuals chronic post-stroke living in the community

BACKGROUND

Intensive, adaptable and engaging telerehabilitation is needed to enhance recovery and maximize outcomes. Such services may be provided under early supported discharge, or later for chronic populations. A novel virtual reality game-based telerehabilitation system was designed for individuals post-stroke to enhance their bimanual upper extremity motor function, cognition, and wellbeing.

OBJECTIVES

To evaluate the feasibility of novel therapeutic game controller and telerehabilitation system for home use.

METHODS

Individuals chronic post-stroke and their caregivers were recruited (n = 8 + 8) for this feasibility study. One was a screen failure and seven completed 4 weeks (20 sessions) of home-based therapy with or without remote monitoring. Standardized clinical outcome measures were taken pre- and post-therapy. Game performance outcomes were sampled at every session, while participant and caregiver subjective evaluations were done weekly.

RESULTS

There was a 96% rate of compliance to protocol, resulting in an average of 13,000 total arm repetitions/week/participant. Group analysis showed significant (p <.05) improvements in grasp strength (effect size [ES] = 0.15), depression (Beck Depression Inventory II, ES = 0.75), and cognition (Neuropsychological Assessment Battery for Executive Function, ES = 0.46). Among the 49 outcome variables, 36 variables (73.5%) improved significantly (p = .001, binomial sign test). Technology acceptance was very good with system rating by participants at 3.7/5 and by caregivers at 3.5/5.

CONCLUSIONS

These findings indicate the feasibility and efficacy of the system in providing home-based telerehabilitation. The BrightBrainer system needs to be further evaluated in randomized control trials and with individuals early post-stroke.

The War on COVID-19 Pandemic: Role of Rehabilitation Professionals and Hospitals

The global outbreak of coronavirus disease 2019 has created an unprecedented challenge to the society. Currently, the United States stands as the most affected country, and the entire healthcare system is affected, from emergency department, intensive care unit, postacute care, outpatient, to home care. Considering the debility, neurological, pulmonary, neuromuscular, and cognitive complications, rehabilitation professionals can play an important role in the recovery process for individuals with coronavirus disease 2019. Clinicians across the nation's rehabilitation system have already begun working to initiate intensive care unit-based rehabilitation care and develop programs, settings, and specialized care to meet the short- and long-term needs of these individuals. We describe the anticipated rehabilitation demands and the strategies to meet the needs of this population. The complications from coronavirus disease 2019 can be reduced by (1) delivering interdisciplinary rehabilitation that is initiated early and continued throughout the acute hospital stay, (2) providing patient/family education for self-care after discharge from inpatient rehabilitation at either acute or subacute settings, and (3) continuing rehabilitation care in the outpatient setting and at home through ongoing therapy either in-person or via telehealth.

Effects of innovative hip-knee-ankle interlimb coordinated robot training on ambulation, cardiopulmonary function, depression, and fall confidence in acute hemiplegia

BACKGROUND

While Walkbot-assisted locomotor training (WLT) provided ample evidence on balance and gait improvements, the therapeutic effects on cardiopulmonary and psychological elements as well as fall confidence are unknown in stroke survivors.

OBJECTIVE

The present study aimed to compare the effects of Walkbot locomotor training (WLT) with conventional locomotor training (CLT) on balance and gait, cardiopulmonary and psychological functions and fall confidence in acute hemiparetic stroke.

METHODS

Fourteen patients with acute hemiparetic stroke were randomized into either the WLT (60 min physical therapy + 30 min Walkbot-assisted gait training) or CLT (60 min physical therapy + 30 min gait training) groups, 7 days/week over 2 weeks. Clinical outcomes included the Berg Balance Scale (BBS), Functional Ambulation Category (FAC), heart rate (HR), Borg Rating of Perceived Exertion (BRPE), Beck Depression Inventory-II (BDI-II), and the activities-specific balance confidence (ABC) scale. The analysis of covariance (ANCOVA) was conducted at P < 0.05.

RESULTS

ANCOVA showed that WLT showed superior effects, compared to CLT, on FAC, HR, BRPE, BDI-II, and ABC scale (P < 0.05), but not on BBS (P = 0.061).

CONCLUSIONS

Our results provide novel, promising clinical evidence that WLT improved balance and gait function as well as cardiopulmonary and psychological functions, and fall confidence in acute stroke survivors who were unable to ambulate independently.

Redefining Pathways into Acute Rehabilitation during the COVID-19 Crisis

The coronavirus disease 2019 (COVID‐19) pandemic has necessitated drastic changes across the spectrum of health care, all of which have occurred with unprecedented rapidity. The need to accommodate change on such a large scale has required ingenuity and decisive thinking. The field of physical medicine and rehabilitation has been faced with many of these challenges. Healthcare practitioners in New York City, the epicenter of the pandemic in the United States, were among the first to encounter many of these challenges. One of the largest lessons included learning how to streamline admissions and transfer process into an acute rehabilitation hospital as part of a concerted effort to make acute care hospital beds available as quickly as possible.

Applicability of the 48/6 Model of Care as a Health Screening Tool, and its Association with Mobility in Community-Dwelling Older Adults

BACKGROUND

The 48/6 Model of Care is an integrative care initiative for improving the health outcomes of hospitalized older patients; however, its applicability in community-dwelling older adults as a health screening tool has not been investigated. The present study aimed to examine the applicability of this model, prevalence of dysfunction in 6 care areas, and its relationship with self-reported mobility in community-dwelling older adults.

METHODS

This was a cross-sectional survey study of community-dwelling adults aged 65 or older. Participants were screened for problems using 9 items corresponding to the 6 care areas of the 48/6 Model of Care (cognitive functioning, functional mobility, pain management, nutrition and hydration, bladder and bowel management, and medication management). Mobility was assessed via the Life-Space Assessment (LSA). We examined the correlation between each screening item and the LSA.

RESULTS

A total of 444 older adults (260 women, 58.6%) participated. The mean number of health problems was 2.3 ± 2.1, with the most common being pain, cognitive impairment, and urinary incontinence. These problems and LSA scores were significantly different by age groups. A multiple regression analysis showed that polypharmacy (β = -10.567, P < 0.001), dysphagia (β = -9.610, P = 0.021), and pain (β = -7.369, P = 0.004) were significantly associated with life-space mobility after controlling for age.

CONCLUSION

The 48/6 Model of Care is applicable to community-dwelling older adults, who show high prevalence of dysfunction in the 6 care areas. This study supports the role of the model in screening for the health status of older adults living in the community, and in estimating mobility.

Inpatient Rehabilitation Delirium Screening: Impact on Acute Care Transfers and Functional Outcomes

BACKGROUND

Delirium is well studied in the acute care setting, but there is limited understanding of its impact in the postacute care setting, particularly in the inpatient rehabilitation facility (IRF).

OBJECTIVE

To investigate the prevalence and related outcomes of delirium in the IRF setting, particularly patients' transfers to acute care hospitals.

DESIGN

Retrospective cohort study.

SETTING

A freestanding IRF.

PARTICIPANTS

Patients discharged from an IRF between January 2016 and December 2016 (12 months).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Transfer to acute care hospitals, motor and cognitive Functional Independence Measures (FIM), length of stay, discharge disposition.

RESULTS

A total of 1567 patients (53.9% female, mean age 72.9 ± 13.9) were included in the analysis. Positive scores were found among 142 (9.1%) patients on a 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM), indicating delirium on admission. Fifty-nine (3.8%) were unscorable on 3D-CAM. Twice as many delirium patients were transferred to acute care hospitals compared to non-delirium patients (22.5% vs. 10.8%, P < .001). Multivariate logistic regression showed that, for patients with 3D-CAM positive scores, there was an increased risk of transfers to acute care hospitals at an odds ratio of 1.61 (1.03-2.53, P = .04) after adjusting for age, gender, neurological diagnosis, and motor FIM score. The delirium group also showed lower gains in motor function, increased lengths of stay, and reduced discharges to home when compared to the non-delirium group (P < .001).

CONCLUSIONS

This study finds that delirium on admission to an IRF is associated with worsened outcomes related to function, length of stay, discharge status, and transfer to acute care hospitals. Positive delirium screening is an independent predictor for transfer to acute care hospitals from an IRF. Early identification of delirium is recommended in order to mitigate preventable transfers.

Preventing Delirium Takes a Village: Systematic Review and Meta-analysis of Delirium Preventive Models of Care

BACKGROUND

Each hospital day of delirium incurs greater healthcare costs, higher levels of care, greater staff burden, and higher complication rates. Accordingly, administrators are incentivized to identify models of care that reduce delirium rates and associated costs.

PURPOSE

We present a systematic review and meta-analysis of delirium prevention models of care.

DATA SOURCES

Ovid MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, and PsycINFO.

STUDY SELECTION

Eligible models of care were defined as provider-oriented interventions involving revision of professional roles, multidisciplinary teams, and service integration. Included studies implemented multidomain, multicomponent interventions, used a validated delirium instrument, and enrolled a control group to evaluate efficacy or effectiveness.

DATA EXTRACTION

We extracted data on study design; Population, model of care, outcomes, and results.

DATA SYNTHESIS

A total of 15 studies were included. All but two studies reported reduction in delirium or its duration, and 11 studies reported statistically significant improvements. Using random effects models, the pooled odds ratios of delirium incidence were 0.56 (95% CI: 0.37-0.85) from three randomized controlled trials, 0.63 (95% CI 0.37-1.07) from four pre-post intervention studies, and 0.79 (95% CI: 0.46-1.37) from three additional nonrandomized studies.

CONCLUSIONS

Several models of care can prevent delirium. In general, higher quality studies were more likely to demonstrate statistical significance of an effect. The diverse models of care included here explored interventions adapted to specific care settings, especially by addressing setting-specific delirium risk factors. These care models illustrate a range of promising strategies that deserve growing recognition, refinement, and implementation.

Life Space Assessment in Stroke Patients

Objective

To evaluate the reliability of the practical life space in post-stroke patients using the Korean version of the Life-Space Assessment (K-LSA) questionnaire and to assess the relationships between the K-LSA and physical function, daily activity, quality of life, and post-stroke depression.

Methods

The LSA questionnaire was translated into Korean, and the translated version was authorized by the author of the LSA questionnaire. In a cross-sectional study, the performance of the K-LSA was evaluated in 34 stroke patients (20 males and 14 females; mean age 65.11±2.39 years) who were receiving physical and occupational therapy at the outpatient clinic in the rehabilitation medicine department of a university medical center at the time of evaluation. Performances were assessed twice by one examiner at a 2-week interval to test the reliability. The patients were evaluated using the Functional Ambulation Category (FAC) scale, Functional Independence Measure (FIM) scale, and mobility subscale of the FIM to assess their relationships with the K-LSA. They were also evaluated using the EuroQol 5 Dimensions questionnaire (EQ-5D) and Geriatric Depression Scale (GDS) to determine the relationship with quality of life and post-stroke depression.

Results

Test-retest reliability at the first (62.20±32.14) and second (63.15±32.22) assessment was 0.993 (p<0.01). The K-LSA showed significant correlations with the FAC (r=0.848, p<0.01), FIM (r=0.765, p<0.01), mobility category of the FIM (r=0.764, p<0.01), GDS (r=-0.657, p<0.01), and EQ-5D (r=0.506, p<0.01).

Conclusion

This study suggests that the practical life space of post-stroke patients, assessed by the K-LSA, has a significant correlation with patients' functional mobility, independence in daily activity, quality of life, and depression.

Quantitative trunk sway and prediction of incident falls in older adults

Poor balance and balance impairments are major predictors of falls. The purpose of the current study was to determine the clinical validity of baseline quantitative static trunk sway measurements in predicting incident falls in a cohort of 287 community-dwelling non-demented older Americans (mean age 76.14±6.82years; 54% female). Trunk sway was measured using the SwayStar™ device, and quantified as angular displacement in degrees in anterior-posterior (pitch) and medio-lateral (roll) planes. Over a one-year follow-up period, 66 elders (23%) reported incident falls. Anterior-posterior angular displacement was a strong predictor of incident falls in older adults in Cox proportional hazards models (hazard ratio adjusted for age, gender, education, RBANS total score, medical comorbidities, geriatric depression scale score, sensory impairments, gait speed, and history of fall in the past 1year ((aHR)=1.59; p=0.033) whereas, angular displacement in the medio-lateral plane was not predictive of falls (aHR=1.35; p=0.276). Our results reveal the significance of quantitative trunk sway, specifically anterior-posterior angular displacement, in predicting incident falls in older adults.

Point-of-care ultrasonography in a physiatric foot clinic

BACKGROUND

Few reports are available for the utility of diagnostic point-of-care (POC) ultrasonography for foot and ankle pain and diagnostic POC ultrasonography in physiatric practice has not yet been demonstrated.

AIM

To describe POC musculoskeletal ultrasonographic (US) findings by location of pain among patients presenting to a foot pain clinic and to evaluate the concordance rate between clinical diagnoses and US findings by region of the foot.

DESIGN

Retrospective chart review.

SETTING

Outpatient clinic.

POPULATION

A total of 111 patients with foot and ankle pain.

METHODS

Retrospective chart review of clinical notes and data from POC US evaluation of patients who presented to the foot pain clinic between November 2013 and January 2015. US evaluations were performed by two physiatric ultrasonographers.

MAIN OUTCOME MEASURES

The concordance rate of clinical diagnosis and findings from US imaging based on the location of foot pain.

RESULTS

One hundred eleven patients out of 205 patients who presented to the foot clinic (54.1%) had POC US evaluation during the initial visit. The data was analyzed for patients with a single location of pain excluding 21 patients with pain more than one location. The mean age was 55.1±14.3 years with 86.5% being female. The most common location of pain was the hindfoot/ankle (N.=71), followed by forefoot (N.=13) and midfoot (N.=6). The overall concordance rate between clinical and ultrasonographic diagnoses was 62.2% (56/90) with a higher concordance rate in the hindfoot (67.6%) compared to the rest of the foot (50% in midfoot, 38.5% in the forefoot, P=0.042). The most common reasons for discordance (N.=34) were failure to reveal abnormality on US (N.=20, 58%) followed by unexpected US findings (N.=7, 20.6%).

CONCLUSIONS

Concordance between clinical evaluation and POC US findings varies depending on the location of foot pain and often no US abnormalities were found in spite of clinical symptoms particularly in forefoot region.

CLINICAL REHABILITATION IMPACT

These new findings will enhance the selective application of POC US and improve its clinical utility in physiatric practice.

Peripheral Neuropathy After Fecal Microbiota Transplantation for Clostridium difficile Infection: A Case Report

We present a case of a 71-year-old man with Clostridium difficile infection who underwent fecal transplantation. The patient was found to have a predominantly demyelinating sensorimotor peripheral polyneuropathy upon electrodiagnostic testing. To our knowledge, only one case of peripheral neuropathy after fecal transplantation has previously been reported. Although the exact cause of this patient's neuropathy cannot be confirmed, it has been speculated that the pathophysiology is an immune-mediated process. Given the increasing incidence of C difficile infections and the emergence of fecal transplantation as treatment, it is important to note that peripheral neuropathy is a potential adverse complication.

Delirium Associated With Lidocaine Patch Administration: A Case Presentation

Delirium is a common complication among hospitalized elderly individuals. Systemic analgesics are known precipitating factors for delirium. However, the risk from topical pain agents is not well documented. We report a case of a woman who developed delirium after the application of a lidocaine patch. Although lidocaine patches are generally perceived as safe, clinicians should be aware of delirium as a potential adverse effect, particularly in older patients. This report also highlights the role of a systematic approach of staff education, use of a standardized protocol, and interdisciplinary communication in the identification and management of delirium in acute rehabilitation facilities.

Severity of spatial neglect during acute inpatient rehabilitation predicts community mobility after stroke

OBJECTIVE

To examine whether stroke survivors with more severe spatial neglect during their acute inpatient rehabilitation had poorer mobility after returning to their communities.

DESIGN

A prospective observational study.

SETTING

Acute inpatient rehabilitation and follow-up in the community.

PARTICIPANTS

Thirty-one consecutive stroke survivors with right-brain damage (women, n = 15 [48.4%]), with the mean (standard deviation) age of 60 ± 11.5 years, were included in the study if they demonstrated spatial neglect within 2 months after stroke.

METHODS

Spatial neglect was assessed with the Behavioral Inattention Test (BIT) (range, 0-146 [a lower score indicates more severity]) and the Catherine Bergego Scale (range, 0-30 [a higher score indicates more severity]). A score of the Behavioral Inattention Test <129 or of the Catherine Bergego Scale >0 defined the presence of spatial neglect.

MAIN OUTCOME MEASUREMENTS

The outcome measure is community mobility, defined by the extent and frequency of traveling within the home and in the community, and is assessed with the University of Alabama at Birmingham Study of Aging Life-Space Assessment (range, 0-120 [a lower score indicates less mobile]). This measure was assessed after participants returned home ≥6 months after stroke. The covariates were age, gender, functional independence at baseline; follow-up interval; and depressed mood, which may affect the relationship between spatial neglect and community mobility.

RESULTS

A lower Behavioral Inattention Test score was a significant predictor of a lower Life-Space Assessment score after controlling for all the covariates (β = 0.009 [95% confidence interval, 0.008-0.017]); P = .020). The proportion of participants unable to travel independently beyond their homes was 0%, 27.3%, and 72.7% for those with mild, moderate, and severe acute neglect, respectively (Catherine Bergego Scale range, 1-10, 11-20, and 21-30, respectively).

CONCLUSIONS

Our result indicates that acute spatial neglect has a negative impact on regaining of functional mobility in the community. Specific screening and treatment of spatial neglect during acute stroke care may be necessary to improve long-term mobility recovery.

Neurorehabilitation: Five new things

Neurologists have a new toolbox of options for neurorehabilitation of disabling brain disorders such as stroke and traumatic brain injury. An emerging intellectual paradigm for neurologic recovery that includes neural regeneration, repair, and dynamic reorganization of functional neural systems, as well as increasing awareness of behavioral principles that may support best return to function and freedom, brought forward treatments based on experience-dependent learning, neurophysiologic stimulation, and a combination of these concepts. In this article, we summarize five rehabilitative approaches to watch: constraint therapy for motor and language recovery, synergy of motor-language rehabilitation, prism adaptation training and other virtual feedback approaches, and noninvasive magnetic and electrical brain stimulation.

Clinically meaningful change in stair negotiation performance in older adults

Stair negotiation is a key marker for independence among older adults; however, clinically meaningful change has not been established. Our objective was to establish the values of clinically meaningful change in stair negotiation time using distribution- and anchor-based approaches. Study participants were 371 community residing older adults (age≥70) in the Einstein Aging Study with time to ascend and descend 3 steps measured at baseline and at one-year follow-up. Anchor-based estimates were obtained using functional decline (defined as one-point increment in disability score) and change in self-reported walking ability over the one-year follow-up period. Small, moderate, and large meaningful change estimates were 0.28, 0.71, and 1.15 s for stair ascent time (0.31, 0.78, and 1.25 s for stair descent time) using the distribution-based approach of effect size. The estimates of meaningful decline range from 0.47 to 0.53 s for stair ascent time (0.33-0.53 s for stair descent time) using the anchor-based approach. The estimates of meaningful improvement were smaller (0.13-0.18 s for stair ascent, 0.06-0.15 for stair descent) compared to those for decline. Based on general consistency between distribution- and anchor-based approaches, preliminary criteria suggested for stair negotiation time is 0.5 s for meaningful decline and 0.2 s for meaningful improvement.

Effect of treadmill training on specific gait parameters in older adults with frailty: case series

BACKGROUND AND PURPOSE

Treadmill-walking training (TWT) as an intervention to improve the gait of frail older adults has not been well studied. In this pilot study, we describe the feasibility, tolerance, and effect of TWT on specific gait parameters during overground walking in 4 frail older adults as a prelude to developing larger-scale exercise intervention trials in this high-risk population.

CASE DESCRIPTION

Four community-residing frail older individuals (age > 70 years) with Mini-Mental State Examination score of 26 or higher and no activity limitations. Frailty was defined as the presence of at least 3 of the following 5 attributes: slow gait (<1 m/s); unintentional weight loss (>10 lb in prior year); self-report of poor grip strength; exhaustion; and low level of physical activity.

INTERVENTION

The TWT consisted of 24 sessions (3 times per week for 8 weeks). Five quantitative gait parameters (velocity, stride length, swing time, percentage of double support phase, and coefficient of variation [COV] of stride length) during overground walking were measured at baseline, weekly during training, and immediately post-TWT.

OUTCOME

All participants tolerated TWT without significant complications. Following TWT, gait velocity increased in all participants by 6.4 to 26.8 cm/s, which was larger than the reported value for meaningful change in gait velocity (4 cm/s). Stride length and double support phase also showed improvement in all participants (mean percentage increase of 10.8% for stride length and 17.1% reduction for double support phase posttraining compared with baseline). Swing time improved in 3 participants (mean reduction of 4.5%). The COV of stride length did not show consistent improvement.

DISCUSSION

This case series shows that TWT is feasible and well tolerated by frail older adults and may improve most gait parameters in this high-risk population.

Walking while talking: investigation of alternate forms

The aim of this study was to develop alternate forms of the walking while talking (WWT) dual task, and to determine whether beginning the WWT in mid-alphabet vs. at the beginning of the alphabet, affects task outcomes. Alternate test forms help reduce practice effects leading to more precise estimates of change over time. We conducted a cross-sectional study in 145 community-residing older adults (mean age, 79.2 ± 6.8 y) without dementia or depression. Subjects performed four WWT trials with a different initial letter (a, b, m or n). There were no differences in velocity, correct letters, or errors on WWT trials beginning at shared points in the alphabet ('a' compared to 'b' and 'm' compared to 'n'). However, trials initiating with letters from the beginning of the alphabet compared to mid-alphabet showed significant differences (with higher number of correct letters and fewer errors for 'a' and 'b' trials) but not for velocity. Thus, starting WWT in mid-alphabet is different from starting at the beginning of the alphabet. Alternate forms of the WWT with two separate initial letters from a shared point of the alphabet (specifically 'a' and 'b' or 'm' and 'n') may be used upon repeated administration to reduce practice effects.

Multisensory integration across the senses in young and old adults

Stimuli are processed concurrently and across multiple sensory inputs. Here we directly compared the effect of multisensory integration (MSI) on reaction time across three paired sensory inputs in eighteen young (M=19.17 years) and eighteen old (M=76.44 years) individuals. Participants were determined to be non-demented and without any medical or psychiatric conditions that would affect their performance. Participants responded to randomly presented unisensory (auditory, visual, somatosensory) stimuli and three paired sensory inputs consisting of auditory-somatosensory (AS) auditory-visual (AV) and visual-somatosensory (VS) stimuli. Results revealed that reaction time (RT) to all multisensory pairings was significantly faster than those elicited to the constituent unisensory conditions across age groups; findings that could not be accounted for by simple probability summation. Both young and old participants responded the fastest to multisensory pairings containing somatosensory input. Compared to younger adults, older adults demonstrated a significantly greater RT benefit when processing concurrent VS information. In terms of co-activation, older adults demonstrated a significant increase in the magnitude of visual-somatosensory co-activation (i.e., multisensory integration), while younger adults demonstrated a significant increase in the magnitude of auditory-visual and auditory-somatosensory co-activation. This study provides first evidence in support of the facilitative effect of pairing somatosensory with visual stimuli in older adults.

Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors

OBJECTIVES

To investigate the incidence of fear of falling (FOF) and the risk factors associated with transient versus persistent FOF in community-dwelling older adults.

DESIGN

Prospective cohort study.

SETTING

Bronx County, New York.

PARTICIPANTS

Three hundred eighty participants without FOF at baseline in the Einstein Aging Study aged 70 and older.

MEASUREMENTS

FOF was assessed at baseline and during follow-up interviews at 2- to 3-month intervals for a minimum 2 years. Incident FOF was classified as transient or persistent FOF. Transient FOF was defined as new-onset FOF reported at only one interview, and persistent FOF was FOF reported at two or more interviews over a 2-year period.

RESULTS

Twenty-four-month cumulative incidence of incident FOF was 45.4%, with 60.0% of FOF being persistent. Predictors of incident FOF included female sex (adjusted hazard ratio (aHR)=1.55, 95% confidence interval (CI)=1.08-2.23), depressive symptoms (aHR=1.16, 95% CI=1.07-1.26), falls (aHR=1.50, 95% CI=1.01-2.21), and clinical gait abnormality (aHR=2.07, 95% CI=1.42-3.01). The proportion of participants with incident FOF increased linearly with increasing number of risk factors. Predictors for transient and persistent FOF were depressive symptoms and clinical gait abnormality. Female sex and previous falls were predictors of persistent but not transient FOF.

CONCLUSION

FOF status in older adults may change over time, with shared and distinct risk factors for persistent and transient FOF. Understanding the dynamic nature of FOF and these risk factors will help identify high-risk groups and design future intervention studies.

Inflammatory markers and gait speed decline in older adults

BACKGROUND

Increased inflammatory activity and gait speed decline are common with aging, but the association between the two is not well established. The objective of this study was to determine the influence of inflammatory markers, interleukin-6 (IL-6), and tumor necrosis factor alpha, on gait speed performance and decline in older adults.

METHODS

We conducted cross-sectional and longitudinal analyses of 333 adults aged 70 and older (61% women) with gait and biomarker assessments identified from participants in the Einstein Aging Study, a community-based aging study. Gait velocity measured at baseline and annual follow-up visits (median follow-up 2.3 years) was the main outcome.

RESULTS

At baseline, higher interleukin-6 levels were associated with slower gait velocity (estimate -4.90 cm/s, p = .008). Adjusted for age, gender, education, and medical illnesses, a one-unit increase in baseline log IL-6 levels was associated with a 0.98 cm/s faster gait speed decline per year (p = .002). The results remained significant after adjustments for additional potential confounders such as physical activity levels, body mass index, and medications. Participants in the highest IL-6 quartile had a 1.75 cm/s/year faster decline in gait velocity compared with those in the lowest quartile (p = .002). Tumor necrosis factor alpha was not associated with gait velocity at cross-section or with gait speed decline.

CONCLUSIONS

IL-6 levels are associated with gait performance in community residing seniors and predicts risk of gait speed decline in aging.

Conventional and robust quantitative gait norms in community-dwelling older adults

OBJECTIVES

To develop and compare norms for widely used gait parameters in adults aged 70 and older using cross-sectional (conventional) and longitudinal (robust) approaches accounting for important confounders such as disease effects on gait.

DESIGN

Cohort study.

SETTING

General community.

PARTICIPANTS

Community-dwelling older adults (> 70, N = 824) without dementia or disability.

MEASUREMENTS

Eight quantitative gait parameters measured using an instrumented walkway.

RESULTS

Of the 824 subjects (conventional normal (CN) sample), 304 were included in a "robust normal" (RN) sample after excluding those with prevalent or incident clinical gait abnormalities developing within 1 year of the baseline assessment to account for disease effects on gait performance. Descriptively, the RN sample showed better performance on all selected gait variables than the CN sample. For instance, mean gait velocity ± standard deviation was 105.9 ± 17.9 cm/s in the RN sample, compared with 93.3 ± 23.2 cm/s in the overall CN sample. Applying one standard deviation below the mean (70.1 cm/s) derived from the CN sample to define slow gait, 15.9% (131) in the overall cohort were classified as abnormal, whereas the RN cut-off (88.0 cm/s) classified 39.7% (327) in the overall cohort as abnormal.

CONCLUSION

Cross-sectional conventional norms may underestimate gait performance in aging. Longitudinal robust norms provide more-accurate estimates of normal gait performance and thus may improve early detection of gait disorders in older adults.

Proximally Placed Alignment Control Strap for Ankle Varus Deformity: A Case Report

Ankle varus is a commonly encountered deformity in patients with neurologic or musculoskeletal disorders. It impedes stability during the stance phase of gait and often causes skin lesions on the lateral ankle area. Plastic or conventional ankle-foot orthoses (AFOs) with supplementary features such as a T-strap or increased contact area of the lateral flange have been used for correctable varus deformities. These supplementary modifications, however, have limitations as effective tools for varus control, and ankle varus may persist despite their use. We are revisiting the concept of a proximally placed alignment control strap for ankle varus, which may overcome the limitations of currently available modifications. This alignment control strap is designed to provide a medially directed force on the tibia and fibula against the force of varus deformation of the ankle. This modification can be easily added to various types of existing AFOs with acceptable aesthetic appearance. We describe 2 cases of manually correctable but persistent varus deformities of the ankle that were successfully controlled by utilization of the proximally placed alignment control strap.