Bianca I. Buijck

Predicting prosthetic use in elderly patients after major lower limb amputation

Background: The main determinants of prosthetic use known from literature apply to the younger patient with lower limb amputation. Studies aimed at identifying determinants of outcome of lower limb amputation in elderly patients with multimorbidity that rehabilitate in skilled nursing facilities (SNFs) are scarce. Objectives: To predict prosthetic use and physical mobility in geriatric patients admitted to SNFs for rehabilitation after lower limb amputation and the impact of multimorbidity. Study Design: Prospective design. Methods: Univariate and multivariate logistic and linear regression analyses were used to identify determinants that were independently related to prosthetic use and the timed-up-and-go test (TUG test). Results: Of 55 eligible patients, 38 had complete assessments on admission and at discharge. Fifty per cent was provided with a prosthesis. Multimorbidity was present in 53% of the patients. Being able to ambulate independently, and having a transtibial amputation (rather than a higher level of amputation), without phantom pain determined prosthetic use (R2=56%), while cognitive abilities, low amputation level, and pre-operative functional abilities were independently associated with the TUG test (R2=82%). Conclusions: Elderly patients referred to an SNF for prosthetic training have a high probability of using a prosthesis when having an independent ambulation after transtibial amputation, without phantom pain. These patients should be considered for prosthetic training. Clinical relevance This study gives more insight into the outcomes of geriatric patients with lower limb amputation after rehabilitation in skilled nursing facilities. This is the first study that focuses on determinants of prosthetic use in these elderly patients, often with multimorbidity.

Neuropsychiatric symptoms in geriatric patients admitted to skilled nursing facilities in nursing homes for rehabilitation after stroke: a longitudinal multicenter study

To investigate the prevalence and course of neuropsychiatric symptoms (NPS) in geriatric patients admitted to skilled nursing facilities (SNFs) for rehabilitation after stroke.

Geriatric rehabilitation of lower limb amputees: a multicenter study.

Purpose: The aim of this study was to determine factors independently associated with successful rehabilitation of patients with lower limb amputation in skilled nursing facilities (SNFs). Methods: All patients admitted to one of the 11 participating SNFs were eligible. Multidisciplinary teams collected the data. Successful rehabilitation was defined as discharge to an independent living situation within 1 year after admission. Functional status at discharge, as measured with the Barthel index (BI), was a secondary outcome. Multivariate regression analyses were used to assess the independent contribution of each determinant to the two outcome measures. Results: Of 55 eligible patients, 48 were included. Mean age was 75 years. Sixty-five percent rehabilitated successfully. Multivariate analyses showed that presence of diabetes mellitus (DM) (OR 23.87, CI 2.26–252.47) and premorbid BI (OR 1.37, CI 1.10-1.70) were the most important determinants of successful rehabilitation, whereas 78% of the variance of discharge BI was explained by premorbid BI, BI on admission, and 1-leg balance. Conclusion: The presence of DM and high premorbid BI were associated with discharge to an independent living situation within 1 year after admission. Premorbid BI, admission BI, and 1-leg balance were independently associated to discharge BI. Implications for Rehabilitation Geriatric patients with amputation in SNFs have a fair prognosis of being discharged to an independent living situation after rehabilitation. Pre-operative functional abilities of geriatric amputees are important in predicting rehabilitation outcome. Improving physical condition before amputation could lead to better rehabilitation outcome.

Geriatric rehabilitation of stroke patients in nursing homes: a study protocol

BackgroundGeriatric patients are typically underrepresented in studies on the functional outcome of rehabilitation after stroke. Moreover, most geriatric stroke patients do probably not participate in intensive rehabilitation programs as offered by rehabilitation centers. As a result, very few studies have described the successfulness of geriatric stroke rehabilitation in nursing home patients, although it appears that the majority of these patients are being discharged back to the community, rather than being transferred to residential care. Nevertheless, factors associated with the successfulness of stroke rehabilitation in nursing homes or skilled nursing facilities are largely unknown. The primary goal of this study is, therefore, to assess the factors that uniquely contribute to the successfulness of rehabilitation in geriatric stroke patients that undergo rehabilitation in nursing homes. A secondary goal is to investigate whether these factors are similar to those associated with the outcome of stroke rehabilitation in the literature.Methods/DesignThis study is part of the Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study in the Netherlands. It is a longitudinal, observational, multicenter study in 15 nursing homes in the Southern part of the Netherlands that aims to include at least 200 patients. All participating nursing homes are selected based on the existence of a specialized rehabilitation unit and the provision of dedicated multidisciplinary care. Patient characteristics, disease characteristics, functional status, cognition, behavior, and caregiver information, are collected within two weeks after admission to the nursing home. The first follow-up is at discharge from the nursing home or one year after inclusion, and focuses on functional status and behavior. Successful rehabilitation is defined as discharge from the nursing home to an independent living situation within one year after admission. The second follow-up is three months after discharge in patients who rehabilitated successfully, and assesses functional status, behavior, and quality of life. All instruments used in this study have shown to be valid and reliable in rehabilitation research or are recommended by the Netherlands Heart Foundation guidelines for stroke rehabilitation.Data will be analyzed using SPSS 16.0. Besides descriptive analyses, both univariate and multivariate analyses will be performed with the purpose of identifying associated factors as well as their unique contribution to determining successful rehabilitation.DiscussionThis study will provide more information about geriatric stroke rehabilitation in Dutch nursing homes. To our knowledge, this is the first large study that focuses on the determinants of success of geriatric stroke rehabilitation in nursing home patients.

Is patient-grouping on basis of condition on admission indicative for discharge destination in geriatric stroke patients after rehabilitation in skilled nursing facilities? The results of a cluster analysis

BackgroundGeriatric stroke patients are generally frail, have an advanced age and co-morbidity. It is yet unclear whether specific groups of patients might benefit differently from structured multidisciplinary rehabilitation programs. Therefore, the aims of our study are 1) to determine relevant patient characteristics to distinguish groups of patients based on their admission scores in skilled nursing facilities (SNFs), and (2) to study the course of these particular patient-groups in relation to their discharge destination.MethodsThis is a longitudinal, multicenter, observational study. We collected data on patient characteristics, balance, walking ability, arm function, co-morbidity, activities of daily living (ADL), neuropsychiatric symptoms, and depressive complaints of 127 geriatric stroke patients admitted to skilled nursing facilities with specific units for geriatric rehabilitation after stroke.ResultsCluster analyses revealed two groups: cluster 1 included patients in poor condition upon admission (n = 52), and cluster 2 included patients in fair/good condition upon admission (n = 75). Patients in both groups improved in balance, walking abilities, and arm function. Patients in cluster 1 also improved in ADL. Depressive complaints decreased significantly in patients in cluster 1 who were discharged to an independent- or assisted-living situation. Compared to 80% of the patients in cluster 2, a lower proportion (46%) of the patients in cluster 1 were discharged to an independent- or assisted-living situation.ConclusionStroke patients referred for rehabilitation to SNFs could be clustered on the basis of their condition upon admission. Although patients in poor condition on admission were more likely to be referred to a facility for long-term care, this was certainly not the case in all patients. Almost half of them could be discharged to an independent or assisted living situation, which implied that also in patients in poor condition on admission, discharge to an independent or assisted living situation was an attainable goal. It is important to put substantial effort into the rehabilitation of patients in poor condition at admission.

Determinants of geriatric patients’ quality of life after stroke rehabilitation

Objectives: Geriatric patients’ physical disabilities, dependency on care, and possible psychological ill-being may negatively affect both the patients quality of life and the informal caregiver burden. Focusing on this interrelationship which can be particularly prominent in geriatric patients with stroke, the objective of this study was to identify determinants of patients’ quality of life and informal caregiver burden. Method: This is a prospective, multicentre, cohort study. Data were collected in 84 geriatric home-dwelling patients with stroke three months after their rehabilitation period in skilled nursing facilities (SNFs). We assessed patients’ quality of life, depressive complaints, neuropsychiatric symptoms, balance, (instrumental) activities of daily living, and informal caregiver burden. Linear regression models were constructed to study the association between the variables. Results: For several domains, high quality of life of these geriatric patients was associated with high functional independence, less neuropsychiatric symptoms, and less depressive complaints. Informal caregiver burden was not associated with patients’ quality of life, but patients’ neuropsychiatric symptoms were a significant determinant of high informal caregiver burden. Conclusion: The presence of neuropsychiatric symptoms (more specifically depressive complaints) negatively affects the quality of life of geriatric patients. Their neuropsychiatric symptoms also affect caregiver burden. Health care professionals in SNFs can play an important role in providing the necessary psychosocial support and aftercare.

Determinants of Quality of Life in Older Adults After Lower Limb Amputation and Rehabilitation in Skilled Nursing Facilities

to 24 years (mean 13.6 years). Twenty-four patients did not complete the follow-up and were excluded from the analysis. Fracture healing interval was 3 to 6 months in 153 fractures (92.73%). Nonunion occurred in 12 fractures (7.27%), and new fixation was implemented with morerigid plating and grafts, with favorable outcome in all cases. Postoperative infection reported in four patients was treated successfully. Cumulative results are reported in Table 1. Two patients developed neurapraxia of the ipsilateral radial nerve after surgical treatment, with nerve functionality restored in a few days without any final functional deficit. Of the 51 patients with preoperative nerve function deficit, two experienced injury to the brachial plexus (no progress noted), whereas the remaining 49 patients experienced radial nerve injury solely. No macroscopic damage of the nerve was observed in 47 patients. A splint for keeping the wrist and fingers in slight extension was suggested postoperatively, and all patients were rehabilitated for a mean of 10 weeks. Full dissection of the radial nerve was observed in one patient, and nerve suturing could not be performed. During the final follow-up, elbow range of motion was very good in 146 patients (153 fractures, 92.7%), whereas an elbow extensor deficit of 10o was recorded in four patients (four fractures, 24.2%). There was no reported motor dysfunction in the ipsilateral shoulder. Nonunion occurred in 12 fractures (7.3%). Thus, results were satisfactory in 146 cases (153 fractures, 92.7%) and unsatisfactory in 12 cases (7.3%). These patients developed mechanical failure of the plate osteosynthesis and fracture pseudarthrosis. The success percentage of functional rehabilitation reaches 92.7% and is similar to the results of other researchers who have used the same technique in patients without osteoporosis. Surgical treatment of humeral shaft fractures based on the principles of stable internal fixation has good results in elderly adults with osteoporosis, but it should be chosen only in cases in which there is absolute indication for surgery.

The Development of Integrated Stroke Care in the Netherlands a Benchmark Study

Introduction: Integrated stroke care in the Netherlands is constantly changing to strive to better care for stroke patients. The aim of this study was to explore if and on what topics integrated stroke care has been improved in the past three years and if stroke services were further developed. Methods: A web based self-assessment instrument, based on the validated Development Model for Integrated Care, was used to collect data. In total 53 coordinators of stroke services completed the questionnaire with 98 elements and four phases of development concerning the organisation of the stroke service. Data were collected in 2012 and 2015. Descriptive-comparative statistics were used to analyse the data. Results: In 2012, stroke services on average had implemented 56 of the 89 elements of integrated care (range 15–88). In 2015 this was increased up to 70 elements on average (range 37–89). In total, stroke services showed development on all clusters of integrated care. In 2015, more stroke services were in further phases of development like in the consolidation and transformation phase and less were in the initiative and design phase. The results show large differences between individual stroke services. Priorities to further develop stroke services changed over the three years of data collection. Conclusions: Based on the assessment instrument, it was shown that stroke services in the Netherlands were further developed in terms of implemented elements of integrated care and their phase of development. This three year comparison showed unique first analyses over time of integrated stroke care in the Netherlands on a large scale. Interesting further questions are to research the outcomes of stroke care in relation to this development, and if benefits on patient level can be assessed.

To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients

OBJECTIVE To investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in skilled nursing facilities (SNFs), particularly the role of multimorbidity. DESIGN Cross-sectional study design. SETTING Fifteen SNFs. PARTICIPANTS All patients who were admitted for rehabilitation after stroke in one of the participating SNFs (N=378) were eligible. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Berg Balance Scale (BBS) was selected as a measure of standing balance and the Functional Ambulation Categories (FAC) as a measure of walking balance. RESULTS Multimorbidity was present in 34% of the patients. The patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on both outcome measures. In linear regression analyses, both the BBS and FAC were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively), while proprioception added only to the variance of the FAC. CONCLUSIONS Multimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs. Muscle strength and the interaction of muscle strength with static sitting balance were important determinants of both standing and walking balance, indicating these factors as essential targets for rehabilitation.

What is desirable care in the opinion of formal and informal caregivers in nursing-home care for patients with dementia?

To examine care characteristics related to desirable care as reported by formal and informal caregivers in Dutch Psycho‐geriatric nursing homes for patients with dementia.