Shai Brill

Programme evaluation of a geriatric rehabilitation day hospital

Objective: To evaluate the rehabilitation programme in a geriatric day hospital. Design: An observational study. Setting: An urban geriatric rehabilitation day hospital. Subjects: Three hundred and fifty-three older patients admitted to a rehabilitation day hospital during 2000: 163 post stroke, 113 with deconditioning and 77 post orthopaedic surgery (hip fracture and joint replacement). Main outcome measures: Functional Independence Measure (FIM), Nottingham Extended ADL Index, timed ‘get up and go’ test. Results: The mean discharge scores of all FIM items were significantly higher than the mean admission scores. Mean score change, however, for each item was less than one point. Most of the patients (70%) improved by less than 5 points, regardless of main admission diagnoses. Patients with a lower admission FIM score improved more than those with a higher admission score. The majority of the enrolled patients (92%) showed an improvement in their Nottingham Extended ADL Index score. The mean (SD) score on admission was 21 (11.9) and at discharge 31 (14.6). In all but three items (self-feeding, using a telephone and driving a car), mean scores at discharge were significantly higher than admission scores (p < 0.001). A significant improvement in timed ‘get up and go’ score was found for all patients regardless of main diagnosis. Performance time decreased by 33% and discharge scores for all patient groups were approximately 20 seconds. Conclusions: The notable improvement in mobility and instrumental activities of daily living on the one hand, and the minor improvements achieved in basic activities of daily living on the other, suggests a need to revise treatment goals of day hospitals.

Is a day hospital rehabilitation programme associated with reduction of handicap in stroke patients

Objective: (1) To assess whether a rehabilitation day hospital programme is associated with a reduced handicap level of stroke patients. (2) To estimate the relationship between the London Handicap Scale (LHS) and other outcome measures. (3) To examine the effect of demographic parameters (age, gender, family status, education) on LHS scores. Design: A prospective longitudinal survey. Setting: An urban geriatric rehabilitation day hospital. Subjects: Two hundred and seven elderly stroke patients admitted between December 1999 and February 2001. Main outcome measures: London Handicap Scale (LHS), Functional Independent Measure (FIM), Nottingham Extended ADL Index, timed get up and go test. Results: LHS scores at discharge changed significantly (p < 0.008) for mobility, physical independence and occupation. The overall change in LHS score was 2.3 points (20%); effect size 0.43. A significant relationship was found between discharge score of LHS and admission score of FIM, Nottingham Index, timed get up and go and age. Multiple linear regressions did not identify a good predictor for the discharge score of LHS. Higher education was associated with higher LHS scores on admission (p= 0.016) but with less success in correcting handicap (p= 0.046). Conclusions: A day hospital programme is associated with reduced level of handicap in stroke patients. The LHS is a useful and simple scale for measuring change in these patients. LHS in stroke patients correlates with other outcome measures, yet they cannot be used interchangeably. A significant relationship between education and level of handicap exists.

Can functional status, after rehabilitation, independently predict long-term mortality of hip-fractured elderly patients?

Background and aims: Hip fractures are one of the most serious causes of functional impairment and death in the elderly. The aim of this study was to evaluate prospectively the predictive value of functional performance, after rehabilitation, of hip fracture on long-term mortality in community-dwelling patients. Methods: One hundred and seventy-one patients aged 60 years and over, admitted to a geriatric rehabilitation day unit after inpatient rehabilitation, were followed for up to 4 years. Main outcome measures were Functional Independent Measure (FIM), Timed Get Up and Go test (GUAG), cognitive status using the Mini-Mental State Examination on admission, and mortality during the follow-up period. KaplanMeier analysis was carried out on survival curves. Results: All 24 deceased patients performed the GUAG test in >20 seconds. Although approaching significance, the survival curves were not statistically different between patients performing the test in ≤20 and those performing it in >20 seconds (p=0.08). Survival curves were significantly higher in patients with a FIM score of ≥90 (p=0.004), no cardio-cerebrovascular (CCV) diseases (p=0.001) and no diabetes mellitus (p=0.01). There were no differences in survival according to age, gender, educational level, marital status, surgical vs conservative treatment, and cognition. A multivariate analysis including FIM score, CCV diseases and diabetes mellitus, demonstrated that only CCV disease was an independent variable for survival (p=0.02). Conclusions: Performance, as evidenced by FIM scores after rehabilitation for hip fracture, may provide additional useful information on long-term survival. However, since functional status after rehabilitation is not an independent risk factor for long-term mortality, its predictive value must be interpreted in view of the comorbidities, mainly CCV diseases, which are more important to the risk of mortality than the event of hip fracture itself.

Get Up and Go -Home

Background and aims: One of the most important objectives of a rehabilitation program is to improve patients’ mobility. Mobility measures are necessary in evaluating treatment effectiveness. The aims of the present study were to assess the usefulness of the “Timed Get Up and Go” (TUG) test as a mobility measure for patients attending a day hospital, and as an additional tool in assisting a multidisciplinary team in clinical decision-making regarding length of stay in a day hospital. Methods: Two hundred and thirty elderly patients, admitted during 2000, were assessed by the TUG test and Functional Independence Measure (FIM) on admission and at discharge. The patients were divided into four performance categories (TUG score <20; 20.01–40; 40.01–60 and >60 seconds). The sensitivity of the test to changes in patients’ mobility level and the relationship between it and other measures were assessed. Results: Mean TUG score on admission was 32.6±24.2 seconds, and upon discharge 21.8±18.3 seconds. The difference in score changes between orthopedic patients (14.2 sec), patients with chronic disabling diseases (10.3 sec) and stroke patients (10.1) was statistically significant (p=0.013). On admission, 35.7% performed the TUG test in <20 seconds and upon discharge in 60.9%. A significant negative correlation was found between TUG scores and FIM and motor FIM scores on admission and at discharge. Conclusions: The TUG test is a sensitive test for measuring changes in the mobility level of patients attending a day hospital. Easy to carry out, the test furnishes additional information that may assist medical personnel in deciding criteria for discharge readiness.

Rehabilitation outcome of post-acute lower limb geriatric amputees

Purpose: To characterize the lower-limb elderly amputee patients admitted to a post-acute rehabilitation program, assess their 1-year survival rate, estimate rate of prosthetic fit and report rate and factors associated with 1-year post-discharge prosthetic use. Methods: A cohort study performed in a post-acute rehabilitation department. Patients were evaluated by the Functional Independence Measure (FIM), motor FIM (mFIM), rate of prosthesis fit, length of stay (LOS), 1-year survival rate and long-term prosthetic use. Results: One-hundred and seventeen lower limb elderly amputee patients consecutively admitted from January 2004 to June 2010 were enrolled in the study. Mean age was 74.7 ± 8.1; 56 patients (47.9%) had transtibial amputation (TTA); 46 (39.3%) transfemoral amputation (TFA) and 15 (12.8%) bilateral amputation. The main cause for amputation was diabetic foot (60.7%). Fifty-four (46.2%) patients died during first year post-admission. Twenty-seven patients (23.1%) were fitted with a prosthesis. When the bilateral amputees were considered separately, the rate of prosthetic fit among unilateral amputees was 24.5% (25/102) whereas among bilateral amputees it was 20% (3/15). Patients with prosthesis rehabilitation had a higher rate of TTA (p = 0.027), better metabolic status (p < 0.001), higher functional and cognitive levels (p < 0.001), and longer LOS (p < 0.001) compared with patients who received wheelchair rehabilitation. Twenty patients were contacted 1 year later: eight (40.0%) reported continuous functional prosthesis use, eight – partial prosthesis use and four (20%) did not use the prosthesis at all. The patient group with 1-year post-discharge prosthesis use had a significantly higher rate of TTA (p = 0.032), lower rate of congestive heart failure (CHF) (p = 0.014) and higher score changes on the FIM and mFIM (p = 0.043). Conclusions: Rehabilitation efforts should best be targeted depending on need. Rehabilitation professionals should make an educated estimate of outcomes at the beginning of rehabilitation based on the characteristics of the patients (level of amputation and functional level on admission). Implications for Rehabilitation Rehabilitation efforts should best be targeted depending on patients’ needs. Admission functional level is the most significant predictor for a successful lower limb prosthesis fit in a post-acute geriatric rehabilitation setting. Rehabilitation professionals should make educated estimates of outcomes at the beginning of rehabilitation based on the characteristics of the patients (level of amputation and functional level on admission).

Mobility assessment of hip fracture patients during a post-acute rehabilitation program

Our aim was to describe improvement in mobility level in hip fracture patients during a post-acute rehabilitation program and examine variables that may impede mobility improvement. A retrospective chart review of 138 patients with a proximal hip fracture, admitted consecutively during 2006 was conducted. Main outcome measurements were: 6-meter-walking-time (6mWT), rate of improvement (RI) in the 6mWT, gait velocity (GV), functional independence measure (FIM), motor FIM (mFIM) and length of stay (LOS). Most patients (118, 85.5%) showed improvement in the 6mWT (mean 16.05 ± 20.2s, median 12.08). At discharge, 117 patients (84.7%) achieved GV within household ambulation (<0.4m/s). Patients with high initial GV needed shorter rehabilitation time compare to patients with low admission GV (27.5 ± 12.1 days vs. 31.7 ± 12.2 days; p=0.042). The high RI group (≥ 1s/day) achieved significantly higher admission and discharge FIM scores (70.7 ± 15.9 vs. 64.1 ± 16.9, p=0.023; 87.3 ± 15.8 vs. 79.9 ± 17.4, p=0.013, respectively) and higher admission and discharge mFIM scores (45.3 ± 12.9 vs. 40.8.1 ± 12.7, p=0.049; 60.7 ± 12.4 vs. 56.2 ± 13.4, p=0.045, respectively) compared with the low performance group (<1s/day). Logistic regression analyzed the variables with significant predictive value for achieving high RI (≥ 1s/day): performance of the 6mWT at FIM ≥ 4 (OR 1.092; 95% CI, 1.056-1.129) and admission FIM score (OR 1.054; 95% CI, 1.023-1.085). Post-acute hip fracture patients capable of bearing weight on their injured leg, with minimal assistance [manual assistance of ≤ 25% (FIM ≥ 4)] may considerably improve their mobility regardless of their disability, cognitive level or neurological history. Most patients achieved GV enabling them to ambulate short distances within the home.

Can hip-fractured elderly patients maintain their rehabilitation achievements after 1 year?

Purpose: The purpose of this study is to characterize hip-fractured patients who maintained or improved their functional ability, 1 year postdischarge from rehabilitation and to identify factors associated with functional achievement maintenance. Methods: A retrospective study performed in a postacute geriatric rehabilitation center. Two hundred thirty-three hip-fractured patients admitted consecutively from January 2006 to September 2007 were enrolled in the study. The patients were evaluated at discharge from rehabilitation and after 1 year, they were classified into two groups: those who maintained or improved their motor Functional Independence Measure (mFIM) scores and those who deteriorated. The differences between the two patient groups relating to functional, clinical, demographic and fracture-related variables were assessed. Results: One year postrehabilitation, 130 (55.8%) patients exhibited a decline in their mFIM score. Patients whose 1-year mFIM score had improved were discharged from rehabilitation with a less favorable mean mFIM score (50.7 ± 18.5 vs. 55.6 ± 15.2; p = 0.032), achieved a lower mean mFIM score gain during rehabilitation (12.0 ± 9.7 vs. 14.6 ± 8.1; p = 0.03), had a higher education level (p = 0.003) and had a lower rate of chronic lung disease (p = 0.020) compared with patients whose 1-year mFIM score had deteriorated. After 1 year, only 21 patients (9%) were functionally independent in activities of daily living and only 19 (8.2%) were able to walk unassisted. Only 13 patients (5.6%) perceived that they had regained their former functional level. Conclusions: A substantial decline in functional ability of hip-fractured patients occurred 1 year postdischarge from rehabilitation. Healthcare providers should be aware of the necessity for a long-term postrehabilitation physical training program to prevent functional decline. Further efforts should be invested in motivating their patients to exercise. Implications for Rehabilitation A considerable decline in functional level occurs in elderly following hip fracture after discharge from post-acute rehabilitation program. Functional deterioration is more noticeable among patients who achieved higher functional performance during rehabilitation. To slow down functional decline, providing continuous physical training to hip-fractured elderly patients after discharge from rehabilitation is recommended.

Measuring rehabilitation outcome in post-acute hip fractured patients

Abstract Purpose: To present our experience in measuring rehabilitation achievements of post-acute hip fractured patients with the FIM instrument; assess its appropriateness as to the patients’ various disability levels and describe our experience with other measuring tools in patients less sensitive to changes in the FIM instrument. Methods: A retrospective study performed in a post-acute geriatric rehabilitation center. Three hundred and eighty-seven hip fractured patients admitted from January 2010 to May 2012 were included in this study. Patients were evaluated by the Functional Independence Measure (FIM), the Timed Get Up and Go (TUG) test and “bed to chair” transfer FIM parameter. The study population was divided into three disability groups according to their admission disability level: high (admission FIM score <40), moderate (FIM 40–79) and low (FIM ≥ 80). The Mann–Whitney U, ANOVA and Chi square tests analyzed the data. Results: The FIM instrument was found most sensitive in identifying functional change in patients with moderate disability. Low disability patients received more physio- and occupational-therapy treatment time, yet achieved a lower mean FIM score change compared to moderately disabled patients. The smallest real difference (SRD = 13) for the FIM score was achieved by 60% of patients with moderate disability. When assessed by the TUG test, most patients (94%) improved their score. The SRD% of 31% was achieved by 71.7% of the patients. Nineteen patients (35.9%) achieved a discharge score of <20 s. The high disability group achieved the lowest mean FIM score change. On admission, 52/64 (81%) patients required considerable help in transferring from bed to chair (FIM 1–2), however, upon discharge, the majority (69.2%) improved to the level of a one man transfer (FIM ≥ 3). Forty-one (64.1%) patients were discharged home. Conclusion: Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited; therefore, it is advisable to use an instrument most suitable to the patients’ disability level. Implication for Rehabilitation Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited. It is advisable to use an instrument most suitable to the patients’ disability level.

Medical treatment for urinary retention in rehabilitating elderly women: Is it necessary?

Background and aims: It is unclear whether medical treatment of elderly women with acute urinary retention in geriatric rehabilitation centers affects the recovery rate. The aims of the present study were to assess the rate of spontaneous recovery from urinary retention in elderly women in rehabilitation centers and to determine whether medical treatment with α adrenergic receptor blockers (α blockers) is effective in resumption of urination in this population. Methods: We surveyed 84 elderly women with urinary retention, admitted to a geriatric rehabilitation center between September 1998 and March 2000. Most had undergone orthopedic surgeries. Postvoiding urine residual (PVR) was measured 3 days after an acute episode of urinary retention. PVR of 250 mL and below was the desirable outcome. Patients with PVR over 250 mL were randomly assigned to two groups, placebo vs Doxazosin. Medication doses in both groups were increased every 3 days and catheterization was used until a desirable outcome was achieved. Results: Seventyeight out of the 84 patients entered the study, of whom 48 (62%) recovered spontaneously prior to initiation of medical treatment. Of the remaining 30, 7 patients dropped out and 23 began medical treatment. Twelve women recovered (a similar rate occurred in the placebo and Doxazosin groups), and 11 did not. The study was terminated due to the high rate of spontaneous recovery and because it became clear from the initial results that Doxazosin had no beneficial effect over placebo in the treatment of urinary retention. Diabetes and poor functional status were found to be prognostic factors for recovery failure. Conclusions: Most elderly women with urinary retention in geriatric rehabilitation centers will probably recover spontaneously. Alpha blockers appear to have no beneficial effect in this population.

Is routine screening for urinary tract infection in rehabilitation day-hospital elderly patients necessary?

It is not known whether all rehabilitation day-hospital patients need to be assessed for urinary tract infection (UTI). The aims of this study were to identify patients at high risk to develop UTI and to determine whether there was an association between the amount of post-void residual urine (PVR) and UTI. We surveyed 211 consecutive patients admitted to the day-hospital unit of a geriatric rehabilitation center between June 1998 and February 1999. The main diagnoses were stroke, orthopedic surgeries and deconditioning. Urine samples for general analysis and bacteriology were collected from each patient upon admission. PVR was measured using portable ultrasound. Telephone interviews were conducted with 141 patients, 3-11 months after the initial screening. The prevalence of UTI at admission was higher in women (P=0.007), and patients with decreased functional level (P=0.001). The incidence rate correlated with the functional level but not with gender or main diagnosis. The relative risk of dependent patients to develop UTI was 7.5 times higher than in independent patients. Significant amounts of PVR were equal in males and females. The relative risk of individuals with significant amounts of PVR to develop UTI was 1.63 times greater then those with negligible and moderate amounts of PVR. Gender, degree of functional level and main diagnosis had no effect on the relationship between PVR and UTI. We conclude that low functional level and significant amounts of PVR are risk factors for prevalence and incidence of UTI in elderly patients in a rehabilitation day-hospital. There is no need for routine urine analysis in every elderly patient admitted to rehabilitation day-hospitals, however, PVR measurements by portable ultrasound are valuable.