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Bladder management and the functional outcome of elderly ischemic stroke patients
Archives of Gerontology and Geriatrics 53 (2011) e125–e128
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Bladder management and the functional outcome of elderly ischemic stroke patients E.H. Mizrahi a,b,*, A. Waitzman a, M. Arad b, T. Blumstein c, A. Adunksy a,b a
Department of Geriatric Rehabilitation, Sheba Medical Center, Tel-Hashomer 52621, Israel The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel c The Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 March 2010 Received in revised form 13 July 2010 Accepted 15 July 2010 Available online 12 August 2010
The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 16.46 vs. 17.59 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = 0.407; p < 0.001) and age (beta = 0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Bladder management Urinary incontinence Outcome Prognosis Rehabilitation Stroke
1. Introduction Stroke is a major cause of global disability (Murray and Lopez, 1997a) and is the second leading cause of death (Murray and Lopez, 1997b). Problems of urinary incontinence and bladder management are common after stroke and affect as much as 60% of patients admitted to rehabilitation settings (Borrie et al., 1986; Barer, 1989; Gelber et al., 1993). Several predictors of poor functional recovery after acute stroke have been identified including age, urinary incontinence, cognitive impairment, delirium, and level of social support (Jongblood, 1986; Wilkinson et al., 1997; Rosenberg and Popelka, 2000; Sze et al., 2000; Wandel et al., 2000). In a large sample of older community-dwelling stroke patients, those with cognitive impairment and urinary inconti-
* Corresponding author at: Department of Geriatric Rehabilitation, Sheba Medical Center, Tel.:-Hashomer 52621, Israel. Tel.: +972 3 5303 398; fax: +972 3 5303 399. E-mail address: [email protected] (E.H. Mizrahi). 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.07.007
nence were more likely to suffer functional decline (Landi et al., 2006). Post-stroke bladder problems are associated with high rates of disability, mortality and institutional care (Anderson et al., 1994; Taub et al., 1994; Patel et al., 2001). In a systematic literature search designed in accordance with the Cochrane Collaboration Criteria, bladder management problems resulting in urinary incontinence were identified as predictors of future residence 6– 12 months after stroke onset (Meijer et al., 2003). Various causes underlay impaired bladder management; these include not only the common post-stroke hyperactive detrusor due to impaired upper motor neuron inhibition, but also conditions associated with hypoactive detrusor or even those with normal urodynamic patterns (Gelber et al., 1993). In addition, other motor, language and various stroke-specific cognitive deficits reduce the ability to recognize basal needs, resulting in different levels of impaired bladder management. While clinical subtypes of urinary incontinence have been identified (Pettersen and Wyller, 2006), little is known about the possible interrelations of bladder management level and functional outcome in terms of FIM scores. This is due to
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the fact that diagnosing urinary incontinence may be irrelevant to patient’s abilities to handle this situation successfully. The present study aimed to evaluate whether, and to what extent, level of bladder management care is interrelated to overall functional outcome of a large group of elderly stroke patients. This would assist in evaluating rehabilitation potential and possibly avoid unrealistic expectations of medical staff and caregivers.
2. Patients and methods The basic hypothesis was that Bladder management at admission to the rehabilitation setting could assist in predicting functional outcome at discharge among elderly patients with ischemic stroke. 2.1. Setting The geriatric rehabilitation department at our medical center is a 36-bed unit. The department utilizes an interdisciplinary team approach, where representative from geriatrics, physiotherapy, nursing, rehabilitation therapies (physical, occupational and speech), social services, and psychology meet twice a week to evaluate the status of each patient. During these meetings, a treatment plan is established and monitored with the purpose of coordinating and integrating staff activities, and promoting effective rehabilitation. The patients undergo a typical amount of 6 h per week of physical and occupational therapy. 2.2. Participants This retrospective study included 1187 patients aged 60–96 years with clinical stroke. Patients were consecutively admitted to our ward during a 7-year period, after a short stay in the departments of internal medicine or neurology. Primary inclusion criteria included age 60, evidence of ischemic stroke (first ever or recurrent) and stable medical status enabling active rehabilitation treatment. Stroke was diagnosed on the basis of clinical presentation of acute onset of focal neurological signs. CT or MRI scans were performed in all cases to confirm the presence and nature of ischemic stroke. Patients with residual brain damage due to infection, trauma or surgery and patients with space occupying lesions or hemorrhagic stroke were excluded, as well as those with a rehabilitation length of stay of less than seven days (assuming that the extent of rehabilitation in such a short period is limited). The presence of arterial hypertension, ischemic heart disease (manifested as stable or unstable anginal syndrome), atrial fibrillation, previous stroke, diabetes mellitus and hyperlipidemia were established by medical history obtained by interview and a complete physical examination. Patients’ cognitive status was assessed by the MMSE (Folstein et al., 1975), within one week after admission to the rehabilitation ward.
2.4. Data analysis Comparisons between the two groups of patients (Low-BMS and High-BMS) as defined above, with regards to demographic and clinical characteristics, were performed using t-tests, chi-square tests, and regression analyses to identify potential confounders. Separate analyses were performed as for total and motor discharge FIM scores, as well as for the corresponding gains. The final model incorporated bladder management scores and those variables that were found to be significantly related to FIM scores. The statistical significance level was set to p < 0.05. The SPSS for Windows software, version 11.0, was used for these analyses. 3. Results A total number of 1187 patients with acute stroke were admitted during the study period. 268 patients were excluded due to age < 60, hemorrhagic nature of stroke, missing data, rehabilitation stays shorter than 7 days and in-hospital death. The final analyses included the data of 919 consecutive patients with ischemic stroke admitted during a 7-year period. The clinico-demographic characteristics of these patients are shown in Table 1. There were no statistically significant differences between Low-BMS (n = 594) and High-BMS (n = 325) by gender, diabetes, hypertension, ischemic heart disease, Parkinson’s disease or a previous stroke. Age (p = 0.002), length of stay (p < 0.001) and MMSE scores (p < 0.001) emerged as the only statistically significant parameters differing between the two groups, respectively. High-BMS presented to rehabilitation with significantly higher total (p = 0.001) and motor (p < 0.001) FIM scores, compared with Low-BMS and were also discharged with higher total (p < 0.001) and motor (p < 0.001) FIM scores (Table 2). Total and motor FIM gains were somewhat higher in Low-BMS, but the differences were statistically non-significant, a fact that is attributed to higher initial scores of the independent group, allowing less room for improvement (ceiling effect). In addition, when analyzed by the different levels of bladder management, Table 1 Patients’ characteristics by bladder management at admission, mean S.D., n (%). Variable
All
High-BMS
Low-BMS
p*
Number Age, years Male gender Length of stay, days Diabetes mellitus Hypertension Ischemic heart disease Parkinson’s disease Previous stroke MMSE score
919 75.70 7.94 403 (44.1) 50.29 27.39 349 (37.9) 648 (70.5) 275 (22.9) 36 (3.9) 203 (22.1) 22.20 5.42
325 74.59 7.61 181 (55.9) 41.89 24.25 120 (36.9) 235 (72.3) 91 (28.0) 10 (27.8) 74 (22.8) 23.88 4.84
594 76.32 8.06 332 (55.9) 54.78 27.95 229 (38.6) 413 (69.5) 184 (31.0) 26 (72.2) 129 (21.7) 21.07 5.49
0.002 0.99 <0.001 0.62 0.37 0.34 0.33 0.71 <0.001
* p calculated using x2-test for categorical variables and Student’s t-test for comparisons of continuous variables.
2.3. Bladder management This includes complete intentional control of bladder and use of equipment or agents necessary for bladder control. FIM bladder scores of 5 points or less commonly identify dependent bladder management level (in need of a helper: 1—total assistance, 2— maximal assistance, 3—moderate assistance, 4—minimal contact assistance, 5—supervision or setup) while higher bladder scores (6—modified independence, 7—complete independence) identified dependent bladder management patients, needing no helper (Linacre et al., 1994). Bladder management level was determined throughout rehabilitation stay and changes of bladder management status were recorded.
Table 2 Functional characteristics by bladder management at admission, mean S.D. Variables
High-BMS
Low-BMS
p*
Number Admission total FIM Discharge total FIM Change in total FIM Admission motor FIM Discharge motor FIM Change in motor FIM
325 87.35 14.31 104.95 15.51 17.59 12.55 58.49 11.71 75.36 11.65 16.86 10.76
594 51.95 21.7 71.45 29.0 19.50 16.46 32.08 14.78 49.53 21.68 17.45 14.30
<0.001 <0.001 0.07 <0.001 <0.001 0.51
* p calculated using x2-test for categorical variables and Student’s t-test for comparisons of continuous variables.
E.H. Mizrahi et al. / Archives of Gerontology and Geriatrics 53 (2011) e125–e128
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High-BMS remained as such, with only 8 (2.5%) deteriorating to low-bladder scores. On the other hand, 178 (30%) out of all LowBMS at admission were classified as having high-bladder scores upon discharge, while the other 416 (70%) remained as Low-BMS. With regards to discharge destination, a key indicator of rehabilitation success, there were marked differences between the groups: 809 patients were discharged to their pre-stroke living arrangement (308 High-BMS and 501 Low-BMS (94.7% vs. 84.3%, respectively, p < 0.01). Other 110 patients were transferred to various nursing homes and downstream-care facilities. 4. Discussion
Fig. 1. The correlation of mean total FIM at discharge with bladder management at admission (r = 0.69; p < 0.001).
statistically significant correlations were found with mean total FIM at discharge (Pearson’s correlation, r = 0.69, p < 0.001) (Fig. 1). No significant association was found between FIM gain at discharge and bladder management at admission (Pearson’s correlation, r = 0.02; p = 0.65). Since the High-BMS defined a younger age group, with a better cognitive status and a better functional starting point, we performed multiple regression analyses to test the net effect of predictors on FIM scores at discharge. These showed (Table 3) that total FIM at discharge was independently, and inversely, associated with Low-BMSs at admission (beta = 0.407; p < 0.001) and advanced age (beta = 0.127; p < 0.001). A higher MMSE score at admission (beta = 0.334; p < 0.001) emerged as an independent predictor of higher total FIM scores at discharge. However, LowBMS at admission did predict higher total FIM gains upon discharge (beta = 0.166, p < 0.001) (Table 4). Patients’ bladder management status tended to remain unchanged throughout their episode of care. 317 (97.5%) of
Table 3 Analysis of factors predicting total FIM at discharge. Variables Bladder management at admission Age Gender Ischemic heart disease Arterial hypertension Diabetes mellitus Previous stroke Parkinson’s disease MMSE *
Beta 0.407 0.127 0.016 0.003 0.013 0.02 0.03 0.03 0.334
*
p
<0.001 <0.001 0.61 0.92 0.68 0.52 0.23 0.21 <0.001
Linear regression analysis.
Table 4 Analysis of factors predicting total FIM gain at discharge. Variables Bladder management at admission Age Gender Ischemic heart disease Arterial hypertension Diabetes mellitus Previous stroke Parkinson’s disease MMSE *
Linear regression analysis.
Beta 0.166 0.187 0.021 0.033 0.02 0.01 0.07 0.06 0.11
*
p
<0.001 <0.001 0.6 0.38 0.6 0.98 0.08 0.11 0.009
The present study analyzed bladder management levels rather than post-stroke urinary incontinence. This is a different way of looking at bladder function that demonstrates the complexity of evaluating the many daily practical difficulties faced by patients and their caregivers, and the accompanying distress, frustration and embarrassment. It represents a different attitude compared with clinically diagnosed subtypes of post-stroke incontinence as assessed upon clinical or urodynamic grounds (Pettersen and Wyller, 2006). This is important since management of clinical syndromes do not necessarily reflect practical issues associated with the difficulties of bladder management. The main finding of this study is that overall functional outcome of elderly stroke patients is better in those with higher admission bladder management scores. Both total and motor FIM scores at discharge, but not FIM gains, were higher in such patients. These results are complementary to previous studies (Ween et al., 1996; Gross, 2000) on the association of urinary incontinence and poor functional outcome, showing that bladder management status predicts higher FIM scores not only when considered at discharge (Gross, 2000), but also upon admission to a rehabilitation setting. The study also underscores the fact that Low-BMS achieves somewhat better gain compared with High-BMS. In addition, we have a positive correlation of the different bladder management levels and FIM scores, with low-bladder scores predicting lower discharge total FIM and total FIM gain, vice versa. This association was independent of a large number of prognostic factors, but remained dependent upon cognitive state and age, known to play a major prognostic role in stroke rehabilitation (Heruti et al., 2002; Hinkle, 2006). In addition, the results extend this observation to a sample of older patients undergoing inpatient rehabilitation course. Overall, these findings suggest significantly adverse functional outcome of patients with low-bladder scores at admission. This adverse outcome is also reflected by another key indicator of rehabilitation success relating to high rates of post-rehabilitation discharge to downstream-care facilities, as recently shown by Wilson et al. (2008). Possible limitations of our study result from its retrospective nature and design. Despite a careful adjustment made for important confounders, still other could have been considered, including the pre-stroke urine control status or data of urine control medications. Moreover, generalizability to other populations rather than elderly stroke patients may be limited and longitudinal follow-up data are needed to better understand the interrelations between urine control and function in later stages. Finally, the study may be criticized for non using a Rasch analysis; linear or interval FIM analyses are still popular and have been used in most of the FIM outcome studies to monitor changes during inpatient rehabilitation, simply because most FIM data do seem to conform closely enough to conventional models. Despite these limitations, the present study is advantageous in the sense that it comprised a large sample of patients, all of whom underwent a similar rehabilitation program in a dedicated ward designed to
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treat elderly stroke patients, thus decreasing any degree of selection bias and increasing the validity of the study. We conclude that functional outcome of elderly patients suffering acute ischemic stroke is more favorable for patients presenting with higher bladder management scores at admission. However, low-bladder scores should not be held as adversely affecting the odds of achieving functional gain during rehabilitation. Clinical trials are warranted to study possible effects of different interventions for bladder management on functional outcomes. Conflict of interest statement None. References Anderson, C.S., Jamrozik, K.D., Broadhurst, R.J., Stewart-Wynne, E.G., 1994. Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study. Stroke 25, 1935–1944. Barer, D.H., 1989. Continence after stroke: useful predictor or goal of therapy? Age Ageing 18, 183–191. Borrie, M.J., Campbell, A.J., Caradoc-Davies, T.H., Spears, G.F.S., 1986. Urinary incontinence after stroke: a prospective study. Age Ageing 15, 177–181. Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. ‘‘Mini-Mental State’’. A practical method for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 12, 189–198. Gelber, D.A., Good, D.C., Laven, U., Verhulst, S.J., 1993. Causes of urinary incontinence after acute hemispheric stroke. Stroke 24, 378–382. Gross, C.J., 2000. Urinary incontinence and stroke outcomes. Arch. Phys. Med. Rehabil. 81, 22–27. Heruti, R.J., Lusky, A., Dankner, R., Ring, H., Dolgopiat, M., Barell, V., Levenkrohn, S., Adunsky, A., 2002. Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome. Arch. Phys. Med. Rehabil. 83, 742–749. Hinkle, J.L., 2006. Variables explaining functional recovery following motor stroke. J. Neurosci. Nurs. 38, 6–12.
Jongblood, L., 1986. Prediction of function after stroke: a critical view. Stroke 17, 765–776. Landi, F., Onder, G., Cesari, M., Zamboni, V., Russo, A., Barillaro, C., Bernabei, R., Silvernet-HC Study Group, 2006. Functional decline in frail community-dwelling stroke patients. Eur. J. Neurol. 13, 17–23. Linacre, J.M., Heinemann, A.W., Wright, B.D., Granger, C.V., Hamilton, B.B., 1994. The structure and stability of the functional independence measure. Arch. Phys. Med. Rehabil. 75, 127–132. Meijer, R., Ihnenfeldt, D.S., De Groot, I.J., Van Limbeek, J., Vermeulen, M., De Haan, R.J., 2003. Prognostic factors for ambulation and activities of daily living in the subacute phase after stroke. A systematic review of the literature. Clin. Rehabil. 17, 119–129. Murray, C.J.L., Lopez, A.D., 1997a. Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet 349, 1436–1442. Murray, C.J.L., Lopez, A.D., 1997b. Mortality by cause for 8 regions of the world: global burden of disease study. Lancet 349, 1269–1276. Patel, M., Coshall, C., Rudd, A.G., Wolfe, C.D., 2001. Natural history and effects on 2year outcomes of urinary incontinence after stroke. Stroke 32, 122–127. Pettersen, R., Wyller, T.B., 2006. Prognostic significance of micturation disturbances after acute stroke. J. Am. Geriatr. Soc. 54, 1878–1884. Rosenberg, C.H., Popelka, G.M., 2000. Post-stroke rehabilitation. A review of the guidelines for patient management. Geriatrics 55, 75–81. Sze, K.H., Wong, E., Or, K.H., Lum, C.M., Woo, J., 2000. Factors predicting stroke disability at discharge: a study of 793 Chinese. Arch. Phys. Med. Rehabil. 81, 876–880. Taub, N.A., Wolfe, C.D.A., Richardson, E., Burney, P.G., 1994. Predicting the disability of first-time stroke sufferers at 1 year, 12-month follow-up of a populationbased cohort in southeast England. Stroke 25, 352–357. Wandel, A., Jorgensen, H.S., Nakayama, H., Raaschou, H.O., Olsen, T.S., 2000. Prediction of walking function in stroke patients with initial lower extremity paralysis: the Copenhagen Stroke Study. Arch. Phys. Med. Rehabil. 81, 736– 738. Ween, J.E., Alexander, M.P., D’Esposito, M., Roberst, M., 1996. Incontinence after stroke in a rehabilitation setting: outcome associations and predictive factors. Neurology 47, 659–663. Wilkinson, P.R., Wolfe, C.D., Warburton, F.G., Rudd, A.G., Howard, R.S., Ross-Russell, R.W., Beech, R.R., 1997. A long term follow-up of stroke patients. Stroke 28, 507– 512. Wilson, D., Lowe, D., Hoffman, A., Rudd, A., Wagg, A., 2008. Urinary incontinence in stroke: results from the UK National Sentinel Audits of Stroke 1998–2004. Age Ageing 37, 542–546.
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Bladder management and the functional outcome of elderly ischemic stroke patients E.H. Mizrahi a,b,*, A. Waitzman a, M. Arad b, T. Blumstein c, A. Adunksy a,b a
Department of Geriatric Rehabilitation, Sheba Medical Center, Tel-Hashomer 52621, Israel The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel c The Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 March 2010 Received in revised form 13 July 2010 Accepted 15 July 2010 Available online 12 August 2010
The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 16.46 vs. 17.59 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = 0.407; p < 0.001) and age (beta = 0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Bladder management Urinary incontinence Outcome Prognosis Rehabilitation Stroke
1. Introduction Stroke is a major cause of global disability (Murray and Lopez, 1997a) and is the second leading cause of death (Murray and Lopez, 1997b). Problems of urinary incontinence and bladder management are common after stroke and affect as much as 60% of patients admitted to rehabilitation settings (Borrie et al., 1986; Barer, 1989; Gelber et al., 1993). Several predictors of poor functional recovery after acute stroke have been identified including age, urinary incontinence, cognitive impairment, delirium, and level of social support (Jongblood, 1986; Wilkinson et al., 1997; Rosenberg and Popelka, 2000; Sze et al., 2000; Wandel et al., 2000). In a large sample of older community-dwelling stroke patients, those with cognitive impairment and urinary inconti-
* Corresponding author at: Department of Geriatric Rehabilitation, Sheba Medical Center, Tel.:-Hashomer 52621, Israel. Tel.: +972 3 5303 398; fax: +972 3 5303 399. E-mail address: [email protected] (E.H. Mizrahi). 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.07.007
nence were more likely to suffer functional decline (Landi et al., 2006). Post-stroke bladder problems are associated with high rates of disability, mortality and institutional care (Anderson et al., 1994; Taub et al., 1994; Patel et al., 2001). In a systematic literature search designed in accordance with the Cochrane Collaboration Criteria, bladder management problems resulting in urinary incontinence were identified as predictors of future residence 6– 12 months after stroke onset (Meijer et al., 2003). Various causes underlay impaired bladder management; these include not only the common post-stroke hyperactive detrusor due to impaired upper motor neuron inhibition, but also conditions associated with hypoactive detrusor or even those with normal urodynamic patterns (Gelber et al., 1993). In addition, other motor, language and various stroke-specific cognitive deficits reduce the ability to recognize basal needs, resulting in different levels of impaired bladder management. While clinical subtypes of urinary incontinence have been identified (Pettersen and Wyller, 2006), little is known about the possible interrelations of bladder management level and functional outcome in terms of FIM scores. This is due to
e126
E.H. Mizrahi et al. / Archives of Gerontology and Geriatrics 53 (2011) e125–e128
the fact that diagnosing urinary incontinence may be irrelevant to patient’s abilities to handle this situation successfully. The present study aimed to evaluate whether, and to what extent, level of bladder management care is interrelated to overall functional outcome of a large group of elderly stroke patients. This would assist in evaluating rehabilitation potential and possibly avoid unrealistic expectations of medical staff and caregivers.
2. Patients and methods The basic hypothesis was that Bladder management at admission to the rehabilitation setting could assist in predicting functional outcome at discharge among elderly patients with ischemic stroke. 2.1. Setting The geriatric rehabilitation department at our medical center is a 36-bed unit. The department utilizes an interdisciplinary team approach, where representative from geriatrics, physiotherapy, nursing, rehabilitation therapies (physical, occupational and speech), social services, and psychology meet twice a week to evaluate the status of each patient. During these meetings, a treatment plan is established and monitored with the purpose of coordinating and integrating staff activities, and promoting effective rehabilitation. The patients undergo a typical amount of 6 h per week of physical and occupational therapy. 2.2. Participants This retrospective study included 1187 patients aged 60–96 years with clinical stroke. Patients were consecutively admitted to our ward during a 7-year period, after a short stay in the departments of internal medicine or neurology. Primary inclusion criteria included age 60, evidence of ischemic stroke (first ever or recurrent) and stable medical status enabling active rehabilitation treatment. Stroke was diagnosed on the basis of clinical presentation of acute onset of focal neurological signs. CT or MRI scans were performed in all cases to confirm the presence and nature of ischemic stroke. Patients with residual brain damage due to infection, trauma or surgery and patients with space occupying lesions or hemorrhagic stroke were excluded, as well as those with a rehabilitation length of stay of less than seven days (assuming that the extent of rehabilitation in such a short period is limited). The presence of arterial hypertension, ischemic heart disease (manifested as stable or unstable anginal syndrome), atrial fibrillation, previous stroke, diabetes mellitus and hyperlipidemia were established by medical history obtained by interview and a complete physical examination. Patients’ cognitive status was assessed by the MMSE (Folstein et al., 1975), within one week after admission to the rehabilitation ward.
2.4. Data analysis Comparisons between the two groups of patients (Low-BMS and High-BMS) as defined above, with regards to demographic and clinical characteristics, were performed using t-tests, chi-square tests, and regression analyses to identify potential confounders. Separate analyses were performed as for total and motor discharge FIM scores, as well as for the corresponding gains. The final model incorporated bladder management scores and those variables that were found to be significantly related to FIM scores. The statistical significance level was set to p < 0.05. The SPSS for Windows software, version 11.0, was used for these analyses. 3. Results A total number of 1187 patients with acute stroke were admitted during the study period. 268 patients were excluded due to age < 60, hemorrhagic nature of stroke, missing data, rehabilitation stays shorter than 7 days and in-hospital death. The final analyses included the data of 919 consecutive patients with ischemic stroke admitted during a 7-year period. The clinico-demographic characteristics of these patients are shown in Table 1. There were no statistically significant differences between Low-BMS (n = 594) and High-BMS (n = 325) by gender, diabetes, hypertension, ischemic heart disease, Parkinson’s disease or a previous stroke. Age (p = 0.002), length of stay (p < 0.001) and MMSE scores (p < 0.001) emerged as the only statistically significant parameters differing between the two groups, respectively. High-BMS presented to rehabilitation with significantly higher total (p = 0.001) and motor (p < 0.001) FIM scores, compared with Low-BMS and were also discharged with higher total (p < 0.001) and motor (p < 0.001) FIM scores (Table 2). Total and motor FIM gains were somewhat higher in Low-BMS, but the differences were statistically non-significant, a fact that is attributed to higher initial scores of the independent group, allowing less room for improvement (ceiling effect). In addition, when analyzed by the different levels of bladder management, Table 1 Patients’ characteristics by bladder management at admission, mean S.D., n (%). Variable
All
High-BMS
Low-BMS
p*
Number Age, years Male gender Length of stay, days Diabetes mellitus Hypertension Ischemic heart disease Parkinson’s disease Previous stroke MMSE score
919 75.70 7.94 403 (44.1) 50.29 27.39 349 (37.9) 648 (70.5) 275 (22.9) 36 (3.9) 203 (22.1) 22.20 5.42
325 74.59 7.61 181 (55.9) 41.89 24.25 120 (36.9) 235 (72.3) 91 (28.0) 10 (27.8) 74 (22.8) 23.88 4.84
594 76.32 8.06 332 (55.9) 54.78 27.95 229 (38.6) 413 (69.5) 184 (31.0) 26 (72.2) 129 (21.7) 21.07 5.49
0.002 0.99 <0.001 0.62 0.37 0.34 0.33 0.71 <0.001
* p calculated using x2-test for categorical variables and Student’s t-test for comparisons of continuous variables.
2.3. Bladder management This includes complete intentional control of bladder and use of equipment or agents necessary for bladder control. FIM bladder scores of 5 points or less commonly identify dependent bladder management level (in need of a helper: 1—total assistance, 2— maximal assistance, 3—moderate assistance, 4—minimal contact assistance, 5—supervision or setup) while higher bladder scores (6—modified independence, 7—complete independence) identified dependent bladder management patients, needing no helper (Linacre et al., 1994). Bladder management level was determined throughout rehabilitation stay and changes of bladder management status were recorded.
Table 2 Functional characteristics by bladder management at admission, mean S.D. Variables
High-BMS
Low-BMS
p*
Number Admission total FIM Discharge total FIM Change in total FIM Admission motor FIM Discharge motor FIM Change in motor FIM
325 87.35 14.31 104.95 15.51 17.59 12.55 58.49 11.71 75.36 11.65 16.86 10.76
594 51.95 21.7 71.45 29.0 19.50 16.46 32.08 14.78 49.53 21.68 17.45 14.30
<0.001 <0.001 0.07 <0.001 <0.001 0.51
* p calculated using x2-test for categorical variables and Student’s t-test for comparisons of continuous variables.
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High-BMS remained as such, with only 8 (2.5%) deteriorating to low-bladder scores. On the other hand, 178 (30%) out of all LowBMS at admission were classified as having high-bladder scores upon discharge, while the other 416 (70%) remained as Low-BMS. With regards to discharge destination, a key indicator of rehabilitation success, there were marked differences between the groups: 809 patients were discharged to their pre-stroke living arrangement (308 High-BMS and 501 Low-BMS (94.7% vs. 84.3%, respectively, p < 0.01). Other 110 patients were transferred to various nursing homes and downstream-care facilities. 4. Discussion
Fig. 1. The correlation of mean total FIM at discharge with bladder management at admission (r = 0.69; p < 0.001).
statistically significant correlations were found with mean total FIM at discharge (Pearson’s correlation, r = 0.69, p < 0.001) (Fig. 1). No significant association was found between FIM gain at discharge and bladder management at admission (Pearson’s correlation, r = 0.02; p = 0.65). Since the High-BMS defined a younger age group, with a better cognitive status and a better functional starting point, we performed multiple regression analyses to test the net effect of predictors on FIM scores at discharge. These showed (Table 3) that total FIM at discharge was independently, and inversely, associated with Low-BMSs at admission (beta = 0.407; p < 0.001) and advanced age (beta = 0.127; p < 0.001). A higher MMSE score at admission (beta = 0.334; p < 0.001) emerged as an independent predictor of higher total FIM scores at discharge. However, LowBMS at admission did predict higher total FIM gains upon discharge (beta = 0.166, p < 0.001) (Table 4). Patients’ bladder management status tended to remain unchanged throughout their episode of care. 317 (97.5%) of
Table 3 Analysis of factors predicting total FIM at discharge. Variables Bladder management at admission Age Gender Ischemic heart disease Arterial hypertension Diabetes mellitus Previous stroke Parkinson’s disease MMSE *
Beta 0.407 0.127 0.016 0.003 0.013 0.02 0.03 0.03 0.334
*
p
<0.001 <0.001 0.61 0.92 0.68 0.52 0.23 0.21 <0.001
Linear regression analysis.
Table 4 Analysis of factors predicting total FIM gain at discharge. Variables Bladder management at admission Age Gender Ischemic heart disease Arterial hypertension Diabetes mellitus Previous stroke Parkinson’s disease MMSE *
Linear regression analysis.
Beta 0.166 0.187 0.021 0.033 0.02 0.01 0.07 0.06 0.11
*
p
<0.001 <0.001 0.6 0.38 0.6 0.98 0.08 0.11 0.009
The present study analyzed bladder management levels rather than post-stroke urinary incontinence. This is a different way of looking at bladder function that demonstrates the complexity of evaluating the many daily practical difficulties faced by patients and their caregivers, and the accompanying distress, frustration and embarrassment. It represents a different attitude compared with clinically diagnosed subtypes of post-stroke incontinence as assessed upon clinical or urodynamic grounds (Pettersen and Wyller, 2006). This is important since management of clinical syndromes do not necessarily reflect practical issues associated with the difficulties of bladder management. The main finding of this study is that overall functional outcome of elderly stroke patients is better in those with higher admission bladder management scores. Both total and motor FIM scores at discharge, but not FIM gains, were higher in such patients. These results are complementary to previous studies (Ween et al., 1996; Gross, 2000) on the association of urinary incontinence and poor functional outcome, showing that bladder management status predicts higher FIM scores not only when considered at discharge (Gross, 2000), but also upon admission to a rehabilitation setting. The study also underscores the fact that Low-BMS achieves somewhat better gain compared with High-BMS. In addition, we have a positive correlation of the different bladder management levels and FIM scores, with low-bladder scores predicting lower discharge total FIM and total FIM gain, vice versa. This association was independent of a large number of prognostic factors, but remained dependent upon cognitive state and age, known to play a major prognostic role in stroke rehabilitation (Heruti et al., 2002; Hinkle, 2006). In addition, the results extend this observation to a sample of older patients undergoing inpatient rehabilitation course. Overall, these findings suggest significantly adverse functional outcome of patients with low-bladder scores at admission. This adverse outcome is also reflected by another key indicator of rehabilitation success relating to high rates of post-rehabilitation discharge to downstream-care facilities, as recently shown by Wilson et al. (2008). Possible limitations of our study result from its retrospective nature and design. Despite a careful adjustment made for important confounders, still other could have been considered, including the pre-stroke urine control status or data of urine control medications. Moreover, generalizability to other populations rather than elderly stroke patients may be limited and longitudinal follow-up data are needed to better understand the interrelations between urine control and function in later stages. Finally, the study may be criticized for non using a Rasch analysis; linear or interval FIM analyses are still popular and have been used in most of the FIM outcome studies to monitor changes during inpatient rehabilitation, simply because most FIM data do seem to conform closely enough to conventional models. Despite these limitations, the present study is advantageous in the sense that it comprised a large sample of patients, all of whom underwent a similar rehabilitation program in a dedicated ward designed to
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treat elderly stroke patients, thus decreasing any degree of selection bias and increasing the validity of the study. We conclude that functional outcome of elderly patients suffering acute ischemic stroke is more favorable for patients presenting with higher bladder management scores at admission. However, low-bladder scores should not be held as adversely affecting the odds of achieving functional gain during rehabilitation. Clinical trials are warranted to study possible effects of different interventions for bladder management on functional outcomes. Conflict of interest statement None. References Anderson, C.S., Jamrozik, K.D., Broadhurst, R.J., Stewart-Wynne, E.G., 1994. Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study. Stroke 25, 1935–1944. Barer, D.H., 1989. Continence after stroke: useful predictor or goal of therapy? Age Ageing 18, 183–191. Borrie, M.J., Campbell, A.J., Caradoc-Davies, T.H., Spears, G.F.S., 1986. Urinary incontinence after stroke: a prospective study. Age Ageing 15, 177–181. Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. ‘‘Mini-Mental State’’. A practical method for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 12, 189–198. Gelber, D.A., Good, D.C., Laven, U., Verhulst, S.J., 1993. Causes of urinary incontinence after acute hemispheric stroke. Stroke 24, 378–382. Gross, C.J., 2000. Urinary incontinence and stroke outcomes. Arch. Phys. Med. Rehabil. 81, 22–27. Heruti, R.J., Lusky, A., Dankner, R., Ring, H., Dolgopiat, M., Barell, V., Levenkrohn, S., Adunsky, A., 2002. Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome. Arch. Phys. Med. Rehabil. 83, 742–749. Hinkle, J.L., 2006. Variables explaining functional recovery following motor stroke. J. Neurosci. Nurs. 38, 6–12.
Jongblood, L., 1986. Prediction of function after stroke: a critical view. Stroke 17, 765–776. Landi, F., Onder, G., Cesari, M., Zamboni, V., Russo, A., Barillaro, C., Bernabei, R., Silvernet-HC Study Group, 2006. Functional decline in frail community-dwelling stroke patients. Eur. J. Neurol. 13, 17–23. Linacre, J.M., Heinemann, A.W., Wright, B.D., Granger, C.V., Hamilton, B.B., 1994. The structure and stability of the functional independence measure. Arch. Phys. Med. Rehabil. 75, 127–132. Meijer, R., Ihnenfeldt, D.S., De Groot, I.J., Van Limbeek, J., Vermeulen, M., De Haan, R.J., 2003. Prognostic factors for ambulation and activities of daily living in the subacute phase after stroke. A systematic review of the literature. Clin. Rehabil. 17, 119–129. Murray, C.J.L., Lopez, A.D., 1997a. Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet 349, 1436–1442. Murray, C.J.L., Lopez, A.D., 1997b. Mortality by cause for 8 regions of the world: global burden of disease study. Lancet 349, 1269–1276. Patel, M., Coshall, C., Rudd, A.G., Wolfe, C.D., 2001. Natural history and effects on 2year outcomes of urinary incontinence after stroke. Stroke 32, 122–127. Pettersen, R., Wyller, T.B., 2006. Prognostic significance of micturation disturbances after acute stroke. J. Am. Geriatr. Soc. 54, 1878–1884. Rosenberg, C.H., Popelka, G.M., 2000. Post-stroke rehabilitation. A review of the guidelines for patient management. Geriatrics 55, 75–81. Sze, K.H., Wong, E., Or, K.H., Lum, C.M., Woo, J., 2000. Factors predicting stroke disability at discharge: a study of 793 Chinese. Arch. Phys. Med. Rehabil. 81, 876–880. Taub, N.A., Wolfe, C.D.A., Richardson, E., Burney, P.G., 1994. Predicting the disability of first-time stroke sufferers at 1 year, 12-month follow-up of a populationbased cohort in southeast England. Stroke 25, 352–357. Wandel, A., Jorgensen, H.S., Nakayama, H., Raaschou, H.O., Olsen, T.S., 2000. Prediction of walking function in stroke patients with initial lower extremity paralysis: the Copenhagen Stroke Study. Arch. Phys. Med. Rehabil. 81, 736– 738. Ween, J.E., Alexander, M.P., D’Esposito, M., Roberst, M., 1996. Incontinence after stroke in a rehabilitation setting: outcome associations and predictive factors. Neurology 47, 659–663. Wilkinson, P.R., Wolfe, C.D., Warburton, F.G., Rudd, A.G., Howard, R.S., Ross-Russell, R.W., Beech, R.R., 1997. A long term follow-up of stroke patients. Stroke 28, 507– 512. Wilson, D., Lowe, D., Hoffman, A., Rudd, A., Wagg, A., 2008. Urinary incontinence in stroke: results from the UK National Sentinel Audits of Stroke 1998–2004. Age Ageing 37, 542–546.