Geriatric rehabilitation

Handbook of Clinical Neurology, Vol. 167 (3rd series) Geriatric Neurology S.T. DeKosky and S. Asthana, Editors https://doi.org/10.1016/B978-0-12-804766-8.00029-7 Copyright © 2019 Elsevier B.V. All rights reserved

Chapter 29

Geriatric rehabilitation GREGORY T. ROBBINS1,2,3,4,5, ERIKA YIH1,2,3,4,5, RAYMOND CHOU1,2,3,4,5, ALEX I. GUNDERSEN1,2,3,4,5, JEFFREY C. SCHNIEDER1,2,3,4,5, JONATHAN F. BEAN1,2,3,4,5, AND ROSS D. ZAFONTE1,2,3,4,5* 1 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States 2

Massachusetts General Hospital, Boston, MA, United States

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Brigham and Women’s Hospital, Boston, MA, United States

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Boston Veterans Administration, Boston, MA, United States 5

Harvard Medical School, Boston, MA, United States

Abstract Rehabilitation of elderly persons is accompanied by unique challenges, as the physiologic changes with aging may be compounded by a multitude of psychologic, social, and genetic factors. In this chapter we present an overview of the impairments that develop with aging. We discuss factors to consider when evaluating a patient with functional complaints and opportunities for treatment. We provide an overview of common injuries encountered in the elderly, prognostication, and general strategies employed for rehabilitation. New treatment options and areas of ongoing research are also discussed.

INTRODUCTION Aging population As human life expectancy increases, societies and healthcare systems across the globe must adapt to an aging population. Although only 8.6% of the world’s population is over the age of 65, this proportion is much larger for affluent nations (Central Intelligence Agency (United States), 2016). At the higher end of this variation, 28.4% of Japan’s population falls within this age group, while the corresponding percentages for the United States, Canada, and members of the European Union range from 12% to 22% (Central Intelligence Agency (United States), 2016). By 2060, 40% of Japan’s population is expected to be older than 65 (National Institute of Population and Social Security Research (Japan), 2012). As discussed in the following sections, aging is accompanied by a variety of processes that can negatively impact one’s function and quality of life.

Frailty Aging is associated with a decrement in a person’s ability to recover from significant stressors, a characteristic referred to as “frailty” (Walston et al., 2006). Frailty progresses at different rates for different individuals; therefore, this condition is identified by a combination of clinical characteristics. The frailty phenotype has been defined by Fried et al. to include at least three of the following: (1) greater than 4.5 kg weight loss over the last year, (2) self-reported exhaustion, (3) grip strength weakness, (4) slow walking speed, and (5) low physical activity (Fried et al., 2001). Within the Cardiovascular Health Study Collaborative Research Group cohort, the frailty phenotype was independently associated with falls, worsening disability, hospitalization, and death after adjusting for baseline disability, comorbidity, and various social factors. A prefrail phenotype was also identified, in which patients with 1–2 of the above criteria demonstrated an increased risk of becoming frail.

*Correspondence to: Ross D. Zafonte, D.O., Ida S. Charlton Professor and Chair, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, United States. Tel: +1-617-952-5227, E-mail: [email protected]

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The frailty phenotype has been validated by multiple research groups and is associated with a variety of socioeconomic, behavioral, and other clinical characteristics (Fried et al., 2001; Woods et al., 2005; Cawthon et al., 2007; Kiely et al., 2009; Theou et al., 2013; Lee et al., 2016). Some of these include lower education, lower income, unmarried, female gender, underweight, obese, African American race, presence of comorbidities, and premorbid disability. In the English Longitudinal Study of Ageing cohort, neuroticism was associated with an increased rate of progression of frailty over a 10-year period, whereas conscientiousness and extroversion were associated with a protective effect (Gale et al., 2017). Systematic screening for frailty in the elderly population is an important endeavor to prevent functional decline and hospitalizations. A variety of scales have been developed for this purpose including the FRAIL scale, the Groningen Frailty Indicator, the Tillburg Frailty Indicator, the Edmonton Frail Scale, and the Frailty Index, the last of which uses a cumulative deficit model, rather than a set of criteria (Theou et al., 2013; Orkaby et al., 2017).

Sarcopenia Sarcopenia is an important contributor to the frailty phenotype and is defined as diffuse muscular atrophy or loss of muscle mass resulting in loss of function and strength (Marty et al., 2017). Typically, 30%–50% of lean muscle mass is lost from the ages of 50 to 80, with an annual rate of 3% after the age of 60 (Marty et al., 2017). The overall reported prevalence of sarcopenia among the elderly ranges from 6% to 22% and varies across healthcare settings (Dent et al., 2018). Sarcopenia is associated with increased risk of falls, poor rehabilitation outcomes, and mortality (Sánchez-Rodríguez et al., 2014). Behavioral factors contributing to sarcopenia include muscle disuse and decreased nutrition, while biologic factors intrinsic to aging include decreased testosterone, decreased growth hormone, chronic inflammation, and decreased myostatin (Marty et al., 2017). Genetic susceptibility to sarcopenia has been evidenced by the association of single nucleotide polymorphisms within various genes related to the function of nerves and muscle (Ben-Avraham et al., 2017; Marty et al., 2017; Willems et al., 2017; Zillikens et al., 2017). Specific rehabilitation diagnoses associated with sarcopenia include stroke, hip/lower extremity fracture, and hospital-associated deconditioning (Sánchez-Rodríguez et al., 2014). Several diagnostic criteria for sarcopenia have been published by several groups, including the International Clinical Practice Guidelines for Sarcopenia (ICFSR), International Working Group on Sarcopenia, Special interest Groups, Asian Working Group on Sarcopenia, European Working Group on Sarcopenia in Older

People, and the Foundation for the National Institutes of Health (Muscaritoli et al., 2010; Fielding et al., 2011; Chen et al., 2014; Studenski et al., 2014; Dent et al., 2018). The requirements shared among these criteria include (1) loss of muscle mass on a DEXA scan and (2) decrease in a physical performance measure such as gait speed, Short Physical Performance Battery (SPPB), or handgrip strength (Marty et al., 2017). Treatment is centered primarily on resistance training and nutritional supplementation (often including the addition of amino acids) (Wakabayashi and Sakuma, 2014). Decreased bed rest time and early mobilization are essential. Selective androgen receptor modulators (SERMs) and myostatin inhibitors are currently in the trial phase as potential treatment options.

Sensory deficits Aging is associated with the development of sensory impairments, especially presbycusis and visual impairment. Among persons over the age of 65, 43% reported difficulty hearing (Ries, 1994). The pathophysiology of presbycusis is multifactorial, with both central and peripheral contributions (Gates and Mills, 2005). Agerelated changes to the visual system include decrements in visual acuity, dark adaptation, contrast sensitivity, and visual processing speed (Whitson et al., 2018). These changes are independent of conspicuous pathology such as glaucoma, macular degeneration, or cataracts. In addition to the direct functional limitations arising from these changes, sensory impairments often have a complex relationship with cognitive impairment and mental health, in which disturbances to one of these domains may compound others (Whitson et al., 2018). Presbycusis, for example, is associated with a 30%–40% increase in the rate of cognitive decline (the direction of causality is not firmly established), while cognitive impairment may lead to challenges in separating speech from background noise (Farias et al., 2009; Sandi, 2013; Whitson et al., 2018). Decrement in one type of sensory input may also lead to increased reliance upon another input, such as increased use of visual fixation for balance in the setting of impaired proprioception or reliance upon visual cues in the setting of hearing impairment (Whitson et al., 2018). Screening for sensory impairments and the use of appropriate adaptive equipment are important for optimizing functional outcomes in the geriatric population.

Cognitive decline, dementia, and delirium Although dementia is discussed in greater detail in other chapters, aging is the most significant risk factor for cognitive decline and Alzheimer’s disease (AD) (Holsinger et al., 2007). Importantly, accelerated cognitive decline

GERIATRIC REHABILITATION often occurs in patients following episodes of hospital delirium (Fong et al., 2009). Delirium is defined as an acute disturbance of consciousness, accompanied by changes in cognition, in the presence of a medical cause that could account for these changes (American Psychiatric Association, 2013). Delirium can be triggered by a variety of factors including surgery, sedating medications, disruption of sleep–wake cycles, infections, constipation, urinary retention, invasive lines, or pain. The use of restraints and antipsychotics may paradoxically worsen agitation behaviors. In addition, it is important to consider more serious causes such as seizures or CNS injury. Although an assessment by an experienced clinician using DSM V criteria is the gold standard method to diagnose delirium, screening tools such as the Richmond Agitation-Sedation Scale (RASS), Confusion Assessment Method (CAM), or 4A’s Test (4AT) may be useful in the acute hospital setting (Oh et al., 2017). In addition to treatment of reversible factors, protocols for early mobilization in the ICU with weaning from sedation have been shown to reduce hospital delirium days (Schweickert et al., 2009). Mobilization of critically ill patients is met with a variety of institutional and practical barriers, as well as real and perceived safety concerns. For this reason, the use of formal safety guidelines for mobilization may help to maintain consistency and buy-in from the various members of the patient’s care team (Dubb et al., 2016; Hashem et al., 2016). Limited staffing of physical therapists in the ICU may also be a barrier at some institutions, in which case it is important for clinicians to advocate for appropriate resources.

SCREENING AND TREATMENT Fall prevention EPIDEMIOLOGY Every year, at least one-third of community-dwelling people over age 65 suffer a fall (Tinetti et al., 1988; Campbell et al., 1990). Falls cause high morbidity and mortality among the elderly, as they can result in not only brain injury, but also spinal cord injury, hip fractures, and other orthopedic trauma. In 2012, there were 24,190 fatal and 3.2 million medically treated nonfatal fall-related injuries, with direct medical costs totaling $616.5 million for fatal and $30.3 billion for nonfatal injuries (Burns et al., 2016). Aside from economic costs, falls are associated with reduced quality of life (Stenhagen et al., 2014), and psychologic consequences, which can lead to a reduction in physical function and social interaction (Yardley and Smith, 2002). Therefore, prevention of falls is highly valuable to the individual, the healthcare system, and society as a whole.

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RISK FACTORS FOR FALLS Risk factors for falls are generally categorized into intrinsic, patient-related factors, and extrinsic, environmentrelated factors (Perell et al., 2001). Intrinsic factors broadly include advanced age, chronic diseases, muscle weakness, balance control, gait disorders, altered mental status, and medications (Tinetti et al., 1988; Robbins et al., 1989). Clinical assessment of balance classically includes the visual system, the proprioceptive system, and the vestibular system (Hansson et al., 2010); however, recent research has extended a role to additional organ systems. The ratio of coronal plane hip strength to proprioceptive discrimination of the ankle, for example, was correlated with increased single leg stance time, decreased falls, and decreased fall-related injuries (Richardson et al., 2014; Richardson, 2017). This did not improve step control within the coronal plane or major life-changing falls on 1 year follow up, however. For patients with diabetic peripheral neuropathy, 60% of the variability in coronal plane gait variation and 100% of fall-related major injuries were predicted by cognitive performance measures including complex reaction time accuracy, simple reaction time latency, and the ratio of these parameters (Richardson et al., 2017). This relationship was not observed for those without peripheral neuropathy, however. Chronic pain, measured according to the number of locations, severity, or interference with daily life, is associated with greater risk of falls in older adults (Leveille et al., 2009), as is cognitive impairment (Quach et al., 2019), particularly impairments in executive function (Johnson et al., 2007; Herman et al., 2010). However, the association between cognitive impairment and fall risk is attenuated by level of social engagement, suggesting that higher levels of social engagement may play a protective role (Quach et al., 2019). Environmental factors are cited as the primary cause for about half of all falls (Tinetti et al., 1988). Examples include uneven or slippery surfaces, loose rugs, inadequate light, and obstacles (Connell, 1996). These in turn can be compounded by behavioral factors, including inattention or hurrying, discomfort during the task, or moving beyond one’s limits of stability (Connell, 1996).

SCREENING MEASURES A proper assessment of fall risk should include a combination of medical history, self-report measures, and performance-based functional measures (Ward et al., 2015; Lusardi et al., 2017). In particular, medical history questions pertaining to fall history, use of psychoactive medications, need for assistance with activities of daily living, self-reported fear of falling, and use of an

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ambulatory assistive device are clinically useful, while the addition of the self-report measures (Geriatric Depression Scale <6 points and Falls Efficacy Scale International >24 points) can provide insight into other potential contributors to fall risk (Lusardi et al., 2017). Of the performance-based measures, single-limb stance <6.5 s and self-selected walking speed <1.0 m/s have been recognized as useful, easily performed screening criteria to identify those in need of more in-depth examination of balance (Lusardi et al., 2017). Chair stand performance (a timed test of five repeated chair stands) has also been associated with recurrent falls (Nevitt et al., 1989; Buatois et al., 2008; Tiedemann et al., 2008), particularly injurious falls (Ward et al., 2015). The more involved evaluations of Berg Balance Scale (<50 points), Timed Up and Go Test (>11 s), and Five Times Sit-to-Stand Test (>12 s) are currently the most evidence-supported performance-based measures to identify individuals at greater risk of falling (Lusardi et al., 2017). However, existing performance-based measures often have ceiling effects and relatively low sensitivity to change and responsiveness (Pardasaney et al., 2012). There is a need for new, more challenging balance measures for better discrimination of balance ability in community-dwelling older adults at higher functional levels (Pardasaney et al., 2012).

HOME ENVIRONMENT ASSESSMENT AND MODIFICATION Assessing and modifying the home environment reduces the risk of falls in the elderly (Gillespie et al., 2012). Home safety interventions appear to be more effective when performed by an occupational therapist, who evaluates the home environment and recommends modifications such as removal of loose rugs, utilization of nightlights, and addition of bathroom grab bars (Gillespie et al., 2012). These interventions are targeted at mitigating the extrinsic risk factors for falls.

EXERCISE-BASED INTERVENTIONS Exercise improves strength (Liu and Latham, 2009), improves balance (Howe et al., 2011), and reduces fear of falling (Kendrick et al., 2014). Given that weakness, physical imbalance, and fear are all risk factors for falls, it should come as no surprise that exercise reduces the number of falls over time by around one-quarter (23%) and also reduces the number of people experiencing one or more falls by around one-sixth (15%) (Sherrington et al., 2019). The optimal features of successful fall prevention exercise programs are not yet clear, but programs that target balance and functional training, as well as multicomponent programs, appear to be most effective (Gillespie et al., 2012; Sherrington et al., 2019). Perhaps because of its multicomponent

nature, tai chi may reduce falls (Tsang and Hui-Chan, 2004; Sherrington et al., 2019). Since poor leg extensor strength has been found to be correlated with 43% higher likelihood of falls at home (Menant et al., 2017), weighted stair-climbing exercise has been targeted as a possible intervention that might be a useful component of a home exercise program to enhance lower extremity muscle power, aerobic capacity, and functional performance (Bean et al., 2002). In addition, pilot programs featuring a combination of behavioral modification, fall prevention education, community/home exercise integration, and moderate to high intensity exercise targeting body system impairments (endurance, leg strength, leg speed of movement, postural stability, limb flexibility, dual tasking) have shown promise in improving mobility in older community-dwelling adults with mobility problems (Brown et al., 2017).

ATTENTION TRAINING Chronic pain and cognitive impairment are both associated with greater fall risk (Leveille et al., 2009; Quach et al., 2019), but they are also associated with each other (Hart et al., 2000; Iezzi et al., 2004; Buckalew et al., 2008; Gijsen et al., 2011). This relationship has been ascertained after exclusion of patients who are taking opioids and other sedating medications. Recent work suggests that chronic pain may compete with performance of cognitive tasks (van der Leeuw et al., 2016). It has been proposed that this is because pain demands attention (defined as a person’s information processing capacity) (Mirsky et al., 1991; Eccleston and Crombez, 1999), and when greater demands are placed on attention, age-related decrements are often observed (Filley and Cullum, 1994; Madden, 2007). Indeed, a recent study showed that in older community-dwelling adults, pain severity is associated with poor selective and sustained attention, and pain interference in daily activities is associated with poor selective attention (van der Leeuw et al., 2018). Attentional demands for postural control increase with aging as sensory information decreases; therefore, it is not surprising that this ultimately leads to a higher risk of falls (Shumway-Cook and Woollacott, 2000). Therapy programs have targeted this link between attention and falls by including a cognitive component in training programs designed to prevent falls in the elderly (van het Reve and de Bruin, 2014; Daly et al., 2015; Lipardo and Tsang, 2018). Compared to a program with only strength and balance components, a training program that included a cognitive program in addition to strength and balance reduced dual task costs of walking and improved gait initiation, and improved divided attention (van het Reve and de Bruin, 2014).

GERIATRIC REHABILITATION

SYSTEMS-BASED PRACTICE AND THE ROLE OF INFORMATION TECHNOLOGY

Initiatives to engage healthcare systems in evaluating and modifying risk factors for fall-related injuries are underway, utilizing comanagement principles, partnering with community-based fall prevention programs, and actively engaging individuals through motivational interviewing and individualization of care based on patient priorities (Reuben et al., 2017). In addition, in the age of advancing technology, mobile telehealth can be utilized to augment therapy programs. One innovative program, the REACH program, delivers home or community-based exercise through a commercially available application on a computerized tablet, which allows limited face-to-face treatment sessions spaced over a longer time period, remote monitoring for an extended period, enhanced exercise performance with provision of videos and communications via an App, and integration of targeted exercise and behavioral strategies (Ni et al., 2017). Future work in this area may yield better strategies for delivering effective fall prevention interventions to the broader community of older adults.

Trauma rehabilitation HIP FRACTURES Hip fractures are a common complication from falls and result in functional decline, increased mortality, and medical complications such as venous thromboembolism or pneumonia. Because of the exponential relationship between age and the incidence of hip fractures, the expected annual incidence was projected to increase from about 1 million annually in 1992 to 6.6 million annually by 2050 (Cooper et al., 1992). This trend may be attenuated, however, by a recent 40% decrease in the age-adjusted risk of femoral neck fractures in the United States from 2003 to 2013 (Ju et al., 2017). The reported mortality rate of a hip fracture after 1 month is generally 10%, while after 1 year it can be as high as 14%–36% (Zuckerman, 1996; Nurmi et al., 2004; Bhandari and Swiontkowski, 2017). Early surgery is recommended to allow earlier mobilization, unless contraindicated due to the patient’s overall surgical risk (Bhandari and Swiontkowski, 2017). Hip fractures are broadly classified as intracapsular (femoral neck) or extracapsular (intertrochanteric and subtrochanteric fractures). Generally, most fractures are treated by internal fixation, although total hip arthroplasty may be recommended for previously healthy, ambulatory, low surgical risk patients over the age of 60 with displaced fractures of the femoral neck (Bhandari and Swiontkowski, 2017). The rate of repeat surgery is reported to range from 10% to 49% (Bhandari and Swiontkowski, 2017).

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Patients who suffer hip fractures require prolonged course of therapies over several months, and many may never recover their premorbid level of function (Wu et al., 2018).

TRAUMATIC BRAIN INJURY IN ELDERLY Elderly individuals have the highest incidence of traumatic brain injury (TBI) of any age group (Taylor et al., 2017). A recent study also found that the overall age-adjusted rate of ED visits because of TBI in the United States increased 47% from 2007 to 2013, with 25.6% of this increase explained by fall-related TBIs in individuals older than 65 years (Taylor et al., 2017). In accordance with this change, elderly patients also account for a growing share of those admitted to acute inpatient rehabilitation facilities (IRFs) after a TBI (Lamm et al., 2019). This increase exceeded what was expected from increases in life expectancy. TBIs in older adults were also more likely to result in hospitalization or death. One study found that the prevalence of comorbidities was twice as high in elderly patients with TBI, while another study found that the number of comorbidities was associated with increased length of stay for rehabilitation (Mosenthal et al., 2004; Yu and Richmond, 2005). Preexisting dementia or other cognitive impairments are additional risk factors for TBI and may interfere with the diagnosis of these injuries while leading to a slower rate of recovery (Plassman et al., 2000; Flanagan et al., 2005; Starkstein and Jorge, 2005; Thompson et al., 2006). Comparison of elderly and young adults in one study, nonetheless, found comparable rates of reintegration into the community after longer, more costly inpatient rehabilitation stay for the elderly patients (Cifu et al., 1996). The level of disability after discharge to this setting, however, continues to be worse for elderly patients with respect to Glasgow Outcome Scale (GOS) and Functional Independence Measure (FIM) (Susman et al., 2002; Thompson et al., 2006).

Cognitive rehabilitation Screening and treatment for cognitive decline in the outpatient setting includes evaluation of the patient’s overall health and psychosocial functioning. Consideration of the time-course and psychosocial stressors such as bereavement are also important. In a systematic review by the United States Preventive Services Taskforce, the Montreal Cognitive Assessment (MoCA) exam was considered useful to screen for dementia but was deemed to have limited utility to screen for mild cognitive impairment (Lin et al., 2013). The Mini Mental Status Examination (MMSE) performed better; however, the test offers limited additional information to guide treatment. A formal evaluation by a neuropsychologist is generally

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recommended if the patient complains that job performance is affected or if the clinician wishes to monitor for progression to dementia. Cognitive therapy includes a combination of four general strategies: (1) external memory devices, (2) metacognitive strategies, (3) attention training, and (4) lifestyle modification to accommodate the impairments (Cicerone et al., 2000). Several evidence-based reviews have been published for cognitive rehabilitation (Cicerone et al., 2000, 2011, 2019; Sohlberg et al., 2003), while evidence-based guidelines that have been published to date include ACRM Cognitive Rehabilitation Manual, the European Federation of Neurological Societies Guidelines on Cognitive Rehabilitation, and the CR Manual (Cappa et al., 2005; Haskins et al., 2012; Kelly and O’Sullivan, 2015). The use of planners, other external organization devices, and metacognitive strategies often have the greatest impact per time invested, while the benefits of attention training are generally task specific (Cicerone et al., 2000; Sohlberg et al., 2003). The above reviews recommended combining attention training with metacognitive strategies and customizing attention training exercises to a patient’s functional goals. Similarly, if a patient does not master the skill of self-cueing, then it is unlikely that the patient will be able to generalize global approaches to problem solving to more than one activity.

Stroke CHALLENGES FOR STROKE IN THE ELDERLY Stroke is a leading cause of disability in the elderly. Seventeen percent of all stroke patients are over the age of 85 (American Heart Association, 2018). Within this age group, stroke patients are reported to have longer hospitalizations and are more likely to be institutionalized (Forti et al., 2012). The elderly stroke population has unique challenges, including multiple medical comorbidities and cognitive impairment, which lead to poorer functional outcomes (Kong et al., 1998; Zinn et al., 2004). However, these patients benefit from poststroke rehabilitation with similar change in FIM total scores and FIM efficiencies as cognitively intact groups (Rabadi et al., 2008).

MECHANISMS AND PATTERNS OF STROKE RECOVERY Most spontaneous neurologic recovery from a stroke occurs during the first 3–6 months (Wade and Hewer, 1987; Kwakkel et al., 2006). The theoretical mechanisms behind this recovery initially include reperfusion of ischemic penumbral tissue and reversal of diaschisis or cerebral shock, and later neuroplastic cortical reorganization and behavioral compensation (Furlan et al., 1996; Calautti and Baron, 2003; Carmichael et al., 2004). Factors that

affect the global functional outcome include neuroimaging findings such as the presence of leukoaraiosis (Kongbunkiat et al., 2017) and axial diffusivity of the corona radiata (Moulton et al., 2015), age, and the initial severity of deficits (Ween et al., 1996). The latter factor has the strongest predictive value. Multiple scales have been used early poststroke to predict severity of deficits and functional outcome, including the NIH Stroke Scale (Kwakkel et al., 2010), Barthel Index (Kwakkel et al., 2011), FIM, and the modified Rankin scale. In one longitudinal study, socioeconomic status did not affect the rate of recovery after adjusting for other characteristics (López-Espuela et al., 2016). Recent studies have suggested a purely biologic model of recovery, in which the amount of function regained is a fixed proportion of lost function (reported R2 80%–90% limited to those with preserved motor evoked potentials), based on the Fugl–Meyer assessment in upper extremity recovery (Stinear et al., 2017). Similar results were demonstrated for lower limb recovery (Smith et al., 2017). Some controversy has surrounded these models, however, as the R2 of a fit for change in impairment becomes inflated when the initial level of impairment is used as a predictive variable (Hope et al., 2019). A regression of change versus initial impairment appears to be useful to identify patients falling off the expected trajectory of recovery; however, converting this analysis to a fit for outcome should result in a more realistic (lower) R2 for the remaining patients. Genetic factors may also play a role, as patients in the Tel Aviv Brain Acute Stroke Cohort (TABASCO), who were screened for loss-of-function mutations of the C–C Chemokine Receptor 5 (CCR5), demonstrated greater gains in motor function and cognition, despite initially having less severe deficits at the time of presentation (Joy et al., 2019). The opposite relationship between initial deficits and recovery would otherwise be expected due to a ceiling effect. CCR5 previously has been implicated in resistance to HIV (Samson et al., 1996). Joy et al. demonstrated similar findings in animals with loss of function mutations, while downregulation of this receptor through genetic silencing or pharmacologic antagonism both resulted in greater functional improvements in animals with experimental strokes and TBIs. Motor recovery has been classically described by Brunnstrom to occur in six stages (Brunnstrom, 1966). The first stage is flaccid paralysis, followed by two stages of increased spasticity in characteristic synergy patterns. The upper extremity typically develops a flexor synergy including shoulder adduction and internal rotation, elbow flexion and pronation, and wrist and finger flexion while the lower extremity usually demonstrates an extensor synergy with hip extension, knee extension, and ankle plantar flexion. The last three stages show

GERIATRIC REHABILITATION progressively decreased spasticity and increased control of movement. In practice, however, the progression of recovery may not always strictly follow these patterns. Generally, greater improvement is seen in the lower extremities. Kwakkel et al. found that after 6 months, 38% of middle cerebral artery stroke patients regained some manual dexterity with only 12% achieving complete recovery (Kwakkel et al., 2003). This can be contrasted with 50% of all stroke patients being able to walk independently and an additional 11% walking with assistance after 3 months (Jørgenson et al., 1995).

STROKE PROGNOSIS The Total Health Risk In Vascular Events-calculation score (THRIVE-c) is a convenient tool for predicting the global likelihood of a poor function outcome, with a reported AUC of 75% for predicting a Modified Rankin Score (mRS) less than 3 (Pan et al., 2018). The mRS is a crude disability scale where a score less than 3 accurately represents patients who do not require assistance at the end of recovery; however, it does not provide guidance regarding the resolution of individual impairments. The inputs to this model include age, initial NIHSS, history of hypertension, and diabetes. Predictors of upper limb recovery include early active finger extension and shoulder abduction (Katrak et al., 1998; Smania et al., 2007). For lower limb recovery, factors associated with better prognosis include the muscle strength of the hemiplegic leg and sitting balance (Kollen et al., 2006). Aphasia recovers mostly within the first 3 months, but recovery can take up to 12 months depending on age and severity of deficits (Ferro et al., 1999). Higher intensity of therapy has been shown to affect improvement (Bhogal et al., 2003), although the optimal dose remains a source of debate. Optimal timing of the therapy is also disputed, as one randomized controlled trial found that aphasic patients who were initiated into speech therapy within the first 12 weeks after stroke demonstrated comparable improvement to those treated after this time window (Wertz et al., 1986).

STROKE REHABILITATION Early rehabilitation within the first 20 days after stroke is suggested to result in improved functional outcome (Paolucci et al., 2000; Salter et al., 2006). The A Very Early Rehabilitation Trial for Stroke (AVERT) trial in Australia found that immediate mobilization during the early days on a stroke unit resulted in improved mobility, in comparison to standard care (Cumming et al., 2011). A team-based, multidisciplinary approach is generally preferred in comparison to an individual, consultative approach to rehabilitation. This approach was supported by a multitude of very old randomized controlled trials

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reviewed by Langhorne and Duncan (2001). More recently a prospective U.S. Medicare study comparing the inpatient rehabilitation setting (IRF) to skilled nursing facilities (SNFs) found that, after adjusting for patient characteristics, mobility was not changed (Gage et al., 2012). Self-care scores, however, were mildly improved at the time of discharge. Another prospective study examining outcomes over a longer timescale, adjusted for patient characteristics in a similar fashion, found that, although improvements in function were marginal at the time of discharge, patients admitted to IRF continued to make improvements thereafter that became much more pronounced after 6 months (Chan et al., 2013). Comprehensive guidelines regarding rehabilitation strategies for stroke have been published by the American Heart Association/American Stroke Association (AHA/ ASA) (Winstein et al., 2016). The recommendations encompass all levels of care and accompany recommendations for nursing needs and prevention of medical complications such as skin breakdown, hemiplegic shoulder pain, and osteoporosis. Some of the domains of rehabilitation discussed include aphasia, cognitive rehabilitation, falls prevention, gait training, hemineglect, apraxia, and orthotics. Common global strategies include task-oriented therapy, in which real-life meaningful tasks for the patient are practiced during therapy, and repetitive therapy, which divides a task into multiple steps for practice. Specific strategies have been developed for the upper extremity, including constraintinduced movement therapy, based on the Extremity Constraint Induced Therapy Evaluation (EXCITE) trial that showed restriction of the less affected upper extremity combined with 6 h of upper extremity training daily for 2 weeks improved upper extremity function for those with at least 20 degrees of wrist extension and 10 degrees of active finger extension (Wolf et al., 2006). For the lower extremity, bodyweight-supported treadmill training has been developed; however, this method has not been shown to have significant benefits compared to overground gait therapy (Moseley et al., 2003). The AHA/ASA guidelines also discuss the evidence behind specific interventions such as Transcutaneous Electrical Nerve Stimulation (TENS), music gait therapy, roboticassisted therapy, biofeedback, water-based therapy, and acupuncture. Pharmacologic and brain stimulation are also being studied as interventions to promote stroke recovery. The Fluoxetine for Motor Recovery after Ischemic Stroke (FLAME) trial showed an improvement in motor recovery in ischemic stroke patients with moderate to severe motor deficits after 3 months on fluoxetine 20 mg (Chollet et al., 2011). The Fluoxetine or Control Under Supervision (FOCUS) trial, however, later showed no difference in the motor outcomes after

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6 months of treatment, while the treated patients demonstrated higher rates of fractures (Martin et al., 2019). Pharmacologic antagonism of the CCR5 receptor (discussed earlier) has also been proposed as a treatment to promote neuroplasticity, and one randomized controlled trial is currently underway in stroke using maraviroc, a medication approved by FDA for treatment of HIV (clinicaltrials.gov; NCT03172026). Gains in motor recovery have been suggested in early studies on transcranial magnetic stimulation (TMS) in chronic stroke patients (Hoyer and Celnik, 2011). Newer neuromodulation techniques such as intracallosal inhibition and paired associative techniques addressing contralesional plasticity (enhancing neural plasticity in the region homologous to the stroke region, in the contralateral hemisphere) provide reason for optimism (Bertolucci et al., 2018; Ferris et al., 2018). The optimal timing, dosage, and combination of therapies necessary to maintain a sustained benefit, however, has not been firmly established.

CONCLUSIONS Elderly patients often have complex rehabilitation needs due to a combination of aging-related changes, comorbidities, and psychosocial factors. This population often requires lower medication doses, longer duration of rehabilitation care, and more vigilant monitoring of cognitive and physical impairments. Providers who are involved in their care should be familiar with their needs, as well as with the core principles of geriatric medicine.

REFERENCES American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, fifth edn. American Psychiatric Association, Arlington, VA. Bean J, Herman S, Kiely DK et al. (2002). Weighted stair climbing in mobility-limited older people: a pilot study. J Am Geriatr Soc 50: 663–670. Ben-Avraham D, Karasik D, Verghese J et al. (2017). The complex genetics of gait speed: genomewide meta-analysis approach. Aging (Albany, NY) 9: 1844–1846. Bertolucci F, Chisari C, Fregni F (2018). The potential dual role of transcallosal inhibition in post-stroke motor recovery. Restor Neurol Neurosci 36: 83–97. https://doi.org/ 10.3233/RNN-170778. Bhandari M, Swiontkowski M (2017). Management of acute hip fracture. N Engl J Med 377: 2053–2062. Bhogal SK, Teasell R, Speechley M (2003). Intensity of aphasia therapy, impact on recovery. Stroke 34: 987–993. Brown LG, Ni M, Schmidt CT et al. (2017). Evaluation of an outpatient rehabilitative program to address mobility limitations among older adults. Am J Phys Med Rehabil 96: 600–606.

Brunnstrom S (1966). Motor testing procedures in hemiplegia; based on sequential recovery stages. Phys Ther 46: 357–375. Buatois S, Miljkovic D, Manckoundia P et al. (2008). Five times sit to stand test is a predictor of recurrent falls in healthy community-living subjects aged 65 and older. J Am Geriatr Soc 56: 1575–1577. Buckalew N, Haut MW, Morrow L et al. (2008). Chronic pain is associated with brain volume loss in older adults: preliminary evidence. Pain Med 9: 240–248. Burns ER, Stevens JA, Lee R (2016). The direct costs of fatal and non-fatal falls among older adults—United States. J Saf Res 58: 99–103. Calautti C, Baron J-C (2003). Functional neuroimaging studies of motor recovery after stroke in adults. Stroke 34: 1553–1566. Campbell AJ, Borrie MJ, Spears GF et al. (1990). Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 19: 136–141. Cappa S, Benke T, Clarke S et al. (2005). Task force on cognitive rehabilitation; European Federation of Neurological Societies. EFNS guidelines on cognitive rehabilitation: report of an EFNS task force. Eur J Neurol 12: 665–680. Carmichael ST, Tatsukawa K, Katsman D et al. (2004). Evolution of diaschisis in a focal stroke model. Stroke 35: 758–763. Cawthon PM, Marshall LM, Yvonne M et al. (2007). Frailty in older men: prevalence, progression, and relationship with mortality. J Am Geriatr Soc 55: 1216–1223. Central Intelligence Agency (United States), Library, publications, the world factbook, field listing: age structure [homepage on the internet] (2016). Available from: https://www. cia.gov/library/publications/the-world-factbook/fields/ 341.html#XX (Accessed). Chan L, Sandel ME, Jette AM et al. (2013). Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke. Arch Phys Med Rehabil 94: 622–629. Chen LK, Liu LK, Woo J et al. (2014). Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc 15: 95–101. Chollet F, Tardy J, Albucher J-F et al. (2011). Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurol 10: 123–130. Cicerone KD, Dahlberg C, Kamar K et al. (2000). Evidencebased cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 81: 316–321. Cicerone KD, Langenbahn DM, Braden C et al. (2011). Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil 92: 519–530. Cicerone KD, Goldin Y, Ganci K et al. (2019). Evidence-based cognitive rehabilitation: systematic review of the literature from 2009 through 2014. Arch Phys Med Rehabil 100: 1515–1533. https://doi.org/10.1016/j.apmr.2019.02.011. Epub ahead of print.

GERIATRIC REHABILITATION Cifu DX, Kreutzer JS, Marwitz JH et al. (1996). Functional outcomes of older adults with traumatic brain injury: a prospective, multicenter analysis. Arch Phys Med Rehabil 77: 883–888. Connell BR (1996). Role of the environment in falls prevention. Clin Geriatr Med 12: 859–880. Cooper C, Campion G, Melton LJ (1992). 3rd Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2: 285–289. Cumming TB, Thrift AG, Collier JM et al. (2011). Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke 42: 153–158. Daly RM, Duckham RL, Tait JL et al. (2015). Effectiveness of dual-task functional power training for preventing falls in older people: study protocol for a cluster randomised controlled trial. Trials 16: 120. Dent E, Morley JE, Cruz-Jentoft AJ et al. (2018). International clinical practice guidelines for sarcopenia (ICFSR): screening, diagnosis and management. J Nutr Health Aging 22: 1148–1161. Dubb R, Nydahl P, Hermes C et al. (2016). Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc 13: 724–730. Eccleston C, Crombez G (1999). Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychol Bull 125: 356–366. Farias ST, Cahn-Weiner DA, Harvey DJ (2009). Longitudinal changes in memory and executive functioning are associated with longitudinal change in instrumental activities of daily living in older adults. Clin Neuropsychol 23: 446–461. Ferris JK, Neva JL, Francisco BA et al. (2018). Bilateral motor cortex plasticity in individuals with chronic stroke, induced by paired associative stimulation. Neurorehabil Neural Repair 32: 671–681. https://doi.org/10.1177/1545968318 785043. [Epub 2018 Jul 4]. Ferro J, Mariano G, Madureira S (1999). Recovery from aphasia and neglect. Cardiovasc Dis 9: 6–22. Fielding RA, Vellas B, Evans WJ et al. (2011). Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. JAMA 12: 249–256. Filley CM, Cullum CM (1994). Attention and vigilance functions in normal aging. Appl Neuropsychol 1: 29–32. Flanagan SR, Hibbard MR, Gordon WA (2005). The impact of age on traumatic brain injury. Phys Med Rehabil Clin N Am 16: 163–177. Fong TG, Jones RN, Shi P et al. (2009). Delirium accelerates cognitive decline in Alzheimer disease. Neurology 72: 1570–1575. Forti P, Maioli F, Procaccianti G et al. (2012). Independent predictors of ischemic stroke in the elderly: prospective data from a stroke unit. Neurology 80: 29–38. Fried LP, Tangen CM, Walston J et al. (2001). Frailty in older adults: evidence for a phenotype. J Geronotol A Biol Sci Med Sci 56: M146–M156.

539

Furlan M, Marchal G, Derlon J-M et al. (1996). Spontaneous neurological recovery after stroke and the fate of the ischemic penumbra. Ann Neurol 40: 216–226. Gage B, Morley M, Smith L, et al. (2012). U.S. Dept of Health and Human Services Centers for Medicare & Medicaid Services (CMS). Post acute care payment reform demonstration (PAC-PRD). Available at: http://www.cms. gov/Reports/Downloads/Flood_PACPRD_RTC_CMS_ Report_Jan_2012.pdf (Accessed). Gale CR, Mo˜ttus R, Sayer AA (2017). Personality and risk of frailty: the English longitudinal study of ageing. Ann Behav Med 51: 128–136. Gates GA, Mills JH (2005). Presbycusis. Lancet 366: 1111–1120. Gijsen CP, Dijkstra JB, van Boxtel MP (2011). Recurrent pain is associated with decreased selective attention in a population-based sample. Pain 152: 188–193. Gillespie LD, Robertson MC, Gillespie WJ et al. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev (9): CD007146. Hansson EE, Beckman A, Ha˚kansson A (2010). Effect of vision, proprioception, and the position of the vestibular organ on postural sway. Acta Otolaryngol 130: 1358–1363. Hart RP, Martelli MF, Zasler ND (2000). Chronic pain and neuropsychological functioning. Neuropsychol Rev 10: 131–149. Hashem MD, Nelliot A, Needham DM (2016). Early mobilization and rehabilitation in the ICU: moving back to the future. Respir Care 61: 971–979. https://doi.org/10.4187/ respcare.04741. Haskins EC, Cicerone KC, Dams-O’Connor K et al. (2012). Cognitive rehabilitation manual, first edn. ACRM Publishing. Herman T, Mirelman A, Giladi N et al. (2010). Executive control deficits as a prodrome to falls in healthy older adults: a prospective study linking thinking, walking, and falling. J Gerontol A Biol Sci Med Sci 65: 1086–1092. Holsinger T, Deveau J, Boustani M et al. (2007). Does this patient have dementia? JAMA 297: 2391–2404. Hope TMH, Friston K, Price CJ et al. (2019). Recovery after stroke: not so proportional after all. Brain 142: 15–22. Howe TE, Rochester L, Neil F et al. (2011). Exercise for improving balance in older people. Cochrane Database Syst Rev (11): CD004963. Hoyer EH, Celnik PA (2011). Understanding and enhancing motor recovery after stroke using transcranial magnetic stimulation. Restor Neurol Neurosci 29: 395–409. Iezzi T, Duckworth MP, Vuong LN et al. (2004). Predictors of neurocognitive performance in chronic pain patients. Int J Behav Med 11 (1): 56–61. Johnson JK, Lui LY, Yaffe K (2007). Executive function, more than global cognition, predicts functional decline and mortality in elderly women. J Gerontol A Biol Sci Med Sci 62: 1134–1141. Jørgenson H, Nakayama H, Raaschou H et al. (1995). Recovery of walking function in stroke patients: the Copenhagen stroke study. Arch Phys Med Rehabil 76: 27–32.

540

G.T. ROBBINS ET AL.

Joy MT, Assayag EB, Shabashov-Stone D et al. (2019). CCR5 is a therapeutic target for recovery after stroke and traumatic brain injury. Cell 176: 1143–1157. Ju DG, Rajaee SS, Mirocha J et al. (2017). Nationwide analysis of femoral neck fractures in elderly patients. J Bone Joint Surg Am99: 1932–1940. https://doi.org/10.2106/JBJS. 16.01247. Katrak P, Bowring G, Conroy P et al. (1998). Predicting upper limb recovery after stroke: the place of early shoulder and hand movement. Arch Phys Med Rehabil 79: 758–761. Kelly ME, O’Sullivan M. (2015). The Alzheimer Society of Ireland, strategies and techniques for cognitive rehabilitation; manual for healthcare professionals working with people with cognitive impairment. [Homepage on the internet]. Available from: https://www.lenus.ie/ handle/10147/580024 (Accessed). Kendrick D, Kumar A, Carpenter H et al. (2014). Exercise for reducing fear of falling in older people living in the community. Cochrane Database Syst Rev (11): CD009848. Kiely DK, Cupples LA, Lipsitz LA (2009). Validation and comparison of two frailty indexes: the MOBILIZE Boston study. J Am Geriatr Soc 57: 1532–1539. Kollen B, Kwakkel G, Lindeman E (2006). Longitudinal robustness of variables predicting independent gait following severe middle cerebral artery stroke: a prospective cohort study. Clin Rehabil 20: 262–268. Kong K-H, Chua KS, Tow AP (1998). Clinical characteristics and functional outcome of stroke patients 75 years old and older. Arch Phys Med Rehabil 79: 1535–1539. Kongbunkiat K, Wilson D, Kasemsap N et al. (2017). Leukoariosis, intracerebral hemorrhage, and functional outcome after acute stroke thrombolysis. Neurology 88: 638–645. Kwakkel G, Kollen BJ, van der Grond J et al. (2003). Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke 34: 2181–2186. Kwakkel G, Kollen B, Twisk J (2006). Impact of time on improvement of outcome after stroke. Stroke 37: 2348–2353. Kwakkel G, Veerbeek J, van Wegen E et al. (2010). Predictive value of the NIHSS for ADL outcome after ischemic hemispheric stroke: does timing of early assessment matter? J Neurol Sci 94: 57–61. Kwakkel G, Veerbeek JM, Harmeling-van der Wel BC et al. (2011). Diagnostic accuracy of the Barthel index for measuring activities of daily living outcome after ischemic hemispheric stroke: does early poststroke timing of assessment matter? Stroke 42: 342–346. Lamm AG, Goldstein R, Giacino J et al. (2019). Changes in patient demographics and outcomes in the inpatient rehabilitation facility traumatic brain injury population from 2002 to 2016: implications for patient care and clinical trials. J Neurotrauma 36 (17): 2513–2520. https://doi. org/10.1089/neu.2018.6014. [Epub 2019 May 16]. Langhorne P, Duncan P (2001). Does the organization of postacute stroke care really matter? Stroke 32: 268–274.

Lee DR, Kawas CH, Gibbs L et al. (2016). Prevalence of frailty and factors associated with frailty in individuals aged 90 and older: the 90 + study. J Am Geriatr Soc 64: 2257–2262. Leveille SG, Jones RN, Kiely DK et al. (2009). Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA 302: 2214–2221. Lin JS, O’Connor E, Rossom RC et al. (2013). Screening for cognitive impairment in older adults: an evidence update for the U.S. Preventive Services Task Force. U.S. Preventive Services Task Force evidence syntheses, formerly systematic evidence reviews report no. 14-05198-EF-1. Lipardo DS, Tsang WWN (2018). Falls prevention through physical and cognitive training (falls PACT) in older adults with mild cognitive impairment: a randomized controlled trial protocol. BMC Geriatr 18: 193. Liu CJ, Latham NK (2009). Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev (3): CD002759. Lo´pez-Espuela F, Pedrera-Zamorano JD, Jim
enez-Caballero PE et al. (2016). Functional status and disability in patients after acute stroke: a longitudinal study. Am J Crit Care 25: 144–151. Lusardi MM, Fritz S, Middleton A et al. (2017). Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability. J Geriatr Phys Ther 40: 1–36. Madden DJ (2007). Aging and visual attention. Curr Dir Psychol Sci 16: 70–74. Martin D, Forbes J, Graham C et al., The FOCUS Trial Collaboration (2019). Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomized, controlled trial. Lancet 393 (10168): 265–274. https://doi.org/10.1016/S0140-6736 (18)32823-X. Marty E, Liu Y, Samuel A et al. (2017). A review of sarcopenia: enhancing awareness of an increasingly prevalent disease. Bone 105: 276–286. https://doi.org/10.1016/j. bone.2017.09.008. Menant JC, Weber F, Lo J et al. (2017). Strength measures are better than muscle mass measures in predicting healthrelated outcomes in older people: time to abandon the term sarcopenia? Osteoporos Int 28: 59–70. Mirsky AF, Anthony BJ, Duncan CC et al. (1991). Analysis of the elements of attention: a neuropsychological approach. Neuropsychol Rev 2: 109–145. Moseley A, Stark A, Cameron I et al. (2003). Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev (3): CD002840. Mosenthal AC, Livingston DH, Lavery RF et al. (2004). The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. J Trauma 56: 1042–1048. Moulton E, Amor-Sahli M, Perlbarg V et al. (2015). Axial diffusivity of the corona radiata at 24 hours post-stroke: a new biomarker for motor and global outcome. PLoS One 10 (11): e0142910. https://doi.org/10.1371/journal.pone. 0142910. eCollection 2015.

GERIATRIC REHABILITATION Muscaritoli M, Anker SD, Argiles J et al. (2010). Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics”. Clin Nutr 29: 154–159. National Institute of Population and Social Security Research (Japan), Population & Household Projection, Population Projection for Japan: 2011–2060, Summary of population trends; (2012). [homepage on the Internet]. Available from: http://www.ipss.go.jp/site-ad/index_english/esuikei/ econ2.html (Accessed). Nevitt MC, Cummings SR, Kidd S et al. (1989). Risk factors for recurrent nonsyncopal falls. A prospective study. JAMA 261: 2663–2668. Ni M, Brown LG, Lawler D et al. (2017). The rehabilitation enhancing aging through connected health (REACH) study: study protocol for a quasi-experimental clinical trial. BMC Geriatr 17: 221. Nurmi I, Narinen A, L€ uthje P et al. (2004). Functional outcome and survival after hip fracture in elderly: a prospective study of 106 consecutive patients. J Orthop Traumatol 5: 7–14. Oh E, Fong TG, Hshieh TT et al. (2017). Delirium in older persons: advances in diagnosis and treatment. JAMA 318: 1161–1174. https://doi.org/10.1001/jama.2017.12067. Orkaby AR, Hshieh TT, Gaziano JM et al. (2017). Comparison of two frailty indices in the physicians’ health study. Ach Gerontol Geriatr 71: 21–27. https://doi.org/10.1016/j. archger.2017.02.009. Pan Y, Peng Y, Chen W et al. (2018). THRIVE-c score predicts clinical outcomes in Chinese patients after thrombolysis. Brain Behav 8: e00927. https://doi.org/10.1002/brb3.927. Paolucci S, Antonucci G, Grasso M et al. (2000). Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy. Arch Phys Med Rehabil 81: 695–700. Pardasaney PK, Latham NK, Jette AM et al. (2012). Sensitivity to change and responsiveness of four balance measures for community-dwelling older adults. Phys Ther 92: 388–397. Perell KL, Nelson A, Goldman RL et al. (2001). Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci 56: M761–M766. Plassman BL, Havlik RJ, Steffens DC et al. (2000). Documented head injury in early adulthood and risk of Alzheimer’s disease and other dementias. Neurology 55: 1158–1166. PubMed: 11071494. Quach LT, Ward RE, Pedersen MM et al. (2019). The association between social engagement, mild cognitive impairment and falls among older primary care patients. Arch Phys Med Rehabil 100 (8): 1499–1505. pii: S0003-9993 (19)30112-1, https://doi.org/10.1016/j.apmr.2019.01.020. Epub ahead of print. Rabadi MH, Rabadi FM, Edelstein L et al. (2008). Cognitively impaired stroke patients do benefit from admission to an acute rehabilitation unit. Arch Phys Med Rehabil 89: 441–448. Reuben DB, Gazarian P, Alexander N et al. (2017). The strategies to reduce injuries and develop confidence in elders intervention: falls risk factor assessment and management,

541

patient engagement, and nurse co-management. J Am Geriatr Soc 65: 2733–2739. Richardson JK (2017). Imbalanced: the confusing circular nature of falls research…and a possible antidote. Am J Phys Med Rehabil 96: 55–59. Richardson JK, DeMott T, Allet L et al. (2014). Hip strength: ankle proprioceptive threshold ratio predicts falls and injury in diabetic neuropathy. Muscle Nerve 50: 437–442. Richardson JK, Eckner JT, Allet L et al. (2017). Complex and simple clinical reaction times are associated with gait, balance, and major fall injury in older subjects with diabetic peripheral neuropathy. Am J Phys Med Rehabil 96: 8–16. Ries PW (1994). Prevalence and characteristics of persons with hearing trouble: United States, 1990–91. Vital Health Stat 10 (188): 1–75. Robbins AS, Rubenstein LZ, Josephson KR et al. (1989). Predictors of falls among elderly people. Results of two population-based studies. Arch Intern Med 149: 1628–1633. Salter K, Jutai J, Hartley M et al. (2006). Impact of early vs delayed admission to rehabilitation on functional outcomes in persons with stroke. J Rehabil Med 38: 113–117. Samson M, Libert F, Doranz BJ et al. (1996). Resistance to HIV-1 infection in Caucasian individuals bearing mutant alleles of the CCR-5 chemokine receptor gene. Nature 382: 722–725. Sa´nchez-Rodrı´guez D, Marco E, Miralles R (2014). Sarcopenia, physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit. Arch Gerontol Geriatr 59: 39–43. https://doi.org/10.1016/j. archger.2014.02.009. Sandi C (2013). Stress and cognition. Wiley Interdiscip Rev Cogn Sci 4: 245–261. Schweickert WD, Pohlman AS, Nigos C et al. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373: 1874–1882. Sherrington C, Fairhall NJ, Wallbank GK et al. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 1: CD012424. Shumway-Cook A, Woollacott M (2000). Attentional demands and postural control: the effect of sensory context. J Gerontol A Biol Sci Med Sci 55: M10–M16. Smania N, Paolucci S, Tinazzi M et al. (2007). Active finger extension: a simple movement predicting recovery of arm function in patients with acute stroke. Stroke 38: 1088–1090. Smith M-C, Byblow WD, Barber PA (2017). Proportional recovery from lower limb motor impairment after stroke. Stroke 48: 1400–1403. Sohlberg MM, Turkstra L, Yorkston K (2003). Practice guidelines for direct attention training. J Med Speech Lang Pathol 11 (3): xix–xxxix. Starkstein SE, Jorge R (2005). Dementia after traumatic brain injury. Int Psychogeriatr 17 (Suppl. 1): S93–S107. Stenhagen M, Ekstrom H, Nordell E et al. (2014). Accidental falls, health-related quality of life and life satisfaction: a prospective study of the general elderly population. Arch Gerontol Geriatr 58: 95–100.

542

G.T. ROBBINS ET AL.

Stinear CM, Byblow WD, Ackerley SJ et al. (2017). Proportional motor recovery after stroke. Stroke 48: 795–798. Studenski SA, Peters KW, Alley DE et al. (2014). The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates. J Gerontol A Biol Sci Med Sci 69 (2014): 547–558. Susman M, DiRusso SM, Sullivan T et al. (2002). Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 53: 219–223. Taylor CA, Bell JM, Breiding MJ et al. (2017). Traumatic brain injury-related emergency department visits, hospitalizations, and deaths-United States, 2007 and 2013. MMWR 66: 1–9. Theou O, Brothers TD, Mitnitski A et al. (2013). Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc 61: 1537–1551. Thompson HJ, McCormick WC, Kagan S (2006). Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc 54: 1590–1595. Tiedemann A, Shimada H, Sherrington C et al. (2008). The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing 37: 430–435. Tinetti ME, Speechley M, Ginter SF (1988). Risk factors for falls among elderly persons living in the community. New Engl J Med 319: 1701–1707. Tsang WW, Hui-Chan CW (2004). Effect of 4- and 8-wk intensive Tai Chi Training on balance control in the elderly. Med Sci Sports Exerc 36: 648–657. van der Leeuw G, Eggermont LH, Shi L et al. (2016). Pain and cognitive function among older adults living in the community. J Gerontol A Biol Sci Med Sci 71: 398–405. van der Leeuw G, Leveille SG, Dong Z et al. (2018). Chronic pain and attention in older community-dwelling adults. J Am Geriatr Soc 66: 1318–1324. van het Reve E, de Bruin ED (2014). Strength-balance supplemented with computerized cognitive training to improve dual task gait and divided attention in older adults: a multicenter randomized-controlled trial. BMC Geriatr 14: 134. Wade DT, Hewer RL (1987). Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry 50: 177–182. Wakabayashi H, Sakuma K (2014). Rehabilitation nutrition for sarcopenia with disability: a combination of both rehabilitation and nutrition care management. J Cachexia Sarcopenia Muscle 5: 269–277. https://doi.org/10.1007/ s13539-014-0162-x. Walston J, Hadley EC, Ferrucci L et al. (2006). Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on aging research conference on frailty in older adults. J Am Geriatr Soc 54: 991–1001.

Ward RE, Leveille SG, Beauchamp MK et al. (2015). Functional performance as a predictor of injurious falls in older adults. J Am Geriatr Soc 63: 315–320. Ween JE, Alexander MP, D’Esposito M et al. (1996). Factors predictive of stroke outcome in a rehabilitation setting. Neurology 47: 388–392. Wertz RT, Weiss DG, Aten JTL et al. (1986). Comparison of clinic, home, and deferred language treatment for aphasia: a Veterans administration co-operative study. Arch Neurol 43: 653–658. Whitson HE, Cronin-Golomb A, Cruickshanks KJ et al. (2018). American Geriatrics Society and National Institute on aging bench-to-bedside conference: sensory impairment and cognitive decline in older adults. J Am Geriatr Soc 66: 2052–2058. https://doi.org/10.1111/jgs.15506. Willems S, Wright D, Day FR et al. (2017). Large-scale GWAS identifies multiple loci for hand grip strength providing biological insights into muscular fitness. Nat Commun8: 16015. https://doi.org/10.1038/ncomms16015. Winstein CJ, Stein J, Arena R et al. (2016). Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 47: e98–e169. https://doi.org/10.1161/STR.0000000000000098. Wolf SL, Winstein CJ, Miller JP et al. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. JAMA 296: 2095. Woods NF, LaCroix AZ, Gray SL et al. (2005). Frailty: emergence and consequences in women aged 65 and older in the women’s health initiative observational study. J Am Geriatr Soc 53: 1321–1330. Wu D, Zhu X, Zhang S (2018). Effect of home-based rehabilitation for hip fracture: a meta-analysis of randomized controlled trials. J Rehabil Med 50: 481–486. Yardley L, Smith H (2002). A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. Gerontologist 42: 17–23. Yu F, Richmond T (2005). Factors affecting outpatient rehabilitation outcomes in elders. J Nurs Scholarsh 37: 229–236. Zillikens MC, Demissie S, Hsu YH et al. (2017). Large metaanalysis of genomewide association studies identifies five loci for lean body mass. Nat Commun 8: 80. https://doi.org/ 10.1038/s41467-017-00031-7. Zinn S, Dudley TK, Bosworth HB et al. (2004). The effect of poststroke cognitive impairment on rehabilitation process and functional outcome. Arch Phys Med Rehabil 85: 1084–1090. Zuckerman JD (1996). Hip fracture. N Engl J Med 334: 1519–1525.

FURTHER READING Benjamin EJ, Virani SS, Callaway CW et al. (2018). Heart Disease and Stroke Statistics—2018 update: a report from the American Heart Association. Circulation 137: e67–e492.

GERIATRIC REHABILITATION Bhandari M, Koo H, Saunders L et al. (1999). Predictors of in-hospital mortality following hip fractures. Int J Surg Investig 1: 319–326. Boyd CM, McNabney MK, Brandt N (2012). Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc 60: E1–E25. Cruz-Jentoft AJ, Baeyens JP, Bauer JM et al. (2010). European Working Group on Sarcopenia in Older, Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 39: 412–423. Dromerick AW, Lang CE, Birkenmeier RL et al. (2009). Very early constraint-induced movement during stroke rehabilitation (VECTORS): a single-center RCT. Neurology 73: 195–201.

543

Gross AL, Jones RN, Habtemariam DA et al. (2012). The long-term effect of delirium on the cognitive trajectory of persons with dementia. Arch Intern Med 172: 1324–1331. Prabhakaran S, Zarahn E, Riley C et al. (2007). Interindividual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair 22: 64–71. Simunovic N, Devereaux PJ, Sprague S et al. (2010). Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ 182: 1609–1616. Tsekoura M, Kastrinis A, Katsoulaki M et al. (2017). Sarcopenia and its impact on quality of life. Adv Exp Med Biol 987: 213–218. https://doi.org/10.1007/978-3319-57379-3_19.