Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery

Archives of Gerontology and Geriatrics 49 (2009) e23–e31

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Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery Katherine S. McGilton a,*, Nizar Mahomed b, Aileen M. Davis b, John Flannery c, Sue Calabrese c a

Toronto Rehabilitation Institute, 130 Dunn Avenue, Toronto, ON M6K 2R7, Canada Toronto Western Research Institute, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada c Toronto Rehabilitation Institute, 47 Austin Terrace Toronto, ON M5R 1Y8, Canada b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 20 September 2007 Received in revised form 20 July 2008 Accepted 25 July 2008 Available online 7 October 2008

The purpose of the study was to evaluate patient and system outcomes regarding older communityresiding adults who participated in a rehabilitation program following HF surgery. The health care professionals on the rehabilitation unit in this feasibility study had never cared for such patients who were so frail, with multiple co-morbidities including cognitive impairment (CI). After an innovative model of care was developed and the staff trained in the novel approach to care, the unit opened for all patients living within the community who had fractured their hip, regardless of their CI. Of the 31 elderly patients consecutively admitted post-HF in this retrospective study, 18 were found to have CI postoperatively as determined by a Mini-Mental State Examination (MMSE) score 23. There were no differences in length of stay (LOS), rehabilitation efficiency, and motor FIM gain scores between the two groups of patients. This feasibility retrospective study suggests that staff can learn how to care for patients with CI in rehabilitation settings, and that such clients can achieve outcomes comparable to those without CI in a setting dedicated to caring for patients with a HF. ß 2008 Elsevier Ireland Ltd. All rights reserved.

Keywords: Hip fracture Rehabilitation outcomes Cognitive impairment Older adults

1. Introduction A HF is often a catastrophic event that is a significant threat to an individual’s independence and ability to live in the community (Naglie et al., 2002). Population trends indicate that an increasing number of individuals are likely to survive to ages at which HF is common (Jaglal et al., 1996). Despite good surgical outcomes, studies have found that functional outcomes after HF surgery are variable, with as few as one-third of people able to regain their prefracture level of physical functioning (Koot et al., 2000; GruberBaldini et al., 2003; Lieberman et al., 2006). A recent review of the Canadian Institute for Health Information data found that 26% of HF patients (many of who were living in the community prefracture) were discharged to long-term care (LTC) facilities and never received appropriate rehabilitation (GTA Rehab. Network, 2006). Furthermore, the outcomes for patients with a HF are often complicated by the presence of CI. About 17% of community dwellers who experience a HF have a diagnosis of CI, and this percentage is expected to rise (Wiktorowicz et al., 2001). Of these

* Corresponding author. Tel.: +1 416 597 3422x2500; fax: +1 416 530 2470. E-mail address: [email protected] (K.S. McGilton). 0167-4943/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2008.07.012

patients, it is not clear what percentage have delirium, dementia or both, nor the extent of their dementia, mild, moderate or severe. Current health care services for people with HF, and those with CI in particular, are fragmented and limited (Wiktorowicz et al., 2001; GTA Rehab. Network, 2006). The several inpatient rehabilitation options after HF surgery include rehabilitation beds in acute-care hospitals or free-standing rehabilitation hospitals, specialized geriatric units, higher level sub-acute long-stay beds, and convalescent care beds. In the United States for example, HF patients with CI are admitted to geriatric sub-acute units located in nursing homes and receive rehabilitation care (Barnes et al., 2004). All of these care settings, however, have their own admission and discharge criteria that are not consistent or complementary. For example, a recent study of eight Geriatric Rehab. Units (GRUs) in Ontario found that acceptance of patients with CI varied across the units (Wells et al., 2008), despite evidence that patients with CI can benefit from rehabilitation programs (Goldstein et al., 1997; Heruti et al., 1999; Naglie et al., 2002; Barnes et al., 2004; Rolland et al., 2004). At present, there is no standardized, integrated continuum of care for HF patients, especially for those with CI in Ontario (Davis et al., 2006). Therefore, these patients are frequently unable to access appropriate rehabilitation in a timely fashion, if at all, which contributes to poor functional and quality care outcomes (Wells

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et al., 2004). Earlier work has shown that access to beds in GRUs is limited and often excludes patients with CI because of their cognitive and behavioral symptoms (Wells et al., 2008), and there is no reason to believe this is different in any other country. Not rehabilitating these patients leads to further physical and mental deconditioning, thereby, compromising patients’ long-term outcomes. In a recent report, Davis et al. (2006) recommended that new models of care be established, including all sectors of the health care continuum, to optimize the function of HF patients with CI. In response to this need, members of our team developed an integrated practice-based model of care, referred to as the Assessment, Patient-Centered Goals, Treatment, Evaluation, and Discharge (ACTED) model of care. This model aims to provide an optimal rehabilitation setting at the appropriate time for the geriatric patient with CI. The innovative aspects of the ACTED model include the following: (1) early admission to rehabilitation (i.e., on or before Day 5 post-op); (2) individualized assessments and interventions focused on the patients’ remaining abilities; (3) assessments for dementia, delirium, and depression within the first 3 days of admission to rehabilitation; (4) patient-centered goals that involve input from patients and their families; (5) individualized rehabilitation care at the bedside if necessary; (6) a focus on care strategies that minimize behavioral and cognitive symptoms related to CI; and (7) education and support to health care providers (HCPs) and facilities to implement the model of care. As part of the ACTED program, a physiatrist, geriatrician, and family physician were available to provide medical guidance on the care of the patients. An advanced practice nurse (APN) in gerontology provided guidance to staff to individualize care. The overall objective of this feasibility study was to evaluate patient and system outcomes for the older adults who participated in the ACTED program of care following HF surgery. 1.1. Literature review and conceptual framework 1.1.1. Rehabilitation of patients with CI following HF A growing body of research has focused on the rehabilitation of persons with CI following a HF. These patients with CI are more prone than other HF patients to delirium (Inouye and Charpentier, 1996), longer lengths of acute hospital stays (Wells et al., 2004), and mortality (Koot et al., 2000). A literature review of 21 studies

from eight countries reported that HF patients with CI can benefit from participating in rehabilitation targeted at improving self-care and motor function (Magaziner et al., 1990; Cummings et al., 1996; Patrick et al., 1996; Goldstein et al., 1997; Heruti et al., 1999; Adunsky et al., 2002; Hoenig et al., 2002; Naglie et al., 2002; Gruber-Baldini et al., 2003; Barnes et al., 2004; Lenze et al., 2004; Rolland et al., 2004; Arinzon et al., 2005; Haentjens et al., 2005; Shyu et al., 2005; Bitsch et al., 2006; GTA Rehab. Network, 2006; Lieberman et al., 2006; Moncada et al., 2006; Yu et al., 2006). 1.1.2. Patient outcomes The primary goal of HCPs in working with persons following a HF is to maximize their functioning (Shabat et al., 2005). Outcomes related to patients’ functioning include improvement in patients’ mobility level during inpatient rehabilitation (Patrick et al., 1996; Heruti et al., 1999) and a return to pre-fracture functional status (Wells et al., 2004; Shabat et al., 2005). HCPs’ secondary goal is to discharge patients back to their previous environment (Wells et al., 2004). 1.1.3. Influence on patient outcomes: the conceptual model A patient-centered rehabilitation model of care (Fig. 1), a modification of Donabedian’s (1966) framework, was selected to guide this research study as it provided a useful framework for understanding how contextual factors (i.e., patient and system characteristics) and processes of care affect the outcomes of people with a HF. Patient characteristics include personal resources needed to participate in the rehabilitation intervention as well as personal and health-related characteristics, such as cognitive level. System characteristics include the physical and social aspects of the environment, such as policies on the unit, and time interval from surgery to admission to the rehabilitation program. Processes of care consist of the components of the intervention conceptualized as being critical for achieving the anticipated outcomes (Lipsey, 1993), such as effective team processes. Concepts of focus for this feasibility study are highlighted in bold (Fig. 1). 1.1.4. Contextual factors 1.1.4.1. Patient characteristics. Several studies of the determinants of HF rehabilitation outcomes have shown that patient characteristics are the primary indicators of functional gain. These include

Fig. 1. Patient-centered rehabilitation model of care.

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the following: age (Arinzon et al., 2005); sex (Rolland et al., 2004); pre-fracture cognitive function (Gruber-Baldini et al., 2003); prefracture functional status (Cummings et al., 1996; Naglie et al., 2002; Moncada et al., 2006); medical co-morbidities (Patrick et al., 1996, 2002); pre-fracture frailty (Arinzon et al., 2005); sensory (hearing and vision) impairment (Rolland et al., 2004); nutritional status (Lieberman et al., 2006); social support (Beaupre et al., 2005); depression (Goldstein et al., 1997; Lenze et al., 2004; Shyu et al., 2005); and delirium or incident CI (Adunsky et al., 2002; Gruber-Baldini et al., 2003; Bitsch et al., 2006). Researchers have found that the type of HF (Haentjens et al., 2005), depression (Fredman et al., 2006), delirium (Bitsch et al., 2006), and level of CI (Moncada et al., 2006) influence the LOS on inpatient rehabilitation units and the cognitive improvement that patients make. MMSE scores at discharge (Lenze et al., 2004), depression (Lenze et al., 2004), living situation (i.e., alone vs. with others, Cummings et al., 1996), and the presence of social support (Beaupre et al., 2005) have been shown to influence the discharge disposition of these patients. 1.1.4.2. System characteristics. System characteristics that may have an impact on rehabilitation outcomes include the following: length of time from the injury to surgery (Adunsky et al., 2002; Hoenig et al., 2002) and the time interval from surgery to admission to inpatient rehabilitation (Adunsky et al., 2002; Yu et al., 2006).

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treated for a HF; and living in the community (home or residential setting) prior to their HF. Patients were excluded from the program and the study if they had a pathologic HF, if the HF was associated with multiple trauma, and/or if they were living at a nursing home at the time of the HF. 2.3. Measures The measures included in this study were appropriate to evaluate the relevant contextual factors and processes that influence patient outcomes. For the feasibility study, the authors did not include every possible variable representing these factors but instead chose those variables most frequently described in the existing research. Process data will be assessed in subsequent studies. Patient characteristics that were collected included age, sex, and cognition (MMSE). System characteristics included time interval from injury to surgery and time interval from surgery to admission to a rehabilitation unit (medical charts). Outcome data included motor functional change (Functional Independence Measure [motor-FIM change from the National Rehabilitation Services Database, NRS]), cognitive change (cognitive-FIM change from the NRS), discharge setting (community, institution, not discharged [i.e., discharged to acute care or death]), and rehabilitation efficiency.

2. Methods

2.3.1. Independent measures The MMSE, which was used as an independence measure, is a screening tool for CI, with scores ranging from 0 to 30 (Cockrell and Folstein, 1988). A score of 23 or less indicates the presence of CI (Folstein et al., 1975). This cutoff has been widely used in rehabilitation and gerontology research to dichotomize samples into cognitively intact or CI groups (Heruti et al., 1999; Espiritu et al., 2001; Yu et al., 2005). Thus, a cutoff score of 23 for CI was adopted for the current study. Test–retest reliability of MMSE scores range from 0.80 to 0.98, and these scores have been found to correlate well with clinical judgment of the patients’ CI (Perneczky et al., 2006). Participants’ sex and age were collected from the NRS data, which all rehabilitation facilities in Ontario collect. System characteristics (time intervals between injury and surgery and surgery to admission to rehabilitation facility) were obtained from a chart review.

2.1. Design and setting

2.3.2. Outcome measures

This was a longitudinal retrospective feasibility study of geriatric patients who underwent HF surgery and were admitted to the ACTED program of care in the inpatient musculoskeletal (MSK) rehabilitation unit at a hospital in Toronto, Ontario, for the period from May to October 2006. This rehabilitation unit has a 10bed capacity dedicated to ACTED patients, and includes an outpatient clinic for the patients’ follow-up visits with the geriatrician and physiatrist. This study was approved by the Research Ethics Board of the rehabilitation facility where the study was conducted.

2.3.2.1. Motor functional gain at discharge. The change in motor subscale of the FIM was calculated by the difference between the patients’ functional status at inpatient rehabilitation admission and discharge (Keith et al., 1987). The FIM, which is an integral component of the NRS (Dodds et al., 1993), must be completed by HCPs for all patients admitted to Ontario inpatient rehabilitation facilities within 72 h of admission and again within 72 h of discharge. Patient ability to complete daily tasks is rated from 1 (total assistance) to 7 (complete independence), resulting in total scores between 13 and 91, with higher scores indicating higher levels of independence. The FIM motor subscale’s reliability and validity are well established, and it demonstrates a high sensitivity for detecting functional improvement in patients with different functional status and varying degrees of co-morbidities (Heruti et al., 1999).

1.2. Objectives The overall objective of this feasibility study was to evaluate patient and system outcomes for the older adults who participated in the ACTED program of care following HF surgery. The specific objectives were to identify the contextual and system factors associated with the four outcome measures, namely, functional gain, cognitive gain, rehabilitation efficiency, and discharge location. The specific research questions were: (1) Are there differences in outcomes (functional gain, cognitive gain, rehabilitation efficiency, and discharge location) between two groups of older adults, those with CI and those with intact cognition? (2) What additional patient characteristics are related to outcomes? and (3) What system characteristics influence outcomes?

2.2. Sample The study participants were older adults who underwent a repair of a HF in an acute care hospital in Toronto. Patients were referred to the rehabilitation facility for immediate rehabilitation to prevent the deterioration of their health condition following surgery. Participant inclusion criteria for admission to the unit and study included the following: 65 years or older; admitted to rehabilitation directly from an acute care hospital after being

2.3.2.2. Cognitive gain at discharge. The change in the cognitive subscale of the FIM was used to characterize the patients’ cognitive gains between inpatient rehabilitation admission and discharge

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(Keith et al., 1987). The FIM cognitive function subscale’s total score is the sum of the scores for all cognitive items, which can range from 5 (requiring total assistance) to 35 (complete independence). The patient’s cognition functional gain was calculated by subtracting the FIM cognitive function subscale score on admission from the score at discharge. 2.3.2.3. Discharge setting change. Discharge locations were defined as institution, community (home or residential care) or not discharged. This information was compared to a change in the prefracture setting. 2.3.2.4. Rehabilitation efficiency. This outcome measure referred to the amount of functional gain achieved for each day of inpatient rehabilitation service and was calculated by dividing functional gain by days of rehabilitation service. 2.4. Data collection The medical records of all the patients who received rehabilitation care for a HF surgery from May to October 2006, were reviewed to obtain patient demographics. The remaining data were extracted from the administrative data in the institution’s NRS. 2.5. Data analyses

Table 1 Characteristics of the sample by cognitive status Characteristics Total sample

No CI

With CI

31a

14a

17a

7 (22.6) 24 (77.4) 86.8  7.0 87.0/71–100

4 (28.6) 10 (71.4) 85.3  7.8 86.0/71–100

3 (17.6) 14 (82.4) 88.6  5.7 88.0/77–100

Sex, n (%) Males Females

13 (41.9) 18 (58.1)

7 (50.0) 7 (50.0)

6 (35.3) 11 (64.7)

MMSE score Mean  S.D. Median/range (0–30)

21.4  6.3 23.0/6–29

26.8  1.2 27.0/25–29

16.9  5.2 18.0/6–23

Fractured hip, n (%) Right hip Left hip

14 (45.2) 17 (54.8)

8 (57.1) 6 (42.9)

9 (52.9) 8 (47.1)

1.000

Weight-bearing status on admission, n (%) WBAT 24 (77.4) 8 (57.1) PWB 2 (6.5) 2 (14.3) FWB 1 (3.2) 1 (7.1) TWB 3 (9.7) 2 (14.3) NWB 1 (3.2) 1 (7.1)

16 (94.1) 0 (0) 0 (0) 1 (5.9) 0 (0)

0.148

Days from injury to surgery 0–2, n (%) 21 (67.7) 3, n (%) 10 (32.3) Mean  S.D. 2.1  1.3 Median/range 2.0/0.5–6.0

13 (76.5) 4 (23.5) 1.8  1.2 2.0/0.5–5.0

Demographic Age (years), n (%) 80 >80 Mean  S.D. Median/range

8 (57.1) 6 (42.9) 2.5  1.5 2.0/1.0–6.0

p-Value

0.291

0.645

<0.001

The data were analyzed using SPSS Version 15.0. Descriptive statistics such as mean, median, standard deviation, range, frequencies, and percentages were calculated to characterize the sample as well as to describe the outcome measures. Study participants were classified into two groups by their cognitive status upon admission. To address research question 1 regarding the significance of the relationship between each outcome measure and patients’ CI, the authors used a Pearson’s correlation test and an independent samples t-test. A paired t-test was used to compare the significance of the difference of the scores upon admission and on discharge for continuous outcomes. A p-value of less than or equal to 0.05 was considered to be statistically significant. To address research questions 2 and 3, patient and system characteristics were dichotomized to describe the frequency of the group characteristic scores on gain scores. Sex was represented as male or female, age included those over or equal to 80 years of age (the median), versus those under 80, and cognition status as CI patients versus those with intact cognition. The system-level data characteristics were also divided into 2 groups: (1) those patients who had waited from 0 to 2 days from injury to surgery (the expectation for the program) versus those who waited longer and (2) those patients who had taken 15 days (the median) or longer prior to being admitted to the rehabilitation facility versus those who took less than 15 days.

fractured hip, number of co-morbidities, number of days from injury to surgery, and number of days from surgery to admission to rehabilitation facility. More patients with CI had weight bearing as tolerated (WBAT) status than those without CI. This difference may be related to the type of fracture, or the surgeon’s realization that clients with CI may not be able to understand partial or feather weight bearing so weight bearing as tolerated is most realistic. The mean motor FIM score (Table 2) for the total sample at admission to rehabilitation was 41, which indicated moderately functionally dependent (Yu et al., 2006). Patients without CI had higher motor FIM admission scores (x = 46.2) and higher cognitive FIM admission scores (x = 33.3) than patients with CI (x = 36.8) and (x = 30.2), respectively (Table 2), which were not statistically different.

3. Results

3.2. Outcomes related to patient’s cognition

3.1. Sample characteristics

As shown in Table 2, a comparison of scores upon admission and on discharge from rehabilitation indicated that there was a highly significant difference in the motor functional gain scores in both groups of patients (p < 0.001). Regardless of cognitive status, patients had improved motor function post-rehabilitation. Motor functional gain for subjects with CI was 27 versus 24 for those with intact cognition (p = 0.62). Cognitive functional gain did not increase over time for patients with CI (p = 0.58) or for those without CI (p = 0.22). The average LOS on the unit for patients with CI was 28 days, and 31 days for those without CI. Rehabilitation

The average age of the 31 patients was 87 years (Table 1). The majority of them were women (58%) and most had weight bearing as tolerated status on admission to the rehabilitation unit. The mean MMSE was 21, with 14 patients not having CI (MMSE  24) and 17 having CI (MMSE  23). On average, patients received surgery 2 days post-injury and were admitted to the rehabilitation facility 13 days post-surgery. There were no differences between the CI group and the non-CI group in terms of age, gender, side of

Days from surgery to admission in the rehabilitation facility 15, n (%) 21 (67.7) 8 (57.1) 13 (76.5) >15, n (%) 10 (32.3) 6 (42.9) 4 (23.5) Mean  S.D. 12.7  6.5 13.3  7.6 12.2  5.5 Median/range 10.0/5–32 10.0/5–32 10.0/5–21

0.162

0.643

WBAT = weight bearing as tolerated; PWB = partial weight bearing; FWB = feather weight bearing; TWB = total weight bearing; NWB = non weight bearing. a Number.

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Table 2 Comparison of rehabilitation outcomes between the groups Characteristics Total sample

No CI

With CI

(n = 31)

(n = 14)

(n = 17)

Motor functional gain Mean  S.D. Median Range

25.8  15.2 25.0 0–55

24.3  11.4 25.0 6–42

27.1  18.0 32.0 0–55

0.621

Motor FIM score at admission Mean  S.D. Median Range

41.0  15.6 44.0 13–67

46.2  13.0 48 25–67

36.8  16.7 41 13–62

0.095

Motor FIM score at discharge Mean  S.D. Median Range

66.8  19.5 75.0 13–85

70.5  12.0 75.0 44–82

63.8  24.0 75.0 13–85

0.351

p for FIM motor functional gain

<0.001y

<0.001y

<0.001y

Cognitive functional gain Mean  S.D. Median Range

0.3  1.2 0 6, 1

0.6  1.7 0 6, 0

0.1  0.4 0 1, 1

0.227

Cognitive FIM score at admission Mean  S.D. Median Range

31.6  4.5 33.0 12–35

33.3  1.1 33.0 31–35

30.2  5.7 33.0 12–35

0.058

Cognitive FIM score at discharge Mean  S.D. Median Range

31.3  4.5 33.0 12–35

32.7  2.2 33.0 27–35

30.2  5.6 33.0 12–34

0.121

p for FIM motor functional gain

0.174

0.218

0.579

Rehabilitation efficiency Mean  S.D. Median Range

0.97  0.63 1.09 0–2.56

0.86  0.40 0.94 0.21–1.62

1.06  0.77 1.23 0–2.56

0.372

LOS Mean  S.D. Median Range

29.6  14.4 28.0 3–58

31.2  14.3 28.0 14–57

28.2  14.7 28.0 3–58

0.575

Discharge location, n (%) Community Acute care hospitals LTC/CCC facilities

25 (80.6) 4 (12.9) 2 (6.5)

12 (85.7) 2 (14.3) 0 (0)

13 (76.5) 2 (11.8) 2 (11.8)

0.413

efficiency for patients with intact cognition was 2.1, in contrast to 2.61 for patients with CI. Discharge location for both groups was predominantly to the community, as 80% returned home. Four patients were discharged to an acute care hospital (2 in each group) for further management of co-morbidities, and 2 of the CI patients were discharged to a LTC facility. 3.3. Additional patient and system characteristics related to outcomes As noted in the frequency graphs in Fig. 2, males had greater motor functional change scores than females. Higher functional gain was achieved for those admitted to the rehabilitation facility within 15 days from the surgery. Likewise, those patients who received surgery closer to their injury had greater motor functional change. Cognitive functional change was greater for patients who were under 80 years of age and male (Fig. 3). Those patients admitted to the rehabilitation unit after 15 days from surgery had the largest cognitive gain. There was no cognitive change for patients who had surgery 3 days or more post-injury. Functional gain achieved for each inpatient day of stay (rehabilitation

Fig. 2. Mean motor functional change by selected factors.

p-Value

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4. Discussion

Fig. 3. Mean cognitive functional change by selected factors.

Fig. 4. Mean rehabilitation efficiency by selected factors.

efficiency) was greater for those patients entering rehabilitation facilities in less than 15 days after surgery and for those having surgery up to 2 days post-injury (Fig. 4). As shown in Fig. 5, those admitted to a LTC facility had one or more of the following characteristics: 80 years of age or older, female, CI, and admitted to the rehabilitation facility within15 days from injury.

Fig. 5. Percentage distribution of patients by discharge setting and selected factors.

In our study, patients with CI did not differ in terms of their demographic characteristics from those with intact cognition. Moreover, both groups achieved greater functional independence after participating in the rehabilitation program, regardless of their CI status. Older adults with CI showed functional gain comparable with that of older adults with intact cognition, in spite of the former’s greater degree of functional dependence at baseline. This functional gain was achieved efficiently, that is, patients with CI did not require more days of rehabilitation than their counterparts to achieve their gains. Older adults with CI were equally as likely to continue to live in the community upon discharge as were those with intact cognition. These findings support the evidence that CI patients can benefit from rehabilitation programs (Goldstein et al., 1997; Heruti et al., 1999; Naglie et al., 2002; Barnes et al., 2004; Rolland et al., 2004). Although results from this study have been supported by other inpatient rehabilitation studies (Goldstein et al., 1997; Heruti et al., 1999; Yu et al., 2006), this study is the first to show preliminary positive outcomes in an MSK rehabilitation facility, where all elders within the community, regardless of their CI status, are given an opportunity for rehabilitation care. For the purpose of understanding the project’s viability, several results warrant comparison to those from previous studies. The motor functional gain achieved by patients in our study (mean gain of 24.0–27.0 points) is higher as compared to those reported in previous inpatient HF rehabilitation studies (mean gain of 16–26 points, Goldstein et al., 1997; Heruti et al., 1999; Adunsky et al., 2002; Lenze et al., 2004). Likewise, just as we found in our study, FIM motor admission scores and FIM motor discharge scores, while statistically significantly different, were usually lower for patients with CI (Goldstein et al., 1997; Rolland et al., 2004; Arinzon et al., 2005). Also, the discharge FIM motor scores were higher in our study (64–71) and Arinzon et al.’s (2005), who reported FIM scores from 56 to 65. These differences may be accounted for by the fact that these patients are in an active rehabilitation in-patient unit and therefore receive daily physiotherapy and occupational therapy, with nursing staff who focus on mobilizing their patients as soon as possible. Further investigation is required, however, to determine whether the FIM motor discharge score or the FIM gain score is a more important outcome to track for purposes of refining the ACTED program of care. Finally, from our data we know that patients spend approximately 30 days in the rehabilitation program, which is not related to any financial limits. This average LOS is in the range of the LOS for other studies (10–48 days) (Lieberman and Lieberman, 2002; Arinzon et al., 2005), and more research is required to determine what is appropriate. Rehabilitation efficiency offers an objective outcome measure of treatment efficiency by taking into consideration both functional gain and days spent on the rehabilitation unit. In our study, rehabilitation efficiency scores ranged between .86 (for patients with intact cognition) and 1.06 (for patients with CI). These differences, which were not statistically significant, are attributable to the fact that CI patients were, on average, on the rehabilitation unit for 3 days less than patients with intact cognition prior to being discharged home. This result was not expected, as previous research has found the opposite: patients with CI usually have longer LOS than those who are cognitively intact (Diamond et al., 1996; Moncada et al., 2006), and patients with CI usually have lower rehabilitation efficiency scores than those patients who are intact (Heruti et al., 1999). These differences in findings may be related to the power of the sample in our study, which must be re-examined in a larger sample. As Adunsky et al. (2002) similarly found, the longer LOS for patients who were cognitively intact did not appear to contribute

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to the achievement of their functional motor gains, which indicates that additional factors may contribute to LOS. The same is most probable for patients with CI, staying longer in rehabilitation would probably not enhance their efficiency scores. A possible explanation for patients who are cognitively intact staying longer involves staffs’ expressed concern that some patients with intact cognition try to re-negotiate later discharge dates. Perhaps to improve efficiencies within the program, for these patients, a 3week expectation of stay should be recommended at the time of admission, so they are able to prepare for discharge. Rationale for patients with CI staying for shorter periods on the rehabilitation unit than patients without CI may be based on the HCPs’ experience that for most patients with CI, there is no place like home. The sooner patients with CI could go back safely to their home, an environment they know well; the better it was for the patient. Additionally, living alone versus with someone else has been found to influence LOS (Beaupre et al., 2005) which was not compared between the groups in our study. Regardless of the patients’ CI status, there were no changes in the patients’ cognitive gain as measured by the cognitive FIM score. On admission, patients with CI had a marginally significant difference in their cognitive FIM score (p = 0.058) from those who were cognitively intact. However, there were no cognitive FIM gains for the CI group, despite noticeable clinical differences. Many of the patients experienced delirium, as noted by confusion assessment method (CAM) testing, which had dissipated by the time the patient was discharged. It would thus appear that the cognitive FIM was not sensitive enough to the subtle changes in patients’ cognitive function. Concern about whether the cognitive FIM scale is a reliable and valid measure in rehabilitation has surfaced elsewhere (Jaglal, 2004). When the program is refined in the future, using the MMSE at discharge from rehabilitation, as Inouye et al. (2006) suggested, will provide a better objective indicator of cognitive gains. To differentiate between delirium and dementia, patients’ pre-fracture mental status must also be obtained in future studies in order to provide appropriate clinical interventions. Additional patient characteristics were also investigated in this feasibility study. From the descriptive analysis, the sex and age of the patient (i.e., 80 years of age and older, and younger than 80) appear to influence outcomes. Males had greater functional and cognitive gain scores, and patients who were younger than 80 had greater cognitive gain scores. Age and sex have been found to influence functional gain in other rehabilitation studies (Rolland et al., 2004; Arinzon et al., 2005). Older patients are more likely to experience post-op delirium which would interfere with cognitive gains (Adunsky et al., 2002). System characteristics that appear to influence outcomes (i.e., functional change scores and rehabilitation efficiency) included having surgery within 2 days of the injury and being admitted to the rehabilitation unit within 15 days of surgery. Additionally, patients who waited three and more days for surgery had no improvement in their cognitive functional scores from admission to discharge in the rehabilitation program. Patients waiting for surgery for greater than 3 days post-injury are more likely to become delirious and therefore optimal cognitive gain may be difficult to achieve. Waiting for surgery has been demonstrated to have a negative effect on functional outcome and recovery, functional independence, and LOS (Zuckerman et al., 1995; Hoenig et al., 1997). These preliminary results point to the need for system changes to support prompt surgery and timely admission to the rehabilitation unit. If patients come to the rehabilitation units within shorter waiting periods after surgery, more optimal functional and cognitive outcomes may be achieved.

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The reported discharge location for the 31 patients further supports the proposition that older adults with CI are very likely to continue to live in the community after participating in rehabilitation services (Goldstein et al., 1997; Huusko et al., 2002). Eighty percent of the patient sample went home. Although 4 patients went to acute care for various reasons (pneumonia, peripheral vascular disease, which required an amputation, cerebral vascular accident while in rehabilitation, and congestive heart failure), they were all encouraged to return to the rehabilitation program. One patient did return and was later discharged to the community. Of the 2 patients with CI who went to LTC, one patient chose this discharge location, and the other patient was discharged to LTC in consultation with the family and the patient, as he could no longer care for himself at home. Both of these patients were on the rehabilitation unit for over 30 days and therefore they did not influence the shorter LOS of patients with CI. Preliminary evidence indicates that this care program assisted with allowing older adults to continue living in the community. This is in contrast to previous research by Diamond et al. (1996) and Lenze et al. (2004), who found that patients with CI were more likely to be discharged to a nursing home. The most probable reason for patients not being discharge to a nursing home is the expectation made clear to family members and patients at admission that the patients will be going back to their home. So, a strong family support most likely assists with the patients’ ability to return home. There are several likely explanations for the rehabilitation benefits of this program for older adults with CI. First, the model of rehabilitation care involved teaching staff strategies to care effectively for persons with dementia (McGilton et al., 2007). Second, both a physiatrist and geriatrician were available for the patients during their rehabilitation stay. Third, an APN was available to staff on all shifts to provide help with transferring principles of dementia care to the practice setting and to implement individualized care. Fourth, as Yu et al. (2005) suggested, the older adults in this study with mild and moderate CI had abilities to learn and retain physical activities that were not as compromised as those of older adults with severe CI. To implement this program of care in other facilities, resources are required to teach staff how to rehabilitate patients with CI, and experts are required to provide consultation. Becoming attuned to the patients’ needs and delivering care in individualized ways are paramount to the success of rehabilitating patients with CI. This feasibility study had three limitations. First, it employed a retrospective design using health care record abstraction, which is bound by time and history. In addition, the data collected with MMSE and FIM were from instruments administered by HCPs as part of assessments. However, reliability and responsiveness of the FIM have been shown even when HCPs collected and entered the data (Dodds et al., 1993; Jaglal, 2004). Lastly, the study size was small, which limits the ability to create predictive models to understand the influence of patient and system characteristics on rehabilitation outcomes. A future study with a large sample is planned to fully evaluate the patient-centered rehabilitation model of care (Fig. 5). Despite the limitations, our data provide preliminary evidence supporting the implementation of the ACTED model. 5. Conclusion Patients with CI can achieve functional independence after hip surgery despite their greater degree of baseline functional dependence. Moreover, such benefit need not demand more days of service. Clearly, our study demonstrated that more days of service are not required for patients with CI, which has often been

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an argument used to prevent their admission to rehabilitation. Creating a rehabilitation model of care that is accessible to all community dwelling elders, regardless of their cognitive status, who have fractured their hip not only optimizes resources, but will enhance the quality of life of older adults. LOS of patients on rehabilitation units can be impacted by a multitude of factors (Fig. 1) such as patient characteristics (most notably post-op delirium), system characteristics, and in-patient processes of care. Future studies with larger sample sizes will focus on determining predictors of LOS and rehabilitation efficiency. In this paper, preliminary evidence was presented that reflects the feasibility of such a program and provides some insights on how to refine the model. Acknowledgements Support for this research was provided by Toronto Rehabilitation Institute and from the Ontario Ministry of Health and LongTerm Care. The views expressed here do not necessarily reflect those of the ministry. We give special thanks to the health care professionals who implemented the new approach to care on their unit. Conflict of interest None. References Adunsky, A., Fleissig, Y., Levenkrohn, S., Arad, M., Noy, S., 2002. A comparative study of Mini-Mental Test, Clock Drawing task and Cognitive-FIM in evaluating functional outcome of elderly hip fracture patients. Clin. Rehabil. 16, 414–419. Arinzon, Z., Fidelman, Z., Zuta, A., Peisakh, A., Berner, Y.N., 2005. Functional recovery after hip fracture in old-old elderly patients. Arch. Gerontol. Geriatr. 40, 327– 336. Barnes, C., Conner, D., Ligault, L., Reznickova, N., Harrison-Felix, C., 2004. Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community. Arch. Phys. Med. Rehab. 85, 1602–1606. Beaupre, L.A., Cinats, J.G., Senthilselvan, A., Scharfenberger, A., Johnston, W., 2005. Does standardized rehabilitation and discharge planning improve functional recovery in elderly patients with hip fracture? Arch. Phys. Med. Rehab. 86, 2231–2239. Bitsch, M.S., Foss, N.B., Kristensen, B.B., Kehlet, H., 2006. Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program. Acta Anaesth. Scand. 50, 428–436. Cockrell, J.R., Folstein, M.F., 1988. Mini-Mental State Examination (MMSE). Psychopharmacol. Bull. 24, 689–692. Cummings, R.G., Klineberg, R., Katelaris, A., 1996. Cohort study of institutionalization after hip fracture. Aust. N. Z. J. Publ. Health 20, 579–582. Davis, A., Mahomed, N., Flannery, J., Brien, H., Saryeddine, T., 2006. Current status of musculoskeletal rehabilitation: an analysis of supply and provider viewpoints on future needs. ACRUE, UHN, GTA Rehab Network. Available at: http:// www.gtarehabnetwork/publications.asp. Diamond, P.T., Felsenthal, G., Macciocchi, S.N., Butler, D.H., Lally-Cassady, D., 1996. Effect of cognitive impairment on rehabilitation outcome. Am. J. Phys. Med. Rehab. 75, 40–43. Dodds, T.A., Martin, D.P., Stolov, W.C., 1993. Functional assessment scales: a study of persons with multiple sclerosis. Arch. Phys. Med. Rehab. 74, 531–536. Donabedian, A., 1966. Evaluating the quality of medical care. Milbank Q. 44 (Suppl.), 166–206. Espiritu, D.A., Rashid, H., Mast, B.T., Fitzgerald, J., Steinberg, J., Lichtenberg, P.A., 2001. Depression, cognitive impairment and function in Alzheimer’s disease. Int. J. Geriatr. Psychiatry 16, 1098–1103. 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. Fredman, L., Hawkes, W.G., Black, S., Bertrand, R.M., Magaziner, J., 2006. Elderly patients with hip fracture with positive affect have better functional recovery over 2 years. J. Am. Geriatr. Soc. 54, 1074–1081. Goldstein, F., Strasser, D.C., Woodard, J., Roberts, V., 1997. Functional outcomes of cognitively impaired hip fracture patients on a geriatric rehabilitation unit. J. Am. Geriatr. Soc. 45, 35–42. Gruber-Baldini, A., Zimmerman, S., Morrison, R., Grattan, L., Hebel, R., Dolan, M., 2003. Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow up. J. Am. Geriatr. Soc. 51, 1227–1236.

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