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Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation
Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2013;94:2373-80
ORIGINAL ARTICLE
Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation Laurence Seematter-Bagnoud, MD, MSc,a,b Estelle Le´cureux, PhD,c Ste´phane Rochat, MD, MM(ClinEPi),a Ste´fanie Monod, MD,a Constanze Lenoble-Hoskovec, PT,a Christophe J. Bu¨la, MDa From the aService of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, Lausanne University Hospital, Lausanne; b Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne; and cMedical Direction, Lausanne University Hospital, Lausanne, Switzerland.
Abstract Objective: To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation. Design: Observational study. Setting: Postacute rehabilitation facility. Participants: Patients (NZ2754) aged 65 years admitted over a 4-year period. Interventions: Not applicable. Main Outcome Measure: Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement. Results: Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean SD, 63.318.0 vs 59.624.7) and at discharge (mean SD, 86.810.4 vs 62.222.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]Z1.51; 95% confidence interval [CI], 1.16e1.98; PZ.003), women (adjusted ORZ1.24; 95% CI, 1.01e1.52; PZ.045), patients living alone (adjusted ORZ1.61; 95% CI, 1.31e1.98; P<.001), and patients without in-home help prior to admission (adjusted ORZ1.39; 95% CI, 1.15e1.69; PZ.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19e23) and those cognitively intact also had increased odds of functional recovery (adjusted ORZ1.56; 95% CI, 1.13e2.15; PZ.007; adjusted ORZ2.21; 95% CI, 1.67e2.93; P<.001, respectively). Conclusions: Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome. Archives of Physical Medicine and Rehabilitation 2013;94:2373-80 ª 2013 by the American Congress of Rehabilitation Medicine
In the context of the ever-increasing demand for postacute rehabilitation and the development of new modalities of rehabilitation care, such as in-home programs and day hospitals, previous studies have attempted to identify patients’ characteristics associated with functional recovery. Older age, depressive symptoms, nutritional status, and No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.
functional status before the event that resulted in acute hospital admission were those most often examined.1-7 In contrast, the relation between cognition and rehabilitation outcome remains less clear,8-11 even though 1 in 3 patients in the rehabilitation setting is cognitively impaired.12 Although several studies concluded that cognitive impairment was associated with limited functional recovery,8,13,14 several more recent studies, including a systematic review, reached different conclusions.5,10,11,15-18 In addition, the effect of cognitive impairment according to its severity has not been thoroughly examined or
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2374 quantified.2,5,10,11,19-21 Overall, results from these studies had limited generalizability to geriatric postacute rehabilitation because they focused on specific pathologies (eg, poststroke or hip fracture1,7,14,16) or a specific setting (eg, day hospital,5,15 home-based rehabilitation,4,22 skilled-nursing facility21), had a limited sample size, or did not take into account important potential confounders, such as comorbid illness or living situation.1,11,14,15,23-25 Two recent reviews, including 1 metaanalysis, concluded that there remains uncertainty about which patients may benefit most from inpatient geriatric postacute rehabilitation.11,26 A greater insight into the significance of these patients’ characteristics (their cognitive status in particular) and a better understanding of their potential influence on the rehabilitation process and outcome are important steps toward developing more appropriate and effective interventions. One long-term implication of optimizing functional recovery is that older patients who do not regain their previous functional status are more likely to need additional in-home services or to be admitted to a nursing home, further raising the pressure on overburdened health services. The objective of this study was to identify patients’ characteristics independently associated with functional recovery in older patients admitted to postacute rehabilitation. In particular, this study aimed to further investigate the specific relation between the severity of cognitive impairment and functional recovery. The hypotheses were that living situation, absence of depressive symptoms, and better functional status would be associated with better functional recovery. In addition, we hypothesized a negative incremental association between the severity of cognitive impairment and functional recovery.
Methods Study population and setting Patients aged 65 years admitted consecutively to general geriatric postacute rehabilitation in an academic medical center over a 4-year period (nZ3104) were included. Most patients were admitted from internal medicine (46%) and orthopedic surgery services (23%), and all lived at home before onset of the acute illness that brought them to the hospital.
L. Seematter-Bagnoud et al Functional recovery was defined as achieving at least 30% improvement in the Barthel Index score from admission compared with the maximum possible room for improvement. Patients who did not reach this threshold were considered as having achieved poor functional recovery. We chose a relative rather than absolute gain in order to avoid a ceiling effect (ie, patients with higher Barthel Index scores at admission have a lower potential gain than those with lower scores). The Barthel Index score was missing in 350 patients at admission and/or at discharge, leaving a sample of 2754 patients. Patients who died during the stay (nZ106) and those who were transferred to acute care because of complications (nZ243) were considered to have poor functional recovery.
Covariates Besides age and sex, adjustment variables were functional and affective status, comorbidity, functional status at admission, use of formal in-home care before admission, and living arrangement because these factors have been shown to influence functional recovery.10,16,22,23
Data analysis Baseline characteristics of the study groups were compared using the chi-square test for categorical variables and the Student t test for continuous variables. A 3-step multivariate logistic model was used to determine the association between patients’ characteristics and functional recovery. First, the model was adjusted for preadmission characteristics only (ie, age, sex, living arrangement, formal home care). Then, adjustment for comorbidity and cognitive and affective status was added. Finally, the last model additionally adjusted for functional status at admission. This final model is the only one presented in the results because there were no significant differences in the odd ratios (ORs) from the first to the third models. Statistical analyses were performed using STATA 12.0.a
Sensitivity analyses Data collection Data on demographics, medical, and mental status were collected on admission. Cognitive and affective status were assessed by the physician in charge of the patient using Folstein Mini-Mental State Examination (MMSE)13 and Yesavage 15-item Geriatric Depression Scale short-form,27 respectively. Medical diagnoses recorded in the discharge summary of the acute stay preceding rehabilitation were also collected.
Functional status measure and definition of functional recovery Functional performance was systematically evaluated by nursing staff within 48 hours of admission and again at discharge using the Barthel Index.28
List of abbreviations: MMSE Mini-Mental State Examination OR odds ratio
A sensitivity analysis was performed to examine the impact of increasing the cutoff to define functional recovery from 30% to 50% improvement (ie, achieving a gain of at least 50% in the difference between the Barthel Index score at admission and the maximum possible room for improvement). Then, for each cutoff defining functional recovery (30% and 50% improvement), sensitivity analyses were performed after excluding (1) patients with a Barthel Index score 90 at admission because of a possible ceiling effect (nZ336), (2) patients who died (nZ106), and (3) patients who were transferred to acute care during the rehabilitation stay (nZ243). The study was approved by the university review board, and patients provided oral informed consent.
Results Characteristics of the total study population are shown in table 1. The average patient was an 81-year-old woman who lived alone and received formal in-home care. Although most patients were cognitively intact, almost half suffered from 5 comorbidities. www.archives-pmr.org
Functional outcome in postacute rehabilitation Table 1
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Characteristics of the study population and comparisons according to rehabilitation outcome Functional Recovery*
Characteristics Age group <75y 75e84y 85y Women Living alone No formal home care prior to admission Comorbidityz Main acute diagnosisx Hip fracture/trauma Osteoarticular diseases (other fractures, joint disease, etc) Cardiovascular diseases Respiratory disease Cerebrovascular diseases Gastrointestinal diseases MMSE scorek 24 19e23 0e18 Depressive symptoms{ Barthel Index score at admission# (mean SD) Barthel Index score at discharge# (mean SD) Length of stay, median (interquartile range)
Total (NZ2754; 100%)
Yes (nZ1935; 70.3%)
No (nZ819; 29.7%)
21.2 43.6 35.2 70.0 60.3 44.8 46.0
22.6 44.3 33.1 72.7 63.8 47.0 44.1
18.0 41.9 40.2 63.4 52.1 39.4 50.3
23.4 21.6
25.8 23.8
17.8 16.3
13.7 6.2 5.3 4.8
13.8 5.8 4.5 4.6
13.6 7.1 7.3 5.3
70.4 17.3 12.3 11.1 62.220.3 79.518.9 22 (15e30)
75.0 16.1 9.0 10.8 63.318.0 86.810.4 22 (16e29)
59.3 20.2 20.5 11.8 59.624.7 62.222.9 21 (15e31)
Py .001
<.001 <.001 <.001 .003 <.001
<.001
.511 <.001 <.001 .040
NOTE. Values are percentages or as otherwise indicated. * Functional recovery defined as at least 30% improvement at discharge in the difference between maximal and admission scores on the Barthel Index. y Chi-square test (categorical variables), Student t test or rank-sum test (continuous variables). z More than 5 diagnoses at the end of acute stay preceding admission to the rehabilitation unit. x Available in patients admitted after an acute stay in the same academic medical center (nZ2005, 72.8%). k Scores range from 0 to 30, with higher score indicating higher cognitive function.27 { Geriatric Depression Scale, short form with 15 items.28 Screening for depression is positive if the score is 6. Patients with an MMSE score <19 (nZ375) are not asked to complete the Geriatric Depression Scale and are excluded from the comparison. # Score ranges from 0 to 100, with higher score indicating better mobility and functional performances.29 Barthel categories of the score correspond to quartiles of the score (first quartile: score 1e44, second quartile: score 45e59, third quartile: score 60e79, fourth quartile: score 80e100).
More than 80% of the study population were eventually discharged home after an average 3-week length of stay in rehabilitation.
Functional recovery Overall, the proportion of patients with an improved, unchanged, or worsened Barthel Index score at discharge was 85%, 10%, and 5%, respectively. More than two thirds (70.3%) of patients met the threshold for functional recovery, as defined in this study. Compared with the others, these latter patients were slightly younger, had fewer comorbidities, and had better cognitive status at admission than patients who did not recover (see table 1). Similarly, patients who achieved functional recovery had a better functional status at admission than those who did not, and this difference was larger at discharge. Regarding the main diagnosis during the acute care stay, hip fracture, trauma, and other orthopedic conditions were more frequent among patients who recovered, whereas patients who did not recover more often presented with a cerebrovascular disease. When stratifying patients into quartiles according to their Barthel Index score at admission, the proportion of patients www.archives-pmr.org
achieving functional recovery was highest among patients in the 2 intermediate quartiles of Barthel Index scores and least frequent among patients in the lowest and highest quartiles, following an inverted U-shape distribution (fig 1). Cognitive impairment showed a clear inverse and dosedependent association with functional recovery. The proportion of patients achieving functional recovery decreased steadily with increasing severity of cognitive impairment (fig 2). The combined influence of baseline functional and cognitive status on the probability of functional recovery at rehabilitation discharge is further illustrated in figure 3. There was a clear double gradient where the proportion of patients achieving functional recovery significantly increased across groups with increasing cognitive and functional performance at the time of admission to rehabilitation. The only exception was the group of patients with the highest Barthel Index score at admission, most likely because they had little room for functional improvement. Table 2 shows results from the fully adjusted multivariate model. Patients who were <75 years old, women, living alone, and without in-home help prior to admission remained at increased odds of functional recovery. In addition, compared with
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90
% patients with functional recovery
80 70
80.5
76.9
71.9
60 50 40
51.2
30 20 10 0 0-44
45-59
60-79
80+
Barthel Index score at admission Fig 1 Proportion of patients with functional recovery according to functional status (Barthel Index score) at admission. Abbreviations: CI, confidence interval; OR, odds ratio from multivariate analysis.
those with moderate-to-severe cognitive impairment (MMSE score <18), patients with mild-to-moderate impairment (MMSE score 19e23) and those cognitively intact also had increased odds of functional recovery. Finally, compared with patients in the highest quartile of the Barthel Index score at admission, those scoring in the 2 intermediate quartiles were about twice as likely to achieve functional recovery in multivariate analyses. In contrast, patients in the lowest quartile of the Barthel Index score had odds of recovery similar to those in the highest quartile. The interplay between functional and cognitive status on the odds of functional recovery observed in bivariate analysis was not confirmed in this multivariate model where the interaction term did not achieve statistical significance. All characteristics significantly associated with functional recovery in the first multivariate model (which only included information from prior to admission) remained significant when adding medical, and later, functional, adjustment variables.
Sensitivity analyses Sensitivity analyses using the 50% instead of 30% improvement cutoff to define functional recovery showed no major changes in the ORs. Similarly, results of analyses that excluded patients who died during the stay and those transferred to acute care were essentially the same. Finally, the exclusion of patients with high Barthel Index scores at admission (90) slightly changed the results for sex: even though the ORs were similar, the association was not statistically significant any more.
Discussion This study provides meaningful observations regarding the main factors associated with functional recovery during general geriatric postacute rehabilitation. It has several methodologic strengths, including its large sample size, which consisted of all www.archives-pmr.org
Functional outcome in postacute rehabilitation
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Fig 2 Proportion of patients with functional recovery according to MMSE score. Abbreviations: CI, confidence interval; OR, odds ratio from multivariate analysis.
patients consecutively admitted over a 4-year period, and the systematic collection of numerous covariates. An important contribution of this study is to provide detailed information on the incremental, dose-dependent, negative association between cognitive impairment and functional recovery when controlling for potential confounders. Although previous studies identified cognitive impairment as a negative predictor of rehabilitation outcome, a few of them were able to include patients with different levels of cognitive impairment and to stratify their sample accordingly.1,2,4,14 Furthermore, the association between mild-to-moderate cognitive impairment and rehabilitation outcome did not always reach statistical significance.5 Results from the current study extend this knowledge by showing that the odds of functional recovery were reduced by as much as 30% to 55% as the severity of cognitive impairment increased. However, the results also show that even in patients with severe impairment (MMSE <19), most (51.5%) still achieved functional recovery. These results add to previous works suggesting that cognitively impaired patients should not be denied rehabilitation services.5,7,14,16,21,29 It is likely that cognitively www.archives-pmr.org
impaired patients require tailored efforts and interventions to ensure they understand and recall instructions. They may need more rehabilitation resources and time and specific strategies to reach their maximal rehabilitation potential.21 This hypothesis is supported by the finding that the magnitude of cognitive impairment’s influence on functional recovery varies according to settings.7 Altogether, these results call for additional studies to investigate how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome. This study also provides original information on the complex, inverted U-shaped association between functional status at admission and functional recovery. The decreased likelihood of recovery in patients in the highest quartile of Barthel Index scores might well be explained by a ceiling effect, that is, those with better function at admission have less room for improvement. At the other end of the spectrum, several hypotheses could be proposed to explain the reduced probability of functional recovery. These range from the absence of rehabilitation potential in some patients to the provision of inappropriate, insufficient, or
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Fig 3
Table 2
Functional recovery according to functional and cognitive performances.
Predictors of functional recovery
Characteristic Age (y) <75 75e84 85 Women Living alone No formal home care prior to admission Comorbidityz MMSE scorex 24 19e23 0e18 Depressive symptomsk Barthel Index score at admission{ 80e100 60e79 45e59 0e44
Unadjusted OR*
95% CI
P
Adjusted ORy
95% CI
1.53 1.28 1 1.53 1.62 1.40 0.78
1.21e1.92 1.07e1.54 1 1.28e1.81 1.37e1.91 1.15e1.61 0.66e0.92
<.001 .008 1 <.001 <.001 <.001 .003
1.51 1.19 1 1.24 1.61 1.39 0.89
1.16e1.98 0.97e1.47 1 1.01e1.52 1.31e1.98 1.15e1.69 0.74e1.06
.045 <.001 .001 .196
2.88 1.82 1 0.78
2.27e3.67 1.36e2.43 1 0.60e0.94
<.001 <.001 1 .046
2.21 1.56 1 0.94
1.67e2.93 1.13e2.15 1 0.72e1.24
<.001 .007 1 .667
1 2.15 1.78 0.56
1 1.73e2.79 1.40e2.25 0.45e0.71
1 <.001 <.001 <.001
1 2.47 2.19 0.98
1 1.94e3.13 1.69e2.85 0.74e1.29
1 <.001 <.001 .882
P .003 .098 1
Abbreviations: CI, confidence interval; NA, not applicable; OR, odds ratio. * Resulting from bivariate logistic regression analysis. y Resulting from multivariate logistic regression analysis, including age, sex, living with others, in-home help prior to admission, comorbidity, cognitive and depressive status, and Barthel Index score at admission. z More than 5 diagnoses at the end of acute stay preceding admission to the rehabilitation unit. x Scores range from 0 to 30, with higher score indicating higher cognitive function.27 k Geriatric Depression Scale, short form with 15 items.28 Screening for depression is positive if the score is 6. { Scores ranges from 0 to 100, with higher score indicating better mobility and functional performances.29 Barthel Index categories of scores correspond to quartiles of score (first quartile: score 1e44, second quartile: score 45e59, third quartile: score 60e79, fourth quartile: score 80e100).
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Functional outcome in postacute rehabilitation ineffective interventions in others. Overall, these results point to a specific population that requires additional investigation to disentangle these issues and determine appropriateness of admitting some of these patients. Other patients’ characteristics examined in this study provide additional information about factors associated with functional recovery. Namely, older age, being a man, and living arrangement were significant, nonmodifiable predictors of lack of recovery, suggesting that patients with these characteristics should be identified as at-risk and strategies should be designed to support the rehabilitation process of these patients. The observation that older patients had decreased odds of functional recovery is not surprising and likely reflects different underlying diseases and health status compared with younger patients. Even though a measure of comorbidity was used (number of chronic diseases), this was rather crude and might not account for the severity of comorbid diseases making residual confounding likely. Interestingly, previous studies inconsistently found an independent negative effect of older age on rehabilitation outcome,2-4,10,21 when potential confounders are taken into account. Whenever present, it is often marginal1,3,30 and interpreted as the fact that the oldest patients require a larger amount of resources to achieve similar outcomes. Contrary to our initial hypothesis, we found no negative association between depressive symptoms and functional recovery. Differences in study samples, settings, and the instruments used to assess depressive symptoms may explain why this association has been inconsistently observed in previous studies.4,6,7 Finally, whereas family support is typically considered to be a positive influence on the rehabilitation process and discharge to the community,30-32 in this study, living alone independently was a strong predictor of functional recovery. A possible explanation is that older persons who live alone view their full functional recovery as more important because they cannot rely on somebody else to manage domestic tasks and face the possibility of nursing home admission in case they do not regain independence. Alternatively, those remaining at home alone until an advanced age might benefit from better psychological resources to face adverse events.
Study limitations Despite the fact that each patient admitted to this unit should benefit from equal care, we have no information about the delivery of rehabilitative care, for example the number of hours of physical therapy; therefore, we are not able to examine the association between care characteristics and functional recovery.
Conclusions This study shows that apart from several sociodemographic characteristics, cognition is the strongest factor that identifies patients less likely to improve during postacute rehabilitation. More specifically, cognitive performance showed a strong dosedependent negative effect on the probability of functional recovery. Nevertheless, about half of the patients having severe cognitive impairment still achieved functional recovery. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of cognitively impaired older persons and optimize their outcome. www.archives-pmr.org
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Keywords Aged; Health services; Recovery of function; Rehabilitation
Corresponding author Laurence Seematter-Bagnoud, MD, MSc, Service of Geriatric Medicine and Geriatric Rehabilitation, CHUV, CUTR Sylvana, Ch de Sylvana #10, CH-1066 Epalinges, Switzerland. E-mail address: [email protected].
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2380 14. Heruti RJ, Lusky A, Dankner R, et al. Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome. Arch Phys Med Rehabil 2002;83:742-9. 15. Hershkovitz A, Brill S. The association between patients’ cognitive status and rehabilitation outcome in a geriatric day hospital. Disabil Rehabil 2007;29:333-7. 16. Rolland Y, Pillard F, Lauwers-Cances V, Busquere F, Vellas B, Lafont C. Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment. Disabil Rehabil 2004;26:425-31. 17. Denkinger MD, Igl W, Jamour M, et al. Does functional change predict the course of improvement in geriatric inpatient rehabilitation? Clin Rehabil 2010;24:463-70. 18. Chen YM, Chuang YW, Liao SC, et al. Predictors of functional recovery (FR) for elderly hospitalized patients in a geriatric evaluation and management unit (GEMU) in Taiwan. Arch Gerontol Geriatr 2010;50(Suppl 1):S1-5. 19. Colombo M, Guaita A, Cottino M, Previdere G, Ferrari D, Vitali S. The impact of cognitive impairment on the rehabilitation process in geriatrics. Arch Gerontol Geriatr Suppl 2004;9:85-92. 20. Hershkovitz A, Kalandariov Z, Hermush V, Weiss R, Brill S. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil 2007;88:916-21. 21. Barnes C, Conner D, Legault L, Reznickova N, Harrison-Felix C. Rehabilitation outcomes in cognitively impaired patients admitted to skilled nursing facilities from the community. Arch Phys Med Rehabil 2004;85:1602-7. 22. Crotty M, Giles LC, Halbert J, Harding J, Miller M. Home versus day rehabilitation: a randomised controlled trial. Age Ageing 2008;37: 628-33.
L. Seematter-Bagnoud et al 23. Handoll HH, Cameron ID, Mak JC, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev 2009;(4):CD007125. 24. Sze KH, Wong E, Or KH, Lum CM, Woo J. Factors predicting stroke disability at discharge: a study of 793 Chinese. Arch Phys Med Rehabil 2000;81:876-80. 25. Halbert J, Crotty M, Whitehead C, et al. Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: a systematic review. J Rehabil Med 2007;39:507-12. 26. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, CloughGorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;340:c1718. 27. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5: 165-73. 28. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1965;14:61-5. 29. Luk JK, Chiu PK, Chu LW. Rehabilitation of older Chinese patients with different cognitive functions: how do they differ in outcome? Arch Phys Med Rehabil 2008;89:1714-9. 30. Hanks RA, Lichtenberg PA. Physical, psychological, and social outcomes in geriatric rehabilitation patients. Arch Phys Med Rehabil 1996;77:783-92. 31. Rudberg MA, Sager MA, Zhang J. Risk factors for nursing home use after hospitalization for medical illness. Gerontol A Biol Sci Med Sci 1996;51:M189-94. 32. Young Y, Resnick B. Don’t worry, be positive: improving functional recovery 1 year after hip fracture. Rehabil Nurs 2009;34:110-7.
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ORIGINAL ARTICLE
Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation Laurence Seematter-Bagnoud, MD, MSc,a,b Estelle Le´cureux, PhD,c Ste´phane Rochat, MD, MM(ClinEPi),a Ste´fanie Monod, MD,a Constanze Lenoble-Hoskovec, PT,a Christophe J. Bu¨la, MDa From the aService of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, Lausanne University Hospital, Lausanne; b Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne; and cMedical Direction, Lausanne University Hospital, Lausanne, Switzerland.
Abstract Objective: To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation. Design: Observational study. Setting: Postacute rehabilitation facility. Participants: Patients (NZ2754) aged 65 years admitted over a 4-year period. Interventions: Not applicable. Main Outcome Measure: Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement. Results: Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean SD, 63.318.0 vs 59.624.7) and at discharge (mean SD, 86.810.4 vs 62.222.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]Z1.51; 95% confidence interval [CI], 1.16e1.98; PZ.003), women (adjusted ORZ1.24; 95% CI, 1.01e1.52; PZ.045), patients living alone (adjusted ORZ1.61; 95% CI, 1.31e1.98; P<.001), and patients without in-home help prior to admission (adjusted ORZ1.39; 95% CI, 1.15e1.69; PZ.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19e23) and those cognitively intact also had increased odds of functional recovery (adjusted ORZ1.56; 95% CI, 1.13e2.15; PZ.007; adjusted ORZ2.21; 95% CI, 1.67e2.93; P<.001, respectively). Conclusions: Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome. Archives of Physical Medicine and Rehabilitation 2013;94:2373-80 ª 2013 by the American Congress of Rehabilitation Medicine
In the context of the ever-increasing demand for postacute rehabilitation and the development of new modalities of rehabilitation care, such as in-home programs and day hospitals, previous studies have attempted to identify patients’ characteristics associated with functional recovery. Older age, depressive symptoms, nutritional status, and No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.
functional status before the event that resulted in acute hospital admission were those most often examined.1-7 In contrast, the relation between cognition and rehabilitation outcome remains less clear,8-11 even though 1 in 3 patients in the rehabilitation setting is cognitively impaired.12 Although several studies concluded that cognitive impairment was associated with limited functional recovery,8,13,14 several more recent studies, including a systematic review, reached different conclusions.5,10,11,15-18 In addition, the effect of cognitive impairment according to its severity has not been thoroughly examined or
0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2013.06.024
2374 quantified.2,5,10,11,19-21 Overall, results from these studies had limited generalizability to geriatric postacute rehabilitation because they focused on specific pathologies (eg, poststroke or hip fracture1,7,14,16) or a specific setting (eg, day hospital,5,15 home-based rehabilitation,4,22 skilled-nursing facility21), had a limited sample size, or did not take into account important potential confounders, such as comorbid illness or living situation.1,11,14,15,23-25 Two recent reviews, including 1 metaanalysis, concluded that there remains uncertainty about which patients may benefit most from inpatient geriatric postacute rehabilitation.11,26 A greater insight into the significance of these patients’ characteristics (their cognitive status in particular) and a better understanding of their potential influence on the rehabilitation process and outcome are important steps toward developing more appropriate and effective interventions. One long-term implication of optimizing functional recovery is that older patients who do not regain their previous functional status are more likely to need additional in-home services or to be admitted to a nursing home, further raising the pressure on overburdened health services. The objective of this study was to identify patients’ characteristics independently associated with functional recovery in older patients admitted to postacute rehabilitation. In particular, this study aimed to further investigate the specific relation between the severity of cognitive impairment and functional recovery. The hypotheses were that living situation, absence of depressive symptoms, and better functional status would be associated with better functional recovery. In addition, we hypothesized a negative incremental association between the severity of cognitive impairment and functional recovery.
Methods Study population and setting Patients aged 65 years admitted consecutively to general geriatric postacute rehabilitation in an academic medical center over a 4-year period (nZ3104) were included. Most patients were admitted from internal medicine (46%) and orthopedic surgery services (23%), and all lived at home before onset of the acute illness that brought them to the hospital.
L. Seematter-Bagnoud et al Functional recovery was defined as achieving at least 30% improvement in the Barthel Index score from admission compared with the maximum possible room for improvement. Patients who did not reach this threshold were considered as having achieved poor functional recovery. We chose a relative rather than absolute gain in order to avoid a ceiling effect (ie, patients with higher Barthel Index scores at admission have a lower potential gain than those with lower scores). The Barthel Index score was missing in 350 patients at admission and/or at discharge, leaving a sample of 2754 patients. Patients who died during the stay (nZ106) and those who were transferred to acute care because of complications (nZ243) were considered to have poor functional recovery.
Covariates Besides age and sex, adjustment variables were functional and affective status, comorbidity, functional status at admission, use of formal in-home care before admission, and living arrangement because these factors have been shown to influence functional recovery.10,16,22,23
Data analysis Baseline characteristics of the study groups were compared using the chi-square test for categorical variables and the Student t test for continuous variables. A 3-step multivariate logistic model was used to determine the association between patients’ characteristics and functional recovery. First, the model was adjusted for preadmission characteristics only (ie, age, sex, living arrangement, formal home care). Then, adjustment for comorbidity and cognitive and affective status was added. Finally, the last model additionally adjusted for functional status at admission. This final model is the only one presented in the results because there were no significant differences in the odd ratios (ORs) from the first to the third models. Statistical analyses were performed using STATA 12.0.a
Sensitivity analyses Data collection Data on demographics, medical, and mental status were collected on admission. Cognitive and affective status were assessed by the physician in charge of the patient using Folstein Mini-Mental State Examination (MMSE)13 and Yesavage 15-item Geriatric Depression Scale short-form,27 respectively. Medical diagnoses recorded in the discharge summary of the acute stay preceding rehabilitation were also collected.
Functional status measure and definition of functional recovery Functional performance was systematically evaluated by nursing staff within 48 hours of admission and again at discharge using the Barthel Index.28
List of abbreviations: MMSE Mini-Mental State Examination OR odds ratio
A sensitivity analysis was performed to examine the impact of increasing the cutoff to define functional recovery from 30% to 50% improvement (ie, achieving a gain of at least 50% in the difference between the Barthel Index score at admission and the maximum possible room for improvement). Then, for each cutoff defining functional recovery (30% and 50% improvement), sensitivity analyses were performed after excluding (1) patients with a Barthel Index score 90 at admission because of a possible ceiling effect (nZ336), (2) patients who died (nZ106), and (3) patients who were transferred to acute care during the rehabilitation stay (nZ243). The study was approved by the university review board, and patients provided oral informed consent.
Results Characteristics of the total study population are shown in table 1. The average patient was an 81-year-old woman who lived alone and received formal in-home care. Although most patients were cognitively intact, almost half suffered from 5 comorbidities. www.archives-pmr.org
Functional outcome in postacute rehabilitation Table 1
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Characteristics of the study population and comparisons according to rehabilitation outcome Functional Recovery*
Characteristics Age group <75y 75e84y 85y Women Living alone No formal home care prior to admission Comorbidityz Main acute diagnosisx Hip fracture/trauma Osteoarticular diseases (other fractures, joint disease, etc) Cardiovascular diseases Respiratory disease Cerebrovascular diseases Gastrointestinal diseases MMSE scorek 24 19e23 0e18 Depressive symptoms{ Barthel Index score at admission# (mean SD) Barthel Index score at discharge# (mean SD) Length of stay, median (interquartile range)
Total (NZ2754; 100%)
Yes (nZ1935; 70.3%)
No (nZ819; 29.7%)
21.2 43.6 35.2 70.0 60.3 44.8 46.0
22.6 44.3 33.1 72.7 63.8 47.0 44.1
18.0 41.9 40.2 63.4 52.1 39.4 50.3
23.4 21.6
25.8 23.8
17.8 16.3
13.7 6.2 5.3 4.8
13.8 5.8 4.5 4.6
13.6 7.1 7.3 5.3
70.4 17.3 12.3 11.1 62.220.3 79.518.9 22 (15e30)
75.0 16.1 9.0 10.8 63.318.0 86.810.4 22 (16e29)
59.3 20.2 20.5 11.8 59.624.7 62.222.9 21 (15e31)
Py .001
<.001 <.001 <.001 .003 <.001
<.001
.511 <.001 <.001 .040
NOTE. Values are percentages or as otherwise indicated. * Functional recovery defined as at least 30% improvement at discharge in the difference between maximal and admission scores on the Barthel Index. y Chi-square test (categorical variables), Student t test or rank-sum test (continuous variables). z More than 5 diagnoses at the end of acute stay preceding admission to the rehabilitation unit. x Available in patients admitted after an acute stay in the same academic medical center (nZ2005, 72.8%). k Scores range from 0 to 30, with higher score indicating higher cognitive function.27 { Geriatric Depression Scale, short form with 15 items.28 Screening for depression is positive if the score is 6. Patients with an MMSE score <19 (nZ375) are not asked to complete the Geriatric Depression Scale and are excluded from the comparison. # Score ranges from 0 to 100, with higher score indicating better mobility and functional performances.29 Barthel categories of the score correspond to quartiles of the score (first quartile: score 1e44, second quartile: score 45e59, third quartile: score 60e79, fourth quartile: score 80e100).
More than 80% of the study population were eventually discharged home after an average 3-week length of stay in rehabilitation.
Functional recovery Overall, the proportion of patients with an improved, unchanged, or worsened Barthel Index score at discharge was 85%, 10%, and 5%, respectively. More than two thirds (70.3%) of patients met the threshold for functional recovery, as defined in this study. Compared with the others, these latter patients were slightly younger, had fewer comorbidities, and had better cognitive status at admission than patients who did not recover (see table 1). Similarly, patients who achieved functional recovery had a better functional status at admission than those who did not, and this difference was larger at discharge. Regarding the main diagnosis during the acute care stay, hip fracture, trauma, and other orthopedic conditions were more frequent among patients who recovered, whereas patients who did not recover more often presented with a cerebrovascular disease. When stratifying patients into quartiles according to their Barthel Index score at admission, the proportion of patients www.archives-pmr.org
achieving functional recovery was highest among patients in the 2 intermediate quartiles of Barthel Index scores and least frequent among patients in the lowest and highest quartiles, following an inverted U-shape distribution (fig 1). Cognitive impairment showed a clear inverse and dosedependent association with functional recovery. The proportion of patients achieving functional recovery decreased steadily with increasing severity of cognitive impairment (fig 2). The combined influence of baseline functional and cognitive status on the probability of functional recovery at rehabilitation discharge is further illustrated in figure 3. There was a clear double gradient where the proportion of patients achieving functional recovery significantly increased across groups with increasing cognitive and functional performance at the time of admission to rehabilitation. The only exception was the group of patients with the highest Barthel Index score at admission, most likely because they had little room for functional improvement. Table 2 shows results from the fully adjusted multivariate model. Patients who were <75 years old, women, living alone, and without in-home help prior to admission remained at increased odds of functional recovery. In addition, compared with
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90
% patients with functional recovery
80 70
80.5
76.9
71.9
60 50 40
51.2
30 20 10 0 0-44
45-59
60-79
80+
Barthel Index score at admission Fig 1 Proportion of patients with functional recovery according to functional status (Barthel Index score) at admission. Abbreviations: CI, confidence interval; OR, odds ratio from multivariate analysis.
those with moderate-to-severe cognitive impairment (MMSE score <18), patients with mild-to-moderate impairment (MMSE score 19e23) and those cognitively intact also had increased odds of functional recovery. Finally, compared with patients in the highest quartile of the Barthel Index score at admission, those scoring in the 2 intermediate quartiles were about twice as likely to achieve functional recovery in multivariate analyses. In contrast, patients in the lowest quartile of the Barthel Index score had odds of recovery similar to those in the highest quartile. The interplay between functional and cognitive status on the odds of functional recovery observed in bivariate analysis was not confirmed in this multivariate model where the interaction term did not achieve statistical significance. All characteristics significantly associated with functional recovery in the first multivariate model (which only included information from prior to admission) remained significant when adding medical, and later, functional, adjustment variables.
Sensitivity analyses Sensitivity analyses using the 50% instead of 30% improvement cutoff to define functional recovery showed no major changes in the ORs. Similarly, results of analyses that excluded patients who died during the stay and those transferred to acute care were essentially the same. Finally, the exclusion of patients with high Barthel Index scores at admission (90) slightly changed the results for sex: even though the ORs were similar, the association was not statistically significant any more.
Discussion This study provides meaningful observations regarding the main factors associated with functional recovery during general geriatric postacute rehabilitation. It has several methodologic strengths, including its large sample size, which consisted of all www.archives-pmr.org
Functional outcome in postacute rehabilitation
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Fig 2 Proportion of patients with functional recovery according to MMSE score. Abbreviations: CI, confidence interval; OR, odds ratio from multivariate analysis.
patients consecutively admitted over a 4-year period, and the systematic collection of numerous covariates. An important contribution of this study is to provide detailed information on the incremental, dose-dependent, negative association between cognitive impairment and functional recovery when controlling for potential confounders. Although previous studies identified cognitive impairment as a negative predictor of rehabilitation outcome, a few of them were able to include patients with different levels of cognitive impairment and to stratify their sample accordingly.1,2,4,14 Furthermore, the association between mild-to-moderate cognitive impairment and rehabilitation outcome did not always reach statistical significance.5 Results from the current study extend this knowledge by showing that the odds of functional recovery were reduced by as much as 30% to 55% as the severity of cognitive impairment increased. However, the results also show that even in patients with severe impairment (MMSE <19), most (51.5%) still achieved functional recovery. These results add to previous works suggesting that cognitively impaired patients should not be denied rehabilitation services.5,7,14,16,21,29 It is likely that cognitively www.archives-pmr.org
impaired patients require tailored efforts and interventions to ensure they understand and recall instructions. They may need more rehabilitation resources and time and specific strategies to reach their maximal rehabilitation potential.21 This hypothesis is supported by the finding that the magnitude of cognitive impairment’s influence on functional recovery varies according to settings.7 Altogether, these results call for additional studies to investigate how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome. This study also provides original information on the complex, inverted U-shaped association between functional status at admission and functional recovery. The decreased likelihood of recovery in patients in the highest quartile of Barthel Index scores might well be explained by a ceiling effect, that is, those with better function at admission have less room for improvement. At the other end of the spectrum, several hypotheses could be proposed to explain the reduced probability of functional recovery. These range from the absence of rehabilitation potential in some patients to the provision of inappropriate, insufficient, or
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Fig 3
Table 2
Functional recovery according to functional and cognitive performances.
Predictors of functional recovery
Characteristic Age (y) <75 75e84 85 Women Living alone No formal home care prior to admission Comorbidityz MMSE scorex 24 19e23 0e18 Depressive symptomsk Barthel Index score at admission{ 80e100 60e79 45e59 0e44
Unadjusted OR*
95% CI
P
Adjusted ORy
95% CI
1.53 1.28 1 1.53 1.62 1.40 0.78
1.21e1.92 1.07e1.54 1 1.28e1.81 1.37e1.91 1.15e1.61 0.66e0.92
<.001 .008 1 <.001 <.001 <.001 .003
1.51 1.19 1 1.24 1.61 1.39 0.89
1.16e1.98 0.97e1.47 1 1.01e1.52 1.31e1.98 1.15e1.69 0.74e1.06
.045 <.001 .001 .196
2.88 1.82 1 0.78
2.27e3.67 1.36e2.43 1 0.60e0.94
<.001 <.001 1 .046
2.21 1.56 1 0.94
1.67e2.93 1.13e2.15 1 0.72e1.24
<.001 .007 1 .667
1 2.15 1.78 0.56
1 1.73e2.79 1.40e2.25 0.45e0.71
1 <.001 <.001 <.001
1 2.47 2.19 0.98
1 1.94e3.13 1.69e2.85 0.74e1.29
1 <.001 <.001 .882
P .003 .098 1
Abbreviations: CI, confidence interval; NA, not applicable; OR, odds ratio. * Resulting from bivariate logistic regression analysis. y Resulting from multivariate logistic regression analysis, including age, sex, living with others, in-home help prior to admission, comorbidity, cognitive and depressive status, and Barthel Index score at admission. z More than 5 diagnoses at the end of acute stay preceding admission to the rehabilitation unit. x Scores range from 0 to 30, with higher score indicating higher cognitive function.27 k Geriatric Depression Scale, short form with 15 items.28 Screening for depression is positive if the score is 6. { Scores ranges from 0 to 100, with higher score indicating better mobility and functional performances.29 Barthel Index categories of scores correspond to quartiles of score (first quartile: score 1e44, second quartile: score 45e59, third quartile: score 60e79, fourth quartile: score 80e100).
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Functional outcome in postacute rehabilitation ineffective interventions in others. Overall, these results point to a specific population that requires additional investigation to disentangle these issues and determine appropriateness of admitting some of these patients. Other patients’ characteristics examined in this study provide additional information about factors associated with functional recovery. Namely, older age, being a man, and living arrangement were significant, nonmodifiable predictors of lack of recovery, suggesting that patients with these characteristics should be identified as at-risk and strategies should be designed to support the rehabilitation process of these patients. The observation that older patients had decreased odds of functional recovery is not surprising and likely reflects different underlying diseases and health status compared with younger patients. Even though a measure of comorbidity was used (number of chronic diseases), this was rather crude and might not account for the severity of comorbid diseases making residual confounding likely. Interestingly, previous studies inconsistently found an independent negative effect of older age on rehabilitation outcome,2-4,10,21 when potential confounders are taken into account. Whenever present, it is often marginal1,3,30 and interpreted as the fact that the oldest patients require a larger amount of resources to achieve similar outcomes. Contrary to our initial hypothesis, we found no negative association between depressive symptoms and functional recovery. Differences in study samples, settings, and the instruments used to assess depressive symptoms may explain why this association has been inconsistently observed in previous studies.4,6,7 Finally, whereas family support is typically considered to be a positive influence on the rehabilitation process and discharge to the community,30-32 in this study, living alone independently was a strong predictor of functional recovery. A possible explanation is that older persons who live alone view their full functional recovery as more important because they cannot rely on somebody else to manage domestic tasks and face the possibility of nursing home admission in case they do not regain independence. Alternatively, those remaining at home alone until an advanced age might benefit from better psychological resources to face adverse events.
Study limitations Despite the fact that each patient admitted to this unit should benefit from equal care, we have no information about the delivery of rehabilitative care, for example the number of hours of physical therapy; therefore, we are not able to examine the association between care characteristics and functional recovery.
Conclusions This study shows that apart from several sociodemographic characteristics, cognition is the strongest factor that identifies patients less likely to improve during postacute rehabilitation. More specifically, cognitive performance showed a strong dosedependent negative effect on the probability of functional recovery. Nevertheless, about half of the patients having severe cognitive impairment still achieved functional recovery. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of cognitively impaired older persons and optimize their outcome. www.archives-pmr.org
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Supplier a. StataCorp, 4905 Lakeway Dr, College Station, TX 77845.
Keywords Aged; Health services; Recovery of function; Rehabilitation
Corresponding author Laurence Seematter-Bagnoud, MD, MSc, Service of Geriatric Medicine and Geriatric Rehabilitation, CHUV, CUTR Sylvana, Ch de Sylvana #10, CH-1066 Epalinges, Switzerland. E-mail address: [email protected].
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