Predictors of outcome of rehabilitation of elderly stroke patients in a geriatric ward

Accuracy of the Australian National Sub-Acute and Non-Acute Patient Classification in predicting rehabilitation length of stay for stroke survivors who are ≥65 years of age and have lateropulsion

BACKGROUND

Lateropulsion is a common impairment after stroke. Regardless of stroke severity, functional recovery is slower in people with lateropulsion, resulting in requirement for longer rehabilitation duration. In Australia, inpatient rehabilitation funding is determined via the Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP). AN-SNAP class is determined using age, diagnosis, weighted Functional Independence Measure (FIM) motor score, and FIM cognitive score.

OBJECTIVES

To explore accuracy of the AN-SNAP to predict length of stay (LOS) for people with poststroke lateropulsion.

METHODS

A retrospective database audit was undertaken. AN-SNAP predicted LOS for each participant was calculated based on 2019 calendar year national benchmarks. A multivariable linear regression model estimated mean differences in reported LOS and AN-SNAP predicted LOS after adjusting for lateropulsion severity (Four Point Pusher Score). A separate logistic regression model assessed whether FIM change during admission was associated with reported LOS exceeding AN-SNAP predicted LOS.

RESULTS

Data were available from 1126 admissions. Reported LOS exceeding AN-SNAP predicted LOS was associated with greater lateropulsion severity on admission. Where AN-SNAP predicted LOS was longer, those with no lateropulsion on admission showed shorter reported than predicted LOS. Greater improvement in FIM during rehabilitation was associated with increased odds of reported LOS exceeding AN-SNAP predicted LOS (OR 1.02, 95%CI 1.01-1.03, p < .001).

CONCLUSIONS

Inclusion of a measure of poststroke lateropulsion in the AN-SNAP classification model would result in more accurate LOS predictions to inform funding. Costs of longer rehabilitation LOS may be countered by optimized long-term physical function, reducing requirement for ongoing care.

Value of Barthel, PLAN and NIHSS scores for predicting the death of patients with acute ischemic stroke during their 5-year follow-up

OBJECTIVE

This study aimed to investigate the value of Barthel, PLAN, and NIHSS scores for predicting death in the 5-year follow-up after patients with AIS are discharged and find a simple and convenient predictive scale.

METHODS

Data were prospectively collected from 678 patients with AIS. Patients' death after 5 years of follow-up was considered the final event. The predictors of death were examined through single-factor and multivariate analysis. The receiver operating characteristic curve (ROC) of the patients' Barthel, PLAN, and NIHSS scores was drawn, and the area under the curve (AUC) was calculated. Differences in the predictive power of the three scales were compared using MedCalc. The goodness of fit between predictive and actual models was evaluated with the Hosmer-Lemeshow method.

RESULTS

Multivariate analysis suggested that the BI score was an independent predictor of death from AIS in the 5-year follow-up. The Barthel, PLAN, and NIHSS scale scores predicted the 5-year mortality AUC values of AIS were 0.687 [95% CI, (0.649-0.722)], 0.621 [95% CI, (0.583-0.659)], 0.637 [95% CI, (0.599-0.674)], the Hosmer-Lemeshow test revealed P > 0.05, indicating that the three models had a good fit. In pairwise comparison, the AUC value of the BI score was significantly greater than that of the NIHSS scores (Pc = 0.0189). BI and PLAN scores were very close to statistical significance (Pc = 0.0513). However, PLAN and NIHSS scores had no significant differences (Pc = 1.7493).

CONCLUSION

Simple BI scores had a high predictive value for the death of Chinese patients with AIS within 5 years.

Post-stroke lateropulsion and rehabilitation outcomes: a retrospective analysis

PURPOSE

A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure - FIM) and lateropulsion severity (Four-Point Pusher Score - 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation.

METHODS

Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005-2018) were analysed using multivariable regression models.

RESULTS

Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p < 0.001).

CONCLUSION

Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement.Implications for RehabilitationWhile people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation.Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Factors Influencing Functional Outcome at Discharge: A Retrospective Study on a Large Sample of Patients Admitted to an Intensive Rehabilitation Unit

OBJECTIVE

Functional outcome represents the most central objective of rehabilitation programs. Understanding which factors could affect functional status at discharge is crucial for the planning of appropriate treatments in both neurologic and orthopedic patients. The aim of this study was to investigate which clinical and demographic variables, collected at the patient's admission, could influence the functional outcome, assessed by the modified Barthel Index (mBI), at discharge.

DESIGN

A retrospective study was conducted on a large cohort (n = 3548) of orthopedic and neurologic patients. Functional, demographic, and clinical records at patient admission and mBI score at discharge were collected. General linear model analysis was performed to assess the influence of these variables on functional outcome at discharge.

RESULTS

The results reported a significant effect of mBI score at admission (P < 0.0001), age (P < 0.0001), and time from the acute event (P < 0.0001) on mBI score at discharge. Moreover, the disease type (neurologic or orthopedic) adjusted by sex (male or female) and presence of different impairments (cognitive and behavioral impairments) and complications (hypertension and cardiovascular diseases) significantly influenced mBI score at discharge (P < 0.05) (R2 = 0.497). No significant interactions between other factors were found (P > 0.05).

CONCLUSION

Several prognostic factors should be considered when planning an appropriate tailored rehabilitation program.

Factors associated with successful home discharge after inpatient rehabilitation in frail older stroke patients

Background

Stroke is a highly prevalent disease among older people and can have a major impact on daily functioning and quality of life. When community-dwelling older people are hospitalized due to stroke, discharge to an intermediate care facility for geriatric rehabilitation is indicated when return to the previous living situation is expected but not yet possible. However, a substantial proportion is still unable to return home after discharge and has to be admitted to a residential care setting. This study aims to identify which factors are associated with home discharge after inpatient rehabilitation among frail and multimorbid older stroke patients.

Methods

This study is a longitudinal cohort study among 92 community-dwelling stroke patients aged 65 years or over. All patients were admitted to one of eight participating intermediate care facilities for geriatric rehabilitation, under the expectation to return home after rehabilitation. We examined whether 16 potentially relevant factors (age; sex; household situation before admission; stroke history; cardiovascular disorders; diabetes mellitus; multimorbidity; cognitive disability; neglect; apraxia; dysphagia; urinary and bowel incontinence; emotional problems; sitting balance; daily activity level; and independence in activities of daily living) measured at admission were associated with discharge to the former living situation. Logistic regression analysis was used for statistical analysis.

Results

Mean age of the patients was 79.0 years (SD 6.4) and 51.1% was female. A total of 71 patients (77.1%) were discharged to the former living situation within 6 months after the start of geriatric rehabilitation. Of the 16 factors analysed, only a higher level of independence in activities of daily living at admission was significantly associated with home discharge.

Conclusions

Our study shows that the vast majority of previously identified factors predicting home discharge among stroke patients, could not predict home discharge among a group of frail and multimorbid older persons admitted to geriatric rehabilitation. Only a higher level of independence in activities of daily living at admission was significantly related to home discharge. Additional insight in other factors that might predict home discharge after geriatric rehabilitation among this specific group of frail older stroke patients, is needed. Trial registration: ISRCTN ISRCTN62286281. Registered 19-3-2010.

Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges

There have been many advances in management of cerebrovascular diseases. However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This review summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation units, and types of rehabilitation resources and services available in Singapore. We also present the challenges faced by the elderly stroke survivors in the local setting and propose strategies to overcome the barriers to rehabilitation in this aging population.

Effective Measurement of the Functional Progress of Stroke Clients

There is a need for occupational therapists to establish a range of outcome measures that can measure change effectively. The aim of this study was to identify effective methods of measuring the functional performance of individuals who had experienced a stroke and had been discharged from a rehabilitation ward. Measures with recorded validity and reliability and in clinical use were selected. The measures were the Barthel Index (Shah version), Nottingham Extended Activities of Daily Living scale, Motricity Index (Upper and Lower Limb), Rivermead Mobility Index and Nine-Hole Peg Test. Assessments were carried out at the point of discharge from hospital and 6 months later.

Responsiveness was analysed using effect size and relative efficiency statistics. The practicality (feasibility) was established by comparing completion rates. The Nottingham Extended Activities of Daily Living scale and the Rivermead Mobility Index were found to be more responsive than the Barthel Index and Lower Limb Motricity Index respectively and to be practical after discharge from hospital. The Nine-Hole Peg Test was found to be more responsive than the Upper Limb Motricity Index but less practical. The analysis suggested that some measures are more suitable than others for tracking change in function after discharge from hospital for a wide case mix of people who have experienced a stroke.

Urinary incontinence as a predictor of death after new-onset stroke: a meta-analysis

BACKGROUND AND PURPOSE

Urinary incontinence (UI) could be an indicator of increased mortality after new-onset stroke. The aim of the present meta-analysis was to characterize this association.

METHODS

A systematic search retrieved all studies exploring the post-stroke period and comparing death among patients suffering from UI with those without UI. Hazard ratios (HRs) were extracted or estimated from the published proportion of deaths. Various meta-analyses pooled unadjusted HRs, HRs adjusted for confounders and HRs stratified by subgroups of strokes (ischaemic or haemorrhagic), using models with random effects. Heterogeneity was explored through stratification of studies and meta-regression of predefined parameters.

RESULTS

The meta-analysis included 24 studies. UI increased the mortality among the general stroke patients in pooled unadjusted (HR, 5.1; 95% CI, 3.9-6.7) and adjusted (HR, 2.2; 95% CI, 1.8-2.7) analyses. This association was also found among ischaemic (HR, 8.5; 95% CI, 4.6-15.7) and haemorrhagic (HR, 3.9; 95% CI, 1.4-11.3) subgroups of strokes. Studies including indwelling catheters, published more than 10 years ago or with the highest quality on the selection criteria of the Newcastle-Ottawa Quality Assessment scale were associated with a greater effect of UI on mortality. Funnel plots showed a clear asymmetry for adjusted associations. After correcting for this potential publication bias, the pooled HRs still demonstrated a positive association between UI and mortality.

CONCLUSIONS

Urinary incontinence indicates high risk of death after a new-onset stroke. Validity of the analyses on adjusted models is limited by an obvious publication bias.

A randomized trial evaluation of the Oswestry Standing Frame for patients after stroke

Background: Standing is believed to have benefits in addressing motor and sensory impairments after stroke. One device to facilitate standing for severely disabled patients is the Oswestry Standing Frame.

Objective: To evaluate the effectiveness of the Oswestry Standing Frame for severely disabled stroke patients.

Design: A single centre, randomized controlled trial.

Setting: An inpatient stroke rehabilitation unit.

Subjects: Patients were recruited if they had a clinical diagnosis of stroke, were medically stable and unable to achieve any score on the Trunk Control Test or unable to stand in mid-line without the assistance of two therapists.

Intervention: The intervention (n=71) and control (n=69) groups both received usual stroke unit care but the intervention group also received a minimum of 14 consecutive days' treatment using the standing frame.

Main outcome measures: The primary outcome measure was the Rivermead Mobility Index (RMI). Secondary measures included the Barthel Index; the Rivermead Motor Assessment; the balanced sitting and sitting to standing components of the Motor Assessment Scale; the Trunk Control Test and the Hospital Anxiety and Depression Scale. Blind assessment was undertaken at baseline, six weeks, 12 weeks and six months post stroke. Information on resource use was also collected.

Results: There was no statistically significant difference between groups in any of the outcome measures or for resource use. Mann-Whitney U-tests for the RMI change from baseline scores to six weeks, 12 weeks and six months post stroke were p=0.310; p=0.970 and p=0.282, respectively.

Conclusion: Use of the Oswestry Standing Frame did not improve clinical outcome or provide resource savings for this severely disabled patient group.

The Stroke unit Discharge Guideline, a prognostic framework for the discharge outcome from the hospital stroke unit. A prospective cohort study

Objective: To investigate which factors during the subacute phase post stroke have predictive value for the discharge outcome from the hospital stroke unit.

Methods: In a prospective cohort of 338 patients admitted to a hospital stroke unit 26 potentially prognostic factors, arranged in clinical and social subdomains, were scored and analysed by binary logistic regression analysis. The outcome of the research consisted of the various discharge destinations.

Results: The overall predictive value of the discharge model is high (91%). Factors predictive of a poor discharge outcome are a low Barthel Index score (odds ratio (OR) 0.78 per point increase; p &lt 0.001), a poor sitting balance (OR 5.96; p &lt 0.001), a depression (OR 7.23; p &lt 0.001), poststroke cognitive disability (OR 3.51; p = 0.007) and older age (OR 1.05 per point increase; p = 0.008). If present, a personality disorder, premorbid cognitive disability and premorbid functional disability all show a tendency towards poor discharge outcome, but these factors did not reach statistical significance in this study, possibly due to their low prevalence. Readiness of the family circle to provide support was only significant in the univariate analysis.

Conclusions: Somatic, biological and psychological factors predict the discharge outcome. Functional and cognitive factors play a decisive role in the future ability to live independently after a stroke. The prognostic importance of social factors could not be demonstrated. Urinary incontinence did not emerge as a prognostic factor. This is in contrast to scientific findings till now, but in accordance with clinical experience.

Interventions for adult family carers of people who have had a stroke: a systematic review

Objective: A systematic review of the effectiveness of interventions for adult family carers of people with stroke, and an exploratory examination of the relationship between the conceptual basis of these interventions and their effectiveness.

Data sources: Seventeen electronic databases and grey literature sources were searched, including ASSIA, BNI, Cochrane Library, CINAHL, EMBASE, MEDLINE, PsycINFO, Social Science Citation Index and the Science Citation Index, HMIC and the National Research Register. Authors of unpublished material were contacted for data and additional publications. Reference and citation tracking was performed on included publications.

Review methods: Inclusion criteria: randomized controlled trials of interventions aimed primarily at adult family carers of people post stroke; carers were the primary sample; primary outcomes reported were for carers. Two independent reviewers screened titles and abstracts to identify publications and extract data. Quality assessment was performed to weight study findings.

Results: Eight papers were found reporting on six complex, generally heterogeneous, interventions: caregiver training; education and counselling; social problem-solving partnerships, delivered principally by telephone; a psycho-educational telephone support group; a nurse-led support and education programme; and a support programme, delivered either to groups in hospital or individuals during home visits. Half of the interventions were based on stress-coping theories; the remainder did not identify a conceptual basis for the intervention.

Conclusions: Some benefits were reported for all interventions, although trials were generally of low quality, preventing firm conclusions being drawn. The presence of a conceptual basis for interventions does not appear to influence effectiveness.

Well-being and instrumental activities of daily living after stroke

Objective: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke.

Design: Cross-sectional with evaluation at six months post stroke.

Subjects: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. Main outcome measures: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named ‘coping’, ‘anxiety’ and ‘satisfaction’ that served as main outcomes.

Results: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension ‘satisfaction’ related significantly to the Nottingham subscale ‘leisure activities’ (β = -0.38, p= 0.01), whereas ‘coping’ was indirectly associated with ‘leisure activities’ by its correlation with ‘satisfaction’ (R= 0.26, p= 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables.

Conclusion: ‘Leisure activities’ demonstrated the strongest association to subjective well-being as expressed by the ‘satisfaction’ dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

Can we forget the Mini-Mental State Examination? A systematic review of the validity of cognitive screening instruments within one month after stroke

Objective:

To review systematically studies investigating the convergent, criterion, and predictive validity of multi-domain cognitive screening instruments in the first four weeks after stroke.

Data sources:

Electronic databases (Pubmed, PsycINFO, CINAHL, Embase) were searched until June 2014.

Review methods:

Studies concerning screening for cognitive dysfunction in stroke patients using multi-domain instruments, within four weeks postinfarct or haemorrhagic stroke, using tests taking no longer than one hour. Convergent, criterion, and predictive validity were examined.

Results:

A total of 51 studies investigating 16 cognitive screening instruments were identified. None of the instruments covered all of the most affected cognitive domains. Only one study investigated the convergent validity of a multi-domain test during the (sub)acute phase after stroke. A total of 15 studies examined the criterion validity of cognitive measurements during the acute phase after stroke. The Montreal Cognitive Assessment and Higher Cortical Function Deficit Test had good criterion validity. A total of 24 studies examined the predictive ability of multi-domain cognitive instruments applied in the acute phase after stroke. The Cognistat, Montreal Cognitive Assessment, and Functional Independence Measure-cognitive showed good predictive validity. The Mini-Mental State Examination is the most widely used cognitive screening instrument, but shows insufficient criterion validity.

Conclusion:

None of the existing instruments fulfils all criteria. The Montreal Cognitive Assessment is the best candidate at present, provided items measuring speed of information processing are added, and further studies investigating the optimal cut-offs are conducted.

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

OBJECTIVES

Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke.

METHOD

The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up.

RESULTS

One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was -1.32 (95% confidence interval: -2.61, -0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19).

CONCLUSION

A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.

Predictors of functional and gait outcomes for persons poststroke undergoing home-based rehabilitation

BACKGROUND

The literature on the impact of home-based rehabilitation on functional outcomes for patients after stroke is limited. The purpose of this study was to describe the outcomes of home-based rehabilitation (HBR) on functional and gait performance for patients after stroke and associated factors that contribute to better outcomes after an episode of care.

METHODS

The nature of the study design was retrospective and the settings used were home care services. The total number of subjects receiving home care services after stroke was 213 (mean age 76.5 ± 9 years, 51% female). Treatment records for patients receiving HBR in 2010 were reviewed at the start of care and discharge. The primary outcome measure was a change in a gait speed and activities of daily living (ADL) performance between admission and discharge from home health care services. The composite score to calculate overall functional status (Outcome Information and Assessment Set-version C [OASIS-C]) was used. Mean change in ADL and gait scores and factors predictive of improvement were identified using an analysis of covariance and multivariate linear models. The main outcome measures were change in the OASIS-C composite scores and gait speed.

RESULTS

After adjustment for age and ADL score at the start of care, discharge from skilled nursing or long-term facilities, presence of confusion most of the times, cognitive impairment, and memory deficits were negatively associated with an improvement in functional scores (ADL). Living in congregate facilities was also negatively associated with an improvement in gait speed. The best multivariate model included age, baseline ADL composite scores, confusion status, and gait speed at the start of care, which predicted 41% of the variance in ADL score changes over the course of intervention.

CONCLUSIONS

Gait speed and ADL scores at the start of care had largest influence on functional and gait improvement. Type of discharge facility, confusion status, and living arrangement had effects on HBR outcomes for stroke survivors.

Survival and quality of life of octogenarians who underwent mechanical valve replacement at a younger age

PURPOSE

Mechanical valve replacement is associated with complications, however, there is little information on the quality of life (QOL) of octogenarians who had undergone mechanical valve replacement at a relatively younger age. We examined survival, valve-related events, and the QOL of octogenarians who had undergone mechanical valve replacement.

METHODS

A total of 56 octogenarians who underwent mechanical valve replacement between 1969 and 1997 (age at the time of surgery, 65.6 ± 6.7 years), completed a questionnaire on survival, valve-related events, and QOL (basic activities of daily living, instrumental activities of daily living, mental health).

RESULTS

The mean follow-up was 12.4 ± 6.6 years, and the cumulative follow-up period was 642.4 patient-years. Six valve-related deaths (0.9%/patient-year) were registered during the follow-up. Furthermore, 11 valve-related events (1.8%/patient-year) were recorded. The mean age of the 21 survivors was 82.9 ± 1.8 years, and 19 of the survivors lived at home. Their QOL was excellent.

CONCLUSION

The valve-related deaths and events in octogenarians who had previously undergone mechanical valve replacement at a younger age were within acceptable limits. The QOL was similar to that of octogenarians described in previous studies.

What is the Probability of Patients who are Nonambulatory after Stroke Regaining Independent Walking? a Systematic Review

Patients after stroke who are nonambulatory require resources, and independent walking becomes a major determinant of the ability to participate in activities of daily living. Our objective was to determine the probability of walking for patients who are nonambulatory in the first month after stroke. We performed a systematic review and meta-analysis of consecutive, prospective studies of nonambulatory patients within the first month after stroke in rehabilitation and acute units. The outcomes were the probability of achieving independent walking at three-, six- and 12 months after stroke. Twenty-six studies were included in the review. Seventeen studies comprising 2856 participants were entered into meta-analyses. For initially nonambulatory stroke patients managed in a rehabilitation unit, the probability of independent walking was 0·60 (95% CI 0·47–0·74, 1373 participants) at three-months, 0·65 (95% CI 0·53–0·77, 444 participants) at six-months and 0·91 (95% CI 0·81–1·00, 24 participants) at 12 months. For patients managed in an acute unit, the probability of independent walking was 0·39 (95% CI 0·27–0·52, 634 participants) at three-months, 0·69 (95% CI 0·46–0·92, 405 participants) at six-months and 0·74 (95% CI 0·59–0·88, 34 participants) at 12 months. 60% of patients managed in a rehabilitation unit who are nonambulatory in the first month after stroke will regain independent walking compared with 39% of those managed in an acute unit. This information can be used clinically to make decisions about allocation of rehabilitation resources, education of patients and carers, and for discharge planning.

Factors associated with functional recovery and home discharge in stroke patients admitted to a convalescent rehabilitation ward

AIMS

This study aimed to determine the predictive factors for functional recovery and home discharge in stroke patients receiving in-hospital rehabilitation.

METHODS

This study included a consecutive series of 174 stroke patients (average age 73.0 ± 10.8) admitted to the convalescent rehabilitation ward at Azumino Red Cross Hospital in Japan after acute rehabilitation. The main outcome measures were functional recovery (functional independence measure [FIM] at discharge and Montebello rehabilitation factor score [MRFS]) and home discharge.

RESULTS

Total FIM improved from 72.6 ± 27.6 to 87.7 ± 29.9 during the hospital stay (P < 0.001). The average MRFS was 0.30 ± 0.28. Of the 174 patients, 151 were discharged home (87%). Age, stroke type, premorbid independence, motor FIM, and cognitive FIM at admission showed a significant association with FIM at discharge, while age, premorbid independence, motor FIM at admission, and cognitive FIM at admission were statistically significant predictors of MRFS. Female sex, not living with family, premorbid independence, and neglect were negatively associated with home discharge.

CONCLUSIONS

Premorbid disability and cognitive dysfunction at admission were both negatively associated with functional recovery and home discharge in patients undergoing inpatient stroke rehabilitation.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important

BACKGROUND

Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed.

METHODS

A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed.

RESULTS

There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care.

CONCLUSION

Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

Depressive symptoms in stroke patients: a 13 month follow-up study of patients referred to a rehabilitation unit

BACKGROUND

Although depression is known to be frequently associated with stroke, it is nonetheless underdiagnosed and under-treated in this patient population. Its effect on outcome for stroke patients is thought to be substantial, but prediction is complicated by other pre- and post stroke factors. The aims of this study was to describe changes in depressive symptoms in elderly stroke patients across a timespan of one year, to examine risk factor for such changes and to explore whether depressive symptoms have any independent impact upon one year mortality and nursing home placement.

METHODS

194 patients diagnosed with an ischaemic or hemorrhagic stroke was recruited from the Stroke Rehabilitation Unit, Ullevaal University Hospital, Oslo, Norway during the period between March 2005 and August 2006 and followed up for a period of 13 months. Pre-stroke assessment was accomplished by means of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Frenchay Activities Index (FAI), the Barthel ADL Index and patient's medical history. Post-stroke assessment at inclusion and follow-up examination was performed with the Mini Mental State Examination (MMSE), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Star Cancellation Test, the Barthel ADL Index, the modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale (NIHSS). Information was collected from the patients' records.

RESULTS

Institutionalization at 13 months was predicted by more depression (MADRS) and cognitive impairment (RBANS) at baseline, together with lower pre-stroke social activity levels (FAI). Two factors predicted death at 13 months: Cognitive impairment (MMSE) and greater age. The prevalence of depression was relatively unchanged from baseline (56%) to 13 month follow-up (48%). Among the patients who were depressed at baseline 55% still had MADRS score above six (persistent depression) at 13 months, while 35% in the non-depressed group at baseline had developed depression (incident depression). Persistent depression was significantly predicted by lower pre-stroke social activity levels (FAI) together with a more severe stroke (NIHSS) and worse overall function (mRS) at baseline. Incident depression was predicted by receipt of municipal home help before the stroke and a lower score on the delayed memory tasks on RBANS at baseline.

Geriatric rehabilitation of stroke patients in nursing homes: a study protocol

BACKGROUND

Geriatric patients are typically underrepresented in studies on the functional outcome of rehabilitation after stroke. Moreover, most geriatric stroke patients do probably not participate in intensive rehabilitation programs as offered by rehabilitation centers. As a result, very few studies have described the successfulness of geriatric stroke rehabilitation in nursing home patients, although it appears that the majority of these patients are being discharged back to the community, rather than being transferred to residential care. Nevertheless, factors associated with the successfulness of stroke rehabilitation in nursing homes or skilled nursing facilities are largely unknown. The primary goal of this study is, therefore, to assess the factors that uniquely contribute to the successfulness of rehabilitation in geriatric stroke patients that undergo rehabilitation in nursing homes. A secondary goal is to investigate whether these factors are similar to those associated with the outcome of stroke rehabilitation in the literature.

METHODS/DESIGN

This study is part of the Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study in the Netherlands. It is a longitudinal, observational, multicenter study in 15 nursing homes in the Southern part of the Netherlands that aims to include at least 200 patients. All participating nursing homes are selected based on the existence of a specialized rehabilitation unit and the provision of dedicated multidisciplinary care. Patient characteristics, disease characteristics, functional status, cognition, behavior, and caregiver information, are collected within two weeks after admission to the nursing home. The first follow-up is at discharge from the nursing home or one year after inclusion, and focuses on functional status and behavior. Successful rehabilitation is defined as discharge from the nursing home to an independent living situation within one year after admission. The second follow-up is three months after discharge in patients who rehabilitated successfully, and assesses functional status, behavior, and quality of life. All instruments used in this study have shown to be valid and reliable in rehabilitation research or are recommended by the Netherlands Heart Foundation guidelines for stroke rehabilitation.Data will be analyzed using SPSS 16.0. Besides descriptive analyses, both univariate and multivariate analyses will be performed with the purpose of identifying associated factors as well as their unique contribution to determining successful rehabilitation.

DISCUSSION

This study will provide more information about geriatric stroke rehabilitation in Dutch nursing homes. To our knowledge, this is the first large study that focuses on the determinants of success of geriatric stroke rehabilitation in nursing home patients.

Impact of Patient's Weight on Stroke Rehabilitation Results

OBJECTIVE

To evaluate the influence of patient's weight on rehabilitation results after first stroke.

DESIGN

Retrospective, comparative study. The sample comprised 84 males and females, first-time stroke patients, who had been hospitalized in the department of rehabilitation at the Hartzfeld Geriatric Hospital, Gedera, Israel for a full 3 mos and who, on admission, had scored between 40 and 60 on the total Functional Improvement Measure (FIM) test. We evaluated the difference in total FIM improvement between normal-weight, overweight, and obese patients.

RESULTS

The relative improvement of FIM score was significantly higher in normal-weight patients than in overweight patients, and improvement in overweight patients was significantly higher than in obese ones. We also found a statistically significant negative correlation (r = -0.27, P = 0.014) between relative improvement of FIM score and body mass index (BMI) in the total sample.

CONCLUSIONS

Our study revealed that during the first 12 wks, rehabilitation is statistically significantly less effective in overweight and, particularly, in obese patients (evaluated by BMI). We also found a statistically significant negative association between the individual's BMI and relative improvement of the FIM score, representing the functional status of the stroke patient.

The Barthel Index and modified Rankin Scale as prognostic tools for long-term outcomes after stroke: a qualitative review of the literature

OBJECTIVE

Providing a quantitative prognosis after a stroke is important to clinicians and patients as well as to researchers interested in projecting the results of clinical trials and other studies. Thus, we critically reviewed the evidence supporting the prognostic value of two frequently-used measures, the Barthel Index (BI) and modified Rankin Scale (mRS) for long-term outcomes.

METHODS

A narrative review of the peer-reviewed medical literature obtained by searching Medline 1966 to January 2004--using the phrase '[stroke] AND [Barthel OR Rankin]'--was conducted to assess the strength of the evidence for these measures and answer three main questions: How good are the BI and mRS at predicting (1) the level of care required, (2) the time-course of recovery, and (3) mortality. Abstracts were screened for the presence of actual data on the prognostic impact of BI and mRS on these endpoints, and selected articles were fully reviewed and abstracted. Additional articles were identified from bibliographies of the retrieved papers.

RESULTS

Of 753 abstracts screened, 89 articles were selected for detailed assessment. Early disability and global outcome (< or = 7 days) were shown in 21 studies to be strong predictors of care needs. This relation appears to be mainly biological, not country-specific. Recovery was shown in 18 studies to be strongly related to early BI. In contrast, the 11 studies examining mortality provided insufficient information to directly support the prognostic value of either measure. Key limitations of this review include heterogeneity of available studies (e.g., time-points, outcome, parameterization) and relative lack of information on the mRS.

CONCLUSIONS

Despite the lack of uniformity in existing studies, the evidence overall is quite strong, supporting the use of BI and mRS as prognostic tools. External non-treatment modifiable factors which also determine long-term outcome (e.g., social support) have to be taken into account.

Impact of stroke etiology, lesion location and aging on post-stroke urinary incontinence as a predictor of functional recovery

This retrospective study aims to assess the relationship of age, gender, lesion location, stroke etiology and recurrence of stroke to post-stroke urinary incontinence, and to evaluate its impact on functional recovery in patient subgroups with different etiologies, lesion locations and ages. One-hundred-and-sixty-three stroke patients participated in the study. Among them, 141 had detailed imaging tests for the definition of lesion locations. Post-stroke urinary incontinence was defined as an inability to respond to questions regarding toilet needs, evidence of elevated post-stroke urinary incontinence and retention. Successful rehabilitation was described as a total functional independence measure score over 80 at discharge. Cerebrovascular lesion locations were categorized as cortical, subcortical and disseminated. The study found that post-stroke urinary incontinence had a significant negative impact on successful stroke rehabilitation. Post-stroke urinary incontinence was a better indicator of negative functional outcome in hemorrhagic versus ischemic stroke patients and patients with cortical versus subcortical lesions. The incidence of post-stroke urinary incontinence in patients aged over 75 years was higher than in patients under 75 years (P=0.031). In conclusion, post-stroke urinary incontinence was a strong negative predictor of poor outcome in all stroke subgroups. It was related to age, but not to any other pre-selected factor investigated in this study.

Predictive value of ischemic lesion volume assessed with magnetic resonance imaging for neurological deficits and functional outcome poststroke: A critical review of the literature

OBJECTIVE

Ischemic lesion volume is assumed to be an important predictor of poststroke neurological deficits and functional outcome. This critical review examines the methodological quality of MRI studies and the predictive value of hemispheric infarct volume for neurological deficits (at body function level) and functional outcome (at activities level).

METHODS

Using Medline, PiCarta, and Embase to identify studies, 13 of the 747 identified studies met the authors' inclusion criteria. Subsequently, studies were tested for adherence to the key methodological criteria for internal, statistical, and external validity. Each criterion was weighted binary, and studies with 6 points or more were judged to be valid for assessing the predictive value of MRI for outcome.

RESULTS

The 13 included studies had several methodological weaknesses with respect to internal validity, and none of them took lesion location into account. Only a few used outcome measures according to the International Classification of Functioning, Disability and Health and followed patients beyond 6 months. Correlation coefficients between MRI lesion volume and outcomes were higher for outcomes defined at body function level (National Institutes of Health Stroke Scale; median 0.67; range: 0.57-0.91) than for those defined at the level of activities (Barthel Index; median -0.49; range: -0.33 to -0.74).

CONCLUSIONS

Methodological shortcomings of most studies confound the prognostic value of MRI in predicting stroke outcome, and few studies have focused on functional outcome. Future studies should investigate the added value of MRI volume over clinical neurological variables in predicting functional outcome beyond 6 months poststroke.

Is fatigue an independent factor associated with activities of daily living, instrumental activities of daily living and health-related quality of life in chronic stroke?

BACKGROUND

To determine the longitudinal association of poststroke fatigue with activities of daily living (ADL), instrumental ADL (IADL) and perceived health-related quality of life (HRQoL) and to establish whether this relationship is confounded by other determinants.

METHODS

A prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation was conducted. ADL, IADL and HRQoL were assessed in 223 patients at 6, 12 and 36 months after stroke. Fatigue was determined by the Fatigue Severity Scale. Random coefficient analysis was used to analyze the impact of fatigue on ADL, IADL and HRQoL. The association between fatigue and outcome was corrected for potential confounders, i.e. age, gender, comorbidity, executive function, severity of paresis and depression. The covariate was considered to be a confounder if the regression coefficient of fatigue on outcome changed by >15%.

RESULTS

Fatigue was significantly related to IADL and HRQoL but not to ADL. The relation between fatigue and IADL was confounded by depression and motor impairment. Depression biased the relation between fatigue and HRQoL, but fatigue remained independently related to HRQoL.

CONCLUSIONS

Fatigue is longitudinally spuriously associated with IADL and independently with HRQoL. These findings suggest that in examining the impact of poststroke fatigue on outcome, one should control for confounders such as depression.

A new method for predicting functional recovery of stroke patients with hemiplegia: logarithmic modelling

OBJECTIVE

To examine the validity and applicability of logarithmic modelling for predicting functional recovery of stroke patients with hemiplegia.

DESIGN

Longitudinal postal survey.

SUBJECTS

Stroke patients with hemiplegia staying in a long-term rehabilitation facility, who had been referred from acute medical service 30-60 days after onset.

METHODS

Functional Independence Measure (FIM) scores were periodically assessed during hospitalization. For each individual, a logarithmic formula that was scaled by an interval increase in FIM scores during the initial 2-6 weeks was used for predicting functional recovery.

RESULTS

For the study, we recruited 18 patients who showed a wide variety of disability levels on admission (FIM scores 25-107). For each patient, the predicted FIM scores derived from the logarithmic formula matched the actual change in FIM scores. The changes predicted the recovery of motor rather than cognitive functions. Regression analysis showed a close fit between logarithmic modelling and actual FIM scores (across-subject R2 = 0.945).

CONCLUSIONS

Provided with two initial time-point samplings, logarithmic modelling allows accurate prediction of functional recovery for individuals. Because the modelling is mathematically simple, it can be widely applied in daily clinical practice.

The Relationship Between Cognition and Mortality in Patients with Stroke, Coronary Heart Disease, or Cancer

Numerous studies have reported an association between cognitive impairment and an increased risk for mortality. Most results are from large epidemiological studies and control for medical conditions that may relate to cognitive decline, as well as an increased mortality risk. The aim of this review was to evaluate the association between cognitive performance and mortality within patient samples of stroke, cancer, or coronary heart disease. After reviewing the PubMed literature for articles on stroke, cancer, and cardiovascular related illnesses, 47 longitudinal studies were identified that met the cognition/mortality search criteria. In general, the results demonstrated that within the clinical groups studied, cognitive performance and cognitive impairment both predict mortality, although results were less consistent for coronary heart disease. This study adds further support for the ubiquity of the association of cognitive performance with health outcomes and mortality. Optimizing health has implications for both cognitive performance and longevity.

Prediction of Social Activity 1 Year Poststroke

OBJECTIVE

To develop an easy-to-use prediction rule for social activity 1 year poststroke that can identify patients at risk for social inactivity.

DESIGN

Inception cohort.

SETTING

Rehabilitation center.

PARTICIPANTS

Patients with a first-ever supratentorial stroke were selected in 4 Dutch rehabilitation centers. Data of 250 patients were available for analysis. Potential prognostic factors measured at admission were sex, age, marital status, prestroke employment status, educational level, type of stroke, hemisphere, motor impairment, trunk control, communication, and activities of daily living (ADL) dependency.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Social activity measured by the Frenchay Activities Index (FAI) at 1 year poststroke.

RESULTS

Multivariate backward linear regression analysis identified sex, age, marital status, motor impairment, communication, and ADL dependency as important predictors of the FAI score 1 year poststroke. An easy-to-use score chart was constructed that could identify patients at risk for social inactivity. The score chart proved to be well able to discriminate poor social functioning from moderate to good social functioning (area under the curve = .85).

CONCLUSIONS

Identifying patients at risk enables health care professionals to focus on the social activity of this patient subgroup at an early stage in the care process.

Prognostic factors in the subacute phase after stroke for the future residence after six months to one year. A systematic review of the literature

OBJECTIVE

To identify evidence-based prognostic factors in the subacute phase after a stroke for future residence at six months to one year post stroke.

DESIGN

Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, PsycLIT and Sociological Abstracts. (2) Reference lists, personal archives and consultation of experts in the field. (3) Guidelines.

METHODS

Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for future residence; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration.

RESULTS

From 1027 potentially relevant studies 10 studies involving a total of 3564 patients met the inclusion criteria. No prognostic factor was identified in at least two level A (i.e., a good level of scientific evidence according to the methodological score) studies, our standard for scientific proof. The following factors were found in at least one level A study: low initial ADL functioning, high age, cognitive disturbance, paresis of arm and leg, not alert as initial level of consciousness, old hemiplegia, homonymous hemianopia, visual extinction, constructional apraxia, no transfer to the stroke unit, nonlacunar stroke type, visuospatial construction problems, urinary incontinence and female gender.

CONCLUSIONS

At present there is insufficient evidence concerning possible predictors in the subacute stage of stroke to make an evidence-based prediction of the future residence. In the scientific research until now social factors and their contribution to the possibility of living independently have not been investigated, or at least less well. None of the studies in this review described a conceptual framework as basis for the choice of the examined prognostic factors.

Prognostic factors for ambulation and activities of daily living in the subacute phase after stroke. A systematic review of the literature

OBJECTIVE

To identify evidence-based prognostic factors in the subacute phase after stroke for activities of daily living (ADL) and ambulation at six months to one year after stroke.

DESIGN

Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, Psyclit, and Sociological Abstracts. (2) Reference lists, personal archives, and consultation of experts. (3) Guidelines.

METHODS

Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for ADL and ambulation; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration.

RESULTS

From 1,027 potentially relevant studies 26 studies involving a total of 7,850 patients met the inclusion criteria. Incontinence for urine is the only prognostic factor identified in three studies with a level A (i.e., a good level of scientific evidence according to the methodological score). The following factors were found in one level A study: initial ADL disability and ambulation, high age, severe paresis or paralysis, impaired swallowing, ideomotor apraxia, ideational apraxia, and visuospatial construction problems; as well as factors relating to complications of an ischaemic stroke, such as extraparenchymal bleeding, cerebral oedema and size of intraparenchymal haemorrhage.

CONCLUSIONS

The present evidence concerning possible predictors in the subacute stage of stroke has insufficient quality to make an evidence-based prediction of ADL and ambulation after stroke because only one prognostic factor was demonstrated in at least two level A studies, our cut-off for sufficient scientific evidence.

Functional gains and therapy intensity during subacute rehabilitation: a study of 20 facilities

OBJECTIVES

To document patient, program characteristics, and therapy service provision in subacute rehabilitation across 3 types of facilities that provide subacute rehabilitation, to examine the determinants of therapy intensity, and to evaluate the contribution of rehabilitation services to functional gains.

DESIGN

A retrospective study linking administrative billing data and patients' functional assessment records.

SETTING

Twenty facilities part of the Uniform Data System for Medical Rehabilitation (UDSMR) subacute database

PARTICIPANTS

A total of 1976 billing records of patients with stroke, orthopedic, and debility impairments, discharged in 1996 and 1997, were retrieved and linked with the FIM trade mark instrument ratings from UDSMR subacute database.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

Total therapy intensity and Rasch-transformed FIM domain gains (ie, gains in self-care, mobility, cognition).

RESULTS

Therapy intensity was mostly determined by impairment and facility type, although variances explained by the predictors were small. Patients in all 3 impairment groups made functional gains; gains were related weakly, although significantly, to therapy intensity and rehabilitation duration after controlling for other variables.

CONCLUSIONS

The provision of rehabilitation therapies varied across facilities. Skilled nursing facilities with subacute rehabilitation units tended to provide more therapies than subacute units in acute or rehabilitation hospitals.

Postadmission function best predicts acute hospital outcomes after stroke

OBJECTIVE

This study was conducted to determine the relative value of selected variables for predicting three acute hospital outcomes (length of stay, charges, discharge destination) after stroke.

DESIGN

Data were obtained prospectively from 92 patients admitted with ischemic stroke to an acute care hospital. The relationship between five independent variables (age, sex, National Institutes of Health Stroke Scale [NIHSS] scores, prestroke Barthel Index scores, and postadmission Barthel Index scores) and the three outcome variables (hospital length of stay, hospital charges, and hospital discharge destination) were examined.

RESULTS

Significant bivariate correlations were found between two predictors (NIHSS scores and Barthel Index scores) and all three outcome variables. Regression analysis showed that once postadmission Barthel Index scores were accounted for, no other variable added to the prediction of hospital length of stay or discharge destination. The NIHSS score added to the explanation of hospital charges provided by postadmission Barthel Index scores.

CONCLUSIONS

Postadmission Barthel Index scores were the best predictor of the three outcomes measured in this study.

Discharge function and length of stay for patients with stroke are predicted by lower extremity muscle force on admission to rehabilitation

OBJECTIVE

We sought to determine the relative value of lower extremity muscle strength as a predictor of discharge function and length of stay of patients with stroke.

METHODS

We studied 72 patients undergoing inpatient rehabilitation after a stroke and documented their outcome using length of stay and function [as measured by the Functional Independence Measure (FIM) at discharge].

RESULTS

Knee-extension force and the total force of four lower extremity muscle actions (hip flexion, knee extension, knee flexion, and ankle dorsiflexion) were correlated significantly with discharge FIM and length of stay. The correlations involving the actions of the weaker side were higher. Admission FIM was also correlated significantly with discharge FIM and length of stay. Previous stroke and age were correlated significantly with discharge FIM but not length of stay. The set of variables offering the best explanation of discharge FIM (R = 0.867) was admission FIM, admission FIM squared, age, and total force of the weaker side. The set of variables offering the best explanation of length of stay (R = 0.812) was knee-extension force of the weaker side squared, admission FIM, admission FIM squared, and age.

CONCLUSIONS

Lower extremity muscle force of the weaker side on admission has value as a predictor of function at discharge and length of stay for patients with stroke admitted to inpatient rehabilitation. Muscle force, therefore, is a reasonable target of measurement and treatment. Knowledge of muscle force on admission can assist clinicians, patients, families, and others to anticipate patient outcomes after rehabilitation.

Prediction of long-term functional outcome after stroke rehabilitation

OBJECTIVE

To find patient characteristics in the early post stroke phase that could predict three years functional outcome.

DESIGN

Prospective study.

SETTING

In-hospital rehabilitation department (admission and discharge). Outpatient department one and three years post stroke.

SUBJECTS

One hundred and forty-two stroke patients (56% women), median age 75 years.

MAIN OUTCOME MEASURES

Barthel Index (BI) score; BI score change; accommodation status; Rankin scale score; and Frenchay Activities Index (FAI) score, all registered three years post stroke.

RESULTS

The percentages of patients still living at home after one and three years were 88% and 83%, respectively. Twenty per cent of the patients had deteriorated according to the BI after three years, mostly due to recurrent strokes (odds ratio (OR) 10.3; 95% confidence interval (CI) 3.0-35.5) and co-morbidity with other disabling disorders (OR 3.9; CI 1.1-13.5). Co-morbidity also emerged as an important risk factor for dependency according to BI score (OR 8.8; Cl 2.4-32.1) as well as for a poor FAI score (OR 4.9; CI 1.9-13.0). BI in the early phase was the strongest predictor for long-term functional outcome. Urinary incontinence emerged as a risk factor for nursing home placement after three years (OR 3.2; CI 0.9-11.3). Cognitive dysfunction was a risk factor for poor FAI scoring (OR 2.7; CI 1.0-7.0).

CONCLUSIONS

After stroke rehabilitation, concomitant chronic disabling disorders and recurrent strokes seem to play an important role regarding dependency, handicap and long-term functional decline.

[Hemiplegia and return to domicile]

OBJECTIVE

We have studied the outcome after a stroke on being discharged from a department of physical medicine and rehabilitation in patients with hemiplegia, and the factors influencing the choice of the orientation.

MATERIAL AND METHOD

This prospective study was based on 93 patients. The mode of discharged was patient's domicile, institution, the number of death was also noted. The potentially influential factors studied were age, the side with hemiplegia, the aetiology of the hemiplegia, co-morbidity, the delay in starting rehabilitation, the neurological damage evaluated by the Orgogozo score, the initial functional damage evaluated by Functional Independence Measure (FIM) and by the functional score carried out within the framework PMSI(1) (computerised programme of medical care), the existence of aphasia, the existence of a depressive syndrome, presence of hemineglect, presence of superficial or profound sensory disorders, incontinence at the start of rehabilitation and at one month after the stroke, the existence of cognitive or psychiatric disorders. The tests used were the non-parametric test of Mann and Whitney, the chi(2) test and the correlation test. The threshold of significance used was 0.05.

RESULTS

Based on 93 patients (47 women and 46 men, average age 64.8) 81 have gone back to their previous domicile, 11 were oriented toward an institution. One patient died. The predictive factors or those linked to an absence of return to the previous domicile were the age, social situation, the delay in starting rehabilitation, presence of aphasia, the initial and final functional damage, the impossibility to walk, the presence of a depressive syndrome, urinary incontinence.

CONCLUSION

The authors stress the importance of familial environment and of functional independence in establishing a prognosis for return to the domicile.

Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources

BACKGROUND

The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed.

METHODS

A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards.

RESULTS

The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients.

CONCLUSIONS

A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.

Geriatric rehabilitation revisited

There is no gold standard for rehabilitation of geriatric patients. Although many studies indicate that a multifaceted team approach, such as seen with specialized stroke units, may enhance outcomes for many patients, how these units achieve this is still unclear. However, the evidence shows that a comprehensive program of both medical and psychosocial support tends to result in patients achieving and maintaining higher levels of function, with less need for readmission, and shorter hospital stays. In addition to interventions aimed at improving function, rehabilitation includes assessment, goal setting, and provision of care to maintain the patient's status. More randomized controlled studies of rehabilitation programs are needed so that we can identify which programs are best for which patients.