Lower Functional Independence Measure Scores Research Articles

Functional prognosis following spontaneous intracerebral hemorrhage in patients on hemodialysis: a retrospective study of 100 consecutive cases

BackgroundRecently, discussions have increasingly focused on “withdrawal from dialysis” among patients undergoing dialysis who experience severe brain dysfunction as post-stroke sequelae. In this context, the lack of understanding regarding functional prognosis after spontaneous intracerebral hemorrhage in patients undergoing hemodialysis becomes a particularly important issue. Therefore, we aimed to evaluate the functional prognosis of intracerebral hemorrhage in patients undergoing hemodialysis when life-saving was prioritized and dialysis was not withdrawn. Furthermore, we sought to identify factors influencing life and functional prognosis.MethodsWe retrospectively analyzed data of 100 consecutive hemodialysis patients who experienced spontaneous intracerebral hemorrhage between 2012 and 2021. The in-hospital mortality rates and modified Rankin Scale (mRS) and Functional Independence Measure (FIM) scores at discharge and 90 days after onset were examined.ResultsThe mean age of the patients was 65.7 years, with 29% of them undergoing life-saving brain surgery. The mRS score at discharge was 0, 1, 2, 3, 4, 5, and 6 (indicating death) in 0, 1, 13, 9, 26, 20, and 31 cases, respectively. Among the 69 surviving patients, the median FIM score at discharge was 37 (19–81), with 14 patients having an FIM score of 18 (i.e., complete dependence). Patients who underwent life-saving brain surgery showed a higher median mRS score [5, interquartile range (IQR) 5–6] and a lower FIM score (18, IQR 18–22) at discharge compared with those who did not undergo the surgery. Patients discharged with mRS and FIM scores of 5 and 18, respectively, had the same functional status at 90 days. The Functional Outcome in Patients With Primary Intracerebral Hemorrhage (FUNC) score and intraventricular extension at admission were predictive of a mRS score ≥ 5 (area under the receiver operating characteristic curve = 0.92, p < 0.0001) and FIM score at discharge (adjusted R2 = 0.3, p = 0.0003).ConclusionIn our single-center study, more than 14% of patients on hemodialysis with cerebral hemorrhage incurred severe, irreversible neurological and functional impairments, necessitating discussions on hemodialysis withdrawal. Moreover, FUNC score and intraventricular extension at admission were highly accurate predictors of functional prognosis.

Acute Kidney Injury and Rehabilitation Outcomes among Elderly Patients with Chronic Kidney Disease

Introduction: The incidence of chronic kidney disease (CKD) is growing rapidly, along with the increasing geriatric population. CKD patients have higher incidence of fractures, stroke, and hospitalizations requiring rehabilitation. This is accompanied with the need for suitable rehabilitation programs to decrease disability and improve functionality to help elderly CKD patients maintain independence in activities of daily living. Considering that survivors of acute kidney injury (AKI) tend to experience decreased quality of life with increased frailty, rehabilitation in the elderly with kidney injury becomes even more complex. The aim of this study was to examine the impact of AKI on the outcomes of rehabilitation among elderly patients with CKD. Methods: For this retrospective, observational study, the electronic medical records of all patients who were hospitalized in the rehabilitation department were reviewed. We assessed functional status at the beginning and end of rehabilitation, renal outcome, and all-cause mortality among elderly patients with CKD who experienced an AKI and compared them to those who did not have an AKI. Results: The study cohort included 183 elderly patients with non-dialysis-dependent CKD. Patients with AKI (23% of study cohort) had a higher prevalence of heart failure and lower baseline estimated glomerular filtration rate, as compared with patients who did not have AKI. They were admitted to rehabilitation at a poorer functional capacity and were also discharged with lower functional independence measure scores. Overall odds ratio for all-cause death among patients with AKI versus without AKI was 3.2 (95% CI: 1.6–6.5; p = 0.001). Conclusion: AKI and CKD are interrelated syndromes. AKI was prevalent among elderly CKD patients and was associated with worse rehabilitation outcomes and higher mortality compared to similar patients without AKI.

Assessing the Impact of Specialized Oral Nutrition Supplementation Use on Wound Healing

Research Objectives Assess utilization and impact of a specialized oral nutrition supplement (ONS) containing arginine, glutamine, and hydroxymethylbutyrate (HMB) on wound healing. Design Retrospective analysis comparing treatment group (51 patients, 161 wounds) receiving standard care plus a specialized ONS for ≥14 days and comparison group (136 patients, 263 wounds) receiving standard care. Between group differences evaluated using t-tests and mixed models with inverse probability weighting. Setting Inpatient rehabilitation hospital. Participants 187 adult patients admitted between 1/2018-12/2019 with ≥1 measured wound and ≥2 wound care nurse assessments. Interventions Specialized oral nutrition supplement administered for 14 days. Main Outcome Measures Wound healing was measured in weekly intervals by decrease in wound surface area (superficial) or volume (non-superficial) in past 1 week. Results While no age differences were reported between groups (50.9 vs 51.0 years, p=1.0), the treatment group had a higher percentage of male patients (90.2% vs 69.9%, p<0.01). Treatment group patients had more wounds (3.3 vs 2.0, p<0.01), lower functional independence measure scores (35.7 vs 40.3, p=0.082), and a higher case mix index (2.3 vs. 2.0, p=0.008) at baseline. Average inpatient stay (44. 8 vs 39.9 days, p=0.36) and wound area at baseline (22.0 vs 13.1 cm2, p=0.18) were higher, but not statistically different, in the treatment group. Treatment group wounds significantly decreased in area (61.0% vs 34.6%, p=0.01) compared to comparison group wounds. The odds of a decrease in wound size were higher in the treatment versus comparison group (OR = 24.1, p<0.01). Conclusions Patients receiving specialized ONS had more wounds and higher acuity level than those in the comparison group but had a significant reduction in wound size. There are several limitations in this retrospective study, including baseline functional and wound size differences. However, these findings support the benefits of specialized ONS in improving wound healing for patients with pre-existing wounds. Author(s) Disclosures KW Kerr, S Sulo and JL Nelson are Abbott employees and stockholders. Study financially supported by Abbott. Assess utilization and impact of a specialized oral nutrition supplement (ONS) containing arginine, glutamine, and hydroxymethylbutyrate (HMB) on wound healing. Retrospective analysis comparing treatment group (51 patients, 161 wounds) receiving standard care plus a specialized ONS for ≥14 days and comparison group (136 patients, 263 wounds) receiving standard care. Between group differences evaluated using t-tests and mixed models with inverse probability weighting. Inpatient rehabilitation hospital. 187 adult patients admitted between 1/2018-12/2019 with ≥1 measured wound and ≥2 wound care nurse assessments. Specialized oral nutrition supplement administered for 14 days. Wound healing was measured in weekly intervals by decrease in wound surface area (superficial) or volume (non-superficial) in past 1 week. While no age differences were reported between groups (50.9 vs 51.0 years, p=1.0), the treatment group had a higher percentage of male patients (90.2% vs 69.9%, p<0.01). Treatment group patients had more wounds (3.3 vs 2.0, p<0.01), lower functional independence measure scores (35.7 vs 40.3, p=0.082), and a higher case mix index (2.3 vs. 2.0, p=0.008) at baseline. Average inpatient stay (44. 8 vs 39.9 days, p=0.36) and wound area at baseline (22.0 vs 13.1 cm2, p=0.18) were higher, but not statistically different, in the treatment group. Treatment group wounds significantly decreased in area (61.0% vs 34.6%, p=0.01) compared to comparison group wounds. The odds of a decrease in wound size were higher in the treatment versus comparison group (OR = 24.1, p<0.01). Patients receiving specialized ONS had more wounds and higher acuity level than those in the comparison group but had a significant reduction in wound size. There are several limitations in this retrospective study, including baseline functional and wound size differences. However, these findings support the benefits of specialized ONS in improving wound healing for patients with pre-existing wounds.

Functional Independence Measure score is associated with mortality in critically ill elderly patients admitted to an intermediate care unit

BackgroundAge alone is not a robust predictor of mortality in critically ill elderly patients. Chronic health status and functional status before admission could be better predictors. This study aimed to determine whether functional status, assessed using the Functional Independence Measure (FIM), could be an independent predictor of mortality in a geriatric population admitted to an intermediate care unit (IMCU).MethodsA monocentric, retrospective, observational study of all patients aged ≥75 years old admitted to Geneva University Hospitals’ geriatric IMCU between 01.01.2012 and 31.05.2016. The study’s primary outcome metrics were one-year mortality’s associations with a pre-admission FIM score and other relevant prospectively recorded prognostic variables.ResultsA total of 345 patients were included (56% female, mean age 85 +/− 6.5 years). Mean FIM score was 66 +/− 26. One-year mortality was 57%. Dichotomized low (≤ 63) and high FIM (> 63) scores were associated with one-year mortalities of 68 and 44%, respectively. Logistic regression calculations found an association between pre-admission FIM score and one-year mortality (p < 0.0001), including variables usually associated with mortality (e.g., age, sex, comorbidities, mini-mental health state score, renal function). Multivariate survival analysis showed a significant difference between groups, with a hazard ratio of 0.29 (95% CI: 0.13–0.65) for patients with high FIM scores.ConclusionsIn the present study, higher functional status, assessed using the FIM tool before admission to an IMCU, was significantly and independently associated with lower one-year mortality. This opens up perspectives on the potential value of FIM for establishing a finer prognosis and better triage of critically ill older patients.

An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation.

To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation. A retrospective cohort design. Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care. Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N=38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care. Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes. Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.

A 20-sec Stepping Test and KINECTTM Sensor Provides Objective Quantification of Movement/Balance Dysfunction in Older Individuals

ABSTRACTBackground: Tests such as the Functional Independence Measure (FIM) are widely used measures of infirmity and burden of care. However, these scales are largely qualitative and especially problematic when assessing movement-based tasks. Effective, reliable analysis of human movement is technically complicated and expensive, but an infrared depth sensor is potentially a low-cost, portable devise which may provide a quantitative aspect to clinical testing. Our purpose was to assess the utility of a 20-sec stepping test (ST) and KinectTM infrared-depth sensor in providing objective evaluation of balance toward identifying disability in older adults.Methods: Men and women between 64 and 90 years of age, consisting of independent (IG; n = 37) and dependent (DG; n = 38) living at community, geriatric day-care center in Japan. Total movement distance (TMD) and greatest displacement (MMD) were calculated from KinectTM recording of the ST.Results: DG had lower FIM scores than IG. TMD and MMD were significantly greater in DG than IG, while step number and rate were lower in DG. Receiver-operator characteristic analysis showed TMD, TMD/step, MMDstep, and MMD corrected for time and height strongly discriminated between assignment to DG or IG with moderate sensitivity and specificity.Conclusions: Greater TMD and MMD observed during a 20-sec ST appear to indicate disability with moderate sensitivity and specificity in older adults. Measures of movement distance (e.g. TMD, MMD) appear indicative of changes in dynamic balance due to a circuitous movement pattern generated by aberrant step replacement with repeated stepping-in-place.

The Impact of Nutritional Status and Body Mass Index on Rehabilitation Outcomes in Patients Receiving Home-Based Medical Care

Background: Home-based medical care is expanding rapidly in Japan.Objectives: We aimed to identify the factors associated with outcomes of therapy in patients receiving home-visit rehabilitation.Methods: One hundred twenty-one patients receiving home-based rehabilitation were investigated. Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF). The Functional Independence Measure (FIM) was employed to assess the activities of daily living (ADL). The body mass index (BMI), medical history, and orthopedic disease-related pain were also recorded. The primary outcome was the improvement in FIM scores in one year.Results: A total of 19 (17%) patients were malnourished and 58 (48%) were at risk of malnutrition. Malnourished patients had a lower FIM score at initiation than those at risk of malnutrition or with normal nutritional status. Only changes in patients’ BMI and MNA-SF scores over one year were significantly associated with improved FIM scores (p = 0.0079 and p = 0.0049, respectively). No association was noted with the other factors.Conclusions: This is the first report to demonstrate that changes in MNA-SF scores and BMI are significantly associated with rehabilitation outcomes in home-based care. Nutritional management is essential along with rehabilitation to improve ADL in the long-term home care setting.

Factors associated with community versus personal care home discharges after inpatient stroke rehabilitation: the need for a pre-admission predictive model

ABSTRACTBackground: Improved risk factor management and interventions have both been shown to improve mortality in stroke patients. Although this has been a success for acute care, it has placed a higher burden on stroke rehabilitation resources.Objectives: This study sought to identify the pre-stroke rehabilitation admission factors that best predict personal care home discharge.Methods: Using a retrospective case-control, chart review design, 60 patients discharged to personal care homes from inpatient stroke rehabilitation between 2008 and 2017 were included. One hundred and eighty-two patients discharged home over the same time span were randomly selected as controls. Statistical analysis was used to identify patient factors independently associated with discharge destination.Results: Patients were more often discharged to personal care homes if they were older (OR 1.09; CI [1.05–1.15]), had a lower functional independence measure score (OR 0.95; CI [0.92–0.97]), had cognitive deficits (OR 6.19; CI [2.37–18.06]), lived alone before their stroke (OR 7.77; CI [2.75–24.55]), and whether or not there was excessive truncal instability limiting Berg balance scale measurability (OR 0.17; CI [0.06–0.45] if able to measure). Combined, the predictive value of personal care home discharge using these variables was 91.6%.Conclusions: A combination of age, admission functional independence measure, cognitive impairment, pre-stroke living situation, and measurability of the Berg balance scale on admission to stroke rehabilitation were highly predictive of eventual personal care home discharge.

Association between anticholinergic drug prescription changes and rehabilitation outcome in post-acute hip fractured patients

Purpose: To follow changes in anticholinergic drug prescriptions throughout hip fractured patients’ rehabilitation; to assess whether a change in anticholinergic burden affects rehabilitation outcome.Methods: Retrospective study of 869 hip fractured patients admitted between January 2011 to October 2015, performed in a post-acute geriatric rehabilitation center. The Anticholinergic Cognitive Burden Scale quantified the anticholinergic burden. Main outcome measures: Functional Independence Measure, motor Functional Independence Measure, Montebello Rehabilitation Factor Score on motor Functional Independence Measure and length of stay. Multiple linear regression analysis tested for independent association between admission anticholinergic burden and anticholinergic burden change during rehabilitation, and rehabilitation outcomes.Results: One hundred and sixty two (18.7%) patients were prescribed additional anticholinergic medications upon discharge; 76 (8.7%) were prescribed fewer. Patients with high admission anticholinergic burden presented with a significantly higher rate of higher education, less likely to reside at home, less independent pre-fracture, exhibited a significantly lower admission and discharge Functional Independence Measure score, a lower Functional Independence Measure score change and a lower Montebello Rehabilitation Factor Score. Admission anticholinergic burden, but not changes in anticholinergic burden during rehabilitation, was found to be independently associated with rehabilitation outcome (discharge FIM score).Conclusions: High admission anticholinergic burden is associated with lower functional ability in hip fractured patients. Changes in anticholinergic drug prescription during rehabilitation were not associated with rehabilitation outcomes.Implications for rehabilitationClinicians should make an effort to reduce AC drug use in hip fractured patients on admission to post-acute rehabilitation.AC burden should be carefully monitored throughout the rehabilitation period and reduced whenever possible.When functional ability does not improve as expected, AC burden should be considered as an intervening factor.

Abstract TP185: Acute Infarct Location and Volume Predicts Rehab Outcomes After Ischemic Stroke

Objective: We evaluated the association between acute infarct location and volume with outcome measures during inpatient rehabilitation facility (IRF) in ischemic stroke patients. Methods: Between 2012 and 2014, we prospectively enrolled consecutive acute ischemic stroke (AIS) patients admitted from a Comprehensive Stroke Center and followed to an IRF in Chicago, Illinois. Their lesion locations and infarct volumes were calculated. The Functional Independence Measure (FIM) measure was extracted. We analyzed the association between acute infarct characteristics and functional measures using adjusted Spearman’s correlation. Results: Among 162 AIS patients (mean age 67.6 years, 48.1% male, 58.6% Caucasian), the median FIM was 52 (IQR 36-62). In adjusted analysis, patients with larger infarct volumes in the left basal ganglia ( r s =-0.44, p=0.02) and frontal lobe ( r s =-0.35, p=0.04) had lower FIM scores. Conclusions and Relevance: There is a strong association between acute infarct volume and specific locations and subsequent FIM scores assessed during AIF. Our findings indicate that functional outcomes can be predicted earlier using index stroke imaging, opening opportunities for targeted rehabilitation.

Timing of emergency interhospital transfers from subacute to acute care and patient outcomes: A prospective cohort study

BackgroundAustralian and international data show that transfer from inpatient rehabilitation to acute care hospitals occurs in one in ten patients. Early unplanned transfers from subacute to acute care hospitals raises questions about the safety of patient transitions between health sectors. ObjectivesTo explore the characteristics of early and late emergency interhospital transfers from subacute to acute care. The investigators defined early transfers as occurring within 1 day and late transfers occurring after 1 day after subacute care admission. DesignThis prospective, exploratory cohort study is a subanalysis of data from a larger case-time-control study. SettingTwenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services’ acute care hospitals. ParticipantsAll patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management wards to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded. MethodsData were collected between 22 August 2015 and 30 October 2016 by record audit. To compare patient and admission characteristics between early and late transfers Cochran-Mantel-Haenszel test (CMH) or logistic regression were used to account for health service clustering effect. ResultsThere were 602 transfers: 54 early (48 patients) and 548 late transfers (505 patients). There was no difference in median age (79.5 vs 80, p = 0.680) or Charlson Comorbidity index (both groups = 3, p = 0.933). Early transfer patients had lower functional independence measure scores on subacute care admission (median 45 vs 66, p < 0.001). Prior to transfer, fewer early transfers had a limitation of medical treatment order in place during their subacute care admission (25.9% vs 48.7%, p < 0.001). The majority of both early and late transfers resulted in acute care hospital readmission (85.1% vs 77.7%, p = 0.204). For patients admitted to acute care, there was no difference in median acute care length of stay (6.5 vs 8 days, p = 0.367). Early transfer patients had fewer in-hospital deaths than late transfer patients (3.8% vs 16.1%, p = 0.004). ConclusionsThe high rates of acute care readmission in both groups suggest that transfer was warranted. Early transfer patients had lower in-patient mortality so emergency interhospital transfers, while resource intensive, appear to have a safety benefit. Early transfer patients were less likely than late transfer patients to have limitation of medical treatment orders, so the influence of resuscitation status and patient goals of care on transfer decisions warrants further investigation.

Prognosis of diffuse axonal injury with traumatic brain injury

Determine the prognostic impact of magnetic resonance imaging (MRI)-defined diffuse axonal injury (DAI) after traumatic brain injury (TBI) on functional outcomes, quality of life, and 3-year mortality. This retrospective single center cohort included adult trauma patients (age > 17 years) admitted from 2006 to 2012 with TBI. Inclusion criteria were positive head computed tomography with brain MRI within 2 weeks of admission. Exclusion criteria included penetrating TBI or prior neurologic condition. Separate ordinal logistic models assessed DAI's prognostic value for the following scores: (1) hospital-discharge Functional Independence Measure, (2) long-term Glasgow Outcome Scale-Extended, and (3) long-term Quality of Life after Brain Injury-Overall Scale. Cox proportional hazards modeling assessed DAI's prognostic value for 3-year survival. Covariates included age, sex, race, insurance status, Injury Severity Score, admission Glasgow Coma Scale Score, Marshall Head computed tomography Class, clinical DAI on MRI (Y/N), research-level anatomic DAI Grades I-III (I, cortical; II, corpus callosum; III, brainstem), ventilator days, time to follow commands, and time to long-term follow-up (for logistic models). Eligibility criteria was met by 311 patients, who had a median age of 40 years (interquartile range [IQR], 23-57 years), Injury Severity Score of 29 (IQR, 22-38), intensive care unit stay of 6 days (IQR, 2-11 days), and follow-up of 5 years (IQR, 3-6 years). Clinical DAI was present on 47% of MRIs. Among 300 readable MRIs, 56% of MRIs had anatomic DAI (25% Grade I, 18% Grade II, 13% Grade III). On regression, only clinical (not anatomic) DAI was predictive of a lower Functional Independence Measure score (odds ratio, 2.5; 95% confidence interval, 1.28-4.76], p = 0.007). Neither clinical nor anatomic DAI were related to survival, Glasgow Outcome Scale-Extended, or Quality of Life after Brain Injury-Overall Scale scores. In this longitudinal cohort, clinical evidence of DAI on MRI may only be useful for predicting short-term in-hospital functional outcome. Given no association of DAI and long-term TBI outcomes, providers should be cautious in attributing DAI to future neurologic function, quality of life, and/or survival. Epidemiological, level III; Therapeutic, level IV.

Impact of timing of ventriculoperitoneal shunt placement on outcome in posttraumatic hydrocephalus.

Posttraumatic hydrocephalus (PTH) is a frequent sequela of traumatic brain injury (TBI) and complication of related cranial surgery. The roles of PTH and the timing of cerebrospinal fluid (CSF) shunt placement in TBI outcome have not been well described. The goal of this study was to assess the impact of hydrocephalus and timing of ventriculoperitoneal (VP) shunt placement on outcome during inpatient rehabilitation after TBI. In this cohort study, all TBI patients admitted to Craig Hospital between 2009 and 2013 were evaluated for PTH, defined as ventriculomegaly, and hydrocephalus symptoms, delayed or deteriorating recovery, or elevated opening pressure on lumbar puncture. Extent of ventriculomegaly was quantified by the Evans index from CT scans. Outcome measures were emergence from and duration of posttraumatic amnesia (PTA) and functional status as assessed by means of the Functional Independence Measure (FIM). Findings in this group were compared to findings in a group of TBI patients without PTH (controls) who were admitted for inpatient rehabilitation during the same study period and met specific criteria for inclusion. A total of 701 patients were admitted with TBI during the study period. Of these patients, 59 (8%) were diagnosed with PTH and were included in this study as the PTH group, and 204 who were admitted for rehabilitation and met the criteria for inclusion as controls constituted the comparison group (no-PTH group). PTH was associated with initial postinjury failure to follow commands, midline shift or cistern compression, subcortical contusion, and craniotomy or craniectomy. In multivariable analyses, independent predictors of longer PTA duration and lower FIM score at rehabilitation discharge were PTH, emergency department Glasgow Coma Scale motor score < 6, and longer time from injury to rehabilitation admission. PTH accounted for a 51-day increase in PTA duration and a 29-point reduction in discharge FIM score. In 40% of PTH patients with preshunt CT brain imaging analyzed, ventriculomegaly (Evans index > 0.3) was observed 3 or more days before VP shunt placement (median 10 days, range 3-102 days). Among PTH patients who received a VP shunt, earlier placement was associated with better outcome by all measures assessed and independently predicted better FIM total score and shorter PTA duration. Posttraumatic hydrocephalus predicts worse outcome during inpatient rehabilitation, with poorer functional outcomes and longer duration of PTA. In shunt-treated PTH patients, earlier CSF shunting predicted improved recovery. These results suggest that clinical vigilance for PTH onset and additional studies on timing of CSF diversion are warranted.

Spatial Neglect Hinders Success of Inpatient Rehabilitation in Individuals With Traumatic Brain Injury

Background. Current knowledge about spatial neglect and its impact on rehabilitation mostly originates from stroke studies. Objective. To examine the impact of spatial neglect on rehabilitation outcome in individuals with traumatic brain injury (TBI). Methods. The retrospective study included 156 consecutive patients with TBI (73 women; median age = 69.5 years; interquartile range = 50-81 years) at an inpatient rehabilitation facility (IRF). We examined whether the presence of spatial neglect affected the Functional Independence Measure (FIM) scores, length of stay, or discharge disposition. Based on the available medical records, we also explored whether spatial neglect was associated with tactile sensation or muscle strength asymmetry in the extremities and whether specific brain injuries or lesions predicted spatial neglect. Results. In all, 30.1% (47 of 156) of the sample had spatial neglect. Sex, age, severity of TBI, or time postinjury did not differ between patients with and without spatial neglect. In comparison to patients without spatial neglect, patients with the disorder stayed in IRF 5 days longer, had lower FIM scores at discharge, improved slower in both Cognitive and Motor FIM scores, and might have less likelihood of return home. In addition, left-sided neglect was associated with asymmetric strength in the lower extremities, specifically left weaker than the right. Finally, brain injury–induced mass effect predicted left-sided neglect. Conclusions. Spatial neglect is common following TBI, impedes rehabilitation progress in both motor and cognitive domains, and prolongs length of stay. Future research is needed for linking specific traumatic injuries and lesioned networks to spatial neglect and related impairment.

Acute rehospitalisation during the first 3 months of in-patient rehabilitation for traumatic brain injury.

Unplanned re-admission to acute care hospitals during in-patient rehabilitation causes disruption to the rehabilitation program and increases the cost of health care. The aims of the present study were to identify the frequency, reasons and duration of disruption to rehabilitation because of acute re-admissions during the first 3 months of in-patient rehabilitation for traumatic brain injury (TBI) and to investigate the correlation between the duration of acute rehospitalisation and the discharge functional independence measure (FIM) score. A retrospective study was conducted on patients admitted for in-patient rehabilitation following TBI to a rehabilitation hospital in Auckland, New Zealand, between January 2009 and August 2013. Data on duration and reasons for acute rehospitalisation, as well as admission and discharge FIM scores, were obtained from electronic patient records. Pearson correlation was used to evaluate the relationship between the duration of acute rehospitalisation and the discharge FIM score. Of the 628 patients admitted for brain injury rehabilitation, 71 (11.3%) required acute rehospitalisation within the first 3 months. The main reasons for acute rehospitalisation were preventable medical causes (43.8%), including urinary tract infections, respiratory tract infections and coronary artery disease. Of the acute re-admissions, 76.6% were within the first month of admission to the rehabilitation centre and 46.6% needed in-patient treatment in the acute care hospital for > 5 days. There was a moderately strong negative correlation between the duration of stay in the acute care hospital and the discharge FIM score (r = - 0.412; P = 0.0005). A significant number of patients admitted for in-patient rehabilitation following TBI require acute rehospitalisation due to preventable medical causes. Because the duration of acute rehospitalisation has a negative impact on rehabilitation functional gain, preventive measures and surveillance need to be further investigated and optimised.

Abstract T P127: Look Past the NIHSS! Rehabilitation Metrics that Predict Home Discharge in Ischemic Stroke Patients

Introduction: The goals of stroke rehabilitation are to restore functional ability and to return patients' home with a good quality of life. There is a paucity of data on stroke rehabilitation tools that both track improvements and help predict the likelihood of home discharge. Hypothesis: Improvement in functional independence measure (FIM) score increases home discharge rates, decreases acute care readmissions and decreases placement in skilled nursing facilities (SNF). Advanced age and infections such as symptomatic UTI (SUTI) negate FIM score improvement. Methods: We merged the prospectively collected Stroke and Neurorehabilitation Registries at our comprehensive stroke center, identifying ischemic stroke patients admitted between January 2011 and November 2013 (n=367). Demographics, rehabilitation metrics and NIHSS were collected. Age, SUTI, discharge FIM and rehabilitation length of stay (LOS Rehab) were included in the multivariate regression. Results: Of 367 ischemic stroke patients, 273 went home, 47 to a SNF, 25 to acute care and 22 to another facility (i.e.,assisted living, board and care). All patients tolerated 3 hours of daily therapy (PT, OT, SLP). Despite median NIHSS values of 9 in both groups (P=0.356), patients with SUTI had lower FIM scores on admission (49.2 ± 13.9 vs. 56.8±15.2; P&lt;0.0001) and discharge (68.5 ± 16.9 vs. 76.3 ± 17.0; P&lt;0.0001). For a one year age increase, there was a 5% increase in SNF admit (OR 1.05, 95%CI 1.02-1.08; P&lt;0.001) compared to home. For a one unit increase in FIM, there was a 4% decrease in another facility admit (OR 0.96, 95% CI 0.93 to 0.99; P&lt;0.01), a 6% decrease in SNF admit (OR 0.94, 95%CI 0.92-0.96; P&lt;0.001) and a 10% decrease in acute care readmit (OR 0.90, 95% CI 0.88-0.94; P&lt;0.0001) compared to home. For a one day increase in LOS Rehab, there was a 19% decrease in acute care readmit (OR 0.81, 95% CI 0.73-0.89; P&lt;0.0001) compared to home, and a 7% increase in home discharge compared to another facility (OR 1.07, 95% CI 1.02 to 1.12; P&lt;0.001). Conclusions: Improved FIM score and increased LOS Rehab were the primary criteria for home discharge after stroke rehabilitation. Advanced age increased the likelihood of SNF placement. SUTI impacted rehabilitation progress, but did not affect discharge to home.

Influence of cognition on treatment outcome in geriatric patients: association between MMSE and gain in activities of daily living

Cognitive impairment or dementia influence the results of geriatric treatment. The aim of the study was to quantify this influence. Data of 2527 patients from the years 2006 to 2009 were analysed in order to quantify the influence of cognition measured with the Mini Mental Status Examination (MMSE) on the improvement of activities of daily living as reflected by the Functional Independence Measure (FIM). Impaired cognition is accompanied by a lower FIM score on admission and on discharge. But the improvement of the FIM of slightly cognitively impaired patients (MMSE 20-26) is the same as in patients without cognitive impairment (MMSE 27-30). Patients with a MMSE below 20 points have smaller improvements in their FIM score but nevertheless 40 % of the patients with a MMSE of 10-19 and still 30 % of the patients with a MMSE of 0-9 points show better improvements than the average of all patients. Patients with a MMSE below 20 should not generally be excluded from geriatric treatment, but individual factors should be considered.

Corrected FIM effectiveness as an index independent of FIM score on admission

Tokunaga M, Nakanishi R, Watanabe S, Maeshiro I, Hyakudome A, Sakamoto K, Okubo T, Nojiri S, Yamanaga H. Corrected FIM effectiveness as an index independent of FIM score on admission. Jpn J Compr Rehabil Sci 2014; 5: 7－11. Objective: To correct Functional Independence Measure (FIM) effectiveness for low FIM scores to obtain an index independent of FIM score on admission. Methods: A total of 1,101 stroke patients in Kaifukuki rehabilitation wards were studied. They were divided into 13 groups according to the motor FIM score on admission, in 6-point increments. The parameter “A” was derived so that motor FIM effectiveness, calculated as motor FIM gain/(A － motor FIM score on admission), was around 0.65. Results: Motor FIM effectiveness was an index independent of motor FIM score on admission when A was 42, 64, 79, 83, 87, 89, or 91 points (when motor FIM on admission was 13－18 points, 19－24 points, 25－30 points, 31－36 points, 37－42 points, 43－48 points, or 49－90 points). Conclusions: Corrected FIM effectiveness, which is independent of FIM on admission, may be useful for comparisons between hospitals admitting patients with varying degrees of severity.

Falls on an Inpatient Rehabilitation Unit: Risk Assessment and Prevention

To determine the relationship between admission diagnosis and admission score on Functional Independence Measure (FIM) to the likelihood that a patient will fall. To measure the effectiveness of a multifactorial program to reduce falls. The Quality Improvement Team put in place a multifactorial program to reduce the incidence of falls on an inpatient rehabilitation unit. The authors reviewed the records of all patients admitted to the rehabilitation unit between January 2006 and December 2009 to determine if the program resulted in a reduced rate of falls. The authors also reviewed the data to evaluate if admission score on the FIM and the diagnosis or impairment group of the patient are related to the risk of fall. FIM score is inversely related to the rate of falls. Patients with admission diagnosis of stroke, brain injury, amputation, neurologic disorders (Parkinson's disease, multiple sclerosis, Guillain-Barre, myopathy, peripheral neuropathy), and spinal cord injury are at higher risk for fall than patients whose admission diagnosis related to orthopedic, cardiac, pulmonary disorders, prolonged stay on medical or surgical units, or trauma without spinal cord injury or head injury. There was a significant reduction in the rate of falls from 14.9% to 7.3% of patients admitted to the IRF. Patients with low FIM scores, disorders of the central and peripheral nervous system, and amputations are at high risk of fall. Compliance with recommended guidelines can reduce the rate of fall and improve patient safety. The rate of falls on an IRF will be determined in part by the case mix and functional levels of the patients on the unit. Strict adherence to appropriate nursing protocols can reduce the rate of falls.

Long-Term Prediction of Functional Outcome After Stroke Using the Alberta Stroke Program Early Computed Tomography Score in the Subacute Stage

Stroke patients who arrive at hospital more than 24 hours after symptom onset could benefit from a simple means of assessing long-term prognosis in this subacute stage. We evaluated whether clinical factors along with ischemic injury assessed subacutely using the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) had predictive value for functional independence after stroke. Computed tomography (CT) scans obtained ≥ 2 days after first-ever ischemic stroke were scored independently and retrospectively by 3 stroke neurologists using the ASPECTS. Functional outcome was measured using the Functional Independence Measure, which assesses the amount of caregiver assistance required by patients during daily activities. Multiple linear regression was used to develop a predictive model for functional prognosis at 1 month, 3 months, and 1 year poststroke. For our 55 patients, CT scanning was done on average 4 days poststroke. The interrater agreement for subacute ASPECTS was excellent, with a κ-weighted value of 0.90. Lesions involving the frontal and superior parietal ASPECTS regions were significant predictors of lower Functional Independence Measure scores at all 3 time points studied. In combination with such factors as age, marital status, and the severity of initial neurologic deficit, a subacute ASPECTS score >5 had significant predictive value for greater functional independence at 3 months (R(2) = 0.701; P < .001) and 1 year (R(2) = 0.528; P < .001) poststroke. Our data indicate that in the subacute stage, ASPECTS is reliable and can help predict which patients may be likely to regain functional independence up to 1 year after sustaining ischemic stroke.