Receipt Of Rehabilitation Research Articles

Longitudinal Association of Fall risk for Community Dwelling Elderly with and without ADRD

There is conflicting evidence regarding the association between insomnia and the onset of mild cognitive impairment (MCI) or dementia. This study aimed to evaluate if time-varying insomnia is associated with the development of MCI and dementia. Data from the Health and Retirement Study (n = 13,833) from 2002 to 2014 were used (59.4% female). The Brief Insomnia Questionnaire was used to identify insomnia symptoms compiled in an insomnia severity index, ranging from 0 to 4. In the analysis, participants’ symptoms could vary from wave-to-wave. Dementia was defined using results from the Health and Retirement Study (HRS) global cognitive assessment tool. Respondents were classified as either having dementia, MCI or being cognitively healthy. Cox proportional hazards models with time-dependent exposure using the counting process (start-stop time) were used for analysis. For each one-unit increase in the insomnia symptom index, there was a 5-percent greater hazard of MCI (HR = 1.05; 95% CI: 1.04–1.06) and dementia (HR = 1.05; 95% CI: 1.03–1.05), after fully adjusting. Using a nationally representative sample of adults aged 51 and older, this study found that time-varying insomnia symptoms are associated with the risk of MCI and dementia. This highlights the importance of identifying sleep disturbances and their change over time as potentially important risk factors for MCI and dementia.

Longitudinal association between falls and Alzheimer’s disease and related dementia (ADRD) in the community dwelling elderly population

AbstractBackgroundFalls are higher amongst elderly with ADRD and are a major cause of functional impairment and increased mortality. The primary purpose of this study was to examine if fall status of community dwelling elderly residents with and without ADRD differ over a four year period and additionally, does receipt of rehabilitation in any year modify this association.MethodData for this analysis was drawn from the 2015‐2018 National Health and Aging Trends Study (NHATS). Participants included sample persons (N=3,235) age 65 and older who resided in the community or residential care facilities that were not nursing homes. Baseline characteristics of individuals in ADRD (n= 264) and non‐ADRD group (n=2,971) was compared using chi square statistic. A generalized estimating equation model (multivariate logistic regression) was used to estimate odds ratio of falls in the two groups, adjusted for sociodemographic and clinical conditions that are predictors of fall risk.ResultAt baseline, ADRD group comprised of older, increased number of racial/ethnic minorities other than non‐Hispanic Whites, more frail individuals who reported increased use of assistive device (AD) and had a presence of depression. Those in the non‐ADRD group at baseline had significantly decreased odds for falls, however no statistically significant change was observed for fall status over four years in the two groups (non‐ADRD vs ADRD) and this association was not modified by receipt of rehabilitation. Males had decreased odds ratio (OR 0.87, 95% CI ‐0.22, ‐0. 012) for falls compared to females in both groups and compared to non‐Hispanic Whites, those who were non‐Hispanic Blacks (OR 0.59, 95% CI ‐0.66, ‐0.36) and Blacks (0.58, 95%CI ‐0.82, ‐0.25) had decreased odds ratio for falls. Those who used AD, had depression and received rehabilitation services showed increased odds for falls. No differences were found in terms of fall status for those who lived alone and were frail.ConclusionFuture studies should examine the bi‐directional interplay between falls and rehabilitation with inclusion of other predictors of fall risk in elderly with ADRD. This can provide further evidence on whether rehabilitation can be used as an effective non‐pharmacological intervention in the management of elderly with ADRD.

Associations of Medicaid Expansion With Access to Care, Severity, and Outcomes for Acute Ischemic Stroke.

Multiple states have not expanded Medicaid under the Affordable Care Act, resulting in higher uninsured rates in states with high stroke burdens. This study aimed to evaluate the association of Medicaid expansion with changes in health insurance coverage, severity of presentation, access to care, and outcomes among patients with acute ischemic stroke. A retrospective, difference-in-differences analysis of Get With The Guidelines-Stroke registry data. The study population comprised first-time ischemic stroke admissions from 2012 to 2018 for patients aged 19 to 64 in 45 states (27 that expanded Medicaid and 18 that did not). A probable low-income cohort was defined based on having Medicaid, no insurance/self-pay, or undocumented insurance. Outcomes analyzed were indicators of health insurance status, stroke severity, use of emergency services, time to acute care, in-hospital mortality, receipt of rehabilitation, discharge disposition, and level of disability. In the starting population (N=342 765), Medicaid-covered stroke admissions rose from 12.2% to 18.1% in expansion states and from 10.0% to only 10.6% in nonexpansion states, while uninsured admissions declined from 15.0% to 6.7% in expansion states and from 24.0% to 19.2% in nonexpansion states. In the low-income cohort (N=95 086; 28% of starting population), Medicaid expansion was associated with increased odds of discharge to a skilled nursing facility (adjusted odds ratio, 1.33 [95% CI, 1.12-1.59]) and transfer to any rehabilitation facility among those eligible (adjusted odds ratio, 1.24 [95% CI, 1.08-1.41]) and lower odds of discharge home (adjusted odds ratio, 0.89 [95% CI, 0.80-0.98]). Expansion was not associated with any other outcomes. Medicaid expansion is associated with fewer uninsured hospitalizations for acute ischemic stroke and increased rehabilitation at skilled nursing facilities. More targeted interventions may be needed to improve other stroke outcomes in the low-income US population. Future research should evaluate the impact of health care reform on primary stroke prevention.

Characteristics Associated with the Use of an Inpatient Rehabilitation or Skilled Nursing Facility after Acute Care in Children with Severe Traumatic Brain Injury

ABSTRACT To characterize inpatient rehabilitation services for children with severe traumatic brain injury (TBI), we included 254 children, whose parents/guardians reported receipt of rehabilitation within a 12-month follow-up period, from a multinational observational study. Children discharged to an inpatient rehabilitation or skilled nursing facility after acute care were classified into the “inpatient rehabilitation” group, and children discharged home after acute care were classified into the “non-inpatient rehabilitation” group. Multivariable regression analyses determined the associations of sociodemographic and clinical characteristics with rehabilitation groups. Children receiving inpatient rehabilitation had a shorter length of acute hospitalization. Children from the UK were less likely to receive inpatient rehabilitation compared to children from the US. Future studies are warranted to extend current findings by identifying the reasons behind differential access to inpatient rehabilitation among children with severe TBI.

Assessment and selection for rehabilitation following acute stroke: a prospective cohort study in Queensland, Australia

Objective: To describe current practice and investigate factors associated with selection for rehabilitation following acute stroke. Design: Prospective observational cohort study. Setting: Seven public hospitals in Queensland, Australia. Subjects: Consecutive patients surviving acute stroke. Measures: Rehabilitation selection processes are assessment for rehabilitation needs, referral for rehabilitation and receipt of rehabilitation. Functional impairment following stroke is modified Rankin Scale (mRS). Results: We recruited 504 patients, median age 73 years (interquartile range (IQR) = 62–82), between July 2016 and January 2017. Of these, 90% (454/504) were assessed for rehabilitation needs, 76% (381/504) referred for rehabilitation, and 72% (363/504) received any rehabilitation. There was significant variation in all rehabilitation selection processes across sites (P < 0.05). In multivariable analyses, stroke unit care (odds ratio (OR) = 2.7; 95% confidence interval (CI) = 1.1, 6.6) and post stroke functional impairment (severe stroke mRS 4–5: OR = 10.9; 95% CI = 4.9, 24.6) were associated with receiving an assessment for rehabilitation. Receipt of rehabilitation was more likely following assessment (OR = 6.5; 95% CI = 2.9, 14.6) but less likely in patients with dementia (OR = 0.2; 95% CI = 0.1, 0.9), end-stage medical conditions (OR = 0.4; 95% CI = 0.2, 0.8) or ischaemic stroke (OR = 0.4; 95% CI = 0.1, 0.9). The odds of receiving rehabilitation increased with greater impairment: OR = 3.0 (95% CI = 1.5, 4.9) for mRS 2–3 and OR = 12.5 (95% CI = 6.5, 24.3) for mRS 4–5. Among patients with mild-moderate impairment (mRS 2–3), 39/117 (33%) received no rehabilitation. Conclusions: There was significant inter-site variation in rehabilitation selection processes. The major factors influencing rehabilitation access were assessment for rehabilitation needs, co-morbidities and post-stroke functional impairment. Gaps in access to rehabilitation were found in those with mild to moderate functional impairment.

Associations between hospital-based rehabilitation for hip fracture and two-year outcomes for mortality and independent living: An Australian database study of 1,724 elderly community-dwelling patients.

To compare rates of mortality, hospital readmissions and independent living status for 2 years following hip fracture in community-dwelling patients with and without hospital-based rehabilitation. Retrospective cohort study. Administrative data-sets were linked for hospital treatment, residential aged care admissions, selected community services and date of death for community-dwelling hip fracture patients. Mortality, readmissions, residency within aged care facilities and independent living status at intervals up to 2 years were compared in multivariate logistic regression for patients with and without hospital-based rehabilitation. Age, sex and comorbidity distributions were similar for 1,050 patients who received rehabilitation and 674 patients who did not. Rehabilitation added 11 days to total hospital stay and $AUD 12,000 to hospital costs. Mortality at 90 days after hip fracture was 4.7% for rehabilitation patients vs 10.7% for others (p < 0.001), and 26.2% vs 37.2% (p < 0.001) at 2 years. Beyond 90 days there was no significant association between receipt of rehabilitation and the proportion of patients meeting criteria for independent living. Hospital readmissions in the year following the index fracture were not significantly different. In-hospital rehabilitation substantially increases total hospital costs. It is associated with improved early and late survival, but not with the likelihood of living independently for up to 2 years after hip fracture.

Neurologic Functional and Quality of Life Outcomes after TBI: Clinic Attendees versus Non-Attendees.

This investigation describes the relationship between TBI patient demographics, quality of life outcome, and functional status outcome among clinic attendees and non-attendees. Of adult TBI survivors with intracranial hemorrhage, 63 attended our TBI clinic and 167 did not attend. All were telephone surveyed using the Extended-Glasgow Outcome Scale (GOSE), the Quality of Life after Brain Injury (QOLIBRI) scale, and a post-discharge therapy questionnaire. To determine risk factors for GOSE and QOLIBRI outcomes, we created multivariable regression models employing covariates of age, injury characteristics, clinic attendance, insurance status, post-discharge rehabilitation, and time from injury. Compared with those with severe TBI, higher GOSE scores were identified in individuals with both mild (odds ratio [OR]=2.0; 95% confidence interval [CI]: 1.1-3.6) and moderate (OR=4.7; 95% CI: 1.6-14.1) TBIs. In addition, survivors with private insurance had higher GOSE scores, compared with those with public insurance (OR=2.0; 95% CI: 1.1-3.6), workers' compensation (OR=8.4; 95% CI: 2.6-26.9), and no insurance (OR=3.1; 95% CI: 1.6-6.2). Compared with those with severe TBI, QOLIBRI scores were 11.7 points (95% CI: 3.7-19.7) higher in survivors with mild TBI and 17.3 points (95% CI: 3.2-31.5) higher in survivors with moderate TBI. In addition, survivors who received post-discharge rehabilitation had higher QOLIBRI scores by 11.4 points (95% CI: 3.7-19.1) than those who did not. Survivors with private insurance had QOLIBRI scores that were 25.5 points higher (95% CI: 11.3-39.7) than those with workers' compensation and 16.8 points higher (95% CI: 7.4-26.2) than those without insurance. Because neurologic injury severity, insurance status, and receipt of rehabilitation or therapy are independent risk factors for functional and quality of life outcomes, future directions will include improving earlier access to post-TBI rehabilitation, social work services, affordable insurance, and community resources.

Posttraumatic stress disorder in older people after a fall

Posttraumatic Stress Disorder (PTSD) is a debilitating psychological condition, never studied in relation to falls in older people. This study determines the prevalence and correlates of PTSD in older people post-fall. A prospective survey study, with baseline data collected by interview in hospital post-fall and by postal self-completion at 12 and 24 weeks post-baseline. A convenience sample of 196 people (> or = 65 years) were serially recruited, 87.9% of those eligible. Information collected at baseline included falls-related data, activity problems, fear of falling, PTSD symptoms, anxiety and depression, and at follow-up PTSD symptoms, anxiety and depression, the receipt of rehabilitation and further falls. In hospital, of 40 participants whose fall had occurred over 1 month previously 35% had full acute PTSD and 17.5% had partial acute PTSD. At follow-up full or partial chronic PTSD was found in 26.1% of participants at first follow-up, and in 27.4% of participants at second follow-up. Older age, pre-fall activity problems, fear of falling, and anxiety assessed at baseline were associated (p < 0.05) with follow-up PTSD diagnosis, as were anxiety and depression assessed concurrently. PTSD occurs in a substantial minority of older people post-fall. No pattern emerged of factors predictive of PTSD, although the association between fear of falling and PTSD suggests some patients thought to have fear of falling may be manifesting PTSD, and require identification to enable therapeutic intervention.

Quality of life and visual rehabilitation: an observational study of low vision in three general practices in West Glamorgan

To survey low vision in an urban population and assess impact on quality of life, rehabilitation and support. In a cross-sectional population survey, 66 patients were identified from databases of three general practices and surveyed by investigator administered questionnaire. Main outcome measures were ocular diagnoses, (US) National Eye Institute Visual Function-Questionnaire (NEI-VFQ) scores assessing visual and nonvisual disability, eligibility for, awareness and receipt of rehabilitation and support. Of 24,420 individuals on the lists of the three study practices, we found 101 registered as blind or partially sighted (prevalence 0.41%). A total of 66 patients participated with ocular diseases of age-related macular degeneration 39 (59%), glaucoma 11 (17%), diabetic retinopathy two (3%), retinitis pigmentosa two (3%), and 12 (18%) 'others'. Better eye visual acuity was counting fingers or worse in 32 (48.5%). NEI-VFQ scores were poor-overall mean 41.5% (SD 23.5). In all, 80% had a social services home visit with one-third of these still in contact. In all, 66% had undergone a low vision aid assessment and 57.6% of these used their aid. The awareness and receipt of benefits arising from registration as visually impaired were lower than for other supportive measures available for reasons unrelated to vision. None had a guide dog. We found expected patterns of low vision but poorer levels of function and support that may reflect age and deprivation in a population failed by the current systems for identification, registration, and rehabilitation based on legislation overtaken by demographic change and social provision independent of visual status.

Variations in care and outcome in the first year after stroke: a Western and Central European perspective

Background: There are significant variations in the short term patterns of care and outcome after a first stroke in Europe. Objective: To estimate the variation in stroke care and outcome...

Towards meaningful research in rehabilitation

Research in rehabilitation is often considered uninteresting, ill-defined and impossible to undertake. It is a revelation to many members of the public and health professionals that rehabilitation as a speciality exists, despite there being well over six million people with disabilities and continuing care needs in the UK (Martin et al, 1988). Those who are involved in the provision and receipt of rehabilitation appear to have no doubt as to its value; nevertheless, the call for ‘proof’ remains. It is not the intention of this editorial to consider appropriate methods of investigation but rather to address some of the assumptions which mitigate against meaningful research being undertaken in rehabilitation.

Rehabilitation service utilization models: Changes in the opportunity structure for disabled women

The focus of this paper is the opportunity structure for rehabilitation and subsequent outcome for disabled women, in comparison with disabled men. From evidence cited in the literature the differential provision of rehabilitation and other supportive services to disabled women suggests variation in outcome, based on two analytic service utilization models of rehabilitation: medical and psychosocial. Aggregate trend data (1972 and 1978) were used in the analysis of adult disabled groups, by gender and selected disabling conditions. There are two striking results from the analysis of these data sets. One indicates that receipt of rehabilitation is greatly influenced by sociodemographic factors, particularly gender and age. A detailed examination of the combination effects of gender and other sociodemographic variables shows that there are subtleties, such as an interaction between race and gender and education and gender, as well as between age and gender, that put uneducated, younger, white women at a disadvantage in their access to rehabilitation resources. The analysis of these sociodemographic factors over two points in time, however, demonstrates what can be considered a diffusion of the distinctions of social inequality, probably due to changes in rehabilitation legislation that redefined eligibility criteria for rehabilitation services and expanded programme goals. The second result of note is that neither form of rehabilitation is associated with a positive outcome, in this case ability to work. In the earlier data set (1972), indications were that neither the medical model of rehabilitation nor the psychosocial model were effective in returning the individual to the work role. This was true for both men and women.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in receipt of rehabilitation by impaired midlife men and women.

Differences in receipt of rehabilitation by impaired midlife men and women.