Home alone: the role of cognition in return to independent living

OBJECTIVE: To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation. DESIGN: Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition. SETTING: A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit. PATIENTS: Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed. MAIN OUTCOME MEASURE: Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS). RESULTS: Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs. CONCLUSION: Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.     

Posttraumatic amnesia: its relation to functional outcome

OBJECTIVE: To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS: Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES: Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS: Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION: Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.     

A comparative study of postmortem MR imaging and pathological examination of human brain specimens

OBJECTIVE: To determine typical outcome "benchmarks" for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared. SUBJECTS: Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation. METHODS: Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation. MAIN OUTCOME MEASURES: Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates. RESULTS: The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities. CONCLUSION: The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.     

Self-esteem level and stability, admission functional status, and depressive symptoms in acute inpatient stroke rehabilitation.

Objectives: Explore the relationship of self-esteem level, self-esteem stability, and admission functional status on discharge depressive symptoms in acute stroke rehabilitation. Research Method: One hundred twenty stroke survivors serially completed a measure of state self-esteem during inpatient rehabilitation and completed a measure of depressive symptoms at discharge. Functional status was rated at admission using the Functional Independence Measure (FIM). Regressions explored main effects and interactions of self-esteem level and stability and admission FIM self-care, mobility, and cognitive functioning on discharge depressive symptoms. Results: After controlling for potential moderating variables, self-esteem level interacted with FIM self-care and cognitive functioning to predict discharge depressive symptoms, such that survivors with lower self-rated self-esteem and poorer functional status indicated higher levels of depressive symptoms. Self-esteem stability interacted with FIM mobility functioning, such that self-esteem instability in the presence of lower mobility functioning at admission was related to higher depressive symptoms at discharge. Implications: These results suggest that self-esteem variables may moderate the relationship between functional status and depressive symptoms. Self-esteem level and stability may differentially moderate functional domains, although this conclusion requires further empirical support. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Classifying rehabilitation inpatients by expected functional gain

OBJECTIVES: To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented here groups patients according to their gains in functional status during the rehabilitation stay. METHODS: Data from 84,492 patients discharged from 252 rehabilitation facilities in 1992 were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The gain-FRGs system used four predictor variables: (1) diagnosis leading to disability, admission scores on the (2) motor and (3) cognitive subscales of the FIM, and (4) patient age. RESULTS: The gain-FRGs system contained 74 patient groups and explained 21% of the variation in functional gain for patients in a different set of records withheld for validation. CONCLUSIONS: The gain-FRGs system should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone.     

Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system

OBJECTIVES: Function-related groups based on the Functional Independence Measure have been proposed as a model for a prospective payment system for medical rehabilitation. This study describes discharge destination and motor function outcomes in a sample of patients with stroke from the FIM-FRG STR1 classification. STUDY DESIGN: A retrospective review of 293 cases of stroke from the years 1993 to 1995. The demographic and outcome characteristics of this sample were described. RESULTS/CONCLUSIONS: Forty-five percent of the patients were discharged to home after a mean length of stay of 23.8 days in acute medical rehabilitation. Patients who were discharged home had higher admission and discharge motor FIM scores than those discharged to a subacute facility or long-term care facility, although the correlation between motor FIM score and discharge destination was low to moderate. Median discharge motor FIM scores indicate considerable residual disability in this classification after rehabilitation. Research problems that address methods to improve the usefulness of the FIM-FRG system in a prospective payment system are discussed.     

A comparison of two functional tests in quadriplegia: the quadriplegia index of function and the functional independence measure

Individuals with spinal cord injury are evaluated according to a set of guidelines based on motor, sensory, and functional tests. The resulting scores are used to quantify the extent of neurological injury and functional loss. The purpose of the present study was to compare certain scoring systems using the same group of patients. Twenty-nine subjects with cervical spine cord injury were evaluated by the same examiner using three scales: (1) The American Spinal Cord Injury Association (ASIA) (2) The Quadriplegia Index of Function (QIF) (3) The Functional Independence Measure (FIM) Assessments were made both at admission to, and discharge from, the rehabilitation center. Positive change in motor score is widely used as an indicator of recovery after spinal cord injury. We assessed the relationship of the two functional tests, the FIM and the QIF, to ASIA scores and found strong correlations in both cases. The feeding and dressing categories of QIF showed an even stronger correlation to ASIA motor scores, though the statistical significance was the same for corresponding categories of FIM and QIF. The percent of recovery on ASIA motor scores was significantly correlated only to gain in QIF scores, not FIM. FIM lacks the category of bed activities. Some additions to the FIM may be useful, especially in the feeding and dressing categories, and a category of bed activities could be included as well, in order to improve sensitivity.     

Trunk control test as an early predictor of stroke rehabilitation outcome

BACKGROUND AND PURPOSE: The aim of this study was to investigate the construct and predictive validity of the Trunk Control Test (TCT) in postacute stroke patients by comparing TCT scores at admission and discharge with the Functional Independence Measure (FIM) scores. METHODS: Forty-nine patients participated in the study. The TCT examines four movements: rolling from a supine position to the weak side (T1) and to the strong side (T2), sitting up from a lying-down position (T3), and sitting balance (T4). The FIM is an 18-item scale (13 motor [motFIM] and 5 cognitive [cognFIM]) used to determine the level of dependence of patients in daily life. RESULTS: Thirty-six patients (73%) increased their TCT overall score at discharge. The TCT item-total correlations were high, both at admission and discharge (P < .0001). The individual TCT items were intercorrelated. Furthermore, the homogeneity of the TCT was confirmed by a high Cronbach's index. High correlations were found between admission and discharge scores in the different tests (TCT, FIM, and motFIM; P < .0001) and between TCT at admission and FIM (P < .0001) and motFIM (P < .0001) at admission. TCT at admission alone explained 71% of the variance in motFIM at discharge. CONCLUSIONS: The TCT showed a good sensitivity to change in assessing recovery of stroke patients. The high item-total correlation and Cronbach's alpha value of the TCT suggest that there is one homogeneous construct underlying the item list. The TCT construct validity was confirmed by the correlation between this test and the FIM scores. TCT at admission predicted motFIM at discharge even better than motFIM at admission alone. Possibly, the TCT captures basic motor skills that foreshadow the recovery of more complex behavioral skills described by the FIM.     

Quality of life in elderly patients with COPD: measurement and predictive factors

OBJECTIVE: To examine the interrater reliability and completion time of the Functional Assessment Measure, which is the Functional Independence Measure (FIM) plus additional items (FIM+FAM). DESIGN: Interrater reliability study. SETTING: Inpatient rehabilitation units of a postacute care brain injury rehabilitation program. PATIENTS: A convenience sample of 53 extremely severely impaired adult survivors of traumatic brain injuries (40 men, 13 women, mean age 38yrs). MAIN OUTCOME MEASURES: Treatment team members' ratings of the 30 FIM +FAM items, and time taken to complete the FIM+FAM. RESULTS: Intraclass Correlation Coefficients (ICCs) were within the good to excellent range (ICC > .60) for 29 of 30 items and for all subscales except psychosocial adjustment. Higher mean ICC values were obtained for motor domain items than for cognitive/psychosocial domain items. Treatment teams became progressively faster over a 12-week period in completing the FIM+FAM. The generally good to excellent range interrater reliability found in this study helps support the use of the FIM+FAM in rehabilitation settings. Further support was obtained for the finding that motor items are more reliable than cognitive and psychosocial items. Administration of the FIM+FAM can be done in a timely manner in a rehabilitation setting.     

Negative symptoms in stroke patients and length of hospital stay

The purpose of this study was to assess whether the presence and severity of psychiatric symptoms in stroke patients correlate with their length of stay (LOS) in a rehabilitation unit, with special emphasis on the role of negative symptoms (NS). Twenty-three stroke patients, consecutively recruited from the inpatient rehabilitation unit, were evaluated on admission with the Mini-Mental State Examination (MMSE), the Positive and Negative Symptom Scale (PANSS), the Hamilton Depression Rating Scale (HDRS), the Scale for Assessment of Negative Symptoms (SANS), and the Functional Independent Measure (FIM). NS scores significantly correlated with LOS, with SANS total score being the most informative, and the attentional impairment subscale the least. The group of patients with pronounced NS stayed in the hospital twice as long as patients with the score on the NS subscale of PANSS below 16. These two groups did not differ in their cognitive performance or in the positive symptom subscale of PANSS scores. Total FIM score on admission was lower and HDRS scores higher in patients with pronounced NS. However, these differences, unlike those of LOS, have not reached statistical significance. The presence and severity of NS in stroke patients are associated with a longer hospital stay. Identification and treatment of NS might lead to a faster discharge from rehabilitation unit.     

Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation.

Objective: To explore self-esteem change during inpatient stroke rehabilitation and moderators of change. Research Method: One hundred twenty survivors of stroke serially completed the State Self-Esteem Scale (SSES) during inpatient rehabilitation, as well as measures of mood and perceived recovery as potential moderators of change. Age, gender, prior stroke, prestroke depression, stroke laterality, and admission Functional Independence Measure (FIM) self-care, mobility, and cognitive scores were also included as moderators. Results: Multilevel modeling of the repeated administrations of the SSES indicated that self-esteem significantly improved during rehabilitation. Female gender, left hemisphere stroke, prior stroke, and lower admission FIM cognitive scores were associated with lower self-esteem ratings at admission, but only age and admission FIM self-care and mobility scores were associated with self-esteem change. Older individuals showed less self-esteem improvement than younger individuals, and higher self-care and mobility scores at admission were associated with greater self-esteem improvement. While mood change significantly covaried with self-esteem, the rate of mood change did not appear to influence rate of self-esteem change. Greater improvement in self-esteem over time was related to lower levels of perceived recovery, but this was likely because of the relationship between perceived recovery and self-esteem at rehabilitation admission. Implications: These results suggest that self-esteem improves during inpatient rehabilitation, and this change may be partially dependent on functional status. Implications for facilitating self-esteem change by the clinician are discussed, as well as future research directions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stroke rehabilitation: clinical predictors of resource utilization

OBJECTIVE: To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission. DESIGN: Statistical analysis of data prospectively collected from stroke rehabilitation patients. SETTING: Large, urban, academic freestanding rehabilitation facility. PARTICIPANTS: A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation. MAIN OUTCOME MEASURES: Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD). METHODS: Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis. RESULTS: Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001). CONCLUSION: Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.     

Increased serum levels of macrophage colony-stimulating factor (M-CSF) in alpha- and beta-thalassaemia syndromes: correlation with anaemia and monocyte activation

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.     

Functional outcome after brain tumor and acute stroke: a comparative analysis

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke. DESIGN: Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit. SUBJECTS: Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion. MAIN OUTCOME MEASURES: The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01). CONCLUSION: Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.     

Analysis of Likert scale data in disability and medical rehabilitation research.

Many clinical evaluations are subjective, resulting in ordinal level measurements. A widely used example in medical rehabilitation is the Functional Independence Measure (FIM), which provides a measure of disability. The FIM is an 18-item, 7-point Likert scale ranging from complete dependence to complete independence. Parametric statistics are commonly used for the analysis of ordinal data. However, Likert scales often lead to violation of many underlying assumptions. This study examined the comparative power of the t test with the Wilcoxon rank-sum test using real pretest/posttest data sets measured on an ordinal scale. FIM scores were obtained on 714 geriatric patients at admit and discharge from a rehabilitation hospital. A Fortran 77 program was written to sample with replacement from each admit and discharge data distribution. Results indicated the Wilcoxon rank-sum test outperformed the t test for almost every sample size and alpha level examined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between self-esteem and functional outcome in the acute stroke-rehabilitation setting.

Objective: To explore the relationship between self-esteem and functional recovery in patients with acute stroke. Design: A nonconsecutive sample of stroke survivors received ratings of functional status and completed self-report measures of self-esteem and depressive symptoms. Bivariate correlational analyses and multivariate regression analyses explored the relationships of functional status and self-report of self-esteem and depressive symptoms. Setting: Acute inpatient rehabilitation hospital. Participants: A group of 176 right- or left-hemisphere stroke participants. Main Outcome Measures: Self-care and mobility domain scores (based on Functional Independence Measure ratings) at admission and discharge. Efficiency scores for each domain. Visual Analogue Self-Esteem Scale (S. M. Brumfitt & P. Sheeran, 1999) and Geriatric Depression Scale (J. A. Yesavage et al., 1983). Results: Regression analyses indicated that lower self-esteem ratings were related to poorer discharge self-care and mobility scores and poorer efficiency in these domains, whereas ratings of depressive symptoms were not. However, interactions between self-esteem ratings and ratings of depressive symptoms were noted. Exploratory analyses suggested that self-esteem ratings mediated the relationship between ratings of depressive symptoms and functional outcome indices. Conclusions: Self-esteem ratings may have a mediating/moderating role in the relationship between emotional functioning and functional outcome. This may have implications for research in this area and the type of mental health treatment available to stroke rehabilitation patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Capabilities of Upper Extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia

OBJECTIVE: To evaluate the reliability and validity of the Capabilities of Upper Extremity (CUE) instrument, designed to measure upper extremity functional limitations in individuals with tetraplegia. Functional limitations are actions such as reaching or grasping and are a link between the domains of impairment and disability. DESIGN: Survey of people with chronic spinal cord injury. SETTING: Regional spinal cord injury center. SUBJECTS: One hundred fifty-four individuals (140 male) with tetraplegia at least 1 year after injury and followed by the center. Mean age was 36.7 years (SD=11.1). Sixty-eight percent were motor complete. METHODS: The 32-item CUE was administered by telephone interview twice about 2 weeks apart. The motor portion of the Functional Independence Measure (FIM) was collected during the first interview. Upper extremity motor scores and motor levels were obtained from the most recent assessment in the outpatient chart. The instrument was evaluated for internal consistency, reliability, and validity. Exploratory factor analysis was performed to examine scale structure. RESULTS: Homogeneity of the scale was excellent. Cronbach's alpha was .96, and item-total correlations ranged from .49 to .78. Test-retest reliability was high (ICC=.94). All but three items had desired levels of agreement (K > .60). Analysis of variance indicated that the CUE distinguished between motor levels of tetraplegia more than one level apart. The CUE was correlated highly with both motor scores and FIM. Regression analysis indicated that the CUE was better than upper extremity motor scores for predicting FIM scores. The model containing the CUE explained 73% of the variance in FIM and was not enhanced by the addition of motor scores. Factor analysis suggested four potential subscales: arm function (bilateral), right hand function, left hand function, and reaching down. CONCLUSION: The CUE exhibits good homogeneity, reliability, and validity; further work is needed to determine its sensitivity to change in function.