Clinical Instability as a Predictor of Negative Outcomes Among Elderly Patients Admitted to a Rehabilitation Ward

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<ul><li><p>Clinical Instability as a Predictorof Negative Outcomes AmongElderly Patients Admitted to aRehabilitation WardRehabCremtory oDio F</p><p>The a</p><p>AddreCarebellel</p><p>Copyr</p><p>DOI:1</p><p>ORIGFabio Guerini, MD, Giovanni B. Frisoni, MD, Sara Morghen, PsyD, Salvatore Speciale, MD, Giuseppe Bellelli, MD,and Marco Trabucchi, MDObjectives: To assess the impact of clinical instability(CI) and delirium on admission to a rehabilitationunit on clinical and functional outcomes (death,transfer to acute care, poor functional recovery) atdischarge, in a population of elderly patients.</p><p>Design: Observational study.</p><p>Setting: Rehabilitation and Aged Care Unit (RACU).</p><p>Participants: Participants were 583 consecutively andfirstly admitted elderly patients.</p><p>Measurements: On admission, all patients underwenta comprehensive geriatric assessment including socio-demographics, cognitive and depressive symptoms,nutritional status, physical health, and functional sta-tus. CI was recorded for all patients on admission, as-sessing 5 vital signs (temperature, heart rate, systolicblood pressure, respiratory rate, and oxygen satura-tion). Delirium was assessed daily with the ConfusionAssessment Method.</p><p>Results: Patients were on average old (mean age: 77.8 9.8), predominantly female (68.6%), with mildilitation and Aged Care Unit Ancelle della Carita Hospital, 26100,ona, Italy; Geriatric Research Group, Brescia, ITALY; LENITEM - Labora-f Epidemiology Neuroimaging &amp; Telemedicine, IRCCS San Giovanni di</p><p>BF, Brescia, Italy; Tor Vergata University, Rome, Italy.</p><p>uthors have no conflicts of interest.</p><p>ss correspondence to Giuseppe Bellelli, MD, Rehabilitation and AgedUnit, Ancelle della Carita Hospital. 26100, Cremona, Italy. E-mail:li-giuseppe@ancelle.it</p><p>ight 2010 American Medical Directors Association0.1016/j.jamda.2009.10.005</p><p>INAL STUDIEScognitive deterioration (MMSE: 22.1 6.3) and de-pressive symptoms (GDS: 5.9 3.5). They had moder-ate comorbidity (means CIRS: 3.1 1.9), andfunctional impairment both before (Barthel Indexpre-admission: 84.5 19.2; IADL: 3.3 3.0) and on ad-mission (Barthel Index: 55.8 27.5). On admission,136 (23.3%) patients were classified as clinically un-stable: 76 (13%) had either CI or delirium, and 60(10.3%) had CI associated to delirium. At discharge,26 patients were transferred to acute care hospitals,and 14 died. Transfer to acute care occurred in morethan 10% of patients with almost one altered condi-tion (CI or delirium), and in one fifth of patients withthe association of CI and delirium. In-RACU death wasobserved only in this latter group. Functional recov-ery at discharge was significantly higher in stable pa-tients than in patients with CI and/or delirium.</p><p>Conclusions: CI and delirium are useful prognosticmarkers of adverse clinical and functional outcomesin a population of elderly subjects admitted to a reha-bilitative unit. (J Am Med Dir Assoc 2010; 11: 443448)</p><p>Keywords: Clinical instability; delirium; outcomes;rehabilitationThere is a general agreement that in order to benefit frominpatient rehabilitation, patients must be medically stable, sothat ongoing medical problems do not interfere with partici-pation in therapy.1 However, the number of patients dis-charged from acute care hospitals to postacute care facilitieswith unstable clinical conditions have significantly grownin the recent years, after the implementation of diagnosis-re-lated group-based prospective payment system.2,3</p><p>A recent retrospective cohort study on patients completinginpatient rehabilitation from 1994 through 2001 showedthat, despite patients similar functional status during thestudy period, mortality at follow-up increased,2 indirectly sug-gesting that medical stability of the patients admitted overthis time may have changed.</p><p>Other studies carried out on hospital-based populationshave shown that the proportion of patients discharged fromacute wards with clinical instability (CI) ranges from 16.8%in hip-fractured subjects to 19% in those with pneumonia,4,5</p><p>and that the presence of CI at discharge predicted a 5-foldGuerini et al 443</p><p>mailto:bellelli-giuseppe@ancelle.it</p></li><li><p>greater risk of death or hospital readmission 60 days after dis-charge.4 Moreover, it has also been shown that delirium per-sists on admission to postacute care facilities in a proportionof patients ranging from 14% to 30%,6,7 and that this condi-tion is associated with adverse rehabilitative outcomes at dis-charge.8</p><p>The aim of this study was to assess the prognostic implica-tion of CI and delirium, alone or in combination, on clinicaland functional outcomes at discharge from rehabilitation.Furthermore, this study also aimed to highlight the need formore clinically oriented assessment in elderly patients under-going rehabilitative training for acute disabling conditions.</p><p>METHODS</p><p>Setting</p><p>The Rehabilitation and Aged Care Unit (RACU) is an 80-bed ward devoted to the rehabilitation of postacute andchronic disabilities of elderly patients. The most frequent rea-sons for RACU admission are postsurgical interventions (hipfracture surgical repair; hip or knee arthroplasty; abdominal,cardiac, or thoracic surgery), stroke (recent or chronic), pe-ripheral vascular diseases, subacute and chronic heart failure,subacute and chronic obstructive pulmonary diseases, Parkin-son diseases and parkinsonisms, or gait and balance disordersowing to a single or mixed etiology, including hypokineticsyndrome.9</p><p>Subjects</p><p>The study population was selected among all patients aged65 years and older (n 5 583) firstly and consecutively admit-ted from acute care hospitals to our RACU from January 1 toDecember 31, 2008.</p><p>The Ethic Committee of Gerontological Sciences of theGeriatric Research Group, Italy, approved all data collectionand the investigators, on RACU admission, obtained an in-formed consent from all patients. A proxy consent was ob-tained for those with moderate to severe dementia or delirium.</p><p>Comprehensive Geriatric Assessment</p><p>On admission, all patients underwent a comprehensive as-sessment including sociodemographics (age, gender), nutri-tional status (serum albumin and cholesterol, body massindex [BMI], Mini-Nutritional Assessment [MNA]),1012</p><p>physical health (Cumulative Illness Rating Score [CIRS],number of drugs),13 cognitive status (Mini-Mental State Ex-amination [MMSE]),14 and depressive symptoms (15-itemGeriatric Depression Scale [GDS]).15 The CIRS is a screeningtool for comorbidity, assessing the chronic medical illnessburden while taking into account the severity of chronic dis-eases; the score for each of the 14 items can range from 1 (ab-sence of pathology) to 5 (maximum level of severity of thedisease). The Index of Disease Severity is the result of the av-erage score of the first 13 items, whereas the Comorbidity In-dex total score represents the number of items with a scoregreater than or equal to 3/5. Functional status was assessed re-ferring to the month before admission (Instrumental Activi-ties of Daily Living [IADL], Barthel Index [BI]),16,17 onadmission (BI), and then at discharge.444 Guerini et alClassification of Clinical Instability</p><p>Patients underwent a clinical examination by trained ger-iatricians (F.G., G.B.), to evaluate the presence of CI and/ordelirium on admission. CI was recorded for all patients refer-ring to 5 vital signs, according to previous studies of Halm andcolleagues4,18: temperature higher or equal to 37.8C; heartrate higher or equal to 100/min; systolic blood pressure lowerthan 90 mm Hg; respiratory rate higher or equal to 24/min;oxygen saturation rate lower than 90% in patients not receiv-ing mechanical ventilation or supplemental oxygen by facemask. Patients were considered clinically unstable if at leastone vital sign was altered in the 24 hours following RACUadmission. Partially differing from Halm et als study,4,18 wedid not consider the inability to eat as a measure of CI becauseof the high prevalence of this condition in disabled patientsbefore admission.</p><p>The presence of delirium (evaluated with the ConfusionAssessment Method [CAM])19 was also recorded. TheCAM diagnostic algorithm involves 4 criteria: (1) an acutechange in mental status with a fluctuating course, (2) inatten-tion, (3) disorganized thinking, and (4) an altered levelof consciousness. Delirium was considered present if CAMcriteria 1 and 2 were present, along with either criterion3 or 4.</p><p>Outcomes at Discharge</p><p>Outcomes at discharge included the following:</p><p>- transfer to acute care hospital wards: we recorded every un-planned patients transfer from the RACU to an acute caremedical or surgical ward;</p><p>- deaths: we recorded only in-RACU deaths and notthose that occurred after a transfer to acute care hospitalwards;</p><p>- poor functional recovery (PFR): according to previous stud-ies,20,21 we assessed this outcome using the Relative Func-tional Gain (RFG) of the BI. The BI was assessed throughcaregivers reports referring to patients functional status 1month before admission (BIpread), on admission (BIad),and at discharge (BIdis). The basis for calculating theRFG is the patients specific potential for improvement(functional loss before admission). Because most of our pa-tients already presented a certain degree of chronic disabil-ity before RACU admission, we considered their pre-admission functional status as the highest functional statuspotentially achievable through rehabilitation. RFG wasthen computed according to equation (1):</p><p>100 BIdis BIadm = BIpreadm BIadm (1)</p><p>PFR was defined as an RFG lower than 100% (ie, patientswho do not achieve their pre-admission functional status).</p><p>Data Management and Statistical Methods</p><p>All analyses were performed using the SPSS (StatisticalPackage for Social Sciences SPSS Inc., Chicago, IL) softwaretool, version 11.5. Significance between variables waschecked using 1-way analysis of variance (ANOVA). WhereJAMDA July 2010</p></li><li><p>Table 1. Demographic, Clinical, and Functional Characteristics of 583 Patients Admitted to a Rehabilitation and Aged Care Unit, Stratified by ClinicalInstability and Delirium</p><p>Clinical Stability(n 5 447, 76.7%)</p><p>Clinical InstabilityOR Delirium(n 5 76, 13.0%)</p><p>Clinical InstabilityAND Delirium(n 5 60, 10.3%)</p><p>P</p><p>Mean SD or n (%) Mean SD or n (%) Mean SD or n (%)</p><p>DemographicsAge, y 76.4 9.9b,c 81.3 6.4a 83.7 6.7a .000Gender female 297 (66.4%) 58 (76.3%) 45 (75.0%) .122</p><p>Cognitive and affective statusMini Mental State Examination (030) 23.5 5.3b,c 18.6 6.7 a,c 15.4 7.6 a,b .000Geriatric Depression Scale (015) 5.6 3.3 7.0 3.8 6.9 4.0 .187</p><p>Health StatusIndex of Disease Severity* (CIRS) 1.7 0.3b,c 1.9 0.3a 2.0 0.3a .000Comorbidity Index* (CIRS) 2.8 1.4b 3.2 1.5a 3.2 1.4 .015Drugs on admission 5.1 3.4c 5.9 1.9 6.4 3.0a .001Serum albumin levels (g/dL) 3.3 0.4 2.9 0.4 2.9 0.6 .115</p><p>Malnutrition (computed with MNA) 20 (5.2%)b,c 16 (25.8%)a,c 19 (43.2%)a,b .000Functional Status</p><p>IADL (functions lost) 2.0 1.8b,c 3.2 1.8a 3.8 1.4a .001Barthel Index Pre-Admission (0100) 86.4 18.1b,c 77.7 22.7 a 78.9 19.6 a .004Barthel Index Admission (0100) 63.5 24.3b,c 32.4 22.3 a 28.3 21.3 a .000Barthel Index Discharge (0100) 83.3 20.6b,c 60.9 28.4 a,c 40.5 31.8 a,b .000</p><p>Length of Stay, days 26.1 11.0b 31.4 11.3 a 26.9 16.2 .000MNA, Mini Nutritional Assessment; IADL, Instrumental Activities of Daily Living.* Index of Disease Severity denotes the average score of the first 13 items at the Cumulative Illnesses Rating Scale (CIRS); Comorbidity Index</p><p>denotes the number of items at the CIRS with a score greater or equal to 3/5. P denotes significance between variables using 1-way analysis ofvariance (ANOVA). Where significant group effects were detected, Bonferroni test indicated significant post hoc differences between individ-ual groups, as follows:</p><p>a significant difference to the group with clinical stability.b significant difference to the group with clinical instability OR delirium.c significant difference to the group with clinical in stability AND delirium.significant group effects were detected, Bonferroni test indi-cated significant post hoc differences between individualgroups.</p><p>RESULTS</p><p>Patient Characteristics</p><p>Patients (n 5 583) were on average old (mean age: 77.8 9.8), predominantly female (68.6%), with mild cognitive de-terioration (MMSE: 22.1 6.3) and depressive symptoms(GDS: 5.9 3.5). They had a moderate comorbidity (meanCIRS-comorbidity score: 3.1 1.9), and functional impair-ment both before (BI pre-admission: 84.5 19.2; IADL:3.3 3.0) and on admission (BI: 55.8 27.5). The meanlength of RACU stay was 26.9 11.8 days.</p><p>On admission, 136 (23.3%) patients were classified as clin-ically unstable: 76 had either CI or delirium (13.0%) and 60had CI associated with delirium (10.3%). Reasons for CI weretemperature (4.3%), respiratory rate (8.7%), heart rate(7.0%), systolic blood pressure (5.8%), and oxygen saturation(7.7%). On RACU admission, 19.2% of all subjects were pos-itive on delirium screening.</p><p>Table 1 shows clinical and functional characteristics of allpatients stratified in 3 groups according to the absence or thepresence of CI and/or delirium. As expected, patients with CIand/or delirium were older, had lower cognitive performanceand more depressive symptoms, worse nutritional status (asexpressed by serum albumin levels and MNA scores), andhigher severity of illnesses in comparison with stable patients.ORIGINAL STUDIESFurthermore, patients with CI were generally more function-ally dependent before RACU admission, had worse func-tional recovery, and were more disabled at dischargecompared with stable patients. All clinical and functionalconditions were significantly worse for patients in the groupwith CI and delirium. As expected, stable patients had theshortest length of stay (LOS). However, although not statis-tically significant, LOS of patients with CI and delirium wasshorter than LOS of patients with CI or delirium (26.9 16.2vs 31.4 11.8 days, respectively), probably because of the fre-quent transfer to acute care hospitals of patients in the firstgroup.</p><p>Outcomes</p><p>During RACU stay, 26 patients (4.6%) were transferred toacute care hospitals, and 14 (1.7%) died; at discharge, 236(40.5%) patients did not obtain a complete recovery of thepre-admission functional status. Figure 1 shows that transferto acute care hospital occurred in 11.8% of patients with atleast 1 altered condition (CI or delirium), and in 18.3% of pa-tients with both CI and delirium. In the RACU, deaths wereobserved only in patients of the latter group (CI and delirium,23.3%). Additionally, patients with CI and delirium had thehighest rate of PFR (88.2%), followed by the patients with CIor delirium (79.5%), then the stable patients (38.2%), in a de-creasing order.</p><p>The risk of death predicted by the presence of CI and de-lirium is striking (no deaths were observed in the otherGuerini et al 445</p></li><li><p>2 0</p><p>38,2</p><p>11,8</p><p>0</p><p>79,5</p><p>18,3 23,3</p><p>88,2</p><p>0</p><p>10</p><p>20</p><p>30</p><p>40</p><p>50</p><p>60</p><p>70</p><p>80</p><p>90</p><p>100</p><p>Transfer to Acute CareHospital (P=.000)</p><p>Death During RACU Staying(P=.000)</p><p>Poor Functional Recovery(P=.000)</p><p>%</p><p>Clinical stability C...</p></li></ul>

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