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Title: Outcomes for Older Adults in an Inpatient Rehabilitation Facility Following
Hip Fracture (HF) Surgery
Author names and affiliations:
Katherine S. McGilton, K. a, RN, PhD.; Nizar Mahomed, N. b, MD; Aileen M. Davis M. b,
PhD., John Flannery,. c, MD, & Sue Calabrese c RN, MN
a Toronto Rehabilitation Institute, 130 Dunn Avenue, Toronto, ON, Canada M6K 2R7;
b Toronto Western Research Institute, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8
[email protected]; [email protected]
c Toronto Rehabilitation Institute, 345 Rumsey Road, Toronto, ON, Canada M4G 2R7; [email protected]; [email protected]
Corresponding author:
McGilton, Katherine, RN, PhD
Toronto Rehabilitation Institute
130 Dunn Avenue, Suite N236B
Toronto, ON Canada M6K 2R7
Phone: (416) 597-3422 ext 2500
Fax: (416) 530-2470
Email: [email protected]
Keywords: Hip fracture, rehabilitation, cognitive impairment, elderly, older adults
Abstract
The purpose of the study was to evaluate patient and system outcomes regarding older
community-residing adults who participated in a rehabilitation program following hip
fracture surgery. The health care professionals on the rehabilitation unit in this feasibility
study had never cared for such patients who were so frail, with multiple co-morbidities
including cognitive impairment (CI). After an innovative model of care was developed and
the staff trained in the novel approach to care, the unit opened for all clients living within
the community who had fractured their hip, regardless of their cognitive impairment. Of the
31 elderly patients consecutively admitted post hip fracture in this retrospective study, 18
were found to have CI postoperatively as determined by a Mini-Mental State Examination
score < 23. There were no difference in length of stay, rehabilitation efficiency, and motor
FIM gain scores between the two groups of patients. This feasibility retrospective study
study suggests that staff can learn how to care for clients with cognitive impairment in
rehabilitation settings, and that such clients can achieve outcomes comparable to those
without CI in a setting dedicated to caring for patients with a hip fracture.
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1. INTRODUCTION
A hip fracture is often a catastrophic event that is a significant threat to an
individual’s independence and ability to live in the community (Naglie et al., 2002).
Population trends indicate that an increasing number of individuals are likely to survive to
ages at which hip fracture is common (Jaglal et al.,1996). Despite good surgical outcomes,
studies have found that functional outcomes after hip fracture surgery are variable, with as
few as one-third of people able to regain their pre-fracture level of physical functioning
(Koot et al., 2000; Gruber-Baldini, et al. 2003; Lieberman et al., 2006). A recent review of
the Canadian Institute for Health Information data found that 26% of hip fracture patients
(many of whom were living in the community pre-fracture) were discharged to long-term
care (LTC) facilities and never received appropriate rehabilitation (GTA Rehab Network,
2006). Furthermore, the outcomes for patients with a hip fracture are often complicated by
the presence of cognitive impairment (CI). About 17% of community dwellers who
experience a hip fracture have a diagnosis of CI, and this percentage is expected to rise
(Wiktorowicz et al., 2001). Of these patients, it is not clear what percentage have delirium,
dementia or both, nor the extent of their dementia, mild, moderate or severe.
Current health care services for people with hip fracture, and those with CI in
particular, are fragmented and limited (Wiktorowicz et al., 2001; GTA Rehab Network,
2006). The several inpatient rehabilitation options after hip fracture surgery include
rehabilitation beds in acute-care hospitals or free-standing rehabilitation hospitals,
specialized geriatric units, higher level sub-acute long-stay beds, and convalescent care
beds. In the United States for example, hip fracture patients with CI are admitted to
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geriatric sub-acute units located in nursing homes and receive rehabilitation care (Barnes et
al., 2004). All of these care settings, however, have their own admission and discharge
criteria that are not consistent or complementary. For example, a recent study of eight
Geriatric Rehab Units (GRUs) in Ontario found that acceptance of patients with CI varied
across the units (Wells et al., 2006), despite evidence that patients with CI can benefit from
rehabilitation programs (Goldstein et al., 1997; Heruti et al., 1999; Naglie et al., 2002;
Barnes et al., 2004; Rolland et al., 2004).
At present, there is no standardized, integrated continuum of care for hip fracture
patients, especially for those with CI in Ontario (Davis et al., 2006). Therefore, these
patients are frequently unable to access appropriate rehabilitation in a timely fashion, if at
all, which contributes to poor functional and quality care outcomes (Wells et al., 2004).
Earlier work has shown that access to beds in GRUs is limited and often excludes patients
with CI because of their cognitive and behavioral symptoms (Wells et al., 2006), and there
is no reason to believe this is different in any other country. Not rehabilitating these patients
leads to further physical and mental deconditioning, thereby, compromising patients’ long-
term outcomes. In a recent report, Davis et al. (2006) recommended that new models of
care be established, including all sectors of the health care continuum, to optimize the
function of hip fracture patients with CI. In the United States for example, hip fracture
patients with CI are admitted to geriatric sub-acute units located in nursing homes and
receive rehabilitation care.
In response to this need, members of our team developed an integrated practice-
based model of care, referred to as the Assessment, Patient-Centered Goals, Treatment,
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Evaluation, and Discharge (ACTED) model of care. This model aims to provide an optimal
rehabilitation setting at the appropriate time for the geriatric patient with CI. The
innovative aspects of the ACTED model include the following: (1) early admission to
rehabilitation (i.e., on or before Day 5 post-op); (2) individualized assessments and
interventions focused on the patients’ remaining abilities; (3) assessments for dementia,
delirium, and depression within the first 3 days of admission to rehabilitation; (4) patient-
centered goals that involve input from patients and their families; (5) individualized
rehabilitation care at the bedside if necessary; (6) a focus on care strategies that minimize
behavioral and cognitive symptoms related to CI; and (7) education and support to health
care providers (HCPs) and facilities to implement the model of care. As part of the ACTED
program, a physiatrist, geriatrician, and family physician were available to provide medical
guidance on the care of the patients. An advanced practice nurse (APN) in gerontology
provided guidance to staff to individualize care. The overall objective of this feasibility
study was to evaluate patient and system outcomes for the older adults who participated in
the ACTED program of care following hip fracture surgery.
1.2. Literature Review and Conceptual Framework
1.2.1 Rehabilitation of Patients with CI Following Hip Fracture
A growing body of research has focused on the rehabilitation of persons with CI
following a hip fracture. These patients with CI are more prone than other hip fracture
patients to delirium (Inouye and Charpentier, 1996), longer lengths of acute hospital stays
(Wells et al., 2004), and mortality (Koot et al., 2000). A literature review of 21 studies from
eight countries reported that hip fracture patients with CI can benefit from participating in
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rehabilitation targeted at improving self-care and motor function (Magaziner et al., 1990;
Cummings et al., 1996; Patrick et al., 1996; Goldstein et al., 1997; Heruti et al., 1999;
Naglie et al., 2002; Adunsky et al., 2002; Hoenig et al., 2002; Gruber-Baldini et al., 2003;
Barnes et al., 2004; Lenze et al., 2004; Rolland et al., 2004; Arinzon et al., 2005; Haentjens
et al., 2005; Shyu et al., 2005; Bitsch et al., 2006; GTA Rehab Network, 2006; Lieberman
et al., 2006; Moncada et al., 2006; Wells et al., 2006; Yu et al., 2006).
1.2.2 Patient Outcomes
The primary goal of HCPs in working with persons following a hip fracture is to
maximize their functioning (Shabat et al., 2005). Outcomes related to patients’ functioning
include improvement in patients’ mobility level during inpatient rehabilitation (Patrick et
al., 1996; Heruti et al., 1999) and a return to pre-fracture functional status (Wells et al.,
2004; Shabat et al., 2005). HCPs’ secondary goal is to discharge patients back to their
previous environment (Wells et al., 2004).
1. 2.3 Influence on Patient Outcomes: The Conceptual Model
A patient-centered rehabilitation model of care (see Figure 1), a modification of
Donabedian’s (1966) framework, was selected to guide this research study as it provided a
useful framework for understanding how contextual factors (i.e., patient and system
characteristics) and processes of care affect the outcomes of people with a hip fracture.
Patient characteristics include personal resources needed to participate in the rehabilitation
intervention as well as personal and health-related characteristics, such as cognitive level.
System characteristics include the physical and social aspects of the environment, such as
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policies on the unit, and time interval from surgery to admission to the rehabilitation
program. Processes of care consist of the components of the intervention conceptualized as
being critical for achieving the anticipated outcomes (Lipsey, 1993), such as effective team
processes. Concepts of focus for this feasibility study are highlighted in bold (see Figure 1).
1. 2.4 Contextual Factors
1.2.4.1 Patient Characteristics
Several studies of the determinants of hip fracture rehabilitation outcomes have
shown that patient characteristics are the primary indicators of functional gain. These
include the following: age (Arinzon et al., 2005); sex (Rolland et al., 2004); pre-fracture
cognitive function (Gruber-Baldini et al., 2003); pre-fracture functional status (Cummings
et al., 1996; Naglie et al., 2002; Moncada et al., 2006); medical co-morbidities (Patrick et
al., 1996, 2002); pre-fracture frailty (Arinzon et al., 2005); sensory (hearing and vision)
impairment (Rolland et al., 2004); nutritional status (Lieberman et al., 2006); social support
(Beaupre et al., 2005); depression (Goldstein et al., 1997; Lenze et al., 2004; Shyu et al.,
2005); and delirium or incident CI (Adunsky et al., 2002; Gruber-Baldini et al., 2003;
Bitsch et al., 2006).
Researchers have found that the type of hip fracture (Haentjens et al., 2005),
depression (Fredman et al., 2006), delirium (Bitsch et al., 2006), and level of CI (Moncada
et al., 2006) influence the length of stay on inpatient rehabilitation units and the cognitive
improvement that patients make. Mini-Mental State Examination (MMSE) scores at
discharge (Lenze et al., 2004), depression (Lenze et al. 2004), living situation (i.e., alone
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vs. with others, Cummings et al., 1996), and the presence of social support (Beaupre et al.,
2005) have been shown to influence the discharge disposition of these patients.
1.2 4.2. System Characteristics
System characteristics that may have an impact on rehabilitation outcomes include
the following: length of time from the injury to surgery (Adunsky et al., 2002; Hoenig et
al., 2002) and the time interval from surgery to admission to inpatient rehabilitation
(Adunsky et al., 2002; Yu et al., 2006).
1.3 Objectives
The overall objective of this feasibility study was to evaluate patient and system
outcomes for the older adults who participated in the ACTED program of care following
hip fracture surgery. The specific objectives were to identify the contextual and system
factors associated with the four outcome measures, namely, functional gain, cognitive gain,
rehabilitation efficiency, and discharge location. The specific research questions were: (1)
Are there differences in outcomes (functional gain, cognitive gain, rehabilitation efficiency,
and discharge location) between two groups of older adults, those with CI and those with
intact cognition? (2) What additional patient characteristics are related to outcomes?, and
(3) What system characteristics influence outcomes?
2. METHODS
2.1 Design and Setting
This was a longitudinal retrospective feasibility study of geriatric patients who
underwent hip fracture surgery and were admitted to the ACTED program of care in the
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inpatient musculoskeletal (MSK) rehabilitation unit at a hospital in Toronto, Ontario, for
the period from May to October 2006. This rehabilitation unit has a 10-bed capacity
dedicated to ACTED patients, and includes an out-patient clinic for the patients’ follow-up
visits with the geriatrician and physiatrist. This study was approved by the Research Ethics
Board of the rehabilitation facility where the study was conducted.
2.2 Sample
The study participants were older adults who underwent a repair of a hip fracture in
an acute care hospital in Toronto. Patients were referred to the rehabilitation facility for
immediate rehabilitation to prevent the deterioration of their health condition following
surgery. Participant inclusion criteria for admission to the unit and study included the
following: 65 years or older; admitted to rehabilitation directly from an acute care hospital
after being treated for a hip fracture; and living in the community (home or residential
setting) prior to their hip fracture. Patients were excluded from the program and the study if
they had a pathologic hip fracture, if the hip fracture was associated with multiple trauma,
and/or if they were living at a nursing home at the time of the hip fracture.
2.3 Measures
The measures included in this study were appropriate to evaluate the relevant
contextual factors and processes that influence patient outcomes. For the feasibility study,
the authors did not include every possible variable representing these factors but instead
chose those variables most frequently described in the existing research. Process data will
be assessed in subsequent studies.
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Patient characteristics that were collected included age, sex, and cognition (MMSE).
System characteristics included time interval from injury to surgery and time interval from
surgery to admission to a rehabilitation unit (medical charts). Outcome data included motor
functional change (Functional Independence Measure [motor-FIM change from the
National Rehabilitation Services Database, NRS]), cognitive change (cognitive-FIM change
from the NRS), discharge setting (community, institution, not discharged [i.e., discharged
to acute care or death]), and rehabilitation efficiency.
2.3.1 Independent Measures
The MMSE, which was used as an independence measure, is a screening tool for
CI, with scores ranging from 0-30 (Cockrell and Folstein, 1988). A score of 23 or less
indicates the presence of CI (Folstein et al., 1975). This cutoff has been widely used in
rehabilitation and gerontology research to dichotomize samples into cognitively intact or CI
groups (Heruti et al., 1999; Espiritu et al., 2001; Yu et al., 2005). Thus, a cutoff score of 23
for CI was adopted for the current study. Test-retest reliability of MMSE scores range from
0.80 to 0.98, and these scores have been found to correlate well with clinical judgment of
the patients’ CI (Perneczky et al., 2006).
Participants’ sex and age were collected from the NRS data, which all rehabilitation
facilities in Ontario collect. System characteristics (time intervals between injury and
surgery and surgery to admission to rehabilitation facility) were obtained from a chart
review.
2.3.2 Outcome Measures
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Motor Functional Gain at Discharge: The change in motor subscale of the FIM was
calculated by the difference between the patients’ functional status at inpatient
rehabilitation admission and discharge (Keith et al.,1987). The FIM, which is an integral
component of the NRS (Dodds et al., 1993), must be completed by HCPs for all patients
admitted to Ontario inpatient rehabilitation facilities within 72 hours of admission and
again within 72 hours of discharge. Patient ability to complete daily tasks is rated from 1
(total assistance) to 7 (complete independence), resulting in total scores between 13 and 91,
with higher scores indicating higher levels of independence. The FIM motor subscale’s
reliability and validity are well established, and it demonstrates a high sensitivity for
detecting functional improvement in patients with different functional status and varying
degrees of co-morbidities (Heruti et al., 1999).
Cognitive Gain at Discharge: The change in the cognitive subscale of the FIM was
used to characterize the patients’ cognitive gains between inpatient rehabilitation admission
and discharge (Keith et al., 1987). The FIM cognitive function subscale’s total score is the
sum of the scores for all cognitive items, which can range from 5 (requiring total
assistance) to 35 (complete independence). The patient’s cognition functional gain was
calculated by subtracting the FIM cognitive function subscale score on admission from the
score at discharge.
Discharge Setting Change: Discharge locations were defined as institution,
community (home or residential care) or not discharged. This information was compared to
a change in the pre-fracture setting.
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Rehabilitation Efficiency: This outcome measure referred to the amount of
functional gain achieved for each day of inpatient rehabilitation service and was calculated
by dividing functional gain by days of rehabilitation service.
2.4 Data Collection
The medical records of all the patients who received rehabilitation care for a hip
fracture surgery from May to October, 2006, were reviewed to obtain patient
demographics. The remaining data were extracted from the administrative data in
institution’s NRS.
2.5 Data Analyses
The data were analyzed using SPSS version 15.0. Descriptive statistics such as
mean, median, standard deviation, range, frequencies, and percentages were calculated to
characterize the sample as well as to describe the outcome measures. Study participants
were classified into two groups by their cognitive status upon admission.
To address research question 1 regarding the significance of the relationship
between each outcome measure and patients’ CI, the authors used a Pearson’s correlation
test and an independent samples t-test. A paired t-test was used to compare the significance
of the difference of the scores upon admission and on discharge for continuous outcomes.
A p-value of less than or equal to .05 was considered to be statistically significant.
To address research questions 2 and 3, patient and system characteristics were
dichotomized to describe the frequency of the group characteristic scores on gain scores.
Sex was represented as male or female, age included those over or equal to 80 years of age
(the median), versus those under 80, and cognition status as CI patients versus those with
intact cognition. The system-level data characteristics were also divided into 2 groups: (1)
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those patients who had waited from 0 to 2 days from injury to surgery (the expectation for
the program) versus those who waited longer, and (2) those patients who had taken 15 days
(the median) or longer prior to being admitted to the rehabilitation facility versus those who
took less than 15 days.
3. RESULTS
3.1 Sample Characteristics
The average age of the 31 patients was 87 years. The majority of them were women
(58%) and most had weight bearing as tolerated status on admission to the rehabilitation
unit. The mean MMSE was 21 (see Table 1), with 14 patients not having CI (MMSE > 24)
and 17 having CI (MMSE < 23). On average, patients received surgery 2 days post injury
and were admitted to the rehabilitation facility 13 days post surgery. There were no
differences between the CI group and the non-CI group in terms of age, gender, side of
fractured hip, number of co-morbidities, number of days from injury to surgery, and
number of days from surgery to admission to rehabilitation facility. More patients with CI
had weight bearing as tolerated (WBAT) status than those without CI. This difference may
be related to the type of fracture, or the surgeon’s realization that clients with CI may not be
able to understand partial or feather weight bearing so weigh bearing as tolerated is most
realistic.
The mean motor FIM score (see Table 2) for the total sample at admission to
rehabilitation was 41, which indicated moderately functionally dependent (Yu et al., 2006).
Patients without CI had higher motor FIM admission scores (x = 46.2) and higher cognitive
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FIM admission scores (x = 33.3) than patients with CI (x = 36.8) and (x = 30.2),
respectively (see Table 2), which were not statistically different.
3.2 Outcomes Related to Patients Cognition
As shown in Table 2, a comparison of scores upon admission and on discharge from
rehabilitation indicated that there was a highly significant difference in the motor functional
gain scores in both groups of patients (p < .001). Regardless of cognitive status, patients
had improved motor function post rehabilitation. Motor functional gain for subjects with CI
was 57.2 versus 57.0 for those with intact cognition (p = .62). Cognitive functional gain did
not increase over time for patients with CI (p = .58) or for those without CI (p = .22). The
average length of stay on the unit for patients with CI was 28 days, and 31 days for those
without CI. Rehabilitation efficiency for patients with intact cognition was .86, in contrast
to 1.06 for patients with CI. Discharge location for both groups was predominantly to the
community, as 80% returned home. Four patients were discharged to an acute care hospital
(2 in each group) for further management of co-morbidities, and 2 of the CI patients were
discharged to a long-term care (LTC) facility.
3.3 Additional Patient and System Characteristics Related to Outcomes
As noted in the frequency graphs in Figure 2, males had greater motor functional
change scores then females. Higher functional gain was achieved for those admitted to the
rehabilitation facility within 15 days from the surgery. Likewise, those patients who
received surgery closer to their injury had greater motor functional change. Cognitive
functional change was greater for patients who were under 80 years of age and male (see
Figure 3. Those patients admitted to the rehabilitation unit after 15 days from surgery had
the largest cognitive gain. There was no cognitive change for patients who had surgery 3
13
days or more post injury. Functional gain achieved for each inpatient day of stay
(rehabilitation efficiency) was greater for those patients entering rehabilitation facilities in
less than 15 days after surgery and for those having surgery up to 2 days post injury (see
Figure 4). As shown in Figure 5, those admitted to a LTC facility had one or more of the
following characteristics: 80 years of age or older, female, CI, and admitted to the
rehabilitation facility within15 days from injury.
4. DISCUSSION
In our study, patients with CI did not differ in terms of their demographic
characteristics from those with intact cognition. Moreover, both groups achieved greater
functional independence after participating in the rehabilitation program, regardless of their
CI status. Older adults with CI showed functional gain comparable with that of older adults
with intact cognition, in spite of the former’s greater degree of functional dependence at
baseline. This functional gain was achieved efficiently, that is, patients with CI did not
require more days of rehabilitation than their counterparts to achieve their gains. Older
adults with CI were equally as likely to continue to live in the community upon discharge
as were those with intact cognition. These findings support the evidence that CI patients
can benefit from rehabilitation programs (Goldstein et al., 1997; Heruti et al., 1999; Naglie
et al., 2002; Barnes et al., 2004; Rolland et al., 2004). Although results from this study have
been supported by other inpatient rehabilitation studies (Goldstein et al., 1997; Heruti et al.,
1999; Yu et al., 2006), this study is the first to show preliminary positive outcomes in an
MSK rehabilitation facility, where all elders within the community, regardless of their CI
status, are given an opportunity for rehabilitation care.
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For the purpose of understanding the project’s viability, several results warrant
comparison to those from previous studies. The motor functional gain achieved by patients
in our study (mean gain of 57.0 to 57.2 points) is higher as compared to those reported in
previous inpatient hip fracture rehabilitation studies (mean gain of 16 to 26 points,
Goldstein et al., 1997; Heruti et al., 1999; Adunsky et al., 2002; Lenze et al., 2004).
Likewise, just as we found in our study, FIM motor admission scores and FIM motor
discharge scores, while statistically significantly different, were usually lower for patients
with CI (Goldstein et al., 1997; Rolland et al., 2004; Arinzon et al., 2005). Also, the
discharge FIM motor scores were higher in our study (94 to 103) and Arinzon et al.’s
(2005), who reported FIM scores from 56 to 65. These differences may be accounted for
by the fact that these patients are in an active rehabilitation in-patient unit and therefore
receive daily physiotherapy and occupational therapy, with nursing staff who focus on
mobilizing their patients as soon as possible. Further investigation is required, however, to
determine whether the FIM motor discharge score or the FIM gain score is a more
important outcome to track for purposes of refining the ACTED program of care. Finally,
from our data we know that patients spend approximately 30 days in the rehabilitation
program, which is not related to any financial limits. This average LOS is in the range of
the LOS for other studies (10 to 48 days) (Lieberman and Lieberman, 2002; Arinzon et al.,
2005), and more research is required to determine what is appropriate.
Rehabilitation efficiency offers an objective outcome measure of treatment
efficiency by taking into consideration both functional gain and days spent on the
rehabilitation unit. In our study, rehabilitation efficiency scores ranged between .86 (for
patients with intact cognition) and 1.06 (for patients with CI). These differences, which
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were not statistically significant, are attributable to the fact that CI patients were, on
average, on the rehabilitation unit for 3 days less than patients with intact cognition prior to
being discharged home. This result was not expected, as previous research has found the
opposite: patients with CI usually have longer LOS than those who are cognitively intact
(Diamond et al., 1996; Moncada et al., 2006), and patients with CI usually have lower
rehabilitation efficiency scores than those patients who are intact (Heruti et al., 1999).
These differences in findings may be related to the power of the sample in our study, which
must be re-examined in a larger sample.
As Adunsky et al. (2002) similarly found, the longer LOS for patients who were
cognitively intact did not appear to contribute to the achievement of their functional motor
gains, which indicates that additional factors may contribute to LOS. The same is most
probable for clients with CI, staying longer in rehabilitation would probably not enhance
their efficiency scores. A possible explanation for clients who are cognitively intact staying
longer involves staffs’ expressed concern that some patients with intact cognition try to re-
negotiate later discharge dates. Perhaps to improve efficiencies within the program, for
these patients, a 3 week expectation of stay should be recommended at the time of
admission, so they are able to prepare for discharge. Rationale for patients with CI staying
for shorter periods on the rehabilitation unit than patients without CI may be based on the
rehabilitation HCPs’ experience that for most patients with CI, there is no place like home.
The sooner patients with CI could go back safely to their home, an environment they know
well; the better it was for the patient. Additionally, living alone versus with someone else
has been found to influence LOS (Beaupre et al., 2005), which was not compared between
the groups in our study.
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Regardless of the patients’ CI status, there were no changes in the patients’
cognitive gain as measured by the cognitive FIM score. On admission, patients with CI had
a marginally significant difference in their cognitive FIM score (p = .058) from those who
were cognitively intact. However, there were no cognitive FIM gains for the CI group,
despite noticeable clinical differences. Many of the patients experienced delirium, as noted
by confusion assessment method (CAM) testing, which had dissipated by the time the
patient was discharged. It would thus appear that the cognitive FIM was not sensitive
enough to the subtle changes in patients’ cognitive function. Concern about whether the
cognitive FIM scale is a reliable and valid measure in rehabilitation has surfaced elsewhere
(Jaglal, 2004). When the program is refined in the future, using the MMSE at discharge
from rehabilitation, as Inouye et al. (2006) suggested, will provide a better objective
indicator of cognitive gains. To differentiate between delirium and dementia, patients’ pre-
fracture mental status must also be obtained in future studies in order to provide appropriate
clinical interventions.
Additional patient characteristics were also investigated in this feasibility study.
From the descriptive analysis, the sex and age of the patient (i.e., 80 years of age and older,
and younger than 80) appear to influence outcomes. Males had greater functional and
cognitive gain scores, and patients who were younger than 80 had greater cognitive gain
scores. Age and sex have been found to influence functional gain in other rehabilitation
studies (Rolland et al., 2004; Arinzon et al., 2005). Older patients are more likely to
experience post-op delirium which would interfere with cognitive gains (Adunsky et al.,
2002).
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System characteristics that appear to influence outcomes (i.e., functional change
scores and rehabilitation efficiency) included having surgery within 2 days of the injury and
being admitted to the rehabilitation unit within 15 days of surgery. Additionally, patients
who waited three and more days for surgery had no improvement in their cognitive
functional scores from admission to discharge in the rehabilitation program. Patients
waiting for surgery for greater than 3 days post injury are more likely to become delirious
and therefore optimal cognitive gain may be difficult to achieve. Waiting for surgery has
been demonstrated to have a negative effect on functional outcome and recovery, functional
independence, and LOS (Zuckerman et al., 1995; Hoenig, 1997). These preliminary results
point to the need for system changes to support prompt surgery and timely admission to the
rehabilitation unit. If patients come to the rehabilitation units within shorter waiting periods
after surgery, more optimal functional and cognitive outcomes may be achieved.
The reported discharge location for the 31 patients further supports the proposition
that older adults with CI are very likely to continue to live in the community after
participating in rehabilitation services (Goldstein et al., 1997; Huusko et al., 2002). Eighty
percent of the patient sample went home. Although 4 patients went to acute care for various
reasons (pneumonia, peripheral vascular disease which required an amputation, cerebral
vascular accident while in rehabilitation, and congestive heart failure), they were all
encouraged to return to the rehabilitation program. One patient did return and was later
discharged to the community. Of the 2 patients with CI who went to LTC, one patient
chose this discharge location, and the other patient was discharged to LTC in consultation
with the family and the patient, as he could no longer care for himself at home. Both of
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these patients were on the rehabilitation unit for over 30 days and therefore they did not
influence the shorter LOS of patients with CI. Preliminary evidence indicates that this care
program assisted with allowing older adults to continue living in the community. This is in
contrast to previous research by Diamond et al. (1996) and Lenze et al. (2004), who found
that patients with CI were more likely to be discharged to a nursing home. The most
probable reason for patients not being discharge to a nursing home is the expectation made
clear to family members and patients at admission that the patients will be going back to
their home. So, strong family support most likely assists with the patients’ ability to return
home.
There are several likely explanations for the rehabilitation benefits of this program
for older adults with CI. First, the model of rehabilitation care involved teaching staff
strategies to care effectively for persons with dementia (McGilton et al., 2007). Second,
both a physiatrist and geriatrician were available for the patients during their rehabilitation
stay. Third, an APN was available to staff on all shifts to provide help with transferring
principles of dementia care to the practice setting and to implement individualized care.
Fourth, as Yu et al. (2005) suggested, the older adults in this study with mild and moderate
CI had abilities to learn and retain physical activities that were not as compromised as those
of older adults with severe CI. To implement this program of care in other facilities,
resources are required to teach staff how to rehabilitate patients with CI, and experts are
required to provide consultation. Becoming attuned to the patients’ needs and delivering
care in individualized ways are paramount to the success of rehabilitating patients with CI.
This feasibility study had three limitations. First, it employed a retrospective design
using health care record abstraction, which is bound by time and history. In addition, the
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data collected with MMSE and FIM were from instruments administered by HCPs as part
of assessments. However, reliability and responsiveness of the FIM have been shown even
when HCPs collected and entered the data (Dodds et al., 1993; Jaglal, 2004). Lastly, the
study size was small, which limits the ability to create predictive models to understand the
influence of patient and system characteristics on rehabilitation outcomes. A future study
with a large sample is planned to fully evaluate the patient-centered rehabilitation model of
care (see Figure 5). Despite the limitations, our data provide preliminary evidence
supporting the implementation of the ACTED model.
5. CONCLUSION
Patients with CI can achieve functional independence after hip surgery despite their
greater degree of baseline functional dependence. Moreover, such benefit need not demand
more days of service. Clearly, our study demonstrated that more days of service are not
required for patients with CI, which has often been an argument used to prevent their
admission to rehabilitation. Creating a rehabilitation model of care that is accessible to all
community dwelling elders, regardless of their cognitive status, who have fractured their
hip not only optimizes resources, but will enhance the quality of life of older adults. LOS
of patients on rehabilitation units can be impacted by a multitude of factors (see Figure 1)
such as patient characteristics (most notably post-op delirium), system characteristics, and
in-patient processes of care. Future studies with larger sample sizes will focus on
determining predictors of LOS and rehabilitation efficiency. In this paper, preliminary
evidence was presented that reflects the feasibility of such a program and provides some
insights on how to refine the model.
20
Acknowledgement
Support for this research was provided by Toronto Rehabilitation Institute and from the Ontario
Ministry of Health and Long-Term Care. The views expressed here do not necessarily reflect those
of the ministry. We give special thanks to the health care professionals who implemented the new
approach to care on their unit.
21
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Figure 1
Patient-Centered Rehabilitation Model of Care
Context In‐Patient Process Intermediate Community Process Longer‐Term
Outcomes Outcomes
‐Re‐Integration to
Normal Living
‐ Pre‐Fracture
Functional Status
Gain
‐Cognitive Gain
‐ Discharge
Setting Change
‐ Pain intensity
change
System Characteristics
‐Injury to OR time interval
‐Injury to Rehab time interval
Patient Characteristics
‐Delirium ‐Depression ‐Cognition ‐Pre fracture functional status ‐Sex ‐Age ‐Level of education ‐Co‐morbidities ‐Social Support
‐Motor Functional Gain
‐Cognitive Gain
‐ Discharge Setting
‐ Rehabilitation
Efficiency
‐In‐Patient
Treatment
‐ Team Integr
Intensity
ation
‐Patient’
Participat
Rehabilitation
ion in
‐Community
Treatment
Intensity
n
Figure 2. Mean Motor Functional Change by selected factors
≤80 >80 Age (yrs)
F MGender
No CI CICognitive Status
0‐2 ≥3Days from injury to surgery
≤15 >15 Days from injury to admission in rehab
Figure 3. Mean Cognitive Functional Change by selected factors
Cognitive Functional Change
-1
-0.9
-0.8
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Mea
n C
og
nit
ive
Fu
nct
ion
al C
han
ge
≤80 >80 Age (yrs)
F M Gender
No CI CICognitive Status
0‐2 ≥3Days from injury to surgery
≤15 >15 Days from injury to admission in rehab
1
Figure 4. Mean Rehabilitation Efficiency by selected factors
≤80 >80
Age (yrs) F M Gender
No CI CICognitive Status
0‐2 ≥ 3Days from injury to surgery
≤15 >15 Days from injury to admission in rehab
2
3
Figure 5. Percentage distribution of patients by discharge setting and selected factors
P erc entag e Dis tribution of P atients by Dis c harg e S etting
0
10
20
30
40
50
60
70
80
90
100
Perce
nt (%
)
≤80 >80
Age (yrs) F M Gender
No CI CI Cognitive Status
0‐2 ≥ 3 Days from injury to surgery
≤15 >15 Days from injury to admission in rehab
Legend: - Community - Acute care hospitals - LTC/ CCC facilities
Table 1. Characteristics of the Sample by Cognitive Status
Characteristic Total Sample
No Cognitive Impairment
Have Cognitive
Impairment
(N > = 31)
(n = 14) (n = 17) p-value
Demographic: Age (years) ≤80 >80 Mean ± SD Median Range Sex, n (%) Male Female
7 (22.6) 24 (77.4) 86.8 ± 7.0 87.0 71-100
13 (41.9) 18 (58.1)
4 (28.6) 10 (71.4)
85.3 ± 7.8
86.0 71-100
7 (50.0) 7 (50.0)
3 (17.6) 14 (82.4)
88.6 ± 5.7
88.0 77-100
6 (35.3) 11 (64.7)
.291
.645
Mini-Mental State Examination (MMSE) Score Mean ± SD Median Range (0-30)
21.4 ± 6.3 23.0 6-29
26.8 ± 1.2 27.0
25-29
16.9 ± 5.2 18.0 6-23
<.001†
Fractured Hip Right Hip Left Hip
14 (45.2) 17 (54.8)
8 (57.1) 6 (42.9)
9 (52.9) 8 (47.1)
1.000
Weight-bearing Status on admission WBAT PWB FWB TWB NWB
24 (77.4) 2 (6.5) 1 (3.2) 3 (9.7) 1 (3.2)
8 (57.1) 2 (14.3)
1 (7.1) 2 (14.3)
1 (7.1)
16 (94.1) 0 (0) 0 (0) 1 (5.9) 0 (0)
.148
Days from injury to surgery 0-2 ≥3 Mean ± SD Median Range
21 (67.7) 10 (32.3) 2.1 ± 1.3
2.0 0.5-6.0
8 (57.1) 6 (42.9)
2.5 ± 1.5
2.0 1.0-6.0
13 (76.5) 4 (23.5)
1.8 ± 1.2
2.0 0.5-5.0
.162
4
Characteristic Total Sample
No Cognitive Impairment
Have Cognitive
Impairment
(N > = 31)
(n = 14) (n = 17) p-value
Days from surgery to admission in the rehabilitation facility ≤15 >15 Mean ± SD Median Range
21 (67.7) 10 (32.3)
12.7 ± 6.5
10.0 5-32
8 (57.1) 6 (42.9)
13.3 ± 7.6
10.0 5-32
13 (76.5) 4 (23.5)
12.2 ± 5.5
10.0 5-21
.643
† p<.001
5
6
Table 2. Comparison of Rehabilitation Outcomes between Groups
Characteristic Total Sample
No Cognitive Impairment
Have Cognitive Impairment
(N = 31) (n = 14) (n = 17) p-value Motor functional gain Mean ± SD Median Range Motor FIM score Admission Mean ± SD Median Range Discharge Mean ± SD Median Range P-value for motor functional gain Cognitive functional gain Mean ± SD Median Range Cognitive FIM score Admission Mean ± SD Median Range Discharge Mean ± SD Median Range P-value for the cognitive functional gain
57.1 ± 16.9
60.0 12-89
41.0 ± 15.6 44.0
13-67
98.2 ± 22.1 106.0
25-118
<.001†
-.3 ± 1.2 0
-6, 1
31.6 ± 4.5 33.0
12-35
31.3 ± 4.5 33.0
12-35
.174
57.0 ± 11.5
58.0 36-76
46.2 ± 13.0 48.0
25-67
103.2 ± 12.7 105.0
77-117
<.001†
-.6 ± 1.7 0
-6, 0
33.3 ± 1.1 33.0
31-35
32.7 ± 2.2 33.0
27-35
.218
57.2 ± 20.7
62.0 12-89
36.8 ± 16.7 41.0
13-62
94.0 ± 27.3 106.0
25-118
<.001†
-.1 ± .4 0
-1, 1
30.2 ± 5.7 33.0
12-35
30.2 ± 5.6 33.0
12-34
.579
.621
.095
.255
.227
.058
.121
Rehabilitation efficiency
7
Characteristic Total Sample
No Cognitive Impairment
Have Cognitive Impairment
(N = 31) (n = 14) (n = 17) p-value Mean ± SD
Median Range
.9 ± .63 1.09
0-2.56
.86 ± .40 .94
2.12-1.62
1.06 ± .77 1.23
0-2.56
.372
Length of stay Mean ± SD Median Range
29.6 ± 14.4
28.0 3-58
31.2 ± 14.3
28.0 14-57
28.2 ± 14.7
28.0 3-58
.575
Discharge location, n (%) Community Acute care hospitals LTC & CCC facilities
25 (80.6) 4 (12.9)
2 (6.5)
12 (85.7) 2 (14.3)
0 (0)
13 (76.5) 2 (11.8)
2 (11.8)
.413
