Covert Subclinical Neurocognitive Sequelae During the Rehabilitation Course of Severe Coronavirus Disease 2019.

ABSTRACT: Apart from respiratory symptoms, encephalopathy and a range of central nervous system complications have been described in coronavirus disease 2019. However, there is a lack of published literature on the rehabilitative course and functional outcomes of severe coronavirus disease 2019 with encephalopathy. In addition, the presence of subclinical neurocognitive sequelae during postacute rehabilitation has not been described and may be underrecognized by rehabilitation providers. We report the rehabilitative course of a middle-aged male patient with severe coronavirus disease 2019 who required intensive care and mechanical ventilation. During postacute inpatient rehabilitation for severe intensive care unit-related weakness, an abnormal cognitive screen prompted brain magnetic resonance imaging, which revealed destructive leukoencephalopathy. Subsequently, detailed psychometric evaluation revealed significant impairments in the domains of processing speed and executive function. After 40 days of intensive inpatient rehabilitation, he was discharged home with independent function. This report highlights the need for an increased awareness of covert subclinical neurocognitive sequelae, the role of comprehensive rehabilitation, and value of routine cognitive screening therein and describes the neurocognitive features in severe COVID-19.

Beyond comanaged inpatient care to community integration: Factors leading to surgical delay in hip fractures and their associated outcomes.

PURPOSE: Early surgery for older adults with hip fracture has been shown to improve outcomes. We aim to study the factors contributing to delay in surgery (defined as surgery performed more than 48 h after admission) and its associated outcomes in a tertiary hospital in Singapore with an integrated hip fracture program. METHODS: This is a prospective cohort study of hip fracture patients aged more than 60 years over 1 year. We collected data on demographics, premorbid mobility and functional status, time to surgery, postoperative complications, and inhospital mortality. Mortality data and functional performance were reviewed at 1 year. RESULTS: High American Society of Anaesthesiologists score independently predicted delay in surgery (odd ratio (OR) = 9.52, 95% confidence interval (CI): 1.69-53.68). Delayed surgery was significantly associated with longer length of stay (median 12.8 days with interquartile range (IQR) 9.7-17.6 days vs. 8.35 days with IQR 5.9-10.9 days, p < 0.01). Surgery within 48 h significantly reduced functional decline (Modified Barthel Index change -3.89 ± 17.23 vs. -9.29 ± 20.30, p = 0.01) and 1-year mortality (3.5% vs. 9.3%, p = 0.03). Surgical delay was an independent risk factor for early postoperative complications (OR = 3.21, 95% CI: 1.21-8.49), and patients were significantly less likely to return to premorbid mobility at 1 year (OR = 0.62, 95% CI: 0.39-0.97). CONCLUSIONS: Delayed hip fracture surgery in older adults is associated with worse short- and long-term outcomes, including early postoperative complications and poorer functional recovery.

Functional improvement of self-care in the elderly after hip fracture: is age a factor?

INTRODUCTION: The aging population is growing rapidly in Asia resulting in an increased number of hip fractures being managed surgically. Though there is evidence of improved quality of patient care and outcomes with well-established models of care, we do not know if the functional recovery in activities of daily living among this group of patients is also dependant on age. We hypothesize that there will be a difference in Modified Barthel Index (MBI) scores between the 'older old' (>85 years) and the 'younger old' (<85 years). PATIENT AND METHODS: Hip fracture patients (>60 years) treated surgically were divided into Group A (below 85 years) and Group B (above 85 years). Demographic data, Charlson's Comorbidity Index (CCI) score, time to surgery and length of stay (LOS) were recorded. To assess the recovery in activities of daily living, the MBI scores were measured for the following intervals; pre-fall, at discharge, at 6-month and at 1-year follow-up. RESULTS: The mean age for Group A (n = 120) was 77 years (60-85) and the mean age for Group B (n = 59) was 91.8 years (86-108). There was no significant difference in the mean CCI (A: 1.14, B: 1.24), mean time to surgery (A: 72.3 h, B: 79.9 h) and mean LOS (A: 10.8 days, B: 10.3 days). The MBI scores were significantly different (P < 0.05) for the pre-injury scores (A = 91.5, B = 84.4); however, there was no significant difference for scores measured at discharge (A = 57.5, B = 52.7), at 6 months (A = 74.6, B = 69.3) and at 1 year (A = 82.2, B = 73.2). Though there was a significant improvement, the scores at 1 year were significantly lower than the pre-injury score for both groups. CONCLUSION: We conclude that age is not a factor in determining functional recovery with regard to activities of daily living in an integrated model of care for geriatric hip fracture patients.

Orthogeriatric model for hip fracture patients in Singapore: our early experience and initial outcomes.

INTRODUCTION: The aging population is growing rapidly in Asia resulting in an increased number of fragility fractures. Studies have shown that an integrated model of care for the elderly can improve the quality of patient care and outcomes. This report describes our concept, initial experience and short-term outcomes of the integrated model of care that was established in managing geriatric hip fractures in Tan Tock Seng Hospital, Singapore. PATIENT AND METHODS: An integrated care pathway model was implemented. The principle of the model is based on (a) timely admission, review, surgery, rehabilitation, transfer, (b) multidisciplinary approach and (c) integration of a care manager. Hip fracture patients (>60 years) were included in our study and were followed up for 1 year. Demographic data, Charlson comorbidity index (CCI), time to surgery, length of stay and modified Barthel index (MBI) scores were recorded. RESULTS: The mean age was 82 years (62-108) with a female predominance (75 %). The mean CCI was 1.8. Time to admission was 3.7 h and mean time taken to be reviewed by an integrated care manager was 21.7 h. Close to 40 % of patients were operated within 48 h with a median time to surgery of 36.7 h. Mean length of stay was 10 days with an inpatient and 1-year mortality rate of 2.3 and 5.9 %, respectively. Complication rate was 5.1 % (urinary tract infection and wound infection) and MBI scores at 1 year revealed significant functional improvement of 95 % (p < 0.01). CONCLUSION: Our integrated model of care for hip fractures can lead to satisfactory outcomes. Though the time to surgery and length of stay can be improved further, our initial results have shown a reasonable time to admission and review by a care manager. Besides a low complication and mortality rate, functional improvement was significant post-operatively.