Why older people stop to drive? A cohort study of older patients admitted to a rehabilitation setting.

The aim of this study is to describe the predictive factors of driving cessation at 6-month follow-up in older patients discharged from a rehabilitation setting and evaluated by an occupational therapist in a multidisciplinary team. Of 95 patients, at 6-month 27.4% ceased to drive. The reasons for driving cessation were a patients' voluntary choice (42.3%) or a choice of their family (23.1%), and only in 34.6% of the patients the license was revoked by a medical commission. In a multivariate analysis greater functional impairment-measured with the Timed Up and Go test-(OR 12.60, CI 2.74-57.89; p < 0.01) was the only predictor of driving cessation. This study shows that the ability to walk safely and independently is a significant predictor of driving cessation. The simple assessment of this factor using the TUG might be an easy screening tool to prompt a second level evaluation to accurately identify unsafe driving.

The association between patient participation and functional gain following inpatient rehabilitation.

OBJECTIVES: To evaluate patients' participation during physical therapy sessions as assessed with the Pittsburgh rehabilitation participation scale (PRPS) as a possible predictor of functional gain after rehabilitation training. METHODS: All patients aged 65 years or older consecutively admitted to a Department of Rehabilitation and Aged Care (DRAC) were evaluated on admission regarding their health, nutritional, functional and cognitive status. Functional status was assessed with the functional independence measure (FIM) on admission and at discharge. Participation during rehabilitation sessions was measured with the PRPS. Functional gain was evaluated using the Montebello rehabilitation factor score (MRFS efficacy), and patients stratified in two groups according to their level of functional gain and their sociodemographic, clinical and functional characteristics were compared. Predictors of poor functional gain were evaluated using a multivariable logistic regression model adjusted for confounding factors. RESULT: A total of 556 subjects were included in this study. Patients with poor functional gain at discharge demonstrated lower participation during physical therapy sessions were significantly older, more cognitively and functionally impaired on admission, more depressed, more comorbid, and more frequently admitted for cardiac disease or immobility syndrome than their counterparts. There was a significant linear association between PRPS scores and MRFS efficacy. In a multivariable logistic regression model, participation was independently associated with functional gain at discharge (odds ratio 1.51, 95 % confidence interval 1.19-1.91). CONCLUSION: This study showed that participation during physical therapy affects the extent of functional gain at discharge in a large population of older patients with multiple diseases receiving in-hospital rehabilitation.

Delirium superimposed on dementia: A quantitative and qualitative evaluation of informal caregivers and health care staff experience.

OBJECTIVE: Delirium superimposed on dementia is common and potentially distressing for patients, caregivers, and health care staff. We quantitatively and qualitatively assessed the experience of informal caregiver and staff (staff nurses, nurse aides, physical therapists) caring for patients with delirium superimposed on dementia. METHODS: Caregivers' and staff experience was evaluated three days after delirium superimposed on dementia resolution (T0) with a standardized questionnaire (quantitative interview) and open-ended questions (qualitative interview); caregivers were also evaluated at 1-month follow-up (T1). RESULTS: A total of 74 subjects were included; 33 caregivers and 41 health care staff (8 staff nurses, 20 physical therapists, 13 staff nurse aides/health care assistants). Overall, at both T0 and T1, the distress level was moderate among caregivers and mild among health care staff. Caregivers reported, at both T0 and T1, higher distress related to deficits of sustained attention and orientation, hypokinesia/psychomotor retardation, incoherence and delusions. The distress of health care staff related to each specific item of the Delirium-O-Meter was relatively low except for the physical therapists who reported higher level of distress on deficits of sustained/shifting attention and orientation, apathy, hypokinesia/psychomotor retardation, incoherence, delusion, hallucinations, and anxiety/fear. The qualitative evaluation identified important categories of caregivers' and staff feelings related to the delirium experience. CONCLUSIONS: This study provides information on the implication of the experience of delirium on caregivers and staff. The distress related to delirium superimposed on dementia underlines the importance of providing continuous training, support and experience for both the caregivers and health care staff to improve the care of patients with delirium superimposed on dementia.

Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience.

OBJECTIVE: Delirium superimposed on dementia is common and is associated with adverse outcomes. Yet little is known about the patients' personal delirium experiences. We used quantitative and qualitative methods to assess the delirium superimposed on dementia experience among older patients. METHODS: We conducted a prospective cohort study among patients with delirium superimposed on dementia who were admitted to a rehabilitation ward. Delirium was diagnosed using DSM-IV-TR criteria. Delirium severity and symptoms were evaluated with the Delirium-O-Meter (D-O-M). The experience of delirium was assessed after delirium resolution (T0) and one month later (T1) with a standardized questionnaire and a qualitative interview. Level of distress was measured with the Delirium Experience Questionnaire. RESULTS: Of the 30 patients included in the study, 50% had mild dementia; 33% and 17% had moderate and severe dementia. Half of the patients had evidence of the full range of D-O-M delirium symptoms. We evaluated 30 patients at T0 and 20 at T1. At T0, half of the patients remembered being confused as part of the delirium episode, and reported an overall moderate level of related distress. Patients reported high distress related to memories of anxiety/fear, delusions, restlessness, hypokinesia, and impaired orientation. Qualitative interviews revealed six main aspects of patient delirium experiences: Emotions; Cognitive Impairment; Psychosis; Memories; Awareness of Change; and Physical Symptoms. CONCLUSIONS: The study provides novel information on the delirium experience in patients with dementia. These findings are the key for health care providers to improve the everyday care of this important group of frail older patients.

Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients.

OBJECTIVE: Delirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation. DESIGN: Prospective cohort study. SETTING: Hospital rehabilitation unit. PARTICIPANTS: A total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006. MEASUREMENTS: Dementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations. RESULTS: The median age was 77 years (interquartile range: 71-83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6-42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8-8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1-2.8; P = .01). CONCLUSIONS: DSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.

Outcomes of nonagenarian patients after rehabilitation following hip fracture surgery.

OBJECTIVE: Hip fractures (HF) are a growing cause of death and disability among older people, especially in the very old. Although the incidence of these events increases with age and nonagenarians represent a population at high risk, few studies selectively focused on these patients and on their potential to recover gait ability after HF. The aim of this study was to describe the clinical, biological, cognitive, and functional characteristics of a population of HF patients aged 90 years or older, to examine their functional recovery in gait (with or without aids), in-hospital mortality and destination at discharge, and, finally, to assess their 1-year survival according to the functional status achieved at discharge. DESIGN: Retrospective study. SETTING: Department of Rehabilitation and Aged Care. PARTICIPANTS: Seventy-six nonagenarians admitted to a department of rehabilitation after HF surgery. MEASUREMENT: Patients underwent a multidimensional assessment on admission and at discharge. Outcome measures at discharge were the global scores of Tinetti and the Barthel Index, the score at the transferring and walking subitems of the Barthel Index, and the independence to walk with or without aids. Furthermore, we assessed the rate of discharge to home after rehabilitation and the rate of in-hospital death. Logistic regressions were used to assess clinical variables associated with the inability to walk at discharge. Postdischarge 12-month survival was assessed with Kaplan Meyer analysis and compared with Cox proportional hazard regression models, adjusted for confounders. INTERVENTION: A standardized rehabilitation treatment of 2 sessions (40 minutes per session) daily from Monday to Friday and of 1 session on Saturday that included exercises of strengthening, transfers, postural and gait training, and adaptive equipment training. RESULTS: Five patients died during their admission to the department. Among the 71 survivors, 84.5% were able to walk at discharge with an assistive device, either a cane or a walker. Comorbidity and prefracture Barthel Index global score were the only 2 variables associated with the failure to be independent in walking at discharge. At 1 year, mortality was significantly higher for those patients who did not recover walking ability after rehabilitation. CONCLUSION: A large proportion of nonagenarians are able to achieve independence in walking ability (with assistive device) after rehabilitation following HF surgery. The achievement of this ability after rehabilitation is also an important prognostic factor for 1-year survival.

Rehabilitation of older adults with hip fracture: cognitive function and walking abilities.

OBJECTIVES: To investigate the association between baseline cognitive function and the achievement of walking independence and its maintenance at 1 year in a population of older adults who underwent post-hip fracture (HF) surgery rehabilitation. DESIGN: Prospective cohort study. SETTING: Department of rehabilitation and aged care. PARTICIPANTS: Three hundred six older adults admitted for post-HF surgery rehabilitation. MEASUREMENTS: All participants aged 65 and older who were completely unable to walk on admission but able to walk before fracture were stratified according to Mini-Mental State Examination score (0-15=moderately severe or severe cognitive impairment (CI), 16-23=mild to moderate CI, ≥24=no CI). Walking ability was defined according to the corresponding Barthel Index subitem, with walking independence at discharge being defined as a score of 12 or more out of 15. Walking ability 1 year after discharge was ascertained by telephone interviews with participants or proxies. RESULTS: At discharge, 29.6% of participants with moderately severe or severe CI (n=24), 51.9% with mild to moderate CI (n=56) and 78.6% of participants without CI (n=92) were able to walk independently. Among those who achieved walking independence and were alive at 1 year, 12 participants with moderately severe or severe CI (57.1%), 31 with mild to moderate CI (57.7%) and 73 without CI (78.9%) were still capable of walking independently. CONCLUSION: Although less frequently than in individuals with better cognitive function, walking independence is achievable after HF surgery rehabilitation, and can be maintained at 1 year also in those with moderately severe or severe CI.

Are fluctuations in motor performance a diagnostic sign of delirium?

BACKGROUND: Although delirium is known as a mental disorder, recent evidence suggests that it is associated with short- and long-term impairment of functional status. OBJECTIVE: To evaluate whether a pattern of fluctuations in motor performance are a diagnostic sign of delirium. DESIGN: Case-controlled study with prospective evaluations of 4 groups of patients. SETTING: Department of Rehabilitation and Aged Care. METHODS: Fifteen patients with incident delirium alone (Del group) and 15 patients with incident delirium superimposed on dementia (DSD group) were compared with 15 patients with neither delirium nor dementia (No Del-No Dem group) and 15 patients with dementia but no delirium (Dem group), respectively. Eligibility criteria were age 65 years or older, ability on admission to maintain sitting position for at least 10 minutes, and absence of visual/hearing impairment or delirium on admission. All patients underwent a multidimensional assessment on admission and serial evaluations of motor performance using Trunk Control Test (TCT) and Tinetti scale. These assessments were fixed at 5 different times, coincident with admission (T(0)), predelirium (T(1)), onset of delirium (T(2)), resolution of delirium (T(3)), and discharge (T(4)). RESULTS: Patients in the Dem, DSD, and Del groups were significantly more impaired at T(0) in cognitive and functional status and motor performance compared with No Del-No Dem patients. At T(1) all groups improved, although in different ways. At T(2) only in the Del and DSD groups, but not in the others, there was a pattern of decline in TCT and Tinetti scores (P < .0005 at t test for pair comparison for both tests) and a specular pattern of improvement at T(3) (P < .0005 at t test for pair comparison for both tests). Patients in the Del and DSD groups had the poorest attentive and executive performances at T(2), which significantly improved at T(3). In No Del-No Dem and Dem groups, attentive and executive functions did not change from T(2) to T(3.) CONCLUSION: Patients with delirium exhibit a pattern of fluctuating motor performance that is chronologically related with the onset and the end of delirium, ie, they decline when delirium develops and improve when delirium ends. This pattern seems to be typical of delirium, as it is appreciable in subjects with dementia developing delirium but not in patients with dementia alone. A fluctuation of motor performance should be considered a diagnostic sign of delirium.

Moderate to severe depressive symptoms and rehabilitation outcome in older adults with hip fracture.

OBJECTIVE: To evaluate if depressive symptoms affect recovery of walking ability and 1-year institutionalization or mortality in older adults who underwent post-hip fracture (HF) surgery rehabilitation. METHODS: Depressive symptoms were assessed on admission using the 15-item Geriatric Depression Scale (GDS), with scores ≥10/15 indicating moderate to severe depressive symptoms. Multidimensional assessment included Mini Mental State Examination, Charlson Comorbidity Index, Body Mass Index, albumin serum levels, number of drugs, antidepressants and Barthel Index (BI) on admission and at discharge. Walking ability was evaluated using the BI walking sub-item referred to 1 month before HF, on admission, and at discharge. Patients scoring ≤3/15 BI walking sub-item on admission (i.e. those fully dependent or requiring major supervision in walking) were included. Walking independence at discharge was defined as a score ≥12/15 at the BI walking sub-item. RESULTS: In multivariate analyses, after adjustment for covariates and potential confounders, patients with moderate to severe depressive symptoms were more likely to fail walking independence at discharge (odds ratio, OR = 3.2; 95% CI = 1.3 to 7.8; p = 0.010) and to be institutionalized or died at 1 year (OR = 3.6, 95% CI = 1.4 to 9.1, p = 0.007). In further analyses, the failure to recover walking independence at discharge partly mediates the relationship between moderate to severe depressive symptoms and 1-year adverse events. CONCLUSIONS: Moderate to severe depressive symptoms affect the recovery of walking independence after HF rehabilitation and are associated with severe adverse outcomes at 1 year.

Depressive symptoms and one year mortality among elderly patients discharged from a rehabilitation ward after orthopaedic surgery of the lower limbs.

The objective of the present prospective observational study is to evaluate the effect of depressive symptoms on 1-year mortality in a population of elderly patients discharged from a rehabilitation unit after orthopaedic surgery of the lower limbs. A total of 222 elderly inpatients were included, and stratified according to 12-months survival. 14 (6.3%) of the patients who were eligible for this study died during the 12-months period after discharge. As expected, patients who died were significantly older, lower cognitive performance, more depressive symptoms, poorer nutritional status and higher comorbidity in comparison to those who survived. Furthermore, they were generally more functionally dependent on admission to the Department, had worse functional recovery and were more disable at discharge, although a longer length of stay comparing to survived patients. In the adjusted logistic regression model, after adjustment for possible confounders and covariates, the presence of severe depressive symptoms significantly predicted a four-fold risk of death at 12 months. The only other factor associated poor 12-months survival was comorbidity, that predicted a 6-fold risk of death. In conclusions this study suggests that severe depressive symptoms on admission predicts 1-year mortality in elderly patients discharged from a post-acute care unit after orthopaedic rehabilitation.

Clinical instability as a predictor of negative outcomes among elderly patients admitted to a rehabilitation ward.

OBJECTIVES: To assess the impact of clinical instability (CI) and delirium on admission to a rehabilitation unit on clinical and functional outcomes (death, transfer to acute care, poor functional recovery) at discharge, in a population of elderly patients. DESIGN: Observational study. SETTING: Rehabilitation and Aged Care Unit (RACU). PARTICIPANTS: Participants were 583 consecutively and firstly admitted elderly patients. MEASUREMENTS: On admission, all patients underwent a comprehensive geriatric assessment including sociodemographics, cognitive and depressive symptoms, nutritional status, physical health, and functional status. CI was recorded for all patients on admission, assessing 5 vital signs (temperature, heart rate, systolic blood pressure, respiratory rate, and oxygen saturation). Delirium was assessed daily with the Confusion Assessment Method. RESULTS: Patients were on average old (mean age: 77.8 +/- 9.8), predominantly female (68.6%), with mild cognitive deterioration (MMSE: 22.1 +/- 6.3) and depressive symptoms (GDS: 5.9 +/- 3.5). They had moderate comorbidity (means CIRS: 3.1 +/- 1.9), and functional impairment both before (Barthel Index pre-admission: 84.5 +/- 19.2; IADL: 3.3 +/- 3.0) and on admission (Barthel Index: 55.8 +/- 27.5). On admission, 136 (23.3%) patients were classified as clinically unstable: 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 more than 10% of patients with almost one altered condition (CI or delirium), and in one fifth of patients with the association of CI and delirium. In-RACU death was observed only in this latter group. Functional recovery at discharge was significantly higher in stable patients than in patients with CI and/or delirium. CONCLUSIONS: CI and delirium are useful prognostic markers of adverse clinical and functional outcomes in a population of elderly subjects admitted to a rehabilitative unit.

Clinical complexity and Occam's razor: navigating between Scylla and Charibdy of the geriatric practice. A case of secondary hypertension in a very old patient.

The clinical approach toward elderly patients is often very complex and associated with an increased risk of medical errors. This case report is an example of how various objective (related to patient) and subjective (related to physicians) factors may influence the optimal diagnostic approach in elderly frail patients. We also discuss geriatric practice, which must be characterized by the intellectual honesty to refuse any sort of prejudices (such as ageism) and by the skill to navigate between the Scylla (ie, viewing clinical problems as unrelated to each other) and the Charibdy (ie, applying the Occam's razor principle) of the patient's complexity.