Red Cell Distribution Width as a Predictor of Functional Outcome in Rehabilitation of Older Stroke Patients.

BACKGROUND: Red cell distribution width (RDW) is a prognostic marker in vascular diseases. While increased RDW predicts mortality and outcomes after ischemic stroke, evidence regarding its prognostic significance in stroke rehabilitation is lacking. Thus, the present study investigated the relationship of RDW with stroke, orthopedic, and deconditioning rehabilitation outcomes. METHODS: This prospective comparative study included three groups (stroke, orthopedic, and deconditioning) of older adult patients hospitalized for rehabilitation. The patients in each group were divided into two subgroups according to whether they had high (>14.5%) or normal (≤14.5%) RDW levels on admission. Functional outcome was assessed by total and motor FIM (Functional Independence Measure) score changes and efficiency at admission and on discharge. RESULTS: Of the 234 eligible patients, 108 (46.2%) had high RDW. Of the 50 stroke rehabilitation patients, 13 (26%) had high RDW. FIM change and efficiency scores were significantly lower in patients with high RDW only in the stroke rehabilitation group. However, multiple linear regression analysis showed that high RDW was not independently associated with total and motor FIM gain or total and motor FIM efficiency. CONCLUSION: High RDW levels on admission to rehabilitation were associated with poor rehabilitation outcome in stroke patients but were not an independent risk factor for rehabilitation outcomes.

[REHABILITATION OF MOBILITY AND MOTOR FUNCTION IN NURSING HOME RESIDENTS WITH DEMENTIA].

BACKGROUND: Few clinical trials have evaluated exercise programs developed specifically for patients with dementia in nursing home settings. OBJECTIVES: To determine if a training program tailored for demented patients, can be implemented in a nursing home setting in order to improve motor performances in patients with dementia who suffered functional decline. METHODS: The present intervention was conducted in wards of patients suffering from dementia in three nursing homes. Patients suffering from dementia and hospitalized in a rehabilitation hospital were the control arm. Eligible patients in the wards assigned to the intervention group (NH; n = 24) received exercise training specifically designed for patients with dementia. Patients in the rehabilitation hospital were observed as a control group (RH; n = 50) and received usual care treatment. Primary endpoints were changes in Functional Independence Measure (FIM), 5X Sit-to-Stand Test, Timed up and go test and ADL. Basic parameters were examined as predictors of positive training response. RESULTS: Both the nursing home residents and rehabilitation hospital patients improved significantly in both primary endpoints (change: in Functional Independence Measure, NH: +119.2 ± 30.8 % versus RH: +83.3 ± 41.9%, p < 0.001; ADL, NH: +143.5 ± 102.6% versus RH: +59.0 ± 90.2%, p < 0.001). Age was found to be a predictor of positive training response. CONCLUSIONS: This functional training program tailored for demented patients can be implemented in a nursing home setting to improve motor performances in patients with dementia. Such interventions should be further evaluated in larger randomized controlled trials.

Awareness and Functional Outcome of Hip Fracture-Related Falls among Patients with a History of Recurrent Falling.

BACKGROUND: There is little evidence about awareness and functional outcome of hip fracture-related falls among patients with a history of recurrent falling. OBJECTIVES: To measure the awareness of recurrent falling in patients and to compare their functional outcomes with those who suffered hip fracture after a sporadic isolated fall. METHODS: A prospective comparative study of patients after a hip fracture-related fall was conducted. Awareness of falls was measured and functional outcome was assessed by total and motor Functional Independence Measure (FIM) score changes and efficiency and scores at admission and on discharge. RESULTS: Of 97 eligible participants, 49 (50.5%) were recurrent fallers. Of these recurrent falls, 19 (38.8%) were not reported, 16 (32.7%) were reported but no action was taken, and 7 (14.3%) were reported and a partial assessment performed. A full assessment was performed in only 7 cases (14.3%). FIM scores on admission and discharge were significantly higher in once-fallers. A multiple linear regression analysis showed that being a once-faller was independently associated with higher total FIM at admission (ß coefficient = 0.290, P = 0.004), higher motor FIM at admission (ß coefficient = 0.295, P = 0.003), higher total FIM at discharge (ß Coefficient = 0.264, P = 0.009), and higher motor FIM at discharge (ß coefficient = 0.230, P = 0.023). CONCLUSIONS: Awareness of the syndrome of recurrent falling is extremely low. Recurrent falls before a hip fracture-related fall is associated with substantial loss of functional independence. Being a recurrent faller adversely affects rehabilitation outcome of hip fracture patients.

Clinical and Microbiological Outcomes of Asymptomatic Bacteriuria in Elderly Stroke Patients.

BACKGROUND: The optimal approach to the evaluation of asymptomatic bacteruria in stroke patients is uncertain. OBJECTIVES: To compare elderly patients after an acute stroke with and without asymptomatic bacteriuria for the development of symptomatic urinary tract infections (UTI). METHODS: We prospectively monitored patients over 65 years of age admitted to our rehabilitation hospital after an acute stroke, with and without asymptomatic bacteriuria, for the development of symptomatic UTIs. The prevalence of bacteriuria was determined by urine cultures obtained 2 and 4 weeks after admission. Patients with and without persistent bacteriuria were compared to identify variables associated with bacteriuria. RESULTS: Fifty-five patients were included in the study. The prevalence of asymptomatic bacteriuria at baseline was 20%. Of all 55 stroke patients, 13 (23.6%) developed a symptomatic UTI during the 30 day follow-up. Patients with stroke and asymptomatic bacteriuria at baseline had an increased risk of developing a symptomatic UTI (54.5% with asymptomatic bacteriuria vs. 15.9% without, P = 0.011). To exclude the effects of several confounders, we performed multivariate Cox regression analysis, which showed that bacteruria remained a significant covariate for symptomatic UTI (hazard ratio 2.86, 95% confidence interval 0.71-10.46, P = 0.051). When subjects who experienced symptomatic urinary infection were included, the prevalence of bacteriuria in the study cohort declined to about 45.5% by 30 days. CONCLUSIONS: Elderly patients with stroke and asymptomatic bacteriuria have an increased risk of developing a symptomatic UTI compared to those without asymptomatic bacteriuria during a 30 day post-stroke follow-up.

[MEDICATIONS DEPRESCRIBING IN ELDERLY NURSING HOME RESIDENTS].

INTRODUCTION: Polypharmacy, inappropriate prescribing and adverse drug reactions are frequent and important among elderly nursing home residents. Few clinical trials have evaluated systematic withdrawal of medications in nursing homes. OBJECTIVES: To compare the effect of a controlled deprescribing intervention against the usual care in elderly nursing home residents. METHODS: The present deprescribing intervention was conducted in two departments at the Shfaram Geriatric Center (Beet Alenaya). Two departments at the "Hemdat Avot" nursing home were the control arm. The intervention was a withdrawal or stepwise tapering of a target medication. The main outcome was the number of participants in whom medication withdrawal or tapering could be achieved. RESULTS: A total of 55 participants completed the intervention and follow-up. The results showed that 65.5 % of the intervention group had discontinued a medication use compared with 27% of the control group (risk difference, 73% [95%CI, 58%-85%]; intracluster correlation, 0.001; number needed to treat, 2.60). Dose reduction occurred in an additional 11%. In multivariate sub-analyses, age greater than 80 years, sex and concomitant polypharmacy (10 drugs or more per day) did not have a significant interaction effect with medication therapy discontinuation. CONCLUSION: A controlled deprescribing intervention in nursing homes was feasible and acceptable to participants. Such interventions should be further evaluated in larger randomized controlled trials.

[FALLS IN PATIENTS WITH DEMENTIA].

Older people with dementia are at increased risk of falls and their consequences. Patients with dementia fall twice as often as elderly cognitively intact people and are at greater risk of injurious falls. Falls in older people with dementia cause higher rates of morbidity, mortality and institutionalization. There is limited literature attempting to show specific risk factors for falls in this population, mainly: Lewy body dementia, dementia related to Parkinson's disease and depression, psychotropic medication, functional disability and behavioral disturbances. The Physiological Profile Assessment (PPAJ has been found to be a good fall risk screening tool in this population. There are few trials that have shown limited effectiveness of targeted fall prevention programs in community-dwelling cognitively impaired elderly. The evidence from hospitals and residential care is not conclusive. However, it has been demonstrated that some interventions, primarily exercise interventions, can modify certain risk factors in patients with dementia. Further research is required in specifically targeting fall prevention in older people with dementia.

Effectiveness of individualized fall prevention program in geriatric rehabilitation hospital setting: a cluster randomized trial.

BACKGROUND AND AIMS: There is no conclusive evidence that hospital fall prevention programs can reduce the number of falls. We aimed to investigate the effect of a targeted individualized falls prevention program in a geriatric rehabilitation hospital. METHODS: This was a two-stage cluster-controlled trial carried out in five geriatric rehabilitation wards. Participants were 752 patients with mean age 83.2 years. The intervention was a two-phase targeted intervention falls prevention program. The intervention included an assessment of patient's risk by a risk assessment tool and an individual management that includes medical, behavioral, cognitive and environmental modifications. Patients with moderate risk received additionally orientation guidance, and mobility restriction. Patients determined as high risk were additionally placed under permanent personal supervision. Outcome measures were falls during hospital stay. RESULTS: In both stages of the trial, intervention and control wards were almost similar at baseline for individual patient characteristics. Overall, 37 falls occurred during the study. No significant difference was found in fall rates during follow-up between intervention and control wards: 1.306 falls per 1000 bed days in the intervention groups and 1.763-1.826 falls per 1000 bed days in the control groups. The adjusted hazard ratio for falls in the intervention groups was 1.36 (95 % confidence interval 0.89-1.77) (P = 0.08) in the first stage and 1.27 (95 % confidence interval 0.92-1.67) (P = 0.12) in the second stage. CONCLUSION: These results suggest that in a geriatric rehabilitation hospital a targeted individualized intervention falls prevention program is not effective in reducing falls.

[Falls in patients with stroke].

Falls are the most common medical complication during the post-stroke period. Falls are of great concern in this population in particular because of their severe consequences. Stroke survivors have an increased frequency of hip fracture and psychosocial problems such as fear of falling. The most important risk factors for falls in these patients are balance and gait deficits. Balance deficits in post-stroke patients entail reduced postural stability during standing and disturbed responses to self-induced and external balance perturbations. Gait deficits in post-stroke patients involve reduced propulsion at push-off, disturbed hip and knee flexion in the swing phase and disturbed stability in the stance phase. Beneficial effects can be expected from fall prevention programs targeting these deficits. The few studies that have evaluated the efficacy of task-oriented exercises have shown that these programs are the most promising in preventing falls in post-stroke patients. Technological advances in assistive devices also have potential for fall reduction. Larger randomized controlled trials are needed to provide more conclusive evidence.

[The effect of an intervention on rates of nursing home residents transfers to emergency departments].

INTRODUCTION: Transfers of nursing home residents to emergency departments can result in iatrogenic complications, morbidity, and excess health care expenditure. Some of these transfers are potentially avoidable. OBJECTIVES: To determine the rate of emergency department transfers of nursing home residents, prior to and following an intervention program that includes a set of tools and strategies designed to reduce these transfers. METHODS: The present study was conducted in four departments at the Shfaram Geriatric Center (Beet Alenaya). The rate of emergency department transfers was determined in 118 residents of the nursing home during the 12 months prior to and during the 12 months following implementation and initiation of the intervention. RESULTS: Following the intervention, a significant reduction in the rate of emergency department transfers was observed in the study population from 2.61 to 1.28 transfers per 1,000 stay days, with a 50.1% transfer reduction (P < 0.005). The most significant reduction was observed among residents staying in the Complex Nursing Care Department (54.7%)(P < 0.05). The reduction rate among long term nursing care residents was modest (20.3%) and did not reach statistical significance. CONCLUSION: The implementation of such an intervention can reduce the rate of transfers of nursing home residents to emergency departments. Such interventions might lead to quality improvement in nursing homes and should be further evaluated in larger randomized controlled trials.

Risk factors for methicillin-resistant Staphylococcus aureus colonization in a geriatric rehabilitation hospital.

BACKGROUND: Knowledge of the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization, and the frequency of transmission is vital for the implementation of MRSA infection control measures in hospitals. We assessed risk factors for and rates of colonization of MRSA upon admission to a geriatric rehabilitation hospital, and studied the contribution of the colonization on hospital mortality. METHODS: This was a prospective study conducted over a 6-month period. All patients were screened at admission, using nasal and throat swabs. Whenever necessary, blood, sputum, urine, or wound cultures were obtained. Data collected on admission included age, sex, functional status, reasons for admission to the rehabilitation unit, previous hospitalizations, known carriage or infection with MRSA in previous hospitalizations, underlying diseases, prescribed antibiotics in previous hospitalization, serum albumin, creatinine clearance, and patient management data. Risk factors for MRSA carriage on admission were estimated by using multivariate analysis. RESULTS: Of the 337 patients admitted during the study period, 24 (7.1%) had a MRSA isolate, and 87.4% of these were detected through screening specimens only. Of the 24 positive admissions with MRSA, 23 (95.8%) were newly identified MRSA carriers. In the multivariate analysis, the following variables were highly associated with MRSA carriage: presence of tracheotomy (p =.0001), hospitalization for deconditioning (p =.007), renal failure (p =.039), and quinolone use prior to hospitalization (p =.037). The morbidity associated with MRSA was very low, and length of stay was not influenced by carriage. CONCLUSION: The prevalence of MRSA carriage on admission to geriatric rehabilitation hospitals is high. Screening on admission is probably useful, as it detects almost all MRSA carriers. However, given the low morbidity associated with MRSA observed in this study, eradication of the MRSA carrier state is questionable. Further studies are needed to determine the usefulness and cost/benefit ratio of screening.

Risk factors and characteristics of falls during inpatient rehabilitation of elderly patients.

The present study investigated the incidence, characteristics, and risk factors predictive of falls in different patient populations hospitalized in a geriatric rehabilitation hospital. Overall 84 fallers and 84 control patients were enrolled in this study. The patients were analyzed into three subgroups: patients hospitalized for stroke rehabilitation, hip surgery rehabilitation, and other rehabilitation patients. All patients were evaluated for their predisposing and situational risk factors for the fall. Each group of fallers was analyzed in relation to the control group. Every group was also analyzed in relation to the other groups. Risk-taking activity and using wheelchairs were common risk factor among patients hospitalized for stroke rehabilitation or hip surgery rehabilitation. Vertigo and anti-hypertensive drugs intake were significant predictors of falling among all fallers in the hospital. Among Stroke patients' vertigo was a significant predictor of falling. Anti-depressant drug intake was the only weakly significant predictor of falling among deconditioned patients. Patient's falls in a geriatric rehabilitation setting tend to demonstrate patterns that may be used to focus prevention strategies. We found that risk factors for falls differ between different groups of rehabilitation patients, and that the selection of type of patients may affect which combination of risk factors is identified.

Effect of non-steroidal anti-inflammatory drugs on natural killer cell activity in patients with dementia.

BACKGROUND: Alteration of innate and acquired immunity can play a role in the mechanism involved in the development of dementia. Epidemiologic studies indicate that the use of non-steroidal anti-inflammatory drugs can delay the onset or slow progression of Alzheimer disease. OBJECTIVES: To determine whether the use of NSAIDs is associated with natural killer activity alteration in AD and multi-infarct vascular dementia patients, as compared with non-demented elderly and healthy young people. METHODS: In this prospective open study four groups of subjects (AD, VD, non-demented elderly, and healthy young people) were treated with an NSAID drug (rofecoxib 12.5 mg/day or ibuprofen 400 mg twice daily) for 7 days. Natural killer cell cytotoxicity was measured after flow cytometry analysis before and after treatment. RESULTS: Of the 49 subjects studied, 15 had a diagnosis of AD (3 men, 12 women; mean age 83.5 +/- 8.1 years), 15 had a diagnosis of multi-infarct VD (7 men, 8 women; mean age 75.5 +/- 8.4), 13 were non-demented elderly (1 man, 12 women; mean age 80.2 +/- 7.2), and 6 were healthy young volunteers (3 men, 3 women; mean age 36.8 +/- 4.4). While all examined subjects showed decreased NK cell cytotoxicity after treatment, this decrease was most prominent and statistically significant in elderly patients suffering from vascular dementia--from an average of 30.5 +/- 11.8% before treatment to 22.5 +/- 16% after treatment (P = 0.04). The decrease in NK cell cytotoxicity was only moderate and not statistically significant in all other elderly and young subjects. Young healthy volunteers exhibited a significantly higher total NK cytotoxicity before and after treatment compared to all age groups (P < 0.001). CONCLUSION: These findings suggest that NSAIDs decrease NK activity in vascular dementia patients. Our findings also suggest that natural killer activity alteration cannot explain the ability of anti-inflammatory drugs to delay the onset or slow the progression of AD.

Candida albicans colonization of dental plaque in elderly dysphagic patients.

BACKGROUND: Dysphagia is a common disorder among the elderly population. As many as 50% of nursing home residents suffer from dysphagia. It is important to identify patients at increased risk for colonization of dental and denture plaque by pathogenic organisms in order to prevent associated disease. OBJECTIVES: To quantify the prevalence and evaluate the effect of dental and denture plaque colonization by Candida albicans in hospitalized elderly dysphagic patients as a complication of stroke, as well as the effect of systemic antimicrobial therapy on C. albicans colonization in these patients. METHODS: We evaluated dysphagia and antibiotic therapy as risk factors for dental and denture plaque colonization by C. albicans in elderly stroke rehabilitating patients with dysphagia, as compared to elderly non-dysphagic stroke and non-stroke rehabilitating patients on days 0, 7 and 14 following admission to the Fliman Geriatric Rehabilitation Hospital. RESULTS: The risk of C. albicans colonization of dental plaque was greater in dysphagic patients than in those without dysphagia on day 0 (50% vs. 21%, P = 0.076), day 7 (58 vs. 15.2%, P = 0.008) and day 14 (58 vs. 15.2%, P = 0.08). Similarly, patients on antibiotic therapy were at greater risk for C. albicans colonization of dental plaque on day 0 (56 vs. 11%, P = 0.002), day 7 (44 vs. 14.8%, P = 0.04) and day 14 (39 vs. 19%, P = 0.18). The risk of C. albicans colonization of denture plaque as opposed to dental plaques in non-dysphagic patients was significantly greater on day 0 (45.7 vs. 21.2%, P = 0.03), day 7 (51.4 vs. 15.1%, P = 0.0016) and day 14 (54.3 vs. 15.1%, P = 0.0007). Dysphagia did not increase the risk of denture plaque colonization by C. albicans. CONCLUSIONS: Both dysphagia and antibiotic therapy are risk factors for C. albicans colonization of dental plaque, and although dysphagia does not significantly increase colonization of denture plaque, denture wearers are at greater risk of such colonization.

Risk factors and characteristics of falls resulting in hip fracture in the elderly.

BACKGROUND: Risk factors for injurious falls among elderly people differ from those for falls in general. The characteristics of falls play an important role in determining the risk of hip fracture. OBJECTIVE: To investigate the risk factors associated with the fall characteristics known to be associated with the majority of hip fractures, e.g., a lateral fall and a subsequent impact on the greater trochanter. METHODS: In this 6 month prospective observational case-control study, 101 individuals aged 65 years and over hospitalized following a hip fracture were interviewed 7-14 days after the accident. Data were also obtained from medical records, focusing on known predisposing and situational risk factors for the fall. We compared the risk factors between two groups: patients who suffered a lateral fall and subsequent impact on the greater trochanter of the femur, and patients who suffered other types of falls. RESULTS: Only 51.5% of the hip fracture patients reported that they had fallen directly to the side. Apart from age, there were no significant differences between the groups in other factors studied. When considering both fall direction and the area that took the main impact, we found that the majority of patients (85%) reported having fallen onto the posterolateral aspect and/or a fall with an impact on the greater trochanter. CONCLUSION: Our findings did not show differences (except for age) in the factors studied between the groups. This study suggests that both fall direction and the area that takes the main impact should be considered in the characteristics of falls that might cause a hip fracture. Characteristics associated with greatest fracture risk include a fall onto the posterolateral aspect and/or a fall with an impact on the greater trochanter. More studies are needed to evaluate potential risk factors associated with this type of injury.