Hypnotic drug use and rehabilitation outcomes in post-acute geriatric hip fracture patients: A retrospective study.

INTRODUCTION: The use of hypnotic drugs is common in the elderly and is associated with negative health outcomes. Our aim was to evaluate the prevalence of hypnotic drug usage amongst hip fracture patients undergoing a rehabilitation program and investigate any potential associations between hypnotic drug use and rehabilitation outcomes in a post-acute care setting. METHODS: A retrospective analysis of 440 geriatric hip fracture patients was conducted from 1/1/2019 to 12/2021 in a geriatric rehabilitation center. The main outcome measures were the Functional Independence Measure (FIM), the motor FIM effectiveness and length of stay (LOS). RESULTS: Two hundred and twenty-eight (51.7 %) patients out of the entire cohort (440)), were prescribed hypnotic drugs. These patients exhibited a significantly lower rate of diabetes (p = 0.025), a higher rate of depression (p = 0.003), and lower albumin levels (p = 0.023) upon admission to rehabilitation in comparison to untreated patients. No significant differences were observed between the two patient groups in functional rehabilitation outcomes or LOS. Moreover, no correlation was established between the hypnotic drug burden during rehabilitation and the outcome measures. Furthermore, no significant differences were found between patients treated with hypnotic drugs on admission and those who were prescribed these drugs during rehabilitation. The type of hypnotic drug did not affect these results. CONCLUSION: The use of hypnotic drugs by elderly individuals undergoing a rehabilitation program after a hip fracture is unlikely to have an adverse impact on their short-term rehabilitation outcomes. Consequently, there may not be an immediate necessity to discontinue these drugs upon admission. Nevertheless, the use of hypnotic drugs should be approached with caution and minimized whenever possible due to an increased fall risk and other adverse effects.

Can nutritional and inflammatory indices predict 90-day mortality in fragility hip fracture patients?

INTRODUCTION: Hip fractures in the elderly are related to increased mortality. The identification of patients at risk is essential. Several nutritional and inflammatory parameters were investigated in an effort to find a prognostic indicator for mortality following fragility hip fractures (FHF) surgery. We aim to evaluate their utility and compare between the different factors. METHODS: A retrospective cohort study of patients 65 years and older, who underwent surgery following fragility hip fractures between January 2012 and June 2020, was conducted. Patients who died within 90 days were matched at a 1:1 ratio with surviving controls, based on age, gender, fracture type, and comorbidities. Nutritional and inflammatory indices, including serum albumin, protein energy malnutrition (PEM), albumin-to-globulin ratio (AGR), prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), and the neutrophile-to-lymphocyte ratio (NLR), were compared between groups. RESULTS: 304 patients were included, 152 in each group. Patients' demographics were similar. Among all indices evaluated, only the PLR significantly differed between the study groups (236.9 ± 193.5 for the study group vs. 186.6 ± 119.3 for the control group (p = 0.007). In patients who survived the initial hospitalization, the PEM was also found to be correlated with 90 days mortality. DISCUSSION: The PLR was found to be correlated with mortality risk following FHF surgery. As it can be easily calculated from accessible blood tests, we recommend its' routine assessment as a screening tool for personalized management of patients at high risk for mortality.

Anticoagulation drug use and rehabilitation outcomes in post-acute hip fractured patients.

PURPOSE: To assess the relationship between anticoagulant use and rehabilitation outcomes in post-acute hip fracture patients. METHODS: A retrospective study (1/2017 to 5/2019) of 299 hip fractured patients. OUTCOME MEASURES: Functional Independence Measure (FIM) and the motor FIM's effectiveness. RESULTS: Patients treated with anticoagulation drugs exhibited a significant longer latency time from fracture to surgery (U = -4.37, p < 0.001) and from surgery to rehabilitation (U=-2.27, p = 0.023), and a significantly higher rate of cardiovascular diseases (χ2=0.15, p= 0.023) compared with untreated patients. No significant differences between the two patient groups were found regarding the rate of blood transfusions, perioperative complications (infections, reoperation), or functional outcome measures. CONCLUSIONS: Oral anticoagulants are not associated with rehabilitation outcomes of hip fracture patients.Implications rehabilitationAnticoagulation drug use is not associated with functional outcome of post-acute hip fracture patients.It is recommended to renew oral anticoagulants for patients on chronic treatment after surgery since no negative outcomes were found during rehabilitation under anticoagulant treatment and in light of the importance of these drugs in preventing thromboembolic complications.

Medication regimen complexity index and rehabilitation outcomes in post-acute hip fracture patients study: a retrospective study.

BACKGROUND: Polypharmacy is a common problem amongst the elderly population. The complexity of the drug regimen refers not only to a simple medication count, but also to the number of daily doses, frequency, and special instructions given for their use. Medication regimen complexity may affect health outcomes, including an increase in hospitalization rates, drug non-adherence, and mortality rates. AIM: To assess whether the admission medication regimen complexity index score is associated with rehabilitation outcomes in hip fracture patients; secondary- to assess whether changes in the medication regimen complexity index scores during rehabilitation are associated with rehabilitation outcomes. METHOD: A retrospective study of 336 hip fracture patients admitted to a post-acute rehabilitation hospital. Primary rehabilitation outcome was assessed via the discharge functional independence measure score. Secondary outcomes included functional independence measure score changes, length of stay and discharge destination. RESULTS: Patients with low admission medication regimen complexity index scores attained significantly higher admission and discharge motor functional independence measure scores (40.1 vs. 37.1, p = 0.044; 57.1 vs. 52.9, p = 0.014, respectively), a higher motor functional independence measure score effectiveness (36.1 vs. 31.3, p = 0.030) and a higher rate of favorable motor functional independence measure effectiveness score (58.1% vs. 42.0%, p = 0.004). A multiple linear regression analysis revealed that the admission medication regimen complexity index score was not associated with the discharge functional independence measure score (standardized coefficient = - 0.058; p = 0.079). CONCLUSION: A high medication regimen complexity which usually implies severe comorbidity should not be considered a barrier for the rehabilitation of older patients.

Does anatomical type of proximal hip fracture affect rehabilitation outcomes among older adults?

BACKGROUND AND PURPOSE: Numerous studies have detailed the potential benefits of inpatient geriatric rehabilitation for older adults with hip fractures. However, data regarding effect of fracture type (femoral neck, intertrochanteric, or subtrochanteric) on rehabilitation outcomes are limited. This study assessed whether the anatomical type of proximal hip fracture affects rehabilitation outcomes among disabled older adults. METHODS: A population-based study was conducted comparing all patients with a recent hip fracture who were admitted to a geriatric rehabilitation facility in Israel. Data were collected retrospectively from an electronic database during a 5-year period (2014-2019). The Functional Independence Measure (FIM) was used to assess physical and cognitive function at admission and discharge. RESULTS: The analyses included 624 older adults with hip fractures. We found significant differences in motor FIM score at admission, as patients with femoral neck fracture performed better than patients with intertrochanteric and subtrochanteric fracture did. The disparity in motor FIM score remained consistent through discharge, with all groups achieving a median gain of 14 points. Within one month of rehabilitation, about a third of all patients achieved a higher functional level. CONCLUSIONS: Patients with femoral neck fracture have better motor ability than do those with intertrochanteric and subtrochanteric fractures, which were retained throughout the course of rehabilitation; yet, the level of improvement remained similar. Clinicians should be aware of such differences in functional ability when discussing goals of care with older adults with hip fractures and consider them when implementing individual rehabilitation programs .

Frail Older Adults with Presymptomatic SARS-CoV-2 Infection: Clinical Course and Prognosis.

BACKGROUND/AIMS: The novel coronavirus SARS-CoV-2 has caused a pandemic threatening millions of people worldwide. This study aimed to describe clinical characteristics, outcomes, and risk factors of SARS-CoV-2-positive, asymptomatic, frail older adults. METHODS: A retrospective cohort study was conducted in 6 designated COVID-19 units, in skilled nursing homes. Subjects were severely frail older adults, positive for SARS-CoV-2, and asymptomatic at the time of their admission in these units. Residents' characteristics and symptoms were obtained via electronic medical records. The primary outcome was a composite of death or hospitalization by day 40. We looked at time to the primary outcome and used Cox regression for a multivariate analysis. RESULTS: During March-November 2020, 849 residents met inclusion criteria. Median age was 84 years. Most were completely dependent for basic activities of daily living and showed cognitive impairment. Six hundred forty-one (75.5%) residents were discharged after considered cured from COVID-19, 125 (14.7%) were hospitalized, and 82 (9.7%) died in the facilities. In survival analysis, 35% reached the primary outcome of death or hospitalization by day 40. Age (hazard ratio [HR] 1.23; 95% confidence interval [CI] 1.1-1.4), male gender (HR 1.41; 95% CI: 1.1-1.88), and COPD (HR 1.8; 95% CI: 1.23-2.67) were significant risk factors. CONCLUSIONS: In this large cohort, we report care and prognosis of asymptomatic older adults with major functional or cognitive impairments during the COVID-19 pandemic. Most presymptomatic patients do not develop severe infection, and age stays a predominant risk factor, even in the frailest older adults.

Are extracapsular and intracapsular hip-fracture patients two distinct rehabilitation subpopulations?

PURPOSE: To assess whether intracapsular and extracapsular hip fracture patients in a post-acute rehabilitation setting differ in their background characteristics and whether fracture type affects rehabilitation outcome. METHODS: A retrospective cohort study. OUTCOME MEASURES: Functional Independence Measure (FIM), motor FIM (mFIM), mFIM effectiveness, length of stay (LOS), and discharge destination. Various tests assessed associations (the Mann-Whitney U, the chi-square, logistic regression), population differences (t-test), and independent predictors of discharge FIM score (multiple linear regression model). RESULTS: Six hundred and eighty-seven patients completed the rehabilitation program. The intracapsular hip fracture patient group was characterized by significantly higher percentages of males, higher education levels, and living with a caregiver compared with the extracapsular hip fracture patient group. Intracapsular hip fracture patients were younger, had longer latency time from fracture to surgery, exhibited higher functional levels on admission and upon discharge, higher cognitive function and shorter rehabilitation time than extracapsular hip fracture patients. Both study groups possessed similar comorbidities, rehabilitation achievements, and discharge destination. Regression analyses showed that the fracture type was not associated with discharge FIM score, nor with the probability of achieving a favorable functional gain. CONCLUSIONS: Post-acute extracapsular and intracapsular hip fracture patients are demographically and clinically two distinct subpopulations. Nevertheless, given additional time, extracapsular hip fracture patients will attain similar functional achievements as intracapsular hip fracture patients.Implications for rehabilitationPost-acute extracapsular and intracapsular hip fracture patients are demographically and clinically two distinct subpopulations.Given additional time, extracapsular hip fracture patients can attain similar functional achievements as intracapsular hip fracture patients.

Vitamin D levels in post-acute hip fractured patients and their association with rehabilitation outcomes.

PURPOSE: To report on serum 25-hydroxyvitamin D (25(OH)D) levels in post-acute hip fractured patients, revealed the associations between serum 25(OH)D levels and hip fractured patients' baseline characteristics and rehabilitation outcomes. MATERIALS AND METHODS: A retrospective study (9/2017-9/2020) of 493 hip fractured patients. 25(OH)D levels were recorded following the patient's baseline characteristics and outcome measures, including the functional independence measure and motor functional independence measure effectiveness. The sample was divided into three groups: deficient (<30 nmol/l), insufficient (30-75 nmol/l) and sufficient (>75 nmol/l) 25(OH)D levels. ANOVA and chi-square test tests compared the groups. Multiple linear analysis assessed the associations between the 25(OH)D and discharge functional independence measure score. RESULTS: 25(OH)D deficiency was found in 20.3% of the patients. The only baseline characteristic significantly associated with serum 25(OH)D levels was dementia. The group with deficient levels of 25(OH)D exhibited a significantly higher rate of low education, low admission albumin levels and a reduced handgrip strength compared to the insufficient/sufficient groups. All functional measure scores were significantly lower in the deficient (25(OH)D) group compared with the insufficient/sufficient patient groups. 25(OH)D levels were found to be significantly associated with the discharge functional independence measure score. CONCLUSIONS: Routine screening for 25(OH)D levels is mandatory in post-acute hip fracture patients as it may affect rehabilitation outcomes.Implications for Rehabilitation25-hydroxyvitamin D 25(OH)D levels are associated with rehabilitation outcomes in post-acute hip fractured patients.A routine screening for 25(OH)D levels and standardized supplementation protocol during the acute and post-acute rehabilitation setting is recommended as it may improve the quality of care.

Rehabilitation under Social Isolation: Outcomes of Older Individuals with Hip Fractures, Admitted to a Postacute Geriatric Rehabilitation Center, during the COVID-19 Pandemic.

BACKGROUND/AIMS: The novel coronavirus SARS-CoV-2 is the cause of an ongoing pandemic. The highest mortality rate is observed among the older adult population. During the first wave of the pandemic (March-June 2020), following a national health decree demanding that no visitors or family members be allowed in health institutions, our geriatric rehabilitation center closed gates to all visitors from the outside. We aimed to assess the rehabilitation outcomes of older patients with hip fractures in the first pandemic wave, who underwent rehabilitation under complete social isolation from primary care givers and family members. METHODS: This was a retrospective cohort study. It took place at a university-affiliated, major postacute geriatric rehabilitation center. Rehabilitation outcomes measured were discharge functional independence measure (FIM) score and motor FIM score, FIM score change, motor FIM score change, favorable motor FIM effectiveness, length of stay, discharge destination, and home aid at discharge. RESULTS: The study group included 36 patients who were admitted during the first wave of the COVID-19 pandemic (March 1, 2020, to June 30, 2020). The control group comprises 106 individuals with hip fractures who were admitted in the respective time periods during the previous 2 years, that is, March 1, 2018, to June 30, 2018, and March 1, 2019, to June 30, 2019. The facility's occupancy rates were much lower during the first wave of the pandemic in comparison with previous years (78 and 99%, respectively). Patients showed similar demographics and comorbidities, but the social isolation group was more severely deconditioned upon admission. All rehabilitation outcomes were similar between groups. CONCLUSION: According to the findings of this retrospective study, social isolation from family and caregivers did not have a detrimental effect on the rehabilitation outcomes of these patients. More evidence must be gathered and presented on the matter.

Characteristics and Outcomes of Hip Fracture Patients Hospitalized in an Orthogeriatric Unit Versus an Orthopedic Department: A Retrospective Cohort Study.

INTRODUCTION: Hip fractures are a significant health risk in older adults and a major cause of morbidity, functional decline and mortality. Our aim was to compare clinical outcomes of older patients hospitalized in an ortho-geriatric (OG) unit to those hospitalized in an orthopedic department (OD) for surgical treatment of a hip fracture. METHODS: A retrospective cohort study of hip fractured patients hospitalized between 2015-2016 in a single tertiary university-affiliated medical center. Included were patients aged 65 and older who had undergone hip fracture surgery and were admitted to either a geriatric or orthopedic ward. RESULTS: 441 patients met the inclusion criteria (195 in the OG unit, 246 in the OD); 257 were transferred to an affiliated geriatric center hospital (107 from the OG unit and 127 from the OD) for rehabilitation. Patients in the OG unit were older, more cognitively and functionally impaired and with more comorbidities. The 1-year mortality rate was significantly lower in the OD group (OR 0.32, CI 95% 0.19-0.53, p < 0.001), however, after propensity matching, the 30-day and 1 year mortality rates were similar in both groups. No difference was found in the rehabilitation length of stay between the groups. The functional independence measure improvement was similar in both groups, with a non-significant trend toward better functional improvement among OG unit patients. CONCLUSIONS: Despite the higher complexity of patients, worse baseline functional capacity in the OG unit, improvement after rehabilitation was similar in both groups. These results demonstrate the advantages of the OG unit in treating and stabilizing frail older adults, thus maximizing their chances for a successful recovery after hip fractures. LEVEL OF EVIDENCE: Level IV.

The Association Between Antipsychotic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study.

Antipsychotic (AP) use may lead to numerous side effects which may affect rehabilitation outcomes. A retrospective cohort study was carried out on 448 hip fractured patients admitted to a post-acute geriatric rehabilitation center. Functional improvement was measured by the Functional Independence Measure (FIM), motor FIM (mFIM), and mFIM effectiveness. A multiple linear regression model and regression analysis was used to evaluate the level of association between AP use and achievement of favorable functional gain. AP users exhibited lower functional ability on admission and at discharge, achieved a significantly lower functional gain and required longer rehabilitation time compared with nonusers. AP use by post-acute hip fractured patients negatively affects their chances of achieving favorable rehabilitation outcome after adjustment for confounders.

Using Machine Learning to Predict Rehabilitation Outcomes in Postacute Hip Fracture Patients.

OBJECTIVE: To use machine learning-based methods in designing a predictive model of rehabilitation outcomes for postacute hip fracture patients. DESIGN: A retrospective analysis using linear models, AdaBoost, CatBoost, ExtraTrees, K-Nearest Neighbors, RandomForest, Support vector machine, XGBoost, and voting of all models to develop and validate a predictive model. SETTING: A university-affiliated 300-bed major postacute geriatric rehabilitation center. PARTICIPANTS: Consecutive hip fracture patients (N=1625) admitted to an postacute rehabilitation department. MAIN OUTCOME MEASURES: The FIM instrument, motor FIM (mFIM), and the relative functional gain on mFIM (mFIM effectiveness) as a continuous and binary variable. Ten predictive models were created: base models (linear/logistic regression), and 8 machine learning models (AdaBoost, CatBoost, ExtraTrees, K-Nearest Neighbors, RandomForest, Support vector machine, XGBoost, and a voting ensemble). R2 was used to evaluate their performance in predicting a continuous outcome variable, and the area under the receiver operating characteristic curve was used to evaluate the binary outcome. A paired 2-tailed t test compared the results of the different models. RESULTS: Machine learning-based models yielded better results than the linear and logistic regression models in predicting rehabilitation outcomes. The 3 most important predictors of the mFIM effectiveness score were the Mini Mental State Examination (MMSE), prefracture mFIM scores, and age. The 3 most important predictors of the discharge mFIM score were the admission mFIM, MMSE, and prefracture mFIM scores. The most contributing factors for favorable outcomes (mFIM effectiveness > median) with higher prediction confidence level were high MMSE (25.7±2.8), high prefacture mFIM (81.5±7.8), and high admission mFIM (48.6±8) scores. We present a simple prediction instrument for estimating the expected performance of postacute hip fracture patients. CONCLUSIONS: The use of machine learning models to predict rehabilitation outcomes of postacute hip fracture patients is superior to linear and logistic regression models. The higher the MMSE, prefracture mFIM, and admission mFIM scores are, the higher the confidence levels of the predicted parameters.

Initial functional recovery as a measure for rehabilitation outcome in post-acute hip fractured patients.

BACKGROUND: The assessment of immediate functional change after hip fracture surgery may assist in predicting rehabilitation outcome and improve program efficiency. OBJECTIVE: To evaluate the potential of the initial functional recovery measure in predicting rehabilitation outcome of hip fractured patients. DESIGN: Retrospective cohort study. SETTING: Post-acute geriatric rehabilitation center. PARTICIPANTS: A total of 630 hip fractured patients admitted from 1/2016-6/2019. METHODS: The initial functional recovery, a measure of functional change from the time of surgery to rehabilitation was calculated for each patient. The association between initial functional recovery and clinical and demographic variables was assessed by the Mann-Whitney and chi-square tests. A multiple linear regression model evaluated the association between initial functional recovery and the discharge functional independence measure score. Regression analysis estimated the association between initial functional recovery and the achievement of a favorable outcome measure. RESULTS: A good correlations were found between initial functional recovery and rehabilitation outcomes but not length of stay (p < 0.001). Multiple linear regression analysis showed that after adjustment for potential confounding variables, the higher the initial functional recovery, the better the discharge functional independence measure score (r2 = 0.783; p < 0.001). Logistic regression revealed that a high initial functional recovery was significantly associated with a higher probability of achieving a favorable functional gain (OR = 1.093; 95% CI = 1.04-1.15, P < 0.001). CONCLUSION: Initial functional recovery is a good predictor of rehabilitation outcomes in hip fractured patients, and may be utilized in decision-making regarding the rehabilitation program in addition to coordinating expectations with patients and their caregivers.

Association between anticholinergic drug prescription changes and rehabilitation outcome in post-acute hip fractured patients.

Purpose: To follow changes in anticholinergic drug prescriptions throughout hip fractured patients' rehabilitation; to assess whether a change in anticholinergic burden affects rehabilitation outcome.Methods: Retrospective study of 869 hip fractured patients admitted between January 2011 to October 2015, performed in a post-acute geriatric rehabilitation center. The Anticholinergic Cognitive Burden Scale quantified the anticholinergic burden. Main outcome measures: Functional Independence Measure, motor Functional Independence Measure, Montebello Rehabilitation Factor Score on motor Functional Independence Measure and length of stay. Multiple linear regression analysis tested for independent association between admission anticholinergic burden and anticholinergic burden change during rehabilitation, and rehabilitation outcomes.Results: One hundred and sixty two (18.7%) patients were prescribed additional anticholinergic medications upon discharge; 76 (8.7%) were prescribed fewer. Patients with high admission anticholinergic burden presented with a significantly higher rate of higher education, less likely to reside at home, less independent pre-fracture, exhibited a significantly lower admission and discharge Functional Independence Measure score, a lower Functional Independence Measure score change and a lower Montebello Rehabilitation Factor Score. Admission anticholinergic burden, but not changes in anticholinergic burden during rehabilitation, was found to be independently associated with rehabilitation outcome (discharge FIM score).Conclusions: High admission anticholinergic burden is associated with lower functional ability in hip fractured patients. Changes in anticholinergic drug prescription during rehabilitation were not associated with rehabilitation outcomes.Implications for rehabilitationClinicians should make an effort to reduce AC drug use in hip fractured patients on admission to post-acute rehabilitation.AC burden should be carefully monitored throughout the rehabilitation period and reduced whenever possible.When functional ability does not improve as expected, AC burden should be considered as an intervening factor.

The association between hand grip strength and rehabilitation outcome in post-acute hip fractured patients.

PURPOSE: Various factors have been shown to affect the rehabilitation outcome of hip fractured patients. Considering the decrease in muscle mass with aging and its impact on mobility, we hypothesized that a relationship exists between hand grip strength and rehabilitation outcome. METHODS: We retrospectively studied 373 post-hip fracture patients, admitted for rehabilitation. Muscle strength was measured by hand grip dynamometer. MAIN OUTCOME MEASURES: functional independence measure motor functional independence measure, motor functional independence measure effectiveness and length of stay). A favorable functional gain was defined as a motor Functional Independence Measure effectiveness score > 0.5. The Spearman correlation assessed the associations between hand grip strength and outcome measures. A multiple linear regression model tested whether hand grip strength was an independent predictor of discharge motor Functional Independence Measure scores and length of stay RESULTS: Significant correlations were found between hand grip strength and functional outcomes. A significant independent association was found between hand grip strength and discharge motor Functional Independence Measure score after adjustment for confounding demographic and clinical variables. High hand grip strength on admission was significantly associated with a greater chance of achieving a favorable functional gain (OR 1.064, 95% CI, 1.01-1.13; p = 0.032). Hand grip strength was not found to be associated with length of stay. CONCLUSION: Hand grip strength is independently associated with rehabilitation outcome in post-acute frail hip fractured patients. Initial screening for hand grip strength on admission may help identify patients who require an intensive resistance exercise program.

Apixaban Levels in Octogenarian Patients with Non-valvular Atrial Fibrillation.

BACKGROUND: There is a paucity of data on apixaban levels among octogenarians with non-valvular atrial fibrillation (NVAF). We aimed to compare apixaban levels between octogenarians (with and without dose reduction) and younger patients, to assess the frequency of high and above-range drug levels. METHODS: A cross-sectional, prospective study of 80 patients treated with apixaban for NVAF was conducted. Apixaban levels were compared among octogenarians treated with 5 mg twice daily (bid), octogenarians with appropriately reduced dose (2.5 mg bid), octogenarians with inappropriately reduced dose and younger patients (age < 70 years). Trough and peak levels were measured by a chromogenic assay calibrated for apixaban and compared to predicted manufacturer levels. RESULTS: A significant proportion of the cohort had above-range trough [n = 11 (13.8%)] and peak [n = 16 (20%)] levels, especially octogenarians with the 5-mg bid dosage [n = 6 (30%) for trough and n = 8 (40%) for peak]. No significant differences were found in the trough or peak geometric mean (GM) levels among the groups, apart from the peak GM levels between the 5-mg octogenarian group and the other two 2.5-mg bid octogenarian groups (p = 0.0004). The frequency of apixaban peak levels within the upper quartile was significantly higher in the 5-mg octogenarian group compared to the other groups [n = 12 (60%) of measurements, p = 0.019), whereas trough levels were comparable between groups. CONCLUSION: High and above-range peak apixaban steady-state levels are highly prevalent in octogenarians receiving the appropriate dosage of 5 mg bid for NVAF stroke prevention. Age above 80 strongly affects apixaban levels. TRIAL REGISTRATION: ClinicalTrials.gov Identifier number NCT02623049.

Stability of extracapsular hip fracture: Does it affect rehabilitation outcome of post-acute patients?

BACKGROUND: Various factors have been shown to affect rehabilitation outcome of hip fractured patients. The degree of extracapsular fracture stability may also affect functional recovery. The aim of our study was to assess the relationship between extracapsular hip fracture stability and rehabilitation outcome in a post-acute setting. METHODS: A retrospective cohort study of 144 hip fractured patients was carried out in a post-acute geriatric rehabilitation center from 1/2014 to 6/2015. The main outcome measures were the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). The associations between patients with stable vs. unstable and clinical, demographic and comorbidity variables, were assessed by the Mann-Whitney U and chi-square tests. A multiple linear regression model was used to estimate the association between fracture stability and LOS score after controlling for sociodemographic characteristics and chronic diseases. RESULTS: Rehabilitation outcomes (FIM and mFIM score changes, mFIM MRFS) were found independent of extracapsular hip fracture stability. Patients with an unstable fracture presented with a significantly longer LOS compared with a stable fracture (p = .008). Multiple linear regression analysis showed that fracture stability was significantly associated with LOS after adjustment for confounding demographic, clinical and functional variables (p = .009). CONCLUSION: Patients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures.

The Association between Anticholinergic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study.

BACKGROUND: Anticholinergic (AC) drugs are associated with significant impairment in cognitive and physical function which may affect rehabilitation in older people. We aimed to evaluate whether AC burden is associated with rehabilitation achievement in post-acute hip-fractured patients. METHODS: A retrospective cohort study carried out in a post-acute geriatric rehabilitation center on 1019 hip-fractured patients admitted from January 2011 to October 2015. The Anticholinergic Cognitive Burden Scale (ACB) was used to quantify the AC burden. Main outcome measures included the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM, and length of stay (LOS). The study population was divided into two groups: individuals with low admission AC burden (ACB ≤ 1) and those with high admission AC burden (ACB ≥ 2). The relationship between the admission AC burden and clinical, demographic and comorbidity variables was assessed using the Mann-Whitney and Chi square tests. A multiple linear regression model was used to estimate the association between admission AC burden and discharge FIM score after controlling for sociodemographic characteristics and chronic diseases. RESULTS: Patients with a high admission AC burden had a significantly higher rate of high education, a significantly lower rate reside at home, they waited a longer period of time from surgery to rehabilitation, were less independent pre-fracture, and presented with a higher rate of vascular disorders and depression compared with patients with a lower admission AC burden. These patients also exhibited a significantly lower FIM score on admission and at discharge, a lower FIM score change, and a lower achievement on the MRFS compared with patients with a lower admission AC burden. A multiple linear regression analysis showed that admission AC burden was significantly associated with the discharge FIM score after adjustment for confounding variables. CONCLUSION: High admission AC drug burden is significantly associated with less favorable discharge functional status in post-acute hip-fractured patients, independent of relevant risk factors.

Characteristics of Patients With Satisfactory Functional Gain Following Total Joint Arthroplasty in a Postacute Rehabilitation Setting.

BACKGROUND AND PURPOSE: Total joint arthroplasty (TJA) is an effective and successful treatment of osteoarthritis of the hip and knee as quantified by several measures, such as pain relief, improved walking, improved self-care, functions, and increased quality of life. Data are lacking as to the definition of a satisfactory functional gain in a postacute setting and identifying the characteristics of older patients with TJA who may achieve that gain. Our aim was to characterize patients who may achieve a satisfactory functional gain in a postacute rehabilitation setting following TJA. METHODS: This was a retrospective study of 180 patients with TJA admitted during 2010-2013. The main outcome measures were the Functional Independence Measure (FIM), the Montebello Rehabilitation Factor Score (MRFS) on the motor FIM, and the Timed Get Up and Go Test. Satisfactory functional gain was defined as an mFIM MRFS score above median score. Comparisons of clinical and demographic characteristics between patients who achieved a satisfactory functional gain versus those who did not were performed by the Mann-Whitney U test and the χ test. RESULTS: The proportion of patients who achieved a satisfactory functional gain was similar in the total knee arthroplasty and total hip arthroplasty (THA) groups. The most significant characteristic of patients who achieved a satisfactory functional gain was their admission functional ability. Age negatively impacted the ability to achieve a satisfactory functional gain in patients with THA. CONCLUSION: Functional level on admission is the best predictive factor for a better rehabilitation outcome for patients with TJA. Age negatively affects functional gain in patients with THA.