Awareness of Imminent Death: Results From a Mixed Methods Study of Israeli Family Caregivers' Perceptions of Their Awareness and That of the Patients for Whom They Cared.

We studied levels of awareness of impending death in older patients and their family caregivers. Using a mixed methods approach, we interviewed 70 family caregivers in Israel. Of the caregivers, 64% reported having been aware of the impending death, 33% were unaware, and 3% uncertain. Caregivers reported their perception that 36% of patients were aware, 27% unaware, and for 37% they were uncertain about the patient's awareness. Mechanisms that increased caregivers' awareness were specific diagnosis, significant deterioration in health, preparation by a health professional, or patient preparations for death. This study clarifies processes which aid awareness, and the relationship between awareness and actual preparation for dying.

Regrets of family caregivers in Israel about the end of life of deceased relatives.

Objective: We aimed to clarify the content of different types of regrets or lack of regret, and the frequency of feeling regret among family caregivers who assisted their relatives during their end of life stage.Method: Seventy primary informal caregivers in Israel were interviewed (17 spouses, 52 children, and 1 cousin) concerning their regret about the end of life of their deceased relative, including a general question about regret and questions about regret concerning life-sustaining treatments. After calculating the frequency of regrets and lack of regret, we conducted a qualitative analysis, using a thematic approach to identify themes and interpret data.Results: A majority of caregivers (63%) expressed regret and about 20% expressed ambivalence involving both regret and denial of regret. Regrets pertained to care given, suffering experienced, and the caregiver's behavior towards, and relationship with the deceased, including missing opportunities to express love and caring toward relatives. Caregivers viewed almost 30% of 75 administered life-sustaining procedures as misguided. Most regrets involved inaction, such as not communicating sufficiently, or not fighting for better care.Conclusion: This article provides a comprehensive description of EoL regrets, and helps clarify the complexity of regrets, lack of regrets, and ambivalence concerning regrets, though the study is limited to one country. Analysis suggests the need for public education concerning the EoL process, and for changes within the health care system to improve communication, to improve understanding of the needs of the terminally ill, and to provide more instruction to family caregivers to help them understand EoL.

After providing end of life care to relatives, what care options do family caregivers prefer for themselves?

OBJECTIVES: We examined how caregivers who had cared for a relative at end of life (EoL) wished to be cared for in the event that they experienced advanced dementia or physical disability in the future, and what factors influenced their preferences for EoL care. METHODS: In this mixed-methods study, 83 participants, recruited from multiple sources in Israel, were interviewed concerning socio-demographic factors, health status, past experience with EoL, preference for extension of life vs. quality of life (QoL), willingness to be dependent on others, and preferences for EoL care. RESULTS: In case of advanced dementia, 58% preferred euthanasia or suicide; around a third chose those for physical disability. Care by family members was the least desired form of care in the advanced dementia scenario, although more desirable than institutional care in the physical disability scenario. QoL was rated as the highest factor impacting preferences for EoL care. Men demonstrated a higher preference than women for extension of life over QoL. CONCLUSION: Our study points to the need for society to consider solutions to the request of participants to reject the type of EoL experienced by their relatives. Those solutions include investing in improving the quality of life at the end of life, and offering alternatives such as euthanasia, which a large proportion of our participants found ethically and medically appropriate within the current system of care in the event of severe physical disability, and more so in the event of advanced dementia.

Family caregiver perceptions of end of life in persons with and without dementia.

BACKGROUND: We compare the End of Life [EoL] period, the period of decline to death, for persons with dementia [PwD] to those without dementia, examining the duration and number of stages, and their precipitating events. METHODS: In this cross-sectional study, 70 primary caregivers of decedents were interviewed. Frequencies were compared using the McNemar statistical test. RESULTS: PwD were more likely to be female and older, compared to those without dementia. For PwD, the reported duration of the EoL period was significantly longer, involved more stages, and included a longer first stage. Precipitating events for EoL were more likely to include cognitive decline for PwD, but for those without, more likely to involve a new medical diagnosis or decline in health status. DISCUSSION: End of Life as the final stage of development differs significantly between the two populations in length and other parameters. This has considerable implications for the experiences of PwD.

Israel Ad Hoc COVID-19 Committee: Guidelines for Care of Older Persons During a Pandemic.

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID-19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long-term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a "soft utilitarian" approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, "biological age" would enter into the triage considerations, but only in the case of distinguishing between people with equal non-age-related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD-19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation. J Am Geriatr Soc 68:1370-1375, 2020.

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.

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.

What Is the End of Life Period? Trajectories and Characterization Based on Primary Caregiver Reports.

Background: As the population lives longer, end of life (EOL) is emerging as a distinct life phase, about which there is still limited understanding. Characterizing this important period is vital for clarifying issues regarding trajectory and decline at EOL and for health service planning on an institutional, communal, and societal level. In this article, we aim to characterize the EOL period, examining the duration and number of EOL stages, as well as functional, attitudinal, and emotional trajectories. Methods: In this cross-sectional study, 70 primary caregivers of deceased persons were interviewed. Standardized rates of functional, attitudinal, and emotional change across the EOL period were calculated. Frequencies were compared using the McNemar statistical test. Results: EOL period was found to have a median length of 3.25 years, and an average of approximately three progressive stages. The duration of EOL stages tended to decrease as death approached. Unexpected events (eg new medical diagnosis/accident) served as the precipitating event for the EOL period for approximately half of the deceased persons, and changes in existing conditions (eg health status/cognitive state) were also reported to precipitate EOL for a similar proportion. Reports of functionality across stages found the steepest decline in the "physical" domain and the most moderate decline in the "social" domain. With each stage, positive indicators, such as "will to live," showed a progressive decline, whereas negative indicators, including "suffering" and "dependence level," progressively increased. Conclusions: Results help characterize EOL trajectories and should inform care planning and decision making at various levels. In addition, they suggest a methodology for better understanding EOL.

Trajectories of End of Life: A Systematic Review.

Objectives: Because End of life (EOL) is becoming an increasingly long life stage, this paper aims to describe the delineation of EOL by reviewing studies which examine (a) terminal decline (TD), the timing of change in slope of decline in specific abilities; and (b) trajectories of decline in areas such as function, health care expenditures, and well-being according to cause of death. Methods: Studies were identified through Google Scholar, PsycNET, and PubMed. Results: TD was identified in diverse domains. Most findings focused on decline of cognitive abilities, and they reported this to occur 3-7 years prior to death. TD in wellbeing was found to begin 3-5 years prior to death. Trajectories by cause of death generally examined sudden death, terminal illness, organ failure, and frailty, and findings described differences in costs, function, and wellbeing, though examining a shorter predeath period than the TD literature. Discussion: Further research is needed to combine methods of investigation in order to assist the health care system in personalizing services to the trajectories of decline, and in enabling caregivers to prepare for the EOL experience.

The relationship between health services standardized costs and mortality is non-linear: Results from a large HMO population.

Older age, male gender, and poor socioeconomic status have been found to predict mortality. Studies have also documented an elevation in health services standardized costs (HSSC) and expenditures in the last years of life. We examined the contribution of HSSC in the last years of life in predicting mortality beyond predictors that have been established in the literature, and whether the impact of HSSC on mortality is linear. Vulnerability, operationalized as being exempt from co-payments due to poverty, being a holocaust survivor, or other reasons, was examined as potentially mediating the relationship between HSSC and mortality. We used longitudinal data obtained from the largest Health Maintenance Organization in Israel. Subjects were insured persons who were over age 65 in 2006 (n=423,140). Predictors included demographics, co-morbidity, and HSSC. All factors significantly predicted time to death. For HSSC, high levels displayed the highest Hazard Ratios (HR), with medium levels having the lowest HRs. The higher mortality rate in the low HSSC group might indicate a risk of underutilizing health services. Vulnerable status remained a predictor of mortality even within a system of universal access to healthcare. There is a need for establishing mechanisms to identify those underutilizing health services. A universal health care system is insufficient for providing equal health care, indicating a need for additional means to increase equality.

Treatment and Communication-That Is What Matters: An Analysis of Complaints Regarding End-of-Life Care.

BACKGROUND: Investigating complaints concerning end-of-life (EoL) care is a necessary step for improving the quality of life at its final stage. OBJECTIVE: We aimed to classify and quantify the aspects of EoL care that require improvement by analyzing caregivers' feedback on the care their relatives received before death. DESIGN: A survey of primary family caregivers of deceased patients. SETTING/SUBJECTS: Relatives of decedents were recruited through two geriatric medical centers and from persons contacted for other studies, who reported losing a relative. Face-to-face interviews of 70 relatives of the deceased were conducted. The participants' mean age was 64, 68.6% were female, and most (57%) were born in Israel. Regarding relationship to the deceased, 74.3% were sons/daughters, 24.3% were spouses, and one (1.4%) was a cousin. MEASURES: Responses to the question "Is there something in the health system or the behavior of the doctors/nurses that you would recommend changing?" were analyzed qualitatively. RESULTS: 82.9% of participants had complaints about the care received. Within this, 62.9% related to provision of services, 51.4% to communication, 27.1% to system issues, 15.7% to institutional issues, and 10.0% to staffing issues. Qualitative analysis revealed potential causal relationships between these EoL issues. We therefore propose a theoretical model involving the distal factors of system, institution, and staff that impact the proximal factors of provision of services and communication. CONCLUSION: The new model has the potential to clarify directions in research, quality assessment, and intervention regarding end-of-life care.

Place orientation and visual construction subdomains of the Mini Mental State Examination test as predictors of rehabilitation outcome of post-acute hip-fractured patients.

PURPOSE: The study aimed at assessing the relationship between various Mini Mental State Examination (MMSE) subdomains and rehabilitation achievements in post-acute hip-fractured patients. METHOD: Six hundred and five hip-fractured patients admitted during 2010-2013 to a post-acute geriatric rehabilitation center were included in the study. Main outcome measures were the Functional Independence Measure (FIM) instrument, the motor FIM (mFIM), the Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). A logistic regression analysis tested the predictive value of MMSE subdomains for achieving a satisfactory functional gain (mFIM MRFS >30%) on operated patients admitted from community. RESULTS: Of all the six MMSE subdomains, place orientation and visual construction demonstrated significant predictive values for rehabilitation outcome. Patients who did not err on place orientation and visual construction MMSE domains had better probabilities [(OR 1.28, 95%CI, 1.05-1.58; p = 0.017); (OR 2.15, 95%CI, 1.28-3.59; p = 0.004), respectively] of achieving better rehabilitation achievements. Similar results were obtained for cognitively impaired patient groups [(OR 1.40 95%CI, 1.11-1.77; p = 0.005); (OR 2.47, 95%CI, 1.15-5.30; p = 0.021), respectively]. For the cognitively intact patient group, the variables with significant predictive value were time orientation and visual construction MMSE subdomains [(OR 2.26, 95%CI, 1.18-4.33; p = 0.014); (OR 2.87, 95%CI, 1.16-7.09; p = 0.022), respectively]. CONCLUSIONS: Post-acute hip-fractured patients scoring normally on place orientation and visual construction MMSE subdomains have a better chance of achieving favorable rehabilitation outcome. Implications for Rehabilitation Post-acute hip-fractured patients have a better chance to achieve a favorable rehabilitation outcome when scoring normally on place orientation and visual construction MMSE subdomains. Patients having difficulties in orientation and visual construction may need more rehabilitation time as they lack planning and organizational capacity to follow instructions. Assessing MMSE subdomains may reveal subtle cognitive impairment in patients scored within the normal range on the MMSE test. Identifying subtle cognitive impairment may assist in coordinating the patients and their caregivers' expectations, efficiently allocating resources and help in advanced care planning.

Trajectories at the end of life: A controlled investigation of longitudinal Health Services Consumption data.

BACKGROUND: Knowledge of individual-level trajectories of Health Services Consumption (HSC) at End-of-Life (EoL) is scarce. Such research is needed for understanding and planning health expenditures. OBJECTIVE: To explore individual-level EoL trajectories in the Israeli population. This approach differs from past studies which aggregated across populations or disease groups. DATA SOURCES: We used HMO (Health Maintenance Organization) longitudinal data for HSC of persons ages 65-90 who died during 2010-2011 (n=35,887) and of an age by sex matched sample of persons who were alive by mid-2012 (n=48,560). DESIGN: HSC per quarter was calculated for each individual. Trajectory-types of HSC were described through k-means cluster analysis. EXTRACTION METHODS: Data were extracted from computerized HMO files. HSC was computed as a standardized function of HMO costs for each individual. RESULTS: In both samples, low HSC trajectories were the most common. However, among the deceased, all trajectories had higher HSC than those who were alive; the low HSC trajectory cluster represented a smaller percentage of the sample; and all relevant trajectories included a HSC peak. In contrast, the most common trajectory among the living was a flat low HSC. Clusters differed significantly by sex, disease status, and age. CONCLUSION: This methodology shows the utility of individual-level analysis of HSC at end-of-life and should inform future research and current debates concerning EoL care and resource distribution.

Measuring rehabilitation outcome in post-acute hip fractured patients.

PURPOSE: To present our experience in measuring rehabilitation achievements of post-acute hip fractured patients with the FIM instrument; assess its appropriateness as to the patients' various disability levels and describe our experience with other measuring tools in patients less sensitive to changes in the FIM instrument. METHODS: A retrospective study performed in a post-acute geriatric rehabilitation center. Three hundred and eighty-seven hip fractured patients admitted from January 2010 to May 2012 were included in this study. Patients were evaluated by the Functional Independence Measure (FIM), the Timed Get Up and Go (TUG) test and "bed to chair" transfer FIM parameter. The study population was divided into three disability groups according to their admission disability level: high (admission FIM score <40), moderate (FIM 40-79) and low (FIM ≥ 80). The Mann-Whitney U, ANOVA and Chi square tests analyzed the data. RESULTS: The FIM instrument was found most sensitive in identifying functional change in patients with moderate disability. Low disability patients received more physio- and occupational-therapy treatment time, yet achieved a lower mean FIM score change compared to moderately disabled patients. The smallest real difference (SRD = 13) for the FIM score was achieved by 60% of patients with moderate disability. When assessed by the TUG test, most patients (94%) improved their score. The SRD% of 31% was achieved by 71.7% of the patients. Nineteen patients (35.9%) achieved a discharge score of <20 s. The high disability group achieved the lowest mean FIM score change. On admission, 52/64 (81%) patients required considerable help in transferring from bed to chair (FIM 1-2), however, upon discharge, the majority (69.2%) improved to the level of a one man transfer (FIM ≥ 3). Forty-one (64.1%) patients were discharged home. CONCLUSION: Post-acute hip fracture patients exhibit variable functional ability. Assessing rehabilitation achievements with a disability measure is limited; therefore, it is advisable to use an instrument most suitable to the patients' disability level.

Rehabilitation outcome of post-acute lower limb geriatric amputees.

PURPOSE: To characterize the lower-limb elderly amputee patients admitted to a post-acute rehabilitation program, assess their 1-year survival rate, estimate rate of prosthetic fit and report rate and factors associated with 1-year post-discharge prosthetic use. METHODS: A cohort study performed in a post-acute rehabilitation department. Patients were evaluated by the Functional Independence Measure (FIM), motor FIM (mFIM), rate of prosthesis fit, length of stay (LOS), 1-year survival rate and long-term prosthetic use. RESULTS: One-hundred and seventeen lower limb elderly amputee patients consecutively admitted from January 2004 to June 2010 were enrolled in the study. Mean age was 74.7 ± 8.1; 56 patients (47.9%) had transtibial amputation (TTA); 46 (39.3%) transfemoral amputation (TFA) and 15 (12.8%) bilateral amputation. The main cause for amputation was diabetic foot (60.7%). Fifty-four (46.2%) patients died during first year post-admission. Twenty-seven patients (23.1%) were fitted with a prosthesis. When the bilateral amputees were considered separately, the rate of prosthetic fit among unilateral amputees was 24.5% (25/102) whereas among bilateral amputees it was 20% (3/15). Patients with prosthesis rehabilitation had a higher rate of TTA (p = 0.027), better metabolic status (p < 0.001), higher functional and cognitive levels (p < 0.001), and longer LOS (p < 0.001) compared with patients who received wheelchair rehabilitation. Twenty patients were contacted 1 year later: eight (40.0%) reported continuous functional prosthesis use, eight - partial prosthesis use and four (20%) did not use the prosthesis at all. The patient group with 1-year post-discharge prosthesis use had a significantly higher rate of TTA (p = 0.032), lower rate of congestive heart failure (CHF) (p = 0.014) and higher score changes on the FIM and mFIM (p = 0.043). CONCLUSIONS: Rehabilitation efforts should best be targeted depending on need. Rehabilitation professionals should make an educated estimate of outcomes at the beginning of rehabilitation based on the characteristics of the patients (level of amputation and functional level on admission).

Can hip-fractured elderly patients maintain their rehabilitation achievements after 1 year?

PURPOSE: The purpose of this study is to characterize hip-fractured patients who maintained or improved their functional ability, 1 year postdischarge from rehabilitation and to identify factors associated with functional achievement maintenance. METHODS: A retrospective study performed in a postacute geriatric rehabilitation center. Two hundred thirty-three hip-fractured patients admitted consecutively from January 2006 to September 2007 were enrolled in the study. The patients were evaluated at discharge from rehabilitation and after 1 year, they were classified into two groups: those who maintained or improved their motor Functional Independence Measure (mFIM) scores and those who deteriorated. The differences between the two patient groups relating to functional, clinical, demographic and fracture-related variables were assessed. RESULTS: One year postrehabilitation, 130 (55.8%) patients exhibited a decline in their mFIM score. Patients whose 1-year mFIM score had improved were discharged from rehabilitation with a less favorable mean mFIM score (50.7 ± 18.5 vs. 55.6 ± 15.2; p = 0.032), achieved a lower mean mFIM score gain during rehabilitation (12.0 ± 9.7 vs. 14.6 ± 8.1; p = 0.03), had a higher education level (p = 0.003) and had a lower rate of chronic lung disease (p = 0.020) compared with patients whose 1-year mFIM score had deteriorated. After 1 year, only 21 patients (9%) were functionally independent in activities of daily living and only 19 (8.2%) were able to walk unassisted. Only 13 patients (5.6%) perceived that they had regained their former functional level. CONCLUSIONS: A substantial decline in functional ability of hip-fractured patients occurred 1 year postdischarge from rehabilitation. Healthcare providers should be aware of the necessity for a long-term postrehabilitation physical training program to prevent functional decline. Further efforts should be invested in motivating their patients to exercise.

Mobility assessment of hip fracture patients during a post-acute rehabilitation program.

Our aim was to describe improvement in mobility level in hip fracture patients during a post-acute rehabilitation program and examine variables that may impede mobility improvement. A retrospective chart review of 138 patients with a proximal hip fracture, admitted consecutively during 2006 was conducted. Main outcome measurements were: 6-meter-walking-time (6mWT), rate of improvement (RI) in the 6mWT, gait velocity (GV), functional independence measure (FIM), motor FIM (mFIM) and length of stay (LOS). Most patients (118, 85.5%) showed improvement in the 6mWT (mean 16.05 ± 20.2s, median 12.08). At discharge, 117 patients (84.7%) achieved GV within household ambulation (<0.4m/s). Patients with high initial GV needed shorter rehabilitation time compare to patients with low admission GV (27.5 ± 12.1 days vs. 31.7 ± 12.2 days; p=0.042). The high RI group (≥ 1s/day) achieved significantly higher admission and discharge FIM scores (70.7 ± 15.9 vs. 64.1 ± 16.9, p=0.023; 87.3 ± 15.8 vs. 79.9 ± 17.4, p=0.013, respectively) and higher admission and discharge mFIM scores (45.3 ± 12.9 vs. 40.8.1 ± 12.7, p=0.049; 60.7 ± 12.4 vs. 56.2 ± 13.4, p=0.045, respectively) compared with the low performance group (<1s/day). Logistic regression analyzed the variables with significant predictive value for achieving high RI (≥ 1s/day): performance of the 6mWT at FIM ≥ 4 (OR 1.092; 95% CI, 1.056-1.129) and admission FIM score (OR 1.054; 95% CI, 1.023-1.085). Post-acute hip fracture patients capable of bearing weight on their injured leg, with minimal assistance [manual assistance of ≤ 25% (FIM ≥ 4)] may considerably improve their mobility regardless of their disability, cognitive level or neurological history. Most patients achieved GV enabling them to ambulate short distances within the home.