Education predicts incidence of preclinical mobility disability in initially high-functioning older women. The Women's Health and Aging Study II.

BACKGROUND: To examine the impact of educational attainment on the incidence of preclinical mobility disability (PCD). METHODS: The Women's Health and Aging II Study is a prospective observational cohort study of 436 initially high-functioning community-dwelling women aged 70-79 years at baseline in Baltimore, Maryland. We measured the association of highest attained education level with preclinical mobility disability (PCD) over an 11-year period. PCD is defined as self-reported modification in any of four tasks without reporting difficulty in those tasks. The tasks were walking ½ mile, climbing up steps, doing heavy housework, and getting in/out of bed or chair. RESULTS: Participants with less than 9 years of education were more likely to acquire incident PCD (hazard ratio: 3.1, 95% confidence interval = 1.2-7.7) than their counterparts with more education after adjusting for income, marital status, number of diseases, and high self-efficacy. CONCLUSIONS: Lower education level is an independent predictor of incident preclinical mobility disability. This association has important implications for primary and secondary prevention and can be easily assessed in clinical encounters.

Osteoporosis treatment following hip fracture: how rates vary by service.

OBJECTIVES: Osteoporosis is a prevalent condition among older people. It is often undiagnosed until patients suffer fragility fractures. Previous studies have shown low rates of initiating osteoporosis treatment during the acute hip fracture hospitalization. It is not clear if this varies by the treating service. We compared the rates of instituting osteoporosis treatment during the acute hospitalization for fragility hip fractures. METHODS: Rates of initiating treatment among previously untreated patients were compared between the orthopedic, medicine, and rehabilitation services using retrospective cross-sectional chart review at an academic medical center. Between January 2005 and August 2008, 191 patients admitted with a fragility hip fracture survived to be discharged from the hospital. RESULTS: There were 67 (35%) patients who were started on some form of osteoporosis treatment during their acute hospital stay. Factors statistically associated with starting treatment included having a discharge diagnosis of osteoporosis (P < 0.0001) and treating service (P < 0.0001). Orthopedics was the least likely of the 3 treating services to initiate treatment, while medicine was the most likely. CONCLUSIONS: Overall rates of osteoporosis treatment initiation were low at 35% of the 191 patients' records surveyed. Efforts to increase adherence during the acute hospital stay should be explored. A promising intervention includes instituting an osteoporosis consultative service to improve the likelihood of starting osteoporosis treatment post fragility fracture.

Disparities in postacute stroke rehabilitation disposition to acute inpatient rehabilitation vs. home: findings from the North Carolina Hospital Discharge Database.

OBJECTIVE: We evaluated the factors associated with discharge disposition to either inpatient rehabilitation or home after acute stroke hospitalization. DESIGN: We analyzed data from three concurrent years of State Hospital Discharge Data (years 2002-2004) of patients admitted with a primary International Classification of Diseases-9 code diagnosis of 430-434.9 and 436 (n = 7810). Logistic regression models tested whether discharge to inpatient rehabilitation vs. home was associated with socio-demographic factors. We controlled for covariates, including medical factors, such as number of intensive care unit days, Charlson Comorbidity Index, therapy charges, and available resources in their county. RESULTS: We found that older age, a greater number of intensive care unit days, higher total therapy charges, and lower poverty in their county of residence were associated with discharge to acute inpatient rehabilitation. Factors associated with discharge to home included younger age, fewer intensive care unit days, lower therapy charges, and higher poverty in their county of residence. CONCLUSIONS: Enabling factors, such as county poverty status and exposure to therapy may be important factors related to postacute stroke disposition.

Acute arterial occlusion after total knee arthroplasty.

There are a number of complications associated with total knee-joint arthroplasty. These include deep venous thromboses, peroneal palsy, infection, anemia, and Ogilvie's syndrome. An uncommon but potentially limb-threatening complication is acute arterial occlusion. Approximately 35 cases have been reported in the orthopedic literature. Prompt recognition and treatment intervention are the keys to successful outcome. We describe the case of one patient who had mild peroneal palsy and developed acute arterial occlusion 9 days postoperatively while on the inpatient rehabilitation service. Prompt aggressive management restored arterial circulation to the lower limb. Careful management of patients after total knee arthroplasty requires an understanding that arterial occlusion is a rare limb-threatening complication of surgery, but that it is treatable with prompt, deliberate management. Physiatrists should be aware that this condition exists in postoperative knee-joint arthroplasty patients. They should pay careful attention to any patient with a history of peripheral vascular disease or postoperative peroneal palsy.

Do racial disparities exist in access to inpatient stroke rehabilitation in the state of Maryland?

OBJECTIVE: Black patients tend to have a greater number and severity of stroke cases. The literature on access to rehabilitative services shows mixed results ranging from no disparities to limited access among minority populations. This study evaluated the association of race and acute discharge to inpatient stroke rehabilitation in Maryland, a diagnostic related group-and postacute care prospective payment system-exempt state. DESIGN: Data from the Maryland Health Services and Cost Review Commission database for 2000 was used to conduct a cross sectional retrospective review to determine the rate of disposition to inpatient rehabilitation facilities (IRF). Multiple logistic regression analyses evaluated factors associated with discharge to IRF in this population. RESULTS: There were a total of 12,208 patients hospitalized with stroke in the year 2000. Compared with urban-dwelling white patients, black patients who lived in urban dwellings were more likely to be discharged to IRF, OR 1.42, 95% CI (1.06, 1.91). CONCLUSION: In the state of Maryland, urban-dwelling black stroke patients were more likely to be discharged to IRF acutely after stroke. Future studies should assess whether this trend persists in states that have larger rural populations.

Racial disparities in access to cardiac rehabilitation.

OBJECTIVE: This study sought to assess the association between race and referral to cardiac rehabilitation programs. DESIGN: A total of 1933 cardiac patients enrolled in the Cardiac Access Study (n = 9275) who met the criteria selection of the American College of Cardiology Guidelines of eligibility for cardiac rehabilitation were evaluated to determine factors associated with accessing cardiac rehabilitation programs. Referral to a cardiac rehabilitation program among eligible participants was the outcome of interest. Potential factors associated with referral were entered into a logistic regression analysis to determine factors associated with referral. RESULTS: Whites were more likely to be referred for cardiac rehabilitation than were blacks (crude odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.75-3.63). After controlling for age, education, socioeconomic status, and insurance, race was still independently associated with referral for cardiac rehabilitation (OR = 1.81; 95% CI = 1.22-2.68). CONCLUSION: Among those patients who were eligible for cardiac rehabilitation, race is independently associated with the likelihood of referral for cardiac rehabilitation. The decreased utilization of such services in this population could lead to further disparity in cardiac outcomes. Future studies should address ways to eliminate this disparity and increase referral to such services.

Prevalence of venous thromboembolism in acute hemorrhagic and thromboembolic stroke.

OBJECTIVE: Deep venous thromboembolism (DVT) is an important health issue in the hospitalized geriatric population that leads to increased length of stay, morbidity, and mortality. Patients with hemorrhagic strokes are usually not placed on prophylactic therapy because of the risk of hemorrhagic extension of the stroke. The purpose of this study was to evaluate the prevalence of DVTs in hospitalized patients with hemorrhagic vs. thromboembolic strokes. DESIGN: Retrospective chart review of data obtained from the Maryland Health Services Cost Review Commission data base for 1999 to determine the prevalence of DVTs in both hemorrhagic and thromboembolic stroke patients hospitalized acutely. Multiple logistic regression was performed to evaluate possible risk factors. RESULTS: There were 1926 patients hospitalized with a primary diagnosis of hemorrhagic stroke and 15599 with thromboembolic stroke. Women in general had more strokes than men did. Older patients were more likely to have strokes as evidenced by the mean ages of 66 and 71 yr for hemorrhagic and thromboembolic strokes, respectively. A total of 37 patients (1.9%) with hemorrhagic strokes had DVTs, whereas 74 patients (0.5%) with thromboembolic strokes had DVTs. Hemorrhagic stroke was an independent risk factor for DVT (odds ratio, 2.60; 95% confidence interval, 1.49-4.55; P = 0.0008). CONCLUSIONS: DVT prevalence and risk was higher among patients with hemorrhagic strokes in comparison with patients with thromboembolic strokes.

Why do older adults decide they are having difficulty with a task?

OBJECTIVE: Previous studies have identified risk factors for decline in physical function, but they have not examined specific reasons older adults report difficulty with mobility tasks. DESIGN: Community-dwelling people ( n = 160) aged 59 yr and older in an observational cohort study were questioned to determine the most common cited reasons for self-reported difficulty in task performance. RESULTS: Mobility tasks were most often reported to be difficult (66%). The reasons cited for difficulty in low exercise tolerance tasks were task modification by method (33%) and rate (33%). For high exercise tolerance tasks, reasons cited included having to modify the rate of performing the task (20%) or the method (13%). Among those who reported difficulty with low exercise tolerance mobility tasks, >80% reported modification (odds ratio, 46.4 [95% confidence limits: 9.75, 220.51]) and 32% also report frequency change (odds ratio, 5.9 [95% confidence limits: 2.72, 12.85]) as the reason for perceiving difficulty. For those who reported difficulty performing high exercise tolerance-demanding tasks, >90% reported modification (odds ratio, 5.5 [95% confidence limits: 2.05, 14.88]) and 61% also report frequency changes (odds ratio, 3.9 [95% confidence limits: 1.93, 8.04]). CONCLUSION: The findings suggest that people are able to cite specific reasons for difficulty with mobility task performance, most commonly related to task modification.

Rehabilitation treatment options for a patient with paraneoplastic cerebellar degeneration.

Paraneoplastic cerebellar degeneration is a neurologic syndrome associated with carcinoma. Medical management is limited to treatment of the underlying malignancy with excision, plasmapharesis, immunosuppression, or chemotherapy. We report on the case of a woman with paraneoplastic cerebellar degeneration who showed improvements in functional mobility after 3 wk of comprehensive inpatient rehabilitation. This case demonstrates the functional improvements of one patient with paraneoplastic cerebellar degeneration after intensive rehabilitation and describes the specific treatment interventions utilized.