Geriatric rehabilitation of stroke patients in nursing homes: a study protocol

Background: Geriatric patients are typically un derrep resen ted in studies on th e functional o u tc o m e of rehabili tation after stroke. Moreover, m os t geriatric stroke patients d o probably no t participate in intensive rehabili tation program s as offered by rehabili tation centers. As a result, very few studies have described the successfulness of geriatric stroke rehabili tation in nursing h o m e patients , a l though it appears th a t the majority of th ese patients are being d ischarged back to th e com m unity , rather than being transferred to residential care. Nevertheless, factors associated with th e successfulness of stroke rehabili tation in nursing h o m e s or skilled nursing facilities are largely unknow n. The primary goal of this study is, therefore, to assess th e factors th a t uniquely contr ibu te to th e successfulness of rehabilitation in geriatric stroke patients th a t u n d e rg o rehabili tation in nursing hom es. A secondary goal is to investigate w h e th e r these factors are similar to tho se associated with th e o u tco m e of stroke rehabili tation in th e literature. Methods/Design: This s tudy is part of th e Geriatric Rehabilitation in AMPutation and Stroke (GRAMPS) study in the Netherlands. It is a longitudinal, observational, m ulticenter s tudy in 15 nursing h o m e s in th e Southern part of the Netherlands th a t aims to include at least 200 patients . All participating nursing h o m e s are selected based on th e existence of a specialized rehabili tation unit and th e provision of ded ica ted multidisciplinary care. Patient characteristics, disease characteristics, functional status, cognition, behavior, and caregiver information, are collected within tw o w eeks after admission to th e nursing hom e. The first follow-up is at discharge from th e nursing h o m e or o n e year after inclusion, and focuses on functional status and behavior. Successful rehabilitation is defined as discharge from th e nursing h o m e to an in d e p e n d e n t living situation within o n e year after admission. The second follow-up is th ree m o n th s after discharge in patients w h o rehabili tated successfully, and assesses functional status, behavior, and quality o f life. All ins trum ents used in this s tudy have show n to be valid and reliable in rehabilitation research or are r e c o m m e n d e d by th e Netherlands Heart Foundation guidelines for stroke rehabilitation. Data will be analyzed using SPSS 16.0. Besides descriptive analyses, bo th univariate and multivariate analyses will be perform ed with th e purpose o f identifying associated factors as well as their un ique contribution to d e te rm in ­ ing successful rehabilitation. Discussion: This study will provide m ore information a b o u t geriatric stroke rehabili tation in Dutch nursing homes. To our know ledge, this is th e first large s tudy th a t focuses on th e de te rm in an ts of success of geriatric stroke rehabili tation in nursing h o m e patients . * Correspondence: [email protected] departm ent of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University NijmegenMedical Centre, Geert Grooteplein 21 Nijmegen 6525 EZ, the Netherlands O © 2010 Eijk et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Bio Med Central Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Spruit-van Eijk et al. BM C Geriatrics 2010, 10:15 http://www.biomedcentral.com/1471-2318/10/15 Page 2 o f 7 Background According to the W orld Health Organization, 15 million people worldwide suffered a stroke in 2004 [1]. It has been reported th a t the m ean stroke incidence rate in W estern countries is 94 per 100.000 person years [2]. Although men are more often affected than women due to a younger age of onset, th is gender difference becom es sm aller w ith increasing age [3]. Stroke inci­ dence typically increases with age and, due to the ageing of the population, stroke incidence rates are expected to rise. High age and low level of physical endurance, due to significant comorbidity, are characteristic of the geria­ tric stroke population . A lthough rehab ilita tion after stroke is an im portan t activity in m any rehabilitation centers worldwide, m ost geriatric stroke patien ts are probably not admitted to these centers and, thus, do not partic ip a te in in tensive reh ab ilita tio n program s [4 ]. T hese patien ts may be referred to nursing hom es or skilled nursing facilities (SNF) th a t provide adapted rehabilitation programs combined with residential care, whereas others may not receive any formal type of m ul­ tidisciplinary rehabilitation at all. As a result, geriatric stroke patients are greatly underrepresented in outcome studies and factors associated with the successfulness of their rehabilitation are largely unknown. Few studies have dealt with the influence of comorbid­ ity and age on the outcome of stroke rehabilitation. Atalay and T u rh an [5] found th a t elderly stroke patien ts (older than 65 years of age) were less likely to be success­ fully rehabilitated despite sim ilar Functional Indepen­ dence M easure (FIM) scores on admission, compared to patients younger than 65 years. Yet, comorbidity and age were not associated with prolonged length of stay in the rehabilitation center. In the same vein, Fischer et al. [6] found that comorbidity and age did not uniquely contri­ bute to predicting length of hospital stay. O n the other hand, there is evidence th a t com orbidity and age are im portan t factors in determ ining functional outcom e after stroke [7]. Several additional studies have em pha­ sized the importance of age for functional outcome after stroke, but estim ates of the true im pact of age seem to vary greatly. W hereas some studies reported a relatively small influence of age [8,9], other studies found that very old age, defined as 85 years and older, was a consistently strong predictor of poor outcome [10 ]. Interestingly, Teasell et al. [4] have reported that reha­ bilitation in 'lower band' patients recovering from severe stroke, who were considered inappropriate for conven­ tional inpatien t rehabilita tion program s, may still be quite successful in term s of gain in independency of self-care and am bulation . H owever, a lthough the patients were on average 72 years of age, this study did not specifically focus on geriatric rehabilitation and did n o t exam ine the influence of com orbidity or age on reh ab ilita tio n ou tcom e. Several o th e r s tu d ies have shown that a substantial num ber of stroke patients that receive rehabilitation in SNFs or nursing hom es can be successfully discharged to the com m unity [11-13]. The probability of discharge greatly depends on individual rehabilitation potential, which is related to stroke sever­ ity and physical capacities. B esides, it appears th a t admission to SNFs increases the likelihood of successful rehabilitation in term s of discharge to the com m unity [1 1 ,12 ]. In general, many studies have investigated the clinical, biological and demographic factors associated with the outcom e after stroke [4-10,14-25]. A large num ber of such factors has been associated with the outcome after stroke rehab ilita tion (table 1 ) , bu t probably m any of these factors are interrelated. This im plicates tha t the unique contribution of these factors to stroke outcome, corrected for association with other factors, still has to be determined in order to be of value for clinical predic­ tion in daily practice. In short, initial disability and age seem to be the m ost promising predictors of long-term activities of daily living (ADL) and discharge destination after rehabilitation. A gainst th is background , the p rim ary goal of th is study is to assess the factors that uniquely contribute to the successfulness of rehabilitation in geriatric stroke patients that undergo rehabilitation in nursing homes. Table 1 Factors associated with stroke outcome disability and discharge destination in the literature Outcome Factors associated with outcome ADL scores FIM Initial FIM, age [8,9] BI Initial BI [14] Initial NIHSS, age, premorbid disability, DM, infarct vo lum e [15] Trunk Impairment Scale, static sitting balance [16] Discharge destination Age, incontinence [18] initial FIM, age [17] prem orbid socia lsupport, FIM bowel, age, C M S A leg, type of premorbid accom m odation [19] initial M M SE, prem orbid living with relatives [8] discharge BI, LOS, age [20] Initial FIM, age, male gender [4 ] sw allow ing disorder [21] FIM functional independence measure, BI barthel index, N IHSS national institute o f health stroke scale, D M diabetes mellitus, C M S A Chedoke-M cM aster stroke assessment, LO S length o f stay Spruit-van Eijk et al. BM C Geriatrics 2010, 10:15 http://www.biomedcentral.com/1471-2318/10/15 Page 3 o f 7 Functional outcome is primarily assessed by discharge to an independent living situation and, secondarily, by var­ ious functional scales. A secondary goal is to investigate w hether the factors tha t are uniquely associated w ith successfulness of rehabilitation in this geriatric popula­ tion are similar to those associated with the outcome of stroke rehabilitation in the literature. To this end, we have set up a m ulticenter study in 15 nursing homes in the Southern part of the Netherlands. All participating nursing homes are selected based on the existence of a specialized stroke rehabilitation unit and the provision of dedicated multidisciplinary care. To our knowledge, this is the first study that focuses on the determ inants of success of geriatric rehabilitation in nursing hom e patients. Methods/Design Study design This prospective study is part of the Nijmegen Geriatric Rehabilitation in A M Putation and Stroke (GRAMPS) study and comprises three measurements. Baseline data (T0) are collected within two weeks after admission to the nursing home. Patients and disease characteristics, functional sta tus, cognition , behavior and caregiver inform ation are registered (table 2). The first follow-up (T1) is at discharge from the nursing home, and focuses on functional status and behavior. Successful rehabilita­ tion is defined as discharge from the nursing hom e to an independent living situation w ithin one year after adm ission. The second follow -up (T2) is at th ree m onths after discharge in patien ts who rehabilitated successfully and focuses on functional status, behavior and quality of life. Data collection has started in January 2008, and will end in July 20 10 . Patients All patients who are consecutively adm itted to one of the specialized rehabilitation wards of the 15 participat­ ing nursing hom es are eligible to partic ipa te in this study. No other inclusion criteria were applied. Inability to give inform ed consent is an exclusion criterion. All participating nursing homes collaborate in the Nijmegen University Nursing Home Network of the Radboud Uni­ versity N ijm egen M edical C en ter. A fter adm ission patients are provided w ith oral inform ation from the treating physician or nurse. In addition, all patients and their caregivers receive w ritten inform ation about the study. The patients indicate themselves whether they are interested to participate. The attending physician judges the legal capacity of h is /h e r pa tien ts. In the case of doubts he/she consults the caregivers. In addition, the GRAMPS website http://www.gramps.nl provides extra information for interested patients and their caregivers. Table 2 Research instruments