Rehabilitation of Older Chinese Patients With Different Cognitive Functions: How Do They Differ in Outcome?

Article Outline

• Abstract
• Methods
  • Setting
  • Participants
  • Intervention
  • Design
  • Independent Variables
  • Dependent Variables
  • Statistical Analyses
    • Efficacy
    • Relative efficacy and efficiency
  • Stratification of C-MMSE Groups
  • Univariate Analysis
  • Multivariate Analysis
• Results
  • The Correlation Between Cognitive Status and Different Outcomes
  • Functional and Motor Outcomes in the 3 Cognitive Groups
  • Independent Predictors
• Discussion
  • Study Limitations
• Conclusions
• References
• Copyright

Abstract 

Luk JK, Chiu PK, Chu LW. Rehabilitation of older Chinese patients with different cognitive functions: how do they differ in outcome?

Objective

To examine the effect of cognition on functional and motor gain in older Chinese patients undergoing geriatric inpatient rehabilitation.

Design

A retrospective cohort study.

Setting

Geriatric rehabilitation units of 2 convalescence hospitals in Hong Kong.

Participants

Older Chinese patients (N=778).

Interventions

Comprehensive geriatric assessment and inpatient rehabilitation by a multidisciplinary team.

Main Outcome Measures

Cognitive status was assessed with the Cantonese version of the Mini-Mental State Examination (C-MMSE). We measured the absolute functional gain and motor gain by using the Barthel Index and Elderly Mobility Scale (EMS) and expressed it as Barthel Index efficacy and EMS efficacy. Relative efficacy was assessed by the Montebello Rehabilitation Factor Score (MRFS). Relative efficiency was deduced by relative efficacy divided by the hospital length of stay (LOS).

Results

There were significant differences in the total Barthel Index and EMS on admission and at discharge, with lower discharge scores in low C-MMSE groups. The change of Barthel Index (Barthel Index efficacy) and EMS (EMS efficacy) during rehabilitation did not differ among different C-MMSE groups. Significant differences were observed in Barthel Index MRFS efficacy and efficiency as well as EMS MRFS efficacy and efficiency in different cognitive groups; those with better cognitive function had better results. Multivariate analysis showed that LOS (odds ratio [OR]=1.02, P=.002) and diagnosis of musculoskeletal problems (OR=2.24, P=.007) were positive predictors for a Barthel Index MRFS efficacy of .25 or higher. C-MMSE was not an independent predictor for a Barthel Index MRFS efficacy of .25 or higher. LOS (OR=1.02, P=.003), admission C-MMSE (OR=1.04, P=.001), body mass index (OR=1.05, P=.006), and diagnosis of musculoskeletal disorders (OR=1.75, P=.04) were significant positive predictors for an EMS MRFS efficacy of .25 or higher, whereas urinary incontinence was a negative predictor for EMS MRFS efficacy (OR=0.69, P=.04).

Conclusions

There was a strong association between admission cognition and relative change in functional and motor efficacy and efficiency. Cognitive function was not associated with absolute functional and motor gain. Cognitive function was an independent predictor for satisfactory mobility outcome but not for functional outcome. Older patients with impaired cognitive function could still benefit from rehabilitation.

Key Words: Elderly, Outcome assessment (health care), Rehabilitation

List of Abbreviations: ANOVA, analysis of variance, BMI, body mass index, CI, confidence interval, C-MMSE, Cantonese version of the Mini-Mental State Examination, EMS, Elderly Mobility Scale, LOS, length of stay, MRFS, Montebello Rehabilitation Factor Score, OR, odds ratio

THERE ARE 6.5 MILLION PEOPLE living in Hong Kong, and its population is aging fast.¹ Older patients account for nearly one half of the patients admitted to the general medical ward.² Older patients tend to have multiple organic, psychologic, cognitive, and social problems.³, ⁴, ⁵ Hence, the use of a holistic approach and multidisciplinary geriatric assessment are necessary to manage complex older patients.⁶, ⁷ In addition, functional decline is common among older patients during or even before hospitalization despite treatment of acute illnesses.⁸, ⁹

The effect of cognition on rehabilitation success has led to many debates and controversies. Older patients may be required to learn skills in exercise and in remembering instructions; impaired memory could affect the success of rehabilitation.¹⁰ Therefore, cognitive impairment has been regarded as an obstacle and a negative factor for rehabilitation success. To date, many studies,¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶ mostly in stroke and femoral fracture patients, have reported that patients who are cognitively impaired have poorer rehabilitation outcomes. Cognitive status also relates to the ability to return to independent living in the community after rehabilitation.¹⁷ Some studies¹⁸, ¹⁹, ²⁰, ²¹, ²² have shown that cognitive impairment does not affect rehabilitation success of older stroke patients. They too can have similar absolute functional gain with re-entry into a community setting. Recently, specific studies²³, ²⁴, ²⁵ in hip fractures and stroke rehabilitation in older patients have shown that although absolute functional gain is not associated with admission cognitive function, cognitive impairment negatively affects the relative rehabilitation outcomes, a measurement taken into consideration of the patient's potential for change and LOS in the hospital.

During the literature review, we could not find any large-scale study in Chinese specifically targeted at this issue. The factors influencing rehabilitation outcomes in whites might not be applicable to the Chinese because of different disease patterns, concepts of rehabilitation, social support systems, and cultural beliefs.²⁶, ²⁷ Because many Asian countries, such as China, are facing an increase in their older population, there is also a need to examine the association between cognition and rehabilitation in a nonwhite population.²⁸

The objective of the present study was to examine the effect of cognition on gain in functional and motor performance. Both absolute and relative gains in the rehabilitation outcomes were analyzed. In addition, we looked at the independent predictors for satisfactory functional and motor outcomes of these patients.

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Methods 

Setting 

The study was performed at the Acute Geriatrics Unit of Grantham Hospital and the geriatrics unit of Tung Wah Hospital, Hong Kong Special Administrative Region, China. There are 38 and 12 geriatric beds in these 2 units, respectively.

Participants 

We recruited older patients (age ≥65y) admitted between May 2004 and August 2006. Patients with acute illnesses are admitted to the University Medical Unit, Queen Mary Hospital, for management first. After stabilization, they are transferred to either of the above 2 geriatric units for rehabilitation. Both units also accept elderly patients directly admitted from the emergency department and nursing homes.

Intervention 

Both units consist of a multidisciplinary team led by a geriatrics specialist. Comprehensive geriatric assessment is performed on all newly admitted patients. After assessment, an individualized care plan is formulated and all patients routinely receive daily physiotherapy and occupational therapy unless they are considered to be unsuitable. If needed, dieticians, speech therapists, and medical social workers are referred for assessment and treatment. Patient progress is discussed in a weekly multidisciplinary case conference where the progress and rehabilitation goals are reviewed. Patients are discharged from the hospital if the multidisciplinary team agrees the patient's progress has reached a plateau and the patient is safe to go home. If community rehabilitation is considered necessary, we refer patients to Geriatric Day Hospital for further training after discharged from the hospital.

Design 

This was a retrospective cohort study, and the study protocol was approved by the local institutional review board. We established a comprehensive database for all elderly patients in May 2004 to capture both independent and dependent variables.

Independent Variables 

Collected data included demography, LOS in the hospital, occurrence of pressure ulcers and urinary incontinence, number of diagnoses, and chief diagnoses leading to admission. Body mass index was measured by the nurses. A C-MMSE was performed by the occupational therapists within 48 hours of admission. C-MMSE is a Cantonese translation of the original MMSE. A local study showed that when using Diagnostic and Statistical Manual of Mental Disorder—Third Edition—Revised criteria for diagnosis of dementia, a cutoff score of 19/20 yielded a high sensitivity rate of 97.5% and specificity of 97.3%.²⁹ If patients were unable to perform C-MMSE because of various reasons such as an impaired conscious state, medical instability, inability to respond to questions, severe deafness, dysphasia, language barrier, or refused cooperation, they were recorded as failed, a C-MMSE score was not given, and they were excluded from the final analysis.

Dependent Variables 

Our physiotherapists and occupational therapists measured the EMS (maximum score, 20) and Barthel Index (maximum score, 100) in each patient, respectively.³⁰, ³¹ For patients who did not complete the rehabilitation program because of death or transfer to other hospitals, their last Barthel Index or EMS was used. We also analyzed the efficacy, relative efficacy, and efficiency in this study to judge rehabilitation outcome.

Statistical Analyses 

Barthel Index efficacy (discharge Barthel Index – admission Barthel Index) and EMS efficacy (discharge EMS – admission EMS) were the net change of these 2 scores on discharge as compared with the admission.

We used the MRFS to calculate the relative efficacy of the Barthel Index and EMS.²³, ²⁴, ²⁵, ³², ³³ MRFS is a method of assessing the relative efficacy in relation to the patient's potential for improvement. It helps to reduce the ceiling effects of validated scores and has been used in previous studies with FIM and Barthel Index scores.²³, ²⁴, ²⁵, ³⁴ The MRFS efficacy and efficiency scores will range from 0 to 1. In this study, the Barthel Index MRFS efficacy was (discharge Barthel Index – admission Barthel Index) ÷ (maximum possible Barthel Index – admission Barthel Index).

The EMS MRFS efficacy was (discharge EMS – admission EMS) ÷ (maximum possible EMS – admission EMS).

The Barthel Index MRFS and EMS MRFS efficiency are their respective MRFS efficacy scores divided by LOS.

Stratification of C-MMSE Groups 

We stratified the patients according to their C-MMSE scores into 3 groups: less than 10, 10 to 19, and 20 or higher. The cutoff point at 20 or higher was chosen because the usual cutoff point for C-MMSE defining impaired cognitive function was less than 20. This was based on the original local validation study showing that a cutoff score of 19/20 yielded a high sensitivity and specificity.²⁹ Demographic and clinical characteristics of the patients were examined in these 3 stratified age groups. In addition, we analyzed the Barthel Index and EMS on admission and discharge as well as the absolute and relative change of these scores across the 3 C-MMSE groups.

Univariate Analysis 

SPSS^a was used in statistical analysis. Continuous variables were expressed as mean ± SD. We used the paired t test to compare the change of continuous variables within group. Chi-square tests and Fisher exact tests were used to compare categoric variables. Simple correlation was performed with the Pearson correlation test. We used the 1-way ANOVA to compare continuous variables among 3 different age groups. Bonferroni adjustment was used for multiple comparisons. Statistical significance was inferred by a 2-tailed P value of .05 or less.

Multivariate Analysis 

A satisfactory functional gain was defined as a Barthel Index MRFS efficacy and EMS MRFS efficacy of .25 or higher. We used the cutoff point of .25 because it represented 25% or more of each patient's possible potential for improvement in the Barthel Index and EMS. Multivariate analysis was performed by using stepwise logistic regression to delineate the independent predictive factors for a satisfactory functional gain after rehabilitation. Variables that had a significant association with satisfactory functional gain to a value of P less than .10 on univariate analyses were entered into the final multivariate analysis. ORs and 95% CIs were used to estimate the association between the independent factors of satisfactory functional gain. Statistical significance was inferred by a 2-tailed P value of .05 or less.

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Results 

Elderly patients (N=1077) were admitted to the acute geriatrics unit of Grantham Hospital and the geriatrics unit of Tung Wah Hospital between May 2004 and August 2006. Seventy-six cases had incomplete data entry and were not included in the review. In the remaining 1001 cases, 223 (22.3%) were excluded from the study because of failure to perform C-MMSE within 48 hours of admission. Seven hundred seventy-eight (77.8%) patients were finally included in this study. There were 334 (42.9%) men and 444 (57.1%) women. Their mean age was 81.5±0.25 years (range, 58–102y). Sixty-one (7.8%) patients did not complete the rehabilitation, and the last Barthel Index or EMS was used for data entry. Table 1 shows the demographic and clinical characteristics of the patients on admission.

Table 1. Demographic and Clinical Characteristics of the Patients

Characteristics	All Patients (N=778)	C-MMSE Score <10 (n=146)	C-MMSE Score 10–19 (n=378)	C-MMSE Score ≥20 (n=254)	P†
Male	334(42.9)	46(31.5)	145(38.4)	143(58.4)	<.001⁎
Age(y)	81.5±0.25	84.4±0.58	82.2±0.36	78.6±0.4	<.001⁎
Single/divorced/widow	438(65.3)	96(65.8)	219(57.9)	123(48.4)	.002⁎
Live at home	582(74.8)	85(58.2)	272(72.0)	225(88.6)	<.001⁎
Illiterate	458(58.9)	110(75.3)	249(65.9)	99(39.0)	<.001⁎
Smoker/ex-smoker	218(28.0)	32(21.9)	95(25.0)	91(35.8)	.003⁎
Drinker/ex-drinker	116(14.9)	20(13.7)	41(10.8)	55(21.7)	.001⁎
LOS	20.7±0.5	23.1±1.24	21.8±0.8	17.7±0.76	<.001⁎
No. of diagnoses	4.81±0.06	4.8±0.14	4.9±0.08	4.67±0.1	.247
BMI	21.9±0.16	20.65±0.3	21.87±0.22	22.7±0.29	<.001⁎
Urinary incontinence	327(42.0)	110(75.3)	172(45.5)	45(17.7)	<.001⁎
Pressure ulcers	60(7.7)	27(18.5)	25(6.6)	8(3.1)	<.001⁎
Chief problems on admission
Chest infection	78(10.0)	16(10.9)	44(11.6)	18(7.1)	.16
Falls	123(15.8)	15(10.3)	65(17.2)	43(16.9)	.12
Stroke	93(11.9)	17(11.6)	47(12.4)	29(11.4)	.92
Infection other than chest	62(7.97)	19(13.0)	29(7.67)	14(5.5)	.027⁎
Heart failure	48(6.16)	12(8.2)	23(6.1)	13(5.1)	.46
Musculoskeletal diseases	61(7.84)	9(6.2)	24(6.3)	28(11.0)	.07
Dementia	50(6.42)	23(15.8)	22(5.8)	5(2.0)	<.001⁎
Gastrointestinal diseases	44(5.65)	7(4.8)	24(6.3)	13(5.0)	.70
Diabetes mellitus	49(6.29)	5(3.4)	25(6.6)	19(7.5)	.26
COPD/asthma	27(3.47)	2(1.36)	11(2.9)	14(5.5)	.07
Cardiovascular diseases other than heart failure	32(4.1)	5(3.4)	10(2.6)	17(6.7)	.04⁎
Parkinsonism	24(3.1)	3(2.0)	8(2.1)	13(5.1)	.074
Malignancy	6(0.8)	1(0.7)	3(0.8)	2(0.8)	.99
Endocrine diseases other than diabetes mellitus	11(1.4)	0(0.0)	5(1.3)	6(2.4)	.15
Dermatologic diseases	5(0.6)	0(0.0)	4(1.1)	1(0.4)	.33
Renal diseases	18(2.3)	2(1.36)	11(2.9)	5(2.0)	.52

NOTE. Values are frequency (%) or mean ± SD.

Abbreviation: COPD, chronic obstructive pulmonary disease.

The Correlation Between Cognitive Status and Different Outcomes 

Table 2 summarizes the results of the Pearson correlations. A significant positive correlation was observed between admission C-MMSE discharge and total Barthel Index scores and EMS (both P<.001). No significant correlation was found between admission C-MMSE scores and Barthel Index efficacy (P=.48) as well as EMS efficacy (P=.39). However, the Barthel Index MRFS efficacy and efficiency, as well as EMS MRFS efficacy and efficiency, had significant correlations with admission C-MMSE (P=.001, P<.001, respectively).

Table 2. Correlation Between C-MMSE and Different Outcome Measures

Functional and Motor Outcomes in the 3 Cognitive Groups 

Table 3 shows the total Barthel Index and EMS on admission and at discharge as well as the change during rehabilitation. Among patients of different C-MMSE groups, there were significant differences in the total Barthel Index and EMS on admission and at discharge, with lower discharge scores in low C-MMSE groups (P<.001). The difference in the change of the Barthel Index (Barthel Index efficacy) and EMS (EMS efficacy) during rehabilitation by 1-way ANOVA test was not significant among the 3 C-MMSE groups (Barthel Index efficacy, P=.30; EMS efficacy, P=.59). However, significant differences were observed in Barthel Index MRFS efficacy (P=.001), Barthel Index MRFS efficiency (P<.001), EMS MRFS efficacy (P<.001), and EMS MRFS efficiency (P=.001) in the 3 cognitive function groups, with the groups with better cognitive function having better results.

Table 3. Total Barthel Index and EMS Scores on Admission and at Discharge as Well as the Change of Barthel Index and EMS Scores During Rehabilitation in Different C-MMSE Groups

NOTE. Values are mean ± SD.

Independent Predictors 

One hundred fifty-three (19.7%) patients achieved a Barthel Index MRFS efficacy of .25 or higher, whereas 225 (28.9%) reached an EMS MRFS efficacy of .25 or higher. Multivariate analysis of variables associated with a satisfactory Barthel Index outcome (Barthel Index MRFS efficacy ≥.25) after rehabilitation included significant variables obtained from univariate analysis including hospital LOS, age, education, diagnosis of heart failure, infection other than pneumonia, and musculoskeletal problems (included osteoarthritis, gouty arthritis, low back pain secondary to degenerative causes). The LOS (OR=1.02; 95% CI, 1.01–1.03; P=.002) and diagnosis of musculoskeletal problems (OR=2.24; 95% CI, 1.25–4.00; P=.007) were both positive independent predictors for a satisfactory Barthel Index MRFS outcome (table 4). The significant variables after univariate analysis for satisfactory EMS outcome (EMS MRFS efficacy, ≥.25) were age, LOS, accommodation, admission C-MMSE, BMI, pressure ulcer, urinary incontinence, and diagnosis of musculoskeletal disorders. Multivariate analysis showed that LOS (OR=1.02; 95% CI, 1.00–1.03; P=.003), admission C-MMSE (OR=1.04; 95% CI, 1.02–1.07; P=.001), BMI (OR=1.05; 95% CI, 1.01–1.09; P=.006), and diagnosis of musculoskeletal disorder (OR=1.75; 95% CI, 1.01–3.00; P=.04) were significant positive independent predictors for EMS MRFS efficacy greater than or equal to .25, whereas urinary incontinence on admission was a significant negative predictor (OR=.69; 95% CI, .48–.98; P=.04) (see table 4).

Tables 4. Results of the Multivariate Analysis

Abbreviation: NA, not applicable.

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Discussion 

This study is one of the few studies involving the evaluation of a heterogeneous group of medical geriatric patients. It delineated the relationship between cognitive status and geriatric rehabilitation clearly. There was no difference in Barthel Index and EMS efficacy across the 3 C-MMSE groups. There was also no correlation between admission C-MMSE and Barthel Index and EMS efficacy. This seemed to suggest that admission cognitive function was not associated with rehabilitation success in older patients. Our finding was similar to previous reports performed by using absolute gain as outcome measures.¹⁵, ²², ²³, ³⁵, ³⁶ However, it has been argued that absolute change of scores could lead to misinterpretation because of ceiling effects, and relative changes should be examined.²³, ²⁴, ²⁵ MRFS is a commonly used method to look at relative gain, and it was used to deduce the relative Barthel Index and EMS efficacy and efficiency here.³², ³³ In contrast to absolute gain, there was a significant difference in Barthel Index and EMS MRFS efficacy and efficiency across the 3 cognitive groups.

Our study further examined the predictors of Barthel Index and EMS MRFS efficacy. A Barthel Index and EMS MRFS efficacy of .25 or higher was defined as a satisfactory outcome. The average Barthel Index MRFS efficacy in this study was .12, whereas that of EMS was .21. Hence, a score of .25 or higher was already higher than average in our patients, and those who could achieve this were hence regarded as satisfactory in outcome here. Both LOS and musculoskeletal disorder were significant predictors for EMS and Barthel Index MRFS efficacy of .25 or higher. It suggested that enough time should be provided to older patients for rehabilitation. Musculoskeletal disorders included conditions such as gouty arthritis, osteoarthritis, and low back pain. Patients with these conditions could have marked improvement in function and mobility after treatment, and this served to explain why musculoskeletal disorders were positive predictors for satisfactory outcomes. C-MMSE was an important predictor for EMS efficacy of .25 or higher but not for Barthel Index efficacy of .25 or higher. One possible explanation was that the patients might need to learn some skills in exercise to improve mobility, and those with better cognitive function would benefit more in motor training.¹⁰ Incontinence and BMI were also predictors for motor outcome. Patients having urinary incontinence and low BMI were probably those who were frail and hence performed poorly in motor rehabilitation.

This study is one of the few studies involving medical geriatric inpatients with multiple outcome measures. The patients were enrolled from 2 different hospitals to achieve a better mixture of subjects. To our knowledge, it is the first study involving a large number of elderly Chinese patients. We believe this information is important for geriatricians and rehabilitation specialists looking after Chinese patients. Some previous studies²², ²³ evaluated the rehabilitation outcomes of older patients by comparing 2 patient groups, namely, cognitively intact and cognitively impaired groups.²², ²³ In this study, the patients were segregated into 3 C-MMSE groups representing 3 different patient cohorts, and the subjects were well represented in each C-MMSE group with 18.7% of patients in the C-MMSE less than 10 group and 32.6% in the C-MMSE 20 or higher group. We had not established any selection criteria for patients transferring to the geriatric wards. This minimized the bias in this study due to nonrandomization and the inclusion of preselected cases only.

Study Limitations 

There are certain limitations in our study. One important question is whether the results are generalizable. This study looks at Hong Kong residents who are predominantly Chinese, and the finding may not be applicable to other cultures. Being a retrospective study, data accuracy is reliant on the quality of documentation in the case notes and the entry into the computer database. Nevertheless, we believe that the large sample size in this study can to a certain extent minimize this potential flaw. Two hundred twenty-three of 1001 cases were excluded from this study because they failed in the C-MMSE assessment in the first 48 hours. We did not investigate the reasons behind each case who failed C-MMSE assessment. We would like to emphasize that failure to perform C-MMSE should not be equivalent to poor rehabilitation potential. Some cases failed simply because of severe deafness, expressive dysphasia, or language barriers. They could still participate in rehabilitation if the therapist knew how to make use of nonverbal instructions. Some patients might fail the C-MMSE assessment because of medical instability in the first 2 days. They could still benefit from rehabilitation after their acute medical problems were resolved. We only measured the functional and motor outcomes during inpatient treatment here. Further study is needed to examine the effect of cognitive status in maintaining the functional and motor gain after discharge from the hospital.

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Conclusions 

There was a strong association between admission cognition and relative change in functional and motor efficacy and efficiency. However, cognitive function was not associated with absolute functional and motor gain, suggesting that patients with impaired cognitive function could still benefit from rehabilitation. Cognitive function was an independent predictor for satisfactory motor outcome but not for functional outcome. This study supports the provision of rehabilitation services to older patients of different cognitive function.

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