An inpatient rehabilitation model of care targeting patients with cognitive impairment

Abstract

BackgroundThe course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium, referred to as cognitive impairment (CI), which limits access to in-patient rehabilitation. In response to this concern, members of our team developed and piloted an in-patient rehabilitation model of care (Patient-Centred Rehabilitation Model; PCRM) targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for community dwelling individuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation.Methods/DesignA non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care. All community dwelling (private home or retirement home) patients following a hip fracture are eligible to participate. Recruitment of both cohorts is taking place at two facilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort. We are also recruiting 70 health care providers (HCPs), who are being trained to implement the PCRM-CI, and their unit managers. Patient data are collected at baseline, discharge, and 6 months post-discharge from an inpatient rehabilitation program. Evaluations include mobility, physical function, and living arrangement. Additional outcome variables are being collected from medical records and from the patients via their proxies. Data on the prevalence and severity of dementia and delirium are being collected. Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation. Data collection began in 2009 and is expected to be completed in 2012. The control cohort of 70 patients has been recruited, and 45 patients have been accrued to the intervention group to date.DiscussionEvaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures.Trial registrationThe study is registered at http://clinicaltrials.gov, Identifier NCT01566136.

Rehabilitation Interventions for Older Individuals With Cognitive Impairment Post-Hip Fracture: A Systematic Review

“…Of the seven relevant studies, two were randomized controlled trials 13,14 , one was a single group pre- and post-test 15 , one was a descriptive comparison between those with and without cognitive impairment 16 , one was a case controlled matched trial 17 , one was a nonequivalent groups trial 18,19 , and one was a case report 20 . As described in Table 3, the interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals.…”

“…Three of the studies tested a team based approach to rehabilitation to augment what would otherwise be referred to as routine rehabilitation and therapy 14,17,18 . In the study by Huusko 14 , individuals were either sent to a specialized rehabilitation facility or usual care and rehabilitation.…”

“…Early admission to rehabilitation was encouraged; individualized assessments related to evaluating and optimizing remaining abilities; assessments for dementia, delirium and depression; development of individual centered goals; individualized timing of treatment and location; and staff education on how to manage the behavioral symptoms associated with dementia was provided. Building on this work, the subsequent intervention developed and tested by McGilton in a controlled trial 18,19 was referred to as the Individual-Centered Rehabilitation Model including individuals with cognitive impairment (PCRM-CI). This was essentially the same approach as the ACTED and included five main components: routine rehabilitation services (daily one hour sessions of physical and occupational therapy five days a week); dementia management as needed, delirium prevention; education and support for the staff providing care to those with cognitive impairment; and education of the caregivers.…”

“…Specifically, McGilton et al 16,18,19 and Huusko et al 14 included all levels of cognitive status and deliberately compared outcomes between those with and without cognitive impairment using a cut off MMSE score of 23 and below as being indicative of cognitive impairment. Two of the studies included those with cognitive impairment unless the impairment was severe (defined as an MMSE of ≤ 14) 15 or there was severe impairment with no caregiver available 13 .…”

Factors Influencing Outcomes of Older Adults After Undergoing Rehabilitation for Hip Fracture

“…6 The PCRM-CI protocol and results to time of discharge from inpatient rehabilitation have been described in detail. 6,24 Inclusion criteria were aged 65 and older, had undergone surgery for hip fracture, admitted to inpatient rehabilitation directly from an acute care hospital, living in the community in a private home or residential setting (that did not provide 24-hour nursing care) at the time of the hip fracture, English speaking, and had a collateral informant (family member or close friend) who was familiar with the individual's prefracture condition. Individuals with a previous hip fracture, pathological hip fracture, or hip fracture associated with multiple traumas were excluded.…”