Mini-Mental State Examination, cognitive FIM instrument, and the Loewenstein Occupational Therapy Cognitive Assessment: relation to functional outcome of stroke patients

OBJECTIVES: To compare 3 cognitive tests, used on admission, for predicting discharge functional outcome and to assess the efficacy of these tests in predicting functional outcome at discharge in stroke patients undergoing rehabilitation. DESIGN: Cohort study. SETTING: Geriatric rehabilitation department of a tertiary care hospital in Israel. PATIENTS: Sixty-six patients undergoing acute inpatient comprehensive rehabilitation after first clinical stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Cognitive status was assessed with the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), the Mini-Mental State Examination (MMSE), and the cognitive subscale of the FIM instrument. The FIM motor subscale was used to assess functional outcome status. Functional gain was determined by the motor FIM gain (efficacy), and the relative (to potential) functional gain was determined by the Montebello Rehabilitation Factor Score. Efficiency was calculated by efficacy divided by the length of hospital stay. RESULTS: A significant increase in total FIM scores (34.8 points) occurred during rehabilitation mainly because of improvement in motor functioning (31.5 points). Significant improvement in global cognitive status was documented by all 3 tests. Intertest correlation coefficients ranged between.47 and.67. The LOTCA showed somewhat higher correlation coefficients with most of the parameters of functional motor outcomes. Correlation between the MMSE and FIM cognitive subscale and these outcome parameters were nearly identical. CONCLUSION: The LOTCA is slightly better than the MMSE and the FIM cognitive subscale in predicting functional status change after stroke rehabilitation but it is a time-consuming and exhausting instrument to use. The FIM cognitive subscale requires a better overall understanding of the patient's situation at time of administration and therefore is less convenient for the initial assessment. The similar correlation of all 3 tests with functional outcomes and the simplicity of administration of the MMSE suggests its use in the initial assessment of stroke patients.     

Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture?

OBJECTIVES: To determine the effect of cognitive status at admission on functional gain during rehabilitation of elderly hip-fractured patients. DESIGN: Cohort study. SETTING: A hospital geriatric rehabilitation department. PATIENTS: Two hundred twenty-four elderly patients admitted consecutively for rehabilitation after surgery for hip fracture. MEASUREMENTS: Cognitive status was assessed by the Mini-Mental State Examination and the cognitive subscale of the Functional Independence Measure (cognFIM); functional status was assessed by the motor subscale of FIM; absolute functional gain was determined by the motor FIM gain (deltamotFIM); and relative functional gain (based on the potential for improvement) by the Montebello rehabilitation factor score (MRFS). RESULTS: A significant increase in FIM scores (19.7) occurred during rehabilitation, mainly due to motor functioning (19.1). When the relative functional gain (as measured by both motor MRFS efficacy [r = .591] and efficiency [r = .376] was compared with the absolute gain (as measured by deltamotFIM [r = .304]), a stronger association between cognFIM and the relative measures was found. In addition, motor FIM efficacy and efficiency were significantly lower in the cognitively impaired patients (p<.01). A better rehabilitation outcome was seen in patients with higher admission cognitive status, adjusting for the effects of age, sex, length of stay, and type of fracture (odds ratio = 2.2, 95% confidence interval 1.5-3.7). CONCLUSIONS: Impaired cognitive status at admission lowered the rehabilitation outcome of elderly hip fracture patients. Cognitive impairment was strongly and directly associated with functional gain in these patients. Absolute motor gain appeared to be independent of cognitive status, whereas the relative motor gain depended on it. These findings support the implementation of comprehensive rehabilitation for selected cognitively impaired elderly hip fracture patients.     

Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment

PURPOSE: To assess the association between cognitive status and functional gain during a rehabilitation programme for elderly patients with hip fracture. METHOD: Prospective study in a hospital geriatric rehabilitation unit. Sixty-one consecutive patients were studied: 28 with cognitive impairment (age 87.6 +/- 7.2 years, Mini Mental State Examination (MMSE) score 11.25 +/- 5.9), 23 with possible cognitive impairment (age 83.9 +/- 6.8 years, MMSE 22.65 +/- 1.6) and 10 without cognitive impairment (age 77.6 +/- 7.4 years, MMSE 29.5 +/- 0.9). Cognitive status was assessed with the MMSE and admission and discharge functional status with the Functional Independence Measure (FIM). Functional gain was calculated by absolute FIM gain (admission FIM minus discharge FIM), relative (to maximum potential) FIM gain with the Montebello Rehabilitation Factor Score (MRFS) and analysis of covariance of the FIM (ANCOVA). RESULTS: Patients without cognitive impairment had significantly higher admission FIM and discharge FIM. Cognitive status was not significantly associated with absolute functional gain. The adjusted (age, gender, sensory impairment, nutritional status, comorbidity and treatment) MRFS score of cognitively impaired patients was significantly lower (p < 0.03). However, the functional gain related to baseline functional status (ANCOVA) was not significantly different between the groups. CONCLUSIONS: In spite of cognitive impairment, elderly patients with hip fracture can benefit from participation in rehabilitation programmes.     

Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment

Purpose:?To assess the association between cognitive status and functional gain during a rehabilitation programme for elderly patients with hip fracture.

Method:?Prospective study in a hospital geriatric rehabilitation unit. Sixty-one consecutive patients were studied: 28 with cognitive impairment (age 87.6?±?7.2 years, Mini Mental State Examination (MMSE) score 11.25?±?5.9), 23 with possible cognitive impairment (age 83.9?±?6.8 years, MMSE 22.65?±?1.6) and 10 without cognitive impairment (age 77.6?±?7.4 years, MMSE 29.5?±?0.9). Cognitive status was assessed with the MMSE and admission and discharge functional status with the Functional Independence Measure (FIM). Functional gain was calculated by absolute FIM gain (admission FIM minus discharge FIM), relative (to maximum potential) FIM gain with the Montebello Rehabilitation Factor Score (MRFS) and analysis of covariance of the FIM (ANCOVA).

Results:?Patients without cognitive impairment had significantly higher admission FIM and discharge FIM. Cognitive status was not significantly associated with absolute functional gain. The adjusted (age, gender, sensory impairment, nutritional status, comorbidity and treatment) MRFS score of cognitively impaired patients was significantly lower (p?<?0.03). However, the functional gain related to baseline functional status (ANCOVA) was not significantly different between the groups.

Conclusions:?In spite of cognitive impairment, elderly patients with hip fracture can benefit from participation in rehabilitation programmes.     

Functional outcome of ischemic stroke: a comparative study of diabetic and non-diabetic patients

BACKGROUND AND PURPOSE: Diabetes is associated with more ischemic strokes and diabetic patients have up to a three-fold increased risk for suffering a stroke, compared with non-diabetics. The aim of this study is to evaluate whether diabetes mellitus may also affect the functional outcome of patients with acute ischemic stroke, undergoing post-acute care rehabilitation. METHODS: A retrospective charts analysis of consecutive older patients with acute ischemic stroke admitted for rehabilitation at a tertiary hospital with post-acute care geriatric rehabilitation wards. Functional outcome of diabetics and non-diabetics was assessed by the Functional Independence Measurement scale (FIM) at admission and discharge. Data were analysed by t-tests, Pearson correlation, and Chi-square test, as well as by linear regression analysis. RESULTS: A total number of 527 patients were admitted, of whom 39% were diabetics. Compared with non-diabetics, diabetic stroke patients were slightly younger (p = 0.0001) but had similar admission FIM scores. FIM gain parameters (total FIM gain, motor FIM gain, daily total and motor FIM gains) upon discharge were similar in both groups. A linear regression analysis showed that higher MMSE scores (beta = 0.08; p = 0.01) and higher admission total FIM scores (beta = 0.87; p < 0.001) predicted higher total FIM scores upon discharge. Diabetes mellitus was not interrelated, whatsoever, with better total FIM scores upon discharge (beta = -0.03; p = 0.27). CONCLUSIONS: The findings suggest that there is no difference in the functional outcome of diabetic and non-diabetic patients, presenting for rehabilitation after acute ischemic stroke. Diabetes should not be considered as adversely affecting rehabilitation of such patients.     

The association between patients' cognitive status and rehabilitation outcome in a geriatric day hospital

PURPOSE: To assess whether and to what extent cognitive status affects functional gain in mobility and extended activities of daily living (ADL) in patients admitted to a geriatric day hospital. METHODS: During 2003, 135 older patients admitted to a rehabilitation day hospital were evaluated by the Mini Mental State Examination (MMSE) and the Cognitive Functional Independence Measure (FIM). On admission and at discharge, they were assessed by the Nottingham Extended ADL Index (NEAI) and the Timed Get Up and Go test (TUG). RESULTS: Orthopedic and stroke patients achieved significant functional gain in mobility regardless of their cognitive status. Nevertheless, cognitively intact stroke patients achieved higher admission and discharge NEAI scores, manifesting greater absolute functional gain than cognitively impaired patients. The patients' ability to extract their rehabilitation potential was significantly better. CONCLUSIONS: Cognitively impaired patients can improve in mobility and performance of extended ADL during day hospital rehabilitation. Evaluation of the patients' cognitive status may enable the multidisciplinary team to develop suitable individual programs and better allocate resources. Cognitively intact stroke patients may benefit from extended rehabilitation treatment compared to impaired stroke patients as they are more capable of utilizing their potential to achieve independence in daily tasks.     

脑卒中患者功能恢复的影响因素

目的 :探讨入院时的运动功能、认知功能、年龄、从发病到康复机构的时间、性别、有无合并症及瘫痪侧别对脑卒中患者功能恢复的影响。方法 :5 5例脑卒中患者接受综合康复治疗 ,采用功能独立性评测 (FIM)评定患者的功能状况 ,在入院 7d及出院 3d内对患者进行初期和末期评定 ,治疗过程中每隔 1个月评定 1次。应用多元逐步回归分析上述因素与功能恢复之间的关系。结果 :入院时的运动功能对功能恢复的贡献最大 ,呈正相关 (P <0 .0 0 1)。入院时的认知功能、年龄、从发病到康复机构的时间与功能恢复呈负相关 (P <0 .0 5 ) ;合并症、瘫痪侧别和性别 3种因素与功能恢复无相关性 (P >0 .0 5 )。结论 :入院时的运动功能、认知功能、年龄、从发病到康复机构的时间与功能恢复高度相关 ,在制定康复治疗方案时 ,应考虑这些因素的影响     

Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture

OBJECTIVE: To identify factors associated with postacute rehabilitation outcome of disabled elderly patients with proximal hip fracture. SETTING: Geriatric rehabilitation center. PARTICIPANTS: One hundred thirty-three older patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument, motor FIM score, absolute functional gain on the FIM and motor FIM scores, relative functional gain on the FIM and motor FIM scores, rate of improvement on the FIM and motor FIM scores, proportion of patients discharged to home, and length of stay (LOS). RESULTS: Mean FIM score improved by 14 points (22%) with a functional gain rate of .56 point per day. No significant differences (P>.05) were found between weight-bearing and non-weight-bearing patients regarding the above outcome measures. Functionally independent and cognitively intact patients achieved significantly better score changes and rates of improvement and showed a higher ability to extract their rehabilitation potential than dependent and cognitively impaired patients. Their LOSs were significantly shorter. Patients with latency time (time delay from fracture to operation) of more than 5 days and patients with a history of stroke had significantly longer LOSs. Mini-Mental State Examination score, albumin levels on admission, and prefracture functional status were the most important parameters associated with FIM discharge scores (r=.756) and relative functional gain on the FIM (r=.583). Depression was the most important factor associated with LOS in patients with weight-bearing instructions on admission. The presence of a caregiver was the significant predictive value variable for returning home. CONCLUSIONS: Cognitive function, nutritional status, preinjury functional level, and depression were the most important prognostic factors associated with rehabilitation success of older patients with proximal hip fracture. Of these, depression and nutritional status are correctable, and early intervention may improve rehabilitation outcome.     

Functional outcome of ischemic stroke: A comparative study of diabetic and non-diabetic patients

Background and purpose. Diabetes is associated with more ischemic strokes and diabetic patients have up to a three-fold increased risk for suffering a stroke, compared with non-diabetics. The aim of this study is to evaluate whether diabetes mellitus may also affect the functional outcome of patients with acute ischemic stroke, undergoing post-acute care rehabilitation.

Methods. A retrospective charts analysis of consecutive older patients with acute ischemic stroke admitted for rehabilitation at a tertiary hospital with post-acute care geriatric rehabilitation wards. Functional outcome of diabetics and non-diabetics was assessed by the Functional Independence Measurement scale (FIM?) at admission and discharge. Data were analysed by t-tests, Pearson correlation, and Chi-square test, as well as by linear regression analysis.

Results. A total number of 527 patients were admitted, of whom 39% were diabetics. Compared with non-diabetics, diabetic stroke patients were slightly younger (p = 0.0001) but had similar admission FIM scores. FIM gain parameters (total FIM gain, motor FIM gain, daily total and motor FIM gains) upon discharge were similar in both groups. A linear regression analysis showed that higher MMSE scores (β = 0.08; p = 0.01) and higher admission total FIM scores (β = 0.87; p < 0.001) predicted higher total FIM scores upon discharge. Diabetes mellitus was not interrelated, whatsoever, with better total FIM scores upon discharge (β = ?0.03; p = 0.27).

Conclusions. The findings suggest that there is no difference in the functional outcome of diabetic and non-diabetic patients, presenting for rehabilitation after acute ischemic stroke. Diabetes should not be considered as adversely affecting rehabilitation of such patients.     

The impact of previous strokes on the rehabilitation of elderly patients sustaining a hip fracture

OBJECTIVE: To evaluate whether a previous stroke may affect the functional outcome gain of elderly patients undergoing rehabilitation for a hip fracture. DESIGN: A retrospective cohort study. SETTING: The division of geriatric medicine with rehabilitation wards at a university-affiliated referral hospital. PARTICIPANTS: Patients with hip fractures (N=460) undergoing a standard rehabilitation course. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The functional outcome of previous stroke- and nonprevious stroke (NPS)-affected patients assessed by the FIM instrument at admission and discharge from the rehabilitation facility. Data were analyzed by t tests, Pearson correlation, chi-square tests, and linear regression analysis. RESULTS: Both admission and discharge total FIM scores were significantly higher in NPS compared with previous stroke patients (63.53+/-19.89 vs 52.19+/-19.37, P<.001) and (84.23+/-24.93 vs 71.37+/-25.03, P=.001), respectively. However, changes in total FIM (20.70+/-11.68 vs 19.17+/-13.32, P=.38) and in motor FIM (19.84+/-10.63 vs 17.96+/-11.21, P=.23) at discharge were not statistically significant between the 2 groups. A linear regression analysis showed that a previous stroke was not predictive of a worse total FIM gain at discharge (P=.58). CONCLUSIONS: NPS hip fracture elderly patients show higher admission and discharge FIM scores compared with previous stroke patients. Nevertheless, both groups achieve similar FIM gains during rehabilitation period. A previous stroke should not be considered as adversely affecting the rehabilitation of such patients.     

脑卒中患者功能恢复的影响因素分析

背景:脑卒中患者的康复结局多种多样,哪些因素能够影响此类患者的功能恢复,文献报道有差异。目的:采用广泛应用的功能独立性评测来评定脑卒中患者康复前后的效果,分析入院时的运动功能、认知功能、年龄、从发病到康复机构的时间、性别、有无合并症、瘫痪侧别对脑卒中患者功能恢复的影响。设计:前后对照观察。单位:山东省立医院康复医学中心,首都医科大学康复医学院。对象:选择2000-03/2002-12山东省立医院收治的脑卒中住院患者55例。均为首次发病,排除双侧大脑半球均受累患者。方法:患者生命体征稳定、已渡过危险期(31～75d)后根据病情给予改善微循环及营养神经药物除外,还进行以Bobath技术、PNF技术、Rood方法为主的康复训练,每日一两个小时,每周训练5次。主要观察指标:患者入院7d内及出院前3d应用功能独立性评测评分进行初期和末期评定。功能独立性评测包括运动、认知等18项,总分126分,108～126分为基本至完全独立,72～107分为轻度依赖;54～71分为中度依赖;36～53分为重度依赖;18～35分为极重度至完全依赖。应用多元逐步回归分析上述因素与功能恢复(以FIM总分增长值表示)之间的关系。结果:55例全部进入结果分析。①患者出院时FIM总分显著高于入院时(93.8±12.0,68.8±11.6,P<0.001),运动、认知得分均高于入院时(P<0.001)。②功能独立性评测运动分的平均每天增长值与总分的增长值相似(0.56±0.21,0.59±0.21),但大于认知分的平均每天增长值(0.03±0.03)。③多元逐步回归方程提示入院时的功能独立性评测运动分、认知分、年龄和从发病到康复科的时间与功能独立性评测总分的增长值高度相关,但瘫痪侧别、性别、有无合并症则与其无相关性(P>0.05)。对功能恢复贡献由大到小的因素依次为入院时的运动功能、认知功能、年龄、从发病到康复科的时间。结论:脑卒中患者的功能恢复与入院时的运动功能、认知功能、患者年龄、康复开始时间的早晚呈显著相关性,其中入院时的运动分对功能恢复影响最大,呈正相关。因此在制定康复治疗方案时应考虑上述因素,因人而异。     

Rehabilitation outcome of Turkish stroke patients: in a team approach setting

The aim of this study was to identify the efficacy of in-patient stroke rehabilitation, to evaluate the relationship between clinical characteristics and functional outcome, and to determine factors predicting functional outcome at discharge in Turkish stroke patients with a team approach. Retrospective data were collected from 102 of 116 patients with first stroke who were admitted to our rehabilitation unit at Ankara University. Demographic data, length of hospital stay (LOHS), onset to admission interval (OAI), type, side and location of stroke lesion, and most common medical complications were recorded. Functional Independence Measure (FIM) and Brunnstrom's motor recovery stages (BMRS) were assessed on admission and at discharge. The mean age was 61.6 +/- 10.9 years and the mean LOHS was 69.7 +/- 28.2 days. The mean FIM total scores were 69.2 +/- 27.4 and 83.2 +/- 25.7 on admission, and at discharge, respectively. The mean FIM total score was significantly correlated to age, LOHS and motor recovery. The FIM total scores of patients with aphasia and depression were found to be lower than those of patients without aphasia and depression. In a stepwise multiple regression analysis, FIM total score on admission, age and OAI were found to be valid predictors of FIM total score at discharge. Functional Independence Measure total score on admission was the strongest variable. Our results suggest that knowledge of the poor prognostic factors effecting functional outcome on admission can provide information to clinicians in identifying severity of stroke. Admission FIM total score, can be used to predict the patients' functional recovery. Advanced age, aphasia and post-stroke depression contribute to lower FIM scores.     

The association between patients' cognitive status and rehabilitation outcome in a geriatric day hospital

Purpose. To assess whether and to what extent cognitive status affects functional gain in mobility and extended activities of daily living (ADL) in patients admitted to a geriatric day hospital.

Methods. During 2003, 135 older patients admitted to a rehabilitation day hospital were evaluated by the Mini Mental State Examination (MMSE) and the Cognitive Functional Independence Measure (FIM). On admission and at discharge, they were assessed by the Nottingham Extended ADL Index (NEAI) and the Timed Get Up and Go test (TUG).

Results. Orthopedic and stroke patients achieved significant functional gain in mobility regardless of their cognitive status. Nevertheless, cognitively intact stroke patients achieved higher admission and discharge NEAI scores, manifesting greater absolute functional gain than cognitively impaired patients. The patients' ability to extract their rehabilitation potential was significantly better.

Conclusions. Cognitively impaired patients can improve in mobility and performance of extended ADL during day hospital rehabilitation. Evaluation of the patients' cognitive status may enable the multidisciplinary team to develop suitable individual programs and better allocate resources. Cognitively intact stroke patients may benefit from extended rehabilitation treatment compared to impaired stroke patients as they are more capable of utilizing their potential to achieve independence in daily tasks.     

Cognitive evaluation and functional outcome after stroke

OBJECTIVE: To investigate the initial overall cognitive ability and its components as a predictor of functional improvement and ambulation during rehabilitation. Initial cognitive status is widely known to be a predictive factor in functional recovery in patients with stroke although some reports have found no such relationship. DESIGN: Baseline cognitive status was scored by Minimental State Examination and its subsections with such headings as "orientation," "registration," "attention and calculation," "recall," and "language" in 43 patients with postacute stroke, aged between 51 and 68 yr. Function was evaluated in terms of motor FIM and functional ambulation as categorized in "Adapted Patient Evaluation and Conference System" functional scale at the time of admission and discharge. RESULTS: Only total baseline Minimental State Examination score showed a significant correlation with discharge motor FIM improvement (r = 0.31, P = 0.04) and baseline orientation score correlated significantly with functional ambulation score improvement (r = 0.31, P = 0.03). In stepwise linear regression model, the same variables had an effect on similar outcome parameters. CONCLUSIONS: Cognitiveion evaluation should be taken as a whole to predict functional outcome in patients with postacute stroke, except for the baseline orientation score that seemed more predictive for ambulation.     

Rehabilitation of the older stroke patient: functional outcome and comparison with younger patients

OBJECTIVE: To evaluate the inpatient rehabilitation progress and functional outcome of stroke patients aged 80 yr and over and make comparisons with a younger (<80 yr) stroke population receiving similar comprehensive rehabilitation therapies. DESIGN: A case series of 223 stroke patients consecutively admitted to the inpatient rehabilitation unit of a tertiary acute general hospital. A total of 44 patients with a first-time stroke were at least 80 yr old and over and 179 initial stroke patients were <80 yr old. The main outcome measures included admission and discharge scores of the FIM trade mark instrument, FIM gain and efficiency, and discharge disposition. RESULTS: The majority (72.7%) of the older stroke group (mean age, 84 yr; standard deviation, 3.7 yr; range, 80-94 yr) was able to return home, although to a lesser extent than the younger segment (90.5%). No continuous or categorical variable studied was related to discharge disposition in the older stroke patients. Admission FIM total was the most significant predictor of discharge FIM total and discharge FIM motor. The older group did have a lower FIM efficiency and made smaller FIM total and motor gains. In comparison with the younger stroke patients, the older stroke group was statistically more likely to be women (P < 0.001), unmarried (P < 0.001), living alone prestroke (P < 0.05), and unemployed ( P< 0.001). CONCLUSION: Most older stroke patients can successfully complete a rehabilitation program and return to the community. Demographic, functional, and outcome differences were found when comparing this population with younger counterparts.     

The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome

Toglia J, Fitzgerald KA, O'Dell MW, Mastrogiovanni AR, Lin CD. The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome.

Objectives

To compare Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) global and subscores in classifying cognitive impairment in persons with mild stroke and to explore the relationship between admission and discharge functional status and improvement.

Design

Retrospective analysis of data.

Setting

Acute rehabilitation unit of a large urban university-affiliated hospital.

Participants

Inpatients with stroke (N=72; mean age, 70y; median time poststroke, 8.5d) and mild neurologic (median National Institutes of Health Stroke Scale score, 4) and cognitive deficits (median MMSE score, 25).

Intervention

Not applicable.

Main Outcome Measure

Admission cognitive status was assessed by using the MMSE and MoCA. The motor subscale of the FIM instrument (mFIM) and motor relative functional efficiency was used to assess discharge functional status and improvement.

Results

The MoCA classified more persons as cognitively impaired than the MMSE (89% vs 63%, respectively; using a cutoff score of 27 on the MMSE and 26 on the MoCA). The MoCA also showed less of a ceiling effect than the MMSE, higher internal reliability (Cronbach α=.78 compared with α=.60), and marginally stronger associations with discharge functional status (r=.40; P<.001) than the MMSE (r=0.30; P<.05). The MoCA visuoexecutive subscore was the strongest predictor of functional status (P=.01) and improvement (P=.02) in global and subscores for both tests.

Conclusions

The MoCA may be an important cognitive screening tool for persons with stroke and mild cognitive dysfunction on an acute rehabilitation unit. Lower visuoexecutive subscores may assist in identifying persons at risk for decreased functional gains in self-care and mobility (mFIM) during inpatient rehabilitation. The findings justify further validation studies of the MoCA in persons with subacute stroke.     

Sleep-related breathing disorders and rehabilitation outcome of stroke patients: a prospective study

OBJECTIVE: Sleep-related breathing disorder (SRBD) is more prevalent in stroke patients than in age- and sex-matched controls, but the relationship between SRBD, functional levels at admission, and subsequent recovery is unclear. We evaluated patients after a first stroke to determine the prevalence of SRBD and the influence of SRBD on the recovery of discharge functional status after a rehabilitation program. DESIGN: In a prospective study, 30 stroke patients were studied by continuous overnight pulse oximetry during sleep for the presence of desaturation events (fall of arterial saturation of > 4% from the baseline). The Respiratory Disturbance Index was defined as number of desaturations per hour of sleep. Functional assessment was done at admission using the FIM instrument. The patients were asked about total hours of sleep and the presence or absence of habitual snoring before and after the stroke. The outcome measure at discharge was the FIM score. RESULTS: On linear regression, after including the FIM score at admission, in the model, the Respiratory Disturbance Index score was negatively correlated with the FIM gain (coefficient, -0.635 +/- 0.27; P = 0.025), and together, the variables explained 20.9% of the total variance (adjusted r2). All patients with an admission FIM score of > or = 70 (only mild functional impairment) had a good outcome (FIM score of > 100 at discharge). However, only two of six of those with FIM scores of < 70 with SRBD (defined as a Respiratory Disturbance Index score of > 10) had significant improvement (> or = 30 points), whereas this occurred in seven of nine of those without SRBD (prevalence ratio, 0.43; 95% confidence interval, 0.13-1.40; P = 0.085) CONCLUSIONS: Even after adjusting for the admission functional status, the presence of hypoxic events during sleep predicts a poorer recovery, especially in stroke patients with poor function at admission.     

Evaluating the effectiveness of stroke rehabilitation: choosing a discriminative measure.

OBJECTIVE: To evaluate the discriminative ability of several measures of physical disability used to determine quality of outcome for poststroke rehabilitation. DESIGN: A comparative study, using Rasch analysis, of the discriminative ability of functional status and mobility measures in rehabilitation patients with stroke. SETTING: A 26-bed rehabilitation unit, on site of a tertiary teaching hospital in Melbourne, Australia. PARTICIPANTS: A consecutive sample of 106 patients with acute stroke admitted for rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rasch analysis of the motor subscale of the FIM instrument, Motor Assessment Scale, Functional Ambulation Classification, gait velocity, and gait endurance. RESULTS: The more difficult items of the FIM motor scale adequately discriminated among higher functioning patients. The gait velocity measure further distinguished 9% of the sample, who functioned at a higher level than could be indicated by FIM motor subscale. The other measures did not add levels of discrimination to that provided by the FIM motor. Ability estimates provided by Rasch analysis of the FIM motor scale were a more accurate indication of ability than raw scores. Raw scores underestimated change in ability observed at higher levels of ability. CONCLUSION: Rasch estimates of the FIM motor subscale provide a discriminative measure for evaluating outcomes and change in ability achieved in stroke rehabilitation.     

Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke

OBJECTIVES: To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition. DESIGN: Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period. SETTING: Free-standing urban rehabilitation hospital in the United States. PARTICIPANTS: Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria. INTERVENTION: Inpatient multidisciplinary comprehensive rehabilitation program. MAIN OUTCOME MEASURES: Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures. RESULTS: The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home. CONCLUSIONS: Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.