Sleep-Disordered Breathing in Patients Enrolled in an Inpatient Stroke Rehabilitation Program

Brooks D, Davis L, Vujovic-Zotovic N, Boulias C, Ismail F, Richardson D, Goldstein RS. Sleep-disordered breathing in patients enrolled in an inpatient stroke rehabilitation program.

Objective

To report the prevalence of sleep-disordered breathing in an inpatient stroke rehabilitation unit and to explore correlations with functional status and health-related quality of life.

Design

Cross-sectional study.

Setting

Rehabilitation center.

Participants

Consecutive patients (N=45; mean age, 67±12y) (28 men) enrolled in inpatient rehabilitation after ischemic (84%) or hemorrhagic stroke (16%).

Interventions

Not applicable.

Main Outcome Measures

Overnight respiratory polysomnography was performed on all subjects. Interviewer-administered scales of sleepiness (Epworth Sleepiness Scale) and functional status (FIM, Barthel Index) were completed. Health-related quality of life was assessed by using a general questionnaire (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]).

Results

Of the 45 subjects tested, only 4 (9%) had an apnea-hypopnea index of less than 10 per hour. The mean apnea-hypopnea index was 32.2 (19.4) per hour; most events were obstructive. There was no relationship between the respiratory index and the components of SF-36 (P values>.2).

Conclusions

There was a dramatically high prevalence of respiratory events in patients after stroke enrolled in an inpatient stroke rehabilitation unit. The awareness of this will influence patient evaluation and management.     

Feasibility of Computerized Adaptive Testing for Collection of Patient-Reported Outcomes After Inpatient Rehabilitation

Objective

To evaluate the feasibility of computer adaptive testing (CAT) using an Internet or telephone interface to collect patient-reported outcomes after inpatient rehabilitation and to examine patient characteristics associated with completion of the CAT-administered measure and mode of administration.

Design

Prospective cohort study of patients contacted approximately 4 weeks after discharge from inpatient rehabilitation. Patients selected an Internet or telephone interface.

Setting

Rehabilitation hospital.

Participants

Patients (N=674) with diagnoses of neurologic, orthopedic, or medically complex conditions.

Interventions

None.

Main Outcome Measure

CAT version of the Community Participation Indicators (CAT-CPI).

Results

From an eligible pool of 3221 patients, 674 (21%) agreed to complete the CAT-CPI. Patients who agreed to complete the CAT-CPI were younger and reported slightly higher satisfaction with overall care than those who did not participate. Among these patients, 231 (34%) actually completed the CAT-CPI; 141 (61%) selected telephone administration, and 90 (39%) selected Internet administration. Decreased odds of completing the CAT-CPI were associated with black and other race; stroke, brain injury, or orthopedic and other impairments; and being a Medicaid beneficiary, whereas increased odds of completing the CAT-CPI were associated with longer length of stay and higher discharge FIM cognition measure. Decreased odds of choosing Internet administration were associated with younger age, retirement status, and being a woman, whereas increased odds of choosing Internet administration were associated with higher discharge FIM motor measure.

Conclusions

CAT administration by Internet and telephone has limited feasibility for collecting postrehabilitation outcomes for most rehabilitation patients, but it is feasible for a subset of patients. Providing alternative ways of answering questions helps assure that a larger proportion of patients will respond.     

Utility of Functional Status for Classifying Community Versus Institutional Discharges After Inpatient Rehabilitation for Stroke

Reistetter TA, Graham JE, Deutsch A, Granger CV, Markello S, Ottenbacher KJ. Utility of functional status for classifying community versus institutional discharges after inpatient rehabilitation for stroke.

Objective

To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke.

Design

Retrospective cross-sectional design.

Setting

Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation.

Participants

Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007.

Interventions

Not applicable.

Main Outcome Measure

Discharge FIM rating and discharge setting (community vs institutional).

Results

Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77).

Conclusions

Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings.     

Neuropsychologic Assessment and Cognitive Rehabilitation in a Patient With Locked-In Syndrome and Left Neglect

Trojano L, Moretta P, Estraneo A, Santoro L. Neuropsychologic assessment and cognitive rehabilitation in a patient with locked-in syndrome and left neglect.We describe a patient affected by severe incomplete locked-in syndrome (LIS) and left neglect caused by a combination of vascular lesions. Our patient's neglect prevented the use of augmentative communication devices based on a computerized eye-tracker system. For this reason, we adapted a visual scanning training for neglect rehabilitation. At the end of the rehabilitative training, the patient had regained full exploration of the monitor and could use the eye-tracker system for communicative purposes. This case report shows that specific rehabilitative approaches can be devised in severely disabled LIS patients with additional brain lesions and specific cognitive defects.     

Long-Term Outcomes of Joint Replacement Rehabilitation Patients Discharged From Skilled Nursing and Inpatient Rehabilitation Facilities

DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh C-H, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities.

Objective

To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF).

Design

Postdischarge follow-up interview study at 7.5 months after admission.

Setting

Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs.

Participants

Patients (N=856): 561 with knee replacement and 295 with hip replacement.

Interventions

None.

Main Outcome Measures

FIM and Short-Form 12-Item Health Survey (SF-12).

Results

Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12–related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes.

Conclusions

At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.