Predictors of basic and instrumental activities of daily living performance in persons receiving rehabilitation services

OBJECTIVE: To examine the relations among cognitive and emotional function and other patient impairment and demographic variables and the performance of daily activities. DESIGN: Cohort. SETTING: Acute inpatient rehabilitation, skilled nursing facilities, home care, and outpatient clinics. PARTICIPANTS: Adults (N=534) receiving services for neurologic (32.3%), lower-extremity orthopedic (42.7%), or complex medical (24.9%) conditions. Mean age was 63.8 years; 55% were women; 88.6% were white; and the time since condition onset ranged from 0.2 to 3.9 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activity Measure for Post-Acute Care: applied cognitive, personal care and instrumental, and physical and movement scales; Mental Health Inventory-5 (MHI-5); and patient-identified problems (vision, grasp). RESULTS: Path analyses resulted in good model fit both for the total sample and 3 patient subgroups (chi(2) test, P>.05; comparative fit index >.95). There was a significant (P<.05) direct relation between the applied cognitive, grasp, and personal care and instrumental variables in all patient groups. There were also significant indirect relations between the MHI-5, visual impairment, and grasp problems with the personal care and instrumental scale through an association with the applied cognitive scale. Strength and significance of associations between age, sex, and physical and movement and personal care and instrumental scales varied more across patient groups. The model R(2) for the personal care and instrumental scale for the total sample was .60, with R(2) values of .10, .72, and .62 for the lower-extremity orthopedic, neurologic, and complex medical groups, respectively. CONCLUSIONS: Results suggest that variations in cognitive function, along with visual impairment and lower perceived well-being are associated with a patient's ability to complete daily activities. Rehabilitation professionals should consider cognitive and emotional factors as well as physical performance when planning treatment programs to restore daily activity function.     

Article 7: Categorization, deductive reasoning, and self-awareness: association to everyday competence in persons with acute brain injury

Objective: To examine the contribution of self-awareness and executive function to the performance of instrumental activities of daily living (IADLs) among adults with acute brain injury. Design: Correlational research design. Setting: Acute neurosurgery unit. Participants: 40 men and women between the ages of 21 to 84 years. Interventions: Not applicable. Main Outcome Measures: Performance on the Toglia Category Assessment (TCA), the Deductive Reasoning Test (DRT), and the Revised Observed Tasks of Daily Living served as dependent variables of interest. Self-awareness was measured using subtests of the TCA and DRT. Results: Categorization and deductive reasoning contributed significantly to IADL performance, suggesting that both executive measures can serve as predictors of IADL in persons with brain injuries. Self-awareness contributed significantly to IADL performance, but its contribution was mediated through categorization ability. Executive function correlated significantly with posttest IADL performance estimation, but not with IADL performance predictions. Conclusions: Executive functions, as well as self-awareness, predicted ADL performance in persons with brain injury. The results are discussed within the framework of a conceptual model that illustrates the multifaceted nature of executive function and its relationship to self-awareness and everyday functional competence.     

Poster 34: Cognitive impairment and everyday competence among 3 groups of persons: an empirical study

Objective: To compare problem-solving skills and everyday competency across clinical groups. Design: Between-groups design. Setting: Acute neurosurgery unit, community for the elderly, assisted living facilities for elderly and people diagnosed with schizophrenia, and nursing homes for the elderly. Participants: 60 older adults (age, ≥65y), 40 adults diagnosed with schizophrenia, and 40 adults with brain injuries. Interventions: Not applicable. Main Outcome Measures: Everyday competency was assessed using the Revised Observed Tasks of Daily Living (OTDL-R). Results: OTDL-R performance was significantly worse for participants diagnosed with schizophrenia than for participants with brain injury or older adults. Performance of the latter 2 groups did not differ. Higher educated persons in each of the 3 groups performed at a significantly higher level than less educated persons. Furthermore, older persons in each group performed worse than younger persons. Conclusions: The OTDL-R is a sensitive performance-based tool of potential importance for occupational therapists in the assessment of instrumental activities of daily living and problem-solving skills. However, education level and age should be taken into consideration during assessment. Additional research is needed to characterize more fully the psychometric properties of the OTDL-R for appropriate use by clinicians and researchers.     

Characterization of power wheelchair use in the home and community

Sonenblum SE, Sprigle S, Harris FH, Maurer CL. Characterization of power wheelchair use in the home and community.

Objective

To characterize the use of power wheelchairs and to determine if multiple measures of mobility and occupancy jointly provide a more comprehensive picture of wheelchair usage and daily activity in full-time power wheelchair users than daily distance alone.

Design

Prospective observational study.

Setting

Subjects’ everyday mobility was measured in their homes and communities for 2 weeks, and prompted recall interviews were conducted by phone.

Participants

A convenience sample (N=25) of nonambulatory, full-time power wheelchair users.

Interventions

Not applicable.

Main Outcome Measures

Wheelchair usage was logged electronically, and geolocation and interview data were used to isolate chair use to (1) in the home, (2) not in the home indoors, or (3) outdoors. Distance wheeled, time spent wheeling, number of bouts, time spent in the wheelchair, and the percentage of time in the wheelchair spent wheeling were measured to describe wheelchair use.

Results

The median wheelchair user spent 10.6 hours (range, 5.0-16.6h) in his/her wheelchair daily and wheeled 1.085km (range, 0.238-10.585km) over 58 minutes (range, 16-173min) and 110 bouts (range, 36-282 bouts). Wheelchair use varied across subjects, within subjects from day to day, and between environments. Mobility bouts outdoors were longer and faster than those wheeled indoors. In a regression analysis, distance wheeled explained only 33% of the variation in the number of bouts and 75% in the time spent wheeling.

Conclusions

Power wheelchair use varies widely both within and between users. Measuring distance, time, and number of bouts provides a clearer picture of mobility patterns than measuring distance alone, whereas occupancy helps to measure wheelchair function in daily activities.     

Assessing the influence of wheelchair technology on perception of participation in spinal cord injury

OBJECTIVE: To investigate factors related to the wheelchair, impairment, and environment that affect perception of participation of persons with spinal cord injury (SCI) in activities performed in 3 settings: in the home, in the community, and during transportation. DESIGN: Cross-sectional study. SETTING: Research centers and a specialized assistive technology (AT) clinic in Pittsburgh (Pitt). Research centers and community-based rehabilitation technology suppliers in Saint Louis (SL). PARTICIPANTS: Seventy wheelchair users with SCI. INTERVENTIONS: Subjects from Pitt and SL completed a written survey of AT usage in daily activities. MAIN OUTCOME MEASURES: Subjects were asked 5 questions within each setting (home, community, transportation) related to their perceived reason for functional limitations. RESULTS: The wheelchair was the most commonly cited factor limiting participation, followed by physical impairment and physical environment. Twenty-one percent of subjects with paraplegia reported pain as a limiting factor for their transportation use, significantly more (P=.047) than subjects with tetraplegia (3%). A trend (P=.099) was seen toward a higher percentage of subjects with tetraplegia (tetraplegia, 7%; paraplegia, 3%) reporting lack of equipment as a limiting factor for use of transportation. Differences were also seen across sites. CONCLUSIONS: The wheelchair was the most commonly cited limiting factor, followed by physical impairment and physical environment. The wheelchair is the most important mobility device used by persons with SCI and the one that users most associate with barriers.     

An examination of social support influences on participation for older adults with chronic health conditions

Abstract

Social support can improve participation in everyday activities among older adults with chronic health conditions, but the specific types of support that are needed are unclear. Purpose: This study examined the types of social support that most strongly predict participation in everyday activities. Method: Two hundred and twenty-seven participants completed a self-administered cross-sectional survey. The sample included adults aged 60 years or more with arthritis, diabetes, chronic obstructive pulmonary disease and/or heart disease. Participation was defined as satisfaction with participation in 11 life areas. Social support was defined as availability of tangible, affectionate, emotional/informational and positive social interaction support. Results: Multiple regression analyses showed that participants who perceived greater tangible support and positive social interaction support had higher satisfaction with participation than participants with lower levels of these types of support. Conclusions: Targeting and developing tangible and social interaction support may help to facilitate satisfaction with participation for older adults with chronic conditions. Creating networks for companionship appears equally as important as providing support for daily living needs.

• Implications for Rehabilitation

• Varying types of social support can improve participation in older adults with chronic health conditions.

• Tangible support and positive social interaction support are the strongest predictors of participation.

• Creating networks for companionship may be equally as important as providing support for daily living needs.

     

Stair negotiation time in community-dwelling older adults: normative values and association with functional decline

Oh-Park M, Wang C, Verghese J. Stair negotiation time in community-dwelling older adults: normative values and association with functional decline.

Objectives

To establish reference values for stair ascent and descent times in community-dwelling, ambulatory older adults, and to examine their predictive validity for functional decline.

Design

Longitudinal cohort study. Mean follow-up time was 1.8 years (maximum, 3.2y; total, 857.9 person-years).

Setting

Community sample.

Participants

Adults 70 years and older (N=513; mean age, 80.8±5.1y) without disability or dementia.

Interventions

Not applicable.

Main Outcome Measures

Time to ascend and descend 3 steps measured at baseline. A 14-point disability scale assessed functional status at baseline and at follow-up interviews every 2 to 3 months. Functional decline was defined as an increase in the disability score by 1 point during the follow-up period.

Results

The mean±SD stair ascent and descent times for 3 steps were 2.78±1.49 and 2.83±1.61 seconds, respectively. The proportion of self-reported and objective difficulty was higher with longer stair ascent and descent times (P<.001 for trend for both stair ascent and descent). Of the 472 participants with at least 1 follow-up interview, 315 developed functional decline, with a 12-month cumulative incidence of 56.6% (95% confidence interval [CI], 52.1%–61.3%). The stair negotiation time was a significant predictor of functional decline after adjusting for covariates including gait velocity (adjusted hazard ratio [aHR] per 1-s increase: aHR=1.12 [95% CI, 1.04–1.21] for stair ascent time; aHR=1.15 [95% CI, 1.07–1.24] for stair descent time). Stair descent time was a significant predictor of functional decline among relatively high functioning older adults reporting no difficulty in stair negotiation (P=.001).

Conclusions

The stair ascent and descent times are simple, quick, and valid clinical measures for assessing the risk of functional decline in community-dwelling older adults including high-functioning individuals.     

Life Habits and Prosthetic Profile of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up

Zidarov D, Swaine B, Gauthier-Gagnon C. Life habits and prosthetic profile of persons with lower-limb amputation during rehabilitation and at 3-month follow-up.

Objective

To assess performance of life habits among persons with lower-limb amputation at admission, at discharge, and 3 months after rehabilitation discharge and describe their prosthetic profile at discharge and follow-up.

Design

Case series.

Setting

Inpatient rehabilitation.

Participants

Unilateral persons with lower-limb amputation (N=19; 14 men; mean age, 53.4±14.6y).

Intervention

Interdisciplinary rehabilitation.

Main Outcome Measures

Life habits performance and prosthetic profile.

Results

In the daily activities subdomain, the lowest performances were observed for mobility and housing at all evaluation times. Within the social role subdomain, employment, recreation, and community life scores were the lowest for the 3 evaluations. Mean scores for all activities of daily living subdomain categories significantly increased (P<.05) during rehabilitation except for personal care and communication. Only community life (social roles subdomain) significantly increased during rehabilitation; life habits remained unchanged after discharge. Fifty-eight percent of patients at discharge versus 68.4% at follow-up used their prosthesis for more than 9 hours a day, and this increased significantly postdischarge (P=.017). Locomotor capability with prosthesis was similarly high at discharge and follow-up.

Conclusions

Among persons with lower-limb amputation, social role life habits appear to be more disturbed than those associated with activities of daily living. At discharge, prosthetic wear and locomotor capabilities with prosthesis were high and tended to improve on return to the community.     

Perceived impacts of a first wheelchair on social participation

Purpose.?To document perceived impacts in users' daily activities and social roles (social participation) following the acquisition of a first manual or powered wheelchair.

Methods.?A qualitative design with a phenomenological approach was used. Semi-structured interviews were conducted. An interview guide was developed based on the 12 social participation categories in the Disability Creation Process (DCP) conceptual model as themes underlying the questions: ‘What has changed in your daily life since you got your new wheelchair?’ and ‘What has not changed in your daily life that you thought you would do differently with your new wheelchair?’

Results and discussion.?The average age of the ten participants was 64.3 years (±16.3) and 90% had received a manual wheelchair. Four main themes emerged from the detailed analysis: changes in daily activities, expectations not met, impacts on social roles and emotional changes. The participants considered the changes in daily activities to be generally positive. Expectations not met mainly related to outdoor mobility. The participants had not anticipated the impacts on social roles and emotional changes, which demonstrate the complexity of human occupation.

Conclusion.?Getting a wheelchair is a major and complex event in a person's life.     

Preliminary results for the PAR-PRO: a measure of home and community participation

OBJECTIVE: To develop a measure of home and community participation related to the World Health Organization's International Classification of Functioning, Disability and Health. DESIGN: Cross-sectional analysis of survey data. SETTING: Nine medical inpatient rehabilitation facilities from 6 states. PARTICIPANTS: A total of 594 patients of mixed impairment type admitted for inpatient rehabilitation in 2002. Mean age was 74.0 years and 61.4% were women. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Reliability and validity of the participation instrument. RESULTS: A 20-item instrument of home and community participation was developed (PAR-PRO). The instrument showed good internal consistency and good Rasch person and item fit statistics. Four subfactors were identified beyond the unidimensional construct of participation including domestic management, socialization, physical vigor, and generative activities. The PAR-PRO total participation score correlated inversely with age (r=-.31, P<.001) but did not differ by sex. CONCLUSIONS: The 20-item PAR-PRO instrument of home and community participation displayed good psychometric characteristics. The instrument shows promise as a broad measure of home and community involvement for persons with disabilities. Further work is needed to support its application for people without disability.     

Racial and ethnic differences in activities of daily living disability among the elderly: the case of Spanish speakers

Tirodkar MA, Song J, Chang RW, Dunlop DD, Chang HJ. Racial and ethnic differences in activities of daily living disability among the elderly: the case of Spanish speakers.

Objective

To compare incident disability patterns across racial and ethnic groups.

Design

Prospective cohort study with 6-year follow-up (1998-2004).

Setting

National probability sample.

Participants

A 1998 Health and Retirement Study sample of 12,288 non-Hispanic whites, 1952 African Americans, 575 Hispanics interviewed in Spanish (Hispanic-Spanish), and 518 Hispanics interviewed in English (Hispanic-English), older than 51 years, and free of disability at baseline.

Interventions

Not applicable.

Main Outcome Measure

Disability in activities of daily living (ADL) tasks (walking, dressing, transferring, bathing, toileting, feeding).

Results

Hispanic-Spanish reported disproportionately lower rates of walking disability (standardized rates, 4.31% vs Hispanic-English [8.57%], black [7.54%], white [7.20%]) despite higher reported Hispanic-Spanish frequencies of lower-extremity dysfunction than other racial and ethnic groups. Across the 6 ADL tasks, the development of walking disability was most frequent among Hispanic-English subjects, African Americans, and whites. In contrast, Hispanic-Spanish subjects reported dressing as the most frequent ADL task disability, whereas walking ranked fourth.

Conclusions

Aggregating all Hispanics, regardless of interview language, may be inappropriate. Future research on linguistic group differences in self-reported health outcomes is necessary to ensure that health status measures will be appropriate for use in diverse racial and ethnic groups.     

Effect of short-duration,limited rehabilitation on maintenance of the activities of daily living in patients with acute phase of COVID-19

[Purpose] To determine whether short-duration, limited rehabilitation is effective in patients with COVID-19. [Participants and Methods] Single-center, retrospective, observational study. Thirty-six inpatients were classified into the three groups: a close contact (CC) group with a negative polymerase chain reaction (PCR) test (n=14); a PCR–positive (PP) group (n=15); and a PCR–positive and transfer (PT) group with severe COVID-19 patients who were transferred to an acute care hospital for treatment and then returned to our hospital (n=7). Short-duration, limited rehabilitation was provided to the CC and PP groups in isolated rooms by a therapist wearing full personal protective equipment, and we assessed the changes in their activities of daily living. [Results] The patients’ clinical characteristics at baseline were similar among the three groups. Functional Independence Measure scores in the CC, PP, and PT groups were not different at baseline (69 ± 29, 53 ± 26, and 63 ± 32), but differed after control of COVID-19 (63 ± 25, 47 ± 24, and 32 ± 19). Multivariate regression analysis showed that the implementation of a customized self-exercise program and the Mini Nutritional Assessment Short-Form at baseline were independently associated with Functional Independence Measure score after control of COVID-19. [Conclusion] These results suggest that even short-duration, limited rehabilitation may be effective for preventing decreases in activities of daily living in patients with COVID-19.     

Comparison of the Responsiveness of the FIM and the interRAI Post Acute Care Assessment Instrument in Rehabilitation of Older Adults

Glenny C, Stolee P, Husted J, Thompson M, Berg K. Comparison of the responsiveness of the FIM and the interRAI Post Acute Care Assessment Instrument in rehabilitation of older adults.

Objective

To compare the responsiveness of 2 major systems developed for rehabilitation settings—the FIM and the interRAI Post Acute Care (PAC) assessment—in older patients.

Design

Trained raters assessed patients with both tools at admission and discharge.

Setting

Musculoskeletal (MSK) and geriatric rehabilitation units (GRUs) in 2 rehabilitation hospitals.

Participants

Older adults receiving rehabilitation (N=208; mean age ± SD, 78.5±9.3; 67% women).

Interventions

Not applicable.

Main Outcome Measures

Responsiveness was evaluated using effect size (ES) and standardized response mean (SRM).

Results

ES and SRM were somewhat higher for the FIM motor (GRU ES=1.68, SRM=1.31; MSK ES=2.12, SRM=2.25) than the PAC (GRU ES=1.64, SRM=1.29; MSK ES=1.57, SRM=1.89) in both patient groups. Both tools were more responsive in MSKs than GRUs. This may reflect the greater frailty and clinical complexity of GRU patients.

Conclusions

Both the FIM motor and the PAC were able to detect clinically relevant improvement in functional ability in older rehabilitation inpatients.