Outcomes for older adults in an inpatient rehabilitation facility following hipfracture (HF) surgery

Katherine S. McGilton a,*, Nizar Mahomed b, Aileen M. Davis b, John Flannery c, Sue Calabrese c

a Toronto Rehabilitation Institute, 130 Dunn Avenue, Toronto, ON M6K 2R7, Canadab Toronto Western Research Institute, 399 Bathurst Street, Toronto, ON M5T 2S8, Canadac Toronto Rehabilitation Institute, 47 Austin Terrace Toronto, ON M5R 1Y8, Canada

Archives of Gerontology and Geriatrics 49 (2009) e23–e31

A R T I C L E I N F O

Article history:

Received 20 September 2007

Received in revised form 20 July 2008

Accepted 25 July 2008

Available online 7 October 2008

Keywords:

Hip fracture

Rehabilitation outcomes

Cognitive impairment

Older adults

A B S T R A C T

The purpose of the study was to evaluate patient and system outcomes regarding older community-

residing adults who participated in a rehabilitation program following HF surgery. The health care

professionals on the rehabilitation unit in this feasibility study had never cared for such patients who

were so frail, with multiple co-morbidities including cognitive impairment (CI). After an innovative

model of care was developed and the staff trained in the novel approach to care, the unit opened for all

patients living within the community who had fractured their hip, regardless of their CI. Of the 31 elderly

patients consecutively admitted post-HF in this retrospective study, 18 were found to have CI

postoperatively as determined by a Mini-Mental State Examination (MMSE) score �23. There were no

differences in length of stay (LOS), rehabilitation efficiency, and motor FIM gain scores between the two

groups of patients. This feasibility retrospective study suggests that staff can learn how to care for

patients with CI in rehabilitation settings, and that such clients can achieve outcomes comparable to

those without CI in a setting dedicated to caring for patients with a HF.

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1. Introduction

A HF is often a catastrophic event that is a significant threat toan individual’s independence and ability to live in the community(Naglie et al., 2002). Population trends indicate that an increasingnumber of individuals are likely to survive to ages at which HF iscommon (Jaglal et al., 1996). Despite good surgical outcomes,studies have found that functional outcomes after HF surgery arevariable, with as few as one-third of people able to regain their pre-fracture level of physical functioning (Koot et al., 2000; Gruber-Baldini et al., 2003; Lieberman et al., 2006). A recent review of theCanadian Institute for Health Information data found that 26% ofHF patients (many of who were living in the community pre-fracture) were discharged to long-term care (LTC) facilities andnever received appropriate rehabilitation (GTA Rehab. Network,2006). Furthermore, the outcomes for patients with a HF are oftencomplicated by the presence of CI. About 17% of communitydwellers who experience a HF have a diagnosis of CI, and thispercentage is expected to rise (Wiktorowicz et al., 2001). Of these

* Corresponding author. Tel.: +1 416 597 3422x2500; fax: +1 416 530 2470.

E-mail address: mcgilton.kathy@torontorehab.on.ca (K.S. McGilton).

0167-4943/$ – see front matter � 2008 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2008.07.012

patients, it is not clear what percentage have delirium, dementia orboth, nor the extent of their dementia, mild, moderate or severe.

Current health care services for people with HF, and those withCI in particular, are fragmented and limited (Wiktorowicz et al.,2001; GTA Rehab. Network, 2006). The several inpatient rehabi-litation options after HF surgery include rehabilitation beds inacute-care hospitals or free-standing rehabilitation hospitals,specialized geriatric units, higher level sub-acute long-stay beds,and convalescent care beds. In the United States for example, HFpatients with CI are admitted to geriatric sub-acute units located innursing homes and receive rehabilitation care (Barnes et al., 2004).All of these care settings, however, have their own admission anddischarge criteria that are not consistent or complementary. Forexample, a recent study of eight Geriatric Rehab. Units (GRUs) inOntario found that acceptance of patients with CI varied across theunits (Wells et al., 2008), despite evidence that patients with CI canbenefit from rehabilitation programs (Goldstein et al., 1997; Herutiet al., 1999; Naglie et al., 2002; Barnes et al., 2004; Rolland et al.,2004).

At present, there is no standardized, integrated continuum ofcare for HF patients, especially for those with CI in Ontario (Daviset al., 2006). Therefore, these patients are frequently unable toaccess appropriate rehabilitation in a timely fashion, if at all, whichcontributes to poor functional and quality care outcomes (Wells

K.S. McGilton et al. / Archives of Gerontology and Geriatrics 49 (2009) e23–e31e24

et al., 2004). Earlier work has shown that access to beds in GRUs islimited and often excludes patients with CI because of theircognitive and behavioral symptoms (Wells et al., 2008), and thereis no reason to believe this is different in any other country. Notrehabilitating these patients leads to further physical and mentaldeconditioning, thereby, compromising patients’ long-term out-comes. In a recent report, Davis et al. (2006) recommended thatnew models of care be established, including all sectors of thehealth care continuum, to optimize the function of HF patientswith CI.

In response to this need, members of our team developed anintegrated practice-based model of care, referred to as theAssessment, Patient-Centered Goals, Treatment, Evaluation, andDischarge (ACTED) model of care. This model aims to provide anoptimal rehabilitation setting at the appropriate time for thegeriatric patient with CI. The innovative aspects of the ACTEDmodel include the following: (1) early admission to rehabilitation(i.e., on or before Day 5 post-op); (2) individualized assessmentsand interventions focused on the patients’ remaining abilities; (3)assessments for dementia, delirium, and depression within thefirst 3 days of admission to rehabilitation; (4) patient-centeredgoals that involve input from patients and their families; (5)individualized rehabilitation care at the bedside if necessary; (6) afocus on care strategies that minimize behavioral and cognitivesymptoms related to CI; and (7) education and support to healthcare providers (HCPs) and facilities to implement the model of care.As part of the ACTED program, a physiatrist, geriatrician, andfamily physician were available to provide medical guidance onthe care of the patients. An advanced practice nurse (APN) ingerontology provided guidance to staff to individualize care. Theoverall objective of this feasibility study was to evaluate patientand system outcomes for the older adults who participated in theACTED program of care following HF surgery.

1.1. Literature review and conceptual framework

1.1.1. Rehabilitation of patients with CI following HF

A growing body of research has focused on the rehabilitation ofpersons with CI following a HF. These patients with CI are moreprone than other HF patients to delirium (Inouye and Charpentier,1996), longer lengths of acute hospital stays (Wells et al., 2004),and mortality (Koot et al., 2000). A literature review of 21 studies

Fig. 1. Patient-centered reha

from eight countries reported that HF patients with CI can benefitfrom participating in rehabilitation targeted at improving self-careand motor function (Magaziner et al., 1990; Cummings et al., 1996;Patrick et al., 1996; Goldstein et al., 1997; Heruti et al., 1999;Adunsky et al., 2002; Hoenig et al., 2002; Naglie et al., 2002;Gruber-Baldini et al., 2003; Barnes et al., 2004; Lenze et al., 2004;Rolland et al., 2004; Arinzon et al., 2005; Haentjens et al., 2005;Shyu et al., 2005; Bitsch et al., 2006; GTA Rehab. Network, 2006;Lieberman et al., 2006; Moncada et al., 2006; Yu et al., 2006).

1.1.2. Patient outcomes

The primary goal of HCPs in working with persons following aHF is to maximize their functioning (Shabat et al., 2005). Outcomesrelated to patients’ functioning include improvement in patients’mobility level during inpatient rehabilitation (Patrick et al., 1996;Heruti et al., 1999) and a return to pre-fracture functional status(Wells et al., 2004; Shabat et al., 2005). HCPs’ secondary goal is todischarge patients back to their previous environment (Wells et al.,2004).

1.1.3. Influence on patient outcomes: the conceptual model

A patient-centered rehabilitation model of care (Fig. 1), amodification of Donabedian’s (1966) framework, was selected toguide this research study as it provided a useful framework forunderstanding how contextual factors (i.e., patient and systemcharacteristics) and processes of care affect the outcomes of peoplewith a HF. Patient characteristics include personal resourcesneeded to participate in the rehabilitation intervention as well aspersonal and health-related characteristics, such as cognitive level.System characteristics include the physical and social aspects ofthe environment, such as policies on the unit, and time intervalfrom surgery to admission to the rehabilitation program. Processesof care consist of the components of the intervention conceptua-lized as being critical for achieving the anticipated outcomes(Lipsey, 1993), such as effective team processes. Concepts of focusfor this feasibility study are highlighted in bold (Fig. 1).

1.1.4. Contextual factors

1.1.4.1. Patient characteristics. Several studies of the determinantsof HF rehabilitation outcomes have shown that patient character-istics are the primary indicators of functional gain. These include

bilitation model of care.

K.S. McGilton et al. / Archives of Gerontology and Geriatrics 49 (2009) e23–e31 e25

the following: age (Arinzon et al., 2005); sex (Rolland et al., 2004);pre-fracture cognitive function (Gruber-Baldini et al., 2003); pre-fracture functional status (Cummings et al., 1996; Naglie et al.,2002; Moncada et al., 2006); medical co-morbidities (Patrick et al.,1996, 2002); pre-fracture frailty (Arinzon et al., 2005); sensory(hearing and vision) impairment (Rolland et al., 2004); nutritionalstatus (Lieberman et al., 2006); social support (Beaupre et al.,2005); depression (Goldstein et al., 1997; Lenze et al., 2004; Shyuet al., 2005); and delirium or incident CI (Adunsky et al., 2002;Gruber-Baldini et al., 2003; Bitsch et al., 2006).

Researchers have found that the type of HF (Haentjens et al.,2005), depression (Fredman et al., 2006), delirium (Bitsch et al.,2006), and level of CI (Moncada et al., 2006) influence the LOS oninpatient rehabilitation units and the cognitive improvement thatpatients make. MMSE scores at discharge (Lenze et al., 2004),depression (Lenze et al., 2004), living situation (i.e., alone vs. withothers, Cummings et al., 1996), and the presence of social support(Beaupre et al., 2005) have been shown to influence the dischargedisposition of these patients.

1.1.4.2. System characteristics. System characteristics that mayhave an impact on rehabilitation outcomes include the following:length of time from the injury to surgery (Adunsky et al., 2002;Hoenig et al., 2002) and the time interval from surgery toadmission to inpatient rehabilitation (Adunsky et al., 2002; Yuet al., 2006).

1.2. Objectives

The overall objective of this feasibility study was to evaluatepatient and system outcomes for the older adults who participatedin the ACTED program of care following HF surgery. The specificobjectives were to identify the contextual and system factorsassociated with the four outcome measures, namely, functionalgain, cognitive gain, rehabilitation efficiency, and dischargelocation. The specific research questions were: (1) Are theredifferences in outcomes (functional gain, cognitive gain, rehabi-litation efficiency, and discharge location) between two groups ofolder adults, those with CI and those with intact cognition? (2)What additional patient characteristics are related to outcomes?and (3) What system characteristics influence outcomes?

2. Methods

2.1. Design and setting

This was a longitudinal retrospective feasibility study ofgeriatric patients who underwent HF surgery and were admittedto the ACTED program of care in the inpatient musculoskeletal(MSK) rehabilitation unit at a hospital in Toronto, Ontario, for theperiod from May to October 2006. This rehabilitation unit has a 10-bed capacity dedicated to ACTED patients, and includes an out-patient clinic for the patients’ follow-up visits with the geriatricianand physiatrist. This study was approved by the Research EthicsBoard of the rehabilitation facility where the study was conducted.

2.2. Sample

The study participants were older adults who underwent arepair of a HF in an acute care hospital in Toronto. Patients werereferred to the rehabilitation facility for immediate rehabilitationto prevent the deterioration of their health condition followingsurgery. Participant inclusion criteria for admission to the unit andstudy included the following: 65 years or older; admitted torehabilitation directly from an acute care hospital after being

treated for a HF; and living in the community (home or residentialsetting) prior to their HF. Patients were excluded from the programand the study if they had a pathologic HF, if the HF was associatedwith multiple trauma, and/or if they were living at a nursing homeat the time of the HF.

2.3. Measures

The measures included in this study were appropriate toevaluate the relevant contextual factors and processes thatinfluence patient outcomes. For the feasibility study, the authorsdid not include every possible variable representing these factorsbut instead chose those variables most frequently described in theexisting research. Process data will be assessed in subsequentstudies.

Patient characteristics that were collected included age, sex,and cognition (MMSE). System characteristics included timeinterval from injury to surgery and time interval from surgeryto admission to a rehabilitation unit (medical charts). Outcomedata included motor functional change (Functional IndependenceMeasure [motor-FIM change from the National RehabilitationServices Database, NRS]), cognitive change (cognitive-FIM changefrom the NRS), discharge setting (community, institution, notdischarged [i.e., discharged to acute care or death]), andrehabilitation efficiency.

2.3.1. Independent measures

The MMSE, which was used as an independence measure, is ascreening tool for CI, with scores ranging from 0 to 30 (Cockrell andFolstein, 1988). A score of 23 or less indicates the presence of CI(Folstein et al., 1975). This cutoff has been widely used inrehabilitation and gerontology research to dichotomize samplesinto cognitively intact or CI groups (Heruti et al., 1999; Espirituet al., 2001; Yu et al., 2005). Thus, a cutoff score of 23 for CI wasadopted for the current study. Test–retest reliability of MMSEscores range from 0.80 to 0.98, and these scores have been found tocorrelate well with clinical judgment of the patients’ CI (Perneczkyet al., 2006).

Participants’ sex and age were collected from the NRS data,which all rehabilitation facilities in Ontario collect. Systemcharacteristics (time intervals between injury and surgery andsurgery to admission to rehabilitation facility) were obtained froma chart review.

2.3.2. Outcome measures

2.3.2.1. Motor functional gain at discharge. The change in motorsubscale of the FIM was calculated by the difference between thepatients’ functional status at inpatient rehabilitation admissionand discharge (Keith et al., 1987). The FIM, which is an integralcomponent of the NRS (Dodds et al., 1993), must be completed byHCPs for all patients admitted to Ontario inpatient rehabilitationfacilities within 72 h of admission and again within 72 h ofdischarge. Patient ability to complete daily tasks is rated from 1(total assistance) to 7 (complete independence), resulting in totalscores between 13 and 91, with higher scores indicating higherlevels of independence. The FIM motor subscale’s reliability andvalidity are well established, and it demonstrates a high sensitivityfor detecting functional improvement in patients with differentfunctional status and varying degrees of co-morbidities (Herutiet al., 1999).

2.3.2.2. Cognitive gain at discharge. The change in the cognitivesubscale of the FIM was used to characterize the patients’ cognitivegains between inpatient rehabilitation admission and discharge

Table 1Characteristics of the sample by cognitive status

Characteristics

Total sample No CI With CI p-Value

31a 14a 17a

Demographic

Age (years), n (%)

�80 7 (22.6) 4 (28.6) 3 (17.6)

>80 24 (77.4) 10 (71.4) 14 (82.4)

Mean � S.D. 86.8 � 7.0 85.3 � 7.8 88.6 � 5.7 0.291

Median/range 87.0/71–100 86.0/71–100 88.0/77–100

Sex, n (%)

Males 13 (41.9) 7 (50.0) 6 (35.3) 0.645

Females 18 (58.1) 7 (50.0) 11 (64.7)

MMSE score

Mean � S.D. 21.4 � 6.3 26.8 � 1.2 16.9 � 5.2 <0.001

Median/range (0–30) 23.0/6–29 27.0/25–29 18.0/6–23

Fractured hip, n (%)

Right hip 14 (45.2) 8 (57.1) 9 (52.9) 1.000

Left hip 17 (54.8) 6 (42.9) 8 (47.1)

Weight-bearing status on admission, n (%)

WBAT 24 (77.4) 8 (57.1) 16 (94.1) 0.148

PWB 2 (6.5) 2 (14.3) 0 (0)

FWB 1 (3.2) 1 (7.1) 0 (0)

TWB 3 (9.7) 2 (14.3) 1 (5.9)

NWB 1 (3.2) 1 (7.1) 0 (0)

Days from injury to surgery

0–2, n (%) 21 (67.7) 8 (57.1) 13 (76.5)

�3, n (%) 10 (32.3) 6 (42.9) 4 (23.5)

Mean � S.D. 2.1 � 1.3 2.5 � 1.5 1.8 � 1.2 0.162

Median/range 2.0/0.5–6.0 2.0/1.0–6.0 2.0/0.5–5.0

Days from surgery to admission in the rehabilitation facility

�15, n (%) 21 (67.7) 8 (57.1) 13 (76.5) 0.643

>15, n (%) 10 (32.3) 6 (42.9) 4 (23.5)

Mean � S.D. 12.7 � 6.5 13.3 � 7.6 12.2 � 5.5

Median/range 10.0/5–32 10.0/5–32 10.0/5–21

WBAT = weight bearing as tolerated; PWB = partial weight bearing; FWB = feather

weight bearing; TWB = total weight bearing; NWB = non weight bearing.a Number.

K.S. McGilton et al. / Archives of Gerontology and Geriatrics 49 (2009) e23–e31e26

(Keith et al., 1987). The FIM cognitive function subscale’s totalscore is the sum of the scores for all cognitive items, which canrange from 5 (requiring total assistance) to 35 (completeindependence). The patient’s cognition functional gain wascalculated by subtracting the FIM cognitive function subscalescore on admission from the score at discharge.

2.3.2.3. Discharge setting change. Discharge locations were definedas institution, community (home or residential care) or notdischarged. This information was compared to a change in the pre-fracture setting.

2.3.2.4. Rehabilitation efficiency. This outcome measure referred tothe amount of functional gain achieved for each day of inpatientrehabilitation service and was calculated by dividing functionalgain by days of rehabilitation service.

2.4. Data collection

The medical records of all the patients who receivedrehabilitation care for a HF surgery from May to October 2006,were reviewed to obtain patient demographics. The remainingdata were extracted from the administrative data in the institu-tion’s NRS.

2.5. Data analyses

The data were analyzed using SPSS Version 15.0. Descriptivestatistics such as mean, median, standard deviation, range,frequencies, and percentages were calculated to characterize thesample as well as to describe the outcome measures. Studyparticipants were classified into two groups by their cognitivestatus upon admission.

To address research question 1 regarding the significance of therelationship between each outcome measure and patients’ CI, theauthors used a Pearson’s correlation test and an independentsamples t-test. A paired t-test was used to compare the significanceof the difference of the scores upon admission and on discharge forcontinuous outcomes. A p-value of less than or equal to 0.05 wasconsidered to be statistically significant.

To address research questions 2 and 3, patient and systemcharacteristics were dichotomized to describe the frequency of thegroup characteristic scores on gain scores. Sex was represented asmale or female, age included those over or equal to 80 years of age(the median), versus those under 80, and cognition status as CIpatients versus those with intact cognition. The system-level datacharacteristics were also divided into 2 groups: (1) those patientswho had waited from 0 to 2 days from injury to surgery (theexpectation for the program) versus those who waited longer and(2) those patients who had taken 15 days (the median) or longerprior to being admitted to the rehabilitation facility versus thosewho took less than 15 days.

3. Results

3.1. Sample characteristics

The average age of the 31 patients was 87 years (Table 1). Themajority of them were women (58%) and most had weight bearingas tolerated status on admission to the rehabilitation unit. Themean MMSE was 21, with 14 patients not having CI (MMSE � 24)and 17 having CI (MMSE � 23). On average, patients receivedsurgery 2 days post-injury and were admitted to the rehabilitationfacility 13 days post-surgery. There were no differences betweenthe CI group and the non-CI group in terms of age, gender, side of

fractured hip, number of co-morbidities, number of days frominjury to surgery, and number of days from surgery to admission torehabilitation facility. More patients with CI had weight bearing astolerated (WBAT) status than those without CI. This difference maybe related to the type of fracture, or the surgeon’s realization thatclients with CI may not be able to understand partial or featherweight bearing so weight bearing as tolerated is most realistic.

The mean motor FIM score (Table 2) for the total sample atadmission to rehabilitation was 41, which indicated moderatelyfunctionally dependent (Yu et al., 2006). Patients without CI hadhigher motor FIM admission scores (x = 46.2) and higher cognitiveFIM admission scores (x = 33.3) than patients with CI (x = 36.8) and(x = 30.2), respectively (Table 2), which were not statisticallydifferent.

3.2. Outcomes related to patient’s cognition

As shown in Table 2, a comparison of scores upon admission andon discharge from rehabilitation indicated that there was a highlysignificant difference in the motor functional gain scores in bothgroups of patients (p < 0.001). Regardless of cognitive status,patients had improved motor function post-rehabilitation. Motorfunctional gain for subjects with CI was 27 versus 24 for those withintact cognition (p = 0.62). Cognitive functional gain did notincrease over time for patients with CI (p = 0.58) or for thosewithout CI (p = 0.22). The average LOS on the unit for patients withCI was 28 days, and 31 days for those without CI. Rehabilitation

Table 2Comparison of rehabilitation outcomes between the groups

Characteristics

Total sample No CI With CI p-Value

(n = 31) (n = 14) (n = 17)

Motor functional gain

Mean � S.D. 25.8 � 15.2 24.3 � 11.4 27.1 � 18.0 0.621

Median 25.0 25.0 32.0

Range 0–55 6–42 0–55

Motor FIM score at admission

Mean � S.D. 41.0 � 15.6 46.2 � 13.0 36.8 � 16.7 0.095

Median 44.0 48 41

Range 13–67 25–67 13–62

Motor FIM score at discharge

Mean � S.D. 66.8 � 19.5 70.5 � 12.0 63.8 � 24.0 0.351

Median 75.0 75.0 75.0

Range 13–85 44–82 13–85

p for FIM motor functional gain <0.001y <0.001y <0.001y

Cognitive functional gain

Mean � S.D. �0.3 � 1.2 �0.6 � 1.7 �0.1 � 0.4 0.227

Median 0 0 0

Range �6, 1 �6, 0 �1, 1

Cognitive FIM score at admission

Mean � S.D. 31.6 � 4.5 33.3 � 1.1 30.2 � 5.7 0.058

Median 33.0 33.0 33.0

Range 12–35 31–35 12–35

Cognitive FIM score at discharge

Mean � S.D. 31.3 � 4.5 32.7 � 2.2 30.2 � 5.6 0.121

Median 33.0 33.0 33.0

Range 12–35 27–35 12–34

p for FIM motor functional gain 0.174 0.218 0.579

Rehabilitation efficiency

Mean � S.D. 0.97 � 0.63 0.86 � 0.40 1.06 � 0.77 0.372

Median 1.09 0.94 1.23

Range 0–2.56 0.21–1.62 0–2.56

LOS

Mean � S.D. 29.6 � 14.4 31.2 � 14.3 28.2 � 14.7 0.575

Median 28.0 28.0 28.0

Range 3–58 14–57 3–58

Discharge location, n (%)

Community 25 (80.6) 12 (85.7) 13 (76.5) 0.413

Acute care hospitals 4 (12.9) 2 (14.3) 2 (11.8)

LTC/CCC facilities 2 (6.5) 0 (0) 2 (11.8)

Fig. 2. Mean motor functional change by selected factors.

K.S. McGilton et al. / Archives of Gerontology and Geriatrics 49 (2009) e23–e31 e27

efficiency for patients with intact cognition was 2.1, in contrast to2.61 for patients with CI. Discharge location for both groups waspredominantly to the community, as 80% returned home. Fourpatients were discharged to an acute care hospital (2 in eachgroup) for further management of co-morbidities, and 2 of the CIpatients were discharged to a LTC facility.

3.3. Additional patient and system characteristics related to outcomes

As noted in the frequency graphs in Fig. 2, males had greatermotor functional change scores than females. Higher functionalgain was achieved for those admitted to the rehabilitation facilitywithin 15 days from the surgery. Likewise, those patients whoreceived surgery closer to their injury had greater motor functionalchange. Cognitive functional change was greater for patients whowere under 80 years of age and male (Fig. 3). Those patientsadmitted to the rehabilitation unit after 15 days from surgery hadthe largest cognitive gain. There was no cognitive change forpatients who had surgery 3 days or more post-injury. Functionalgain achieved for each inpatient day of stay (rehabilitation

Fig. 3. Mean cognitive functional change by selected factors.

Fig. 4. Mean rehabilitation efficiency by selected factors.

K.S. McGilton et al. / Archives of Gerontology and Geriatrics 49 (2009) e23–e31e28

efficiency) was greater for those patients entering rehabilitationfacilities in less than 15 days after surgery and for those havingsurgery up to 2 days post-injury (Fig. 4). As shown in Fig. 5, thoseadmitted to a LTC facility had one or more of the followingcharacteristics: 80 years of age or older, female, CI, and admitted tothe rehabilitation facility within15 days from injury.

Fig. 5. Percentage distribution of patients by discharge setting and selected factors.

4. Discussion

In our study, patients with CI did not differ in terms of theirdemographic characteristics from those with intact cognition.Moreover, both groups achieved greater functional independenceafter participating in the rehabilitation program, regardless of theirCI status. Older adults with CI showed functional gain comparablewith that of older adults with intact cognition, in spite of theformer’s greater degree of functional dependence at baseline. Thisfunctional gain was achieved efficiently, that is, patients with CIdid not require more days of rehabilitation than their counterpartsto achieve their gains. Older adults with CI were equally as likely tocontinue to live in the community upon discharge as were thosewith intact cognition. These findings support the evidence that CIpatients can benefit from rehabilitation programs (Goldstein et al.,1997; Heruti et al., 1999; Naglie et al., 2002; Barnes et al., 2004;Rolland et al., 2004). Although results from this study have beensupported by other inpatient rehabilitation studies (Goldsteinet al., 1997; Heruti et al., 1999; Yu et al., 2006), this study is the firstto show preliminary positive outcomes in an MSK rehabilitationfacility, where all elders within the community, regardless of theirCI status, are given an opportunity for rehabilitation care.

For the purpose of understanding the project’s viability, severalresults warrant comparison to those from previous studies. Themotor functional gain achieved by patients in our study (mean gainof 24.0–27.0 points) is higher as compared to those reported inprevious inpatient HF rehabilitation studies (mean gain of 16–26points, Goldstein et al., 1997; Heruti et al., 1999; Adunsky et al.,2002; Lenze et al., 2004). Likewise, just as we found in our study,FIM motor admission scores and FIM motor discharge scores, whilestatistically significantly different, were usually lower for patientswith CI (Goldstein et al., 1997; Rolland et al., 2004; Arinzon et al.,2005). Also, the discharge FIM motor scores were higher in ourstudy (64–71) and Arinzon et al.’s (2005), who reported FIM scoresfrom 56 to 65. These differences may be accounted for by the factthat these patients are in an active rehabilitation in-patient unitand therefore receive daily physiotherapy and occupationaltherapy, with nursing staff who focus on mobilizing their patientsas soon as possible. Further investigation is required, however, todetermine whether the FIM motor discharge score or the FIM gainscore is a more important outcome to track for purposes of refiningthe ACTED program of care. Finally, from our data we know thatpatients spend approximately 30 days in the rehabilitationprogram, which is not related to any financial limits. This averageLOS is in the range of the LOS for other studies (10–48 days)(Lieberman and Lieberman, 2002; Arinzon et al., 2005), and moreresearch is required to determine what is appropriate.

Rehabilitation efficiency offers an objective outcome measureof treatment efficiency by taking into consideration both func-tional gain and days spent on the rehabilitation unit. In our study,rehabilitation efficiency scores ranged between .86 (for patientswith intact cognition) and 1.06 (for patients with CI). Thesedifferences, which were not statistically significant, are attribu-table to the fact that CI patients were, on average, on therehabilitation unit for 3 days less than patients with intactcognition prior to being discharged home. This result was notexpected, as previous research has found the opposite: patientswith CI usually have longer LOS than those who are cognitivelyintact (Diamond et al., 1996; Moncada et al., 2006), and patientswith CI usually have lower rehabilitation efficiency scores thanthose patients who are intact (Heruti et al., 1999). Thesedifferences in findings may be related to the power of the samplein our study, which must be re-examined in a larger sample.

As Adunsky et al. (2002) similarly found, the longer LOS forpatients who were cognitively intact did not appear to contribute

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to the achievement of their functional motor gains, which indicatesthat additional factors may contribute to LOS. The same is mostprobable for patients with CI, staying longer in rehabilitationwould probably not enhance their efficiency scores. A possibleexplanation for patients who are cognitively intact staying longerinvolves staffs’ expressed concern that some patients with intactcognition try to re-negotiate later discharge dates. Perhaps toimprove efficiencies within the program, for these patients, a 3-week expectation of stay should be recommended at the time ofadmission, so they are able to prepare for discharge. Rationale forpatients with CI staying for shorter periods on the rehabilitationunit than patients without CI may be based on the HCPs’experience that for most patients with CI, there is no place likehome. The sooner patients with CI could go back safely to theirhome, an environment they know well; the better it was for thepatient. Additionally, living alone versus with someone else hasbeen found to influence LOS (Beaupre et al., 2005) which was notcompared between the groups in our study.

Regardless of the patients’ CI status, there were no changes inthe patients’ cognitive gain as measured by the cognitive FIM score.On admission, patients with CI had a marginally significantdifference in their cognitive FIM score (p = 0.058) from those whowere cognitively intact. However, there were no cognitive FIMgains for the CI group, despite noticeable clinical differences. Manyof the patients experienced delirium, as noted by confusionassessment method (CAM) testing, which had dissipated by thetime the patient was discharged. It would thus appear that thecognitive FIM was not sensitive enough to the subtle changes inpatients’ cognitive function. Concern about whether the cognitiveFIM scale is a reliable and valid measure in rehabilitation hassurfaced elsewhere (Jaglal, 2004). When the program is refined inthe future, using the MMSE at discharge from rehabilitation, asInouye et al. (2006) suggested, will provide a better objectiveindicator of cognitive gains. To differentiate between delirium anddementia, patients’ pre-fracture mental status must also beobtained in future studies in order to provide appropriate clinicalinterventions.

Additional patient characteristics were also investigated in thisfeasibility study. From the descriptive analysis, the sex and age ofthe patient (i.e., 80 years of age and older, and younger than 80)appear to influence outcomes. Males had greater functional andcognitive gain scores, and patients who were younger than 80 hadgreater cognitive gain scores. Age and sex have been found toinfluence functional gain in other rehabilitation studies (Rollandet al., 2004; Arinzon et al., 2005). Older patients are more likely toexperience post-op delirium which would interfere with cognitivegains (Adunsky et al., 2002).

System characteristics that appear to influence outcomes (i.e.,functional change scores and rehabilitation efficiency) includedhaving surgery within 2 days of the injury and being admitted tothe rehabilitation unit within 15 days of surgery. Additionally,patients who waited three and more days for surgery had noimprovement in their cognitive functional scores from admissionto discharge in the rehabilitation program. Patients waiting forsurgery for greater than 3 days post-injury are more likely tobecome delirious and therefore optimal cognitive gain may bedifficult to achieve. Waiting for surgery has been demonstrated tohave a negative effect on functional outcome and recovery,functional independence, and LOS (Zuckerman et al., 1995;Hoenig et al., 1997). These preliminary results point to the needfor system changes to support prompt surgery and timelyadmission to the rehabilitation unit. If patients come to therehabilitation units within shorter waiting periods after surgery,more optimal functional and cognitive outcomes may beachieved.

The reported discharge location for the 31 patients furthersupports the proposition that older adults with CI are very likely tocontinue to live in the community after participating inrehabilitation services (Goldstein et al., 1997; Huusko et al.,2002). Eighty percent of the patient sample went home. Although 4patients went to acute care for various reasons (pneumonia,peripheral vascular disease, which required an amputation,cerebral vascular accident while in rehabilitation, and congestiveheart failure), they were all encouraged to return to therehabilitation program. One patient did return and was laterdischarged to the community. Of the 2 patients with CI who wentto LTC, one patient chose this discharge location, and the otherpatient was discharged to LTC in consultation with the family andthe patient, as he could no longer care for himself at home. Both ofthese patients were on the rehabilitation unit for over 30 days andtherefore they did not influence the shorter LOS of patients with CI.Preliminary evidence indicates that this care program assistedwith allowing older adults to continue living in the community.This is in contrast to previous research by Diamond et al. (1996)and Lenze et al. (2004), who found that patients with CI were morelikely to be discharged to a nursing home. The most probablereason for patients not being discharge to a nursing home is theexpectation made clear to family members and patients atadmission that the patients will be going back to their home.So, a strong family support most likely assists with the patients’ability to return home.

There are several likely explanations for the rehabilitationbenefits of this program for older adults with CI. First, the model ofrehabilitation care involved teaching staff strategies to careeffectively for persons with dementia (McGilton et al., 2007).Second, both a physiatrist and geriatrician were available for thepatients during their rehabilitation stay. Third, an APN wasavailable to staff on all shifts to provide help with transferringprinciples of dementia care to the practice setting and toimplement individualized care. Fourth, as Yu et al. (2005)suggested, the older adults in this study with mild and moderateCI had abilities to learn and retain physical activities that were notas compromised as those of older adults with severe CI. Toimplement this program of care in other facilities, resources arerequired to teach staff how to rehabilitate patients with CI, andexperts are required to provide consultation. Becoming attuned tothe patients’ needs and delivering care in individualized ways areparamount to the success of rehabilitating patients with CI.

This feasibility study had three limitations. First, it employed aretrospective design using health care record abstraction, which isbound by time and history. In addition, the data collected withMMSE and FIM were from instruments administered by HCPs aspart of assessments. However, reliability and responsiveness of theFIM have been shown even when HCPs collected and entered thedata (Dodds et al., 1993; Jaglal, 2004). Lastly, the study size wassmall, which limits the ability to create predictive models tounderstand the influence of patient and system characteristics onrehabilitation outcomes. A future study with a large sample isplanned to fully evaluate the patient-centered rehabilitationmodel of care (Fig. 5). Despite the limitations, our data providepreliminary evidence supporting the implementation of the ACTEDmodel.

5. Conclusion

Patients with CI can achieve functional independence after hipsurgery despite their greater degree of baseline functionaldependence. Moreover, such benefit need not demand more daysof service. Clearly, our study demonstrated that more days ofservice are not required for patients with CI, which has often been

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an argument used to prevent their admission to rehabilitation.Creating a rehabilitation model of care that is accessible to allcommunity dwelling elders, regardless of their cognitive status,who have fractured their hip not only optimizes resources, but willenhance the quality of life of older adults. LOS of patients onrehabilitation units can be impacted by a multitude of factors(Fig. 1) such as patient characteristics (most notably post-opdelirium), system characteristics, and in-patient processes of care.Future studies with larger sample sizes will focus on determiningpredictors of LOS and rehabilitation efficiency. In this paper,preliminary evidence was presented that reflects the feasibility ofsuch a program and provides some insights on how to refine themodel.

Acknowledgements

Support for this research was provided by Toronto Rehabilita-tion Institute and from the Ontario Ministry of Health and Long-Term Care. The views expressed here do not necessarily reflectthose of the ministry. We give special thanks to the health careprofessionals who implemented the new approach to care on theirunit.

Conflict of interest

None.

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