JAMDA
Volume 10, Issue 5 , Pages 335-341, June 2009

Predictors of Rehabilitation Outcome Among Frail Elderly Patients Living in the Community

  • Domenico Fusco, MD

      Affiliations

    • Department of Gerontology and Geriatrics, Catholic University of Sacred Heart, Rome, Italy
    • ,
  • Giovanni B. Bochicchio, MD

      Affiliations

    • Department of Gerontology, ASL 1, Venosa (PZ), Potenza, Italy
    • ,
  • Graziano Onder, MD

      Affiliations

    • Department of Gerontology and Geriatrics, Catholic University of Sacred Heart, Rome, Italy
    • ,
  • Christian Barillaro, MD

      Affiliations

    • Department of Gerontology and Geriatrics, Catholic University of Sacred Heart, Rome, Italy
    • ,
  • Roberto Bernabei, MD

      Affiliations

    • Department of Gerontology and Geriatrics, Catholic University of Sacred Heart, Rome, Italy
    • ,
  • Francesco Landi, MD, PhD

      Affiliations

    • Department of Gerontology and Geriatrics, Catholic University of Sacred Heart, Rome, Italy
    • Corresponding Author InformationAddress correspondence to Francesco Landi, MD, PhD, Centro di Medicina dell'Invecchiamento (CE.M.I.), Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8 00168 Rome, Italy.
    • ,
  • The SILVERNET-HC Study Group of Basilicata Region

Article Outline

Background and Purpose

Physical therapy is frequently offered to community-dwelling frail elderly as part of home care rehabilitation programs. A better knowledge of predictors of rehabilitative success could allow a better targeting of limited resources. The purpose of this study is to evaluate the association of medical indicators of health status on functional recovery during rehabilitation of frail elderly living in the community.

Subjects

Subjects included 598 patients aged 70 years or more admitted consecutively to a home care rehabilitation program from January 2004 to December 2004.

Methods

A comprehensive geriatric multidisciplinary evaluation was offered to all patients, based on the Minimum Data Set for Home Care (MDS-HC) assessment form. Predictors of functional recovery were identified by a multiple logistic regression model. Data analyses were based on the items contained in the MDS-HC form.

Results

An improvement in ADL score was seen in 33% of patients, while the others remained unchanged or worsened. In multivariate analysis the negative predictors of functional improvement were as follows: cognitive impairment (OR 0.67; CI 0.60–0.74), depression (OR 0.89, CI 0.82–0.96), visual (OR 0.32, CI 0.21–0.50) and hearing impairment (OR 0.42, CI 0.27–0.67), and urinary (OR 0.21, CI 0.14–0.33) and bowel incontinence (OR 0.16, CI 0.10–0.26).

Conclusions

Cognitive impairment, depressed mood, sensory impairment, and incontinence are key factors that need to be assessed in order to individuate patients at risk of failure in rehabilitation. A targeted intervention in these areas could offer the opportunity of improving rehabilitation outcome.

Keywords: Rehabilitation outcome, frail elderly, home care

 

The prevalence of disability is steadily increasing in western countries.1, 2, 3, 4 This can be regarded as the combined result of the growing proportion of elderly in the general population as well as of the advances in medical knowledge. Older patients have a higher risk of experiencing acute illnesses (eg, stroke, hip fracture, acute myocardial infarction) that result in chronic functional impairment, with devastating consequences on general health status and quality of life.5, 6 In this respect, during the past decades, we have observed an increased need for rehabilitative interventions.7 Postacute in-patient rehabilitation centers are one of the best-validated opportunities.8, 9, 10, 11 The role of rehabilitation programs in the home care setting is still a matter of debate. There is some evidence that this kind of intervention can improve functional abilities and prevent further decline in physical performance,8, 9, 10, 11 even though their cost-effectiveness is still disputed.

The demand for rehabilitation programs is continuously increasing, while the available health and social resources are lacking, even for less expensive interventions such as home care rehabilitative programs. A better targeting of these limited resources could be eased by the knowledge of factors that can anticipate functional improvement, in order to allow a selection of patients. Previous studies have suggested that age, incontinence, cognitive impairment, delirium, mood disorders, admission functional deficits, and level of social support are predictors of functional recovery after acute events (ie, hip fracture or stroke).12, 13, 14, 15, 16, 17 However, the heterogeneous characteristics of the studied population and rehabilitation setting, the types of assessment and/or intervention, and the use of different outcome measures makes it difficult to draw definitive conclusions about their power in anticipating the outcome of rehabilitation programs. In particular, many of these studies were designed for institutionalized patients, and it is difficult to apply their conclusions to patients living in the community.

The aim of the present study was to assess the effects of functional and medical indicators of health status on the outcome of a large sample of older patients admitted to a home care rehabilitation program. This was accomplished using the new, internationally validated assessment instrument, the Minimum Data Set for Home Care (MDS-HC).18, 19

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Methods 

Setting and Sample 

All patients aged 70 years or more (n = 598) consecutively admitted to the rehabilitative Home Care Program of Basilicata Region, from January 2004 to December 2004, entered the study. Informed consent was obtained from all patients or, in the case of cognitive impairment, from their relatives. Procedures were in accordance with guidelines provided by the Catholic University Ethical Committee; the study was also approved and monitored by the local Steering Committee of Basilicata Region. To guarantee privacy, patients' identities were kept reserved and a numerical code was used to identify participants. Individual data were kept in a secret register hold by the coordinating center at the Catholic University, not accessible by any person except the main investigator of the study.

Rehabilitation Program 

All patients enrolled in the study (n = 598) were given a rehabilitation program of physical therapy directly in their home. This program focused on frail elderly patients with difficulties in activities of daily living (ADL) and general mobility, as a result of problems that included cerebrovascular accidents, Parkinson's disease, arthritis, fractures, osteoporosis, and respiratory and cardiac diseases. The rehabilitation program involved the patients for a mean of 3 hours per week and included all purposeful activities to achieve maximal functional independence in mobility, prevent or correct disability, and maintain health. Physical therapy treatment addressed the following areas: functional mobility training (ie, bed mobility and transfer training, progressive gait training), neuromuscular re-education (ie, postural training, balance activities, techniques to facilitate normal motor control), muscle tone management (ie, manual techniques and positioning to facilitate or inhibit tone), and contracture prevention and treatment. Patients also received medical assistance (regular visits by a physician and/or a nurse) and social help (mainly for cooking meals, doing the housework, and giving help in activities of daily living).

MDS-HC Assessment Data 

Patients were evaluated by a well-trained multidisciplinary team of professionals (general practitioner, nurses, and geriatrician) with the MDS-HC assessment form18 soon after the admission, and at the end of treatment. A reevaluation was possible at any time during this period, whether a substantial change in baseline conditions was observed, and it was always made at 6 months and, if treatment was continued beyond 6 months, it was made at 12 months from the beginning. The MDS-HC has been designed to be a useful patient assessment system that might inform and guide comprehensive care planning in the home care setting across the world. The MDS instruments—MDS-HC is one of a series of MDS instruments—are developed for different settings, such as home care, acute care, postacute care, nursing home care, and psychiatric care. Each of these instruments involves a person-specific assessment that enables the health care staff to assess multiple key domains such as physical and cognitive function, health status, and social support. The MDS instruments include over 300 items derived, where available, from a literature-proven face validity and have demonstrated an excellent reliability.20, 21 In particular, the MDS-HC is a scientifically based instrument with consistent and well-defined measures of the following typical domains of the frail elderly living in the community: cognition, communication/hearing, vision, mood and behavior, social functioning, physical functioning (self-performance of instrumental and personal activities of daily living), continence, disease diagnoses, health conditions, nutrition/hydration status, dental status, skin condition, medications, social support.

Among others, 2 summary scales based on MDS-HC items are designed to describe the performance in personal activities of daily living (ADL scale), and the level of cognitive function (Cognitive Performance Scale [CPS]). The validity and reliability of these summary scales have been documented, also in comparison with other research instruments.20, 22, 23 Furthermore, the implementation of the Minimum Data Set for nursing home residents or for home care clients has already paved the way to a nationally representative database that has been proven to represent a powerful tool for health services research.17, 24

Analytic Approach 

Data were first analyzed by descriptive statistics. Continuous variables are presented as mean values ± standard deviation. We evaluated differences in sociodemographic variables and indicators of disease severity using the Fisher exact test. Differences between continuous variables were assessed by analysis of variance (ANOVA) comparisons for normally distributed parameters; then, the Kruskal-Wallis test was adopted. A P < .05 level was chosen for statistical significance.

Physical function was evaluated using the 7-item ADL scale: mobility in bed, transfer, locomotion, dressing, eating, toilet use, bathing. For the purpose of this study, patients were classified as disabled in each ADL if they needed assistance or were totally dependent in performing the task18, 20 and the total number of ADLs with disability was calculated. Based on the number of ADLs with disability at baseline and after the rehabilitation program, patients were classified as follows:

1.improved physical function, defined by improvement in the number of ADLs with disability after the rehabilitation program;

2.unchanged or worsened physical function, defined as worsened or unchanged number of ADLs with disability after the rehabilitation program.

The cognitive performance was scored based on a 7-point ordinal scale that includes 2 cognitive items (short-term memory and skills on decision making), a measure of communication ability (understood by others), self-performance in eating, and presence of comatose status. Patients were classified as normal (CPS score 0–1), moderately impaired (CPS score 2–4), and severely impaired (CPS score 5, 6).14, 16 The prevalence of specific medical diagnoses was determined based on the active clinical diagnoses listed on the MDS-HC.18, 20

Depression was assessed by the use of a validated 11-point ordinal scale (MDS Depression Rating Scale).20 Depression is defined as MDS Depression Rating Scale of 3 or higher.

To identify predictors of functional recovery we constructed a multiple logistic regression model having as dependent variable the improvement of one or more points in the ADL scale. We included in the analysis all of the potential negative predictors of functional recovery available in the MDS-HC assessment form: age, gender, social support, cognitive status, depression, delirium, sensory impairment (vision and hearing), pressure ulcer, urinary and fecal incontinence, and comorbidity. The Instrumental Activities of Daily Living (IADL) score was excluded from the multivariate analysis to limit the confounding effect of collinearity with the ADL scale and the CPS scale scores. Furthermore, to test the hypothesis that baseline level of physical function could influence the rate of recovery, we constructed a model in which all the variables were adjusted for the baseline values of ADL score. The improvement or the worsening in functional status after rehabilitation program has been analyzed excluding all the subjects with minimal and maximal functional impairment, too. From these models, we derived odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

Statistical analyses were performed using SPSS software (SPSS, Inc., Chicago, IL).

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Results 

The main sociodemographic and functional characteristics stratified by gender of the study population are shown in Table 1. Patients were most frequently female (64.2%); the mean age was 82.0 ± 6.9 years, with significant differences between male and female (80.4 ± 8.4 versus 82.7 ± 5.7, respectively, P = .001). Overall, patients had a moderate to severe impairment in basic activities of daily living (ADL score 5.3 ± 2.1). Cognitive function was compromised in a small number of patients: only 53 patients (8.9% of total population) had a clinical diagnosis of dementia, whereas average CPS score was 2.6 ± 2.1. We found a high prevalence of urinary (41%) and fecal (36%) incontinence. Visual impairment was present in one quarter of the study sample and one third had some form of hearing impairment. The large majority of subjects had a good social support, with only 70 patients (12%) living alone. In particular, the primary caregiver for 247 (41%) subjects was the spouse and for 206 (34%) subjects was the child; 75 subjects (13%) lived with others but not spouse or children.

Table 1. Descriptive Analysis of Baseline Sociodemographic, Functional, and Clinical Parameters According to Gender∗
CharacteristicsTotal (n = 598)Male (n = 214)Female (n = 384)P
Age, mean ± SD82.0 ± 6.980.4 ± 8.482.7 ± 5.7.001
Marital status
Married262 (43.8)146 (68)146 (30)<.001
Widowed297 (49.7)57 (27)240 (62)
Never married39 (6.5)11 (5)28 (8)
Living alone70 (11.7)20 (9)50 (13).1
Sensory impairment
Hearing147 (24.6)47 (22)100 (26).1
Vision193 (32.3)56 (26)137 (35).01
Urinary incontinence245 (41)77 (36)168 (43).03
Fecal incontinence215 (36)65 (30)150 (39).02
Pressure ulcer135 (22.6)36 (17)99 (26).001
ADL score, mean ± SD5.3 ± 2.15.1 ± 2.05.3 ± 21.06
CPS score, mean ± SD2.6 ± 1.52.7 ± 2.12.6 ± 1.5.1
No. of diseases, mean ± SD2.3 ± 1.52.4 ± 1.52.3 ± 1.5.4
No. of medications, mean ± SD3.5 ± 2.23.5 ± 2.23.5 ± 2.2.4
Depression score, mean ± SD3.2 ± 2.33.1 ± 2.13.2 ± 2.3.1
Main diseases†
Cerebrovascular accidents265 (44.3)112 (52)153 (40).002
Hip fractures190 (31.8)52 (24)138 (36).002
Osteoarthritis66 (11.0)12 (6)54 (14).001
Parkinson's disease57 (9.5)26 (12)31 (8).9
Associated diseases
Hypertension211 (35.3)66 (31)145 (38).1
Congestive heart failure72 (12)25 (12)47 (12).4
Dementia53 (8.9)13 (6)40 (10).04
Diabetes101 (16.9)34 (16)67 (17).3
COPD52 (8.7)31 (15)21 (5)<.001

ADL, activity of daily living (range 0–7, a higher number indicates higher impairment); CPS, cognitive performance scale (range 0–6, a higher number indicates higher impairment); Depression, Minimum Data Set Depression Rating Scale (range 0–11; a higher number indicates higher impairment); COPD, chronic obstructive pulmonary disease.

∗Data are given as number (percent) unless otherwise indicated.

†Diseases correlated with rehabilitation program.

Comorbidity was a common condition, with an average number of diseases of 2.4 ± 1.5, without significant differences between male and female. Table 1 summarizes the prevalence of the most common clinical conditions. Patients were admitted to a domiciliary program of rehabilitation most frequently after stroke (44%) and hip fracture (31%), but also for osteoarthritis (11%) and Parkinson's disease (10%). Cardiovascular diseases, diabetes mellitus, dementia of any type, and chronic obstructive pulmonary disease (COPD) were the most frequent associated diseases.

The mean length of stay in the rehabilitation program was around 6 months. Figure 1 summarizes changes in functional performance expressed by the difference in the ADL scale scores from baseline to follow-up. After a mean of 6 months of rehabilitative in-home care program, 196 patients (33%) had presented an improvement in the ADL scale score.

Table 2 shows the impact of demographic and health characteristics on functional recovery among frail elderly persons who underwent a domiciliary rehabilitation program. In the unadjusted model, patients with cognitive impairment, depression, urinary incontinence, bowel incontinence, or with sensory impairment (vision and hearing) were more likely to significantly decline in physical functioning at the end of the rehabilitation program. After adjusting our model simultaneously for all the potential confounders (Table 2, Model 1), only 4 “negative” factors remained significant: cognitive impairment (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.75–0.85), urinary incontinence (OR, 0.44; 95% CI, 0.27–0.70), bowel incontinence (OR, 0.47; 95% CI, 0.27–0.81), and visual impairment (OR, 0.55; 95% CI, 0.32–0.92). Similar results were obtained when the main diagnoses (stroke, hip fracture, osteoarthritis, Parkinson diseases) were considered in the adjusted model (Table 2, Model 2).

Table 2. Predictive Factors of Functional Recovery Among Study Sample
VariableUnivariate Odds Ratio (95% CI)Model 1 Odds Ratio (95% CI)Model 2 Odds Ratio (95% CI)Model 3 Odds Ratio (95% CI)Model 4 Odds Ratio (95% CI)
Age, y
≤ 74 y1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
> 75 y0.97 (0.95–1.00)0.99 (0.97–1.02)0.96 (0.65-1.44)0.97 (0.95–1.01)0.92 (0.60–1.40)
Gender
Male1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Female1.01 (0.70–1.44)1.21 (0.81–1.79)1.06 (0.70–1.63)1.01 (0.70–1.44)1.09 (0.70–1.71)
Living alone
No1.0 (Referent)1.0 (Referent)2.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes1.33 (0.79–2.23)1.21 (0.68–2.14)1.34 (0.74–2.41)1.33 (0.79–2.23)1.38 (0.74–2.56)
Cognitive Performance Scale
0–11.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
≥ 20.72 (0.66–0.79)0.85 (0.75–0.95)0.87 (0.73–0.96)0.67 (0.60–0.74)0.32 (0.16–0.65)
No. of diseases
0–21.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
≥ 30.96 (0.85–1.07)1.01 (0.89–1.15)1.02 (0.88–1.17)0.96 (0.85–1.07)1.01 (0.87–1.18)
Depression
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.89 (0.82–0.96)0.94 (0.86–1.02)0.97 (0.88–1.07)0.89 (0.82–0.96)0.92 (0.83–1.02)
Behavioral disturbances
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.82 (0.64–1.04)1.04 (0.80–1.35)1.06 (0.80–1.40)0.82 (0.64–1.04)1.09 (0.82–1.45)
Pressure ulcer
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.82 (0.54–1.24)1.30 (0.79–2.13)0.97 (0.57–1.64)0.82 (0.54–1.26)0.94 (0.54–1.63)
Urinary incontinence
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.24 (0.16–0.36)0.44 (0.27–0.70)0.43 (0.26–0.72)0.21 (0.14–0.33)0.42 (0.25–0.71)
Fecal incontinence
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.21 (0.13–0.32)0.47 (0.27–0.81)0.51 (0.29–0.91)0.16 (0.10–0.26)0.48 (0.27–0.86)
Hearing impairment
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.44 (0.28–0.69)1.22 (0.69–2.16)1.20 (0.66–2.16)0.42 (0.27–0.67)1.22 (0.66–2.26)
Visual impairment
No1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)1.0 (Referent)
Yes0.35 (0.23–0.53)0.55 (0.32–0.92)0.60 (0.35–1.04)0.32 (0.21–0.50)0.56 (0.32–0.98)

CI, confidence interval; Model 1, adjusted simultaneously for all the variables listed; Model 2, adjusted also for main diseases (stroke, hip fracture, osteoarthritis, Parkinson disease); Model 3, adjusted also for the baseline ADL scale scores; Model 4, adjusted for all the variables listed excluding subjects with minimal and maximal functional impairment.

Furthermore, to test the possibility that functional recovery could be influenced by the baseline level of physical function, we constructed a multivariate model in which all the variables were adjusted for the baseline ADL scale scores. In this model, impaired cognitive performance, depression, urinary incontinence, bowel incontinence, and sensory impairment (vision and hearing) were associated with the higher risk of poor improvement in physical functional performance (Table 2, Model 3).

Finally, the improvement or the worsening in functional status after the rehabilitation program have been analyzed excluding all the subjects with minimal (n = 34) and maximal (n = 247) functional impairment, too. To minimize floor and ceiling effects, a model adjusted for all the potential confounders was constructed. Again, cognitive performance impairment, urinary incontinence, bowel incontinence, and vision impairment were associated with the higher risk of poor improvement in physical functional performance (Table 2, Model 4).

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Discussion 

The goal of rehabilitation is to restore functional independence when possible and to facilitate psychosocial adjustment to residual disability. The results of our study demonstrate that domiciliary rehabilitation programs, as part of a multidisciplinary home care intervention, based on comprehensive geriatric assessment of patients needs, can prevent a further loss of autonomy in frail elderly with different kind of disabling diseases. These results are in line with other studies.9, 10, 25, 26, 27, 28 A systematic review of published randomized clinical trials demonstrated that early hospital discharge and home-based rehabilitation may obtain the same clinical outcomes, reducing the use of hospital beds and this could be a cost-saving alternative to conventional in-hospital rehabilitation.11 Only 30% of patients in our study improved significantly after 6 months of rehabilitative treatment, whereas functional abilities remained unchanged in most of our clients. The outcome could seem poor, but one has to keep in mind the peculiar characteristics of the sample, which was formed by elderly frail persons. Frailty is associated with progression in disability and loss of function. Most of the times this trend cannot be reverted, but it is possible to slow or stop its progression. Even keeping the existing functional status and preventing a further loss of independence in basic activities of everyday life can be regarded as a success.

An outstanding problem is to individuate subjects who can benefit from the greater improvement in rehabilitation, in order to offer a health care program that is tailored to individual needs. This can be accomplished by identifying those clinical factors that can modify the course and outcome of rehabilitation. Among many common health problems in the geriatric population, we were able to individuate 5 predictors of poor functional outcome: cognitive impairment, urinary incontinence, fecal incontinence, sensory impairment, and depression.

Participation in a rehabilitation program can be significantly affected by cognitive impairment. Other studies have documented a well-established association between rehabilitation outcome and cognitive abilities, with diminished cognitive performance negatively influencing rehabilitation goal attainment.17, 29, 30, 31 Several studies have documented that in geriatric patients with orthopedic or neurologic diagnoses, cognitive impairment affects the overall rehabilitation course, even though some abilities, such as walking or stair climbing, can be less severely affected.32, 33 Furthermore, a well-designed home care program could possibly slow down deterioration of cognitive performance.34

The presence of incontinence is a strong predictor of poor rehabilitation outcome. Many studies have demonstrated that urinary and fecal incontinence are clinical factors associated with increased mortality, morbidity, and greater disability among patients with neurological and orthopedic diseases and are associated with a high risk of institutionalization.35, 36, 37, 38 The great prognostic value of incontinence emphasizes the importance of interventions aimed at promoting continence, curing remediable conditions (eg, infections) and coping with the problem both at the individual and caregiver levels.39

Hearing and vision impairment have strong independent impacts on disability, physical functioning, mental health, and social functioning.40 Visual impairment is common in elderly people, both institutionalized and living in the community, and is associated with cognitive and functional decline in older people.41 Both contrast sensitivity and visual acuity loss contribute independently to deficits in performance on everyday tasks and the relationship of disability to the vision measures is mostly linear.42 A significant amount of the associated visual disability may be remediable43 and big efforts should be made by general practitioners and health workers to find out and correct them, as well as to prevent risk factors for visual impairment (eg, diabetes, hypertension, glaucoma). The same is true for hearing impairment, a condition that requires careful examination in the aging population, given its high incidence and the possibility of correction by the use of hearing aids. It has been demonstrated that these devices may protect against cognitive impairment and disability, improving quality of life of aged people.44, 45, 46

In our regression model, the presence of depressed mood was a significant predictor of poor outcome only when adjusting for ADL status at baseline. Depression is associated with higher mortality rates, even though the evidence for an association in the elderly remains inconclusive.47, 48 Disability and depressive symptoms are strongly interrelated processes in later life.49 Because a depressed affect is a major source of potentially treatable morbidity in older people, increased efforts are needed to ensure access to appropriate treatment.

Some limitations of the present study need to be cited. We did not distinguish between different types of diseases. In fact, the small sample size precluded any definitive subgroup analyses (eg, analyses of different age strata or of patients with different conditions). Second, our data do not allow us to verify whether different kinds of rehabilitation programs vary with different clinical context. The different prognostic implication of physical therapy, occupational therapy, and combined physical and occupational therapy also deserve evaluation. A more critical consideration is that our sample was composed only of patients considered eligible for home care programs, indicating that a health problem was still in place. In this respect we are not authorized to extend the results to patients in other health care settings. This is true in particular for the problem of cost-effectiveness, which could not be addressed by our study, given the lack of data about the consumption of resources and hospitalization. Finally, in this longitudinal observational study, results may be confounded by unmeasured factors. In the absence of randomization, it is likely that there are significant, not considered differences between the evaluation groups that may have biased the study results and conclusions. We lack some potential important information that could better explain the results observed in this study. In particular, we have no data about the number of physician visits, the number of nurse visits, and the number of rehabilitation sessions for each subject. However, our homogeneous population of old people elected for home care rehabilitation programs in a well-defined geographical area minimizes the possibility that selected subjects had substantially better health care or health knowledge.

More studies are needed to identify specific interventions that can address all the issues implied in disability process. Cognitive impairment, depressed mood, sensory deprivation, and incontinence are key factors that have to be assessed to individuate those patients who are at risk of failure in rehabilitation. Specific strategies aimed at improving autonomy in these areas could allow a better prognosis for these patients.

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 This study was supported by a grant from a project founded by the “Health Ministry” of Italy to the Basilicata Region.

PII: S1525-8610(09)00082-6

doi:10.1016/j.jamda.2009.02.004

JAMDA
Volume 10, Issue 5 , Pages 335-341, June 2009

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