ORIGINAL PAPERS Adv Clin Exp Med 2010, 19, 6, 755–764 ISSN 1230-025X © Copyright by Wroclaw Medical University Joanna Szczepańska-Gieracha1, Joanna Kowalska1, Iwona Malicka1, Joanna Rymaszewska1, 2 Cognitive Impairment, Depressive Symptoms and the Efficacy of Physiotherapy in Elderly People Undergoing Rehabilitation in a Nursing Home Facility Zaburzenia poznawcze i objawy depresyjne a skuteczność fizjoterapii osób starszych usprawnianych w warunkach długoterminowej hospitalizacji zakładu opiekuńczo-leczniczego 1 2 Department of Physiotherapy, University School of Physical Education, Wroclaw, Poland Division of Consultation-Liaison Psychiatry & Behavioral Medicine Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland Abstract Objectives. The aim of this study was to assess factors affecting the efficacy of three months of physiotherapy carried out in nursing home (NH) conditions. Material and Methods. The study involved 71 patients undergoing rehabilitation in a NH. The mean age was 77.4 (± 7.3) years; 81.7% were women; 25.4% had had orthopedic injuries; 56.3% had had a stroke; and 18.3% were patients with chronic diseases. The Mini Mental State Examination (MMSE) was used to test the patients’ state of cognitive function. The Geriatric Depression Scale (GDS-15) was used to determine their mood, and the Barthel Index (BI) was used to assess their functional status. The efficacy of physiotherapy (EP) was specified after each month of physiotherapy (EP1, EP2, EP3). Results. Cognitive impairments (MMSE < 24) were found in 73% of the patients, and symptoms of depression (GDS > 5) in 65% of the patients. The average BI score upon admission to the facility was 38.6 (± 20.2), and after three months it was 59.2 (± 24.5) (p < 0.00001). The average EP3 was 20.6 (± 15.0). In the case of 31% of the patients, EP3 was very low: 4.8 (± 3.6). A significant relationship was revealed between EP3 and MMSE (p = 0.00113), EP3 and GDS (p = 0.01223), EP3 and diagnosis (p = 0.0106) as well as EP3 and EP1 (p < 0.00001). Conclusions. An increased risk of physiotherapy failure in NH conditions was observed in patients with profound cognitive impairments (MMSE < 11) and severe depressive symptoms (GDS > 10). The strongest rehabilitation progress in the NH was observed among patients undergoing rehabilitation due to orthopedic injuries. The best and the most precise prognostic factor for the outcome of physiotherapy after a three-month NH stay is the effectiveness of physiotherapy after one month of hospitalization. A lack of an improvement in functional status after the first month of rehabilitation could indicate a need for the standard model of rehabilitation to be modified, or for the patient to be transferred to a specialized rehabilitation unit (Adv Clin Exp Med 2010, 19, 6, 755–764). Key words: elderly patients, efficacy of physiotherapy, long-term care unit. Streszczenie Cel pracy. Ocena czynników wpływających na skuteczności 3-miesięcznej fizjoterapii prowadzonej w warunkach HN. Materiał i metody. Badania przeprowadzono w zakładzie opiekuńczo-leczniczym (NH). Do badań włączono 71 osób: średnia wieku wynosiła 77,4 (± 7,3) lat; 81,7% stanowiły kobiety, 25,4% to osoby po urazach ortopedycznych, 56,3% pacjenci po przebytym udarze mózgu, a 18,3% seniorzy usprawniani z powodu chorób przewlekłych wieku podeszłego. Badano stan funkcji poznawczych i nastrój za pomocą Mini Mental State Examination (MMSE) i Geriatric Depression Scale (GDS-15) oraz stan funkcjonalny za pomocą Barthel Index (BI). Określono skuteczność fizjoterapii (EP) po każdym miesiącu rehabilitacji (EP1, EP2, EP3). Wyniki. Zaburzenia funkcji poznawczych (MMSE < 24) stwierdzono w przypadku 73% badanych, objawy depresji (GDS > 5) u 65%. Średni wynik BI przy przyjęciu na oddział wyniósł 38.6 (± 20,2), a po trzech miesiącach hospita- 756 J. Szczepańska-Gieracha et al. lizacji wzrósł istotnie do 59,2 (± 24,5) (p < 0,00001). Średnia skuteczność fizjoterapii (EP3) wyniosła 20.6 (± 15,0). Niską skuteczność fizjoterapii osiągnęło 31% (n = 22) badanej grupy. Wykazano istotną zależność pomiędzy EP3 i MMSE (p = 0,00113), EP3 i GDS (p = 0,01223), EP3 i rozpoznaniem (p = 0,0106) oraz EP3 i EP1 (p < 0,00001). Wnioski. Zwiększone ryzyko niepowodzenia fizjoterapii w warunkach NH obserwuje się u pacjentów z głębokimi zaburzeniami poznawczymi (MMSE < 11) oraz nasilonymi objawami depresji (GDS > 10). Największą szansę na pomyślny przebieg procesu usprawniania w NH mają osoby rehabilitowanie z powodu urazów ortopedycznych. Najlepszym i najbardziej trafnym czynnikiem prognostycznym rezultatów fizjoterapii w NH jest skuteczność fizjoterapii po miesiącu hospitalizacji. Brak poprawy stanu funkcjonalnego po pierwszym miesiącu pobytu w NH jest wskazaniem do modyfikacji przyjętego modelu usprawniania lub przeniesienia pacjenta do specjalistycznego oddziału rehabilitacyjnego (Adv Clin Exp Med 2010, 19, 6, 755–764). Słowa kluczowe: wiek podeszły, skuteczność fizjoterapii, opieka długoterminowa. Due to the steadily increasing average life expectancy, the percentage of elderly people requiring both medical care and physical rehabilitation in a round-the-clock hospitalization setting is increasing every year. Efficient rehabilitation processes can considerably shorten the inpatient stay, and the final results of rehabilitation are a major factor in determining whether the patient will be able to function independently at home or if permanent institutional care will be required. These are very important issues, both in terms of costs incurred by the healthcare system and social services, as well as the quality of life of elderly people. Therefore, studies are often undertaken in order to identify factors negatively affecting the efficiency and the final outcomes of the process of physiotherapy among elderly people [1–5]. It is assumed that accurate identification of those factors will enable appropriate action to be taken at the initial stage of rehabilitation, which will finally lead to improvement in the effectiveness of the rehabilitation process. In the literature one can find many publications on the efficacy of physiotherapy (EP) conducted in specialized inpatient rehabilitation (IR) units. However, in many countries, including Poland, physiotherapy for elderly people is also carried out in less specialized centers such as nursing homes (NH). Rehabilitation performed in a NH is less intensive and less specialized, but because of the lower costs of the patient’s stay, the healthcare system offers more places in such facilities than in specialized rehabilitation units. Due to the limited access to IR and the increasing needs of the aging population, it is necessary to manage existing resources appropriately so that facilities offering round-the-clock medical care and rehabilitation are utilized effectively. As previously mentioned, there are many reports in the literature on physiotherapy being carried out in IR conditions. These publications usually relate to a particular disease entity such as a stroke or hip fracture [4–8]. This is required for methodological reasons, but it also means that this type of data is less useful in the differing condi- tions of an NH, where patients with various diseases are admitted, and the main criteria are a high degree of disability and an inability to function independently at home. A review of scientific literature shows that there is no mention of the efficacy of physiotherapy carried out in less specialized units treating more diverse groups of patients. Such studies would help to identify patients who may significantly benefit from their stay in this type of facility, and those who should be transferred to more specialized rehabilitation centers. It is important for the decision regarding the optimal placement of elderly rehabilitation patients to be taken as soon as possible, and not after several weeks or even months of ineffective or minimally effective rehabilitation at an NH. Therefore, the purpose of the current study was to evaluate the efficacy of three months of physiotherapy carried out in a NH facility and to evaluate the impact of several variables on the efficacy of physiotherapy, including the patient’s age, functional status upon admission to the facility, the major cause of the disability and the presence of cognitive impairment and/or depressive symptoms. To maximize the usefulness of the results and taking into consideration the observational nature of the study, the variables put forward for analysis were those commonly used in assessing patients upon admission to the facility (functional status, cognitive impairment, depressive symptoms). Material and Methods The study was performed in a nursing home (NH). The study group consisted of geriatric patients admitted to the NH during the 12-month research period who met the criteria for inclusion. The patients agreed to participate in the study after being informed of the purpose and protocol of the study and of the possibility of resigning at any stage of the study. The inclusion criteria for participation in the project were age over 60 years and the ability to take a full cognitive function test. Efficacy of Physiotherapy in Nursing Home The criteria for exclusion from participation in the study were aphasia; severe loss of vision or hearing impairment preventing the patient from taking a cognitive function test based on the Mini Mental State Examination (MMSE); alcoholism; current delirium or severe cognitive disorders; serious mental disorders in the past, such as schizophrenia or other delusional disorders; bipolar disorder; treated depressive disorders; or the patient’s refusal at any stage of the study. Among the 78 people who qualified to participate in the study, seven died during hospitalization, so the study ultimately included 71 people aged from 61 to 97 years. The mean age was 77.4 (± 7.3) years; 81.7% of the participants were women. The medical diagnoses of the main causes of the disabilities requiring rehabilitation were as follows: 25.4% of the participants had had orthopedic injuries (broken limbs resulting from a fall), 56.3% had had a stroke, and 18.3% were being rehabilitated for chronic diseases of old age (changes in degenerative arthritis, complications with diabetes and arteriosclerosis). The MMSE was used to assess cognitive impairment (CI) [9]. The scoring ranges from 0 to 30 points; the lower the score, the more severe the cognitive impairment is. The examination was performed twice, first upon admission to the facility, between the third and fifth day of hospitalization (MMSE0), and a second time after a threemonth stay in the NH (MMSE3). In the case of seniors whose intellectual state allowed accurate examination of mood (MMSE ≥ 15, n = 51) [10, 11], a shortened 15-question version of the Geriatric Depression Scale (GDS) was performed. Results above five points indicate the presence of mood disorders; the higher the score, the more severe the symptoms of depression [12, 13]. The assessment of mood and well-being was performed upon admission to the facility – between the third and fifth day of hospitalization (GDS0) – and after every month of the patient’s stay at the NH (GDS1, GDS2, GDS3). The Barthel Index (BI) was used to evaluate the functional status of NH residents. This is a commonly used scale that measures functional performance of basic daily tasks (dressing, washing, using the toilet alone, eating, walking, etc.) [14]. It is a universal tool that can be used to evaluate every disease that limits a patient’s physical condition, because it assesses the capacity for self-sufficient functioning rather than any specific motor dysfunction characterized by a particular disease entity. A record sheet was completed by medical personnel on the basis of observations of the patient’s real abilities, and not the opinion of the therapist in charge. The scoring ranges from 0 to 100, where 100 means fully functional status, and 757 a result less than 20 indicates a severe condition and a need for round-the-clock care. BI measurement was performed four times: upon admission to the facility (BI0), after one month of rehabilitation (BI1), after two months (BI2) and after three months of rehabilitation (BI3). The variables were selected due to their universality in everyday practice: The variables analyzed were those that are typically evaluated upon admission to the facility (functional status, cognitive impairment, depressive symptoms), and they were measured using the same tools/scales that are used daily by the medical staff. All of these instruments have been commonly used for many years by geriatric services. They are characterized by high repeatability and reliability, and – just as importantly – are simple and not time-consuming to perform. The only modification of everyday NH procedures made in the study was the repetition of the assessment procedures in subsequent months of hospitalization. Regular evaluation of the functional status of the rehabilitation patients (BI0, BI1, BI2, and BI3) allowed the progress of the physiotherapy to be monitored and the effectiveness of this process in a given unit of time to be assessed. Similarly, evaluation of the mood and well-being of hospitalized patients in subsequent months (GDS0, GDS1, GDS2, and GDS3) provided insight into the dynamics of mood changes during the patients’ stay at the NH. The patients’ cognitive status was tested only twice (MMSE0, MMSE3) since it is not as dynamic a variable as the remaining two, particularly since no form of cognitiveimpairment therapy was used in the center where the study was carried out. Absolute functional gain was deemed the measurement of the EP. The method for calculating absolute functional gain was adapted from Rolland (2004), using the Barthel Index (BI) instead of the Functional Independence Measure [8]. On that basis, the following parameters describing the progress of the rehabilitation process were calculated. 1) EP1 – The efficacy of physiotherapy after the first month of rehabilitation (BI1 – BI0). 2) EP2 – The efficacy of physiotherapy after the second month of rehabilitation (BI2 – BI0). 3) EP3 – The efficacy of physiotherapy after the third month of rehabilitation (BI3 – BI0). After that, on the basis of the EP3 parameter, the patients were divided into the following subgroups: – low efficacy of physiotherapy (from 0 to 10 points), – medium efficacy of physiotherapy (from 15 to 25 points), – high efficacy of physiotherapy (from 30 to 65 points). 758 J. Szczepańska-Gieracha et al. Within these groups, analysis was carried out based on the differences in the level of cognitive disorders and severity of depressive symptoms, as well as the age of patients and their functional status upon admission and in the subsequent months of hospitalization. The correlation between particular parameters was also assessed. All analyses were performed for the entire group (n = 71) as well as in subgroups formed on the basis of the diagnosis (orthopedic injuries, stroke and chronic diseases). Non-parametric methods were used for statistical analysis: the Wilcoxon test, the MannWhitney test, Spearman’s rank correlation, the Kruskal-Wallis test and multiple regression. Results Within the framework of the research project 71 patients admitted to the rehabilitation unit went through the full evaluation process. Detailed characteristics of the study group are presented in Table 1. On the basis of the MMSE test upon admission, dementia of varying severity (MMSE < 24) was found in 73% of the patients and low mood (GDS > 5) in 65% of the respondents who were able to take the Geriatric Depression Scale (MMSE ≥ 15). Only 11% of the group showed a proper intellectual performance (MMSE 27–30) and were simultaneously free of mood disorders (GDS scores in the 0–5 range). After three months of hospitalization the cognitive status of participants did not change significantly (p = 0.10564), but a significant improvement in mood was observed (p < 0.00001). The percentage of patients with depressive symptoms (GDS > 5) decreased from 65% to 31%. The average BI score at admission was 38.6 (± 20.2), and after three months of hospitalization increased significantly to a level of 59.2 (± 24.5) (p < 0.00001), which implies a significant improvement in the functional status of the rehabilitated patients. Nonetheless, the efficacy of physiotherapy after three months of hospitalization differed greatly among individual patients, varying from 0 to 65 points, with an average of 20.6 (± 15.0). A low EP3 was found in 31% of the study group, 38% of them had an average EP3, and the remaining 31% achieved a high EP3. A correlation analysis showed that, among other variables, the efficacy of physiotherapy was dependent on the level of cognitive function in patients at the time of admission to the facility (p = 0.00113) as well as after three months of hospitalization (p = 0.00022) (Table 2). The worse the cognitive state at both of the measured points, the lower the efficacy of physiotherapy, understood as the change in the BI within the given time period (BI3–BI0). The relationship between EP3 and GDS1 was on the verge of statistical significance (p = 0.05145); a strong relationship between EP3 and GDS3 (p = 0.01223) was also observed. EP3 was lower among patients with severe depressive symptoms in the first and third month of hospitalization (Table 2). There was no interdependence between BI0 and EP3: The functional status of the patient upon admission to the facility did not significantly influence the EP after three months of rehabilitation. Nonetheless, the parameters BI1, BI2 and BI3, assessing functional status in successive months of hospitalization, did show a significant relationship with EP3 (Table 2). These observations were also confirmed by comparing patients who achieved Table 1. Characteristics of the study group Tabela 1. Charakterystyka grupy badanej Variables (Zmienna) n x min max sd Age MMSE0 MMSE3 GDS0 GDS1 GDS2 GDS3 BI0 BI1 BI2 BI3 EP1 EP2 EP3 71 71 71 51 51 51 51 71 71 71 71 71 71 71 77.44 19.13 20.17 6.88 5.88 5.33 4.57 38.59 49.01 54.51 59.23 10.42 15.92 20.63 61.00 7.00 0.00 1.00 0.00 1.00 0.00 0.00 0.00 0.00 5.00 0.00 0.00 0.00 97.00 29.00 30.00 12.00 13.00 13.00 12.00 80.00 85.00 90.00 95.00 35.00 45.00 65.00 7.28 6.48 6.49 2.98 3.12 2.89 2.95 20.23 20.99 23.22 24.50 9.36 11.50 15.00 MMSE – Mini Mental State Examination, GDS – Geriatric Depression Scale, BI – Barthel Index, EP – efficacy of physiotherapy. 759 Efficacy of Physiotherapy in Nursing Home Table 2. Efficacy of physiotherapy (EP3), Spearman’s correlation, MMSE (0–30) Tabela 2. Skuteczność fizjoterapii (EP3), korelacja rang Spearmana, MMSE (0–30) Pair of variables (Pary zmiennych) n R t(N-2) P value (Wartość p) EP3 & age EP3 & MMSE0 EP3 & MMSE3 EP3 & GDS 0 EP3 & GDS1 EP3 & GDS2 EP3 & GDS3 EP3 & BI0 EP3 & BI1 EP3 & BI2 EP3 & BI3 EP3 & EP1 EP3 & EP2 71 71 71 51 51 51 51 71 71 71 71 71 71 0.06817 0.37870 0.42535 –0.22733 –0.27428 –0.17804 –0.34842 –0.01481 0.34794 0.44552 0.57867 0.85138 0.95210 0.56757 3.39886 3.90394 –1.63408 –1.99653 –1.26649 –2.60196 –0.12307 3.08283 4.13368 5.89389 13.48223 25.86319 0.57217 0.00113 0.00022 0.10865 0.05145 0.21132 0.01223 0.90241 0.00295 0.00010 0.00000 0.00000 0.00000 MMSE – Mini Mental State Examination, GDS – Geriatric Depression Scale, BI – Barthel Index, EP – efficacy of physiotherapy. Table 3. Comparison of groups with low vs. high efficacy of physiotherapy, Mann-Whitney test Tabela 3. Porównanie grup niska vs wysoka skuteczność fizjoterapii, test U Manna-Whitneya Variables (Zmienna) low EP high EP U Mann-Whitney test n x sd n x sd U Z p Age MMSE0 MMSE3 GDS0 GDS1 GDS2 GDS3 BI0 BI1 BI2 BI3 EP1 EP2 22 22 22 10 10 10 10 22 22 22 22 22 22 76.82 15.45 16.77 8.80 8.50 7.60 7.10 34.77 35.68 37.73 39.55 0.91 2.95 6.27 6.47 6.73 2.90 3.41 3.53 3.11 21.13 20.89 22.19 21.87 1.97 3.33 22 22 22 19 19 19 19 22 22 22 22 22 22 78.45 21.18 23.14 6.47 5.21 4.84 3.89 35.23 55.45 64.32 74.09 20.23 29.09 7.76 5.80 4.57 3.04 2.46 2.24 2.77 14.84 12.04 12.94 14.45 8.09 6.84 219.500 126.000 113.500 53.0000 43.5000 54.0000 35.0000 241.000 101.000 75.5000 45.0000 2.00000 0.00000 –0.51640 –2.71109 –3.00450 1.90415 2.34004 1.85827 2.73005 –0.01174 –3.29790 –3.89646 –4.61237 –5.62169 –5.66864 0.60558 0.00671 0.00266 0.05689 0.01928 0.06313 0.00633 0.99064 0.00097 0.00010 0.00000 0.00000 0.00000 MMSE – Mini Mental State Examination, GDS – Geriatric Depression Scale, BI – Barthel Index, EP – efficacy of physiotherapy. the lowest efficacy of physiotherapy (0–10) versus the highest (30–65) after three months of rehabilitation (Table 3). To determine the “critical” (lowest) level of cognitive function upon admission that later influences the course of rehabilitation, a correlation analysis was carried out excluding people with profound dementia (MMSE0 < 11). MMSE scores were no longer correlated with PF3 scores (p = 0.06879). An analogical analysis was also carried out excluding those who showed symptoms of severe depression after a month of rehabilitation (GDS > 10). In this case too the GDS1 scores were not correlated with the EP3 scores (p = 0.30463). In terms of the disability diagnoses, the stroke patients started rehabilitation in the worst condition as far as functional status was concerned. A better level of functioning was represented by the patients being rehabilitated due to chronic diseases of old age and seniors with orthopedic injuries. The differences between these groups increased during hospitalization (Table 4). Although the stroke patients had the lowest functional condition upon admission to the facility, they achieved final rehabilitation results comparable to those of seniors with chronic diseases, which means that the EP in the case of the stroke patients was higher. This observation is confirmed by the analyses of the EP performed in the successive months of the patients’ stay at the facility. The lowest EP was 760 J. Szczepańska-Gieracha et al. noted in the patients with chronic diseases; slightly better results were achieved by the stroke patients; and by far the highest EP was achieved by seniors being rehabilitated due to fractures and orthopedic injuries. After the first month of rehabilitation the difference between the groups was insignificant (p = 0.2691), but it had clearly increased in the subsequent months: It was (p = 0.0221) for EP2, and (p = 0.0106) for EP3 (Table 4). As for the other parameters tested, the compared groups varied significantly in age, cognitive function upon admission to the facility as well as in the GDS value in the second and third months of rehabilitation (Table 4). The post-stroke patients were far younger than the other two groups (p = 0.0094). Despite their advanced age, the patients being rehabilitated due to orthopedic injuries had the highest MMSE values upon admission to the facility (p = 0.0166), which signifies the best intellectual status. The analysis of the GDS values in the initial period of hospitalization (GDS0, GDS1) indicated that at the beginning all groups displayed similar severity of depressive symptoms. After the second and third months, the most severe mood symptoms were observed in the stroke patients. The differences between the groups were (p = 0.0040) for GDS2 and (p = 0.0927) for GDS3 (Table 4). After the third month of hospitalization, 42.0% of the stroke patients continued to show symptoms of depression (GDS > 5), in contrast to 28% of the chronic-disease patients and 12.5% of the orthopedic-injury group. A correlation analysis indicated that among the stroke patients, the values of GDS0, GDS1, GDS2 and GDS3 are significantly related to the EP3. The greater the severity of the depressive disorders, the lower the efficacy of rehabilitation is after three months of the rehabilitation process (Table 5). No correlation between GDS and EP3 was observed in the remaining groups. However, among the orthopedic patients, functional status upon admission to the facility (BI0) was significantly related to the efficacy of physiotherapy after three months (EP3) (p = 0.0204). This was not revealed in the other two groups (Table 5). Multiple regression analysis was used to identify a set of factors that significantly influenced the efficacy of physiotherapy performed in NH conditions. During the drafting of the regression model from the available variables, those which showed no significant relation to the EP were rejected (age, BI0, GDS0), and it was assumed that only those variables that were known at the early stage of rehabilitation would be analyzed (no later than after one month of a patient’s stay in the NH). The first model, in which BI1, GDS1, MMSE0 and EP1 were taken into account, proved to be statistically significant (p < 0.00001, R2 = 0.5983), but out of all the components of the model only EP1 played a significant role (p < 0.00001). In the second model, in addition to EP1, the type of disease that led to the rehabilitation was also taken into account. This entire model was significant (p < 0.00001), as were each of its components. Over 70% of this model was explained by the variability of the parameter EP3 (R² = 0.70193). The parameter EP1 had the largest prognostic value for the efficacy of physiotherapy. In 95% of the patients who did not show any signs of functional improvement after the first month, the efficacy of physiotherapy after Table 4. Comparison of subgroups by main diagnosis, Kruskal-Wallis test Tabela 4. ANOVA rang Kruskala-Wallisa w grupach pacjentów utworzonych ze względu na rodzaj schorzenia będącego główną przyczyną rehabilitacji Variable (Zmienna) Orthopedic injuries (Urazy ortopedyczne) Strokes (Udary mózgu) Chronic diseases (Choroby przewlekłe) p-value (Wartość p) Age (Wiek) MMSE0 MMSE3 GDS0 GDS1 GDS2 GDS3 BI0 BI1 BI2 BI3 EP1 EP2 EP3 81.11 (± 6.16) 22.44 (± 6.08) 23.67 (± 4.99) 6.19 (± 3.33) 5.13 (± 2.83) 4.44 (± 1.97) 3.56 (± 2.71) 45.83 (± 18.88) 59.44 (± 15.42) 58.61 (± 15.79) 75.83 (± 16.91) 13.61 (± 9.97) 22.78 (± 11.40) 30.00 (± 15.62) 75.10 (± 7.00) 17.80 (± 5.88) 18.90 (± 6.05) 7.54 (± 2.71) 6.68 (± 3.20) 6.43 (± 3.16) 5.32 (± 3.01) 33.75 (± 20.22) 43.25 (± 21.50) 47.88 (± 23.83) 52.00 (± 25.16) 9.50 (± 9.04) 14.13 (± 10.68) 18.25 (± 13.85) 79.54 (± 7.29) 18.62 (± 7.61) 19.23 (± 8.15) 5.86 (± 2.97) 4.43 (± 2.88) 3.00 (± 1.00) 3.86 (± 2.73) 43.46 (± 19.30) 52.31 (± 21.08) 55.38 (± 22.40) 58.46 (± 21.25) 8.85 (± 9.16) 11.92 (± 10.90) 15.00 (± 12.58) 0.0094 0.0166 0.0164 0.1431 0.1510 0.0040 0.0927 0.0522 0.0209 0.0068 0.0028 0.2691 0.0221 0.0106 MMSE – Mini Mental State Examination, GDS – Geriatric Depression Scale, BI – Barthel Index, EP – efficacy of physiotherapy. 761 Efficacy of Physiotherapy in Nursing Home Table 5. Correlations in study subgroups by main diagnosis Tabela 5. Korelacja rang Spearmana w grupach pacjentów utworzonych ze względu na główną przyczynę rehabilitacji Pairs of variables (Pary zmiennych) Spearman’s correlation p-value orthopedic injuries strokes chronic diseases EP3 & age EP3 & MMSE0 EP3 & MMSE3 EP3 & GDS0 EP3 & GDS1 EP3 & GDS2 EP3 & GDS3 EP3 & BI0 EP3 & BI1 EP3 & BI2 EP3 & BI 3 EP3 & EP1 EP3 & EP2 0.86186 0.29869 0.04285 0.82383 0.83457 0.43418 0.87860 0.02042 0.38978 0.62999 0.20695 0.00053 0.00000 0.45540 0.16701 0.11627 0.05135 0.01975 0.04688 0.00463 0.32192 0.00132 0.00018 0.00001 0.00000 0.00000 0.31860 0.07656 0.08487 0.53847 0.87222 0.71160 0.87222 0.46429 0.36337 0.21626 0.08039 0.00000 0.00000 MMSE – Mini Mental State Examination, GDS – Geriatric Depression Scale, BI – Barthel Index, EP – efficacy of physiotherapy. three months of hospitalization was unsatisfactory (from 0 to 10 points on the Barthel scale). Discussion The main aim of this research was to assess the efficacy of three months of physiotherapy carried out in a NH. The authors have established that in the case of 1/3 of the elderly patients undergoing rehabilitation in these conditions, EP3 is unsatisfactory (from 0 to 10 points on the Barthel scale). Factors connected with low EP3 were then sought, to enable those patients who are at the highest risk of physiotherapy failure to be identified as quickly as possible, so that the model of rehabilitation can be modified appropriately or the patients can be transferred to centers offering more specialized therapy. Finding a way to identify such patients on the basis of parameters that are known in the initial phase of their qualifying for a stay in a NH (age, BI0, MMSE0, GDS0, diagnosis) would be considered a full success. However, the results obtained in the study have not provided such a possibility. EP & Age The current study has not demonstrated any significant relationship between the efficacy of physiotherapy and the age of the participants, even though some authors report a clear interdependence: The younger the patients, the better the effects of rehabilitation [1, 2, 15]. The nature of our study, which in contrast to the cited reports compares people with various different ailments, probably had a significant impact on the results obtained. The highest average age was reported among the patients being rehabilitated due to orthopedic injuries; this same group was also characterized by the best state of cognitive functions in both assessments (MMSE0, MMSE3) and the lowest intensity of depressive symptoms in the second and third months of hospitalization. Even after the first month of their stay at the facility this group of patients showed significant improvement in functional status, manifested both in absolute BI values and in better efficacy of physiotherapy (EP2, EP3) (Table 4). It therefore appears that in the population of patients hospitalized in the NH, age is not an independent factor increasing the risk of physiotherapy failure, even among the oldest patients. Rather, it is the type of disability and other additional factors (cognitive impairment, depression) which largely determine the outcome of rehabilitation. EP & BI0 In this study the authors initially assumed that the patient’s level of functional performance upon admission to the facility may be a significant factor shaping the course of the physiotherapy process. Many publications support such a criterion [1–5, 16, 17]. However, it is worth noting the methodological differences between particular experiments. In the cited studies the researchers usually assessed the effects of physiotherapy by considering the functional status at particular measuring points – for example, after one two and three months, and also over longer periods, one year to three years after the completion of rehabilitation. They concluded that the worse the initial condi- 762 J. Szczepańska-Gieracha et al. tion, the worse the patient’s condition was at the subsequent measurement points. In contrast, the current study assessed the difference between the final and the initial functional status – it was this change that was regarded as defining the efficacy of physiotherapy. The results obtained do not support the thesis that the worse the initial condition, the worse the EP will be after three months of rehabilitation. This means that even people with a very severe degree of disability can benefit considerably from rehabilitation carried out in NH conditions, and can improve their functional performance in a way comparable to patients who commenced hospitalization in better physical condition. EP & MMSE Discussion has been going on for many years regarding the impact of cognitive impairment on the course and final outcomes of the process of physiotherapy, and the conclusions are ambiguous. CI is regarded as one of the factors related to the length of stay in geriatric rehabilitation units [18]. Many authors argue moreover that CI patients achieve poorer end results in physiotherapy [19–22]. On the basis of such arguments one can suppose that demented patients are characterized by a reduced capacity to benefit from rehabilitation. More in-depth analysis suggests that the cause of failure may also be a higher rate of in-hospital falls and significantly less individual and group therapy per hospital day [23]. There are, however, also reports of patients with CI achieving comparable effects from physiotherapy as cognitively-normal individuals, if we adopt absolute functional gain as the measure of the efficacy of therapy (discharge functional status minus admission functional status) [8, 24]. In the current study a significant correlation has been shown between the level of cognitive impairment (MMSE value) and reduced efficacy of physiotherapy, defined as the difference between the final and initial states (BI3–BI0). But after excluding the most severely demented patients (MMSE < 11) from the analysis, the presence of CI ceases to correlate with EP. Therefore, it seems that within the studied group of elderly people being rehabilitated in NH conditions, only patients with severe dementia show an increased risk of physiotherapy failure. The reason for this may be communication problems with this type of patient, or the presence of intensified behavioral disorders. This leads to a reduced amount of treatment received, because the time that can be devoted to the patient is used inefficiently. Furthermore, it must be remembered that most of the more intellectually capable patients improve their physical fitness by doing daily activities (self-washing, dressing, tidying up, moving around within the center, etc.), while people who are deeply disturbed often have problems carrying out daily activities, or even (in the absence of appropriate stimuli from care workers) give up such activities. As a result, such patients are washed, dressed, etc., entirely by the staff, which has a negative influence on their physical condition, and subsequently on the effects of physiotherapy. The majority of these issues can, however, be avoided through appropriate organization of work at the facility, the selection of appropriate therapy methods, and the proper conduct of medical personnel who can effectively communicate with the patient, react in the event of behavioral disorders and ensure essential daily activity. Lenze et al. (2007) reported that CI people who received therapy at inpatient rehabilitation facilities had significantly better functional outcomes than similarly impaired patients at nursing homes [ 25]. Thus it appears that the presence of severe cognitive impairment is an indication for rehabilitation in a specialized unit and not in a NH. EP & Depression As in the case of CI, there is no clear and definite opinion regarding the impact of mood disorders on the outcomes of rehabilitation. Depending on the methodological assumptions of individual research projects (the ways functional capabilities are assessed, the duration of the observation of patients, the type of disease, etc.), the literature reveals different and sometimes conflicting reports. Many authors argue that the presence of depression negatively impinges on the course of the physiotherapy process [6, 7], which can prolong the duration of rehabilitation [26] and even result in a transfer to a nursing home [7]. Van de Weg et al., however, believe that there is no significant difference between those with depression and those without depression as far as functional gain achieved due to rehabilitation is concerned [27]. Similarly, Cassidy (2004) argues that depression is not a determining factor either for the effectiveness of rehabilitation or for the length of inpatient stay [4]. The results of the current study are also ambiguous. On the one hand, we disproved the hypothesis that GDS0 correlates with EP3. But GDS1 does show a significant relationship with EP3 (more intensified mood disorders reduce the effectiveness of physiotherapy after a three-month stay in a NH). Perhaps the screening tests performed in the first days of hospitalization are affected by a major error arising from temporary mood disorders associated with the elderly patient’s adaptation Efficacy of Physiotherapy in Nursing Home to new conditions, and it’s only after four weeks at the facility that the assessment reflects the patient’s real emotional state. It therefore seems more reliable and credible when the assessment is carried out after a period of adaptation, and not in the first few days after admission to the NH or other longterm care facility. Moreover, this study established that there is also a significant correlation between GDS3 and EP3. However, in our understanding, the presence of depressive symptoms in this case is a result of physiotherapy failure rather than its cause. People whose functional status is clearly improving have reasons to be happy and feel well, while the remaining patients have real grounds for concern about their health and their chances for independent existence, and this negatively impacts their emotional state. Another observation that arises from the analysis of the results obtained is the fact that the severity of depressive symptoms varies from one particular disease entity to another; it is clearly the highest among stroke patients. This is also the only group in which there is no significant improvement in mood regardless of the rehabilitation carried out: After three months of therapy, 42% of the respondents still exhibit symptoms of depression. Furthermore, it is in post-stroke individuals that the relationship of depression with EP3 is the strongest in all of the stages of hospital- 763 ization (GDS0, GDS1, GDS2 and GDS3). It should be emphasized, however, that – as in the case of the entire population studied at the NH – if the patients with the greatest severity of mood disorders (GDS > 10) are excluded from the analysis, the GDS value ceases to have a relationship with EP. Thus, the increased risk of physiotherapy failure in NH conditions occurs primarily in post-stroke patients whose intensified depressive symptoms have been established (GDS > 10). It seems justified to carry out the rehabilitation of such patients in a specialized unit where antidepressant therapy can be provided along with a standard rehabilitation process. The aforementioned study by Lenze et al. (2007) found that people with depression rehabilitated in this type of facility achieve comparable results to patients without mood disorders [25]. The authors concluded that an increased risk of physiotherapy failure in NH conditions was observed in patients with profound cognitive impairments (MMSE < 11) and severe depressive symptoms (GDS > 10). The strongest progress in rehabilitation in the NH was observed among patients being rehabilitated due to orthopedic injuries. The best prognostic factor for the outcome of physiotherapy after a three-month stay in a NH is the efficacy of physiotherapy after one month of hospitalization. References [1] Musicco M, Emberti L, Nappi G et al.: Early and long-term outcome of rehabilitation in stroke patients: the role of patient characteristics, time of initiation, and duration of interventions. Arch Phys Med Rehabil 2003, 84(4), 551–558. [2] Simanski C, Bouillon B, Lefering R et al.: What prognostic factors correlate with activities of daily living (Barthel Index) 1 year after para-articular hip fracture? A prospective observational study. Unfallchirurg 2002, 105(2), 99–107. [3] Di Monaco M, Vallero F, Di Monaco R et al.: Functional recovery and length of stay after hip fracture in patients with neurologic impairment. Am J Phys Med Rehabil 2003, 82(2), 143–148. [4] Cassidy E, O’Connor R, O’Keane V: Prevalence of post-stroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation. Disabil Rehabil 2004, 21, 26(2), 71–77. [5] Pettersen R, Dahl T, Wyller TB: Prediction of long-term functional outcome after stroke rehabilitation. Clin Rehabil 2002, 16(2), 149–159. [6] Clark MS, Smith DS. The effects of depression and abnormal illness behaviour on outcome following rehabilitation from stroke. Clin Rehabil 1998, 12(1), 73–80 [7] Lenze EJ, Munin MC, Dew MA et al.: Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture. Int J Geriatr Psychiatry 2004, 19, 472–478. [8] Rolland Y, Pillard F, Lauwers-Cances V et al.: Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment. Disabil Rehabil 2004, 8, 26(7), 425–431. [9] Folstein MF, Folstein SE, McHugh PR: Mini-Mental State: A practical guide for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975, 12, 189–198. [10] McGivney SA, Mulvihill M, Taylor B: Validating the GDS depression screen in the nursing home. J Am Geriatr Soc 1996, 44(1), 98–100. [11] Snowdon J, Lane F: Use of the Geriatric Depression Scale by nurses. Aging Ment Health 1999, 3(3), 227–234. [12] Yesavage JA, Brink TL, Rose TL et al.: Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982–1983, 17(1), 37–49. [13] Almedia OP, Almedia SA: Short versions of the Geriatric Depression Scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry 1999, 14, 858–865. [14] Mahoney F, Barthel DW: Functional evaluation: The Barthel Index. Md State Med J 1965, 14, 51–61. 764 J. Szczepańska-Gieracha et al. [15] Adunsky A, Levenkron S, Fleissig Y et al.: In-hospital referral source and rehabilitation outcome of elderly stroke patients. Aging (Milano) 2001, 13(6), 430–436. [16] Baztán JJ, Fernández-Alonso M, Aguado R et al.: Outcome at year after rehabilitation of proximal femur fracture in older than 84 years. An Med Interna 2004, 21(9), 433–440. [17] Hegener K, Krause T, von Renteln-Kruse W: Patient characteristics and factors associated with unfavourable in-hospital rehabilitation therapy outcome in very old geriatric patients with first-ever ischemic stroke – a retrospective case-control study. Gerontol Geriatr 2007, 40(6), 457–462. [18] Bertozzi B, Barbisoni P, Franzoni S et al.: Factors related to length of stay in a geriatric evaluation and rehabilitation unit. Aging (Milano) 1996, 8(3), 170–175. [19] Mysiw WJ, Beegan JG, Gatens PF: Prospective cognitive assessment of stroke patients before inpatients rehabilitation. The relationship of the Neurobehavioral Cognitive Status Examination to functional improvement. Am J Phys Med Rehabil 1989, 68(4), 168–171. [20] O’Neill BF, Evans JJ: Memory and executive function predict mobility rehabilitation outcome after lower-limb amputation. Disabil Rehabil 2009, 31(13), 1083–1091. [21] Friedman PJ, Baskett JJ, Richmond DE: Cognitive impairment and its relationship to gait rehabilitation in the elderly. N Z Med J 1989, 22, 102(880), 603–606. [22] Landi F, Bernabei R, Russo A et al.: Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital. J Am Geriatr Soc 2002, 50, 679–684. [23] Rösler A, Krause T, Niehuus C et al.: Dementia as a cofactor for geriatric rehabilitation – outcome in patients with osteosynthesis of the proximal femur: a retrospective, matched-pair analysis of 250 patients. Arch Gerontol Geriatr 2009, 49(1), 36–39. [24] Beloosesky Y, Grinblat J, Epelboym B et al.: Functional gain of hip fracture patients in different cognitive and functional groups. Clin Rehabil 2002, 16(3), 321–328. [25] Lenze EJ, Skidmore ER, Dew MA et al.: Does depression, apathy or cognitive impairment reduce the benefit of inpatient rehabilitation facilities for elderly hip fracture patients? Gen Hosp Psychiatry 2007, 29(2), 141–146. [26] Webber AP, Martin JL, Harker JO et al.: Depression in older patients admitted for postacute nursing home rehabilitation. Geriatr Soc 2005, 53, 1017–1022. [27] Van de Weg FB, Kuik DJ, Lankhorst GJ: Post-stroke depression and functional outcome: a cohort study investigating the influence of depression on functional recovery from stroke. Clin Rehabil 1999, 13, 268–272. Address for correspondence: Joanna Kowalska Department of Physiotherapy University School of Physical Education J. Paderewskiego 35 51-612 Wrocław Poland Tel.: +48 71 347-3522 E-mail: joanna.kowalska@awf.wroc.pl Conflict of interest: None declared Received: 18.07.2010 Revised: 23.08.2010 Accepted: 1.12.2010