Intermediate Care as a Means of Improving Mental Status in Post-Acute Elderly Patients.

Intermediate care as a means of improving mental status in post-acute elderly patients.

Aging Clin Exp Res. 2013 May 22;
Fiorini G, Pandini S, De Matthaeis A, Seresini M, Dragoni R, Sfogliarini R

AIM OF THE STUDY: To evaluate the impact of residential intermediate care (IC) on the cognitive status of post-acute older patients and its correlation with the improvement in physical independence. METHODS: This prospective observational study involved 299 subjects (116 males and 183 females; mean age 80.1 ± 8.3 years) transferred to IC. The Mini Mental State Examination (MMSE) and a panel of laboratory and functional parameters were evaluated upon admission to IC (T0) and at the time of discharge (T1). The functional evaluations included the Cumulative Illness Rating Scale, the Barthel Index (BI) and the Morse Fall Scale (MFS). Afterwards, the patients were grouped on the basis of their MMSE score at T1: those with an unchanged or worse MMSE score (group A) and those with a better MMSE score (group B). The laboratory and functional parameters of the two groups were then compared. RESULTS: There was a significant improvement between T0 and T1 in the MMSE score (18.1 ± 7.5 vs 19.6 ± 7.3, P < 0.001) and the BI (42.1 ± 27.7 vs 53.6 ± 30.0, P < 0.001), as well as brain natriuretic peptide, C-reactive protein and blood glucose levels. Group B had a significantly better BI (57.7 ± 29.1 vs 47.2 ± 31.5, P = 0.003) and a slightly better MFS. There was a close relation between the MMSE scores and BI. CONCLUSIONS: Residential IC is a type of rehabilitation that favourably affects the cognitive status and physical independence of older post-acute patients. HubMed – rehab

Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post-stroke spasticity.

Cochrane Database Syst Rev. 2013 Jun 5; 6: CD009689
Demetrios M, Khan F, Turner-Stokes L, Brand C, McSweeney S

BACKGROUND: Spasticity may affect stroke survivors by contributing to activity limitations, caregiver burden, pain and reduced quality of life (QoL). Spasticity management guidelines recommend multidisciplinary (MD) rehabilitation programmes following botulinum toxin (BoNT) treatment for post-stroke spasticity. However, the evidence base for the effectiveness of MD rehabilitation is unclear. OBJECTIVES: To assess the effectiveness of MD rehabilitation, following BoNT and other focal intramuscular treatments such as phenol, in improving activity limitations and other outcomes in adults and children with post-stroke spasticity. To explore what settings, types and intensities of rehabilitation programmes are effective. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (February 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 12), MEDLINE (1948 to December 2011), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), AMED (1985 to January 2012), LILACS (1982 to September 2012), PEDro, REHABDATA and OpenGrey (September 2012). In an effort to identify further published, unpublished and ongoing trials we searched trials registries and reference lists, handsearched journals and contacted authors. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared MD rehabilitation (delivered by two or more disciplines in conjunction with medical input) following BoNT and other focal intramuscular treatments for post-stroke spasticity with placebo, routinely available local services, or lower levels of intervention; or studies that compared MD rehabilitation in different settings, of different types, or at different levels of intensity. We excluded RCTs that assessed the effectiveness of unidisciplinary therapy (for example physiotherapy only) or a single modality (for example stretching, casting, electrical stimulation or splinting only). The primary outcomes were validated measures of activity level (active and passive function) according to the World Health Organization’s International Classification of Functioning, Disability and Health. Secondary outcomes included measures of symptoms, impairments, participation, QoL, impact on caregivers and adverse events. DATA COLLECTION AND ANALYSIS: We independently selected the trials, extracted data, and assessed methodological quality using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Due to the limited number of included studies, with clinical, methodological and statistical heterogeneity, quantitative meta-analysis was not possible. Therefore, GRADE provided qualitative synthesis of ‘best evidence’. MAIN RESULTS: We included three RCTs involving 91 participants. All three studies scored ‘low quality’ on the methodological quality assessment, implying high risk of bias. All studies investigated various types and intensities of outpatient rehabilitation programmes following BoNT for upper limb spasticity in adults with chronic stroke. Rehabilitation programmes included: modified constraint-induced movement therapy (mCIMT) compared with a neurodevelopmental therapy programme; task practice therapy with cyclic functional electrical stimulation (FES) compared with task practice therapy only; and occupational, manual therapy with dynamic elbow extension splinting compared with occupational therapy only. There was ‘low quality’ evidence for mCIMT improving upper limb motor function and spasticity in chronic stroke survivors with residual voluntary upper limb activity, up to six months, and ‘very low quality’ evidence for dynamic elbow splinting and occupational therapy reducing elbow range of movement at 14 weeks. Task practice therapy with cyclic FES did not improve upper limb function more than task practice therapy alone, only at 12 weeks. No studies addressed interventions in children and those with lower limb spasticity, or after other focal intramuscular treatments for spasticity. AUTHORS’ CONCLUSIONS: At best there was ‘low level’ evidence for the effectiveness of outpatient MD rehabilitation in improving active function and impairments following BoNT for upper limb spasticity in adults with chronic stroke. No trials explored the effect of MD rehabilitation on ‘passive function’ (caring for the affected limb), caregiver burden, or the individual’s priority goals for treatment. The optimal types (modalities, therapy approaches, settings) and intensities of therapy for improving activity (active and passive function) in adults and children with post-stroke spasticity, in the short and longer term, are unclear. Further research is required to build evidence in this area. HubMed – rehab

Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer’s disease and vascular dementia.

Cochrane Database Syst Rev. 2013 Jun 5; 6: CD003260
Bahar-Fuchs A, Clare L, Woods B

BACKGROUND: Cognitive impairments, particularly memory problems, are a defining feature of the early stages of Alzheimer’s disease (AD) and vascular dementia. Cognitive training and cognitive rehabilitation are specific interventional approaches designed to address difficulties with memory and other aspects of cognitive functioning. The present review is an update of previous versions of this review. OBJECTIVES: The main aim of the current review was to evaluate the effectiveness and impact of cognitive training and cognitive rehabilitation for people with mild Alzheimer’s disease or vascular dementia in relation to important cognitive and non-cognitive outcomes for the person with dementia and the primary caregiver in the short, medium and long term. SEARCH METHODS: The CDCIG Specialized Register, ALOIS, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS and many other clinical trial databases and grey literature sources, was most recently searched on 2 November 2012. SELECTION CRITERIA: Randomised controlled trials (RCTs), published in English, comparing cognitive rehabilitation or cognitive training interventions with control conditions, and reporting relevant outcomes for the person with dementia and/or the family caregiver, were considered for inclusion. DATA COLLECTION AND ANALYSIS: Eleven RCTs reporting cognitive training interventions were included in the review. A large number of measures were used in the different studies, and meta-analysis could be conducted for 11 of the primary and secondary outcomes of interest. Several outcomes were not measured in any of the studies. The unit of analysis in the meta-analysis was the change from baseline score. Overall estimates of treatment effect were calculated using a fixed-effect model, and statistical heterogeneity was measured using a standard Chi(2) statistic. One RCT of cognitive rehabilitation was identified, allowing examination of effect sizes, but no meta-analysis could be conducted. MAIN RESULTS: Cognitive training was not associated with positive or negative effects in relation to any reported outcomes. The overall quality of the trials was low to moderate. The single RCT of cognitive rehabilitation found promising results in relation to a number of participant and caregiver outcomes, and was generally of high quality. AUTHORS’ CONCLUSIONS: Available evidence regarding cognitive training remains limited, and the quality of the evidence needs to improve. However, there is still no indication of any significant benefit derived from cognitive training. Trial reports indicate that some gains resulting from intervention may not be captured adequately by available standardised outcome measures. The results of the single RCT of cognitive rehabilitation show promise but are preliminary in nature. Further, well-designed studies of cognitive training and cognitive rehabilitation are required to obtain more definitive evidence. Researchers should describe and classify their interventions appropriately using available terminology. HubMed – rehab