The ARISE Project
Criteria for the Identification of Rehabilitation Potentials – Predictors for Successful Rehabilitation in Elderly Stroke Patients (2003-2010)
Primary Investigator: Andreas Kruse, Ph.D., Professor
Project Partner: AOK Baden-Württemberg
Project Team: Dr. Gabriele Becker (Responsible Project Member), Dr. Anne Natus, Andrea Wetzel (AOK Baden-Württemberg)
The project ARISE tries to deduce predictions for successful rehabilitation in elderly stroke patients, in order to enable an individual and efficient rehabilitation planning.
Stroke in Germany, as one of the most frequent neurological diseases, is placed third in the statistics of the causes of death. It comes second in the reasons of long term care and is the most frequent disease in geriatric rehabilitation. Although the incidence rate is decreasing due to the success of prevention, the demographic development will show an increasing rate of stroke patients. Economically, stroke is considered as one of the most expensive diseases. Nowadays, nearly one million people suffer under the consequences of stroke, which means a considerable restriction of life quality - for the affected persons as well as for their relatives. This emphasizes the high importance of rehabilitative interventions. When resources get scarcer, the quality management of rehabilitation becomes a main topic in health service research.
1. Project phase
The first part of the project (2003-2006) aimed to develop an assessment for the prediction of successful rehabilitation after stroke.
In two rehabilitation hospitals we set up a consecutive sample of 327 stroke patients at the age of 65 and older. The success in rehabilitation was described longitudinal. Differentiations in certain courses of disease were done. Assessments of 267 patients were taken at three predetermined times during the inpatient rehabilitation and a fourth time six weeks after discharge of hospital in the private home or in the nursing home. Dysfunctions and disability, the cognitive status and psychological features were assessed by different tests.
Results of the first phase of the project:
1. The rehabilitation process was mainly successful even under different conditions of the patients. After the inpatient rehabilitation, the processes show a high variability. Being able to demonstrate the processes sensitively, the use of a differentiated assessment which itself is able to show up big differences in the characteristic of a stroke but also little changes in functional improvement, was necessary.
2. Stroke patients show a high risk of complication – in most of the cases an inpatient care is inevitable. Within the time of observation of averagely 70 days, the process of about two-third of the patients was disturbed because of complications like pneumonia, falls and infections of the urinary tract.
3. The main predictors for a successful rehabilitation were the premorbid IADL-competence, comorbidity, degree of the stroke, dysphagia, cognitive-communicative competences, depression and motivation for rehabilitation.
4. On the base of these results a practicable assessment was developed, which is able to deduce predictions for successful rehabilitation, in order to enable an individual and efficient rehabilitation planning.
2. Project phase
In the second phase of the project (2007-2008) the applicability and feasibility of the assessment in acute care in the hospital as well as its contribution towards case management were studied in a sample of 171 stroke patients.
This study was conducted in acute geriatric units as well as in neurology departments. The further process in the different care pathways (inpatient rehabilitation, outpatient rehabilitation, home care or nursing home) were documented too.
Results of the second phase of the project
1. The assessment was administered at the end of the acute care and checked for its applicability. Of all included scales only the Geriatric Depression Scale had its limitations in case of cognitive or communicative impairment (about 15% of the patients in our study). On average it took 30 minutes to complete the assessment.
2. At a given rehabilitation ability, an individual recommendation for the subsequent care pathway is possible on the rehabilitation prognosis of the assessment. A high agreement was determined when comparing the assessment recommendation with those of the clinician. Differences were found in about 15% of the cases. These were by the majority patients who despite a good rehabilitation prognosis were not admitted to an inpatient rehabilitation because of superior organisational or personal reasons. In addition there was a small group of patients who would have been recommended to an outpatient rehabilitation instead of an inpatient rehabilitation.
3. Conclusions: For the majority of stroke patients inpatient rehabilitation is the essential form of care. However, the rehabilitation potential cannot be always exploited to its optimum. The actual care pathway also depends on practical reasons (already having a reservation in a nursing home, unavailable therapists in the area) or personal requests.
With the assessment an existing rehabilitation potential is proven and the influence of the rehabilitation prognosis on the case control is strengthened. This can be used as support for decisions for care pathways.
3. Project phase
In the third part of the study (2009-2010) quality of prognosis and also validity of the assessment concerning neurological rehabilitation were tested. In a sample of 105 stroke patients predictors for rehabilitation success were identified by the assessment and compared with the individual rehabilitation outcomes.
The quality of prognosis could not be replicated in the field of neurological rehabilitation.
We found three main reasons:
1. There were significant differences in sociodemographic und medical variables between the geriatric and neurological sample. 105 patients from the neurological rehabilitation on average were younger, with a lower amount of premorbid functional and cognitive impairments. There was a tendency to lower comorbidity.
2. Important predictors concerning geriatric patients were not confirmed in the neurological sample like motivation and dysphagia. Severity of stroke, age, premorbid status and bowel incontinence are contributing to the prognosis of rehabilitation success.
3. In this sample critical values of the predictors were not so frequently, a critical cumulation of risks too rarely was founded, so that this criterion could not be used. An approach by an geriatric assessment collecting competences and risks seemed not to work in the context of neurological rehabilitation.
Becker, G., Kruse, A., Tronnier, J., Roepke-Brandt, B., Natus, A., Theissen, H. & Wetzel, A. (2006). Rehabilitationsverlauf und Nachhaltigkeit - erste Ergebnisse einer Studie zur Rehabilitation älterer Schlaganfallpatienten. [Rehabilitation processes and sustainability-First results of a rehabilitation study of geriatric stroke patients.] Zeitschrift für Gerontologie und Geriatrie 39, 365-37
Clinic for Neurology, Dr. Johannes Bayerl
Clinic for Geriatric Rehabilitation, Dr. Hans-Georg Schäfer
Geriatric Center, Dr. med. Brigitte R. Metz
Geriatric Center, Prof. Dr. med. Peter Oster
Kliniken Schmieder Allensbach
Medical director Neurorehabilitation Prof. Dr. med. Joachim Liepert
St. Rochus Kliniken Bad Schönborn
Clinic for Neurology, Dr. med. Wolfgang Rössy