Background
According to the World Health Organization, 15 million people worldwide suffered a stroke in 2004 [
1]. It has been reported that the mean stroke incidence rate in Western countries is 94 per 100.000 person years [
2]. Although men are more often affected than women due to a younger age of onset, this gender difference becomes smaller with increasing age [
3]. Stroke incidence typically increases with age and, due to the ageing of the population, stroke incidence rates are expected to rise. High age and low level of physical endurance, due to significant comorbidity, are characteristic of the geriatric stroke population. Although rehabilitation after stroke is an important activity in many rehabilitation centers worldwide, most geriatric stroke patients are probably not admitted to these centers and, thus, do not participate in intensive rehabilitation programs [
4]. These patients may be referred to nursing homes or skilled nursing facilities (SNF) that provide adapted rehabilitation programs combined with residential care, whereas others may not receive any formal type of multidisciplinary rehabilitation at all. As a result, geriatric stroke patients are greatly underrepresented in outcome studies and factors associated with the successfulness of their rehabilitation are largely unknown.
Few studies have dealt with the influence of comorbidity and age on the outcome of stroke rehabilitation. Atalay and Turhan [
5] found that elderly stroke patients (older than 65 years of age) were less likely to be successfully rehabilitated despite similar Functional Independence Measure (FIM) scores on admission, compared to patients younger than 65 years. Yet, comorbidity and age were not associated with prolonged length of stay in the rehabilitation center. In the same vein, Fischer et al. [
6] found that comorbidity and age did not uniquely contribute to predicting length of hospital stay. On the other hand, there is evidence that comorbidity and age are important factors in determining functional outcome after stroke [
7]. Several additional studies have emphasized the importance of age for functional outcome after stroke, but estimates of the true impact of age seem to vary greatly. Whereas some studies reported a relatively small influence of age [
8,
9], other studies found that very old age, defined as 85 years and older, was a consistently strong predictor of poor outcome [
10].
Interestingly, Teasell et al. [
4] have reported that rehabilitation in 'lower band' patients recovering from severe stroke, who were considered inappropriate for conventional inpatient rehabilitation programs, may still be quite successful in terms of gain in independency of self-care and ambulation. However, although the patients were on average 72 years of age, this study did not specifically focus on geriatric rehabilitation and did not examine the influence of comorbidity or age on rehabilitation outcome. Several other studies have shown that a substantial number of stroke patients that receive rehabilitation in SNFs or nursing homes can be successfully discharged to the community [
11‐
13]. The probability of discharge greatly depends on individual rehabilitation potential, which is related to stroke severity and physical capacities. Besides, it appears that admission to SNFs increases the likelihood of successful rehabilitation in terms of discharge to the community [
11,
12].
In general, many studies have investigated the clinical, biological and demographic factors associated with the outcome after stroke [
4‐
10,
14‐
25]. A large number of such factors has been associated with the outcome after stroke rehabilitation (table
1), but probably many of these factors are interrelated. This implicates that the unique contribution of these factors to stroke outcome, corrected for association with other factors, still has to be determined in order to be of value for clinical prediction in daily practice. In short, initial disability and age seem to be the most promising predictors of long-term activities of daily living (ADL) and discharge destination after rehabilitation.
Table 1
Factors associated with stroke outcome disability and discharge destination in the literature
ADL scores
| |
FIM
| - Initial FIM, age [ 8, 9] |
BI
| |
| - Initial NIHSS, age, premorbid disability, DM, infarct volume [ 15] |
| - Trunk Impairment Scale, static sitting balance [ 16] |
Discharge destination
| |
| |
| |
| - premorbid social support, FIM bowel, age, CMSA leg, type of premorbid accommodation [ 19] |
| - initial MMSE, premorbid living with relatives [ 8] |
| - discharge BI, LOS, age [ 20] |
| - Initial FIM, age, male gender [ 4] |
| - swallowing disorder [ 21] |
Against this background, the primary goal of this study is to assess the factors that uniquely contribute to the successfulness of rehabilitation in geriatric stroke patients that undergo rehabilitation in nursing homes. Functional outcome is primarily assessed by discharge to an independent living situation and, secondarily, by various functional scales. A secondary goal is to investigate whether the factors that are uniquely associated with successfulness of rehabilitation in this geriatric population are similar to those associated with the outcome of stroke rehabilitation in the literature. To this end, we have set up a multicenter study in 15 nursing homes in the Southern part of the Netherlands. All participating nursing homes are selected based on the existence of a specialized stroke rehabilitation unit and the provision of dedicated multidisciplinary care. To our knowledge, this is the first study that focuses on the determinants of success of geriatric rehabilitation in nursing home patients.
Discussion
To our knowledge, this is the first large study that focuses on the determinants of success of geriatric stroke patients admitted to nursing homes. It will provide more detailed information about the factors that are uniquely associated to the successfulness of geriatric stroke rehabilitation and that can, thus, be used in building a clinical prediction model of discharge destination from nursing homes.
All selected outcome measures have proven to be reliable and valid, or are recommended by the Netherlands Heart Foundation.
Because legally incapable patients are excluded from this study, its external validity may be slightly affected. Therefore, general patient characteristics of the excluded patients are registered and compared to those of the included patients. Besides age, length of stay in the nursing home, and discharge destination are recorded to compare both groups. This multicenter research uses multidisciplinary teams to collect the data over a period of two-and-a-half years and, thus, may suffer from some measurement inaccuracies. To minimize such inaccuracies, over 90 people working in 15 Dutch nursing homes received the same instructions about performing the outcome measures during collective meetings before the start of the study. To ensure the quality of data collection during the study, each nursing home has 2 to 3 specially assigned professionals who maintain contact with the main researchers. In addition, a newsletter is provided every 6-8 weeks to keep everybody involved, informed, and motivated with regard to the progress of the study.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MS and BB are the primary investigators of the GRAMPS study, they designed the study and wrote the manuscript. The collected data will be processed and analyzed by MS and BB. SZ will help in the analysis of the data, and he participated in writing the manuscript. FV participated in the design of the study, and he reviewed this study protocol. AG participated in designing this study, writing the manuscript, and he will help in the analysis of the data. RK participated in the design of the study, and writing the manuscript, and he will help with the analysis of the data. All authors have given final approval of the version to be published.